An Anatomical Feasibility Study on the Use of the Hypoglossal and Hemihypoglossal Nerve as a Donor Motor Nerve for Free Functioning Muscle Transfer in Upper Extremity Reconstruction.

PURPOSE: Brachial plexus injuries (BPI) with complete root avulsions remains a clinical challenge due to a paucity of nerves available for nerve transfer and innervation of free functioning muscle transfers (FFMT). The hypoglossal and hemihypoglossal nerve has not been studied as a donor nerve option for FFMTs in brachial plexus reconstruction, despite successful outcomes of hypoglossal nerve transfers in facial reanimation surgery. We hypothesized that the hypoglossal nerve could be an appropriate candidate for surgical repair of BPI using FFMT. METHODS: A cadaveric study was performed to determine the anatomic feasibility of using the hypoglossal and hemihypoglossal nerves as donor nerves to neurotize the gracilis or latissimus dorsi muscle in an FFMT to restore elbow flexion. Twelve cadavers (6 males and 6 females) were studied. The hypoglossal nerve, thoracodorsal nerve, and obturator nerve branches to the gracilis muscle were dissected, measured, and analyzed. RESULTS: The average length of the hypoglossal nerve was 6.3 ± 0.5 cm in both sexes. The average distance between the lowest point of the hypoglossal nerve and the lateral clavicle was 8.4 ± 1.3 cm in males and 7.7 ± 0.8 cm in females. When the hypoglossal nerve was transected distally, the average distance to the clavicle was 4.5 ± 1.6 cm in males and 3.8 ± 1.5 cm in females. CONCLUSIONS: The maximum theoretical length of the donor nerve required to perform an adequate FFMT using the hypoglossal nerve was 8.9 ± 1.2 cm, which was well exceeded by the lengths of the thoracodorsal nerve (14.5 ± 1.3 cm) and nerve to the gracilis muscle (12.7 ± 1.7 cm). CLINICAL RELEVANCE: This cadaveric study demonstrated that the hypoglossal or hemihypoglossal nerves may be used as potential motor donor nerves to innervate a free gracilis or latissimus dorsi muscle transfer for the restoration of elbow flexion via a direct nerve transfer without the need for nerve grafting.

Outcomes After Distal Radius Fracture Treatment With Percutaneous Wire Versus Plate Fixation: Meta-Analysis of Randomized Controlled Trials.

Multiple methods for surgical fixation of distal radius fractures exist, including percutaneous pinning with Kirschner wires and open reduction volar plating. Despite increased costs, the hypothesis of this study was that open reduction and volar plating does not provide improved outcomes over wire fixation. Following Transparent Reporting of Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a meta-analysis of randomized controlled trials was conducted comparing these two methods with regard to clinical outcomes, radiographic parameters, and complications. Seven trials with a total of 858 patients were included. Plating was not favored over pinning with regard to clinical outcomes and radiographic parameters. Pinning was associated with a higher superficial infection risk compared with plating, though the risk of repeat surgery was not different. It was concluded that Kirschner wire fixation, which may be associated with lower costs, is associated with similar clinical and radiographic outcomes when compared with volar plate fixation, although wire fixation is associated with higher superficial infection risk.

Novel posterior technique to temporize life-threatening hemorrhage after great vessel laceration during posterior osteotomy.

PURPOSE: Great vessel injury during posterior 3-column osteotomy is rare, but potentially fatal. Literature review revealed limited data guiding spine surgeons during this major catastrophe. In this study our aim was first, to present our case of mortality; second, to discuss a novel technique that can be performed to temporize hemorrhage in a life-threatening situation where an iatrogenic great vessel injury occurs and hemodynamic stability cannot be achieved through usual means of hemostasis; third, a cadaveric study to determine if this novel technique is feasible. METHODS: Three fresh cadavers including thoracic, lumbar, and pelvis were used. A thoraco-abdominal approach was used to access great vessels at the level of L3. The aorta and vena cava were identified and tagged. The cadavers were turned prone; a pedicle subtraction osteotomy was performed at the level of L3. A novel posterior peri-vertebral approach was used to reach the great vessels. The aorta and vena cava were occluded digitally with this approach and success confirmed visually through the thoraco-abdominal incision. Timing of the procedure and structures at risk were recorded. RESULTS: In all three cadavers, we were able to successfully occlude the great vessels from a prone position. The average amount of time it took to digitally occlude the great vessels was less than a minute. Structures at risk included the L1 and L2 nerve roots, lumbosacral plexus, and the sympathetic trunk. CONCLUSIONS: The posterior peri-vertebral approach can potentially be used by a spine surgeon during a life-threatening situation to temporarily occlude great vessel hemorrhage while waiting for the assistance of a vascular/trauma team.

Bioabsorbable Pin Fixation in Late Presenting Pediatric Radial Neck Fractures.

BACKGROUND: Current treatment algorithms for pediatric radial neck fractures reserve open treatment for severe residual angulation. There is a paucity of literature guiding treatment for delayed presentation resulting in malunion. Bioabsorbable pins have been used successfully for many other fracture types in the upper extremity. The purpose of this study is to determine whether open reduction, bioabsorbable fixation with an osteotomy when necessary is a reasonable treatment option in delayed pediatric radial neck fractures by assessing pain, range of motion, functional, and radiographic outcomes. METHODS: Radial neck fractures were evaluated in 7 children, 4 to 12 years old, with delayed initial presentation averaging 20 days. Patients presented with an average angular deformity of 63 degrees and translational deformity of 57% (6.1 mm) in the AP plane, all with painful and reduced range of motion. Patients underwent open reduction and fixation with Self-Reinforced Poly-L-Lactic Acid pins after failed closed reduction. Four patients required formal osteotomies. Postoperative follow-up averaged 9.2 months and consisted of radiographic and clinical evaluation with Wong-Baker FACES Visual Analog scale and the Mayo Elbow Performance (MEP) score. RESULTS: Final radiographs demonstrate an improvement in angular deformity by 56 degrees and translational deformity by 51%. Final clinical outcomes demonstrated significantly improved pain-free range of motion with excellent MEP scores in 6 of the 7 patients. One patient developed a radioulnar synostosis, subsequently undergoing synostosis excision with a final MEP score of 80/100. There was no evidence of physeal closure or avascular necrosis and no cases requiring hardware removal or complicated by local inflammatory reactions. CONCLUSIONS: This small series shows encouraging results in the treatment of pediatric radial neck fractures with delayed presentation using open reduction, bioabsorbable fixation, and when necessary an osteotomy. Bioabsorbable fixation may eliminate issues surrounding subsequent hardware removal and pin-site infections. Despite these encouraging results, radioulnar synostosis after open surgery is still a concern. LEVEL OF EVIDENCE: Level IV-case series.

Independent assessment of a new pedicle probe and its ability to detect pedicle breach: a cadaveric study.

OBJECT: The authors undertook an independent, non-industry funded cadaveric study to evaluate the efficacy of a pedicle-probing device, which uses impedance measurement to warn of impending and actual pedicle screw breach. METHODS: A previously validated fresh-frozen cadaver model (saline-soaked spine) was used. Individuals at 3 levels of training (attending spine surgeon, orthopedic surgery resident, and medical student) used a cannulated pedicle-probing device to cannulate each of the levels between T-2 and S-1. Each pedicle was cannulated freehand using 2 approaches: 1) a standard trajectory through the middle of the pedicle, and 2) a medial trajectory aimed to breach the medial wall of the pedicle. A 16-slice helical CT scanner was used. The images were interpreted and analyzed by 2 orthopedic spine surgeons and a neuroradiologist. RESULTS: The sensitivity of the pedicle probe to detect impending breach or breach of 4 mm or less was 90.06%. The sensitivity in detecting medial wall breach was 95.8%. The positive predictive value was 87.1%. The device detected medial breach more often than lateral breach. CONCLUSIONS: This study showed that this pedicle-probing device could reasonably be used to detect impending breach and actual breach of 4 mm or less. Medial breach was detected better than lateral breach. Use of the pedicle probe may improve patient safety.