Safiye Ozkan

Tibialis posterior tendon transfer for persistent drop foot after peroneal nerve repair.

Despite advances in the surgical treatment of peroneal nerve injuries, a significant fraction of patients do not recover adequately. Among 35 patients who had previous repair of the peroneal nerve, 19 had permanent drop foot, and 16 of these patients underwent tibialis posterior (TP) tendon transfer. Mean duration of paralysis was 26.7 (range, 7 to 192) months. TP tendon was carried to the anterior compartment via the circumtibial route, and then attached to the tibialis anterior, extensor hallucis longus, extensor digitorum communis, and peroneus tertius tendons using tendon-tendon anastomosis. All patients except for one achieved active dorsiflexion to or beyond neutral. Mean preoperative drop foot angle increased from -33.8 degrees to + 9.7 degrees. According to the Stanmore system, the results were excellent in 10 patients (62.5%), good in 4 (25.0%), fair in 1 (6.2%), and poor in 1 (6.2%). The average Stanmore score was 85, which corresponded to an excellent result. We believe that the TP tendon transfer is a straightforward and reliable solution in the treatment of drop foot.

The results of surgical repair of sciatic nerve injuries

OBJECTIVES The aim of this study was to evaluate surgical treatment and follow-up results of patients who presented to our department with sciatic nerve injuries. METHODS The study included 13 patients (12 males, 1 female; mean age 23 years; range 11 to 35 years) who underwent surgical treatment for sciatic nerve injuries. The etiologies of sciatic nerve injuries were penetrating trauma in five patients, firearm injuries in four patients, and motor vehicle accidents in four patients. Injuries involved the knee level in five patients, and above-the-knee level in eight patients. Peroneal nerve involvement was seen in all the patients, and the tibial nerve was involved in 11 patients. Primary repair was performed in six patients, neurolysis in three patients, and nerve grafting in three patients. One patient underwent neurolysis for the peroneal portion, and nerve grafting for the tibial portion. Muscle strength and reflex changes were recorded at every stage of the treatment. Muscle strength was assessed according to the British Medical Research Council scale. The Semmes-Weinstein monofilament test was used for sensory evaluation. The mean follow-up period was 4 years (range 1 to 6 years). RESULTS In 11 patients with tibial nerve injuries, the soleus/gastrocnemius strength was measured as follows: M1 in one patient, M3 in four patients, M4 in four patients, and M5 in two patients. Plantar sensation was absent in four patients, while seven patients had at least adequate protective sensation. In 13 patients with a peroneal nerve injury, the strength of the anterior tibial muscle was measured as follows: M0 in three patients, M2 in three patients, M3 in one patient, M4 in three patients, and M5 in three patients. Of these, four patients had persistent insensitivity in the dorsum of the foot, while six patients had protective sensation, and three patients had normal sensation. Two patients with inadequate anterior tibial muscle strength following nerve repair underwent posterior tibial tendon transfer for restoration of foot dorsiflexion. The greatest functional improvement was obtained in cases in which neurolysis was performed; patients undergoing primary repair had better outcomes compared to those where nerve grafts were used. The results were better in thigh level injuries than those in the gluteal region. CONCLUSION Low expectations after sciatic nerve repair in the past are now being rapidly replaced by a more optimistic approach. Advances in microsurgery and use of treatment algorithms based on scientific research account for this significant improvement in outcomes after sciatic nerve surgery. Tendon transfers can enhance the success rate and be combined with nerve repair in selected cases.

Brachioradialis transposition for elbow extension in obstetrical brachial plexus palsy.

Disorders of elbow extension occur following traumatic or neurologic injuries of the triceps muscle. Restoration of elbow extension is an integral part of the entire upper extremity surgical reconstruction to improve the following daily activities: bringing down an object from above, handwriting, using the hand in the supine position, steering a wheelchair, driving a car, and swimming. The transfer of the posterior head of the deltoid muscle to triceps (Moberg procedure) and the transfer of the biceps to triceps (Friedenberg procedure) are previously described procedures for the functional restoration of triceps function. In conditions where these procedures cannot be used, we describe a new technique for restoration of elbow extension. In 4 cases with obstetrical palsy sequela, where shoulder abduction was established with the latissimus dorsi and teres major transfer, restoration of elbow extension was planned to aid in activities performed while the hand is above the head. To achieve this goal, the brachioradialis muscle was transposed bipedically to the triceps muscle.

Does primary brachial plexus surgery alter palliative tendon transfer surgery outcomes in children with obstetric paralysis

BackgroundThe surgical management of obstetrical brachial plexus palsy can generally be divided into two groups; early reconstructions in which the plexus or affected nerves are addressed and late or palliative reconstructions in which the residual deformities are addressed. Tendon transfers are the mainstay of palliative surgery. Occasionally, surgeons are required to utilise already denervated and subsequently reinnervated muscles as motors. This study aimed to compare the outcomes of tendon transfers for residual shoulder dysfunction in patients who had undergone early nerve surgery to the outcomes in patients who had not.MethodsA total of 91 patients with obstetric paralysis-related shoulder abduction and external rotation deficits who underwent a modified Hoffer transfer of the latissimus dorsi/teres major to the greater tubercle of the humerus tendon between 2002 and 2009 were retrospectively analysed. The patients who had undergone neural surgery during infancy were compared to those who had not in terms of their preoperative and postoperative shoulder abduction and external rotation active ranges of motion.ResultsIn the early surgery groups, only the postoperative external rotation angles showed statistically significant differences (25 degrees and 75 degrees for total and upper type palsies, respectively). Within the palliative surgery-only groups, there were no significant differences between the preoperative and postoperative abduction and external rotation angles. The significant differences between the early surgery groups and the palliative surgery groups with total palsy during the preoperative period diminished postoperatively (p < 0.05 and p > 0.05, respectively) for abduction but not for external rotation. Within the upper type palsy groups, there were no significant differences between the preoperative and postoperative abduction and external rotation angles.ConclusionsIn this study, it was found that in patients with total paralysis, satisfactory shoulder abduction values can be achieved with tendon transfers regardless of a previous history of neural surgery even if the preoperative values differ.

Restoration of Pronation and Radial Deviation in “The Beggar’s Hand” Deformity by Switch Technique

Objective/Hypothesis: In this study, our aim is to present our results with the “switch technique” in the dynamic restoration of forearm pronation and wrist radial deviation in patients with “the beggar’s hand” caused by obstetric brachial plexus palsy. In the “switch technique,” the tendons of two functional muscles are sectioned at two different levels, and the proximal muscular units are transposed to the presectioned distal tendon ends in a cross fashion. This technique enables the dynamic restoration of the paralytic and complex deformity. Materials and Methods: Eleven obstetric palsy patients (6 male, 5 female) with ages ranging between 5 and 10 years (mean age of 7.6 years) were operated for the correction of supination deformity and ulnar deviation of the wrist. Soft tissue releases were performed at the forearm and the wrist. Extensor carpi ulnaris (ECU), brachioradialis (BR), abductor pollicis longus (APL), and the flexor carpi ulnaris (FCU) muscles were prepared. The ECU tendon was sectioned and disinserted from its insertion whereas the BR tendon was sectioned just distal to the myotendinous junction. The distal end of the BR tendon was rotated around the radius from the dorsal to the volar, and then, it was advanced proximally along the interosseous membrane after being passed through a pulley that was prepared from the distal end of the FCU tendon. The ECU tendon was advanced from the dorsal to the volar, and it was sutured to the BR tendon as a pronator. The APL tendon was sectioned from a proximal level, and the distal end of this tendon was sutured to the proximal end of the BR tendon as a wrist radial deviator. The mean follow-up time was 14 months (4-31 months). Forearm pronosupination, wrist flexion-extension, and ulnar-radial deviation were assessed by goniometric measurements. Results: Mean active forearm pronation was −42.5° preoperatively. After the surgery, 38.75° degrees of active forearm pronation was achieved. Preoperative and postoperative mean active radial deviation values were −7.5° and 10.75°, respectively. All patients reported that they became more capable in activities such as turning pages and holding a mug. Conclusions: The tendons that are used in the “switch technique” are not paralytic, and they are functional. In fact, this is a major difference with classic tendon transfers. With this technique, the original muscle bellies and the routes of the tendons are switched. They are used for impaired targets, and they are reorganized for the restoration of insufficient functions. Correction of the deformity improves the appearance of the limb and the self-confidence of the child and allows the patients to integrate well into the society. These results suggest that selected cases may benefit from restoration of “the beggar’s hand” deformity with the “switch technique” that may produce a critical improvement in functional capabilities.