Objective Evaluation of Laparoscopic Experience Based on Muscle Electromyography and Accelerometry Performing Circular Pattern Cutting Tasks: A Pilot Study.

Purpose.The aim of this work is to present a new physical laparoscopy simulator with an electromyography (EMG)/accelerometry-based muscle activity recording system, EvalLap EMG-ACC, and perform objective evaluation of laparoscopic skills based on the quantification of muscle activity of participants with different levels of laparoscopic experience. Methods. EMG and ACC signals were obtained from 14 participants (6 experts, 8 medical students) performing circular pattern cutting tasks using a laparoscopic box trainer with the Trigno (Delsys Inc, Natick, MA) portable wireless system of 16 wireless sensors. Sensors were placed on the proximal and distal muscles of the upper extremities. Seven evaluation metrics were proposed and compared between skilled and novice surgeons. Results. The proximal and distal arm muscles (trapezius, deltoids, biceps, and forearms) were most active while executing laparoscopic tasks. Laparoscopic experience was associated with differences in EMG amplitude (Aavg), muscle activity (iEMG), hand acceleration (iACH), user movement (iAC), and muscle fatigue. For the cutting task, the deltoid, bicep, forearm EMG amplitude, and user movement significantly differed between experience groups. Conclusion. This pilot study demonstrates that different muscle groups are preferentially activated during laparoscopic tasks depending on the level of surgical experience. Expert surgeons showed less muscle activity compared with novices. EvalLap EMG-ACC represents a promising means to distinguish surgeons with basic cutting skills from those who have not yet developed these skills.

Terminal nerve entry points' locations to muscles of the thigh for selective peripheral neurectomy in the adult population: a cadaveric study.

PURPOSE: Spasticity is the result of a variety of lesions to the central nervous system and one of the most common causes of disability worldwide. Selective peripheral neurectomy (SPN) is a surgical procedure that permanently decreases focal spasticity. The authors' objective is to provide recommendations, in terms of probabilities, for locating terminal motor entry points to muscles of the thigh, as alternatives for proximal incision sites to SPN. METHODS: The femoral, obturator, and sciatic nerves, and its corresponding motor rami, were systematically dissected on cadaveric specimens, and terminal motor entry points to each muscle of the thigh were located and carefully measured, relative to the length of the thigh. Measurement distributions were obtained and normal transformations were used when necessary. RESULTS: In 23 adult cadaveric specimens, 779 motor rami were dissected. Entry points' locations are presented as a percentage of the length of the thigh in means and standard deviations, which roughly corresponds to 64 and 95% probability of finding a motor entry point. CONCLUSION: Alternative incisions directly over the motor entry points, for the muscles of the thigh, may be helpful when considering SPN as treatment for focal spasticity. A prior degree of certainty of the location of the nerve to be severed may simplify surgical approach.

Bilateral Ulnar Nerve Injury in the Wrist: Comparison of First Webspace Muscle Reconstruction by Opponens Nerve Transfer in the Right Hand Versus Direct Ulnar Nerve Repair in the Left Hand.

We report a case of a bilateral glass injury to the wrist with transection of flexor tendons and the ulnar nerve and artery in a 60-year-old male patient. Two days after his accident, we repaired all divided structures, and on the right hand, we added the transfer of the opponens motor branch to the deep terminal division of the ulnar nerve aimed at first dorsal interosseous and adductor pollicis muscle reinnervation. After surgery, the patient was followed over 24 months. Postoperative dynamometry of the hand, which included grasping, key-pinch, subterminal-key-pinch, pinch-to-zoom, and first dorsal interosseous muscle strength, indicated recovery only in the nerve transfer side.

Carotid artery and soft tissue reconstruction with superficial femoral artery-sartorius muscle-anteromedial thigh chimeric free flap: A case report and review of the literature.

Tumoral involvement of the carotid artery may require en-bloc resection in order to achieve a better regional control. Among the carotid reconstruction methods at disposal, autologous tissues appear to be more reliable in cases with high risk of infection and poor tissue healing like in radiated necks. We describe a case of a 55 year old man, who suffered from recurrent squamous cell carcinoma in the neck region, invading the common carotid artery. After en-bloc resection of the tumor together with skin, internal jugular vein, vagus nerve and common carotid artery, carotid reconstruction was performed with a flow-through chimeric flap based on superficial femoral vessels (15 cm). After resection of the tumor, the flap was used to replace the soft tissue defect (23 × 12 cm). Anteromedial thigh skin paddle (8 × 5 cm) and sartorius muscle (12 × 3 cm) were included in the flap. The superficial femoral vessels were reconstructed with 8-mm ringed polytetrafluoroethylene graft interposition. Thanks to an accurate surgical planning and a 2-team approach, the ischemia time of the leg was 42 min and there were no limb ischemia nor pathologic neurological signs after surgery. During the 12-month follow up, no other complication was registered. In our experience, microsurgical carotid reconstruction represents a reliable option with important advantages such as resistance to infection, optimal size matching, and good tissue healing between the irradiated carotid stump and the vascular graft.

Surgical Anatomy of the Endoscopic Gastrocnemius Recession.

The objective of this investigation was to analyze the surgical anatomy of the endoscopic gastrocnemius recession procedure with reference to the curved nature of the aponeurosis. A consecutive series of 34 magnetic resonance imaging scans were evaluated under the direction of a musculoskeletal radiologist. An angular calculation of the effective curvature of the aponeurosis was measured 2 cm distal to the musculotendinous junction based on the maximal posterior excursion and terminal medial and lateral edges. A frequency count was additionally performed of the number of deep intramuscular septa extending from the aponeurosis, as well as a description of the location of the neurovascular bundle in this location. The mean effective curvature was 126.5 degrees (standard deviation [SD] = 6.3 degrees, range 115-143 degrees, 95% confidence interval 124.3-128.7 degrees). We observed an average of 1.2 (SD = 0.5, range = 0-2) deep intramuscular septa extending from the aponeurosis, and that 20.6% of neurovascular bundles were located superficial to the aponeurosis in this location. In conclusion, we found that a straight cannula needs to be navigated around an approximate 125-degree angle during performance of the EGR procedure. We think that this information provides evidence of potentially unrecognized complications of this procedure and leads to future investigations demonstrating anatomic and procedural outcomes.

Serie de casos: colgajo sóleo-gastrocnemio en pacientes con defectos de partes blandas en miembros inferiores / Case series: soleo-gastrocnemius muscle flap in patients with defects of soft tissue-lower limbs

Antecedentes: La exposición ósea puede ser consecuencia de fracturas traumáticas abiertas o cerradas con complicaciones, así como secundarias a procesos infecciosos. La cobertura del miembro inferior con defecto cutáneo se basa en la preservación de la perfusión sanguínea y nerviosa para favorecer la consolidación ósea y así el salvamento del miembro. Descripción de los casos: Se describe la reconstrucción con colgajo muscular rotacional pediculado de sóleo y/o gastrocnemio en 16 pacientes con complicaciones asociadas a fracturas expuestas en miembros inferiores con defectos de partes blandas y pérdida de cobertura cutánea, realizados en el Servicio de Ortopedia y Traumatología del Hospital Escuela (HE) durante el período 2012-2015. Se realizó colocación de colgajo con sóleo en 50.0% (8/16) y gastrocnemio en 50.0% (8/16). El éxito terapéutico calificado quirúrgica y funcionalmente fue del 87.5% (14/16). Conclusión: Con la técnica de reconstrucción realizada a estos pacientes se logró disminuir la frecuencia de complicaciones y por consiguiente evitar la amputación de la extremidad afectada...(AU)

The proximal humeral attachment of the lateral head of the triceps brachii: a cadaveric study and potential site for radial nerve compression.

BACKGROUND: Knowledge of potential compression sites of peripheral nerves is important to the clinician and surgeon alike. One anatomical location for potential compression of the radial nerve, which is rarely mentioned in the literature, is at the proximal humeral attachment of the lateral head of the triceps brachii at the level of the proximal spiral groove. As no anatomical studies have been devoted to this band, the present study was conducted. METHODS: Ten adult fresh-frozen cadavers were dissected and the lateral head's attachment onto the posterior humerus evaluated for a band. This anatomy and its relation to the radial nerve during range of motion of the elbow and forearm were evaluated. RESULTS: A band was found on 15 of 20 arms. On five sides, the band was comprised of grossly muscle fibers of the lateral head of the triceps brachii and was not tendinous. The bands were crescent-shaped, straight, and duplicated on nine, five, and one arm, respectively. The length of the bands ranged from 1.1 to 2.2 cm (mean 1.54 cm). The width of the bands ranged from 0.5 to 1.1 cm (mean 0.8 cm). With elbow extension and the forearm in neutral, all bands were lax. With elbow extension and the forearm supinated, the bands became tauter less the muscular bands. In elbow extension and with the forearm in supination, the bands became most taut less the muscular bands. CONCLUSIONS: The presence of a fibrous band extending from the lateral head of the triceps brachii is common and should be among the differential diagnoses of anatomical sites for potential proximal radial nerve compression when other more common locations are ruled out.

Medial Hemisoleus Flap for Middle Third of the Tibia Defects.

Covering soft tissue defects of the tibia is challenging, especially in the presence of underlying osseous trauma. The soleus muscle flap remains the treatment of choice for soft tissue defects in the middle third of the tibia. The flap is reliable and requires a relatively short operative time while maintaining minimal donor site morbidity. However, when the muscle flap is performed without a modified fasciocutaneous composite, it requires a split-thickness skin graft. Muscle flaps have the additional advantage of improving vascularity and fighting infection.

New Surgical Model for Bone-Muscle Injury Reveals Age and Gender-Related Healing Patterns in the 5 Lipoxygenase (5LO) Knockout Mouse.

Signaling lipid mediators released from 5 lipoxygenase (5LO) pathways influence both bone and muscle cells, interfering in their proliferation and differentiation capacities. A major limitation to studying inflammatory signaling pathways in bone and muscle healing is the inadequacy of available animal models. We developed a surgical injury model in the vastus lateralis (VL) muscle and femur in 129/SvEv littermates mice to study simultaneous musculoskeletal (MSK) healing in male and female, young (3 months) and aged (18 months) WT mice compared to mice lacking 5LO (5LOKO). MSK defects were surgically created using a 1-mm punch device in the VA muscle followed by a 0.5-mm round defect in the femur. After days 7 and 14 post-surgery, the specimens were removed for microtomography (microCT), histopathology, and immunohistochemistry analyses. In addition, non-injured control skeletal muscles along with femur and L5 vertebrae were analyzed. Bones were microCT phenotyped, revealing that aged female WT mice presented reduced BV/TV and trabecular parameters compared to aged males and aged female 5LOKO mice. Skeletal muscles underwent a customized targeted lipidomics investigation for profiling and quantification of lipid signaling mediators (LMs), evidencing age, and gender related-differences in aged female 5LOKO mice compared to matched WT. Histological analysis revealed a suitable bone-healing process with osteoid deposition at day 7 post-surgery, followed by woven bone at day 14 post-surgery, observed in all young mice. Aged WT females displayed increased inflammatory response at day 7 post-surgery, delayed bone matrix maturation, and increased TRAP immunolabeling at day 14 post-surgery compared to 5LOKO females. Skeletal muscles of aged animals showed higher levels of inflammation in comparison to young controls at day 14 post-surgery; however, inflammatory process was attenuated in aged 5LOKO mice compared to aged WT. In conclusion, this new model shows that MSK healing is influenced by age, gender, and the 5LO pathway, which might serve as a potential target to investigate therapeutic interventions and age-related MSK diseases. Our new model is suitable for bone-muscle crosstalk studies.

Remodeling of the soleus muscle of ovariectomized old female rats submitted to resistance training and different diet intake.

Sarcopenia is a common condition that is associated mainly with hormonal factors, nutritional status, physical activity, leading to a lower quality of life. Thus, this study aimed to evaluate the effects of diets with vegetable or animal proteins (AP) associated with resistance training on the structure of the soleus muscle in aged Wistar rats. The histochemical technique was used for the typing of muscle fibers, the cross-sectional area of myocytes, and volume densities of myocytes and interstitium. Picrosirius stain was used to quantify the collagen density. Diet intake, mainly animal protein, associated with resistance training leaded to muscle remodeling, and increased deposit of collagen fibers. We observed hypertrophy in animal groups that consumed animal protein diet, even the sedentary group, although more evident in those trained.

Suprapectoral biceps tenodesis with bicortical drilling procedures: anatomic analysis of chondral and axillary nerve risk with transhumeral pin guide.

BACKGROUND: Many biceps tenodesis (BT) procedures are described for treating proximal biceps pathology. Axillary nerve injury has been reported during BT using bicortical drilling techniques with variable results depending on the location. In addition, there is a risk of potential articular damage during suprapectoral BT. We sought to determine the distance between the axillary nerve and the posterior passage of a bicortical pin, as well as the risk of articular damage, and to analyze whether a lateral inclination of the pin could avoid the chondral risk during suprapectoral BT with bicortical drilling. METHODS: Ten cadaveric shoulders were divided into 2 groups. In the first group, we determined the axillary nerve distance from the posterior exit point of 3 pins in a suprapectoral position 15 mm distal to the humeral cartilage: perpendicular, 10° caudal, and 20° caudal inclination. We measured 2 distances from the pin: to the axillary nerve and to the cartilage border. In the second group, we set one pin at the same perpendicular position and set the second pin 15° laterally tilted to determine its extra-articular passage. RESULTS: No pin injured the nerve, whereas all pins showed a transchondral direction. The 20° caudal inclination was the nearest to the nerve (18.8 mm [95% confidence interval, 5.5-32 mm]), but the perpendicular position was the safer position (38.8 mm [95% confidence interval, 28-49.6 mm]). Tilting the pin direction 15° laterally prevented cartilage damage (P = .008). CONCLUSIONS: Suprapectoral BT with bicortical drilling performed 15 mm distal to the humeral cartilage is a safe procedure regarding the axillary nerve. A potential humeral chondral injury could be prevented with 15° of lateral inclination of the pin guide.

Complications of Arthroscopic Versus Open Biceps Tenodesis in the Setting of Arthroscopic Rotator Cuff Repairs: An Analysis of the American Board of Orthopaedic Surgery Database.

INTRODUCTION: The purpose of this study was to compare complication rates between arthroscopic versus open biceps tenodesis in the setting of arthroscopic rotator cuff repair and to determine the effect of fellowship training on complication rates. METHODS: The American Board of Orthopaedic Surgery database was used to identify cases of arthroscopic and open biceps tenodesis in the setting of rotator cuff repair between 2012 and 2016. Surgical, medical, and anesthetic complications, location, fellowship training, surgery year, and patient demographic data were recorded. Overall and specific complication rates were calculated and analyzed. Chi-square or Fisher exact tests were used to determine statistical significance. RESULTS: Altogether, 1,725 cases of arthroscopic biceps tenodesis and 1,637 cases of open biceps tenodesis with arthroscopic rotator cuff repair were analyzed. No significant difference was found between overall complication rates between arthroscopic (11.4%) versus open (13.1%) biceps tenodesis (P = 0.14). Although open tenodesis had statistically significant higher rates of wound healing issues (0.7% versus 0.2%, P = 0.02), hematoma/seroma formation (0.5% versus 0.1%, P = 0.02), nerve injury (1.5% versus 0.4%, P < 0.01), deep vein thrombosis (0.49% versus 0.12%, P ≤ 0.05), and general anesthetic complications (0.75% versus 0.06%, P = 0.03), these rates remain comparably low. Shoulder arthroscopy fellowship-trained surgeons were more likely to use arthroscopic techniques than non-fellowship-trained surgeons (P < 0.01) but had a higher complication rate (P = 0.01). DISCUSSION: No differences were found in overall complication rates between open and arthroscopic biceps tenodesis in the setting of rotator cuff repairs. Although open techniques had statistically significant higher rates of nerve injury, wound complications, and hematoma/seroma formation, this may not reflect clinical significance because these complication rates remained <2% in both techniques. Higher complication rates were seen among fellowship-trained surgeons, which may reflect greater case complexity. Both open and arthroscopic biceps tenodesis in the setting of rotator cuff repair show low complication rates, and the technique should be based on surgeon preference and patient factors. LEVEL OF EVIDENCE: Level IV, case series.

Partial traumatic amputation of an upper limb with excellent functional recovery: A 13-year follow-up clinical case.

Introducción: Se han publicados pocos informes sobre el seguimiento a largo plazo de la reparación quirúrgica de una amputación parcial. Algunos estudios de largo plazo han registrado tasas similares de discapacidad entre los pacientes con amputaciones y los sometidos a operación reconstructiva. Objetivo: Informar un caso clínico de una amputación traumática parcial de una extremidad superior con recuperación funcional después de 13 años de seguimiento. Caso clínico: Paciente masculino de ocho años con traumatismo grave en la extremidad superior izquierda, desprendimiento de los músculos bíceps y tríceps y una fractura diafisaria oblicua del húmero distal. La fractura se fijó de manera transitoria con alambres de Kirschner de 2.0 mm, seguido de inmovilización con aparato de Sarmiento y al final se realizó reducción abierta y fijación interna con placa de compresión dinámica de 3.5 mm. La integridad muscular y neurovascular permitió la reparación microquirúrgica del nervio radial y la rehabilitación neuromuscular. Conclusiones: Este informe clínico representa un caso de una recuperación funcional excelente atestiguada a través de un periodo de seguimiento de 13 años.

Introduction: There are just a few reports that deal with long-term outcomes of a partial amputation surgical repair. Long-term studies have reported similar rates of disability among patients with amputations and those that have been undergoing reconstructive surgery. Objective: The purpose of this report is describing a clinical case of a patient with partial traumatic amputation of an upper limb with an excellent functional recovery after 13 years of follow-up. Clinical case: The case of an 8 year old male patient with severe trauma to the upper left limb is described. The lesions included an oblique diaphyseal open fracture of the distal region of the humerus, along with detachment of the biceps and triceps muscles. The fracture was fixed transiently with 2.0 mm Kirschner's wire followed by immobilization with Sarmiento's brace, and finally, open reduction and internal fixation with a 3.5 mm dynamic compression plate were performed. The muscular and neurovascular integrity allowed microsurgical repair of the radial nerve and neuromuscular rehabilitation. Conclusion: This clinical report represents a case with an excellent functional recovery witnessed through a 13-year follow-up period.

Anatomical study of the transfer of flexor digitorum superficialis nerve branch of median nerve to restore wrist extension and forearm pronation.

OBJECTIVE: To analyze the anatomical variations of the innervation of the flexor digitorum superficialis muscle and to determine if the branch of the median nerve that supply this muscle is connected to the branches to the extensor carpi radialis brevis and the pronator teres muscles, without tension, and how close to the target-muscles the transfer can be performed. METHODS: Fifty limbs of 25 cadavers were dissected to collect data on the anatomical variations of the branches to the flexor digitorum superficialis muscle. RESULTS: This muscle received innervation from the median nerve in the 50 limbs. In 22 it received one branch, and in 28 more than one. The proximal branch was identified in 22 limbs, and in 12 limbs it shared branches with other muscles. The distal branch was present in all, and originated from the median nerve as an isolated branch, or a common trunk with the anterior interosseous nerve in 3 limbs, and from a common trunk with the flexor carpi radialis muscle and anterior interosseous nerve in another. It originated distally to the anterior interosseous nerve at 38, in 5 on the same level, and in 3 proximal to the anterior interosseous nerve. In four limbs, innervation came from the anterior interosseous nerve, as well as from the median nerve. Accessory branches of the median nerve for the distal portion of the flexor digitorum superficialis muscle were present in eight limbs. CONCLUSION: In 28 limbs with two or more branches, one of them could be connected to the branches to the extensor carpi radialis brevis and pronator teres muscles without tension, even during the pronation and supination movements of the forearm and flexion-extension of the elbow.

Surgical Exposures for Total Elbow Arthroplasty.

Indications for total elbow arthroplasty (TEA) were traditionally reserved for patients with advanced rheumatoid disease and posttraumatic conditions of the elbow. The indications have expanded for TEA to include patients with acute elbow trauma, dysfunctional instability, and end-stage osteoarthritis. Many of these patients are younger and place a greater demand on their TEA. This evolution of TEA use combined with the concern of soft tissue handling and triceps function has led to increased interest regarding surgical exposure for TEA. Three generalized approaches to TEA are predicated on the handling of the triceps tendon: triceps reflecting, triceps splitting, and triceps sparing. Each of these approaches has its own inherent advantages and disadvantages. As indications grow for TEA and the possibility of revision surgery increases with use in younger, higher demand patients, it is important for treating surgeons to use these various exposures so that they are capable of treating patients in a variety of settings.

Critical evaluation of the surgical techniques to correct the equinus deformity. / Avaliação crítica das técnicas cirúrgicas de correção do equino.

The equinus deformity causes changes in the foot contact and may affect more proximal anatomical regions, such as the knee, hip and trunk, potentially leading to gait disorders. The equinus is usually secondary to retraction, shortening and/or spasticity of the triceps surae, and it may require surgical correction. Surgery for the correction of equinus is one of the oldest procedures in Orthopedics, and it was initially performed only at the calcaneus tendon. The technique has evolved, so that it could be customized for each patient, depending on the degree of deformity, the underlying disease, and patient´s profile. The aim is to correct the deformity, with minimal interference in muscle strength, thus reducing the incidence of disabling complications such as crouch gait and calcaneus foot. We conducted a literature search for the most common surgical techniques to correct the equinus deformity using classic books and original articles. Further, we performed a database search for articles published in the last ten years. From the anatomical perspective, the triceps surae presents five anatomical regions that can be approached surgically for the equinus correction. Due to the complexity of the equinus, orthopedic surgeons should be experienced with at least one procedure at each region. In this text, we critically approach and analyze the most important techniques for correction of the equinus, mainly to avoid complications.

A deformidade em equino leva a diversos transtornos da marcha, ao causar alterações no apoio do pé e afetar regiões anatômicas mais distantes, como o joelho, quadril e tronco. Geralmente é secundária à retração, encurtamento ou espasticidade do tríceps sural, de modo que algumas intervenções cirúrgicas podem ser necessárias para corrigi-la. Trata-se de um dos procedimentos mais antigos da Ortopedia, antes realizado apenas no tendão calcâneo e que, ao longo do tempo, evoluiu com técnicas diferentes de acordo com o grau de deformidade, doença de base e perfil do paciente. Busca-se corrigir a deformidade, com a menor interferência possível na força muscular e, com isso, diminuir a incidência de complicações, como marcha agachada, arrastada e pé calcâneo. Do ponto de vista anatômico, o tríceps sural apresenta cinco regiões que podem ser abordadas cirurgicamente para correção do equino. Em virtude da complexidade do paciente com equino, os ortopedistas devem ter experiência com ao menos uma técnica em cada zona. Neste texto são abordadas e analisadas criticamente as técnicas mais importantes para correção do equino, principalmente de modo a evitar complicações. Foi realizada uma busca sobre técnicas cirúrgicas mais comuns de correção do equino em livros clássicos e identificação e consulta aos artigos originais. Em seguida, fez-se uma busca em bases de dados nos últimos dez anos.

Linear and nonlinear measures of gait variability after anterior cruciate ligament reconstruction.

The objective of this study was to assess gait variability after anterior cruciate ligament reconstruction (ACLR), as an indicative of possible altered gait pattern and a measure of recovery compared to control subjects. Forty subjects (32 male), divided into 4 groups of 10 participants, were enrolled in the study: a control group (CG), and observational groups OG-I (90 days), OG-II (180 days), and OG-III (360 days) after ACLR. All subjects underwent the same rehabilitation program for six months. For kinematic recording, each subject walked on a treadmill for 4 min at a preferred walking speed. Linear gait variability was assessed using average standard deviation (VAR) and normalized root mean square of medial-lateral (ML) trunk acceleration (RMSratio). Gait stability was assessed using the margin of stability (MoS) and local dynamic stability (LDS), and nonlinear variability was assessed using sample entropy (SEn). Compared to the CG, the VAR ML increased significantly in the OG-I group and decreased incrementally in OG-II and OG-III. MoS increased significantly in the OG-I group and tends to maintain in OG-II and OG-III, while LDS was greater in the CG and decreased incrementally in the OG groups. The SEn was higher in the OG groups than in the CG and increased in OG-II and OG-III. The results indicated that ACL reconstruction was followed by a progressive increase in stability and a progressive increase in variability over the postoperative rehabilitation period. In terms of stability and gait variability, six months of physiotherapy for rehabilitation after ACL reconstruction appears to be effective, but it is insufficient for a complete recovery as compared to healthy individuals.

Technique tip: EDL-to-EHL double loop transfer for extensor hallucis longus reconstruction.

BACKGROUND: Extensor hallucis longus (EHL) tendon injuries often occur in the setting of lacerations to the dorsum of the foot. End-to-end repair is advocated in acute lacerations, or in chronic cases when the tendon edges are suitable for tension free repair. Reconstruction with allograft or autograft is advocated for cases not amenable to a primary direct repair. This is often seen in cases with tendon retraction and more commonly in the chronic setting. In many countries the use of allograft is very limited or unavailable making reconstruction with autograft and tendon transfers the primary choice of treatment. Tendon diameter mismatch and diminished resistance are common issues in other previously described tendon transfers. METHODS: We present the results of a new technique for reconstruction of non-reparable EHL lacerations in three patients using a dynamic double loop transfer of the extensor digitorum longus (EDL) of the second toe that addresses these issues. RESULTS: At one-year follow up, all patients recovered active/passive hallux extension with good functional (AOFAS Score) and satisfaction results. No reruptures or other complications were reported in this group of patients. No second toe deformities or dysfunction were reported. CONCLUSIONS: Second EDL-to-EHL Double Loop Transfer for Extensor Hallucis Longus reconstruction is a safe, reproducible and low-cost technique to address EHL ruptures when primary repair is not possible. LEVEL OF EVIDENCE: IV (Case Series).

Post-operative nerve injuries after cervical spine surgery.

Although relatively rare, post-operative nerve injuries may occur after cervical spine procedures. The most common post-operative neural disorder is C5 nerve palsy. The risk factors for C5 nerve palsy are male gender, OPLL, and posterior cervical approaches. It generally presents with deltoid and/or biceps weakness, and may present immediately or several days after surgery. Treatment is generally conservative due to transient duration of symptoms, but evaluation of residual compression at C4-5 is essential. PTS (Parsonage-Turner syndrome) is an idiopathic plexopathy generally presenting with severe neuropathic pain in the shoulder, neck, and arms, followed by neurological deficits involving the upper brachial plexus. The deficits typically present in a delayed fashion after the onset of pain. Once residual nerve compression is ruled out, initial treatment is based on pain control and physical therapy. Post-operative C8-T1 nerve palsies occur with weakness of the five intrinsic muscles of the hand innervated by the medial nerve, with sensory symptoms in the territory innervated by the ulnar nerve (ulnar two digits of the hand), and also the medial forearm. The risk factors for C8-T1 nerve injuries after surgery are C7 pedicle subtraction osteotomies and posterior fixation of the cervico-thoracic junction, especially in patients with preoperative C7-T1 stenosis. A wide foraminal decompression at C7-T1 region is necessary to minimize risk of this complication. Finally, Horner's syndrome can occur post-operatively, especially after anterolateral approaches to the middle and lower levels of the cervical spine. It is characterized by ipsilateral papillary miosis, facial anhydrosis, and ptosis secondary to injury of the cervical sympathetic nerves. Avoid using the cautery on the lateral border of the longus colli muscle, where the sympathetic chain lies and place the retractors properly underneath the muscle to decrease the chance of sympathetic injuries. It can also occur from iatrogenic compression or injury to the T1 nerve root, as the sympathetic chain gets some of its fibers from that level. Understanding the most common potential nerve injuries after cervical spine procedures is helpful in prevention, early diagnosis, and appropriate management.