Nerve Transposition Research Articles

Does the Surgical Assistant Influence Perioperative Outcomes Surrounding Cubital Tunnel Surgery?

Background: Ulnar neuropathy at the elbow is the second most common upper extremity compressive neuropathy and surgical treatment often involves surgical trainee involvement. The primary aim of this study is to determine the effect of trainees and surgical assistants on outcomes surrounding cubital tunnel surgery. Methods: This retrospective study included 274 patients with cubital tunnel syndrome who underwent primary cubital tunnel surgery at two academic medical centres between 1 June 2015 and 1 March 2020. The patients were divided into four main cohorts based on primary surgical assistant: physician associates (PA, n = 38), orthopaedic or plastic surgery residents (n = 91), hand surgery fellows (n = 132), or both residents and fellows (n = 13). Exclusion criteria included patient age <18 years, revision surgery as the index procedure, prior traumatic ulnar nerve injury and concurrent procedures not related to cubital tunnel surgery. Demographics, clinical variables and perioperative findings were collected through chart reviews. Univariate and bivariate analyses were performed, and p < 0.05 was considered significant. Results: Patients in all cohorts had similar demographic and clinical characteristics. There was a significantly higher rate of subcutaneous transposition in the PA cohort (39.5% PA vs. 13.2% Resident vs. 19.7% Fellow vs. 15.4% Resident + Fellow). Presence of surgical assistants and trainees had no association with length of surgery, complications and reoperation rates. Although male sex and ulnar nerve transposition were associated with longer operative times, no explanatory variables were associated with complications or reoperation rates. Conclusions: Surgical trainee involvement in cubital tunnel surgery is safe and has no effect on operative time, complications or reoperation rates. Understanding the role of trainees and measuring the effect of graduated responsibility in surgery is important for medical training and safe patient care. Level of Evidence: Level III (Therapeutic).

Efficacy and safety of anteriortransposition of the ulnar nerve for distal humerus fractures: A systematic review and meta-analysis.

This systematic review and meta-analysis was performed to summarize available evidence of anterior transposition of the ulnar nerve for patients with distal humerus fractures. The databases were searched from PubMed, Cochrane, Embase, Scopus, Web of Science, Chinese National Knowledge Infrastructure (CNKI), Chongqing VIP Database (VIP), and Wan Fang Database up to June 2022. The clinical outcome included operation time, fracture healing time, hospital stays, elbow joint function, and ulnar neuritis rate. Statistical analysis was performed with Review Manager 5.3 (Cochrane Collaboration). A total of 17 studies were included (8 RCTs and 9 retrospective studies), and 1280 patients were analyzed. The results of this meta-analysis showed anterior transposition group had longer operation time (MD = 20.35 min, 95%CI: 12.56-28.14, P < 0.00001). There was no significant difference in fracture healing time (SMD = -0.50, 95%CI: -1.50-0.50, P = 0.33), hospital stays (MD = -1.23 days, 95%CI: -2.72--0.27, P = 0.11), blood loss (MD = 2.66 ml, 95%CI: -2.45-7.76, P = 0.31), and ulnar neuritis rate (OR = 1.23, 95%CI: 0.63-2.42, P = 0.54) between two groups. Finally, elbow joint motion, elbow joint function, fracture nonunion, and post-operative infection (P > 0.05) between two groups were not significantly statistic difference. This meta-analysis showed that anterior transposition group is not superior to non-transposition group for patients with distal humerus fractures without ulnar nerve injury. On the contrary, non-transposition group have shorter operation time than that of anterior transposition group. Non-transposition group did not increase the post-operative ulnar neuritis rate. Therefore, both anterior transposition group and non- transposition group are the treatment options for patients with distal humerus fractures without ulnar nerve injury. Besides, these findings need to be further verified by multi-center, double-blind, and large sample RCTs.

Distal anterior interosseous nerve to ulnar nerve motor branch reverse end-to-side transfer in a case of severe ulnar neuropathy.

Reverse end-to-side (RETS) distal transfer is gaining popularity in cases of proximal nerve damage with the nerve in continuity, allowing the nerve to potentially retain its ability to regenerate and recover. While preserving the original axon pool, RETS could provide an additional pool of motor axons and/or possibly "babysit" the muscle endplates and distal denervated nerve Schwann cells until reinnervation from the original pool occurs. The authors present a video demonstrating anterior subcutaneous transposition of the ulnar nerve at the elbow coupled with a distal anterior interosseous nerve to ulnar nerve RETS in a case of severe posttraumatic ulnar neuropathy at the elbow. The video can be found here: https://stream.cadmore.media/r10.3171/2022.9.FOCVID2282.

Surgical bone augmentation procedures for oral rehabilitation of patients with oligodontia: A review with a systematic approach

Oligodontia is a developmental dental anomaly defined by the absence of 6 or more permanent teeth, excluding the third molars. We performed a review with a systematic approach and proposed a guideline for the choice of the bone augmentation surgery. The different bone augmentation technique terms were searched in the PubMed and Science Direct database. Clinical studies were eligible if they reported on pre-implant surgery in patients with oligodontia. The database search yielded 400 studies after duplicates removed. Thirty studies were finally included, involving 410 patients. Sixty-three sinus lifts were performed in 37 patients with no failure. Thirteen out of 33 patients with iliac bone transplantation and two out of 24 with parietal bone transplantation had resorption, one out of 4 patients who received allogeneic bone block had complete failure. Seventy-eight patients underwent guided bone regeneration, none had bone loss. No failure was found with the alveolar distraction osteogenesis technique. Four out of thirteen patients developed permanent hypoesthesia after inferior alveolar nerve transposition. The cumulative implant survival rate was 94.4% after bone augmentation procedures. Extensive edentulous areas should be grafted with parietal bone, as iliac grafts present a greater risk of resorption. Smaller edentulous areas should be treated by endobuccal harvesting or guided bone regeneration. Osteogenesis distraction and nerve transposition are effective surgeries for medium-to-large mandibular edentulous spaces. The implant survival rate is not significantly different between implants placed in grafted and nongrafted bone, the appropriate choice of bone augmentation technique can reduce the risk of peri‑implant bone resorption.

DIFFICULTIES IN RECOVERING THE ELBOW JOINT AFTER INJURIES

The unique qualities of the elbow joint as a result of its specific function in the upper extremity make it well studied. The elbow functions by employing the concerted activity of its musculotendinous and bony structures. The shoulder determines the special position of the limb, whereas the elbow regulates the limb length and height to optimize the hand position and function. The evaluation of an elbow injury depends on the correlating symptoms and the history with a careful physical and radiographic examination. The high degree of congruity of the articular surfaces and the relatively small capsular volume makes the elbow joint very complicated. Any significant distortion of the normal anatomy, including bony deformity (congenital post-traumatic), bony or fibrous ankylosis and in some cases, prior surgery (ulnar nerve transposition) plays a major role in its functional recovery. It is often impossible to identify the exact etiologic abnormality responsible for the elbow stiffness and pain. This is one of the most frustrating aspects of treating patients with elbow trauma. There are many theoretic explanations of the possible etiologies, responsible for the common types of elbow joint complications, concerning the anatomic structure, physiologic abnormality or biomechanical alteration responsible for the problems of reaching full range of motion.

Endonasal Exposure of Lateral Recess of the Sphenoid Sinus: Significance of Pterygoid Process Pneumatization.

Caudal pneumatization of the pterygoid process may impact endonasal exposure of the lateral recess of sphenoid sinus (LRSS). This study aims to explore the implications of a pneumatized pterygoid process for an endonasal transpterygoid approach to the LRSS and to define strategies regarding the preservation or sacrifice of the vidian nerve. Dissection of the LRSS (11 sides) was performed on 6 cadaveric specimens, preselected for the radiographic presence of an LRSS. In addition, the dimensions of the LRSS were measured on the deidentified CT images of 120 patients (240 sides). The sphenoid sinus was subdivided into 3 categories: Type 1 (no identifiable LRSS), Type 2 (lateral pneumatization of the greater wing above the vidian canal), and Type 3 (pneumatization of both the greater wing and the pterygoid process). On the cadaveric specimens, a Type 2 pneumatization often allowed access to the LRSS above the level of the vidian canal; thus, sparing the vidian neurovascular bundle. In Type 3 pneumatization, a frontal corridor through the pterygoid base could be created to reach the LRSS with preservation of the vidian nerve. Extreme Type 3 pneumatization, however, required the transposition or sacrifice of the vidian nerve to facilitate a full direct access to the superolateral LRSS. Measurements on CT images revealed that the extent of caudal pneumatization of the pterygoid process had no statistically significant correlation with the superolateral extension of the lateral recess in patients with Type 3 LRSS (P > .05). Pneumatization of the LRSS toward a caudal or superolateral direction may develop independent from each other. Caudal pneumatization of the pterygoid process seems to variably impact the endonasal exposure of the LRSS.

Evaluation of outcome in arc of motion of elbow after arthrolysis in post-traumatic stiff elbow through posterior triceps reflecting anconeus pedicle approach

Background: The elbow is a synovial hinge joint, with a high chance of stiffness. A stiff elbow is an elbow with a loss of extension of &gt;30° and flexion of &lt;120 which can result due to post-traumatic events around elbow. Surgical intervention is required if conservative treatment fails. The arthrolysis of the elbow by posterior approach has been reported less widely. Aims and Objectives: This study aims at reporting the arc of motion of the elbow after arthrolysis by posterior approach by TRAP approach. Material and Methods: This study was done on 26 patients with post-traumatic elbow stiffness through posterior triceps reflecting anconeus pedicle graft approach. The mean age of patients in our study is 30.8, ranging from 15 to 54 years. After surgery, patients were reviewed to assess arc of motion and fixed flexion deformity (FFD) improvement, MAYO and oxford score. Results: Our study showed increase in arc of motion from 50.7° to 90.7°, FFD decrease from 31.3° to 18.2° and MAYO score which had a pre-operative mean of 77.3, increased to 90 postoperatively with excellent result in 18 cases (69.2%) and good in eight cases (30.8%). Oxford score had an improvement from 21.8 to 40.3 showing satisfactory result in 11 cases. Conclusion: The approach described in our study is ideal for posterior bony blocks with maintaing intact extensor mechanism and less chance of neurovascular damage. Stability of the joint is maintained with feasability to do ulnar nerve transposition.

Variety of thoracodorsal nerve branching variants

Background. Accurate knowledge of the anatomy of all branches of peripheral nerves is necessary for successful neurotization and muscle plasty.&#x0D; Aim. Anatomical substantiation of the use of branches of the thoracodorsal nerve in neurotization and muscle plasty.&#x0D; Material and methods. The study was carried out on 121 preparations of the thoracodorsal nerve and the latissimus dorsi muscle from 105 cadavers of men and women aged 36100 years. Variants of extra- and intramuscular branching of the thoracodorsal nerve were studied, a classification was developed and the possibilities of using it in reconstructive surgery were shown. A database was formed from the obtained indicators in the MS Excel 2012 program, and their processing was carried out using Statistica for Windows 12. The article presents only those indicators that do not follow the normal distribution according to the single-sample ShapiroWilk test. When describing the studied indicators, the median (Me) and quartile values (Q1, Q3) were determined.&#x0D; Results. Anatomical layering and macromicroscopic dissection revealed 13 variants of extramuscular branching of the thoracodorsal nerve, which were combined into three groups. In the first group, which is 6.6%, the thoracodorsal nerve penetrates the latissimus dorsi muscle in one trunk and is divided into intramuscular branches of the first and second orders. In the second group (40.5%), the thoracodorsal nerve is divided into extramuscular branches of the first order, which penetrate into the latissimus dorsi muscle and branch into intramuscular branches of the first and second orders. In the third group (52.9%), the thoracodorsal nerve branches into extramuscular branches of the first and second orders, which are divided in the latissimus dorsi muscle into intramuscular branches of the first and second orders.&#x0D; Conclusion. The thoracodorsal nerve is characterized by 13 variants of extramuscular and a wide variety of intramuscular branching, which is a factor that determines the tactics of nerve transposition and muscle plasty.

A Comprehensive Review of Cubital Tunnel Syndrome.

Cubital Tunnel Syndrome (CuTS) is the compression of the ulnar nerve as it courses through the cubital tunnel near the elbow at the location colloquially referred to as the "funny bone". CuTS is the most commonly diagnosed mononeuropathy after carpal tunnel syndrome. Cubital tunnel syndrome can manifest as numbness, tingling, or pain in the ring/small fingers and dorsoulnar hand. Repetitive pressure, stretching, flexion, or trauma of the elbow joint are known causes of CuTS. Chronic ulnar nerve compression and CuTS, when left untreated, can lead to atrophy of the first dorsal interosseus muscle and affect one's quality of life to the point that they are no longer able to participate in daily activities involving fine motor function. It is estimated that up to 5.9% of the general population have had symptoms of CuTS. CuTS is underdiagnosed due to lack of seeking of treatment for symptoms. Compression or damage to the ulnar nerve is the main cause of symptoms experienced by an individual with CuTS. Repetitive elbow pressure or a history or elbow joint trauma or injury are additional known causes that can lead to CuTS. Common presentations of CuTS include paresthesia, clumsiness of the hand, hand atrophy and weakness. The earliest sign of CuTS is most commonly numbness and tingling of the ring and 5th finger. Older patients tend to present with motor symptoms of chronic onset; younger patients tend to have more acute symptoms. Pain and point tenderness at the medial elbow may also be seen. CuTS lacks universally agreed upon diagnostic and treatment algorithms. CuTS can be diagnosed by physical exam using Tinel's sign, flexion-compression tests, palpating the ulnar nerve for thickening presence of local tenderness along the nerve. Ultrasound and nerve conduction studies may be used in combination with physical exam for diagnosis. Conservative treatment for CuTS is almost always pursued before surgical treatment and includes elbow splints, braces, and night-gliding exercises. Surgical treatment may be pursued in severe CuTS refractory to conservative treatment. Surgical options include open and endoscopic in-situ decompression, medial epicondylectomy, and anterior transposition of the ulnar nerve. CuTS is a prevalent disease that, if left untreated, can significantly alter an individual's quality of life. Therefore, an accurate diagnosis and appropriate treatment is paramount in reducing further damage and preventing worsening or future symptoms.

Clinical Outcomes of Ulnar Collateral Ligament Surgery in Nonthrowing Athletes

Background: Ulnar collateral ligament (UCL) surgery continues to demonstrate excellent clinical outcomes and a high return-to-play (RTP) rate with a low complication rate. Recent studies have demonstrated similar clinical outcomes for baseball players who have undergone either UCL reconstruction or UCL repair. In comparison, few studies have assessed the clinical outcomes of UCL surgery for nonthrowing athletes. Purpose/Hypothesis: The primary objective of this study is to provide clinical outcomes of UCL surgery performed in nonthrowing athletes at a single institution with a minimum 2-year follow-up. Our hypothesis was that these patients would have similar clinical outcomes, complication rates, and RTP rates when compared with throwing athletes. Level of Evidence: Case series; Level of evidence, 4. Methods: From our longitudinal elbow registry, 40 nonthrowing athletes were identified who underwent UCL surgery (repair or reconstruction) between 2011 and 2019. Participant characteristics were recorded: age, sex, laterality, arm dominance, sport, level of competition, and type of surgery (UCL repair or reconstruction). Outcomes included RTP rate and average time, American Shoulder and Elbow Surgeons (ASES) scores, and complications. Results: From the 40 patients eligible for inclusion in this study with a minimum 2-year follow-up, 37 (93%) were successfully contacted: 16 male (43%) and 21 female (57%). Mean ± standard deviation age at the time of surgery was 18.0 ± 3.7 years. From the 37 technical procedures, 28 (76%) were UCL repairs and 9 (24%) were UCL reconstructions. For these patients, 15 (41%) had partial tears, 20 (54%) had complete tears, 1 (3%) had a medial epicondyle avulsion, and 1 (3%) had an unspecified pathology. Sports included football (n = 11), gymnastics (11), cheerleading (7), wrestling (4), volleyball (2), basketball (1), and acrobatics (1). Quarterbacks were excluded from the football patients, as quarterbacks are throwing athletes. Level of competition included high school (n = 26), college (8), professional (2), and youth sports (1). The RTP rate was 93% (26/28) at a mean 7.4 months for UCL repair and 100% (9/9) at a mean 10.0 months for UCL reconstruction. Mean ASES scores were 94.4 and 98.7 for UCL repair and reconstruction, respectively. Complications were low, with 2 patients in the UCL repair group requiring ulnar nerve transposition for ulnar nerve paresthesia. Conclusion: In nonthrowing athletes, patients undergoing UCL repair and UCL reconstruction show favorable outcomes at minimum 2-year follow-up. RTP and clinical outcomes are consistent with previous studies in baseball players as well as a parallel ongoing study conducted on non–baseball throwing athletes.

Controlling axonal regeneration with acellular nerve allograft limits neuroma formation in peripheral nerve transection: An experimental study in a swine model.

Symptomatic neuromata are a common indication for revision surgery following amputation. Previously described treatments, including traction neurectomy, nerve transposition, targeted muscle re-innervation, and nerve capping, have provided inconsistent results or are technically challenging. Prior research using acellular nerve allografts (ANA) has shown controlled termination of axonal regrowth in long grafts. The purpose of this study was to determine the ability of a long ANA to prevent neuroma formation following transection of a peripheral nerve in a swine model. Twenty-two adult female Yucatan miniature swine (Sus scrofa; 4-6months, 15-25 kg) were assigned to control (ulnar nerve transection only, n= 10), treatment (ulnar transection and coaptation of 50 mm ANA, n= 10), or donor (n= 2) groups. Nerves harvested from donor group animals were treated to create the ANA. After 20 weeks, the transected nerves including any neuroma or graft were harvested. Both qualitative (nerve architecture, axonal sprouting) and quantitative histologic analyses (myelinated axon number, cross sectional area of nerve tissue) were performed. Qualitative histologic analysis of control specimens revealed robust axon growth into dense scar tissue. In contrast, the treatment group revealed dwindling axons in the terminal tissue, consistent with attenuated neuroma formation. Quantitative analysis revealed a significantly decreased number of myelinated axons in the treatment group (1232 ± 540) compared to the control group (44,380 ± 7204) (p< .0001). Cross sectional area of nerve tissue was significantly smaller in treatment group (2.83 ± 1.53 mm2 ) compared to the control group (9.14 ± 1.19 mm2 ) (p= .0012). Aberrant axonal growth is controlled to termination with coaptation of a 50 mm ANA in a swine model of nerve injury. These early results suggest further investigation of this technique to prevent and/or treat neuroma formation.

Expanding the Surgeon's Armamentarium: Use of the Tubing Technique to Preserve the Inferior Alveolar Nerve During Transposition Procedure.

Severe edentulous posterior mandible atrophy with inadequate bone height superior to the inferior alveolar canal may increase the risk of neurosensory impairment and other complications during inferior alveolar nerve (IAN) transposition (IANT) prior to dental implant insertion. The current report describes the tubing technique as a practical and feasible procedure that ensures IAN preservation during IANT. The technique involves wrapping a standard suction catheter around the exposed nerve to facilitate full coverage. This work presents a retrospective review of 31 patients undergoing IANT procedures followed by immediate placement of dental implants between January 2015 and January 2020. IANT was performed either unilaterally or bilaterally on all patients, followed by IAN tubing before implant placement. A total of 46 IANT procedures involving the tubing technique were performed. Overall, 149 dental implants were inserted during IANT surgeries, with a success rate of 98.6%. Sensory disturbance was documented in 47.8% of the treated sites (left/right mandible) at 1 month (22/46 sites), 21.7% at 3 months (10/46 sites), 6.5% at 6 months (3/46 sites), and 2.2% at 12 months (1/46 sites) postimplantation. In total, except for 1 case, sensory disturbance was fully resolved by the end of the 12-month follow-up period. Taken together, the tubing technique described herein is a practical and reproducible method for protecting the IAN during transposition.

SHORT IMPLANTS IN POSTERIOR JAWS– A LITERATURE REVIEW

One of the greatest challenges that dentists face today is to rehabilitate severe atrophied alveolar ridges in partially and completely edentulous patients with implants. Loss of bone volume at the level of the posterior maxilla and mandible can complicate rehabilitation with implants, since it leads to a reduction in the distance to the maxillary sinus and the inferior alveolar nerve, respectively. Various techniques have been used for many years to avoid damaging these structures, such as alveolar ridge augmentation procedures, bone grafting, tooth nerve transposition, or even zygomatic implants. An alternative to these surgical treatments is the use of short implants in areas where bone availability is reduced.

Prevalence, management, and outcomes of nerve injury after shoulder arthroplasty: a case-control study and review of the literature

Neurologic injury is a rare and potentially devastating complication of shoulder arthroplasty. Patients typically present with a mixed plexopathy or mononeuropathy, most commonly affecting the axillary and radial nerves. Given the paucity of studies available on the topic, our goal was to elucidate the prevalence of nerve injury after shoulder arthroplasty and to describe the treatment course and outcomes of neurologic injuries. This is a retrospective case-control study performed at a single, urban, academic institution. Consecutive patients who underwent anatomic total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (RSA) by a single surgeon from 2014 to 2020 were reviewed, and patients with a documented nerve injury were identified. A control group of patients without nerve injury were selected in a 2:1 ratio controlling for age and procedure type (TSA vs. RSA; primary vs. revision). Data collected included demographics, comorbidities as per the Charlson Comorbidity Index, radiographic evaluations, surgical and implant details, patient-reported outcome measures, and perioperative complications. Of 923 patients, 33 (3.6%) sustained an iatrogenic nerve injury: 10 (2.1%) after TSA, 23 (5.0%) after RSA, and 3 (7.8%) after revision arthroplasty. Axillary mononeuropathy was most common (42%), followed by brachial plexopathies (18%). There was no significant difference in age, sex, race, body mass index, and preoperative diagnoses between groups. Patients with nerve injury had fewer comorbidities (Charlson Comorbidity Index <3, 33 vs. 65%, P<.001). Patients with nerve injury had higher rates of cervical spine pathology (15 vs. 6%; P= .15) and increased postoperative lateralization (8.9 mm [7.2] vs. 5.5 mm [7.3]; P<.06). The majority (91%) were managed with observation alone. Three (9%) underwent an additional procedure: carpal tunnel release (1, 3%), ulnar nerve decompression (1, 3%), and ulnar nerve transposition (1, 3%) for peripheral compressive neuropathies. At the final follow-up, 19 (57%) nerves fully recovered, and 14 (43%) showed mild residual sensorimotor dysfunction. The mean time to first sign of recovery and ultimate recovery were 11 (7.2) and 36 (23.5) weeks, respectively. At the final follow-up, patients with nerve injury performed worse on patient-reported outcomes, including visual analog score pain (2.2 vs. 1.0, P<.001), American Shoulder and Elbow Surgeons score (67.8 vs. 84.8, P<.001), and Single Assessment Numeric Evaluation scores (62 vs. 77, P= .009). Nerve injury after shoulder arthroplasty is rare, occurring in 3.6% of our patient population. Axillary mononeuropathy and brachial plexopathies are the most common. Most patients can be managed expectantly with observation and will recover at least partial nerve function, although clinical outcomes remain inferior to those without nerve complication.

What's New in Orthopaedic Trauma.

What's New in Orthopaedic Trauma.

Local Environment Induces Differential Gene Expression in Regenerating Nerves

IntroductionApproximately 80% of amputations are complicated by neuromas. Methods for neuroma management include nerve translocation into bone and implantation into skeletal muscle grafts, which have also facilitated the development of regenerative neural interfaces to enable fixation of prosthetics with motor and sensory feedback. However, molecular-level differences between nerves in these environments have not been investigated. This study aimed to elucidate the physiology of regenerating nerves in different settings by assessing gene expression. Materials and methodsNew Zealand white rabbits underwent transfemoral amputation with sciatic nerve transposition into the femur or tacked to skeletal muscle. At 5 wk, ribonucleic acid (RNA) sequencing of samples of distal nerve terminating in bone or muscle and nerve of the contralateral limb (control) identified differentially expressed genes (DEGs) and biochemical pathways (α = 0.05). ResultsThree samples of nerve housed in bone, four of nerve tacked to muscle, and seven naïve controls were analyzed. Relative to controls, nerve housed in bone had little within-group variation and 13,028 DEGs, and nerve tacked to muscle had dramatic within-group variation and 12,811 DEGs. These samples upregulated the following pathways: lysosome, phagosome, antigen processing/presentation, and cell adhesion molecule. Relative to nerve housed in bone, nerve tacked to muscle had 12,526 DEGs, demonstrating upregulation of pathways of B-cell receptor signaling, focal adhesion, natural killer–cell mediated cytotoxicity, leukocyte transendothelial migration, and extracellular matrix–receptor interactions. ConclusionsNerve housed in bone has a more predictable molecular profile than does nerve tacked to muscle. Thus, the intramedullary canal may provide a more reliable setting for neuroma prevention and neural interfacing.

Neural Reconstruction for Facial Nerve Palsy

The basic techniques of nerve reconstruction surgery for facial nerve palsy are end-to-end nerve suture and end-to-side nerve suture. The latter has the epineural window method and the partial neurectomy/neurotomy method for the treatment of "side" nerves. Hypoglossal-facial nerve cross-link graft is a method of nerve reconstruction in which the hypoglossal and facial nerves are bridged by autologous nerve transposition with end-to-side nerve suture. It has been shown to be effective in treating the sequelae of established facial nerve palsy, but there are some issues that prevent the achievement of stable results.

Paper 13: None: Clinical Outcomes of Ulnar Collateral Ligament Surgery in Non-Throwing Athletes

Objectives:Ulnar collateral ligament (UCL) surgery continues to improve since its inception by Dr. Frank Jobe in 1974. There is now ample data on the outcomes of surgery for throwing athletes, such as baseball players, who undergo either UCL reconstruction or UCL repair. In comparison, there is very little available data regarding outcomes of UCL surgery for non-throwing athletes who are seeking similar benefit from the procedure. The primary objective of this study is to provide clinical outcomes of UCL surgery performed in non-throwing athletes at a single institution with a minimum two-year follow-up.Methods:Forty non-throwing athletes who underwent UCL surgery (repair or reconstruction) between 2011 and 2019 were identified. All surgeries were performed by one of three fellowship-trained sports medicine surgeons at our institution utilizing a uniform technique for repair or reconstruction. Demographics were recorded including age, sex, laterality, arm dominance, sport, level of competition, and type of surgery (UCL repair or reconstruction). Outcomes included return to play (rate and average time), American Shoulder and Elbow Surgeons (ASES) scores, and complications.Results:Thirty-seven patients (92.5%) were available for evaluation with a minimum two-year follow-up consisting of 16 males (43%) and 21 females (57%). Mean age at the time of surgery was 18±3.7 years.28 UCL repairs (76%) and 9 UCL reconstructions (24%) were performed.Sports included football (n=11), gymnastics (11), cheerleading (7), wrestling (4), volleyball (2), basketball (1), and acrobatics (1). Quarterbacks were excluded from the football patients as quarterbacks are throwing athletes. Level of competition included youth (1), high school (26), college (8), and professional (2).Return to play rate was 93% (26 of 28) at a mean of 7.4 months for UCL repair, and 100% (9 of 9) at a mean of 10 months for UCL reconstruction.Mean ASES scores were 94.4 and 98.7 for UCL repair and reconstruction, respectively.Two Patients in the UCL repair group required ulnar neurolysis and revision ulnar nerve transposition.Conclusions:Both UCL reconstruction and UCL repair show favorable outcomes at minimum two-year follow-up in non-throwing athletes.93% or greater returned to play with good functional outcomes and minimal complications.Table 1.Patient CharacteristicsTable 2.Outcomes Comparison

Submuscular transposition of the ulnar nerve for persistent or recurrent cubital tunnel syndrome: Results of a prospective case series

Submuscular transposition (SMT) of the ulnar nerve is frequently performed as secondary procedure in patients with persistent or recurrent cubital tunnel syndrome (CuTS) despite previous surgery. Good results have been reported for this surgical strategy, but mainly in small retrospective case series. The goal of the present study is therefore to analyze the results prospectively using a patient-reported outcome measure (PROM): patient-rated ulnar nerve evaluation (PRUNE). SMT of the ulnar nerve was performed in 30 consecutive patients who were referred because of persistent or recurrent CuTS despite previous surgery. Objective outcome was measured in the outpatient clinic using the Likert scale. The PRUNE questionnaire was obtained pre-operatively, 6 weeks, 3 months, 6 months, and 12 months after the surgery. Simultaneously, 20 patients with primary surgery for CuTS, that underwent simple decompression, were followed. Good outcome (Likert 1 or 2) was obtained in 67% after SMT for persistent/recurrent CuTS and 85% after decompression as primary surgical treatment. PRUNE scores were significantly decreased in both groups at all follow-up moments after surgery compared with pre-operative for the total questionnaire and subscales "pain," "sensory/motor symptoms," and "specific activities." In both groups, PRUNE score remained stable until 12 months of follow-up. This prospective study confirms previous results from retrospective studies showing that SMT is an effective surgical option for persistent or recurrent CuTS. Prospective (randomized controlled) trials are needed to compare the effectiveness of SMT to the surgical alternative of subcutaneous transposition of the ulnar nerve.

Comparison of Surgical Treatment Outcomes of Pediatric Medial Epicondyle Fractures With and Without Elbow Dislocation

The aim of this study was to compare surgical treatment outcomes of pediatric medial epicondyle fractures with and without elbow dislocation. A total of 139 patients (75 boys and 64 girls; mean ± SD age, 9.6 ± 3.3 years) who received surgical treatment for medial epicondyle fractures at the Children's Hospital of Nanjing Medical University from January 2012 to December 2018 were included in our study. There were 99 cases that had a medial epicondyle fracture alone (group A) and 40 cases had a concomitant elbow dislocation (group B). Pain, ulnar nerve palsy, and stability of the elbow joint were recorded. Robert's criteria was used to assess elbow function. The prevalence of ulnar nerve palsy was lower in group A compared to group B, both before and after surgery. More patients underwent ulnar nerve transposition in group B than in group A. The incidence of elbow valgus instability was higher in group B than in group A. At the final follow-up, all patients had achieved good radiographic restoration of the elbow joint. Clinical outcomes in group A, according to Robert's criteria, were better than those in groupB. Elbow dislocation was associated with poorer functional outcomes following surgical treatment of medial epicondyle fractures in children. Therapeutic IV.