OBJECTIVES:Nerve transfer is a promising intervention for restoring hand and upper limb function after cervical spinal cord injury (SCI), but the timeline of neurophysiological recovery in humans remains unclear. This study aimed to define recovery profiles after nerve transfers to restore upper limb function. METHODS:Individuals with traumatic cervical SCI who received nerve transfer surgery in at least 1 limb were evaluated during routine clinical visits for up to 2 years post-transfer. The primary outcome was the time to detect reinnervation, defined as the appearance of voluntary motor unit potentials on needle electromyography. Representative muscles were assessed for 5 nerve transfer procedures: (1) supinator to posterior interosseous nerve; (2) brachialis to anterior interosseous nerve (AIN); (3) extensor carpi radialis longus to AIN; (4) extensor carpi radialis brevis to AIN; and (5) axillary to triceps. In a subset of participants who continued needle electromyography after reinnervation was detected, an ordinal grading system characterized motor unit potential maturity and the presence of pathological spontaneous activity over time. RESULTS:A total of 44 individuals with traumatic cervical SCI were enrolled. Mean times to detect reinnervation were 6.9 months (supinator-posterior interosseous nerve), 10.4 months (brachialis-AIN), 9.6 months (extensor carpi radialis longus-AIN), 9.6 months (extensor carpi radialis brevis-AIN), and 9.0 months (axillary-triceps). Over time, reinnervated muscles showed reduced pathological spontaneous activity and progression from nascent to mature motor unit potentials. INTERPRETATION:These findings establish benchmark timelines for first detection of neurophysiological reinnervation after nerve transfer in cervical SCI, providing a foundation for setting clinical expectations, planning rehabilitation, and designing future interventional studies. ANN NEUROL 2026.

Nerve transfer surgery (NTS) shows promise in restoring movement to muscles paralyzed by spinal cord (SCI) and peripheral nerve injury (PNI). Yet, motor outcomes vary, and the neurophysiological factors influencing responders and non-responders remain unclear. As the fundamental goal of NTS is to reinnervate paralyzed muscles by creating new motor units (MUs), we examined MU properties after NTS for individuals with SCI and PNI. Nine participants (3 SCI, 6 PNI, 50.3 ± 13.9 years) >18 months post-NTS were evaluated and compared to either age-matched controls (SCI) or the contralateral limb (PNI). We used a sophisticated, signal processing software known as Decomposition-Based Quantitative Electromyography (DQEMG) and near-fiber EMG to examine MU characteristics sampled from needle electromyography signals recorded during low-intensity contractions. The NTS muscle MU potentials (MUP) were larger, and near-fiber MUPs (NFM) were more temporal dispersed than controls. Measures of neuromuscular junction instability were greater in NTS muscles compared to controls (p < 0.05). Firing rates of MU, and MUP phases and turns were not different between groups (p > 0.05). Overall, these data suggest the quality of reinnervation post-surgery requires further investigation as a potential mediator of motor outcome and the required time for successful reinnervation may be longer than currently predicted.

Purpose Careful patient selection and optimal surgical timing are essential to the success of nerve transfers. It is important to understand what factors contribute to this decision-making. The purpose of this study was to describe the characteristics of patients referred to interdisciplinary peripheral nerve clinics with traumatic upper extremity injuries and compare those who went on to nerve transfer surgery with those who did not. Methods Patient and injury characteristics, preoperative physical examination and electrodiagnostic findings, and patient-reported outcome measures were examined. Inclusion criteria were subjects ≥18 years of age presenting to an interdisciplinary peripheral nerve clinic with traumatic upper extremity peripheral nerve injuries. Subjects were stratified into surgical and non-surgical groups for comparison. Results Eighty-three subjects met the inclusion criteria, and 36 subjects received nerve transfer surgery. More male subjects went on to have surgery than female subjects. The surgical group demonstrated a significantly higher ratio of weak and denervated muscle groups than the non-surgical group (p < 0.05). No other statistically significant differences were identified between operative and non-operatively managed subjects. Conclusion Subjects that received nerve transfer surgery demonstrated a significantly higher ratio of weak and denervated muscles than those managed non-surgically, and males were disproportionately represented in the surgical group. These findings suggest that anticipated motor recovery is the most important factor driving surgical decision-making and that male subjects may be more likely to proceed with surgery. Understanding which patients undergo nerve transfer surgery allows clinicians to interrogate their decision-making, address patient-related barriers to surgery, and better understand surgical outcomes.

Background:Delivery of immediate breast reconstruction (IBR) was severely restricted during the coronavirus disease 2019 (COVID-19) pandemic, with irreversible consequences for breast cancer survivors. This study aimed to determine the pandemic's effect on the provision of IBR services, quality of care delivered, and reconstructive outcomes. Methods:For this multi-institutional, retrospective cohort study, data were obtained from all IBR cases during the study periods defined as "pre-COVID-19" (October 1, 2018, to March 14, 2020) and "COVID-19" (March 15, 2020, to October 31, 2021). Patient demographics, reconstructive strategy types, and oncological and surgical characteristics were analyzed. Safety and quality outcomes, including readmission, infection, seroma, mastectomy flap necrosis, and wait times were recorded. Results:A cohort of 525 patients was included in this study. Patient and tumor characteristics were similar between the 2 study periods. There was a significantly lower odds of undergoing a single-stage alloplastic surgery (odds ratio [OR] = 0.40, 95% confidence interval [CI] = 0.17-0.94, P = 0.0365) or autologous immediate reconstruction with a deep inferior epigastric perforator (DIEP) flap (OR = 0.42, 95% CI = 0.21-0.85, P = 0.015) during the COVID-19 era, with a reciprocal 53% higher odds of 2-stage alloplastic surgery (OR = 1.53, 95% CI = 1.03-2.27, P = 0.0359) during that time. Median wait time from first-stage to second-stage reconstruction was significantly shorter during COVID-19 (P = 0.0017). There were no differences in safety outcomes between the periods. Conclusions:Reconstructive strategies differed during the COVID-19 era of resource limitations with more 2-stage alloplastic procedures and fewer single-stage alloplastic and autologous immediate DIEP flap procedures.

BACKGROUND:Quantitative muscle ultrasound (qMUS) provides morphological measurements that can support clinical observation of muscle atrophy and weakness. As the use of qMUS continues to expand, and its potential for broader implementation in neuromuscular evaluation grows, there is a clear need for further validation, particularly in pathologies frequently encountered in electrodiagnostic laboratories, such as cubital tunnel syndrome caused by ulnar neuropathy at the elbow (UNE). OBJECTIVE:To evaluate the validity of qMUS evaluation of ulnar-innervated intrinsic hand muscles. DESIGN:Cross-sectional study. PARTICIPANTS:Individuals 18 years or older with chronic UNE and healthy controls (HC). MAIN OUTCOME MEASUREMENT:qMUS parameters (muscle thickness [MT], cross-sectional area [CSA], echogenicity) were measured in the first dorsal interosseous (FDI) and abductor digiti minimi (ADM) and were correlated to corresponding negative peak amplitude of the compound muscle action potential measured (CMAP) and key pinch grip strength. RESULTS:Sixteen adults (8 HC, 8 UNE) participated in the study. Key pinch strength was significantly correlated with FDI MT (r = 0.45, p = .03 [95% CI, 0.05-0.73]) and echogenicity (rho = -0.60, p = .002 [95% CI, -0.82 to -0.24]). FDI MT and echogenicity explained 20% and 36% of pinch strength variance, respectively. Echogenicity was significantly correlated with corresponding CMAP amplitudes (FDI: rho = -0.59, p = .004 [95% CI, -0.81 to -0.21]; ADM: rho = -0.62, p = .002 [95% CI, -0.83 to -0.26]). No statistically significant relationship was found between key pinch strength and FDI CSA (r = 0.35 p = .104 [95% CI, -0.08-0.67]). Furthermore, FDI CMAP was not significantly associated with FDI MT (rho = 0.14, p = .55 [95% CI, -0.32-0.54]) or FDI CSA (rho = 0.041, p = .86 [95% CI, 0.04-0.47]). CONCLUSION:qMUS measures of echogenicity and MT (indicators of muscle fibrosis and size, respectively), correlated with key pinch strength and CMAP amplitudes in the FDI and ADM, in a heterogenous group including UNE and HC limbs. qMUS parameters may provide useful complementary markers and deeper insight into neuromuscular health in entrapment neuropathy.

"State of the Art" Learning Objectives: This manuscript serves to provide the reader with a general overview of the contemporary approaches to peripheral nerve reconstruction as the field has undergone considerable advancement over the last 3 decades. The learning objectives are as follows: To provide the reader with a brief history of peripheral nerve surgery and some of the landmark developments that allow for current peripheral nerve care practices. To outline the considerations and management options for the care of patients with brachial plexopathy, spinal cord injury, and lower extremity peripheral nerve injury. Highlight contemporary surgical techniques to address terminal neuroma and phantom limb pain. Review progressive and future procedures in peripheral nerve care, such as supercharge end-to-side nerve transfers. Discuss rehabilitation techniques for peripheral nerve care.

Introduction: Breast cancer care requires both oncologists and plastic surgeons. Coordinating these specialists and combining extirpative and reconstructive procedures before adjunctive therapies can cause delays in care. For patients with less advanced disease, surgery is performed before adjunctive therapies, requiring early specialist coordination and the possibility of surgical complications. We compare these patients to those with more advanced disease requiring adjunctive therapies before surgery. Methods: A retrospective chart review identified 337 post-mastectomy + immediate breast reconstruction (IBR) patients. Patients were divided into surgery first (SF) and neoadjuvant chemotherapy (NC) first groups with reconstructive subgroups. Wait times between care pathway milestones were compiled and compared to national standards. Results: SF experienced longer wait times from consultation to treatment initiation (47 ± 51.5 vs 22 ± 22, P<.001) and from first to second treatment modality (62 ± 35 vs 39 ± 17, P<.001). Furthermore, only 29% of SF met the standard of receiving treatment within 4 weeks from consultation compared to 63% of NC ( P<.001). Within subgroups, SF alloplastic reconstructions had shorter wait times compared to SF autologous reconstructions. For SF, only 31% of alloplastic and 24% of autologous reconstruction initiated treatment within 4 weeks of consultation. Conclusion: In this cohort of Canadian breast cancer patients, those receiving surgery first experienced prolonged wait times to treatment, particularly with autologous reconstruction. Patients should be informed of the potential impact on adjunctive therapies when considering reconstructive modality.

Introduction: Breast cancer is the most frequently diagnosed cancer worldwide. For those undergoing mastectomy, the choice of alloplastic immediate breast reconstruction (IBR) is increasingly favored. Post-operative chronic pain is an important consideration in this decision, but there is a paucity of data for those undergoing alloplastic IBR. We sought to examine the prevalence, severity, and risk factors for the development of chronic pain in this cohort using validated patient-reported outcome measures. Methods: A cross-sectional survey study was conducted among patients receiving mastectomy with alloplastic IBR. Participants completed 3 surveys querying chronic pain, specifically the Breast Cancer Pain Questionnaire (BCPQ), Brief Pain Inventory (BPI), and BREAST-Q. Participant medical records were reviewed for demographic and surgical variables. Results: A total of 118 patients participated in the study-a response rate of 33.6%. Chronic pain prevalence was high (52.5%), and only 29.0% of these patients had consulted a physician regarding their pain. Among those reporting chronic pain (n = 62), the median severity of pain was 3.1 on an 11-point scale. Chronic pain was associated with radiation (p = .018), bilateral reconstruction (p = .05), worse emotional health (p = .0003), less self (p = .022), and sexual confidence (p = .044). Inter-tool reliability was high, with no significant difference in responses between the 3 surveys. Conclusion: In this cohort, chronic pain is supported as a significant concern among patients who have undergone mastectomy with alloplastic IBR. Given the burden of chronic pain, there is an opportunity to intervene with preventative measures and support for its management.

Introduction/AimsThere is a dearth of knowledge regarding the status of infralesional lower motor neurons (LMNs) in individuals with traumatic cervical spinal cord injury (SCI), yet there is a growing need to understand how the spinal lesion impacts LMNs caudal to the lesion epicenter, especially in the context of nerve transfer surgery to restore several key upper limb functions. Our objective was to determine the frequency of pathological spontaneous activity (PSA) at, and below, the level of spinal injury, to gain an understanding of LMN health below the spinal lesion.MethodsNinety-one limbs in 57 individuals (53 males, mean age = 44.4 +/- 16.9 years, mean duration from injury = 3.4 +/- 1.4 months, 32 with motor complete injuries), were analyzed. Analysis was stratified by injury level as (1) C4 and above, (2) C5, and (3) C6-7. Needle electromyography was performed on representative muscles innervated by the C5-6, C6-7, C7-8, and C8-T1 nerve roots. PSA was dichotomized as present or absent. Data were pooled for the most caudal infralesional segment (C8-T1).ResultsA high frequency of PSA was seen in all infralesional segments. The pooled frequency of PSA for all injury levels at C8-T1 was 68.7% of the limbs tested. There was also evidence of PSA at the rostral border of the neurological level of injury, with 58.3% of C5-6 muscles in those with C5-level injuries.DiscussionThese data support a high prevalence of infralesional LMN abnormalities following SCI, which has implications to nerve transfer candidacy, timing of the intervention, and donor nerve options.

Purpose:Previous studies have shown an increase in the number of women electing for immediate breast reconstruction at the time of mastectomy. Although often not known at the time, some of these women will require postoperative radiation therapy. The purpose of this study was to investigate if exposure to radiation therapy after mastectomy with immediate breast reconstruction is associated with an increased risk of further surgery to manage complications arising from radiation.Methods and Materials:This retrospective, population-based cohort study included all patients who underwent mastectomy with immediate reconstruction from 2007 to 2014 in the province of Ontario, Canada. Exposure to adjuvant radiation therapy was captured using data from Ontario Health. The study outcome was reoperation for breast reconstruction performed during the follow-up window. Cox proportional hazard models were used to assess the effect of radiation therapy exposure on risk of breast reconstruction reoperation.Results:We identified 2342 patients who underwent mastectomy with immediate reconstruction over an 8-year period in Ontario, of whom 378 (16.1%) underwent adjuvant radiation therapy. Patients who received radiation were significantly more likely to undergo reoperation during follow-up (hazard ratio, 1.76; 95% confidence interval, 1.49-2.08; P < .0001). Patients with implant-based reconstructions (n = 1629, 69.6%) were not more likely to undergo reoperation than those with flap-based procedures (n = 713, 30.4%) (hazard ratio, 1.01; 95% confidence interval, 0.85-1.21; P = .885).Conclusions:Adjuvant radiation therapy initiated after mastectomy with immediate breast reconstruction is associated with an increased risk of additional breast reconstruction surgery, regardless of the type of reconstruction used. Patients with breast cancer who choose to undergo immediate reconstruction after mastectomy should be advised that additional reconstruction procedures may be required.

The health of the infralesional lower motor neuron (LMN) has received little attention in individuals with traumatic cervical spinal cord injuries (SCI). Infralesional LMN health is clinically relevant in the context of nerve transfer surgery to restore critical upper limb functions, as those demonstrating LMN damage below the neurological level of injury may experience irreversible sequelae of denervation (e.g., atrophy, fibrosis) without timely intervention. In this two-centre retrospective cohort study, we examined the health of the infralesional LMN in individuals with traumatic cervical SCI, using data derived from the clinical electrodiagnostic examination performed early after SCI. We assessed 66 limbs in 42 individuals with traumatic cervical SCI (40 males, mean age = 43.6±17.2, mean duration from injury = 3.3±1.5 months, 25 with motor complete injuries). Analysis was stratified by injury level as 1) C4 and above, 2) C5 and 3) C6-7. EMG performed on representative muscles from C5-6, C6-7, C7-8 and C8-T1, were included in analysis. LMN abnormality was dichotomized as present (abnormal spontaneous activity) or absent. Data were pooled for the most caudal infralesional segment (C8-T1). Overall, a high frequency of denervation potentials was seen in all infralesional segments for all injury levels. The pooled frequency of denervation potentials at C8-T1 was 74.6% of limbs tested. There was also evidence of denervation potentials at the rostral border of the neurological level of injury, as high as 64.3% of C5-6 muscles for C5 injuries. These data support a high prevalence of infralesional LMN abnormality following SCI, which has implications to candidacy, timing of the intervention, donor nerve options and motor prognosis following SCI.### Competing Interest StatementThe authors have declared no competing interest.### Funding StatementThis study did not receive any funding.### Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:Ethical approval for retrospective data analysis was obtained from the local institutional ethical review boards at the University of British Columbia and Northwestern University.I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesAll data produced in the present study are available upon reasonable request to the authors.

Abstract Study Design: Two-centre retrospective cohort study. Objectives: We examined the health of the infralesional LMN in individuals with traumatic cervical SCI, using data derived from the clinical electrodiagnostic examination performed early after SCI. Setting: Academic hospitals. Methods: We assessed 66 limbs in 42 individuals (40 males, mean age = 43.6±17.2, mean duration from injury = 3.3±1.5 months, 25 with motor complete injuries). Analysis was stratified by injury level as 1) C4 and above, 2) C5 and 3) C6-7. EMG performed on representative muscles from C5-6, C6-7, C7-8 and C8-T1, were included in analysis. LMN abnormality was dichotomized as present (abnormal spontaneous activity) or absent. Data were pooled for the most caudal infralesional segment (C8-T1). Results: A high frequency of denervation potentials was seen in all infralesional segments for all injury levels. The pooled frequency of denervation potentials at C8-T1 was 74.6% of limbs tested. There was also evidence of denervation potentials at the rostral border of the neurological level of injury, as high as 64.3% of C5-6 muscles for C5 injuries. Conclusion: These data support a high prevalence of infralesional LMN abnormality following SCI, which has implications to candidacy, timing of the intervention and donor nerve options.

AIMS:As a result of COVID-19, there have been restrictions on surgical interventions across Canada. Immediate breast reconstruction (IBR), while an essential component of cancer care, is classified as elective surgery and therefore has been restricted in access over the course of the pandemic. The purpose of this study was to compare wait times for breast cancer patients undergoing surgical intervention for IBR before and since the COVID-19 pandemic.METHODS:This was a retrospective cross-sectional study of consecutive patients who underwent IBR between July 2018 and October 2021 by 5 plastic surgeons at a single Canadian health center. Wait times to consultation and surgical intervention between pre- and post-COVID cohorts were analyzed.RESULTS:A total of 161 patients met inclusion criteria. For ablative surgery, there was no difference in wait times to surgical oncology consultation (14.0 ± 12.3 vs 14.0 ± 11.0 days, P = 0.991) and surgical intervention with IBR (41.0 ± 49.8 vs 35.0 ± 58.0 days, P = 0.621) between the pre- and post-COVID cohorts. For breast reconstruction, while time to consultation with plastic surgery (12.5 ± 14.8 vs 11.0 ± 12.8 days, P = 0.775) remained unchanged, usage of autologous techniques was reduced [n = 13 (16%) vs n = 2 (2%), P = 0.006], and time to second-stage alloplastic reconstruction increased (230 ± 102 vs 325 ± 224 days, P = 0.044) post-COVID.CONCLUSIONS:Swift adoption of evidence driven protocols has resulted in comparable wait times for breast cancer ablative procedures. However, utilization of autologous techniques and wait times to second-stage reconstructions have increased.

Background: Breast reconstructive services are medically necessary, time-sensitive procedures with meaningful health-related quality of life benefits for breast cancer survivors. The COVID-19 global pandemic has resulted in unprecedented restrictions in surgical access, including access to breast reconstructive services. A national approach is needed to guide the strategic use of resources during times of fluctuating restrictions on surgical access due to COVID-19 demands on hospital capacity. Methods: A national team of experts were convened for critical review of healthcare needs and development of recommendations and strategies for patients seeking breast reconstruction during the pandemic. Following critical review of literature, expert discussion by teleconference meetings, and evidenced-based consensus, best practice recommendations were developed to guide national provision of breast reconstructive services. Results: Recommendations include strategic use of multidisciplinary teams for patient selection and triage with centralized coordinated use of alternate treatment plans during times of resource restrictions. With shared decision-making, patient-centered shifting and consolidation of resources facilitate efficient allocation. Targeted application of perioperative management strategies and surgical treatment plans maximize the provision of breast reconstructive services. Conclusions: A unified national approach to strategically reorganize healthcare delivery is feasible to uphold standards of patient-centered care for patients interested in breast reconstruction.

Nerve transfer surgery is an important new addition to the treatment paradigm following nerve trauma. The following rehabilitation plan has been developed over the past 15 years, in an interdisciplinary, tertiary peripheral nerve program at the "Roth|McFarlane Hand and Upper Limb Centre." This center evaluates more than 400 patients with complex nerve injuries annually and has been routinely using nerve transfers since 2005. The described rehabilitation program includes input from patients, therapists, physiatrists, and surgeons and has evolved based on experience and updated science. The plan is comprised of phases which are practical, reproducible and will serve as a framework to allow other peripheral nerve programs to adapt and improve the "Roth|McFarlane Hand and Upper Limb Centre" paradigm to enhance patient outcomes.

OBJECTIVE:The purpose of this systematic review and meta-analysis was to determine the effect of nerve transfer surgery for brachial plexus injury (BPI) on patient-reported outcomes. LITERATURE SURVEY:MEDLINE, EMBASE, and CINAHL were searched and screened in duplicate for relevant studies on September 25, 2019 and repeated June 24, 2020. METHODOLOGY:The patient population included male and female patients who received nerve transfer surgery for BPI. Further inclusion criteria were: (1) all levels of evidence; (2) published in English; (3) conducted in humans; and (4) report of patient-reported outcome. Two reviewers independently abstracted data regarding injury type, surgical technique, surgical timing, follow-up duration, strength, and patient-reported outcome measures. Quality was assessed in duplicate using the Methodological Index for Non-Randomized Studies criteria. SYNTHESIS:Twenty-one studies involving 464 participants were included in analyses. The mean age ± SD was 32.4 ± 1.8 (range: 5-77) and 89.2% of included participants were male. The mean time to surgery was 5.6 ± 0.6 months and the mean follow-up time was 48.1 ± 8.4 months. The most used patient-reported outcome was the Disabilities of Arm, Shoulder and Hand (DASH), where scores variably improved postoperatively, although the degree of disability remained high. Return to work was reported in five studies, with 66.0% of participants returning to work. Patient satisfaction was assessed in four studies with an overall satisfaction proportion of 64.0%. Pain was assessed in 12 studies using various measures. In studies reporting pain intensity postoperatively, 29.3% of patients were "pain-free" or had "no pain." CONCLUSIONS:Patient-reported outcomes following nerve transfer for BPI are infrequently reported in the literature. Although patient-reported outcomes demonstrate variable postoperative improvement, there is evidence of ongoing limitations and postoperative DASH scores report a high degree of ongoing disability. Future studies with greater reporting as well as validation of patient-reported outcomes within BPI are warranted.

Purpose Anterograde homodigital neurovascular island flaps are a reconstructive option for volar fingertip injuries and confer the advantage of preserving fingertip sensation after surgery. However, the amount of flap advancement and wound coverage provided by stepwise and triangular flap designs remains unknown. This study sought to investigate how incremental proximal dissection of the pedicle influences flap advancement and whether advancement and/or coverage differ between the triangular and stepwise flap designs using 22 paired cadaveric digits. Methods Flap advancement and wound coverage were evaluated in a pairwise design such that each pair of digits received 1 stepwise flap and 1 triangular flap. After creating a standardized injury to the volar fingertip, pedicled flaps were dissected from the middle phalanx and advanced distally under consistent tension. Advancement was measured for each 5 mm of proximal mobilization of the pedicle to a maximum of 30 mm. Results On average, 2.6 +/- 0.2 mm of flap advancement could be achieved for every 10 mm of pedicle mobilization. With 30 mm of proximal mobilization of the pedicle, 11.8 +/- 2.8 mm of advancement and 57.2% +/- 16.1% of wound coverage could be expected. There were no significant differences between the flap designs. Conclusions The stepwise and triangular anterograde homodigital neurovascular island flaps offer comparable and consistent reconstructive outcomes for volar fingertip injuries. Clinical relevance The findings in this study suggest that the choice of flap design need not be influenced by the considerations of advancement or coverage; rather, surgeon preference or technical differences between the 2 flap designs may be of more importance. (J Hand Surg Am. 2022;47(10):1012.e1-e7. Copyright (c) 2022 by the American Society for Surgery of the Hand. All rights reserved.)

SUMMARY:Brachial plexopathy after conservative therapy or surgical treatment of clavicular fractures is an uncommon, yet serious complication that is associated with compression of the brachial plexus or the subclavian artery and vein because they traverse through the thoracic outlet. Surgical decompression of the brachial plexus is the recommended treatment if this condition is to occur. Although there are multiple reports of these cases in the literature, at present, there are no clear guidelines for their management. We are highlighting an institutional management algorithm, illustrated by a small retrospective case series, that uses a multidisciplinary approach in an effort to minimize complications associated with the management of clavicle nonunion.

Kristine M. Chapman, Michael J. Berger , Christopher Doherty, Dimitri J. Anastakis, Heather L. Baltzer, Kirsty Usher Boyd, Sean G. Bristol, Brett Byers, K. Ming Chan , Cameron J.B. Cunningham, Kristen M. Davidge, Jana Dengler, Kate Elzinga, Jennifer L. Giuffre, Lisa Hadley, A Robertson Harrop, Mahdis Hashemi, J. Michael Hendry, Kristin L. Jack, Emily M. Krauss, Timothy J. Lapp, Juliana Larocerie, Jenny C. Lin, Thomas A. Miller, Michael Morhart, Christine B. Novak, Russell O’Connor, Jaret L. Olsen, Benjamin R. Ritsma, Lawrence R. Robinson , Douglas C. Ross, Christiaan Schrag, Alexander Seal, David T. Tang, Jessica Trier, Gerald Wolff, Justin Yeung