Zoubir Belkheyar

Functional Outcome of Glenohumeral Fusion in Brachial Plexus Palsy: A Report of 54 Cases

PURPOSE The restoration of shoulder function is a major issue in brachial plexus palsy. Although several tendon and nerve transfers have been described, shoulder arthrodesis remains a reliable technique in this context. This study planned to compare surgical and functional outcomes of 2 glenohumeral arthrodesis bone graft techniques: massive subacromial corticocancellous versus cancellous only grafts. METHODS We reviewed 54 patients who had shoulder arthrodesis according to 2 parameters after a mean follow-up of 37 months. The primary outcome measure was the rate of fusion according to the surgical technique. A total of 26 patients received a massive subacromial corticocancellous bone autograft, and 28 patients received only cancellous bone. The secondary outcome measure was the range of scapulothoracic motion measured by a video-assisted method according to type of neurological lesion. Brachial plexus palsy was complete in 32 cases and partial in 22 cases. All patients had recovered active elbow flexion before undergoing shoulder arthrodesis. Of the 54 patients, 48 had no postoperative immobilization. RESULTS The overall fusion rate was 76% after the first surgical procedure and 94% at last follow-up. Reoperation led to fusion in 10 cases, whereas 3 cases never fused. Pseudarthrosis rate after first surgery was 4% in the group with massive subacromial graft versus 43% in the group with cancellous bone graft. The mean range of motion was 59° in abduction (57° for complete palsy and 62° for partial palsy) with 42 cases 45° or greater. The mean range of motion was 48° in rotation (50° for complete palsy and 46° for partial palsy) with 35 cases 45° or greater. CONCLUSIONS Shoulder fusion provided active abduction greater than 45° in more than 75% of cases and active rotation greater than 45° in almost 65% of cases. Using a massive subacromial graft significantly reduced pseudarthrosis rate (P < .001). TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

Elbow flexion restoration using pedicled latissimus dorsi transfer in seven cases

PURPOSE The aim of this study is to analyse the results of a series of pedicled latissimus dorsi transfers to restore elbow flexion. Moreover, we describe a new technique of distal fixation of the muscle to the proximal third of the ulnar diaphysis to increase the lever arm and improve strength. METHODS We retrospectively reviewed seven patients aged from 18 to 49 years. Elbow flexion paralysis was secondary to destruction of the anterior arm compartment in four cases and to brachial plexus palsy in three cases. The humeral insertion of the latissimus dorsi was relocated on the coracoid process in five cases and not relocated in two cases. The patients were assessed using the Medical Research Council grading system, the maximum weight lifted by the wrist and the active elbow range of motion. RESULTS At the last follow-up (mean 26.6 months), five patients recovered M4 elbow flexion strength (0.5 to 8kg), one patient recovered M3 strength and the last transfer failed because of triceps brachii co-contractions. The mean active elbow flexion was 91° (range, 45 to 130°). Patients with destruction of the anterior arm compartment and particularly whose forearm was not paralyzed had better strength than patients with a brachial plexus palsy (3.25 versus 1kg). A skin island with the latissimus dorsi muscle flap was particularly useful in case of arm soft tissue defect. DISCUSSION A destroyed anterior compartment of the arm is a good indication for latissimus dorsi transfer to restore elbow flexion. The muscle is usually too weak in high brachial plexus palsy. Finally, the latissimus dorsi needs an objective, reproducible and reliable preoperative evaluation. LEVEL OF EVIDENCE Level IV.

Digitalization of the second finger in type 2 central longitudinal deficiencies (clefting) of the hand.

In central longitudinal deficiency of the hand type 2 (Manske and Halikis), the second finger presents itself anatomically and functionally as a second thumb. It is therefore necessary to undertake digitalization of the index, performed exactly as a reverse pollicization technique, with the same principles: minimum volar scarring and reconstruction of a large first web space without scars at the fold of the commissure. The incision surrounds the second digit at the level of the midproximal phalanx, extends over the dorsal edge of the cleft, and finishes on the radial side of the third finger where the second web space is to be created. Through this approach, the index metacarpal is freed (extraperiosteally), preserving the dorsal venous network, and translocated into the space of the missing third ray. After internal bone fixation, the flap, with its wide and safe volar cutaneous pedicle, is easily transposed to reconstruct the first web space, avoiding the need for skin grafting. This technique is easier and safer and does not impair the normal thumb musculature compared with the classic Snow-Littler procedure.

Bipolar transfer of the pectoralis major muscle for restoration of elbow flexion in 29 cases

BACKGROUND This study evaluated the functional outcomes of bipolar pedicled pectoralis major (PM) transfer to restore elbow flexion. METHODS We retrospectively reviewed 29 transfers in 28 patients with a mean age of 31.2 years (range, 5-65 years). The loss of elbow flexion was due to brachial plexus palsy in 24 patients, elbow flexors necrosis in 4, and poliomyelitis in 1. The entire PM muscle was mobilized and fixed proximally to the coracoid process. Intraoperative positioning and postoperative immobilization of the shoulder and the elbow flexed at 60° and 120°, respectively, allowed direct distal fixation of the muscle to the biceps brachii tendon. RESULTS At the last follow-up (mean, 13 months; range, 4-37 months), 41% of the transfers (n = 12) recovered grade 4 elbow flexion strength and were able to lift 2.2 kg on average (range, 0.5-5 kg), 52% (n = 15) recovered grade 3 strength, and 7% (n = 2) had a poor result (ie, grade 2 elbow flexion). The mean active elbow flexion was 100° (ranging, 30°-150°), and the patients had 0° to 10° elbow flexion contracture. CONCLUSIONS Our results indicate that bipolar PM transfer is a reliable and effective procedure to restore elbow flexion. Flexion of the shoulder and elbow allowed the transfer to reach the elbow fold and avoided an interposition graft between the distal PM and the biceps brachii tendon.

Spinal accessory nerve repair using a direct nerve transfer from the upper trunk: results with 2 years follow-up

Spinal accessory nerve grafting requires identification of both nerve stumps in the scar tissue, which is sometimes difficult. We propose a direct nerve transfer using a fascicle from the posterior division of the upper trunk. We retrospectively reviewed 11 patients with trapezius palsy due to an iatrogenic injury of the spinal accessory nerve in nine cases. The mean age was 38 years (range 21–59). Preoperatively, patients showed shoulder weakness and limited range of motion. At a mean follow-up of 25 months, active shoulder abduction improvement averaged 57°. Trapezius muscle strength graded M4 or M5 in 10 cases and M3 in one case. No deltoid or triceps impairment was reported. Scapula kinematics was considered normal in seven patients. This technique gave satisfactory functional results and may be an alternative to spinal accessory nerve grafting for the management of trapezius palsies if direct repair is not feasible. Level of evidence: IV

Arthrodèse glénohumérale chez l’adulte présentant des séquelles de paralysie obstétricale du plexus brachial (à propos de 8 cas)

La paralysie obstetricale du plexus brachial entraine une deformation precoce de l’articulation glenohumerale avec une perte de la sphericite de la tete humerale qui se luxe en posterieur et une retroversion de la glene, compromettant la fonction du membre superieur. Le traitement chez l’adulte des sequelles paralytiques a l’epaule n’est pas consensuel. Le but de ce travail etait d’etudier les resultats fonctionnels de l’arthrodese glenohumerale realisee a l’âge adulte. Une arthrodese de l’epaule a ete realisee chez huit patients âges entre 19 et 55 ans de 2015 et 2017. Tous presentaient des sequelles de paralysie obstetricale majeure deja operes ou non. Tous avaient des muscles stabilisateurs de la scapula fonctionnels et une flexion active du coude possible. L’evaluation preoperatoire etait clinique et radiographique. Un scanner de l’epaule permettait d’analyser l’importance des deformations osseuses. La fixation glenohumerale s’effectuait par une plaque scapulo-humerale prealablement moulee a 120°. La position de l’arthrodese etait de 30° de rotation mediale si la main etait fonctionnelle, de 0° dans le cas contraire. Le membre etait ensuite immobilise par une attelle en abduction pendant 6 semaines. L’evaluation postoperatoire comprenait une analyse video-assistee des amplitudes articulaires de l’epaule, ainsi que la satisfaction des patients. Au recul moyen de 5 mois, les amplitudes actives d’abduction et de rotation externe de l’epaule etaient respectivement de 78° (60°–100°) et de 37° (30°–40°). Tous les patients se jugeaient satisfaits de l’intervention. La fusion de l’arthrodese etait obtenue chez tous les malades entre 3 et 6 mois et aucun n’ont presente de douleur residuelle. Dans la litterature, l’arthrodese glenohumerale donne les meilleurs resultats chez les patients ayant des sequelles de paralysie obstetricale du plexus brachial. Par ailleurs, l’amelioration de l’abduction est plus importante qu’apres une osteotomie de derotation humerale. Dans les sequelles a l’epaule de paralysie obstetricale du plexus brachial, avec limitation de l’abduction et de la rotation externe, l’arthrodese de l’epaule est une technique fiable qui redonne la stabilite a l’articulation et ameliore le secteur de mobilite active.

A New Rerouting Technique for the Extensor Pollicis Longus in Palliative Treatment for Wrist and Finger Extension Paralysis Resulting From Radial Nerve and C5C6C7 Root Injury.

Wrist and finger extension paralysis is a consequence of an injury to the radial nerve or the C5C6C7 roots. Despite these 2 different levels of lesions, palliative treatment for this type of paralysis depends on the same tendon transfers. A large majority of the patients are able to compensate for a deficiency of the extension of the wrist and fingers. However, a deficiency in the opening of the first web space, which could be responsible for transfers to the abductor pollicis longus, the extensor pollicis brevis, and the extensor pollicis longus (EPL), frequently exists. The aim of this work was to evaluate the feasibility of a new EPL rerouting technique outside of Lister’s tubercle. Another aim was to verify whether this technique allows a better opening of the thumb-index pinch in this type of paralysis. In the first part, we performed an anatomic study comparing the EPL rerouting technique and the frequently used technique for wrist and finger extension paralyses. In the second part, we present 2 clinical cases in which this new technique will be practiced. Preliminary results during this study favor the EPL rerouting technique. This is a simple and reproducible technique that allows for good opening of the first web space in the treatment of wrist and finger extension paralysis.