Evaluating the Ability of Brachial Plexus-Injured Patients to Control an Externally Powered (Myoelectric) Hand Prosthesis.

BACKGROUND: Restoration of hand function after traumatic brachial plexus injury (BPI) remains a formidable challenge. Traditional methods such as nerve or free muscle transfers yield suboptimal results. Advancements in myoelectric prostheses, characterized by novel signal acquisition and improved material technology, show promise in restoring functional grasp. This study evaluated the ability of adults with a BPI injury to control an externally powered prosthetic hand using nonintuitive signals, simulating the restoration of grasp with a myoelectric prosthesis. It also assessed the effectiveness of a comprehensive multidisciplinary evaluation in guiding treatment decisions. METHODS: A multidisciplinary brachial plexus team assessed adults with compromised hand function due to BPI. The feasibility of amputation coupled with fitting of a myoelectric prosthesis for grasp reconstruction was evaluated. Participants' ability to control a virtual or model prosthetic hand using surface electromyography (EMG) as well as with contralateral shoulder motion-activated linear transducer signals was tested. The patient's input and injury type, along with the information from the prosthetic evaluation, were used to determine the reconstructive plan. The study also reviewed the number of participants opting for amputation and a myoelectric prosthetic hand for grasp restoration, and a follow-up survey was conducted to assess the impact of the initial evaluation on decision-making. RESULTS: Of 58 subjects evaluated, 47 (81%) had pan-plexus BPI and 42 (72%) received their initial assessment within 1 year post-injury. Forty-seven patients (81%) could control the virtual or model prosthetic hand using nonintuitive surface EMG signals, and all 58 could control it with contralateral uniscapular motion via a linear transducer and harness. Thirty patients (52%) chose and pursued amputation, and 20 (34%) actively used a myoelectric prosthesis for grasp. The initial evaluation was informative and beneficial for the majority of the patients, especially in demonstrating the functionality of the myoelectric prosthesis. CONCLUSIONS: The study indicates that adults with traumatic BPI can effectively operate a virtual or model myoelectric prosthesis using nonintuitive control signals. The simulation and multidisciplinary evaluation influenced informed treatment choices, with a high percentage of patients continuing to use the myoelectric prostheses post-amputation, highlighting its long-term acceptance and viability. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Injury and Biological Factors Impact Shoulder Function following Autogenous Grafting of Spinal Nerves for Pan-Brachial Plexus Reconstruction.

BACKGROUND: Shoulder function following spinal nerve grafting in pan-brachial plexus injuries(Pan-BPI) is not well described. The purpose of this study was twofold: 1)to evaluate shoulder abduction(ABD) and external rotation(ER) after grafting of viable spinal nerves to the suprascapular nerve(SSN), axillary nerve(AxN), or posterior division of the upper trunk(PDUT); and 2)to determine patient characteristics, injury severity/characteristics, and nerve graft factors that influenced outcomes. METHODS: 362 Pan-BPI reconstruction patients from a single institution were reviewed for those who underwent spinal nerve grafting for shoulder reanimation between 2001 and 2018. Patient demographics, injury severity scores(ISS), graft characteristics, strength, range of motion for shoulder ABD and ER, and patient-reported outcomes were recorded. Patients were divided into three groups based on the recovery of shoulder function: no return, ABD only, and ABD and ER. RESULTS: 110 patients underwent spinal nerve grafting, with 41 meeting inclusion criteria. 17(41.5%) had no return of shoulder function, 14(34.1%) had ABD alone, and 10(24.4%) had ABD and ER. Patients with recovery of both ABD and ER were significantly younger(18.6±5.56), had lower BMI(22.4±4.0), and lower ISS(10.5±6.24, p=0.003). Multivariable analysis found that with increasing age(OR:0.786, 95%CI:0.576,0.941) and ISS(OR:0.820, 95%CI:0.606-0.979), odds for return of ABD and ER significantly decreased. CONCLUSIONS: In Pan-BPI, 24.4% of patients demonstrated return of both ABD and ER following spinal nerve grafting to SSN and either AxN or PDUT. Age, BMI, and ISS were associated with poorer recovery of shoulder function. Careful patient selection and consideration of age, BMI, and ISS may improve outcomes of spinal nerve grafting for shoulder reanimation. LEVEL OF EVIDENCE: III.

The role of vascularized bone grafting for scaphoid nonunions in adolescents.

A total of 26 adolescent patients were treated for scaphoid nonunion with a vascularized bone graft from either the medial femoral condyle or dorsal distal radius. There was an 85% union incidence, improved carpal alignment and a low incidence of complications.

Validation of the Root Analysis Score for C5 Viability in Patients With Pan-Brachial Plexus Injury.

PURPOSE: Pan-brachial plexus injury patients present a reconstructive challenge. The root analysis score, developed from parsimonious multivariable modeling of 311 pan-brachial plexus injury patients, determines the probability of having a viable C5 nerve based on four categories: positive C5 Tinel test, intact C5 nerve on computed tomography myelogram, lack of hemidiaphragmatic elevation, and absence of midcervical paraspinal fibrillations. METHODS: Root analysis scores were calculated for a separate cohort of patients with pan-brachial plexus injuries. Scores were validated by the presence or absence of a graftable C5 root, based on supraclavicular exploration and intraoperative electrophysiologic testing. Receiver operating characteristic curve, accuracy, and concordance statistic of the scores were calculated. Patients were divided into three root analysis score cohorts: less than 50 (low), 50-75 (average), and 75-100 points (high) based on dividing the score into quartiles and combining the lowest two. The probability, sensitivity, and specificity of each cohort having an available C5 nerve were based on the intraoperative assessment. RESULTS: Eighty patients (mean age, 33.1 years; 15 women and 65 men) were included. Thirty-one patients (39%) had a viable C5 nerve. The root analysis calculator had an overall accuracy of 82.5%, a receiver operating characteristic of 0.87, and a concordance statistic of 0.87, demonstrating high overall predictive value; 6.5% of patients with a score of less than 50 (94% sensitivity and 43% specificity), 16.1% of patients with a score of 50-75 (94% sensitivity and 67% specificity), and 77.4% of patients with a score of 75-100 (77% sensitivity and 90% specificity) had a graftable C5 nerve. CONCLUSIONS: The root analysis score demonstrated high accuracy and predictive power for a viable C5 nerve. In patients with a score of less than 50, the necessity of supraclavicular root exploration should balance patient factors, presentation timing, and concomitant injuries. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnosis II.

The failed adult traumatic brachial plexus reconstruction.

Traumatic adult brachial plexus injuries typically cause immediate loss of upper limb function. Timely multidisciplinary treatment in specialized centres often results in a useful helper arm. Both the patient and the surgical team can benefit from an open discussion to set realistic expectations. Surgical reconstruction is customized for each patient, considering their injury factors and functional objectives. Optimizing pain control, adherence to procedure indications and using meticulous surgical techniques help minimize the risk of failing to meet the patient's goals. The need for potential alternative treatment(s) if the desired result is not achieved should be detailed before the initial reconstruction. This review discusses late treatment options, including tendon transfers, joint fusions, free functioning muscle transfers and prosthetics, for managing the failed primary reconstruction of the traumatic adult brachial plexus.

Triceps-to-Biceps Tendon Transfer for Restoration of Elbow Flexion in Brachial Plexus Injury.

PURPOSE: Restoring elbow flexion is a reconstructive priority in patients with brachial plexus injuries. This study aimed to evaluate the results and assess factors contributing to outcomes of triceps-to-biceps tendon transfer in patients presenting with delayed or chronic upper brachial plexus injury. METHODS: Patients with traumatic brachial plexus injuries undergoing triceps-to-biceps tendon transfer at a single institution's multidisciplinary brachial plexus center between 2001 and 2021 were retrospectively reviewed. The entire triceps tendon was transferred around the lateral aspect of the arm, secured to the radius with a tenodesis button, and reinforced with a side-to-side tendon transfer to the biceps tendon. Primary outcomes include the modified British Medical Research Council (mBMRC) elbow flexion strength and active elbow range of motion. RESULTS: Twelve patients (eight men and four women; mean age, 45.2 years) were included. The mean follow-up was 10.4 (range, 5-34) months. Nine patients achieved mBMRC ≥3. Five patients achieved mBMRC 4. Average active elbow flexion was 119°, with average extension deficit of 11°. There were three patients with unsatisfactory results, achieving mBMRC 2 elbow flexion. CONCLUSIONS: Triceps-to-biceps tendon transfer is an excellent tendon transfer option for restoring elbow flexion in certain patients with an adequately functioning triceps muscle, who present with a delayed or chronic brachial plexus injury. Although most patients achieved mBMRC ≥3 elbow flexion, there was an expected permanent loss of elbow active extension with a residual elbow flexion contracture. LEVEL OF EVIDENCE: Therapeutic IV.

Factors Affecting C5 Viability and Demographic Variability in Two Brachial Plexus Centers.

Complete brachial plexus injuries are devastating injuries. A viable C5 spinal nerve can offer additional sources of axons and alter surgical treatment. We aimed to determine factors that portend C5 nerve root avulsion. Methods: A retrospective study of 200 consecutive patients with complete brachial plexus injuries at two international centers (Mayo Clinic in the United States and Chang Gung Memorial Hospital in Taiwan) was performed. Demographic information, concomitant injuries, mechanism, and details of the injury were determined, and kinetic energy (KE) and Injury Severity Score were calculated. C5 nerve root was evaluated by preoperative imaging, intraoperative exploration, and/or intraoperative neuromonitoring. A spinal nerve was considered viable if it was grafted during surgery. Results: Complete five-nerve root avulsions of the brachial plexus were present in 62% of US and 43% of Taiwanese patients, which was significantly different. Increasing age, the time from injury to surgery, weight, body mass index of patient, motor vehicle accident, KE, Injury Severity Score, and presence of vascular injury significantly increased the risk of C5 avulsion. Motorcycle (≤150cc) or bicycle accident decreased the risk of avulsion. Significant differences were found between demographic variables between the two institutions: age of injury, body mass index, time to surgery, vehicle type, speed of injury, KE, Injury Severity Score, and presence of vascular injury. Conclusions: The rate of complete avulsion injury was high in both centers. Although there are a number of demographic differences between the United States and Taiwan, overall the KE of the accident increased the risk of C5 avulsion.

Clinical Predictors of C5 Spinal Nerve Viability in Pan-Brachial Plexus Injuries.

BACKGROUNDS: In pan-brachial plexus injury patients, distinguishing between pre-ganglionic and post-ganglionic injuries is crucial to reconstructive planning. This study aimed to identify pre-operative factors that would accurately predict a reconstructible C5 spinal nerve. METHODS: Pan-brachial plexus injury patients from a single institution between 2001 and 2018 were reviewed. Patient demographics, clinical examination, diagnostic imaging, and electrodiagnostic results were recorded. C5 viability was determined based on supraclavicular exploration and intraoperative electrophysiologic testing. Univariate analysis identified significant factors for regression analysis. Multivariable parsimonious model was created using stepwise high performance logistic regression. RESULTS: 311 patients (mean age 29.9 years; 46 females, 265 males; Injury Severity Score 17.2) were included. 134 (43%) had a viable C5 and 50 (12%) patients had a viable C6 nerve. Intact C5 spinal nerve on CT myelogram (OR 5.4), positive Tinel's test (OR 2.6), M ≥ 4 rhomboid (OR 1.3) or M ≥ 4 serratus anterior (OR 1.4), and rhomboid needle EMG (OR 1.8) were predictive of having a viable C5 spinal nerve. The multivariable parsimonious stepwise model (AUC 0.77) included four factors: positive Tinel's test, intact C5 spinal nerve on CT myelogram, hemi-diaphragmatic elevation, and mid-cervical paraspinal fibrillations. CONCLUSIONS: In this cohort of pan-brachial plexus patients with major polytrauma, there was a 43% incidence of viable C5 spinal nerve. A positive Tinel's test (OR 2.1) and intact C5 spinal nerve on CT myelogram (OR 4.9) predicted a viable C5 nerve. In contrast, hemi-diaphragmatic elevation (OR 3.1) and mid-cervical paraspinal fibrillations (OR 2.92) predicted root avulsion.

Surgical management of peroneal nerve injuries.

BACKGROUND: Traumatic peroneal nerve injuries are typically associated with high-energy injuries. The aim of this study was to evaluate the demographics and outcomes following surgical management of peroneal nerve injuries. METHODS: Patients evaluated at a single institution with peroneal nerve injuries between 2001 and 2022 were retrospectively reviewed. Mechanism of injury, time to surgery, pre- and postoperative examinations, and operative reports were recorded. Satisfactory outcome, defined as the ability to achieve anti-gravity dorsiflexion strength or stronger following surgery, was compared between nerve grafting and nerve transfers in patients with at least 9 months of postoperative follow-up. RESULTS: Thirty-seven patients had follow-up greater than 9 months after surgery, with an average follow-up of 3.8 years. Surgeries included neurolysis (n=5), direct repair (n=2), tibial motor nerve fascicle transfer to the anterior tibialis motor branch (n=18), or interposition nerve grafting using sural nerve autograft (n=12). At last follow-up, 59.5% (n=22) of patients had anti-gravity strength or stronger dorsiflexion. Nineteen (51.4%) patients used an ankle-foot orthosis during all or some activities. In patients that underwent nerve grafting only across the peroneal nerve defect, 44.4% (n=4) were able to achieve anti-gravity strength or stronger dorsiflexion. In patients that had a tibial nerve fascicle transfer to the tibialis anterior motor branch of the peroneal nerve, 42.9% (n=6) were able to achieve anti-gravity strength or stronger dorsiflexion at last follow-up. There was no statistical difference between nerve transfers and nerve grafting in postoperative dorsiflexion strength (p = 0.51). CONCLUSION: Peroneal nerve injuries frequently occur in the setting of knee dislocations and similar high-energy injuries. Nerve surgery is not universally successful in restoration of ankle dorsiflexion, with one-third of patients requiring an ankle-foot orthosis at mid-term follow-up. Patients should be properly counseled on the treatment challenges and variable outcomes following peroneal nerve injuries.

Stem cell therapy for traumatic brachial plexus injury.

Stem cell therapy is rapidly evolving, with preclinical studies showing various stem cell types successfully promoting peripheral nerve regeneration. Despite the lack of clinical studies demonstrating efficacy and safety, the number of commercial entities marketing and promoting this treatment direct to patients is also increasing. We describe three adult traumatic brachial plexus injury (BPI) patients who had stem cell therapies prior to consultation in a multidisciplinary brachial plexus clinic. No functional improvement was noted at long-term follow-up despite claims reported by the commercial entities. Considerations and implications of stem cell application in BPI patients are reviewed.

Utility of preoperative MRI for assessing proximal fragment vascularity in scaphoid nonunion.

Aims: The benefit of MRI in the preoperative assessment of scaphoid proximal fragment vascularity remains controversial. The purpose of this study is to compare preoperative MRI findings to intraoperative bleeding of the proximal scaphoid. Methods: A retrospective review of 102 patients who underwent surgery for scaphoid nonunion between January 2000 and December 2020 at a single institution were identified. Inclusion criteria were: isolated scaphoid nonunion; preoperative MRI assessing the proximal fragment vascularity; and operative details of the vascularity of the proximal fragment with the tourniquet deflated. MRI results and intraoperative findings were dichotomized as either 'yes' or 'no' for the presence of vascularity. A four-fold contingency table was used to analyze the utility of preoperative MRI with 95% confidence intervals. Relative risk was calculated for subgroups to analyze the association between variables and MRI accuracy. Results: Preoperative MRI identified 55 proximal scaphoid fragments with ischaemia and 47 with vascularized proximal fragments. After the proximal fragment was prepared, the tourniquet was deflated and assessed for bleeding; 63 proximal fragments had no bleeding and 39 demonstrated bleeding. MRI was not reliable or accurate in the assessment of proximal fragment vascularity when compared with intraoperative assessment of bleeding. No patient or MRI factors were identified to have a statistical impact on MRI accuracy. Conclusion: Current preoperative MRI protocols and diagnostic criteria do not provide a high degree of correlation with observed intraoperative assessment of proximal fragment bleeding. While preoperative MRI may assist in surgical planning, intraoperative assessment remains the best means for assessing proximal fragment vascularity in scaphoid nonunion. Future efforts should focus on the development of objective measures of osseous blood flow that may be performed intraoperatively.

Osteochondral Autograft Transplantation for Proximal Pole Scaphoid Nonunions.

PURPOSE: Osteochondral autograft transplantation (OAT) is a technique to reconstruct the proximal pole scaphoid nonunion associated with an intact dorsal and volar scapholunate ligament. This study aimed to report the clinical and radiographic outcomes in patients who underwent OAT for this indication. METHODS: A retrospective review of patients who underwent proximal pole scaphoid nonunion reconstruction with a femoral trochlea OAT was undertaken between 2018 and 2022. Patient demographics, scaphoid nonunion characteristics, surgery details, and clinical and radiographic outcomes were obtained. RESULTS: Eight patients underwent the procedure at an average of 18.2 months from injury. Four patients failed prior attempts at scaphoid union surgery, one of whom failed two prior surgeries. Four had no prior surgery. The average follow-up was 11.8 months. The postoperative wrist flexion-extension arc of motion was 125° or 87% of the contralateral wrist. Grip strength averaged 30.0 kg or 86% of the contralateral side. Adjusted grip strength for hand dominance was 81% of the contralateral side. All OATs healed. Computed tomography scan confirmed the union in 6 patients between 6 and 10 weeks. Two patients whose radiographs demonstrated OAT incorporation at the time of follow-up did not undergo advanced imaging. CONCLUSIONS: Osteochondral autograft transplantation is an attractive surgical reconstructive procedure for patients with proximal pole scaphoid nonunions associated with an intact scapholunate ligament. Osteochondral autograft transplantation mitigates the need for vascularized bone grafting, has a rapid time to osseous incorporation, and has a simple postoperative course in which patients can expect early union, near-full range of motion, and grip strength. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Vasculogenic gene therapy: No role for revitalization of structural bone allografts.

Segmental bone defects are often performed with cryopreserved allografts. They provide immediate stability, but risk nonunion, infection and late stress fracture. Improving the rate and extent of bone revitalization may improve results. Angiogenesis from surgically placed arteriovenous (AV) bundles improves bone blood flow and vitality in cryopreserved rat femora, augmented by vasculogenic growth factors. This study tests the same principal in Yucatan mini-pigs with a tibial diaphyseal defect, combining surgical angiogenesis with angiogenic gene therapy within cryopreserved orthotopically-placed allografts. Tibial diaphyseal defects were reconstructed with cryopreserved allografts and rigid internal fixation in 16 mini pigs. Half of the cranial tibial AV bundles placed within the allograft medullary canal were transfected with an adeno-associated virus containing vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF) genes (AAV9.VEGF.PDGF). Bone remodeling, angiogenesis, and allograft healing were assessed. During the postoperative survival period 5 of 8 transfected animals developed cutaneous benign vascular lesions at sites remote from the operated hindlimb, causing excessive bleeding. Within the allograft, both medullary (p = 0.013) and cortical (p = 0.009) vascular volumes were higher and vessels more mature than nontransfected allografts. Bone turnover (p = 0.013), bone mineralization (p = 0.018), bone healing (p = 0.008) and graft incorporation (p = 0.006) were all significantly higher in the gene therapy group. In a large animal tibial defect model, gene therapy of implanted AV bundles improved revascularization, remodeling and healing of cryopreserved allografts used for limb reconstruction. However, benign vascular lesions causing excessive bleeding developed in 5 out of 8 pigs transfected with AAV containing genes for VEGF and PDGF. This unforeseen complication makes vasculogenic gene therapy unacceptable for clinical use.

Restoration of Grasp after Single-Stage Free Functioning Gracilis Muscle Transfer in Traumatic Adult Pan-Brachial Plexus Injury.

BACKGROUND: A variety of approaches have been described to obtain rudimentary grasp after traumatic pan-brachial plexus injury in adults. The aim of this study is to evaluate hand prehension after a gracilis single-stage free functioning muscle transfer. METHODS: Twenty-seven patients who underwent gracilis single-stage free functioning muscle transfer for elbow flexion and hand prehension after a pan-plexus injury were included. All patients presented with a minimum of 2 years of follow-up. Postoperative finger flexion, elbow flexion strength, preoperative and postoperative Disability of the Arm, Shoulder, and Hand questionnaire scores, secondary hand procedures, complications, and demographic characteristics were analyzed. RESULTS: Twenty patients (74%) demonstrated active finger pull-through. Only six patients (25%) considered their hand function useful for daily activities. Disability of the Arm, Shoulder, and Hand score improved by 13.1 ± 13.7 ( P < 0.005). All patients were expected to require one secondary procedure (wrist fusion, thumb carpometacarpal fusion, and/or thumb interphalangeal fusion) because no extensor reconstruction was performed. These were performed in 89%, 78%, and 74% of patients, respectively. Four postoperative complications (hematoma, seroma, wound dehiscence, and skin paddle loss) occurred. No flap loss occurred. CONCLUSIONS: In pan-plexus injuries, the use of a gracilis single-stage free functioning muscle transfer is an alternative to the double free functioning muscle transfer procedure and contralateral C7 transfer, especially for patients who are unable to undergo two to three important operations in a short period of time. Further research and studies are required to improve hand function in these patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The effect of surgical revascularization on the mechanical properties of cryopreserved bone allograft in a porcine tibia model.

Cryopreserved bone allografts(CBA) are susceptible to infection, nonunion, and late stress fracture. Although surgical revascularization by intramedullary implantation of an arteriovenous bundle (AV bundle) generates a neoangiogenic blood supply, there is potential for vascular ingrowth-mediated bone resorption to weaken the graft. For this reason, we have evaluated changes in CBA mechanical properties of structural tibial allografts with and without surgically induced angiogenesis. Cryopreserved tibia bone allografts were transplanted to reconstruct a 3.5 cm segmental tibial defect in 16 Yucatan mini pigs. Surgical revascularization was performed in half by implantation of a cranial tibial AV bundle, (revascularization group). A control group of identical size had a ligated AV bundle implanted, (ligated group). At 20 weeks micro-computed tomography (CT) measured bone mineral density (BMD) as well as bone union. Reference point indentation (RPI) compared cortex material properties, and axial compression determined the allotransplant compressive modulus. Seven of eight tibiae in the angiogenesis group were healed at both junction points at 20 weeks. Only four of eight tibiae healed in the ligated control group. There was no significant difference between the revascularization and ligated control groups in BMD and axial compression test. Similarly, RPI parameters were statistically equal. In paired comparisons with contralateral tibias, however, some RPI values were significantly worse in the ligated control group tibiae. This study demonstrates no adverse effect of surgical angiogenesis on cryopreserved structural bone allograft biomechanical properties in a large animal orthotopic segmental tibial defect model. These data suggest the potential value of surgical angiogenesis in clinical limb-sparing reconstructive surgery.

Factors Associated with Poorer Outcomes from Triceps Motor Branch to Anterior Axillary Nerve Transfer: A Case-Control Study.

INTRODUCTION: We sought to identify predictors of failed triceps motor branch transfer to the anterior division of the axillary nerve (AN) for shoulder abduction reconstruction after a brachial plexus injury (BPI). METHODS: A case-control study of adult AN or brachial plexus patients treated with a triceps motor branch transfer to the anterior division of the AN with a minimum 18 months of follow-up was performed. The failure group (case group) was defined as modified British Medical Research Council muscle scale (mBMRC) postoperative deltoid grade ≤2 and was compared to the successful outcome group (control group), defined as mBMRC postoperative deltoid grade ≥3. Clinical variables, injury mechanism, time from injury to surgery, root avulsion status, electrodiagnostic studies, rotator cuff injuries, scapula fracture, Disabilities of the Arm Shoulder and Hand scores, and preoperative triceps strength were analyzed. Subgroup analysis was performed for patients with isolated AN injuries and those with BPI. RESULTS: A total of 69 patients met inclusion/exclusion criteria, of whom 23 regained ≥M3 deltoid muscle strength and 52° ± 69° of shoulder abduction (successful outcome group) and 46 regained ≤M2 deltoid muscle strength and 27° ± 30° of shoulder abduction (failure group). Preoperative triceps weakness (M ≤4) was significantly more common in the failure group (63% vs. 30%, P = 0.032); preoperative triceps muscle fibrillations were significantly more common in the failure group (61% vs. 30%, P = 0.02). Isolated AN injuries presented better preoperative motion and postoperative outcomes results compared to BPI. CONCLUSIONS: Use of triceps motor branch associated with fibrillations or weakness resulted in statistically poorer outcomes compared to the use of a normal triceps motor branch in the restoration of anterior AN function after nerve transfer.

The Role of Amputation and Myoelectric Prosthetic Fitting in Patients with Traumatic Brachial Plexus Injuries.

BACKGROUND: A cohort of patients with traumatic brachial plexus injuries (BPIs) underwent elective amputation following unsuccessful surgical reconstruction or delayed presentation. The results of amputation with and without a myoelectric prosthesis (MEP) using nonintuitive controls were compared. We sought to determine the benefits of amputation, and whether fitting with an MEP was feasible and functional. METHODS: We conducted a retrospective review of patients with BPI who underwent elective upper-extremity amputation at a single institution. Medical records were reviewed for demographics, injury and reconstruction details, amputation characteristics, outcomes, and complications. Prosthesis use and MEP function were assessed. The minimum follow-up for clinical outcomes was 12 months. RESULTS: Thirty-two patients with BPI and an average follow-up of 53 months underwent elective amputation between June 2000 and June 2020. Among the cases were 18 transhumeral amputations, 12 transradial amputations, and 2 wrist disarticulations. There were 29 pan-plexus injuries, 1 partial C5-sparing pan-plexus injury, 1 lower-trunk with lateral cord injury, and 1 lower-trunk injury. Amputation occurred, on average, at 48.9 months following BPI and 36.5 months following final reconstruction. Ten patients were fitted for an MEP with electromyographic signal control from muscles not normally associated with the intended function (nonintuitive control). Average visual analog scale pain scores decreased post-amputation: from 4.8 pre-amputation to 3.3 for the MEP group and from 5.4 to 4.4 for the non-MEP group. Average scores on the Disabilities of the Arm, Shoulder and Hand questionnaire decreased post-amputation, but not significantly: from 35 to 30 for the MEP group and from 43 to 40 for the non-MEP group. Patients were more likely to be employed following amputation than they were before amputation. No patient expressed regret about undergoing amputation. All patients in the MEP group reported regular use of their prosthesis compared with 29% of patients with a traditional prosthesis. All patients in the MEP group demonstrated functional terminal grasp/release that they considered useful. CONCLUSIONS: Amputation is an effective treatment for select patients with BPI for whom surgical reconstruction is unsuccessful. Patients who underwent amputation reported decreased mechanical pain, increased employment rates, and a high rate of satisfaction following surgery. In amputees with sufficient nonintuitive electromyographic signals, MEPs allow for terminal grasp/release and are associated with high rates of prosthesis use. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A multidisciplinary approach to the management of brachial plexus injuries: experience from the Mayo Clinic over 100 years.

A multidisciplinary brachial plexus clinic has been a relatively new concept, offering different surgical speciality perspectives on the treatment of brachial plexus injuries. The resulting collaborative effort has proven to be greater than the sum of its parts. In this review, the history, philosophy of care, development/implementation and impact of a creation of a multidisciplinary brachial plexus team at the Mayo Clinic are detailed.

Persistent and profound peripheral nerve injuries following reverse total shoulder arthroplasty.

BACKGROUND: Peripheral nerve injuries associated with reverse total shoulder arthroplasty (rTSA) are rarely reported and are often dismissed as neuropraxias, particularly in the setting of perioperative nerve blocks. The purpose of this study was to evaluate nerve injuries following rTSA to determine if there is a pattern of injury and to evaluate outcomes of patients who sustain an intraoperative nerve injury. METHODS: A retrospective review was performed identifying patients who underwent rTSA and had a concomitant major nerve injury who were referred to a multidisciplinary peripheral nerve injury clinic. Demographic data, preoperative nerve block use, physical examination, electrodiagnostic studies, injury pattern, and time from injury to referral was collected. Radiographs, Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) score, and outcomes surveys were obtained at final follow-up. RESULTS: Twenty-two patients were identified with postoperative nerve injuries. Average time from injury to referral was 9.0 months, with 18.8 months' follow-up. Eight patients had undergone prior shoulder surgery, and 11 patients had prior shoulder trauma. Injury patterns were variable and involved diffuse pan-plexopathies with severity localized to the posterior and medial cords (11), the upper trunk (5), lateral cord (2), and axillary nerve (4). The average postoperative acromiohumeral distance (AHD) was 3.7 cm, with an average change of 2.9 cm. The average postoperative lateral humeral offset (LHO) was 1.1 cm, with an average change of 0.2 cm. Seventeen patients were confirmed to have undergone preoperative nerve blocks, which were initially attributed as the etiology of nerve injury. Eighteen patients were initially treated with observation: 11 experienced residual debilitating neuropathic pain and/or disability, and 7 had substantial improvement. One patient underwent nerve transfers, whereas the others underwent procedures for hand dysfunction improvement. The average QuickDASH score was 53.5 at average of 4 years post rTSA. CONCLUSIONS: Although uncommon, permanent peripheral nerve injuries following rTSA do occur with debilitating effects. Preoperative regional blocks were used in most cases, but none of the blocks could be directly attributed to the nerve injuries. Nerve injuries were likely secondary to traction at the time of arthroplasty and/or substantial distalization and lateralization of the implants. Patients with medial cord injuries had the most debilitating loss of hand function. Surgeons should be cognizant of these injuries and make a timely referral to a peripheral nerve specialist.

Factors Impacting the Success of Free Functioning Gracilis Muscle Transfer for Elbow Flexion in Brachial Plexus Reconstruction.

BACKGROUND: Free functioning muscle transfer is a reconstructive option to restore elbow flexion in brachial plexus injuries. The authors determined the impact of body mass index, age, and location of distal tendon attachment on elbow flexion strength after free functioning muscle transfer in traumatic brachial plexus injury patients. METHODS: A retrospective review of patients who underwent free functioning muscle transfer for elbow flexion as part of their brachial plexus injury reconstruction with a minimum 2-year follow-up were evaluated. Outcomes assessed included elbow flexion strength (British Medical Research Council grade) and change in Disabilities of the Arm, Shoulder and Hand questionnaire and visual analogue scale pain scores. RESULTS: One hundred six patients met inclusion criteria. The average age was 32 years, and the average body mass index was 27.1 kg/m2; 56.5 percent of patients achieved M3 or greater muscle grade using the authors' strict modification of the British Medical Research Council scale. Disabilities of the Arm, Shoulder and Hand questionnaire scores improved from 45.7 to 38.8 (p < 0.05). Visual analogue scale pain scores decreased, but this trend did not obtain significance. Age and body mass index both had a significant negative impact on final free functioning muscle transfer grade (p < 0.05). Use of a distal tendon insertion led to improved muscle grade outcomes, with targeting of wrist extension being superior to finger flexion (p < 0.05). Simultaneous musculocutaneous nerve grafting did not significantly alter final elbow flexion strength. CONCLUSIONS: Increasing age and body mass index both imparted a deleterious effect on free functioning muscle transfer muscle grade. Distal muscle targets had better strength outcomes than when the biceps tendon was used. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.