Motor Branching Pattern of the Radial Nerve for Hyperselective Neurectomy: From Anatomy to Clinical Translation.

PURPOSE: Predominant or isolated spasticity of the triceps following upper motor neuron injury is rare and often unmasked once the spastic elbow flexors are addressed. The purpose of this study was to delineate the motor branching pattern of the radial nerve to determine the feasibility of hyperselective neurectomies (HSN) for triceps spasticity. METHODS: Dissections of the motor branch to each triceps head were performed on 11 upper-extremity specimens. The numbers of trunks, branching patterns, and muscle entry points were recorded in reference to the acromion to interepicondylar line. Based on anatomic studies, 10 patients underwent a combined fractional lengthening and HSN procedure for triceps spasticity. Patient demographics, time from diagnosis, and complications were recorded. Preoperative and postoperative Modified Ashworth Scale (MAS) and total active elbow arc of motion were compared. RESULTS: The first branch from the radial nerve was consistently a single trunk to the long triceps head. There were many variations in the branching pattern and number of trunks to the lateral and medial heads of the triceps with motor entry points between 31% and 95% of the acromion to interepicondylar line distance. Ten patients (six men and four women; mean age: 48.5 years) underwent the combined procedure. Mean total active elbow arc of motion improved from 78° before surgery to 111° after surgery, with a 17.5° increase in active elbow flexion. Compared with a mean preoperative triceps MAS of 2.75, nine patients had triceps MAS of 0 at a mean of 10.2 months of follow-up. There was no loss of functional elbow extension and no directly related complications. CONCLUSIONS: Given the variable motor entry points, HSN to each triceps head would require extensive dissection. Therefore, a combined approach consisting of fractional lengthening of the long head and lateral head with HSN of the triceps medial head is recommended to address triceps spasticity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

The Effects of Radial Longitudinal Deficiency on Long-Term Use of the Thumb in Pediatric Patients Following Index Pollicization.

PURPOSE: To assess the effect of radial longitudinal deficiency on the function of pollicized digits as determined by the Thumb Grasp and Pinch (T-GAP) assessment. METHODS: We retrospectively evaluated 25 hands with thumb hypoplasia that underwent index finger pollicization. Patients were followed for an average of 10.4 years. Hands were divided by severity into two groups: no or mild radial longitudinal deficiency (RLD) (Group 1 = 16) and moderate to severe RLD (Group 2 = 9). We collected demographic information and completed physical examination measures, including hand strength, elbow, wrist, and hand range of motion, the Kapandji opposition score, active grasp span, and T-GAP total score. RESULTS: Patients with moderate to severe forms of RLD had stiffer long fingers, lower Kapandji opposition scores, and limited active and passive range of motion for elbow flexion, wrist ulnar deviation, and pollicized thumb interphalangeal flexion. They had shorter forearms, decreased active grasp span, and fewer thumb creases at the interphalangeal thumb joint. In addition, the T-GAP total score was significantly lower when comparing the two groups. Children with mild dysplasia were able to achieve 32% of age-matched normal grasp strength. Patients with more severe radial dysplasia averaged 17% less grasp strength compared with children with mild dysplasia. Patients with moderate to severe RLD also had lower T-GAP total scores and strength measurements if they had limited wrist ulnar deviation. CONCLUSIONS: Individuals with moderate to severe RLD have unique anatomical factors that affect outcomes after pollicization. These individuals use their thumbs for fewer activities, have weaker grasp, and retain more primitive grasp patterns compared with those who have milder forms of RLD. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Combined Wrist Extensor Tenodesis and Tendon Transfers for Severe Spastic Flexed Wrist Deformity: Surgical Technique and Case Series.

Spastic wrist flexion deformities both limit the functional use of the hand for grasp and pinch producing a stigmatizing appearance. Tendon transfers and total wrist arthrodesis are treatment options for this condition depending on the patient's characteristics, the latter the most commonly used in patients with severe wrist flexion deformities. Tendon transfers alone in this scenario have the tendency for recurrent deformity due to tenorrhaphy failure or soft tissue creep and resultant loss of tension. Total wrist arthrodesis is a more invasive procedure, which can have hardware or fusion problems and that is irreversible. We propose a novel technique that incorporates a distally based wrist extensor tendon slip and suture tape tenodesis to the distal radius. The rationale of this technique is to act as a protective, internal splint to prevent recurrent deformity after primary or revision tendon transfer for moderate to severe spastic flexed wrist deformities, avoiding the need to perform a total wrist arthrodesis.

Proximal Row Carpectomy With Soft Tissue Interposition: A Systematic Review of Clinical Outcomes.

Proximal row carpectomy (PRC) with soft tissue interposition arthroplasty (STIA) presents an alternative approach to addressing wrist arthritis patterns involving the capitate and/or lunate fossa, in lieu of wrist arthrodesis. This systematic review aimed to evaluate clinical outcomes and techniques associated with PRC-STIA in patients with advanced wrist arthritis. We conducted a systematic review using databases including PubMed, Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials. Inclusion criteria involved articles reporting outcomes of patients who underwent PRC-STIA with at least 1 relevant outcome. The analysis encompassed 8 studies involving 106 patients (108 wrists) meeting the inclusion criteria. A majority of patients were men (69%, n = 88), with a mean age of 54.4 ± 12.7 years and an average follow-up of 4.8 ± 6.3 years. Dorsal capsule was the most commonly interposed tissue (63%, 5 out of 8 studies). Patients receiving STIA achieved comparable patient-reported outcome measures scores to those undergoing PRC alone. Postoperative pain, measured by the Visual Analog Scale, averaged 3.7 ± 0.6. The Disabilities of the Arm, Shoulder, and Hand score averaged 27.8 ± 8, while the Patient-Rated Wrist Evaluation score averaged 41.5 ± 25.9. Five complications were reported in three studies. The addition of STIA into PRC for patients with capitate and/or lunate fossa cartilage degeneration yielded outcomes akin to traditional PRC, improving wrist function, pain, and grip strength in a safe and straightforward manner. Future research should prioritize high-quality comparative studies, extended follow-up periods, and standardized core outcome measures for a more comprehensive understanding of its role in wrist arthritis treatment.

Human alveolar lining fluid from the elderly promotes Mycobacterium tuberculosis intracellular growth and translocation into the cytosol of alveolar epithelial cells.

The elderly population is highly susceptible to developing respiratory diseases, including tuberculosis, a devastating disease caused by the airborne pathogen Mycobacterium tuberculosis (M.tb) that kills one person every 18 seconds. Once M.tb reaches the alveolar space, it contacts alveolar lining fluid (ALF), which dictates host-cell interactions. We previously determined that age-associated dysfunction of soluble innate components in human ALF leads to accelerated M.tb growth within human alveolar macrophages. Here we determined the impact of human ALF on M.tb infection of alveolar epithelial type cells (ATs), another critical lung cellular determinant of infection. We observed that elderly ALF (E-ALF)-exposed M.tb had significantly increased intracellular growth with rapid replication in ATs compared to adult ALF (A-ALF)-exposed bacteria, as well as a dampened inflammatory response. A potential mechanism underlying this accelerated growth in ATs was our observation of increased bacterial translocation into the cytosol, a compartment that favors bacterial replication. These findings in the context of our previous studies highlight how the oxidative and dysfunctional status of the elderly lung mucosa determines susceptibility to M.tb infection, including dampening immune responses and favoring bacterial replication within alveolar resident cell populations, including ATs, the most abundant resident cell type within the alveoli.

Lesiones del plexo braquial en adultos: una revisión narrativa de la literatura / Brachial plexus injuries in adults: a narrative review of the literature

La patología traumática del plexo braquial comprende un amplio espectro de lesiones potencialmente devastadoras para la funcionalidad de los pacientes. El objetivo del presente trabajo es realizar una revisión narrativa de la literatura enfocada en el diagnóstico y estudio de las lesiones del plexo braquial en adultos, además de entregar nociones básicas sobre el manejo de esta compleja patología

Traumatic brachial plexus injuries comprise a wide spectrum of lesions that are potentially devastating to the functionality of the patients. The aim of the present review is to perform a narrative review of the literature focused on the diagnosis and study of brachial plexus injuries in adults, in addition to providing basic guidelines on the management of this complex pathology.