BACKGROUND:Surgical strategy to treat incomplete brachial plexus injury with palsies of the shoulder and elbow by using proximal nerve graft/transfer or distal nerve transfer is still debated. The ...aim of this study was to compare both strategies with respect to the recovery of elbow flexion.
METHODS:One hundred forty-seven patients were enrolled76 patients underwent reconstruction using proximal nerve graft/transfer, and 71 patients underwent reconstruction using distal nerve transfer. All patients were evaluated preoperatively and postoperatively to assess the recovery rate and muscle strength of elbow flexion. Shoulder abduction and hand grip power were also recorded to assess any concomitant postoperative changes between the two methods.
RESULTS:The best recovery rate for functional elbow flexion (p = 0.006) and the fastest recovery to M3 strength (p < 0.001) were found in the double fascicular transfer group. However, recovery of shoulder abduction with proximal nerve graft/transfer was significantly better than with distal nerve transfer (80.3 percent versus 66.2 percent in shoulder abduction ≥60 degrees; and 56.6 percent versus 38.0 percent in shoulder abduction ≥90 degrees). A significant decrease in grip strength between the operative and nonoperative hands was also found in patients undergoing distal nerve transfer (p = 0.001).
CONCLUSIONS:Proximal nerve graft/transfer offers more accurate diagnosis and proper treatment to restore shoulder and elbow function simultaneously. Distal nerve transfer can offer more efficient elbow flexion. Combined, both strategies in primary nerve reconstruction are especially recommended when there is no healthy or not enough donor nerve available.
CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, III.
Over the course of the past two decades, improved outcomes following brachial plexus reconstruction have been attributed to newer nerve transfer techniques. However, key factors aside from surgical ...techniques have brought improved consistency to elbow flexion techniques in the latter decade.
One-hundred seventeen patients who underwent brachial plexus reconstruction from 1996 to 2006 were compared with 120 patients from 2007 to 2017. All patients were evaluated preoperatively and postoperatively to assess the recovery time and of elbow flexion strength.
In the first decade, nerve reconstruction methods included proximal nerve grafting, intercostal nerve transfer, and Oberlin-I transfer. In the second decade, newer methods such as double fascicular transfer and ipsilateral C7 division transfer to the anterior division of upper trunk were introduced. About 78.6% of the first decade group versus 87.5% of the second decade group were able to reach M3 flexion strength (
= 0.04), with shorter time recovery to reach M3 in the 2nd decade. About 59.8% of the first decade group versus 65.0% of the second decade group were able to reach M4 (
= 0.28), but no significant difference in time of recovery. In both groups, the double fascicular nerve transfer had the highest impact when introduced in the second decade. More precise magnetic resonance imaging (MRI) techniques helped to diagnose the level of injury, the roots involved and evaluate the health of the donor nerves in preparation for intraplexus transfer.
In addition to modified techniques in nerve transfers, (1) MRI-assisted evaluation and surgical exploration of the roots with (2) more judicious choice of donor nerves for primary nerve transfer were factors that ensured reliable and outcomes in the second decade.
The restoration of finger movement in total brachial plexus injuries (BPIs) is an ultimate challenge. Pedicled vascularized ulnar nerve graft (VUNG) connecting a proximal root to distal target nerves ...has shown unpredictable outcomes. We modified this technique by harvesting VUNG as a free flap to reinnervate median nerve (MN). We analyzed the long-term outcomes of these methods.
From years 1998 to 2015, 118 acute total brachial plexus patients received free VUNG to innervate the MN. Patients were followed up at least 5 years after the initial surgery. Donor nerves included the ipsilateral C5 root (25 patients) or contralateral C7 root (CC7 = 93 patients). Recovery of finger and elbow flexion was evaluated with the modified Medical Research Council system. Michigan Hand Score and Quick-DASH were used to represent the patient-reported outcomes.
For finger flexion, ipsilateral C5 transfer to MN alone yielded similar outcomes to MN + MCN (musculocutaneous nerve), while CC7 had significantly better finger flexion when coapted to MN alone than to MN + MCN. Approximately 75% patients were able to achieve finger flexion with nerve transfer alone. For elbow flexion, best outcome was seen in the ipsilateral C5 to MCN and MN.
In acute total BPI, the priority is to identify the ipsilateral C5 root to innervate MN, with concomitant innervation of MCN to establish the best outcomes for finger and elbow flexion. CC7 is more reliable when used to innervate one target (MN).
III.
BACKGROUND:Functioning free muscle transplantation (FFMT) is currently the gold standard for the reconstruction of facial paralysis, focusing more on the upper lip reconstruction rather than the ...lower lip. This study aimed to compare different lower lip reconstructive methods when performing FFMT for facial reanimation.
MATERIALS AND METHODS:Retrospective review of FFMT for facial reanimation from 2007 to 2015 was performed. Patients were divided into three groupsGroup 1 (n=15), a free plantaris tendon graft anchored to the gracilis muscle was passed into the lower lip to create a loop within; Group 2 (n=12), an aponeurosis tail of the gracilis muscle was attached to the lower lip; Group 3 (n=18), no suspension of lower lip was performed. All patients had at least two years of follow-up. Outcomes were assessed by photos and videos, including subjective evaluation of midline deviation and horizontal tilt and objective analysis of smile dimensions and area.
RESULTS:A total of 45 patients were included. Results from the subjective evaluation demonstrate group 1 patients having the best improvement (overall scorep=0.004 & 0.005, Fisher’s exact test). The objective evaluation showed group 1 and 2 patients with better results compared to group 3 (Horizontal component p=0.009, vertical component p=0.004, and area distribution p<0.001, Kruskall-Wallis test).
CONCLUSION:Both plantaris tendon graft and gracilis aponeurosis achieved better improvement in subjective and objective evaluations than those who had no reconstruction of the lower lip. In particular, the plantaris tendon graft can achieve the most lower lip excursion with overall improved symmetry.
Long nerve grafts will affect muscle recovery. Aim of this study is to investigate if supercharged end-to-side (SETS) sensory nerve transfer to long nerve graft can enhance functional outcomes in ...brachial plexus animal model.
A reversed long nerve graft (20-23-mm) was interposed between C6 and musculocutaneous nerve (MCN) in 48 SD rats. The sensory nerves adjacent to the proximal and distal coaptation sites of the nerve graft were used for SETS. There were four groups with 12 rats in each: (A) nerve graft alone, (B) proximal SETS sensory transfer, (C) distal SETS sensory transfer, and (D) combined proximal and distal SETS sensory transfers. Grooming test at 4, 8, 12 and 16 weeks, and compound muscle action potentials (CMAP), biceps tetanic muscle contraction force, muscle weight and MCN axon histomorphologic analysis at 16 weeks were assessed.
Grooming test was significantly better in group C and D at 8 weeks (
= 0.02 and
= 0.04) and still superior at 16 weeks. There was no significant difference in CMAP, tetanic muscle contraction force, or muscle weight. The axon counts showed all experimental arms were significantly higher than the unoperated arms. Although the axon count was lowest in group C and highest in group D (
= 0.02), the nerve morphology tended to be better in group C overall.
Distal sensory SETS transfer to a long nerve graft showed benefits of functional muscle recovery and better target nerve morphology. Proximal sensory inputs do not benefit the outcomes at all.
BACKGROUND:Loss of elbow flexion commonly occurs following acute brachial plexus injury. The double fascicular transfer is often used in acute C5-C6 and C5-C7 root injuries, but is rarely applied in ...cases involving concomitant C8 or T1 root injury. The authors designed a rat model using varying severities of lower trunk injury to determine whether partial injury to the lower trunk affects nerve transfers for elbow flexion.
METHODS:There were four different rat groups in which 0, 25, 75, or 100 percent of the donor lower trunk remained intact. One-fourth of the cross-sectional area of the ulnar nerve was then transferred to the musculocutaneous nerve immediately. The authors assessed outcomes using a grooming test, muscle mass, retrograde labeling of sensory/motor neurons that regenerated axons, and immunohistochemical stain of regenerated axons.
RESULTS:Five months after nerve transfer, rats that underwent partial injury of the lower trunk fared significantly worse than the rats in whom the donor lower trunk remained 100 percent intact, but significantly better than the rats with 0 percent intact lower trunk. Rats with 25 or 75 percent of the lower trunk intact recovered equivalent function, at both the donor and recipient sites.
CONCLUSIONS:Although relatively weak compared with the 100 percent intact donor lower trunk group, the partially injured donor nerve was still functional; even though the nerve sustained a partial injury, the residual axons reinnervated the target muscles. The power of the muscles following either 25 percent or 75 percent injuries was equal after the recovery. Resorting to this approach may be useful in cases in which no alternatives are available.
Restoring elbow function is challenging after late presenting brachial plexus birth injury (BPBI). Free functioning muscle transplantation (FFMT) using the gracilis muscle is a reliable procedure to ...restore elbow flexion in patients with impaired function after spontaneous recovery or failed surgical reconstruction.
A retrospective review was performed on BPBI patients more than 2 years of age who received a FFMT between January 1993 and January 2018, with the aim of improving elbow flexion as the primary or secondary functional goal. Patients with preoperative elbow flexion Medical Research Council (MRC) grades less than 3 with more than or equal to 18 months of follow-up duration were included in the analysis. Patient demographic information and pre/postoperative clinical parameters including elbow flexion MRC scale, passive elbow range of motion, and complications were recorded. Surgical data including donor nerve choice, site of the FFMT tendon attachment, and necessity of concomitant procedures or reoperation were also analyzed.
Fifty-six FFMTs were performed for the primary (29 patients) or secondary (26 patients) objective of restoring elbow flexion. The mean age at the time of the procedure was 9.6 years (standard deviation SD = 6.29,
= 3-35). Mean follow-up was 7.9 years (SD = 5.2). Elbow flexion improved from a median MRC grade 2 to 4 after a FFMT (
< 0.05). Patients who had a FFMT to restore two functions had 86% lower elbow flexion MRC grades than those who had a FFMT to restore flexion only (
< 0.05). Patients less than 12 years old at the time of surgery had more complications, reoperations, and rates of a flexion contracture more than or equal to 30 degrees than those aged more than 12 years (
< 0.05).
FFMT is a reliable option for upper extremity reanimation. Patients aged less than 12 years old at the time of FFMT had significantly more complications, reoperations, and rates of postoperative elbow flexion contracture more than or equal to 30 degrees, but equivalent elbow flexion MRC grades.
III.
