Rotator cuff pathology is the main cause of shoulder pain and dysfunction in older adults. When a rotator cuff tear involves the subscapularis tendon, the symptoms are usually more severe and the prognosis after surgery must be guarded. Isolated subscapularis tears represent 18% of all rotator cuff tears and arthroscopic repair is a good alternative primary treatment. However, when the tendon is deemed irreparable, tendon transfers are the only option for younger or high-functioning patients. The aim of this review is to describe the indications, biomechanical principles, and outcomes which have been reported for tendon transfers, which are available for the treatment of irreparable subscapularis tears.

The best tendon to be transferred remains controversial. Pectoralis major transfer was described more than 30 years ago to treat patients with failed surgery for instability of the shoulder. It has subsequently been used extensively to manage irreparable subscapularis tendon tears in many clinical settings. Although pectoralis major reproduces the position and orientation of the subscapularis in the coronal plane, its position in the axial plane – anterior to the rib cage – is clearly different and does not allow it to function as an ideal transfer. Consistent relief of pain and moderate recovery of strength and function have been reported following the use of this transfer. In an attempt to improve on these results, latissimus dorsi tendon transfer was proposed as an alternative and the technique has evolved from an open to an arthroscopic procedure. Satisfactory relief of pain and improvements in functional shoulder scores have recently been reported following its use. Both pectoralis minor and upper trapezius transfers have also been used in these patients, but the outcomes that have been reported do not support their widespread use.

Cite this article: Bone Joint J 2024;106-B(9):970–977.

Nerve transfer is an emerging treatment to restore upper limb function in people with tetraplegia. The objective of this study is to examine if a flexible collage sheet (FCS) can act as epineurial-like substitute to promote nerve repair in nerve transfer. A preclinical study using FCS was conducted in a rat model of sciatic nerve transection. A prospective case series study of nerve transfer was conducted in patients with C5-C8 tetraplegia who received nerve transfer to restore upper limb function. Motor function in the upper limb was assessed pre-treatment, and at 6-,12-, and 24-months post-treatment. Macroscopic assessment in preclinical model showed nerve healing by FCS without encapsulation or adhesions. Microscopic examination revealed that a new, vascularised epineurium-like layer was observed at the FCS treatment sites, with no evidence of inflammatory reaction or nerve compression. Treatment with FCS resulted in well-organised nerve fibres with dense neurofilaments distal to the coaptation site. Axon counts performed proximal and distal to the coaptation site showed that 97% of proximal axon count of myelinated axons regenerated across the coaptation site after treatment with CND. In the proof of concept clinical study 17 nerve transfers were performed in five patients. Nerve transfers included procedures to restore triceps function (N=4), wrist/finger/thumb extension (N=6) and finger flexion (N=7). Functional motor recovery (MRC ≥3) was achieved in 76% and 88% of transfers at 12 and 24 months, respectively. The preclinical study showed that FCS mimics epineurium and enable to repair nerve resembled to normal nerve tissue. Clinical study showed that patients received nerve transfer with FCS experienced consistent and early return of motor function in target muscles. These results provide proof of concept evidence that CND functions as an epineurial substitute and is promising for use in nerve transfer surgery

Abstract. Objective. Radial to axillary nerve and spinal accessory (XI) to suprascapular nerve (SSN) transfers are standard procedures to restore function after C5 brachial plexus dysfunction. The anterior approach to the SSN may miss concomitant pathology at the suprascapular notch and sacrifices lateral trapezius function, resulting in poor restoration of shoulder external rotation. A posterior approach allows decompression and visualisation of the SSN at the notch and distal coaptation of the medial XI branch. The medial triceps has a double fascicle structure that may be coapted to both the anterior and posterior division of the axillary nerve, whilst preserving the stabilising effect of the long head of triceps at the glenohumeral joint. Reinnervation of two shoulder abductors and two external rotators may confer advantages over previous approaches with improved external rotation range of motion and strength. Methods. Review of the clinical outcomes of 22 patients who underwent a double nerve transfer from XI and radial nerves. Motor strength was evaluated using the MRC scale and grade 4 was defined as the threshold for success. Results. 18/22 patients had adequate follow-up (Mean: 29.5 months). Of these, 72.2% achieved ≥grade 4 power of shoulder abduction and a mean range of motion of 103°. 64.7% achieved ≥grade 4 external rotation with a mean range of motion of 99.6°. Conclusions. The results suggest the use of the combined nerve transfer for restoration of shoulder function via a posterior approach, involving the medial head branch of triceps to the axillary nerve and the XI to SSN

Upper limb amputations, ranging from transhumeral to partial hand, can be devastating for patients, their families, and society. Modern paradigm shifts have focused on reconstructive options after upper extremity limb loss, rather than considering the amputation an ablative procedure. Surgical advancements such as targeted muscle reinnervation and regenerative peripheral nerve interface, in combination with technological development of modern prosthetics, have expanded options for patients after amputation. In the near future, advances such as osseointegration, implantable myoelectric sensors, and implantable nerve cuffs may become more widely used and may expand the options for prosthetic integration, myoelectric signal detection, and restoration of sensation. This review summarizes the current advancements in surgical techniques and prosthetics for upper limb amputees.

Cite this article: Bone Joint J 2021;103-B(3):430–439.

Aims

Brachial plexus injury (BPI) is an often devastating injury that affects patients physically and emotionally. The vast majority of the published literature is based on surgeon-graded assessment of motor outcomes, but the patient experience after BPI is not well understood. Our aim was to better understand overall life satisfaction after BPI, with the goal of identifying areas that can be addressed in future delivery of care.

Aims

To describe and analyze the mid-term functional outcomes of a large series of patients who underwent the Hoffer procedure for brachial plexus birth palsy (BPBP).

Aims. Improvements in the evaluation of outcomes following peripheral nerve injury are needed. Recent studies have identified muscle fatigue as an inevitable consequence of muscle reinnervation. This study aimed to quantify and characterize muscle fatigue within a standardized surgical model of muscle reinnervation. Patients and Methods. This retrospective cohort study included 12 patients who underwent Oberlin nerve transfer in an attempt to restore flexion of the elbow following brachial plexus injury. There were ten men and two women with a mean age of 45.5 years (27 to 69). The mean follow-up was 58 months (28 to 100). Repeated and sustained isometric contractions of the elbow flexors were used to assess fatigability of reinnervated muscle. The strength of elbow flexion was measured using a static dynamometer (KgF) and surface electromyography (sEMG). Recordings were used to quantify and characterize fatigability of the reinnervated elbow flexor muscles compared with the uninjured contralateral side. Results. The mean peak force of elbow flexion was 7.88 KgF (. sd. 3.80) compared with 20.65 KgF (. sd . 6.88) on the contralateral side (p < 0.001). Reinnervated elbow flexor muscles (biceps brachialis) showed sEMG evidence of fatigue earlier than normal controls with sustained (60-second) isometric contraction. Reinnervated elbow flexor muscles also showed a trend towards a faster twitch muscle fibre type. Conclusion. The assessment of motor outcomes must involve more than peak force alone. Reinnervated muscle shows a shift towards fast twitch fibres following reinnervation with an earlier onset of fatigue. Our findings suggest that fatigue is a clinically relevant characteristic of reinnervated muscle. Adoption of these metrics into clinical practice and the assessment of outcome could allow a more meaningful comparison to be made between differing forms of treatment and encourage advances in the management of motor recovery following nerve transfer. Cite this article: Bone Joint J 2019;101-B:867–871

Abstract. Nerve transfer has become a common and often effective reconstructive strategy for proximal and complex peripheral nerve injuries of the upper limb. This case-based discussion explores the principles and potential benefits of nerve transfer surgery and offers in-depth discussion of several established and valuable techniques including: motor transfer for elbow flexion after musculocutaneous nerve injury, deltoid reanimation for axillary nerve palsy, intrinsic re-innervation following proximal ulnar nerve repair, and critical sensory recovery despite non-reconstructable median nerve lesions

Supercharged end-to-side nerve transfer for severe cubital tunnel syndrome is a recently developed technique which involves augmenting the ulnar motor branch with anterior interosseous nerve (AIN). Previous studies suggested that this technique augments or “babysits” the motor end plates until reinnervation occurs, however, some authors suggested possible reinnervation by the donor nerve. We present two cases where this transfer was done for rapid progressive (6–9 months) cubital tunnel syndrome. The first case was a 57 year-old right hand dominant female who presented to us with severe right cubital tunnel syndrome clinically, including intrinsic wasting and claw deformity. The patient had significant loss of function and visible atrophy to her hand intrinsics over the last few months. Electrodiagnostic studies confirmed the diagnosis of severe cubital tunnel syndrome demonstrating axonal loss, positive sharp waves and fibrillations in the ulnar nerve distribution distally. The patient underwent cubital tunnel ulnar nerve release, subcutaneous anterior transposition, Guyon's canal release along with an AIN to ulnar motor nerve end-to-side transfer. Patient-based functional outcome instruments were prospectively collected with improved overall pain and function as demonstrated from a quickDASH score of 9.1 1 year post-op in comparison to a score of 34.1 pre-op. Recovery was monitored clinically and electrodiagnostic studies at 6 months and 1 year post-operatively. She demonstrated improved intrinsic muscle bulk and strength. The nerve studies at one year showed reinnervation with large amplitude motor unit potentials in the 1st dorsal interosseous and abductor digiti minimi but the 5th finger sensory response remained absent. The second case was a 58 year-old right hand dominant male diagnosed with severe and progressive right cubital tunnel syndrome. Clinically, he had significant muscle wasting and weakness and confirmed denervation on electrodiagnostic studies. He underwent the same surgical procedure as described for the first case and follow-up regimen. The patient demonstrated improved pain score and significant overall function recovery with a quickDASH score of 11.4 one year post-op in comparison to 72.7 pre-op. Nerve studies at one year confirmed our clinical impression, showing ulnar nerve reinnervation with large amplitude motor unit potentials in the 1st dorsal interosseous, while sensory response remained absent. It is yet unclear if end-to-side nerve transfers allow reinnervation of the target muscles. Previous studies have demonstrated clinical improvement with this transfer, however we are unaware of any electrodiagnostic studies demonstrating this effect. These two cases support the notion of reinnervation after an end-to-side procedure. Further studies are needed to assess outcomes of such nerve transfers

In combined high median and ulnar nerve injury, transfer of extensor digiti minimi (EDM) and extensor carpi ulnaris (ECU) nerve branches to restore intrinsic hand function is previously described. A segment of nerve graft is required in this operation. The aim of this study was to evaluate the feasibility of using the sensory branch of radial nerve (SRN) as an “in situ vascular nerve bridge'” (IVNB) instead of sural nerve graft. Twenty fresh cadavers were dissected. In proximal forearm incision, the feasibility of transferring the EDM/ECU branches to the distal stump of transected SRN was evaluated. In distal forearm incision, the two distal branches of the SRN were transected near the radial styloid process to determine whether transfer of the proximal stumps of these branches to the motor branches of the median (MMN) and ulnar (MUN) nerves is possible. The number of axons in each nerve was determined. The size of the dissected nerves and their location demonstrate that tension free nerve coaptation is easily possible in both proximal and distal incisions. Utilisation of the SRN as an IVNB instead of the conventional sural nerve graft has some advantages. Firstly, the sural nerve graft is a single branch and could be sutured to either the MMN or MUN, whereas the SRN has two terminal branches and can address both of them. Secondly, the IVNB has live Schwann cells and may accelerate the regeneration. Finally, this IVNB does not require leg incision and could be performed under regional anesthesia. The SRN as an IVNB is a viable option which can be used instead of conventional nerve graft in some brachial plexus or high median and ulnar nerve injuries when restoration of intrinsic hand function by transfer of EDM/ECU branches is attempted

Aims

Improvements in the evaluation of outcome after nerve transfers are required. The assessment of force using the Medical Research Council (MRC) grades (0 to 5) is not suitable for this purpose. A ceiling effect is encountered within MRC grade 4/5 rendering this tool insensitive. Our aim was to show how the strength of flexion of the elbow could be assessed in patients who have undergone a re-innervation procedure using a continuous measurement scale.

Aims

Between 2002 and 2011, 81 patients with a traumatic total brachial plexus injury underwent reconstruction by double free muscle transfer (DFMT, 47 cases), single muscle transfer (SMT, 16 cases) or nerve transfers (NT, 18 cases).

The aim of this study was to evaluate the feasibility of using the intact S1 nerve root as a donor nerve to repair an avulsion of the contralateral lumbosacral plexus. Two cohorts of patients were recruited. In cohort 1, the L4–S4 nerve roots of 15 patients with a unilateral fracture of the sacrum and sacral nerve injury were stimulated during surgery to establish the precise functional distribution of the S1 nerve root and its proportional contribution to individual muscles. In cohort 2, the contralateral uninjured S1 nerve root of six patients with a unilateral lumbosacral plexus avulsion was transected extradurally and used with a 25 cm segment of the common peroneal nerve from the injured leg to reconstruct the avulsed plexus.

The results from cohort 1 showed that the innervation of S1 in each muscle can be compensated for by L4, L5, S2 and S3. Numbness in the toes and a reduction in strength were found after surgery in cohort 2, but these symptoms gradually disappeared and strength recovered. The results of electrophysiological studies of the donor limb were generally normal.

Severing the S1 nerve root does not appear to damage the healthy limb as far as clinical assessment and electrophysiological testing can determine. Consequently, the S1 nerve can be considered to be a suitable donor nerve for reconstruction of an avulsed contralateral lumbosacral plexus.

Cite this article: Bone Joint J 2015; 97-B:358–65.

We conducted an anatomical study to determine the best technique for transfer of the anterior interosseous nerve (AIN) for the treatment of proximal ulnar nerve injuries. The AIN, ulnar nerve, and associated branches were dissected in 24 cadaver arms. The number of branches of the AIN and length available for transfer were measured. The nerve was divided just proximal to its termination in pronator quadratus and transferred to the ulnar nerve through the shortest available route. Separation of the deep and superficial branches of the ulnar nerve by blunt dissection alone, was also assessed. The mean number of AIN branches was 4.8 (3 to 8) and the mean length of the nerve available for transfer was 72 mm (41 to 106). The transferred nerve reached the ulnar nerve most distally when placed dorsal to flexor digitorum profundus (FDP). We therefore conclude that the AIN should be passed dorsal to FDP, and that the deep and superficial branches of the ulnar nerve require approximately 30 mm of blunt dissection and 20 mm of sharp dissection from the point of bifurcation to the site of the anastomosis. The use of this technique for transfer of the AIN should improve the outcome for patients with proximal ulnar nerve injuries. Cite this article: Bone Joint J 2014;96-B:789–94

In adults with brachial plexus injuries, lack of active external rotation at the shoulder is one of the most common residual deficits, significantly compromising upper limb function. There is a paucity of evidence to address this complex issue. We present our experience of isolated latissimus dorsi (LD) muscle transfer to achieve active external rotation. This is a retrospective review of 24 adult post-traumatic plexopathy patients who underwent isolated latissimus dorsi muscle transfer to restore external rotation of the shoulder between 1997 and 2010. All patients were male with a mean age of 34 years (21 to 57). All the patients underwent isolated LD muscle transfer using a standard technique to correct external rotational deficit. Outcome was assessed for improvement in active external rotation, arc of movement, muscle strength and return to work. The mean improvement in active external rotation from neutral was 24° (10° to 50°). The mean increase in arc of rotation was 52° (38° to 55°). Mean power of the external rotators was 3.5 Medical Research Council (MRC) grades (2 to 5).

A total of 21 patients (88%) were back in work by the time of last follow up. Of these, 13 had returned to their pre-injury occupation. Isolated latissimus dorsi muscle transfer provides a simple and reliable method of restoring useful active external rotation in adults with brachial plexus injuries with internal rotational deformity.

Cite this article: Bone Joint J 2013;95-B:660–3.

We investigated the predictive value of intra-operative neurophysiological investigations in obstetric brachial plexus injuries. Between January 2005 and June 2011 a total of 32 infants of 206 referred to our unit underwent exploration of the plexus, including neurolysis. The findings from intra-operative electromyography, sensory evoked potentials across the lesion and gross muscular response to stimulation were evaluated. A total of 22 infants underwent neurolysis alone and ten had microsurgical reconstruction. Of the former, one was lost to follow-up, one had glenoplasty and three had subsequent nerve reconstructions. Of the remaining 17 infants with neurolysis, 13 (76%) achieved a modified Mallet score > 13 at a mean age of 3.5 years (0.75 to 6.25). Subluxation or dislocation of the shoulder is a major confounding factor. The positive predictive value and sensitivity of the intra-operative EMG for C5 were 100% and 85.7%, respectively, in infants without concurrent shoulder pathology. The positive and negative predictive values, sensitivity and specificity of the three investigations combined were 77%, 100%, 100% and 57%, respectively.

In all, 20 infants underwent neurolysis alone for C6 and three had reconstruction. All of the former and one of the latter achieved biceps function of Raimondi grade 5. The positive and negative predictive values, sensitivity and specificity of electromyography for C6 were 65%, 71%, 87% and 42%, respectively.

Our method is effective in evaluating the prognosis of C5 lesion. Neurolysis is preferred for C6 lesions.

Cite this article: Bone Joint J 2013;95-B:699–705.

The December 2012 Wrist & Hand Roundup. 360. looks at: the imaging of scaphoid fractures; splinting to help Dupuytren’s disease; quality of life after nerve transfers; early failure of Moje thumbs; electra CMCJ arthroplasty; proximal interphalangeal joint replacement; pronator quadratus repair in distal radius fractures; and osteoporosis and wrist fractures