Nerve Transfers to Restore Shoulder Function

Retrospective MRI analysis of 418 adult shoulder joints to assess the physiological morphology of the glenoid in a low-grade osteoarthritic population

BACKGROUND

Due to the difference in size between the humeral head and the glenoid, the shoulder joint is prone to instability. Therefore, the reconstruction of the physiological joint morphology is of great importance in shoulder joint preservation and replacement surgery. The aim of this study was to describe physiological reference parameters for the morphology of the glenoid for the first time.

MATERIAL AND METHODS

MRI images of the shoulder joints of 418 patients (mean age: 50.6 years [± 16.3]) were retrospectively analysed in a low-grade osteoarthritic population. The glenoid distance in coronal (GDc) and axial view (GDa), glenoid inclination (GI) and version (GV) as well as scapula neck length (SNL) were measured. Parameters were studied in association for age, gender, side and degeneration grade.

RESULTS

Mean GDc was 33.4 mm (± 3.6), mean GDa 26.8 mm (± 3.2), mean GI 10.5° (± 6.4), mean GV -0.4 mm (± 5.4) and mean SNL was 33.4 mm (± 4.7). GDa was significant higher in right shoulders (p < 0.001). GDc and GDa showed significant higher mean values in older patients (p < 0.001) and in shoulders with more severe degenerative changes (p < 0.05). While GDc, GDa and SNL were significant larger in male patients (p < 0.001), GI had a higher mean value in female shoulders (p = 0.021).

CONCLUSION

Age, gender and shoulder joint degeneration influence changes in the morphological parameters of the glenoid. These findings have to be considered in shoulder diagnostics and surgery.

CLINICAL TRIAL NUMBER

Not applicable.

Distal nerve transfers for peripheral nerve injuries: indications and outcomes

Distal nerve transfer is a refined surgical technique involving the redirection of healthy sacrificable nerves from one part of the body to reinstate function in another area afflicted by paralysis or injury. This approach is particularly valuable when the original nerves are extensively damaged and standard repair methods, such as direct suturing or grafting, may be insufficient. As the nerve coaptation is close to the recipient muscles or skin, distal nerve transfers reduce the time to reinnervation. The harvesting of nerves for transfer should usually result in minimal or no donor morbidity, as any anticipated loss of function is compensated for by adjacent muscles or overlapping cutaneous territory. Recent years have witnessed notable progress in nerve transfer procedures, markedly enhancing the outcomes of upper limb reconstruction for conditions encompassing peripheral nerve, brachial plexus and spinal cord injuries.

Current perspectives on peripheral nerve repair and management of the nerve gap

From the first surgical repair of a nerve in the 6th century, progress in the field of peripheral nerve surgery has marched on; at first slowly but today at great pace. Whether performing primary neurorrhaphy or managing multiple large nerve defects, the modern nerve surgeon has an extensive range of tools, techniques and choices available to them. Continuous innovation in surgical equipment and technique has enabled the maturation of autografting as a gold standard for reconstruction and welcomed the era of nerve transfer techniques all while bioengineers have continued to add to our armamentarium with implantable devices, such as conduits and acellular allografts. We provide the reader a concise and up-to-date summary of the techniques available to them, and the evidence base for their use when managing nerve transection including current use and applicability of nerve transfer procedures.

Posterior Deltoid Function After Transfer of Branch to the Long Head Triceps Brachii of the Radial Nerve to the Anterior Branch of the Axillary Nerve

PURPOSE

The aim of this study was to evaluate the function of the posterior part of the deltoid after nerve transfer of the long head triceps branch of the radial nerve to the anterior branch of the axillary nerve in patients with an upper brachial plexus injury or isolated axillary nerve injury.

METHODS

We retrospectively reviewed 26 patients diagnosed with an upper brachial plexus injury or isolated axillary nerve injury who underwent nerve transfer of the long head triceps muscle branch of the radial nerve to the anterior branch of the axillary nerve in our institute between 2012 and 2017. Data on age, sex, the mechanism of injury, the pattern of injury, and operative treatment were collected from medical records. Preoperative and postoperative clinical examinations, including motor powers of shoulder abduction and extension according to Medical Research Council grading, were evaluated. At a minimum of 2 years after the operation, we evaluated the recovery of the posterior deltoid function using the swallow-tail test.

RESULTS

Twenty-two patients (84.6%) had recovery of posterior deltoid function confirmed by the swallow-tail test. There were 23 patients (88.5%) who achieved at least Medical Research Council grade 4 of shoulder abduction.

CONCLUSIONS

Nerve transfer from the branch to the long head triceps to the anterior branch of the axillary nerve is an effective technique for restoring deltoid function in an upper brachial plexus injury or isolated axillary nerve injury. This technique can provide shoulder abduction and shoulder extension, which are the functions of the posterior deltoid muscle.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Management of Brachial Plexus Birth Palsies: The Stanford Experience

The start of Stanford's brachial plexus birth palsy (BPBP) experience dates back to 1983, when Dr. Vincent Rod Hentz visited Dr. Alain Gilbert on sabbatical. Since then, our principles of care for patients with BPBP have evolved based on our group's longitudinal experience caring for children with the entire spectrum of sequelae that arise in children with BPBP. We base our clinical decision making on frequent serial examinations and use intraoperative evoked potentials to guide surgical decisions. Here, we discuss our current principles on surgical indications, timing of surgery, and preferred techniques for secondary surgery in patients with BPBP.

Latissimus dorsi tendon transfer to restore shoulder abduction in patients with deltoid paralysis: A novel technique

Background

Shoulder abduction is an essential movement for placement of the hand in space and thus for upper limb function. The objective of this study was to introduce and test the effectiveness of a new technique of latissimus dorsi tendon transfer to deltoid insertion to restore shoulder abduction.

Methods

We prospectively included 10 male patients with a lost deltoid function. Their mean age was 34.6 years (range, 25-46). We describe a new technique to compensate for the loss of the deltoid function using a latissimus dorsi tendon transfer augmented with a semitendinosus tendon graft. The tendon graft is passed over the acromion and attached to the anatomical deltoid insertion. Postoperatively, a shoulder spica in 90° abduction was used for six weeks followed by physiotherapy.

Results

Patients were followed up for a mean of 25.4 months (range, 12-48). The mean range of active shoulder abduction rose to 110° (range, 90-140°) with a mean gain of 83° of abduction.

Conclusions

This procedure can be a useful technique for restoration of a significant range and strength of active shoulder abduction.

Nerve transfers for brachial plexus injuries: grading of volitional control

OBJECTIVE

After brachial plexus injuries (BPIs), nerve transfers are used to restore lost muscle function. Brain plasticity underlies the process of regaining volitional control, which encompasses disconnection of the original donor nerve-related programs and reconnection to acceptor nerve programs. To the authors' knowledge, the levels of disconnection and reconnection have never been studied systematically. In this study, the authors developed a novel 4-point plasticity grading scale (PGS) and assessed the degree of volitional control achieved, identifying clinical correlations with this score.

METHODS

Patients with BPI who underwent a phrenic, spinal accessory, median, and/or ulnar fascicle nerve transfer to restore biceps and deltoid function were asked to maximally contract their target muscle as follows: 1) by using only the donor nerve program, and 2) by activating the target muscle while consciously trying to avoid using the donor nerve, with assessment each time of the Medical Research Council (MRC) scale grade for muscle strength. The authors' PGS was used to rate the level of volitional control achieved. PGS grade 1 represented the lowest independent volitional control, with MRC grade 4 obtained in response to the donor command and MRC grade 0 in response to the acceptor command (minimum brain plasticity), whereas PGS grade 4 was no noticeable contraction in response to the donor command and MRC grade 4 in response to the acceptor command (maximum brain plasticity).

RESULTS

In total, 153 patients were studied. For biceps restoration, the phrenic nerve was used as a donor in 44 patients, the spinal accessory nerve in 40 patients, and the median and/or ulnar fascicles in 44 patients. A triceps branch was used to restore deltoid function in 25 patients. The level of volitional control achieved was PGS grade 1 in 1 patient (0.6%), grade 2 in 21 patients (13.7%), grade 3 in 103 patients (67.3%), and grade 4 in 28 patients (18.3%). The median PGS grade did not differ significantly between the four donor nerves. No correlations were observed between age, time from BPI to surgery, duration of follow-up, or compliance with rehabilitation and PGS grade.

CONCLUSIONS

Just around 20% of the authors' patients developed a complete disconnection of the donor program along with complete independent control over the reinnervated muscle. Incomplete disconnection was present in the vast majority of the patients, and the level of disconnection and control was poor in approximately 15% of patients. Brain plasticity underlies patient ability to regain volitional control after a nerve transfer, but this capacity is limited.

Comparison of Anterior vs. Dorsal Approach for Spinal Accessory to Suprascapular Nerve Transfer in Patients With a Brachial Plexus Injury and Its Outcome on Shoulder Function

Background

Brachial plexus injuries are frequently encountered in the domain of plastic surgery, mostly secondary to road traffic accidents, gunshot injuries, or falls from a height. Many modalities have been described in the management, depending on the level and duration of the injury. C5, C6 and C5, C6, C7 are two common patterns in which nerve repair and transfers are described. At our center, we practice spinal accessory to suprascapular nerve transfer in all patients with upper trunk brachial plexus injury. There are two described approaches for the spinal accessory nerve to suprascapular nerve transfer, i.e. anterior or dorsal. The rationale for doing the posterior approach is that this approach avoids damaging the suprascapular nerve at its entrance in the suprascapular notch under the suprascapular ligament during exploration due to traction.

Materials and methods

This is a retrospective study with a consecutive sampling of 23 patients presenting at Liaquat National Hospital, Karachi, with upper trunk brachial plexus injuries during the time period from January 2016 to December 2017, i.e. two years. We divided these 23 patients into two groups, one with the anterior approach and the other with a dorsal approach for spinal accessory to suprascapular nerve transfer for shoulder abduction. The mean duration of post-surgical follow-up was from 18 to 24 months and recovery and functional outcomes were assessed.

Results

Out of the 23 patients that were included, 10 patients were operated on with an anterior approach and 13 with a posterior approach. Fifty percent (50%) of patients operated with the anterior approach and 84% of patients with the posterior showed the best motor grade recovery of M4, respectively, with better performance in patients with the posterior approach as compared to the anterior approach.

Conclusion

We advocate taking a posterior approach for spinal accessory to suprascapular nerve transfer for shoulder abduction, as it has shown better results with reliable outcomes concerning shoulder abduction, angle of abduction, and range of motion.

The impact of Fascial Distortion Model on shoulder girdle dysfunction

Introduction: Shoulder girdle as highly specialized set of structures is particularly susceptible to overloading and injuries. In current literature USG and MRI results shows poor correlation with the function, which lead to some problems in correct diagnosis. The structure contributing to this issue might be fascia. One of the methods examination and treatment is very poorly known Fascial Distortion Model. The aim of our research was to assess the impact of the Fascial Distortion Model on shoulder girdle dysfunction. Materials and methods: The subject of research were 78 patients with shoulder dysfunction. Experimental group of 50 patients underwent six 30-minutes FDM treatments, performed every second day. The control group of 28 patients were subjected standard physiotherapy. Measurement of mobility and pain was done by: functional tests, DASH questionnaire, modified CONSTANT scale and VAS scale. Results: The experimental group obtained better results than control group. This was due to less pain (M = 0.56, SD = 1.03) vs (M = 6.71, SD = 1.88) and a greater limb function (M = 3.46, SD = 7.80) vs (M = 42.72, SD = 16.52). Participants treated with FDM improved in ROM, DASH score and VAS at the significance level (p = .000). Conclusions: 1. Fascial distortions may contribute to dysfunction of the shoulder complex. 2. Connective tissue problems can limit the range of movement 3. Fascia disorders may contribute pain.

Considerations in the Selection of Donor Nerves for Nerve Transfer for Reanimation of Elbow and Shoulder in Traumatic Brachial Plexus Injuries

The advent of nerve transfers has revolutionised the treatment of brachial plexus and peripheral nerve injuries of the upper extremity. Nerve transfers offer faster reinnervation of a denervated muscle by taking advantage of a donor nerve, branch or fascicle close to the recipient muscle. A number of considerations in respect of donor selection for nerve transfers underlie their success. In this review article, we discuss the principles of donor selection for nerve transfers, the different options available and our considerations in choosing a suitable transfer in reanimating the elbow and the shoulder. We feel this will help nerve surgeons navigate the controversies in the selection of donor nerves and make appropriate treatment decisions for their patients. Level of Evidence: V (Therapeutic).

Addressing common orthopaedic calamities with microsurgical solutions

Reconstructive microsurgery has been an essential aspect of orthopaedic surgery and extremity reconstruction since the introduction of the operating microscope in the mid-20^th century. The reconstructive ladder ranges from simple healing by secondary intention to complex procedures such as free tissue transfer and vascularized composite allotransplantation. As orthopaedic surgery has evolved over the past 60 years, so too have the reconstructive microsurgical skills that are often needed to address common orthopaedic surgery problems. In this article, we will discuss a variety of complex orthopaedic surgery scenarios ranging from trauma to infection to tumor resection as well as the spectrum of microsurgical solutions that can aid in their management.

Outcomes of Shoulder Functions in Spinal Accessory to Suprascapular Nerve Transfer in Brachial Plexus Injury: A Comparison between Anterior and Posterior Approach

Background  Restoration of shoulder functions is important in brachial plexus injury (BPI). The functional outcomes of spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer by the anterior supraclavicular approach and the posterior approach is a matter of debate. This article aims to compare the outcomes of the shoulder functions by the SAN to the SSN transfer using the two approaches. Methods  Retrospective data was collected in 34 patients who underwent SAN to SSN transfer from January 2016 to June 2018. Group A included 16 patients who underwent nerve transfers by anterior approach, and Group B included 18 patients who underwent nerve transfers by posterior approach. Functional outcomes were measured by grading the muscle power as per the British Medical Research Council (MRC) grading (graded as M) and the range of motions (ROM) of the shoulder at 6 months and 18 months. Results  Early recovery was seen in group B with 7 patients (39%) showing M1 abduction power at 6 months as compared with one patient (6%) in group A . This difference was statistically significant ( p value = 0.04). At 18 months, 10 patients (62%) in group A had good recovery (MRC grade ≥3), while 13 patients (72%) in group B had a good recovery. This difference was not found to be statistically significant (Fisher exact test p value = 0.71) There was no statistical difference in the outcomes of ROM in shoulder abduction, external rotation, and motor power at 18 months of follow-up. Conclusions  Early recovery was observed in the anterior approach group at 6 months, however, there was no significant difference in the outcomes of shoulder functions in muscle power and ROM in the two groups at 18 months of follow-up.

Five Reliable Nerve Transfers for the Treatment of Isolated Upper Extremity Nerve Injuries

LEARNING OBJECTIVES

After studying this article and accompanying videos, the participant should be able to: 1. Understand and apply the principles of nerve transfer surgery for nerve injuries. 2. Discuss important considerations when performing nerve transfers, such as aspects of surgical technique and perioperative decision-making. 3. Understand indications for end-to-end versus supercharged reverse end-to-side nerve transfers. 4. Understand an algorithm for treating nerve injuries to include the indications and surgical techniques of five nerve transfers commonly performed for the treatment of isolated upper extremity nerve injuries. 5. Understand the outcomes and postoperative management of the discussed nerve transfers.

SUMMARY

Nerve transfers are gaining wide acceptance because of their superior results in the management of many nerve injuries of the upper extremity. This article presents five nerve transfers for the treatment of isolated nerve injuries in the authors' upper extremity nerve practice that offer reliable results. Indications, surgical techniques, outcomes, and postoperative management are reviewed. To maximize functional outcomes in patients with nerve injuries, the treatment should be individualized to the patient, and the principles for nerve transfers as described herein should be considered.

Apoptosis of proximal stump postganglionic brachial plexus injury, before and after six months post-trauma

Background

The success of the micro-surgery procedure for the treatment of postganglionic brachial plexus injury was influenced by several factors, including the surgical timing and also the viability of the proximal stump. This study evaluates the evidence of apoptosis in the brachial plexus proximal stump and its correlation with the surgical timing.

Methods

Proximal stump biopsy of postganglionic brachial plexus injury patients were obtained during nerve procedure surgery. The samples were grouped based on the surgical timing, before six months post-trauma (early group) and after six months post-trauma (late group). The apoptosis of motorneurons was evaluated by immunohistochemistry expression of Caspase-3, TNF-α, Caspase-8, and Caspase-9.

Results

Immunohistochemistry findings showed higher expression of Caspase-3 in the late group compared to the early group, as well as the expression of Caspase-8 and Caspase-9 (p < 0,05), and with a positive correlation between Caspase-8 and Caspase-9 to Caspase-3. Meanwhile, TNF-α expression was higher in the early group than the late group (p < 0,05) and with no correlation between TNF-α to Caspase-3.

Conclusion

Apoptosis of proximal stump motorneuron plexus brachialis on more than six months post-trauma is higher than on less than six months post-trauma.

•

Study of apoptosis of the brachial plexus proximal stump of the postganglionic BPI.

•

Compare between before 6 months post-trauma and after 6 months post-trauma.

•

Evaluate the apoptosis, the extrinsic and intrinsic pro-apoptosis pathway.

•

The apoptosis of more than 6 months post-trauma is higher than before 6 months.

Nerve transfers in the upper extremity: A review

Injury of the brachial plexus and peripheral nerve often result in significant upper extremity dysfunction and disability. Nerve transfers are replacing other techniques as the gold standard for brachial plexus and other proximal peripheral nerve injuries. These transfers require an intimate knowledge of nerve topography, a technically demanding Intraneural dissection and require extensive physical therapy for retraining. In this review, we present a summary of the most widely accepted nerve transfers in the upper extremity described in the current literature.

C5/C6 brachial plexus palsy reconstruction using nerve surgery: long-term functional outcomes

INTRODUCTION

In traumatic proximal brachial plexus lesions (i.e., C5/C6), reconstruction of the musculocutaneous, axillary and suprascapular nerves yields satisfactory short- and medium-term functional outcomes.

HYPOTHESIS

Early functional outcomes after nerve surgery will be maintained in the long-term.

METHODS

A retrospective analysis was done using the medical records of 29 patients with C5/C6 palsy treated by nerve surgery. Active range of motion and strength at the elbow (i.e., flexion) and shoulder (i.e., flexion, abduction, external rotation with the elbow at the side of the body and with the arm 90° abducted ) were evaluated clinically using a goniometre and the British Medical Research Council grading scale, respectively.

RESULTS

At a mean follow-up of 46±15 months (25;76), the mean active elbow flexion was 126°±18° (90;150) and the mean strength was 3.8±0.5 (2;4). At the shoulder, mean active flexion, abduction, external rotation with the elbow at the side of the body and with the arm 90° abducted were 109°±39° (0;180), 99°±38° (0;180°), 12°±34° (-80;70) and 3°±21° (-40;50), while mean strength was 3.6±0.8 (0;4), 3.6±0.8 (0;4), 3.4±0.9 (0;4) and 2.5±1.2 (0;4), respectively.

DISCUSSION

In cases of C5/C6 palsy, early nerve surgery yields satisfactory functional outcomes that are maintained over time for elbow flexion and shoulder elevation. However, when the teres minor is not reinnervated, it is difficult to restore satisfactory shoulder external rotation.

LEVEL OF EVIDENCE

IV, Retrospective case study.

Double-Nerve Transfer to the Axillary Nerve in Traumatic Upper Trunk Brachial Plexus Injuries Using an Axillary Approach: Anatomical Description and Preliminary Case Series

BACKGROUND

Restoration of shoulder external rotation remains challenging in patients with C5/C6 brachial plexus injuries (BPI).

OBJECTIVE

To describe a double-nerve transfer to the axillary nerve (AN), targeting both its anterior and posterior motor branches, through an axillary route.

METHODS

A total of 10 fresh-frozen cadaveric brachial plexuses were dissected. Using an axillary approach, the infraclavicular brachial plexus terminal branches were exposed, including the axillary, ulnar, and radial nerves. Under microscopic magnification, the triceps long head motor branch (TLHMB), anteromedial fascicles of the ulnar nerve (UF), the anterior motor branch of the axillary nerve (AAMB), and the teres minor motor branch (TMMB) were dissected and transected to simulate 2 nerve transfers, THLMB-AAMB and UF-TMMB. Several anatomical criteria were assessed, including the overlaps between fascicles when placed side-by-side. Six patients with C5/C6 BPI were then operated on using this technique.

RESULTS

TLHMB-AAMB and UF-TMMB transfers could be simulated in all specimens, with mean overlaps of 37.1 mm and 6.5 mm, respectively. After a mean follow-up of 23 mo, all patients had recovered grade-3 strength or more in the deltoid and teres minor muscles. Mean active shoulder flexion, abduction, and external rotation with the arm 90° abducted were of 128°, 117°, and 51°, respectively. No postoperative motor deficit was found in the UF territory.

CONCLUSION

A double-nerve transfer, based on radial and ulnar fascicles, appears to be an adequate option to reanimate both motor branches of the AN, providing satisfactory shoulder active elevations and external rotation in C5/C6 BPI patients.

Contralateral C7 transfer to axillary and median nerves in rats with total brachial plexus avulsion

Background

Contralateral cervical 7 nerve (cC7) was used to repair two recipient nerves simultaneously for patients with total brachial plexus avulsion (TBPA).

Objective

To evaluate the effect of cC7 transfer to axillary and median nerves in rats with TBPA.

Methods

Eighty S-D rats were divided into 4 groups randomly on average. Group A: cC7-median nerve, Group B: cC7-axillary nerve, Group C: cC7-median and axillary nerves, Group D: TBPA without repair. The evaluation tools included behavioral tests, electromyogram (EMG), measurement of cross-sectional area of muscle fiber, nerve fiber count and gene expression assay.

Results

The effective rates of EMG were 90 and 70% in Flexor Carpi Radialis (FCR) in Group A and C, while 70 and 60% in deltoid (DEL) in Group B and C, respectively. In behavioral test, the differences of effective rates between groups were not significant. The mean cross-sectional area of FCR in Group A or C was significantly larger than that in Group D. Either the number of median or axillary nerve fibers in Group A, B or C was statistically more than that in Group D. No matter for FCR or DEL, there were no significant differences in the ratios of relative expression of Muscle Atrophy F-box(MAFBOX)and Muscle RING Finger 1(MURF1)among these groups.

Conclusion

Compared with cC7 transfer to median nerve, cC7 transfer to both median and axillary nerves did not affect median nerve recovery. The deltoid muscle also could be restored. The recovery proportion of axillary nerve was less than that of median nerve.

Using the main elbow flexion skin crease as an intraoperative parameter to determine the degree of exorotation needed for humeral derotational osteotomies in upper-type brachial plexus patients

Even though one of the surgical techniques most frequently used to correct external rotation deformity of the shoulder in brachial plexus patients is a humeral derotational osteotomy, few intraoperative parameters has yet been identified to determine the appropriate degree of rotation. We present in this technical note our initial experience using the main elbow flexion skin crease to quantify the correct rotation of the humerus in four young, male patients with upper-type brachial plexus injuries. All patients had a functional elbow and a stable shoulder, but also an external rotation deficit. Via a deltopectoral approach, we used the main elbow flexion crease as an intraoperative surgical parameter to determine the degree of external rotation of the humerus required to achieve a better positioning of the hand in space. After surgery, increased elbow flexion range and enhanced hand-to-face movement was observed, while internal rotation was preserved for performing midline activities. Moreover, all patients exhibited increased active elbow flexion and osteotomy consolidation, with mean elbow flexion increasing from 66.3° to 97.5° pre to postoperatively, and a mean 56.3° of internal rotation correction ultimately achieved. We propose that the main elbow flexion crease is a useful intraoperative parameter to determine the degree of intraoperative external rotation necessary to restore the plane of hand-face movements in upper-type palsies.

LEVEL OF EVIDENCE

IV; case series.

Adult Traumatic Brachial Plexus Injuries

Adult traumatic brachial plexus injuries are devastating life-altering injuries occurring with increasing frequency. Evaluation includes a detailed physical examination and radiologic and electrodiagnostic studies. Critical concepts in surgical management include knowledge of injury patterns, timing of surgery, prioritization in restoration of function, and management of patient expectations. Options for treatment include neurolysis, nerve grafting, or nerve transfers and should be generally performed within 6 months of injury. The use of free functioning muscle transfers can improve function both in the acute and late setting. Modern patient-specific management can often permit consistent restoration of elbow flexion and shoulder stability with the potential of prehension of the hand. Understanding the basic concepts of management of this injury is essential for all orthopaedic surgeons who treat trauma patients.

Comparative study of single and dual nerve transfers for repairing shoulder abduction

OBJECTIVE

The purpose of this study was to compare the effects of single and dual nerve transfer for the repair of shoulder abduction in patients with upper or upper and middle trunk root avulsion.

METHODS

We carried out a retrospective analysis of 20 patients with C5-C6 or C5-C7 root avulsion treated by nerve transfer in our hospital. The patients were divided into two groups according to the different operation methods. In group A, ten patients had transferred the spinal accessory nerve to the suprascapular nerve. Ten patients in group B underwent dual nerve transfer to reconstruct shoulder abduction, including the spinal accessory nerve transfer to the suprascapular nerve and two intercostal nerves or the long head of triceps nerve branch transfer to the anterior branch of the axillary nerve. There was no difference in age, preoperative interval, follow-up time, and injury type between the two groups. We used shoulder abduction strength, shoulder abduction angle, and Samardzic's shoulder joint evaluation standard as the postoperative evaluation index. Shoulder abductor muscle strength equals or above M3 was considered to be an effective recovery.

RESULTS

Of the 20 cases, 15 obtained equals or more M3 of shoulder abduction strength, and the overall effective rate was 75%. The effective rate of shoulder abduction power in group A was 60% (6/10) while group B was 90% (9/10); however, the difference was not statistically significant (p > 0.05). The average shoulder abduction angle was 55° (SD = 19.29) in group A and 77° (SD = 20.44) in group B; the angle was significantly better in group B than that in group A (p < 0.05). Based on Samardzic's standard, the excellent and good rate of group A was 90% and in group B was 50%. The difference was statistically significant (p < 0.05).

CONCLUSION

For patients with nerve root avulsion of C5-C6 or C5-C7, repairing suprascapular nerve and axillary nerve at the same time is more effective than repairing suprascapular nerve alone in terms of shoulder abduction angle and excellent rate of functional recovery of the shoulder joint. Therefore, we recommend the repair of the suprascapular nerve and the axillary nerve simultaneously if conditions permit.

Surgical strategy in extensive proximal brachial plexus palsies

PURPOSE

To describe and assess an overall surgical strategy addressing extensive proximal brachial plexus injuries (BPI).

METHODS

Forty-five consecutive patients' charts with C5-C6-C7 and C5-C6-C7-C8 BPI were reviewed. Primary procedures were nerve transfers to restore elbow function and grafts to restore shoulder function when a cervical root was available; when nerve surgery was not possible or had failed, tendon transfers were conducted at the elbow while addressing shoulder function with glenohumeral arthrodesis or humeral osteotomy. Tendon transfers were used to restore finger extension.

RESULTS

Forty-one patients underwent elbow flexion reanimation: thirty-eight had nerve transfers and eight received tendon transfers, including five cases secondary to nerve surgery failure; grade-3 strength or greater was reached in thirty-seven cases (90%). Twenty-nine patients had nerve transfers to restore elbow extension: twenty-five recovered grade-3 or grade-4 strength (86%). Forty-one patients underwent shoulder surgery: fourteen had nerve surgery and thirty-one received palliative procedures, including four cases secondary to nerve surgery failure; thirty patients recovered at least 60° of abduction and rotation (73%). Distal reconstruction was performed in thirty-seven patients, providing finger full extension in all cases but two (95%).

CONCLUSIONS

A standardized strategy may be used in extensive proximal BPI, providing overall satisfactory outcomes.

Outcome of reverse shoulder arthroplasty with pedicled pectoralis transfer in patients with deltoid paralysis

BACKGROUND

Management of shoulder arthritis associated with deltoid paralysis can be very challenging. The purpose of this study was to report the outcome of reverse shoulder arthroplasty with pedicled pectoralis transfer to reconstruct the anterior deltoid in patients with symptomatic shoulder arthritis and a paralyzed deltoid.

METHODS

This study included 31 patients with an average age of 51 years (range, 27-73 years). All patients had chronic deltoid paralysis with significant loss of function due to progressive arthritis associated with rotator cuff deficiency. All patients underwent reverse shoulder arthroplasty with pedicled pectoralis muscle transfer. Additional transfers were performed in patients with no preoperative external rotation: 5 underwent latissimus transfer, and 3 underwent direct lower trapezius transfer to the infraspinatus.

RESULTS

At an average follow-up of 37 months, 29 patients had significant improvements in pain; the shoulder subjective value; the Disabilities of the Arm, Shoulder and Hand score; and shoulder range of motion, mainly flexion of 83° and external rotation of 15°. Two patients sustained postoperative acromial fractures and had persistent pain after surgery with minimal improvement in shoulder flexion and external rotation. One of them had a failed attempt at open reduction-internal fixation of the acromion.

CONCLUSION

Reverse shoulder arthroplasty with pedicled pectoralis transfer is a promising procedure that may lead to improved pain and function in patients with shoulder arthritis associated with deltoid paralysis.