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Post-stroke spasticity and contracture remain prevalent and pose significant challenges in stroke rehabilitation. While non-surgical management is the mainstay, surgical reconstruction offers a valuable adjunct when conservative measures are exhausted. This clinical review article provides an overview of surgical reconstruction for limb spasticity and contracture following adult stroke, encompassing the rationale and specifics of these interventions. It highlights the underutilization of surgical reconstruction in rehabilitation of adult stroke patients with spasticity and contracture, and the importance of multidisciplinary collaboration including surgeons in stroke rehabilitation to optimize functional outcomes.
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Purpose: Surgical reconstruction of elbow extension can help restore function in patients with tetraplegia and triceps paralysis because of spinal cord injury. Both posterior deltoid-to-triceps tendon transfer and transfer of the branch of the axillary nerve to the triceps motor branch of the radial nerve have been described for triceps reanimation. This systematic review aimed at reviewing current evidence in the two schools of surgery in terms of their outcome and complication profile. Methods: A systematic review was conducted using MEDLINE (1974-2023) and EMBASE (1946-2023) databases. The keyword terms "elbow extension," "triceps," "deltoid," "nerve transfer," "spinal cord injury," "tetraplegia," "quadriplegia," and "tetraplegic" were used in the initial search, which was supplemented with manual searches of the bibliographies of retrieved articles. Results: Twenty studies met our inclusion criteria, with 14 studies (229 limbs) on posterior deltoid-to-triceps tendon transfer, 5 studies (23 limbs) on axillary to radial nerve transfer, and 1 study (1 limb) on combined transfer. For the tendon transfer group, the majority of studies reported a median triceps power of grade 3, with a wide range of failure percentage to reach antigravity (0% to 87.5%). Common complications included gradual stretching of the musculotendinous unit, rupture of the tendon transferred, elbow contracture, and infection. For the nerve transfer group, the majority of studies also reported a median triceps power reaching grade 3. There were no reported complications or loss of power in donor action of shoulder abduction or external rotation. Conclusions: Transfer of the axillary nerve branch to the triceps motor branch of the radial nerve in tetraplegia shows promising results, with comparable triceps muscle power compared to traditional tendon transfer and a low incidence of complication. Type of Study/Level of Evidence: Systematic Review III.
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Sacral sore is a common problem in patients with spinal cord injury. It leads to prolonged hospitalization and recurrent infections which might require repeated surgery to treat. Flap reconstruction allows soft tissue coverage of sacral sore under the premise of infection-free wound base. Maggot debridement therapy (MDT) has been described as an alternative non-surgical management as opposed to the traditional surgical debridement in case of infected sore, reducing number of surgeries under anaesthesia. However, MDT and surgery are not mutually exclusive. In this article we describe a hybrid approach combining MDT and flap reconstruction with multi-disciplinary effort in management of sacral sore, which accelerates wound healing and prevents morbidities, while lowering the risks associated with repeated surgical debridement at the same time.
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INTRODUCTION AND IMPORTANCE: Although 'congenital' or paediatric trigger thumb is commonly seen in the paediatric age group, adult presentation is very rare. However it is crucial to acknowledge the occurrence of unusual manifestations of paediatric trigger thumbs, since paediatric trigger thumbs are considered a separate disease entity compared to the commonly seen stenosing tenosynovitis in adults. CASE PRESENTATION: We report a case of a 18-year-old young lady presenting with atraumatic locked trigger thumb, which was successfully treated surgically with intra-operative finding confirming abnormally thickened flexor pollicis longus tendon signifying a paediatric trigger thumb pathology. CLINICAL DISCUSSION: Adult and paediatric trigger thumbs have different aetiology, with thickened A1 pulley and tendon sheath being the culprit in adults, whereas in paediatric thumbs thickened tendon nodules (Notta's node) are usually the causes of triggering. CONCLUSION: This uncommon presentation in this case report is atypical in the age group presentation of paediatric trigger thumb, and should be distinguished from the usual trigger thumb pathology in adults. Although a transient period of extension lag in the early post-operative period may be evident, it can still be successfully treated with surgical release.
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Psoas hematoma is a rare yet potentially serious complication following posterior spinal surgery as it is a possible nidus for infection. We present a case of psoas hematoma formation following scoliosis surgery due to intraoperative violation of the intertransverse plane. A 13-year-old female patient with adolescent idiopathic scoliosis underwent a posterior deformity correction and instrumented fusion which was complicated with intraoperative inadvertent violation of the intertransverse plane during dissection of the posterolateral gutter leading to a unilateral psoas hematoma. She experienced abdominal pain and a CT scan confirmed the presence of a psoas hematoma. Antibiotic coverage was provided in view of positive blood culture of Bacillus species to avoid infective seeding of the hematoma. Resolution of the hematoma was observed on the reassessment CT one month postoperatively. It is not uncommon for patients to develop atrophic transverse processes due to spinal deformity. This may cause difficulties in identification of the anatomy intraoperatively and thus, extra caution should be exercised during dissection to prevent violation of the intertransverse plane and subsequent psoas hematoma complication.
