Redefining the Inclusion Criteria for Successful Steindler Flexorplasty Based on the Outcomes of a Case Series in Eight Patients

Background (rationale)  Steindler flexorplasty (SF) is aimed at restoring independent elbow flexion in the late stages of dysfunction of the primary elbow flexors. Selection criteria for successful SF have been defined. Objectives  The purpose of this study was to redefine the inclusion criteria for successful SF based on functional outcomes. Methods  Eight patients received SF after an average of 50.8 months after injury or dysfunction. Three patients (37.5%) met all five Al-Qattan inclusion criteria (AQIC), and another five patients (62.5%) met four or less AQIC. Patients were followed up for at least 9 months, and the maximum range of active elbow flexion (REF) was measured. Functional results of SF were assessed using the Al-Qattan scale (in accordance with Al-Qattan's scale). Results  The mean maximum REF was 100 degrees (70 to 140 degrees). Five patients reached REF greater than 100 degrees. One patient had a poor outcome, two patients (25%) had a fair outcome, three patients (37.5%) had a good outcome, and two patients (25%) had an excellent outcome of SF on the Al-Qattan scale. The impact of each AQIC on functional outcome has been critically reviewed from a biomechanical point of view. Conclusions  The sufficient number of inclusion criteria required for successful SF can be reduced from five (according to AQIC) to two; Normal or near-normal function (M4 or greater on the MRC scale) of the muscles of the flexor-pronator mass should be considered an obligatory inclusion criterion, while primary wrist extensors may be considered an optional inclusion criterion.

Nerve transfers in a patient with asymmetrical neurological deficit following traumatic cervical spinal cord injury: simultaneous bilateral restoration of pinch grip and elbow extension. Illustrative case

BACKGROUND

Cervical spinal cord injury (CSCI) causes severe motor deficit in upper extremities. The mixed segmental CSCI pattern is reflected in the combination of time-sensitive (TS) and non-TS myotomes in the upper extremities. Nerve transfers (NTs) restore upper extremity function yet remain TS procedures. A combination of neurological, magnetic resonance imaging (MRI), and electromyography (EMG) studies allows the identification of TS and non-TS myotomes in the upper extremities.

OBSERVATIONS

Nineteen months after NTs, flexor pollicis longus (FPL) and deep flexor of the index finger (FDP2) recovered to M4 (right UE), FPL recovered to M3 and FDP2 to M2 (left EU). The long head of the triceps brachii muscle recovered to M4 bilaterally. The Capabilities of Upper Extremity Questionnaire (CUE-Q) score for unilateral arm functionality increased by 44% (right) and 112.5% (left) and for bilateral arm functionality by 400%; the CUE-Q score for unilateral hand and finger function increased by 283% (right) and 166% (left).

LESSONS

The combination of neurological, MRI, and EMG studies before surgery and data obtained during surgery provides reliable information on the CSCI pattern, specifically the availability of motor donor nerves. Simultaneous bilateral restoration is required in the event of CSCI and significantly improves the unilateral and bilateral function of the UEs.

Transfer of the anterior C3 levator scapulae motor nerve branch for spinal accessory nerve injury: illustrative case

BACKGROUND

Injury to the spinal accessory nerve (Acc) results in loss of motor function of the trapezius muscle and leads to severe shoulder problems. A vast number of surgical strategies have been proposed to reinnervate (suture, grafting, and nerve transfers) or compensate (tendon and muscle transfers) the lost function of the trapezius muscle.

OBSERVATIONS

The authors report a successful case of Acc reconstruction 5 months after the injury with the anterior C3 levator scapulae motor nerve branch transfer in omotrapezoid triangle of the neck.

LESSONS

The advantages of the proposed technique over preexisting nerve transfers were discussed. We believe that this technique can be considered as an alternative to already existing techniques for proximal injuries to Acc.

Choosing the target wisely: partial tibial nerve transfer to extensor digitorum motor branches with simultaneous posterior tibial tendon transfer. Could this be a way to improve functional outcome and gait biomechanics?

OBJECTIVE

The objective of this study was clinical assessment of the reduction of pathological motor phenomena with the recovery of long toe extensors, and evaluation of functional outcome with simultaneous nerve and tendon transfer in cases of common peroneal nerve (CPN) injuries.

METHODS

Seven male patients (mean age 26.4 years) received a partial tibial nerve transfer to the extensor hallucis longus muscle (MEHL) and extensor digitorum longus muscle (MEDL) motor branches, after a mean of 2.7 months following a traction-type injury to the CPN. Tibialis posterior muscle (MTP) tendon transfer through the interosseous route was performed on the same day. The follow-up period included a clinical neurological examination, a modified Stanmore System questionnaire (MSSQ), electromyographic examination of the interference pattern, and a video-based analysis of the gait biomechanics in the 3rd and 12th months. Video analysis of the gait investigated the presence or reduction of "stair-climbing maneuver" (SCM), foot slap (FS), and foot stability during the gait cycle.

RESULTS

The average range of active dorsiflexion in the 3rd month was 0.85°. SCM accompanied walking in 6 patients (86%). FS accompanied walking in 3 patients (43%) and 3 patients (43%) avoided FS by planting the entire foot on the ground. All patients required orthopedic support (shoe inserts) to compensate for mediolateral foot instability. The average MSSQ score was 80.4 points. The average duration for the effective recovery of function (≥ 4 points on the Medical Research Council grading system) of long toe extensors was 11.2 months. The average range of active dorsiflexion in the 12th month increased to 4.4°. A reduction of FS was observed in 5 patients (71%). Excessive foot eversion was reduced in 4 patients (57%). Another 3 patients (43%) required no specific orthopedic shoe inserts. Reduction of pathological motor phenomena with recovery of the long toe extensors resulted in an increase of functional outcome. The average MSSQ score after 12 months was 92.4 points.

CONCLUSIONS

Partial tibial nerve transfer to the motor branches of the extensor hallucis longus and the long toe extensors along with the simultaneous tibialis posterior tendon transfer produce the reduction of FS and bring mediolateral stability to the foot, i.e., improved gait biomechanics. The reduction of pathological motor phenomena at the time of recovery of the long toe extensors is reflected in an increase in patients' functional perception of the injured lower extremity during daily walking.