Citations

Chronic proximal interphalangeal (PIP) joint instability is a rare and difficult problem to treat, with the main options including collateral ligament reconstruction and joint arthrodesis. To date, there are minimal described techniques for collateral ligament reconstruction. We describe a novel technique utilizing a slip of the flexor digitorum superficialis (FDS), harvested through a single minimal incision. This technique can be used for collateral ligament reconstruction with multiple applications, including chronic recurrent PIP joint dislocations and instability during PIP joint arthroplasty.

BACKGROUND Peripheral nerve injuries in the lower extremities impose significant functional and quality-of-life challenges. Loss of plantar flexion is a major deficit. Novel nerve transfers are being introduced to restore function. A novel nerve transfer—partial superficial peroneal to a gastrocnemius branch of the tibial nerve—aimed at restoring plantar flexion is presented in a patient with an incomplete proximal thigh-level sciatic nerve injury. OBSERVATIONS The case of a 27-year-old policeman with a right sciatic nerve injury from a gunshot wound sustained 11 months earlier, characterized by intact dorsiflexion and eversion but with complete loss of plantar flexion and inversion, is presented. The patient underwent a nerve transfer from the superficial peroneal nerve to the lateral gastrocnemius branch of the tibial nerve at 10 months postinjury. At the 2-year follow-up, the patient achieved M4 strength in plantar flexion while maintaining M5 strength in ankle eversion, dorsiflexion, and toe extension, with ongoing signs of reinnervation to the lateral gastrocnemius on electromyography. LESSONS Partial transfer of the superficial peroneal nerve to the lateral gastrocnemius branch of the tibial nerve offers a promising solution for restoring plantar flexion in partial sciatic nerve injuries affecting the tibial division. Tailored distal nerve transfers can enhance recovery, underscoring the importance of surgical innovation in treating complex peripheral nerve injuries. https://thejns.org/doi/10.3171/CASE24888

Background: Early surgical intervention in nerve palsies with a high probability of nerve integrity and natural recovery risks unnecessary surgery. Understanding the variables influencing surgeons to offer surgery might provide insight into variations in surgeon beliefs and guide treatment recommendations. Methods: Sixty-nine surgeons of the Science of Variation Group participated in a survey consisting of 6 traumatic and 3 nontraumatic nerve palsy scenarios. Participants were asked what their preferred treatment was and how likely they were to offer surgery on a scale from 0 to 10. Participants were randomized to choose for themselves (n = 31) or for a patient of their age and sex (n = 38). Results: There was no difference in the overall likelihood of offering surgery or in the types of treatment offered to patients compared with oneself. Surgery was least recommended for idiopathic palsies and most for ulnar (β = 0.91; 95% CI, 0.10 to 1.7; P = 0.027) or radial (β = 0.92; 95% CI, 0.12 to 1.7; P = 0.025) nerve palsy following closed distal radius or humerus fractures. Longer symptom duration increased the likelihood of offering surgery. Conclusions: Surgeons were moderately likely to recommend surgery for nerve palsies, with no variation in opinions regardless of whether they were deciding for themselves or for patients. For specific nerve palsies with a documented benign natural history, this likely represents overtreatment. Future studies can assess whether balancing awareness of a benign natural history with the pressure to act and the sense that recovery is “taking too long” might limit the offer of unnecessary surgery.

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.