The Outcome of Single Versus Double Nerve Transfers in Shoulder Reconstruction of Upper and Extended Upper-Type Brachial Plexus Injuries.

Purpose: The objective of this study was to compare the outcomes of a single nerve transfer (SNT) with double nerve transfer (DNT) in the restoration of shoulder function in patients with upper (C5-6) or extended upper-type (C567) brachial plexus injuries. Methods: A retrospective review of patients with C5-6 or C567 brachial plexus injuries operated on with nerve transfers from January 1, 2005, to December 31, 2017, was completed. The outcomes between SNT and DNT groups were evaluated with the Filipino Version of the Disabilities of the Arm, Shoulder, and Hand (FIL-DASH) scores, pain scores, muscle strength recovery, and range of motion. A subgroup analysis on surgical delay (< or ≥ 6 months), diagnosis (C5-6 or C567), and length of follow-up (< or ≥ 24 months) was also performed. All statistical significance was set at P < .05. Results: A total of 22 patients with SNT and 29 with DNT were included in this study. There was no significant difference between the SNT and DNT groups as to postoperative FIL-DASH scores, pain, recovery of ≥M4, and range of motion for shoulder abduction and external rotation, although the absolute values for shoulder function were greater in the DNT than the SNT group. There was no significant difference between the SNT and DNT groups for surgical delay, diagnosis, and length of follow-up. A stronger recovery of ≥M4 for external rotation was observed in the DNT group compared to the SNT group if nerve transfer was performed in less than 6 months (86% vs 41%). Conclusions: The outcomes for shoulder function between the 2 groups were similar, although the DNT group performed slightly better, especially with external rotation. Patients operated on less than 6 months from injury will benefit more from DNT for shoulder function, especially for external rotation. Clinical relevance: Double nerve transfer may result in improved shoulder function.

Nerve Transfers for Elbow Reconstruction in Upper and Extended Upper-Type Brachial Plexus Injuries: A Case Series.

BACKGROUND: Nerve transfers for elbow flexion in brachial plexus injuries have been used with increasing frequency because of the higher rate of success and acceptable morbidity. This is especially true in upper and extended upper-type brachial plexus injuries. OBJECTIVE: To present the clinical outcomes of nerve transfers for elbow flexion in patients with upper and extended upper-type brachial plexus injuries. METHODS: A retrospective cohort review was done on all patients with upper and extended upper-type brachial plexus injuries from 2006 to 2017, who underwent nerve transfers for the restoration of elbow flexion. Outcome variables include Filipino version of the disability of the arm, shoulder, and hand (FIL-DASH) score, elbow flexion strength and range of motion, and pain. All statistical significance was set at P < .05. RESULTS: Fifty-six patients with nerve transfers to restore elbow flexion were included. There was a significant improvement in FIL-DASH scores in 28 patients after the nerve transfer procedure. Patients with C56 nerve root injuries and those with more than 2 years' follow-up have a higher percentage of regaining ≥M4 elbow flexion strength. Those with double nerve transfers had a higher percentage of ≥M4 elbow flexion strength, greater range of elbow flexion, and better FIL-DASH scores compared with single nerve transfers, but this did not reach statistical significance. CONCLUSION: Nerve transfer procedures improve FIL-DASH scores in upper and upper-type brachial plexus injuries. After nerve transfer, stronger elbow flexion can be expected in patients with C56 injuries, and those with longer follow-up.

Analysis of shoulder abduction by dynamic shoulder radiograph following suprascapular nerve repair in brachial plexus injury.

BACKGROUND: Suprascapular nerve repair is a widely-prioritized procedure for shoulder reconstruction following brachial plexus injury. Although this procedure only reconstructs glenohumeral joint motion, the standard clinical assessment of shoulder function also includes the scapulothoracic joint contribution. The purpose of this preliminary study was to develop an objective method to accurately analyze shoulder abduction following suprascapular nerve repair in brachial plexus injury patients. METHODS: We introduced an objective method to accurately analyze independent shoulder abduction performed by supraspinatus muscle with the help of dynamic shoulder radiography. Antero-posterior radiographs of both shoulders in adduction and maximal active abduction were obtained. Five parameters were measured. They included global abduction, abduction in glenohumeral, scapulothoracic and clavicular joints along with lateral flexion of thoracic spine. Data were analyzed to distinguish glenohumeral joint contribution from that of scapulothoracic motion. The detailed biomechanics of glenohumeral motion were also analyzed in relation to scapulothoracic motion to separately define the contribution of each in global shoulder abduction. RESULTS: The test-retest, intra-examiner and inter-examiner reliabilities of the measurements were assessed. Intra-class correlation coefficient, Bland-Altman plots and repeatability coefficients showed excellent reliability for each parameter. The range of glenohumeral abduction showed high correlation to subtraction of the range of scapulothoracic from the range of global abduction. However, not all negative ranges of glenohumeral abduction meant non-recovery after nerve repair, because scapulothoracic motion contributed in parallel but not uniformly to global shoulder motion. CONCLUSION: The conventional measurement of shoulder global abduction with goniometer is not an appropriate method to analyze the results of suprascapular nerve repair in brachial plexus palsy patients. We recommend examination of glenohumeral and scapulothoracic motions separately with dynamic shoulder radiographic analysis. With scapulothoracic contribution to the global shoulder motion, the glenohumeral motion can be wrongly assessed.

Functioning free muscle transfer for the restoration of elbow flexion in brachial plexus injury patients.

BACKGROUND: Restoration of elbow function in traumatic brachial plexus injury patients remains the priority in the reconstruction of the involved extremity. In cases of complete nerve root injuries and in delayed cases, the only option for elbow reconstruction is the functional free muscle transfer. The purpose of this paper was to present the clinical outcomes and complications of functioning free muscle transfers using the gracilis muscle for the restoration of elbow flexion in brachial plexus injury patients in a tertiary institution from January 1, 2005 to January 31, 2014. PATIENT AND METHODS: A retrospective review of all patients who had functioning free muscle transfers for elbow flexion was done with a minimum of 12 months follow-up. Outcome measures were elbow flexion in terms of range of motion in degrees, muscle strength of the transferred muscle, VAS (visual analogue scale) for pain, postoperative DASH scores and complications of the procedure. RESULTS: There were 39 males and three females. The average age at the time of surgery was 28.6 (SD, 8.5) years. The average delay to surgery was 16 months (range, 3-120 months). The flap success rate for viability was achieved in 38 of 42 patients. The average follow-up for the 38 patients was 30 months (range, 12-103 months, SD 19 months). Success rate of at least M3/5 muscle strength was achieved in 37 of 42 patients with an average range of elbow flexion of 107° (SD, 20.4°). The average post-operative VAS for pain was 3.6 (SD, 3.0). The average post-operative DASH score was 43.09 (SD, 14.9). There were a total of 10 minor complications and five major complications. CONCLUSION: Functioning free muscle transfer using the gracilis muscle was a reliable procedure in the restoration of elbow flexion in patients with incomplete brachial plexus injury treated beyond 6 months from the time of injury and in patients with complete injuries.