|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.|
| Conversely, in the last 100 cases, the percentage of clavicle divisions rose to 13%. We now consider that this gives greater safety in controlling the whole length of the subclavian artery and permits better identification of lesions of the C8 and D1 roots. Division of the clavicle has a low complication rate when the osteosynthesis is made with screwed-on plates. Up to the present, in 23 clavicle divisions, we have seen only one septic condition, and that had no adverse consequence on bone healing. Finally, this procedure does not lengthen the operative time; on the contrary, it may shorten it by making dissection easier, especially when the most proximal roots of the brachial plexus are retracted behind the clavicle.
Therapeutic options in the field of direct repair of brachial plexus lesions keep getting better. Only one matter remains controversial today, namely neurolysis. In our view, end-to-end suture of brachial plexus elements is possible only in cases of laceration. Fascicular or truncular grafting remains the most frequently used technique. Neurotizations are procedures of last resource, reserved for the most severe plexus lesions.
Microsurgical neurolysis of the brachial plexus is a controversial procedure with uncertain results, but could be indicated if a conduction block (neurapraxia) does not resolve itself spontaneously. This condition is generally caused by a dense perineural fibrosis. Fibrotic reaction is usually triggered by post-traumatic hematoma but can also be found after stretch injuries. Operative palpation of roots and fasciculi reveals the characteristic intraneural sclerous nodules. Only intraneural and interfascicular neurolysis can free the fasciculi, but the method provokes devascularization with a risk of new fibrosis.
Actually, it is often the surgeon's experience that determines the type of neurolysis used. The danger in performing a strictly extraneural neurolysis is that it may leave undetected a complete rupture hidden under the apparent continuity of fibrotic epineurium. Fibrosis and lack of flexibility of the nerve trunk must impel the surgeon to be aggressive and look for the fascicular rupture by intraneural dissection.
Our results demonstrate the difficulty of the procedure. Objective amelioration after neurolysis was observed in less than 50% of our patients. On the other hand, 10% were made worse and 40% had no amelioration following this microsurgical technique.
Experience showed us that when clinical and electromyographic manifestations of nerve regeneration tend to stagnate, it is legitimate to propose a neurolysis before the sixth month postinjury.
In our series of 386 cases of surgical procedures on the brachial plexus, we have done only five primary repairs for lacerations, all of them by suture.
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