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In this study, the fruit of Terminalia chebula, commonly known as chebulic myrobalan, is used as the precursor for carbon for its application in supercapacitors. The Terminalia chebula biomass-derived sponge-like porous carbon (TC-SPC) is synthesized using a facile and economical method of pyrolysis. TC-SPC thus obtained is subjected to XRD, FESEM, TEM, HRTEM, XPS, Raman spectroscopy, ATR-FTIR, and nitrogen adsorption-desorption analyses for their structural and chemical composition. The examination revealed that TC-SPC has a crystalline nature and a mesoporous and microporous structure accompanied by a disordered carbon framework that is doped with heteroatoms such as nitrogen and sulfur. Electrochemical studies are performed on TC-SPC using cyclic voltammetry, galvanostatic charge-discharge, and electrochemical impedance spectroscopy. TC-SPC contributed a maximum specific capacitance of 145 F g-1 obtained at 1 A g-1. The cyclic stability of TC-SPC is significant with 10,000 cycles, maintaining the capacitance retention value of 96%. The results demonstrated that by turning the fruit of Terminalia chebula into an opulent product, a supercapacitor, TC-SPC generated from biomass has proven to be a potential candidate for energy storage application.

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Rhabdomyolysis is a triad syndrome of myalgia, muscle weakness and myoglobinuria due to muscle necrosis. Trauma, exertions, strenuous exercise, infections, metabolic and electrolyte disorders, drug overdoses, toxins and genetic defects are the most common causes of rhabdomyolysis. The etiologies of foot drop are diverse. A few cases of rhabdomyolysis-associated foot drop are reported in the literature. We present five patients with foot drop secondary to rhabdomyolysis; two underwent neurolysis and distal nerve transfer (superficial peroneal nerve to the deep peroneal nerve) surgeries and follow-up evaluations. We found five-foot drop patients secondary to rhabdomyolysis among the 1022-foot drop patients who consulted our clinic since 2004, representing a 0.5% incidence. In two patients, rhabdomyolysis was caused by drug overdose and abuse. In the other three patients, the causes were an assault with a hip injury, a prolonged hospitalization due to multiple illnesses, and an unknown cause with compartment syndrome. Pre-operatively, a 35-year-old male patient had aspiration pneumonia, rhabdomyolysis and foot drop resulting from prolonged ICU hospitalization and a medically induced coma due to a drug overdose. The second patient (a 48-year-old male) had no history of trauma but had a sudden onset of right foot drop after compartment syndrome following the insidious onset of rhabdomyolysis. Both patients had difficulty dorsiflexing their involved foot and walked with a steppage gait before surgery. In addition, the 48-year-old patient had foot slapping while walking. However, both patients had strong plantar flexion (5/5). After 14 and 17 months of surgery, both patients had improved foot dorsiflexion to an MRC grade of 4/5 with an improved gait cycle and walked with no or minimal slapping, respectively. Distal motor nerve transfers in the lower limb facilitate faster recovery and less surgical dissection because of the shorter regeneration distance from the donor axons to the targeted motor end plates through residual neural network connections and descending motor signals.

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Background: Injury to the neurological pathway that enables ankle dorsiflexion is likely to cause foot drop. This pathway includes the motor cortex; lumbosacral plexus; and the sciatic, tibial, and peroneal nerves. Nerve damage typically occurs due to compression, entrapment, traction, or direct trauma to the nerve due to several etiologies. However, there are limited reports on the incidence, etiology, and factors associated with foot drop. Methods: The authors reviewed their clinic's data from 1022 patients with foot drop from 2004 to present to determine the incidence, causes, and risk factors of foot drop. Microsoft Excel was used for descriptive statistical data analysis and graphing. Results: A total of 21 causes of foot drop were found. Of 1022 patients, 142 (13.9%) had foot drop after lumbosacral (LS) spine surgery, while 131 patients (12.8%) with LS spine complications who had not undergone surgery also reported foot drop. The LS spine complications and surgeries were influenced by age (median age, 63 and 55 years, respectively) and were marginally higher in male patients (54%). A total of 79 patients (7.8%) with foot drop had previously undergone hip replacement surgery. Older age (median age, 60 years) and female sex (85%) were risk factors for hip replacement surgery resulting in foot drop. In contrast, younger age and male sex were the risk factors for gunshot and stab wounds, injection drug use, drug or medication overdoses, and motor vehicle accidents resulting in foot drop. Conclusions: Failed back surgery syndrome is the leading cause of foot drop after lumbosacral spine and hip replacement surgeries in both male and female older (median age, 60 years) patients. However, most (85%) of the foot drop patients in the present study who underwent hip replacement surgery were female patients. Sports and recreational activities, motor vehicle accidents, drug use, and violence are common causes of foot drop in younger male adults.

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BACKGROUND Cervical spine deformities can occur because of genetic, congenital, inflammatory, degenerative, or iatrogenic causes. CASE REPORT We report a 45-year-old woman who presented to our clinic with complete paralysis of the left upper extremity 5 months after C4-C6 discectomy and fusion surgery. The electrodiagnostic and EMG reports 3 months after her previous surgery revealed left C5-C7 polyradiculopathy involving the upper trunk, lateral and posterior cords, and atrophy of the left deltoids, triceps, and biceps muscles. She underwent the following nerve transfer procedures with the senior author (RKN): The median nerve fascicles were transferred to the biceps and brachialis branches of the musculocutaneous nerve. Radial nerve triceps branches were transferred to the deltoid and teres minor branches of the axillary nerve. The patient could fully abduct her left shoulder to 170°, and the LUE functions were restored to nearly normal 17 months after the surgery. CONCLUSIONS Neurolysis combined with nerve transfer might be the most effective treatment for cervical spinal root injuries. Advances in peripheral nerve rewiring, transcranial magnetic stimulation, brain-computer interface robotic technologies, and emerging rehabilitation will undoubtedly increase the possibility of reviving the extremities in patients with central pathology by restoring the descending motor signals through the residual neural network connections.

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Chebulic Myrobalan is the main ingredient in the Ayurvedic formulation Triphala, which is used for kidney and liver dysfunctions. Herein, natural nitrogen-doped carbon dots (NN-CDs) were prepared from the hydrothermal carbonization of Chebulic Myrobalan and were demonstrated to sense heavy metal ions in an aqueous medium. Briefly, the NN-CDs were developed from Chebulic Myrobalan by a single-step hydrothermal carbonization approach under a mild temperature (200 °C) without any capping and passivation agents. They were then thoroughly characterized to confirm their structural and optical properties. The resulting NN-CDs had small particles (average diameter: 2.5 ± 0.5 nm) with a narrow size distribution (1-4 nm) and a relatable degree of graphitization. They possessed bright and durable fluorescence with excitation-dependent emission behaviors. Further, the as-synthesized NN-CDs were a good fluorometric sensor for the detection of heavy metal ions in an aqueous medium. The NN-CDs showed sensitive and selective sensing platforms for Fe3+ ions; the detection limit was calculated to be 0.86 µM in the dynamic range of 5-25 µM of the ferric (Fe3+) ion concentration. Moreover, these NN-CDs could expand their application as a potential candidate for biomedical applications and offer a new method of hydrothermally carbonizing waste biomass.

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Background: Most peroneal nerve injuries resulting in foot drop are secondary to trauma or iatrogenic. Foot drop can occur due to potential complications from the hip, lumbosacral spine, and knee surgeries, which are critical to diagnose and manage. Methods: We reviewed our foot drop patients' data to determine the incidence and iatrogenic causes of the injury and managed surgically by neurolysis of the peroneal nerve and transfer of functional fascicles of either the superficial peroneal or the tibial nerve to the deep peroneal nerve. Results: We found 28 iatrogenic foot drop patients who have had surgery and postoperative follow-up evaluations with us. Before the onset of foot drop, all except one (27 of 28) patient have had surgeries in other clinics before presenting to our institution. Foot drop in one patient was due to infection and hip wound after he was intubated and stayed in ICU for 4 weeks. Thirteen of the 28 patients have had lumbosacral (L3-4, L4-L5, and L5-S1) fusion or laminectomy, eight have had hip surgery, and five have had knee surgery. One patient had a fasciotomy due to compartment syndrome and another patient had two previous surgeries for posterior tibial entrapment and tarsal tunnel syndrome at other institutions. NCS and EMG reports showed that these patients had injuries to the peroneal or tibial nerve after their prior surgeries. One patient had a femoral nerve injury. Preoperatively, 10 patients had severe foot drop with muscle weakness and a functional grade of 0/5; 16 patients had grades ranging from 1 to 2/5; and two patients had 3/5. Overall, 23 of the 28 patients (83%) had improvement in their ankle dorsiflexion with anti-gravity and regained a healthier gait after the decompression, neurolysis, and nerve transfer at our clinic. Conclusion: Twenty-three of the 28 (83%) iatrogenic foot drop patients in this report regained a healthier gait with improved ankle dorsiflexion and anti-gravity after the neurolysis, and nerve transfer of the peroneal or tibial nerve and transfer of functional fascicles of either the superficial peroneal or the tibial nerve to the deep peroneal nerve at our clinic.

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Background: External Rotational Humeral osteotomy is used to address the external rotation deficit in older children with obstetric brachial plexus Injury (OBPI). Although this procedure improves the cosmetic effect of shoulder subluxation, it has no effect on the underlying structural (glenohumeral deformity and scapular elevation and rotation) and functional problems. In this study, improvements in glenohumeral joint alignment; scapular hypoplasia, elevation, and rotation (SHEAR) deformity; and upper extremity functional movements were demonstrated in adult patients with OBPI 1 year after the mod Quad and/or triangle tilt surgeries. Methods and Patients: The outcome of humeral rotational osteotomy reported in the literature was compared with the results from 43 adult patients with OBPI (21 men and 22 women; 23 right and 20 left sides) with a mean age of 21.3 years (range, 17 to 38 years) who underwent mod Quad and/or triangle tilt surgeries and had over 12 months of postoperative follow-up (mean 22.9 months; range, 12 to 50 months). Results: The preoperative average modified total Mallet score, including supination, was 14.6 ± 3.5 (P < 0.0001) in the 43 adult patients with OBPI in this report. This total Mallet score was significantly improved to 22 ± 3.9 (P < 0.0001) over 12 months after mod Quad and/or triangle tilt surgeries. Thirty-two (75%) of the patients showed great improvement in all upper extremity functions: shoulder abduction, external rotation, hand-to-mouth, hand-to-neck, hand-to-spine, and supination. The improvement after humeral osteotomy reported in the literature was a cosmetic effect that did not address the underlying structural and functional problems and was found to decrease the improved shoulder abduction in long-term follow-up. Conclusions: Thirty-two (75%) of 43 adult patients with OBPI showed great improvement in all upper extremity functions 1 year after mod Quad and/or triangle tilt surgeries. The other 11 patients (25%) showed improvement in hand-to-mouth movement and/or supination. In contrast, humeral osteotomy, as reported in the literature, improved the cosmetic effect of shoulder subluxation but had no effect on the underlying structural and functional problems.

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Nanomaterials are endowed with unique features and essential properties suitable for employing in the field of nanomedicine. The nanomaterials can be classified as 0D, 1D, 2D, and 3D based on their dimensions. The nanomaterials can be malleable and ductile and they can be drawn into wires and sheets. Examples of nanomaterials are quantum dots (0D), nanorods, nanowires (1D), nanosheets (2D), and nanocubes (3D). These nanomaterials can be synthesized using top-down and bottom-up approaches. The achievements of 0D and 1D nanomaterials are used to detect trace heavy metal (e.g., Pb2+) and have higher sensitivity with the order of five as compared to conventional sensors. The achievements of 2D and 3D nanomaterials are used as diagnostic and therapeutic agents with multifunctional ability in imaging systems such as PET, SPECT, etc. These imaging modalities can be used to track the drug in living tissues. This review comprises the state-of-the-art of the different dimensions of the nanomaterials employed in theranostics. The nanomaterials with different dimensions have unique physicochemical properties that can be utilized for therapy and diagnosis. The multifunctional ability of the nanomaterials can have a distinct advantage that is used in the field of theranostics. Different dimensions of the nanomaterials would have more scope in the field of nanomedicine.

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BACKGROUND: Scapular winging, muscle weakness, chronic discomfort, and overall impairment of shoulder function are commonly caused by injuries to and/or compression of the upper brachial plexus, long thoracic, and accessory nerves. These injuries can have significant social and financial impacts on patients. METHODS: Twenty-one adults who sustained shoulder injuries (a bilateral injury in two patients and a total of 23 shoulder surgeries) presented with winged scapulas, limited shoulder range of motion, and severe shoulder pain. RESULTS: Patients underwent unilateral decompression, neurolysis of the upper brachial plexus/long thoracic nerve (LTN), and partial resection of the scalene muscle. The mean shoulder abduction/flexion improved significantly, and 15 of 21 (71%) patients regained full range of motion (180°) postoperatively. In addition, the winged scapula appearance improved significantly in 20 of 21 patients (96%) postoperatively. CONCLUSION: All except one of 21 patients with scapular winging, muscle weakness, chronic discomfort, and overall impairment of shoulder function improved following unilateral decompression, neurolysis of the upper brachial plexus/LTN, and partial resection of the scalene muscle.

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Injuries to the long thoracic nerve, which directly branches off of the C6, C7, and C8 brachial plexus nerve roots, can cause scapular winging and affect shoulder movements. Long thoracic nerve injuries resulting from accidents, violence, or overuse can be severe lesions requiring challenging surgeries. We evaluated the long-term functional outcomes of neuroplasty and the scalene muscle resection procedures in patients with long thoracic nerve injury and winging scapula. METHODS: All 15 patients who underwent scalene muscle resection with decompression and neurolysis of the long thoracic nerve in a single institution to treat winged scapula and limited shoulder movements between March 2007 and May 2020 with follow-up over 2 years were included in the study. RESULTS: Shoulder abduction and arm flexion improved significantly to 158 ± 52 degrees and 165 ± 53 degrees from a mean of 108 ± 54 degrees and 104 ± 52 degrees (P < 0.02) over 2 years after surgery (mean 3.4 years). Overall, there was a significant reduction in the scapular winging, as assessed by estimating the decrease in the angle between the scapular plane and the posterior chest wall. The extent of the score greatly improved post-surgically from a mean of 1.2 ± 0.4 to 3.5 ± 0.9 (range 1-4; 1-severe, 2-moderate, 3-mild, and 4-minimal) (P < 0.01). CONCLUSION: The improvement in shoulder movements and reduced scapular winging was significant and stable over 2 years of surgery in 81% of our study patients.

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OBJECTIVES: This study aimed to assess the surgical outcomes of patients with work-related upper extremity musculoskeletal disorders (UE-MSDs) who failed conservative treatment. MATERIAL AND METHODS: This was a retrospective study of 17 patients who had work-related UE-MSDs and underwent the following surgeries and follow-up evaluations: decompression, external and internal neurolysis of the upper trunk of the brachial plexus and the long thoracic nerve (LTN), and a partial resection of the anterior and middle scalene muscle. A detailed history of clinical presentation including pain, physical and clinical examinations of the extent of scapular winging (ESW), and upper extremity anatomical postures, such as active forward arm flexion and shoulder abduction, were recorded before and after 3 months of the surgery. Nerve conduction velocity and electromyography examination reports were obtained to assess the sensory or motor loss of the nerve injury before their operation. RESULTS: All 17 patients included in this report showed some improvement anatomically in the scapula appearance and functionally in their shoulder movements. More specifically, 9 (53%) patients got a restored to near healthy appearance of the scapula, and 11 (65%) patients recovered a full range of motion, 180° post-surgically. Overall, the mean shoulder flexion and abduction improved to 157±37.5° and 155±40.2° after the surgery from 106±30.2° and 111±34.8°, respectively (p < 0.0001). The ESW score also significantly improved from a mean of 1.5±0.51 to 3.5±0.71 (p < 0.0001). The post-surgical improvements were statistically highly significant (p < 0.0001). CONCLUSIONS: Decompression and neurolysis of the upper brachial plexus and the LTN, and the partial release of the scalene muscle contracture procedures have fostered improvements in the shoulder anatomical appearance and movements in all 17 patients. Int J Occup Med Environ Health. 2021;34(3):427-35.

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Background: Peripheral nerve injuries make up many upper extremity musculoskeletal disorders (UE-MSDs), as peripheral nerves in the upper extremities are susceptible to damage due to their superficial course and length. The health and economic burdens of peripheral nerve injuries are rising. Upper-limb peripheral nerve injuries caused by prone positioning in COVID-19 patients in intensive care have occurred during the current global pandemic. Understanding the incidence and causation of these injuries is essential, as these affect primarily young workers and athletes with skeletal immaturity and contribute to significant morbidity. Methods and Patients: A total of 789 patients, 481 of whom were male and 308 female, with limited upper-extremity movements, scapular winging, and pain due to upper brachial plexus, long thoracic and accessory nerve injuries (459 right, 282 left, and 48 bilateral) were included in the study. Patient age at the onset of injury ranged between 11 months and 68 years. Results: A total of 18 causes of peripheral nerve injury were identified among the 789 patients with UE-MSD. The most affected patients (12.7%) were involved in sports and related activities, with 20 different sports and related activities reported in this patient population. Weightlifting caused the most (10.9%) number of injuries in this group. Incidences in the least affected patients were due to massage and viral infection, at 0.6% and 0.6% respectively. Conclusions: Sports and recreational-related physical activities are essential components of a healthy lifestyle, and may help decrease the incidence of obesity, diabetes, and cardiovascular diseases. Injury and fear of impairment, however, can be barriers in the participation of these activities. Surgery and other interventions can help maximize return to work and regular activities after UE-MSDs.

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Untreated adult obstetric brachial plexus injury (OBPI) patients, in general, use compensatory strategies to achieve their lost upper extremity functions; they cause some adverse effects. Our present study is a case series of 3 female adult OBPI patients, aged 46, 23 and 21 years old. They all had a modified Quad surgical procedure. All patients were assessed preoperatively and postoperatively by evaluating video recordings of standardized upper extremity movements using the modified Mallet scale. The average postoperative follow-up was 4.3 months (1 to 9 months). Total Mallet score significantly improved from 15 and 18 to 21 in two patients. Supination angle measured from active movement of these 3 patients improved from 40°, 0° and -60° to 80°, 40° and -40°, respectively. The modified Quad surgical procedure significantly improves active abduction and other shoulder functions not only in young pediatric and adolescent patients, as we have previously reported, but also in adult patients with muscle imbalance secondary to brachial plexus injury sustained at birth.

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Introduction: In teens, athletes, in general, have been found to have shoulder pain and or winging scapula resulting from long thoracic or spinal accessory nerve injuries. Accident (fall) and stretch injuries due to overuse and poor sports techniques mainly cause these injuries that affect their upper extremity movements and functions. Here, we report a significant improvement in scapula winging and shoulder active range of motion in 16 teen patients after long thoracic nerve decompression and neurolysis. Patients and Methods: This was a retrospective study of 16 teen patients who had severe winging scapula and poor shoulder movements and function. Therefore, they underwent decompression and neurolysis of long thoracic nerve with us, between 2005 and 2016. The average patient age was 17 years (range, 14-19 years). These patients had been suffering from paralysis for an average of 15 months (range, 2-48 months). All patients underwent a preoperative electromyographic assessment in addition to clinical evaluation to confirm the long thoracic nerve injury. Results: Scapula winging was severe in 10 of 16 patients (63%), moderate in 2 patients (12%), and mild in 4 patients (25%) in our present study. Mean shoulder abduction (128°) and flexion (138°) were poor preoperatively. Shoulder abduction and flexion improved to 180° in 15 patients (94%) and good (120°) in 1 patient (6%) at least 2 months after surgery. In 11 patients (69%), the winged scapula was completely corrected postsurgically and it was less prominent in other 5 patients. Conclusion: Long thoracic nerve decompression and neurolysis significantly improved scapular winging in all 16 teen patients in our present study, producing "excellent" shoulder movements in 15 patients (94%) and "good" result in 1 patient (6%).

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BACKGROUND Acute flaccid myelitis is an emerging polio-like illness mostly affecting young children, characterized by rapid onset of extremity weakness and paralysis in 1 or more limbs. Certain viruses, including enteroviruses such as EV-68, EV-71, poliovirus, and West Nile virus, can cause this disorder. The largest known outbreak of EVD68 in the United States was in the summer of 2014, causing severe respiratory illness and acute flaccid myelitis, mainly in young children. Furthermore, the US Centers for Disease Control and Prevention noted an increase in the number of patients with clinical symptoms of acute flaccid myelitis in 2018, and 134 confirmed cases by December 2018 were reported in the USA. CASE REPORT The patient in our present study was a 5-year-old female who had significant weakness and paralysis in all 4 extremities due to acute flaccid myelitis. EV-D68 had caused this disorder in this patient in August 2014. Conservative management had not helped her condition. Specific areas of concern were both shoulders and biceps, and the femoral and peroneal nerves in both sides. Of these, the right shoulder function was the worst, at less than grade 3. The patient also had marked atrophy and weakness of the right quadricep muscles. The patient underwent surgical treatment and had steady improvements in all 4 extremity functional movements. CONCLUSIONS We demonstrated that decompression, neurolysis, and nerve transfer surgical procedures can be used successfully to correct the paralyzed upper and lower extremity movements in acute flaccid myelitis patients.

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AIM: To evaluate whether obstetric brachial plexus injury (OBPI) children who had mod Quad and triangle tilt surgeries maintained their recovered upper extremity functional movements over 10 years. BACKGROUND: The short-term outcomes of surgery in OBPI patients are well documented. However, only a few publications with results over 10-year postoperative follow-up exist. We have previously reported the outcomes of these 2 surgeries in OBPI after 1, 2, and 5 years. Here, we report the successful outcomes in 17 of these patients over 10 years. METHODS: Seventeen OBPI patients, who had mod Quad, a modified muscle release operation and triangle tilt, a bony surgical procedure with us between 2005 and 2008, had postoperative follow-up of 10 years and met the inclusion criteria. Patients who had multiple surgeries and did not have 10-year follow-up are excluded in this study. RESULTS: Fifteen of 17 children maintain their recovered upper extremity functions for extended long period (mean, 10 years; range, 9-13 years). There was statistically significant improvement in total functional Mallet score after 3 years (mean, 18.8 ± 2.1; P ≤ 0.01) from the preoperative mean total Mallet score of 14.5 ± 1.2. This improvement was not only maintained for extended period but also improved (mean total Mallet score, 20.35 ± 2.3; P ≤ 0.01) in some patients. CONCLUSIONS: Overall, all upper extremity functions improved greatly after mod Quad and triangle tilt surgeries in OBPI children, and they were able to maintain their recovered functional movements over extended period of 10 years.

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Background: Functional free gracilis muscle transfer is an operative procedure for elbow reconstruction in patients with complete brachial plexus nerve and avulsion injuries and in delayed or prolonged nerve denervation, as well as in patients with inadequate upper extremity function after primary nerve reconstruction. Methods: We retrospectively reviewed our patient records and identified 24 patients with complete brachial plexus nerve injury (13 obstetric, 11 males and 2 females; 11 traumatic, 9 males and 2 females) whose affected arm and shoulder were totally paralyzed and their voluntary elbow flexion or the biceps function was poor preoperatively (mean M0-1/5 in MRC grade). These patients had undergone the functional free gracilis muscle transfer procedure at our clinic since 2005. Results: Ninety-two percent of all patients showed recovery and improvement. Successful free gracilis muscle transfer is defined as antigravity biceps muscle strength of M3-4/5 and higher, which was observed in 16 (8 obstetric and 8 traumatic) of our 24 patients (67%) in this study at least 1 year after functional free gracilis muscle transfer. This is statistically significant (P < .000001) in comparison with their mean preoperative score (M0-1/5). There was no improvement in motor level of the biceps muscle (M0/5) in 2 patients (1 from each group). The donor site of these 24 patients showed no deficit in motor and sensory functions. Conclusions: Taken together, a significant number (92%) of patients in both obstetric and traumatic brachial plexus injury groups had recovery and improvement and most of these patients (64%) achieved antigravity and elbow flexion at least 1 year after free gracilis muscle transfer at our clinic.

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Background: Injury to the common peroneal nerve disrupts the motor control pathway to ankle dorsiflexors and evertors, as well as toe extensors, resulting in pathological gait and foot drop. Direct external compression on the fibular head is the most frequent cause of peroneal nerve impairment and has poor prognosis. Methods and Patients: Here, we report the surgical outcome of 21 patients with foot drop (9 males and 12 females) who underwent nerve transfer procedure of either the superficial peroneal nerve or the tibial nerve fascicles to the motor branch of the tibialis anterior and to the deep peroneal nerve. They had at least 6 months postoperative follow-up (mean = 17; range, 6-32 months). Results: Among 21 patients who had no ankle dorsiflexion (BMRC 0/5) preoperatively, 9 patients had successful restoration of ankle dorsiflexion (BMRC 4 to 4+/5), 7 patients had BMRC 2 to 3+/5, and 4 patients had no or poor restoration of dorsiflexion (BMRC 0 to 1+/5) but achieved good ankle eversion (BMRC 3 to 4+/5). Overall statistically significant clinical improvement of ankle dorsiflexion and eversion from preoperative BMRC grade 2.6 ± 0.5 to postoperative BMRC grade 3.6 ± 0.7 (P = .0000004) was achieved. Conclusion: Overall statistically significant clinical improvement of ankle dorsiflexion and eversion was achieved in 80% of our study patients. Most of these patients gained antigravity and were able to walk with minimal steppage gait. In the other 4 patients (20%), there was good improvement in ankle eversion but poor or no ankle dorsiflexion.

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BACKGROUND: Injury to long thoracic and the spinal accessory nerves can cause winging scapula as a result of weakness and paralysis of the trapezius and serratus anterior muscles. Although these nerve and muscle operations have been reported to correct winging scapula due to various causes, there is no report on comparing the outcomes of these procedures in peer-reviewed Pubmed-indexed literature. In this article, we compared the improvements in the restoration of shoulder functions in winging scapula patients after long thoracic nerve decompression (LTND) in our present study with outcomes of muscle and tendon transfer operations published in the literature (Aetna cited articles). METHODS: Twenty-five winging scapula patients met the inclusion criteria, who had LTND and neurolysis at our clinic since 2008. Electromyographic evaluation of the brachial plexus and long thoracic nerve distribution was performed preoperatively for all our patients in this study. Operating surgeon (R.K.N.) examined all patients and measured pre- and postoperative range of motion of the affected shoulder. The mean follow-up was 23 months (range, 13-46 months). Age of our patients in this study at the time of surgery was between 13 and 63 years. These patients had winging scapula between 5 days (tennis injury) and several years before surgery and some were unknown. RESULTS: Shoulder flexion and abduction improved to an average of 163˚ (P < 0.000006) and 157˚ (P < 0.0000005) from 104˚ and 97˚ at least 1-year post-LTND in 25 winging scapula patients in our present study. This is statistically significant in comparison to the reported improvements resulting from muscle and tendon transfer procedures in the Pubmed-indexed (Aetna cited) literature. CONCLUSION: This meta-analysis suggests that nerve surgeries such as LTND and neurolysis are effective techniques in correcting winging scapula in comparison with muscle transfer operations.

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AIM: To compare outcomes of our revision surgical operations in obstetric brachial plexus palsy (OBPP) patients to results of conventional operative procedures at other institutions. METHODS: We analyzed our OBPP data and identified 10 female and 10 male children aged 2.0 to 11.8 years (average age 6.5 years), who had prior conventional surgical therapies at other clinics. Of the 20 patients, 18 undergone triangle tilt, 2 had only mod Quad. Among 18 patients, 8 had only triangle tilt and 10 had also mod Quad as revision surgeries with us. We analyzed the anatomical improvements and functional modified Mallet statistically before and after a year post-revision operations. RESULTS: Pre-revision surgery average modified Mallet score was 12.0 ± 1.5. This functional score was greatly improved to 18 ± 2.3 (P < 0.0001) at least one-year after revision surgical procedures. Radiological scores (PHHA and glenoid version) were also improved significantly to 31.9 ± 13.6 (P < 0.001), -16.3 ± 11 (P < 0.0002), at least one-year after triangle tilt procedure. Their mean pre-triangle tilt (yet after other surgeon's surgeries) PHHA, glenoid version and SHEAR were 14.6 ± 21.7, -31.6 ± 19.3 and 16.1 ± 14.7 respectively. CONCLUSION: We demonstrate here, mod Quad and triangle tilt as successful revision surgical procedures in 20 OBPP patients, who had other surgical treatments at other clinics before presenting to us for further treatment.