Soutetsu Sakamoto

Outcome of Surgical Reconstruction After Traumatic Total Brachial Plexus Palsy

BACKGROUND Double free muscle transfer for the treatment of traumatic total brachial plexus injury provides useful prehensile function. We studied the outcome of this muscle transfer procedure, including the changes in disability and quality-of-life scores. METHODS Thirty-six patients with traumatic total brachial plexus injury who underwent double free muscle transfer for reconstruction from 2002 to 2008 and had a minimum follow-up of twenty-four months after the second free muscle transfer were studied. All were evaluated preoperatively and postoperatively with use of the Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form-36 (SF-36) questionnaires. A separate questionnaire was used to determine job status, pain, use of the reconstructed hand, and satisfaction with the procedure. RESULTS The mean patient age was twenty-nine years (range, sixteen to forty-nine years), and the mean duration of follow-up was thirty-six months (range, twenty-four to seventy-nine months). The mean active range of motion was 23° (range, 0° to 80°) for shoulder flexion, 31° (range, 0° to 90°) for shoulder abduction, -18° (range, -80° to 40°) for shoulder external rotation, 62° (range, 0° to 130°) for the shoulder rotation arc, 119° (range, 90° to 150°) for elbow flexion, and -33° (range, -60° to -20°) for elbow extension. The power of elbow flexion was M4 in twenty-five patients and M3 in eleven. Twenty-three patients had triceps nerve reconstruction; extension was M0 in two of these patients, M1 in seven, M2 in ten, and M3 in four. Total active motion of the fingers was 46° (range, 0° to 98°), with a mean hook grip strength of 4 kg (range, 0 to 12 kg). Wilcoxon tests revealed significant improvements in the DASH score and the SF-36 physical functioning, role physical, and physical component summary scores. The majority of patients worked but had changed their type of work, used the reconstructed hand in activities of daily living that required both hands, and were satisfied with the procedure. CONCLUSIONS Double free muscle transfer yielded satisfactory function and allowed use of the reconstructed hand in activities that required both hands. The improvement in the DASH score was greater than that in the SF-36 score.

Early breakage of a titanium volar locking plate for fixation of a distal radius fracture: case report.

This report presents a case demonstrating the early breakage of a titanium volar locking plate implanted for internal fixation of a dorsally displaced distal radius fracture in which the dorsal cortex was severely comminuted. Careful selection of the proper plate and appropriate surgical technique and postoperative management are necessary to avoid this complication.

Sensory recovery of the hand with intercostal nerve transfer following complete avulsion of the brachial plexus.

Background: Restoration of sensory function is imperative when prehensile function is restored after irreparable brachial plexus injury. However, there are few reports that focus on the results of sensory recovery after brachial plexus reconstruction. The purpose of this article is to report the results of sensory recovery of the hand with intercostal nerve transfer following complete brachial plexus injury. Methods: Seventeen patients with complete brachial plexus injury underwent sensory reconstruction of the hand with intercostal nerve transfer to the median or ulnar nerve. All patients underwent double free-muscle transfer to restore the prehensile function of the hand. Sensory recovery of the hand was assessed with Semmes-Weinstein monofilament testing, two-point discrimination, vibration perception, temperature perception, and the location of perception of sensibility. The average follow-up period was 4.1 years. Results: All patients perceived at least the 6.65 filament at the territory of the median or ulnar nerve. Best result on Semmes-Weinstein monofilament test was perception of the 4.31 filament in two patients. None of the patients had two-point discrimination. Vibration with 30-cycles/second stimuli was perceived in 12 patients, whereas vibration with 256-cycles/second stimuli was perceived in only six patients. Eight patients had perception of warmth, and 13 patients had perception of cold. Seven patients felt sensation in the cutaneous distribution of the repaired nerve of the hand in situ. Conclusions: Sensory reconstruction with intercostal nerve transfer can provide limited sensibility of the hand. However, this limited sensory recovery is useful for activities of daily living in severely handicapped patients with brachial plexus injury.

Delayed rupture of extensor digitorum communis tendon following volar plating of distal radius fracture.

We present a case of delayed rupture of extensor digitorum communis tendon seven years after volar plating of distal radius fracture. Drill bit penetration during surgery and prominent screw tips into the fourth extensor compartment have a potential risk to damage the tendons. Careful and accurate use of internal fixation instruments is necessary to avoid this complication.

Vascularized Pedicled Bone Graft for Avascular Necrosis of the Capitate: Case Report

Avascular necrosis of the capitate is a rare disorder of unknown etiology that causes wrist pain and limitation of function. We present a case of a 15-year-old boy successfully treated with vascularized pedicled bone graft from the dorsal aspect of the distal radius.

Capsulectomy and Debridement for Primary Osteoarthritis of the Elbow Through a Medial Trans-Flexor Approach

PURPOSE Debridement arthroplasty combined with capsulectomy for primary osteoarthritis of the elbow is a useful procedure to relieve pain and increase mobility. We have used a medial trans-flexor approach without tendon detachment for debridement arthroplasty of the elbow and evaluated the outcome of this procedure. METHODS Thirty-one elbows with primary osteoarthritis in 31 patients treated with debridement arthroplasty were available for follow-up at a mean of 19 ± 7 months. Twenty-four patients were men, and 7 were women. The mean age at the time of surgery was 59 ± 10 years. All elbows were painful only at the end points of motion. The anterior compartment of the elbow was accessed by splitting of the pronator flexor muscle group without tendon detachment. Routine anterior subcutaneous transposition of the ulnar nerve was used in all elbows. In 10 elbows, osteophytes or loose osseous bodies from the lateral compartment were removed through an additional lateral approach. RESULTS Twenty-three elbows had no pain, and 8 elbows had mild pain. The mean preoperative limitation of extension decreased from 29° ± 9° to 15° ± 9° and the mean preoperative flexion increased from 100° ± 10° to 126° ± 7°. Thus, the mean arc of elbow motion increased by 40° ± 13°. The mean Mayo Elbow Performance Score was 94 ± 7 compared with 60 ± 5 before surgery. The results were excellent for 22 elbows and good for 9. Hematomas developed in 3 elbows, but they did not require surgical drainage. CONCLUSIONS Debridement arthroplasty using the medial trans-flexor approach without tendon detachment yields satisfactory short-term clinical results. This approach is associated with a low rate of complications and is safe and effective for the treatment of primary osteoarthritis of the elbow. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Anatomic Variations in Branching Patterns of the Axillary Artery: A Multidetector-Row Computed Tomography Angiography Study

Anatomic variations in branching pattern of axillary artery (AxA) are common and typically involve subscapular artery (SsA) and posterior circumflex humeral artery (PCHA). Several skin and muscle flaps are based on the branches of AxA. Furthermore, these branches are frequently used as recipient vessels in functioning free muscle transfers for upper extremity reconstruction and in breast reconstruction. Accurate knowledge of the normal anatomy and variations in branching pattern of AxA is of significant clinical importance for the reconstructive microsurgeon. The purpose of this article is to report the variable branching pattern of AxA based on multidetector-row computed tomography angiography study of 62 upper extremities. The thoracoacromial artery consistently originated from the first or second part of AxA. The classic origin and branching patterns of SsA and PCHA were observed in 21 cases (33.9%). Anatomic variations of SsA and PCHA were observed in 41 upper extremities (66.1%). In addition to the classic pattern, five distinct variations were noted.

Viability of the skin paddle does not predict the functional outcome in free muscle transfers with a second ischemic event: a report of three cases.

Conventional skin flap monitoring is one of the widely used methods to assess postoperative circulation in innervated free muscle transfer (IFMT). However, following reexploration for vascular compromise and reestablishing circulation, functional recovery of the muscle despite surviving skin flap is not clear. The purpose of this article is to report three such cases and determine the reliability of viable skin flap in an IFMT with a second ischemic event. Long-term functional results were assessed in terms of reinnervation time, elbow range of motion, strength of elbow flexion, finger function in terms of total active motion, and power lifting with hook grip. These IFMTs developed complete or partial necrosis of the muscle and could not obtain satisfactory function. The conventional monitoring of the skin flap did not promptly reflect vascularity of IFMT, and a surviving skin flap after reexploration for compromised vascularity does not guarantee complete survival of the muscle. There is a need for earlier and rapid detection of vascular compromise in IFMTs.

Contralateral lower trapezius transfer for restoration of shoulder external rotation in traumatic brachial plexus palsy: a preliminary report and literature review

The importance of external rotation of the shoulder is well accepted. Patients with inadequate recovery of shoulder function after nerve transfers for a brachial plexus injury have difficulty in using their reconstructed limb. The options for secondary procedures to improve shoulder function are often limited, especially if the spinal accessory nerve has been used earlier for nerve transfer or as a donor nerve for a free functioning muscle transfer. We have used the contralateral lower trapezius transfer to the infraspinatus in three cases, to restore shoulder external rotation. All patients had significant improvement in shoulder external rotation (mean 97°; range 80°–110°) and improved disability of the arm, shoulder and hand scores. The rotation occurred mainly at the glenohumeral joint, and was independent of the donor side. All patients were greatly satisfied with the outcome. Contralateral lower trapezius transfer appears to help in overall improvement of shoulder function by stabilizing the scapula. The results have remained stable after mean follow-up of 58 months (range 12–86). No donor site deficit was seen in any patient.

Postoperative monitoring in free muscle transfers for reconstruction in brachial plexus injuries.

Free gracilis transfers are done for reanimation of the upper limb in traumatic total brachial plexus palsy. Because of buried nature of the free muscle and monitoring skin flap in the axillary or infraclavicular region, it is always a tricky situation for continuous and repeated monitoring to assess vascular status. Critical ischemia times vary between the muscle and monitoring skin flap because of which signs of ischemic changes in the monitoring skin flap are always delayed with respect to the muscle. We describe a novel method that uses the principle of evoked potentials from the muscle to assess the vascular status of the free muscle and detects vascular compromise early before the skin changes are apparent.