Pulos, Nicholas

OBJECTIVE Triceps motor branch transfer to the anterior division of the axillary nerve (AXN) was originally described for patients with a loss of deltoid function secondary to upper trunk (UT) brachial plexus injuries but has evolved to restore deltoid function in isolated peripheral AXN injuries. The purpose of this study was to compare functional outcomes in patients who had undergone this procedure in the setting of UT brachial plexus injury versus peripheral AXN injury. METHODS The records of patients who had undergone triceps branch to anterior division of the AXN transfer at a single academic institution between 2001 and 2023 were retrospectively reviewed. Patients were included in the study if they had either a UT or an AXN injury and were excluded if their follow-up was less than 2 years. Pre- and postoperative outcomes, including modified British Medical Research Council grade and range of motion, were compared between the two groups. RESULTS Forty-two patients met the criteria for inclusion. Thirty cases were classified as UT injury and 12 cases as AXN injury. The mean postoperative abduction strength was significantly higher in the AXN injury group (3.2 ± 1.5 vs 1.9 ± 1.2, p = 0.007), as was the postoperative change in abduction strength (2.8 ± 1.7 vs 1.6 ± 1.4, p = 0.01). The mean postoperative forward flexion (136° ± 57° vs 79° ± 54°, p = 0.005) and abduction (129° ± 64° vs 59° ± 47°, p = 0.004) were significantly better in the AXN group, although postoperative changes in flexion and abduction were not different between the groups. Triceps strength preoperatively was similar to that postoperatively in both groups. CONCLUSIONS Patients with an AXN injury, compared to those with a UT injury, had better postoperative abduction strength and shoulder range of motion after triceps branch transfer to the anterior division of the AXN. Triceps strength was not significantly changed after the procedure in the two groups. The study findings suggest that the outcomes of triceps branch transfer to the anterior division of the AXN are different based on the location and type of injury, providing insight into prognosis while counseling patients.

Case: A multicenter series of 3 patients with amyoplasia of the upper extremity were indicated for gracilis free functional muscle transfer (FFMT) to restore elbow flexion and found to have an absent gracilis. A final case is discussed detailing standardized evaluation with ultrasound to confirm gracilis before surgical intervention. Conclusion: In amyoplasia, the gracilis muscle may be absent or have fatty infiltration, making this donor muscle inadequate. Preoperative ultrasound to determine the presence of the gracilis is noninvasive and recommended in patients with amyoplasia of the upper extremity being considered for FFMT.

ABSTRACT Purpose: To determine and evaluate the distal forearm and wrist's cutaneous blood supply and vascular territories. Methods: Four cadaveric upper extremities were injected with a radiopaque, lead-based contrast agent through the brachial artery. After the lead-based contrast agent set, the cadaveric limbs underwent computed tomographic (CT) scanning to assess the perforators to the cutaneous skin of the distal forearm and wrist. High-resolution axial CT and three-dimensional reconstructions were generated to highlight perforating vessels stemming from their parent arteries. Subsequently, anatomic microdissections were performed to identify and trace the perforating vessels identified on CT. Results: CT analysis and anatomic microdissection demonstrated that the dorsal surface of the distal forearm and wrist are supplied by numerous perforators stemming predominantly from the anterior interosseous artery with some anastomotic contribution from the posterior interosseous, radial, and ulnar arteries. Perforators from the radial and ulnar arteries supply the volar surface. There are large anastomotic networks formed between the perforating vessels. Conclusions: The distal forearm and wrist have a robust anastomotic blood supply that has contributions from the anterior interosseous, posterior interosseous, radial, and ulnar arteries. Clinical relevance: The extensive perforator-derived blood supply to the skin likely accounts for the excellent soft tissue healing potential of the wrist following surgery utilizing multiple incisions. Highlights Distal radius fractures may require multiple incisions for anatomic reduction and fixation.Multiple incisions about the wrist are thought to predispose to wound complications and/or skin breakdown.The distal forearm and wrist have a robust anastomotic blood supply from the anterior interosseous, posterior interosseous, radial, and ulnar arteries.Multiple incisions do not necessarily predispose to wound complications given robust anastamosis.

Background: Restoration of hand function after traumatic brachial plexus injury (BPI) remains a formidable challenge. Traditional methods such as nerve or free muscle transfers yield suboptimal results. Advancements in myoelectric prostheses, characterized by novel signal acquisition and improved material technology, show promise in restoring functional grasp. This study evaluated the ability of adults with a BPI injury to control an externally powered prosthetic hand using nonintuitive signals, simulating the restoration of grasp with a myoelectric prosthesis. It also assessed the effectiveness of a comprehensive multidisciplinary evaluation in guiding treatment decisions. Methods: A multidisciplinary brachial plexus team assessed adults with compromised hand function due to BPI. The feasibility of amputation coupled with fitting of a myoelectric prosthesis for grasp reconstruction was evaluated. Participants' ability to control a virtual or model prosthetic hand using surface electromyography (EMG) as well as with contralateral shoulder motion-activated linear transducer signals was tested. The patient’s input and injury type, along with the information from the prosthetic evaluation, were used to determine the reconstructive plan. The study also reviewed the number of participants opting for amputation and a myoelectric prosthetic hand for grasp restoration, and a follow-up survey was conducted to assess the impact of the initial evaluation on decision-making. Results: Of 58 subjects evaluated, 47 (81%) had pan-plexus BPI and 42 (72%) received their initial assessment within 1 year post-injury. Forty-seven patients (81%) could control the virtual or model prosthetic hand using nonintuitive surface EMG signals, and all 58 could control it with contralateral uniscapular motion via a linear transducer and harness. Thirty patients (52%) chose and pursued amputation, and 20 (34%) actively used a myoelectric prosthesis for grasp. The initial evaluation was informative and beneficial for the majority of the patients, especially in demonstrating the functionality of the myoelectric prosthesis. Conclusions: The study indicates that adults with traumatic BPI can effectively operate a virtual or model myoelectric prosthesis using nonintuitive control signals. The simulation and multidisciplinary evaluation influenced informed treatment choices, with a high percentage of patients continuing to use the myoelectric prostheses post-amputation, highlighting its long-term acceptance and viability. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

A total of 26 adolescent patients were treated for scaphoid nonunion with a vascularized bone graft from either the medial femoral condyle or dorsal distal radius. There was an 85% union incidence, improved carpal alignment and a low incidence of complications.

Traumatic adult brachial plexus injuries typically cause immediate loss of upper limb function. Timely multidisciplinary treatment in specialized centres often results in a useful helper arm. Both the patient and the surgical team can benefit from an open discussion to set realistic expectations. Surgical reconstruction is customized for each patient, considering their injury factors and functional objectives. Optimizing pain control, adherence to procedure indications and using meticulous surgical techniques help minimize the risk of failing to meet the patient’s goals. The need for potential alternative treatment(s) if the desired result is not achieved should be detailed before the initial reconstruction. This review discusses late treatment options, including tendon transfers, joint fusions, free functioning muscle transfers and prosthetics, for managing the failed primary reconstruction of the traumatic adult brachial plexus.

Distal radial fractures represent the most common fractures of the upper extremity. Operative treatment is performed for approximately one-third of distal radial fractures in the adult population. Complications following operative treatment of distal radial fractures vary depending on the treatment modality and can be stratified into preoperative and postoperative complications. Complications can occur in the near, intermediate and long term. The most common complications seen are tendon irritation and rupture, chronic regional pain syndrome (CRPS), carpal tunnel syndrome, ulnar or radial neuropathy, compartment syndrome, malunion, inadequate fixation or loss of fixation, symptomatic hardware, post-traumatic arthritis, stiffness and infection. Careful planning, treatment and patient selection can help to mitigate these complications. Level of evidence: V

AbstractModulating the nerve's local microenvironment using exosomes is proposed to enhance nerve regeneration. This study aimed to determine the optimal dose of purified exosome product (PEP) required to exert maximal neurite extension. An in vitro dorsal root ganglion (DRG) neurite outgrowth assay was used to evaluate the effect of treatment with (i) 5% PEP, (ii) 10% PEP, (iii) 15% PEP, or (iv) 20% PEP on neurite extension (N = 9/group), compared to untreated controls. After 72 h, neurite extension was measured to quantify nerve regeneration. Live cell imaging was used to visualize neurite outgrowth during incubation. Treatment with 5% PEP resulted in the longest neurite extension and was superior to the untreated DRG (p = 0.003). Treatment with 10% PEP, 15% PEP, and 20% PEP was found to be comparable to controls (p = 0.12, p = 0.06, and p = 0.41, respectively) and each other. Live cell imaging suggested that PEP migrated towards the DRG neural regeneration site, compared to the persistent homogenous distribution of PEP in culture media alone. 5% PEP was found to be the optimal concentration for nerve regeneration based on this in vitro dose–response analysis.