Cement extrusion and radial nerve palsy during revision shoulder and elbow arthroplasty: Beware of the cortical breach

Iatrogenic nerve injuries can cause patients and surgeons a great deal of distress and anxiety. To help prevent such injuries, surgeons should remain mindful for potential distortion of anatomy due to scarring and adhesions. Peripheral nerves are vulnerable to thermal injury, as well as mechanical injury by laceration and traction.Revision arthroplasty may involve removal of the implant and cement mantle. During this removal process, breaches in cortical bone can occur, with resultant cement extrusion within the soft tissues. Screw holes left vacant following screw removal may also allow for cement leakage. Thermal energy is released during the exothermic polymerisation process of cement curing. As a result, this thermal energy can also lead to injury to neural tissue.In this article, we present three cases of radial nerve palsy associated with cement extrusion during revision arthroplasty, in order to highlight pitfalls and learning points in the management. In addition, we propose strategies to avoid such injuries. Surgeons are reminded to be vigilant for cortical breaches intraoperatively, and if recognised, steps should be taken to minimise the risk of nerve injury.     

Experimental study on slow-speed elongation injury of the peripheral nerve: electrophysiological and histological changes

Slow-speed elongation of the sciatic nerves was induced in 41 rabbits by lengthening the osteotomized femur by 2.1 mm/day with an external fixator. Time courses were monitored. About 2 weeks after elongation began, the amplitude of the compound nerve action potentials decreased, and delayed latency began. Histological observations showed that the wavy structure of the nerve fibers was lost during the stage at which reduction in the amplitude of action potentials occurred. In some nerve fibers, narrowing of the axons was observed. Further elongation caused delay in the percent latency. Histologically, collagen fibers were noted in the nerve fascicles, as well as narrowing in all the nerve fibers. When elongation ceased at the stage at which a reduction in the amplitude of action potential was noted, recovery from nerve damage followed. When elongation did not cease until the stage at which latency was delayed, however, recovery was not apparent, either histologically or electrophysiologically. The critical level of percent amplitude for recovery was at 82.4% of the original level (the critical rate for bone lengthening was 20.5%). Received: April 25, 2000 / Accepted: January 16, 2001     

An unusual cause of radial nerve palsy

Neurapraxia frequently occurs following traction injury to the nerve intraoperatively, leading to radial nerve palsy which usually recovers in 5-30 weeks. In our case, we had operated a distal one-third of humeral shaft fracture and fixed it with 4.5 mm limited contact dynamic compression plate. The distal neurovascular status of the limb was assessed postoperatively in the recovery room and was found to be intact and all the sensory-motor functions of the radial nerve were normal. On the second postoperative day, following the suction drain removal and dressing, patient developed immediate radial nerve palsy along with wrist drop. We reviewed the literature and found no obvious cause for the nerve palsy and concluded that it was due to traction injury to the radial nerve while removing the suction drain in negative pressure.     

Smoking cessation advice in limb reconstruction: An opportunity not to be missed

The adverse health effects of smoking are well known, including its effects on the musculoskeletal system. Limb reconstruction using external fixators is a high intensity process with high levels of patient contact time, complications and cost. The aim of this study was to examine smoking patterns in this group and in particular to assess trends in smoking cession.Data was collected from 41 patients all undergoing treatment using circular frame external fixation, for a variety of pathologies, most commonly acute tibial trauma. A patient reported questionnaire was used. Data was collected over a six-month period.In our population 56.1% of patients were smokers. During the study 47.8% patients stopped smoking and a further 39.1% decreased their smoking behaviour. 78.3% of patients could recall being given smoking cessation advice. In our group, 87% of patients were unaware of the effects of smoking on bone healing. Once made aware during discussion of proposed treatment, 73.9% stated that it was, in part, this knowledge that prompted them to positively change their smoking habits.The results of this study show that advice regarding smoking cessation during limb reconstruction treatment can potentially have a positive impact on patients smoking habits. The effect of smoking should be linked to the patient pathology and discussed during the consent process.Taking the time with the patient for this simple free intervention can have a positive impact on patient health, and potentially on the outcome of their current treatment, and is an opportunity not to be missed.     

肌腱移位治疗桡神经不可逆损伤72例报告

目的总结Ｒｉｏｒｄａｎ肌腱移位术治疗桡神经不可逆损伤的疗效。方法对１９６０～１９９６年间，采用Ｒｉｏｒｄａｎ肌腱移位术治疗不可逆桡神经损伤７２例进行回顾性的分析。作者制定的疗效评定标准：优：腕关节能主动背伸４５～６０度；当腕关节背伸３０度时掌指关节伸直达０度，腕关节背伸０～１０度时手指屈距远端掌纹０ｃｍ。良：腕关节能主动背伸３０度；当腕关节背伸１０度时掌指关节能伸至０度，腕关节背伸１０～２５度时手指屈距远端掌纹０ｃｍ。结果术后平均随访３个月，疗效优良者６３例，优良率达８７．５％。结论在众多晚期桡神经功能重建术中，Ｒｉｏｒｄａｎ肌腱移位术是目前最合理的术式，术后均能取得较为满意的疗效。     

Fibular head transfixion wire and its relationship to common peroneal nerve: cadaveric analysis

Proximal tibio-fibular joint is routinely stabilised during leg lengthening, peri-articular fractures and deformity corrections of tibia. Potential injury to the common peroneal nerve at the level of the fibula head/neck junction during wire insertion is a recognised complication. Previous studies have mapped the course of the common peroneal nerve and its branches at the level of the fibular head, and guidelines are published regarding placement of proximal tibial wires. This study aims to relate the course of the common peroneal nerve to the placement of a lateral insertion fibula head transfixion wire. Standard 1.8-mm Ilizarov ‘olive’ wires were inserted in the fibula head of 10 un-embalmed cadaveric knees. Wires were inserted percutaneously to the fibula head using surface anatomy landmarks and palpation technique. The course of the common peroneal nerve was then dissected. Distances from wire entry point to the course of the common peroneal nerve were measured post-wire insertion. The mean distance of the common peroneal nerve from the anterior aspect of the broadest point of the fibular head was 24.5 mm (range 14.2–37.7 mm). Common peroneal nerve was seen to cross the neck of fibula at a mean distance of 34.8 mm from the tip of fibula (range 21.5–44.3 mm). Wire placement was found to be on average, 52 % of the maximal AP diameter of the fibula head and 64 % of the distance from tip of fibula to the point of nerve crossing fibula neck. When inserting a fibula head transfixion wire, care must be taken not to place wire entry point too distal or posterior on the fibula head. Observing a safe zone in the anterior half of the proximal 20 mm of the fibula head would avoid injury to the nerve. In cases where palpation of fibula is difficult due to patient habitus, we recommend consideration of the use of fluoroscopic guidance during wire transfixion of the proximal tibio-fibular articulation to avoid wire insertion too distally and subsequent potential nerve injury.     

New treatment for peripheral nerve defects: Reconstruction of a 2 cm,monkey median nerve gap by direct lengthening of both nerve stumps

We have developed a new treatment for peripheral nerve defects: nerve‐lengthening method, and confirmed the efficacy and safety of our method using cynomolgus monkeys. A 20‐mm defect in the median nerve of monkey's forearms was repaired through the simultaneous lengthening of both nerve stumps with original nerve‐lengthening device. To evaluate nerve regeneration after neurorrhaphy, electrophysiological, histological, and functional recovery were examined and compared to the standard autografting. Nerve conduction velocity, axon maturation, and the result of functional test were superior in the nerve‐lengthening method than in the autografting. And there were no adverse events associated with our method. We concluded that this method is practical for clinical application. © 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 30:153–161, 2012     

Pyoderma gangrenosum. A diagnosis not to be missed.

We describe a case of pyoderma gangrenosum which presented with severe wound breakdown after elective hip replacement. The patient was treated successfully with minimal wound debridement and steroids. This diagnosis should always be considered when confronted with an enlarging painful skin lesion which does not grow organisms when cultured and fails to respond to antibiotic therapy, especially if there are similar lesions in other sites. In patients who have a past history of pyoderma gangrenosum, prophylactic steroids may be indicated at the time of surgery or may be required early in the postoperative period.     

肱骨干骨折合并桡神经损伤一期桡神经探查与保守治疗的疗效比较

目的 比较肱骨干骨折合并桡神经损伤一期桡神经探查与保守治疗的疗效.方法 1995年3月至2005年10月共收治且有完整随访资料的86例肱骨干骨折合并桡神经损伤患者,男63例,女23例;年龄15～66岁,平均34.0岁.根据对桡神经损伤治疗方法的不同分为两组,其中一期桡神经探查（A组）52例,一期保守治疗（B组）34例,比较两组患者的神经功能恢复时间及恢复率.结果 86例患者术后获6～103个月（平均31.2个月）随访.A组52例中有4例（7.7%）需二次手术;最终50例（96.2%）神经功能完全恢复,1例（1.9%）部分恢复,1例（1.9%）无恢复.B组34例中30例（88.2%）神经功能自发性恢复,4例（11.8%）需二期神经探查;最终33例（97.1%）神经功能完全恢复,1例（2.9%）部分恢复.两组神经功能恢复率比较差异无统计学意义（x2=0.050,P=1.000）.A组神经功能开始恢复时间及完全恢复时间平均分别为（5.3±4.1）、（14.7±8.2）周,B组分别为（4.5±3.9）、（11.6±8.7）周,两组比较差异均无统计学意义（P〉0.05）.结论 肱骨干骨折合并桡神经损伤选择保守治疗与一期神经探查具有相当的神经功能恢复率,桡神经损伤不影响肱骨干骨折治疗方式的选择,对闭合性肱骨干骨折合并的桡神经损伤采取保守治疗是一种良好的选择.     

Repair of peripheral nerve defect with direct gradual lengthening of the proximal nerve stump in rats.

We investigated the effect of direct gradual lengthening on the proximal nerve stump and subsequent nerve regeneration in rats. A 10-mm-long nerve segment was resected from the sciatic nerve of each rat. The proximal nerve stump was directly lengthened at a rate of 1 mm/day using an original external nerve distraction device. Experiment I: After distraction periods of 10, 15, and 20 days, the length of each nerve was evaluated, and the lengthened nerve stump was also examined by immunohistochemical analysis. Experiment II: After a distraction period of 20 days, both nerve stumps were refreshed and direct end-to-end neurorrhaphy was performed. For control, 10-mm nerve grafting was immediately performed after nerve resection. Nerve regeneration was evaluated electrophysiologically and histologically 7, 9, and 15 weeks after nerve resection in both groups. The whole proximal nerve stump, including the endoneurium and the axon, could be lengthened in proportion to the distraction period. There were no significant differences in motor nerve conduction velocity and tetanic muscle contraction force between both groups. Histologically, the total number of myelinated fibers was significantly greater in the nerve lengthening group than in the autografting group. This study demonstrated that the whole proximal nerve stump including the endoneurium and the axon could be lengthened by direct gradual distraction, and that this method might have potential application in the repair of peripheral nerve defects.     

Long-term results of transplantations to repair median, ulnar, and radial nerve lesions by a microsurgical interfascicular autogenous cable graft technique

A comprehensive analysis of 187 patients (78 median, 86 ulnar, and 23 radial nerve lesions) treated by an interfascicular autogenous nerve grafting technique is presented. After a follow-up of at least 18 months good motor recovery was achieved in 72% of median nerve lesions, 77% of ulnar nerve lesions, and 57% of radial nerve lesions. Good functional sensory recovery was found in 36% of median, 45% of ulnar, and 48% of radial nerve lesions. It appears by multivariate analysis that the results obtained generally were better in younger patients, in patients with a shorter preoperative delay, and in cases with a shorter transplant.     

高频超声在肱骨骨折合并桡神经损伤诊断中的应用

目的 评价高频超声对肱骨骨折合并桡神经损伤的诊断价值.方法 对36例肱骨骨折术后并发桡神经完全损伤的患者,于神经损伤后1～3个月行神经电生理检查及高频超声诊断检查,28例患者进行了桡神经松解或桡神经修复手术治疗,8例保守治疗.结果 按照神经巢状结构、神经瘤以及外部组织压迫神经等三方面,将桡神经损伤分成4型:Ⅰ型4例,Ⅱ型9例,Ⅲa型12例,Ⅲb型7例,Ⅳ型4例.31例患者经神经手术或非手术治疗功能恢复良好;5例(Ⅲb型3例,Ⅳ型2例)患者接受二期功能重建手术,功能恢复良好.结论 肱骨骨折术后出现桡神经损伤,超声诊断可以提供早期、直观以及正确的辅助诊断方法,同时根据超声诊断的分型选择合适的治疗方法,对桡神经预后有一定的参考意义.     

超声检查在桡神经自发性多段缩窄病变中的应用

目的 探讨超声检查在桡神经自发性多段缩窄病变中的应用.方法 对3例临床和神经电生理诊断为自发性桡神经损伤的患者,采用高频超声检查和手术探查.结果 经手术探查证实,3例桡神经在上臂及前臂行走通路上均有多段缩窄,但无外在压迫因素存在;缩窄部位和程度与超声诊断完全相符.结论 超声检查对诊断和治疗桡神经自发性多段缩窄病变有重要的临床意义,值得推广应用.     

Posterior interosseous nerve compression secondary to a parosteal lipoma: Case report and literature review

An unusual case of limited radial nerve palsy secondary to a parosteal lipoma is presented, along with a thorough review of the literature. Palsy of the posterior interosseous nerve secondary to compression by a lipoma is a rare occurrence. Most cases tend to occur in the fifth to eighth decades of life. The pattern of physical symptoms may be quite variable. A high degree of suspicion must be maintained in the setting of unexplained symptoms. The literature review revealed the presence of a diagnostic proximal forearm radiolucent mass in 13 of 15 patients. Although they are used as diagnostic aids, computed tomography and magnetic resonance imaging have not been shown to alter management. Though benign tumours constitute a minority of such cases, a plain radiograph is recommended in addition to electromyographic and nerve conduction studies.     

Tendon transfers for radial, median, and ulnar nerve injuries: current surgical techniques

Tendon transfers are performed predominantly to restore hand function or balance due to injuries of the radial, median, and ulnar nerves. Current surgical techniques for the most common tendon transfers for reconstruction of radial, median, and ulnar nerve palsies are demonstrated. These techniques can also be applied to restore flexion and extension of the fingers and thumb after injuries to the extrinsic flexor and extensor muscles and tendons of the forearm or intrinsic muscles of the hand.     

桡神经深支损伤的诊断与治疗分析

目的：分析桡神经深支损伤的临床特点和治疗效果，以提高对桡神经深支损伤的早期诊断和治疗水平。方法：对前臂在多发性损伤的情况下，拇指中立位伸指功能障碍，手和前臂感觉功能正常的11例患者，做出桡神经深支损伤的早期诊断，积极地进行手术治疗并对其疗效进行分析。结果：术中证实诊断正确率100％；随访时间3～13个月，平均6．6个月。急性损伤急诊手术7例，术后功能完全恢复；陈旧性损伤4例，择期手术后功能完全恢复2例，部分恢复2例。结论：根据手和前臂的感觉功能及拇指在中立位伸指功能的障碍，可对前臂多发性损伤时的桡神经深支损伤做出早期诊断。早期手术疗效满意。     

非创伤性桡神经麻痹24例临床分析

目的对非创伤性桡神经麻痹的病因,临床表现,治疗结果进行分析。方法自 1985年 1月～ 2000年 1月,共治疗 24例患者,其中男 18例,女 6例;年龄 10～ 65岁,平均 38岁。重体力劳动者及手工劳动者 11例。 1例行肌腱移位术, 23例行桡神经探查,其中 18例行神经松解术, 5例将病变神经段切除（ 2例直接吻合, 3例行游离神经移植）。结果行桡神经探查发现,神经卡压性病变 12例,包括 8例卡压部位位于旋后肌, 1例位于指总伸肌起点腱性部分, 3例多部位多重卡压;神经束带样病变 5例,外在肿物压迫 4例 (2例腱鞘囊肿, 1例脂肪瘤, 1例血管瘤 ),神经肿瘤 1例,不明原因神经病变 1例。 18例神经松解患者术后随访 6个月～ 15年, 14例完全恢复, 1例术后无效, 3例恢复不全; 5例神经吻合或移植患者术后随访 4个月～ 6年, 3例恢复满意, 2例 (1例神经吻合, 1例神经游离移植 )由于术后时间短,仍在恢复中。结论非创伤性桡神经麻痹病因较多,手术治疗效果良好。     

Traumatic bilateral dissections of the internal carotid artery: an infrequent diagnosis not to be missed

We report the case of two patients involved in a car crash and victims of multiple injuries. The diagnosis of bilateral dissection of the internal carotid arteries was only evoked belatedly in view of the increase of the neurologic symptoms. They benefitted from anticoagulant treatment. The clinical evolution was good. Dissection of both carotid arteries from blunt head or neck trauma has been reported but is unusual. Diagnosis and treatment are discussed.