Wu, Kitty Y.

Background: Electrodiagnostic studies are critical for surgical decision-making in nerve injuries. Surgeons typically rely on the electrodiagnostician’s reports and lack formal training in electrodiagnostic study interpretation. This knowledge gap highlights a need for accessible and effective educational resources for surgeons to improve their understanding of electrodiagnostic studies and enhance patient care. Methods: The educational module consisted of a prelecture knowledge assessment, a 42-minute video lecture on interpreting electrodiagnostic study results, and a postlecture knowledge assessment. Knowledge retention was assessed by means of an additional survey distributed 3 months after module completion. Results: This study, involving 119 participants (79% attending surgeons, 8% fellows, 9% surgical residents, and 2% who described their position as “other”), demonstrated that a 42-minute video-based learning module significantly improved knowledge of electrodiagnostic study interpretation. Median scores increased from 7 to 9 (P < 0.001), with improvement persisting at 3 months (median retention score, 11; P < 0.025). Among surgeons completing the 3-month assessment, 65.5% reported that knowledge gained from the module had changed their clinical practice. Conclusion: This study demonstrates that a concise, video-based learning module can effectively enhance surgeon knowledge of electrodiagnostic study interpretation and may serve as a valuable tool for surgical education and improving patient selection in nerve surgery.

Background: This study aimed to evaluate and compare the outcomes of proximal row carpectomy (PRC) with interposition arthroplasty using dorsal wrist capsule interposition, lateral meniscus allograft, or dermal allograft in patients with lunate facet/capitate degeneration. Methods: Patients who underwent PRC with interposition arthroplasty between 2010 and 2022 at a single institution were identified. Preoperative and postoperative visual analog scale (VAS) pain, functional outcomes, and complications were recorded. Results: Twenty-one patients (11 dorsal capsule, 6 meniscus, 4 dermal matrix) were identified with a mean follow-up of 65.8 months. Postoperative pain and functional outcome scores significantly improved. The mean postoperative Quick Disabilities of the Arm, Shoulder, and Hand score was 20.3. In total, 89.5% of patients returned to work, including 75% of manual laborers. Conclusions: No significant differences were found between dorsal capsular flap versus allograft groups. Proximal row carpectomy with interposition arthroplasty is an effective motion-sparing procedure for patients with proximal capitate and/or lunate fossa arthritis, improving pain and function.

Background: Patients with spastic equinus, equinovarus, and claw toe deformities can experience marked pain and functional limitations in the ability to weight-bear comfortably, ambulate efficiently, or mobilize independently. Seen in 80% of patients with cerebral palsy and 18% of patients with stroke (1, 2), the spastic foot and ankle deformities, and its secondary sequelae of static joint contractures, osseous changes, and chronic pain, are unfortunately common. Methods: Adult and pediatric patients undergoing combined hyperselective and selective partial motor neurectomies for varus or claw toe deformities were reviewed. Patient demographics and complications were recorded. Pre- and postoperative Modified Ashworth Scale scores were compared. Results: Twenty-three patients (16 adults and seven pediatric) met inclusion criteria and were included in analysis. At early 6-month follow-up, the mean preoperative Modified Ashworth Score of 2.8 in adult patients and 3.0 in pediatric patients decreased to 0.6 postoperatively. Complications in three adult patients included one patient with temporary dysesthesias to the plantar foot, one with a popliteal abscess requiring incision and drainage, and one superficial wound dehiscence that was managed conservatively. Conclusions: A combined technique of hyperselective and partial motor neurectomies are effective in decreasing tone in the correction of spastic foot and ankle deformities in both adult and pediatric patients in short-term 6-month follow-up.

AbstractWithin the past decade, there have been multiple innovations in the field of nerve surgery. In this review, we highlight critical changes and innovations that have helped advance the field and present opportunities for further study. This includes the modification and clarification of the classification schema for nerve injuries which informs prognosis and treatment, and a refined understanding and application of electrodiagnostic studies to guide patient selection. We provide indications for operative intervention based on this nerve injury classification and propose strategies best contoured for varying injury presentations at differing time points. Lastly, we discuss new developments in surgical techniques and approaches based on these advancements.

Background: Surgical management of failed metacarpophalangeal (MCP) arthroplasties includes revision arthroplasty and arthrodesis. The purpose of this study was to review the indications and outcomes of arthrodesis as a salvage procedure for failed MCP arthroplasties. Methods: This was a retrospective cohort study of all patients undergoing salvage MCP arthrodesis at a single institution from 1990 to 2020. Patient charts were reviewed for patient demographics, indication for salvage, surgical technique, revision rate, and time to radiographic union. Patient-reported outcomes, including the Michigan Hand Outcomes Questionnaire and an MCP-specific questionnaire detailing pain, functional, appearance, and patient satisfaction, were also collected. Results: Eleven digits in 9 patients (6 women, 3 men, median age of 66) with median 36-month follow-up were included. The majority (91%) of patients also had concomitant soft tissue deformities, including joint contractures, extension lag, and collateral ligament insufficiency. The overall revision rate following arthrodesis was 45% with 3 digits requiring one revision each, and 2 digits undergoing 3 revisions. The overall union rate was 91% with median time to union of 4 months from most recent arthrodesis. Patient-reported outcomes obtained from 4 patients demonstrated improvements in pain and function. Conclusion: Despite a high revision rate of 45%, salvage MCP arthrodesis following arthroplasty has a high eventual union rate of 91% and is associated with improved pain and function based on 4 patients’ experiences. Arthrodesis as a salvage procedure for failed MCP arthroplasties should be considered in patients with persistent joint instability and functionally limiting soft tissue deformities.

Background: Shoulder function after spinal nerve grafting in pan–brachial plexus injuries (pan-BPI) is not well described. The authors evaluated shoulder abduction (ABD) and external rotation (ER) after spinal nerve grafting to the suprascapular nerve, axillary nerve, or posterior division of the upper trunk and determined patient characteristics, injury severity and characteristics, and nerve graft factors that influenced outcomes. Methods: A total of 362 patients undergoing pan-BPI reconstruction and spinal nerve grafting for shoulder reanimation in a single institution between 2001 and 2018 were reviewed. Patient demographics, Injury Severity Score (ISS), graft characteristics, strength, range of motion for shoulder ABD and ER, and patient-reported outcomes were recorded. Patients were divided into 3 groups based on recovery of shoulder function: no return, ABD only, and ABD and ER. Results: A total of 110 patients underwent spinal nerve grafting, with 41 meeting inclusion criteria. Seventeen (41.5%) had no return of shoulder function, 14 (34.1%) had ABD alone, and 10 (24.4%) had ABD and ER. Patients with recovery of both ABD and ER were significantly younger (18.6 ± 5.56 years), had lower body mass index (22.4 ± 4.0), and had a lower ISS (10.5 ± 6.24; P = 0.003). Multivariable analysis found that with increasing age (OR, 0.786; 95% CI, 0.576, 0.941) and ISS (OR, 0.820; 95% CI, 0.606, 0.979), odds for return of ABD and ER decreased significantly. Conclusions: In pan-BPI, 24.4% of patients demonstrated return of both ABD and ER after spinal nerve grafting to suprascapular nerve and either axillary nerve or posterior division of the upper trunk. Age, body mass index, and ISS were associated with poorer recovery of shoulder function. Careful patient selection and consideration of age, body mass index, and ISS may improve outcomes of spinal nerve grafting for shoulder reanimation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Spastic wrist flexion deformities both limit the functional use of the hand for grasp and pinch producing a stigmatizing appearance. Tendon transfers and total wrist arthrodesis are treatment options for this condition depending on the patient’s characteristics, the latter the most commonly used in patients with severe wrist flexion deformities. Tendon transfers alone in this scenario have the tendency for recurrent deformity due to tenorrhaphy failure or soft tissue creep and resultant loss of tension. Total wrist arthrodesis is a more invasive procedure, which can have hardware or fusion problems and that is irreversible. We propose a novel technique that incorporates a distally based wrist extensor tendon slip and suture tape tenodesis to the distal radius. The rationale of this technique is to act as a protective, internal splint to prevent recurrent deformity after primary or revision tendon transfer for moderate to severe spastic flexed wrist deformities, avoiding the need to perform a total wrist arthrodesis.

Abstract Background Hemiarthroplasty may be indicated for patients with distal radioulnar joint (DRUJ) arthritis. Recently, the use of the pyrocarbon metacarpophalangeal implant has been proposed as a novel means of treating DRUJ arthritis due to the materials improved mechanical properties and wear characteristics. Purpose This study compares midterm outcomes of metallic and pyrocarbon hemiarthroplasties for the treatment of symptomatic DRUJ arthritis. Questions of interest included outcomes and complications. Materials and Methods In total, 32 hemiarthroplasties, 10 metallic and 22 pyrocarbon, were performed between 2010 and 2020 by three surgeons at one tertiary medical center. Patients' retrospective outcomes were extracted from the electronic medical record. Results Postoperatively, the metallic implant group (mean follow-up: 38 months) demonstrated decreased pain but no changes in range of motion. Comparatively, the pyrocarbon group experienced an improved range of motion and postoperative pain (p < 0.05). Radiographic analysis demonstrated 10% of metallic implants and 9% of pyrocarbon implants to have resulted in thinning of the lateral cortex of the radius at the final follow-up. Minor complications in metallic and pyrocarbon implant groups warranting reoperation occurred at rates of 10 and 13.5% while implant failure occurred at a rate of 30 and 18%, respectively. Discussion Within this study, pyrocarbon implants resulted in significant functional improvement with comparable complication and failure rates to the metallic implant. Long-term stability demonstrated efficacy for both techniques in symptomatic DRUJ treatment. Type of Study/Level of Evidence Observational Case Series IV.

BACKGROUND Eagle’s syndrome (ES) classically describes dysphagia, globus sensation, and otalgia from an elongated and calcified styloid process or stylohyoid ligament. Compression of the spinal accessory nerve (SAN) has not been reported as an associated feature of ES or related variants. OBSERVATIONS The authors describe two cases of an atypical “winged” variant with SAN palsy resulting from compression by a posteriorly angulated or calcified styloid process. Both patients exhibited lateral scapular winging and atrophy of the trapezius and sternocleidomastoid muscles. Electrophysiological studies demonstrated motor unit preservation; therefore, surgical exploration, styloidectomy, and SAN decompression were performed through a transcervical approach. Postoperatively, both patients had improvements in pain and shoulder mobility, the return of muscle strength, and electrophysiological evidence of trapezius reinnervation. LESSONS Compression of the SAN, which can be identified both clinically and on electrodiagnostic testing, is an atypical finding that can result from a posteriorly angulated or calcified styloid process. This winged variant of ES should be included in the differential for SAN palsy, and a multidisciplinary approach is recommended for assessment and management.

BACKGROUND Adipose lesions of nerve are rare tumors that can cause nerve symptoms from either intrinsic or extrinsic compression. OBSERVATIONS The authors present a case of a patient with a 10-year history of progressive, persistent leg pain and dorsal foot paresthesias/dysesthesias. Imaging revealed several nondistinct nodules of indeterminate significance along the course of the superficial peroneal nerve (SPN). Surgery demonstrated six distinct extraneural lipomas studded on a 10-cm segment of the main SPN and one of its muscular branches in the midleg. The lesions were adherent to the SPN, without an easy dissection plane; therefore, a neurectomy was performed. Histology revealed the nerve was associated with multiple extraneural lipomas with focal evidence of prior trauma. At 4 months postoperatively, the patient’s pain had resolved completely, and she was able to resume normal physical activities. LESSONS The current classification of adipose lesions of nerve includes intraneural and extraneural lipomas and lipomatosis of nerve (fibrolipomatous hamartoma). The unique features of the present case include the discrete and segmental nature of the extraneural lipomas adherent to the nerve. Its etiology is unknown, and the histology would be suggestive of either a traumatic or a degenerative process.