Wu, Kitty Y.

» Thorough patient presurgical counseling should emphasize individual patient goals, which may include improving ambulation, reducing reliance on orthoses, alleviating pain, or facilitating caregiver support. » Careful physical examination is essential to differentiate whether the primary cause of dysfunction is weakness, spasticity, or both. » Diagnostic adjuncts including botulinum toxin, short-acting blocks, instrumented gait analysis, and dynamic electromyography provide valuable insight and guide operative decisions. » Surgical treatment must be individualized, with nerve-based procedures indicated for pure spasticity and tendon lengthening, tenotomy, or joint procedures being required to treat soft tissue and joint contractures.

ABSTRACT Introduction/Aims In severe ulnar neuropathy at the elbow (UNE), occasionally surgeons will employ an end‐to‐side (ETS) nerve transfer of the anterior interosseous nerve (AIN) motor branch of pronator quadratus (PQ) to the ulnar motor component distally (AIN ETS). We used an ultrasound (US)‐guided near‐nerve monopolar needle stimulation of the AIN to determine the specific contribution of the transferred PQ motor branch to the ulnar‐innervated hand intrinsic muscles following AIN ETS in patients with UNE. Methods After inserting the monopolar needle under US guidance, direct stimulation of the AIN was performed while recording from the abductor digiti minimi (ADM), first dorsal interosseous (FDI), and flexor pollicis longus (FPL). The presence or absence of a compound muscle action potential (CMAP) was noted from each muscle. Results The technique was used in two patients with chronic UNE, one with a cubital tunnel decompression and AIN ETS and the other with a decompression alone. In the patient with decompression and AIN ETS, direct stimulation of the AIN revealed a low amplitude CMAP recorded from the FDI and FPL, suggesting AIN axonal contribution to FDI in the setting of prior AIN ETS. In the patient with decompression alone, near‐nerve stimulation generated an expected CMAP in the FPL but no response in the hand intrinsics. Discussion This study may demonstrate the utility of US‐guided near‐nerve monopolar needle AIN stimulation and suggests that it is a reliable technique to isolate the AIN contribution to hand intrinsic reinnervation following AIN ETS.

ABSTRACT Introduction/Aims Ultrasound (US) guidance may ensure proper needle placement during electromyography (EMG) when assessing for suitable donor muscles for upper limb reconstruction. A distinct intermuscular fascial border aids in delineating the separation between the brachioradialis (BR) and extensor carpi radialis longus (ECRL) muscles. However, this border may be absent, making correct needle placement complex and assessment more difficult. The purpose of this study was to describe the presence and absence of this fascial border in healthy individuals to help with accurate EMG needle placement. Methods Twenty healthy patients underwent sonographic examination by a single sonographer physician of the ECRL and BR to identify the presence or absence of the intermuscular fascial border. Results The fascial border that routinely separates the ECRL and BR was absent in at least one arm in 20% of subjects (12.5% of upper limbs). One subject had an absent fascial border in both upper limbs. Discussion US can assess for the presence or absence of intermuscular fascial borders. This assessment is important for accurate EMG needle placement and localization. While the clinical significance of an absent ECRL‐BR fascial border is currently unknown, future studies should examine the effect of absent ECRL‐BR fascial borders on wrist extension.

Purpose Lower extremity spasticity can cause pain and limit function. This study examined the safety and efficacy of hyperselective neurectomy (HSN) of the gastrocnemius-soleus complex (GSC) in addressing spastic equinus deformities in pediatric patients. Methods Pediatric patients that underwent HSN of the GSC by a single surgeon were retrospectively reviewed. Preoperative and postoperative Modified Ashworth Score and passive ankle dorsiflexion (°) were compared using Wilcoxon signed-rank test and Student's paired two-tailed t-test, respectively. Results Ten lower extremities in seven patients with a mean age of 10 years were reviewed. Mean follow-up was 15 months. All extremities demonstrated improvement in spasticity. All exhibited improved passive ankle dorsiflexion range of motion with the knee in extension (mean change +17°, SD = 8°, p = 0.000). Five patients demonstrated improved passive dorsiflexion with the knee in flexion while two remained unchanged from preoperative assessment (mean change +13°, SD = 9°, p = 0.002). One complication, wound dehiscence, was noted and managed conservatively. No patients reported loss of strength or sensation. Four patients underwent subsequent staged surgery on the ipsilateral extremity for concomitant contractures. Conclusion HSN of the GSC is safe in pediatric patients and effectively reduces spastic equinus deformity and improves ankle passive dorsiflexion in short-term follow-up.

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.