Restoration of Elbow Flexion in Traumatic Upper Brachial Plexus Palsy in Adults: Outcome with Intraplexus Distal Nerve Transfers in 78 Patients

Objective To present the functional outcomes of distal nerve transfer techniques for restoration of elbow flexion after upper brachial plexus injury. Method The files of 78 adult patients with C5, C6, C7 lesions were reviewed. The attempt to restore elbow flexion was made by intraplexus distal nerve transfers using a fascicle of the ulnar nerve (group A, n » 43), or a fascicle of themedian nerve (group B, n » 16) or a combination of both (group C, n » 19). The result of the treatment was defined based on the British Medical Research Council grading system: muscle strength < M3 was considered a poor result. Results The global incidence of good/excellent results with these nerve transfers was 80.7%, and for different surgical techniques (groups A, B, C), it was 86%, 56.2% and 100% respectively. Patients submitted to ulnar nerve transfer or double transfer (ulnar þ median fascicles transfer) had a better outcome than those submitted to median nerve transfer alone (p < 0.05). There was no significant difference between the outcome of ulnar transfer and double transfer. Conclusion In cases of traumatic injury of the upper brachial plexus, good and excelent results in the restoration of elbow flexion can be obtained using distal nerve transfers.

Thirty-Day Perioperative Adverse Outcomes After Peripheral Nerve Surgery: An Analysis of 2351 Patients in the American College of Surgeons National Surgical Quality Improvement Program Database.

BACKGROUND: Because peripheral nerve surgery has become more common in recent years, the pressure to increase this procedure's health care safety and cost-effectiveness has increased. Given our limited understanding, we evaluated prospectively identified and randomly sampled patients who underwent peripheral nerve surgery from 2005 to 2014 through the American College of Surgeons National Surgical Quality Improvement Program database. METHODS: We used bivariate testing and multivariate logistic regression analysis to identify patient- and surgery-related risk factors for postoperative complications and unplanned readmission in peripheral nerve surgery patients, and especially to estimate the impact of the nerve grafting procedure. RESULTS: Overall, 2351 patients underwent peripheral nerve surgery, 120 complications were identified in 100 patients (4.25%), and 103 patients (4.38%) received nerve grafting. Thirty-one of the 1593 patients (1.95%) underwent unplanned readmission. Nerve grafting procedures had no association with postoperative complications and unplanned readmission rates. Patients who experienced an inpatient procedure (odds ratio [OR], 2.54; P < 0.001), a longer operative time (OR, 1.00; P < 0.001), and worse wound classifications (OR, 1.83; P < 0.001) all had increased odds of postoperative complications. An inpatient procedure (OR, 2.74; P = 0.014) and any complications (OR, 24.43; P < 0.001) were significantly associated with unplanned readmission. CONCLUSIONS: Our study confirms that peripheral nerve surgery and nerve graft procedures can be safely performed with low complication risks and low unplanned readmission rates. We also identified the risks associated with perioperative adverse outcomes, and these data may be used as an adjunct for risk stratification for patients under consideration for peripheral nerve surgery. This approach may enable the improved targeting of the most costly and harmful complications of preventive measures.

The impact of residency and fellowship training on the practice of microsurgery by members of the american society for surgery of the hand.

PURPOSE: The purpose of this study was to assess the microsurgical training background of current members of the American Society for Surgery of the Hand (ASSH) and then determine the impact that prior training had on current microsurgical practice. METHODS: A 174-item anonymous Web-based survey was sent to all active ASSH members. Items addressed prior residency and fellowship training, practice setting, and training, comfort, and practice of specific microsurgical procedures. Data were analyzed using frequency tables, cross-tabulations, χ tests, and other established statistical methods. RESULTS: Surveys were received from 377 of 2019 ASSH members (18.7% response rate). Residency training was in orthopedics (n=249, 66.9%), plastic surgery (n=56, 15.1%), or general surgery (n=55, 14.8%). Fellowship training was in orthopedic (n=242, 65.1%), combined (n=65, 17.5%), and plastic surgery (n=15, 4%) programs. Microsurgical procedures involving nerves were performed by 96.6% of surgeons (n=337), with no significant differences between surgeons trained in plastic surgery versus orthopedic surgery residencies, and no differences between those who had completed orthopedic versus combined fellowships. Of the surgeons completing the survey, 56.1% (n=208) performed general microvascular procedures, 50% (n=179) performed replantations, and 30.6% (n=113) performed free flaps. Hand surgeons who completed plastic surgery residencies were more likely to perform general microvascular procedures, replantations, and free flaps than surgeons trained in orthopedic residencies. When comparing training in orthopedic and combined fellowships, there was no difference in performance of replantations, free flaps, general microvascular surgery, or microsurgical procedures involving nerves. CONCLUSIONS: Training backgrounds have a substantial impact on current microsurgical practice, with residency having the most significant effect. Specifically, hand surgeons trained in plastic surgery residency programs are more likely to perform replantations, free tissue transfer, and general microvascular surgery than those who completed orthopedic residencies. Fellowship training background does not significantly affect microsurgical practice.

A systematic review of nerve transfer and nerve repair for the treatment of adult upper brachial plexus injury.

Nerve reconstruction for upper brachial plexus injury consists of nerve repair and/or transfer. Current literature lacks evidence supporting a preferred surgical treatment for adults with such injury involving shoulder and elbow function. We systematically reviewed the literature published from January 1990 to February 2011 using multiple databases to search the following: brachial plexus and graft, repair, reconstruction, nerve transfer, neurotization. Of 1360 articles initially identified, 33 were included in analysis, with 23 nerve transfer (399 patients), 6 nerve repair (99 patients), and 4 nerve transfer + proximal repair (117 patients) citations (mean preoperative interval, 6 ± 1.9 months). For shoulder abduction, no significant difference was found in the rates ratio (comparative probabilities of event occurrence) among the 3 methods to achieve a Medical Research Council (MRC) scale score of 3 or higher or a score of 4 or higher. For elbow flexion, the rates ratio for nerve transfer vs nerve repair to achieve an MRC scale score of 3 was 1.46 (P = .03); for nerve transfer vs nerve transfer + proximal repair to achieve an MRC scale score of 3 was 1.45 (P = .02) and an MRC scale score of 4 was 1.47 (P = .05). Therefore, for elbow flexion recovery, nerve transfer is somewhat more effective than nerve repair; however, no particular reconstruction strategy was found to be superior to recover shoulder abduction. When considering nerve reconstruction strategies, our findings do not support the sole use of nerve transfer in upper brachial plexus injury without operative exploration to provide a clear understanding of the pathoanatomy. Supraclavicular brachial plexus exploration plays an important role in developing individual surgical strategies, and nerve repair (when donor stumps are available) should remain the standard for treatment of upper brachial plexus injury except in isolated cases solely lacking elbow flexion.

Nerve transfer surgery for adult brachial plexus injury: a 10-year experience at Louisiana State University.

OBJECTIVE: To review the clinical outcomes in our patients who have undergone nerve transfer operations for brachial plexus reconstruction at the Louisiana State University (LSU) over a 10-year period. A secondary objective is to compare clinical outcomes in patients who had only nerve transfer operations as compared with patients whose nerve transfers were supplemented with direct repair of brachial plexus elements. METHODS: Retrospective review of the medical records, imaging, and electrodiagnostic studies (electromyographic and nerve conduction studies) of patients with brachial plexus injuries who underwent nerve transfer operations at LSU over a period of 10 years. RESULTS: A total of 81 patients were treated between 1995 to 2005 at the LSU Health Sciences Center; 7 of these patients were lost to follow-up, leaving 74 patients, with an average follow-up of 3.5 years, for review. We evaluated recovery of elbow flexion and shoulder abduction. Ninety percent of patients with medial pectoral to musculocutaneous nerve transfers recovered to LSU grade 2 (Medical Research Council grade 3), and 60% of those patients with intercostal to musculocutaneous nerve transfer regained similar strength in elbow flexion. Shoulder abduction recovery to LSU grade 2 (Medical Research Council grade 3) after spinal accessory to suprascapular and/or thoracodorsal to axillary nerve transfer, was 95% and 36%, respectively. There was a tendency for better motor recovery when nerve transfer operations were combined with direct repair of plexus elements. CONCLUSION: Nerve transfers for repair of brachial plexus injuries result in excellent recovery of elbow and shoulder functions. Patients who had direct repair of brachial plexus elements in addition to nerve transfers tended to do better than those who had only nerve transfer operations.

Comparison of the long-term results of anterior transposition of the ulnar nerve or simple decompression in the treatment of cubital tunnel syndrome--a prospective study.

OBJECTIVE: In order to assess their late benefits we present the long-term results of a comparison of treating cubital tunnel syndrome with anterior submuscular transposition or simple decompression. METHODS: Of 40 patients initially recruited to this study 33 were available for long term follow-up. Sixteen patients underwent anterior submuscular transposition (group A); simple decompression was performed in 17 of the patients (group B). The indications for inclusion were a typical clinical presentation confirmed by abnormal nerve conduction studies. The mean duration of the symptoms before operation was 13 months (range 2 to 84 months) in group A and 8.4 months (range 1.5 to 36 months) in group B. All patients were seen 2 months after surgery and at least 3 years later. The mean duration of follow-up was 63.1 month in the first group and 52 months in the second group. RESULTS: No complications were seen in either group. In the group treated by anterior transposition, ten of 16 patients were completely free of signs and symptoms; slight residual hypesthesia or paresthesia was observed in two patients. Paresis and atrophy was observed in only one person. In the simple decompression group, 11 of 17 patients were completely free of signs and symptoms. In five patients slight residual symptoms were observed; no paresis or atrophy was reported in any of this group. CONCLUSION: These long-term results show that both surgical techniques have a good outcome. Thus, the less invasive simple decompression should be preferred.