Posterior Deltoid Function After Transfer of Branch to the Long Head Triceps Brachii of the Radial Nerve to the Anterior Branch of the Axillary Nerve.

PURPOSE: The aim of this study was to evaluate the function of the posterior part of the deltoid after nerve transfer of the long head triceps branch of the radial nerve to the anterior branch of the axillary nerve in patients with an upper brachial plexus injury or isolated axillary nerve injury. METHODS: We retrospectively reviewed 26 patients diagnosed with an upper brachial plexus injury or isolated axillary nerve injury who underwent nerve transfer of the long head triceps muscle branch of the radial nerve to the anterior branch of the axillary nerve in our institute between 2012 and 2017. Data on age, sex, the mechanism of injury, the pattern of injury, and operative treatment were collected from medical records. Preoperative and postoperative clinical examinations, including motor powers of shoulder abduction and extension according to Medical Research Council grading, were evaluated. At a minimum of 2 years after the operation, we evaluated the recovery of the posterior deltoid function using the swallow-tail test. RESULTS: Twenty-two patients (84.6%) had recovery of posterior deltoid function confirmed by the swallow-tail test. There were 23 patients (88.5%) who achieved at least Medical Research Council grade 4 of shoulder abduction. CONCLUSIONS: Nerve transfer from the branch to the long head triceps to the anterior branch of the axillary nerve is an effective technique for restoring deltoid function in an upper brachial plexus injury or isolated axillary nerve injury. This technique can provide shoulder abduction and shoulder extension, which are the functions of the posterior deltoid muscle. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The Intercostal Nerves Transfer to the Radial Nerve Branch to the Long Head Triceps Muscle: Influencing Factor and Outcome of 55 Cases.

PURPOSE: The objective of this study was to report the functional outcomes and factors affecting the result of intercostal nerves transfer to the radial nerve branch to the long head triceps muscle for restoration of elbow extension in patients with total brachial plexus palsy or C5 to C7 palsy with the loss of triceps muscle function. METHODS: Fifty-five patients with total brachial plexus palsy or C5 to C7 palsy with no triceps muscle function had a reconstruction of elbow extension by transferring the third to fifth intercostal nerves to the radial nerve branch to the long head triceps muscle. The functional outcomes determined by the Medical Research Council grading were evaluated. Factors influencing the outcomes were determined using logistic regression analysis. RESULTS: At the follow-up of at least 2 years, 36 patients (65%) had antigravity motor function (Medical Research Council grade, ≥3). Multivariable logistic regression analysis showed that the body mass index, time to surgery, and injury of the dominant limb were associated with the outcome. CONCLUSIONS: The third to fifth intercostal nerves transfer to the radial nerve branch to the long head triceps muscle is an effective procedure to restore elbow extension. We would recommend using 3 intercostal nerves without grafts; in cases of nerve root avulsion in which there is no chance of spontaneous recovery, early surgery should be considered. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Dorsoradial Ligament Reconstruction in Trapeziometacarpal Joint Arthritis.

BACKGROUND: The main purpose of the study is to present the alternative novel surgical technique in treating patients with trapeziometacarpal (TMC) joint arthritis using dorsoradial ligament (DRL) reconstruction technique and report the clinical outcomes. METHODS: Patients who were diagnosed with TMC joint arthritis and underwent DRL reconstruction were evaluated. Visual analog pain score; Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score; grip, tip pinch, tripod pinch, and key pinch strengths along with range of motion of the thumb; and Kapandji score were recorded in the preoperative period and at follow-up. Stress examination was also performed under a fluoroscope. RESULTS: Eleven patients were included in the study. Median follow-up time was 13 months. At follow-up, postoperative visual analog scale and QuickDASH score improved in all patients. Grip, tip pinch, tripod pinch, and key pinch strengths also improved. The range of motion and Kapandji score were slightly improved compared with the preoperative period except for the thumb metacarpophalangeal flexion. Two patients had numbness at the thumb and spontaneously recovered after 3 months. CONCLUSIONS: According to recent evidence which proposed the importance of DRL in TMC joint stability, our DRL reconstruction technique may be an alternative treatment in treating patients presented with TMC joint arthritis. Further study with a longer follow-up period is needed.

Outcomes of Spinal Accessory Nerve and Intercostal Nerve Transfers for Shoulder Stabilisation and Elbow Extension in Patients with C5,6,7 Root Avulsion Injury.

Background: Upper arm type brachial plexus palsy results in decreased shoulder and elbow function. Reanimation of shoulder and elbow function is beneficial in these patients. The aim of this study is to report the results of restoring the shoulder abduction and elbow extension in patients with C5,6,7 root avulsion injury by simultaneous transfer of the spinal accessory nerve for the supraspinatus muscle combined with the transferring of the sixth and seventh intercostal nerves for the serratus anterior muscle along with the third to fifth intercostal nerves to the triceps muscle. Methods: All patients who underwent the above set of nerve transfers and had at least 2 years of follow-up were included in the study. The outcome measures included the Medical Research Council (MRC) grading of motor strength of shoulder abduction and elbow extension and range of motion of shoulder abduction and shoulder external rotation. Results: The study included 10 patients with an average age of 27. The mean time from injury to surgery was 6 months and the mean follow-up period was 35 months. M4 grade shoulder abduction was restored in five patients, M3 grade in three patients and M2 grade in two. M4 grade elbow extension was achieved in four patients, M3 grade in four patients and M2 grade in two patients. The average arc of shoulder abduction and external rotation was 71° and -21°, respectively. Conclusions: The spinal accessory nerve and the sixth and seventh intercostal nerves transfer to the supraspinatus muscle and serratus anterior muscle with the third to fifth intercostal nerves transfer to the triceps muscle provided satisfactory results for both shoulder abduction and elbow extension in C5,6,7 root avulsion injury. Level of Evidence: Level IV (Therapeutic).

Perspectives and Consensus among International Orthopaedic Surgeons during Initial and Mid-lockdown Phases of Coronavirus Disease.

With a lot of uncertainty, unclear, and frequently changing management protocols, COVID-19 has significantly impacted the orthopaedic surgical practice during this pandemic crisis. Surgeons around the world needed closed introspection, contemplation, and prospective consensual recommendations for safe surgical practice and prevention of viral contamination. One hundred orthopaedic surgeons from 50 countries were sent a Google online form with a questionnaire explicating protocols for admission, surgeries, discharge, follow-up, relevant information affecting their surgical practices, difficulties faced, and many more important issues that happened during and after the lockdown. Ten surgeons critically construed and interpreted the data to form rationale guidelines and recommendations. Of the total, hand and microsurgery surgeons (52%), trauma surgeons (32%), joint replacement surgeons (20%), and arthroscopy surgeons (14%) actively participated in the survey. Surgeons from national public health care/government college hospitals (44%) and private/semiprivate practitioners (54%) were involved in the study. Countries had lockdown started as early as January 3, 2020 with the implementation of partial or complete lifting of lockdown in few countries while writing this article. Surgeons (58%) did not stop their surgical practice or clinics but preferred only emergency cases during the lockdown. Most of the surgeons (49%) had three-fourths reduction in their total patients turn-up and the remaining cases were managed by conservative (54%) methods. There was a 50 to 75% reduction in the number of surgeries. Surgeons did perform emergency procedures without COVID-19 tests but preferred reverse transcription polymerase chain reaction (RT-PCR; 77%) and computed tomography (CT) scan chest (12%) tests for all elective surgical cases. Open fracture and emergency procedures (60%) and distal radius (55%) fractures were the most commonly performed surgeries. Surgeons preferred full personal protection equipment kits (69%) with a respirator (N95/FFP3), but in the case of unavailability, they used surgical masks and normal gowns. Regional/local anesthesia (70%) remained their choice for surgery to prevent the aerosolized risk of contaminations. Essential surgical follow-up with limited persons and visits was encouraged by 70% of the surgeons, whereas teleconsultation and telerehabilitation by 30% of the surgeons. Despite the protective equipment, one-third of the surgeons were afraid of getting infected and 56% feared of infecting their near and dear ones. Orthopaedic surgeons in private practice did face 50 to 75% financial loss and have to furlough 25% staff and 50% paramedical persons. Orthopaedics meetings were cancelled, and virtual meetings have become the preferred mode of sharing the knowledge and experiences avoiding human contacts. Staying at home, reading, and writing manuscripts became more interesting and an interesting lifestyle change is seen among the surgeons. Unanimously and without any doubt all accepted the fact that COVID-19 pandemic has reached an unprecedented level where personal hygiene, hand washing, social distancing, and safe surgical practices are the viable antidotes, and they have all slowly integrated these practices into their lives. Strict adherence to local authority recommendations and guidelines, uniform and standardized norms for admission, inpatient, and discharge, mandatory RT-PCR tests before surgery and in selective cases with CT scan chest, optimizing and regularizing the surgeries, avoiding and delaying nonemergency surgeries and follow-up protocols, use of teleconsultations cautiously, and working in close association with the World Health Organization and national health care systems will provide a conducive and safe working environment for orthopaedic surgeons and their fraternity and also will prevent the resurgence of COVID-19.

Surgical anatomy of the dorsal cutaneous branch of the ulnar nerve and its clinical significance in surgery at the ulnar side of the wrist.

The dorsal cutaneous branch of the ulnar nerve can be easily injured during surgery at the ulnar side of the wrist. We sought to identify the surgical anatomy, the pathway around the ulnar styloid process and the safe zone of the dorsal cutaneous branch of the ulnar nerve. In 44 forearm dissections, we found that the dorsal cutaneous branch of the ulnar nerve originated at a median distance of 6.8 cm proximal to the tip of the ulnar styloid. We classified the crossing pattern of the dorsal cutaneous branch of the ulnar nerve at a vertical axis into three types. The most common type featured the dorsal cutaneous branch of the ulnar nerve crossing the vertical axis at a median distance of 10.0 mm distal to the tip of the ulnar styloid. In 14% of specimens, the dorsal cutaneous branch of the ulnar nerve crossed the vertical axis at the level of the tip of the ulnar styloid. By mapping the course of the nerve using a Cartesian coordinate system, it was found that the areas located proximal and palmar to the tip of the ulnar styloid had a very high density of dorsal cutaneous branches of the ulnar nerve. We were unable to establish a safe zone. We recommend identifying the dorsal cutaneous branch of the ulnar nerve in every patient undergoing surgery at the ulnar side of the wrist.

Simultaneous Phrenic and Intercostal Nerves Transfer for Elbow Flexion and Extension in Total Brachial Plexus Root Avulsion Injury.

BACKGROUND: To report the results of restoring the elbow flexion and extension in patients with total brachial root avulsion injuries by simultaneous transfer of the phrenic nerve to the nerve to the biceps and three intercostal nerves to the nerve of the long head of the triceps. METHODS: Ten patients with total brachial root avulsion injuries underwent the spinal accessory nerve transfer to the suprascapular nerve for shoulder reconstruction. Simultaneous transfer of the phrenic nerve to the nerve to the biceps via the sural nerve graft and three intercostal nerves to the nerve of the long head of the triceps was done for restoration of the elbow flexion and extension. Trunk flexion exercise program was used for all patients postoperatively. The mean follow up period was 36 months. RESULTS: For elbow flexion, there were two M4, seven M3, and one M1. For elbow extension, there were three M4, four M3, two M2, and one M1. No patient demonstrated a respiratory problem clinically postoperatively. The average FVC% decreased to 61% of the predicted value at 24 months after surgery. CONCLUSIONS: The simultaneous nerve transfer using the phrenic nerve to the nerve to the biceps and 3 intercostal nerves to the nerve of the long head of the triceps with postoperative trunk flexion exercise provide a comparable result for restoration of elbow function in total brachial plexus root avulsion injury. The patients who appear to have a respiratory problem and are unable to comply with the post-operative respiratory muscles training should be contraindicated for this simultaneous transfer.

Painful Snapping of Thumb Caused by Osteochondroma of Trapezium.

Osteochondroma is the most common benign bone tumor. Lesions occurring at the carpal bones are extremely rare. There are very few cases of osteochondroma at the trapezium had been reported in the English literature. We reported a 47-year-old patient with an osteochondroma of the left trapezium presented with painful snapping of abductor pollicis longus tendon.

Nerve Transfers to Restore Shoulder Function.

The restoration of shoulder function after brachial plexus injury represents a significant challenge facing the peripheral nerve surgeons. This is owing to a combination of the complex biomechanics of the shoulder girdle, the multitude of muscles and nerves that could be potentially injured, and a limited number of donor options. In general, nerve transfer is favored over tendon transfer, because the biomechanics of the musculotendinous units are not altered. This article summarizes the surgical techniques and clinical results of nerve transfers for restoration of shoulder function.

Polyester tape scapulopexy for chronic upper extremity brachial plexus injury.

PURPOSE: To report the results of scapular stabilization for winging in patients with chronic upper brachial plexus injury. METHODS: Eight patients, mean age 36 years, who had a winged scapula after successful restoration of major shoulder function by nerve transfer underwent scapular stabilization to the ribcage using polyester tape. The follow-up period ranged from 24 to 40 months (mean, 38 mo). Data collection included radiographic analysis, active range of motion measurement, University of California Los Angeles shoulder score, and visual analog scale pain score. RESULTS: All patients had clinical improvement with resolution of scapular winging. Five patients had no winging and 3 had mild winging after the surgery. Mean active forward flexion increased from 101° preoperatively to 127° postoperatively. Mean active shoulder abduction increased from 91° preoperatively to 121° postoperatively. Mean University of California Los Angeles shoulder score improved from 17 to 27 and mean visual analog scale pain score improved from 6.1 to 0.7. In addition, mean lateral deviated angle increased from 4° from neutral preoperatively to 9° at the last follow-up. All patients reported satisfaction with postoperative appearance. CONCLUSIONS: Outcomes of polyester tape scapulopexy in the short to intermediate term were favorable in terms of improved appearance, upper extremity function, and pain reduction in patients with winged scapula resulting from chronic upper brachial plexus injury, and with successful restoration of shoulder motion by previous nerve transfers. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Surgical anatomy of the axillary nerve branches to the deltoid muscle.

Variations in the innervation of the posterior deltoid muscle by the anterior branch of the axillary nerve have been reported. The objective of this study is to clarify the anatomy of the axillary nerve branches to the deltoid muscle. One hundred and twenty-nine arms (68 right and 61 left) from 88 embalmed cadavers (83 male and 46 female) were included in the study. The anterior and posterior branches of the axillary nerve were identified and their lengths were measured from the point of emergence from the axillary nerve to their terminations in the deltoid muscle. In all cases, the axillary nerves split into two branches (anterior and posterior) within the quadrangular space and none split within the deltoid muscle. In all specimens, the anterior and middle parts of the deltoid muscle received their nerve supplies from the anterior branch of the axillary nerve. The posterior part of the deltoid muscle was supplied only by the anterior branch of the axillary nerve in 2.3% of the specimens, from the posterior branch in 8.5%, and from both branches in 89.1%. There were two sub-branches of the anterior branch in 4.7% of the specimens. The anterior branch of the axillary nerve supplied not only the anterior and middle parts of the deltoid muscle but also the posterior part in most cases (91.5%).

Nerve transfer to the deltoid muscle using the nerve to the long head of the triceps with the da Vinci robot: six cases.

BACKGROUND: Nerve transfer to the deltoid muscle using the nerve to the long head of the triceps is a reliable method for restoration of deltoid function. The aim of this retrospective study was to report the results of nerve transfer to the deltoid muscle using the nerve to the long head of the triceps procedure using a robot. METHODS: Our series included six patients (mean age 36.3 years) with total deltoid muscle paralysis. A da Vinci-S robot was placed in position. After dissection of the quadrilateral and triangular spaces, the anterior branch of the axillary nerve and the branch to the long head of the triceps were transected, and then robotically sutured with two 10-0 nylon stiches. In two cases, an endoscopic procedure was tried under carbon dioxide (CO2) insufflation. RESULTS: In all patients except one, deltoid function against resistance (M4) was obtained at the last follow-up evaluation. The average shoulder abduction was 112 degrees. No weakness of elbow extension was observed. In two cases with the endoscopic technique, vision was blurred and conversion to open technique was performed. CONCLUSION: The advantages of robotic microsurgery are motion scaling and disappearance of physiological tremor. Reasons for failure of the endoscopic technique could be explained by insufficient pressure. We had no difficulty using the robot without the sensory feedback. The robot-assisted nerve transfer to deltoid muscle using the nerve to the long head of the triceps was a feasible application for restoration of shoulder abduction after brachial plexus or axillary nerve injury. Therapeutic Study. Level of Evidence IV.

Proximal ulnar stump stability after using the pronator quadratus muscle transfer combined with the Suavé-Kapandji procedure in rheumatoid wrist.

The pronator quadratus muscle transfer combined with the Sauvé-Kapandji procedure was used to treat the distal radioulnar joint disorder in ten rheumatoid wrists for prevention against instability of the proximal ulnar stump. All patients were female with a mean age of 46.6 years. The mean follow-up time was 24.2 months. Postoperatively, supination increased in all patients with a mean of 50 degrees. Pain decreased significantly and none complained of prominence of the proximal ulnar stump in normal pronated position and during a tight grip. The wrist radiographs of both coronal and sagittal planes in normal and stress fisting views were used to evaluate the postoperative static and physiologic loaded stability of the proximal ulnar stump. It had shown this procedure provided good static proximal ulnar stump stability in both coronal and sagittal planes. However, in physiologic loaded condition, it was able to provide stability only in the sagittal plane.

Surgical anatomy of the radial nerve branches to triceps muscle.

The objectives of the study are to demonstrate the innervation patterns of the triceps muscles and the most suitable branch of the radial nerve for nerve transfer to restore the motor function of the deltoid muscle in patients with complete C5-C6 root injury. Seventy-nine arms (40 left arms and 39 right arms) from 46 embalmed cadavers (24 male and 22 female) were included in the study. The nerves to the triceps were dissected from the triceps muscles (long head, lateral head, and medial head). The lengths of the branches were measured from the main trunk. The distance from the inferior margin of the teres major muscle to the origin of the nerve to the long head, lateral head, and medial head of the triceps were recorded as well. The first branch was the nerve to the long head of the triceps in 79 arms (100%). The second branch was the nerve to the upper medial head in 30 arms (38%), nerve to the medial head in 8 arms (10.1%), nerve to the upper lateral head in 35 arms (44.3%) and nerve to the lateral head in 6 arms (7.6%). The patterns of branches to the triceps were classified according to our dissections. The nerve to the long head of the triceps was constant as the first branch of the nerve to the triceps branch of the radial nerve in the vicinity of the inferior margin of the teres major muscle.

Simultaneous intercostal nerve transfers to deltoid and triceps muscle through the posterior approach.

PURPOSE: This study reports the results of restoring the deltoid and triceps functions in patients with C5, C6, and C7 root avulsion injuries by simultaneously transferring 4 intercostal nerves to the anterior axillary nerve and the nerve to the long head of the triceps through the posterior approach. METHODS: Nine patients with C5, C6, and C7 root avulsion injuries underwent spinal accessory nerve transfer to the suprascapular nerve combined with transfer of the third and fourth intercostal nerves to the anterior axillary nerve for shoulder reconstruction. Simultaneous transfer of the fifth and sixth intercostal nerves to the radial nerve branch of the triceps was done to restore elbow extension. RESULTS: For shoulder function, 8 patients had M4 recovery and 1 patient had M2 recovery. Average shoulder abduction and external rotation were 69° and 42°, respectively. For elbow extension, 3 patients achieved M3 recovery, 5 patients had M2 recovery, and 1 patient had M1 recovery. CONCLUSIONS: Reconstruction of 2 muscles with intercostal nerves is possible when both muscles act synergistically, such as shoulder abduction and elbow extension. Two intercostal nerves are adequate to transfer for deltoid reconstruction but not enough for elbow extension against gravity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Bilateral congenital hypoplasia of the extensor tendons of the hand: a case report.

Congenital hypoplasia of the extensor tendons, which is defined as a congenital anomaly of the hand involving the extensor mechanism, is a rare condition and there are few previous reports in literature. We reported a case of bilateral congenital hypoplasia of the extensor tendons in a 12-year-old boy who presented with inability to extend his middle and ring fingers treated by the flexor carpi radialis tendon transfers.

End-to-side radial sensory to median nerve transfer to restore sensation and relieve pain in C5 and C6 nerve root avulsion.

PURPOSE: To report the results of end-to-side nerve transfer of the superficial radial nerve into the median nerve for restoration of sensation and pain relief at the dorsal radial aspect of the hand in C5 and C6 root avulsion. METHODS: Eight patients with a mean age of 32 years, with paresthesia and pain at the dorsal radial aspect of the hand due to upper brachial plexus injuries, had end-to-side nerve transfer of the superficial radial nerve into the ulnovolar part of the median nerve. Five patients had S0 and 3 patients had S1 sensory evaluation at the dorsal radial aspect of the affected hand. We evaluated patients for pain using a visual analog scale. We assessed sensory recovery with the Semmes-Weinstein monofilament test and British Medical Research Score, respectively. The follow-up period ranged from 24 to 36 months (average, 28 mo). RESULTS: Six patients had S2 and 2 patients had S3. All patients perceived at least one number lower of the Semmes-Weinstein filament in the dorsal radial aspect of the affected hand compared with the preoperative status. The best result was perception of the 3.61 filament in 2 patients. No downgrading of the donor nerve was observed after surgery. All patients had relief of pain 2 weeks after surgery, and the pain decreased dramatically at the last follow-up. CONCLUSIONS: This method is a reliable, effective, and simple procedure. We recommend this sensory nerve transfer as an additional procedure to the combined motor nerve transfers to relieve pain and restore sensation in the dorsal radial aspect of the hand in patients who have C5 and C6 root avulsion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Nerve transfer for wrist extension using nerve to flexor digitorum superficialis in cervical 5, 6, and 7 root avulsions: anatomic study and report of two cases.

PURPOSE: To evaluate the feasibility of restoring wrist extension in patients with complete cervical root 5 (C5), 6, and 7 avulsion injuries by transferring the most proximal branch of the median nerve that innervates flexor digitorum superficialis (FDS) muscle (proximal FDS branch) to the branch of the radial nerve that innervates extensor carpi radialis brevis (ECRB) muscle (ECRB branch) in an anatomic study and 2 case reports. METHODS: The study was performed on 10 fresh cadavers. The nerve branches of the median nerve and the radial nerve were measured for length, diameter, and sites of origin of their nerve branches. The nerve branches of the median nerve, the posterior interosseous nerve, and the ECRB branch of the radial nerve were processed for histomorphometric evaluation. Using image analysis software, we took all histomorphometric measurements of the nerve sections. Based on this anatomical study, the proximal FDS branch was transferred directly to the ECRB branch without nerve graft in 2 patients. RESULTS: The average distance from the origin of nerve branches to the interepicondylar line was 3.5 and 2.3 cm, respectively, for the proximal FDS and ECRB branches. The average length of the proximal FDS branch and ECRB branch was 2.8 and 3.3 cm, respectively. The average number of myelinated nerve fibers of the proximal FDS branch and ECRB branch was 983 and 2,797, respectively. At 2 years' follow-up, preliminary clinical results demonstrated that wrist extension had gained strength against resistance (grade M4). The arc of motion for wrist extension was 30 degrees in the first patient and 70 degrees in the second one. Useful functional recovery was achieved and classified as good result in both cases. CONCLUSIONS: The anatomic study and 2 reported results supports our hypothesis that transfer of the proximal FDS branch of median nerve to the ECRB branch of radial nerve could be an alternative method for reconstructiing wrist extension in C5, 6, and 7 avulsion injuries.

Nerve transfer to serratus anterior muscle using the thoracodorsal nerve for winged scapula in C5 and C6 brachial plexus root avulsions.

PURPOSE: To report the results of nerve transfer to the serratus anterior muscle using the thoracodorsal nerve for winged scapula in C5 and C6 brachial plexus avulsion. METHODS: Five patients with a mean age of 27 years with loss of shoulder abduction due to upper brachial plexus injuries and with winged scapula had nerve transfer using 1 branch (1 medial and 4 lateral) of the thoracodorsal nerve to the long thoracic nerve. The spinal accessory nerve and the nerve to the long head of the triceps were used simultaneously for nerve transfer to the suprascapular nerve and the axillary nerve, respectively. The follow-up period ranged from 24 to 33 months (mean, 28 months). RESULTS: All patients recovered serratus anterior muscle function. Two patients had no winged scapula, whereas 3 patients had mild winged scapula after the surgery at the last follow-up evaluation. The result was excellent for 2 patients, good for 2 patients, and fair for 1 patient. The mean arcs of motion of shoulder abduction and external rotation were 134 degrees and 124 degrees , respectively. No notable weakness of shoulder adduction was observed. CONCLUSIONS: Use of the branch of the thoracodorsal nerve ensured adequate return function of the serratus anterior muscle by decreasing or correcting winged scapula in upper brachial plexus injury. We recommend nerve transfer for winged scapula for achieving optimum shoulder function. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Restoration of winged scapula in upper arm type brachial plexus injury: anatomic feasibility.

BACKGROUND: The patients who have C5-C6 root avulsion in brachial plexus injury, suffered from loss of elbow flexion, shoulder abduction and winged scapula. The purpose of study is to provide anatomic feasibility of thoracodorsal nerve (medial and lateral branches) and long thoracic nerve for restoration of the shoulder function caused by winged scapula. MATERIAL AND METHOD: To study the length of thoracodorsal nerve and long thoracic nerve from the apex of the posterior axillary line to the insertion of the latissimus dorsi muscle and the serratus anterior muscle respectively, 10 fresh cadavers were dissected. The distance between the thoracodorsal nerve and long thoracic nerve, and the numbers of fascicles and axon were measured by histomorphometry. We transferred the lateral branch of the thoracodorsal nerve to the long thoracic nerve in order to restore the serratus anterior muscle function. RESULTS: The mean length of the thoracodorsal nerve from apex of posterior axillary line to bifurcation before separation to medial and lateral branches was 31.5 mm. The average length of the thoracodorsal nerve and long thoracic nerve from bifurcation to the insertion of the latissimus dorsi muscle and the serratus anterior muscle were 10.3, 82.2, and 99.5 mm, respectively. The distance between the lateral branch of the thoracodorsal nerve and long thoracic nerve was 33.4 mm. The mean number of myelinated nerve fiber of the thoracodorsal nerve medial and lateral branches and long thoracic nerve were 973.8, 1843.3 and 1135.3 axons, respectively. CONCLUSION: The anatomic study of the thoracodorsal nerve and long thoracic nerve showed that the lateral branch of the thoracodorsal nerve is proper in the length and numbers of axon to transfer to the long thoracic nerve for restoration of shoulder function caused by the winged scapula.