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Howard M. Clarke - One of the best experts on this subject based on the ideXlab platform.

  • long term hand function outcomes of the surgical management of complete brachial plexus birth injury
    Journal of Hand Surgery (European Volume), 2021
    Co-Authors: Brad T Morrow, Isaac Harvey, Howard M. Clarke
    Abstract:

    Purpose Hand function outcomes of primary Nerve Reconstruction for total brachial plexus birth injury (BPBI) are confounded by Nerve roots left in continuity, inclusion of secondary procedures, and no assessment of the ability to perform activities of daily living. The purpose of this study was to evaluate the long-term hand function outcomes in a cohort of patients with a complete BPBI who had no Nerve root in continuity prior to primary Nerve Reconstruction targeting the lower trunk. Methods This single-center retrospective case series of complete BPBI included patients who underwent primary Nerve Reconstruction. The outcomes were assessed using the active movement scale (AMS) and brachial plexus outcome measure preoperatively and at the age of 4 and 8 years. Results Fifty patients with a complete BPBI, of whom 82% (41/50) had an avulsion of C8-T1, underwent primary Nerve Reconstruction at a mean age of 4.1 months. Compared with the preoperative AMS scores, a statistically significant increase of AMS scores was observed at 4 and 8 years of age for all movements except forearm pronation. Between 4 and 8 years of age, there was a statistically significant improvement of external rotation of the shoulder and elbow flexion as well as diminution of thumb flexion. In the brachial plexus outcome measure assessment, there were 83% (24/29) at 4 years and 81% (21/26) at 8 years who had sufficient functional movement to perform wrist, finger, and thumb activities. Conclusions Functional hand outcome was restored to sufficiently perform bimanual activity tasks in 81% (21/26) of patients with a complete BPBI at 8 years of age. This affirmed that primary Nerve Reconstruction reinnervating the lower trunk can result in a functional extremity. Type of study/level of evidence Therapeutic IV.

  • suprascapular Nerve Reconstruction in obstetrical brachial plexus palsy spinal accessory Nerve transfer versus c5 root grafting
    Plastic and Reconstructive Surgery, 2011
    Co-Authors: Jeffrey R Marcus, Christine G Curtis, Annie Dupuis, Howard M. Clarke
    Abstract:

    Background: The purpose of this study was to determine whether there is any difference in external rotation following Reconstruction of the suprascapular Nerve using Nerve grafts from the proximal C5 root or Nerve transfer using the spinal accessory Nerve. Methods: External rotation was assessed using the Active Movement Scale immediately before surgery and 3 years postoperatively. Patients with less than 3 years of follow-up were excluded. For patients who underwent secondary shoulder surgery before the 3-year follow-up, the Active Movement Scale score before shoulder surgery was used as the outcome. Results: One-hundred-six patients underwent Nerve grafting, while 71 patients underwent spinal accessory Nerve transfer. The spinal accessory Nerve transfer group had a greater proportion of patients with total plexus palsies, more avulsions, and an earlier age at surgery (p < 0.001). In the C5 Nerve graft group, the mean Active Movement Scale score increased from 0.4 to 2.2 (p < 0.001). In the Nerve transfer group, the mean score increased from 0.2 to 3.0 (p < 0.001). Preoperatively, the C5 Nerve graft group had significantly better scores than the Nerve transfer group (p = 0.03). Postoperatively, there was no significant difference between treatments (p = 0.1). Further statistical analysis failed to demonstrate a significant advantage of one surgical treatment over the other. Conclusions: There was no difference in external rotation after suprascapular Nerve Reconstruction with either Nerve grafting from the proximal C5 root or spinal accessory Nerve transfer. The choice of suprascapular Nerve Reconstruction can be selected depending on specific requirements of the individual lesion.

Susan E. Mackinnon - One of the best experts on this subject based on the ideXlab platform.

  • alternatives to sural Nerve grafts in the upper extremity
    Hand, 2015
    Co-Authors: Louis H Poppler, Kristen M Davidge, Jim Armstrong, Ida K Fox, Susan E. Mackinnon
    Abstract:

    Background The sural Nerve is the most common Nerve graft donor despite requiring a second operative limb and causing numbness of the lateral foot. The purposes of this study were to review our experience using Nerve autografts in upper extremity Nerve Reconstruction and develop recommendations for donor selection.

  • Nerve Reconstruction in the hand and upper extremity
    Clinics in Plastic Surgery, 2011
    Co-Authors: Kirsty U Boyd, Andre S Nimigan, Susan E. Mackinnon
    Abstract:

    In the management of traumatic peripheral Nerve injuries, the severity or degree of injury dictates the decision making between surgical management versus conservative management and serial examination. This review explores some of the recent literature, specifically addressing recent basic science advances in end-to-side and reverse end-to-side recovery, Schwann cell migration, and neuropathic pain. The management of Nerve gaps, including the use of Nerve conduits and acellularized Nerve allografts, is examined. Current commonly performed Nerve transfers are detailed with focus on both motor and sensory Nerve transfers, their indications, and a basic overview of selected surgical techniques.

  • same modality Nerve Reconstruction for accessory Nerve injuries
    Otolaryngology-Head and Neck Surgery, 2008
    Co-Authors: Christina K Magill, Amy M Moore, Susan E. Mackinnon
    Abstract:

    The standard repair of a Nerve gap under tension is to use a sensory autograft, such as the medial antebrachial cutaneous or the sural Nerve. The practice of using sensory grafts to repair motor Nerve defects is challenged by the discovery of preferential motor reinnervation and modality specific Nerve regeneration. In this article, two clinical cases are presented where accessory Nerve injuries are repaired with either a motor Nerve transfer (a branch of C7) or a motor autograft (obturator Nerve), and excellent functional results are reported. These cases provide a stimulus to consider the use of motor Nerve grafts or transfers in the repair of motor Nerve deficits.

  • temporal factors in peripheral Nerve Reconstruction with suture scaffolds an experimental study in rodents
    Restorative Neurology and Neuroscience, 2006
    Co-Authors: Jason D Keune, Ida K Fox, Michael J Brenner, Katherine E Schwetye, Daniel A Hunter, Susan E. Mackinnon
    Abstract:

    PURPOSE This study investigated Nerve regeneration following Nerve repair with longitudinally oriented sutures, with emphasis on timing. Prior work in rodents has shown that suture scaffolds are comparable to Nerve grafting when assessments are made at late time points. However, rodents have exceptional regenerative capacity, making it difficult to detect key differences at late time points. This study therefore investigated regeneration across suture scaffolds both at early (4 week) and late (12 week) endpoints. METHODS Rodents were randomized to Nerve gap, transection and repair, Nerve grafting, and suture scaffold groups. Nerve regeneration was evaluated at 4 and 12 weeks. Histomorphometry parameters were evaluated using binary image analysis of toluidine blue-stained Nerve cross sections. RESULTS Compared to Nerve grafts, suture scaffolds were associated with significantly decreased neural density (4208 +/- 3546 vs. 193 +/- 416, fibers/mm;2, p<0.05) and fiber width (1.92 +/- 1.21 vs. 0.75+/- 1.16, microm, p<0.05). At 12 weeks, differences between groups were no longer detectable. CONCLUSION When evaluated at optimal time points for rodents, suture scaffolds fail to support regeneration comparable to the existing gold standard of Nerve grafting. This finding raises significant concerns regarding the clinical application of suture scaffolds.

  • Nerve Reconstruction in lumbosacral plexopathy. Case report and review of the literature.
    Journal of Neurosurgery: Pediatrics, 2005
    Co-Authors: Thomas H. Tung, D Zachary Martin, Christine B. Novak, Carl Lauryssen, Susan E. Mackinnon
    Abstract:

    Neurological injury to the lumbosacral plexus associated with pelvic and sacral fractures has traditionally been treated conservatively, despite significant and often debilitating functional deficits of the lower extremities. The authors report a case of Reconstruction of the lumbosacral plexus, including Nerve grafting to restore lower-extremity function caused by severe trauma to the pelvis. A 16-year-old boy sustained pelvic and sacral fractures in a motor vehicle accident. After stabilization of his orthopedic injuries, he suffered from paresis of his right gluteal and hamstring muscles and had no motor or sensory function below his knee. Two months later, he underwent Reconstruction of his lumbosacral plexus performed using a Nerve graft from his L-5 and S-1 Nerve roots proximal to the inferior gluteal Nerve and distal to a branch to the hamstring muscles. After another 2 months, his recovering saphenous Nerve was transferred to the sensory component of the posterior tibial Nerve by using cabled sural Nerve grafts to restore sensation to the sole of his foot. After 2.5 years, he experienced reinnervation of his gluteal and hamstring muscles and could perceive vibration on the sole of his foot. With the assistance of a foot-drop splint, the patient ambulates well and is able to ski. Operative details and the relevant literature are reviewed.

Peter M Waters - One of the best experts on this subject based on the ideXlab platform.

  • outcomes of late microsurgical Nerve Reconstruction for brachial plexus birth injury
    Journal of Hand Surgery (European Volume), 2020
    Co-Authors: Michael C Daly, Andrea S Bauer, Hayley M Lynch, Donald S Bae, Peter M Waters
    Abstract:

    Purpose Microsurgical Nerve Reconstruction has been advocated between 3 and 9 months of life in select patients with brachial plexus birth injury (BPBI), yet some patients undergo indicated surgery after this time frame. Outcomes in these older patients remain poorly characterized. We analyzed outcomes of Nerve Reconstruction performed after 9 months of age and hypothesized that (1) Active Movement Scale (AMS) scores improve after surgery, and (2) there are no differences in AMS scores between patients undergoing Nerve transfers versus those undergoing Nerve grafting. Methods From 2000 to 2014, 750 patients at 6 U.S. centers were prospectively enrolled in a multicenter database. We included patients treated with Nerve Reconstruction after 9 months of age with minimum 12 months’ follow-up. Patients were evaluated using AMS scores. To focus on the results of microsurgery, only outcomes prior to secondary surgery were analyzed. We analyzed baseline variables using bivariate statistics and change in AMS scores over time and across treatment groups using linear mixed models. Results We identified 32 patients (63% female) with median follow-up of 29.8 months. Median age at microsurgery was 11.2 months. Twenty-five (78%) had an upper trunk injury. Compared with before surgery, total AMS scores improved modestly at 1 year and 2 or more years follow-up. At 1 year follow-up, AMS scores improved for shoulder function (abduction, external rotation) and elbow flexion. Between-group comparisons found no differences in total AMS scores or AMS subscales between graft and transfer groups at 1 year or 2 or more years after surgery, so we cannot recommend one strategy over the other based on our findings. Conclusions Overall, Nerve Reconstruction in patients with BPBI after 9 months of age resulted in improved function over time. There was no difference in outcomes between Nerve transfer and Nerve graft groups and 1 or 2 or more years follow-up. Type of study/level of evidence Therapeutic IV.

  • current concepts in the management of brachial plexus birth palsy
    Journal of Hand Surgery (European Volume), 2010
    Co-Authors: Holly B Hale, Donald S Bae, Peter M Waters
    Abstract:

    Brachial plexus birth palsy, although rare, may result in substantial and chronic impairment. Physiotherapy, microsurgical Nerve Reconstruction, secondary joint corrections, and muscle transpositions are employed to help the child maximize function in the affected upper extremity. Many present controversies regarding natural history, microsurgical treatment, and secondary shoulder reconstructive surgery remain unresolved in infants with brachial plexus birth palsies. Recent literature has enhanced our understanding of the pathoanatomy and natural history of the injury as well as the surgical indications, expected outcomes, and complications; this literature has led to improved care of these patients. Based on the present evidence, recommendations for both microsurgery and shoulder Reconstruction with tendon transfer and arthroscopic and open reductions are presented.

Alexander Y Shin - One of the best experts on this subject based on the ideXlab platform.

  • outcomes of shoulder abduction after Nerve surgery in patients over 50 years following traumatic brachial plexus injury
    Journal of Plastic Reconstructive and Aesthetic Surgery, 2019
    Co-Authors: Joshua A Gillis, Allen T Bishop, Joseph S Khouri, Michelle F Kircher, Robert J Spinner, Alexander Y Shin
    Abstract:

    Summary Purpose There is controversy regarding the effectiveness of brachial plexus Reconstruction in older patients, as outcomes are thought to be poor. The aim of this study is to determine the outcomes of shoulder abduction obtained after Nerve Reconstruction in patients over the age of 50 years and factors related to success. Methods Forty patients over the age of 50 years underwent Nerve surgery to improve shoulder function after a traumatic brachial plexus injury. Patients were evaluated pre- and postoperatively for shoulder abduction strength and range of motion (ROM); Disability of the Arm, Shoulder and Hand (DASH) scores; pain; age bracket; gender; body mass index (BMI); delay from injury to operation; concomitant trauma; severity of trauma; and type of Reconstruction. Results The average age was 58.2 years (range 50–77 years) with an average follow-up of 18.8 months. The average modified British Medical Research Council (BMRC) shoulder abduction grade improved significantly from 0.23 to 2.03 (p   6 months. The mean DASH score decreased from 45.3 to 40.7 postoperatively, and the average pain score decreased from 3.7 to 3.0. Patients with a higher postoperative BMRC grade for shoulder abduction had improved postoperative DASH scores and VAS for pain (p = 0.011 and 0.005, respectively). Conclusion Brachial plexus Nerve Reconstruction for shoulder abduction in patients over the age of 50 years can yield useful BMRC scores and ROM, and age should not be used to exclude Nerve Reconstruction in these patients.

  • the role of Nerve graft substitutes in motor and mixed motor sensory peripheral Nerve injuries
    Journal of Hand Surgery (European Volume), 2017
    Co-Authors: Nadia Rbia, Alexander Y Shin
    Abstract:

    Alternatives to Nerve autograft have been invented and approved for clinical use. The reported outcomes of these alternatives in mixed motor Nerve repair in humans are scarce and marked by wide variabilities. The purpose of our Current Concepts review is to provide an evidence-based overview of the effectiveness of Nerve conduits and allografts in motor and mixed sensory/motor Nerve Reconstruction. Nerve graft substitutes have good outcomes in mixed/motor Nerves in gaps less than 6 mm and internal diameters between 3 and 7 mm. There is insufficient evidence for their use in larger-gap and -diameter Nerves; the evidence remains that major segmental motor or mixed Nerve injury is optimally treated with a cabled Nerve autograft.

  • motor Nerve recovery in a rabbit model description and validation of a noninvasive ultrasound technique
    Journal of Hand Surgery (European Volume), 2016
    Co-Authors: Liselotte F Bulstra, Caroline A Hundepool, Patricia F Friedrich, Tim H J Nijhuis, Allen T Bishop, Alexander Y Shin
    Abstract:

    Purpose To develop and validate a noninvasive ultrasound technique for the longitudinal analysis of functional recovery after segmental peroneal Nerve Reconstruction in a rabbit model. Methods Twelve male New Zealand White rabbits underwent a 1-cm peroneal Nerve autograft Reconstruction. Ultrasound measurements were performed before surgery and at 1, 2, 4, 8, 12, and 16 weeks postoperatively. All rabbits were managed with manual restraint for the ultrasound procedure, avoiding the risks of anesthetics. At 12 and 16 weeks, we evaluated functional recovery using compound muscle action potential, isometric tetanic force measurements, wet muscle weight, and Nerve histomorphometry. Data were compared with ultrasound measurements by calculating the Pearson correlation coefficient. We determined intra-rater and inter-rater reliability of the ultrasound measurements. Results Ultrasound demonstrated good correlation with isometric tetanic force measurements and wet muscle weight, good correlation with Nerve histomorphometry, and moderate correlation with compound muscle action potential. Both intra-rater and inter-rater reliability of the ultrasound technique was excellent. Conclusions Ultrasound analysis of the tibialis anterior muscle provided a reliable method for analysis of functional recovery in a rabbit peroneal Nerve Reconstruction model. The noninvasive nature allowed for longitudinal follow-up within the same animal and measurement of early recovery without the use of anesthesia. Clinical relevance Application of this noninvasive technique can reduce the variability and sample size necessary in peripheral Nerve Reconstruction studies and may provide an ideal tool for comparative studies in larger animal models.

  • axillary Nerve Reconstruction anterior posterior exposure with sural Nerve cable graft pull through technique
    Techniques in Hand & Upper Extremity Surgery, 2015
    Co-Authors: Heather L Baltzer, Allen Thorp Bishop, Richard J Spinner, Alexander Y Shin
    Abstract:

    Deltoid paralysis after axillary Nerve injury results in limitations in shoulder function and stability. In the setting of an isolated axillary Nerve injury with no clinical or electromyographic evidence of recovery that is within 6 to 9 months postinjury, the authors' preferred technique to reinnervate the deltoid is to reconstruct the axillary Nerve with sural Nerve grafting. Intraoperative neuromuscular electrophysiology is critical to determine the continuity of the axillary Nerve before proceeding with Reconstruction. The majority of the time, both an anterior and posterior incision and dissection of the axillary Nerve is required to adequately delineate the zone of injury. This also ensures that both proximally and distally, uninjured axillary Nerve is present before graft inset and also facilitates the ability to perform a meticulous microsurgical inset of the Nerve graft posteriorly. The Nerve graft must be pulled through from posterior to anterior to span the zone of injury and reconstruct the axillary Nerve. Careful infraclavicular brachial plexus dissection is necessary to prevent further injury to components of the brachial plexus in the setting of a scarred bed. Patients will require postoperative therapy to prevent limitations in shoulder range of motion secondary to postoperative stiffness. This paper presents a detailed surgical technique for axillary Nerve Reconstruction by an anterior-posterior approach with a pull-through technique of a sural Nerve cable graft.

Mitchel Seruya - One of the best experts on this subject based on the ideXlab platform.

  • recovery of elbow flexion after Nerve Reconstruction versus free functional muscle transfer for late traumatic brachial plexus palsy a systematic review
    Plastic and Reconstructive Surgery, 2018
    Co-Authors: Don Hoang, Vivi W Chen, Mitchel Seruya
    Abstract:

    Background In late presentation of brachial plexus trauma, it is unclear whether donor Nerves should be devoted to Nerve Reconstruction or reserved for free functional muscle transfer. The authors systematically reviewed recovery of elbow flexion after Nerve Reconstruction versus free functional muscle transfer for late, traumatic brachial plexus palsy. Methods A systematic review was performed using the PubMed, Embase, and Cochrane databases to identify all cases of traumatic brachial plexus palsy in patients aged 18 years or older. Patients who underwent late (≥12 months) Nerve Reconstruction or free functional muscle transfer for elbow flexion were included. Age, time to operation, and level of brachial plexus injury were recorded. British Medical Research Council grade for strength and range of motion were evaluated for elbow flexion. Results Thirty-three studies met criteria, for a total of 103 patients (Nerve Reconstruction, n = 53; free functional muscle transfer, n = 50). There were no differences across groups regarding surgical age (time from injury) and preoperative elbow flexion. For upper trunk injuries, 53 percent of Reconstruction patients versus 100 percent of muscle transfer patients achieved grade M3 or greater strength, and 43 percent of Reconstruction patients versus 70 percent of muscle transfer patients achieved grade M4 or greater strength. Of the total brachial plexus injuries, 37 percent of Reconstruction patients versus 78 percent of muscle transfer patients achieved grade M3 or greater strength, and 16 percent of Reconstruction patients versus 46 percent of muscle transfer patients achieved grades M4 or greater strength. Conclusion In late presentation of traumatic brachial plexus injuries, donor Nerves should be reserved for free functional muscle transfer to restore elbow flexion. Clinical question/level of evidence Therapeutic, IV.

  • spinal accessory Nerve transfer outperforms cervical root grafting for suprascapular Nerve Reconstruction in neonatal brachial plexus palsy
    Plastic and Reconstructive Surgery, 2015
    Co-Authors: Mitchel Seruya, Shi Hong Shen, Sibon Fuzzard, Christopher J Coombs, David Mccombe, Bruce R Johnstone
    Abstract:

    Background:The authors evaluated long-term shoulder function in patients with neonatal brachial plexus palsy undergoing suprascapular Nerve Reconstruction with cervical root grafting or spinal accessory Nerve transfer.Methods:A retrospective review was performed on all infants presenting with neonat