Rehabilitation Following Nerve Transfer Surgery.

Nerve transfer surgery is an important new addition to the treatment paradigm following nerve trauma. The following rehabilitation plan has been developed over the past 15 years, in an interdisciplinary, tertiary peripheral nerve program at the "Roth|McFarlane Hand and Upper Limb Centre." This center evaluates more than 400 patients with complex nerve injuries annually and has been routinely using nerve transfers since 2005. The described rehabilitation program includes input from patients, therapists, physiatrists, and surgeons and has evolved based on experience and updated science. The plan is comprised of phases which are practical, reproducible and will serve as a framework to allow other peripheral nerve programs to adapt and improve the "Roth|McFarlane Hand and Upper Limb Centre" paradigm to enhance patient outcomes.

Comparing Flap Advancement and Wound Coverage of Anterograde Homodigital Neurovascular Island Flap Designs: A Cadaveric Model.

PURPOSE: Anterograde homodigital neurovascular island flaps are a reconstructive option for volar fingertip injuries and confer the advantage of preserving fingertip sensation after surgery. However, the amount of flap advancement and wound coverage provided by stepwise and triangular flap designs remains unknown. This study sought to investigate how incremental proximal dissection of the pedicle influences flap advancement and whether advancement and/or coverage differ between the triangular and stepwise flap designs using 22 paired cadaveric digits. METHODS: Flap advancement and wound coverage were evaluated in a pairwise design such that each pair of digits received 1 stepwise flap and 1 triangular flap. After creating a standardized injury to the volar fingertip, pedicled flaps were dissected from the middle phalanx and advanced distally under consistent tension. Advancement was measured for each 5 mm of proximal mobilization of the pedicle to a maximum of 30 mm. RESULTS: On average, 2.6 ± 0.2 mm of flap advancement could be achieved for every 10 mm of pedicle mobilization. With 30 mm of proximal mobilization of the pedicle, 11.8 ± 2.8 mm of advancement and 57.2% ± 16.1% of wound coverage could be expected. There were no significant differences between the flap designs. CONCLUSIONS: The stepwise and triangular anterograde homodigital neurovascular island flaps offer comparable and consistent reconstructive outcomes for volar fingertip injuries. CLINICAL RELEVANCE: The findings in this study suggest that the choice of flap design need not be influenced by the considerations of advancement or coverage; rather, surgeon preference or technical differences between the 2 flap designs may be of more importance.

Reverse End-to-Side Anterior Interosseous Nerve-to-Ulnar Motor Transfer for Severe Ulnar Neuropathy.

BACKGROUND: Reverse end-to-side anterior interosseous nerve transfer has been reported to enhance treatment of severe, proximal ulnar neuropathy. The authors report on patients with severe neuropathy treated with ulnar nerve transposition and distal reverse end-to-side anterior interosseous nerve transfer. METHODS: Thirty patients with severe ulnar neuropathy at the elbow were reviewed. Clinical parameters included preoperative and postoperative Medical Research Council muscle strength, clawing, and degree of wasting. Electrodiagnostic data included compound motor action potential and sensory nerve action potential amplitudes. Summary statistics were used for demographic and clinical data. The t test and Wilcoxon signed rank test were used where appropriate. RESULTS: Average follow-up was 18.6 months. Preoperatively, 20 patients had Medical Research Council less than or equal to grade 1 in hand intrinsics, small finger sensory nerve action potentials were absent in all patients except for three, and average compound motor action potentials were severely reduced (absent in nearly 40 percent) confirming severity. All groups had a statistically significant increase in strength. More than three-quarters of patients noted partial or complete resolution of clawing and intrinsic muscle wasting. Seventy-three percent of patients regained Medical Research Council greater than or equal to grade 3 and 47 percent achieved Medical Research Council greater than or equal to grade 4. Mean time to observation of nascent units was 8.5 months, and 77 percent of patients demonstrated an augmentation of motor unit numbers with forearm pronation on needle electromyography CONCLUSION:: Proximal subcutaneous ulnar nerve transposition when combined with reverse end-to-side anterior interosseous nerve-to-ulnar nerve transfer demonstrates significant clinical and electrodiagnostic improvement of intrinsic muscle function. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Test-retest reliability of near-fibre jiggle in the ulnar intrinsic hand muscles.

OBJECTIVE: Near-fibre (NF) jiggle is one method of measuring the shape variability of motor unit potentials (MUPs) from successive firings during voluntary contractions. MUP shape variability has been associated with neuromuscular stability and health. The purpose of this study was to analyze the test-retest reliability of NF jiggle in the ulnar nerve innervated intrinsic hand muscles of healthy subjects. METHODS: Twenty healthy adult were tested (Mean age = 23.2 ±â€¯1.9; 8 females). Measurements of NF jiggle were assessed with a standard concentric needle during mild-moderate contractions from the first dorsal interosseous (FDI), the abductor digiti minimi (ADM), and the forth dorsal interosseous (4DI) muscles. Test-retest reliability were evaluated using intraclass-correlation coefficient (ICC). RESULTS: NF jiggle showed good test-retest reliability in the FDI, ADM and 4DI muscles with ICC values of 0.86, 0.85, and 0.87, respectively. The SEM for the FDI, ADM, and 4DI were 1.9%, 2.1%, and 2.5%. Finally, the MDC of the FDI, ADM and 4DI were 4.4%, 5.0%, and 7.1%. CONCLUSION: To date, this is the first investigation to explore NF jiggle in the intrinsic hand muscles. NF Jiggle demonstrates good test-retest reliability coefficients and with low measurement error.

Spinal accessory nerve injury: A potentially missed cause of a painful, droopy shoulder.

BACKGROUND: Spinal accessory nerve (SAN) injury can be an overlooked cause of scapular winging and shoulder dysfunction. The most common etiology is iatrogenic injury following surgical procedures at the posterior triangle of the neck. We present three cases of isolated injury to the SAN following trauma. OBJECTIVE: To improve detection of SAN injuries through highlighting the clinical presentation, diagnosis and treatment via three cases in which the injuries were initially missed. METHODS: Clinical case series and narrative review. RESULTS: Three (3) patients were evaluated by history, physical exam and electrodiagnostic study (EMG). Clinical symptoms included, a painful, droopy shoulder and difficulties with overhead activities. Clinical signs included the observation of scapular winging, and focal atrophy of the trapezius and in some cases the sternocleidomastoid (SCM). Novel clinical signs such as the active elevation lag sign and triangle sign were also helpful clinically to highlight the SAN as the site of pathology. EMG revealed denervation and reduced motor unit recruitment in the trapezius and SCM. CONCLUSIONS: Early detection of SAN injuries can be improved through appropriate clinical suspicion, a detailed history and careful physical exam. EMG testing can help guide prognosis, direct conservative and surgical treatment, and reduce patient morbidity.

Nerve transfers and neurotization in peripheral nerve injury, from surgery to rehabilitation.

Peripheral nerve injury (PNI) and recent advances in nerve reconstruction (such as neurotization with nerve transfers) have improved outcomes for patients suffering peripheral nerve trauma. The purpose of this paper is to bridge the gap between the electromyographer/clinical neurophysiologist and the peripheral nerve surgeon. Whereas the preceding literature focuses on either the basic science behind nerve injury and reconstruction, or the surgical options and algorithms, this paper demonstrates how electromyography is not just a 'decision tool' when deciding whether to operate but is also essential to all phases of PNI management including surgery and rehabilitation. The recent advances in the reconstruction and rehabilitation of PNI is demonstrated using case examples to assist the electromyographer to understand modern surgical techniques and the unique demands they ask from electrodiagnostic testing.