全膝关节置换治疗血友病关节炎围手术期处理及短期疗效评价

 目的 探讨血友病关节炎全膝置换围手术期管理、凝血因子调控及早期临床疗效。方法 回顾性分析2009年3月至2014年3月采用全膝关节置换治疗8例（10膝）血友病膝关节炎患者资料,均为男性患者,年龄31~47岁,平均（38.3±5.0）岁;术前活化部分凝血活酶时间为（63.9±4.0） s,凝血因子活性为2.6%±0.9%;膝关节均有屈曲畸形,伸膝-12.0°±5.9°,屈膝-88.0°±11.4°。其中3例（3膝）合并外翻畸形,外翻角平均-3.0°±5.4°;2例（4膝）合并内翻畸形,内翻角平均-4.5°±6.0°。8例患者中,甲型6例,乙型2例,分别补充冻干人凝血八因子和凝血酶原复合物后手术。骨缺损根据AORI分型方法,T1、T2型采用骨水泥充填,T3包容型采用同种异体骨打压植骨、螺钉支撑内固定修复,T3节段型通过自体骨结构性植骨,并加用胫骨延长杆修复。采用美国特种外科医院（hospital for special surgery, HSS）膝关节评分评价膝关节功能。结果 8例患者均获得随访,随访时间9~26个月,平均14.3个月。末次随访时伸膝0°,屈膝98.5°±6.7°;HSS评分由术前（42.3±10.9）分提高到术后（88.3±4.6）分;X线片示植骨存活,假体、螺钉均未见松动、断裂。结论 全膝关节置换治疗血友病关节炎短期疗效满意,术前的预输试验有助于确定凝血因子的补充剂量。     

围截骨区卫星棒技术在严重脊柱畸形三柱截骨术中的应用

 目的 探讨严重脊柱畸形三柱截骨术中围截骨区卫星棒技术的可行性,并评估其临床应用价值。方法 回顾性分析2012年7月至2014年1月期间应用卫星棒技术行严重脊柱畸形三柱截骨并有完整临床及影像学资料的13例患者,男6例,女7例;年龄12~57岁,平均（30.9±19.1）岁。分别测量患者手术前后及末次随访时侧凸Cobb角、最大后凸Cobb角（global kyphosis,GK）、冠状面平衡（distance between C₇ plumb line and center sacral vertical line,C₇PL-CSVL）和矢状面平衡（sagittal vertical axis,SVA）。患者初诊及每次随访均填写SF-36量表。结果 随访时间平均为（15.8±3.8）个月。术前侧凸Cobb角平均为86.3°±22.6°,术后为45.2°±19.7°,较术前明显改善,平均矫正率为47.7%±19.1%;末次随访为39.9°±19.8°,随访期间未见明显矫正丢失。术前GK为80.9°±18.7°,术后为35.1°±14.5°,平均矫正率为57.8%±13.8%;末次随访时未见明显丢失,平均为36.3°±10.0°。手术前后C₇PL-CSVL分别为（43.7±36.8） mm、（18.8±5.6） mm,术后有明显改善;末次随访时维持良好,平均为（19.2±8.3） mm。SVA由术前平均（55.0±51.5） mm减小至术后（29.3±19.5） mm,末次随访为（34.2±17.5） mm,亦无明显矫正丢失。13例患者术中监测均无信号异常。术后1例患者1枚螺钉位置偏上穿出上终板,1例患者1枚螺钉位置偏外。患者随访期间均无明显矫形丢失及断钉、断棒等内固定并发症。结论 严重脊柱畸形三柱截骨引入卫星棒技术既满足坚强固定需要又起到分散应力作用,术后矫形效果满意,随访期间矫正丢失及内固定失败等并发症少。     

股骨颈骨折空间移位的三维重建研究

 目的 通过三维重建研究并测量移位型股骨颈骨折中股骨头的空间移位,探讨股骨颈骨折严重程度及判断预后。方法 收集80例移位型股骨颈骨折患者（Garden分型Ⅲ型40例、Ⅳ型40例）双侧股骨近端多层螺旋CT扫描的薄层原始数据（DICOM格式）,导入三维重建软件生成双侧股骨近端三维模型。在健侧股骨近端生成患侧的镜像模型并与健侧相配准,使患侧镜像模型在健侧处形成新的蒙罩,在蒙罩上进行关键点标记,通过三维测量技术来计算股骨头空间移位参数,并对数据进行整理和分析。结果 GardenⅢ型骨折股骨头小凹最深点位移为（23.70±10.00）mm,Ⅳ型（30.24±8.96） mm,两者比较差异有统计学意义;GardenⅢ型骨折中股骨头中心的位移为（14.36±5.61）mm,Ⅳ型为（18.77±5.45） mm,两者比较差异有统计学意义;GardenⅢ型骨折中股骨头空间偏转的角度为29.18°±15.74°,Ⅳ型为39.08°±17.08°,两者比较差异有统计学意义。移位型股骨颈骨折股骨头移位方向主要为后下方。结论 Garden分型对移位型骨折的认识存在一定局限性;三维重建及空间测量技术能更科学、准确地评价股骨颈骨折后股骨头移位的程度,为骨科医生评估骨折类型、严重程度及预后,制定更合理的手术方案提供更为宽广的临床思路。     

外侧入路联合前内侧入路治疗肘关节“恐怖三联征”的手术疗效

 目的 探讨采用外侧入路联合前内侧入路治疗肘关节“恐怖三联征”的手术疗效。方法 回顾性分析2008年7月至2011年1月,采用外侧入路联合前内侧入路治疗23例肘关节“恐怖三联征”患者,其中21例获得完整随访资料,男17例,女4例;年龄17~63岁,平均38.4岁;坠落伤15例,运动损伤4例,交通伤2例;受伤至手术时间为2~8 d,平均4 d。尺骨冠突骨折O’Driscoll分型：A1型5例,A2型12例,B2型4例;桡骨头骨折Mason分型：Ⅰ型2例,Ⅱ型12例,Ⅲ型7例;软组织损伤仲飙等分型：Ⅰ型6例,Ⅱ型12例,Ⅲ型3例。先采用Kocher入路内固定或人工桡骨小头置换治疗桡骨小头骨折,暂时修补外侧副韧带复合体,而后通过前内侧入路固定冠突骨折并修补内侧副韧带损伤;术后采用铰链式外固定支具辅助固定。术后分别采用Mayo肘关节评分（Mayo elbow performence score, MEPS）和Broberg-Morrey分级评估患者肘关节功能及创伤性关节炎程度。结果 21例患者均获得随访,随访时间24~48个月,平均32个月。末次随访时,患者肘关节屈伸及前臂旋转平均活动度分别为126°（范围,115°~135°）和139°（范围,125°~145°）;MEPS评分为85~100分,平均95分,其中19例评定为优,2例为良,优良率为100%,无一例发生肘关节复发不稳定。术后1周,1例发生伤口浅表感染,经清创及静脉使用抗生素治疗后愈合;术后3个月,发生异位骨化症2例,桡骨头骨折骨不连1例,尺神经麻痹1例,均未行手术处理。结论 采用外侧入路联合前内侧入路治肘关节“恐怖三联征”具有一期同时重建骨结构和恢复软组织稳定性的优势,术后患者能早期进行功能锻炼,利于肘关节功能恢复。     

严重僵硬型颈椎后凸畸形的手术入路选择

 目的 探讨严重僵硬型颈椎后凸畸形的影像学特征及不同类型的手术入路选择。方法 回顾性分析2007年1月至2012年1月,治疗17例严重僵硬型颈椎后凸畸形患者完整资料,男8例,女9例;年龄21~72岁,平均49.7岁;炎症3例,退变3例,神经纤维瘤病3例,全椎板切除术后3例,特发性2例,陈旧性颈椎骨折2例,神经肌肉源性疾病1例;后凸累及节段（4.3±1.2）个。患者临床均表现为颈部疼痛,视觉模拟评分（visual analogue scale, VAS）（7.6±1.5）分,颈椎后凸畸形进行性发展,其中合并脊髓病变4例、神经根痛2例、不能平视3例、吞咽困难1例。患者术前均摄颈椎过伸、过屈位及颈椎牵引位X线片,并通过矢状位CT重建片评价颈椎僵硬来源。继续颅骨牵引下,根据脊髓压迫情况、后凸累及节段及僵硬来源等因素分别采用前路、后路及前后路联合手术入路,术后根据颈椎后凸Cobb角恢复及Odom标准评价疗效。结果 术后17例患者均获得随访,随访时间2~5年。根据CT检查结果,17例患者中,僵硬来源于前方骨性强直7例、后方6例、前后方4例。采用前路手术4例,后路2例,前后路5例,后前路3例,前-后-前路1例,后-前-后路2例。术前Cobb角平均49.3°±14.6°,末次随访平均2.1°±6.8°,平均矫正角度47.2°;Odom 标准：优7例,良8例,可2例,优良率88.2%（15/17）。1例患者术后3个月出现近端交界区后凸,遂行翻修术;17例患者术后均获骨性融合,随访期内无一例发生后凸矫正角度显著丢失。结论 CT有利于判断颈椎后凸畸形的僵硬来源;手术入路的选择取决于脊髓是否受压、后凸累及节段的长短、颈椎后凸畸形的僵硬来源等因素;僵硬来源于颈椎前方骨性强直采用前路手术,来源于后方强直采用后路手术,来源于前后方强直需前后路联合手术。     

髂腰内固定治疗创伤性脊柱骨盆分离

 目的 探讨创伤性脊柱骨盆分离的临床特点及后路髂腰内固定治疗该损伤的临床效果。方法 回顾性分析2008年7月至2012年12月收治12例创伤性脊柱骨盆分离患者资料,男8例,女4例;年龄18~50岁,平均（34.6±9.2）岁。致伤原因：坠落伤11例,车祸伤1例。所有骨折均为闭合性损伤,均有不同程度的合并伤。骶骨骨折按形态学分型：U型4例,H型6例,Y型2例。Roy-Camille分型：Ⅱ型6例,Ⅲ型6例。采用髂腰固定对12例患者进行手术治疗,并对6例有明显神经损害表现且有明确手术指征的患者同时行神经减压术。临床疗效评价采用Majeed标准,神经损伤按照Gibbons评价方法进行评定。结果 12例患者均获得随访,随访时间12~36个月,平均（15.5±6.3）个月。9例患者在受伤早期存在误诊或漏诊,12例患者均有不同程度的神经损害表现。术后所有骨折均获得愈合,骨折愈合时间4~8个月,平均（4.8±2.8）个月。根据Majeed标准,优4例、良4例、可2例、差2例,优良率66.7%（8/12）。12例患者术后患肢感觉、运动功能恢复率为91.7%（11/12）。6例行神经减压术的患者术后感觉、运动功能恢复率为83.3%（5/6）。末次随访时,Gibbons神经评分由术前平均（3.25±0.75）分降至术后平均（1.67±0.99）分,差异有统计学意义。结论 创伤性脊柱骨盆分离是一种少见的高能量损伤,其合并伤及神经损害的发生率很高;后路髂腰内固定是一种值得推荐的治疗方式,对有指征的患者早期行神经减压有利于神经功能的恢复。     

保留与不保留残端重建前十字韧带的前瞻性随机对照研究

 目的 评估保留与不保留残端对重建前十字韧带（anterior cruciate ligament,ACL）的意义及临床疗效。方法 2010年1月至2012年10月,收治93例残端存留的ACL损伤患者,前瞻性随机将其分为保留组（保留残端）和不保留组（切除残端）。保留组48例,男34例,女14例;平均年龄30.4岁;左侧25例,右侧23例;损伤至手术时间13.5 d;合并内侧半月板损伤7例,外侧半月板损伤16例,内侧副韧带损伤4例。不保留组45例,男33例,女12例;平均年龄28.8岁;左侧22例,右侧23例;损伤至手术时间14.9 d;合并内侧半月板损伤7例,外侧半月板损伤12例,内侧副韧带损伤2例。两组重建ACL移植物均为自体四股腘绳肌腱。术后两组患者分别行膝关节功能评估、稳定性评估、本体感觉功能测量和二次关节镜手术探查。结果 82例患者完成随访,其中保留组42例,随访时间（25.4±1.9）个月;不保留组40例,随访时间（25.2±1.7）个月。IKDC分级：保留组A级32例,B级9例,C级1例;不保留组A级30例,B级8例,C级2例。Lysholm评分：保留组（95.9±5.2）分,不保留组（95.4±1.7）分。Lachman试验：保留组,阴性38例,1度阳性4例;不保留组,阴性36例,1度阳性4例。轴移试验：保留组,阴性37例,1度阳性5例;不保留组,阴性34例,1度阳性6例。KT-1000测量侧-侧差值：保留组（1.1±1.2） mm,不保留组（1.2±0.9） mm。本体感觉测量关节位置觉侧-侧差值：保留组3.6°±1.8°,不保留组3.9°±2.2°。以上指标两组均无明显差异。二次手术探查移植物滑膜覆盖分型,保留组A型11例,B型6例,C型2例,D型2例;不保留组A型10例,B型5例,C型2例,D型2例。结论 保留较不保留残端并使用自体肌腱移植重建ACL对术后膝关节主观功能、稳定性、本体感觉和移植物滑膜覆盖无促进作用。     

慢病毒介导的shRNA干扰PTEN表达促皮层神经元轴突再生及脊髓损伤修复

 目的 观察慢病毒介导特异性短发夹RNA（short hairpin RNA,shRNA）干扰第l0号染色体同源丢失性磷酸酶张力蛋白基因（phosphatase and tensin homology deleted on chromosome ten,PTEN）表达对皮层神经元轴突再生及脊髓损伤修复的影响。方法 体内实验和体外实验两部分各分四组：阴性对照组（DMEM）、空载慢病毒组（Lenti��control）、空白载体组（Lenti��scramble）、慢病毒介导shRNA组（Lenti��shRNA）。体外神经元转染72 h后,Western blot检测各组PTEN表达情况,免疫荧光检测神经元轴突再生能力;体内载体注射1周后,Western blot检测各组PTEN表达情况;6周后荧光显微镜观察皮质脊髓束穿越脊髓损伤局部周围增强绿色荧光蛋白荧光强度及突触素表达情况。采用大鼠脊髓损伤评分评价大鼠后肢运动恢复情况。结果 慢病毒介导shRNA组体外转染神经元后PTEN表达水平比阴性对照组下降83.75%±2.85%,与其他组比较具有统计学意义（F=4277,P< 0.05）;轴突长度（249.70±10.70）μm,大于阴性对照组（95.71±20.24） μm、空载慢病毒组（97.00 ± 22.82）μm及空白载体组（87.57±19.34）μm,差异具有统计学意义（F=84.74,P< 0.05）;每个神经元一级突起数量（5.800±0.359）个,大于阴性对照组（2.800±0.678）个、空载慢病毒组（2.900±0.389）个及空白载体组（3.000±0.877）个,其差异具有统计学意义（F=16.47,P< 0.05）;神经元突起穿越硫酸软骨素蛋白多糖基质的百分比20.60%±1.80%,大于阴性对照组6.70%±1.45%、空载慢病毒组5.50%±1.69%、空白载体组5.60%±1.77%,其差异具有统计学意义（F=94.90,P<0.05）。慢病毒介导shRNA注射大脑皮层运动区后,第6周大鼠脊髓损伤评分达（13.29±0.42）分,高于阴性对照组（7.00±1.48）分,空载慢病毒组（6.43±1.43）分,空白载体组（6.29±1.22）分,其差异具有统计学意义（F=44.85,P< 0.05）。皮层组织PTEN表达水平下降84.57%±1.87%,损伤中心尾端见绿色荧光,突触素染色阳性面积明显增大。结论 慢病毒介导shRNA下调PTEN基因表达后可明显提高脊髓损伤后轴突再生能力,促进神经功能修复。     

脊髓损伤后脑萎缩对运动功能恢复的影响

 目的 探讨脊髓损伤后脑部萎缩情况以及脑萎缩对患者运动功能恢复的影响。方法 回顾性分析2012年10月至2014年3月,25例接受脊柱内固定治疗的脊髓损伤患者完整随访资料,根据随访6个月后的运动功能恢复情况分为恢复较好组和恢复一般组,同时另选取25例年龄、性别相匹配的健康人作为对照组。恢复较好组10例,男6例,女4例;年龄24~55岁,平均（37.9±13.9）岁;入院时ASIA评级A级1例,B级4例,C级3例,D级2例;6个月后ASIA评级均有一个以上好转,其中A级0例,B级1例,C级3例,D级3例,E级3例;入院时ASIA运动评分为（71.9±16.3）分,6个月后为（85.5±1.5）分。恢复一般组15例,男8例,女7例;年龄24~55岁,平均（35.8±11.5）岁;入院时ASIA评级A级7例,B级3例,C级3例,D级2例）;6个月时ASIA评级未见明显改善;入院时ASIA运动评分为（71.9±16.3）分,6个月后为（85.5±1.5）分。对照组25名,男15名,女10名,年龄（36.5±9.3）岁。采用MRI扫描三组受试者脑部结构信息,运用CIVET软件及DtiStudio软件对比三组大脑灰质和白质萎缩的区域。运用Pearson相关性分析探讨脑皮层萎缩与患者运动功能恢复率之间的相关性。结果 与健康对照组相比,脊髓损伤恢复较好组和恢复一般组均存在双侧初级运动皮层的灰质萎缩,但恢复一般组的萎缩程度更广泛和严重,同时还出现右侧辅助运动区和运动前区的灰质萎缩。恢复较好组未见明显的脑内皮质脊髓束萎缩,而恢复一般组脑内皮质脊髓束初级运动皮层区域及内囊区域均出现白质萎缩。此外,脊髓损伤患者辅助运动区的灰质体积（r=0.75,P< 0.001）及初级运动皮层的白质体积（r=0.76,P< 0.001）与患者6个月后的运动恢复率存在正相关关系。结论 在脊髓损伤早期,运动感觉中枢即可出现明显的萎缩现象,同时这种萎缩对患者的运动功能恢复存在不利影响。     

经椎弓根不对称截骨重建强直性脊柱炎胸腰椎侧后凸畸形患者双平面平衡

 目的 探讨经椎弓根不对称截骨（asymmetrical pedicle subtraction osteotomy, APSO）在强直性脊柱炎（ankylosing spondylitis, AS）胸腰椎侧后凸畸形患者冠状面和矢状面平衡重建中的作用。方法 回顾性分析2005年10月至2012年6月采用APSO手术治疗16例AS胸腰椎侧后凸畸形患者资料,男13例,女3例;年龄22~48岁,平均35.4岁。术前、术后及末次随访均摄站立位全脊柱正、侧位X线片,测量冠状面和矢状面参数：冠状面Cobb角,冠状面躯干偏移（central sacral vertical line,CSVL）、胸腰椎最大后凸角（global kyphosis,GK）、矢状面躯干偏移（sagittal vertical axis,SVA)、胸椎后凸角（thoracic kyphosis,TK)、腰椎前凸角（lumbar lordosis,LL）、骨盆倾斜角（pelvic tilt,PT）、骶骨倾斜角（sacral slope,SS）和骨盆投射角（pelvic incidence,PI）。采用SF-36量表评估AS胸腰椎侧后凸畸形患者术前和末次随访的生活质量。结果 随访时间24~63个月。冠状面Cobb角由术前25.8°矫正至术后7.6°,矫正率70.5%;CSVL由术前5.6 cm矫正至术后1.8 cm;GK由术前76.8°矫正至术后25.6°,矫正率66.7%;SVA由术前15.1 cm矫正至术后3.8 cm。LL、PT和SS分别由术前的-0.4°、33.6°和10.3°矫正至术后44.1°、22.6°和20.9°,差异均有统计学意义。末次随访时,冠状面Cobb角、CSVL、GK、SVA、LL、PT和SS出现轻度矫正丢失。末次随访时AS患者躯体疼痛、一般健康状况、社会功能和情感职能评分均获得明显提高。结论 AS胸腰椎侧后凸畸形患者同时伴有冠状面和矢状面失平衡,导致其生活质量严重降低。APSO手术在矫正其矢状面失平衡的同时,还可明显改善冠状面躯干失平衡,可实现满意的双平面重建;患者生活质量较术前也获得明显提高。     

Restoration of shoulder function with nerve transfers in traumatic brachial plexus palsy patients

Shoulder stabilization is of utmost importance in upper extremity reanimation following paralysis from devastating injuries. Although secondary procedures such as tendon and muscle transfers have been used, they never achieve a functional recovery comparable to that following successful reinnervation of the supraspinatus, deltoid, teres minor, and infraspinatus muscles. Early restoration of suprascapular and axillary nerve function through timely brachial plexus reconstruction offers a good opportunity to restore shoulder-joint stability, adequate shoulder abduction, and external rotation function. Overall, in our series, 79% of patients achieved good and excellent shoulder abduction (muscle grade, +3 or more), and 55% of patients achieved good or excellent shoulder external rotation after reinnervation of the suprascapular nerve. The best results were seen when direct neurotization of the suprascapular nerve from the distal spinal accessory nerve or neurotization by the C5 root was carried out. Concomitant neurotization of the axillary nerve yields improved outcomes in shoulder abduction and external rotation function.     

Axillary nerve neurotization with the anterior deltopectoral approach in brachial plexus injuries

Combined neurotization of both axillary and suprascapular nerves in shoulder reanimation has been widely accepted in brachial plexus injuries, and the functional outcome is much superior to single nerve transfer. This study describes the surgical anatomy for axillary nerve relative to the available donor nerves and emphasize the salient technical aspects of anterior deltopectoral approach in brachial plexus injuries. Fifteen patients with brachial plexus injury who had axillary nerve neurotizations were evaluated. Five patients had complete avulsion, 9 patients had C5, six patients had brachial plexus injury pattern, and one patient had combined axillary and suprascapular nerve injury. The long head of triceps branch was the donor in C5,6 injuries; nerve to brachialis in combined nerve injury and intercostals for C5‐T1 avulsion injuries. All these donors were identified through the anterior approach, and the nerve transfer was done. The recovery of deltoid was found excellent (M5) in C5,6 brachial plexus injuries with an average of 134.4° abduction at follow up of average 34.6 months. The shoulder recovery was good with 130° abduction in a case of combined axillary and suprascapular nerve injury. The deltoid recovery was good (M3) in C5‐T1 avulsion injuries patients with an average of 64° shoulder abduction at follow up of 35 months. We believe that anterior approach is simple and easy for all axillary nerve transfers in brachial plexus injuries. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

Nerve transfer to deltoid muscle using the nerve to the long head of the triceps,part II: a report of 7 cases

PURPOSE: This study reports the results of nerve transfer to the deltoid muscle using the nerve to the long head of the triceps. METHODS: Seven patients with an average age of 25 years with loss of shoulder abduction secondary to upper brachial plexus injuries had nerve transfer using the nerve to the long head of the triceps to the anterior branch(es) of the axillary nerve through the posterior approach. The spinal accessory nerve was used simultaneously for nerve transfer to the suprascapular nerve. The follow-up period ranged from 18 to 28 months (average, 20 mo). RESULTS: All patients recovered deltoid power against resistance (M4) at the last follow-up evaluation. Useful functional recovery was achieved in all 7 patients; 5 had excellent recoveries and 2 had good results. The average shoulder abduction was 124 degrees. No notable weakness of elbow extension was observed. CONCLUSIONS: This method is a reliable and effective procedure for deltoid reconstruction in brachial plexus injury (upper-arm type) and should be combined with spinal accessory nerve transfer to the suprascapular nerve to obtain good shoulder abduction.     

Transfer of the accessory nerve to the suprascapular nerve in brachial plexus reconstruction

PURPOSE: Transfer of the accessory nerve to the suprascapular nerve is a common procedure, performed to reestablish shoulder motion in patients with brachial plexus palsy. We propose dissecting both nerves via a distal oblique supraclavicular incision, which can be prolonged up to the scapular notch. The results of the transfer to the suprascapular nerve are compared with those of the combined repair of the suprascapular and axillary nerves. METHODS: Thirty men between the ages of 18 and 37 years with brachial plexus trauma had reparative surgery within 3 to 10 months of their injuries. In partial injuries with a normal triceps, a triceps motor branch transfer to the axillary nerve was performed. The suprascapular and accessory nerves were dissected via an oblique incision, extending from the point at which the plexus crosses the clavicle to the anterior border of the trapezius muscle. In 10 patients with fractures or dislocations of the clavicle, the trapezius muscle was partially elevated to expose the suprascapular nerve at the suprascapular notch. RESULTS: In all cases, transfer of the accessory to the suprascapular nerve was performed without the need for nerve grafts. A double lesion of the suprascapular nerve was identified in 1 patient with clavicular dislocation. In those with total palsy, the average improvement in range of abduction was 45 degrees , but none of the patients with total palsy recovered any active external rotation. Patients with upper-type injury recovered an average of 105 degrees of abduction and external rotation. If only patients with C5-C6 injuries were considered, the range of abduction and external rotation increased to 122 degrees and 118 degrees , respectively. CONCLUSIONS: Use of the accessory nerve for transfer to the suprascapular nerve ensured adequate return of shoulder function, especially when combined with a triceps motor branch transfer to the axillary nerve. The supraclavicular exposure proposed here for the suprascapular and accessory nerves is advantageous and can be extended easily to explore the suprascapular nerve at the scapular notch.     

Combined nerve transfers for C5 and C6 brachial plexus avulsion injury

PURPOSE: To report the results of combined nerve transfer in C5 and C6 brachial plexus avulsion injury. METHODS: Fifteen patients had nerve transfers: spinal accessory nerve to the suprascapular nerve, a part of the ulnar nerve to the biceps motor branch, and the nerve to the long head of the triceps to the anterior branch of the axillary nerve. Patients were evaluated with regard to elbow flexion, shoulder abduction, and shoulder external rotation. RESULTS: All patients had recovered full elbow flexion: 13 scored M4 and 2 scored M3. Thirteen of the 15 patients obtained good results. The weight the patients could lift ranged from 0 to 7 kg. All patients had recovery of the deltoid function: 13 scored M4 and 2 scored M3. All 15 patients achieved useful functional recovery. Ten patients experienced excellent recoveries and 5 were classified as having good results. The mean shoulder abduction was 115 degrees . Shoulder external rotation strength was scored as M4 in 9 patients, M3 in 4 patients, and M2 in 2 patients. The range of motion of external rotation that was measured from full internal rotation averaged 97 degrees . No clinical donor nerve deficits were observed. CONCLUSIONS: We recommend combined nerve transfers for C5 and C6 avulsion root injuries. These nerve transfers have the advantage of a quick recovery time as a result of the short regeneration distance without nerve graft. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Functional Evaluation of Levator Scapulae Tendon to Supraspinatus in Adult Brachial Plexus Injuries

Introduction  Brachial plexus injuries are severe life-altering injuries. The surgical method to restore shoulder abduction in adult upper brachial plexus injuries involves the usage of nerve grafts and nerve transfers targeting the suprascapular and/or the axillary nerve. When the primary nerve surgery has been unsuccessful or recovery has been incomplete or with a late presentation, muscle transfer procedures are needed to provide or improve shoulder abduction. Levator scapulae to supraspinatus is a transfer to improve shoulder abduction in posttraumatic brachial plexus injuries. Material and Methods  The study included 13 patients with the age ranging from 17 to 47 years with a mean age of 30 years. All these patients had preop shoulder abduction of Medical Research Council (MRC) grade ≤3. All had a minimum of MRC grade 4 of active elbow flexion. Eleven patients had primary surgery. Only patients with a minimum of 1 year postoperative follow-up were included. All 13 patients underwent levator scapulae transfer only. Results  All patients had a stable shoulder postoperatively. The average increase in active shoulder abduction was from 6.15°(median: 0°) preoperatively to 61.92°(median: 60°), with an average gain in shoulder abduction of 49.61°(median: 50°). Conclusions  Transfer of levator scapulae tendon to the supraspinatus is an option to improve shoulder abduction in posttraumatic brachial plexus. In conditions where supraspinatus alone is not functioning, levator scapulae is the best available transfer, considering its strength and maintaining the form of the shoulder unlike trapezius transfer. In patients with previous surgery where supraspinatus has recovered partially but not functionally significant, this tendon transfer can be considered for the augmentation of the existing shoulder abduction.     

Nerve Transfers for Treatment of Isolated Axillary Nerve Injuries

BACKGROUND:

The most common neurological defect in traumatic anterior glenohumeral dislocation is isolated axillary nerve palsy. Most recover spontaneously; however, some have persistent axillary neuropathy. An intact rotator cuff may compensate for an isolated axillary nerve injury; however, given the high rate of rotator cuff pathology with advancing age, patients with an axillary nerve injury are at risk for complete shoulder disability.

OBJECTIVE:

To review reconstruction of the axillary nerve to alleviate shoulder pain, augment shoulder stability, abduction and external rotation to alleviate sole reliance on the rotator cuff to move and stabilize the shoulder.

METHODS:

A retrospective review of 10 patients with an isolated axillary nerve injury and an intact rotator cuff who underwent a triceps nerve branch to axillary nerve transfer was performed. Patient demographics, surgical technique, deltoid strength, donor-site morbidity, complications and time to surgery were evaluated.

RESULTS:

Ten male patients, mean age 38.3 years (range 18 to 66 years), underwent a triceps to axillary nerve transfer for isolated axillary nerve injury 7.4 months (range five to 12 months) post-traumatic shoulder dislocation. Deltoid function was British Medical Research Council grade 0/5 in all patients preoperatively and ≥3/5 deltoid strength in eight patients at final follow-up (14.8 months [range 12 to 25 months]). There were no complications and no donor-site morbidity.

CONCLUSION:

A triceps to axillary nerve transfer for isolated axillary neuropathy following traumatic shoulder dislocation improved shoulder pain, stability and deltoid strength, and potentially preserves shoulder function with advancing age by alleviating sole reliance on the rotator cuff for shoulder abduction and external rotation.     

Contralateral motor rootlets and ipsilateral nerve transfers in brachial plexus reconstruction

OBJECT: The goal of this study was to evaluate outcomes in patients with brachial plexus avulsion injuries who underwent contralateral motor rootlet and ipsilateral nerve transfers to reconstruct shoulder abduction/external rotation and elbow flexion. METHODS: Within 6 months after the injury, 24 patients with a mean age of 21 years underwent surgery in which the contralateral C-7 motor rootlet was transferred to the suprascapular nerve by using sural nerve grafts. The biceps motor branch or the musculocutaneous nerve was repaired either by an ulnar nerve fascicular transfer or by transfer of the 11th cranial nerve or the phrenic nerve. The mean recovery in abduction was 90 degrees and 92 degrees in external rotation. In cases of total palsy, only two patients recovered external rotation and in those cases mean external rotation was 70 degrees. Elbow flexion was achieved in all cases. In cases of ulnar nerve transfer, the muscle scores were M5 in one patient, M4 in six patients, and M3+ in five patients. Elbow flexion repair involving the use of the 11th cranial nerve resulted in a score of M3+ in five patients and M4 in two patients. After surgery involving the phrenic nerve, two patients received a score of M3 + and two a score of M4. Results were clearly better in patients with partial lesions and in those who were shorter than 170 cm (p < 0.01). The length of the graft used in motor rootlet transfers affected only the recovery of external rotation. There was no permanent injury at the donor sites. CONCLUSIONS: Motor rootlet transfer represents a reliable and potent neurotizer that allows the reconstruction of abduction and external rotation in partial injuries.     

Shoulder reanimation in posttraumatic brachial plexus paralysis

Introduction

Posttraumatic brachial plexus paralysis invariably involves the upper roots leading to paralysis of the shoulder region musculature. Early neurotisation of the suprascapular and the axillary nerve should be one of the priorities in plexus reconstruction in order to reanimate the shoulder.

Patients and methods

From 1998 to 2007, 78 patients with posttraumatic brachial plexus palsy were operated in our department. Forty-three patients presented with supraclavicular lesions with involvement of C5 and C6 roots in all cases. Reconstruction of the shoulder function was achieved with neurotisation of the suprascapular nerve in 41 patients. Extraplexus donors were utilised in 34 patients, while intraplexus donors via nerve grafts in 7 patients. Neurotisation of the axillary nerve was performed in 25 patients, utilising intraplexus donors in 16 patients, extraplexus donors in 4, and combination of intraplexus and extraplexus donors in 5 patients.

Results

Suprascapular nerve neurotisation gave good or excellent results (supraspinatus > M3+ or shoulder abduction > 40°) in 35 patients. Intraplexus donors regained good or excellent function in 5 out of 6 patients (83%), while extraplexus neurotisations achieved good or excellent function of the supraspinatus in 30 out of 34 patients (88%). Axillary nerve neurotisation offered good or excellent results (deltoid > M3+ or shoulder abduction > 60°) in 14 patients (58%). Direct neurotisation of the axillary nerve via the motor branch for the long head of the triceps gave shoulder abduction of >110°, as well as external rotation of >30° in 3 out of 5 patients. Combined neurotisation of suprascapular and axillary nerves gave the best outcome achieving shoulder abduction of >60° as well as external rotation of >30°.

Conclusions

Shoulder reanimation should be one of the first priorities in brachial plexus reconstruction. Early neurotisation of the suprascapular, and if possible the axillary nerve offers the best outcome.     

Anatomical relationships of the transmuscular portal to its surrounding structures in arthroscopic treatment of superior labrum anterior posterior lesions: A cadaveric study and preliminary report

ObjectiveThis study aims to investigate the anatomical relationships of the transmuscular portal to its surrounding structures in arthroscopic treatment of superior labrum anterior posterior (SLAP) lesions in a human cadaveric model.MethodsIn this anatomic study, bilateral shoulder girdles of 12 adult formalin embalmed cadavers were used. All cadavers were male, and the mean age was 63.4±7.3 years. The portal entry point was determined as midway between the anterior and posterior borders of the acromion, approximately 1 cm lateral from the edge of the acromion. After a guidewire was placed in the glenoid cavity at the 12 o’clock position where the SLAP lesion typically occurs, a switching stick was inserted there. Each glenoid was then drilled with a 2.4 mm drill through an arthroscopic cannula. Subsequently, anatomical dissection was executed to assess the relationship of the transmuscular portal with the suprascapular nerve, axillary nerve, supraspinatus tendon, acromion, and biceps tendon. Lastly, the shortest distance between the aforementioned structures with the drill was measured by a sensitive caliper to determine whether there was a penetration of the structures. Differences between the right and left sides were analyzed.ResultsThe mean distance between the portal and the axillary nerve was 55.5 mm±6.0 mm, and the mean length of the suprascapular nerve was 61.2 mm±7.0 mm. The mean distance between the portal and the supraspinatus tendon was 2.8 mm±1.5 mm. No penetration of the axillary nerve, suprascapular nerve, and supraspinatus tendon was observed in any cadaver. No differences were detected for measured anatomical parameters between the right and left sides (p>0.05).ConclusionFindings from this cadaveric study revealed that the transmuscular portal may allow for a reliable anchor placement without any nerve or tendon penetration during arthroscopic SLAP repair.Level of EvidenceLevel V