Background. We searched -in transverse ultrasound view- the value of the difference (Delta) between -proximal to the tunnel- CSA (a) and -in the tunnel's inlet- CSA (b) for separating normal from abnormal median nerves. Methods. 51 patients –suspicious for CTS- underwent Phalen and Tinnel tests. After that, we used a high frequency ultrasound to measure CSAa, CSAb and Delta CSA in both hands. 33 of our 51 patients did not experience any clinical symptoms at the contralateral hand, so that we could perform a comparative study of normal and pathological median nerves (on the same patients). Then, all of them completed a Q-DASH questionnaire and a visual analogue scale (VAS 100/100) and they carried through with a nerve conduction study (NCS). Results. We found that a CSAb more than 0,010 and a Delta CSA > 0,003 are both very sensitive findings for CTS, but only DeltaCSA has good specificity. Comparing to NCS the Delta CSA>0,003 had no statistical difference in sensitivity, specificity, true negative and true positive results. Furthermore, patients with Delta CSA>0,009 were suffering from heavy CTS according to NCS, Q-DASH and VAS. On the other way, a Delta CSA between 0,003 and 0,006 suggests a mild or moderate CTS. Conclusion. Delta CSA could be the golden standard for the detection of CTS in patients that feel uncomfortable to undergo NCS. We propose a grading scale that distinguish mild or moderate syndromes (where we could try a conservative treatment) from heavy syndromes and help as on decision-making

Aims: Muscle fat degeneration and fibrosis following long time denervation is today the main cause of poor functional recovery after peripheral nerve surgery especially for reconstruction of proximally located lesions of median and ulnar nerves such as those at brachial plexus level. External electro-stimulation is actually one possible way to avoid muscular atrophy and degeneration and is frequently used in the post-operative of patients with neurological palsy. A new approach that has been proposed to prevent denervation-related muscle atrophy is sensory protection performed by direct neurotization of a denervated muscle with a branch of a sensitive nerve passing nearby. The aim of this study was to study the effectiveness of sensory protection on denervated muscles as a technique to avoid their atrophic process. Methods: In four groups of rats (A,B,C and D), the median nerves were transected at right and left forearm. In group A,B and C, denervated muscles were “reinnervated” with a sensory nerve (sensory protection). Animals of group A was sacrificed after six months for a morphologic study of muscles. Animals of groups B and C were reinnervated after six months either keeping sensory protection (group B) or removing it (group C) and sacrificed after one year. Group D (without sensory protection) was reinnervated after six months and sacrificed after one year (control group). Muscle histology was performed on all samples. Functional comparison of different group was perfor-mend by means of the grasping test. Results: Histological analysis showed that sensory protection led to a better muscular trophism in all experimental groups. Also the functional testing showed better performances in sensory protected animals and especially in group C (de-protected before re-innervation) compared with group B (not de-protected before re-innervation) and D (control). Conclusions: Initial data analisys obtained in this study showed that sensory protection is effective in reducing denervation-related muscle atrophy. De-protection of the muscle before its reinnervation is also important to ameliorate post-surgical functional recovery. A new trial will be carried out with a larger number of cases in order to confirm these results which could have important applications in the clinical perspective

Introduction: End-to-side nerve repair is an experimental technique for repairing peripheral nerves when severe injury renders the proximal nerve stump not available for end-to-end repair or for conventional nerve grafting techniques. This study uses a large animal model to compare two variations of end-to-side neurorrhaphy techniques with conventional clinically established methods of nerve repair to assess the feasibility of end-to-side suture as a technique for possible future clinical use. Methods: 12 age and weight matched sheep underwent end-to-side neurorrhaphy of the distal stump of the transected median nerve to the lateral side of the adjacent intact ulnar nerve through an epineurial window. 12 sheep underwent the same procedure as above but with the proximal stump of the transected median nerve similarly attached 2cm proximal to the first neurorrhaphy site to create a double end-to-side model. 18 sheep underwent conventional methods of nerve repair. All the experiments were randomized and the author performed all the surgery. The nerve repairs were assessed electrophysiologically and histologically and the muscles supplied by the repaired nerves were assessed physiologically at one-year post repair. Normal median nerves and donor ulnar nerves were also tested in the same ways. Results: There were no significant differences in the outcomes of nerve repair between different conventional techniques. Half the end-to-side repairs failed but the double end-to-side repair consistently supported nerve regeneration. Both end-to-side methods were inferior to conventional techniques of nerve repair in all measures of outcome except twitch and tetanic muscle tensions. The function of the donor ulnar nerves in terms of conduction velocity was compromised in the double end-to-side repair but not the end-to-side repair. Discussion and Conclusions: End–to-side nerve repair did support nerve regeneration but it was all or nothing. It is likely that the double end-to-side neurorrhaphies regenerated more consistently than the single end-to-side neurorrhaphies due the conduit effect of the donor ulnar nerve bridge supporting axon growth. Donor ulnar nerve damage in the double end-to-side group suggests regeneration may have occurred from terminal sprouts rather than collateral sprouts. Although end-to-side neurorrhaphy did support nerve regeneration with sometimes good return of muscle function, the use of this technique as a clinical tool at this time cannot be recommended

Post-traumatic elbow stiffness is a disabling condition that remains challenging for upper limb surgeons. Open elbow arthrolysis is commonly used for the treatment of stiff elbow when conservative therapy has failed. Multiple questions commonly arise from surgeons who deal with this disease. These include whether the patient has post-traumatic stiff elbow, how to evaluate the problem, when surgery is appropriate, how to perform an excellent arthrolysis, what the optimal postoperative rehabilitation is, and how to prevent or reduce the incidence of complications. Following these questions, this review provides an update and overview of post-traumatic elbow stiffness with respect to the diagnosis, preoperative evaluation, arthrolysis strategies, postoperative rehabilitation, and prevention of complications, aiming to provide a complete diagnosis and treatment path.

Cite this article: Bone Joint Open 2020;1-9:576–584.

The October 2015 Children’s orthopaedics Roundup³⁶⁰ looks at: Radiographic follow-up of DDH; When the supracondylar goes wrong; Apophyseal avulsion fractures; The ‘pulled elbow’; Surgical treatment of active or aggressive aneurysmal bone cysts in children; Improving stability in supracondylar fractures; Biological reconstruction may be preferable in children’s osteosarcoma; The paediatric hip fracture