Surgical repair of ulnar nerve lesions caused by gunshot and shrapnel: results in 407 lesions

OBJECT: Ulnar nerve lesions caused by gunshot wounds have rarely been reported in the current literature. The authors describe the outcome after surgical repair of such injuries, and the factors influencing the results of treatment. METHODS: This retrospective study includes 455 patients with 462 ulnar nerve injuries caused by gunshot wounds who were treated at Gulhane Military Medical Academy over a 40-year period. A total of 407 ulnar lesions were surgically repaired at that institution between 1966 and 2005; 237 patients were injured by shrapnel and 218 patients by gunshot. The authors evaluated the motor, sensory, and electrophysiological recovery in these patients, as well as the patients' judgment of the outcome. The authors also tested the effect of repair level, nerve graft length, time to operation, repair technique used, and the presence of coexisting damages in the nerve repair region. The final outcome in these patients was defined as poor, fair, or good on the basis of the British Medical Research Council scores. RESULTS: A good outcome was noted in 15.06% of patients who underwent high-level repair, 29.60% of patients who underwent intermediate-level repair, and 49.68% of patients after low-level repair. On average, patients with successful outcomes had a significantly shorter time to operation than those with unsuccessful outcomes. The critical period for surgery was within 6 months of injury. Although the optimal graft length was found to be 5 cm, this finding was not statistically significant. CONCLUSIONS: The reported outcome of repairs to ulnar nerves damaged by gunshot has varied in the literature, but there is a consensus that the duration of the interval to surgery, the repair level, and the graft length used influence the outcome of surgical repair for ulnar nerve lesions.     

Surgical treatment of common peroneal nerve injuries: indications and results. A series of 62 cases

AIM: Common peroneal nerve (CPN) injuries represent the most common nerve lesions of the lower limb and can be due to several causative mechanisms. Although in most cases they recover spontaneously, an irreversible damage of the nerve is also likely to occur. Nerve regeneration following CPN repair is poorer if compared to other peripheral nerves and this can explain the reluctant attitude of many physicians towards the surgical treatment of these patients. Among the several factors advocated to explain the poor outcome following surgery, it has been suggested that reinnervation might be obstacled by the force imbalance between the functioning flexors and the paralysed extensors that eventually results in the fixed equinism of the foot, due to the excessive contracture of the active muscles and the shortening of the heel cord. Therefore the early correction of these forces might favour nerve regeneration. Following such hypothesis, the authors treat irreversible CPN injuries performing a one-stage procedure of nerve repair and tibialis tendon transfer. We report our experience, describing the indications to surgical treatment, the operative technique and the postoperative clinical outcome correlated with the causative mechanisms of the injuries. METHODS: A 62-patient series controlled over a period of 15 years with a post-traumatic palsy of the CPN is reported. All the patients underwent surgery. In open wounds, when a nerve transection was suspected, surgery was performed at emergency (2 cases). In closed injuries, operative treatment was advised when no spontaneous regeneration occurred 3-4 months after the injury. From 1988 till 1991, 9 patients were elected for surgery : in 6 cases treatment consisted of neuroma resection and nerve repair by means of a graft. In 3 patients it was performed only a CPN decompression at the fibular neck. Since 1991, surgical treatment has always consisted of nerve repair associated with a tendon transfer during the same procedure. Fifty-three patients were elected for surgery. Nerve repair was achieved by direct suture in 1 case and by means of a graft in 46 patients. Decompression of the CPN at the fibular neck was performed in 6 patients where nerve continuity was demonstrated. RESULTS: In the first group of patients, nerve repair outcome was highly disapponting: no recovery in 5 cases, reinnervation occurred in 1 patient only (M1-2). CPN decompression was followed by complete recovery in 2 cases, no improvement was observed in 1 case. Nerve repair associated with tibialis tendon transfer dramatically improved the postoperative outcome: at 2 year follow-up, neural regeneration was demonstrated in 90% of the patients. Surgical outcome depends on the causative mechanisms of the lesion: sharp injuries and severe dislocations of the knee had an excellent recovery, while in crush injuries and gunshot wounds good recovery was less common. CONCLUSION: Surgical treatment of CPN injuries can nowadays be highly rewarding. CPN palsies in open wounds should undergo surgical exploration at emergency. In close injuries with no spontaneous recovery within 4 months after the injury, patients should be advised to seek surgical treatment regardless the causative mechanism of the lesion. According to our experience, the association of a transfer procedure to nerve repair enhances neural regeneration, dramatically improving the surgical outcome of these injuries.     

Civilian gunshot wounds to the brachial plexus

Many gunshot wounds (GSW's) to the brachial plexus do not improve spontaneously with time and are therefore candidates for surgery. Over an 18-year period, 141 patients with GSW's were evaluated, 90 of whom were operated on; 75 of the surgical cases were followed for 2 years or more. Thirty operative patients had initial vascular repair, while eight required thoracotomies. Total plexus palsy was present in 19 of those selected for operation. The average interval between injury and operation was 17 weeks. Six patients required early operation for an expanding aneurysm with progressive neural loss. Persistent complete loss of function in the distribution of one or more elements and/or noncausalgic pain not managed by medications provided the major operative indications. Four patients required sympathectomies for causalgia. Of 166 lesions in continuity believed to be complete, based on clinical examination and electromyography, 48 with preserved intraoperative nerve action potentials (NAP's) were spared resection or were treated with a split repair with excellent eventual results on a weighted grading system. By comparison, only seven of 55 elements believed to have incomplete loss or to be recovering did not have NAP's and required repair. Fifty-three of 98 lesions repaired by grafts and 18 of 26 wounds with suture repair recovered to a Grade 3 level or better. Most elements were in continuity but 14 were found "blown apart" and required repair, usually by grafting. The best outcome was achieved with upper trunk and lateral and posterior cord lesions, but recovery occurred with some C-7 to middle trunk and medial cord to median repairs. Results with lower trunk and most medial cord lesions were poor unless early regeneration was proved by operative NAP's, in which case either neurolysis or split repair could be performed. Surgery is warranted for selected GSW's to the plexus.     

Surgical management and outcome in patients with radial nerve lesions

OBJECT: The goal of this paper was to review surgical management and outcomes in patients treated for radial nerve (RN) lesions at Louisiana State University Health Sciences over a period of 30 years. METHODS: Two hundred sixty patients with RN injuries were evaluated. The most common mechanisms of injuries involving the RN included fracture of the humerus, laceration, blunt contusions, and gunshot wounds. One hundred and eighty patients (69%) underwent surgery. Lesions not in continuity required primary or secondary end-to-end suture repairs or graft repairs. With the use of direct intraoperative nerve action potential recording, RN injuries in which the lesion was in continuity required external or internal neurolysis or resection of the lesion followed by end-to-end suture or graft repair. A minimum of 1.5 years follow-up review was available in 90% of the patients who underwent surgery. Motor function recovery to Grade 3 or better was observed in 10 (91%) of 11 patients who underwent primary suture repair, 25 (83%) of 30 who underwent secondary suture repair, 43 (80%) of 54 who received graft repair, and 63 (98%) of 64 in whom neurolysis was performed. Sixteen (71%) of 21 patients with superficial sensory RN injury achieved satisfactory pain relief after complete resection of a neuroma or neurolysis. CONCLUSIONS: This study clearly demonstrates that excellent functional recovery can be achieved with proper surgical management of RN injuries.     

An analysis of 124 surgically managed brachial artery injuries

BACKGROUND: A 3-year review of surgically managed brachial artery injuries is presented. METHODS: The medical records were analyzed for demographic data, mechanism of injury, associated injuries, treatment, and outcome. RESULTS: There were 113 males and 11 females with a mean age of 28.7 years. The majority of the injuries were caused by stab and gunshot wounds in 57.3% and 29%, respectively. Primary anastomosis was possible in 47 patients, whereas 73 patients required vein interposition grafting. Lower arm fasciotomy was performed in 15 patients (12.1%). Associated injuries included peripheral nerve lesions in 77 (62.1%), nonpaired brachial vein injuries in 17 (13.7%), and concomitant humerus fracture in 12 (9.7%) patients. Thirty-nine patients (31.5%) had remote injuries. CONCLUSIONS: The primary repair of penetrating brachial artery injuries was possible in approximately one third of the patients. Approximately two thirds of the patients had associated nerve lesions. Critical limb ischemia rarely occurred.     

Outcomes of surgery in 1019 brachial plexus lesions treated at Louisiana State University Health Sciences Center

OBJECT: Outcomes of 1019 brachial plexus lesions in patients who underwent surgery at Louisiana State University Health Sciences Center during a 30-year period are reviewed in this paper to provide management guidelines. METHODS: Causes of brachial plexus lesions included 509 stretches/contusions (50%), 161 plexus tumors (16%), 160 thoracic outlet syndromes (TOSs, 16%), 118 gunshot wounds (12%), and 71 lacerations (7%). Many features of clinical presentation, including prior treatment, patient's neurological status, results of electrophysiological studies, intraoperative findings, and postoperative level of function, were studied. The minimum follow-up period was 18 months and the mean follow-up period was 42 months. Repairs were best for injuries located at the C-5, C-6, and C-7 levels, the upper and middle trunk, the lateral cord to the musculocutaneous nerve, and the median and posterior cords to the axillary and radial nerves. Conversely, results were poor for injuries at the C-8 and T-1 levels, and for lower trunk and medial cord lesions, with the exception of injuries of the medial cord to the median nerve. Outcomes were most favorable when patients were carefully evaluated and selected for surgery, although variables such as lesion type, location, and severity, as well as time since injury also affected outcome. This was true also of TOSs and tumors arising from the plexus, especially if they had not been surgically treated previously. CONCLUSIONS: Surgical exploration and repair of brachial plexus lesions is technically feasible and favorable outcomes can be achieved if patients are thoroughly evaluated and appropriately selected.     

Microsurgical reconstruction of the cauda equina after traumatic transecting injury

Introduction

The microsurgical reconstruction of the cauda equina nerve roots (MRCER) after traumatic injury is a highly controversial procedure with very few reports in the literature.

Methods

We report on four patients who had a penetrating traumatic injury in the lumbosacral area and underwent primary MRCER at our institution during the last decade.

Results

All four patients presented complete distal sensory and motor palsy affecting the lower lumbosacral roots. Primary microsuture was feasible in three patients harboring stab wounds, whereas autologous nerve graft interposition was necessary in the patient who had a gunshot wound. At the 5-year follow-up, we observed a marked improvement in motor function in two patients, but no sensory recovery.     

Successful vascular reconstruction. Determinants of disability

Improvements in limb salvage during the last decade are a reflection of advances in angiography, antibiotics and technique. We report a 100 per cent success rate with vascular repair and a 100 per cent disability outcome in extremity injuries. Ten male patients, with a mean age of 27.3 (range 18 to 41) years, sustained trauma to the extremity with vascular injury. The etiology of injury was gunshot wounds (5), blunt trauma (4), and stab wounds (1). Time from injury to vascular repair was a mean of 186 (range 60 to 360) min. Vessels injured included popliteal artery and vein (4), tibial artery and vein (2), subclavian artery and vein (2), and axillary artery (1). Six of the injuries were associated with fracture of the adjacent bone and treated with external skeletal fixation. All patients had an associated nerve injury. Five patients underwent fasciotomy; nine were treated with 500 ml Dextran-40 for 48 hr (each day for 2 days). All patients received cephalosporin antibiotics pre-, intra-, and post-operatively. All patients had successful vascular repair, as identified by Doppler ultrasound (10 patients) and intra-/post-operative arteriography (5 patients). The median follow-up period was 22 (range 18 to 30) months. There were no primary amputations (within 30 days); there were four late amputations (2, no function and foot ulcer; 2, causalgia). The five popliteal/tibial injuries had no dorsiflexion and foot drop, two had no function and leg ulcers; two patients had femoral and sciatic nerve injury at the thigh; and three patients had injuries to the brachial plexus.(ABSTRACT TRUNCATED AT 250 WORDS)     

Primary repair of crush nerve injuries by means of biological tubulization with muscle-vein-combined grafts

Despite extensive research and surgical innovation, the treatment of peripheral nerve injuries remains a complex issue, particularly in nonsharp lesions. The aim of this study was to assess the clinical outcome in a group of 16 patients who underwent, in emergency, a primary repair for crush injury of sensory and mixed nerves of the upper limb with biological tubulization, namely, the muscle-vein-combined graft. The segments involved were sensory digital nerves in eight cases and mixed nerves in another eight cases (four median nerves and four ulnar nerves). The length of nerve defect ranged from 0.5 to 4 cm (mean 1.9 cm). Fifteen of 16 patients showed some degree of functional recovery. Six patients showed diminished light touch (3.61), six had protective sensation (4.31), and three showed loss of protective sensation (4.56) using Semmes-Weinstein monofilament test. All the patients who underwent digital nerve repair had favorable results graded as S4 in one case, S3+ in six cases, and S3 in one case. With respect to mixed nerve repair, we observed two S4, two S3+, two S3, one S2, and one S0 sensory recovery. Less favorable results were observed for motor function with three M4, one M3, two M2, and two M0 recoveries. Altogether, the results of this retrospective study demonstrates that tubulization nerve repair in emergency, in case of short nerve gaps, may restore the continuity of the nerve avoiding secondary nerve grafting. This technique preserves donor nerve and, in case of failure, does not preclude a delayed repair with a nerve graft.     

A prospective, randomized clinical trial of wound debridement versus conservative wound care in soft-tissue injury from civilian gunshot wounds

While clear-cut evidence exists documenting the extensive tissue destruction from blast and cavitation in high-velocity projectile injury and that wounds from projectiles of all velocities can be contaminated by bacteria potentially leading to infection, less is known about the tissue effects of lower-velocity projectile injury from gunshot wounds seen in the civilian sector. Despite this, traditional recommendations have supported debridement, admission, and aggressive wound care in these patients. This study will determine the effect of two methods of wound care on the outcome of soft-tissue gunshot wounds. Patients who had suffered a gunshot wound and were transported to the Trauma Center at the University of Florida Health Science Center postinjury were considered eligible for this study. All patients with torso injury, skeletal injury, neurovascular injury, or vascular proximity were excluded. Patients were then randomized to two treatment regimens based on a previously determined scheme. All wound care, follow-up, and healing evaluations were performed by the same individual. A total of 163 patients met the study criteria and they were randomized to the two treatment regimens: 89 patients, debridement and wound care; 74 patients, wound care alone. Each group was similar in age, sex, time to treatment, and caliber/velocity. Patients available for follow-up were similar in each group. Four patients in the wound-debridement group and two patients in the conservative wound-care group developed superficial infections. All infections responded to prompt local therapy. This study supports the conservative treatment of soft-tissue injury from low-velocity gunshot wounds.     

Peripheral nerve injuries following gunshot fracture of the humerus

Current best evidence supports observation for peripheral nerve palsies following a fracture of the humerus unless associated with an open fracture. However, the indications for nerve exploration with humerus gunshot fractures are unclear. All patients aged 18 to 89 years who were treated for a gunshot fracture of the humerus at an academic trauma center between 2004 and 2008 were retrospectively reviewed. Patient demographics, fracture characteristics, fracture healing, nerve injury, and intraoperative findings were examined. Twelve patients were identified, of which 6 had nerve palsies at presentation. Three patients had an isolated single nerve palsy, and all recovered spontaneously within 90 days with observation. The other 3 patients had a concomitant brachial artery laceration, and all required a secondary nerve procedure, including 1 primary nerve repair for a near complete transection and 2 re-explorations with neurolysis due to lack of spontaneous recovery by 90 days. Nerve palsies are common after gunshot fractures of the humerus, but nerve transections are uncommon. We observed 1 nerve transection in 12 cases. However, in all 3 cases with a brachial artery injury, a nerve injury required surgical intervention. Subsequently, we recommend continued observation of isolated nerve palsies associated with gunshot fractures of the humerus. However, consider early nerve exploration of palsies when associated with a concomitant vascular injury.     

Surgical outcomes of 654 ulnar nerve lesions

OBJECT: In this article the authors present a retrospective analysis of 654 surgical outcomes in patients with ulnar nerve entrapments, injuries, and tumors during a 30-year period. METHODS: Data were gathered between 1968 and 1998 at Louisiana State University Health Sciences Center. Mechanisms of injuries or lesions included 460 entrapments at the elbow level (70%), 76 lacerations (12%), 52 stretches/contusions (8%), 34 fractures/dislocations (5%), 12 gunshot wounds (2%), two injection-induced injuries (0.3%), and 13 nerve sheath tumors (2%). In cases of entrapment, direct operative recordings uniformly demonstrated a slowing of conduction at the elbow, even in cases in which preoperative noninvasive studies had been nondiagnostic. Intraoperative electrical "inching" studies also demonstrated significant conduction abnormalities that lie just proximal to and through the olecranon notch rather than distal, beneath the flexor carpi ulnaris muscle. There were only eight exceptions to this. Lesions not in continuity due to the injury required primary or secondary end-to-end sutures or graft repair. Aided by intraoperative nerve action potential recording, lesions in continuity received either external or internal neurolysis and split repair or resection followed by end-to-end suture or graft repair. Functional recoveries of Grade 3 or better were seen in 81 (92%) of 88 patients who underwent neurolysis, 42 (72%) of 58 patients who received suture repair, and 24 (67%) of 36 patients who received graft repair. Nevertheless, fewer Grade 4 or 5 recoveries were reached than those seen in patients with radial or median nerve injuries. Nerve sheath tumors were resected with preservation of preoperative function in five of seven patients. CONCLUSIONS: Although difficult to obtain, useful functional recovery can be achieved with proper surgical management of ulnar nerve entrapments and injuries.     

Primary epineural repair of the ulnar nerve in children

Transectional nerve injuries are uncommon in children. We report the outcome of 19 children aged < or = 13 years with acute transectional injuries to the ulnar nerves who were treated by primary epineural repair. There were 13 boys and 6 girls with a mean age at the time of injury of 6.7 years (range, 2-12 years). The site of injury was the palm in 4 children, wrist in 10, forearm in 4, and above the elbow in 1. Associated injuries to other structures occurred in 13 children. The mean recovery (Medical Research Council scale) of the first dorsal interosseous muscle was grade 4.0 (range, grade 3-5) and the mean outcome for the abductor digiti minimi was grade 3.9 (range, grade 2-5). The mean static 2-point discrimination was 6 mm (range, 2-20 mm). The mean follow-up period was 50 months (range, 12-103 months). Although proximal injuries (at or above the elbow) had a poorer outcome, satisfactory function of the intrinsic hand muscles still occurred; this finding contrasts to results reported in adults. Similarly, associated injuries to adjacent structures had no impact on ulnar nerve recovery. Primary epineural repair of the acutely transected ulnar nerve leads to a satisfactory recovery in both motor and sensory function in children younger than 13 years.     

Selective non-operative management of solid organ injury following abdominal gunshot wounds

BACKGROUND: The objective of this study was to evaluate the outcome of patients sustaining a torso gunshot wound with documented solid organ injury. Our hypothesis was that the non-operative management of isolated solid organ injuries is a safe management option for a select group of patients. METHODS: A retrospective review of a prospectively collected database was conducted to identify all patients sustaining a torso gunshot resulting in a solid organ injury undergoing non-operative management over a 5-year period (12/1999-01/2005). Patient demographics, injury details, diagnostic imaging, outcome and follow-up were reviewed. RESULTS: Of 644 gunshot wounds to the torso, 144 (22%) underwent non-operative management. Thirteen of these patients (9%) had 16 solid organ injuries (10 liver, 4 kidney and 2 spleen). CT characterisation of the isolated solid organ injury ranged from AAST Grade I-IV. One of 13 patients failed non-operative management and subsequently underwent laparotomy, which was non-therapeutic. Clinical follow-up was available in all patients for an average of 101 days (median 27, range 6-473). The organ salvage rate was 100%. SUMMARY: In select haemodynamically stable patients without peritonitis able to undergo serial clinical examination, solid organ injury is not a contra-indication to non-operative management. In the appropriate setting, non-operative management of solid organ injury after gunshot wounding is associated with a high rate of success and organ salvage.     

Common peroneal nerve injuries

The authors report their experience in the treatment of common peroneal nerve (CPN) injuries using a one-stage procedure of nerve repair and tibialis posterior tendon transfer. A series of 45 patients with traumatic injury and graft repair of the CPN is presented. From 1988 to 1991, the six patients elected for surgery had only nerve repair: five ultimately did not recover, while muscle contraction in the remaining patient was graded M1-2. Since 1991, nerve surgery in our clinic was associated with tendon transfer procedures (39 cases) which were followed by a satisfactory reinnervation rate. Nerve transection and iatrogenic injuries, torsion/dislocation of the knee, complex biosseous fractures of the leg, and gunshot wounds showed excellent to fair results in decreasing order: in nerve sections, muscle recovery scored M3 or M4+ in all the patients, and in nerve ruptures due to severe dislocation of the knee, it was M3 or M4+ in 85% of cases. The association of microsurgical nerve repair and tendon transfer has changed the course of CPN injuries.     

Common peroneal nerve injuries: results with one-stage nerve repair and tendon transfer

The authors report their experience in the treatment of common peroneal nerve (CPN) injuries using a one-stage procedure of nerve repair and tibialis posterior tendon transfer. A series of 45 patients with traumatic injury and graft repair of the CPN is presented. From 1988 to 1991, the six patients elected for surgery had only nerve repair: five ultimately did not recover, while muscle contraction in the remaining patient was graded M1-2. Since 1991, nerve surgery in our clinic was associated with tendon transfer procedures (39 cases) which were followed by a satisfactory reinnervation rate. Nerve transection and iatrogenic injuries, torsion/dislocation of the knee, complex biosseous fractures of the leg, and gunshot wounds showed excellent to fair results in decreasing order: in nerve sections, muscle recovery scored M3 or M4+ in all the patients, and in nerve ruptures due to severe dislocation of the knee, it was M3 or M4+ in 85% of cases. The association of microsurgical nerve repair and tendon transfer has changed the course of CPN injuries.     

Peripheral nerve lesions in hemophilia.

Between 1962 and 1986, eighty-one of the 1351 admissions of patients who had hemophilia to the Nuffield Orthopaedic Centre were for peripheral nerve lesions. Eighty-eight such lesions were identified in fifty-four patients, and thirty-nine of these patients (sixty-one lesions) had adequate follow-up (mean, 8.4 years; range, four months to eighteen years). The femoral nerve was most commonly involved, but involvement of other peripheral nerves also occurred. In thirty (49 per cent) of the sixty-one lesions, the nerve had full motor and sensory recovery; in twenty-one (34 per cent), a residual sensory deficit; and in ten (16 per cent), both a persistent motor and sensory deficit. Patients who had antibodies to factor VIII were significantly less likely to recover full motor or sensory function than were those who did not have such antibodies, and the time to full motor recovery in these patients was significantly longer.     

Brachial plexus injury: a survey of 100 consecutive cases from a single service

OBJECTIVE: We analyzed the epidemiology, preoperative management, operative findings, operative treatment, and postoperative results in a group of 99 patients who sustained 100 injuries to the brachial plexus. METHODS: The charts of 100 consecutive surgical patients with brachial plexus injuries were reviewed. RESULTS: The patient group comprised 80 males and 19 females ranging from 5 to 70 years of age. One male patient had bilateral brachial plexus palsy. Causes of injury were largely sudden displacement of head, neck, and shoulder and included 27 motorcycle accidents. There were 23 open wounds, including 8 gunshot wounds, 6 other penetrating wounds, and 9 wounds caused by operative or iatrogenic trauma. Loss was exhibited at C5-C6 in 19 patients, at C5-C7 in 15 patients, and at C5-T1 in 39 patients, and 8 patients had another spinal root pattern of injury. Nineteen patients had injury at the cord or the cord to nerve level. Associated major trauma was present in 59 patients. Emergency surgery for vessel or nerve repair was necessary in 18 patients. Myelography (n = 57) or magnetic resonance imaging (n = 7) revealed at least one root abnormality in 52 patients. The median interval from trauma to operation was 7 months. Operative exposures used included anterior supraclavicular, infraclavicular, combined supra- and infraclavicular, or a posterior approach in 5, 14, 77, and 4 patients, respectively. The surgical procedures performed included neurolysis alone in 12 patients and nerve grafting, end-to-end anastomosis, and/or neurotization in 81, 5, and 47 patients, respectively. Postoperative follow-up of at least 36 months was conducted in 78% of the patients. Grade 3 recovery according to Louisiana State University Medical Center criteria means contraction of proximal muscles against some resistance and of distal muscles against at least gravity. Among the 18 patients with open wounds, 14 (78%) recovered to a Grade 3 or better level, as did 35 (58%) of 60 patients with stretch injuries. In all cases of C5-C6 stretch injuries repaired by nerve grafting (n = 10), the patients recovered useful arm function. CONCLUSION: Brachial plexus injury represents a severe, difficult-to-handle traumatic event. The incidence of such injuries and the indications for surgery have increased during recent years. Graft repair and neurotization procedures play an important role in the treatment of patients with such injuries.     

Management and outcomes in 318 operative common peroneal nerve lesions at the Louisiana State University Health Sciences Center

OBJECTIVE: This study analyzes 318 operative knee-level common peroneal nerve lesions managed at the Louisiana State University Health Sciences Center between 1967 and 1999. METHODS: Each patient was retrospectively evaluated for injury mechanism, preoperative neurological status, electrophysiological studies, lesion type, and operative technique, i.e., neurolysis, suture, or graft repair. All lesions in continuity had intraoperative nerve action potential recordings. RESULTS: There were 141 stretch/contusions without fracture/dislocations (44%), 39 lacerations (12%), 40 tumors (13%), 30 entrapments (9%), 22 stretch/contusions with fracture/dislocations (7%), 21 compressions (7%), 13 iatrogenic injuries (4%), and 12 gunshot wounds (4%). After neurolysis, 107 (88%) of 121 knee-level common peroneal nerve lesions with recordable intraoperative nerve action potentials recovered useful function. Nineteen patients underwent end-to-end suture repair, and 16 (84%) of these achieved good recovery by 24 months. Graft repair was performed in 138 peroneal injuries. Thirty-six patients (26%) had grafts less than 6 cm long, of which 27 (75%) achieved Grade 3 or greater peroneal function. Twenty-four (38%) of 64 patients with 6- to 12-cm grafts, and only 6 (16%) of 38 patients with 13- to 24-cm grafts, attained good peroneal function. Longer grafts correlated with more severe injuries and thus poorer outcomes. Thirty-two (80%) of 40 tumors were resected with preservation of preoperative clinical function. CONCLUSION: Surgical exploration and repair of peroneal nerve lesions achieved good results with timely operations and thorough intraoperative evaluations. Useful function was achieved in 27 (75%) of 36 patients with grafts less than 6 cm in length and in only 88 (44%) of 202 patients with grafts greater than 6 cm in length.     

Comparison of assessment tools to score recovery of function after repair of traumatic lesions of the median nerve.

In this paper the recovery after repair of the median nerve has been used to compare different assessment tools for evaluation of peripheral nerve function: touch (moving 2-point discrimination (2PD); Semmes-Weinstein (SW) monofilament, motor (Medical Research Council (MRC) scale), combined motor and sensory (Dellon modification of the Moberg pick up test; Moberg Recognition test), and pain (visual analogue scale; pinprick-test). The mean (SD) age of our 28 patients was 28 (12) years. The mean (SD) follow-up period was 5 years, 2 months (2 years, 8 months). On the operated side three patients (11%) had a moving 2PD of less than 4 mm. The results of the moving 2PD were compared with those of the SW monofilaments, but with a poor correlation. The MRC score correlated well with opposition movement of the thumb and muscle wasting (p<0.01). We recommend a number of tests to evaluate (the chronological return of) peripheral nerve function.