Frédéric Teboul

Transfer of Fascicles from the Ulnar Nerve to the Nerve to the Biceps in the Treatment of Upper Brachial Plexus Palsy

BACKGROUND The transfer of one or more ulnar nerve fascicles to the nerve to the biceps can restore elbow flexion in patients with upper brachial plexus palsy. The purposes of the present retrospective study were to evaluate the results of this procedure, to measure the delay in reinnervation of the biceps muscle, and to define the indications for a secondary Steindler flexorplasty. METHODS Thirty-two patients with an upper nerve-root brachial plexus injury were reviewed at an average of thirty-one months after the nerve fascicle transfer. The average age of the patients was twenty-eight years. The average time between the injury and the operation was nine months. Patients were evaluated with regard to reinnervation of the biceps, ulnar nerve function, elbow flexion strength, and grip strength. RESULTS The average time required for reinnervation of the biceps after nerve fascicle transfer was five months. No motor or sensory deficits related to the ulnar nerve were noted clinically. The average grip strength at the time of the last follow-up was 25 kg (an improvement of 9 kg compared with the preoperative value). After the nerve transfer, twenty-four patients achieved grade-3 elbow flexion strength or better according to the grading system of the Medical Research Council. A Steindler flexorplasty was performed as a secondary procedure in ten patients with persistent grade-3 flexor strength or worse. In eight of these cases, elbow flexion strength improved after nerve transfer and flexorplasty. Overall, thirty of the thirty-two patients achieved a good result (grade-4 strength) or a fair result (grade-3 strength). CONCLUSIONS We recommend this procedure for brachial plexus injuries involving the C5-C6 or C5-C6-C7 nerve roots. This procedure spares the C5 nerve root and other nerves for grafting or transfer elsewhere. A secondary Steindler flexorplasty is indicated for patients who have persistent grade-3 elbow flexion strength or worse for at least twelve months after nerve fascicle transfer.

In vitro acoustic waves propagation in human and bovine cancellous bone.

The acoustic behavior of cancellous bone with regard to its complex poroelastic nature has been investigated. The existence of two longitudinal modes of propagation is demonstrated in both bovine and human cancellous bone. Failure to take into account the presence of these two waves may result in inaccurate material characterization.

Surgical Management of Trapezius Palsy

BACKGROUND Injury to the spinal accessory nerve in the posterior cervical triangle leads to paralysis of the trapezius muscle. The aim of this study was to determine the indications for nerve repair or reconstructive surgery according to the etiology, the duration of the preoperative delay, and specific patient characteristics. METHODS Of twenty-seven patients with a trapezius palsy, twenty were treated with neurolysis or surgical repair (direct or with a graft) of the spinal accessory nerve and seven were treated with the Eden-Lange muscle transfer procedure. Lymph node biopsy was the main cause of the nerve injury. The nerve repairs were performed at an average of seven months after the injury, and the reconstructive procedures were done at an average of twenty-eight months. Nerve repair was performed for iatrogenic injuries of the spinal accessory nerve, within twenty months after the onset of symptoms, and in one patient with spontaneous palsy. Reconstructive surgery was performed for cases of trapezius palsy secondary to radical neck dissection, for spontaneous palsies, and after failure of nerve repair or neurolysis. The mean follow-up period was thirty-five months. The functional outcome was assessed clinically on the basis of active shoulder abduction, pain, strength of the trapezius on manual muscle-testing, and level of subjective patient satisfaction. RESULTS The results were good or excellent in sixteen of the twenty patients treated with nerve repair and in four of the seven patients treated with the Eden-Lange procedure. Poor results were seen in older patients and in patients with a previous radical neck dissection. CONCLUSIONS Good results can be expected from a repair of the spinal accessory nerve if it is performed within twenty months after the injury, as the nerve is basically a purely motor nerve and the distance from the injury to the motor end plates is short. Muscle transfer should be performed in patients with spontaneous trapezius palsy, when previous nerve surgery has failed, or when the time from the injury to treatment is over twenty months. Treatment is less likely to succeed when the patient is older than fifty years of age or the palsy was due to a radical neck dissection, penetrating injury, or spontaneous palsy.

Restoration of Elbow Flexion in Brachial Plexus Injury by Transfer of Ulnar Nerve Fascicles to the Nerve to the Biceps Muscle

In recent times, surgical treatment of brachial plexus injuries no longer needs to be justified and is, in fact, recommended. The primary aim of surgery in supraclavicular brachial plexus palsies is restoration of elbow flexion. In complete palsies, nerve reconstruction consists of connecting ruptured roots in the neck with suitable target nerves by nerve grafting or nerve transfers from outside the brachial plexus. In cases of upper-arm palsy involving loss of shoulder function and the flexion of the elbow, the C5 and C6 roots are often found avulsed from the medulla, and this precludes nerve grafting. In such cases, conventional surgery involved palliative procedures such as a Steindler flexorplasty combined with arthrodesis of the shoulder or nerve transfers to suprascapular (spinal accessory nerve) and musculocutaneous (intercostal nerves) nerves. The transfer of some fascicles from the intact ulnar nerve to the nerve to the biceps is a new technique supported by several hypotheses:

Reanimation of elbow extension with intercostal nerves transfers in total brachial plexus palsies

Restoration of flexion in the elbow is the priority in the management of brachial plexus injuries. Current techniques of reconstructions, combining both nerve grafting and nerve transfer, allow more extensive repair, with additional targets: shoulder, elbow extension, hand. The transfer of intercostal nerves onto the nerve of the triceps long head is used to restore elbow extension. The aim of this retrospective study is to evaluate the results of this procedure, in total brachial plexus palsies with uninjured C5 and C6 roots.

Scapulothoracic fusion for serratus anterior paralysis

Paralysis of the serratus anterior may lead to severe disability. Many surgical options are available, from soft-tissue procedures to scapulothoracic fusion. We report the results of 10 consecutive scapulothoracic fusions in 10 patients (7 men and 3 women) treated between 1980 and 1997. The mean age at surgery was 39 years (range, 22-57 years). Paralysis of the serratus anterior was isolated in five patients. One patient was lost to follow-up, and one patient died from an unrelated cause. Fusion was not achieved in three patients, two of whom had successful revision within 1 year postoperatively. One patient with an excellent result had a traumatic arthrodesis fracture and underwent successful revision. Results were assessed in 8 patients, including 3 who had reoperation. At a mean follow-up of 6.2 years (range, 1-15 years), 6 patients had a very good or good result and returned to manual labor. The mean active mobility was limited to 93 degrees in abduction and 101 degrees in forward elevation but was well tolerated. Two patients had a poor result because of nonunion and frozen shoulder, respectively. Scapulothoracic fusion may not be recommended as a primary procedure in the treatment of winging of the scapula due to serratus anterior paralysis. However, with the use of a careful technique, this method may be an alternative to muscle transfer, especially in patients in whom a previous soft-tissue procedure has failed or in patients with strenuous activities or combined muscular lesions.

Surgical Management of Trapezius Palsy: Surgical Technique

BACKGROUND: Injury to the spinal accessory nerve in the posterior cervical triangle leads to paralysis of the trapezius muscle. The aim of this study was to determine the indications for nerve repair or reconstructive surgery according to the etiology, the duration of the preoperative delay, and specific patient characteristics. METHODS: Of twenty-seven patients with a trapezius palsy, twenty were treated with neurolysis or surgical repair (direct or with a graft) of the spinal accessory nerve and seven were treated with the Eden-Lange muscle transfer procedure. Lymph node biopsy was the main cause of the nerve injury. The nerve repairs were performed at an average of seven months after the injury, and the reconstructive procedures were done at an average of twenty-eight months. Nerve repair was performed for iatrogenic injuries of the spinal accessory nerve, within twenty months after the onset of symptoms, and in one patient with spontaneous palsy. Reconstructive surgery was performed for cases of trapezius palsy secondary to radical neck dissection, for spontaneous palsies, and after failure of nerve repair or neurolysis. The mean follow-up period was thirty-five months. The functional outcome was assessed clinically on the basis of active shoulder abduction, pain, strength of the trapezius on manual muscle-testing, and level of subjective patient satisfaction. RESULTS: The results were good or excellent in sixteen of the twenty patients treated with nerve repair and in four of the seven patients treated with the Eden-Lange procedure. Poor results were seen in older patients and in patients with a previous radical neck dissection. CONCLUSIONS: Good results can be expected from a repair of the spinal accessory nerve if it is performed within twenty months after the injury, as the nerve is basically a purely motor nerve and the distance from the injury to the motor end plates is short. Muscle transfer should be performed in patients with spontaneous trapezius palsy, when previous nerve surgery has failed, or when the time from the injury to treatment is over twenty months. Treatment is less likely to succeed when the patient is older than fifty years of age or the palsy was due to a radical neck dissection, penetrating injury, or spontaneous palsy.

Management of Hand Palsies in Isolated C7 to T1 or C8, T1 Root Avulsions

ABSTRACT Thirteen patients were operated on for hand palsies in cases of C7 to T1 or C8, T1 root avulsions. Finger flexion and intrinsic function were paralyzed in all patients. Finger extension was paralyzed in 12 patients. Wrist flexion and extension were present in all patients. Tendon transfers were performed to restore the different functions. The extensor carpi radialis longus was transferred to the flexor digitorum profundus. The brachioradialis tendon was transferred to the flexor pollicis longus tendon for thumb flexion, with a tendon translocation procedure in 6 patients. Intrinsic function was reanimated with passive capsulorrhaphy techniques or other equivalent techniques in 9 patients. Extensor tenodesis was performed to restore hand opening with active wrist flexion in all patients. Moreover, sensory neurotization was performed to restore sensation on the ulnar side of the hand. All patients recovered finger flexion with an average pulp-to-palm distance of 2 cm. Finger extension occurred in 30 degrees wrist flexion. The average Kapandji score was 3. Key pinch was present in all patients. The average grip strength was 8 kg; the average key pinch was 5 kg. All patients recovered a protective sensation with a mean time of 19.5 months. Injury with C7 to T1 or C8, T1 root avulsions is a rare entity. Motor nerve surgery is not possible in these cases. However, surgery remains a challenge and may greatly improve these patients. Therefore, we propose a new tendon transfer and sensory neurotization protocol.

Tumeurs desmoïdes et plexus brachial

The aim of our paper is to assess the functional results and specific difficulties encountered in the treatment of desmoid tumors located near the brachial plexus. Seven patients with a desmoid tumor in this region were followed for at least 2 years (average 59 months). All patients were managed operatively. The resection was marginal in 6 patients and intralesional in one. Three patient had postoperatively chemotherapy and 1 patient had radiation therapy. At review, none of the 7 patients had had to undergo upper limb amputation and the mean functional results were good or excellent in 6 patients (mean MSTS = 72.8). The margins of desmoid tumor resection have to be wide to avoid local recurrence. However, nerves and blood vessels have to be preserved in order to maintain upper limb function and there may well be a need for adjuvant therapy.

Capitate pyrocarbon prosthesis in radiocarpal osteoarthritis.

Scapholunate dissociation or scaphoid pseudarthrosis may lead to osteoarthritis of the wrist. When osteoarthritis affects the midcarpal joint, proximal row carpectomy is no longer possible and only 4 corners fusion or capitolunate arthrodesis may be indicated. However, in some cases, osteoarthritis or bone necrosis may involve the lunatum, making partial arthrodeses impossible. Total arthrodesis may be proposed in such cases, but with a loss of range-of-motion. Total prosthesis may be considered but the results of this procedure are not always encouraging. Consequently, in these situations, we perform pyrocarbon prosthesis implant, replacing the head of the capitatum. This article describes the procedure and the results of a preliminary study.