Digital vs Conventional OSCE in Orthopedic Surgery: A Feasibility Cross-Sectional Study.

OBJECTIVE: Remote OSCEs (Objective Structured Clinical Examination) are an alternative evaluation method during pandemic periods but they have never been evaluated in orthopedic surgery. We aimed to evaluate whether remote OSCEs would be feasible, and efficient for assessment of undergraduate medical students. METHODS: A cross-sectional study was performed. Thirty-four students were randomly assigned into 2 equal groups, either the conventional OSCE group or the digital OSCE group. Three types of skills were assessed: technical procedure, clinical examination, and radiographic analysis. Students were graded and they filled in a satisfaction questionnaire for both types of OSCEs. RESULTS: The mean score, out of 20, was 14.3 ± 2.5 (range 9.3-19) for the digital sessions, versus 14.4 ± 2.3 (range 10-18.6) for conventional sessions (p = 0.81). Bland Altman Plot showed that 88% of students scored within agreement. The average global feedback was different for item repeatability, relevance, and OSCEs preference (p < 0.0001, p = 0.0001, and p < 0.0001 respectively). However, they did not report differences for the item concerning the organization (p = 0.2). CONCLUSION: The results of this comparative study between digital and conventional OSCEs showed comparable distance learning scores between the 2 groups, whatever the skill assessed. However, the student's evaluation showed some reticence to conduct again OSCEs remotely.

Anatomical variations in the sensory innervation of the dorsal surface of the first digit space, a cadaveric study with clinical consequences.

INTRODUCTION: Radial nerve palsy is a classical complication of a humeral shaft fracture. In clinical practice, motor palsy of the radial nerve is sometimes observed without an abnormality felt in the sensory territory. HYPOTHESIS: We hypothesised that this dissociation between sensory and motor involvement is related to anatomical variations of the sensory innervation of the dorsal surface of the first digit space, thus, we decided to study the nature and frequency of these variations. MATERIAL AND METHOD: A cadaveric study was conducted on 24 upper limbs to analyse the truncal origin of the sensory branches innervating the dorsal surface of the first digit space. RESULTS: The sensory branch of the radial nerve (SBRN) participated in the innervation of the dorsal surface of the first digit space in 22 limbs, an anatomical variation was present in 2 cases with a mixed innervation by the SBRN and the lateral cutaneous nerve of forearm (LCNF) in 1 case and singular innervation by LCNF, with no SBRN involvement, in 1 case. Communications between SBRN and LCNF were found in 7 cases. DISCUSSION: Pure motor radial damage, without a sensory deficit of the dorsal surface of the first digit space, does not preclude a complete traumatic injury of the radial nerve. The sensory innervation of this region can be relayed by a branch of the LCNF. LEVEL OF EVIDENCE: IV; cadaveric study.

Ankle syndesmosis biomechanical evaluation by shear-waves elastography in healthy young adults: Assessment of the reliability and accuracy of the measurements and definition of a corridor of normality.

BACKGROUND: Aims of this study were: 1/ to evaluate the shear wave speed (SWS) properties of the anteroinferior tibiofibular ligament (AITFL) and the distal interosseous membrane (DIOM) in neutral, dorsal flexion and plantar flexion positions in a cohort of healthy adult volunteers; 2/ to assess the reliability and reproducibility of these measurements. METHODS: Both ankles were analyzed by shear wave elastography (SWE) in 20 healthy patients (10 females/10 males) standing on a hinge support with their ankles in neutral, 20° dorsal flexion and 30° plantar flexion positions. Stiffness of AITFL and DIOM was evaluated by SWS measurement. RESULTS: The SWS of AITFL and DIOM were minimal in the plantar flexion position (4.28 m/s [2.65-5.11] and 3.35 m/s [1.69-4.55], respectively). It increased significantly for both ligaments in neutral position (4.69 m/s [3.53-5.71] and 3.81 m/s [1.91-4.74], respectively; p < 0.0001), and reached their maximum values in dorsal flexion (6.58 m/s [5.23-8.34] and 4.79 m/s [3.07-6.19], respectively; p < 0.0001). There was no correlation between each ligament regardless the positions. SWS of AITFL was independent of demographic characteristics analyzed. SWS of DIOM was negatively correlated with height in dorsal flexion (ρ = -0.35; p = 0.03) and in plantar flexion (ρ = -0.37; p = 0.02). Female gender was associated with increased DIOM SWS in neutral (p = 0.005), dorsal flexion (p = 0.003), and plantar flexion (p = 0.001) positions. Moreover, foot morphology (foot arch, hind foot frontal deviation) did not impact AITFL nor DIOM SWS. Inter- and intra-observer measurements were all good or excellent. CONCLUSION: The AITFL and DIOM, stabilizers of the distal tibiofibular syndesmosis, increase in stiffness while dorsal flexion increases. This study describes a reliable and reproducible protocol to assess their stiffness by SWE, and defines a corridor of normality.

An ultra-thinned groin flap for reconstruction of complete digital ring avulsion injuries.

In complete digital ring avulsions, amputation is usually carried out when replantation of the avulsed tissue is not an option or has failed. The purpose of this study was to report our experience in treating Urbaniak Class III degloved fingers using an ultra-thinned pedicled groin flap. Sixteen patients from ages 11 to 26 years were included. In all cases, the flexor digitorum superficialis tendon, extensor apparatus and proximal interphalangeal joint were intact. Rehabilitation included immediate active mobilization, with flap division at day 21. At a mean follow-up of 15 months, all patients but one were satisfied with the appearance. Two had mild subjective cold intolerance. No flap failure was recorded. The mean total active motion was 183° and the mean QuickDASH score was 8.8/100. Patients recovered S1 sensibility according to the Mackinnon and Dellon classification. The ultra-thinned groin flap has proved to be a reliable technique for non-replantable ring avulsions.Level of evidence: IV.

Transfer of a C7 Fascicle for the Pectoralis Major to the Suprascapular Nerve: A 3-Year Follow-Up Patient Series.

BACKGROUND: In patients with C5-C6 brachial plexus injury, spinal accessory nerve transfer to the suprascapular nerve is usually performed for the restoration of shoulder abduction. In order to minimize donor deficits, we transferred one fascicle of the ipsilateral C7 root, dedicated to the pectoralis major muscle, to the suprascapular nerve. METHODS: Ten patients with a mean age of 33 years (range, 19 to 51 years) were operated on at a mean delay of 4 months after their trauma (range, 2 to 7 months). Patients had C5-C6 brachial plexus palsy with avulsed roots on spinal magnetic resonance imaging scan. In addition to the partial C7 transfer, patients sustained nerve transfers to the posterior branch of the axillary nerve and to the motor branches of the musculocutaneous nerve for the biceps and brachialis muscles. RESULTS: At a mean follow-up of 36 months (range, 29 to 42 months), mean shoulder abduction and external rotation ranges of motion were, respectively, 99 degrees (range, 60 to 120 degrees; p = 0.001) and 58 degrees (range, 0 to 80 degrees; p = 0.001). In nine patients, shoulder abduction strength was graded M4, according the British Medical Research Council grading scale, against 1.6 kg (range, 1 to 2 kg), and was graded M3 in one patient. External rotation strength was graded M4 in nine patients and M3 in one patient. Residual strength of the pectoralis major muscle was graded M4+ in every patient. CONCLUSIONS: C7 partial transfer to the suprascapular nerve showed satisfactory results at long-term follow-up for active shoulder abduction and external rotation recovery in C5-C6 brachial plexus palsies. This technique replaced spinal accessory nerve transfer in the authors' practice. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Sarcomas of the hand: A retrospective series of 26 cases.

BACKGROUND: Hand sarcomas frequently suffer from a delayed diagnosis, and the current guidelines for their management are often not followed. METHODS: The objectives of our study were to determine: (1) the rate of inadequate initial treatments; (2) the rates of mortality, recurrence, and complementary excision in a cohort of patients with a sarcoma of the hand who were treated at our reference center between 2000 and 2015. RESULTS: The series comprised 26 patients (mean age 40 years). Of the 20 patients not initially treated at a reference center, 17 had inadequate initial treatment. Of the six patients treated at our center, one had inadequate initial care. Significantly more patients had inadequate initial care outside a reference center (p=0.0045). The cumulative probabilities of recurrence or metastases at 5 years were 15% and 30%, respectively. Survival by cumulative incidence was 71% at 5 years and 56% at 10 years. CONCLUSIONS: Sarcomas of the hand are a deadly pathology. All diagnostic uncertainty warrants referral of the patient to a reference center. LEVEL OF PROOF: IV.

Induced membrane technique applied to the forearm: Technical refinement, indications and results of 13 cases.

INTRODUCTION: The unique anatomical characteristics of the forearm bones makes their reconstruction challenging. The aim of this study was to report the surgical methods and results of the induced membrane technique applied to traumatic forearm bone defects. MATERIAL AND METHODS: We evaluated retrospectively a case series of 13 patients operated between 2010 and 2017. The first surgical step consisted of debridement of the fracture site and implantation of a cement spacer with appropriate fixation. The anatomy of the forearm skeleton had to be restored. The second step, done 6 weeks later, consisted of removing the cement spacer and applying cancellous bone autograft harvested from the iliac crest. The outcome measures were radiological bone union, need for surgical revision, and postoperative wrist range of motion. RESULTS: All 13 patients were men, with a mean age of 39 years (18-67). The average follow-up was 2.5 years. Eleven patients were suffering from a nonunion and two from a post-traumatic bone defect. Six patients had an identified preoperative infection. Three patients had previously undergone an unsuccessful treatment for their nonunion with bone addition. The maximum length of bone reconstruction was 12 cm. Union was achieved in 12 of 13 patients in a mean of 5 months (3-8). The other patient died during the postoperative course. Two patients needed revision surgery: ulnar shortening osteotomy (1 case) and additional tendon reconstruction (1 case). The mean pronosupination range was 123° on average (55-180°). The mean flexion-extension range was 106° (90-130°). CONCLUSION: The induced membrane technique is a reliable reconstruction technique that is well suited to reconstruction of the forearm skeleton. LEVEL OF EVIDENCE: IV, retrospective study.

Ulnar neuropathy at the elbow.

At the elbow, the ulnar nerve (UN) may be the site of a static compression (by the cubital tunnel retinaculum and Osborne's ligament between the two heads of the flexor carpi ulnaris), or a dynamic compression, especially when the nerve is unstable (subluxation/dislocation outside the ulnar groove). The clinical basis for the diagnosis of ulnar neuropathy involves looking for subjective and objective signs of sensory and/or motor deficit in the ulnar nerve's territory in the hand, a pseudo-Tinel's sign, and doing manipulations to provoke UN irritation. The diagnosis is confirmed by electromyography and ultrasonography. In the early stages, patient education and elimination of flexion postures or repeated elbow flexion motions can provide relief. If this fails or signs of sensory and/or motor deficit are present, surgical treatment is proposed. If the nerve is stable, in-situ nerve decompression is typically done as the first-line treatment. If the nerve is unstable, anterior nerve transposition - generally subcutaneous - or more rarely, a medial epicondylectomy can be done. If surgical treatment fails, the patient's history is reviewed, and diagnostic tests can be repeated. Except in cases of a fibrotic scar, the main causes of failure are neuroma of a branch of the medial cutaneous nerve of the forearm, instability of the nerve and persistence of a compression point. In the latter two cases, surgical revision is justified and anterior nerve transposition or epicondylectomy can be proposed.

C5/C6 brachial plexus palsy reconstruction using nerve surgery: long-term functional outcomes.

INTRODUCTION: In traumatic proximal brachial plexus lesions (i.e., C5/C6), reconstruction of the musculocutaneous, axillary and suprascapular nerves yields satisfactory short- and medium-term functional outcomes. HYPOTHESIS: Early functional outcomes after nerve surgery will be maintained in the long-term. METHODS: A retrospective analysis was done using the medical records of 29 patients with C5/C6 palsy treated by nerve surgery. Active range of motion and strength at the elbow (i.e., flexion) and shoulder (i.e., flexion, abduction, external rotation with the elbow at the side of the body and with the arm 90° abducted ) were evaluated clinically using a goniometre and the British Medical Research Council grading scale, respectively. RESULTS: At a mean follow-up of 46±15 months (25;76), the mean active elbow flexion was 126°±18° (90;150) and the mean strength was 3.8±0.5 (2;4). At the shoulder, mean active flexion, abduction, external rotation with the elbow at the side of the body and with the arm 90° abducted were 109°±39° (0;180), 99°±38° (0;180°), 12°±34° (-80;70) and 3°±21° (-40;50), while mean strength was 3.6±0.8 (0;4), 3.6±0.8 (0;4), 3.4±0.9 (0;4) and 2.5±1.2 (0;4), respectively. DISCUSSION: In cases of C5/C6 palsy, early nerve surgery yields satisfactory functional outcomes that are maintained over time for elbow flexion and shoulder elevation. However, when the teres minor is not reinnervated, it is difficult to restore satisfactory shoulder external rotation. LEVEL OF EVIDENCE: IV, Retrospective case study.

ALGINATE versus NPWT in the Preparation of Surgical Excisions for an STSG: ATEC Trial.

A calcium alginate dressing (ALGINATE) and negative pressure wound therapy (NPWT) are frequently used to treat wounds which heal by secondary intention. This trial compared the healing efficacy and safety of these 2 treatments. METHODS: This randomized, non-inferiority trial enrolled patients who underwent skin excision (>30 cm2), which was left open to heal by secondary intention. They received ALGINATE or NPWT by a centralized randomization. Follow-up was performed weekly until optimal granulation tissue was obtained. The primary outcome was time to obtain optimal granulation tissue for a split thickness skin graft take (non-inferiority margin: 4 days). Secondary outcomes were occurrence of adverse events (AEs) and impact of the treatments on the patient's daily life. RESULTS: ALGINATE and NPWT were applied to 47 and 48 patients, respectively. The mean time to optimal granulation was 19.98 days (95% CI, 17.7-22.3) with ALGINATE and 20.54 (95% CI, 17.6-23.5) with NPWT. Between group difference was -0.56 days (95% CI -4.22 to 3.10). The non-inferiority of ALGINATE versus NPWT was demonstrated. No AE related to the treatment occurred with ALGINATE versus 14 AEs with NPWT. There was no difference in the impact of the treatments on the patient's daily life. CONCLUSION: This trial demonstrates that ALGINATE has a similar healing efficacy to that of NPWT and that is markedly better with regard to patient safety.

Induced-membrane treatment of refractory humeral non-union with or without bone defect.

INTRODUCTION: Treatment of humeral non-union with or without bone defect is complex, with non-negligible rates of complication and failure. Few reports focused on management of treatment failure. OBJECTIVE: The study hypothesis was that the induced-membrane technique associated in a 2-stage strategy to internal fixation provides systematic bone healing in refractory humeral non-union. MATERIAL AND METHODS: The study included 15 patients, with a median age of 46.6 years, with humeral non-union of a mean 24 months' progression and mean history of 3 attempted revision surgeries. Seven patients showed bone defect, exceeding 5cm in 2 cases. Six had history of radial palsy. RESULTS: Consolidation was achieved in all cases, at a mean 4.6 months. Ten patients underwent radial nerve transposition, 6 of whom had shown radial motor nerve palsy; all recovered within 2 to 5 months. There was 1 case of superficial infection, and 1 of seroma. DISCUSSION: The induced-membrane technique ensures bone healing due to the biological properties of the membrane; the main drawback is the need for 2-stage surgery. When bone defect exceeds 5cm, a multi-perforated fibula segment can be placed inside the membrane to increase primary stability and enhance bone integration. CONCLUSION: The induced-membrane technique is suited to humeral non-union, with or without bone defect. The 2-stage strategy is mandatory in case of suspected latent infection. In the 2-stage procedure, anteromedial radial nerve transposition facilitates the bone-graft stage. LEVEL OF EVIDENCE: IV, retrospective study.

Fast-track teaching in microsurgery.

INTRODUCTION: In France, microsurgery is taught in University diploma courses, for a mean 100hours (range, 45-120hours) extending over several months. This training, spread over the year, encounters problems of maintaining high-quality supervision and enduring acquisition of skills. These difficulties risk leading to withdrawal of certain courses, already suffering from funding issues and administrative requirements for animal welfare. MATERIAL AND METHOD: We report our experience with a 2-week module comprising nine 4-hour sessions (total, 36hours), with continuous supervision of 5 students in each of 2 groups (10 students), enabling personalized learning. At the end of each session, an assessment questionnaire was filled out by teachers and students. RESULTS: Students' scores increased from a mean 23.9/30 points (range, 20 - 30) at session 3 to 26.9 points (range, 23 - 30) at session 9 (p=0.012). At the end of session 3, students were grouped as good, average or beginners, based on the first assessments: i.e., with differences in level between groups at session 3. At the end of session 9, all 3 groups showed statistically comparable levels. Comparison between student and teacher questionnaire responses showed a significant discrepancy in 7 of the 10 cases in week 1, and no significant discrepancy in 7 of the 10 cases by the end of week 2. DISCUSSION: The efficacy of condensed learning is based on immediate repetition of exercises, following Ebbinghaus: without repetition, memory decays exponentially, whereas if the information is rapidly repeated, the curve flattens and memory is consolidated. The present rapid improvement in the acquisition of the principles of microsurgery stimulated the enthusiasm of both students and teachers for what is reputed to be a demanding type of training. The study showed that acquisition, assessed in terms of vascular suture reliability, was achieved by the end of a 36-hour module, regardless of the student's baseline level.

Anatomy of the posterior branch of the medial antebrachial cutaneous nerve: A cadaveric study.

PURPOSE: The posterior branch of the medial antebrachial cutaneous nerve (MACN) is at risk to be damaged during cubital tunnel surgery. The purpose of this study was to identify the location of the posterior branch of the MACN (PBMACN) in relation to surgical landmarks pertinent in cubital tunnel surgery. METHODS: We performed an anatomical study on 20 limbs from 13 fresh cadavers. The nerve was dissected from 10cm proximal to 10cm distal of the medial epicondyle. We measured the distance between the nerve and the medial epicondyle, and also the distance separating the PBMACN from the ulnar nerve passage between the two heads of the flexor carpi ulnaris. Measurements were performed with the elbow at 45° and 90° of flexion, as well as in full pronation and supination. RESULTS: After its emergence from the main trunk of the MACN, the posterior branch ran anteriorly to the medial epicondyle, taking an oblique direction toward the ulnar shaft. The PBMACN was in average 2.53cm under the medial epicondyle when the elbow was flexed at 45°, and 2.96cm when the elbow was flexed at 90°. Average distance between the PBMACN and the penetrating point of the ulnar nerve within the flexor carpi ulnaris was 1.54cm when the elbow was flexed at 45°, and 1.62cm when the elbow was flexed at 90°. Pronation and supination positions of the forearm did not significantly modify our measurements. CONCLUSIONS: Understanding the position of MACN posterior branch during ulnar nerve release surgery at the elbow may help in preventing iatrogenic injury. According to our measurements, incision and superficial dissection anterior to the medial epicondyle or distal to the ulnar nerve penetrating point between the two heads of the flexor carpi ulnaris should be avoided or done with an elbow flexed at 90°.

Reconstruction of lateral pinch in an isolated paralysis of the first dorsal interosseous muscle - A new surgical technique.

Lack of function of the first interosseous muscle (FDI) might be responsible for insufficient stabilisation of the index finger during lateral pinch, and may induce disability in hand function. The first cause of FDI palsy is ulnar nerve palsy. We describe a new tendon transfer to reanimate the FDI muscle, using the extensor indicis proprius tendon. The tendon is sectioned at its distal insertion and rerouted in the first extensor tendon compartment. We report one case of isolated first interosseous muscle palsy secondary to direct trauma. Preoperatively, the patient complained of a severe lack of strength during key pinch with an ulnarly deviated index finger. Thirty months postoperatively, the patient recovered active abduction of the index finger and lateral pinch was measured at 5.5kg (54N). Compared to the original Bunnell transfer our technique restores the native moment arm of the FDI muscle and does not require a tendon graft.

Three-dimensional-printed patient-specific Kirschner-wire guide for percutaneous fixation of undisplaced scaphoid fractures: a cadaveric study.

Undisplaced scaphoid waist fractures can be managed by percutaneous fixation. The purpose of this study is to compare percutaneous fixation using a three-dimensional (3-D)-printed guide with the conventional method in a cadaveric study. Twelve wrists were divided into two groups: standard fluroscopic technique group, and a patient-specific 3-D-printed guide group. In the patient-specific group, using high resolution CT scans, we manufactured a mould-guide including a wire guide sleeve aligned with the planned ideal path, and 3-D printed it. On postoperative CT scans we measured the angular deviation of the screw axis from the ideal axis, and compared the two groups. The angular deviation was significantly lower in the patient-specific guide group. We concluded that a 3-D-printed guide for scaphoid percutaneous fixation allows a more accurate placement of the screw than a fluoroscopy guide in our cadaveric model.

Isolated open anterior shoulder release in brachial plexus birth palsy.

BACKGROUND: In children with brachial plexus birth palsy (BPBP), a shoulder joint internal contracture is commonly observed, which may result in glenohumeral osseous deformities and posterior joint subluxation. The purpose of this retrospective study was to evaluate the impact of an isolated anterior shoulder release on osteoarticular disorders and assess the subsequent clinical improvements. METHODS: Forty consecutive BPBP patients with glenohumeral dysplasia underwent an open anterior shoulder release. Shoulder scans (ie, magnetic resonance imaging preoperatively and computed tomography postoperatively) were conducted to assess glenoid version and the percentage of the humeral head anterior to the middle of the glenoid fossa. Clinical data including analytical shoulder range of motion and modified Mallet scores were collected. RESULTS: After a mean follow-up period of 23 months, glenoid version and the percentage of the humeral head anterior to the middle of the glenoid fossa significantly improved from -32° and 18%, respectively, to mean postoperative values of -12° (P < .001) and 45% (P < .001), respectively. Passive and active external rotation increased from -2° and -43°, respectively, to 76° (P < .001) and 54° (P < .001), respectively. The mean modified Mallet score significantly improved from 14.2 to 21.4 points (P < .001). In 8 children with satisfactory passive motion, a latissimus dorsi transfer was performed secondarily to obtain satisfactory active motion. CONCLUSION: In BPBP patients with glenohumeral deformities, isolated open anterior release of the shoulder induces significant remodeling of the joint, reducing posterior joint subluxation and improving both passive and active shoulder ranges of motion. Additional latissimus transfer remains mandatory in selected cases to achieve satisfactory function.

Glenohumeral fusion in adults with sequelae of obstetrical brachial plexus injury: a report of eight cases.

The purpose of this study was to assess the outcomes of glenohumeral fusion performed in adulthood in patients with poor recovery after obstetric brachial plexus injury. We reviewed eight patients with obstetrical brachial plexus injury who had undergone shoulder arthrodesis. The mean age was 28 years (range 16 to 55). All of the patients had active periscapular and elbow flexor muscles. At an average follow-up of 20 months, the active range of abduction and external rotation of the affected shoulder was 67° (range 50° to 85°) and 21° (range 0° to 40°), respectively. All of the patients were satisfied with the outcome of the intervention. Fusion was obtained between 3 and 6 months, and none of the patients experienced residual pain. Shoulder fusion improved the active shoulder abduction and external rotation in adults with residual obstetrical brachial plexus paralysis. Level of evidence: IV.

Bipolar transfer of the pectoralis major muscle for restoration of elbow flexion in 29 cases.

BACKGROUND: This study evaluated the functional outcomes of bipolar pedicled pectoralis major (PM) transfer to restore elbow flexion. METHODS: We retrospectively reviewed 29 transfers in 28 patients with a mean age of 31.2 years (range, 5-65 years). The loss of elbow flexion was due to brachial plexus palsy in 24 patients, elbow flexors necrosis in 4, and poliomyelitis in 1. The entire PM muscle was mobilized and fixed proximally to the coracoid process. Intraoperative positioning and postoperative immobilization of the shoulder and the elbow flexed at 60° and 120°, respectively, allowed direct distal fixation of the muscle to the biceps brachii tendon. RESULTS: At the last follow-up (mean, 13 months; range, 4-37 months), 41% of the transfers (n = 12) recovered grade 4 elbow flexion strength and were able to lift 2.2 kg on average (range, 0.5-5 kg), 52% (n = 15) recovered grade 3 strength, and 7% (n = 2) had a poor result (ie, grade 2 elbow flexion). The mean active elbow flexion was 100° (ranging, 30°-150°), and the patients had 0° to 10° elbow flexion contracture. CONCLUSIONS: Our results indicate that bipolar PM transfer is a reliable and effective procedure to restore elbow flexion. Flexion of the shoulder and elbow allowed the transfer to reach the elbow fold and avoided an interposition graft between the distal PM and the biceps brachii tendon.

Spinal accessory nerve repair using a direct nerve transfer from the upper trunk: results with 2 years follow-up.

Spinal accessory nerve grafting requires identification of both nerve stumps in the scar tissue, which is sometimes difficult. We propose a direct nerve transfer using a fascicle from the posterior division of the upper trunk. We retrospectively reviewed 11 patients with trapezius palsy due to an iatrogenic injury of the spinal accessory nerve in nine cases. The mean age was 38 years (range 21-59). Preoperatively, patients showed shoulder weakness and limited range of motion. At a mean follow-up of 25 months, active shoulder abduction improvement averaged 57°. Trapezius muscle strength graded M4 or M5 in 10 cases and M3 in one case. No deltoid or triceps impairment was reported. Scapula kinematics was considered normal in seven patients. This technique gave satisfactory functional results and may be an alternative to spinal accessory nerve grafting for the management of trapezius palsies if direct repair is not feasible. LEVEL OF EVIDENCE: IV.