Updates on and Controversies Related to Management of Radial Nerve Injuries.

Radial nerve injuries are among the most common major traumatic peripheral nerve injuries. Recent literature has updated our knowledge of aspects ranging from radial nerve anatomy to treatment options. Observation and tendon transfers were, and still are, the mainstays of management. However, the improved outcomes of nerve repair even 5 months after injury have changed the treatment algorithm. Nerve repair techniques using conduits, wraps, autograft, and allograft allow tension-free coaptations to improve success. Nerve transfers have evolved to allow a more anatomic recovery of function if used in a timely manner. This review offers an update on radial nerve injuries that reflects recent advances.

[Evolution of surgical indications in upper limb functional surgery for tetraplegic patients: Retrospective study of 428 procedures]. / Évolution des indications chirurgicales dans la chirurgie fonctionnelle du membre supérieur chez le patient tétraplégique : étude rétrospective à propos de 428 interventions.

INTRODUCTION: Regarding surgical strategy for upper limb functional rehabilitation in patients with traumatic tetraplegia, there are few publications and the case series are quite small. PATIENTS AND METHOD: We reviewed all traumatic quadriplegic patients, operated one by one surgeon, professor Marc Revol, for functional surgery of the upper limb in the same department from 1989 to 2018. For each patient, we recorded their gender, their group according to the international classification, their age at the time of the first surgical procedure, the length of time between the accident and the first surgery and between two procedures, the average duration of the whole surgical program, and the surgical technique used for the elbow, the wrist, the long fingers and the thumb. RESULTS: We reviewed 158 cases, representing 428 surgical procedures. Some surgical principles have remained unchanged through the years: the hand opening stage comes before the closing one, and systematically includes intrinsic active palliative procedures using lassos; and restoration of long fingers grasping is consistently associated with restoration of thumb gripping and with flexor tendons tenolysis in the lassos region. Other strategic points have evolved over time: restoration of active elbow extension now systematically uses the biceps over the deltoid transfer; brachio radialis (BR) to extensor digitorum communis (EDC) and to extensor pollicis longus (EPL) transfer has been replaced by tenodesis; in groups 2, 3, 4 and 5, the hand opening stage has been consistently associated with the biceps transfer, thus shortening the surgical program to two procedures instead of three for each upper limb; split distal flexor pollicis longus (FPL) tenodesis has replaced thumb arthrodesis; and, whenever it was possible, BR has been spared from group 3 and beyond. CONCLUSION: In groups 2 to 5, the indications have evolved towards the following strategy. The first surgical step includes restoration of elbow extension using biceps transfer and hand opening reinforcement through four lassos, one split distal FPL tenodesis for the thumb, and EDC and EPL tenodesis to the retinaculum. The second surgical procedure consists of restoration of long fingers and thumb flexion using one unique motor (BR or extensor carpi radialis longus), and closed tenolysis of the flexor tendons in case of adhesions in the lassos area.

Future Perspectives in the Management of Nerve Injuries.

AIM: The author presents a solicited "white paper" outlining her perspective on the role of nerve transfers in the management of nerve injuries. METHODS: PubMed/MEDLINE and EMBASE databases were evaluated to compare nerve graft and nerve transfer. An evaluation of the scientific literature by review of index articles was also performed to compare the number of overall clinical publications of nerve repair, nerve graft, and nerve transfer. Finally, a survey regarding the prevalence of nerve transfer surgery was administrated to the World Society of Reconstructive Microsurgery (WSRM) results. RESULTS: Both nerve graft and transfer can generate functional results and the relative success of graft versus transfer depended on the function to be restored and the specific transfers used. Beginning in the early 1990s, there has been a rapid increase from baseline of nerve transfer publications such that clinical nerve transfer publication now exceeds those of nerve repair or nerve graft. Sixty-two responses were received from WSRM membership. These surgeons reported their frequency of "usually or always using nerve transfers for repairing brachial plexus injuries as 68%, radial nerves as 27%, median as 25%, and ulnar as 33%. They reported using nerve transfers" sometimes for brachial plexus 18%, radial nerve 30%, median nerve 34%, ulnar nerve 35%. CONCLUSION: Taken together this evidence suggests that nerve transfers do offer an alternative technique along with tendon transfers, nerve repair, and nerve grafts.

Tendon versus nerve transfers in elbow, wrist, and hand reconstruction: a literature review.

Upper extremity reconstruction forces the surgeon to chose between several available procedures, among them tendon and nerve transfer. Few guidelines exist to assist the surgeon in this regard, and the authors, therefore, undertook a retrospective review of case series describing tendon and nerve transfer. The authors discovered a scarcity of robust reporting, particularly in regard to tendon transfer, making an objective comparison between the two techniques difficult. Tendon transfers are popular and familiar. Nerve transfers promise distinct advantages; however, excellent evidence of their superiority is lacking.

Update of the physiology and biomechanics of tendon transfer surgery.

Tendon transfer surgery has evolved over the past decade. Unique muscle properties have been elucidated in terms of potential force generation, excursion, and metabolic properties. The choice of an appropriate donor muscle is becoming more of a science than an art. The measurement of sarcomere length has progressed from the laboratory into surgery. Methods of tendon coaptation have advanced to allow early mobilization. This article reviews recent advances in our understanding of tendon transfer surgery of the hand and upper extremity.

Update on tendon transfers for peripheral nerve injuries.

Tendon transfer surgery to restore fundamental wrist and hand function is made possible by the redundancy that exists among the actions of our upper-extremity musculature. Potential donors for transfer are those muscles with adequate power to motor the recipient tendon, similar tendon excursion to the recipient, and function in phase with the recipient. Resolution of wound healing, union of fractures, and mobilization of stiff joints are prerequisites for a functioning tendon transfer. Injuries to the radial, median, and ulnar nerves occur above (high nerve injury) and below the elbow (low nerve injury). High and low nerve injuries result in different functional deficits that require unique tendon transfers to enhance function. This report discusses the various tendon transfers necessary to overcome deficits resulting from high and low radial, median, and nerve injuries.

[Surgical management of soft tissue sarcomas: principles of resection and reconstructive plastic procedures]. / Weichgewebssarkome: Resektionsprinzipien und Wiederherstellungschirurgie.

1. Adequate complete surgical resection with a oncologic radical or wide margin of normal tissue represents the most important measure to prevent a local recurrence. Limited excision with "shelling-out" of the tumor, through its "pseudocapsule" almost invariably means positive microscopic margins. The pathohistologically or macroscopically marginal or intralesional positive resection margins make a salvage surgery necessary. 2. A close safety margin of < 1 cm due to neighboured anatomic structures indicates a high risk of local recurrence and makes an adjuvant radiotherapy mandatory. Plastic-reconstructive surgery should prepare the radiotherapy fields, to avoid cavities or ulcerations. 3. Facts should be stated in the clinical record and the operation report, e.g. the safety margin should be defined by the surgeon and the pathologist; the histopathologic stage and grade are absolutely basic requirements. If necessary, a second histopathologic review should be asked for. 4. Tumor resection and reconstructive oncoplastic measures should correspond individually to the oncologic parameters, to the functional demands and to the age of the patient. 5. Multidisciplinary cooperation in a tumorboard is a precondition for an adequate treatment.

The future of anterior cruciate ligament restoration.

Advancements in the understanding of anatomy, kinematics, and physiology should improve future treatment of anterior cruciate ligament injured knees. The ultimate goal of full restoration of an anterior cruciate ligament injured knee to preinjury status, may be possible in the distant future through genetic manipulation inducing regeneration of tissues. In the midterm future, resorbable stents with incorporated bioactive growth factors have the potential of inducing normal anterior cruciate ligament anatomy without the need for detrimental harvesting of the patient's tissues, or risk of microbial transmission with the use of an allograft. In the near future, the development of more benign autografts and allografts is possible along with methods of resorbable fixation of the graft to bone. Future development of 3-dimensional arthroscopic visualization and robotic surgical techniques have the potential for improvement in graft placement. Advancements in treatment of anterior cruciate ligament deficient knees also can be expected from nonsurgical areas, such as control of muscle atrophy, enhancing cerebellar-proprioceptive rehabilitation, and better bracing techniques. The basic principle of therapy should be to maximize the functional load acceptance and transference capacity of the knee with the least degree of risk to the patient.

Simultaneous tendon transfer and autogenous augmentation of the first web space of the hand with intrinsic paralysis

Simultaneous tendon transfer and dermofat graft augmentation of the first web space of the hand with intrinsic paralysis is described. Fifty per cent over-correction of the web space volume is recommended in anticipation of postoperative graft resorption. Other techniques of fat auto-transplantation are discussed.

Opponensplasty by extensor indicis and flexor digitorium superficialis tendon transfer

From 1977 to 1988, 166 patients with median nerve paralysis of varied aetiology underwent opponensplasty. In 50 of these the extensor indicis was used, and in 116 the flexor digitorum superficialis of the ring finger. An analysis of these hands showed that the EI opponensplasty was best in supple hands and FDS opponensplasty was more suitable for less pliable hands. There were fewer complications seen after FDS opponensplasty if the detachment of the donor tendon was done through a volar oblique incision rather than the conventional lateral incision.