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We studied the patterns of dominance in the palmar digital arteries of the fingers in 39 fresh cadaver arms which had been injected with coloured latex solution. We also performed photoplethysmographic studies in 20 hands. The ulnar digital artery in the index finger and the radial digital artery of the little finger were usually dominant, and their counterparts were slim and often hypoplastic. The findings are relevant to digit revascularization and might influence the planning of digital island-flaps or toe transfers. [ABSTRACT FROM PUBLISHER]

We report the use of a bone graft harvested from the palmar and ulnar aspect of the distal radius and vascularized by the palmar carpal artery for the treatment of scaphoid nonunion in 17 patients, ten of whom had already had unsuccessful surgery. Union was obtained in all cases at an average of 60 days (range, 45–90 days).The average follow-up was 16 months (range, 12–36 months). There were no failures. [ABSTRACT FROM PUBLISHER]

Abstract Purpose The aim of this study was to compare functional data of different nerve-gap bridging materials evaluated in rat experiments by means of a systematic review. Materials and methods A systematic review was conducted, searching MEDLINE, HTS and CENTRAL to identify all trials evaluating functional recovery of artificial nerve conduits in the rat model. Results There was a trend towards a favourable outcome of conduits coated with Schwann-cells compared to the plain synthetics. Histomorphometry, electrophysiology and muscle-weight correlated poorly with functional outcome. Conclusion Schwann-cell coated conduits showed promising results concerning functional recovery. Further standardization in outcome reporting is encouraged.

The article discusses a study on the revascularization of the lunate in Kienbock's disease by a vascularized bone graft.

Overboarding politcal influence in Germany concerning medical issues has come to a new peak. The report by the IGES Institute published in 2022 made an important contribution in this regard. Unfortunately, only that part of the recommendations of this report were implemented in a new version of the contract for outpatient surgery according to Section 115b SGB V (AOP contract), that called for an expansion of outpatient surgery. In particular, those aspects that are important from a medical point of view for a patient-specific adjustment of outpatient surgery (e. g. old age, frailty, comorbidities) as well as the important structural requirements for outpatient postoperative care were included in the new AOP contract at best in a rudimentary manner. For this reason, the German Society for Hand Surgery felt compelled to give its members a recommendation as to which medical aspects must be taken into account, especially when performing hand surgery operations, in order to ensure the highest level of safety for the patients entrusted to us while performing outpatient surgery. An expert group of experienced hand surgeons and hand therapists who work in hospitals of all levels of care as well as resident surgeons was formed in order to formulate mutually agreed recommendations for action., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Management of scapholunate dissociations remains a significant challenge. Open approaches suffer from a disadvantageous further impairment of the stabilizing local structures. The minimally invasive arthroscopic technique described provides reliable stability of the scapholunate interosseous ligament complex in dynamic lesions. The anatomic key structure is the dorsal capsuloligamentous scapholunate septum, which provides a mechanical connection between the scaphoid, lunate, and dorsal capsule of the wrist. Arthroscopic capsuloplasty aims to tighten and stabilize this complex structure in long term. This approach preserves the adjacent structures, namely the secondary wrist stabilizers and their neuromuscular feedback loops. With a certain degree of experience in wrist arthroscopy, the technique is reliably adaptable and reproducible., Competing Interests: Conflicts of Interest and Source of Funding: The authors report no conflicts of interest and no source of funding., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Ulnocarpal impaction syndrome is a common cause for ulnarsided wrist pain caused by an abutment between the ulnar head and the lunotriquetral complex. This pain is typically triggered by load bearing and rotation of the forearm. Radiographic examination is often associated with positive ulnar variance and cysts in the lunate, edema of the ulnoproximal lunate is shown in MRI. Operative treatment aims to reduce load on the lunate, either by open ulnar shortening osteotomy or arthroscopic wafer procedure., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Arthroscopic decompression (wafer procedure) of the ulnocarpal compartment in patients with ulnar impaction syndrome., Indications: The arthroscopic wafer procedure is recommended in ulnar-plus situations with up to 3 mm length-excess. To perform this procedure the ulnar head needs to be accessible for the burr through a pre-existing, impaction-related, centroradial lesion of the triangular fibrocartilage complex (TFCC). The additional presence of a distal radioulnar joint (DRUJ) type C confirms the indication., Contraindications: The wafer procedure is contraindicated if there is no consistent TFCC injury ensuring access to the ulnar head and furthermore in ulna-plus situations of more than 3 mm. Relative contraindications: in young patients due to lack of evidence-based studies., Surgical Technique: Arthroscopic, semicircular, partial resection of the ulnar head in terms of oblique-helicoidal osteotomy using a 4.2 mm burr, while sparing the DRUJ and the dorsal and the palmar radioulnar ligaments., Postoperative Management: Immobilization for 1 week in a palmar splint with immediate intensive exercising of pro- and supination under physiotherapeutic instruction., Results: Between 2008 and 2010, an arthroscopic wafer procedure was performed in 24 patients. The resection of the ulnar head was 2.5 mm on average. After a mean follow-up time of 13.25 months, very good results were archived in 23 of 24 patients; the ulnar impingement test was negative. On a visual analog scale (0-10) average postoperative pain was 1.16 at rest and 4.5 under stress. The mean postoperative DASH score was 13.4.

The aim of this study was to determine a definition of recurrence of Dupuytren disease that could be utilized for the comparison of the results independently from the treatment used. 24 hand surgeons from 17 countries met in an international consensus conference. The participants used the Delphi method to evaluate a series of statements: (1) the need for defining recurrence, (2) the concept of recurrence applied to the Tubiana staging system, (3) the concept of recurrence applied to each single treated joint, and (4) the concept of recurrence applied to the finger ray. For each item, the possible answer was given on a scale of 1-5: 1=maximum disagreement; 2=disagreement; 3=agreement; 4=strong agreement; 5=absolute agreement. There was consensus on disagreement if 1 and 2 comprised at least 66% of the recorded answers and consensus on agreement if 3, 4 and 5 comprised at least 66% of the recorded answers. If a threshold of 66% was not reached, the related statement was considered "not defined". A need for a definition of recurrence was established. The presence of nodules or cords without finger contracture was not considered an indication of recurrence. The Tubiana staging system was considered inappropriate for reporting recurrence. Recurrence was best determined by the measurement of a specific joint, rather than a total ray. Time 0 occurred between 6 weeks and 3 months. Recurrence was defined as a PED of more than 20° for at least one of treated joint, in the presence of a palpable cord, compared to the result obtained at time 0. This study determined the need for a standard definition of recurrence and reached consensus on that definition, which we should become the standard for the reporting of recurrence. If utilized in subsequent publications, this will allow surgeons to compare different techniques and make is easier to help patients make an informed choice., (© Georg Thieme Verlag KG Stuttgart · New York.)

Diagnosis-related groups (DRGs) are a patient classification system grouping related types of patients treated to the resources they consumed. In this analysis we compared the Italian and the German DRG systems regarding hand surgery with an emphasis on reimbursement of clinical cases. The 15 most common hand surgical diagnoses and their corresponding operative treatment in our clinic in 2009 were processed using a DRG grouper. The underlying data were transferred to the Italian system. Thus, the length of stay and the reimbursement of both countries could be obtained and compared. The latter was adjusted and corrected by the purchasing power of each country. The mean of the upper threshold of length of stay was 10 days in the German as well as the Italian system whereas the median was 2 times higher in Italy (6 vs. 12 days). Fifteen out of 19 cases showed higher reimbursement in Germany. The case mix index (CMI) of 0.917 in Germany represents a mean payment of 2,676 € per case. In Italy the hypothetical CMI of 0.635 resulted in a mean reimbursement of 1,853 € per case. The biggest difference in remuneration could be found for replantation of multiple fingers. For this service the German health-care system pays 12,320 € more than the Italian. Total proceeds of the top 15 diagnoses applying the number of cases treated in our clinic revealed 1.7 million € in the German and 1.2 million € in the Italian DRG system. Considering the purchasing power utilizing consumer prize parities, the difference of reimbursement between the countries decreased to 300,000 €. There is no mean length of stay per DRG in Italy, only the upper threshold of length of stay is determined. In most cases the latter is higher in Italy compared to Germany. The consumption of resources for finger replantation is not adequately represented in the Italian DRG system compared to finger amputation. Reimbursement of inpatient care is influenced by multiple factors not being subject to the free market economy. For this reason only descriptive comparison is feasible., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: To determine transfection efficiency of FuGENE HD© lipofection and AMAXA© nucleofection on rat Schwann cells (SC)., Methods: The ischiadic and median nerves of 6-8 week old Lewis rats were cultured in modified melanocyte-growth medium. SCs were genetically transfected with green fluorescent protein (GFP) as reporter gene using FuGENE HD© lipofection and AMAXA© nucleofection. Transfection rates were determined by visualization of GFP fluorescence under fluorescence microscopy and cell counting. Transfected cell to non-transfected cell relation was determined., Results: Purity of Schwann cell culture was 88% as determined by immunohistologic staining. Transfection rate of FuGENE HD© lipofection was 2%, transfection rate of AMAXA© nucleofection was 10%. With both methods, Schwann cells showed pronounced aggregation behavior which made them unfeasible for further cultivation. Settling of Schwann cells on laminin and poly-L-ornithine coated plates was compromised by either method., Conclusion: Non-viral transfection of rat SC with FuGENE HD© lipofection and AMAXA© nucleofection is basically possible with a higher transfection rate for nucleofection than for lipofection. As cell viability is compromised by either method however, viral transfection is to be considered if higher efficiency is required.

Background: Composite Tissue Allotransplantation (CTA) is a new medical field of growing importance. This paper focuses on the infrastructure and organisation of European CTA centres and discusses the differences between national health systems., Material/methods: Eight European centres (Valencia, Innsbruck, Munich, Lyon, Amiens, Creteil, Wroclaw, Monza) were sent with a specially-designed, standardized, 20-item questionnaire., Results: Five of the eight centres returned our questionnaire: Munich, Innsbruck, Lyon, Amiens, Wroclaw. Since 1998, CTA has been performed at these centres. In both French centres and the Polish centre public funding is available in addition to the coverage provided by health insurers. In Munich the costs for a double upper-arm transplantation were Euro 150,000 with an additional Euro 50,000-70,000 per year. In Lyon the costs for a singular hand transplantation were Euro 70,000 per year and in Wroclaw (Poland) the costs for a hand or upper arm transplantation were Euro 20,000-30,000. As many as 17 different medical professions are involved in the CTA at the different centres., Conclusions: CTA is an innovative promising therapeutic tool that is based on the experiences of solid organ transplantation and profound microsurgical skills. Due to the complexity of the infrastructure, sourcing and the organisation CTA can only be successfully performed at specialized centres. A European network with an international European waiting list and a central coordination for CTA should be established. In order to advance CTA as an important tool in reconstructive surgery we must turn our attention to how the costs will be met, the legal environment for procurement of adequate donors and open ethical questions.

The efficacy of Schwann-cell cultivation can be enhanced by in vitro predegeneration of the harvested cells compared to immediate culture. The aim of this study was to improve Schwann-cell culture efficacy by comparing three different durations of predegeneration. The sciatic and median nerves of 6-8-week-old Lewis rats were harvested and subjected to either 2-day, 7-day, or 14-day predegeneration in Dulbecco's Modified Eagle's Medium supplemented with 10% fetal calf serum and 1% Penicillin/Streptomycin. Afterward, tissue was enzymatically dissociated and placed in a modified melanocyte growth medium. The cell count was determined immediately after dissociation while the cell purity was determined one subculture/trypsinization cycle later after cell attachment to the culture plate by means of optical microscopy and immunocytochemistry. Particular attention was then paid to the Schwann-cell-to-fibroblast relation. The cumulative cell count in the culture was 5.8 x 10(5) for 2-day, 1.12 x 10(6) for 7-day, and 1.48 x 10(6) for 14-day predegeneration. The culture purity was approximately equal for 2- and 7-day predegeneration (88% Schwann cells, 12% fibroblasts after 2 days; 85% Schwann cells, 15% fibroblasts after 7 days). After 14 days, however, cell cultures were significantly debased by fibroblast proliferation (57% Schwann cells, 43% fibroblasts). In vitro predegeneration is a particularly suitable procedural method to increase the cultural Schwann-cell yield. The number of cultivated rat Schwann cells is doubled by 7-day in vitro predegeneration in comparison to 2-day predegeneration. After 14-day predegeneration, however, the culture is significantly debased by fibroblasts. Therefore, 7-day in vitro predegeneration is an advisable predegeneration period.

Nerve injuries may result in sensory and motor deficits when not treated appropriately. Especially the surgical management of nerve defects still represents a challenge for the surgeon. In these cases the grafting of autologous nerves represents the only reasonable approach. Due to the side effects associated with this method (sacrifice of donor nerves, neuroma formation in the harvesting area, limited availability of donor nerves, etc.), numerous alternatives were proposed in order to avoid the transplantation of autologous tissue. This review provides a general view on the state of the art of how to supply gaping injuries in the peripheral nerve. Furthermore new approaches emphasizing tubulization techniques for the reconstruction of lost nerve tissue are described with a special focus on various materials with their advantages and disadvantages.

Purpose: The improvement of regeneration and functional recovery after peripheral nerve injury is a major challenge in neurosurgery. Although microsurgical techniques for nerve reconstruction have seen great advancements over the last years, the clinical outcome with patients is often unsatisfactory. The aim of the present study was to investigate if administration of the iron chelator Deferroxamine (DFO), can improve postoperative outcome in the rat median nerve reconstruction model., Methods: After complete transection, the right median nerve was repaired by end-to-end neurorrhaphy. The suture site was wrapped by a 1-cm-long external jugular vein segment, either empty or filled with DFO-loaded lipid particles (Perineurin or with a vehicle (unloaded lipid particles) alone. Functional testing was carried out weekly by means of the grasping test. At the time of withdrawal, 12 weeks post-operatively, muscle tropism recovery was assessed by weighing flexor digitorum sublimis muscle that is innervated by the median nerve only. Before harvesting of the nerve specimens electrophysiological analyses were performed with measuring the latency, the threshold and the conduction velocity. Finally, the repaired nerves were withdrawn for immunocytochemistry with a neurofilament antibody and axon quantitative morphology., Results: The comparison between the groups showed that intraoperative application of the DFO-loaded lipid particles at the neurorrhaphy site led to a significant increase in the density of regenerating axons as well as to an accelerated recovery of both muscle tropism and motor function. The electrophysiological results demonstrated a decrease of the threshold, a lower latency, and a higher conduction velocity in the Perineurin-treated animals., Conclusions: The results of the present study suggest that local administration of Perineurin might have a therapeutic potential for improving the postoperative outcome after microsurgical nerve reconstruction in patients.

The traumatic boutonnière (or buttonhole) deformity develops after unsuccessful primary treatment of a lesion of the extensor tendon at the level of the proximal interphalangeal joint. Knowledge of the mechanisms leading to this deformity is fundamental for choosing and executing reconstructive procedures. The most frequently used methods are illustrated in this article. Because none of these procedures has been shown to be successful in all situations, we recommend a staged reconstructive approach. Even then, this deformity often results in incomplete reconstruction. Therefore, for these lesions especially, correct primary diagnostics and repair are required.

Background: The purpose of this study was to investigate neuroma formation in a rat median nerve model., Methods: In three groups, the median nerve was exposed and a gap was created. In the first group, a short gap of 1 cm (n = 12) was created; in the second, a long gap of 2 cm (n = 12) was created in the nerve. Another group was used to analyze the development of neuroma formation when the proximal stump was buried in adjacent muscle with an additional gap of 2 cm (n = 12). The use of different lengths should allow one to gain information about dilution effects of distal stump factors that may contribute to neuroma formation. Nine months later, specimens were gathered and histologically analyzed. The cross-sectional areas of neuromas were measured and the neural/connective tissue ratios were estimated., Results: The cross-sectional areas demonstrated that neuroma formation was significantly higher in the short-gap group than in the long-gap group, and smallest in the muscle-covered group. The percentage of neural tissue was highest in the muscle-covered and long-gap groups and lowest in the short-gap group., Conclusions: These results demonstrate an association between neuroma formation and distal stump distance. This observation may be explained by the factors originating from the distal stump that were blocked when the proximal nerve stump was completely buried in the muscle. For clinical application, the authors recommend not only burying the proximal stump in a muscle but also surgically augmenting the gap between the proximal and distal stumps.

At the moment autologous nerve grafting remains the only reasonable technique for reconstruction of peripheral nerve defects. Unfortunately, this technique has a lot of complications and disadvantages. These problems are related to the autologous nerve that is harvested for this procedure. Donor site morbidity with loss of sensitivity, painful neuroma formation and of course the restricted availability of autologous nerves stimulates the idea for alternative techniques on that field. In this paper we describe our experience with different graft materials for reconstruction of a 2 cm nerve gap in a median nerve model in rats. After implantation of various materials (biological/synthetic) the main experiments were conducted with a synthetic, biodegradable nerve conduit seeded with autologous Schwann cells. With this material we were able to reconstruct successfully a 2 cm gap in the rat median nerve. Regeneration with this material was found to be equally to an autologous nerve graft.

Purpose: Recently we successfully used a conduit of epsilon-caprolactone-co-trimethylene carbonate filled with Schwann cells (SC) across a 20 mm gap in a rat median nerve. In this study we applied the tubes with SC across a 40 mm gap in order to analyse the regenerative potential of the tubes in long nerve defects., Methods: To augment the nerve defect a cross-chest procedure was used and the tubes were implanted with injected isogeneic SCs inside (group 3). Both ulnar nerves were used for a 40 mm autograft (group 2). For control group non-operated animals were used (group 1). The grasping test, histology (S-100, PAM), electrophysiology, and the muscle weight were used to assess regeneration., Results: After 12 months, grasping was seen only in three animals of group 3 (3.6 g [95% CI: 0 to 7.6 g]). However, in group 2 all rats had a partial functional regeneration (42.8 g [95% CI: 39.1 to 46.6 g]). The grasping force of the non-operated animals (group 1) was 240.9 g [95% CI: 237.2 to 244.7 g] at the time. Histology from group 3 confirmed an irregular arrangement of fibres in contrast to more organized structures in group 2. Electrophysiology in group 3 displayed potentials only in the three animals with functional regeneration. In group 2 all animals exhibited potentials. A significant decrease of muscle weight was observed in groups 2 and 3, most prominent in the latter., Conclusion: Regeneration was not successful across the 40 mm gap using the applied tube in combination with SC. For future experiments further consideration should be taken in optimizing the cellular and material components that are critical for a successful application to overcome very large nerve gaps.

Background: In spite of considerable progress in microsurgical techniques, the treatment of long distance defects in peripheral nerves remains challenging for the surgeon. Autologous nerve grafting has been the only applicable procedure to overcome such defects in the past. Due to the known disadvantages of this procedure (neuroma formation and sensory deficits at the donor-site, limited availability of donor-material, etc.) and impaired regenerative results, different tubulisation techniques are discussed more frequently as alternatives to the autologous nerve grafts., Aim of the Study: In this work, the authors summarise their experiences and results with different synthetically developed materials, cellular and acellular tubes and venous conduits for the reconstruction of peripheral nerve defects., Material and Methods: To analyse peripheral nerve regeneration, we utilised a median nerve model in rats. In these studies nerve gaps up to 40 mm were induced. Guiding tubes of various materials (trimethylene carbonate-epsilon-caprolactone, polyethylene, veins, and collagen) were employed. Furthermore, we introduced Schwann cells as cellular elements into some of the trimethylene carbonate-epsilon-caprolactone tubes. The longest postoperative observation period was nine months., Results: The results demonstrated that only in the case of cellular filled tubes (syngenic Schwann cells) did regeneration occur across the 20 mm gap. This regeneration was comparable to that induced after autologous grafting. Across a 40 mm gap the autologous graft demonstrated the best results.

A new animal model for the study of nerve regeneration in rats across a 40 mm gap between both median nerves is described. For autologous grafting, the ulnar nerves were dissected and sutured together. From the left median nerve, they were transplanted across the chest to the right median nerve. Animals having undergone this operation were observed for 12 months and periodically assessed using the grasping test and measurements of body-weight. For histological analysis rats were sacrificed after this period and axon counts were determined at the suture points of operated animals and in the median nerve of non-operated animals. Functional recovery could be seen, although partially, beginning as early as the fifth postoperative month, as demonstrated by the grasping test. Quantification of the number of axons demonstrated axonal regeneration across all three coaptation points. This model provides a new approach for analysis of long distance peripheral nerve regeneration without impairment of behaviour.

Objective: Our purpose was to evaluate the feasibility of sonography in identifying nerve abnormalities in patients with traction injury of the brachial plexus., Conclusion: Sonography of the brachial plexus was technically feasible, although the entire brachial plexus could not be evaluated. Sonography appears to be a useful bedside imaging technique for assessing brachial plexus injury. The potential of sonography as a complementary diagnostic tool in the evaluation of these patients warrants further investigation.

Background: In recent studies a central nervous system involvement in the pathogenesis of Complex Regional Pain Syndrome (CRPS) was suggested, stimulating the introduction of central acting drugs. Animal studies have demonstrated an increased expression of the N-methyl-D-aspartate (NMDA) receptors in experimental neuropathic pain., Purpose: The aim of this study was to investigate the relationship between NMDA receptor blockers and CRPS., Method: Three patients suffering from CRPS of one upper extremity where treated with oral NMDA antagonist Memantine for eight weeks. Patients expressed their pain levels with a visual analog scale ranging from zero to ten at rest and after fist clenching. Furthermore, the range of movement of the fingers and the wrist were documented. To assess force, a pinchmeter and a dynamometer were used. Cortical reorganisation was studied with functional Magnetic Resonance Imaging (fMRI) and Magnetoencephalography (MEG)., Results: Six months after treatment with Memantine no rest pain was present in any of the patients. Furthermore, an increase in finger movement was observed after six-month follow-up with no deficits and free movement ranges. Additionally, wrist movement was improved and an increase of force was measured after six months with the dynamometer and the pinchmeter. Moreover the functional impairment, cortical reorganisation was observed in all patients before treatment. These changes returned to a normal pattern after eight weeks of treatment with Memantine., Conclusion: These first results demonstrate central nervous system involvement in the development and maintenance of CRPS. The results (functional, pain, fMRI, MEG) after treatment with Memantine indicate the importance of the NMDA receptor system in neuropathic pain syndromes and provide a promising approach for the treatment of CRPS.

Object: In a rat model, nerve regeneration was evaluated across a 2-cm defect in the median nerve by using a resorbable artificial nerve conduit. The aim of this study was to develop an artificial, biocompatible nerve guide to induce regeneration in the peripheral nervous system., Methods: The authors compared a nerve conduit of trimethylenecarbonate-co-epsilon-caprolactone (TMC/CL) filled with autologous Schwann cells with both an empty hollow conduit and an autologous nerve graft. Animals that did not undergo surgery served as the control group. Nerve regeneration was evaluated with the grasping test, histological analysis of the nerve, muscle weight analysis (flexor digitorum superficialis muscle), and electrophysiological examination. After an observation period of 9 months, regeneration occurred only in animals that had received an autologous graft or a Schwann cell containing nerve conduit. No signs of regeneration were found in animals supplied with the empty conduit., Conclusions: Results of this study reveal the important role of Schwann cells in the regeneration process across a 2-cm defect in the rat median nerve. Furthermore, Schwann cell-filled nerve conduits induced functional recovery, as demonstrated in the grasping test, that was comparable with that of the autologous graft 9 months after implantation.

We report our experience of vascularized bone graft harvested from the volar aspect of the distal radius for carpal bone reconstruction. Thirty cadaveric dissections showed in all cases the volar carpal artery which born from the radial artery. Between 1994 to 2001, we treated 87 scaphoid non-unions with an average follow-up of 41 months (range 6 to 65 months). Union was obtained in 80 patients (92%) with an average delay of 8.6 weeks (range 6 to 24). Between 1994 to 2000 we treated 22 patients with a Kienbock's disease. A radius shortening was always added to the revascularization of lunate by this vascularized bone graft. Preoperative and postoperative MRI was systematically done. The average follow-up was 55 months (range 24 to 92 months). MRI showed healing with good revascularization in 16 cases (74%). Lesions of lunate were stabilized in five cases and we had one failure with secondary palliative procedure. This simple but meticulous technique needs only one approach and allows a sufficient revascularisation.

Transfer of the latissimus dorsi to the rotator cuff is widely used for restoring shoulder abduction and external rotation in sequelae of brachial plexus palsy; however, its long-term results are not well known. Because persistence of clinical benefits is crucial for children with brachial plexus palsy, the aim of our study was to evaluate retrospectively the long-term results of this transfer in 203 children. Patients were classified according to type of paralysis (C5-C6, C5-C6-C7, and complete), degree of preoperative shoulder function according to Gilbert, and age at surgery. Active abduction and external rotation were measured at 1, 3, 6, 10, and 15 years and the results were analyzed statistically. Children with sequelae of C5-C6 palsy gained in abduction and external rotation more than children with C5-C6-C7 or complete palsy. Patients with mild preoperative shoulder dysfunction achieved the best results. The data showed the clinical results were related to the type of paralysis and to preoperative shoulder function, but not to age at surgery. They also showed progressive deterioration of abduction began at 6 years despite preserved active external rotation.

From 1978 to 2002, the authors have operated on 723 babies for obstetric brachial plexus repair. Complete paralyses and associated root ruptures and avulsions are severe, and the results cannot be evaluated before the end of growth. A series of 73 patients operated on from 1978 to 1994 were followed with a mean follow-up of 6.4 years. Secondary operations (mainly on the shoulders) were necessary 123 times. Although the results show that the shoulders and elbows did not do as well as in upper-type lesions, the results at the level of the hand were encouraging, showing 75% useful results after 8 years, even in patients with avulsion injuries of the lower roots. These results demonstrate the usefulness of early exploration and repair of the obstetric plexus.