Functional outcome and quality of life after traumatic total brachial plexus injury treated by nerve transfer or single/double free muscle transfers

Treatment of Complete Brachial Plexus Injuries Using Double Free Muscle Transfer

PURPOSE

The purpose of this study was to examine the surgical outcomes of double free muscle transfer (DFMT) performed in patients with complete brachial plexus injury (BPI).

METHODS

We retrospectively analyzed the outcomes of DFMT for 12 patients with complete BPI who were followed up for more than 2 years after the final muscle transplantation. Their mean age was 29 years (range, 18-41). Three patients underwent contralateral C7 nerve root transfer before the DFMT. The range of motion (ROM) of the shoulder, elbow, and fingers was measured. Patient-reported outcome measures, including Disability of the Shoulder, Arm, and Hand (DASH) scores and visual analog scale (VAS) scores for pain, were also examined.

RESULTS

The mean shoulder ROM against gravity was 22° ± 8° in abduction and 33° ± 5° in flexion. Seven patients underwent phrenic nerve (PhN) transfer to the suprascapular nerves, and five exhibited asymptomatic lung impairment on spirography more than 2 years after PhN transfer. The mean elbow ROM against gravity was 111° ± 9° in flexion and -32° ± 7° in extension. All patients obtained elbow flexion >90° against a 0.5-kg weight. All patients obtained touch sensation and two recognized warm and cold sensations in the affected palm. The mean total active motion of the affected fingers was 44° ± 11°. All patients exhibited hook function of the hands. The mean preoperative and postoperative DASH scores were 70.3 ± 13.4 and 51.8 ± 15.9, respectively. The mean pain VAS score was 28 ± 31 at the final follow-up.

CONCLUSIONS

Double free muscle transfer provided patients with complete brachial plexus palsy with good elbow flexion and hand hook functions.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Surgical management and outcomes of traumatic global brachial plexus injury: A concise review and our center approach

Global brachial plexus injury (GBPI) mainly affects adults and causes severe life-changing consequences that lead to the deterioration of patients' quality of life. Several surgical approaches have been described and reported in the literature to improve patients' functional ability. A literature review is done on PubMed/MEDLINE and Embase using specific keywords to retrieve relevant articles assessing different surgical approaches for GBPI management. Inclusion and exclusion criteria were applied, and eligible articles were included in the review. The literature survey revealed that various surgical options had been used to manage GBPI patients. In this concise review, we discuss and compare the different surgical approaches related to GBPI and its outcome in terms of restoring elbow flexion and extension, shoulder abduction, and wrist and hand function. The primary surgical intervention relies mainly on transferring single or multiple nerves with/without nerve grafts to restore the function of the targeted muscle. Different techniques using a variety of nerve donors and recipients are compared to assess the functional outcomes of each option. Moreover, further options are addressed for delayed GBPI injuries or failed nerve transfer procedures, as in free functional muscle transfer techniques. In addition, information about brachial plexus injury cases faced in our center is presented along with our center's approach to diagnosing and managing partial and GBPI cases.

Restoration of Grasp after Single-Stage Free Functioning Gracilis Muscle Transfer in Traumatic Adult Pan-Brachial Plexus Injury

BACKGROUND

A variety of approaches have been described to obtain rudimentary grasp after traumatic pan-brachial plexus injury in adults. The aim of this study is to evaluate hand prehension after a gracilis single-stage free functioning muscle transfer.

METHODS

Twenty-seven patients who underwent gracilis single-stage free functioning muscle transfer for elbow flexion and hand prehension after a pan-plexus injury were included. All patients presented with a minimum of 2 years of follow-up. Postoperative finger flexion, elbow flexion strength, preoperative and postoperative Disability of the Arm, Shoulder, and Hand questionnaire scores, secondary hand procedures, complications, and demographic characteristics were analyzed.

RESULTS

Twenty patients (74%) demonstrated active finger pull-through. Only six patients (25%) considered their hand function useful for daily activities. Disability of the Arm, Shoulder, and Hand score improved by 13.1 ± 13.7 ( P < 0.005). All patients were expected to require one secondary procedure (wrist fusion, thumb carpometacarpal fusion, and/or thumb interphalangeal fusion) because no extensor reconstruction was performed. These were performed in 89%, 78%, and 74% of patients, respectively. Four postoperative complications (hematoma, seroma, wound dehiscence, and skin paddle loss) occurred. No flap loss occurred.

CONCLUSIONS

In pan-plexus injuries, the use of a gracilis single-stage free functioning muscle transfer is an alternative to the double free functioning muscle transfer procedure and contralateral C7 transfer, especially for patients who are unable to undergo two to three important operations in a short period of time. Further research and studies are required to improve hand function in these patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Outcomes of gracilis free-flap muscle transfers and non-free-flap procedures for restoration of elbow flexion: A systematic review

PURPOSE

Elbow flexion is one of the most important functions to restore following brachial plexus damage. The authors sought to systematically review available evidence to summarize outcomes of free gracilis and non-free muscle transfers in restoring elbow flexion.

METHODS

MEDLINE, EMBASE, and Cochrane were searched to identify articles reporting on elbow flexion reanimation in terms of transfer failure rates, strengths, range of motion (ROM), and/or Disabilities of the Arm, Shoulder and Hand (DASH) scores. A systematic review was chosen to select studies and reported according to PRISMA guidelines.

RESULTS

Forty-six studies met the inclusion criteria for this study. A total of 432 cases were gracilis free-flap muscle transfers (FFMT), and 982 cases were non-free muscle transfers. FFMT were shown to have higher Medical Research Council (MRC) strength scores than non-free muscle transfer groups. However, 42 studies, totaling 1,266 cases, were useful in evaluating graft failure, showing failure (MRC<3) in 77/419 (∼18.4%) of gracilis free-flap transfers and 215/847 (∼25.4%) of non-free muscle transfers. Sixteen articles, 285 cases, were useful to evaluate ROMs (total range: 0-140°), and eight articles, 215 cases, provided DASH scores (total range: 8-90.8).

CONCLUSIONS

Of patients who underwent gracilis FFMT procedures, higher mean strength scores and lower failure rates were observed when compared with non-free muscle transfers. Articles reporting non-free muscle transfer procedures (pectoralis, pedicled, Steindler, vascularized ulnar nerve grafts, Oberlin, single/double nerve transfers) provided comprehensive insight into outcomes and indicated that they may result in pooerer poorer DASH scores and ROM.

Psychometric Evaluation of the Disabilities of the Arm, Shoulder and Hand Outcome Questionnaire for Brachial Plexus Injury Using Rasch Analysis

Background: Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire is the most widely used patient-reported outcome measure (PROM) for assessment of upper extremity disability assessment. However, DASH is a multidimensional measurement with different difficulty levels and ratio apportionment of the items categorised by ordinal scale. This has caused a misinterpretation of the total disability scores. We created a modified DASH adapted to the Rasch model. The aim of this study is to compare the functional recovery and quality of life (QOL) improvement and to assess the validity of the original DASH and modified DASH between C56/C567, C5-8 and total types of brachial plexus injury (BPI) following surgical reconstruction. Methods: A total of 183 BPI patients who underwent reconstructive surgery were evaluated for functional recovery using the range of motion and power of the affected limb, and improvement in QOL with DASH. The collected data were analysed using Rasch measurement theory to detect the misfit items. The original and modified DASH were compared under the three different types of BPI after item reduction by removing the misfit items. Results: There were significant differences in functional recovery between three types of palsy. However, PROM using DASH score with or without misfit items (12 items) did not show any significant differences. Conclusions: DASH is not suitable for comparison of upper extremity disabilities even after being corrected mathematically due to the inclusion of items from many different domains unequally. Therefore, each item of the function (with or without compensation of the uninjured hand), pain and impact to the patients should be evaluated separately. Level of Evidence: Level IV (Prognostic).

Functional outcome of contralateral C7 nerve transfer combined with free functional gracilis transplantation to repair total brachial plexus avulsion: a report of thirty-nine cases

Purpose

Treatment of total brachial plexus avulsion (TBPA) is a challenge in the clinic, especially the restoration of hand function. The current main surgical order is from proximal to distal joints. The purpose of this study was to demonstrate the outcomes of “distal to proximal” surgical method.

Methods

Thirty-nine patients underwent contralateral C7 (CC7) nerve transfer to directly repair the lower trunk (CC7-LT) and phrenic nerve transfer to the suprascapular nerve (PN-SSN) during the first stage, followed by free functional gracilis transplantation (FFGT) for elbow flexion and finger extension. Muscle strength of upper limb, degree of shoulder abduction and elbow flexion, and Semmes–Weinstein monofilament test and static two-point discrimination of the hand were examined according to the modified British Medical Research Council (mBMRC) scoring system.

Results

The results showed that motor recovery reached a level of M3 + or greater in 66.7% of patients for shoulder abduction, 87.2% of patients for elbow flexion, 48.7% of patients for finger extension, and 25.6% of patients for finger flexion. The mean shoulder abduction angle was 45.5° (range 0–90°), and the average elbow flexion angle was 107.2° (range 0–142°), with 2.5 kg average flexion strength (range 0.5–5 kg). In addition, protective sensibility (≥ S2) was found to be achieved in 71.8% of patients.

Conclusion

In reconstruction of TBPA, CC7 transfer combined with free functional gracilis transplantation is an available treatment method. It could help patients regain shoulder joint stability and the function of elbow flexion and finger extension and, more importantly, provide finger sensation and partial finger flexion function. However, the pick-up function was unsatisfied, which needed additional surgery.

Scapulothoracic Dissociation: A Review of an Orthopedic Emergency

Scapulothoracic dissociation is a rare and devastating injury that is considered an orthopedic emergency. It is critical to recognize this injury early based on mechanism, physical examination, and radiographic parameters. Initial management should be focused on resuscitation and evaluation for potential limb-threatening ischemia.

Outcome of free gracilis muscle transfer for the restoration of elbow flexion in traumatic brachial plexus palsy

Objectives

The aim of this study was to evaluate the functional outcomes of patients with free gracilis muscle transfer (FGMT) for the restoration of elbow flexion.

Patients and methods

Between January 2012 and January 2019, a total of 16 patients (13 males, 3 females; mean age: 27.3±11.7 years; range: 18 to 53 years) who underwent FGMF to achieve elbow flexion after traumatic brachial plexus palsy (TBPP) were retrospectively analyzed. Data including demographic and clinical characteristics of the patients, etiology, affected side, injury level, accompanying injuries, time between injury and surgery, follow-up time, complications, whether nerve reconstruction and artery repair were performed previously, and details of the procedure were recorded. The outcome measures were elbow range of motion in degrees, muscle strength, and Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form-36 (SF-36) scores.

Results

The mean follow-up was 30±11.5 (range, 24 to 42) months. Two patients had C5-C8 injuries, two patients had C6-T1 injuries, and all other patients had injuries to the C5-T1 roots. Muscle strength was M3/M4 in 11 (68.8%) patients, M2 in two (12.5%) patients, and M0 in one (6.2%) patient. The median active range of motion of the elbow joint in patients with successful results (M3 and above) was measured as 75 (range, 30 to 100) degrees. A statistically significant improvement was observed in the pre- and postoperative DASH scores and in some SF-36 subscale scores of patients with successful results.

Conclusion

Free gracilis muscle flap is a reliable option in the restoration of elbow flexion in patients with TBPP. Although there is an improvement in functional results, disability, and quality of life, there may be no change in patients’ mental status and pain.

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.

Evaluation of muscle strength following peripheral nerve surgery: A scoping review

Peripheral nerve injury (PNI) can result in devastating loss of function, often with poor long-term prognosis. Increased use of peripheral nerve surgical techniques (eg, nerve transfer, nerve grafting, and nerve repair) has resulted in improved muscle strength and other functional outcomes in patients with PNI. Muscle strength has largely been evaluated with the British Medical Research Council (MRC) scale. MRC is convenient to use in clinical settings, but more robust measures of muscle function are necessary to fully elucidate patient recovery. This scoping review aims to examine alternative instruments used to assess muscle function in studies of peripheral nerve surgery for PNI of the upper and lower limbs. A scoping review was conducted using Ovid MEDLINE, CINAHL, EMBASE, and PubMed databases in May and December of 2020, yielding a total of 20 studies pertaining to the review question. Studies pertaining to handheld dynamometry, grip and pinch dynamometry, Rotterdam Intrinsic Hand Myometers, isokinetic dynamometry, ultrasonography, and electromyography were reviewed. We provide a synopsis of each method and current clinical applications and discuss potential benefits, disadvantages, and areas of future research.

Pearls and Pitfalls of Phrenic Nerve Transfer for Shoulder Reconstruction in Brachial Plexus Injury

Objectives  The purpose of this study was to report the functional outcomes of phrenic nerve transfer (PNT) to suprascapular nerve (SSN) for shoulder reconstruction in brachial plexus injury (BPI) patients with total and C5–8 palsies, and its pulmonary complications.

Methods  Forty-four out of 127 BPI patients with total and C5–8 palsies who underwent PNT to SSN for shoulder reconstruction were evaluated for functional outcomes in comparison with other types of nerve transfers. Their pulmonary function was analyzed using vital capacity in the percentage of predicted value and Hugh-Jones (HJ) breathless classification. The predisposing factors to develop pulmonary complications in those patients were examined as well.

Results  PNT to SSN provided a better shoulder range of motion significantly as compared with nerve transfer from C5 root and contralateral C7. The results between PNT and spinal accessory nerve transfer to SSN were comparable in all directions of shoulder motions. There were no significant respiratory symptoms in majority of the patients including six patients who were classified into grade 2 HJ breathlessness grading. Two predisposing factors for poorer pulmonary performance were identified, which were age and body mass index, with cut-off values of younger than 32 years old and less than 23, respectively.

Conclusions  PNT to SSN can be a reliable reconstructive procedure in restoration of shoulder function in BPI patients with total or C5–8 palsy. The postoperative pulmonary complications can be prevented with vigilant patient selection.

Approach to the Pan-brachial Plexus Injury: Variation in Surgical Strategies among Surgeons

Treatment of pan-brachial plexus injuries has evolved significantly over the past 2 decades, with refinement and introduction of new surgical techniques, particularly free functional muscle transfer. The extent to which contemporary brachial plexus surgeons utilize various techniques as part of their treatment algorithm for pan-plexus injuries and the rationale underlying these choices remain largely unknown.

Methods

A case scenario was posed to 12 brachial plexus surgeons during semi-structured qualitative interviews. The case involved a young patient presenting 6 weeks after a pan-plexus injury from a motorcycle accident. Surgeons were asked to formulate a treatment plan. Inductive thematic analysis was used to identify commonalities and variation in approach to treatment.

Results

For shoulder function, the majority of surgeons would graft from a viable C5 nerve root, if possible, though the chosen target varied. Two-thirds of the surgeons would address elbow flexion with nerve transfers, though half would combine this with a free functional muscle transfer to increase elbow flexion strength. Free functional muscle transfer was the technique of choice to restore finger flexion. Finger extension, intrinsic function, and sensation were not prioritized.

Conclusions

Our study sheds light on current trends in the approach to pan-plexus injuries in the U.S. and identifies areas of variability that would benefit from future study. The optimal shoulder target and the role for grafting to the MCN for elbow flexion merit further investigation. The role of FFMT plays an increasingly prominent role in treatment algorithms.

Reoperation Rate and Indication for Reoperation after Free Functional Muscle Transfers in Traumatic Brachial Plexus Injury

Background

Free functional gracilis muscle transfers (FFGT) are an option for reconstruction after traumatic brachial plexus injury. Few studies report the rate of revision surgeries following free functional muscle transfers. We examined the reoperation rate and indication for reoperation after primary reconstruction of upper extremity function with a free gracilis transfer after brachial plexus injury.

Methods

From 2003-2016, we identified 25 patients who underwent a free functional gracilis muscle transfer for restoration of upper extremity function. We reviewed their medical charts to record patient, injury, and treatment characteristics. Indication for reoperation and reoperative procedure were also identified.

Results

Fourteen out of 25 patients (56%) had a reoperation after FFGT. Four flaps were re-explored for vascular compromise, but there were no flap failures. The majority of reoperations involved adjustment of tendon excursion (8/14) which demonstrated that tenolysis was the main procedure.

Conclusion

Despite promising results of free functional gracilis transfers, reoperation is relatively common and should be discussed with the patient as a preoperative strategy. Early exploration of vascular compromise may decrease the flap failure. Poor tendon excursion is a common unpredicted consequence after FFMT and is the main indication for reoperation.

Free Gracilis Muscle Transfers Compared with Nonfree Muscle Flaps for Reanimation of Elbow Flexion: A Meta-Analysis

Objectives  Elbow flexion loss is a debilitating upper extremity injury. Surgical treatment options include nonfree muscle transfers (tendon transfers, nerve transfers, Steindler procedure, Oberlin transfers, and pedicled muscle transfers) or free muscle transfers. We sought to determine if free muscle transfers and nonfree muscle transfers have similar outcomes for elbow flexion reanimation. Materials and Methods  A literature search for studies evaluating free and nonfree muscle transfers for elbow flexion reanimation was performed. Included studies reported on transfer failure (strength <M3, unable to flex arm against gravity), strength, range of motion (ROM), or Disabilities of the Arm, Shoulder, and Hand (DASH) score. Pooled odds ratios were used to calculate failure rate, and pooled mean differences were used to calculate differences in strength, ROM, and DASH scores. Results  Six studies were included ( n = 331 patients). Free muscle patients experienced lower failure rates than nonfree muscle patients. There was no significant difference in ROM. A nonsignificant trend toward better mean strength and DASH scores among free muscle patients was observed. Conclusion  Free muscle transfers may be superior to nonfree muscle transfers for elbow flexion reanimation, given their lower failure rates. Well-powered future studies may reveal differences in strength and DASH scores between free and nonfree muscle transfers.

Systematic review on outcome of free functioning muscle transfers for elbow flexion in brachial plexus injuries

Elbow flexion is widely regarded as the most important function to restore in brachial plexus injuries. Free functioning muscle transfer surgery is indicated in patients with delayed presentation or failure of other primary procedures. Results of the transfer surgeries have been reported in the form of case series, but no further studies are available. This systematic review aims to provide a deeper understanding of this complex surgery and consists of 19 articles that include 364 patients. Data on injury characteristics, surgical techniques, complications as well as outcome measures were analysed. Our results show that functional muscle transfer for elbow flexion enables 87% and 65% of patients to achieve a useful power grade of ≥ 3 and ≥ 4, respectively, although other important outcome factors should be considered.

Quantitative assessment of elbow flexion by handheld dynamometry in brachial plexus palsy

The purpose of this study was to assess the relative and absolute reliability of a handheld dynamometer when used for examining elbow flexion power in patients with brachial plexus palsy. The assessment of the intra-rater and inter-rater reliability coefficients for the handheld dynamometer was done using the stationary Kin-Com® dynamometer as the reference standard. We determined the measurement errors and checked the systematic biases of the handheld dynamometer. The inter-rater and intra-rater reliabilities of the handheld dynamometer had a very high intraclass correlation coefficient. The values of handheld dynamometer readings had a high correlation to Kin-Com® readings. The Medical Research Council grading was a comparatively inaccurate method for quantitative assessment of motor power. We conclude that a handheld dynamometer measurement is more precise and reliable than the Medical Research Council grading for measuring recovery of elbow flexion in patients with brachial plexus palsy. Level of evidence: III.