Elective brachial plexus decompression in neurogenic thoracic outlet syndrome.

We aimed to evaluate functional outcome following elective brachial plexus decompression by compressive fibrous band resection and limited on-demand bone abnormality resection in patients with neurogenic thoracic outlet syndrome (N-TOS). A retrospective continuous observational study was conducted in 17 patients (15 women and 2 men), with a mean age of 42 years, operated on between 2013 and 2021. Twenty brachial plexus decompressions were performed, for 13 objective and 7 subjective N-TOSs, including 3 recurrent N-TOSs. At last follow-up, outcomes were evaluated in terms of residual pain, paresthesia and hand motor deficit, plus patient-reported assessment and Quick-DASH functional scoring. No postoperative complications occurred. At a median follow-up of 12 months (range 6-48 months), complete pain relief and paresthesia resolution were found in 11/15 and 9/14 cases, respectively. All patients reported that their symptoms had improved. In contrast, hand muscle atrophy persisted in all cases (n = 11). Sensorimotor recovery seemed to be poorer and mean Quick-DASH score better in objective than subjective N-TOS patients. Elective brachial plexus decompression seemed to be a safe procedure, providing constant improvement in subjective symptoms related to lower trunk irritation. However, nerve release did not provide hand muscle recovery in patients with objective N-TOS. LEVEL OF EVIDENCE: IV.

Endometriotic lesions of the lower troncular nerves.

Although exceptional, endometriotic lesions of the troncular nerves of the lower limb may occur and are often diagnosed with delay. We report, hereby, the first case of femoral nerve endometriosis the treatment of which consisted of radical resection with femoral nerve transplant. We completed a review of the literature on sciatic nerve endometriotic lesions and discussed the physiopathology and surgical treatment.

Surgical treatment of brachial plexus posterior cord lesion: a combination of nerve and tendon transfers, about nine patients.

Lesions of the posterior cord of the brachial plexus are rare. The symptoms are usually described as palsy of the deltoid and triceps brachii muscles and of the extensor muscles of the wrist, thumb and fingers. If there is no recovery, our strategy is to operate on these patients 6 months after the injury using a combination of nerve and tendon transfers. We present a series of nine patients, two with a partial palsy and seven with a complete palsy of the posterior cord. We performed five nerve transfers to the axillary nerve, four using intercostal nerves and one using the ulnar nerve. Six patients benefited from a transfer to one of the nerves to the triceps brachii (medial or lateral head), five using the ulnar nerve and one using two intercostal nerves. We performed eight tendon transfers for radial palsy. The results demonstrated significant restoration of the deltoid muscle (grade 4 strength, mean active abduction of 120°). Active elbow extension was restored in all patients with an average strength measured at 5.6kg and 48% of the contralateral strength. All tendon transfers were successful with recovery of active wrist extension (40°), long fingers extension and thumb abduction and extension (12.5cm between the tips of index and thumb). With this method, we were able to restore function to the upper limb of patients who presented with debilitating palsy of the posterior cord of the brachial plexus.

The psychoflexed hand: new perspectives in diagnosis, classification and treatment.

The psychoflexed hand is a rare clinical condition characterized by fixed finger contractures undetermined by organic etiology, often associated with a psychiatric pathology. We report a series of 20 patients (nine males and 11 females, mean aged 56.2 years). We have introduced a new classification of the various possible patterns of finger deformities: 1) Type 1: prevalent flexion contracture at the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of the last two or three fingers; the thumb and the index are not affected; 2) type 2: prevalent flexion contracture at the PIP and distal interphalangeal (DIP) joints of the last two or three fingers; 3) type 3: flexion contracture of all the long fingers; 4) type 4: flexion contracture of all the fingers of the hand, including the thumb (clenched fist syndrome); 5) type 5: isolated flexus-adductus thumb (the long fingers are not affected); 6) type 6: flexion of digits associated with flexion contractures of other joints of the upper extremity. The treatment was conservative in 14 patients with recent deformities and surgical in six patients. Both forms of treatment were followed by a rigorous rehabilitation program, mostly based on home self-rehabilitation. The correction of the deformities was obtained in all cases and maintained over time.

Elbow flexion restoration using pedicled latissimus dorsi transfer in seven cases.

PURPOSE: The aim of this study is to analyse the results of a series of pedicled latissimus dorsi transfers to restore elbow flexion. Moreover, we describe a new technique of distal fixation of the muscle to the proximal third of the ulnar diaphysis to increase the lever arm and improve strength. METHODS: We retrospectively reviewed seven patients aged from 18 to 49 years. Elbow flexion paralysis was secondary to destruction of the anterior arm compartment in four cases and to brachial plexus palsy in three cases. The humeral insertion of the latissimus dorsi was relocated on the coracoid process in five cases and not relocated in two cases. The patients were assessed using the Medical Research Council grading system, the maximum weight lifted by the wrist and the active elbow range of motion. RESULTS: At the last follow-up (mean 26.6 months), five patients recovered M4 elbow flexion strength (0.5 to 8kg), one patient recovered M3 strength and the last transfer failed because of triceps brachii co-contractions. The mean active elbow flexion was 91° (range, 45 to 130°). Patients with destruction of the anterior arm compartment and particularly whose forearm was not paralyzed had better strength than patients with a brachial plexus palsy (3.25 versus 1kg). A skin island with the latissimus dorsi muscle flap was particularly useful in case of arm soft tissue defect. DISCUSSION: A destroyed anterior compartment of the arm is a good indication for latissimus dorsi transfer to restore elbow flexion. The muscle is usually too weak in high brachial plexus palsy. Finally, the latissimus dorsi needs an objective, reproducible and reliable preoperative evaluation. LEVEL OF EVIDENCE: Level IV.

Results of 24 nerve repairs at more than one year post-injury.

There is no consensus in the literature as to the maximum delay for nerve repair following nerve injury. Our aim is to estimate the maximum delay at which a nerve can be successfully reconstructed. Eighteen patients (24 procedures) were operated at more than 12 months (12 to 36) post-injury. Mean age was 38 (17 to 74). There were 18 nerve transfers, four grafts and two secondary sutures for six target muscles. Evaluation of muscle power was scored and assessed against weights starting 12 months follow-up. Finally, two patients had contraction against 7 kg, two against 5 kg, six M4. Two were scored M3 and six were M2, thus 12 good results (67%). This study showed that excellent results could be obtained for nerve repair even after 24 months delay. Further study may be needed to determine the cut-off point of delay after which nerve recovery is unlikely.

Gunshot injuries to the nerves.

The authors report their 10-year experience in the treatment of war injuries in the Gaza strip. Bullet injuries to nerves can be assessed using Sunderland's classification. Grade 4 and 5 lesions must be repaired in the same way as any traumatic nerve injuries. A detailed series of sciatic nerve repair is presented. In this series, 12 nerve gaps were repaired by direct nerve coaptation using 90° knee flexion for six weeks. The results of this technique at 1 to 4 years follow-up are better than to those of sciatic nerve grafting.

The middle radioulnar joint and triarticular forearm complex.

The forearm is composed of the radial and ulnar shafts, which are linked by the interosseous membrane and intercalated between the elbow and wrist. The radius and ulna are connected by three joints, the proximal, middle, and distal radioulnar joints. The forearm ensures pronation/supination and longitudinal load transfer. The biomechanical and clinical relevance of the proximal and distal radioulnar joints is well established. In contrast, the middle radioulnar joint was considered relatively unimportant until studies published in the last decade showed that it fulfils crucial biomechanical functions and is of considerable clinical significance. We believe the conventional concept in which the forearm is viewed as part of either the elbow or the wrist is outdated and that a more relevant concept describes the forearm as a triarticular complex that functions as a full-fledged entity. In this concept, the three forearm radioulnar joints (proximal, middle, distal) work together to provide stability, mobility and load transfer. Here, we will argue for the relevance of the triarticular complex concept based on published data about forearm biomechanics and pathological conditions.

Transfer of the recovered biceps to the long flexors of the digits to restore grip function following complete traumatic brachial plexus palsy.

Restoration of grip function was achieved through transfer of the recovered biceps tendon to the long digital flexors using a fascia lata graft in seven patients with complete brachial plexus palsy. Initial nerve repair was followed by biceps transfer with stabilising wrist and hand fusions. The biceps recovered to Medical Research Council (MRC) grade 4 in all cases. Patients were reviewed at a mean time of 26.7 (range 7-63) months after biceps transfer. After transfer, the total active movement of the digits averaged 55 (range 30-90)8. The strongest measurable grip strength was 6 kg. Patient satisfaction was high. The excellent excursion of the elbow provides a good basis for a transfer to power grip function, enabling a greater total active movement of the fingers to be achieved. We recommend this method as a useful adjunct to the treatment of the complete brachial plexus palsy.

Transfer of the first intercostal nerve to supra- and infraspinatus muscles: an anatomical study and report of the first case.

We have assessed the anatomical feasibility of a transfer of the first intercostal nerve to the supra- and infraspinatus muscles and report on the first clinical application. Ten fresh cadavers were dissected for this study. Histomorphometric analysis showed the fascicular surface area of the first intercostal nerve at its origin (0.38 mm(2)) to be comparable to the suprascapular nerve (0.81 mm(2)). The first intercostal nerve is usually a pure motor nerve. Preservation of the spinal accessory nerve, lack of donor site morbidity and direct suture without nerve graft are the other advantages of this transfer. Its principal indication is in lesions of the upper brachial plexus, used in association with neurotisation of two other intercostal nerves to the anterior branch of the axillary nerve. At 21 months follow-up there was useful motor reinnervation in the first clinical case.

Nerve transfers in brachial plexus palsies.

It has been many years now since the introduction of nerve transfers for repair of traumatic brachial plexus lesions and more recently, we have seen its application in the field of obstetric brachial plexus palsy. These nerve transfers do not represent an alternative to anatomical repair by means of nerve grafting, but represent an additional possibility to increase the reconstructive options and improve the final results. This pushes the surgeon to decide: which function is to be restored by nerve grafting, which one by nerve transfer? What is the more reliable procedure? Does the age of the patient, the delay after the accident, or the type of accident influence this choice? If we add in the possibilities of palliative treatment, one can state that many therapeutic options are available today for brachial plexus reconstruction, and that no real consensus does exist. But some tendencies, some trends are apparent.

Anatomic variations in a cleft hand of an elder cadaveric specimen.

Cleft hand is a rare and complex malformation in which the central part of the hand is missing. Since the nineteenth century, a very small number of dissections in cleft hand have been reported and very few reports describe the soft-tissue abnormalities. We report a case of an elderly cadaveric specimen with bilateral cleft hand. X-ray, CT-scan with 3D reconstruction and dissection were performed on the right hand and forearm. On both the sides, we noted the absence of the index, middle and ring finger. Malformation and degenerative arthrosis at the carpal bones level have been identified. The flexor and extensor tendons of the absent fingers fuse with one another over the end of the remaining carpal bones, forming a radial and an ulnar tendinous plexus and two tendon loops. Data concerning intrinsic muscles, vessels and nerves are entirely recorded. Soft-tissue abnormal distribution is due to the abnormal bony configuration. Correction of the bone abnormalities does not resume the surgical treatment of a cleft hand. Hand surgeons need to be aware of the soft-tissue disorders and their surgical implications.

[Management of neuropathic pain after brachial plexus injury in adult patients: a report of 60 cases]. / Prise en charge des douleurs neuropathiques des lésions traumatiques du plexus brachial chez l'adulte. A propos de 60 cas.

An observational study including 60 patients with brachial plexus injury was carried out in order to evaluate the rate of chronic pain, to assess the incidence of neuropathies using the questionnaire DN4 and to record the management of pain in these patients. Chronic pain of neuropathic type according to the questionnaire DN4 was found in 95% of the patients. Although 75% of these cases were treated, only 37% of the patients were satisfied. All of these 37% who were relieved of intense pain (EVA<4) or hyperalgic crisis had an appropriate treatment in the early stages. The proportion of cases considered refractory to an appropriate treatment was lower than 2%. An effort to inform the patients and the carers must be made to improve the management of these injuries. The fact that this pathology is rare must lead to a specialized opinion in order to improve pain management.

[Bilateral juvenile trapezometacarpal osteoarthritis in congenital hyperlaxity]. / Rhizarthrose juvénile bilatérale dans une laxité constitutionnelle.

We report a rare case of major trapezometacarpal instability observed in a 31-year-old woman with congenital hyperlaxity. The patient presented major functional impotency of both thumbs, closure of the first commissure, and absence of effective opposition except between the lateral borders of the long fingers due to severe pain in the trapezometacarpal joint attributed to osteoarthritis. The patient underwent bilateral trapezectomy with ligamentoplasty. The gross examination of the trapezeal specimens revealed major cartilage destruction on the medial portion of the trapezeal joint surface. Three months after surgery, the patient was able to resume occupational and recreational activities. At one year, she was pain free with normal function. No other similar case could be identified in the literature and search for a pathological condition which could have contributed to the altered collagen was negative. It was observed that since stabilization was achieved by ligamentoplasty, recurrence should not be expected in congenital hyperlaxity if the tendons are unaffected.

[Comparative anatomy of the hand]. / Anatomie comparée de la main.

The pentadactyl scheme is common to all tetrapods, even in case of adaptative phenomenon (five digits are observed during ontogenesis), or in case of functional convergence The carpal organization with two rows is common too, if we take into account the desappearing of the central bones in mature man. The sellar shape of the trapeziometacarpal joint of the thumb, to often attributed to Man and his only thumb, is in fact the regular shape of all carpometacarpal articulations and present in very ancient primitive primate fossils. Some discontinuous caracters in Man (entepicondylar tunnel) are present in all individuals of some species (carnivors). Rarely present in Man, it can exceptionally produce a real pathology.

Morphometry by computerized three-dimensional reconstruction of the human carpal bones during embryogenesis.

Carpal skeleton shows drastic developmental changes during embryogenesis. At this stage, the cartilaginous matrices appear and later form models of the limb bones. The purpose of this study was to investigate the morphometry of carpal bones in humans during embryological development. We obtained digitalized histological serial sections of 18 human embryos and early fetuses from the Institute of Anatomy in Paris. Surfdriver and MSC.Patran software were used for three-dimensional reconstruction and morphometry. There was a strong correlation between the volume of the carpal cartilaginous structure and the size of the embryos (P<0.001) and an exponential correlation between the carpal volume and the percentage of volume presented by the proximal carpal row (P=0.005). According to inertia parameters, the geometry of carpal cartilaginous structure, initially plane, becomes curved during embryogenesis. Carpal bones growth follows non-homothetic transformation. The innovations in embryo reconstruction serve as new tool for scientific investigation. A hypothesis of carpal development is proposed.

Ligamentoplasty of the forearm interosseous membrane using the semitendinosus tendon: anatomical study and surgical procedure.

Total longitudinal disruptions of the interosseous membrane can allow proximal radius migration and are seen in Essex-Lopresti lesions. We propose an original technique of ligamentoplasty using the semitendinosus tendon. The graft corresponds to the forearm rotation axis for an optimized isometry and longitudinal stabilization. Our ligamentoplasty technique was performed on ten fresh frozen right forearms. We successively assessed the innocuousness, efficiency and resistance of the ligamentoplasty. The ligamentoplasty induced neither passive limitation of pronation-supination nor neurovascular lesions. It prevented from radius proximal migration. The mean load to failure was 28 kg at both ulnar and radial sides of the graft. Our technique is original for the type and position of the graft. It seems safe, efficient and resistant enough for in vivo procedures. This technique decreases longitudinal loads on the radius. It should be indicated in patients with Essex-Lopresti syndrome, in association with radial head internal fixation or arthroplasty.

[Ralstonia pickettii osteomyelitis of the trapezium]. / Osteite du trapèze a Ralstonia pickettii: a propos d'un cas et revue de la littérature.

An immunocompromised 29-year-old man presented with a Ralstonia pickettii osteomyelitis affecting the trapezium bone. The patient underwent two surgical debridement stages, including trapezectomy and long-term drainage. The type of the contaminant organism and the trapezium localization make this observation atypical.