Robert D. Leffert

Technical problems with ulnar nerve transposition at the elbow: Findings and results of reoperation

Ten patients who had persistent or recurrent paresthesias, muscular weakness, or sensory loss following transposition of the ulnar nerve at the elbow were explored. Operative findings included compression of the nerve at the intermuscular septum or at the entrance to the cubital tunnel, dense scarring after intramuscular transposition, and constriction by fascial slings. The average interval from the previous operation to re-exploration was 13 months. All patients were improved following neurolysis and submuscular transposition. Recovery was incomplete in nine patients. The average follow-up was 14.5 months.

Anterior submuscular transposition of the ulnar nerves by the Learmonth technique

Thirty-eight patients with progressive posttraumatic ulnar neuropathy at the elbow underwent anterior submuscular transposition of their nerves. Multiple mechanical causes of neuropathy were identified. Fourteen patients had undergone previous surgery for ulnar neuropathy, while 24 had not. Postsurgical follow-up averaged 23.1 months. The operative technique is described and illustrated in detail. Complications attributable to surgery were minimal. No absolute prognostic factors could be identified, and even those patients with significant muscular atrophy or time delay before operation were generally benefited. If prior surgery had induced significant scarring and neural damage, the prognosis for recovery was considerably worse, as it also was for patients who had severe preoperative dysesthesia or pain. Four patients thought to represent examples of double crush or compression syndrome were identified.

Results of transfer of the pectoralis major tendon to treat paralysis of the serratus anterior muscle

BACKGROUND Paralysis of the serratus anterior muscle can be functionally disabling. As a result of the scapular winging associated with such paralysis, the scapula does not remain apposed to the thorax when the upper extremity is elevated forward at the shoulder. This produces functional disability associated with pain and loss of a stable base for movement of the upper extremity. METHODS We reviewed the results of transfer of the pectoralis major tendon with the addition of a fascial graft in sixteen patients who had paralysis of the serratus anterior. The average age of the patients at the time of the operation was thirty-three years (range, twenty to fifty-five years). Electrodiagnostic studies confirmed the presence of an isolated injury of the long thoracic nerve. The index operation was performed sixteen months to eleven years after the onset of pain and weakness. The etiology of the paralysis was idiopathic in two patients, traumatic in seven, and secondary to operative intervention in seven. All patients had pain in the shoulder on the side of the paralysis. RESULTS The result was excellent for eight patients, good for five, and fair for one at an average of four years and three months (range, two years and one month to nine years) postoperatively. There were two failures, both of which occurred after a traumatic event. Of the fourteen patients in whom the procedure did not fail, eight were asymptomatic and had normal function, five had intermittent mild discomfort, and one had frequent mild pain without any winging of the scapula. The average Constant and Murley score for the fourteen patients in whom the procedure did not fail increased from 36 points preoperatively to 92 points postoperatively. CONCLUSIONS The index procedure successfully alleviated the functional disability caused by paralysis of the serratus anterior muscle.

The treatment of upper extremity reflex sympathetic dystrophy with prolonged continuous stellate ganglion blockade

Twenty-nine consecutively treated patients over a 5-year period with upper extremity reflex sympathetic dystrophy were admitted to Massachusetts General Hospital for prolonged continuous stellate ganglion blockade. Diagnosis was based on the presence of pain, decreased joint motion, trophic changes, and vasomotor disturbances. Selection for blockade was made on the failure to improve with outpatient physical therapy, tranquilizers, and mild analgesics. Treatment consisted of indwelling-catheter injections of bupivacaine hydrochloride every eight hours to the stellate ganglion for an average of 7 days, supplemented with vigorous physical therapy. Improvement during treatment was documented in all but two patients with regard to pain and decreased joint motion and in two-thirds with regard to trophic and vasomotor changes. Longterm follow-up demonstrated a relapse rate of 25%, but marked improvement persisted in the rest and normal status was attained in four of 26 patients at an average of 3 years later.

Thoracic outlet syndrome. Results of 282 transaxillary first rib resections.

Thoracic outlet syndrome may follow trauma but also may be seen as a result of postural abnormalities of the shoulder girdle. Cervical ribs and other anatomic variations are not prerequisites for the diagnosis, although they may be more common in patients with thoracic outlet syndrome. The diagnosis is made by history and physical examination. There is no reliable laboratory diagnostic test to confirm or exclude the diagnosis. Proper selection of candidates for surgery can produce excellent and good results in a high percentage of cases. The transaxillary approach to first rib resection is tolerated well, and serious complications should be unusual when the procedure is performed by an experienced surgeon. Postoperative attention to shoulder girdle mechanics is important in the prevention of recurrence of symptoms and treating them should they occur.

Direct Injury to the Axillary Nerve in Athletes Playing Contact Sports

We performed long-term followup (31 to 276 months) of 11 contact athletes who had sustained isolated in juries to their axillary nerves during athletic competi tion. There were no known shoulder dislocations. Elec tromyographs were taken of 10 patients, and all patients had confirmation of clinically defined injuries that were confined to their axillary nerves. Nine injuries were sustained while tackling opposing players in foot ball ; two were sustained in hockey collisions. In seven athletes, the mechanism of injury was a direct blow to the anterior lateral deltoid muscle. In four athletes, there were simultaneous contralateral neck flexion and ipsilateral shoulder depression. At followup, all patients had residual deficits of axillary sensory and motor nerve function. There had been no deltoid muscle im provement in three patients, moderate improvement in two patients, and major improvement in six patients. However, shoulder function remained excellent, with all athletes maintaining full range of motion and good- to-excellent motor strength. Axillary nerve exploration and neurolysis in four patients did not significantly affect the outcomes. Although no patient had full re covery of axillary nerve function, 10 of 11 athletes returned to their preinjury levels of sports activities, including professional athletics.

Massive allograft replacement of hemiarticular traumatic defects of the elbow

Four elbow osteoarticular allografts were done for four patients as salvage procedures for unreconstructable elbow fracture malunions. With a mean follow-up of 60 months (range, 12 to 72 months) all elbows were stable, free of pain, and had mean motion of 130 degrees active flexion and 27 degrees of flexion deformity, 67 degrees pronation and 62 degrees supination (preoperative mean: 104 degrees flexion, 42 degrees flexion contracture, 20 degrees pronation, and 34 degrees supination). Complications occurred in two elbows. One had a deep infection necessitating graft removal and subsequent regrafting. The second had an olecranon osteotomy nonunion. Elbow allografting is recommended as a salvage procedure for massive posttraumatic articular defects, bone loss, or malunion when neither arthrodesis nor conventional arthroplasty is indicated.

The relationship between dead arm syndrome and thoracic outlet syndrome.

A relationship exists between anterior shoulder subluxation and thoracic outlet syndrome that is responsible for the more florid symptoms of dead arm syndrome (DAS) in some patients. This relationship was demonstrated in eight of 27 patients (30%) in a consecutive series of Bankart operations for treatment of subluxation. The mechanism is associated with a disturbance in the kinesiology of the shoulder-joint complex that alters the position of the scapula relative to the rib cage and neurovascular supply to the upper limb. Therapy is directed toward restoration of the stability of the glenohumeral joint so that normal biomechanics can be reestablished. In advanced stages of thoracic outlet syndrome, however, DAS may initially require surgical decompression of the nerves and vessels. Careful attention to postural mechanics is essential for rational diagnosis and treatment of DAS.

Distraction-fixation in the primary treatment of metacarpal bone loss

Nine patients seen in civilian practice with severe open injuries of the hand, including loss of portions of some or all of the metacarpals, were treated by primary restoration of metacarpal length and alignment by distraction-fixation with the use of transverse intermetacarpal Kirschner wires. An external fixation device was added in two of the nine patients. Severe associated soft tissue injuries were present in all but one patient. Two injuries were caused by firearms, and the other seven by heavy machinery. Contractures of the joints were prevented by the use of a second set of wires to position the metacarpophalangeal joints in 70 degrees of flexion and the first metacarpal in abduction and pronation. Staged closure of wounds by local or distant flaps and secondary reconstructions by bone, nerve, and tendon grafts or transfers were necessary in all and required an average of almost 2 years until treatment was completed. All except the one child and the one most recently injured patient have returned to employment or vocational retraining. Follow-up was 24 to 78 months from injury.

The Vincula: With Particular Reference To Their Vessels And Nerves

The blood vessels and nerves of the vincula in the human hand were studied by anatomical dissection, serial histological section, and angiography. The segmental blood supply of the flexor tendon through the vincula was seen to come from constant branches of the digital vessels that pierce the fibrous sheath proximal to both the proximal and distal interphalangeal joints. These were traced with their accompanying nerves into the flexor tendons. Communication between the interosseous circulation and that of the tendons was demonstrated. The clinical implication of these findings and their application to tendon surgery are discussed.