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Purpose: To compare the long-term results of transfers of the ipsilateral C7 (IC7) plus spinal accessory nerve (SAN) with those of triple nerve transfers (TNT) using one fascicle of the ulnar nerve to the biceps motor branch (Oberlin's procedure), SAN transferred to the suprascapular nerve, and transfer of the long head of triceps nerve branch to the anterior branch of axillary nerve to treat C5-C6 avulsion of the brachial plexus., Methods: The IC7 group included 9 patients undergoing transfers of IC7 to the upper trunk and SAN to the suprascapular nerve. Median age at surgery was 26 years and interval between injury and surgery was 2.8 months. Patients were observed for a median of 118 months. The TNT group contained 13 patients, median age 33 years; interval between injury and surgery was 3.1 months. Patients were observed for a median of 103 months., Results: In the IC7 group, median shoulder abduction was 105° and median external rotation of the shoulder was 64°, which was similar to that of the TNT group (89° abduction and 58° external rotation). Eight of nine patients recovered at least M3 (Modified Narakas scale) strength of deltoid in the IC7 group, which was similar to that in the TNT group (11 of 13 patients). Six of nine patients achieved at least Medical Research Council grade 3 (MRC3) strength of biceps in the IC7 group, which was similar to that in the TNT group (11 of 13 patients). Of 4 patients in the IC7 group with a preoperative latissimus dorsi strength of MRC3 or less, 3 gained a deltoid strength of M3 or less, and 3 a biceps strength of MRC2 or less., Conclusions: Transfers of IC7 plus SAN provide results comparable to those of TNT for treatment of C5-C6 avulsion., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2020 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: The study was to explore whether the 3-dimensional printing guiding plate system could facilitate the modified procedure for arthroscopic treatment of nondisplaced scaphoid nonunion., Methods: Patients, diagnosed with scaphoid nonunion without displacement, were randomly assigned into two groups. In Group A, the 3-dimensional printing guiding plate system was used for guiding fixation during the surgery. In Group B, fixation was performed with intra-operative fluoroscopy. The bone operation time was recorded during the surgery. The patients were evaluated before surgery and followed-up after six post-operative months, including motion ratio, strength ratio, Visual Analogue Scale, modified Mayo Scores, Patient Rated Wrist Evaluation scores, plain radiography and CT scan., Results: Sixteen patients were recruited for the study. The average bone operation time in Group A was statistically shorter than that in Group B., Conclusions: 3-dimensional printing technique-assisted arthroscopic bone graft and fixation of scaphoid nonunion constitute an effective and accurate clinical treatment option., The Translational Potential of This Article: The concept and technique of 3D printing assisted percutaneous fixation introduced in this paper have the potential to be applied in a variety of operations requiring accurate percutaneous fixation, especially for the joint injuries., Competing Interests: The authors have no conflicts of interest to disclose in relation to this article., (© 2020 The Authors.)

Objective: Major histocompatibility complex class I (MHCI), paired-immunoglobulin-like receptor B (PirB), and cluster of differentiation 3ζ (CD3ζ) negatively regulate neuronal plasticity in developing and adult brains. The aim of this study was to evaluate expressive changes of these factors in motor cortical representations of the brachial plexus (MCRBP) after total brachial plexus root avulsion (tBPRA)., Methods: A total of 45 rats were randomly and equally divided into 3 groups for evaluating mRNA and protein expression levels of MHCI, PirB, and CD3ζ: 7 days, 3 months, and control. In the 7-day and 3-month groups, expressions were examined at 7 days and 3 months, respectively, after left tBPRA. In the control group, the brachial plexus was uninjured. Three rats from each group were used for examining expressions of MHCI, PirB, and CD3ζ proteins by immunofluorescence labeling, 6 rats for quantification of MHCI, PirB, and CD3ζ mRNAs by real-time quantitative polymerase chain reaction, and the remaining 6 animals for quantification of MHCI, PirB, and CD3ζ proteins by Western blotting., Results: In the original MCRBP, mRNA and protein expression levels of MHCI, PirB, and CD3ζ were down-regulated 7 days postinjury compared with control (P < 0.01). Interestingly, mRNA and protein expression levels of these factors were up-regulated at 3 months compared with 7 days (P < 0.01), excepting PirB protein, whose expression was not increasing (P > 0.05). Recovery of protein expressions were initiated from near the border region of the original MCRBP., Conclusions: MHCI, PirB, and CD3ζ may participate in motor cortical reorganization after tBPRA., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Brachial plexus injury (BPI) is a serious peripheral nerve injury, and clinical outcomes are generally unsatisfactory. It has been reported that cortical plasticity could influence the restoration of motor function. However, the neurologic mechanism of BPI is unclear, which provides a basis for further investigation. The supplementary motor area (SMA) plays an important role in the regulation of motor function. This study aims to explore SMA-whole brain functional connectivity after deafferentation of the brachial plexus., Methods: Study subjects included 16 patients with BPI and 8 healthy volunteers. The seed region was defined by a block-design functional magnetic resonance imaging program that used unilateral imaginary hand grasp motion as a task stimulus. Next, the voxel-wise functional connectivity between the predefined region and the other regions of the brain was calculated., Results: We discovered decreased voxel-wise functional connectivity between the SMA and multiple brain regions, including precuneus, posterior cingulum cortex, and anterior cingulum cortex, that are closely associated with information integration or motor processing in patients with BPI., Conclusions: Patients with BPI showed weakened functional connectivity between hand grasp-related areas and the SMA and multiple regions associated with motor processing or information integration. A clear image of the functional status of the brain after deafferentation was provided. On the basis of this discovery, a relationship between changes in neuroimaging measurements and clinical outcomes can be determined in future studies., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Previously, we have reconstructed the motor function of patients with C7-T1 brachial plexus palsies through combined nerve and tendon transfers. However, these patients lose not only the motor function of the hand but also the sensation on the ulnar side of the hand. Without sensory recovery, the injured hand may be further damaged, particularly by burns in this contact zone. Therefore, we described a technique to restore the sensation at the ulnar aspect of the hand by performing a transfer of the radial branch of the superficial radial nerve to the sensory branch of the ulnar nerve., (Copyright © 2015. Published by Elsevier Ltd.)

Objective: We assessed the diagnostic value of triple stimulation technique (TST) in eight patients with neurogenic thoracic outlet syndrome (TOS) by revealing the conduction block of the proximal lower trunk of the brachial plexus and locating the compression site., Methods: Eight patients fulfilling the conventional criteria of the lower-trunk neurogenic TOS were enrolled in our study. TST along with the central motor-conduction time was evaluated. The parameters including the TST amplitude ratio and the TST area ratio were compared between patients and controls., Results: The amplitude ratio was significantly lower in the patient group than in the control group (patients: 0.518 ± 0.113; control: 0.954 ± 0.020, P<0.01), so was the area ratio (patients: 0.453 ± 0.194; control group: 0.955 ± 0.192, P<0.01). No significant difference of central motor-conduction time (CMCT) was seen between the patient group and the control group (patients: 6.62 ± 0.36 ms; control: 6.54 ± 0.36 ms; P=0.528). Surgical procedures proved the compression of the lower trunk in all patients., Conclusion: Our results indicated that there was conduction block besides axon loss in neurogenic TOS patients, and the conduction block was located between the nerve root emerging site and the supraclavicular stimulation site., Significance: We first applied TST in diagnosing neurogenic TOS, and we showed that the patient's TST ratio was significantly lower than normal. Combined with clinical manifestations, TOS can be more precisely diagnosed., (Copyright © 2015 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.)

Objective: Total brachial plexus avulsion injury (BPAI) results in the total functional loss of the affected limb and induces extensive brain functional reorganization. However, because the dominant hand is responsible for more cognitive-related tasks, injuries on this side induce more adaptive changes in brain function. In this article, we explored the differences in brain functional reorganization after injuries in unilateral BPAI patients., Methods: We applied resting-state functional magnetic resonance imaging scanning to 10 left and 10 right BPAI patients and 20 healthy control subjects. The amplitude of low-frequency fluctuation (ALFF), which is a resting-state index, was calculated for all patients as an indication of the functional activity level of the brain. Two-sample t-tests were performed between left BPAI patients and controls, right BPAI patients and controls, and between left and right BPAI patients., Results: Two-sample t-tests of the ALFF values revealed that right BPAIs induced larger scale brain reorganization than did left BPAIs. Both left and right BPAIs elicited a decreased ALFF value in the right precuneus (P < 0.05, Alphasim corrected). In addition, right BPAI patients exhibited increased ALFF values in a greater number of brain regions than left BPAI patients, including the inferior temporal gyrus, lingual gyrus, calcarine sulcus, and fusiform gyrus., Conclusion: Our results revealed that right BPAIs induced greater extents of brain functional reorganization than left BPAIs, which reflected the relatively more extensive adaptive process that followed injuries of the dominant hand., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Ulnar impaction syndrome generally occurs with positive ulnar variance. The solution to the problem is to unload the ulnocarpal joint. Effective surgical options include diaphyseal ulnar shortening osteotomy, open wafer osteotomy, and arthroscopic wafer osteotomy. Recently, Slade and Gillon described an open procedure of ulnar shortening in the osteochondral region of the ulnar head. The procedure minimizes the risk of hemarthrosis and does not require hardware removal, which are problems with other surgical options. This article introduces a new arthroscopic technique of distal metaphyseal ulnar shortening osteotomy for ulnar impaction syndrome. This technique offers the advantages of minimizing surgical injury to the dorsal capsule of the distal radoulnar joint and so protects its stability., (Copyright © 2013 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To explore long-term recovery of elbow flexion and extension after transferring the phrenic nerve and intercostal nerves, respectively, in adults with global brachial plexus avulsion injuries., Methods: Seven adults with global brachial plexus avulsion injuries had the phrenic nerve transferred to the musculocutaneous nerve (or to the anterior division of upper trunk) and intercostal nerves transferred to the triceps branch of the radial nerve at our hospital 7 to 12 years ago. The results of elbow motor strength testing using the Medical Research Council grading scale, and electrodiagnostic findings using electromyogram examinations, were studied retrospectively. Pulmonary function tests were also performed at final visits., Results: Functional elbow flexion was obtained in most of the 7 cases (M2, 1; M3, 3; M4, 2; and M5, 1) but elbow extension was absent or insufficient in all subjects (M0, 1; M1, 3; and M2, 3). Electrical results showed successful biceps reinnervation in 6 patients and successful triceps reinnervation in 5. No patient experienced breathing problems, and pulmonary function results were within normal range., Conclusions: In the long term, after brachial plexus avulsion injury in most patients who underwent both phrenic nerve and intercostal nerve transfer to achieve elbow flexion and extension eventually obtained satisfactory elbow flexion but poor elbow extension. We recommend against transferring the intercostal nerves to the triceps branch of radial nerve in conjunction with primary phrenic to musculocutaneous nerve transfer., Type of Study/level of Evidence: Therapeutic IV., (Copyright 2010 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

We investigated the distribution of sympathetic preganglionic fibers in each spinal nerve of the brachial plexus, and its correlation with presence of Horner's syndrome in the pup and adult rats. According to surgical intervention to the C7-T1 spinal nerves in the right side, rats of 7 days postnatal (P7), P14 and adulthood (24 for each age group) were subdivided into four subgroups of six each, respectively, i.e., C7 or C8 or T1 spared subgroup--where C7 or C8 or T1 alone was kept intact with avulsion of the other two spinal nerves and division of the sympathetic chain caudal to the stellate ganglion; C7-T1 avulsed subgroup--where C7-T1 were all avulsed but the sympathetic chain kept intact. Fluoro-Gold (FG) was injected bilaterally into the superior cervical ganglion (SCG) for labeling of sympathetic preganglionic neurons (SPNs). Furthermore, Horner's syndrome was examined after avulsion of different spinal nerves for P14 and adult rats. In C7 spared subgroups, FG-labeled neurons accounted averagely for 16.9% in P7, 13.5 in P14 and 1.0 in adult rats, and difference was statistically significant between P7 and adults (Z=-2.9, P=0.004), P14 and adults (Z=-2.9, P=0.004). When both C7 and C8 were avulsed, Horner's syndrome was more prone to be produced in pups than in adults (chi(2)=4.2, P=0.04). These results indicate that some SPNs project to SCG via C7 in the pup, but this pathway disappears during postnatal development. It suggests that in newborns with brachial plexopathy, presence of Horner's syndrome may be correlated with avulsion of C7., (2009. Published by Elsevier B.V.)

Purpose: To retrospectively determine the risks and benefits of contralateral C7 nerve root transfer in infants and children., Methods: In 12 infants and children with brachial plexus root avulsions from birth injury or other trauma, the common trunk of the contralateral C7 root was transferred to the trunk, division, cord, or nerve branch(es) on the affected side with 2 different types of interposition grafts. The surgery was performed in 1 stage for 5 patients and in 2 stages for 7 patients., Results: Patients were followed up for a mean of 42 months, with a minimum of 21 months. Noteworthy function (> or = M2+, modified British Medical Research Council grading system) was gained in 10 of 12 patients and sensory function (> or = S3, British Medical Research Council grading system) was gained in all patients. Improvements in strength and sensation were accompanied by little synchronous motion and sensibility changes in the donor limb in 7 children, to whom the repaired nerves were those innervating the shoulder and/or elbow or both the musculocutaneous and median nerves. In addition to slight damage to the sensory function of the median nerve, 2 infants also had temporarily reduced shoulder abduction on the healthy side., Conclusions: For contralateral C7 transfer in infants and children with brachial plexus root avulsions, the deficit created by the procedure is minimal and motor and sensory function is gained. Transfer of the contralateral C7 root to different nerves for a child may improve the quality of functional recovery., Type of Study/level of Evidence: Therapeutic, Level IV.