Volar versus dorsal approach for supinator to posterior interosseous nerve transfer: An anatomical study in cadavers.

INTRODUCTION: Supinator to posterior interosseous nerve (SPIN) transfer allows reconstruction of finger/thumb extension and thumb abduction for low radial nerve palsy, incomplete C6 tetraplegia, and brachial plexus injury affecting C7-T1. No study has compared dorsal versus volar approach to perform SPIN transfer. This comparison is studied in the present work, assessing supinator motor branch length and ability to achieve nerve transfer from either approach. METHODS: Ten fresh frozen cadavers were randomly allocated to receive either a dorsal or volar approach to PIN and supinator radial and ulnar branches (RB = radial, UB = ulnar). Supinator head innervation patterns were documented. RB and UB lengths, forearm lengths measured from ulnar styloid to olecranon, visualization of extensor carpi radialis brevis (ECRB) motor nerve without additional dissection, and ability to perform tension-free nerve transfer were assessed. RESULTS: Nine of 10 specimens had supinator branches innervating both heads. The ECRB nerve was visualized in all volar but only one dorsal approach. No significant differences in forearm length were found. Volar with elbow extended: mean RB length was 35 ± 7.8 mm and UB was 37.8 ± 9.3 mm. Dorsal with elbow extended: mean RB length was 30 ± 4.1 mm and UB was 38.8 ± 7.3 mm. Dorsal with elbow flexed 90°: RB was 25.6 ± 3.8 mm and UB was 34.8 ± 4.8 mm. No significant differences were found in branch lengths between approaches (dorsal vs. volar UB, p = .339; dorsal vs. volar RB, p = .117). All limbs achieved tension-free coaptation. CONCLUSION: Neither approach demonstrated superiority in achieving tension-free nerve transfer. Volar permitted immediate identification of ECRB nerve whereas this was only visualized in one dorsal specimen without additional dissection. Overall, the volar approach allows direct coaptation in elbow extension, mimicking maximal physiologic tension for neurorrhaphy. It simultaneously permits additional procedures for pinch reconstruction via single exposure, circumventing limb/microscope maneuvering, dorsal dissection, and increased operative time. Ultimate choice of approach should depend on surgeon familiarity and potential need for additional simultaneous transfers.

Surgical Excision of Postaxial Polydactyly Type B in the Office Setting.

BACKGROUND: Simple postaxial polydactyly (type B) is a common congenital hand malformation often treated by suture or clip ligation. METHODS: We present a case series of patients with simple postaxial polydactyly treated by surgical excision using local anesthesia in an office setting. RESULTS: The procedure was performed on 78 digits in 48 children with a mean age of 10.2 weeks. There were no intraoperative or early postoperative complications. A follow-up by phone interview was performed at an average of 3.2 years postoperatively. All patients were reported to be pain-free and have normal function without a perceived range of motion deficits. All parents selected the highest level of satisfaction regarding cosmetic outcomes and overall experience with the procedure. CONCLUSIONS: These results demonstrate that an office-based surgical excision is a safe, effective, and economical treatment option and has developed into our standard of care for this common condition.

Acute Flaccid Myelitis: A Single Pediatric Center Experience From 2014 to 2019.

BACKGROUND: Acute flaccid myelitis has emerged as the leading cause of acute flaccid paralysis in children. Acute flaccid myelitis leads to significant physical disability; hence, objective outcome measures to study disease severity and progression are desirable. In addition, nerve transfer to improve motor function in affected children needs further study. METHODS: Retrospective study of acute flaccid myelitis subjects managed at Children's Healthcare of Atlanta from August 2014 to December 2019. Clinical, electromyography and nerve conduction study, neuropsychological functional independence (WeeFIM), and nerve transfer data were reviewed. RESULTS: Fifteen children (11 boys and 4 girls) mean age 5.1±3.2 years (range 14 months to 12 years) were included. All subjects (n = 15) presented with severe asymmetric motor weakness and absent tendon reflexes. Motor nerve conduction study of the affected limbs in 93% (n = 14) showed absent or markedly reduced amplitude. Ten patients received comprehensive inpatient rehabilitation and neuropsychological evaluation. Admission and discharge WeeFIM scores showed deficits most consistent and pronounced in the domains of self-care and mobility. Multiple nerve transfer surgery was performed on 13 limbs (9 upper and 4 lower extremities) in 6 children. Postsurgery (mean duration of 10.4 ± 5.7 months) follow-up demonstrated improvement on active movement scale (AMS) in 4 subjects. CONCLUSION: Acute flaccid myelitis affects school-age children with asymmetric motor weakness, absent tendon reflexes, and reduced or absent motor amplitude on nerve conduction study. Comprehensive rehabilitation and nerve transfer led to improvement in motor function on neuropsychology WeeFIM and AMS scores.

Reconstruction of the Suprascapular Nerve in Brachial Plexus Birth Injury: A Comparison of Nerve Grafting and Nerve Transfers.

BACKGROUND: Shoulder external rotation recovery in brachial plexus birth injury is often limited. Nerve grafting to the suprascapular nerve and transfer of the spinal accessory nerve to the suprascapular nerve are commonly performed to restore shoulder external rotation, but the optimal surgical technique has not been clearly demonstrated. We investigated whether there was a difference between nerve grafting and nerve transfer in terms of shoulder external rotation recovery or secondary shoulder procedures. METHODS: This is a multicenter, retrospective cohort study of 145 infants with brachial plexus birth injury who underwent reconstruction with nerve grafting to the suprascapular nerve (n = 59) or spinal accessory nerve to suprascapular nerve transfer (n = 86) with a minimum follow-up of 18 months (median, 25.7 months [interquartile range, 22.0, 31.2 months]). The primary outcome was the Active Movement Scale (AMS) score for shoulder external rotation at 18 to 36 months. The secondary outcome was secondary shoulder surgery. Two-sample Wilcoxon and t tests were used to analyze continuous variables, and the Fisher exact test was used to analyze categorical variables. The Kaplan-Meier method was used to estimate the cumulative risk of subsequent shoulder procedures, and the proportional hazards model was used to estimate hazard ratios (HRs). RESULTS: The grafting and transfer groups were similar in Narakas type, preoperative AMS scores, and shoulder subluxation. The mean postoperative shoulder external rotation AMS scores were 2.70 in the grafting group and 3.21 in the transfer group, with no difference in shoulder external rotation recovery between the groups (difference, 0.51 [95% confidence interval (CI), -0.31 to 1.33]). A greater proportion of the transfer group (24%) achieved an AMS score of >5 for shoulder external rotation compared with the grafting group (5%) (odds ratio, 5.9 [95% CI, 1.3 to 27.4]). Forty percent of the transfer group underwent a secondary shoulder surgical procedure compared with 53% of the grafting group; this was a significantly lower subsequent surgery rate (HR, 0.58 [95% CI, 0.35 to 0.95]). CONCLUSIONS: Shoulder external rotation recovery in brachial plexus birth injury remains disappointing regardless of surgical technique, with a mean postoperative AMS score of 3, 17% of infants achieving an AMS score of >5, and a high frequency of secondary shoulder procedures in this study. Spinal accessory nerve to suprascapular nerve transfers were associated with a higher proportion of infants achieving functional shoulder external rotation (AMS score of >5) and fewer secondary shoulder procedures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Microsurgery for Brachial Plexus Injury Before Versus After 6 Months of Age: Results of the Multicenter Treatment and Outcomes of Brachial Plexus Injury (TOBI) Study.

BACKGROUND: Infants with more severe brachial plexus birth injury (BPBI) benefit from primary nerve surgery to improve function. The timing of the surgery, however, is controversial. The Treatment and Outcomes of Brachial Plexus Injury (TOBI) study is a multicenter prospective study with the primary aim of determining the optimal timing of this surgical intervention. This study compared outcomes evaluated 18 to 36 months after "early" microsurgery (at <6 months of age) with the outcomes of "late" microsurgery (at >6 months of age). METHODS: Of 216 patients who had undergone microsurgery, 118 were eligible for inclusion because they had had a nerve graft and/or transfer followed by at least 1 physical examination during the 18 to 36-month interval after the microsurgery but before any secondary surgery. Patients were grouped according to whether the surgery had been performed before or after 6 months of age. Postoperative outcomes were measured using the total Active Movement Scale (AMS) score as well as the change in the AMS score. To address hand reinnervation, we calculated a hand function subscore from the AMS hand items and repeated the analysis only for the subjects with a Narakas grade of 3 or 4. Our hypothesis was that microsurgery done before 6 months of age would lead to better clinical outcomes than microsurgery performed after 6 months of age. RESULTS: Eighty subjects (68%) had early surgery (at a mean age of 4.2 months), and 38 (32%) had late surgery (at a mean age of 10.7 months and a maximum age of 22.0 months). Infants who underwent early surgery presented earlier in life, had more severe injuries at baseline, and had a significantly lower postoperative AMS scores in the unadjusted analysis. However, when we controlled for the severity of the injury, the difference in the AMS scores between the early and late surgery groups was not significant. Similarly, when we restricted our multivariable analysis to patients with a Narakas grade-3 or 4 injury, there was no significant difference in the postoperative AMS hand subscore between the early and late groups. CONCLUSIONS: This study suggests that surgery earlier in infancy (at a mean age of 4.2 months) does not lead to better postoperative outcomes of BPBI nerve surgery than when the surgery is performed later in infancy (mean age of 10.7 months). LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Early Predictors of Microsurgical Reconstruction in Brachial Plexus Birth Palsy.

Background: Microsurgical reconstruction is indicated for infants with brachial plexus birth palsy (BPBP) that demonstrate limited spontaneous neurological recovery. This investigation defines the demographic, perinatal, and physical examination characteristics leading to microsurgical reconstruction. Methods: Infants enrolled in a prospective multicenter investigation of BPBP were evaluated. Microsurgery was performed at the discretion of the treating provider/center. Inclusion required enrollment prior to six months of age and follow-up evaluation beyond twelve months of age. Demographic, perinatal, and examination characteristics were investigated as possible predictors of microsurgical reconstruction. Toronto Test scores and Hospital for Sick Children Active Movement Scale (AMS) scores were used if obtained prior to three months of age. Univariate and multivariate logistic regression analyses were performed. Results: 365 patients from six regional medical centers met the inclusion criteria. 127 of 365 (35%) underwent microsurgery at a median age of 5.4 months, with microsurgery rates and timing varying significantly by site. Univariate analysis demonstrated that several factors were associated with microsurgery including race, gestational diabetes, neonatal asphyxia, neonatal intensive care unit admission, Horner's syndrome, Toronto Test score, and AMS scores for finger/thumb/wrist flexion, finger/thumb extension, wrist extension, elbow flexion, and elbow extension. In multivariate analysis, four factors independently predicted microsurgical intervention including Horner's syndrome, mean AMS score for finger/thumb/ wrist flexion <4.5, AMS score for wrist extension <4.5, and AMS score for elbow flexion <4.5. In this cohort, microsurgical rates increased as the number of these four factors present increased from zero to four: 0/4 factors = 0%, 1/4 factors = 22%, 2/4 factors = 43%, 3/4 factors = 76%, and 4/4 factors = 93%. Conclusions: In patients with BPBP, early physical examination findings independently predict microsurgical intervention. These factors can be used to provide counseling in early infancy for families regarding injury severity and plan for potential microsurgical intervention.Level of Evidence: Prognostic Level I.

Outcomes of Operative Treatment of Triangular Fibrocartilage Tears in Pediatric and Adolescent Athletes.

BACKGROUND: Triangular fibrocartilage complex (TFCC) tears have been treated with increasing frequency in pediatric and adolescent patients over the past decade. There is little information on these injuries in young athletes and a scarcity of data regarding their ability to return to preinjury levels of athletic participation. The purpose of this study was to review the outcomes of pediatric and adolescent athletes with operatively treated TFCC tears with or without a concurrent ulnar shortening osteotomy and to determine their ability to return to their preoperative level of activity. METHODS: A retrospective chart review was performed for all patients who underwent operative treatment of TFCC tears between 2006 and 2012 within one Upper Extremity practice. Patients were included if they were high-level athletes, unable to participate in their sport secondary to wrist pain and desired to return to their sport. All operative patients had imaging studies and clinical findings consistent with TFCC injury as the primary source of their activity-limiting pain and had failed nonoperative management prior to surgery. Patients without at least 3 months of documented postoperative follow up were excluded. RESULTS: In total, 22 patients were included in the chart review with 20 patients willing to participate in a telephone survey and PODCI. Eighty percent of patients returned to their sport following operative treatment of their injury at an average of 4.8 months. Seven of the 22 patients underwent a concurrent ulnar shortening osteotomy for ulnar positive variance. All 20 patients reported satisfaction with the outcomes of their surgery and treatment. CONCLUSIONS: Operative treatment of TFCC injuries in adolescent and pediatric athletes after failure of conservative treatment allowed return to sport at the previous level of participation. Concurrent ulnar shortening osteotomy in the setting of ulnar positive variance did not prohibit return to high-level athletic participation. LEVEL OF EVIDENCE: Level IV.

Surgical treatment of upper extremity contractures in Emery-Dreifuss muscular dystrophy.

Emery-Dreifuss muscular dystrophy is a rare form of muscular dystrophy. In the present study we present two patients with Emery-Dreifuss muscular dystrophy and severe upper extremity contractures treated successfully with contracture release and musculotendinous lengthenings. For each of these patients a chart review was carried out and surgical technique reviewed. Patient 1 demonstrated elbow flexion contractures of 65° (right) and 60° (left) preoperatively and ∼45° (right) and 20° (left) postoperatively. Patient 2 demonstrated flexion contractures of 75° bilaterally preoperatively and 45° bilaterally postoperatively. For more severe elbow contractures, surgical treatment resulted in improved range of motion without a significant sacrifice of strength, allowing these patients to remain independent.

Extensor pollicis longus ruptures in distal radius fractures: clinical and cadaveric studies with a new therapeutic intervention.

We conducted a study to evaluate aspiration of the third dorsal compartment as a therapeutic option for preventing extensor pollicis longus ruptures in association with distal radius fractures. A cadaveric model with a nondisplaced distal radius fracture was created, and radiopaque (Hypaque) dye was injected into the fracture site. Pressure readings were taken from the third dorsal compartment before and after dye injection. The compartment was aspirated with an 18-gauge needle, and compartment pressures were measured again. There was a significant decrease in pressures after aspiration. Results in our cadaveric model were consistent with those in in vitro decompression of the third dorsal compartment. Clinical studies may determine that in-office needle aspiration is beneficial in preventing extensor pollicis longus rupture in nondisplaced distal radius fractures.

Remodeling potential of phalangeal distal condylar malunions in children.

PURPOSE: Distal condylar phalangeal (DCP) fractures in children are uncommon, but their periarticular location makes them problematic. Malunions are particularly difficult to treat. These fractures are generally thought to have a poor remodeling potential because their location is far from the phalangeal physis. We present 8 cases of DCP malunion in children with a mean 5-year follow-up demonstrating consistent remodeling. METHODS: In this study, DCP fractures were defined as those occurring at or distal to the collateral ligament recess of the proximal or middle phalanx in skeletally immature patients. Radiographic parameters examined at the time of established malunion and at final follow-up included coronal and sagittal plane deformity and translational malalignment of the distal fragment in relation to the proximal shaft. Range of motion was measured, and a brief questionnaire was implemented to establish patient satisfaction. RESULTS: We examined 8 patients with a minimum 1-year follow-up (mean, 5.3 y). Average age at injury was 8.8 years (range, 2-14 y). In the sagittal plane, fractures remodeled from an initial mean deformity of 30.9° to 0.0°; in the coronal plane, from 10.5° to 3.9°. Fracture translation in the sagittal plane corrected, as well, from a mean 57.5% at injury to 0.0% at final follow-up. There was no functionally limiting loss of motion of the digit in any patient. Subjectively, only 2 patients complained of cosmetic deformity, both of which were coronal plane deformities of the small finger. CONCLUSIONS: In this case series, DCP malunions in children remodeled significantly and completely in the sagittal plane, and all patients had good final range of motion. Furthermore, patients were satisfied with nonsurgical treatment at long-term follow-up. This series describes the remodeling potential of DCP fractures in children, lending support to the previously reported cases. These findings support treating late-presenting pediatric DCP malunions nonsurgically. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Surgical restoration of arm and hand function in people with tetraplegia.

Improved hand and arm function is the most sought after function for people living with a cervical spinal cord injury (SCI). Surgical techniques have been established to increase upper extremity function for tetraplegics, focusing on restoring elbow extension, wrist movement, and hand opening and closing. Additionally, more innovative treatments that have been developed (implanted neuroprostheses and nerve transfers) provide more options for improving function and quality of life. One of the most important steps in the process of restoring upper extremity function in people with tetraplegia is identifying appropriate candidates - typically those with American Spinal Injury Association (ASIA) motor level C5 or greater. Secondary complications of SCI can pose barriers to restoring function, particularly upper extremity spasticity. A novel approach to managing spasticity through high-frequency alternating currents designed to block unwanted spasticity is being researched at the Cleveland FES Center and may improve the impact of reconstructive surgery for these individuals. The impact of these surgeries is best measured within the framework of the World Health Organization's International Classification of Function, Disability and Health. Outcome measures should be chosen to reflect changes within the domains of body functions and structures, activity, and participation. There is a need to strengthen the evidence in the area of reconstructive procedures for people with tetraplegia. Research continues to advance, providing more options for improved function in this population than ever before. The contribution of well-designed outcome studies to this evidence base will ultimately help to address the complications surrounding access to the procedures.