Bone tissue response to titanium implant surfaces modified with carboxylate and sulfonate groups.

The present study assessed in vivo new bone formation around titanium alloy implants chemically grafted with macromolecules bearing ionic sulfonate and/or carboxylate groups. Unmodified and grafted Ti-6Al-4V exhibiting either 100% carboxylate, or 100% sulfonate, or both carboxylate and sulfonate groups in the percent of 50/50 and 80/20 were bilaterally implanted into rabbit femoral condyle. Neither toxicity nor inflammation were observed for all implants tested. After 4 weeks, peri-implant new bone formation varied as a function of the chemical composition of the titanium surfaces. The percent bone-implant contact (BIC) was the lowest (13.4 +/- 6.3%) for the implants modified with grafted carboxylate only. The value of BIC on the implants with 20% sulfonate (24.6 +/- 5.2%) was significantly (P < 0.05) lower than that observed on 100% sulfonate (38.2 +/- 13.2%) surfaces. After both 4 and 12 weeks post-implantation, the BIC value for implants with more than 50% sulfonate was similar to that obtained with the unmodified Ti-6Al-4V. The grafted titanium alloy exhibiting either 100% sulfonate or carboxylate and sulfonate (50% each) groups promoted bone formation. Such materials are of clinical interest because, they do not promote bacteria adhesion but, they support new bone formation, a condition which can lead to osseointegration of bone implants while preventing peri-implant infections.

Embedding of bone samples in methylmethacrylate: a suitable method for tracking LacZ mesenchymal stem cells in skeletal tissues.

Considerable research has been focused on the use of bone marrow-derived mesenchymal stem cells (MSCs) for the repair of non-unions and bone defects. To date, the question of whether transplanted MSCs survive and engraft within newly formed tissue remains unresolved. The development of an easy and reliable method that would allow cell fate monitoring in transplant recipients is a pressing concern for the field of tissue engineering. To demonstrate the presence of transplanted cells in newly formed bone, we established a xenograft nude rat model allowing the detection of murine LacZ MSCs in vivo. MSCs were isolated from transgenic lacZ mice, seeded onto bioabsorbable collagen sponges, and transplanted to repair a calvarial defect in nude rats. As a preliminary step, the histological procedure was adapted to optimize the detection of LacZ cells in bone tissue embedded in methylmethacrylate (MMA). Four fixatives and four fixation times were evaluated. Among all the fixatives tested, 2% formaldehyde/0.2% glutaraldehyde at 4C for 4 days gave the best results for X-gal staining at pH 7.4 on both cell cultures and bone explants. All fixatives were effective for immunodetection of beta-gal. In the chimeric LacZ/nude rat animal model, MSCs were detected in vivo for up to 4 weeks after implantation and contributed to the repair and the neovascularization of the bone defect. LacZ is a suitable phenotypic marker to track MSCs in skeletal tissues embedded in MMA.

Engineering of implantable cartilaginous structures from bone marrow-derived mesenchymal stem cells.

Fabrication of implantable cartilaginous structures that could be secured in the joint defect could provide an alternative therapeutic approach to prosthetic joint replacement. Herein we explored the possibility of using biodegradable hydrogels in combination with a polyglycolic acid (PGA) scaffold to provide an environment propitious to mesenchymal stem cells (MSCs) chondrogenic differentiation. We examined the influence of type I collagen gel and alginate combined with PGA meshes on the extracellular matrix composition of tissue-engineered transplants. MSCs were isolated from young rabbits, expanded in monolayers, suspended in each hydrogel, and loaded on PGA scaffolds. All constructs (n=48) were cultured in serum-free medium containing transforming growth factor beta-1, under dynamic conditions in specially designed bioreactors for 3-6 weeks. All cell-polymer constructs had a white, shiny aspect, and retained their initial size and shape over the culture period. Their thickness increased substantially over time, and no shrinkage was observed. All specimens developed a hyalin-like extracellular matrix containing glycosaminoglycans (GAGs) and type II collagen, but significant differences were observed among the three different groups. In PGA/MSCs and collagen-PGA/MSCs constructs, the cell growth phase and the chondrogenic differentiation phase of MSCs occurred during the first 3 weeks. In alginate-PGA/MSCs constructs, cells remained round in the hydrogel and cartilage extracellular matrix deposition was delayed. However, at 6 weeks, alginate-PGA/MSCs constructs exhibited higher contents of GAGs and lower contents of type I collagen. These results suggest that the implied time for the transplantation of in vitro engineered constructs depends, among other factors, on the nature of the scaffold envisioned. In this study, we demonstrated that the use of a composite hydrogel-PGA scaffold supported the in vitro growth of implantable cartilaginous structures cultured in a bioreactor system.

Tissue-engineered bone regeneration.

Bone lesions above a critical size become scarred rather than regenerated, leading to nonunion. We have attempted to obtain a greater degree of regeneration by using a resorbable scaffold with regeneration-competent cells to recreate an embryonic environment in injured adult tissues, and thus improve clinical outcome. We have used a combination of a coral scaffold with in vitro-expanded marrow stromal cells (MSC) to increase osteogenesis more than that obtained with the scaffold alone or the scaffold plus fresh bone marrow. The efficiency of the various combinations was assessed in a large segmental defect model in sheep. The tissue-engineered artificial bone underwent morphogenesis leading to complete recorticalization and the formation of a medullary canal with mature lamellar cortical bone in the most favorable cases. Clinical union never occurred when the defects were left empty or filled with the scaffold alone. In contrast, clinical union was obtained in three out of seven operated limbs when the defects were filled with the tissue-engineered bone.

Engineering aspect of alumina on alumina hip prosthesis.

Alumina on the alumina sliding system in a total hip replacement is recognized as a breakthrough in orthopaedic surgery. Advantages and problems with this material are explained and discussed in the light of 36 years of clinical application. Laboratory data as well as clinical ones are summarized.

Effect of microstructure on the mechanical properties of Haversian cortical bone.

The mechanical properties of cortical bone have been extensively studied at the macrostructural scale. However, knowledge of the macroscopic mechanical properties is not sufficient to predict local phenomena, such as damage or bone remodeling, both of which are dependent on local mechanical behavior. The objective of this study is to quantify the mechanical properties of cortical bone at several length scales, with emphasis on the microstructure of Haversian systems. Samples of mature bovine cortical bone, with a Haversian microstructure, were obtained from the posterior area of the mid-femoral diaphysis. A nanoindentation technique was used to measure the local Young's modulus. The distribution of the bone mineral content was obtained by backscattered electron imaging using a scanning electron microscope. A novel compression device employing microextensometry techniques was developed to quantify local strains. Digital image correlation was performed on the microstructure imaged by optical microscopy during compression tests. This study demonstrated that the local Young's modulus and strain were heterogeneous at the scale of an osteon. For both properties, the ratio between the maximum and minimum values was approximately two. The local Young's modulus and bone-mineral content were reasonably correlated (r2 = 0.75; P < 0.0001), but this was not the case for the distribution of local strains versus bone mineral content (r2 = 0.395; P < 0.0001). Hence, local strains cannot be described simply in terms of the bone mineral content, as the Haversian canal and osteonal microstructure have a major influence on these properties. In conclusion, the microstructure must be considered in evaluating the local strain and stress fields of cortical bone.

[Femoral reconstruction with impacted macroporous calcium phosphate ceramic in revision hip arthroplasty]. / Reconstruction fémorale par céramique de phosphate de calcium macroporeuse impactée au cours des reprises d'arthroplastie de hanche.

PURPOSE OF THE STUDY: Management of bone stock loss remains one of the most challenging problems for revision hip surgery. The aim of this retrospective study was to report the preliminary results of peri-prosthetic femoral defect reconstruction with impacted granules of calcium phosphate ceramic. MATERIAL AND METHODS: Fourteen hips in 13 patients (3 men and 10 women) were evaluated. Age at surgery ranged from 30 to 79 years (mean 66.1 years). All revised devices had been cemented. Femoral revision was indicated for loosening in eleven hips (including six septic cases), femoral osteolysis (one hip), persistent pain (one hip), and recurrent dislocation (one hip). On the preoperative radiological evaluation, bone defects were assessed as SOFCOT grade II in seven case, and grade III in fourteen. None was rated grade IV. Once the loose prosthesis had been removed, bone graft or ceramic granules (14 cases) were firmly impacted in the femoral canal. The stem was standard and always cemented using modern cementing technique. RESULTS: At a mean follow-up of 34 +/- 15 months (range 14-76 months), eleven of fourteen hips were rated good or very good according to the Postel-Merle-d'Aubigné score. One diaphyseal femoral fracture occurred and later united. Two hips required re-revision (one aseptic femoral loosening, one septic recurrence). Direct bonding between synthetic graft and bone was observed on standard radiographs in eleven cases. Stem subsidence occurred in two cases and was limited (mean 4.5 mm). DISCUSSION: Femoral bone reconstruction using impacted calcium phosphate ceramic in revision hip arthroplasty provided encouraging results in the short to mid term. Femoral stock restoration was achieved in the great majority. No adverse effect related to the use of a synthetic graft was noted. Further long-term evaluation is required before wider application.

[Idiopathic tumoral calcinosis: two cases and review of the literature]. / Calcinose tumorale idiopathique: A propos de deux cas et revue de la litterature.

Two black patients from Africa presented idiopathic tumoral calcinosis. This rare disease, defined by the presence of calcified deposits in peri-articular tissues remains poorly elucidated. Pathogenesis is still hypothetical. The diagnosis can be established with careful physical examination and appropriate complementary exams, allowing early complete surgical resection without biopsy. Pathology examination is required for formal differential diagnosis. The present tumors were particularly large, but did not produce signs of compression. In the first patient, the tumor developed after pregnancy in the zone of antibiotic injections. The second patient presented multiple bilateral symmetrical localizations with bone invasion. Histology confirmed the nature of the lesions and revealed bony metaplasie in the first patient, an element rarely described. Prognosis is excellent with early treatment. Recurrence is the rule in the event of incomplete resection. We discuss the appropriate diagnostic and therapeutic management.

De novo reconstruction of functional bone by tissue engineering in the metatarsal sheep model.

Large bone defects are still a challenge to orthopedic surgeons. In this study, a massive bone defect with a clinically relevant volume was efficiently reconstructed by transplanting an engineered bone in which mesenchymal stem cells (MSCs) expanded in autologous serum (AS) were combined with a porous scaffold. In the first step, we established that the way in which the MSCs are distributed over the scaffold affects the ultimate bone-forming ability of the transplant: constructs consisting of a natural coral scaffold and a pseudo-periosteal layer of MSCs surrounding the implant (coral-MSC3D) formed significantly more bone than constructs in which the MSCs were distributed throughout the implant (p = 0.01). However, bone healing occurred in only one sheep, owing to the high resorption rate of natural coral scaffold. To overcome this problem, constructs in which MSCs were combined with a porous coralline-based hydroxyapatite (CHA) scaffold having the same architecture as natural coral but a lower resorption rate were prepared. After their implantation, these constructs were found to have the same osteogenic potential as autologous bone grafts in terms of the amount of newly formed bone present at 4 months (p = 0.89) and to have been completely replaced by newly formed, structurally competent bone within 14 months. Nevertheless, although the rate of bone healing was strikingly improved when CHA-MSC3D constructs were used (five of seven animals healed) as compared with the coral-MSC3D construct (one of seven healed), it was still less satisfactory than that obtained with autografts (five of five healed).

Surgical management of trapezius palsy.

BACKGROUND: Injury to the spinal accessory nerve in the posterior cervical triangle leads to paralysis of the trapezius muscle. The aim of this study was to determine the indications for nerve repair or reconstructive surgery according to the etiology, the duration of the preoperative delay, and specific patient characteristics. METHODS: Of twenty-seven patients with a trapezius palsy, twenty were treated with neurolysis or surgical repair (direct or with a graft) of the spinal accessory nerve and seven were treated with the Eden-Lange muscle transfer procedure. Lymph node biopsy was the main cause of the nerve injury. The nerve repairs were performed at an average of seven months after the injury, and the reconstructive procedures were done at an average of twenty-eight months. Nerve repair was performed for iatrogenic injuries of the spinal accessory nerve, within twenty months after the onset of symptoms, and in one patient with spontaneous palsy. Reconstructive surgery was performed for cases of trapezius palsy secondary to radical neck dissection, for spontaneous palsies, and after failure of nerve repair or neurolysis. The mean follow-up period was thirty-five months. The functional outcome was assessed clinically on the basis of active shoulder abduction, pain, strength of the trapezius on manual muscle-testing, and level of subjective patient satisfaction. RESULTS: The results were good or excellent in sixteen of the twenty patients treated with nerve repair and in four of the seven patients treated with the Eden-Lange procedure. Poor results were seen in older patients and in patients with a previous radical neck dissection. CONCLUSIONS: Good results can be expected from a repair of the spinal accessory nerve if it is performed within twenty months after the injury, as the nerve is basically a purely motor nerve and the distance from the injury to the motor end plates is short. Muscle transfer should be performed in patients with spontaneous trapezius palsy, when previous nerve surgery has failed, or when the time from the injury to treatment is over twenty months. Treatment is less likely to succeed when the patient is older than fifty years of age or the palsy was due to a radical neck dissection, penetrating injury, or spontaneous palsy.

[An uncommon form of delayed radio-induced brachial plexopathy]. / Une forme inhabituelle de plexopathie brachiale radio-induite tardive.

Radiation therapy of the neck or axillary areas for cancer may result in delayed brachial plexus palsy. Differential diagnosis between radiation and tumor brachial plexopathy is difficult. We report the case of a 38-year-old woman, treated by radiation therapy for osteosarcoma of the humeral head 22 years before, who exhibited a rapidly progressive incomplete hand palsy. EMG study revealed a conduction block at the level of the lateral cord. In this case, MRI could not distinguish between a delayed radiation injury and tumor infiltration. The diagnosis was clarified with an ultrasonographic examination. Neurolysis and epineurotomy of the median trunk in the brachial and axillary areas were performed. Histological examination confirmed radiation-induced nerve injury. The characteristics of this uncommon form are reviewed with regard to the previously reported descriptions.

Bone resorption at the femoral neck is dependent on local factors in nonosteoporotic late postmenopausal women: an in vitro-in vivo study.

Local mediators of bone resorption may be involved in bone loss in recently postmenopausal women and in osteoporosis. In the present study, we investigated the production of cytokines and the formation of osteoclast-like cells in marrow cultures from 16 late postmenopausal nonosteoporotic women (mean age: 66 +/- 8 years; time after menopause: 15 +/- 8 years) undergoing hip replacement for arthrosis. Marrow adherent mononuclear cells (MMNC) isolated from femoral diaphysis marrow were cultured for 10 days in the absence or in the presence of 1,25(OH)2D3. In vivo bone resorption was concomitantly assessed by histomorphometry on femoral neck bone sections. The number of TRAP+ multinucleated cells obtained after 10 days in MMNC cultured in the presence of 1,25(OH)2D3 correlated with the number of osteoclasts measured on the bone femoral neck biopsies (r = 0.65, p < 0.01), suggesting that the formation of multinucleated cells in vitro could reflect the osteoclast differentiation in vivo. Furthermore, the number of osteoclasts was related to the eroded volume and the trabecular separation of the femoral neck bone biopsies. Finally, the release of interleukin-1 (IL-1), IL-6, and TNF-alpha by cultures of peripheral blood mononuclear cells (PBMC) and MMNC was measured by radioimmunoassay. The cytokine levels of basal and 1,25(OH)2D3-treated MMNC decreased from days 2 to 5 and then reached a plateau to day 10. The number of TRAP+ multinucleated cells obtained after 10 days in MMNC cultures correlated with the basal IL-6 release in the same cultures determined at day 2 (r = 0.55, p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of different sterilization processing methods on the mechanical properties of human cancellous bone allografts.

Use of new sterilization methods applied to human bone is likely to affect both the mechanical and biological properties of human cancellous grafts. The mechanical properties of the transplanted bone inevitably determine the short- and mid-term results of the orthopedic procedure performed. The aim of this study was to compare, under similar conditions, the mechanical effects of gamma irradiation, lipid extraction, and treatment with 6M urea on trabecular bone samples, through conventional mechanical tests and measurement of the ultrasound wave propagation rate. Deteriorations measured for gamma irradiation and lipid extraction were low: 2.4% and 2.5%, respectively, for ultrasound propagation wave measurements. They were clearly significant for protocol including 6M urea, corresponding to a loss of 30% in values measured in the control sample for the stress to failure, inciting prudence when grafted bone is used for support in orthopedic assembly. High consistency in the results obtained between travel time of the ultrasound wave, easily done, and measurement of stress to failure through conventional tests, favor the use of ultrasound protocol, described as a quality test performed on bone grafts in the tissue bank before distribution and implantation.

Effects of chitosan on rat knee cartilages.

The aim of this work is to study the effects of chitosan on rat knee cartilages. 0.2 ml of 0.1% chitosan solution pH = 6.9 were injected inside rat knees articular cavity. One, three and six weeks after injection, histological and histomorphometric studies were performed on undecalcified samples embedded in polymethylmetacrylate. Results show that after 1 and 6 weeks: (i) chitosan slows significantly (P < 0.005) the decrease in epiphyseal cartilage thicknesses and (ii) increases significantly articular cartilage chondrocyte densities (P < 0.002). However chitosan solution induces a proliferation of fibrous tissue with abundant fibroblasts, fibrocytes and monocytes inside the joint and this proliferation is still present after 6 weeks. This study suggests that chitosan could act on the growth of epiphyseal cartilage and wound healing of articular cartilage.

A biodegradable fibrin scaffold for mesenchymal stem cell transplantation.

A potential therapy to enhance healing of bone tissue is to deliver isolated mesenchymal stem cells (MSCs) to the site of a lesion to promote bone formation. A key issue within this technology is the development of an injectable system for the delivery of MSCs. Fibrin gel exploits the final stage of the coagulation cascade in which fibrinogen molecules are cleaved by thrombin, convert into fibrin monomers and assembled into fibrils, eventually forming fibers in a three-dimensional network. This gel could have many advantages as a cell delivery vehicle in terms of biocompatibility, biodegradation and hemostasis. The objective of this study was to explore the possibility of using fibrin gel as a delivery system for human MSCs (HMSCs). To this end we have determined the optimal fibrinogen concentrations and thrombin activity for loading HMSCs in vitro into the resultant fibrin gels to obtain cell proliferation. We found that a concentration of 18 mg/ml of fibrinogen and a thrombin activity of 100 IU/ml was optimal for producing fibrin scaffolds that would allow good HMSCs spreading and proliferation. In these conditions, cells were able to proliferate and expressed alkaline phosphatase, a bone marker, in vitro. When implanted in vivo, HMSCs were able to migrate out of the fibrin gel and invade a calcium carbonate based ceramic scaffold suggesting that fibrin gel could serve as a delivery system for HMSCs.

Osteogenesis with coral is increased by BMP and BMC in a rat cranioplasty.

Autologous bone marrow cells (BMC), bone morphogenetic protein (BMP) and natural coral exoskeleton (CC) were used to enhance the repair of large skull bone defects in a craniotomy model. Nine millimeter calvarial defects were created in adult rats and were either left empty (control defects) or implanted with CC alone, CC-BMC, CC-BMP, or CC-BMC-BMP. After 1 or 2 months, osteogenesis was insufficient to allow union when defects were left empty or filled with CC. Addition of BMC alone to CC had no positive influence on osteogenesis at any time and increased CC resorption at 2 months (0.1 +/- 0.1 mm2 versus 0.5 +/- 0.3 mm2). In contrast addition of BM P or BM P/BMC to CC led to a significant increase in osteogenesis and allowed bone union after 1 month. At 2 months, the combination of CC-BM P-BMC was the most potent activator of osteogenesis. Filling a defect with CC-BMP-BMC resulted in significantly increased bone surface area (11 +/- 2.7 mm2) in comparison to filling a defect with CC-BMP (7.0 +/- 1.4 mm2), CC-BMC (3.5 +/- 1.1 mm2) or CC (4.5 +/- 0.4 mm2). CC resorption was significantly decreased in the presence of BMP with or without BMC at both times. These data are in accordance with the presence of progenitor cells in bone marrow that are inducible by BMP to the osteogenic pathway in a cranial site. The increase in material resorption in defects filled with CC-BMC could suggest that cells from the granulocyte-macrophage lineage survived the grafting procedure and were still active after 2 months.

A reflection scanning acoustic microscope for bone and bone-biomaterials interface studies.

A relatively simple scanning acoustic microscope (SAM) that operates in the reflection mode has been constructed. The system uses a 20 MHz spherically focused transducer, acting both as transmitter and as detector, to obtain acoustic impedance information on a thin surface layer at a maximum resolution of approximately 100 micron. The specimen is mounted on an X-Y driving system (precision, 5 micron) under computer control in order to scan a grid of 256 x 256 points across areas ranging from 6.5 to 1300 mm2. An algorithm is used to reference the data against standards; specially developed software provides for pseudo-color mapping, three-dimensional images, zooming to 16 x magnification, contouring, and single line profiles of the data. The system has been used to determine inhomogeneities in surface acoustic properties of mineralized tissues and implant materials, in many cases as a complement to using ultrasonic wave propagation techniques to measure the bulk anisotropic properties.

The evaluation of bone remodeling about orthopaedic implants with ultrasound.

Total hip arthroplasty causes biomechanical changes in the normal femur, including a redistribution and concentration of stress. These mechanical alterations in the femur cause local remodeling and resorption that affect the geometry and mechanical properties of the bone. Two complementary ultrasonic techniques were used to study the local adaptive remodeling of bone due to prosthesis implantation. An ultrasonic wave propagation technique was used to determine elastic properties and a new scanning acoustic microscope (SAM) mapped the acoustic impedance profile of each section. The effects of the implantation of two types of hip prostheses, an uncemented bipolar prosthesis with an Austin-Moore type stem and a cemented Charnley prosthesis, were investigated. Both prostheses had a detrimental effect on local elastic properties as determined by acoustic velocity measurements. The SAM system provided information about local inhomogeneities in bone properties not obtainable by any other means. The acoustic impedance maps highlighted bone resorption and bone remodeling on a microstructural level.

Surgical management of trapezius palsy.

BACKGROUND: Injury to the spinal accessory nerve in the posterior cervical triangle leads to paralysis of the trapezius muscle. The aim of this study was to determine the indications for nerve repair or reconstructive surgery according to the etiology, the duration of the preoperative delay, and specific patient characteristics. METHODS: Of twenty-seven patients with a trapezius palsy, twenty were treated with neurolysis or surgical repair (direct or with a graft) of the spinal accessory nerve and seven were treated with the Eden-Lange muscle transfer procedure. Lymph node biopsy was the main cause of the nerve injury. The nerve repairs were performed at an average of seven months after the injury, and the reconstructive procedures were done at an average of twenty-eight months. Nerve repair was performed for iatrogenic injuries of the spinal accessory nerve, within twenty months after the onset of symptoms, and in one patient with spontaneous palsy. Reconstructive surgery was performed for cases of trapezius palsy secondary to radical neck dissection, for spontaneous palsies, and after failure of nerve repair or neurolysis. The mean follow-up period was thirty-five months. The functional outcome was assessed clinically on the basis of active shoulder abduction, pain, strength of the trapezius on manual muscle-testing, and level of subjective patient satisfaction. RESULTS: The results were good or excellent in sixteen of the twenty patients treated with nerve repair and in four of the seven patients treated with the Eden-Lange procedure. Poor results were seen in older patients and in patients with a previous radical neck dissection. CONCLUSIONS: Good results can be expected from a repair of the spinal accessory nerve if it is performed within twenty months after the injury, as the nerve is basically a purely motor nerve and the distance from the injury to the motor end plates is short. Muscle transfer should be performed in patients with spontaneous trapezius palsy, when previous nerve surgery has failed, or when the time from the injury to treatment is over twenty months. Treatment is less likely to succeed when the patient is older than fifty years of age or the palsy was due to a radical neck dissection, penetrating injury, or spontaneous palsy.

Complete traumatic brachial plexus palsy. Treatment and outcome after repair.

Seventy-eight patients who had a complete brachial plexus palsy caused by a stretching injury were operated on by the same surgeon between January 1980 and December 1991. The aim of the operative intervention was to obtain the best functional result, including at the level of the hand, that was possible in view of the initial lesions and the intraoperative findings. Therefore, the treatment strategy included not only nerve repair with grafting (124 grafts) or nerve transfer (twenty-seven transfers) but also palliative procedures, the latter of which sometimes were performed several years later. Sixty-three patients were evaluated by an independent observer at least three years postoperatively. The results associated with each type of lesion and each type of nerve repair were assessed according to the function of the muscles that were innervated by the recipient nerve. Six patients had a neurolysis only. The remaining fifty-seven patients had grafts or nerve transfers to repair the biceps. Thirty-six of the fifty-seven received a rating of 3+ or more (meaning that the patient was able to flex the elbow repeatedly); the remaining twenty-one received a rating of 3 or less (meaning that the patient was able to flex the elbow only once or not at all), which we considered unsatisfactory. The function of the triceps recovered after eleven of thirty-one procedures that were performed to restore that nerve; that of the extensor carpi radialis, after five of thirty-one procedures; that of the flexor carpi radialis, after six of thirty-one procedures; and that of the flexor digitorum, after four of thirty-one procedures. A statistical analysis revealed that an operative delay of less than six months was a significant factor with respect to recovery of the function of the biceps (p = 0.003). The thirty-nine grafts that were sutured onto the lateral or posterior cord produced better results than did the thirty-six that were sutured onto the distal branches (the musculocutaneous and radial nerves); however, with the numbers available, this difference was not found to be significant (p = 0.08). Eleven patients had a successful result (a rating of 3+ or more) and eight, a fair or poor result, with respect to recovery of biceps function after transfer of the spinal accessory nerve to the musculocutaneous nerve. Overall, twenty-nine patients had relief of pain postoperatively. Sixteen patients had grade-3 pain preoperatively compared with only three after the operation. According to a self-rating scale, twenty-five patients were satisfied with the overall result, sixteen were fairly satisfied, and twenty-two were dissatisfied.