Cost-Effectiveness Analysis of Combined Dual Motor Nerve Transfers versus Alternative Surgical and Nonsurgical Management Strategies to Restore Shoulder Function Following Upper Brachial Plexus Injury

Safety and efficacy of outpatient versus inpatient adult brachial plexus surgery

Purpose

Outpatient orthopedic surgery is becoming more common as a method of providing safe and cost-effective medical care. The purpose of this study was to compare outcomes between adult patients undergoing outpatient versus inpatient brachial plexus surgery.

Methods

A single institution database was queried for patients with brachial plexus injuries undergoing brachial plexus exploration with or without concomitant reconstructive procedures from 2010 to 2022. Outcome measures included 90-day major and minor complications, as well as longer term pain scores and reoperation rates. Multivariate analysis was performed to compare outcomes between the cohorts.

Results

In a group of 51 adult patients, 36 (70.6 %) were admitted for at least one night following surgery and 15 (29.4 %) underwent outpatient surgery. The cohorts were similar with respect to demographics. When compared to brachial plexus procedures performed between 2010 and 2016, those performed between 2017 and 2022 were 67 % more likely to be outpatient (OR 0.33; p = 0.11). The overall major complication rate during the 90-day episode of care was 11.8 % (n = 6), all of which occurred in the inpatient cohort. There was no significant difference in minor complication rate. 90-day reoperation rate due to complications was 2.8 % in the inpatient cohort and 0.0 % in the outpatient cohort.

Conclusion

No prior study has assessed the safety of brachial plexus exploration and reconstruction in an outpatient setting. This study demonstrates that outpatient brachial plexus surgery is a safe option for properly selected patients. Procedures were more often performed outpatient in recent years, reflecting a continuing evolution of our practice.

Nerve Regeneration after a Nerve Graft in a Rat Model: The Effectiveness of Fibrin Glue

BACKGROUND

Simulating the post-traumatic continuity defect of small human peripheral nerves, we compared the effectiveness of fibrin glue with neurorrhaphy for nerve gap restoration.

METHODS

In twenty-four male Wistar rats, a fifteen mm defect in one sciatic nerve only was made and immediately repaired with an inverted polarity autograft. According to the used technique, rats were divided into Group A (Control), using traditional neurorrhaphy, and Group B (Study), using fibrine glue sealing; in total, 50% of rats were sacrificed at 16 weeks and 50% at 21 weeks. Before sacrifice, an assessment of motor function was done through Walking Track Analysis and an electroneurophysiological evaluation. After sacrifice, selected muscle mass indexes and the histology of the regenerated nerves were assessed. All data were evaluated by Student's t test for unpaired data.

RESULTS

No significant differences were found between the two groups, with only the exception of a relative improvement in the tibialis anterior muscle's number of motor units in the study group.

CONCLUSION

Despite the fact that the use of fibrin glue as a nerve sealant is not superior in terms of functional recovery, its effectiveness is comparable to that of microsurgical repair. Hence, the faster and technically easier glueing technique could deserve broader clinical application.

Catastrophic Health Care Expenditure Following Brachial Plexus Injury

PURPOSE

Brachial plexus injuries (BPIs) are devastating to patients not only functionally but also financially. Like patients experiencing other traumatic injuries and unexpected medical events, patients with BPIs are at risk of catastrophic health expenditure (CHE) in which out-of-pocket health spending exceeds 40% of postsubsistence income (income remaining after food and housing expenses). The individual financial strain after BPIs has not been previously quantified. The purpose of this study was to assess the proportion of patients with BPIs who experience risk of CHE after reconstructive surgery.

METHODS

Administrative databases were used from 8 states to identify patients who underwent surgery for BPIs. Demographics including age, sex, race, and insurance payer type were obtained. Inpatient billing records were used to determine the total surgical and inpatient facility costs within 90 days after the initial surgery. Due to data constraints, further analysis was only conducted for privately-insured patients. The proportion of patients with BPIs at risk of CHE was recorded. Predictors of CHE risk were determined from a multivariable regression analysis.

RESULTS

Among 681 privately-insured patients undergoing surgery for BPIs, nearly one-third (216 [32%]) were at risk of CHE. Black race and patients aged between 25 and 39 years were significant risk factors associated with CHE. Sex and the number of comorbidities were not associated with risk of CHE.

CONCLUSIONS

Nearly one-third of privately-insured patients met the threshold for being at risk of CHE after BPI surgery.

CLINICAL RELEVANCE

Identifying those patients at risk of CHE can inform strategies to minimize long-term financial distress after BPIs, including detailed counseling regarding anticipated health care expenditures and efforts to optimize access to appropriate insurance policies for patients with BPIs.

Free functional muscle transfer for upper limb paralysis - A systematic review

BACKGROUND

Functional restoration of upper limb paralysis represents a major reconstructive challenge. Free functional muscle transfer (FFMT) enables reanimation in patients with a lack of local donor tissues or delayed presentation. This systematic review summarises the evidence for FFMT in the reconstruction of upper limb paralysis.

METHODS

A comprehensive search of MEDLINE and EMBASE was performed with a systematic review using methodology adapted from the Cochrane Handbook and the PRISMA statement. Data from included studies were compiled and narratively synthesised. Studies were assessed for risk of bias.

RESULTS

A total of 1155 records were screened, with 39 observational studies of 904 patients included. The most common aetiology was brachial plexus injury (736, 81.4%). Mean time from injury to intervention was 26 months. Restoration of elbow flexion was the commonest reconstructive goal. The most common donor muscle was gracilis (91.5%). Reported outcomes were heterogeneous with patient-reported outcome measures (PROMs) available in only 7 of 39 studies. Nearly half of FFMTs had a post-operative MRC grade of <4 and 18.1% had an MRC <3. Mean flap failure rate was 3.6% (range 0-10.5%). All studies were at high risk of bias.

CONCLUSIONS

FFMT may be an effective surgical intervention for upper limb paralysis; however, the current evidence has significant shortcomings. There is no consensus regarding outcome measures nor is it possible to identify prognostic factors for its effectiveness. This review highlights a need for improved study design with pre-operative assessment, standardisation in outcome reporting, and the use of PROMs to determine the effectiveness of FFMT in upper limb paralysis.

Direct Cost of Surgically Treated Adult Traumatic Brachial Plexus Injuries

Purpose

The economic implications of brachial plexus injuries (BPI) in the United States are not well understood. The purpose of our study was to quantify the direct costs associated with surgical treatment of BPI after traumatic injury in adults, which would enable future study of the societal value of surgical reconstruction.

Methods

Using an administrative database of patients with commercial insurance, a cohort of patients aged 18 to 64 years with BPI treated surgically from 2007 to 2015 was assembled and assessed for index admission associated with BPI surgery and all payments toward claims (including medical, surgical, therapy, and pharmacy claims) for 1 year after surgery.

Results

Among 189 patients undergoing surgery for BPI, median direct payments were $38,816 (interquartile range: $18,209 to $72,411; minimum: $3,512; maximum: $732,641).

Conclusions

Relative to recently published data for the indirect cost of traumatic BPI (median: $801,723), direct payments for 1 year after surgical treatment represent 4.6% of the total long-term cost of BPI. In the context of existing literature demonstrating cost-effectiveness in models of BPI surgical care, our data suggest that surgery and other interventions to maximize return to work after traumatic BPI in adults may be beneficial to society.

Type of study/level of evidence

Economic and Decision Analyses IV.