Verrucous Carcinoma of the Foot: A Single Canadian Center Experience on Diagnosis, Management, and Outcomes.

INTRODUCTION: Verrucous carcinoma (VC) was first described in 1948 by Dr. Ackerman. It is a low-grade cutaneous squamous carcinoma that usually develops in the oral cavity, the anogenital region, and the plantar surface of the foot. Clinically, there is low suspicion for malignancy given the slow growth of VC lesions and their wart-like appearance. Diagnosis can be difficult because of the benign histological appearance with well-differentiated cells and absence of dysplasia. Surgical excision is the only satisfactory form of treatment for plantar VC; however, this becomes difficult given its benign clinical appearance and the pathologic misinterpretation of the lesion as a benign hyperplasia. While there are case reports and retrospective studies of patients with plantar VC in the literature, we present the largest case series of plantar VC within North America, with recurrence despite negative margins. METHODS: We report on all the plantar VC excised between 2014-2023. We report six cases of VC, their treatment, and their outcomes. RESULTS: Six patients obtained a diagnosis of plantar VC by incisional biopsy. All patients underwent excision of their lesions and had negative margins reported on the final pathology. All patients developed nonhealing wounds at the site of their lesion excision; therefore, biopsies were performed to confirm a recurrence. All patients had a recurrence of VC at the initial site. All patients underwent re-excision of the lesions. Despite negative margins again on final pathology, all patients had a subsequent second recurrence. Ultimately, all patients underwent an amputation as definitive management. Each patient had an average of 3 operations. There were 4 different surgeons and different pathologists reporting their findings. CONCLUSIONS: Our experience with plantar VC suggests that an aggressive approach to surgical management is needed. Furthermore, management is optimized with the combined expertise of an experienced dermatopathologist and surgeon. Despite negative margins and repeated excisions, VC lesions recur and invade local tissues to the extent that only amputation of the involved foot has resulted in cure.

Upper Extremity Nerve Transfers for Treatment of Nerve Injury After Cervical Spine Surgery: A Single-Center Retrospective Review.

PURPOSE: Nerve transfers to restore or augment function after spinal cord injury is an expanding field. There is a paucity of information, however, on the use of nerve transfers for patients having undergone spine surgery. The incidence of neurologic deficit after spine surgery is rare but extremely debilitating. The purpose of this study was to describe the functional benefit after upper extremity nerve transfers in the setting of nerve injury after cervical spine surgery. METHODS: A single-center retrospective review of all patients who underwent nerve transfers after cervical spine surgery was completed. Patient demographics, injury features, spine surgery procedure, nerve conduction and electromyography study results, time to referral to nerve surgeon, time to surgery, surgical technique and number of nerve transfers performed, complications, postoperative muscle testing, and subjective outcomes were reviewed. RESULTS: Fourteen nerve transfers were performed in 6 patients after cervical spine surgery. Nerve transfer procedures consisted of a transfer between a median nerve branch of flexor digitorum superficialis into a biceps nerve branch, an ulnar nerve branch of flexor carpi ulnaris into a brachialis nerve branch, a radial nerve branch of triceps muscle into the axillary nerve, and the anterior interosseous nerve into the ulnar motor nerve. Average patient age was 55 years; all patients were male and underwent surgery on their left upper extremity. Average referral time was 7 months, average time to nerve transfer was 9 months, and average follow-up was 21 months. Average preoperative muscle grading was 0.9 of 5, and average postoperative muscle grading was 4.1 of 5 ( P < 0.00001). CONCLUSIONS: Upper extremity peripheral nerve transfers can significantly help patients regain muscle function from deficits secondary to cervical spine procedures. The morbidity of the nerve transfers is minimal with measurable improvements in muscle function.

Synovial Lipomatosis With Extra-articular Extension in the Arthritic Wrist: An Unexpected Diagnosis.

ABSTRACT: Synovial lipomatosis is a rare condition characterized by adipocyte proliferation within joint synovial tissue. It most commonly affects the knee and is typically intra-articular. Only 5 published case reports describe extra-articular synovial lipomatosis of the wrist. We present a case of a sexagenarian patient seen for his wrist arthropathy. His x-ray revealed pan-wrist arthritis and inflammatory soft tissue swelling. The patient was slated for a wrist fusion and Darrach procedure. Following the dorsal skin incision in the operating room, an unusual adipose mass was identified infiltrating all extensor compartments: midcarpal, radiocarpal, and distal radioulnar joints. The mass was excised and sent to pathology prior to proceeding with the slated surgery. Synovial lipomatosis was diagnosed postoperatively based on histopathology. Six weeks postoperatively, the wrist fusion had healed clinically and radiographically, and his pain had improved. There was no evidence of recurrence. Synovial lipomatosis is a rare entity that may imitate multiple other pathologies. It is possible that synovial lipomatosis may represent a secondary occurrence following degenerative articular disease or trauma in older patients. This is the first case report to date describing synovial lipomatosis of the wrist with extra-articular extension in the setting of pan-carpal wrist arthritis.

A Comparative Study of 2-Corner, 3-Corner, and 4-Corner Arthrodesis for Midcarpal Arthritis.

BACKGROUND: Four-corner fusion (4CF) is a common treatment for midcarpal arthritis; however, alternatives including 2-corner fusion (2CF) and 3-corner fusion (3CF) have been described. Limited literature suggests 2CF and 3CF may improve range of motion but have higher complication rates. Our objective is to compare function and patient-reported outcomes following 4CF, 3CF, and 2CF at our institution. METHODS: Adult patients undergoing 4CF, 3CF, and 2CF from 2011 to 2021 who attended at least one follow-up were included. Four-corner fusion patients were compared with those who underwent either 3CF or 2CF using staple fixation. Outcomes include nonunion rate, reoperation rate, progression to wrist fusion, range of motion, and patient-reported pain, satisfaction, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. RESULTS: A total of 58 patients met inclusion criteria. There were 49 4CF and 9 2CF or 3CF patients. Nonunion rates, progression to wrist fusion, and repeat surgery for any indication were not significantly different among groups. Range of motion (flexion-extension, radial-ulnar deviation) and grip strength at postoperative visits were not significantly different. Significantly more 4CF patients required bone grafting. Pain, overall satisfaction, and DASH scores were similar. CONCLUSIONS: Although prior studies suggest increased risk of nonunion and hardware migration after 2CF/3CF, we did not observe higher complication rates compared with 4CF. Range of motion, strength, and patient-reported outcomes were similar. While 4CF is traditionally the procedure of choice for midcarpal fusion, we found that when using a staple fixation technique, 2CF and 3CF have comparable clinical and patient-reported outcomes yet decrease the need for autologous bone grafting.

Malignant Peripheral Nerve Sheath Tumors of the Brachial Plexus: A Single-Center Experience on Diagnosis, Management, and Outcomes.

INTRODUCTION: The incidence of malignant peripheral nerve sheath tumors (MPNSTs) is 0.001%. Commonly, MPNST arise in neurofibromatosis; however, they can occur sporadically, de novo or from a preexisting neurofibroma. Malignant peripheral nerve sheath tumors are aggressive tumors with high rates of local recurrence and metastasis. The prognosis is poor with 5-year survival rates of 15% to 50%. Unfortunately, given the rarity of these tumors, it is not clear how to best manage these patients. The purposes of this study were (1) to discuss our experience with MPNST and particularly our difficulties with diagnosis and management, and (2) to review the literature. MATERIALS AND METHODS: We report on all tumors of the brachial plexus excised between 2013 and 2019. We report 3 cases of MPNST, their treatment, and their outcomes. RESULTS: Thirteen patients underwent surgical excision of an intrinsic brachial plexus mass. Three of these patients (2 male, 1 female; average age, 36 years) were diagnosed with an MPNST. Two patients with an MPNST had neurofibromatosis type 1. All patients with an MPNST had a tumor >8 cm, motor and sensory deficits, and pain. All 3 patients with MPNST underwent a magnetic resonance imaging (MRI) before diagnosis. The average time from initial symptom onset to MRI was 12.3 months. Only 1 of the MRIs suggested a malignant tumor, with no MRI identifying an MPNST. One patient underwent an excisional biopsy, and 2 had incisional biopsies. Because of the lack of diagnosis preoperatively, all patients had positive margins given the limited extent of surgery. Returning for excision in an attempt to achieve negative margins in a large oncologically contaminated field was not possible because defining the boundaries of the initial surgical field was unachievable; therefore, the initial surgery was their definitive surgical management. All patients were referred to oncology and received radiation therapy. CONCLUSIONS: Malignant peripheral nerve sheath tumors must be suspected in enlarging masses (>5 cm) with the constellation of pain, motor, and sensory deficits. Computed tomography- or ultrasound-guided core needle biopsy under brachial plexus block or sedation is required for definitive diagnosis to allow for a comprehensive approach to the patient's tumor with a higher likelihood of disease-free survival.

Hemihamate Arthroplasty Revisited: A Retrospective Review of 11 Cases.

PURPOSE: Proximal interphalangeal joint (PIPJ) fracture dislocations are complex injuries that can result in persistent pain, stiffness, and angulation. Hemihamate arthroplasty (HHA) can be used to reconstruct the base of the middle phalanx in cases of unstable PIPJ fracture dislocations. Despite previous case series describing good outcomes with HHA, it has not gained widespread use. The purpose of this study is to describe our straightforward, reproducible technique and to demonstrate the benefit in motion after the procedure in chronic unstable PIPJ fracture dislocations. METHODS: All patients with chronic, unstable PIPJ fracture dislocations requiring joint resurfacing of greater than 40% of the base of the middle phalanx treated with HHA were retrospectively reviewed. Patient demographics, injury features, surgical technique, preoperative and postoperative PIPJ range of motion and arc of motion, time to surgery, and complications were reviewed. Any fracture amenable to fixation or cases with radiographic evidence of arthritis or injury to the head of the proximal phalanx were excluded. RESULTS: Eleven cases were reviewed. The mean patient age was 35 years. The mean time from injury to surgery was 6 months. The mean joint surface involved was 64%. The mean PIPJ arc of motion was 17 degrees preoperatively and 63 degrees postoperatively. The mean bone block size required was 8 × 8 × 8 mm. The mean follow-up was 26 months. Postoperative pain at the PIPJ on the visual analog scale was 0.4 (scale of 0 to 10). Complications included 2 patients requiring tenolysis. CONCLUSIONS: Despite the lack of a perfect geometric recreation of the base of the middle phalanx with the hamate, patients recover acceptable PIPJ motion and have minimal pain. Hemihamate arthroplasty is a good option for any patient with minimal motion of their PIPJ and a chronic, unstable fracture dislocation.

Reconstruction of Quadriceps Function Using a Single Functional Gracilis Muscle Transfer With an Adductor Longus Nerve to Femoral Nerve Branch of the Rectus Femoris Nerve Transfer.

BACKGROUND: A femoral nerve injury may result in cutaneous sensory disturbances of the anteromedial thigh and complete paralysis of the quadriceps femoris muscles resulting in an inability to extend the knee. The traditional mainstay of treatment for femoral neuropathy is early physiotherapy, knee support devices, and pain control. Case reports have used the anterior division of the obturator nerve as a donor nerve to innervate the quadriceps femoris muscles; however, a second nerve transfer or nerve grafting is often required for improved outcomes. We suggest a novel technique of combining an innervated, pedicled gracilis transfer with an adductor longus to rectus femoris nerve transfer to restore the strength and stability of the quadriceps muscles. METHODS: This is a case series describing the use of a pedicled gracilis muscle transposed into the rectus femoris position with a concomitant nerve transfer from the adductor longus nerve branch into the rectus femoris nerve branch to restore quadriceps function after iatrogenic injury (hip arthroplasty) and trauma (gunshot wound). RESULTS: With electrodiagnostic confirmation of severe denervation of the quadriceps muscles and no evidence of elicitable motor units, 2 patients (average age, 47 years) underwent a quadriceps muscle reconstruction with a pedicled, innervated gracilis muscle and an adductor longus to recuts femoris nerve transfer. At 1 year follow-up, the patients achieved 4.5/5 British Medical Research Council full knee extension, a stable knee, and the ability to ambulate without an assistive aid. CONCLUSIONS: The required amount of quadriceps strength necessary to maintain quality of life has not been accurately established. In the case of femoral neuropathy, we assumed that a nerve transfer alone and a gracilis muscle transfer alone would not provide enough stability and strength to restore quadriceps function. We believe that the restoration of the quadriceps function after femoral nerve injury can be achieved by combining an innervated, pedicled gracilis transfer with an adductor longus to rectus femoris nerve transfer with low morbidity and no donor defects.

Surgical Treatment of Parsonage Turner Syndrome With Primary Nerve Transfers: A Case Series and Cadaver Dissection.

ABSTRACT: Parsonage Turner syndrome (PTS) is the development of severe, spontaneous pain with subsequent nerve palsy. Unfortunately, many patients never achieve full functional recovery, and many have chronic pain. The use of nerve transfers in PTS has not been reported in the literature. We present 4 cases of PTS treated surgically with primary nerve transfer and neurolysis of the affected nerve following the absence of clinical and electrodiagnostic recovery at 5 months from onset. In addition, we present a cadaver dissection demonstrating an interfascicular dissection of the anterior interosseous nerve (AIN) into its components to enable a fascicular transfer in partial AIN neuropathy. Two patients with complete axillary neuropathy underwent a neurorrhaphy between the nerve branch to the lateral head of the triceps and the anterior/middle deltoid nerve branch of the axillary nerve. Two patients with partial AIN neuropathy involving the FDP to the index finger (FDP2) underwent a neurorrhaphy between an extensor carpi radialis brevis nerve branch and the FDP2 nerve branch. All patients had neurolysis of the affected nerves. All subjects recovered at least M4 motor strength. The cadaver dissection demonstrates 3 separate nerve fascicles of the AIN into FPL, FDP2, and pronator quadratus that can be individually selected for reinnervation with a fascicular nerve transfer. Functional recovery for patients with PTS with neurolysis alone is variable. Surgical treatment with neurolysis and a nerve transfer to improve functional recovery when no recovery is seen by 5 months is an option.

Anterior Interosseous-to-Ulnar Motor Nerve Transfers: A Single Center's Experience in Restoring Intrinsic Hand Function.

Background: Transfer of the anterior interosseous nerve (AIN) into the ulnar motor branch improves intrinsic hand function in patients with high ulnar nerve injuries. We report our outcomes of this nerve transfer and hypothesize that any improvement in intrinsic hand function is beneficial to patients. Methods: A retrospective review of all AIN-to-ulnar motor nerve transfers, including both supercharged end-to-side (SETS) and end-to-end (ETE) transfers, from 2011 to 2018 performed by 2 surgeons was conducted. All adult patients who underwent this nerve transfer for any reason with greater than 6 months' follow-up and completed charts were included. Primary outcome measures were motor function using the British Medical Research Council (BMRC) grading system and subjective satisfaction with surgery using a visual analog scale. Secondary outcome measures included complications and donor site deficits. Results: Of the 57 patients who underwent nerve transfer, 32 patients met the inclusion criteria. The average follow-up and average time to surgery were 12 and 15.6 months, respectively. The overall average BMRC score was 2.9/5, with a trend toward better recovery in patients who received earlier surgery (<12 months = BMRC 3.7, ≥12 months = BMRC 2.2; P < .01). Patients with an SETS transfer had better results that those with an ETE transfer (SETS = 3.2, ETE = 2.6). There were no donor deficits after operation. One patient developed complex regional pain syndrome. Conclusions: Patients with earlier surgery and an in-continuity nerve (receiving an SETS transfer) showed improved recovery with a higher BMRC grade compared with those who underwent later surgery. Any improvements in intrinsic hand function would be beneficial to patients.

The Addition of a Nerve Transfer to the Treatment of Peroneal Neuropathy Secondary to Intraneural Ganglion: Case Series.

ABSTRACT: Peroneal intraneural ganglia are rare, and their management is controversial. Presently, the accepted treatment of intraneural ganglia is decompression and ligation of the articular nerve branch. Although this treatment prevents recurrence of the ganglia, the resultant motor deficit of foot drop in the case of intraneural peroneal ganglia is unsatisfying. Foot drop is classically treated with splinting or tendon transfers to the foot. We have recently published a case report of a peroneal intraneural ganglion treated by transferring a motor nerve branch of flexor hallucis longus into a nerve branch of tibialis anterior muscle in addition to articular nerve branch ligation and decompression of the intraneural ganglion to restore the patient's ability to dorsiflex. We have since performed this procedure on 4 additional patients with appropriate follow-up. Depending on the initial onset of foot drop and time to surgery, nerve transfer from flexor hallucis longus to anterior tibialis nerve branch may be considered as an adjunct to decompression and articular nerve branch ligation for the treatment of symptomatic peroneal intraneural ganglion.

Immediate Nerve Transfer for Treatment of Peroneal Nerve Palsy Secondary to an Intraneural Ganglion: Case Report and Review.

Intraneural ganglion cysts, which occur within the common peroneal nerve, are a rare cause of foot drop. The current standard of treatment for intraneural ganglion cysts involving the common peroneal nerve involves (1) cyst decompression and (2) ligation of the articular nerve branch to prevent recurrence. Nerve transfers are a time-dependent strategy for recovering ankle dorsiflexion in cases of high peroneal nerve palsy; however, this modality has not been performed for intraneural ganglion cysts involving the common peroneal nerve. We present a case of common peroneal nerve palsy secondary to an intraneural ganglion cyst occurring in a 74-year-old female. The patient presented with a 5-month history of pain in the right common peroneal nerve distribution and foot drop. The patient underwent simultaneous cyst decompression, articular nerve branch ligation, and nerve transfer of the motor branch to flexor hallucis longus to a motor branch of anterior tibialis muscle. At final follow-up, the patient demonstrated complete (M4+) return of ankle dorsiflexion, no pain, no evidence of recurrence and was able to bear weight without the need for orthotic support. Given the minimal donor site morbidity and recovery of ankle dorsiflexion, this report underscores the importance of considering early nerve transfers in cases of high peroneal neuropathy due to an intraneural ganglion cyst.

Les kystes mucoïdes nerveux du nerf fibulaire commun sont rarement responsables d'un pied tombant. La norme actuelle pour traiter ce type de kystes consiste à 1) décomprimer le kyste et 2) ligaturer le rameau nerveux pour éviter les récurrences. Les transferts nerveux doivent être effectués rapidement pour récupérer la dorsiflexion de la cheville en cas de paralysie importante du nerf fibulaire commun. Toutefois, cette intervention n'a jamais été effectuée en cas de kyste mucoïde nerveux. Les auteurs présentent le cas d'une femme de 74 ans atteinte d'une paralysie du nerf fibulaire commun causée par un kyste mucoïde nerveux. Cette femme a consulté parce qu'elle souffrait depuis cinq mois dans la distribution du nerf fibulaire commun droit et que son pied tombait. Elle a subi simultanément une décompression du kyste, une ligature du rameau nerveux articulaire et un transfert nerveux du rameau moteur du muscle long fléchisseur de l'hallux au rameau moteur du muscle tibial antérieur. Au dernier suivi, la patiente avait totalement retrouvé la dorsiflexion de sa cheville (M4+), ne présentait plus de douleurs ni de manifestations de récurrence et pouvait soutenir son poids sans orthèse. Étant donné la morbidité minime au site du donneur et la récupération de la dorsiflexion de la cheville, ce rapport fait ressortir l'importance d'envisager un transfert nerveux précoce en cas de neuropathie fibulaire importante causée par un kyste mucoïde nerveux.

Canadian Trends in Carpal Tunnel Surgery.

PURPOSE: Treatment patterns of carpal tunnel surgery by members of the American Society of Surgery of the Hand (ASSH) have recently been published. The majority of cases in this study were performed in the general operating room with intravenous (IV) sedation or a Bier block. Patients were most commonly prescribed hydrocodone for postoperative pain. The majority of carpal tunnel releases at our center are performed under local anesthesia alone, with plain acetaminophen (Tylenol) or codeine prescribed for postoperative pain. The authors were interested in determining whether these differences were specific to our center or whether there were nationwide differences among the Canadian Society of Plastic Surgery (CSPS) members compared to the ASSH members. We aimed to conduct a similar study to assess current trends across members of the CSPS to assess similarities and differences compared with current practices by members of the ASSH. METHODS: A 10-question survey, modeled after a previously published study, was sent electronically to Canadian plastic surgeons (n = 400). A description and a link to the survey was sent via e-mail and data were anonymously submitted and analyzed using descriptive statistics. RESULTS: The online survey was completed by 183 surgeons (46%). The local procedure room is used by 161 (surgeons 88%), whereas 15 surgeons (8%) used the general operating room. Subcutaneous local anesthetic is used by 98 surgeons (54%), a median nerve block by 68 (7%), a full wrist block used by 6 (3%), local anesthesia with IV sedation used by 6 (3%), a Bier block used by 3 (2%), and a general anesthetic used by 1 (0.5%). After surgery, 70 surgeons (38%) prescribed codeine, 49 (27%) prescribed plain paracetamol, 24 (13%) prescribed nonsteroidal anti-inflammatories, 21 (12%) prescribed tramadol, and 21 (12%) prescribed a narcotic stronger than codeine. CONCLUSIONS: Compared with data obtained from ASSH members, differences in practice by Canadian plastic surgeons responding to this survey appear to be related to type of anesthetic used and postoperative analgesia provided. The majority of procedures in this study were performed in a local procedure room under local anesthetic alone and the majority of patients are discharged with codeine or paracetamol. CLINICAL RELEVANCE: This study draws comparisons between Canadian plastic surgeons and members of the ASSH with respect to carpal tunnel surgery and adherence to the American Academy of Orthopaedic Surgeons Clinical Practice Guideline on the Diagnosis and Treatment of Carpal Tunnel Syndrome.

Immediate Nerve Transfer for the Treatment of Peroneal Nerve Palsy Secondary to an Intraneural Ganglion: Case Report and Review.

Intraneural ganglion cysts that occur within the common peroneal nerve are a rare cause of foot drop. The current standard of treatment for intraneural ganglion cysts involving the common peroneal nerve involves (1) cyst decompression and (2) ligation of the articular nerve branch to prevent recurrence. Nerve transfers are a time-dependent strategy for recovering ankle dorsiflexion in cases of high peroneal nerve palsy; however, this modality has not been performed for intraneural ganglion cysts involving the common peroneal nerve. We present a case of common peroneal nerve palsy secondary to an intraneural ganglion cyst occurring in a 74-year-old female. The patient presents with a 5-month history of pain in the right common peroneal nerve distribution and foot drop. The patient underwent simultaneous cyst decompression, articular nerve branch ligation, and nerve transfer of the motor branch to the flexor hallucis longus to a motor branch of the anterior tibialis muscle. At final follow-up, the patient demonstrated complete (M4+) return of ankle dorsiflexion, no pain, and no evidence of recurrence and was able to weight bare without the need of orthotic support. Given the minimal donor site morbidity and recovery of ankle dorsiflexion, this report underscores the importance of considering early nerve transfers in cases of high peroneal neuropathy due to an intraneural ganglion cyst.

Les kystes intraneuraux de ganglions qui se forment sur le péronier proximal sont une rare cause de pied tombant. La norme actuelle du traitement de ce type de kyste sur le péronier proximal comprend 1) la décompression du kyste et 2) la ligature de la ramification du nerf articulaire pour éviter une récurrence. Le transfert des nerfs est une stratégie limitée dans le temps pour récupérer la dorsiflexion de la cheville en cas de paralysie importante du péronier. Cependant, cette modalité n'a pas été utilisée pour traiter des kystes intraneuraux du ganglion touchant le nerf du péronier proximal. Les auteurs présentent le cas d'une paralysie du péronier proximal causée par un kyste intraneural de ganglion chez une femme de 74 ans. La patiente a consulté parce qu'elle ressentait une douleur dans le péronier proximal droit et avait un pied tombant depuis cinq mois. Elle a subi une décompression du kyste, une ligature de la ramification du nerf articulaire et le transfert du nerf de la ramification motrice du long fléchisseur de l'hallux à une ramification motrice du muscle du tibia antérieur. Au dernier suivi, elle présentait une récupération complète (M4+) de la dorsiflexion de la cheville, ne souffrait plus d'aucune douleur et n'avait aucune trace de récurrence. Elle pouvait supporter son poids sans orthèse. Compte tenu de la morbidité minime au site du donneur et de la récupération de la dorsiflexion de la cheville, le présent rapport fait ressortir l'importance d'envisager le transfert précoce des nerfs en cas de neuropathie importante du péronier causée par un kyste intraneural de ganglion.

Excision With Interpositional Nerve Grafting: An Alternative Technique for the Treatment of Morton Neuroma.

INTRODUCTION: "Morton neuroma" is a common cause of forefoot pain with numbness frequently occurring in the distribution of the third common digital nerve. After the failure of nonoperative measures, decompression with excision of the neuroma is common practice. Residual numbness and recurrent pain has been reported as a consequence of this treatment option. This study describes excision of the neuroma with interpositional nerve grafting as a treatment option for Morton neuroma. This proposed technique has the benefit of reducing pain, reducing recurrent secondary neuromas and restoring postexcision sensory deficits. METHODS: A retrospective chart review of patients who underwent elective primary excision of a Morton neuroma with interpositional nerve grafting was undertaken. Patient demographics, surgical technique, and clinical outcomes, such as pain, neuroma recurrence, 2-point discrimination, numbness, and weight-bearing status at minimum of 1 year postoperation, are reported. RESULTS: Eight patients (9 neuromas) underwent excision of the Morton neuroma with interpositional nerve grafting after failing nonoperative measures. At final follow-up, all patients had improvement of pain and there were no neuroma recurrences. Sensation to the grafted hemi-toe returned in all but 1 case. All patients returned to full weight-bearing status. Although no major complications were reported, wound dehiscence secondary to a hematoma occurred in 1 case. CONCLUSIONS: Excision and interpositional nerve grafting is an effective treatment for Morton neuroma as it alleviates pain, numbness and restores sensation with minimal morbidity and complications.

Immediate Great Toe Transfer for Thumb Reconstruction After Tumor Resection: Report of 3 Cases.

BACKGROUND: Modern oncologic surgery aims not only to obtain tumor-free margins but also to spare or reconstruct limb function and preserve quality of life. A negative tumor margin in the digit generally requires amputation; therefore, function is preserved with reconstruction. We report results of simultaneous ablative tumor resection and reconstruction with a great toe transfer in patients requiring surgery for aggressive benign and malignant thumb tumors. METHODS: Between 2000 and 2009, three patients with extensive soft tissue tumors of the distal thumb underwent amputation to obtain wide negative surgical margins. In each case, an immediate trimmed toe-to-thumb transfer was performed. Results, evaluated retrospectively, included a review of perioperative complications, donor-site morbidity, oncologic status, objective functional outcomes, and subjective patient satisfaction. RESULTS: Three patients were found with either locally aggressive benign (n = 1) or malignant (n = 2) tumors of the thumb. All patients underwent immediate reconstruction after amputation through the base of the proximal phalanx for tumor eradication. No perioperative complications were encountered, and all toes survived. Full thumb opposition and protective sensation were achieved in all patients. All patients returned to their previous occupation without functional limitations. There is no local or distant tumor recurrence. Delayed wound healing at the ipsilateral foot donor site occurred in all 3 patients. Wet-to-dry dressing changes were successful in 2 patients, whereas the third patient required full-thickness skin grafting. All patients were satisfied with their reconstruction. CONCLUSIONS: An immediate great toe-to-thumb transfer should be considered when thumb amputation is required to satisfy adequate oncologic margins. Such a transfer provides simultaneous restoration of digit length, position, sensation, and acceptable esthetics. This procedure is technically demanding and requires an experienced microsurgical team as well as appropriate patient counseling and consent before surgery.

Fixation and Grafting After Limited Debridement of Scaphoid Nonunions.

PURPOSE: To evaluate a surgical technique of treating nondisplaced waist and proximal pole scaphoid nonunions without avascular necrosis (AVN). METHODS: We performed a retrospective review of all patients with nondisplaced, scaphoid waist or proximal pole nonunions without AVN treated with the following technique. Two K-wires are positioned along the scaphoid axis to stabilize the proximal and distal poles. Debridement with a curette or burr is performed parallel to the nonunion site until the K-wires are visualized and punctate bleeding of the proximal and distal fragments is encountered. The volar, radial fibrous union is left intact. Distal radius cancellous bone graft is packed into the nonunion site. A headless screw is placed perpendicular to the fracture and the K-wires are removed. RESULTS: Between 2012 and 2014, 12 patients (ages 13-29 y) with clinical and radiographic evidence (10 had computed tomography or magnetic resonance imaging; 2 had radiographs only) of scaphoid nonunion were identified (10 transverse waist and 2 proximal pole fractures). Median interval from injury to surgery was 38 weeks (range, 3 mo to 9 y). Four patients were active smokers and 2 had failed previous iliac crest bone grafting. All patients healed as confirmed by computed tomography. Average time to union was 14 weeks (range, 6-31 wk). Four patients had delayed union requiring a bone stimulator. All patients had resolution of pain and there were no complications. CONCLUSIONS: The technique described is an effective and efficient method of treating nondisplaced scaphoid nonunions without AVN. We suggest that complete debridement of the nonunion is not essential to achieve union. In addition, pinning the proximal and distal scaphoid poles initially and maintaining the volar fibrous union of the scaphoid nonunion stabilizes the fracture fragments, increasing the technical ease of grafting and fixation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Nerve Transfers for Treatment of Isolated Axillary Nerve Injuries.

BACKGROUND: The most common neurological defect in traumatic anterior glenohumeral dislocation is isolated axillary nerve palsy. Most recover spontaneously; however, some have persistent axillary neuropathy. An intact rotator cuff may compensate for an isolated axillary nerve injury; however, given the high rate of rotator cuff pathology with advancing age, patients with an axillary nerve injury are at risk for complete shoulder disability. OBJECTIVE: To review reconstruction of the axillary nerve to alleviate shoulder pain, augment shoulder stability, abduction and external rotation to alleviate sole reliance on the rotator cuff to move and stabilize the shoulder. METHODS: A retrospective review of 10 patients with an isolated axillary nerve injury and an intact rotator cuff who underwent a triceps nerve branch to axillary nerve transfer was performed. Patient demographics, surgical technique, deltoid strength, donor-site morbidity, complications and time to surgery were evaluated. RESULTS: Ten male patients, mean age 38.3 years (range 18 to 66 years), underwent a triceps to axillary nerve transfer for isolated axillary nerve injury 7.4 months (range five to 12 months) post-traumatic shoulder dislocation. Deltoid function was British Medical Research Council grade 0/5 in all patients preoperatively and ≥3/5 deltoid strength in eight patients at final follow-up (14.8 months [range 12 to 25 months]). There were no complications and no donor-site morbidity. CONCLUSION: A triceps to axillary nerve transfer for isolated axillary neuropathy following traumatic shoulder dislocation improved shoulder pain, stability and deltoid strength, and potentially preserves shoulder function with advancing age by alleviating sole reliance on the rotator cuff for shoulder abduction and external rotation.

HISTORIQUE: La paralysie isolée du nerf axillaire est la principale anomalie neurologique après une dislocation glénohumérale traumatique antérieure. La plupart guérissent spontanément, mais certains souffrent de neuropathie axillaire persistante. Une coiffe des rotateurs intacte peut compenser une lésion isolée du nerf axillaire. Cependant, compte tenu du fort taux de pathologies de la coiffe des rotateurs liées au vieillissement, les patients ayant une lésion du nerf axillaire risquent une invalidité complète de l'épaule. OBJECTIF: Examiner la reconstruction du nerf axillaire pour soulager la douleur de l'épaule et en accroître la stabilité, l'abduction et la rotation externe afin d'éviter de se fier uniquement à la coiffe des rotateurs pour bouger et stabiliser l'épaule. MÉTHODOLOGIE: Les chercheurs ont procédé à l'analyse rétrospective de dix patients ayant une lésion isolée du nerf axillaire et une coiffe des rotateurs intacte qui ont subi un transfert de la branche du nerf du triceps sur le nerf axillaire. Ils ont évalué la démographie des patients, la technique chirurgicale, la force du deltoïde, la morbidité du site du donneur, les complications et le délai avant l'opération. RÉSULTATS: Dix patients de sexe masculin, d'un âge moyen de 38,3 ans (plage de 18 à 66 ans), ont subi un transfert du nerf du triceps sur le nerf axillaire en raison d'une lésion isolée du nerf axillaire, et ce, 7,4 mois (plage de cinq à 12 mois) après une dislocation traumatique de l'épaule. Chez tous les patients avant l'opération, la fonction du deltoïde était de 0 sur une échelle de 5 selon le British Medical Research Council, tandis que la force du deltoïde était d'au moins 3 sur 5 chez huit patients au suivi final (14,8 mois [plage de 12 à 25 mois]). Il n'y a eu aucune complication et aucune morbidité au site du donneur. CONCLUSION: Le transfert du nerf du triceps sur le nerf axillaire pour soigner une neuropathie axillaire isolée après une dislocation traumatique de l'épaule soulageait la douleur et la stabilité de l'épaule et la force du deltoïde et assurait la préservation potentielle de la fonction de l'épaule malgré le vieillissement, car la coiffe des rotateurs n'était plus l'unique mode d'abduction et de rotation externe de l'épaule.

The best of tendon and nerve transfers in the upper extremity.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Identify the prerequisite conditions to perform a tendon or a nerve transfer. 2. Detail some of the current nerve and tendon transfer options in upper extremity peripheral nerve injuries. 3. Understand the advantages and disadvantages of tendon and nerve transfers used in isolation and in combination. 4. Appreciate the controversies that surround the nerve/tendon transfers. 5. Realize the treatment outcomes of peripheral nerve injuries. SUMMARY: Traditional treatment of a Sunderland fourth- or fifth-degree peripheral nerve injury has been direct neurorrhaphy, nerve grafting, or tendon transfers. With increasing knowledge of nerve pathophysiology, additional treatment options such as nerve transfers have become increasingly popular. With an array of choices for treating peripheral nerve injuries, there is debate as to whether tendon transfers and/or nerve transfers should be performed to restore upper extremity function. Often, tendon and nerve transfers are used in combination as opposed to one in isolation to obtain the most normal functioning extremity without unacceptable donor deficits. The authors tend to prefer reconstructive techniques that have proven long-term efficacy to restore function. Nerve transfers are becoming more common practice, with excellent results; however, the authors are wary of using nerve transfers that sacrifice possible secondary tendon reconstruction should the nerve transfer fail.