Intercostal Nerve Transfer for Biceps Reinnervation in Obstetrical Brachial Plexus Palsy: A Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Individual Patient Data Systematic Review using Individualized Fusion and Comparison to Supraclavicular Exploration and Nerve Grafting.

Introduction: The objective of this study was to search existing literature on nerve reconstruction surgery in patients with obstetric brachial plexus palsy to determine whether treatment with supraclavicular exploration and nerve grafting produced better elbow flexion outcomes compared to intercostal nerve transfer. Methods: This study was a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Individual Patient Data guidelines. A systematic search was conducted using multiple databases. An ordinal regression model was used to analyze the effect of using supraclavicular exploration and nerve grafting or intercostal nerve on elbow flexion with the two scores measured: elbow flexion Medical Research Council scores and Toronto active movements scale scores for elbow flexion. Results: A final patient database from 6 published articles consisted of 83 supraclavicular exploration and nerve grafting patients (73 patients with Medical Research Council and 10 patients with Toronto score) and 7 published articles which consisted of 131 intercostal nerve patients (84 patients with Medical Research Council and 47 patients with Toronto scores). Patients who underwent supraclavicular exploration and nerve grafting presented with an average Medical Research Council score of 3.9 ± 0.72 and an average Toronto score of 6.2 ± 2.2. Patients who underwent intercostal nerve transfer presented with an average Medical Research Council score of 3.9 ± 0.71 and an average Toronto score of 6.4 ± 1.2. There was no statistical difference between supraclavicular exploration and nerve grafting and intercostal nerve transfer when utilizing Medical Research Council elbow flexion scores (ordinal regression: 0.3821, standard error: 0.4590, p = 0.2551) or Toronto Active Movement Scale score for elbow flexion (ordinal regression: 0.7154, standard error: 0.8487, p = 0.2188). Conclusion: Regardless of surgical intervention utilized (supraclavicular exploration and nerve grafting or intercostal nerve transfers), patients had excellent outcomes for elbow flexion following obstetric brachial plexus palsy when utilizing Medical Research Council or Toronto scores for elbow flexion. The difference between these scores was not statistically significant. Type of study/Level of evidence: Therapeutic Study: Investigating the Result of Treatment/level III.

Rehabilitation protocols in neonates undergoing primary nerve surgery for upper brachial plexus palsy: A scoping review.

INTRODUCTION: Surgical management is recommended in patients with severe neonatal brachial plexus palsy (NBPP) within the first 6 months of age to regain best possible function. Rehabilitation post-surgery remains relatively unexplored. This is a scoping review that explores, which rehabilitation modalities exist and how they vary for different microsurgical approaches in NBPP. MATERIALS AND METHODS: A systematic search was conducted to include articles about upper trunk obstetric brachial plexus nerve microsurgery in pediatric patients that made mention of rehabilitation protocols. The aims of rehabilitation modalities varied and were grouped: "passive" movement to prevent joint contracture or stiffness, "active" or task-oriented movement to improve motor function, or "providing initial motor recovery". Surgical approach was described as either exploration of the brachial plexus (EBP) or nerve transfer without root exploration (NTwoRE). Technique was categorized into transfers and non-transfers. RESULTS: Thirty-six full-text articles were included. Initiation of rehabilitation was 22.26 days post-surgery. Twenty-eight studies were EBP, and six were NTwoRE. Of studies classifiable by aims, nine were "passive", nine were "active", and five were "providing initial motor recovery". Only 27.7% of EBP studies mentioned active therapy, while 75.0% of NTwoRE studies mentioned active therapy. The average age of patients in the EBP procedure category was 7.70 months, and NTwoRE was 17.76 months. Within transfers, the spinal accessory to suprascapular group was more likely to describe an active shoulder exercise therapy, whereas contralateral C7 group was more likely to describe "initial motor recovery", especially through the use of electrostimulation. All articles on electrostimulation recommended 15-20-minute daily treatment. CONCLUSION: Information on rehabilitation is limited post-nerve surgery in NBPP. However, when mentioned, the aims of these therapies vary with respect to surgical approach and technique. The type of therapy to employ may be a multifaceted decision, involving factors such as patient age, initial deformity, and goals of the care team.

Educational quality of YouTube content on brachial plexus injury and treatment.

INTRODUCTION: While surgical literature exists on birth-related brachial plexus injury (BPI), there are not validated sources of information on BPI for patients, which can impact patient autonomy and decision-making. With YouTube as a popular source for patients to research diagnoses, this study aims to evaluate the quality of information regarding BPI and its treatment available on the platform. MATERIALS AND METHODS: BPI YouTube videos were screened independently by two reviewers. Videos were categorized by source: (1) academic, government, and non-profit organizations; (2) private practices, companies, and for-profit organizations; (3) independent users. Each video was evaluated for reliability, credibility, and quality using the modified DISCERN criteria (scale, 0-5), Journal of the American Medical Association (JAMA) criteria (scale, 0-4), and Global Quality Scale (GQS; scale, 1-5). Surgical treatment videos were analyzed by the senior author using a modified "treatment" DISCERN criteria (scale, 8-40). Non-English videos were excluded from this study. Analysis of variance tests were used to compare means. RESULTS: One hundred and fifteen videos were selected for final analysis. The mean modified DISCERN score was 3.26; JAMA was 2.31; GQS was 3.48. Videos were subdivided according to source. Group 1, 2, and 3 had 45, 24, and 46 videos, respectively. Modified DISCERN score was greater for Group 1 than Group 2 (3.58 vs. 3.04, p < .001) and Group 3 (3.58 vs. 3.07, p < .001). JAMA score was greater for Group 1 than Group 2 (2.63 vs 2.15, p = .041) and Group 3 (2.63 vs. 2.08, p = .002). GQS score was greater for Group 1 than Group 2 (3.93 vs. 3.31, p = .031) and Group 3 (3.93 vs. 3.13, p < .001). Of the 34 videos (44.7%) that mentioned treatment, the DISCERN score was 14.32. CONCLUSION: The videos analyzed were found to have moderate reliability, credibility, and quality. The reliability of information regarding treatments for BPI was poor. Healthcare providers should supply additional information on treatment of BPI.

Local zinc treatment enhances fracture callus properties in diabetic rats.

The effects of locally applied zinc chloride (ZnCl2 ) on early and late-stage parameters of fracture healing were evaluated in a diabetic rat model. Type 1 Diabetes has been shown to negatively impact mechanical parameters of bone as well as biologic markers associated with bone healing. Zinc treatments have been shown to reverse those outcomes in tests of nondiabetic and diabetic animals. This study is the first to assess the efficacy of a noncarrier mediated ZnCl2 on bony healing in diabetic animals. This is a promising basic science approach which may lead to benefits for diabetic patients in the future. Treatment and healing were assessed through quantification of callus zinc, radiographic scoring, microcomputed tomography (µCT), histomorphometry, and mechanical testing. Local ZnCl2 treatment increased callus zinc levels at 1 and 3 days after fracture (p ≤ 0.025). Femur fractures treated with ZnCl2 showed increased mechanical properties after 4 and 6 weeks of healing. Histomorphometry of the ZnCl2 -treated fractures found increased callus cartilage area at Day 7 (p = 0.033) and increased callus bone area at Day 10 (p = 0.038). In contrast, callus cartilage area was decreased (p < 0.01) after 14 days in the ZnCl2 -treated rats. µCT analysis showed increased bone volume in the fracture callus of ZnCl2 -treated rats at 6 weeks (p = 0.0012) with an associated increase in the proportion of µCT voxel axial projections (Z-rays) spanning the fracture site. The results suggest that local ZnCl2 administration improves callus chondrogenesis leading to greater callus bone formation and improved fracture healing in diabetic rats.

Trends of Age and Geographical Location in Microsurgical Treatment of Obstetric Brachial Plexus Palsy.

BACKGROUND: Debate over the optimal age at time of surgery for treatment of brachial plexus birth injury (BPBI) remains controversial, and there exists geographical varia- tion in surgical preference for age at time of surgery. The objective of this review was to analyze trends in age and geography in brachial plexus microsurgery for treatment of brachial plexus birth injury (BPBI) over time. METHODS: Review of the literature in this study was con- ducted according to the Preferred Reporting Items for Sys- tematic Reviews and Meta-Analysis (PRISMA) guidelines. PubMed, Cochrane, Web of Science, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched. RESULTS: Pediatric patients undergoing brachial plexus microsurgery described in published reports before 2011 had a mean of 7.15 ± 6.56 months of age, while pediatric patients undergoing brachial plexus microsurgery surgery described in published reports after 2011 had a mean of 11.23 ± 9.76 months of age (p < 0.05). The mean age at surgery was lower in publications from Asian countries (6.29 months) than in publications from North America (11.34 months; p < 0.05). CONCLUSIONS: Age at time of microsurgery for treatment of BPBI is increasing, with mean age at surgeries occurring in and after 2011 being 4 months higher than thos occuring before 2011. The mean age at surgery was about 5 months higher in North American publications than in Asian pub- lications.

Malpractice litigation following orthopaedic surgery of the hip: Frequency, reasons for lawsuit, and outcomes.

Medical malpractice litigation in the United States has resulted in the widespread adoption of defensive medicine practices. Orthopaedic surgery is among the specialties most likely to face a malpractice lawsuit, and hip-related surgeries are commonly involved. This study aimed to analyse malpractice litigation as it relates to hip surgery in the United States. The purpose of this study was to seek answers to the following questions: Has there been an increase or a decrease in the number of hip surgery malpractice cases in recent years? What are the most common reasons for a patient to pursue litigation? Which surgical complications are most likely to result in a lawsuit? What trends do we see in terms of outcomes? The Westlaw legal database was queried for all relevant cases from 2008 to 2018. A retrospective review of cases was conducted and descriptive analyses were performed in order to identify factors associated with hip surgery malpractice litigation. A total of 82 cases were analysed. There was a downtrend in the number of cases per year. Total hip arthroplasty (47 cases, 57.3%) was the procedure most often involved. Procedural error was noted as a reason for litigation in 71 (86.6%) cases. Neurological injury (22 cases, 26.8%), malpositioned hardware (15 cases, 18.3%) and leg length discrepancy (8 cases, 9.8%) were the most common complications listed. The majority of cases resulted in a verdict in favour of the defendant orthopaedic surgeon (48 cases, 58.5%). The mean payout for a plaintiff verdict (20 cases, 24.4%) was $1,647,981 (range, $1,852-$7,000,000) and the mean payout for a settlement (13 cases, 15.9%) was $657,823 (range, $49,000-$3,000,000) (p = 0.063). The study concluded that, within the 10-year period, there was a significant downtrend in hip surgery malpractice cases filed per year. Orthopaedic surgeons were found liable in the minority of cases. As expected, verdicts in favour of plaintiffs resulted in seemingly higher payouts than settlements.

Surgical timing in neonatal brachial plexus palsy: A PRISMA-IPD systematic review.

BACKGROUND: Neonatal brachial plexus palsy (NBPP) is a serious complication of high-risk deliveries with controversy surrounding timing of corrective nerve surgery. This review systematically examines the existing literature and investigates correlations between age at time of upper trunk brachial plexus microsurgery and surgical outcomes. METHODS: A systematic screening of PubMed, Cochrane, Web of Science, and CINAHL databases using PRISMA-IPD guidelines was conducted in January 2020 to include full-text English papers with microsurgery in upper trunk palsy, pediatric patients. Spearman rank correlation analysis and two-tailed t-tests were performed using individual patient data to determine the relationship between mean age at time of surgery and outcome as determined by the Mallet, Medical Research Council (MRC), or Active Movement Scale (AMS) subscores. RESULTS: Two thousand nine hundred thirty six papers were screened to finalize 25 papers containing individual patient data (n = 256) with low to moderate risk of bias, as assessed by the ROBINS-I assessment tool. Mallet subscore for hand-to-mouth and shoulder abduction, AMS subscore for elbow flexion and external rotation, and MRC subscore for elbow flexion were analyzed alongside the respective age of patients at surgery. Spearman rank correlation analysis revealed a significant negative correlation (ρ = -0.30, p < .01, n = 89) between increasing age (5.50 ± 2.09 months) and Mallet subscore for hand-to-mouth (3.43 ± 0.83). T-tests revealed a significant decrease in Mallet hand-to-mouth subscores after 6 months (p < .05) and 9 months (p < .05) of age. No significant effects were observed for Mallet shoulder abduction, MRC elbow flexion, or AMS elbow flexion and external rotation. CONCLUSION: The cumulative evidence suggests a significant negative correlation between age at microsurgery and Mallet subscores for hand-to-mouth. However, a similar correlation with age at surgery was not observed for Mallet shoulder abduction, MRC elbow flexion, AMS external rotation, and AMS elbow flexion subscores.

A Review of Orthopaedic Resident Case Logs to Identify Fluctuations in Exposure to Adult Orthopaedic Procedures.

INTRODUCTION: Orthopaedic surgery resident case exposure is an important component of surgical training and is monitored by the Accreditation Council for Graduate Medical Education (ACGME) to ensure resident readiness for graduation. The purpose of this study was to investigate trends in exposure to adult orthopaedic surgical procedures and analyze the impact of the 2013 update in ACGME case logging expectations. METHODS: A retrospective review of ACGME case log data was conducted for adult orthopaedic procedures performed by graduating orthopaedic surgery residents from 2012 to 2020. Trends in the number of cases logged and the case share by anatomical location were investigated. Linear regression analysis was performed to analyze changes in case number over the 9-year period. RESULTS: For all surgical categories, there was stability in the average case number per resident from 2012 to 2013, followed by a precipitous decrease from 2013 to 2014. From 2014 to 2020, there has been a gradual increase in case number for all categories except "other musculoskeletal (MSK)," resulting in a total 46% recovery since the 2014 decline. Concomitant with the decline, there was a relative increase in pelvis/hip and femur/knee procedures and decrease in shoulder, other MSK, and spine procedures. From 2014 to 2020, shoulder, humerus/elbow, pelvis/hip, leg/ankle, foot/toes, and spine cases have gradually accounted for a larger proportion of total cases while femur/knee and "other MSK" cases have accounted for less. CONCLUSIONS: The 2013 update in ACGME case logging expectations was associated with a significant decrease in case number. This is likely a reflection of residents correctly entering 1 primary Current Procedural Terminology code for each surgical case. Programs should be aware of a general increase in case number since 2014 and acknowledge the fact that some procedure types may be given priority from a logging standpoint when multiple Current Procedural Terminology codes apply.

Clinical Outcomes After Neurolysis for the Treatment of Peroneal Nerve Palsy: A Systematic Review and Meta-Analysis.

BACKGROUND: Neurolysis techniques have been adapted for decompression of peripheral nerves in multiple locations, including the common peroneal nerve (CPN) at the fibular neck. The aim of this study was to conduct a systematic review and meta-analysis to summarize the clinical outcomes of neurolysis for the management of peroneal nerve palsy (PNP). METHODS: Preferred Reporting Systems for Systematic Reviews and Meta-Analyses guidelines were followed for this meta-analysis. Four databases were queried, and randomized clinical trials, cohort studies, case-control studies, and case series with n > 10 published in English that evaluated clinical outcomes of neurolysis for the treatment of PNP and foot drop were included. Two reviewers completed screening and data extraction. Methodological quality was evaluated using the Newcastle-Ottawa Scale. RESULTS: A total of 493 articles were identified through literature search. Title and abstract screening identified 39 studies for full-text screening. Ten articles met the inclusion criteria for qualitative analysis, and 8 had complete data for meta-analysis.Overall, there were 368 patients (370 nerves) who had neurolysis of the CPN for PNP, of which 59.2% (n = 218) were men and 40.8% (n = 150) were women. The mean age of the patients was 47.1 years (SD, 10.0 years), mean time to surgery was 9.65 months (SD, 6.3 months), and mean follow-up time was 28 months (SD, 14.0 months). The median preoperative Medical Research Council (MRC) score was 1 (IQR 0, 3), with 42.2% (n = 156) having MRC score of 0. The median postoperative MRC score was 5 (IQR 4, 5), with 53.9% (n = 199) having MRC score of 5. Complications of neurolysis of the peroneal nerve for treatment of PNP included postoperative infection (0.54%, n = 2), wound dehiscence (0.27%, n = 1), hematoma (0.54%, n = 2), bleeding (0.27%, n = 1), relapse of PNP (0.27%, n = 1), and 1 case of mortality due to sepsis. CONCLUSIONS: Our meta-analysis shows that neurolysis of the CPN is safe and improves ankle dorsiflexion strength in patients with PNP. Future studies should use a standardized method of measuring sensory outcomes, and studies of higher levels of evidence are needed to better assess the clinical outcomes of neurolysis for treatment of PNP.