A systematic review of clinical and laboratory studies comparing vascularised versus non-vascularised nerve grafts in peripheral nerve reconstruction.

BACKGROUND: Peripheral nerve injuries (PNIs) are common, with complex defects posing a significant reconstructive challenge. Although vascularised (VNGs) and non-vascularised nerve grafts (NVNGs) are established treatment options, there is no comprehensive summary of the evidence supporting their clinical, electrophysiological, and histological outcomes. This review aims to systematically evaluate the clinical and laboratory literature comparing VNGs and NVNGs to inform future clinical practice and research. METHODS: This review was prospectively registered and reported according to PRISMA guidelines. PubMed, EMBASE, SCOPUS, and the Cochrane Register were systematically searched. Studies comparing VNGs and NVNGs in PNIs were included. Meta-analyses were performed for outcomes reported in ≥3 laboratory studies. Functional outcomes were synthesised by vote-counting based on direction of effect for clinical studies. Risk-of-bias was assessed using RoB2, ROBINS-I, and SYRCLE, and the certainty of evidence was evaluated using GRADE. RESULTS: Seven clinical and 34 laboratory studies were included. Of the clinical comparisons, 90% and 56% identified an effect on recovery of sensibility (p = 0.01) and motor function (p = 0.05), respectively, that favoured VNGs. Nine (of 13) separate meta-analyses of laboratory studies demonstrated reduced muscular atrophy, superior axonal regeneration, and remyelination in VNGs. VNGs eliminated the 3-day interval of ischaemia otherwise sustained by NVNGs. Overall, the quality of evidence was low. CONCLUSION: This systematic review indicates that VNGs may offer some advantages over NVNGs in PNI reconstruction. However, due to the low quality of evidence, significant statistical heterogeneity, and clinical diversity of the included studies, these conclusions should be interpreted with caution. Further high-quality clinical trials are necessary to validate these findings.

Neurolysis of the Long Thoracic Nerve for Scapular Winging due to Isolated Serratus Anterior Palsy: Early and Midterm Results in 29 Patients.

Objective: This study aimed to report our surgical outcomes of thoracic long thoracic nerve (LTN) decompression in patients with isolated LTN palsy, using a clinical scoring system designed to facilitate the grading of scapular winging severity. Methods: This was a retrospective review of patients who had undergone decompression and neurolysis of the LTN for scapular winging. Each patient underwent needle electromyography of the serratus anterior for confirmation of diagnosis and were refractory to a minimum of 6 months of nonoperative management. Preoperatively and at final follow-up, shoulder range of motion and the Wrightington Winging Score (WWS) was used to objectively grade the dynamic and static components of winging. Results: Between 2014 and 2020, 29 patients who underwent thoracic neurolysis for scapular winging were analyzed. These were 16 males and 13 females with a mean age of 37 years. The injury mechanism was due to trauma in 19 cases and neuralgic amyotrophy in 10. The median duration between winging onset and surgery was 30 months. There were significant improvements in mean active shoulder abduction and forward flexion. Winging was noticeably improved in 22 patients. At presentation, the median WWS was 3, which improved to 1 at final follow-up. Conclusion: In patients with isolated LTN palsy causing persistent scapular winging which is not responsive to conservative treatment, neurolysis of the thoracic portion of the LTN can be considered. Level of Evidence: IV.

Round table discussion: the management of idiopathic cubital tunnel syndrome.

Idiopathic cubital tunnel syndrome is the second most common neuropathy in the upper limb. Best evidence regarding the surgical management of this condition has evolved from anterior or submuscular transposition as the former reference standard, to in situ simple release. Differences of opinion remain regarding the timing of surgery, type of surgery and adjunctive surgery. Four surgeons with Level 5 expertise were asked to answer specific questions regarding this condition.

Long Thoracic Nerve Palsy: When Is Decompression Indicated.

Scapular winging due to long thoracic nerve palsy can occur through traumatic injuries and nontraumatic events. The traditional view is that most patients will achieve spontaneous recovery within 2 years of winging onset. However, there is evidence that points to a less clear-cut natural history, with residual winging, muscle weakness, and fatigability being exhibited in a significant percentage of patients. Reports from proponents of a more proactive approach have shown that the surgical decompression of the long thoracic nerve beyond 12 months, through thoracic, supraclavicular, or combined approaches, can yield satisfactory results. This review examines our current understanding of long thoracic nerve palsy and explores the varying treatment strategies with their reported outcomes.

Outcome of Nerve Grafting for Radiation-Induced Brachial Plexopathy.

BACKGROUND: There is no consensus on the optimal treatment for radiation-induced brachial plexopathy (RIBP). OBJECTIVE: To present our experience of using nerve resection and autografting as a treatment strategy for this challenging condition. METHODS: From September 2014 to January 2020, 8 patients with RIBP were treated with segmental nerve resection and autografting, with or without other supplementary procedures. All patients underwent sural nerve grafting to the musculocutaneous nerve. All were female with a mean age of 53 (range 38-64) years. Seven were on the left, and 1 was on the right. The mean follow-up duration was 33 (range 17-72) months. RESULTS: By the final review, 7 of 8 patients regained at least antigravity elbow flexion. Four patients reached Medical Research Council (MRC) grade 4, 3 MRC grade 3, and MRC grade 2 recovery in the biceps. The mean Visual Analog Score for pain improved from 2.6 preoperatively to 0.6 postoperatively ( P = .042). CONCLUSION: Nerve resection and autografting may restore satisfactory elbow flexion in patients with RIBP.

Patterns of Nerve Injury and Recovery Rates of Infraclavicular Brachial Plexus Lesions Following Anterior Shoulder Dislocation.

PURPOSE: We reviewed our cases of infraclavicular brachial plexus injuries associated with anterior shoulder dislocation to determine patterns of injury, recovery rates, and factors associated with a poor motor outcome. METHODS: This was a retrospective review of patients who had sustained a concomitant nerve injury following dislocation of the glenohumeral joint treated with closed manipulation. The data collected included patient demographics, injury factors, and patterns of neurological deficits. The Medical Research Council (MRC) grade for motor power was the primary outcome measure, where a grade of 4 or 5 was regarded as achieving good motor recovery. Univariate and multivariable analyses were used to identify factors associated with persistent motor weakness (MRC grades 0-3) at the final follow-up. RESULTS: Between 2015 and 2019, 61 patients were assessed. There were 36 males and 25 females, with a median age of 64 years (interquartile range [IQR], 53-73 years). Four patterns of injury were identified: (1) isolated axillary nerve lesions; (2) single cord lesions; (3) combined lesions involving the medial and posterior cords; and (4) diffuse lesions affecting all 3 cords. Of 28 patients with isolated axillary nerve injuries, 22 recovered. All lateral cord injuries (11/11) and 20 of 24 posterior cord injuries recovered spontaneously. Recovery of hand intrinsic function from medial cord injuries had the worst outcome, with 14 of 27 patients not recovering beyond MRC grades 0 to 3. The median duration of dislocation before reduction was 6 hours (IQR, 3-12 hours). A multivariate analysis showed an association between the duration of shoulder dislocation and the likelihood of persistent motor weakness. CONCLUSIONS: Shoulder dislocations with motor deficits should be regarded as orthopedic emergencies and reduced expediently. Persistent motor weakness may be associated with a prolonged duration of dislocation prior to glenohumeral relocation. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Outpatient Neuromodulation May Avert the Need for Surgery in Patients with Painful Cutaneous Neuromas.

Background: Traumatic neuromas are a result of abnormal neural regeneration after nerve injury. Neuropathic pain arising from neuroma can be debilitating. Methods: This was a retrospective review of a consecutive series of patients who presented with a painful cutaneous neuroma secondary to direct trauma or surgery. The diagnosis was made by the presence of neuropathic symptoms in the dermatome of a cutaneous nerve and a positive Tinel sign. Local anaesthetic injection was performed for confirmation of diagnosis. Each patient was offered optimisation of medical therapy and physiotherapy for desensitisation. Outpatient neuromodulation was offered as an alternative to neuroma surgery. The primary aim of treatment was symptom reduction such that neuroma surgery was no longer required. Results: This study included 50 patients with painful cutaneous neuromas. Surgery was the commonest cause. The most frequently injured nerves were superficial radial nerve, digital nerve and dorsal ulnar cutaneous nerve, together comprising over 60% of cases. After receiving neuromodulation, 18 (36%) patients experienced sufficient symptom relief and did not wish to pursue neuroma surgery. Conclusions: Surgery is the commonest cause of a painful cutaneous neuroma. Following optimisation of pharmacotherapy and physiotherapy, neuromodulation may offer symptom relief such that neuroma surgery may be avoided in approximately one third of cases.

Scapular winging secondary to serratus anterior dysfunction: analysis of clinical presentations and etiology in a consecutive series of 96 patients.

BACKGROUND: This study aimed to establish the relative incidence of etiologies causing serratus anterior (SA) dysfunction in patients with proven abnormality on needle electromyography. METHODS: This was a retrospective review of patients with scapular winging secondary to SA dysfunction. Each patient underwent a detailed clinical, radiological, and neurophysiological assessment to arrive at the precise etiological diagnosis. Patients with atypical clinical features were referred for a neurologist's assessment. Hematological and genetic testing were requested at the discretion of the neurologist. A scapular winging severity score based on clinical signs was devised to aid clinical grading. RESULTS: Between 2014 and 2020, a consecutive series of 108 patients with suspected SA dysfunction were assessed, of whom 96 met the inclusion criteria. There were 34 females and 62 males, with a mean age of 38 years (range, 15-77 years). Winging affected the right scapulae in 69 patients, the left scapulae in 17 patients, and was bilateral in 10 patients. This was caused by a myopathic disorder in 12 (12%) patients. Eighty-four (88%) patients had a long thoracic nerve lesion, caused by cervical pathology (2), iatrogenic injury (2), trauma (33), and neuralgic amyotrophy (NA) (47). Among those with NA, winging resolved spontaneously within 3 years of onset in 22 patients (mean duration, 16 months; range, 3-36 months). No patients recovered fully if their duration of winging lasted longer than 3 years. Patients with palsy secondary to NA tended to have a worse severity of winging than those due to a traumatic cause (P = .04). CONCLUSION: NA accounted for approximately half of the patients with SA dysfunction; therefore, it is essential to also consider the differentials of myopathy, trauma, iatrogenic injury, and spinal pathology. We recommend the judicious employment of ancillary tests and a low threshold of referral to a neurologist, in order to arrive at the exact diagnosis to accurately guide patient treatment.

Sequential spontaneous compartment syndrome in multiple limbs in a young adult with GYG1 gene mutation.

Compartment syndrome is a surgical emergency requiring immediate intervention. Majority of compartment syndromes are associated with trauma or surgery. Spontaneous compartment syndrome in multiple limbs is rare and alternative diagnosis should be sought. We report a young adult man who developed compartment syndrome in all four limbs sequentially over 4 years. On further evaluation, he was found to have a gene mutation in exon 3 of GYG1 gene. Spontaneous compartment syndrome in patients with GYG1 gene mutation does not appear to have been previously recognised. Although a direct causality cannot be confidently drawn, this gene is involved in muscle energy utilisation and is known to cause metabolic defect. Acute compartment syndrome, once diagnosed, warrants emergency surgical decompression. The subsequent management of spontaneous compartment syndrome demands a thorough medical assessment to identify any underlying metabolic or genetic predisposition.

Wrist arthroscopy for the treatment of scaphoid delayed or nonunions and judging the need for bone grafting.

This study reports outcomes of arthroscopy in the treatment of delayed or nonunions of 25 scaphoids (25 patients). The surgery was performed between 8 and 43 weeks after injury. Intraoperatively, 11 fractures were deemed stable to probing and underwent percutaneous screw fixation only; 14 were unstable and received arthroscopic bone grafting with percutaneous screw fixation. All fractures united. At a mean follow-up of 21 months (range 12-48), the mean Mayo wrist score was 96, and patient-rated wrist evaluation was 4, and the flexion-extension arc was 90% of the contralateral wrist. We conclude that arthroscopy is valuable in the treatment of scaphoid delayed or nonunions and in judging the need for bone grafting. Our data indicate that regardless of cystic formation in the scaphoid, bone grafting is not always necessary. Percutaneous fixation alone is sufficient when scaphoid delayed or nonunions are between 8 weeks and 1 year following injury, without scaphoid nonunion advanced collapse or dorsal intercalated segment instability, and when forceful probing confirms stability of the scaphoid arthroscopically. Level of evidence: IV.

Wide-Awake Wrist and Small Joints Arthroscopy of the Hand.

The minimally invasive nature of wrist and small joint arthroscopy renders it particularly suitable for the application of the wide-awake local anesthesia no tourniquet (WALANT) technique. The application of WALANT wrist and small joint arthroscopy has given surgeons the ability to visualize both static and dynamic movements of a joint, to show the pathology and discuss with the patient, and to visualize a patient's repaired structures. This reinforces confidence in surgeons and encourages patients to comply with postoperative rehabilitation.

The Palmar Cutaneous Branch Mimicking the Recurrent Motor Branch of the Median Nerve.

We report an unusual anatomical variant of the palmar cutaneous branch (PCB) of the median nerve in a 46-year-old man presenting with recurrent carpal tunnel syndrome. At surgery, after neurolysis, the PCB was visualized arising at the level of the proximal margin of the transverse carpal ligament, mimicking the appearance of the recurrent motor branch. To date, there has been no description of this branch arising at this level. We aim to remind surgeons of this variation and highlight the importance of maintaining vigilance to avoid iatrogenic nerve injury.

Effect of immobilization of the distal interphalangeal joint of fingers on grip strength.

Arthrodesis of the distal interphalangeal joint of the finger is an effective salvage treatment for end-stage arthropathy of the joint. This study aimed to evaluate the effect of simulated fusion of individual distal interphalangeal joints on the overall grip strength of the hand. Custom moulded thermoplastic splints were used to simulate fusion by immobilizing the index, middle, ring and little fingers' distal interphalangeal joints in turn in both hands of 56 healthy participants. Testing was performed with no immobilization and after immobilization of each of the individual digits. Grip strengths reduced significantly following immobilization of the distal interphalangeal joint. The degree of reduction became progressively more pronounced from the index to the little fingers (12%, 18%, 24% and 25%, respectively) and was similar for the dominant and non-dominant hands. This information may have clinical application when counselling patients regarding fusion of the distal interphalangeal joint of the fingers.

Management of Atraumatic Posterior Interosseous Nerve Palsy.

The posterior interosseous nerve (PIN) is susceptible to a number of traumatic and atraumatic pathologies. In this article, we aim to review our current understanding of the etiology, pathology, diagnosis, treatment options, and published outcomes of atraumatic PIN palsy. In general, the etiology of atraumatic PIN palsy can be divided into mechanical, which is caused by an extrinsic compressive force on the nerve, and nonmechanical, which is caused by an intrinsic inflammatory reaction within the nerve. As per this discussion, there are 3 causes for atraumatic PIN palsy. These are entrapment neuropathy, Parsonage-Turner syndrome, and spontaneous "hourglass" constriction. The typical presentation of atraumatic PIN palsy is a patient with spontaneous onset of weakness of fingers/thumb metacarpophalangeal joints extension. However, the wrist extension is preserved with radial deviation due to preservation of extensor carpi radialis longus/brevis function. Magnetic resonance imaging is the imaging of choice and neurophysiology is indicated in all patients. If there is an obvious structural cause of the nerve palsy, prompt decompression and removal of the causative lesion are recommended to avoid irreversible damage to the nerve/muscles. Otherwise, in general, we would recommend consideration for exploration should there be no sign of recovery after 6 weeks of observation.

When can a professional athlete return to play following scapholunate ligament delayed reconstruction?

BACKGROUND: The aim of this study was to determine the outcomes in relation to return-to-play in professional athletes who had undergone a delayed scapholunate ligament reconstruction. METHODS: We searched our prospectively managed database and identified 15 professional athletes who had undergone the modified Brunelli procedure for scapholunate instability. They were contacted to complete a telephone interview. We established the duration between the operation and return-to-play, the level of competition before and after the procedure and if applicable, reasons for reduction in the level of competition. RESULTS: Between 2008 and 2011, 15 professional male athletes underwent the modified Brunelli procedure. One was lost to follow-up and 14 athletes (11 rugby, 2 boxing and 1 golf) were contactable. The mean age of the patients was 30 years (range 18-42). The mean follow-up period was 25 months (range 3-43). Eleven of the 14 (79%) athletes returned to play within 4 months of surgery. By the final review, 9 of the 14 (64%) athletes had returned to play at their preinjury level of competition. CONCLUSIONS: A majority (approximately 80%) of professional athletes return to competitive playing within 4 months of undergoing a scapholunate ligament reconstruction. Approximately two-thirds return to play at their preinjury level of competition.

Symptomatic chronic long head of biceps rupture: Surgical results.

PURPOSE: Chronic rupture of the long head of biceps (LHB) tendon is usually asymptomatic. However, some active patients suffer with long-term cramping pain associated with repetitive biceps use. The aim of this study is to review the outcomes of biceps tenodesis performed for chronic LHB ruptures. MATERIALS AND METHODS: We performed a retrospective review of 11 consecutive patients who underwent biceps tenodesis for symptomatic chronic LHB ruptures over a 4-year period. RESULTS: There were 10 men and one woman with an average age at surgery of 41 years (range 23-65). The mean follow-up was 29 months (range 6-60). In five cases a tendon was still identifiable and suitable for repair with an 'in-bone' interference screw. However, in six cases the tendon was not possible to tenodese with an interference screw. In these cases we used an 'on-bone' technique with suture anchors. All, except one, patients reported improvement in their arm pain (78%), strength (74%) and appearance. All, except one, were glad to have had the surgery. CONCLUSIONS: Symptomatic chronic LHB ruptures improve with a biceps tenodesis procedure. Due to the chronicity of the injury and possible degeneration of the tendon, a suitable tendon for 'in-bone' tenodesis may not be possible. In these cases an 'on-bone' footprint repair with suture anchors achieves good results. LEVEL OF EVIDENCE: IV (retrospective case series).

An aid to the explanation of surgical risks and complications: the International Spinal Surgery Information Sheet.

STUDY DESIGN: Presentation and analysis of a patient information sheet. OBJECTIVE: To produce an evidence-based information sheet that will serve as an aide-memoire to the process of taking informed consent prior to spinal surgery. SUMMARY OF BACKGROUND DATA: Consent for a surgical intervention is the end of a process of discussion between the surgeon and the patient. It is essential that the patient has been provided with sufficient information to make an informed judgment as to whether the benefits of a proposed procedure will outweigh its risks. METHODS: We searched MEDLINE, the Cochrane database of systematic reviews and personal libraries for articles reporting complications of the surgical treatment of spinal diseases with particular reference to the most commonly treated conditions. A draft document was drawn up referencing the odds of specific complications. This was circulated to the National Health Service Scotland Central Legal Office for scrutiny and to an English language expert at the University of Edinburgh for translation to lay English. Finally, the document was issued to 50 patients in the outpatient clinic and scored on visual analog scales (VAS) for the ease of understanding, usefulness, and length. RESULTS: The product of this project was a two-page A4 sheet, with the front page outlining information applicable to spinal surgery "in general" and a back page detailing all common risks, relating to a headline procedure, that a Court of Law would expect a surgeon to discuss. The patients' VAS score (0-10) for "ease of understanding" was 8.8 ± 1.3 and for "usefulness" 8.9 ± 1.0 (means ± SD). Forty-three of 50 patients (86%) indicated that the length of the document was "just right" and seven (14%) of them that it was "too long." CONCLUSION: The ISSiS is user friendly and can be employed as a tool in the process of obtaining consent.