Helical plates are preferably used for proximal humeral shaft fracture fixation and potentially avoid radial nerve irritation as compared to straight plates. Aims:(1) to investigate the safety of applying different long plate designs (straight, 45°-, 90°-helical and ALPS) in MIPO-technique to the humerus. (2) to assess and compare their distances to adjacent anatomical structures at risk. MIPO was performed in 16 human cadaveric humeri using either a straight plate (group1), a 45°-helical (group2), a 90°-helical (group3) or an ALPS (group4). Using CT-angiography, distances between brachial arteries and plates were evaluated. Following, all specimens were dissected, and distances to the axillary, radial and musculocutaneous nerve were evaluated. None of the specimens demonstrated injuries of the anatomical structures at risk after MIPO with all investigated plate designs. Closest overall distance (mm(range)) between each plate and the radial nerve was 1(1-3) in group1, 7(2-11) in group2, 14(7-25) in group3 and 6(3-8) in group4. It was significantly longer in group3 and significantly shorter in group1 as compared to all other groups, p<0.001. Closest overall distance (mm(range)) between each plate and the musculocutaneous nerve was 16(8-28) in group1, 11(7-18) in group2, 3(2-4) in group3 and 6(3-8) in group4. It was significantly longer in group1 and significantly shorter in group3 as compared to all other groups, p<0.001. Closest overall distance (mm(range)) between each plate and the brachial artery was 21(18-23) in group1, 7(6-7) in group2, 4(3-5) in group3 and 7(6-7) in group4. It was significantly longer in group1 and significantly shorter in group3 as compared to all other groups, p<0.021. MIPO with 45°- and 90°-helical plates as well as ALPS is safely feasible and showed a significant greater distance to the radial nerve compared to straight plates. However, distances remain low, and attention must be paid to the musculocutaneous nerve and the brachial artery when MIPO is used with ALPS, 45°- and 90°-helical implants. Anterior parts of the deltoid insertion will be detached using 90°-helical and ALPS implants in MIPO-technique

The patterns of nerve and associated skeletal injury were reviewed in 84 patients referred to the brachial plexus service who had damage predominantly to the infraclavicular brachial plexus and its branches. Patients fell into four categories: 1. Anterior glenohumeral dislocation (46 cases); 2. ‘Occult’ shoulder dislocation or scapular fracture (17 cases); 3. Humeral neck fracture (11 cases); 4. Arm hyperextension (9 cases). The axillary (38/46) and ulnar (36/46) nerves were most commonly injured as a result of glenohumeral dislocation. The axillary nerve was ruptured in only 2 patients who had suffered high energy trauma. Ulnar nerve recovery was often incomplete. ‘Occult’ dislocation refers to patients who had no recorded shoulder dislocation but the history was suggestive that dislocation had occurred with spontaneous reduction. These patients and those with scapular fractures had a similar pattern of nerve involvement to those with known dislocation, but the axillary nerve was ruptured in 11 of 17 cases. In cases of humeral neck fracture, nerve injury resulted from medial displacement of the humeral shaft. Surgery was performed in 7 cases to reduce and fix the fracture. Arm hyperextension cases were characterised by injury to the musculocutaneous nerve, with the nerve being ruptured in 8 of 9. Five had humeral shaft fracture or elbow dislocation. There was variable involvement of the median and radial nerves, with the ulnar nerve being least affected. Most cases of infraclavicular brachial plexus injury associated with shoulder dislocation can be managed without operation. Early nerve exploration and repair should be considered for:. Axillary nerve palsy without recorded shoulder dislocation or in association with fracture of the scapula. Musculocutaneous nerve palsy with median and/or radial nerve palsy. Urgent operation is necessary for nerve injury resulting from fracture of the humeral neck to relieve ongoing pressure on the nerves

Objective: Search for operation timing and methods for obstetrical brachial plexus injury(OBPI). Methods: Thirty-two children with upper OBPI were treated by microsurgical procedure from October 1997 through April 2001, The average time of operation is 10 months of age, ranged from 3 months to 24 months, of which 19 were below 6 months while 13 were over 6 months. Surgical procedure included neurolysis (n=11), coaption after resection of the neroma without function(n=6), phrenic nerve transfer to anterior cord of upper trunkor musculocutaneous nerve (n=7) and intercostal nerves transfer to musculocutaneous nerve (n=6). The children were underwent operation by microsurgical technique and 7–0 or 9–0 nylon were used for nerve suture. Results: Thirty cases were followed-up 21 months postoperatively, the excellent and good rate is 76.7%(23/30). The results of the children under 6 months is better than that over 6 months . Conclusions: We concluded that the microsurgical operation might be considered at 3 to 6 months of age in infants who have shown little or no improvement in elbow flexion . Patients undergoing neurolysis and nerve coaption had more favorable outcome than those undergoing neurotization. The appropriate procedure must be selected according to the findings of exploration

The standard approach is through the deltopectoral interval. Among patients with prior incisions, one makes every effort to either utilise the old incision or to incorporate it into a longer incision that will allow one to approach the deltopectoral interval and retract the deltoid laterally. The deltopectoral interval is most easily developed just distal to the clavicle, where there is a natural infraclavicular triangle of fat that separates the deltoid and pectoralis major muscles even in very scarred or stiff shoulders. Typically, the deltoid is retracted laterally leaving the cephalic vein on the medial aspect of the exposure. The anterior border of the deltoid is mobilised from the clavicle to its insertion on the humerus. The anterior portion of the deltoid insertion together with the more distal periosteum of the humerus may be elevated slightly. The next step is to identify the plane between the conjoined tendon group and the subscapularis muscle. Dissection in this area must be done very carefully due to the close proximity of the neurovascular group, the axillary nerve, and the musculocutaneous nerve. Scar is then released from around the base of the coracoid. The subacromial space is freed of scar and the shoulder is examined for range of motion. Particularly among patients with prior rotator cuff surgery, there may be severe scarring in the subacromial space. Internal rotation of the arm with dissection between the remaining rotator cuff and deltoid is critical to develop this plane. If external rotation is less than 30 degrees, one can consider incising the subscapularis off bone rather than through its tendinous substance. For every 1 cm that the subscapularis is advanced medially, one gains approximately 20 to 30 degrees of external rotation. The rotator interval between the subscapularis and supraspinatus is then incised. This release is then continued inferiorly to incise the inferior shoulder capsule from the neck of the humerus. This is performed by proceeding from anterior to posterior with progressive external rotation of the humerus staying directly on the bone with electrocautery and great care to protect the axillary nerve. The key for glenoid exposure as well as improvement in motion is deltoid mobilization, a large inferior capsular release, aggressive humeral head cut and osteophyte removal

Purpose:. We aimed to assess the short and medium term complications of patients who had undergone Latarjet procedures. We also compared this to a group of patients who over a similar period underwent an open Bankhart procedure to assess the complication profiles between the two groups. Method:. We retrospectively reviewed the notes and X-rays of all patients identified by surgical log books and or operation codes for instability. Eighty seven patients (88 shoulders) underwent Latarjet procedures between 2002 and 2010. Patients were phoned to obtain a telephonic Oxford shoulder score. There were 44 patients with 46 shoulders in the open Bankhart group. Results:. Complications were seen in 27 patients in the Latarjet group. These included: 5 nerve injuries (3 axillary nerves, 1 musculocutaneous nerve, 1 possible suprascapular nerve) 4 of which resolved; 6 screw related complications and 7 early recurrences of the instability. There was a total reoperation rate of 8%. Patients who developed complications had an average post op Oxford score at last follow up of 36.1, while those without complications had an average score of 14.8. In the group of patients who underwent Bankhart procedures there were no recorded short or medium term complications. We specifically did not look at recurrence rates in either group as we felt our follow up times would not reflect this adequately. Conclusion:. Modified Latarjet procedure appears to have a higher short and medium term complication rate compared to the open Bankhart procedure. Once a complication occurs following a Latarjet reconstruction outcomes are significantly worse

Compared with general anaesthesia, brachial plexus (BP) anaesthesia improves patient satisfaction and accelerates hospital discharge after ambulatory hand surgery; however, variable success rates and typical onset times up to 30 minutes have limited its widespread use. Increasing availability of high-resolution portable ultrasound has renewed interest in more proximal approaches to the BP, previously thought to carry unacceptable risk. The aim of this study was to compare the onset times of ultrasound guided supraclavicular and infraclavicular BP block in patients undergoing ambulatory hand surgery. With ethics committee approval, patients presenting for hand surgery were prospectively randomised to either supraclavicular (trunks/divisions) or infraclavicular (cords) BP block. A single experienced operator (MF) placed all blocks using ultrasound only guidance. A blinded observer (AP, SY) assessed pinprick sensory and motor block on 3-point scale (normal=2, reduced=1, absent=0) in the median, ulnar, radial and musculocutaneous nerve territories every five minutes, or until blocks were complete. A single general anaesthesia without influence from the unblended anaesthetist. Of the first 27 patients recruited, block placement details and Intraoperative data are presented in There was a trend to faster onset times and higher success in group infraclavicular, however, this did not reach statistical significance. Interim results are so far inconclusive for the superiority of one approach. Both techniques were well tolerated and had a high success rate for surgical anaesthesia

Aim: We prove the importance of the medial ligamentary system of the elbow for its stability and the usefulness of the ligamentoplasty by palmaris longus tendon as reconstructive technique. Methods and patients: 9 patients aged between 17 and 58 (17,18,28,32,35,38,40,56,58,), 6 male, 3 female suffered the following injuries:1)elbow luxation or sub-luxation with rupture of the medial collateral elbow ligament, associated with: 1)Forearm bone fractures, 2)Ulnar nerve pulsy, 3)fracture of the coronoidal process, 4)Fracture of the radius head, 5)fracture of the humerus with radial and musculocutaneous nerve pulsy. The lesions happened since 2 week, 2 month and 2 yrs respectively. The 17 yrs old young man was injured during a weightlifting championship game and the next 4 suffered traffic and work accidents, while the 18 yrs old last one suffered an iatrogenic ligamentary lesion, the rest of the lesions have been caused to work accidents or to motor vehicle accidents. All patients were operated by ligamentoplasty with palmaris longus by medial incision, fenestration of the medial epicondyl and olecranon and transoseus pivoting of the palmaris longus which was enforced by 2 anchor sutures. An elbow flexion-extension functional splint was applied postoperatively, initially fixated between 110–85 degrees. The splint was removed 2 months postoperatively, while full rang of motion has been obtained. Results: Follow up was between 6 and 18 month. The 16 yrs old boy return in full sport activity and obtained at the elbow joint full range of motion. the second –young man-patient presents an extension defect of 15 degrees and the 56 yrs old women has a 25degreed deficit of both extension and flexion but she continues the therapy program. Conclusion: The medial ligamentary system lesion with elbow instability must be repaired by medial ligamentoplasty and the well done technique followed by correct therapy program improved results

Aim: To study the functional outcome ofmusculocutaneous nerve neurotization in brachial plexus palsy patients. Methods: From 1998 to 2001, 51 adult patients (mean age 24,6 years) with posttraumatic brachial plexus palsy were operated. Exploration of the brachial plexus was performed in 39 patients with a mean denervation time of 6 months (1 to 14 months). Seven patients had an extended infraclavicular lesion, while from the 32 supraclavicular lesions, 21 had the element of avulsion (4 global, 10 four-root and 7 three-roots avulsions). Neurotization of the musculocutaneous was performed in 25 via nerve grafts from intraplexus donors (C5, C6, C7)and from extraplexus donors in 14. In 7 patients, the phrenic was used alone or with intraplexus donor (5), in 3 cases the accessory nerve, in one patient the accessory and cervical plexus motor branches and þnally in 3 patients 3 intercostal nerves were used. Results: All intraplexus neurotizations of the musculocutaneous nerve, but two, regained useful biceps function (M3+ to M4+). From the extraplexus neurotizations the phrenic n. as a conjunctant donor gave functional result, when used alone gave M3 and M3−; the accessory n. gave M3+ in combination with cervical motors and M3− when used alone. The intercostal neurotizations gave M2+ and M3−. Conclusions: In brachial plexus paralysis, when avulsion is present the reconstruction often is based in extraplexus donors. The return of biceps function is greater and faster when intraplexus donors are used. Extraplexus neurotizations yield satisfactory results used in combinations Vertebral osteoporosis and fracture

Acute trauma and repetitive nicrotrauma connected with certain athletic activities are oftenmentioned when describing the etiology of nerve entrapment syndromes. According to the literature it is obvious that nerve entrapment syndromes in athletes are not as rare as they were once considered to be. Certain sports or physical activities have been mentioned that lead to specific nerve entrapment syndromes – for example, cyclist’s palsy and bowler’s thumb. Unlike nerve entrapment syndromes, vascular and neurovascular syndromes in athletes seem to be more common and have been described in greater detail, while nerve entrapment syndromes in athletes have been reported only recently. To support this contention, I present currently available information about nerve entrapment syndromes in athletes. For each syndrome possible cause of compression, clinical symptoms and signs, and the most effective treatment is presented. On the upper extremity are described: spinal accessory nerve, thoracic outlet syndrome, brachial plexus, long thoracic nerve, suprascapular nerve, axillary nerve, musculocutaneous nerve, lateral ante-brachial cutaneous nerve, radial nerve above the elbow, radial tunnel syndrome, Wartenberg’s disease, distal posterior interosseous nerve, ulnar nerve at the elbow and in Guyon’s canal, median nerve at the elbow and in carpal canal, anterior interosseous nerve and digital nerves. The syndromes described on the lower extremity are: groin pain, piriformis muscle syndrome, pudendus nerve, meralgia paresthetica, sural nerve, common peroneal nerve, superficial peroneal nerve, deep peroneal nerve, tarsal tunnel syndrome, the first branch of the lateral plantar nerve, medial plantar nerve (jogger’s foot) and interdigital neuromas (metatrsalgia. In conclusion I stress that nerve entrapment syndromes must be considered in the diferential diagnosis of pain in athletes

Introduction and purpose: Different neurovascular structures may be damaged when making arthroscopic portals to the shoulder joint. The description of new portals poses new challenges. The goal of the present study is to provide an update on the anatomic vasculonervous responses of the current approaches to shoulder arthroscopy. Materials and methods: 16 fresh cadavers were systematically dissected. The most usual arthroscopic portals were marked and, then, the dissection started on a plane-to-plane basis. Relationships were identified and distances were measured to the most important neurovascular elements with a standard caliber (accuracy: 0.5mm). Results: The portals studied and the structures at risk were the following:. * Posterior portal: anterior branch of the axillary nerve and posterior circumflex artery 3.4 cm (range: 1.4 – 5); cutaneous branch of the axillary nerve 6.3 cm (range: 3.8 – 8.3), suprascapular nerve 2.8 cm (range: 2.1–3.3). * Anterosuperior portal: main branch of the musculocutaneous nerve 6.5 cm (range: 3.8 – 11). * Lateral subacromial portal: axillary nerve and posterior circumflex artery 3.7 cm (range: 2– 5.5). * Anteroinferior subaxillary portal 4 cm (range: 3.1 –6). * Supraspinatus portal: suprascapular nerve 3.2 cm (range: 2.4 – 4). Conclusions: Although the crucial elements at risk when performing a shoulder arthroscopy are multiple, the axillary and suprascapular nerves were the most vulnerable structures to the different approaches. In spite of the presence of the “safe areas” described above, the neurovascular bundle was frequently affected by passage through the anteroinferior subaxillary portal. The results suggest that the use of this portal is not safe for routine arthroscopic practice

Purpose of the study: We compared the reinnervation capacities of two nerve transfers onto the common trunk of the musculocutaneous nerve (MC), several bundles of the ulnar nerve (UN) and three intercostal nerves (IC) in patients with high brachial plexus palsy (C5C6 or C5C6C7). Material and methods: Prospective consecutive study of two groups: group 1: 24 transfers and two to three UN bundles in 20 patients with C5C6 and four with C5C6C7, mean age at surgery 29.5 years; group 2: 15 neurotisations of the MC by CI in four C5C6 palsies and in 11 CC5C6C7 palsies, mean age at surgery 25.7 years. Mean time from accident to operation was 5.7 months, mean follow-up 29.4 months. Results: The first contractions of the biceps were perceived clinically at 5.2 months after the surgery in group1 versus 9.9 months for group 2. Four patients in group 1 (17.0%) did not recover active flexion greater than M3 versus four (27%) in group 2. Mean force using the BMRC score was 3.6 in group 1 versus 3.2 in group 2. When elbow flexion was ≥3 (BMRC), force could be measured at 4.5kg in group 1 and 3.0 kg in group 2. For time to management up to seventh month, the two groups were comparable concerning pertinent results, but after that delay, none of the patients in group 2 achieved elbow flexion ≥3 versus 66% in group 1 up to one year. Up to the age of 40 years, results were comparable; no pertinent result was obtained after that age in group 2 versus 66% in group 1. C5C6C7 palsies had less favourable results irrespective of the technique. Discussion: Our results show the superiority of UN transfer over CI transfer. In patients who undergo surgery before the seventh month, the rate of pertinent outcome was comparable although the flexion force was significantly greater in group 1. After seven months, only UN transfer offers hope of a useful result, up to the twelfth month. Before the age of 25 years, results are comparable, after 40, no pertinent result was observed after CI transfer while useful contraction could be obtained up to 45 years with UN transfer. C5C6C7 forms recover less well irrespective of the technique

Introduction: Latarjete operation for anterior shoulder instability, first described by Latarjete in 1954 consists of transfer of the coracoid process through the sub-scapularis tendon to the neck of the scapula. Many modifications were described in the English literature as described by Mc Murray in 1958, by Bonin in 1969 or May in 1970. In 1985, Braly and Tullos emphasized that the Bankart lesion, when present, should be corrected. Rockwood transplants the entire coracoid process onto the neck by “laying it flat” onto the neck of the scapula using two screws instead of one, which gives a larger base for the coracoid transplant. The disadvantages of this procedure, as described in the English literature, are relative shortening of the sub-scapularis tendon, thereby decreasing internal rotation power, limited external rotation and the possibility to damage the musculocutaneous nerve. Purpose of the Study: To demonstrate that transplantation of the coracoid process with its tendon attachments through a split in the subscapularis muscle and tendon without shifting the capsula gives better results then transplant of the coracoid process with capsule-labral repair. The goal of this report is to review the result of our series. Patients and Methods: Between January 2000 and June 2005, 26 Latarjete operations (Rockwood modification) were performed by the senior author. The indication for surgery was failed artroscopic Bankart repair or anterior shoulder instability associated with anterior inferior glenoid deficiencies (“inverted pear” deformity). Five cases were excluded having less than 6 months follow-up. In the first 5 cases in addition to the coracoid process transfer, labral repair with capsular shift was performed whereas in the next 21 cases only coracoid process transplant with excision of the damaged labrum/scar tissue and no capsular shift was performed. The postoperative rehabilitation program was the same for both groups. The patients age and sex was very close in both groups. The parameters for comparison between the two groups were: range of motion, stability after 6 months, return to work and sport activity, satisfaction, and complication rate. Results: 6 months after surgery all patients of both groups returned to full work and sport activity including contact sports. No recurrent dislocation was encountered during this short period of follow up. All patients who underwent this procedure, with or without capsule-labral repair, were satisfied with the procedure. In the small group that included capsulo-labral repair an average of 10 degrees decrease of external rotation was encountered compared to the opposite shoulder. In the second group no decrease in range of motion was found. Conclusion: Transfer of the coracoid process through the subscapularis tendon alone has better results then Latarjete operation complemented with capsulo-labral repair in regard of range of motion. The procedure is simple and of short duration giving the best solution for failed artroscopic procedures or for cases of shoulder instability having anterior inferior glenoid deficiencies. The authors are aware that longer follow up is mandatory

Aims

The Mathys Affinis Short is the most frequently used stemless total shoulder prosthesis in the UK. The purpose of this prospective cohort study is to report the survivorship, clinical, and radiological outcomes of the first independent series of the Affinis Short prosthesis.