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Clinical surgical study of tumors involving brachial plexus
16
immediately after surgery but more often it improves gradually over a period of 4 to 12 weeks. In 95%, of patients the result at 6 months was the same as that at 1 year. All the patients have experienced a reduction in pain, 37 (20%) a modest improvement, 46 (24%) a significant improvement, 104 (56%) a very good improvement (minimum pain on stress or no pain at all). Despite the complete denervation of the pronator quadratus no patient reported a deficit in pronosupination or reduction in grip strength.
Conclusion We have found this method of wrist denervation to be a simple, fast and reliable means of reducing the pain in many wrist conditions with the added advantage of allowing further surgery to be performed for other pathology.
Wrist denervation: surgical considerations A. Ferreres, S. Suso, G. Foucher, D. R u a n o
SOS Main, Strasbourg, France, Hand Unit, Hospital Clinic, and Department of Anatomy, Faculty of Medicine, University of Barcelona, Spain
T H E J O U R N A L OF H A N D SURGERY VOL. 21B S U P P L E M E N T 1
(less than 50%). Part&l denervation. We classified the results according to pain improvement and patient satisfaction. We found a common pattern consisting of an initial improvement at 3 and 6 months postop., that tended to decrease by 12th. Results were classified according to pain/satisfaction. There were 11/8 good, 10/11 fair and 9/11 bad results at the end of follow-up.
Discussion When looking at partial denervation for the similar indications as total denervation, our results were worse than 90% previously reported. Our follow-up was longer, and that may be the cause of our worse results. The indications proposed for partial denervation are more suitable for a wide denervation since longer follow-up in this study has demonstrated that results deteriorate with time.
Conclusions Pain is the only parameter that allows evaluation of the results. Complete denervation of the wrist is a useful method for treating wrist pain when other choices compromise functional capacity or a long period of postoperative recovery is not desired. Wrist denervation has the advantage of not precluding further surgery.
Introduction Good results after complete denervation of the wrist have been reported to be between 51 and 69%. Other authors reported 90% good results after neurectomy of the posterior interosseous nerve (PIN) alone in patients suffering from similar problems.
Materials and methods We retrospectively reviewed a series of 22 patients that were operated on using Wilhelm's technique at SOS Main, Strasbourg, by one of us (GF). They presented the following pathology: scaphoid non-union (six), old sprain (five), old fracture (four), synovitis (two) and a variety of affections (five). There were 17 men and five women. Their ages ranged from 26 to 70 years (means 50.1). After surgery they were evaluated according to mobility, grip strength, radiology and pain. Follow-up ranged between 1 and 10 years (median 5.4). 30 patients were treated by PIN denervation alone, at the Hospital Clinic of the University of Barcelona after a nerve block of the PIN had reduced wrist pain. There were 20 men and ten women, aged from 21 to 56 years (mean 34.4) complaining, of an old articular fracture of the radius (seven), Galeazzi fracture-dislocation (two), necrosis of the lunate (five), old Colles' fracture (five), patients having had miscellaneous wrist operations (five), other injuries (six; three scaphoid non-union, two old sprain, one scapholunate instability). Follow-up ranged between 3 and 14 years (average 4.7) and we determined mobility, patient satisfaction and pain. For analysis of the results different variables were tested in order to compare their values before and after the surgical procedure, by applying the Student Fischer 't' test for comparing means between paired groups of variables.
Results Total denervation. From the statistical analysis, we concluded that preoperative and postoperative data of mobility and strength were homogeneous; so the only parameter that could be used to classify the results was pain and this was measured in a VAS (visual analogue scale). Nine patients were considered to have obtained an excellent result (improvement of more than 80%), ten a good result (50 to 80%) and three a bad result
Clinical surgical study of tumors involving brachial plexus R. Cosentino, C. Benedetti de Cosentino, S. D a r o d a , P. Pereira
Fundaci6n Mainetti, Gonnet, La Plata, Argentina 22 patients (13 females and nine males) with 22 brachial plexus tumors involving either primary or secondary trunks have been evaluated since 1987. Clinical examination, electromyography, iconographic and histological studies were performed in every case. We suggest the following classification of tumors according to the different cases we treated: Primary:
1-Benign (5 cases) 2-Malignant (3 cases) Secondary: 1-Invasive ~ Benign (3 cases) ---) Malignant (6 cases) 2-Infiltrative (5 cases) 3-Metastatic (1 case)
Invasive tumors are those originated in adjacent structures, injuring the brachial plexus through compression. Infiltrative tumors are those originated in neurological or non-neurological structures, penetrating the plexus trunks. The most frequent neoplasms found in the anatomophatological studies were Schwannoma in primary tumors and adenocarcinoma in secondary tumors. Tumoral localizations were: 3 cases in roots, 4 cases in primary trunks and 15 cases in secondary trunks. Pain was the dominant symptom in all patients. However, paralysis and oedema were found in the second place. All patients underwent surgery: benign tumors were treated with microsurgical techniques and malignant tumors with large extirpations. Secondary tumors were treated with neurolysis to palliate pain. The patients' follow-up was performed to determine the surgical results and the disease behaviour. Pain and oedema
SESSION 5
improvement were the outstanding results. Paralysis ameliorated in benign cases treated with reconstruction microsurgery. Surgery improves the quality of life in malignant cases.
Extensor indicis proprius transfer for restoration of extensor pollicis longus function: results and new aspects M. H. M. Lemmen, T. A. R. Schreuders, S. E. R. Hovius
Department of Plastic and Reconstructive Surgery and Department of Rehabilitation and Handtherapy, Academic Hospital Rotterdam, Dijkzigt, The Netherlands Lesions of the extensor pollicis longus tendon (EPL), especially following indirect trauma, can be restored with a tendon transfer, as for instance the extensor indicis proprius tendon (EIP). The aim of our study was to assess our results following EIP transfer to the EPL with emphasis on the results of thumb function, donor-site morbidity and accuracy of well described evaluation methods. Between 1987 and 1994, 20 EIP transfers were performed in the Academic Hospital Rotterdam. 17 patients were available
17
for follow-up. The Geldmacher evaluation scheme, together with our modification, was used and included the function of thumb and index finger; the active and passive ROM, the strength of thumb extension and index extension, the pinch strength and grip strength. Measurements were compared with those of the non-operated side. A questionnaire was completed by the patients to obtain a subjective evaluation. Based on our evaluation scheme, we report 59°/,, excellent, 12% good, 29% fair and no poor results. There was no particular loss of independent extension of the index finger; there was a slight loss of extension strength.
Conclusions ° Transfer of the EIP should be the first choice for reconstruction of the EPL, based on anatomical features; force, fiber/length and line of pull are remarkably similar. • There is no important loss of index finger function or strength. ° Our new proposed Specific EPL Evaluation Method is probably more reliable and more specific for the evaluation of the function of the EPL than the Geld-macher evaluation scheme.
immediately after surgery but more often it improves gradually over a period of 4 to 12 weeks. In 95%, of patients the result at 6 months was the same as that at 1 year. All the patients have experienced a reduction in pain, 37 (20%) a modest improvement, 46 (24%) a significant improvement, 104 (56%) a very good improvement (minimum pain on stress or no pain at all). Despite the complete denervation of the pronator quadratus no patient reported a deficit in pronosupination or reduction in grip strength.
Conclusion We have found this method of wrist denervation to be a simple, fast and reliable means of reducing the pain in many wrist conditions with the added advantage of allowing further surgery to be performed for other pathology.
Wrist denervation: surgical considerations A. Ferreres, S. Suso, G. Foucher, D. R u a n o
SOS Main, Strasbourg, France, Hand Unit, Hospital Clinic, and Department of Anatomy, Faculty of Medicine, University of Barcelona, Spain
T H E J O U R N A L OF H A N D SURGERY VOL. 21B S U P P L E M E N T 1
(less than 50%). Part&l denervation. We classified the results according to pain improvement and patient satisfaction. We found a common pattern consisting of an initial improvement at 3 and 6 months postop., that tended to decrease by 12th. Results were classified according to pain/satisfaction. There were 11/8 good, 10/11 fair and 9/11 bad results at the end of follow-up.
Discussion When looking at partial denervation for the similar indications as total denervation, our results were worse than 90% previously reported. Our follow-up was longer, and that may be the cause of our worse results. The indications proposed for partial denervation are more suitable for a wide denervation since longer follow-up in this study has demonstrated that results deteriorate with time.
Conclusions Pain is the only parameter that allows evaluation of the results. Complete denervation of the wrist is a useful method for treating wrist pain when other choices compromise functional capacity or a long period of postoperative recovery is not desired. Wrist denervation has the advantage of not precluding further surgery.
Introduction Good results after complete denervation of the wrist have been reported to be between 51 and 69%. Other authors reported 90% good results after neurectomy of the posterior interosseous nerve (PIN) alone in patients suffering from similar problems.
Materials and methods We retrospectively reviewed a series of 22 patients that were operated on using Wilhelm's technique at SOS Main, Strasbourg, by one of us (GF). They presented the following pathology: scaphoid non-union (six), old sprain (five), old fracture (four), synovitis (two) and a variety of affections (five). There were 17 men and five women. Their ages ranged from 26 to 70 years (means 50.1). After surgery they were evaluated according to mobility, grip strength, radiology and pain. Follow-up ranged between 1 and 10 years (median 5.4). 30 patients were treated by PIN denervation alone, at the Hospital Clinic of the University of Barcelona after a nerve block of the PIN had reduced wrist pain. There were 20 men and ten women, aged from 21 to 56 years (mean 34.4) complaining, of an old articular fracture of the radius (seven), Galeazzi fracture-dislocation (two), necrosis of the lunate (five), old Colles' fracture (five), patients having had miscellaneous wrist operations (five), other injuries (six; three scaphoid non-union, two old sprain, one scapholunate instability). Follow-up ranged between 3 and 14 years (average 4.7) and we determined mobility, patient satisfaction and pain. For analysis of the results different variables were tested in order to compare their values before and after the surgical procedure, by applying the Student Fischer 't' test for comparing means between paired groups of variables.
Results Total denervation. From the statistical analysis, we concluded that preoperative and postoperative data of mobility and strength were homogeneous; so the only parameter that could be used to classify the results was pain and this was measured in a VAS (visual analogue scale). Nine patients were considered to have obtained an excellent result (improvement of more than 80%), ten a good result (50 to 80%) and three a bad result
Clinical surgical study of tumors involving brachial plexus R. Cosentino, C. Benedetti de Cosentino, S. D a r o d a , P. Pereira
Fundaci6n Mainetti, Gonnet, La Plata, Argentina 22 patients (13 females and nine males) with 22 brachial plexus tumors involving either primary or secondary trunks have been evaluated since 1987. Clinical examination, electromyography, iconographic and histological studies were performed in every case. We suggest the following classification of tumors according to the different cases we treated: Primary:
1-Benign (5 cases) 2-Malignant (3 cases) Secondary: 1-Invasive ~ Benign (3 cases) ---) Malignant (6 cases) 2-Infiltrative (5 cases) 3-Metastatic (1 case)
Invasive tumors are those originated in adjacent structures, injuring the brachial plexus through compression. Infiltrative tumors are those originated in neurological or non-neurological structures, penetrating the plexus trunks. The most frequent neoplasms found in the anatomophatological studies were Schwannoma in primary tumors and adenocarcinoma in secondary tumors. Tumoral localizations were: 3 cases in roots, 4 cases in primary trunks and 15 cases in secondary trunks. Pain was the dominant symptom in all patients. However, paralysis and oedema were found in the second place. All patients underwent surgery: benign tumors were treated with microsurgical techniques and malignant tumors with large extirpations. Secondary tumors were treated with neurolysis to palliate pain. The patients' follow-up was performed to determine the surgical results and the disease behaviour. Pain and oedema
SESSION 5
improvement were the outstanding results. Paralysis ameliorated in benign cases treated with reconstruction microsurgery. Surgery improves the quality of life in malignant cases.
Extensor indicis proprius transfer for restoration of extensor pollicis longus function: results and new aspects M. H. M. Lemmen, T. A. R. Schreuders, S. E. R. Hovius
Department of Plastic and Reconstructive Surgery and Department of Rehabilitation and Handtherapy, Academic Hospital Rotterdam, Dijkzigt, The Netherlands Lesions of the extensor pollicis longus tendon (EPL), especially following indirect trauma, can be restored with a tendon transfer, as for instance the extensor indicis proprius tendon (EIP). The aim of our study was to assess our results following EIP transfer to the EPL with emphasis on the results of thumb function, donor-site morbidity and accuracy of well described evaluation methods. Between 1987 and 1994, 20 EIP transfers were performed in the Academic Hospital Rotterdam. 17 patients were available
17
for follow-up. The Geldmacher evaluation scheme, together with our modification, was used and included the function of thumb and index finger; the active and passive ROM, the strength of thumb extension and index extension, the pinch strength and grip strength. Measurements were compared with those of the non-operated side. A questionnaire was completed by the patients to obtain a subjective evaluation. Based on our evaluation scheme, we report 59°/,, excellent, 12% good, 29% fair and no poor results. There was no particular loss of independent extension of the index finger; there was a slight loss of extension strength.
Conclusions ° Transfer of the EIP should be the first choice for reconstruction of the EPL, based on anatomical features; force, fiber/length and line of pull are remarkably similar. • There is no important loss of index finger function or strength. ° Our new proposed Specific EPL Evaluation Method is probably more reliable and more specific for the evaluation of the function of the EPL than the Geld-macher evaluation scheme.