Functioning Free Muscle Transplantation to Restore Finger Movement for Sequalae of Volkmann Ischemic Contracture.

Volkmann ischemic contracture (VIC) is a devastating condition that results from neglected compartment syndrome, which leads to prolonged ischemia, irreversible tissue necrosis, and various degrees of muscle and nerve damage, causing serious motor and sensory functional implications for the limb and a spectrum of diseases associated with worsening deformities. A thorough understanding of the anatomy and VIC pathophysiology is needed to plan an appropriate strategy. Functioning free muscle transplantation (FFMT) can restore finger movement in a paralyzed limb but requires a three-staged approach to maximize the benefits of FFMT, leading to meaningful finger extrinsic function.

Staged Phrenic Nerve Elongation and Free Functional Gracilis Muscle Transplantation-A Possible Option for Late Reconstruction in Chronic Brachial Plexus Injury.

PURPOSE: In patients with late brachial plexus birth injuries, sequelae after acute flaccid myelitis, or chronic adult brachial plexus injury, donor nerves for functioning muscle transplantation are often scarce. We present the results of a potential strategy using the phrenic nerve with staged free gracilis transplantation for upper extremity reanimation in these scenarios. METHODS: A retrospective review was performed on an institutional database of brachial plexus injury or patients with palsy. All patients underwent a staged reconstruction in which the ipsilateral phrenic nerve was extended by an autogenous nerve graft (PhNG), followed by free-functioning gracilis transplantation (PhNG-gracilis). RESULTS: Nine patients (6 cases of late brachial plexus birth injuries, 2 of acute flaccid myelitis, and 1 of adult chronic brachial plexus injury) were included in this study. The median follow-up period following the PhNG-gracilis procedure was 27 months (range, 12-72 months). The goals of the staged PhNG and PhNG-gracilis were primarily finger extension or finger flexion. In some patients, the technique was used to improve both elbow and finger function, tunneling the muscle through the flexor compartment of the upper arm and under the mobile wad at the elbow. All patients exhibited improvement of muscle strength, including in finger extension (4 patients) from M0 to M2; finger flexion (3 patients) from M0 to M3; elbow extension (1 patient) from M0 to M2; and elbow flexion (1 patient) from M2 to M4. CONCLUSIONS: A 2-stage PhNG-gracilis may restore or enhance the residual elbow and/or finger paralysis in chronic brachial plexus injuries. A minimum follow-up period of 3 years is recommended. This technique may remain useful as one of the last reconstructive options to increase power in patients with scarce donor nerves. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Phrenic Nerve as an Alternative Donor for Nerve Transfer to Restore Shoulder Abduction in Severe Multiple Root Injuries of the Adult Brachial Plexus.

PURPOSE: Nerve transfer is the gold standard to restore shoulder abduction in acute brachial plexus injuries. The aim of this study was to compare the phrenic nerve (Ph) to the spinal accessory nerve (XI) as the donor nerve for this purpose. METHODS: A retrospective chart review was performed on 136 patients with acute brachial plexus injuries who received a nerve transfer of the shoulder with either the Ph (94 patients) or XI (42 patients). Each group was divided into 3 subgroups based on the recipient nerve. The maximum degree of shoulder abduction was recorded after 2 years of postoperative follow-up. A generalized estimating equation model was performed to examine the variables affecting shoulder abduction over time. RESULTS: The maximum degrees of shoulder abduction achieved were 61.9° ± 38.7° in patients with Ph and 51.1° ± 37.3° in patients with XI. More than M3 shoulder abduction was achieved by 67% of patients with Ph versus 59% of patients with XI. The regression analysis showed that the age at the time of surgery correlated more with the functional outcome over time than the choice of donor nerve. CONCLUSIONS: In multiple root brachial plexus injuries, the Ph exhibited similar outcomes to the XI for shoulder abduction. Our routine exploration of the supraclavicular plexus exposes the Ph conveniently for nerve transfer. The phrenic nerve should be considered as an alternative when the XI is not available or is reserved for secondary reconstruction. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Thoracic Outlet Syndrome: Past and Present-88 Surgeries in 30 Years at Chang Gung.

BACKGROUND: Thoracic outlet syndrome (TOS) is a highly controversial clinical entity. There is much debate on its terminology, existence, diagnosis, and treatment. The purpose of this study was to describe our opinions about these controversial topics of TOS and the treatment of TOS over the past 30 years. METHODS: From 1985 to 2014, a total of 80 patients underwent decompressive surgery for TOS. Eight patients requested a second surgery on the contralateral limb. They all had at least 1-year follow-up. Preoperative evaluation included provocative tests, plain X-ray, magnetic resonance angiography/computed tomography angiography, and electromyography. Surgical intervention for each patient involved a supraclavicular approach and near-total resection of the anterior scalene muscle and the first rib and of any cervical rib if it was present. Rib resection was performed with the use of Kerrison bone punch forceps. The operative time was typically 2 hours. RESULTS: Major postoperative complications were rare. Nearly all patients (98%) experienced significant symptom relief, with improvement in soreness and tightness of the shoulder, neck, and arm immediately on the first postoperative day or within a few weeks thereafter. There were no cases with symptoms recurring. CONCLUSIONS: It is evident that decompressive surgery through a supraclavicular approach for TOS not only is an effective and safe procedure but also provides a diagnosis of the cause of TOS. For a patient who meets the criteria for surgical indication, decompressive surgery usually results in resolution of symptoms and no recurrence.

Reconstruction of the buccal mucosa following release for submucous fibrosis using two radial forearm flaps from a single donor site.

BACKGROUND: Oral submucous fibrosis is a collagen disorder affecting the submucosal layer and can severely limit mouth opening. The use of bilateral forearm flaps to fill buccal defects following trismus release has proven to be effective and reliable. However, it requires the sacrifice of radial arteries from both forearms. We have developed a technique that allows for the harvest of two independent flaps from a single forearm donor site. METHODS: Two separate flaps are designed on the same radial artery and concomitant vein pedicle. The distal flap is marked in the standard fashion and the proximal skin paddle is designed in the middle third of the forearm, based on septocutaneous branches of the radial artery. The two flaps are elevated and subsequently divided into two independent free flaps. Between June 2004 and June 2007, a total of 16 flaps were harvested from eight donor sites for buccal mucosa defects following trismus release. Improvements in mouth opening and buccal pliancy were evaluated by comparing preoperative and postoperative inter-incisal distance (IID) and maximal mouth capacity. RESULTS: All flaps survived completely, and all donor sites were closed primarily, except for one. The mean flap size was 6.6x2.6cm (range: 6x2.5cm-7x3cm), mean pedicle length was 5.7cm, mean ischaemia time was 46min and mean total operating time was 8h 45min. At an average of 19.8 months follow-up, the inter-incisal distance averaged 29.13mm, an increase of 20.88mm compared with the preoperative measurement. The maximal mouth capacity averaged 55.63cc, an increase of 9.38cc compared with the preoperative measurement. CONCLUSION: Two independent small flaps can be harvested safely from one radial forearm donor site. This approach is a useful option for reconstruction of bilateral buccal defects, particularly following submucous fibrosis release. The donor-site morbidity is minimal and limited to one forearm.