Defects of the sciatic nerve and its divisions treated by direct suturing in 90 degrees knee flexion: report on the first clinical series.

OBJECTIVE: To evaluate functional results after treatment of large defects of the sciatic nerve and its divisions by direct nerve suturing in high knee flexion. METHODS: A retrospective review was conducted in patients treated for lower extremity nerve defects between 2011 and 2019. Inclusion criteria were a defect > 2 cm with a minimal follow-up period of 2 years for the sciatic nerve and 1 year for its divisions. Nerve defects were bridged by an end-to-end suture with the knee flexed at 90° for 6 weeks. Functional results were assessed based on the Medical Research Council's grading system. RESULTS: Seventeen patients with a mean age of 27.6 years were included. They presented with seven sciatic nerve defects and ten division defects, including eight missile injuries. The mean time to surgery was 12.3 weeks and the mean nerve defect length was 5 cm. Overall, 21 nerve sutures were performed, with eight in the tibial distribution and 13 in the fibular distribution. Post-operatively, there was no significant knee stiffness related to the immobilization. The mean follow-up time was 24.5 months. Meaningful motor and sensory recovery were observed after 7 of 8 sutures in the tibial distribution and 11 of 13 sutures in the fibular distribution. A functional sural triceps muscle with protective sensibility of the sole was restored in all patients. There were no differences according to the injury mechanisms. CONCLUSION: Temporary knee flexion at 90° allows for direct coaptation of sciatic nerve defects up to 8 cm, with promising results no matter the level or mechanism of injury.

Treatment of upper extremity nerve defects by direct suturing in high elbow or wrist flexion.

PURPOSE: To evaluate functional outcomes after direct suturing of upper extremity nerve defects in high elbow or wrist flexion. METHODS: A retrospective review was conducted in patients treated for median, ulnar, or radial nerve defects between 2011 and 2019. Inclusion criteria were a defect > 1 cm and a minimal follow-up period of 1 year. Nerve defects were bridged by an end-to-end suture in 90° elbow flexion or 70° wrist flexion for 6 weeks. RESULTS: Nine patients with a mean age of 30.2 years were included. The patients presented with two ulnar nerve defects, four median nerve defects, and three radial nerve defects at various levels. The mean time to surgery was 13.5 weeks for recent injuries. The mean defect length was 2.9 cm, and the mean follow-up time was 22.4 months. Two patients had joint stiffness that was more likely related to the associated injuries than the 6-week immobilization. Successful outcomes were achieved in eight of the nine patients. Meaningful motor recovery was observed in seven patients, and all recovered meaningful sensation. Excellent nerve recovery was noted in pediatric patients and in those with distal nerve defects. CONCLUSION: Temporary high joint flexion allows for direct coaptation of upper extremity nerve defects up to 4 cm located near the elbow or wrist. In this small and heterogenous cohort, functional outcomes seemed to be comparable to those obtained with short autografting.

Ballistic peripheral nerve injuries: basic concepts, controversies, and proposal for a management strategy.

Ballistic injuries to peripheral nerves are devastating injuries frequently encountered in modern conflicts and civilian trauma centers. Such injuries often produce lifelong morbidity, mainly in the form of function loss and chronic pain. However, their surgical management still poses significant challenges concerning indication, timing, and type of repair, particularly when they are part of high-energy multi-tissue injuries. To help trauma surgeons, this article first presents basic ballistic concepts explaining different types of missile nerve lesions, described using the Sunderland classification, as well as their usual associated injuries. Current controversies regarding their surgical management are then described, including nerve exploration timing and neurolysis's relevance as a treatment option. Finally, based on anecdotal evidence and a literature review, a standardized management strategy for ballistic nerve injuries is proposed. This article emphasizes the importance of early nerve exploration and provides a detailed method for making a diagnosis in both acute and sub-acute periods. Direct suturing with joint flexion is strongly recommended for sciatic nerve defects and any nerve defect of limited size. Conversely, large defects require conventional nerve grafting, and proximal injuries may require nerve transfers, especially at the brachial plexus level. Additionally, combined or early secondary tendon transfers are helpful in certain injuries. Finally, ideal timing for nerve repair is proposed, based on the defect length, associated injuries, and risk of infection, which correlate intimately to the projectile velocity.

Single versus double tendon transfer for foot drop due to post-traumatic common fibular nerve palsy.

PURPOSE: To compare functional outcomes of single versus double tendon transfer for foot drop correction and toe drop prevention in posttraumatic common fibular nerve palsy. METHODS: A retrospective study was conducted on data from patients with posttraumatic common fibular nerve palsy treated by tendon transfer between 2001 and 2018. In cases of single tendon transfer (STT) the tibialis posterior (TP) tendon was transferred anteriorly through the interosseous membrane to a new insertion on the lateral cuneiform. In cases of double tendon transfer (DTT), the same TP tendon transfer was combined with a transfer of the flexor digitorum longus to the extensor digitorum longus and extensor hallucis longus tendons. Functional assessment was based on the Carayon score to evaluate foot drop correction and on the Yeganeh score to evaluate toe drop prevention. RESULTS: A total of 27 patients were included: 13 in the STT group and 14 in the DTT group. Functional results were comparable between groups in terms of reduction of foot drop, active range of ankle motion and Carayon score. Prevention of toe drop, active toe extension and Yeganeh score were significantly greater in the DTT group, however, active toe extension of was only restored in only 8 cases in the DTT group. CONCLUSIONS: Double transfer of TP and FDL tendons is a reliable method to restore balanced ankle dorsiflexion and prevent toe drop. However, recovery of active toe extension was inconsistent and Carayon scores were not superior to those obtained with a single TP tendon transfer.

Rethinking surgical strategy in the management of obstetrical palsy.

The widespread use of the operating microscope for nerve repairs has inspired operative treatment for obstetric paralysis. For a long time, the standard treatment has been based on early nerve surgery. However, the generally accepted strategy for treating obstetric paralysis is far from satisfactory. The main sequels we have observed are due to incorrect treatment of the deficits or due to devastating early nerve surgery. Therefore, a different approach should be considered and designed to prevent and treat the main deficits. After examining over 1000 non-operated patients over almost four decades and in three different countries, I have never encountered anyone who has not recovered active contraction of shoulder muscles or relatively strong elbow flexion. Therefore, I recommend not to have early nerve surgery.

Direct Suturing of Sciatic Nerve Defects in High-degree Knee Flexion: An Experimental Study.

OBJECTIVE: We sought to elucidate the conditions of direct suturing of sciatic nerve defects in high-degree knee flexion. We aimed to establish a correlation among the defect length, defect location, degree of knee flexion, and eventual need for hip immobilization in extension. METHODS: We performed an experimental study by completing bilateral dissection of the sciatic nerve in 6 cadavers. Three groups of lesions were identified: at the buttock (BG), in the thigh (TG), and in the popliteal fossa (PG). For each defect, a direct, tensionless suture was performed with minimal knee flexion. Next, the hip was progressively flexed until rupture. The nerve defect length correlated with the degree of knee flexion and hip extension required to perform and protect the installed sutures. RESULTS: A 30° knee flexion allowed for direct suturing of defects >2 cm in the 3 groups. The largest suturable nerve defects measured 7 cm in the TG and PG and 6 cm in the BG. When considering the same-size defects, the required knee flexion tended to be significantly greater in the BG. A bowstringing effect was noted at the buttock and popliteal levels. Hip flexion placed tension on the nerve suture at all locations. CONCLUSIONS: The middle third of the thigh was the most compliant level, because the largest defects will be suturable without a visible bowstringing effect. Hip immobilization should be considered as soon as the defect has exceeded 2 cm, regardless of the location.

Management of Sciatic Nerve Defects: Lessons Learned and Proposal for a New Strategy.

Management of sciatic nerve injuries can be difficult for surgeons without a special interest in nerve surgery as they would only treat a handful of such cases for many years. Sciatic nerve defects pose the greatest repair challenges, with nerve grafting producing mixed results because of the large size of the nerve in both diameter and length. This article first presents the peculiarities of sciatic nerve defects management, based on the authors experience and a literature review. Various issues are dealt with: When to operate depending on the injury mechanism? What are the results of nerve autografting and allografting? On which component should the repair focus in very large defects? Subsequently, alternatives to conventional nerve grafting are proposed. The authors stress the usefulness of direct nerve suture with knee flexion at 90 degrees, which permits bridging of gaps as much as 8 cm in length. For larger defects, other procedures should be considered: long vascularized nerve grafting in complete lesions, short grafting with knee flexed, or tendon transfers in partial lesions.

Missile Injury of the Sciatic Nerve: Observational Study Supporting Early Exploration and Direct Suture With Flexed Knee.

Missile injuries of the sciatic nerve are frequently encountered in modern violent conflicts. Gunshot and fragment wounds may cause large nerve defects, for which management is challenging. The great size of the sciatic nerve, in both diameter and length, explains the poor results of nerve repair using autografts or allografts. To address this issue, we used a simple technique consisting of a direct suture of the sciatic nerve combined with knee flexion for 6 weeks. Despite a published series showing that this procedure gives better results than sciatic nerve grafting, it remains unknown or underutilized. The purpose of this cases study is to highlight the efficiency of direct sciatic nerve coaptation with knee flexed through three cases with missile injuries at various levels. At the follow-up of two years, all patients were pain free with a protective sensory in the sole and M3+ or M4 gastrocnemius muscles, regardless of the injury level. Recovery was also satisfying in the fibular portion, except for the very proximal lesion. No significant knee stiffness was noticed, including in a case suffering from an associated distal femur fracture. Key points to enhance functional recovery are early nerve repair (as soon as definitive bone fixation and stable soft-tissue coverage are achieved) and careful patient selection.

Results of heterodigital flexor digitorum profundus hemi-tendon transfer for 23 flexor tendon injuries in zones 1 or 2.

We report outcomes of reconstruction of zone 1 or 2 flexor tendon injuries using a heterodigital hemi-tendon transfer of the flexor digitorum profundus in 23 fingers of 23 patients. At mean follow-up of 57 months, the mean total active motion of the three finger joints including the metacarpophalangeal joint was 128 degrees preoperatively and 229 degrees at final follow up. According to Strickland criteria, the function was excellent for 14 fingers, good for seven fingers and poor for two fingers. The subgroup analysis showed that the results were better in cases of primary surgery, children, and for the index and little fingers. Complications included stiffness of three fingers, and rupture in one finger that was converted to a two-stage tendon reconstruction. We conclude that this technique restores good function in most patients with zone 1 and 2 flexor tendon injuries, in which primary tendon repair has not been performed or was unsuccessful, and where pulley reconstruction is not required. LEVEL OF EVIDENCE: IV.

Functional outcome of glenohumeral fusion in brachial plexus palsy: a report of 54 cases.

PURPOSE: The restoration of shoulder function is a major issue in brachial plexus palsy. Although several tendon and nerve transfers have been described, shoulder arthrodesis remains a reliable technique in this context. This study planned to compare surgical and functional outcomes of 2 glenohumeral arthrodesis bone graft techniques: massive subacromial corticocancellous versus cancellous only grafts. METHODS: We reviewed 54 patients who had shoulder arthrodesis according to 2 parameters after a mean follow-up of 37 months. The primary outcome measure was the rate of fusion according to the surgical technique. A total of 26 patients received a massive subacromial corticocancellous bone autograft, and 28 patients received only cancellous bone. The secondary outcome measure was the range of scapulothoracic motion measured by a video-assisted method according to type of neurological lesion. Brachial plexus palsy was complete in 32 cases and partial in 22 cases. All patients had recovered active elbow flexion before undergoing shoulder arthrodesis. Of the 54 patients, 48 had no postoperative immobilization. RESULTS: The overall fusion rate was 76% after the first surgical procedure and 94% at last follow-up. Reoperation led to fusion in 10 cases, whereas 3 cases never fused. Pseudarthrosis rate after first surgery was 4% in the group with massive subacromial graft versus 43% in the group with cancellous bone graft. The mean range of motion was 59° in abduction (57° for complete palsy and 62° for partial palsy) with 42 cases 45° or greater. The mean range of motion was 48° in rotation (50° for complete palsy and 46° for partial palsy) with 35 cases 45° or greater. CONCLUSIONS: Shoulder fusion provided active abduction greater than 45° in more than 75% of cases and active rotation greater than 45° in almost 65% of cases. Using a massive subacromial graft significantly reduced pseudarthrosis rate (P < .001). TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Morphogenesis of the human palma arch using three-dimensional geometric modeling.

The hand goes through complex morphological modifications during embryogenesis. The goal of this study was to use geometric modeling to study the morphometric modifications of the palmar arch. Five embryos were used for the study (sizes: 15, 17, 23, 30, and 44 mm). After digitalization of histologic sections (Sony DXC-930P 3CCD camera, Leica Qwin) and segmentation of the metacarpal cartilaginous matrices (Winsurf 4.3 software), geometric modeling and calculations were performed using MSC.Patran 2005r2 software. Correlations (r > 0.99) were found between embryo size and metacarpal volume, metacarpal surface, and the surface of the modeled palmar arch. The growth of the palmar arch is nonhomothetic. Significant reduction (P = 0.05) in the divergence of the 2nd, 3rd, 4th, and 5th metacarpals was observed. Deepening of the palmar arch is correlated with embryo size and age (r > 0.99). Geometric modeling allows 3D rendering of histologic sections and thus quantitative description of the morphogenesis. The results of this study support the hypothesis that opposition of the thumb in correlation with deepening of the palmar arch appears early in embryological development. It constitutes a specific morphological characteristic that appears very early in the human phylum. The fact that the human thumb is naturally in opposition in the resting position is a consequence of this morphogenesis. The thumb's resting position has received little attention in clinical settings and should be considered as the reference position for biomechanical analysis of the thumb column.

Digitalization of the second finger in type 2 central longitudinal deficiencies (clefting) of the hand.

In central longitudinal deficiency of the hand type 2 (Manske and Halikis), the second finger presents itself anatomically and functionally as a second thumb. It is therefore necessary to undertake digitalization of the index, performed exactly as a reverse pollicization technique, with the same principles: minimum volar scarring and reconstruction of a large first web space without scars at the fold of the commissure. The incision surrounds the second digit at the level of the midproximal phalanx, extends over the dorsal edge of the cleft, and finishes on the radial side of the third finger where the second web space is to be created. Through this approach, the index metacarpal is freed (extraperiosteally), preserving the dorsal venous network, and translocated into the space of the missing third ray. After internal bone fixation, the flap, with its wide and safe volar cutaneous pedicle, is easily transposed to reconstruct the first web space, avoiding the need for skin grafting. This technique is easier and safer and does not impair the normal thumb musculature compared with the classic Snow-Littler procedure.

Recovery of brachial plexus injury after shoulder dislocation.

Brachial plexus injury is an underestimated complication from anterior dislocation of the shoulder. To our knowledge, there is limited information available about the factors that influence neurological recovery of this injury. We reviewed 15 upper extremities in 14 patients with brachial plexus injuries caused by anterior shoulder dislocation. Two-thirds of the cases had total brachial plexus palsy. With the conservative treatment, the motor recoveries of all cases are full or nearly full within 20 months except intrinsic muscle of the hand. Intrinsic muscle recovery may be better in a younger age group (less than 50 years). Nerve exploration is usually unnecessary. However, reconstructive surgery for the residual neurological deficit can provide improvement of hand function.

Closed flexor pulley rupture of the thumb: case report and review of literature.

Closed flexor pulley rupture of the thumb is extremely rare. We report a case with this condition. The anatomic and biomechanical studies, clinical and operative finding as well as the management of the closed flexor pulley rupture of the thumb are discussed.

Acute deep hand burns covered by a pocket flap-graft: long-term outcome based on nine cases.

OBJECTIVE: We evaluated the long-term outcome of the "pocket flap-graft" technique, used to cover acute deep burns of the dorsum of the hand, and analyzed surgical alternatives. METHODS: This was a 6-year, retrospective study of 8 patients with extensive burns and 1 patient with a single burn (11 hands in all) treated by defatted abdominal wall pockets. We studied the medical records of the patients, and conducted a follow-up examination. RESULTS: All hands had fourth-degree thermal burns caused by flames, with exposure of tendons, bones, and joints, and poor functional prognosis. One third of patients had multiple injuries. Burns affected an average of 36% of the hand surface, and mean coverage was 92.8 cm(2). One patient died. The 8 others were seen at 30-month follow-up: the skin quality of the flap was found to be good in 55% of the cases, the score on the Vancouver Scar Scale was 2.4, the Kapandji score was 4.5, and total active motion was 37% of that of a normal hand. Hand function was limited in only 2 cases, 8 patients were able to drive, and 3 patients had gone back to work. CONCLUSION: The pocket flap-graft allows preservation of hand function following severe burns, when local or free flaps are impossible to perform. Debulking of the flap at the time of elevation limits the need for secondary procedures.

Extensor tenodesis for plexic hands with C7 to T1 or C8, T1 root avulsions: a new technique.

In C7 to T1 or C8, T1 root avulsion palsies, restoration of finger active extension is not possible. Only tenodesis may restore hand opening in active wrist flexion. Many techniques have been described to restore this motion. In routine techniques, extensor tendons are fixed on radius or sutured on dorsal retinaculum. However, in these procedures, progressive tendon lengthening or ruptures may occur and salvage procedure may be difficult to perform. Therefore, we proposed a new extensor tenodesis technique. The extensor digitorum communis tendons are sutured on the paralyzed flexor digitorum superficialis tendons through interosseous membrane. This procedure allows performing a strong tendon to tendon suture more resistant than radius or retinaculum fixation. As other tenodesis techniques, wrist flexion has to be active to obtain hand opening.

Hourglass-like constriction of the axillary nerve: report of two patients.

Among the various etiologies of compressive lesions, the development of an hourglass-like constriction of the nerve that is unrelated to any recognizably compressive structure is a very rare phenomenon. This problem has been reported previously for the radial nerve and its branch posterior interosseous nerve and for the anterior interosseous nerve, a branch of median nerve. Here we report 2 cases of hourglass-like constriction of the axillary nerve that were observed during surgery; the constrictive segment was unrelated to any compressive structure.

The "muscular hernia sign": an original ultrasonographic sign to detect lesions of the forearm's interosseous membrane.

The total disruption of the forearm's interosseous membrane can lead to an Essex-Lopresti syndrome. The diagnosis must be done early for a better prognostic. Incomplete lesions can aggravate and an early diagnosis of incomplete lesions is a challenging problem. Magnetic resonance imaging is the gold standard but remains expensive, and is hard to obtain in an emergency. On the contrary, ultrasonography is cheap, accessible in an emergency, and dynamical tests can be performed easily. Twelve fresh frozen forearms were randomized in four groups. The membrane was divided into three parts (proximal, middle, and distal thirds). Each group was prepared with variable patterns of lesions. Two radiologists performed an ultrasonographic (US) examination of these forearms. They were blinded with respect to the lesional status of the forearms. Each examination consisted of two stages: static and dynamic. During the dynamic examination, the radiologist looked for the "muscular hernia sign". The results of their examinations were compared with the real lesional status. The static examination was very efficient in the proximal and middle parts of the membrane, and less reliable in the distal third. With the dynamical examination, no mistake occurred at the proximal and middle parts of the forearm, and there was only one at the distal part. The US examination of the interosseous membrane is very efficient to detect incomplete lesions, mostly, if dynamical tests are performed looking for a "muscular hernia sign".