Purpose of the study: We compared the reinnervation capacities of two nerve transfers onto the common trunk of the musculocutaneous nerve (MC), several bundles of the ulnar nerve (UN) and three intercostal nerves (IC) in patients with high brachial plexus palsy (C5C6 or C5C6C7).

Material and methods: Prospective consecutive study of two groups: group 1: 24 transfers and two to three UN bundles in 20 patients with C5C6 and four with C5C6C7, mean age at surgery 29.5 years; group 2: 15 neurotisations of the MC by CI in four C5C6 palsies and in 11 CC5C6C7 palsies, mean age at surgery 25.7 years. Mean time from accident to operation was 5.7 months, mean follow-up 29.4 months.

Results: The first contractions of the biceps were perceived clinically at 5.2 months after the surgery in group1 versus 9.9 months for group 2. Four patients in group 1 (17.0%) did not recover active flexion greater than M3 versus four (27%) in group 2. Mean force using the BMRC score was 3.6 in group 1 versus 3.2 in group 2. When elbow flexion was ≥3 (BMRC), force could be measured at 4.5kg in group 1 and 3.0 kg in group 2. For time to management up to seventh month, the two groups were comparable concerning pertinent results, but after that delay, none of the patients in group 2 achieved elbow flexion ≥3 versus 66% in group 1 up to one year. Up to the age of 40 years, results were comparable; no pertinent result was obtained after that age in group 2 versus 66% in group 1. C5C6C7 palsies had less favourable results irrespective of the technique.

Discussion: Our results show the superiority of UN transfer over CI transfer. In patients who undergo surgery before the seventh month, the rate of pertinent outcome was comparable although the flexion force was significantly greater in group 1. After seven months, only UN transfer offers hope of a useful result, up to the twelfth month. Before the age of 25 years, results are comparable, after 40, no pertinent result was observed after CI transfer while useful contraction could be obtained up to 45 years with UN transfer. C5C6C7 forms recover less well irrespective of the technique.

Purpose of the study: The slightest alteration of the antebrachial anatomic configuration, which constitutes a complex and precise biomechanical system, yields a limitation in pronosupination. Unlike the metaphysical region, little is known about rotational malunion involving the radial shaft. Kasten et all demonstrated in 30 cases that a rotational malunion of the radial shaft leads to significant loss in the pronosupination arc. If the proximal and distal radioulnar joints are intact, the interosseous membrane (IOM) probably plays an important role in this limitation.

Material and methods: The purpose of our study was to evaluate the impact of releasing the IOM on the pro-nosupination arc in an experimental model with a rotational malunion of the radial shaft inducing pronation.

Results: The study involved eight cadaver forearms free of all muscle structures and devoid of prior trauma. After stabilizing the elbow at 90°, the upper limb was fixed on a metal frame used as the reference to measure pronosupination. For each specimen, motion was measured initially, after osteotomy of the radius shaft to induce pronation then associated with longitudinal section of the IOM. A midshaft transverse osteotomy induced 78±7 pronation on average and was fixed with a DCP.

Discussion: The mean pronosupination arc was initially 175 in our population (81 pronation, 94 supination). After the creating the rotational malunion, this arc decreased significantly to 126 (SD. p> 0.05) (99 pronation, 27 supination). Release of the IOM increased this arc significantly from 27 to 153 (SD, p> 0.05) (105 pronation, 48supination)

Conclusion: Our study confirms the impact of rotational malunion on the pronosupination arc and shows the positive effect of releasing the IOM. Suppression of the IOM leads to a simpler biomechanics for the antebrachial system, allowing greater mobility of the bone one over the other. There are several clinical applications of this observation for the correction of shaft malunion of the antebrachial bones, but also certain corrective osteotomies for malpositions in the neurological patient.

Purpose of the study: Construction of a key grip is the final objective of programmed functional surgery of the upper limb in the tetraplegic. Three phases are necessary: activation of the grip, simplification of the poly-articular chain, and positioning the thumb column. For this operative phase, two techniques can be used, either fusion of the articulation with a trapezometacarpal arthrodesis (TMA) or a soft tissue procedure (tenodesis of the abductor pollicis longus). Our study compared analytically these two techniques, considering grip force and stability and the quality of the key grip opening.

Material and methods: This was a retrospective study of 38 key grips with a mean follow-up of 7.4 years in a population of tetraplegic patients (groups 1 – 5 in the International Classification of Giens. Seventeen active key grips including 11 with TMA and 21 passive key grips including 16 without TMA with regulation of the thumb position by soft tissue procedures. The active and passive grips according to the procedures were comparable statistically for their median ASIA motor scores.

Results: The force of the active key grips with TMA (mean 2.7± 1.3 kg) was significantly greater than that obtained after tenodesis (1.3±0.7 kg) (p=0.05). For passive key grips, the difference was not significant, 1.1±0.6 kg with TMA versus 1.0±0.9 kg without. Twenty-three percent of the grips were unstable after TMA versus 24% after tenodesis. Regarding grip opening, the mean distance between the pulp of the thumb and the index was 3.7 cm for active key grips after TMA by tenodesis effect and 5.4 cm for holding large objects while without TMA these values were 3.2 cm and 6.4 cm respectively. For passive grips, these same values were 2.2 and 3.4 cm after TMA versus 2.4 and 6.8 after tenodesis.

Discussion: For the active key grip, TMA enables a stronger grip but with loss of opening distance for large objects. Conversely, for the passive key grip, TMA does not enable a stronger grip but significantly limits passive opening. Globally TMA yields a more constant result. In patients with a limited motor potential, it is important to favour the creation of two different grips.

Purpose of the study: There is no satisfactory surgical solution for symptomatic osteoarthritis of the elbow joint with preserved functional motion if arthroplasty is not indicated (age, functional demand). The same is true for resistant epicondylalgia. The joint denervation techniques applied for the wrist and proximal inter-phalangeal joints have demonstrated their efficacy. We conducted an anatomic study of elbow innervation as a preliminary step to the development of a standardized surgical procedure for complete denervation of the elbow compartment.

Material and methods: The study was conducted on 15 right and left unprepared fresh cadaver specimens. A standardized dissection method was used. The terminal branches of the brachial plexus were dissected proximally to distally under magnification, from the root of the arm to the mid third of the forearm.

Results: Innervation of the medial compartment arose: anteriorly, from one of the two capsuloperiosteal branches arising from the medial nerve; in the epitrochleo-olecraneal gutter, from capsular branches issuing from the trunk of the radial nerve at the root of the arm and running with the ulnar nerve. The innervation of the lateral compartment arose: anteriorly, from an inconstant capsular branch issuing from the musculo-cutaneous nerve arising 4 to 7 cm downstream from the joint space and running between the bones. In the other cases, this zone was innervated by a nerve branch coming from the dorsal cutaneous nerve of the forearm issuing from the radial nerve. This branch innervated the apex of the laeral epicondyle in all cases. The posterior part of the lateral compartment was constantly innervated by a branch arising from the radial nerve in the proximal part of the arm, running between the deep hed of the triceps and the vastus lateralis, giving rise of nerves innervating the joint and terminating in the body of the anconeus muscle.

Discussion: Our study enabled the description of new sources of elbow innervation not reported by Wilhelm.

Conclusion: This systematization study of elbow joint innervation is a preliminary step to the development of a complete procedure for unicompartmental lateral or medial denervation of the elbow joint. The fields of application are the treatment of symptomatic osteoarthritis of the elbow joint in patients with preserved joint motion and resistant epicondylalgia.

Purpose: The approach chosen for total elbow arthrolysis is crucial. It should allow access to all lesions causing joint stiffness yet avoid excessive mutilation. We report our experience with the transhumeral approach respecting the lateral structures.

Material and methods: Thirteen transhumeral elbow arthrolyses were performed from 1996 to 2002 and reviewed retrospectively at mean 18 months (6–63). Mean age at surgery was 44 years. Stiffness resulted from trauma in five patients and degenerative disease in eight. The SOFCOT classification was severe in two, moderate in ten and minimal in one. Arthroysis was performed by the posterior transtricipital technique. After releasing the fossa and the olecranon beak, the coronoid process and the anterior capsule were released using a transhumeral bone window. Two patients also underwent ulnar nerve transposition. Rehabilitation was initiated early and continued for 17 weeks on average.

Results: At last follow-up, active elbow extension improved from −39±9° to 21±9° and flexion from 109±14° to 129±7°, corresponding to an increase in motion of 38±14° (70° preoperatively and 108° postoperatively). This gain in motion was the same in the trauma and degeneration groups. Pain, evaluated with a visual analogue scale from 0 to 10 improved from 3.2±1.3 to 2.4±2.0 for posttraumatic stiffness and from 7.4±1.3 to 4.1±2.0 for degenerative stiffness. There was on postoperative irritation of the ulnar nerve which regressed partially.

Discussion: Transhumeral arthrolysis allows posterior and anterior release while preserving the lateral structures. This technique has been very effective for olecranon bone blockage, posterior and anterior capsule retraction, and for coronoid anterior block. For degenerative elbows, pain relief was achieved in 70%.

Conclusion: Transhumeral elbow arthrolysis initially proposed for the degenerative elbow can be used for posttraumatic stiffness in patients with a moderate form without limiting pronosupination nor injuring the lateral ligaments. The best indication is fracture of the humeral plate.

Purpose: Scapulohumeral arthrodesis is principally indicated for plexus brachial paralysis. It is a controversial indication with limited use for non-neurological conditions. We report a series of shoulder arthrodeses performed for non-neurological conditions searching for the appropriate indications for this procedure.

Material and methods: The series included nine patients, six men and three women, mean age 48 years (23–89). The dominant side was fused in three and the non-dominant in six. Seven patients had had at least one operation prior to arthrodesis. The procedure was performed in one patient to remove a foreign body in a prosthetic cuff tendon, in three for off-centred joint degeneration with massive cuff tears and in two for degenerative disease with multidirectional instability. In all patients except one, the posterior approach was used for internal screw fixation associated with external fixation (left in place for 2.5 months on average).

Results: Subjectively, all patients except one were satisfied with the result (mainly because of pain relief). Objectively, active motion was 65° flexion, 65° abduction, 50° internal rotation (mean fusion position 20° flexion, 25° abduction, and 30° internal rotation). Two groups were identified for assessment with the absolute Constant score. The score improved 16 points (24 to 40) in the group without instability (pain score improved from 3 to 13) and decreased 14 points (66 to 52) in patients with instability (attributed to lesser motion, mean motion scores decreasing from 38 to 14). Complications included one case each of radial palsy, non-union, and gravity oedema of the upper limb.

Discussion: Pain relief and stability are not the sole objectives of shoulder arthrodesis. The procedure can also provide useful improvement in function (hand mouth, hand perineum, thoracobrachial clamp. It can be useful if prosthetic arthroplasty cannot be used (infectious arthritis, advanced osteoarthritis in young subjects and failed stabilisation of multidirectional instability). It is a predictable procedure in terms of outcome. We continue to use scapulohumeral arthrodesis for rare indications.

Purpose: Blast injury of the hand generally occurs during manipulations of unstable explosives. The explosion greatly damages the first commissure. The aim of this study was to define a classification system useful for establishing therapeutic strategy.

Material and methods: From 1988 to 2002, we treated eight patients (nine hands, five dominant) with blast injury of the hand. Mean age was 24 years. Five hands were injured during manipulation of firecrackers and four during manipulation of munitions. The thumb was amputated on five hands, including three cases of index or medius amputation. Thumb revascularisation was successful in only one case. Two proximal thumb amputations were treated by twisted toe transfer. For one of these patients, the transfer was prepared by translocation of M2 on M1 using an inguinal flap. Two patients required a composite osteocutaneous reconstruction of M1 using the index as the bone source. In one final patient, lesions were limited to soft tissues.

Discussion: Blast injured hands present several types of lesions: extensive soft tissue damage, diffuse vessel damage making revascularisation difficult or impossible, combined thenar and joint lesions leading to secondary closure of the first commissure. We distinguished three stages. Stage 1 involves only muscle and skin damage. After opening the first commissure with M1-M2 pinning, cover is achieved with a posterior interosseous flap or a skin graft. Stage 2 involves osteoarticular damage. Bone loss of M1 and P1 is often associated with dislocation. Bone reconstruction is often achieved using the distally amputated or greatly damaged thumb. Stage 3 involves amputation or devascularisation of the thumb. Reconstruction of the thumb is particularly difficult in these cases. If the amputation is distal beyond MP, M1 lengthening or classical toe transfer can be used. If the amputation is proximal, prior M1 reconstruction is required with a skin envelope using M2 fashioned with an interosseous or inguinal flap, followed by twisted toe transfer of the second toe. Stage 3 translocations are difficult because of the often damaged index and scar formation.

Purpose: We analysed outcome in a retrospective consecutive series of 30 Kapandju-Sauvé procedures performed between January 1993 and September 2000 for correction of antebrachial injuries (five patients) and distal radioulnar injuries (25 patients).

Material and methods: All patients (mean age 42 years) were reviewed by the same observer at a mean follow-up of 44 months. Mean time from initial trauma to surgery was 26 months.

Results: For the distal radio-ulnar injuries, the objectives were achieved (158° pronation-supination) with preservation of force (73% of healthy side). The Mayo Clinic functional score, as modified, was 72/100 at last follow-up and 24/25 patients were satisfied. For the ante-brachial injuries, outcome was slightly inferior: 110° pro-nation-supination, force 48% of healthy side, functional score 56/100, three out of five patients very satisfied or satisfied, resumed occupational activity in four out of five patients. There were however no cases with an unstable ulnar stump in this group.

Conclusion: This study confirmed the efficacy of the Kapandji-Sauvé procedure for the treatment of sequelae of distal radio-ulnar injuries, particularly in young patients. The novel indication for antebrachial injuries also provided satisfactory results after a simple procedure compared with shaft osteotomy of the two ante-brachial bones.

Purpose: Operative wounds are commonly washed with a more or less diluted antiseptic solution to prevent infection or to treated overt infection. Chlorhexidine is widely used. We report the cases of nine patients who developed joint destruction attributed to peroperative irrigation with a chlorhexidine solution.

Material and methods: Nine patients (three men and six women) who had undergone surgery in another facility were referred to our unit for unexplained postoperative chondrolysis. The joint localisations were: wrists (n=7) after surgery for a dorsal arthrosynovial cyst (mean age 37 years); elbow (n=1) after surgery for epicondylalgia (age 49 years); shoulder (n=1) after arthroscopy for sub-acromial impingement (age 51 years).

The time between surgery and the first consultation in our unit varied from three to nine years (mean five years four months). Persistent stiffness had been noted in the postoperative period with pain at joint mobilisation which worsened progressively. For the patients with chondrolysis of the wrist: the x-rays demonstrated destruction of the radius-first ray joint in one, the medio-carpal joint in four and overall destruction in two. Overall joint destruction was also observed in the elbow and shoulder patients. Search for other causes of joint destruction was negative; infection and inflammatory rheumatoid disease were ruled out. The common feature identified in all patients was joint irrigation with a chlorhexidine solution (Biseptine®).

Results: Four of the nine patients underwent surgical treatment: a four-bone arthrodesis with scaphoidectomy was used for the three patients with mediocarpal involvement and a shoulder arthrodesis was performed in one patient. The pathology study demonstrated cartilage defects filled with dense strongly hyalinised acellular tissue. Bacteriological specimens were all negative.

Discussion: The chondrolytic effect of chlorhexidine, a member of the biguanide family, was first reported in 1986 with a few cases described with knee involvement. Experimentally, there would be a dose-dependent effect. The mechanism involves a disorganisation of the cell membrane with cartilaginous necrosis and ostocartilaginous resorption. Individual predisposition cannot be ruled out.

Conclusion: In light of these observations, it would be advisable to avoid peroperative joint irrigation with chlorhexidine solution.

Purpose: Prolonged denervation resulting from deferred nerve repair or long distance between the muscle and the repaired nerve, leads to major alterations concerning muscle fibre degeneration and their replacement by fibrous or fatty tissue. These structural modifications of the muscle are unfavourable for reinnervation and consequently affect the final functional outcome after peripheral nerve repair with its corollary of reduced muscle force. The purpose of this work was to assess the potential for regeneration of denervated-reinnervated muscles and their improvement with adjuvant cell therapy using in situ transfer of cultured autologus satellite cells.

Material and methods: This work was conducted with the tibialis anterior muscle in different groups of New Zealand rabbits. The experimental model was a sectioned common fibular nerve and immediate or deferred (two months) microsurgical nerve suture. In vivo functional measurements and histomorphological analyses were performed four months after nerve repair.

Results: Reinervation led to loss of mucle weight and maximal force (Fmax) which were greater with longer deferral of repair. Transfer of satellite cells performed immediately after reinervation did not improve muscle properties. Conversely, transfer of satellite cells two months after nerve suture increased Fmax 25% (p < 0.01) and muscle weight 28% (p = 0.005) in comparison with control muscles undergoing reinervation without cell transfer. Furthermore, the morphology of the muscle was improved as demonstrated by anti-myosine labelling studies.

Discussion: Adjuvant cell therapy allows, in certain conditions, an improvement in functional recovery after peripheral nerve injury. Its clinical application still raises a certain number of ethical issues but taking into consideration data currently available, it would be reasonable to propose this therapeutic approach in humans to reduce involution of the denervated muscle and improve its receptivity for regenerating axons after peripheral nerve repair. Better post-operative results could be expected

Purpose: Until recently, evaluation of surgical treatment for brachial plexus palsy has been purely analytic, not taking into account the patient’s overall functional capacity nor his/her quality of life. The unilateral nature of these palsies and the fact that the limb remains healthy requires a global assessment of outcome. We propose here to associate the classical analytical evaluation with a global quality of life evaluation to determine the beneficial effect of surgical treatment for partial or total brachial plexus palsy.

Material and methods: Forty-four patients, mean age 30 years (17–60) were reviewed with a mean follow-up of 34 months. These patients were divided into two groups: C5–C6 ± C7 palsy (n=18), C5-T1 palsy (n=26). In each group, we recorded a complete muscle analysis, a visual analogue scale test of pain, and results of three quality of life questionnaires (DASH, Abilhand, MOS SF-36). We studied for each group the influence of recovered elbow flexion (biceps ≥ M3+), recovered shoulder function (abduction ≥ M3+), and residual pain on quality of life.

Results: The overall analysis did not demonstrate any difference in quality of life between partial and complete palsy. The three questionnaires were correlated with each other (p< 0.03). Residual pain (visual analogue scale ≥ 4 in 59% of the patients) was correlated with quality of life (p< 0.05) while involvement of the dominant side did not have any influence. In the partial palsy group, recovery of shoulder function (61%, n=11) improved significantly all the quality of life scores (p< 0.01). Conversely, recovery of elbow flexion (72%, n=13) did not improve quality of life in patients with a functional shoulder (p< 0.02). In the group with total palsy, recovery of shoulder function (77%, n=20) appeared to be as least as important as elbow flexion on quality of life (p ≤ 0.05).

Discussion: Unlike generally accepted notions, postoperative assessment of quality of life in these brachial plexus palsy patients demonstrates the importance of shoulder function which appears to be as least as important as recovery of elbow flexion. Furthermore, persistent pain appeared as one of the main negative factors affecting quality of life. Appropriate management is necessary.

Purpose: Reactivation of upper limb function in high-tetraplegia patients requires two successive procedures: restoration of elbow extension, then construction of the key grip. Performing both procedures during the same operative time can reduce the operative time. We compared this combined technique with the classical programme, particular for patients requiring transfer of the brachioradialis to construct the key grip.

Material and methods: The study series included 16 upper limbs in 15 tetraplegic patients. Two distinct operative programmes were used. Group A (nine limbs): transfer of the posterior deltoid to the triceps and active key grip by transfer of the brachioradialis on the flexor pollicis longus. According to the Giens classification there were three group 2, five group 3 and one group 4. Group B (seven limbs): transfer of the biceps on the triceps and passive tenodesis key grip. The Giens classification was five group 2 and two group 3. Five of these limbs exhibited supination attitude of the forearm that was treated initially with isolated osteotomy of the radius. Mean follow-up was ten months. A control group underwent the same surgical programmes but with two distinct operative times.

Results: Mean hospital stay was shortened compared with the control group 4.1±0.8 months versus 10±1.0 months). Elbow extension force according to the BMRC scale was 3.8±0.6 in Group A versus 3.5 for the control group and 3.2±0.5 for Group B compared with 2.8 for the control group. Mean active key grip force was 1.8±0.9 kg for Group A versus 1.9 for controls and 0.9±0.6 kg for the passive key grips in Group B versus 0.9 for controls. Functional independence improved postoperatively, the QIF improved from 40.0±18.0 to 55.2±17.0.

Discussion: This work demonstrated that a single operation shortens hospital stay without affecting the final outcome and that the brachioradial can be transferred on the flexor pollicis longus for reactivation of elbow extension. In our experience, only 46% of the tetraplegic patients starting a functional surgery programme benefit from reactivation of the elbow and hand. Procedures performed during a single operation allow a more systematic approach.

Purpose: Recovery of muscle function after nerve repair remains incomplete despite progress in microsurgical techniques. Potential for muscle recovery could be greatly improved. The purpose of our study was to demonstrate the functional impact of exogenous satellite cells in degenerated muscles.

Material and methods: We used the anterior tibialis muscle (Ta) in rabbits (n=24) as our experimental model. Muscle degeneration was created by bilateral injections of cardio-toxin into the Ta. Five days later, the left Ta was injected with autologous satellite cells (SC) at multiple points. The same volume of culture medium was injected into the right Ta. Two months later, maximal isometric muscle force and stress resistance of the Ta was measured. Histoimmuno-chemical labellings were made.

Results: The volume of cardiotoxin injected created two categories of muscles: recovery of former function was not possible with low dose cardiotoxin injections. Maximal isometric muscle force was less than 35% of the control. Transfer of SC restored nearly normal muscle force. Resistance to stress followed the same pattern. Recovery of maximal muscle force was possible with high-dose cardiotoxin injections. Resistance to stress was greater than the control (+ 35%). Transfer of SC did not modify results.

The weight of the Ta increased for both cardiotoxin doses. There was an increase in the size of the fibres with or without SC transfer.

Discussion: Injection of cardiotoxin induced muscle degeneration. With greater muscle degeneration, regeneration of muscle capacity was greater. Transfer of SC improved the functional result when muscle degeneration was incomplete. Improved resistance to stress after injection of high-dose cardiotoxin could result from changes in muscle myosin and fibrillary structure.

Conclusion: Further studies are needed before clinical application to better understand the underlying mechanisms operating with satellite cell injections. Many applications could be proposed, particularly for surgical nerve repair, ischaemic heart failure, and myopathy.

Purpose: Transfer of the vascularised fibula causes an imbalance in the lower limb due to the small calibre of the bone compared with the recipient bone (femur, tibia). “Femorisation” or “tibialisation” is slow, requiring prolonged protection with an orthesis. The doubled fibula or “shotgun” technique which maintains fibular periosteal vascularisation may overcome this inconvenience.

Material and methods: We report a series of eight free vascular shotgun fibular transfers at a mean four years follow-up (1–11). The recipient site was the lower limb in all patients who had undergone multiple operations, seven for chronic osteitis and one for chondrosarcome (five femoral supracondylar grafts, one knee arthrodesis, two metaphyseal tibial grafts). A cortico-cancellous autologous graft was associated during the same operation for six patients; Osteo-synthesis was achieved in seven cases with an external fixator and in one case with locked centromedullary nailing.

Results: The bone scintigraphy obtained in all cases at the third postoperative day showed intense uptake in the graft in six cases. We had seven cases of osteitis with no case of recurrent sepsis. Mean delay to bone healing assessed radiographically was 5.2 months. Hypertrophy of the fibula was noted at last follow-up in four cases. The external fixator was removed on the average at 6.8 months (5–9). Weight bearing was allowed in all cases with an adjustable protective orthesis. There was one fracture of the graft in a patient with a knee arthordesis which was treated with a corticocancellous autologous bone graft.

Conclusion: This series demonstrates the interest of doubling the free fibular transplant compared with other bone transfers to the lower limbs, improving the balance of the bone calibre and resistance. For patients with loss of supracondylar femoral bone, we describe a widened posterior access allowing the preparation of the recipient site with a single installation for the graft harvesting and fibular transfer.