Publications
Dual Anatomic Variations in the Median Nerve:
Adding Layers of Complexity for Carpal Tunnel Release
Abstract
Anatomical variations in the median nerve have been extensively documented since the inception of carpal tunnel surgery. We report a dual anatomic variation in the median nerve encountered during the carpal tunnel decompression. The bifid median nerve was associated with preligamentous thenar motor branch arising from the ventral aspect of the radial portion of the median nerve, remaining deep to antebrachial fascia and then piercing the transverse carpal ligament to reach the thenar muscles. Lanz described the various anomalies of the median nerve in the carpal tunnel and classified the bifid median nerve as group III. Various abnormalities associated with the bifid median nerve are further classified by Al-Qattan et al and classified the bifid median nerve associated with aberrant nerve branches as group VI.
Author – Madhusudhan NC (Corresponding Author), Bharath K Kadadi (Co-author), Niranjan Mallanaik (Co-author), Vijay HD Kamath (Co-author).
DUAL ANATOMIC VARIATIONS OF THE MEDIAN NERVE – ADDING LAYERS OF COMPLEXITY FOR CARPAL TUNNEL RELEASE.
For reference:https://www.thieme.in/thieme-e-Journals/jpnspdf/new/15_49-52_23100062.pdf
A Rare Anatomical Variant of the Thenar Motor Branch Encountered during Carpal Tunnel Release
Abstract
Iatrogenic injury to the thenar motor branch of median nerve, though rare, is a serious complication during carpal tunnel decompression. The incidence is high when there is variation in the thenar motor branch and hence we should be aware of the common as well as unusual and rare anatomical variants. As uncommon variations render the thenar branch more prone for iatrogenic injury knowing more would surely save one’s day while doing a carpal tunnel release. We present a rare anatomical variant of the thenar motor branch of the median nerve that we encountered during open carpal tunnel release. The thenar motor branch was originating from the ulnar side of the median nerve proximal to the transverse carpal ligament, traversing subligamentous and joining a communicating branch from the median nerve distal to the transverse carpal ligament. The nerve was accidentally cut intraoperatively, which was immediately identified and repaired. At the postoperative follow-up after 6 months, patient has recovered thenar function with the ability to write with his right hand with good opposition.
Author – Madhusudhan NC (Co-author), Vigneswaran Varadharajan (Co-author), Praveen Bhardwaj (Corresponding author), S. Raja Sabapathy (Co-author).
A RARE ANATOMICAL VARIANT OF THE THENAR MOTOR BRANCH ENCOUNTERED DURING CARPAL TUNNEL RELEASE.
For reference:https://www.thieme.in/thieme-e-Journals/jpnspdf/new/14_45-48_23100061.pdf
Role of External Rotation Osteotomy of the Humerus in Patients with Brachial Plexus Injury
Abstract
Background: A deficit of external rotation of the shoulder is a common sequelae of brachial plexus injury (BPI). This internally rotated posture of the limb becomes more apparent and functionally limiting once the patient recovers elbow flexion resulting in the hand striking the abdomen on attempted flexion (‘tummy flexion’). This precludes hand-to-mouth reach, resulting in an inability to eat with the involved hand. The aim of this study is to present the outcomes of an external rotation osteotomy of the humerus in adult BPI.
Methods: All BPI patients who underwent an external rotation osteotomy of the humerus at our institution over a 5-year period from January 2015 to December 2020 were included in this study. Data with regard to the age, gender, type of BPI, time from injury to nerve surgery and from nerve surgery till external rotation osteotomy, degree of pre- and postoperative external rotation, time to union, patient satisfaction and complications were recorded.
Results: The study included 19 patients (18 men and one woman) with an average age of 30 years (range 20-58). The average time interval from the injury to the nerve surgery was 3.8 months, and between the nerve surgery and the external rotation osteotomy was 29.5 months. No patient had any preoperative external rotation and all attained a resting posture of 15°-20° of external rotation, were able to reach the mid-line of the body, and none complained of loss of internal rotation. There was an implant failure in one patient that was managed with splinting till union and removal of implants later.
Conclusions: External rotation osteotomy of the humerus is a simple and effective procedure to place the limb in a better aesthetic and functional position.
Level of Evidence: Level IV (Therapeutic).
Author – Madhusudhan NC, Bhardwaj P, Varadharajan V, Venkatramani H, Sabapathy SR.
Role of External Rotation Osteotomy of the Humerus in Patients with Brachial Plexus Injury. J Hand Surg Asian Pac Vol. 2022 Sep 28:1-8.
For reference: https://www.worldscientific.com/doi/10.1142/S2424835522500722?
Distal nerve transfer for restoring elbow extension- role and outcome
Abstract
Background: In a patient with good hand function, elbow extension is essential for “reaching out” for the objects especially for overhead activities and its absence drastically reduces the working space of the hand. The choice of the procedure for restoration of elbow extension would be quite case-specific; however, in select situations we performed partial nerve transfer of a fascicle of ulnar nerve to the triceps long head motor branch. We, herein, discuss our indications and selection criteria and present outcome in five cases.
Methods: Between2010 and 2020, five patients underwent the procedure as part of the management of their brachial plexus injury who did not require ulnar nerve as a donor for restoration of elbow flexion. Only the patients who underwent nerve transfer surgery were included in the study. Preoperative and postoperative strength of triceps was noted as per Medical Research Council grading.
Results: All the five cases in this series recovered anti gravity elbow extension at a minimum follow-up of 14months (grade 4 in 2 and grade 3 in 3 patients). All the patients felt that the procedure improved their function and were extremely satisfied with the outcome.
Conclusion: Though elbow flexion reconstruction still remains a priority, in patients with good hand function we always consider innervating the triceps. Restoration of elbow extension greatly improves the overall limb function and patient satisfaction. Ulnar nerve fascicle transfer to the triceps long head was found to be effective and safe.
Author – Praveen Bhardwaj (Corresponding author), Madhusudhan NC (Co-author), Vigneswaran Varadharajan (Co-author), Obuli Vijayshankar (Co-author), Hari Venkatramani (Co-author), S. Raja Sabapathy (Co-author).
Distal nerve transfer for restoring elbow extension- role and outcome.
For reference: https://www.thieme.in/thieme-e-Journals/jpnspdf/new/07_3-9_22120046.pdf
Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial
Abstract
Background: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications.
Methods: HIP ATTACK was an international, randomized, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896).
Findings: Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4-9) in the accelerated-surgery group and 24 h (10-42) in the standard-care group (p<0·0001). 140 (9%) patients assigned to accelerated surgery and 154 (10%) assigned to standard care died, with a hazard ratio (HR) of 0·91 (95% CI 0·72 to 1·14) and absolute risk reduction (ARR) of 1% (-1 to 3; p=0·40). Major complications occurred in 321 (22%) patients assigned to accelerated surgery and 331 (22%) assigned to standard care, with an HR of 0·97 (0·83 to 1·13) and an ARR of 1% (-2 to 4; p=0·71).
Interpretation: Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared with standard care.
Funding: Canadian Institutes of Health Research.
The HIP ATTACK Investigator – Accelerated surgery versus standard care in hip fracture (HIP ATTACK): An international, randomized, controlled trial.
For reference: https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S0140673620300581?
Accelerated Surgery Versus Standard Care in Hip Fracture (HIP ATTACK-1): A Kidney Substudy of a Randomized Clinical Trial
The HIP ATTACK Investigator – Accelerated Surgery Versus Standard Care in Hip Fracture (HIP ATTACK-1): A Kidney Substudy of a Randomized Clinical Trial
For reference: https://www.clinicalkey.com/#!/content/playContent/
THUMB
DUPLICATION
Introduction
Thumb duplication or preaxial polydactyly is the most prevalent congenital anomaly of hand, with an incidence between 0.8 per 1,000 live births to 1 per 3000 live births1. Commonly being described as “duplication” the presentation can vary from a vestigial skin tag to a complete splitting type. However, it is important to understand that the two thumbs are not duplicated with equal size and function, rather neither is ‘normal’. More commonly, one thumb is more anatomically and functionally developed than the other, leading to the introduction of the term ‘‘split thumb’’. Radial polydactyly originally was classified as a ‘‘duplication’’ by the International Federation of Societies for the Surgery of the Hand. It was thereafter reclassified as “malformation,’’ which is a failure of axis formation, and/or differentiation of the radioulnar hand plate as described by Oberg, Manske, and Tonkin2. They classified anomalies based on developmental biology and pathogenesis rather than on morphologic features and described that, processes such as formation and differentiation occur together and not independently. The duplicated thumb usually has both the sensory and motor units that work in concert with the entire hand, leading to minimal functional disability. Duplication alone is typically unilateral and sporadic, with only 20 percent being bilateral (Fig 1); however, duplication in the setting of a triphalangeal thumb is inherited in an autosomal dominant pattern1.
Author – Mithun Pai, Madhusudhan NC.
Thumb Duplication: Indian Society for Surgery of the Hand (ISSH) Academics.
Restoration of Hand Function in Isolated Lower Brachial Plexus Injury with Brachioradialis to Flexor Pollicis Longus and Biceps to Flexor Digitorum Profundus Transfer
Abstract
Background: Isolated lower (C8T1) brachial plexus injury (BPI) is uncommon and the aim of treatment is to achieve a satisfactory grasp enabling the use of the hand for daily activities. The aim of this study is to report the outcomes of the transfer of brachioradialis (BR) to flexor pollicis longus (FPL) and biceps to the flexor digitorum profundus (FDP) for an isolated lower BPI.
Methods: This is a retrospective study of all patients with an isolated lower BPI who underwent a BR to FPL and biceps to FDP transfer for restoration of digital flexion over a 1-year period from May 2019 to June 2020. Patient demographic and injury data were collected at the presentation. Outcomes data included the ability to grasp and perform activities of daily living and DASH score.
Results: The study included three patients (all men) with an average age of 30.3 years. All sustained an isolated lower BPI following a road traffic accident and tendon transfers were performed at a mean of 9.3 months after the initial injury. At a mean of 1-year follow-up, all three recovered grade M4 motor power of digital flexion, achieved good grasp function with pulp-to-palm distance of <1 cm. All are able to use the hand for independent as well as bimanual activities. The individual DASH scores were 36, 30 and 30.
Conclusions: BR to FPL for thumb flexion and biceps to FDP using fascia lata graft to restore finger flexion is simple and effective surgeries in patients with isolated lower BPI.
Level of Evidence: Level V (Therapeutic).
Author – Kummari VK, Bhardwaj P, Varadharajan V, Madhusudhan NC, Venkatramani H, Raja Sabapathy S.
Restoration of Hand Function in Isolated Lower Brachial Plexus Injury with Brachioradialis to Flexor Pollicis Longus and Biceps to Flexor Digitorum Profundus Transfer. J Hand Surg Asian Pac Vol. 2022 Aug;27(4):599-606.