Oliver Rühmann

Reconstructive operations for the paralyzed shoulder in brachial plexus palsy: concept of treatment.

Sixty-three patients with persistent brachial plexus palsy underwent a transfer of the trapezius muscle and 14 patients a shoulder arthrodesis. Thirteen female and 64 male patients were treated with a mean age of 31 yr (17-69 yr). The average follow-up period was 14 months (6-50 months). In all cases, the trapezius transfer resulted in increased abduction from 6.1 degrees to an average of 36.4 degrees (20-80 degrees) and forward flexion from 13.8 degrees to an average of 31.9 degrees (10-90 degrees). The multidirectional shoulder instability was improved in 60 patients. Strength and functional improvement was, on average, greater following shoulder arthrodesis (abduction from 9.6 to 59.3 degrees (40-90 degrees), forward flexion from 11.4 to 50.7 degrees (30-90 degrees)). In patients with brachial plexus palsy, trapezius transfer resulted in an improvement of shoulder function and stability as well as subjectively. The increase in function was, however, less pronounced in comparison with shoulder arthrodesis. The advantages of the transfer are the regaining of normal passive function and the shorter duration of surgery. Shoulder fusion is more suitable for those patients who require the best possible extent of function and strength in the shoulder.

Trapezius transfer in brachial plexus palsy. Correlation of the outcome with muscle power and operative technique.

Between March 1994 and June 2003, 80 patients with brachial plexus palsy underwent a trapezius transfer. There were 11 women and 69 men with a mean age of 31 years (18 to 69). Before operation a full evaluation of muscle function in the affected arm was carried out. A completely flail arm was found in 37 patients (46%). Some peripheral function in the elbow and hand was seen in 43 (54%). No patient had full active movement of the elbow in combination with adequate function of the hand. Patients were followed up for a mean of 2.4 years (0.8 to 8). We performed the operations according to Sahas technique, with a modification in the last 22 cases. We demonstrated a difference in the results according to the pre-operative status of the muscles and the operative technique. The transfer resulted in an increase of function in all patients and in 74 (95%) a decrease in multidirectional instability of the shoulder. The mean increase in active abduction was from 6 degrees (0 to 45) to 34 degrees (5 to 90) at the last review. The mean forward flexion increased from 12 degrees (0 to 85) to 30 degrees (5 to 90). Abduction (41 degrees) and especially forward flexion (43 degrees) were greater when some residual function of the pectoralis major remained (n = 32). The best results were achieved in those patients with most pre-operative power of the biceps, coracobrachialis and triceps muscles (n = 7), with a mean of 42 degrees of abduction and 56 degrees of forward flexion. Active abduction (28 degrees) and forward flexion (19 degrees) were much less in completely flail shoulders (n = 34). Comparison of the 19 patients with the Saha technique and the 15 with the modified procedure, all with complete paralysis, showed the latter operation to be superior in improving shoulder stability. In all cases a decrease in instability was achieved and inferior subluxation was abolished. The results after trapezius transfer depend on the pre-operative pattern of paralysis and the operative technique. Better results can be achieved in patients who have some function of the biceps, coracobrachialis, pectoralis major and triceps muscles compared with those who have a complete palsy. A simple modification of the operation ensures a decrease in joint instability and an increase in function.

Biomechanical and Kinematic Influences of a Total Infrapatellar Fat Pad Resection on the Knee

Background This biomechanical study was performed to evaluate the consequences of total infrapatellar fat pad resection on knee kinematics and patellar contact pressure. Hypothesis Resection of the infrapatellar fat pad produces significant changes in knee kinematics and patellar contact pressure. Study Design Biomechanical cadaveric study. Methods Isokinetic knee extension was simulated on 10 human knee cadaveric specimens (6 men, 4 women; mean age at death, 44 years). Joint kinematics were evaluated by an ultrasound-based 3D motion analysis system, and retro-patellar contact pressure was measured using an electronic pressure-sensitive film. All data were taken before and after resection of the infrapatellar fat pad and statistically analyzed. Results A total resection of the infrapatellar fat pad resulted in a significant decrease of the tibial external rotation relative to the femur between 63° of flexion and full knee extension (maximum: 3° rotation difference at 0° knee flexion, P = .011), combined with a significant medial translation of the patella between 29° and 69° of knee flexion (range, 0.9-1.3 mm, P = .017-.028). Retro-patellar contact pressure was significantly reduced (from 20% to 25%, P = .008-.021) at all flexion angles. Conclusion A resection of the infrapatellar fat influences patellar biomechanics and knee kinematics. Clinical Relevance The infrapatellar fat pad may have a biomechanical function and may play a role in anterior knee pain syndrome.

Osteotomy of the Humerus to Improve External Rotation in Nine Patients with Brachial Plexus Palsy

Malfunction of the infraspinatus muscle and teres minor muscle illustrate the typical clinical picture in patients with brachial plexus palsy. The arm hangs down in an inwardly rotated position and elbow flexion is hindered by striking of the lower arm against the thorax. Between 1995 and 2000, we have done external rotational osteotomy of the humerus for nine patients with brachial plexus palsy. The mean age of the patients at the time of operation was 29 years (range 15 to 42). The mean follow-up time was 24 (6 to 69) months. Preoperatively, the patients all had appreciable deficits of external rotation (mean deficit 37°, range 10° to 70°). As a result of osteotomy, external rotation was improved in all patients, the mean increase being 42° (range 25° to 60°). All patients were subjectively content with the improved position of the arm and its function. They were able to move their hands to their faces without striking the lower arm against the chest on elbow flexion, or without compensatory evasive movement of the shoulder.

Trapezius transfer after brachial plexus palsy: INDICATIONS, DIFFICULTIES AND COMPLICATIONS

Most brachial plexus palsies are due to trauma, often resulting from motorcycle accidents. When nerve repair and physiotherapy are unsuccessful, muscle transfer may be considered. Paralysis of the deltoid and supraspinatus muscles can be addressed by transfer of the trapezius. Between March 1994 and June 1997 we treated 38 patients with brachial plexus palsy by trapezius transfer and reviewed 31 of these (7 women, 24 men) after a mean follow-up of 23.8 months (12 to 39), reporting the clinical and radiological results and subjective assessment. The mean age of the patients was 29 years (18 to 46). The operations had been performed according to the method of Saha described in 1967, involving transfer of the acromion with the insertion of the trapezius to the proximal humerus, and immobilisation in an abduction support for six weeks. Rehabilitation started on the first postoperative day with active exercises for the elbow, hand and fingers, and electrical stimulation of the transferred trapezius. All 31 patients had improved function with a decrease in multidirectional instability of the shoulder. The average increase in active abduction was from 7.3 degrees (0 to 45) to 39 degrees (25 to 80) at the latest review. The mean forward flexion increased from 20 degrees (0 to 85) to 44 degrees (20 to 90). Twenty-nine of the 31 were satisfied with the improvement in stability and function. Trapezius transfer for brachial plexus palsy involving the shoulder improves function and stability with clear subjective benefits.

Transposition of local muscles to restore elbow flexion in brachial plexus palsy

Between 1994 and 2001, triceps to biceps transfers were done in 10 men and a transfer of the forearm flexors and extensors (Steindler procedure) in nine. All had suffered from a post-traumatic lesion of their brachial plexus, resulting in loss of elbow flexion. Their mean age at the time of the original accident was 27 years (range 16-50 years) and at the time of muscle transfer 35 years (range 22-56 years), with a mean observation period of 20 months (range 6-51 months). In 16 patients, a neurosurgical procedure had been performed after the trauma, and in 22 patients other reconstructive operations had been done. Transfer of the forearm flexors and extensors resulted in active elbow flexion with a mean of 94 degrees (range 70-130 degrees ). After triceps to biceps transposition a mean of 109 degrees (range 70-140 degrees ) was reached. A mean deficit of passive extension of 12 degrees (range 0-30 degrees ) remained after the Steindler procedure, and of 5 degrees (range 0-10 degrees ) after triceps to biceps transposition. Two complications occurred with the Steindler procedure. The transfer of the triceps muscle to the tendon of the biceps and the transfer of the forearm flexors or extensors on loss of elbow flexion, therefore, resulted in adequate movement and strength. Both procedures involve operating close to the elbow joint and had minimal complications. The triceps to biceps transfer is particularly suitable for co-contraction of triceps and biceps.

Patients With Impingement Syndrome With and Without Rotator Cuff Tears Do Well 20 Years After Arthroscopic Subacromial Decompression

PURPOSE To present the long-term outcome of arthroscopic subacromial decompression (ASD) for patients with impingement syndrome with or without rotator cuff tears as well as with or without calcific tendinitis in a follow-up of 20 years. METHODS We included 95 patients after a mean follow-up of 19.9 (19.5 to 20.5) years. All patients underwent ASD, including acromioplasty, resection of the coracoacromial ligament, and coplaning without cuff repair. The Constant score was used to assess the functioning of the shoulder. In addition, we defined a combined failure end point of a poor Constant score and revision surgery. RESULTS Revision surgery was performed in14.7% of the patients. The combined end point showed successful results in 78.8% of all cases. All patients with isolated impingement syndrome achieved successful results. Those with partial-thickness tears had successful outcomes in 90.9% of all cases, and patients with full-thickness tears had successful outcomes in 70.6% of all cases. The tendinitis calcarea group showed the poorest results, with a 65.2% success rate. CONCLUSIONS Our long-term results show that patients with impingement syndrome who received ASD, including acromioplasty, resection of the coracoacromial ligament, and coplaning do well 20 years after the index surgery. ASD without cuff repair even appears to be a safe, efficacious, and sustainable procedure for patients with partial rotator cuff tears. LEVEL OF EVIDENCE Level IV, therapeutic case series.

TRICEPS TO BICEPS TRANSFER TO RESTORE ELBOW FLEXION IN THREE PATIENTS WITH BRACHIAL PLEXUS PALSY

Between April 1994 and April 1998, triceps to biceps transfers were done for three men with posttraumatic lesions of the brachial plexus and consequent loss of elbow flexion. Their mean age at the time of their accidents was 33 years (range 19-41) and at the time of muscle transfer 40 years (28-46), with a mean observation period of 21 months (12-31). The transfer resulted in active elbow flexion in all patients with a mean of 113° (90°-130°) and a degree of strength 4-5 (contraction against resistance) with no remaining deficit of passive extension. Two patients were satisfied with the result of the operation and the other was content. No complications were noted. The transfer of the triceps muscle to the tendon of the biceps muscle on loss of elbow flexion resulted in adequate movement and degree of strength. The triceps to biceps transfer involves operating close to the elbow joint and minimal complications, is cosmetically satisfactory, and is particularly suitable for co-contraction of triceps and biceps.Between April 1994 and April 1998, triceps to biceps transfers were done for three men with post-traumatic lesions of the brachial plexus and consequent loss of elbow flexion. Their mean age at the time of their accidents was 33 years (range 19-41) and at the time of muscle transfer 40 years (28-46), with a mean observation period of 21 months (12-31). The transfer resulted in active elbow flexion in all patients with a mean of 113 degrees (90 degrees-130 degrees) and a degree of strength 4-5 (contraction against resistance) with no remaining deficit of passive extension. Two patients were satisfied with the result of the operation and the other was content. No complications were noted. The transfer of the triceps muscle to the tendon of the biceps muscle on loss of elbow flexion resulted in adequate movement and degree of strength. The triceps to biceps transfer involves operating close to the elbow joint and minimal complications, is cosmetically satisfactory, and is particularly suitable for co-contraction of triceps and biceps.

MRT bei Spondylitis und Spondylodiszitis

ZusammenfassungDas MRT besitzt für die Diagnose der Spondylitis und Spondylodiszitis eine hohe Sensitivität sowie Spezifität und ist diesbezüglich allen anderen radiologischen Methoden überlegen. Bei hohem Weichteilkontrast und hervorragender anatomischer Auflösung sind frühzeitig Pathologien erkennbar und die Ausdehnung der Erkrankung darstellbar. Die betroffenen Wirbelkörper und Bandscheiben zeigen stadienabhängig typische Veränderungen der Signalintensität in den T1- und T2-gewichteten Sequenzen, die Anwendung von Kontrastmittel hat sich bewährt.Da man mit dem MRT auch wichtige Differentialdiagnosen wie Tumoren und degenerative Veränderungen erkennen und den Verlauf der Erkrankung dokumentieren kann, ist das MRT die Methode der Wahl zur weiterführenden Diagnostik und Verlaufsbeobachtung der Spondylitis und Spondylodiszitis.AbstractMagnetic resonance imaging (MRI) is highly sensitive and specific for the diagnosis of spondylitis and in that respect is superior to other radiologic methods. Its excellent morphological resolution allows early recognition of pathologies and spread of the spondylitis. Affected vertebral bodies and discs reveal typical alterations in T1- andT2-weighted images; post-gadolinium images are necessary to improve specificity.MRI helps to diagnose tumors and degenerative changes. Thus, MRI is the method of first choice in the diagnosis and surveillance of spondylitis and spondylodiscitis.

Z-Plastik und Umleitung der Bizepssehne mit Release der Membrana interossea zur Wiederherstellung der Pronation bei lähmungsbedingten Supinationsfehlhaltungen und -kontrakturen

OBJECTIVE Reduction of paralytic supination posture and contracture of the forearm. Improved spontaneous posture of the paralyzed arm with a more normal anatomic relationship of ulna and radius. Improvement of the activities of daily living, especially activities requiring active pronation (eating, dressing, writing). Prevention of recurrence or increase of the deformity during the growth period in obstetric brachial plexus palsy. Partly restoration of active pronation. INDICATIONS Unopposed supination by the biceps in the presence of paralysis of the pronators as a result of --brachial plexus palsy, --poliomyelitis, --quadriplegia, --paralysis from other causes. CONTRAINDICATIONS Ongoing spontaneous or postoperative nerve regeneration and possible improvement of paralyzed pronators. Posttraumatic or degenerative ankylosis of the elbow joint; the extent of the preoperative passive pronation determines the postoperative result. Insufficient power (< M(4)) of the triceps (inadequate triceps function can lead to a flexion contracture of the elbow). SURGICAL TECHNIQUE After exposure of the biceps tendon a long Z-plasty is used to lengthen the tendon and allow its distal segment to be rerouted around the neck of the radius mediolaterally. The tendon ends are sutured. The technique allows the biceps to become a pronator instead of a supinator while preserving its original function of elbow flexion. In case of interosseous membrane contracture a release of the membrane is necessary. POSTOPERATIVE MANAGEMENT Immobilization in an upper plaster cast or Gilchrist bandage with the elbow in 90 degrees flexion and the forearm in neutral rotation or pronation, no extension below 90 degrees flexion/no supination for 6 weeks. Passive and active exercises of elbow extension, flexion and pronation until the maximally possible range of motion has been reached (12-18 months); dynamic pronation orthosis, if needed. RESULTS Eleven children with obstetric brachial plexus palsy and an average age of 6 years (4-12 years) were operated. In eight cases, besides rerouting of the biceps tendon, a release of the interosseous membrane was performed. Average follow-up time is 36 months (10-55 months). In all patients, an improved and more normal spontaneous posture of the paralyzed forearm resulted: difference of forearm position/increase of pronation 87 degrees (70-100 degrees). 91% of the patients reached an active pronation at least to neutral rotation, 46% were able to pronate up to 30 degrees and more.ZusammenfassungOperationszielReduzierung der lähmungsbedingten Supinationskontraktur und -fehlhaltung.Verbesserte Spontanhaltung des von der Lähmung betroffenen Arms und anatomiegerechtere Position von Ulna und Radius.Verbesserung der Gebrauchsfähigkeit, insbesondere der Tätigkeiten, die eine aktive Pronation erfordern (essen, anziehen, schreiben).Prävention der wachstumsbedingten Zunahme der Deformität bei geburtstraumatischen Armplexusschäden. Teilweise Wiederherstellung der aktiven Pronation. Indikationen Kontraindikationen Operationstechnik Weiterbehandlung ErgebnisseIndikationenNicht antagonisierte Supination durch den funktionsfähigen Musculus biceps bei Lähmung der Pronatoren als Folge von– Armplexuslähmungen,– Poliomyelitis,– Tetraplegie,– anderen Lähmungen.KontraindikationenMögliche Besserung der Lähmung der Pronatoren durch weitere Reinnervation, spontan oder nach neurochirurgischem Eingriff.Posttraumatisch oder arthrotisch eingesteiftes Ellbogengelenk; das Ausmaß der passiven Pronation bestimmt das postoperative Ergebnis.Unzureichender Kraftgrad (< M4) des Musculus triceps (bei inadäquater Trizepsfunktion besteht die Gefahr der Ausbildung einer Ellbogenbeugekontraktur).OperationstechnikDie Sehne des Musculus biceps wird dargestellt und Z-förmig gespalten. Der distale Sehnenanteil wird von medial nach lateral um den Radius herumgeführt und umgeleitet. Nach Wiedervereinigung des distalen und proximalen Sehnenanteils behält der Musculus biceps seine ursprüngliche Funktion als Ellbogenbeuger, wirkt durch die Umleitung seiner Ansatzsehne aber als Pronator und nicht mehr als Supinator.Bei bestehender Kontraktur der Membrana interossea ist eine Erweiterung des Eingriffs mit Release der Membran erforderlich.WeiterbehandlungImmobilisation in einem gespaltenen Oberarmgipsverband oder Gilchrist-Verband in 90° Flexionsstellung und Neutralrotation oder Pronation des Unterarms, keine Streckung unter 90°/keine Supination für 6 Wochen. Danach werden die passive Ellbogenstreckung und aktive Pronation sowie Ellbogenbeugung bis zum Erreichen des maximal möglichen Bewegungsausmaßes beübt (Dauer 12–18 Monate); ggf. Versorgung mit einer dynamischen Pronationsorthese.ErgebnisseElf Kinder mit geburtstraumatischer Plexus-brachialis-Läsion und einem durchschnittlichen Alter von 6 Jahren (4–12 Jahre) wurden operiert. In acht Fällen wurde additiv zur Umleitung der Bizepssehne ein Release der Membrana interossea durchgeführt. Der durchschnittliche Beobachtungszeitraum beträgt 36 Monate (10–55 Monate). Die spontane Supinationsfehlhaltung wurde bei allen Patienten zugunsten einer verbesserten Unterarmposition beseitigt: Änderung der Unterarmposition/Zuwachs Pronation 87° (70–100°). 91% der Patienten war postoperativ aktiv eine Pronation mindestens bis zur Neutralstellung möglich, 46% konnten bis 30° und mehr pronieren.AbstractObjectiveReduction of paralytic supination posture and contracture of the forearm. Improved spontaneous posture of the paralyzed arm with a more normal anatomic relationship of ulna and radius.Improvement of the activities of daily living, especially activities requiring active pronation (eating, dressing, writing).Prevention of recurrence or increase of the deformity during the growth period in obstetric brachial plexus palsy.Partly restoration of active pronation.IndicationsUnopposed supination by the biceps in the presence of paralysis of the pronators as a result of– brachial plexus palsy,– poliomyelitis,– quadriplegia,– paralysis from other causes.ContraindicationsOngoing spontaneous or postoperative nerve regeneration and possible improvement of paralyzed pronators.Posttraumatic or degenerative ankylosis of the elbow joint; the extent of the preoperative passive pronation determines the postoperative result.Insufficient power (< M4) of the triceps (inadequate triceps function can lead to a flexion contracture of the elbow).Surgical TechniqueAfter exposure of the biceps tendon a long Z-plasty is used to lengthen the tendon and allow its distal segment to be rerouted around the neck of the radius mediolaterally. The tendon ends are sutured. The technique allows the biceps to become a pronator instead of a supinator while preserving its original function of elbow flexion.In case of interosseous membrane contracture a release of the membrane is necessary.Postoperative ManagementImmobilization in an upper plaster cast or Gilchrist bandage with the elbow in 90° flexion and the forearm in neutral rotation or pronation, no extension below 90° flexion/no supination for 6 weeks.Passive and active exercises of elbow extension, flexion and pronation until the maximally possible range of motion has been reached (12–18 months); dynamic pronation orthosis, if needed.ResultsEleven children with obstetric brachial plexus palsy and an average age of 6 years (4–12 years) were operated. In eight cases, besides rerouting of the biceps tendon, a release of the interosseous membrane was performed. Average follow-up time is 36 months (10–55 months). In all patients, an improved and more normal spontaneous posture of the paralyzed forearm resulted: difference of forearm position/increase of pronation 87° (70–100°). 91% of the patients reached an active pronation at least to neutral rotation, 46% were able to pronate up to 30° and more.