Anterior Interosseous Nerve to Ulnar Nerve Transfers: A Systematic Review

Background There has been an increasing utilization of end-to-end (ETE) and reverse “supercharged” end-to-side (SETS) anterior interosseous nerve (AIN) to ulnar nerve transfers (NTs) for treatment of high ulnar nerve injury. This study aimed to review the potential indications for, and outcomes of, ETE and SETS AIN–ulnar NT. Methods A literature review was performed, and 10 articles with 156 patients who had sufficient follow-up to evaluate functional outcomes were included. English studies were included if they reported the outcome of patients with ulnar nerve injuries treated with AIN to ulnar motor NT. Outcomes were analyzed based on the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire scores, grip and key pinch strength, and interosseous Medical Research Council–graded motor strength. Comparisons were made using the independent t-test and the chi-square test. No nerve graft control group was required for eligibility. Ulnar nerve injury types varied. Results NT resulted in 77% of patients achieving M3+ recovery, 53.7 ± 19.8 lb grip strength recovery, 61 ± 21% key pinch recovery, and a mean DASH score of 33.4 ± 16. In this diverse group, NT resulted in significantly greater M3+ recovery and grip strength recovery measured in pounds than in the nerve graft/conventional treatment group, and ETE repairs had significantly better outcomes compared with SETS repairs for grip strength, key pinch strength, and DASH scores, but heterogeneity limits interpretation. Conclusion ETE and SETS AIN–ulnar NTs produce significant restoration of ulnar nerve motor function for high ulnar nerve injuries. For ulnar nerve transection injuries at or above the elbow, ETE NT results in superior motor recovery compared with nerve grafting/conventional repair. However, further research is needed to determine the best treatment for other types of ulnar nerve injury and the role of SETS NT.

Comparison of Outcome of Lateral Pinning Versus Medial and Lateral Cross Pinning in Childhood Supracondylar Fractures of Humerus

Objectives: To compare the complications and outcomes of lateral entry pin fixation with medial and lateral pin fixation for Gartland type III supracondylar fractures of humerus. Methodology: This prospective comparative study involving 190 patients of Gartland type III close supracondylar fractures were included. from March-2019 to Dec-2020. In all patients, initially the elbow was mobilized using the splint placed above the elbow joint at 30 to 45 degrees’ flexion. After closed reduction, lateral pinning was applied in group I and in group II lateral and medial cross pinning was applied using the standard protocol. Patients were followed for iatrogenic ulnar nerve injury, radiologic and function outcomes in-terms of loss of reduction, elbow range of motion, loss in carrying angle and functional outcomes. Results: The two groups were comparable for loss of elbow range of motion, loss of carrying angle and loss of Bauman's angle. On clinical examination, immediate post-operative ulnar nerve injury was diagnosed in 4 (4.2%) cases in group II and in no patient in group I (p-value 0.12). Satisfactory functional outcomes were achieved in 85 (89.5%) patients in group I and in 88 (92.6%) patients in group II (p-value 0.44). Conclusion: Lateral pinning provided stable fixation clinically and radiologically as compared to lateral and medial cross pinning. Keywords: Supracondylar fracture of Humerus, Iatrogenic ulnar nerve injury, Lateral pin entry, lateral and medial cross pin entry.

Prevalence of Vascular Trauma and Related Factors in Iran: A Systematic Review

Background: Managing patients with Vascular Trauma (VT) is essential. This study aimed to determine the prevalence of VT and its related factors in Iran. Methods: This systematic review was performed by two skilled researchers. To access all the Persian and English articles on VT and its influencing factors (from 2000 to August 2019), in addition to Google Scholar search engine, other international databases, such as PubMed/ Medline, Scopus, Embase, Cochrane Library, Science Direct, Web of Science (ISI), and domestic databases, such as Magiran, IranDoc, National Library of Iran Organization, SID, and Barakatkns were used. Data analysis was conducted by MA (CMA) software. Results: The incidence of lower Lower Vascular Trauma (LVI) trauma was equal to 58.4 (95%CI: 41.1-73.8) (I2= 94.67, Q=112.57, P<0.001); the prevalence of upper LVI trauma was measured to be 31.5 (95%CI: 17.7-49.7) (I2=94.48, Q=108.70, P<0.001); the prevalence of penetrating trauma was calculated as 61.3 (95% CI: 49.5-71.9); the prevalence of ulnar nerve injury equaled 9.8 (95%CI: 2.8-28.6); the prevalence of radial nerve trauma was equal to 7.7 (95%CI: 1.2-35.4); the prevalence of death cases was reported as 12.3 (95%CI: 5.1-26.9); the prevalence of amputation rate was observed as 8.8 (95%CI: 5.7-13.4); the prevalence of fasciotomy rate was equal to 22.2 (95%CI: 13.2-34.5); the prevalence of complete artery cutting equaled 55.7 (95% CI: 35.4-74.3),and the prevalence of incomplete artery cutting was measured as 25.5 (95%CI: 12.1-45.9). Conclusion: According to the study results, VT has led to various complications in patients; thus, it is critical to provide the necessary conditions to preserve the patient’s life and prevent life-threatening complications. Such goals could be achieved by preventing this type of trauma and its related complications.

Comparison of functional outcome and complications in Gartland’s Type III fracture Supracondylar Humerus in paediatric population by different pinning technique

Background: Fracture Supracondylar humerus is one among common fracture in children betweenage 5-7 years. Boys are frequently affected than girls. Extension variety is more common. Theconventional approach to treat fracture supracondylar humerus (Type III) is a close reduction withpercutaneous fixation. There have been controversies as to which surgical technique should be used,cross pinning or two-wire lateral pinning. This study aims to find which method of pinning is mostappropriate to fix fracture supracondylar humerus. Method and material: A Retrospectivecomparative study was designed to analyze the outcome of the cross pinning and lateral pinningmethod. A total of 60 patients were included in the study. They were divided into two groups of 30each. Group A comprised of fixation by cross pinning method. Group B comprised of fixation by two-wire lateral pinning method. Results of both groups were analysed about Flynn’s criteria andcomplications. Result: The mean age in Group A was 5.1 years and in Group B was 4.8 years. Onepatient was lost to follow up in Group A. On the final follow up, there was statistically no differencein terms of outcome according to Flynn’s criteria in both groups. According to Flynn’s criteria>95%of patients had a satisfactory outcome in both groups. Among Group A, there were 2 cases ofiatrogenic ulnar nerve praxis whereas in group B there was one case of pin loosening. Conclusion:On comparing both techniques there was no significant difference in the outcome. However, there isa slight increase in the chances of iatrogenic ulnar nerve injury in the cross pinning method.

Direct End-to-End Neurorrhaphy for Wrist-Level Long Nerve Defect with Fixation of the Wrist in Flexion: Technique Note

Background For a nerve gap, end-to-end neurorrhaphy would either be difficult or would include tension. The use of a nerve graft or conduit could be a solution, but it might compromise the reinnervation. We describe a method for wrist-level ulnar and/or median long nerve injury by fixing the wrist in the flexion position with K-wire (s) to make possible an end-to-end and tension-free neurorrhaphy. Patients and Methods Two patients had wrist-level ulnar nerve injury for 2 and 3 months and nerve gaps of 2.5 cm and 3.5 cm, respectively, after the neuroma excision. K-wires were used to transfix from the radius to carpal bones, in order to keep their wrists in flexion of 45 and 65 degrees, respectively, with which the tension-free end-to-end neurorrhaphy could be achieved. The K-wires were removed in 6 weeks after surgery, and their wrists were kept in the splint for a progressive extension program. Results Both patients were noted to have an improved claw hand deformity 4 months after the surgery. The ulnar nerve motor and sensory function could be recovered mostly in the 12-month follow-up. The wrist flexion and extension motion arc both achieved, at least, 150 degree in the 12-month follow-up. There were no complications related to the K-wire fixation. Conclusion With the wrist fixed in a flexed position, maintaining a longer nerve gap to achieve a direct end-to-end and tension-free neurorrhaphy would be more likely and safer. Without the use of nerve graft, innervation of the injured nerve would be faster.

Acellular Nerve Allografts in Major Peripheral Nerve Repairs: An Analysis of Cases Presenting With Limited Recovery

Background: Acellular nerve allografts have been used successfully and with increasing frequency to reconstruct nerve injuries. As their use has been expanded to treat longer gap, larger diameter nerve injuries, some failed cases have been reported. We present the histomorphometry of 5 such cases illustrating these limitations and review the current literature of acellular nerve allografts. Methods: Between 2014 and 2019, 5 patients with iatrogenic nerve injuries to the median or ulnar nerve reconstructed with an AxoGen AVANCE nerve allograft at an outside hospital were treated in our center with allograft excision and alternative reconstruction. These patients had no clinical or electrophysiological evidence of recovery, and allograft specimens at the time of surgery were sent for histomorphological examination. Results: Three patients with a median and 2 with ulnar nerve injury were included. Histology demonstrated myelinated axons present in all proximal native nerve specimens. In 2 cases, axons failed to regenerate into the allograft and in 3 cases, axonal regeneration diminished or terminated within the allograft. Conclusions: The reported cases demonstrate the importance of evaluating the length and the function of nerves undergoing acellular nerve allograft repair. In long length, large-diameter nerves, the use of acellular nerve allografts should be carefully considered.