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We evaluated the feasibility of external epineurial splinting as a way of alleviating tension caused by sutures in the reconstruction of peripheral nerve injuries, utilizing Wistar rat median nerve injury on 40 animals, in four experimental groups with 10 animals on each surgical setting. The nerve regeneration outcomes of four surgical procedures were compared: 1) primary end-to-end sutures (EES); 2) alleviated tension sutures (ATS) with a removal of 7 mm nerve segment, namely external epineurial splinting, utilizing a polypropylene mesh as a protective scaffold; 3) sutures under tension with a 7 mm gap between nerve stumps; and 4) sham (C) (n = 10 animals). Regeneration of the median nerve postneurorrhaphy was followed by means of functional evaluations, including time to first day of finger flexion recovery, and grasp strength; quantification of atrophy of the flexor pronator muscle group; and mRNA expression of nerve growth factor and neurotrophin-3 by polymerase chain reaction-reverse transcriptase. Similar, significant median nerve regeneration was observed in the EES-treated and ATS-treated groups, relative to controls. The EES and ATS surgical procedures methods demonstrated important similar results considering functional and molecular biology analysis of the median nerve injury., (Copyright © 2011 Wiley-Liss, Inc.)

Eleven patients over 40 years old, with median nerve lesions at the wrist, were operated on an average of 5 months after their injury. In six patients, the median nerve was repaired using a polypropylene mesh applied to secure the nerve stumps in contact, thereby allowing for direct repair with microsutures. Six patients had their median nerve repaired with sural grafts. The average gap length was 2.8 cm for the mesh repair, whereas it was 3.7 cm for the graft repair group. Eighteen months after surgery, pressure thresholds were perceived in the index and thumb pulp by all six patients with a mesh repair but in only two of five patients with a graft repair. Five in the mesh repair group recovered function in the abductor pollicis brevis muscle, versus none in the graft group. These preliminary results suggest that, in older patients, the use of a mesh to splint the coaptation site followed by direct nerve repair yields better recovery than conventional sural grafts., (Copyright © 2011 Wiley-Liss, Inc.)

We treated a patient with tetraplegia who had paralysis of thumb and finger extension by transferring supinator motor branches to the posterior interosseous nerve. Surgery was performed bilaterally, 7 months after a spinal cord injury. Six months after surgery, with the wrist in neutral, extension of the thumb and finger were almost full, bilaterally. In tetraplegic patients with strong wrist extensors, supinator motor branch transfer is a promising new alternative for the reconstruction of thumb and finger extension., (Copyright © 2010 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Object: In C7-T1 palsies of the brachial plexus, shoulder and elbow function is preserved, but finger motion is absent. Finger flexion has been reconstructed using tendon or nerve transfers. Finger extension has been restored ineffectively by attaching the extensor tendons to the distal side of the dorsal radius (that is, tenodesis). In these types of nerve palsy, supinator muscle function is preserved because innervation stems from the C-6 root. In the present study, the authors investigated the anatomy and the feasibility of transferring the supinator motor branches to the posterior interosseous nerve. Sacrifice of the supinator motor branches does not abolish supination because biceps muscle function is preserved in lower-type injuries of the brachial plexus., Methods: The posterior interosseous nerve was dissected in 20 formalin-fixed forearms. Through posterior forearm access, the posterior interosseous nerve and its motor branches to the supinator muscle were dissected. Specimens were removed for histological study., Results: In the vicinity of the supinator muscle's proximal margin (that is, the Frohse arcade), 2 nerve branches arose laterally and medially from the posterior interosseous nerve to innervate the superficial and deep heads of the supinator muscle, respectively. The supinator motor nerves, when divided, could be coapted directly to the posterior interosseous nerve. The number of myelinated fibers in the supinator motor branches corresponded to 70% that of the posterior interosseous nerve., Conclusions: The supinator motor nerves can be transferred directly to the posterior interosseous nerve to restore thumb and finger extension in patients with C7-T1 brachial plexus lesions.

Purpose: The purpose of this study was to investigate the insertion of the plantaris tendon in terms of shape, length, width and size, to define if there is available bony insertion for future use as reconstructive procedure in secondary tendon graft in hand surgery., Methods: In 30 limbs, the plantaris tendon was anatomically dissected to investigate its bony attachments to the calcaneus., Results: The plantaris was present in 29 of 30 dissections and regularly inserted in the calcaneus., Conclusions: The tendo-osseous plantaris graft is, according to this research, amenable to be used as a viable choice in reconstruction of secondary flexor tendon injuries related to its length shape and size and especially due to the bone stock adequate to strong phalanx fixation.

Purpose: Secure methods of graft attachment ensure safe early motion after flexor tendon grafting. This has been achieved at the proximal graft juncture using Pulvertaft's technique. For secure distal attachment, we investigate the results of flexor tendon grafting using the plantaris tendon with a fragment of attached bone fixed with a screw to the distal phalanx., Methods: Thirteen digits from 10 patients with longstanding flexor tendon injuries in zone II had surgical reconstruction. A plantaris tendon-bone graft was attached to the distal phalanx using a mini-screw. This was followed by immediate active motion. At 3 and 8 months after surgery, total active motion was calculated as the sum of the degrees of active flexion in the proximal and distal interphalangeal joints minus the sum of the degrees of extension deficits for each of these joints. The results of total active motion were compared to the normal contralateral digit., Results: Three months after surgery, the mean rate of recovery, relative to the normal contralateral finger, was 74%, whereas 8 months after surgery, this value was 70%. This difference was statistically significant. There were no failures or poor results (ie, less than 50% recovery)., Conclusions: The tendon-bone plantaris graft employed here ensured immediate active motion and early use of the involved hand in daily activities., Type of Study/level of Evidence: Therapeutic IV.

Objective: The pattern of triceps innervation is complex and, as yet, has not been fully elucidated. The purposes of this study were 1) to clarify the anatomy of the triceps motor branches, and 2) to evaluate their possible uses as a donor or receiver for nerve transfer., Methods: The radial nerve and its motor and cutaneous branches were bilaterally dissected from the axilla and posterior arm regions of 10 embalmed cadavers., Results: A single branch innervates the triceps long head, whereas double innervation was identified for the lateral and medial heads. The upper branch to the lateral head originated from the radial nerve, whereas the lower branch to the lateral head stemmed from the lower medial head motor branch, which ultimately innervated the anconeus muscle. Both the long head and the upper medial head motor branches originated in the axillary region in the vicinity of the latissimus dorsi tendon., Conclusion: Each of the triceps' motor branches might be used as a donor for transfer. The triceps long head motor branch should be used preferentially when the intention is to establish triceps reinnervation.

Object: Grafting or nerve transfers to the axillary nerve have been performed using a deltopectoral approach and/or a posterior arm approach. In this report, the surgical anatomy of the axillary nerve was studied with the goal of repairing the nerve through an axillary access., Methods: The axillary nerve was bilaterally dissected in 10 embalmed cadavers to study its variations. Three patients with axillary nerve injuries then underwent surgical repair through an axillary access; the axillary nerve was repaired by transfer of the triceps long head motor branch., Results: At the lateral margin of the subscapularis muscle, the axillary nerve was found in the center of a triangle bounded medially by the subscapular artery, laterally by the latissimus dorsi tendon, and cephalad by the posterior circumflex humeral artery. At the entrance of the quadrangular space, the axillary nerve divisions were loosely connected to each other, and could be clearly separated and correctly identified. Surgery for the axillary nerve repair through the axillary access was straightforward. Eighteen months after surgery, all three patients had recovered deltoid strength to a score of M4 on the Medical Research Council scale and had improved abduction strength by 50%. No deficit was evident in elbow extension., Conclusions: The axillary nerve and its branches can be safely dissected and repaired by triceps motor nerve transfer through an axillary access.