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Objectives: Orthopedic residency training program in Saudi Arabia is one of the relatively new programs that are being expanded to accommodate a growing need. This program has not been studied systematically before. As such, assessing orthopedic trainees' needs and evaluating the program from the trainees' perspective are essential components to ensure optimal training. The purpose of this study was to assess Saudi orthopedic trainees' perceptions of the content and adequacy of their current training and its impact on knowledge and skills acquisition. Methods: Electronic questionnaire surveys were sent to all postgraduate orthopedic trainees in Saudi Arabia. A 36-items questionnaire was constructed and piloted. A 5-point Likert scale was used to obtain trainees' rating of six main areas of training. Results: Seventy-four out of 104 trainees responded to the survey (71%). Sixty-five percent of trainees rated their satisfaction with the current program as neutral (46%) or satisfactory (20%) and 34% were dissatisfied. A perceived lack of rotation-specific learning objectives (63%), suboptimal technical skills training and practice opportunities including exposure as the primary surgeon (80%), and lack of feedback (80%) were some of the main concerns expressed by trainees. Conclusions: This study highlights several areas for improvement in the current program to address trainees' learning needs and optimize surgical competency. The observed large percentage of trainees' dissatisfaction seems to be predominantly related to the lack of surgical exposure; a parameter that could be improved. In addition, research to address the training needs of orthopedic educators and program directors' perspective is required.

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Objectives: There is insufficient data about female orthopedic residents in the Gulf Cooperation Council (GCC) region. This study was performed to survey what influences females to take up orthopedics, and the barriers, mental pressures, and obstacles they face while a resident in training. Methods: This is a cross-sectional study, which was conducted using an online self-reported validated questionnaire. Our population consisted of 569 orthopedic trainees who met our inclusion criteria, and we received 254 anonymous responses (44.6%). Results: The response rate was 78.7% for females (37 out of 47 total females who were sent the questionnaire) and 41.6% for males (217 out of 522 total number of males). The gender distribution of those who responded was 14.6% (n=37) females and 85.4% (n=217) of males. Around half of the females (48.6%) in the study decided to join orthopedic programs during their undergraduate studies. The majority of female residents (75.7%) agreed that orthopedics is physically tiring and 89.2% of them agreed that there are gender intolerances. The need to increase the number of female residents was another notion shared by 86.5% of them. On the contrary, 62.2% of the male responders disagreed to the need of increasing the female orthopedic residents and 34% were with the opinion that female residents are not fit to cover on-call duties. Conclusion: Gender intolerances exist in the GCC orthopedic programs. This might discourage female physicians from pursuing orthopedic careers. All of the concerns raised by the residents are adjustable and attainable, such as offering maternity leaves, encouraging positive behavioral changes in male surgeons, and providing equal opportunities for applicants to orthopedic boards' acceptance.

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Objective: A symptomatic digital neuroma may have a devastating impact on a person's life. There is no gold standard method of treatment. We hypothesise that the reconstruction of neuroma with nerve allograft will reduce the sensitisation and cortical reorganisation associated with peripheral nerve injury. In this study, we aim to assess the effect of neuroma reconstruction with nerve allograft on patient-reported pain and satisfaction. Methods: We conducted a retrospective review of patients who underwent nerve allograft reconstruction for painful digital neuroma at our unit, from July 2015 to July 2018. We measured pre- and post-operative visual analogue scale (VAS) pain scores, patient satisfaction and patient evaluation measure (PEM) scores. Results: In 10 patients, we reconstructed 12 neuromata. In nine of these patients (11 neuromata), we demonstrated a post-operative reduction in pain, with a change in median VAS score from 7.5 to 1. Patients were satisfied with their operation, with a median satisfaction score of 10/10. The procedure was unsuccessful in two patients, one with a static VAS score and one with a satisfaction score of <8/10, giving a success rate of 80%. Conclusion: Our results show that neuroma reconstruction with nerve allograft can improve patient-reported pain with a success rate of 80%. In our unit, this has become a primary indication for the use of allograft.

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Osteoporosis is well recognized in children as a consequence of several factors. Therefore, the present review sheds light on the role of diabetes mellitus (DM), malabsorption, glucocorticoids, nutrition, free radicals, and oxidative stress in the induction of osteoporosis. It may also provide valuable information regarding the early detection of osteoporosis to improve not only the bone health of schoolchildren but also their general quality of life. Measurement of bone mineral density (BMD) does not capture all the risk factors of bone fractures and/or osteoporosis. Therefore, bone resorption and formation markers such as osteoprotegerin; prolidase; osteocalcin; bone alkaline phosphatase and Vitamin D; parathyroid hormones; and macroelements such as calcium, phosphorus, and magnesium should be measured beside BMD in the plasma of school-aged children. Moreover, endocrine abnormalities, high levels of free radicals, and induction of oxidative stress showed an adverse effect on the skeleton and cause osteoporosis. It has been found that there is a strong correlation between osteoporosis and DM, malnutrition, and glucocorticoids in both pediatric and adult patients. Inhibition of antioxidant enzyme activities, such as superoxide dismutase, catalase, and glutathione peroxidase, was found to increase the production of reactive oxygen species by osteoclasts. Therefore, oxidative stress and other factors are important mediators of bone loss and also osteoporosis. Furthermore, antioxidants should be provided to maintain bone integrity because a deficiency of antioxidant vitamins has been found in the osteoporotic children.

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These are challenging times for Surgical Educators. Limitations on working hours, resource constraints, rapidly evolving technological advances in the way, we communicate and interact, and increasing patient expectations are threatening the traditional and time-tested apprenticeship model of surgical training. It is imperative on the part of today's Surgical Educators to respond to these challenges in ways that enhance and promote the training of future surgeons. This has led to the birth of a new specialty of Surgical Education. Although generic Health Sciences/Medical Education programs are widely available and do serve a useful purpose, it may be argued that surgical trainees have unique needs that may not be adequately addressed by the generic programs. Thus, there is a need for focused Surgical Education programs. This review aims to identify these needs and to discuss the current Surgical Education programs available. It also aims to suggest additional issues that may need to be addressed to make these programs even more useful.

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Objectives: Anterior cervical discectomy and fusion (ACDF) is a common procedure in cervical degenerative disorders and cervical trauma patients. However, this procedure and approach are associated with peri- and post-operative complications. This study aims to report peri- and early postoperative complications occurred during ACDF and also tries to find any relation between dysphagia and plating, smoking, or age. Methods: This is a multicentric prospective study conducted on 165 patients; 116 males (70.3%) and 49 females (29.7%); their age range was 33—61 years (mean age, 42.5 years). The study started from January 2013 to February 2017. The follow-up was for 6 weeks, and we evaluated the clinical and radiographic signs of complications. Results: Fifty-seven patients (34.5%) had transient dysphagia and two patients (1.2%) each had a dural tear, surgical-site infection, and postoperative hematoma. One patient (0.6%) each had an esophageal injury, slippage of the cage, Brown—Sequard syndrome, acute implant extrusion, and Horner syndrome. No patient had a recurrent laryngeal nerve injury. The risk factors for dysphagia include female sex, multilevel surgery, plating, and smoking, most of the dysphagic symptoms were mild in severity and lasted <6 weeks. Conclusion: Not all complications of ACDF require surgical intervention, and most of them could be treated nonoperatively with careful follow-up. Our results are comparable with what was reviewed in the literature. The incidence of complications is increased with more than one-level fusion and in multiple comorbid disorders (including diabetes mellitus and smoking). Most of the postoperative dysphagic symptoms are mild and last <6 weeks.

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Objectives: Crouch gait in cerebral palsy (CP) is characterized by excessive knee flexion throughout stance. Single-event multilevel orthopedic surgery is the standard of care to improve gait and function through correcting lever arm deformities in children with CP. A limited number of prospective studies on single-event multilevel orthopedic surgery for crouching CP children are available. We intended to evaluate the effectiveness of single-event multilevel surgery (SEMLS) regarding functional mobility, energy consumption during gait, and the mental, attitudinal, and lifestyle status of CP children with crouch gait on the short term. Methods: Thirty-four limbs in 18 children with bilateral spastic and crouching CP were enrolled prospectively and subjected to SEMLS. The mean age was 12 years (range, 5.5–18). Outcome measures included clinical couch examination parameters, walking speed, physiological cost index (PCI), functional mobility scale (FMS), and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). In addition, we used instrumented three-dimensional gait analysis as an outcome measure for some participants. Results: At a mean follow-up of 16 months (range, 12–22), the couch examination parameters, FMS at 5, 50, and 500 m, walking speed, PCI, and WHODAS 2.0 score showed a highly statistically significant improvement (P < 0.01). Conclusions: SEMLS for CP children and adolescents with crouch gait is effective for improving function, independence, energy consumption, and quality of life on the short term.

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Objectives: Musculoskeletal disorders are an occupational hazard between physicians. Physicians whose practice involves physical undertakings, such as surgeons, are prone to musculoskeletal pain, which can lead to decreased productivity. This study aimed to compare surgical and nonsurgical specialties musculoskeletal pain prevalence, as well as assess whether certain factors contribute to their pain. Methods: A cross-sectional study that utilized a self-administered questionnaire handed out to 140 conveniently selected surgical and nonsurgical residents at King Abdulaziz Medical City, Riyadh. The questionnaire included a demographics section and a section inquiring about nine anatomical areas derived from the Nordic Musculoskeletal Questionnaire. Results: The mean age was 27 years old, and 79% were male. Surgical residents comprised 39% (n = 55) of the participants. Of all the residents, 82.9% (n = 116) suffered from a musculoskeletal complaint, with the majority involving the lower back (53%). Surgical residents were more likely to take time off work (16% vs. 4%) and attributed their pain to their profession (38% vs. 15%). Lower back pain was related positively to body mass index (P = 0.04). Multivariate logistical regression revealed that being a surgeon (odds ratio [OR] = 5.08 and confidence interval [CI] = 0.27–94.14) and spending time doing interventional procedures (10 h; OR = 0.97 and CI = 0.05–18.61) are predisposing factors to musculoskeletal pain. Conclusion: Ergonomic changes are needed to enhance productivity and decrease time off work. Surgical residents need to be aware of the risk of experiencing musculoskeletal pain and be educated on ways to avoid or cope with their pain.

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Objectives: The primary aim was to determine whether a dynamic suture marker method of measuring ulnar nerve strain yields comparable results to strain gauges. The secondary aim was to assess the effect of elbow flexion, shoulder abduction and medial epicondylectomy on strain. Methods: In four embalmed elbows, ulnar nerve strain was measured using suture markers during elbow flexion and shoulder abduction before and after medial epicondylectomy. Linear regression analysis and Wilcoxon signed-rank test were used to analyse the results. Results: Ulnar nerve strain increased in direct proportion to elbow flexion angle before and after medial epicondylectomy, with one exception. At 90° shoulder abduction, strain was 0%–17%. Strain was greatest at 90° and least at 110° before and after medial epicondylectomy, P > 0.05. The effect of medial epicondylectomy varied. Strain was reduced at 90° by 5%, at 110° by 0% and at 120° by 1%; P > 0.05. Conclusions: The suture marker method yielded comparable results to strain gauges. Both shoulder abduction and medial epicondylectomy did not have statistically significant effects on ulnar nerve strain. However, only four embalmed elbows were studied in this preliminary study, so a large difference would be needed to produce a significant change. The finding that medial epicondylectomy fails to reduce strain raises questions about its role in treating cubital tunnel syndrome and highlights the need for further research. The authors believe that the technique described for dynamic strain assessment is applicable in an in vivo setting and therefore, should be used to compare strain properties of cadaveric and in vivo nerves.

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Objectives: Pilon fractures are challenging to treat and associated with complications such as skin necrosis and superficial and deep infections that can potentially lead to amputation. This meta-analysis aimed to compare the postoperative outcomes following open reduction and internal fixation (ORIF) versus external fixation for pilon fractures. Methods: We searched several databases from January 1990 to July 2017, for any observational or experimental studies that evaluated the postoperative outcomes of pilon fractures. We pooled the effect sizes using fixed-effect models that compared the postoperative outcomes of ORIF versus external fixation. Descriptive and qualitative data were also extracted. Results: Of the 485 articles identified, 13 were eligible for the meta-analysis, with a total of 683 pilon fractures in 679 patients. The pooled estimate for major infection in external fixation of pilon fractures showed comparable events compared to those who underwent ORIF (odds ratio [OR] = 1.06, 95% confidence interval [CI]: 0.56–1.96, I²= 42.2%). External fixation was also found to be associated with higher events for minor infection (OR = 2.83, 95% CI: 1.63; 4.93, I²= 0.00%), delayed union (OR = 2.42, 95% CI: 1.02; 5.72, I²= 0.00%), nonunion (OR = 1.58, 95% CI: 0.79; 3.18, I²= 0.00%), malunion (OR = 3.14, 95% CI: 1.65; 5.97, I²= 0.00%), and posttraumatic arthritis (OR = 2.55, 95% CI: 1.40; 4.63, I²= 0.00%). These results did not change even after doing sensitivity analysis comparing limited internal fixation with external fixation, uniplanar external fixation, and circular external fixator, to ORIF. Conclusions: External fixation was associated with the same chance of having adverse events that required additional procedure(s) or intravenous antibiotics compared to ORIF in pilon fractures, but the difference in bone healing complication was much more observed. ORIF allows accurate articular reduction with comparable infection rates and lower bone healing complications.

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Objectives: Linburg–Comstock (LC) anomaly is a developmental defect, characterized by flexion of thumb causing flexion of the index finger with pain in the wrist and forearm due to a tendinous interconnection between the flexor pollicis longus and flexor digitorum profundus. Methods: We carried out a random cross-sectional study in 2016. Undergraduate students were recruited; we excluded those with inflammation, hand or forearm trauma or surgery. Data were analyzed descriptively and categorically using Microsoft Excel and SPSS-20. Results: The study included 331individuals; 164 (49.5%) were male, and 167 (50.5%) were female, out of which 130 (39%) had LC anomaly. The mean age was 23 years (standard deviation ± 5.3). LC anomaly was found bilaterally in 43 (12.9%), in the right hand in 51 (15.4%) and in the left hand in 35 (10.5%). It was found bilaterally in females in 17 (10.1%) participants, and in males in 26 (15.8%), P = 0.37. The right-hand dominance was found in 294 (89%) versus left-hand in 37 (11%). Conclusion: The prevalence of LC anomaly was 39%, which matches with the global prevalence, the males showed slightly more prevalence of bilateral LC anomaly. The right-hand dominance was found in 89% as opposed to 11% having left-hand dominance.

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Objective: The aim of treatment of tear of the anterior cruciate ligament (ACL) in any military soldiers is to restore normal/near normal stability and function of the knee, preventing further damage to other knee structures and quick return to duty. We studied the functional outcome of arthroscopic-guided ACL reconstruction using quadrupled hamstring tendon graft (QHTG) and femoral side graft fixation using ACL TightRope and also to evaluate its complications. Methods: In this prospective study, evaluation parameters Lachman test, pivot test, and hamstring strength were assessed pre- and post-operatively at 3, 6, 12, 18, and 36 months. Lysholm test was assessed postoperatively. Results: A total of 300 male soldiers with a mean age of 26.5 years were evaluated. Injury due to military training, sports, fall, and road traffic accident was a common cause. Preoperatively, all patients had a positive pivot and anterior drawer tests, 4+ score of Lachman test, and 4/5 muscle strength with restriction of movement to <10°. Mean ± standard deviation Lysholm score at 3, 6, and 12 months were 81.19 ± 10.21, 83.86 ± 12.44, and 89.17 ± 8.32, respectively. At the 3^rd month, negative Lachman test was seen in 83.6% (251/300) of patients, 13.6% (41/300) had 1+ laxity, and 2.6% (8/300) patients had 2+ laxity. None had positive pivot shift test. At 3 and 12 months, 91.3% (274/300) and 100% (300/300) had a grade of 5/5 power in hamstring muscles. Fifteen cases developed postoperative complications such as infection and graft failure. Conclusion: Autologous ipsilateral QHTG is a near anatomical and good choice for ACL reconstruction and is associated with fewer complications.

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Introduction: Motor vehicle accidents (MVAs) and noncompliance to seat belt have been a continuing safety issue in Saudi Arabia for decades. The aim of this study is to determine the prevalence of seat belt use and distracted driving behaviors among health-care providers in Saudi Arabia and its comparison with nonhealth-care providers. Methods: This is a cross-sectional survey. Data were collected through an online questionnaire distributed among Saudi health-care providers in Saudi Arabia through E-mails and social media using a snowball sampling approach. The data were statistically analyzed. Results: Of 695 respondents, 356 (51.2%) were health-care providers and 339 (48.8%) were nonhealth-care providers. Seat belt wearing rates were 43% among health-care providers and 13.3% among nonhealth-care providers. Most common distracting driving behavior was cell phone usage while driving in both groups (98.6% vs. 86.5%). Conclusion: The present study revealed a statistically significant difference in compliance to seat belt usage by health-care providers compared to nonhealth-care providers. We believe that this is due to a better exposure and knowledge about the consequences of the MVA cases, as well as a high awareness about traffic rules. No statistically significant difference was observed in regard to distracted driving behavior between both groups. We would like to strongly recommend the need of various levels of awareness campaigns regarding the importance of wearing seat belt and avoiding distractive driving behavior in Saudi Arabia.

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Objectives: Molecular diagnosis of a large Saudi family presenting an autosomal dominant form of osteogenesis imperfecta (OI). Methods: Genetic analysis of the index patient was performed through 100× paired end whole exome sequencing (WES) covering 24,000 coding genes of the human genome. The causative variant was filtered out among the previously known 23 genes' panel reported for 17 subtypes of OI. The dominant segregation of the causative variant with the disease phenotype was confirmed by Sanger sequencing. Pathogenicity of the altered protein was predicted through SIFT, PolyPhen, and MutationTaster software. Results: A heterozygous variant (c.1801G>A; p. Gly601Ser) in exon 31 of collagen 1α2 was identified. In this study, WES was successfully applied to identify the molecular basis of OI in the proband. The rest of family members were confirmed through Sanger validation confirming the autosomal dominant mode of inheritance in large Saudi family. Conclusion: OI is a rare heterogeneous disorder of connective tissues with 17 overlapping subtypes, for which 23 genes are known. Our work adds to the growing list of disease-causing variants in COL1A2. Reporting the disease-causing variants is one of the best ways to share data for better and accurate variants interpretation. We tested that WES can be used as an efficient tool for the molecular diagnosis of this rare phenotype.

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Objectives: Interscalene blocks are commonly performed with the shoulder surgery, nerve injuries are reported to have the prevalence of 14% at 10 days postoperatively. While clinicians may be aware of the associated risk of nerve injury from either the surgery or the block, they may not recognize these nerve injuries. Our objectives were to determine factors contributing to injury and late referral. Methods: We searched our peripheral nerve injury database to identify a consecutive series of nerve injuries-associated with interscalene nerve block and the shoulder surgery. The identified cases were subject to clinical review and a review of the medical records including the consent form, anesthetic records, operation note, and the neurophysiology records. Results: Six cases of nerve injury were identified during a 24-month period. Half the patients experienced a delay of >6 months from injury to review, despite the documentation of persisting sensory and motor dysfunction. Regional anesthesia technique was not uniform. All patients required a specialist treatment from a regional peripheral nerve injury service. Conclusions: Clinicians should be aware that prolonged block duration is a feature of the potential nerve injury. The presence of a Tinel sign, autonomic dysfunction, and nerve pain in the distribution of the injured nerve are features suggesting nerve injury. Orthopedic surgeons should be able to recognize the nerve injury and seek early referral to the appropriate specialists. Where doubt exists, the patient should be referred for an urgent review by a peripheral nerve injury specialist.

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Background: Cervical spinal cord injury (CSCI) is a devastating consequence of trauma. Restoration of upper limb function can improve quality of life, reduce long-term care needs and is highly rated by patients. Methods: We performed a non-systematic review of all studies reporting nerve transfer in CSCI to derive a putative reconstructive algorithm based primarily on nerve transfers. Results: For CSCIs above C5, no intraplexal donors exist. For CSCIs at C5 or below, axillary nerve (C5) branches may be transferred to triceps to restore elbow extension, musculocutaneous nerve (C6) branches may be transferred to the median nerve to restore pronation/ finger flexion whilst nerve branches to supinator (C6) may be transferred to re-innervate finger extensors. Further functional gains such as re-innervation of hand intrinsics, accessory respiratory function and postural control of the trunk may be possible but are not reported. Conclusions: Nerve transfers following CSCI represent an emerging area of upper limb surgery where bespoke surgical strategies undertaken early during rehabilitation course have the potential to change functional outcomes.

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Objectives: Scar tissue formation around the peripheral nerves causes nerve compression and ischemia, but it also causes adherence of nerves to the surrounding tissues, decreasing the nerve's ability to glide, and therefore, causing neurostenalgia – nerve pain with motion due to tether. Our unit has been using a porcine submucosal extracellular matrix (AxoGuard^® AxoGen Inc., Alachua, FL, USA) nerve wrap to prevent nerve scarring. The aim of this study is to present a case series of our use of the AxoGuard^® and early follow-up data. Methods: This study describes the use of AxoGuard^® nerve protectors, including the indications, anatomic locations, and complications. After obtaining ethics approval from the Institutional Audit Review Board, a retrospective review was performed of all cases where AxoGuard^® nerve protectors were used from June 2015 to July 2018. Results: Over a 3-year period, AxoGuard^® nerve wraps were used in 71 cases. The indication for surgery was a scarred nerve after trauma surgery in 32 cases, scarring after primary nerve surgery in 19 cases, primary trauma in 9 cases, nerve scarring after elective nonnerve surgery in 5 cases, and nerve tumors in 5 cases. There have been no complications directly related to the use of the AxoGuard^® nerve protector and no cases of postoperative infection. Conclusions: The AxoGuard^® nerve protector has many clinical indications, an excellent safety profile with no reported complications directly related to the nerve wrap, and is effective in mitigating the effects of neurostenalgia following revision neurolysis.

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Objectives: Children with flatfoot are more vulnerable to have foot pain, foot injury, stress fractures, knee pain, and poor exercise performance. Some children may not experience any of these symptoms and the only predominant complaint would be foot pain. Flatfoot is considered a health issue that was not studied well in Saudi Arabia. The study aims to determine flatfoot prevalence among school-age children 7–14 years in Almadinah Almunawwarah and to know the effect of age, gender, and body mass index on the prevalence of flatfoot. Furthermore, a secondary aim is to find if there is a relationship between flatfoot and postactivity foot pain and participation in sports. Methods: This is a cross-sectional analytic study conducted on children aged 7–14 years living in Almadinah Almunawwarah, Saudi Arabia. Flatfoot was diagnosed using Staheli's Plantar Index. Binary logistics regression was used to predict the likelihood effect of sociodemographic data among children with flatfoot. Results: A total of 403 children had been voluntarily recruited in this study. Boys were 193 (47.9%) while 210 (52.1%) were girls. The prevalence of flatfoot was 29.5% (119), 96.6% of them were flexible flatfeet and a relatively very low incidence (3.4%) of rigid flatfeet. Age has a significant relationship on the prevalence of flatfoot (P = 0.050) where 7–8-year-old group was rated highest among other age groups in the prevalence of flatfoot. Conclusion: We found 29.5% of the children had flatfoot in the study sample. This prevalence is still high in comparison to developed countries. Furthermore, this study found a significant association between age and flatfoot in children.

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Distal femur physeal fractures can lead to growth disturbance such as premature physeal closure (PPC), leg length discrepancy (LLD), and angular deformity (AD). This study aims to systematically review the literature to assess whether surgical management is associated with a different rate of growth disturbances compared to nonsurgical treatment. We searched several databases from 1966 to 2018 for studies that evaluated surgical versus nonsurgical treatment of distal femur physeal fractures. Descriptive and quantitative data were extracted, and a meta-analysis was performed using a random-effects model to pool odds ratio (OR) for the comparison of PPC, LLD, and AD rate between children undergoing surgical versus nonsurgical treatment. Of the 470 articles identified, 11 case series were eligible, with a total of 527 distal femur physeal fractures. The pooled OR of PPC between surgical and nonsurgical treatments showed no statistically significant difference (OR = 0.30, 95% confidence interval [CI]: 0.30–3.03; I² = 73.4%, P = 0.01). No significant difference in the rates of LLD (OR = 1.03, 95% CI: 0.36–2.94; I² = 0%, P= 0.87) and AD (OR = 0.40, 95% CI: 0.10–1.57; I² = 0%, P = 0.79) was detected between surgical and nonsurgical treatments. Despite the current evidence to date does not support an association between the method of treatment of distal femur physeal fractures and the risks of PPC, LLD, and AD, a significant clinical relevance cannot be carried out. Surgeons can use both treatment methods as dictated case by case.

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Following injury to a peripheral nerve, a neuroma may form and cause severe debilitating neuropathic pain. End neuromas are the result of an amputation or are found at the proximal stump in a complete nerve transection or rupture. Neuromas-in-continuity follows traction or compression injury and may complicate repair of a nerve transection or rupture. Symptomatic neuromas should be assessed and treated by a peripheral nerve surgeon working within a multi-professional team. The objectives of the initial treatment should encompass pain management, psychological support and physical therapies with the aim of restoration of normal nerve response thresholds to afferent stimuli and optimisation of the perineuroma environment. Surgical intervention should be reserved for non-responders and in cases where reconstruction of nerve function is deemed essential for useful functional recovery and pain resolution.

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Loss of shoulder abduction and external rotation reduces the working space for the upper limb and hand. Paralysis may follow C5 nerve root avulsion, upper trunk rupture or isolated injuries to the suprascapular and axillary nerves. Motor nerve transfer surgery involves a direct transfer of an expendable motor branch from a muscle in the vicinity of the paralyzed muscle and direct transfer with microsurgical end-to-end coaptation to the nerve to the denervated muscle close to its motor point. Reinnervation is rapid and robust. The technique was described for the restoration of deltoid function more than a century ago but was not adopted into wide spread use until the past two decades. This article explores the various options of nerve transfer surgery to restore function of shoulder function and reviews the evidence. Refinements in the procedure have resulted with the current algorithm for management, which will be described with its rationale and a review of clinical outcomes.

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