[Nerve transfers]. / Les transferts nerveux.

Nerve transfers are recent surgical techniques where an unaffected nerve or part of its fascicules is transferred onto another nerve and co-apted end-to-end, or sometimes end-to-side, in order to "reanimate", sensitive or motor deficits. The technique is indicated when the proximal nerve stump has been destroyed or is of bad histological quality (brachial plexus root avulsion, or stump hidden in an extended scar), far from the target (important loss of substance), or difficult to access. Nerve transfers may be indicated for the microsurgical repair of brachial or lumbo-sacral plexus lesions, and in specific upper and lower limb peripheral nerve injuries : rupture of the axillary nerve in the quadrilateral space, irreversible lesion of the upper trunk of the brachial plexus, and in facial nerve surgery.

[Paediatric brachial plexus injury--an interdisciplinary challenge to obstetricians, neonatologists and plexus surgeons]. / Die kindliche Plexusparese--eine interdisziplinäre Herausforderung für Geburtshelfer, Neonatologen und Plexuschirurgen.

Brachial plexus injuries are an interdisciplinary challenge to obstetricians, neonatologists and plexus surgeons. The incidence of brachial plexus injuries is 1-4/1,000 live births, and the incidence of permanent lesions has been estimated to be 1/10,000 live births. Shoulder dystocia is associated with a 75-100-fold increase in plexus injuries. The antenatal (intrauterine) development of brachial plexus injuries is still a matter of controversial debate. The early recognition of antenatal risk factors of shoulder dystocia and its proper management by experienced obstetricians are mandatory; 90% of brachial plexus injuries recover without clinical sequelae for the newborn, however, 10% of the cases may lead to severe pareses requiring surgical intervention. Microsurgical nerve reconstruction should be performed in these cases within the first three months after birth. In this context, the intraoperative findings are of high prognostic relevance. The pathophysiology of birth-associated plexus brachialis injuries has been investigated in recently published experimental studies. An open dialogue between the specialists involved may be a great support for the parents of newborns suffering from plexus brachialis injuries. Medico-legal conflicts lasting for years should be avoided, and appropriate plexus surgical treatment by an experienced surgeon should be offered in good time after a careful diagnosis.

Critical review of pathophysiologic mechanisms in thoracic outlet syndrome (TOS).

BACKGROUND: Thoracic outlet syndrome is a complex and multifactorial disease. There are multiple diagnostic steps and possible treatment options. The scientific literature not always contributes to a "unifying vision". METHOD: We did an overview of the actual literature on TOS in the last 20 years and confronted these views with our surgical experience (about 50 cases and 10 operations). After preparing a special issue in the German Journal of Hand Surgery (Handchirurgie Mikrochirurgie Plastische Chirurgie), where landmark papers were edited on anatomy, pathophysiology, diagnosis and treatment, we summarise our knowledge in this "strategic" paper. FINDINGS: To understand and treat TOS correctly, surgical experience in brachial plexus surgery is mandatory. The very well written basic papers on anatomy and its variations must be studied in detail. Neurophysiologic and vascular examinations are mandatory. A conservative treatment always must be tried first. Postoperative outcome should be clearly correlated with the technical steps within the surgical procedure. CONCLUSION: TOS diagnosis and treatment is complex, but rewarding. The symptom complex must be identified and no longer be considered as psychogenic. There is still need for better spread of information among neurologists, surgeons, and work compensation companies.

Direct Nerve Sutures in (Extended) Upper Obstetric Brachial Plexus Repair.

Background In rare, selected cases of severe (extended) upper obstetric brachial plexus palsy (OBPP), after supraclavicular exposure and distal mobilization of the traumatized trunks and careful neuroma excision, we decided to perform direct nerve coaptation with tolerable tension and immobilized the affected arm positioned in adduction and 90-degree elbow flexion for three weeks. Objectives We present our surgical technique and preliminary results in a prospective open patient series, including 22 patients (14 right and 8 left side affected) between 2009 and 2016, operated at a mean age of 8.4 months. Methods Analysis of functional results after a minimum of 18 months was conducted using the British Medical Research Council (BMRC) scale. Results All children reached 60-90° of elbow flexion and 75° of shoulder abduction at already six months after surgery. For those patients having already passed one year post surgery, the mean active shoulder abduction reached 92°, and for those who past the 18 months 124°. We discuss the actual knowledge about nerve coaptation under "reasonable" tension including its advantages and drawbacks. Conclusion This technique may be indicated in preoperatively selected cases of (extended) upper OBPP and may give good functional results.

[Systematic and critical consideration of the thoracic outlet syndrome: clinical picture and therapy]. / Systematisch-kritische Betrachtung der Problematik des Thoracic-outlet-Syndroms: Klinik und Therapie.

Based on actual references from international well-known surgical colleagues with large experience, this article summarises the clinical and surgical strategy when treating thoracic outlet syndrome.

The Surgical Strategy to Correct the Rotational Imbalance of the Glenohumeral Joint after Brachial Plexus Birth Injury.

In upper brachial plexus birth injury, rotational balance of the glenohumeral joint is frequently affected and contracture in medial rotation of the arm develops, due to a severe palsy or insufficient recovery of the lateral rotators. Some of these children present with a severe glenohumeral joint contracture in the first months, although regular physiotherapy has been provided, a condition associated with a posteriorly subdislocated or dislocated humeral head. These conditions should be screened early by a pediatrician or specialized physiotherapist. Both aspects of muscular weakness affecting the lateral rotators and the initial or progressive glenohumeral deformity and/or subdislocation must be identified and treated accordingly, focusing on the reestablishment of joint congruence and strengthening of the lateral rotators to improve rotational balance, thus working against joint dysplasia and loss of motor function of the shoulder in a growing child. Our treatment strategy adapted over the last 20 years to results from retrospective studies, including biomechanical aspects on muscular imbalance and tendon transfers. With this review, we confront our actual concept to recent literature.

The cervical rib. A predisposing factor for obstetric brachial plexus lesions.

Controversy surrounds the aetiology of obstetric brachial plexus lesions. Most authors consider that it is caused by traction or compression of the brachial plexus during delivery. Some patients, however, present without a history of major traction during delivery, and some delivered by Caesarean section also suffer the injury. In our series of 42 infants, 28 had an Erb's palsy, and the remaining 14 presented with a more extensive lesion, involving the lower roots. In five of these, a complete ossified cervical rib was found. We believe that anatomical variations, such as cervical ribs or fibrous bands, can cause narrowing of the supracostoclavicular space, and render the adjacent nerves more susceptible to external trauma.

Surgical correction of supination deformity in children with obstetric brachial plexus palsy.

We present a series of 40 children who were operated on for supination contracture following severe obstetric brachial plexus palsy. Surgery was done at an average age of 7 years and the mean postoperative follow-up was 4 years. In the 23 cases treated by an open or closed radial osteotomy, the mean intraoperative derotation was 78 degrees, the immediate postoperative position was 29 degrees pronation and it stabilized at follow-up at 17 degrees pronation. Biceps rerouting was performed in 17 cases without any recurrence of supination deformity and the final position was 22 degrees pronation. Some active forearm rotation was obtained in a few cases. These surgical corrections are part of an overall treatment plan and allow the "begging hand" to be corrected to a more functional and less noticeable position.

[Surgical treatment of fractures of the distal radius--a closed therapy concept. Initial results with the bowl osteosynthesis]. / Die operative Behandlung distaler Radiusfrakturen--ein geschlossenes Therapiekonzept. Erste Ergebnisse mit der Kelchosteosynthese.

We present our treatment strategy for distal radius fractures, based on intrafocal pinning (Kapandji) and further combination with a palmar plate resulting in bowl osteosynthesis (Nonnenmacher). Even with a changing surgical team, we got more than 80% good results and rapid revalidation. We thus favor dynamic minimal osteosynthesis close to the fracture physiopathology. Indication for external fixation becomes limited to open or comminutive fractures.

[Secondary procedures in obstetric brachial plexus lesions]. / Die kindliche Armplexusparese--Eine aktuelle Ubersicht sekundärer Operationsverfahren.

Secondary surgery following obstetric brachial plexus palsy is usually performed between two and six years of age, but also later when the patient presents later. Surgery consists of contracture releases and transpositions of muscles and tendons. Indication for surgery must be assessed and discussed individually. Only a real functional improvement in ADL is a success. We describe usual techniques according to topography and present an overview of our results. This knowledge should influence all decisions about reconstructive surgery in these children.

[Obstetric brachial plexus palsy--clinics, pathophysiology and surgical treatment]. / Die kindliche Armplexusparese--Ubersicht zur Klinik, Pathophysiologie und chirurgischen Behandlungsstrategie.

Obstetric brachial plexus palsy is a rare but sometimes severe traction injury. Peripheral nerve microsurgery (neurolysis, interfascicular grafting) and secondary procedures including muscle and tendon transfers altogether with contracture releases have improved the prognosis over the last 20 years. This article includes a historical review, the ongoing discussion about the pathophysiology (frequent traction injury vs. rare intrauterine maladaptation) and the clinics. Based on a patient group of 500 children with 100 microsurgical plexus reconstructions, we describe the surgical technique and our experience with primary nerve reconstruction. A concept about secondary procedures according to the joint levels is shortly exposed together with various modalities of postoperative evaluation, including video-assisted movement analysis. We conclude that severe upper and complete plexus palsies without significant recovery should be explored and reconstructed by microsurgical techniques.

[Locoregional flaps for the hand: functional anatomy and case examples. An overview]. / Lokoregionale Lappen für die Hand: Funktionelle Anatomie und Fallbeispiele. Eine Ubersicht.

Among the multitude of actually proposed loco-regional flaps and their variants, we describe our options and technical viewpoints for common coverage problems in hand surgery, according to the guidelines of functional anatomy. Special emphasis is placed on newer techniques such as microsurgical free flaps, venous flaps, and reverse flow vascularisation.

[Arteriovenous dysplasia of the hand. A case report and attempts at conservative therapy]. / Arteriovenöse Dysplasie an der Hand. Ein Fallbericht und konservative Therapieversuche.

We present a 44-year old man with an hemorrhagic dorsal skin wound of the left ring finger, which after angiography led to the diagnosis of an arteriovenous dysplasia with fistulas involving the whole left forearm and hand. The local problem was successfully treated by surgical hemostasis and skin flaps, but the underlying vascular pathology seems to be untreatable. Compressive gloves as used in burn treatment are a simple help in this particular case.

[Neurofibroma of the palm of the hand in Recklinghausen disease. A case report]. / Neurofibrom der Hohlhand bei Recklinghausen-Krankheit. Fallbericht.

We present a six-year-old boy with a slowly growing tumor in the palm of the left hand. Sensibility and motor function were normal, neurofibromatosis Recklinghausen had been diagnosed previously. Surgical treatment allowed macroscopically complete neurofibroma resection, but there was inflammatory infiltration of the flexor tendon sheaths and untreatable fibromatosis within the median nerve proximally.

Pedicled hypothenar fat flap for median nerve coverage in recalcitrant carpal tunnel syndrome.

We report the use of a hypothenar pedicled fat flap to cover the median nerve in recalcitrant carpal tunnel syndrome. Forty-five patients with recurrent symptoms after previous carpal tunnel surgery were included in this study. Patients with incomplete release of the transverse carpal ligament were not included. We performed an anatomical study on 30 cadavers. The original technique with the section of the deep branch of ulnar artery was modified. The flap could be transferred onto the median nerve without stretching. The median follow-up was 45 months (range, 12-80 months). Pain completely disappeared in 41 patients with normal nerve conduction. Based on clinical and electromyographic signs, the global results showed excellent results (49%), 19 good results (45%), two average results (4.5%) and two failures (2%). The use of a hypothenar pedicled fat flap to cover the median nerve in recalcitrant carpal tunnel syndrome is a simple and efficient technique which improves the trophic environment of the median nerve and relieves pain.

Percutaneous humeral derotational osteotomy in obstetrical brachial plexus palsy: a new technique.

Thirty three per cent of children with obstetrical brachial plexus palsy with incomplete neurological recovery develop shoulder internal contracture associated with osseous deformity. Some of the older children are treated by humeral derotational osteotomy. The classical technique of open approach to the humeral diaphysis and plate fixation imposes a longitudinal scar and carries significant risks (nonunion, nerve palsy); a secondary procedure for plate removal is necessary in a significant proportion of patients. The authors report a new technique of percutaneous humeral osteotomy with osteosynthesis by Hoffmann external fixator. In six cases bone healing was obtained at an average of 45 days, without adverse complication. The postoperative results showed improved shoulder function. This new technique is simple and safe; it represents a new option for the treatment of sequelae of obstetrical brachial plexus palsy.

Poster - Thur Eve - 19: Risk assessment of clinical radiation processes using failure modes and effect analysis.

The aim of this work was to apply failure modes and effect analysis (FMEA) to assess risk in two radiation planning and treatment processes; our on-call (out-of-clinical hours) process and our tomotherapy process. The motivation was provided by analysis of 2506 adverse incidents reported over a 5 year period, the on-call process for giving rise to a higher than expected number of incidents and our tomotherapy process for the reverse. For the on-call scenario, three separate processes were analysed: our current process, our current process incorporating a software upgrade eliminating several planning steps and a fully integrated process in which the patient is imaged, planned and treated on a single platform (TomoTherapy Hi Art, Accuray Incorporated, Sunnyvale, CA). After construction of a detailed process map for each case, a multidisciplinary group identified potential failure modes for each process step, the effects of each failure and existing controls. Risk probability numbers were determined from severity, frequency of occurrence and detectability scores assigned to each failure mode according to a standard scale. The results were analysed to identify and prioritise feasible and effective process improvements. For the on-call process, our current workflow was identified as incurring the highest risk of the three processes analysed, demonstrating quantitatively the value of the software upgrade and providing a clear rationale for the associated expense. In summary, we have found FMEA to be a feasible tool for assessing relative risk in a clinical process. However, operational and resource issues must be considered separately.

The free vascularised fibular transfer as a definitive treatment in femoral septic non-unions.

Free vascularised bone transfer (fibula, iliac crest, or rib) is an accepted method of bone grafting in malignant and non-union bone surgery. The vascular microanastomoses have transformed the bone healing by creeping substitution seen after non-vascularised grafting (a long and often insufficient process) into normal healing of the fracture site. The presence of its own vascular support allows bone healing in such compromised circumstances as sclerosis and infection. We present the clinical history of five patients with septic femoral non-unions, in which only the final vascular fibular graft provided an acceptable outcome. Discussion about the indication and timing of this microsurgical salvage procedure is still controversial.