Sciatic nerve palsy following total hip arthroplasty (THA) is a relatively rare yet potentially devastating complication. The purpose of this case series was to report the results of patients with a sciatic nerve palsy who presented between 2000 and 2010, following primary and revision THA and were treated with neurolysis. A retrospective review was made of 12 patients (eight women and four men), with sciatic nerve palsy following THA. The mean age of the patients was 62.7 years (50 to 72; standard deviation 6.9). They underwent interfascicular neurolysis for sciatic nerve palsy, after failing a trial of non-operative treatment for a minimum of six months. Following surgery, a statistically and clinically significant improvement in motor function was seen in all patients. The mean peroneal nerve score function improved from 0.42 (0 to 3) to 3 (1 to 5) (p < 0.001). The mean tibial nerve motor function score improved from 1.75 (1 to 4) to 3.92 (3 to 5) (p = 0.02).The mean improvement in sensory function was a clinically negligible 1 out of 5 in all patients. In total, 11 patients reported improvement in their pain following surgery.

We conclude that neurolysis of the sciatic nerve has a favourable prognosis in patients with a sciatic nerve palsy following THA. Our findings suggest that surgery should not be delayed for > 12 months following injury.

Cite this article: Bone Joint J 2015;97-B:1345–9

Ulnar neuropathy presents as a complication in 5% to 10% of total elbow replacements, but subsequent ulnar neurolysis is rarely performed. Little information is available on the surgical management of persistent ulnar neuropathy after elbow replacement. We describe our experience with the surgical management of this problem.

Of 1607 total elbow replacements performed at our institution between January 1969 and December 2004, eight patients (0.5%) had a further operation for persistent or progressive ulnar neuropathy. At a mean follow-up of 9.2 years (3.1 to 21.7) six were clinically improved and satisfied with their outcome, although, only four had complete recovery. When transposition was performed on a previously untransposed nerve the rate of recovery was 75%, but this was reduced to 25% if the nerve had been transposed at the time of the replacement.

We studied 21 patients with a spontaneous palsy of the anterior interosseous nerve. There were 11 men and 10 women with a mean age at onset of 39 years (17 to 65).

Pain around the elbow or another region (forearm, shoulder, upper arm, systemic arthralgia) was present in 17 patients and typically lasted for two to three weeks. It had settled within six weeks in every case. In ten cases the palsy developed as the pain settled. A complete palsy of flexor pollicis longus and flexor digitorum profundus to the index finger was seen in 13 cases and an isolated palsy of flexor pollicis longus in five. All patients were treated without operation. The mean time to initial muscle contraction was nine months (2 to 18) in palsy of the flexor digitorum profundus to the index finger, and ten months (1 to 24) for a complete palsy of flexor pollicis longus. An improvement in muscle strength to British Medical Research Council grade 4 or better was seen in all 15 patients with a complete palsy of the flexor digitorum profundus and in 16 of 18 with a complete palsy of flexor pollicis longus.

There was no significant correlation between the duration of pain and either the time to initial muscle contraction or final muscle strength. Prolonged pain was not always associated with a poor outcome but the age of the patient when the palsy developed was strongly correlated. Recovery occurred within 12 months in patients under the age of 40 years who achieved a final British Medical Research Council grade of 4 or better. Surgical decompression does not appear to be indicated for young patients with this condition.

Thirty-two operations on the common peroneal nerve for leprous neuritis are reported. A combined medical and surgical approach to treatment is recommended, and the technique of operation is described. Recovery of motor power was satisfactory but depended on many factors, including the duration of the neuritis, the extent of the compression, the immunopathological status of the patient and the efficacy of medical treatment. The main indication for neurolysis is hyperalgesic neuritis. The only contraindication is painless long-standing paralysis; in this condition the degree of neural fibrosis prevents any hope of improvement.

Purpose: Serratus anterior palsy is usually part of a Parsonnage and Turner syndrome. When occurring alone, it may be secondary to compression of the long thoracic nerve. The anatomic point of contact has been described at the level of the second rib. We report our experience with a musculofascial serratus anterior flap showing that the crossing point of the long thoracic nerve and the thoracic branch of the thoracodorsal artery, the serratus anterior fascia could also be a potential point of compression.

Material and method: We cared for two patients with complete and isolated palsy of the serratus anterior. In the first patient, the paralysis developed over one year and in the second had started three months before treatment. In both patients, the preoperative electromyogram showed an absence of serratus anterior activity. We therefore performed exoneurolysis of the long thoracic nerve in both cases. At surgery, the nerve was clearly compressed at the point where the long thoracic nerve crossed the thoracic branch of the thoracodorsal artery.

Results: The first patient recovered normal muscle activity one year after surgery. Complete recovery was achieved in the second patient at three months.

Discussion: These two cases would support the hypothesis that the long thoracic nerve can become compressed within the serratus anterior fascia. In all cases with serratus anterior palsy secondary to suspected mechanical compression, we propose exoneurolysis of the long thoracic nerve.

The purpose of this study was to establish whether exploration and neurolysis is an effective method of treating neuropathic pain in patients with a sciatic nerve palsy after total hip replacement (THR). A total of 56 patients who had undergone this surgery at our hospital between September 1999 and September 2010 were retrospectively identified. There were 42 women and 14 men with a mean age at exploration of 61.2 years (28 to 80). The sciatic nerve palsy had been sustained by 46 of the patients during a primary THR, five during a revision THR and five patients during hip resurfacing. The mean pre-operative visual analogue scale (VAS) pain score was 7.59 (2 to 10), the mean post-operative VAS was 3.77 (0 to 10), with a resulting mean improvement of 3.82 (0 to 10). The pre- and post-neurolysis VAS scores were significantly different (p < 0.001). Based on the findings of our study, we recommend this form of surgery over conservative management in patients with neuropathic pain associated with a sciatic nerve palsy after THR.

Cite this article: Bone Joint J 2013;95-B:20–2.

We investigated the predictive value of intra-operative neurophysiological investigations in obstetric brachial plexus injuries. Between January 2005 and June 2011 a total of 32 infants of 206 referred to our unit underwent exploration of the plexus, including neurolysis. The findings from intra-operative electromyography, sensory evoked potentials across the lesion and gross muscular response to stimulation were evaluated. A total of 22 infants underwent neurolysis alone and ten had microsurgical reconstruction. Of the former, one was lost to follow-up, one had glenoplasty and three had subsequent nerve reconstructions. Of the remaining 17 infants with neurolysis, 13 (76%) achieved a modified Mallet score > 13 at a mean age of 3.5 years (0.75 to 6.25). Subluxation or dislocation of the shoulder is a major confounding factor. The positive predictive value and sensitivity of the intra-operative EMG for C5 were 100% and 85.7%, respectively, in infants without concurrent shoulder pathology. The positive and negative predictive values, sensitivity and specificity of the three investigations combined were 77%, 100%, 100% and 57%, respectively.

In all, 20 infants underwent neurolysis alone for C6 and three had reconstruction. All of the former and one of the latter achieved biceps function of Raimondi grade 5. The positive and negative predictive values, sensitivity and specificity of electromyography for C6 were 65%, 71%, 87% and 42%, respectively.

Our method is effective in evaluating the prognosis of C5 lesion. Neurolysis is preferred for C6 lesions.

Cite this article: Bone Joint J 2013;95-B:699–705.

Introduction and purpose: The most frequent neurological complication of humeral fractures is radial nerve palsy. Most patients with humeral fractures and radial nerve palsy recover with conservative treatment. But a small percentage of patients require surgical treatment; these are patients who show no clinical improvement of their nerve lesion after 3 months of conservative treatment, those with an open fracture, an associated vascular lesion, secondary radial palsy or patients who require open fracture osteosynthesis. The aim of this study is to assess and analyze humeral fractures with radial palsy that have required surgical treatment. Materials and methods: A prospective pre and postoperative study with a protocol was carried out between 1999 and 2007 in which 28 patients with humeral fractures and radial palsy required surgical treatment. Of the patients studied 10 were women and 18 were men. Their ages varied from 18 to 74 years of age. As to the type of radial palsy, it was primary in 11 patients, secondary in 2 patients (included in the fracture callus) and postoperative in 15. Neurolysis was performed in 20 patients and fascicular grafts were used in 8. Results: Time to fracture healing was 14.2 + 5.6 weeks. The period of radial nerve recovery was 7.2 + 5.7 months. Neurolysis was performed in 20 patients and fascicular grafts in 8. There were 20 complete recoveries, 4 incomplete but useful, in 4 cases there was no recovery and palliative surgery was subsequently performed. Conclusions: Surgical treatment of humeral fractures with radial palsy is indicated in patients who show no clinical improvement of their nerve lesion after 3 months of conservative treatment, those with an open fracture, an associated vascular lesion, secondary radial paralysis or in patients who require an open fracture osteosynthesis. Functional recovery rates are high if surgery is carried out during the appropriate period of time. Treatment is neurolysis or fascicular grafts. Palliative surgery is reserved for cases in which complete recovery is not achieved

Purpose: Meralgia paraesthetica is usually caused by entrapment of the lateral femoral cutaneous nerve (LFCN) at the inguinal ligament. We present our experience with 114 patients who underwent surgical management for meralgia paraesthetica. Material: We reviewed 114 patients (48 men, 66 women, five bilateral cases) who underwent surgery for meralgia paraesthetica between 1987 and 1999; local anaesthesia was used for neurolysis in most cases. We identified five aetiologies: idiopathic (n=69, three bilateral), abdominal surgery (n=19), iliac graft harvesting (n=12, one bilateral), hip surgery (n=7), trauma (n=7, one bilateral). Methods: We analysed outcome at more than two years follow-up for the entire series and by aetiology using a standard 12-point evaluation scale accounting for residual pain, sensorial disorders, and patient satisfaction. Results: The overall results were good, mean score 9/12 (range 1–12). Ninety-two patients were very satisfied or satisfied. Among the 27 patients who were not satisfied, five developed recurrence. Mean time to full pain relief was 70 days (range 1 – 364 days). Recovery of thigh sensitivity was noted at 128 days (range 1 – 364). Discussion: The essential criteria of poor prognosis were duration of the meralgia before surgery and its aetiology. Neurolysis of an LFCN injured by trauma or iliac graft harvesting provided less satisfactory results (scores 7 and 6 respectively) than for idopathic meralgia paraesthetica or abdominal-surgery injury (scores 9 and 10 respectively). Eight of the neurolysis procedures in this series did not provide satisfactory results (score 5). Conclusion: Neurolysis appears to be the surgical treatment of choice for mearlgia paraesthetica. In skilled hands, neurolysis can be performed under local anaesthesia, although certain difficulties can be encountered: obesity, modified anatomy due to prior operations, nerve variability (frequent). Knowledge of these different elements is essential not only to achieve neurolysis but also prevent iatrogenic injury

The anatomical integrity of the epi- and para-nevrium is the most relevant factor for the correct gliding of the median nerve, and when they are surrounded by scar tissue, the result is a chronic neuropathy. This recurrent compressive neuropathy represents a very challenging clinical and surgical problem. Neurolysis can not always improve the recovery of nerve function, and the soft tissue coverage is necessary to prevent recurrent scar and to achieve a useful mobilization of the median nerve. The autogenous vein graft wrapping technique has shown great promise for the treatment of chronic compressive neuropathy after other procedures have failed. The author present their experience using the Basilic vein grafting as a valid alternative to the Saphenous one. All our patients presented symptoms in the median nerve distribution, including pain, swelling and numbness, and grip strength reduction. Four of these patients presented a CRPS and have been evaluated before treatment in a multidisciplinary dedicated equipe to plan the surgical procedure. The vein graft wrapping represents a simple technique without problem in donor area. In the authors’ casuistry it presented also as a very useful technique in the treatment of median neuropathy in CRPS

Hamstring muscle strain is a common sports related injury. It has been reported in a variety of sports, following acceleration or deceleration while running or jumping. Injury may vary from simple muscle strains to partial or complete rupture of the hamstring origin. Avulsion fracture of the ischial tuberosity has also been described. Simple hamstring muscle strains are treated conservatively. Surgical exploration and repair is currently advocated for partial or complete rupture of the hamstring origin. A few case series exists in literature suggesting the benefits of early intervention. We report a series of 8 athletes who presented between 2002 and 2006 with complete tear of their hamstring origin. Avulsion of the ischial tuberosity was excluded in these cases. After confirming the diagnosis, early surgical exploration and repair or reattachment was performed. The patients were braced for 8 weeks. This was followed by specialist physiotherapy and a supervised rehabilitation programme over 6 months. All patients were followed up to monitor return to normal activities and sports. The sciatic nerve was scarred to the avulsed tendon in three cases. Neurolysis led to a rapid relief of symptoms. Cases where the hamstring origin had retracted more than 3 cm required a figure 7 incision. There were no major complications including nerve palsies. An excellent functional outcome was noted by 12 months in all 8 patients. 7 of them returned to their previous level within 6-9 months of injury. One person despite a very good recovery, opted out of sports. No other complications were seen as a result of the surgical procedure. In conclusion, a tear of the origin of hamstring muscles is a significant injury. Early surgical repair and physiotherapy is associated with a good outcome and enables an early return to high level sports

We studied a consecutive series of 58 patients with penetrating missile injuries of the brachial plexus to establish the indications for exploration and review the results of operation. At a mean of 17 weeks after the initial injury, 51 patients were operated on for known or suspected vascular injury (16), severe persistent pain (35) or complete loss of function in the distribution of one or more elements of the brachial plexus (51). Repair of the nerve and vascular lesions abolished, or significantly relieved, severe pain in 33 patients (94%). Of the 36 patients who underwent nerve graft of one or more elements of the plexus, good or useful results were obtained in 26 (72%). Poor results were observed after repairs of the medial cord and ulnar nerve, and in patients with associated injury of the spinal cord. Neurolysis of lesions in continuity produced good or useful results in 21 of 23 patients (91%). We consider that a vigorous approach is justified in the treatment of penetrating missile injury of the brachial plexus. Primary intervention is mandatory when there is evidence of a vascular lesion. Worthwhile results can be achieved with early secondary intervention in patients with debilitating pain, failure to progress and progression of the lesion while under observation. There is cause for optimism in nerve repair, particularly of the roots C5, C6 and C7 and of the lateral and posterior cords, but the prognosis for complete lesions of the plexus associated with damage to the cervical spinal cord is particularly poor

Aim: To present and analysis the neurological complications after ORIF with plates of bicondylar fractures of the humerus. Material and Methods: For the period 1996 – 2003 77 bicondylar fractures were operated with plates. All of them were followed up. 36 Man and 41 women. Dominant hand was affected in 43 patients. The AO types were C1- 25, C2 – 28, C3 – 24. There were 18 open fractures (I–II degree). High-energy trauma caused 19 fractures. 14 were with associated ipsilateral fractures of the upper limb. All patients were operated by the standard AO technique. In all patients the ulnar nerve was identified. There was no case where the radial nerve was exposed. In 36 patients the nerve was transposed anteriorly subcutaneosly and for the rest it was not. Results: We observed 20 postoperative ulnar and radial nerve disfunctions (19 ulnar nerve and 1 radial nerve disfunctions). Electromiography was performed in all cases. 7 of 36 (with transposition) cases finished with temporary ulnar nerve palsy. 3 of 41 (without transposition) cases finished with permanent ulnar nerve palsy and the other 9 of 41 finished with temporary disfunction. The disfunction of the radial nerve was temporary. The temporary neurological disfunctions recovered completely for 3–7 months. Neurolysis and anterior transposition of the ulnar nerve was performed in the cases with permanent ulnar nerve palsy. Conclusions: We suggest that ulnar nerve transposition is a method of choice in operative treatment of bicondylar fractures of the humerus. Careful management of the ulnar nerve is mandatory. Meticulous soft-tissue dissection and hemostasis help to prevent perineural fibrosis

Purpose of the study: Surgical management of neurological injury encountered in patients with a ruptured pelvic girdle remains exceptional. In this work, we present our experience and compare our results with data in the literature. Material and methods: This retrospective analysis concerned four clinical css. Mean patient age was 20.2 years for two men and two women. All patients were victims of high-energy trauma and presented type C (Tile) pelvic girdle injury. All presented a paralysis of the lumbosacral plexus. One patient presented bilateral paralysis of the pudendal plexus. The work-up included: saccora-diculography, myeloscan, lumbar magnetic resonance imaging. One patient presented a pseudomeingocele. Results: Surgical exploration was performed within a mean delay of 3.75 months. Two types of exploration were used: for two patients the transperitoneal approach was used because of a suspected lesion of the lumbosacral trunk and for two others, the trans-sacral approach because of suspected intra-spinal rupture. Neurolysis was performed for three patients and an caudia equina nerve graft for one. Nervous injuries involved section or rupture of the roots. There were no cases of medullary avulsion. All patients presented signs of nerve regeneration at last follow-up (mean 5.5 years). Discussion: Even though injury to the lumbosacral plexus is exceptional, advances in surgical techniques offer therapeutic options adapted to each type of injury and nerve territory. One or more motor functions can be restored. Microsurgical nervous repair of the lumbo-sacral plexus is possible irrespective of the level of the injury. Nerve repair by grafting or neurotization can be achieved via a combination of trans-sacral and anterior retroperitoneal approaches or even a transabdominal approach

Purpose of the study: Neurolysis is required for the treatment of non-regressive posttraumatic or spontaneous palsy of the anterior interosseous nerve. This technique is difficult because of the anatomic variability of the nerve and the neighbouring structures. The purpose of this study was to determine the imperative elements for neurolysis by analysing the anatomic relations of the anterior interosseous nerve and identifying the potentially compressive musculo-aponeurotic and vascular structures. Material and methods: Twelve fresh anatomic specimens were dissected unilateral; the subjects (six male, six female) were aged 82.6 years on average at death. Emergences of the anterior interosseous nerve and its division branches were studied. The relations with the following structures and their anatomic variations were analysed: the lacertus fibrosus, the fibrous arcades of the pronator teres, and the flexor digitorum superficialis, the accessory head (if present) of the flexor pollicis longus (Gantzer muscle) and the vascular structures in close contact with the nerve. The topographic landmarks were noted in relation to the bi-epicondylar line. Results: Emergence of the anterior interosseous nerve was situated, on average 54.5 mm below the bi-epicondylar line, on the posterior (n=9) or ulnar (n=3) aspect of the median nerve. The relative situations of its division branches were variable. A fibrous arcade was found between the lacertus fibrosus and the pronator teres in two specimens. Nine specimens had two arcades at the pronator teres and the flexor digitalis superficialis, but three specimens only had one. The presence of an accessory head within the flexor digitalis superficialis was a configuration with risk of nerve compression. The Gantzer muscle was present in six specimens and crossed the nerve superficially. Two types of potentially compressive vascular arcades were found in eight specimens. Discussion: Sites of compression of the anterior interosseous nerve were found a various positions and in variable numbers in the different anatomic specimens. The presence of several sites of compression in the same individual could explain why the electromyogram fails to identify the level of the nerve compression in certain cases, leading to the standardised neurolysis technique recalled here. Conclusion: This study demonstrates that several sites of potential compression of the anterior interosseous nerve can coexist in the same patient. The surgeon should be perfectly aware of these “at risk” sites when performing neurolysis

Aims

Acetabular fractures are associated with long-term morbidity. Our prospective cohort study sought to understand the recovery trajectory of this injury over five years.

Purpose: This retrospective analysis was designed to determine the contribution of arthroscopy in the management of moderately stiff elbows arising from degenerative disease or trauma. Material and methods: Between 1992 and 2001, we performed 31 arthroscopic examinations of the elbow in patients with moderately stiff elbows. Mean preoperative motion was 94.8°. Men age at surgery was 41.6 years; there were nine women and 22 men. The dominant side was involved in 70% of the cases. Twentyfive patients were available for clinical review at a mean 32 months follow-up (range 5 months to 9 years). The causal event was trauma in 13 cases. The stiff elbow was a consequence of degenerative disease in 13 cases with no notion of trauma. Three elbows had been exposed to repeated microtrauma. For the majority of the cases, the intervention consisted in an anterior time via two portals then a posterior time. In five cases, anterior capsulotomy was performed. The other interventions were limited to joint cleaning. For two elbows, we used the Kashiwagi Outerbridge technique. Neurolysis of the ulnar nerve was performed at the elbow level during the same operative time. Results: Elbow motion in flexion was significantly improved after arthroscopy (P=0.01) and the flexion of the stiff elbow was reduced significantly (P=0.0001). At last follow-up none of the patients felt arthroscopy had worsened the elbow condition. The gain in joint motion was 25°. This gain was significantly greater when we performed anterior capsulotomy at the end of the procedure (P< 0.001). In three cases, there was a postoperative loss of motion. We did not have any intra or postoperative complications. Eighty percent of the patients felt arthroscopy had improved their elbow. Discussion: Arthroscopy of the stiff elbow arising from variable causes remains a difficult intervention which in our series provided gain in motion comparable to that reported in other series in the literature. This could be an interesting less invasive alternative to open surgery in the case of moderately stiff elbow

Aims

Brachial plexus injury (BPI) is an often devastating injury that affects patients physically and emotionally. The vast majority of the published literature is based on surgeon-graded assessment of motor outcomes, but the patient experience after BPI is not well understood. Our aim was to better understand overall life satisfaction after BPI, with the goal of identifying areas that can be addressed in future delivery of care.