OKOJ, Volume 8, No. 6

Nerve Repair: Basic Science and Current Concepts

Peripheral nerve injuries are common in the orthopaedic practice. Most of these injuries are incomplete. Seddon classified nerve injuries into three types: neurapraxia, axonotmesis, and neurotmesis. When axons are transected or crushed, neurons undergo degeneration, followed by regeneration of axons from the proximal stump. Growth cones, located at the tips of the daughter axons, seek out connections with the degenerated distal stumps through contact-mediated and chemotactic factors. Epineurial repair using nylon sutures is the current standard of surgical repair. Group fascicular repair can also be performed, although this technique is more technically challenging. Currently, there are no significant data suggesting that one method is better than the other. To span larger nerve defects without placing undue tension on the repair, nerve grafts may be used. Today, there is much ongoing research regarding the use of artificial nerve-guidance channels, pharmacologic agents, immune system modulators, and enhancing factors, which may offer promise for future improvements in nerve repair outcomes.

    • Keywords:
    • peripheral nerve injuries

    • acute nerve injury

    • chronic nerve injury

    • Seddon nerve injury classification

    • Sunderland nerve injury classification

    • axonotmesis

    • neurapraxia

    • neurotmesis

    • epineurial repair

    • group fascicular repair

    • nerve grafting

    • peripheral nerve allograft

    • peripheral nerve autograft

    • conduits

    • axon guidance channels

    • Subspecialty:
    • Hand and Wrist

    • Basic Science

Arthrogryposis Multiplex Congenita (Amyoplasia)

Arthrogryposis multiplex congenita, or amyoplasia, is a distinct form of arthrogryposis characterized by multiple joint contractures in the upper and lower extremities and markedly decreased muscle development. This syndrome, which is present at birth, is not progressive, although deformity of an affected joint may worsen over time. The cause of amyoplasia remains unknown, but the musculoskeletal implications are profound. Initial treatment ideally begins at birth, with physical therapy and splinting to improve the contractures; however, surgical intervention is often necessary. Soft-tissue releases in conjunction with splinting may improve joint position. In patients with more severe contractures, osseous surgery may be necessary. Much additional research is needed to clarify which interventions yield the greatest benefit in each situation. Nevertheless, at present it is encouraging to note that through a combination of multidisciplinary care and the patients' own intelligence and adaptability, many patients with amyoplasia are indeed able to gain an increased level of function and develop a measure of independence into adulthood.

    • Keywords:
    • arthrogryposis multiplex congenita

    • AMC

    • amyoplasia

    • distal arthrogryposis

    • multiple congenital contracture

    • multiple congenital joint contractures

    • scoliosis

    • joint deformity

    • limb malformations

    • equinovarus foot deformity

    • hip dislocation

    • knee flexion contracture

    • hip flexion contractures

    • thumb-in-palm deformity

    • elbow extension contracture

    • wrist contractures

    • posteromedial release

    • Quengel hinge

    • distal femoral extension osteotomy

    • Ilizarov fixation

    • external rotational humeral osteotomy

    • posterior elbow capsulotomy

    • triceps lengthening

    • Steindler flexorplasty

    • triceps tendon transfer

    • dorsal trapezoid closing-wedge intercarpal osteotomy

    • posterior segmental spinal fusion with instrumentation

    • talectomy

    • Subspecialty:
    • Pediatric Orthopaedics

Arthroscopic Capsular Release of the Glenohumeral Joint

Dr. Murthi performs an arthroscopic capsular release of the glenohumeral joint on a 55-year-old, right-hand-dominant female with a year-long history of left shoulder pain and stiffness. A long period of nonsurgical treatment, including corticosteroid injections and physical therapy, has failed to produce range-of-motion improvement. Prior to surgery, the patient exhibits a forward elevation of approximately 70 degrees;, roughly 45 degrees of abduction, 5 degrees to 10 degrees of external rotation, and, within the limited amount of abduction, only 5 degrees of rotation in each plane. The goal of the arthroscopic procedure is to release the thickened and contracted capsular tissues surrounding the glenohumeral joint so as to improve the patient's range of motion. In a demonstration of his surgical approach, Dr. Murthi shows how to mark the shoulder for arthroscopic portal placement and complete the anterior and posterior capsular releases. Upon completion of the arthroscopy, Dr. Murthi examines the patient's range of motion, revealing the successful outcomes of the surgery: full elevation of the shoulder to 170degrees, external rotation of 80 degrees to 90 degrees, and greater than 90 degrees of abduction. Postsurgical therapy includes an interscalene block plus a combination of anti-inflammatory medications, ice machines to reduce swelling, and range-of-motion therapy.

    • Keywords:
    • adhesive capsulitis

    • anterior capsular release

    • arthroscopic anterior capsular release

    • arthroscopic capsular release

    • capsular contracture

    • capsular release

    • capsulitis of the shoulder

    • coracohumeral ligament

    • frozen shoulder

    • frozen shoulder syndrome

    • glenohumeral joint

    • glenohumeral ligament release

    • interscalene nerve block

    • posterior capsular release

    • shoulder arthroscopy

    • shoulder joint capsule

    • shoulder stiffness

    • shoulder manipulation

    • subacromial release

    • Subspecialty:
    • Shoulder and Elbow