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.

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.

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.

For many surgeons amputation is the usual treatment in sarcoma of the foot. The aim of our study was to report the functional and oncologic results of treatment in 54 sarcomas of the foot to assess if conservative treatment was acceptable

We retrospectively reviewed the records of 54 patients with sarcomas of the foot, aged 6 to 50 (mean 17), 30 females and 26 males. At time of referral, 18 had a local recurrence of a previous inadequate treatment. There were 27 soft tissue sarcomas (STS: 10 synovial sarcomas, 6 rhadomyosarcomas, 1 liposarcomas and 10 others) and 27 bone tumours (16 Ewing's, 8 chondrosarcomas, 3 osteosarcomas). Toes tumours were excluded, 18 tumours involved the metatarsal, 12 the plantar soft tissues, 11 the calcaneum, 3 the talus, 2 the midtarsal bones.

Surgery consisted in 19 resection without reconstruction, 21 resections with bone reconstruction, 9 partial amputations of the foot, and 6 trans tibial amputations.

In 34 cases surgical margins were adequate (R0), in 13 patients resection was inadequate (9 R1 and 4 R2). In 7 cases the margins were not assessed.

After a 5.5 years average follow-up (3m to 17y), 31 patients had no evidence of disease, 8 were in second remission, 4 had an evolutive disease and 11 were deceased. The mean MSTS score was 26/30 (31 cases).

In conclusion, a conservative treatment is feasible in metatarsal bones with skin coverage by flap if necessary. In STS adequate margins are difficult to achieve with a high rate of local recurrence. In calcaneus and talus, a conservative treatment is possible in tumours limited to bone after good response to chemotherapy. In other cases conservative treatment is debatable because amputation gives excellent functional results.

Purpose of the study: Neurolysis is required for the treatment of non-regressive posttraumatic or spontaneous palsy of the anterior interosseous nerve. This technique is difficult because of the anatomic variability of the nerve and the neighbouring structures. The purpose of this study was to determine the imperative elements for neurolysis by analysing the anatomic relations of the anterior interosseous nerve and identifying the potentially compressive musculo-aponeurotic and vascular structures.

Material and methods: Twelve fresh anatomic specimens were dissected unilateral; the subjects (six male, six female) were aged 82.6 years on average at death. Emergences of the anterior interosseous nerve and its division branches were studied. The relations with the following structures and their anatomic variations were analysed: the lacertus fibrosus, the fibrous arcades of the pronator teres, and the flexor digitorum superficialis, the accessory head (if present) of the flexor pollicis longus (Gantzer muscle) and the vascular structures in close contact with the nerve. The topographic landmarks were noted in relation to the bi-epicondylar line.

Results: Emergence of the anterior interosseous nerve was situated, on average 54.5 mm below the bi-epicondylar line, on the posterior (n=9) or ulnar (n=3) aspect of the median nerve. The relative situations of its division branches were variable. A fibrous arcade was found between the lacertus fibrosus and the pronator teres in two specimens. Nine specimens had two arcades at the pronator teres and the flexor digitalis superficialis, but three specimens only had one. The presence of an accessory head within the flexor digitalis superficialis was a configuration with risk of nerve compression. The Gantzer muscle was present in six specimens and crossed the nerve superficially. Two types of potentially compressive vascular arcades were found in eight specimens.

Discussion: Sites of compression of the anterior interosseous nerve were found a various positions and in variable numbers in the different anatomic specimens. The presence of several sites of compression in the same individual could explain why the electromyogram fails to identify the level of the nerve compression in certain cases, leading to the standardised neurolysis technique recalled here.

Conclusion: This study demonstrates that several sites of potential compression of the anterior interosseous nerve can coexist in the same patient. The surgeon should be perfectly aware of these “at risk” sites when performing neurolysis.

The transfer of part of the ulnar nerve to the musculocutaneous nerve, first described by Oberlin, can restore flexion of the elbow following brachial plexus injury. In this study we evaluated the additional benefits and effectiveness of quantitative electrodiagnosis to select a donor fascicle. Eight patients who had undergone transfer of a simple fascicle of the ulnar nerve to the motor branch of the musculocutaneous nerve were evaluated. In two early patients electrodiagnosis had not been used. In the remaining six patients, however, all fascicles of the ulnar nerve were separated and electrodiagnosis was performed after stimulation with a commercially available electromyographic system. In these procedures, recording electrodes were placed in flexor carpi ulnaris and the first dorsal interosseous. A single fascicle in the flexor carpi ulnaris in which a high amplitude had been recorded was selected as a donor and transferred to the musculocutaneous nerve. In the two patients who had not undergone electrodiagnosis, the recovery of biceps proved insufficient for normal use. Conversely, in the six patients in whom quantitative electrodiagnosis was used, elbow flexion recovered to an M4 level. Quantitative intra-operative electrodiagnosis is an effective method of selecting a favourable donor fascicle during the Oberlin procedure. Moreover, fascicles showing a high-amplitude in reading flexor carpi ulnaris are donor nerves that can restore normal elbow flexion without intrinsic loss

Objective: To determine patient characteristics and outcomes for extremity rhabdomyosarcoma (RMS) utilizing an international cohort of prospectively treated patients.

Methods: Data were collected from 566 patients (1984 through 2003) treated on cooperative protocols : US IRS III, IV Pilot, IV studies – SIOP 84, 89, 95 studies – Italian ICG 79, 88, 96 studies – German CWS81, 86, 91, 96 studies.

Results: 29 % of the patients were < 3 year old, 36 % were 3 to 10 year old and 35 % > 10 year old. 350 (63%) patients had alveolar RMS and 116 (22%) had regional nodes.

The overall survival and EFS were 65% and 51% at 5 years respectively and 59% and 48% at 10 years respectively.

By univariate analysis, EFS was influenced by age below 3 years but not by age over 10 years (EFS were 61%, 49% and 46% for patients below 3 years, from 3 to 10 and 10 years or more respectively). It was also influenced by tumor invasiveness, tumor size, lymph node involvement, histology, completeness of surgery at diagnosis and cooperative groups. In multivariate analysis of EFS, size, lymph nodes, quality of surgery, cooperative groups had independent impact. Age and histology had no more impact.

OS (univariate analysis) was influenced by age below 3 years but not by age over 10 years (OS were 77%, 61% and 58% for patients below 3 years, from 3 to 10 and 10 years or more respectively). In multivariate analysis, age, lymph nodes, tumour invasiveness, quality of surgery at diagnosis had independent impact. Histology, tumour size and cooperative groups had no more impact.

Conclusion: This analysis shows that significant cut-point for age is 3 years, that histology per se has no impact on OS and EFS. It also underscores the impact of initial surgery on outcome.

The Euro-E.W.I.N.G. 99 trial aimed to improve the dismal prognosis of patients with primary disseminated multifocal Ewing tumors (PDM-ET) with a dose-intense treatment concept.

From 1999 to 2005, 281 patients with PDM-ET were enrolled onto the EURO-E.W.I.N.G. 99 trial. Median age was 16.2 years (0.4–49). Recommended treatment consisted of 6 VIDE, one VAI cycle, local treatment (surgery and/or radiotherapy), and high-dose busulfan-melphalan followed by autologuous stem cell transplantation (HDT/SCT).

After a median follow up of 3.8 years, event-free survival (EFS) and overall survival (OS) at 3 years for all 281 patients were 27%±3% and 34%±4%. Six VIDE cycles were completed by 250 patients (89%); 169 (60%) received HDT/SCT. Forty-six children less than 14 years and HDT/SCT achieved a 3-year EFS of 45%. Cox regression analyses demonstrated increased risk at diagnosis for patients over 14 years (HR 1.6), a primary tumor volume > 200ml (HR 1.8), more than one bone metastatic site (hazard ratio: HR 2.0, bone marrow metastases (HR 1.6) and additional lung metastases (HR 1.5). An “up front” risk score based on these HR factors identified three groups with EFS rates of 50% for score ≤3 (82 patients), 25% for score > 3 to < 5 (102 patients), and 10% for score ≥5 (70 patients), p< 0.0001.

PDM-ET patients may survive with intensive multimodal therapy. Age, tumor volume, and extent of meta-static spread are relevant risk factors. A score based on these factors identifies PDM-ET patients may facilitate risk adapted treatment approaches.

Purpose of the study: Surgical management of neurological injury encountered in patients with a ruptured pelvic girdle remains exceptional. In this work, we present our experience and compare our results with data in the literature.

Material and methods: This retrospective analysis concerned four clinical css. Mean patient age was 20.2 years for two men and two women. All patients were victims of high-energy trauma and presented type C (Tile) pelvic girdle injury. All presented a paralysis of the lumbosacral plexus. One patient presented bilateral paralysis of the pudendal plexus. The work-up included: saccora-diculography, myeloscan, lumbar magnetic resonance imaging. One patient presented a pseudomeingocele.

Results: Surgical exploration was performed within a mean delay of 3.75 months. Two types of exploration were used: for two patients the transperitoneal approach was used because of a suspected lesion of the lumbosacral trunk and for two others, the trans-sacral approach because of suspected intra-spinal rupture. Neurolysis was performed for three patients and an caudia equina nerve graft for one. Nervous injuries involved section or rupture of the roots. There were no cases of medullary avulsion. All patients presented signs of nerve regeneration at last follow-up (mean 5.5 years).

Discussion: Even though injury to the lumbosacral plexus is exceptional, advances in surgical techniques offer therapeutic options adapted to each type of injury and nerve territory. One or more motor functions can be restored. Microsurgical nervous repair of the lumbo-sacral plexus is possible irrespective of the level of the injury. Nerve repair by grafting or neurotization can be achieved via a combination of trans-sacral and anterior retroperitoneal approaches or even a transabdominal approach.

Purpose of the study: We wanted to assess long-term outcome after treatment for Ewing tumor of the pelvis.

Material and method: We reviewed 62 patients aged 5 to 28 years treated from 1983 through 1993. There were 35 males and 27 males. Sixteen patients had pulmonary metastases at diagnosis. Patients were given chemotherapy using three protocols (Ew 84, Ew 88, Ew 93) proposed by the French Society of Pediatric Oncology. Fourteen patients were give high-dose chemotherapy with a bone marrow graft. The local treatment was not randomized. Radiotherapy was used alone in 25 patients and 15 underwent surgery and radiotherapy. Eighteen underwent surgery without complementary radiotherapy. For patients were not given local treatment. Outcome at last follow-up was assessed retrospectively.

Results: Mean follow-up was 6.6 years (3 months to 18 years); 29 patients were in remission, 6 had progressive disease, and 27 had died. Two patients who had bone marrow grafts developed a second tumor in the radiated territory. The overall chances of survival were 55±6% at five years and 53±7% at ten years. There was no significant difference by type of chemotherapy. In the group of operated patients, the five year survival was 68% versus 43% in the group of non-operated patients (p=0.007). In patients with initial metastases, chances of survival at ten years were 19.7±10% versus 65.9±7% in patients without metastasis. Only two patients who presented metastases initially were in remission at last follow-up. Five patients developed local recurrence after surgery and none had been radiated despite incomplete response to chemotherapy or presence of contaminated resections.

Discussion: Rigorous comparison between operated and non-operated patients is hindered due to the different indications. Results of treatment of Ewing tumors of the pelvis without metastasis are comparable to those obtained for tumors in other localizations. The fact that a second tumor can develop in the radiated territory is a particularly important factor in patients given high-dose chemotherapy with a bone marrow graft.

Conclusion: Surgical treatment appears to improve local control of Ewing tumors of the pelvis. If initial metastasis is not present, the prognosis appears to be similar to other localizations. Radiotherapy remains and indispensable adjuvant in the event of surgical resection or incomplete response to chemotherapy.

Purpose of the study: Balistic nerve injury is not common in civil medicine. We analyzed a series of 30 patients who underwent surgery for this type of injury suffered in the Gaza strip between 2002 and 2004. All patients presented paralysis of the sciatic nerve or one of its major branches. All injuries were caused by war weapons.

Material and methods: The series included 28 men and two women, mean age 22 years (range 2.5–65). The injury had occurred more than one year earlier for 33% of patients. The injury was situated at the knee level in twelve patients and in the thigh in ten. Complete nerve section was observed in 12 patients and partial section in two. Loss of nervous tissue was significantly greater for lesions around the knee. Nineteen patients underwent surgery for: neurolysis (n=3), direct nerve suture (n=8) and nerve grafts (n=8). Eleven patients were reviewed at mean 13.7 months (range 3–30 months). There were no failures. Results of reinnervation of the tibial nerve territory were better than for the fibular nerve. Sixteen patients underwent palliative transfer for a hanging foot for more than six months: 15 transfers of the posterior tibial muscle through the interosseous membrane and hemitransfer of the Achilles tendon. Seven patients underwent Achilles tendon lengthening at the same time and five had a reinnervation procedure on the common fibular nerve.

Results: Seven patients were reviewed with a mean follow-up of 1.8 years (range 4–30 months. None of the patients used an anti-equin orthesis. There were three cases of forefoot malposition. The overall Stanmore score was good at 75.4/100 (range 59–100).

Discussion: High-energy ballistic trauma creates a specific type of injury. Nervous surgery can be indication early to favor spontaneous recovery. Palliative surgery for fibular lesions provides regularly good results.

Conclusion: Nerve injuries due to ballistic trauma should be explored surgically because of the possibility of direct nerve repair. In addition, depending on the type of paralysis, reliable palliative surgery can be proposed.

Purpose of the study: Proximal replantation is a technically feasible but life-threatening procedure. Indications must be restricted to patients in good condition with a good functional prognosis. The goal of replantation must be focused not only on reimplanting the amputated limb but also on achieving a good functional outcome. For the lower limb, simple terminalization remains the best choice in many cases. When a proximal amputation is not suitable for replantation, the main aim of the surgical procedure must be to reconstruct a stump long enough to permit fitting a prosthesis preserving the function of the adjacent joint. If the proximal stump beyond the last joint is very short, it may be possible to restore some length by partial replantation of spared tissues from the amputated part. We present here the results we obtained following this policy.

Materials and methods: This series included 16 cases of partial replantations, 14 involving the lower limb and 2 the upper limb. All were osteocutaneous microsurgical transfers. For the lower limb, all transfers recovered protective sensitivity following tibial nerve repair. The functional calcaeoplantar unit was used in 13 cases. The transfer of this specialized weight bearing tissue provided a stable distal surface making higher support unnecessary. In one case, we raised a 13-cm vascularized tibial segment covered with foot skin for additional length. For the upper limb, the osteocutaneous transfer, based on the radial artery, was not reinnervated, but this lack of sensitivity did not impair prosthesis fitting.

Results: One vascular failure was finally amputated. This was the only unsuccessful result. For all other patients, the surgical procedure facilitated prosthesis fitting and preserved the proximal joint function despite an initially very proximal amputation.

Discussion: The advantages of partial replantation are obvious compared with simple terminalization or secondary reconstruction. There is no secondary donor site and, because there is no major muscle mass in the distal fragment, the overall risk is very low compared with the risk of total proximal leg replantation.

The palmar ligaments of the wrist were dissected in 15 adult cadaver wrists and demonstrated by MRI in three. Ten fetal wrists (10 to 19 weeks' gestation) were studied in histological sections. The palmar scaphotriquetral ligament was found in them all. Its attachment to the triquetrum is substantial but that to the scaphoid is thin and fan-shaped, its fibres interdigitating with those of the radioscaphocapitate ligament. The contribution of the ligament to carpal stability has yet to be studied, but it may help to support the head of the capitate when the wrist is dorsiflexed.