Processed nerve allografts for peripheral nerve reconstruction: a multicenter study of utilization and outcomes in sensory, mixed, and motor nerve reconstructions.

PURPOSE: As alternatives to autograft become more conventional, clinical outcomes data on their effectiveness in restoring meaningful function is essential. In this study we report on the outcomes from a multicenter study on processed nerve allografts (Avance® Nerve Graft, AxoGen, Inc). PATIENTS AND METHODS: Twelve sites with 25 surgeons contributed data from 132 individual nerve injuries. Data was analyzed to determine the safety and efficacy of the nerve allograft. Sufficient data for efficacy analysis were reported in 76 injuries (49 sensory, 18 mixed, and 9 motor nerves). The mean age was 41 ± 17 (18-86) years. The mean graft length was 22 ± 11 (5-50) mm. Subgroup analysis was performed to determine the relationship to factors known to influence outcomes of nerve repair such as nerve type, gap length, patient age, time to repair, age of injury, and mechanism of injury. RESULTS: Meaningful recovery was reported in 87% of the repairs reporting quantitative data. Subgroup analysis demonstrated consistency, showing no significant differences with regard to recovery outcomes between the groups (P > 0.05 Fisher's Exact Test). No graft related adverse experiences were reported and a 5% revision rate was observed. CONCLUSION: Processed nerve allografts performed well and were found to be safe and effective in sensory, mixed and motor nerve defects between 5 and 50 mm. The outcomes for safety and meaningful recovery observed in this study compare favorably to those reported in the literature for nerve autograft and are higher than those reported for nerve conduits.

Posterior elbow capsulotomy with triceps lengthening for treatment of elbow extension contracture in children with arthrogryposis.

BACKGROUND: Flexion of one elbow is essential to enable children with arthrogryposis to achieve independent function such as self-feeding and self-care of the face and hair. We analyzed the outcomes of posterior elbow capsulotomy with triceps lengthening for the treatment of elbow extension contractures in a series of children with arthrogryposis multiplex congenita. METHODS: The medical records of all children with arthrogryposis who had been followed for a minimum of two years after treatment with elbow capsulotomy and triceps lengthening were retrospectively reviewed. The postoperative range of motion and ability to reach the mouth were compared with the preoperative status. RESULTS: Posterior capsulotomy with triceps lengthening was performed in twenty-nine elbows of twenty-three children with an average age of thirty-five months (range, seven months to thirteen years). The average duration of follow-up was 5.4 years. The arc of motion of all twenty-nine elbows improved from an average of 32 degrees (range, 0 degrees to 75 degrees) preoperatively to an average of 66 degrees (range, 10 degrees to 125 degrees) at the time of final follow-up. All children were able to reach the mouth using passive assistance (e.g., table-push, trunk-sway, and cross-arm techniques), and twenty-two children were able to feed themselves independently. No child underwent subsequent tendon transfer surgery. CONCLUSIONS: Elbow capsulotomy with triceps lengthening successfully increases passive elbow flexion and the arc of elbow motion of children with arthrogryposis, enabling hand-to-mouth activities. In contrast to studies in which tendon transfer surgery was used to increase elbow flexion, none of the children in this series underwent subsequent tendon transfer surgery.

Functional outcome of en bloc excision and osteoarticular allograft replacement with the Sauve-Kapandji procedure for Campanacci grade 3 giant-cell tumor of the distal radius.

PURPOSE: Multiple options have been reported for reconstruction of Campanacci grade 3 giant-cell tumor of the distal radius after resection. In 1990, the senior author described an allograft reconstruction combined with a Sauve-Kapandji procedure after distal radius resection and reported preliminary results in 3 patients. The purpose of this study was to assess with validated patient outcome surveys the intermediate to long-term outcomes of all patients treated with this surgery and to analyze their functional results and document tumor control. METHODS: All cases of distal radius osteoarticular allograft combined with the Sauve-Kapandji reconstruction for Campanacci grade 3 giant-cell tumors performed from 1986 to 2000 by a single surgeon were evaluated by clinical and radiologic examinations; the Disabilities of the Arm, Shoulder, and Hand questionnaire; the Short Form-36; and Mayo Wrist scores. RESULTS: Nine consecutive patients (7 women, 2 men) with an average age at follow-up evaluation of 42 years and with a Campanacci grade 3 giant-cell tumor of the distal radius formed the study population. Clinical follow-up time after reconstruction averaged 7 years. Examination showed an average of 51 degrees of extension and 19 degrees of flexion of the wrist and 63 degrees of supination and 79 degrees of pronation of the forearm. Grip strength measured in 5 patients averaged 23 kg. The Disabilities of the Arm, Shoulder, and Hand questionnaire; the Short Form-36; and the Mayo Wrist scores averaged 15, 72, and 73, respectively. These scores indicate modest functional impact. No patient had tumor recurrence, metastases, nonunion, or proximal ulna instability. CONCLUSIONS: En bloc resection of a Campanacci grade 3 giant-cell tumor of the distal radius followed by reconstruction with an osteoarticular allograft and a Sauve-Kapandji procedure with autogenous bone graft results in a reasonable functional outcome at intermediate to long-term follow-up evaluation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Shoulder external rotation tendon transfers for brachial plexus birth palsy.

Children with brachial plexus birth palsy may have permanent loss of shoulder external rotation strength. This impairment may result to a difficulty in reaching the face and head with the affected hand for grooming activities, and in reaching overhead for participation in sports or work-related tasks. In addition, the contracture that results from unopposed internal rotation may further restrict range of motion and cause glenohumeral joint deformity and subluxation.A combination of muscle release and transfers reliably improves the child's ability to position the hand, and may halt the development of joint deformity. Postoperative rehabilitation is necessary to maximize the strength and range of motion obtained from this operation.