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Femoral nerve injury is a rare but devastating complication of direct anterior approach total hip arthroplasty that occurs in about 1% of the cases and could potentially lead to debilitating loss of knee extension. In this case report, we present a case of femoral nerve injury following direct anterior approach hip arthroplasty with an inability to extend the affected knee, gait instability, and multiple falls. For this patient, an innovative functional adductor magnus muscle transfer was performed to restore knee extension. At 6 months after surgery, the patient’s knee extension was partly restored, and ambulation was significantly improved.

Global brachial plexus injury (GBPI) mainly affects adults and causes severe life-changing consequences that lead to the deterioration of patients’ quality of life. Several surgical approaches have been described and reported in the literature to improve patients’ functional ability. A literature review is done on PubMed/MEDLINE and Embase using specific keywords to retrieve relevant articles assessing different surgical approaches for GBPI management. Inclusion and exclusion criteria were applied, and eligible articles were included in the review. The literature survey revealed that various surgical options had been used to manage GBPI patients. In this concise review, we discuss and compare the different surgical approaches related to GBPI and its outcome in terms of restoring elbow flexion and extension, shoulder abduction, and wrist and hand function. The primary surgical intervention relies mainly on transferring single or multiple nerves with/without nerve grafts to restore the function of the targeted muscle. Different techniques using a variety of nerve donors and recipients are compared to assess the functional outcomes of each option. Moreover, further options are addressed for delayed GBPI injuries or failed nerve transfer procedures, as in free functional muscle transfer techniques. In addition, information about brachial plexus injury cases faced in our center is presented along with our center’s approach to diagnosing and managing partial and GBPI cases.

Secondary surgical procedures can be used in brachial plexus birth injury to correct shoulder movement imbalances. This study compares outcomes of the two secondary surgical procedure types: humeral osteotomies and soft tissue procedures. Outcome measures assessed included active and passive internal and external rotation, active and passive abduction and adduction, active and passive flexion and extension, percentage of the humeral head anterior to the middle glenoid fossa, glenoid version, and Mallet Score. Nineteen full-text articles were included in the analysis. Humeral osteotomies resulted in a loss of internal rotation postoperatively (−15.94°). Active internal rotation was not evaluated for soft tissue procedures. All other assessed outcomes were improved postoperatively for bony and soft tissue procedures. Bony procedures exhibited a greater degree of active external rotation postoperatively when compared to soft tissue procedures (+67° vs. +40°). Both bony and soft tissue procedures Improve shoulder function in children with neonatal brachial plexus palsy, however, soft tissue procedures showed greater consistency in outcomes.Level of Evidence: IV

Background: To optimize patients' functional external rotation outcomes, reverse total shoulder arthroplasties (rTSAs) including a latissimus dorsi tendon transfer were undertaken with promising early results and no significant increase in complications in comparison to traditional rTSAs. This was especially utilized for patients with a pronounced combined loss of elevation and external rotation. The purpose of this study is to evaluate and synthesize the findings of all relevant publications assessing the outcomes of rTSAs with associated latissimus dorsi transfer. Methods: We thoroughly searched the literature within the PubMed database using a standardized methodology. For our inclusion criteria, we included any study regarding rTSAs that contained functional outcome scores for postoperative range of motion (such as elevation, external rotation, etc.) or postoperative outcomes such as complications (reoperation, infection, etc.) and patient satisfaction. For the extraction of data, we used pilot-tested Google Forms to record extracted data. These data were then converted to spreadsheets (Microsoft Excel [Microsoft, Redmond, WA, USA]). This was done on 2 separate scenarios by 2 authors to ensure accuracy. We used the modified Coleman Methodology Score to assess the methodological quality of the studies in our samples. Meta-analysis mathematics and statistical analysis were performed using Stata software 17 (StataCorp, College Station, TX, USA). Results: Our search returned a total of 12 studies containing data of 213 shoulders receiving RTSAs with a latissimus dorsi transfer. Functional outcomes were available for 160 shoulders. The mean preoperative elevation of the affected shoulder was 73.57 degrees, and the mean postoperative elevation was 141.80 degrees. For external rotation, the mean preoperative average was −6.71 degrees, and the mean postoperative average was 22.73 degrees. The absolute Constant score average was 31.56 preoperatively, while the postoperative value was 68.93. In our sample, 25 patients (11.73%) required a revision of the RTSA implant due to complications. Discussion: Combined loss of elevation and external rotation can be a severely debilitating condition for those with a glenohumeral pathology. Latissimus dorsi transfer for this condition has been proven to be an effective modality. The reoperation and complication rate appears to be sizable, and as such surgeons should consider this when considering this modality for their patients.

Background: After latissimus dorsi transfer (LDT), an increase in scapulothoracic (ST) contribution in thoracohumeral (TH) elevation is observed when compared to the asymptomatic shoulder. It is not known which shoulder muscles contribute to this change in shoulder kinematics, and whether the timing of muscle recruitment has altered after LDT. The aim of the study was to identify which shoulder muscles and what timing of muscle recruitment are responsible for the increased ST contribution and shoulder elevation after LDT for a massive irreparable posterosuperior rotator cuff tear (MIRT). Methods: Thirteen patients with a preoperative pseudoparalysis and MIRT were recruited after LDT with a minimum follow-up of 1 year. Three-dimensional electromagnetic tracking was used to assess maximum active elevation of the shoulder (MAES) in both the LDT and the asymptomatic contralateral shoulder (ACS). Surface electromyography (EMG) tracked activation (% EMG max) and activation timing of the latissimus dorsi (LD), deltoid, teres major, trapezius (upper, middle and lower) and serratus anterior muscles were collected. MAES was studied in forward flexion, scapular abduction and abduction in the coronal plane. Results: In MAES, no difference in thoracohumeral motion was observed between the LDT and ACS, P = .300. However, the glenohumeral motion for MAES was significantly lower in LDT shoulders F(1,12) = 11.230, P = .006. The LD % EMG max did not differ between the LDT and ACS in MAES. A higher % EMG max was found for the deltoid F(1,12) = 17.241, P = .001, and upper trapezius F(1,10) = 13.612, P = .004 in the LDT shoulder during MAES. The middle trapezius only showed a higher significant difference in % EMG max for scapular abduction, P = .020 (LDT, 52.3 ± 19.4; ACS, 38.1 ± 19.7).The % EMG max of the lower trapezius, serratus anterior and teres major did not show any difference in all movement types between the LDT and ACS and no difference in timing of recruitment of all the shoulder muscles was observed. Conclusions: After LDT in patients with a MIRT and preoperative pseudoparalysis, the LD muscle did not alter its % EMG max during MAES when compared to the ACS. The cranial transfer of the LD tendon with its native %EMG max, together with the increased %EMG max of the deltoid, middle and upper trapezius muscles could be responsible for the increased ST contribution. The increased glenohumeral joint reaction force could in turn increase active elevation after LDT in a previous pseudoparalytic shoulder.

Background Restoring elbow function is challenging after late presenting brachial plexus birth injury (BPBI). Free functioning muscle transplantation (FFMT) using the gracilis muscle is a reliable procedure to restore elbow flexion in patients with impaired function after spontaneous recovery or failed surgical reconstruction. Methods A retrospective review was performed on BPBI patients more than 2 years of age who received a FFMT between January 1993 and January 2018, with the aim of improving elbow flexion as the primary or secondary functional goal. Patients with preoperative elbow flexion Medical Research Council (MRC) grades less than 3 with more than or equal to 18 months of follow-up duration were included in the analysis. Patient demographic information and pre/postoperative clinical parameters including elbow flexion MRC scale, passive elbow range of motion, and complications were recorded. Surgical data including donor nerve choice, site of the FFMT tendon attachment, and necessity of concomitant procedures or reoperation were also analyzed. Results Fifty-six FFMTs were performed for the primary (29 patients) or secondary (26 patients) objective of restoring elbow flexion. The mean age at the time of the procedure was 9.6 years (standard deviation [SD] = 6.29, R = 3-35). Mean follow-up was 7.9 years (SD = 5.2). Elbow flexion improved from a median MRC grade 2 to 4 after a FFMT (p < 0.05). Patients who had a FFMT to restore two functions had 86% lower elbow flexion MRC grades than those who had a FFMT to restore flexion only (p < 0.05). Patients less than 12 years old at the time of surgery had more complications, reoperations, and rates of a flexion contracture more than or equal to 30 degrees than those aged more than 12 years (p < 0.05). Conclusion FFMT is a reliable option for upper extremity reanimation. Patients aged less than 12 years old at the time of FFMT had significantly more complications, reoperations, and rates of postoperative elbow flexion contracture more than or equal to 30 degrees, but equivalent elbow flexion MRC grades. Level of Evidence III [ABSTRACT FROM AUTHOR]

Heri Suroto,1– 3 Indrayuni Lukitra Wardhani,4 Ratna Darjanti Haryadi,4 Dina Aprilya,5 Steven Samijo,6 Firman Pribadi1 1Master of Hospital Administration, Universitas Muhammadiyah Yogyakarta, Yogyakarta, Indonesia; 2Department of Orthopedics & Traumatology, Faculty of Medicine, Universitas Airlangga/Dr. Soetomo General Academic Hospital, Surabaya, Indonesia; 3Cell & Tissue Bank Regenerative Medicine, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia; 4Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Universitas Airlangga/Dr. Soetomo General Academic Hospital, Surabaya, Indonesia; 5Orthopedic and Traumatology, Siloam Agora Hospital, Jakarta, Indonesia; 6Orthopedic and Traumatology, Zuyderland Medisch Centrum, Limburg, NetherlandsCorrespondence: Heri Suroto, Department of Orthopedics & Traumatology, Faculty of Medicine, Universitas Airlangga/Dr. Soetomo General Academic Hospital, Surabaya, Indonesia, Tel +6231 5020251, Fax +6131 5022472, Email heri-suroto@fk.unair.ac.id; heri.suroto.psc21@mail.umy.ac.idPurpose: Traumatic brachial plexus injury (TBPI) causes severe disabilities to the patients, affecting not only upper limb function but also the psychosocial and economic aspects. Free functional muscle transfer (FFMT) is one of the reconstruction modalities for the management of TBPI. The aim of this study is to evaluate the functional outcomes and their correlation to patient factors.Patients and Methods: This is a retrospective study of 131 patients who suffered from complete TBPI (C5-T1) and were treated with the FFMT procedure to restore elbow flexion and wrist extension from 2010 to 2018 in our institution. We evaluated the active range of motion (AROM), muscle power with MRC (Medical Research Council) scale, DASH score, and complications, with a minimum of 12-month follow-up.Results: Following FFMT surgery, elbow flexion was significantly and successfully restored (MRC ≥ 3) in 75.5% of patients with an average AROM of 88.17 ± 41.29°. The wrist extension was restored in 42% of the patients with an average AROM of 20.69 ± 18.72°. There was no correlation between age, side of injury, and time to surgery with the functional outcomes. There was a weak correlation between education level, rehabilitation compliance, and elbow functional outcomes.Conclusion: FFMT is a reliable surgical option to restore elbow flexion in TBPI with a high satisfactory result. Our findings suggested that the FFMT indication is potentially expanded regardless of the patient factors.Keywords: brachial plexus neuropathies, FFMT, free tissue flaps, muscle transfer, traumatic brachial plexus injury, peripheral nerve injuries

Limited objective evidence exists on the benefits of functional muscle transfers following quadriceps resection in sarcoma. In particular, no studies have compared patients with functional transfers to those without. In this study, objective and subjective assessments were performed with 3D Gait Analysis, Environmental Simulator, Electromyography (EMG) and Patient-Reported Outcomes. Thirty-four patients at the Scottish Sarcoma Network Glasgow Centre/ Canniesburn Plastic Surgery Unit underwent quadriceps resection for sarcoma between 2009 – 2019, including 24 patients with functional reconstruction and 10 without. Both groups were equivalent for the extent of quadriceps resection (2.58 versus 2.85 components, p=0.47). Primary outcome measure was 3D Gait Analysis and Gait Profile Score (GPS), and secondary outcome was the Toronto Extremity Salvage Score (TESS) score. Ancillary analyses included environmental simulation with the Motek CAREN system and EMG of transferred muscles. Outcomes measures were better in functional reconstruction patients when compared to those without – the GPS score was 8.04 versus 10.2 (p=0.0019), and the TESS score was 81.85 versus 71.17 (p=0.028). Environmental simulator tasks found that functional reconstruction patients could complete activities of daily living including shopping and collision avoidance tasks, without significantly slowing their walking speed. Patients without a functional reconstruction could not complete weighted shopping tasks. EMG showed that transferred hamstrings co-activated with the ipsilateral rectus femoris during the gait cycle. These are the first objective data demonstrating the superiority of muscle transfers for functional restoration in quadriceps resection versus patients without functional transfers. Critically, these also provide answers to patient-oriented questions relating to the recovery of function and activities of daily living. [ABSTRACT FROM AUTHOR]

Aims: The aim of facial reanimation isto restore facial symmetry in spontaneous, mimic, and emotional movements. One of the important reconstructive treatment options in patients with long-term facial paralysis is free muscle transfers. The first stage in two-stage muscle transfers is the cross facial nerve graft (CFNG). In this study, our aim is to investigate the importance of Tinel's sign and EMG in the selection of patients who have had CFNG due to long-term facial paralysis and who can undergo muscle transfer repair and investigate the effectiveness of these methods. Patients and Methods: Ten patients who underwent crossfacial nerve grafting for long-term facial nerve paralysis between 2012 and 2018 were prospectively included in the study. Results: No complications were observed during the operation and follow-up of the patients. The reliability of EMG is lower than the Tinel's sign when making a muscle transfer decision in patients who undergo CFNG. Conclusions: In conclusion, the etiology of facial paralysis (severity of injury in traumatic paralysis), age of patients, comorbid conditions, surgical experience, postoperative physical therapy process and patient compliance play an active role in providing reinnervation.

The aim of this study was to evaluate the thoracohumeral (TH) and glenohumeral (GH) motion with muscle activity after latissimus dorsi transfer (LDT) in a shoulder with a massive irreparable posterosuperior rotator cuff tear (MIRT) and pseudoparalysis compared with the asymptomatic contralateral shoulder (ACS). We recruited and evaluated 13 patients after LDT in a shoulder with preoperative clinical pseudoparalysis and an MIRT on magnetic resonance imaging, with a minimum follow-up period of 1 year, and with a Hamada stage of 3 or less. Three-dimensional electromagnetic tracking was used to assess shoulder active range of motion in both the LDT shoulder and the ACS. The maximal active elevation of the shoulder (MAES) was assessed and consisted of forward flexion, scapular abduction, and abduction in the coronal plane. Maximal active internal rotation and external rotation were assessed separately. Surface electromyography (EMG) was performed to track activation of the latissimus dorsi (LD) and deltoid muscles during shoulder motion. EMG was scaled to its maximal isometric voluntary contraction recorded in specified strength tests. In MAES, TH motion of the LDT shoulder was not significantly different from that of the ACS (F 1,12 = 1.174, P =.300) but the GH contribution was significantly lower in the LDT shoulder for all motions (F 1,12 = 11.230, P =.006). External rotation was significantly greater in the ACS (26° ± 10° in LDT shoulder vs. 42° ± 11° in ACS, P <.001). The LD percentage EMG maximum showed no significant difference between the LDT shoulder and ACS during MAES (F 1,11 = 0.005, P =.946). During maximal active external rotation of the shoulder, the LDT shoulder showed a higher percentage EMG maximum than the ACS (3.0% ± 2.9% for LDT shoulder vs. 1.2% ± 2.0% for ACS, P =.006). TH motion improved after LDT in an MIRT with pseudoparalysis and was not different from the ACS except for external rotation. However, GH motion was significantly lower after LDT than in the ACS in active-elevation range of motion. The LD was active after LDT but not more than in the ACS except for active external rotation, which we did not consider relevant as the activity did not rise above 3% EMG maximum. The favorable clinical results of LDT do not seem to be related to a change in LD activation and might be explained by its effect in preventing proximal migration of the humeral head in active elevation. [ABSTRACT FROM AUTHOR]

Background  Postparalytic synkinesis presents with a combination of hypo- and hypertonic muscles, leading to facial asynchrony with animation and at rest. One ubiquitous finding is a hypertonic depressor anguli oris (DAO) muscle and a weak depressor labii inferioris (DLI) muscle. The goal of this study was to evaluate the utility of DAO myectomy with or without its transfer to the weakened DLI in improving critical components of the dynamic smile. Methods  From 2018 to 2020, this single-center, prospective study included of postparetic facial synkinetic patients with evidence of DAO hypertonicity who underwent DAO myectomy with or without transfer to DLI. Objective facial measurements were used to compare the effectiveness of DAO to DLI transfer to pure DAO myectomy in improving asymmetry of the synkinetic hemiface. Results  Twenty-one patients with unilateral postparetic facial synkinesis with DAO hypertonicity were included; 11 underwent DAO myectomy, while 10 underwent DAO to DLI transfer. Baseline demographics and facial measurements were similar between the groups. DAO myectomy resulted in increased modiolus resting position, closed-mouth smile modiolus angle and excursion, open-mouth smile modiolus angle, excursion, dental show, and decreased lower lip height deviation. DAO to DLI transfer demonstrated similar findings but lacked significant increase in excursion and resulted in worsened lower lip height deviation. Conclusion  These findings illustrate the utility of DAO myectomy in improving imbalance in the synkinetic patient and necessitate further technical refinements for DAO transfers or a different approach for improving lower lip depression in this subgroup of patients. [ABSTRACT FROM AUTHOR]

Aims: The aim of facial reanimation isto restore facial symmetry in spontaneous, mimic, and emotional movements. One of the important reconstructive treatment optionsin patients with long-term facial paralysisisfree muscle transfers. The firststage in two-stage muscle transfers is the cross facial nerve graft (CFNG). In this study, our aim is to investigate the importance of Tinel’s sign and EMG in the selection of patients who have had CFNG due to long-term facial paralysis and who can undergo muscle transfer repair and investigate the effectiveness of these methods. Patients and Methods: Ten patients who underwent crossfacial nerve grafting for long-term facial nerve paralysis between 2012 and 2018 were prospectively included in the study. Results: No complications were observed during the operation and follow-up of the patients. The reliability of EMG is lower than the Tinel’s sign when making a muscle transfer decision in patients who undergo CFNG. Conclusions: In conclusion, the etiology of facial paralysis (severity of injury in traumatic paralysis), age of patients, comorbid conditions, surgical experience, postoperative physical therapy process and patient compliance play an active role in providing reinnervation. [ABSTRACT FROM AUTHOR]

Facial nerve palsy can cause significant distress for patients. We investigated the innervation of the orbicularis oculi muscle (OOM) and assessed the viability of unipedicle contralateral muscle transfer to restore symmetrical and spontaneous blinking. Cadaveric dissection and measurements were performed on lite fixed cadavers (n = 15). Medial innervation of the OOM was identified prior to raising and transposing a flap to the contralateral eyelid. Measurements were performed in-situ and following transposition. A medial ascending branch of the buccal nerve innervating the OOM was identified bilaterally in all cadavers. The average length of flap raised was 59.85 mm (± 4.69 mm) with no difference between the left and right. Flaps with pedicles not dissected off the bone covered 48% of the ciliary margin length (CM) and 62% of the palpebral length (PL). Flaps dissected off the bone covered 72% of the CM and 92% of the PL. The results demonstrate that a flap can theoretically transpose to >50% of the contralateral eyelid length. Increased coverage of the eyelid was achieved by releasing the pedicle from the underlying bone. Little attention was focused on buccal innervation of the eyelids, and this consistent medial pattern may allow an innervated flap transfer to restore symmetrical blinking, something that eludes modern paralysis surgery in a single-stage procedure. [ABSTRACT FROM AUTHOR]

Purpose: Quantifying changes in shoulder external rotation range of motion and strength after lower trapezius transfer in children with obstetric brachial plexus palsy (OBPP). Methods: This prospective study included five children with sequelae of OBPP, with a mean age of 6.4 years (range: 4–12 years) who underwent lower trapezius tendon transfer to restore active external rotation (ER) of the shoulder. Pre-operatively and at a 12-month follow-up assessment, we analyzed the passive and active shoulder ER, the modified Mallet score, and the shoulder rotator muscles strength using an isokinetic device. Results: Clinical parameters improved significantly after trapezius transfer pre-operative passive ER from −8° (range: −20–0°) to 37° (range: 15–50°) (p = 0.035), the modified Mallet score from 13 (range: 10–15) to 18 (range: 17–19) (p = 0.035). Strength testing revealed improved ER muscle strength in all five cases; the mean Peak Torque increased from 1.95 to 4.46 N·m, albeit non-significantly (p = 0.062). Two patients exhibited a winged scapula post-operatively. Conclusion: Lower trapezius transfer seems encouraging to restore shoulder external rotation in OBPP children but with non-significant strength improvement. Trial registration: 18/07/31/5783, December 22, 2018 [ABSTRACT FROM AUTHOR]

Aims: To review patients treated with a functional latissimus dorsi flap for congenital and acquired elbow flexion deficits. Methods: Retrospective review of functional latissimus dorsi flaps performed in one regional unit. Patient notes were reviewed to determine aetiology, pre-op deficits and function, surgical technique, complications and outcomes. Results: A total of six functional latissimus dorsi transfers were performed on four patients. Two patients had bilateral latissimus dorsi transfers for congenital defects. The remaining two procedures were for traumatic defects. Post-operatively both children had excellent outcomes with full range of active movement allowing them to perform key activities of daily living. Surgical Technique: Epimysium of latissimus dorsi folded to form a pseudo-tendon, tunnelled subcutaneously and either attached to a remnant of biceps tendon or secured to the radius. Congenital patients achieved better outcomes; pre-operatively, there was no active elbow flexion in all four elbows but 90–100 of passive flexion. Complications: One latissimus dorsi dehiscence which required revision surgery. Two donor-site seromas. Conclusions: Functional latissimus dorsi transfer has been shown to achieve excellent elbow flexion in patients with congenital absence of biceps and brachialis muscles. Outcomes in older patients with traumatic injuries have been less successful in achieving a full range of active flexion. [ABSTRACT FROM AUTHOR]

Femoral nerve injury is a rare but devastating complication of direct anterior approach total hip arthroplasty that occurs in about 1% of the cases and could potentially lead to debilitating loss of knee extension. In this case report, we present a case of femoral nerve injury following direct anterior approach hip arthroplasty with an inability to extend the affected knee, gait instability, and multiple falls. For this patient, an innovative functional adductor magnus muscle transfer was performed to restore knee extension. At 6 months after surgery, the patient's knee extension was partly restored, and ambulation was significantly improved., (© 2024 The Authors.)

Background  The aim of this study was to compare postoperative elbow flexion outcomes in patients receiving functioning free muscle transplantation (FFMT) innervated by either intercostal nerve (ICN) or spinal accessory nerve (SAN) grafts. Methods  A comprehensive systematic review on FFMT for brachial plexus reconstruction was conducted utilizing Medline/PubMed database. Analysis was designed to compare functional outcomes between (1) nerve graft type (ICN vs. SAN) and (2) different free muscle graft types to biceps tendon (gracilis vs. rectus femoris vs. latissimus dorsi). Results  A total of 312 FFMTs innervated by ICNs (169) or the SAN (143) are featured in 10 case series. The mean patient age was 28 years. Patients had a mean injury to surgery time of 31.5 months and an average follow-up time of 39.1 months with 18 patients lost to follow-up. Muscles utilized included the gracilis (275), rectus femoris (28), and latissimus dorsi (8). After excluding those lost to follow-up or failures due to vascular compromise, the mean success rates of FFMTs innervated by ICNs and SAN were 64.1 and 65.4%, respectively. Conclusion  This analysis did not identify any difference in outcomes between FFMTs via ICN grafts and those innervated by SAN grafts in restoring elbow flexion in traumatic brachial plexus injury patients. [ABSTRACT FROM AUTHOR]

Purpose: The primary objective of this retrospective study was to validate electrophysiological results of latissimus dorsi tendon transfer (LDTT) to determine if this transfer is active for different daily living tasks, and the secondary objective was to correlate these clinical results.Methods: With a mean follow-up of 4.7 years, 14 latissimus dorsi tendon transfers were retrospectively reviewed. Patients were clinically evaluated with the constant score and the SSV. Healing of the tendon on the greater tuberosity and atrophy of the LDTT muscle was determined by ultrasound and compared with the contralateral side. Electrical activity was analyzed by electromyography in active elevation, abduction, and external rotation.Results: Twelve patients are satisfied (SSV). At the last follow-up, the EMG found a significant electrical activity in the abduction and external rotation and a lower activity in adduction and internal rotation. The mean constant score increased from 29 to 51, the mean forward elevation increased from 89° to 135°, the mean abduction from 92° to 105°, and the external rotation from 12° to 24°. The ultrasound found 12 healed tendons and two ruptures at the myotendinous junction.Conclusion: Electrical activity in abduction and external rotation testifies that the LDT transfer acts as an active muscle transfer and acts not only a muscle tenodesis that covers the humeral head. [ABSTRACT FROM AUTHOR]

Purpose: This systematic review assesses evidence for improvements in outcome for all reported types of treatment modalities [physical therapy, tenotomy or tenodesis of the long head of the biceps, debridement, partial repair, subacromial spacer, deltoid flap, muscle transfer, rotator cuff advancement, graft interposition, superior capsular reconstruction (SCR), and reversed shoulder arthroplasty (RSA)] used for irreparable posterosuperior rotator cuff tears without glenohumeral osteoarthritis. The primary aim was to be able to inform patients about expectations of the amount of clinical improvement after these treatments.Methods: A systematic search was conducted in MEDLINE, EMBASE, CINAHL, and Cochrane databases for studies on irreparable posterosuperior rotator cuff lesions without glenohumeral osteoarthritis, published from January 2007 until January 2019, with minimum 2-year follow-up. Studies with pre-operative and/or intra-operative determination of cuff tear irreparability were included. We defined the non-adjusted Constant Score as the primary outcome.Results: Sixty studies (2000 patients) were included with a fair mean quality score, according to the Modified Coleman Methodology Score. The employed definitions of 'irreparable' were mainly based on MRI criteria and were highly variable among studies. The smallest weighted mean preoperative to post-operative improvements in Constant Score were reported for biceps tenotomy/tenodesis (10.7 points) and physical therapy (13.0). These were followed by debridement (21.8) and muscle transfer (27.8), whereas the largest increases were reported for partial repair (32.0), subacromial spacer (32.5), rotator cuff advancement (33.2), RSA (34.4), graft reconstruction (35.0), deltoid flap (39.8), and SCR (47.4). Treatment using deltoid flap showed highest mean weighted improvement in Constant Score among studies with available medium-term (4-5-year) follow-up. Treatments deltoid flap, muscle transfer, and debridement were the only treatments with available long-term (8-10-year) follow-up and showed similar improvements in Constant Score at this time point.Conclusion: The variability in patient characteristics, co-interventions, outcome reporting, and length of follow-up in studies on irreparable rotator cuff tears without osteoarthritis complicates sound comparison of treatments. Clinically important treatment effects were seen for all 11 different treatment modalities.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Elbow flexion is widely regarded as the most important function to restore in brachial plexus injuries. Free functioning muscle transfer surgery is indicated in patients with delayed presentation or failure of other primary procedures. Results of the transfer surgeries have been reported in the form of case series, but no further studies are available. This systematic review aims to provide a deeper understanding of this complex surgery and consists of 19 articles that include 364 patients. Data on injury characteristics, surgical techniques, complications as well as outcome measures were analysed. Our results show that functional muscle transfer for elbow flexion enables 87% and 65% of patients to achieve a useful power grade of ≥ 3 and ≥ 4, respectively, although other important outcome factors should be considered. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To investigate the feasibility of using free gracilis muscle transfer along with the brachialis muscle branch of the musculocutaneous nerve to restore finger and thumb flexion in lower trunk brachial plexus injury according to an anatomical study and a case report. METHODS: Thirty formalin-fixed upper extremities from 15 adult cadavers were used in this study. The distance from the point at which the brachialis muscle branch of the musculocutaneous nerve originates to the midpoint of the humeral condylar was measured, as well as the length, diameter, course and branch type of the brachialis muscle branch of the musculocutaneous nerve. An 18-year-old male who sustained an injury to the left brachial plexus underwent free gracilis transfer using the brachialis muscle branch of the musculocutaneous nerve as the donor nerve to restore finger and thumb flexion. Elbow flexion power and hand grip strength were recorded according to British Medical Research Council standards. Postoperative measures of the total active motion of the fingers were obtained monthly. RESULTS: The mean length and diameter of the brachialis muscle branch of the musculocutaneous nerve were 52.66±6.45 and 1.39±0.09 mm, respectively, and three branching types were observed. For the patient, the first gracilis contraction occurred during the 4th month. A noticeable improvement was observed in digit flexion one year later; the muscle power was M4, and the total active motion of the fingers was 209°. CONCLUSIONS: Repairing injury to the lower trunk of the brachial plexus by transferring the brachialis muscle branch of the musculocutaneous nerve to the anterior branch of the obturator nerve using a tension-free direct suture is technically feasible, and the clinical outcome was satisfactory in a single surgical patient.

Secondary surgical procedures can be used in brachial plexus birth injury to correct shoulder movement imbalances. This study compares outcomes of the two secondary surgical procedure types: humeral osteotomies and soft tissue procedures. Outcome measures assessed included active and passive internal and external rotation, active and passive abduction and adduction, active and passive flexion and extension, percentage of the humeral head anterior to the middle glenoid fossa, glenoid version, and Mallet Score. Nineteen full-text articles were included in the analysis. Humeral osteotomies resulted in a loss of internal rotation postoperatively (-15.94°). Active internal rotation was not evaluated for soft tissue procedures. All other assessed outcomes were improved postoperatively for bony and soft tissue procedures. Bony procedures exhibited a greater degree of active external rotation postoperatively when compared to soft tissue procedures (+67° vs. +40°). Both bony and soft tissue procedures Improve shoulder function in children with neonatal brachial plexus palsy, however, soft tissue procedures showed greater consistency in outcomes. Level of Evidence : IV., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Azer, Mendiratta, Saad, Duan, Cedarstrand, Chinta, Hanna, Shihora, McGrath and Chu.)

Background This study evaluated the functional outcomes of bipolar pedicled pectoralis major (PM) transfer to restore elbow flexion. Methods We retrospectively reviewed 29 transfers in 28 patients with a mean age of 31.2 years (range, 5-65 years). The loss of elbow flexion was due to brachial plexus palsy in 24 patients, elbow flexors necrosis in 4, and poliomyelitis in 1. The entire PM muscle was mobilized and fixed proximally to the coracoid process. Intraoperative positioning and postoperative immobilization of the shoulder and the elbow flexed at 60° and 120°, respectively, allowed direct distal fixation of the muscle to the biceps brachii tendon. Results At the last follow-up (mean, 13 months; range, 4-37 months), 41% of the transfers (n = 12) recovered grade 4 elbow flexion strength and were able to lift 2.2 kg on average (range, 0.5-5 kg), 52% (n = 15) recovered grade 3 strength, and 7% (n = 2) had a poor result (ie, grade 2 elbow flexion). The mean active elbow flexion was 100° (ranging, 30°-150°), and the patients had 0° to 10° elbow flexion contracture. Conclusions Our results indicate that bipolar PM transfer is a reliable and effective procedure to restore elbow flexion. Flexion of the shoulder and elbow allowed the transfer to reach the elbow fold and avoided an interposition graft between the distal PM and the biceps brachii tendon. [ABSTRACT FROM AUTHOR]

The purpose of this study was to evaluate long-term outcomes of the free functioning gracilis transfer in children with traumatic total brachial plexus palsy. We used the free functioning gracilis transfer to reconstruct elbow flexion and prehension in 17 children with a mean age of 13.4 years (range 3–17) who were followed-up over a mean period of 6 years (range 2–16). The transferred gracilis delivered a stable elbow flexion with a useful power, as well as reconstructed active finger motion. In 3–11-year-old patients we noted a tendency towards developing a progressive flexion contracture of the elbow. The limb length discrepancy observed in our patients was not different from the brachial plexus palsy patients treated without the free functioning gracilis transfer. In conclusion, the free functioning gracilis transfer is a reliable reconstructive technique for reanimating upper extremity in children of all ages capable of delivering stable function over a long period of time.Level of evidence: IV [ABSTRACT FROM AUTHOR]

Brachial plexus injuries can be debilitating. We have observed that manual reduction of the patients' shoulder subluxation improves their pain and have used this as a second reason to perform the trapezius to deltoid muscle transfer beyond motion. The authors report a series of nine patients who all had significant improvement of pain in the shoulder girdle and a decrease in pain medication use after a trapezius to deltoid muscle transfer. All patients were satisfied with the outcomes and stated that they would undergo the procedure again if offered the option. The rate of major complications was low. The aim is not to describe a new technique, but to elevate a secondary indication to a primary for the trapezius to deltoid transfer beyond improving shoulder function: pain relief from chronic shoulder subluxation.