Quantitation of and landmarks for the muscular branches of the ulnar nerve to the forearm for application in peripheral nerve neurotization procedures

Object In neurotization procedures, donor nerves—either whole or in part—with relatively pure motor function can be carefully chosen to provide the optimal nearby motor input with as little donor site morbidity as possible. In this context, the ulnar nerve branches to the forearm muscles are relatively dispensable; however, quantitation of and landmarks for these branches are lacking in the literature. Methods The ulnar branches to the flexor carpi ulnaris (FCU) and flexor digitorum profundus (FDP) muscles in 20 upper extremities obtained in adult cadaveric specimens were dissected and quantified. In the forearm, a mean of four nerve branches led to the FCU and FDP muscles. A mean of 3.4 branches led to the FCU muscle; of these, one to three were medial branches and zero to two were lateral. Medial branches to the FCU muscle originated a mean of 2.7 cm inferior to the medial epicondyle. Lateral branches to the FCU muscle originated at a mean of 3.3 cm inferior to the medial epicondyle. The mean length of the medial branches was 3.2 cm, whereas the mean length of the lateral branches was 3.3 cm. All nerves had a single trunk for the FDP muscle, and in all specimens this branch was located deep to the main ulnar nerve trunk, originating from the ulnar nerve a mean of 2.7 cm inferior to the medial epicondyle. These branches had a mean length of 5.6 cm. The mean diameter of all medial and lateral branches to the FCU muscle was 1 mm, and the mean diameter of the branch to the FDP muscle was 2.1 mm. All branches to both the FCU and FDP muscles arose from the ulnar nerve, over its first approximately 5 cm from the level of the medial epicondyle. Additionally, all branches could be easily lengthened by gentle proximal dissection from the main ulnar nerve. Conclusions Ulnar branches to the forearm can be easily localized and used for neurotization procedures. The branch to the FDP muscle had the greatest diameter and longest length, easily reaching the median nerve and posterior interosseous nerve via a transinterosseous membrane tunneling procedure. Furthermore, this branch could be teased away from the main ulnar nerve trunk and made to reach the distal branches of the musculocutaneous nerve in the arm.

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ANATOMIC CHARACTERISTICS OF A FASCIA AND ITS BANDS OVERLYING THE ULNAR NERVE IN THE PROXIMAL FOREARM: A CADAVER STUDY

Journal of Hand Surgery (European Volume) ◽

10.1016/j.jhsb.2006.12.015 ◽

2007 ◽

Vol 32 (3) ◽

pp. 302-307 ◽

Cited By ~ 30

Author(s):

M. SIEMIONOW ◽

G. AGAOGLU ◽

R. HOFFMANN

Keyword(s):

Ulnar Nerve ◽

Cadaver Study ◽

Upper Extremities ◽

Flexor Digitorum Profundus ◽

Type I ◽

Type Ii ◽

Flexor Carpi Ulnaris ◽

The Mean ◽

Proximal Forearm ◽

Flexor Digitorum

This study describes the characteristics of a fascia overlying the ulnar nerve for 10 cm distal to the midpoint of the retrocondylar groove. A total of 28 cadaver upper extremities were dissected. The ulnar nerve between the flexor carpi ulnaris and flexor digitorum profundus was traced distally underneath a thin fascia. The length of the fascia was measured and examined for the presence of segmental fascial thickenings, referred to as ‘Bands’. Two types of fascia were found. In Type I, three Bands were identified within the fascia and the mean length of the fascia was 5.6 cm. In Type II, four Bands were identified and the mean length of the fascia was 7.7 cm. The presence of Bands within the fascia overlying the ulnar nerve in the proximal forearm may require release at the time of decompression, or anterior transposition, of the ulnar nerve at the cubital tunnel.

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Minimum 2-Year Outcomes of All-Arthroscopic Capsular Autograft Labral Reconstruction

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967121s00242 ◽

2021 ◽

Vol 9 (7_suppl4) ◽

pp. 2325967121S0024

Author(s):

Michael Kucharik ◽

Paul Abraham ◽

Mark Nazal ◽

Nathan Varady ◽

Wendy Meek ◽

...

Keyword(s):

Body Mass Index ◽

Body Mass ◽

Donor Site ◽

Donor Site Morbidity ◽

Labral Tear ◽

Labral Repair ◽

Inclusion Criteria ◽

The Mean ◽

Tönnis Grade

Objectives: Acetabular labral tears distort the architecture of the hip and result in accelerated osteoarthritis and increases in femoroacetabular stress. Uncomplicated tears with preserved, native fibers can be fixed to acetabular bone using labral repair techniques, which have shown improved outcomes when compared to the previous gold standard, labral debridement and resection. If the tear is complex or the labrum is hypoplastic, labral reconstruction techniques can be utilized to add grafted tissue to existing, structurally intact tissue or completely replace a deficient labrum. The ultimate goal is to reconstruct the labrum to restore the labral seal and hip biomechanics. Clinical outcomes using autografts and allografts from multiple sources for segmental and whole labral reconstruction have been reported as successful. However, reconstruction using autografts has been associated with substantial donor-site morbidity. More recently, all-arthroscopic capsular autograft labral reconstruction has been proposed as a way to repair complex or irreparable tears without the downside of donor-site morbidity. Since all-arthroscopic capsular autograft labral reconstruction is a novel technique, there is limited data in the literature on patient outcomes. The purpose of this study is to report outcomes in patients who have undergone this procedure at a minimum 2-year follow-up. Methods: This is a retrospective case series of prospectively collected data on patients who underwent arthroscopic acetabular labral repair by a senior surgeon between December 2013 and May 2017. Patients who failed at least 3 months of conservative therapy and had a symptomatic labral tear on magnetic resonance angiography (MRA) were designated for hip arthroscopy. The inclusion criteria for this study were adult patients age 18 or older who underwent arthroscopic labral repair with capsular autograft labral reconstruction and completion of a minimum 2-year follow-up. Intraoperatively, these patients were found to have a labrum with hypoplastic tissue (width < 5 mm), complex tearing, or frank degeneration of native tissue. Patients with lateral center edge angle (LCEA) ≤ 20° were excluded from analysis. Using the patients’ clinical visit notes with detailed history and physical exam findings, demographic and descriptive data were collected, including age, sex, laterality, body mass index (BMI), and Tönnis grade to evaluate osteoarthritis. Patients completed patient-reported outcome measures and postoperatively at 3 months, 6 months, 12 months, and annually thereafter. Results: A total of 72 hips (69 patients) met inclusion criteria. No patients were excluded. The cohort consisted of 37 (51.4%) male and 35 (48.6%) female patients. The minimum follow-up was 24 months, with an average follow-up of 30.3 ± 13.2 months (range, 24-60). The mean patient age was 44.0 ± 10.4 years (range 21-64), with mean body mass index of 26.3 ± 4.3. The cohort consisted of 6 (8.3%) Tönnis grade 0, 48 (66.7%) Tönnis grade 1, and 18 (25.0%) Tönnis grade 2. Two (2.8%) progressed to total hip arthroplasty. Intraoperatively, 5 (6.9%) patients were classified as Outerbridge I, 14 (19.4%) Outerbridge II, 45 (62.5%) Outerbridge III, and 8 (11.1%) Outerbridge IV. Seventy-two (100.0%) patients had a confirmed labral tear, 34 (47.2%) isolated pincer lesion, 4 (5.6%) isolated CAM lesion, and 27 (37.5%) had both a pincer and CAM lesion. The mean of differences between preoperative and 24-month postoperative follow-up PROMs was 22.5 for mHHS, 17.4 for HOS-ADL, 32.7 for HOS-Sport, 22.9 for NAHS, 33.9 for iHOT-33. (Figure 1) The mean of differences between preoperative and final post-operative follow-up PROMs was 22.1 for mHHS, 17.6 for HOS-ADL, 33.2 for HOS-Sport, 23.3 for NAHS, and 34.2 for iHOT-33. (Table 1) Patient age and presence of femoroacetabular impingement were independently predictive of higher postoperative PROM improvements at final follow-up, whereas Tönnis grade was not. (Table 2) The proportion of patients to achieve the minimally clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) thresholds were also calculated. (Table 3) Conclusions: In this study of 72 hips undergoing arthroscopic labral repair with capsular autograft labral reconstruction, we found excellent outcomes that exceeded the MCID thresholds in the majority of patients at an average 30.3 months follow-up. When compared to capsular reconstruction from autografts and allografts, this technique offers the potential advantages of minimized donor-site morbidity and fewer complications, respectively. [Table: see text][Table: see text][Table: see text]

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ANATOMICAL STUDY OF ARCADE OF STRUTHERS

Hand Surgery ◽

10.1142/s0218810410004941 ◽

2010 ◽

Vol 15 (03) ◽

pp. 157-159 ◽

Cited By ~ 3

Author(s):

Piyapong Tiyaworanan ◽

Surut Jianmongkol ◽

Tala Thammaroj

Keyword(s):

Ulnar Nerve ◽

Anatomical Study ◽

Medial Epicondyle ◽

Anatomical Location ◽

Greater Tuberosity ◽

Lateral Epicondyle ◽

Surgical Exploration ◽

Fresh Frozen ◽

The Mean ◽

Proximal Border

The incidence and the anatomical location of the arcade of Struthers as related to the arm length were studied in 62 arms of adult fresh-frozen cadavers. The distance between the greater tuberosity and the lateral epicondyle was designated as the arm length. The arcades of Struthers were identified in 85.4%. The mean arm length was 27.85 ± 1.3 cm. The mean of the distance between proximal border of the arcade of Struthers and the medial humeral epicondyle was 8.24 ± 2.06 cm. The mean ratio between the distance from the proximal border of the arcade to the tip of the medial epicondyle and arm length was 0.29 ± 0.07. We concluded that the anatomical location of the arcade as related to the arm length was 29% proximally, from the tip of the medial epicondyle. This report of the anatomical location of the arcade of Struthers related to the arm length can be useful to identify this structure in the arms which have differences in arm length during the surgical exploration and anterior transposition of the ulnar nerve procedures.

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OUTCOME OF TRACTION TENOLYSIS IN OPEN TRIGGER FINGER RELEASE — A RETROSPECTIVE REVIEW

Hand Surgery ◽

10.1142/s0218810413500421 ◽

2013 ◽

Vol 18 (03) ◽

pp. 375-379 ◽

Cited By ~ 1

Author(s):

Muntasir Mannan Choudhury ◽

Shian Chao Tay

Keyword(s):

Flexor Tendon ◽

Group Versus ◽

Trigger Finger ◽

Flexor Digitorum Profundus ◽

Flexor Digitorum Superficialis ◽

Active Motion ◽

Total Active Motion ◽

The Mean ◽

Flexor Digitorum ◽

A1 Pulley

Surgical treatment for trigger finger involves division of the A1 pulley. Some surgeons perform an additional step of traction tenolysis by sequentially bringing the flexor digitorum superficialis and flexor digitorum profundus tendons out of the wound gently with a Ragnell retractor. There is currently no study which states whether flexor tendon traction tenolysis should be routinely performed or not. The objective of this study is to compare the outcome in patients who have traction tenolysis performed (A group) versus those who did not have traction tenolysis (B group) performed. It was noted that even though the mean total active motion (TAM) for the B group in our study was lower preoperatively, it was consistently higher than the A group in all the 3 post-operative visits demonstrating a better outcome in the B group. Even though it was not statistically significant, our data also showed that patients with traction tenolysis appeared to have more postoperative pain compared to those without.

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Gender Disparity between Donor Sites of the Trochlea Used for Autologous Osteoarticular Transfer: An MRI Analysis

The Journal of Knee Surgery ◽

10.1055/s-0039-1677813 ◽

2019 ◽

Vol 33 (04) ◽

pp. 357-364

Author(s):

Kelly M. Rogers ◽

Daniel C. Berman ◽

Justin W. Griffin ◽

Kevin F. Bonner

Keyword(s):

Standard Deviation ◽

Trochlear Dysplasia ◽

Donor Site ◽

Donor Site Morbidity ◽

Gender Disparity ◽

Measurement Tool ◽

Level Of Evidence ◽

Osteochondral Autograft Transfer ◽

Males And Females ◽

The Mean

AbstractThe purpose of this study was to assess potential gender differences in size of the lateral and medial trochlea of the male and female knee as well as the variation within gender of potential osteochondral autograft transfer (OAT) donor site area. Two hundred and twelve skeletally mature patients, 106 males and 106 females, who underwent a 3T magnetic resonance imaging of the knee for a variety of indications were utilized for analysis. Exclusion criteria included degenerative arthritis, trochlear dysplasia, and poor image quality. Medial and lateral femoral trochlear cartilage width was obtained using a linear radiologic measurement tool. Widths were measured from a reproducible anatomic location representing the maximal trochlear dimension in a region where donor plugs are commonly harvested. Trochlear width was also plotted as a function of patient height. Statistical analysis was performed using a two-sample t-test. The mean and standard deviation of the lateral trochlear cartilage width (mm) for males and females were 23.38 +/− 2.14 and 20.44 +/− 2.16, respectively (p < 0.00001). The mean and standard deviation of the medial trochlear cartilage width (mm) for males and females were 14.16 +/− 2.17 and 11.78 +/− 2.03, respectively (p < 0.00001). The overall range in trochlear width for both the lateral and medial sides was 22.22 and 19.73 mm for males and females, respectively. A graft measuring 10 mm could represent as little as 34% of the lateral trochlea in males versus as much as 65% in females. Our results indicate that donor OAT plug diameter relative to available trochlear cartilage width will vary significantly both between genders and individual patients. Trochlear width variability and its potential implications on donor site morbidity may be an important consideration when contemplating osteochondral plug harvest for OAT or other indications. The level of evidence is IV.

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Application of Proximal Lateral Leg Perforator Flaps for Head and Neck Reconstructions

Otolaryngology ◽

10.1177/0194599814549731 ◽

2014 ◽

Vol 151 (5) ◽

pp. 791-796 ◽

Cited By ~ 3

Author(s):

Honda Hsu ◽

Peir-Rong Chen ◽

Sou-Hsin Chien ◽

Jiunn-Tat Lee

Keyword(s):

Head And Neck ◽

Donor Site ◽

Tertiary Care ◽

Case Series ◽

Functional Results ◽

Donor Site Morbidity ◽

Head And Neck Reconstruction ◽

Complication Rates ◽

Recipient Site ◽

The Mean

Objective Analyze the reliability, complications, and donor site morbidity of the proximal lateral leg flap when applied to head and neck reconstruction. Study Design Case series and chart review. Setting Tertiary care teaching hospital. Subjects and Methods Nineteen patients who underwent reconstruction of various head and neck defects with this flap were analyzed. The patient demographics, flap characteristics, method of donor site closure, scars of the donor area, complication rates, as well as functional results at the recipient site were assessed. Results The flap size ranged from 4 × 4 cm to 11 × 8 cm. Vascular pedicle length ranged from 5 to 9 cm. The mean distance of the perforator from the fibula head was 9.2 cm. The mean thickness of this flap was 5.5 mm. All the donor wounds were closed primarily. The flap survival rate was 100%. Conclusion This flap has the advantages of thinness, short harvesting time, minimal donor site morbidity, and primary closure at the donor site when the flap width is less than 6 cm. This flap may be useful for reconstruction in selected patients with small and thin heads and neck defects.

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Autologous osteochondral graft for traumatic defects of finger joints

Journal of Hand Surgery (European Volume) ◽

10.1177/1753193411412870 ◽

2011 ◽

Vol 37 (3) ◽

pp. 251-257 ◽

Cited By ~ 5

Author(s):

W. C. Wu ◽

M. W. M. Fok ◽

K. Y. Fung ◽

K. H. Tam

Keyword(s):

Donor Site ◽

Joint Space ◽

Donor Site Morbidity ◽

Finger Joint ◽

Osteochondral Graft ◽

Range Of Movement ◽

No Donor ◽

The Mean ◽

Open Injuries

Finger joint defects in 16 adults were treated with an autologous osteochondral graft from the base of the second metacarpal, the radial styloid, the base of the third metacarpal or the trapezoid and these patients were followed up from between 12 and 62 months. There was no donor site morbidity. One patient had resorption of the graft and developed pain. The joint was subsequently fused. The mean range of movement was 55.8% of the opposite normal joint. At follow up, 15 patients had no discomfort or mild discomfort. Three had mild narrowing of the joint space and two had slight joint subluxation. Only two patients with concomitant severe injury to the same limb had difficulty performing daily activities. Ten were open injuries and these had poorer outcomes. A hemicondylar defect of a finger joint can be treated using an osteochondral graft obtained from the same hand.

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Laparoscopic Harvesting of Omental Flaps for Breast Reconstruction—A Review of the Literature and Outcome Analysis

Plastic Surgery ◽

10.1177/2292550317731762 ◽

2017 ◽

Vol 26 (2) ◽

pp. 126-133 ◽

Cited By ~ 4

Author(s):

Hani Shash ◽

Becher Al-halabi ◽

Salah Aldekhayel ◽

Tassos Dionisopoulos

Keyword(s):

Breast Reconstruction ◽

Donor Site ◽

Patient Characteristics ◽

Donor Site Morbidity ◽

Outcome Analysis ◽

Complication Rates ◽

Search Terms ◽

The Mean ◽

Pedicle Flaps

Background: Evidence on the use of omental flaps for breast reconstruction in patients with breast cancer is lacking, and no published reviews report an outcome-based assessment of such flap. This review explores available data and evidence for change in complication rates following the shift toward laparoscopic harvesting. Methods: We searched the databases Excerpta Medica database, MEDLINE, and PubMed from inception until December 2015 using search terms “omental flaps“ and “breast reconstruction.” Data extracted were patient characteristics, technique used, and outcome measures reported and were then analyzed based on the technique of harvesting. Results: Twenty-two articles reporting 651 patients who underwent mastectomies and breast-conserving surgeries were included in this review. Most flaps, 537 (82.5%), were harvested by laparoscopy, and 626 (96.2%) of the flaps were pedicle flaps. The mean age was 47.7 years (standard deviation: 4.29), and mean follow-up was 38.1 months. There were 88 reported complications among 562 patients in 16 reports. The rate of any complication was calculated to be 15.0%, with a higher rate (29.1%) occurring with the open technique in comparison to laparoscopy (12.6%). The commonest complications were postoperative infection and breast firmness each reported in 2.22%. Most authors reported advantages of malleability and excellent aesthetic outcomes and disadvantages in terms of inability to estimate the volume of the flap and variability in size. Conclusion: Omentum use is safe and has advantages in breast reconstruction where other options are limited including a natural feeling and minimal donor site morbidity if harvested laparoscopically.

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Versatility of Latissimus Dorsi Free Flap-a Prospective Study

Journal of Dhaka Medical College ◽

10.3329/jdmc.v28i2.51149 ◽

2021 ◽

Vol 28 (2) ◽

pp. 142-152

Author(s):

Abu Faisal Md Ariful Islam ◽

Mohammad Rabiul Karim Khan ◽

Sharmin Akter Sumi ◽

Mohammad Hedayet Ali Khan ◽

Md Abul Kalam

Keyword(s):

Soft Tissue ◽

Free Flap ◽

Latissimus Dorsi ◽

Donor Site ◽

Donor Site Morbidity ◽

Soft Tissue Defect ◽

Latissimus Dorsi Flap ◽

Tissue Defect ◽

Medical College ◽

The Mean

Introduction: Free flaps offer a great variable of available tissues to cover larger, multifocal or multistructural defects. The choice among different free flap is dependent upon their recipient site requirement. Reconstruction with latissimus dorsi flap is now versatile tool in coverage. It can resurface large wound with reliable vascularity, consistent anatomy ,long pedicle length, opportunity for tailoring of flap. It has less donor site morbidity and has very little post-operative complications. Objective: To evaluate the versatility of free Latissimus dorsi flap for soft tissue reconstruction. Materials and methods: A prospective, observational study design was used in Department of Plastic Surgery of Dhaka Medical College and Hospital. Here 20 patients with soft tissue defect of variable sizes over lower limb, head neck and trunk underwent coverage with microvascular surgery. The study was carried out from July 2017 to June 2018. Result: Regarding the age distribution, the mean age was 35.65with an SD of + 10.81. The lowest age was 20years and the highest age was 56 years, Male female ratio was 3:2.The major cause (65.0%) of soft tissue defect of the samples was RTA. The flap was used to reconstruct the soft tissue defect over lower leg in 13 (65%)cases, on scalp 05 (25%) cases and over anterior trunk in two cases. The mean flap dimension was 229.25cm2 and its range was between 120 – 384 cm2. The standard myocutaneous flap was harvested in 80% cases, chimeric (10%) and partial Latissimus muscle flap in two cases. The donor site in all the 20 (100%) cases was closed primarily. The outcome of reconstruction was excellent in 16(80%), good in 02 (10%) cases and poor in 02 (10%) cases. There was no significant complication during the three months postoperative period. Conclusion: The Latissimus dorsi flap is a versatile option for resurfacing the soft tissue defect in different areas of the body with variable flap components and with minimal donor site morbidity. J Dhaka Medical College, Vol. 28, No.2, October, 2019, Page 142-152

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The 7 Structures Distal to the Elbow That Are Critical to Successful Anterior Transposition of the Ulnar Nerve

Hand ◽

10.1177/1558944718771390 ◽

2018 ◽

Vol 14 (6) ◽

pp. 776-781 ◽

Cited By ~ 3

Author(s):

John M. Felder ◽

Susan E. Mackinnon ◽

Megan M. Patterson

Keyword(s):

Ulnar Nerve ◽

Ulnar Artery ◽

Cubital Tunnel Syndrome ◽

Medial Epicondyle ◽

Cubital Tunnel ◽

Anterior Transposition ◽

Straight Line ◽

Tunnel Syndrome ◽

Poor Outcomes ◽

Flexor Digitorum

Background: Ulnar nerve transposition (UNT) surgery is performed for the treatment of cubital tunnel syndrome. Improperly performed UNT can create iatrogenic pain and neuropathy. The aim of this study is to identify anatomical structures distal to the medial epicondyle that should be recognized by all surgeons performing UNT to prevent postoperative neuropathy. Methods: Ten cadaveric specimens were dissected with attention to the ulnar nerve. Intramuscular UNT surgery was simulated in each. Distal to the medial epicondyle, any anatomical structure prohibiting transposition of the ulnar nerve to a straight-line course across the flexor-pronator mass was noted and its distance from the medial epicondyle was measured. Results: Seven structures were found distal to the medial epicondyle whose recognition is critical to ensuring a successful anterior transposition of the ulnar nerve: (1) Branches of the medial antebrachial cutaneous (MABC) nerve; (2) Osborne’s fascia; (3) branches from the ulnar nerve to the flexor carpi ulnaris (FCU); (4) crossing vascular branches from the ulnar artery to the FCU; (5) the distal medial intermuscular septum between the FCU and flexor digitorum superficialis (FDS); (6) the combined muscular origins of the flexor-pronator muscles; and (7) the investing fascia of the FDS. Measurements are given for each structure. Conclusions: Poor outcomes and unnecessary revision surgeries for cubital tunnel syndrome can be avoided with intraoperative attention to 7 structures distal to the medial epicondyle. Surgeons should expect to dissect up to 12 cm distal to the medial epicondyle to adequately address these and prevent kinking of the nerve in transposition.

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