Versatility of the double fascicular transfer in reconstruction of elbow flexion paralysis: Intermediate term follow-up and patient-related outcome measures

OBJECTIVES

The use of fascicle transfers in the reconstruction of traumatic brachial plexus injury is well established, but limited evidence is available regarding their use in atraumatic elbow flexion paralysis. This retrospective case review aimed to verify whether median and ulnar fascicle transfers are similarly effective in atraumatic versus traumatic elbow flexion paralysis when measured using the British Medical Research Council (MRC) scale, Brachial plexus Assessment Tool (BrAT) and Stanmore Percentage of Normal Elbow Assessment (SPONEA) scores at long-term follow-up.

METHODS

All median and ulnar fascicle transfer cases performed at the Queen Elizabeth Hospital Birmingham between August 2007 and November 2018 were reviewed to compare the outcomes of transfers performed for traumatic and atraumatic indications. Data on patient demographics, mechanism and nature of injury, date of injury or symptom onset, date of operation, and other nerve transfers performed were collected. Outcome measures collected included the British MRC scale and two patient-reported outcome measures (PROMs), BrAT and SPONEA.

RESULTS

In total, 34 patients with 45 median and ulnar fascicle transfers were identified. This included 27 traumatic and seven atraumatic brachial plexus insults. Thirty patients had sufficient follow-up to be included in MRC analysis and 17 patients had sufficient follow-up to be included in PROM analysis. No significant differences were found between traumatic and atraumatic subgroups for median MRC, BrAT, or SPONEA scores.

CONCLUSIONS

This study suggests that nerve transfers might be considered effective reconstructive options in atraumatic pathology and provides validation for further research on the subject.

Functional reconstruction of elbow flexion with latissimus dorsi muscle rotational transfer: two case reports

BACKGROUND

We report two cases of biceps brachii and brachialis paralysis due to musculocutaneous nerve injury in which elbow joint flexion was reconstructed using rotational transfer of the latissimus dorsi muscle with sutures to the radial and ulnar tuberosities, thereby enabling flexion by simultaneous activation of the humeroradial and humeroulnar joints. In cases of associated brachialis paralysis, weaker flexion strength can be expected when the forearm is in a pronated position than when it is in a supinated state. To the best of our knowledge, no previous study has reported the rotational position of the forearm during elbow joint flexion reconstruction.

CASE PRESENTATION

Case 1 involved a 30-year-old Asian male who presented with a rupture of the musculocutaneous, median, radial, and ulnar nerves. Reconstruction was performed by rotational transfer of the latissimus dorsi muscle. In this case, the supination and pronation flexion forces were equal. Case 2 involved a 50-year-old Asian man who presented with partial loss of the musculocutaneous nerve, biceps brachii, and pectoralis major due to debridement. Reconstruction was performed by rotational transfer of the latissimus dorsi muscle. In this case, supination and pronation flexion strengths were demonstrated to be equal. Our reconstruction method used the rotational transfer of the latissimus dorsi muscle; the distal muscle flap was divided into radial and ulnar sides to allow elbow joint flexion by simultaneously activating the humeroradial and humeroulnar joints. These sides were then fixed to the anchors at the radial and ulnar tuberosities. Finally, they were wrapped around the myotendinous junction of the biceps brachii or brachialis and secured using sutures.

CONCLUSIONS

Although larger studies are required to verify these methods, this case study successfully demonstrates the following: (1) the flexion strength in the supinated position was equal to that in the pronated position; (2) the stability of the humeroradial and humeroulnar joints was unaffected by the forearm's rotational position; and (3) a satisfactory range of motion of the elbow joint was obtained, with no complications.

Tendon transfer from a re-innervated triceps to the biceps for restoration of elbow flexion in total brachial plexus palsy

OBJECTIVES

This study aimed to evaluate the outcomes of the tendon transfer from a reinnervated triceps to biceps in the context of total brachial plexus palsy.

METHODS

We conducted a retrospective study. Patients had reinnervation of the triceps either by spontaneous recovery or by nerve transfer. Functional results were assessed by strength and range of motion. The level of patient satisfaction was measured on a scale from 0 to 10.

RESULTS

Six patients (6 transfers) were included. Two triceps had spontaneous reinnervation and the other four through neurotization of intercostal nerves. All patients recovered strength to M4 in flexion with an average secondary deficit of 10° (5°-15°). The mean level of satisfaction was measured at 7/10 (6-8).

CONCLUSIONS

This tendon transfer is a reliable and simple solution for supportive restoration of elbow flexion. Systematic reinnervation of active extension of the elbow should be proposed for the gain in function that it represents but also for the supportive therapeutic opportunity that it offers should nerve surgery for elbow flexion fail.

LEVEL OF EVIDENCE: 4

Optimal Distal Tendon Insertion Point for Elbow Flexion in Free-Functioning Gracilis Muscle Transfer for Panbrachial Plexus Injuries: A Cadaveric Study

PURPOSE

Following pan-brachial plexus injuries, restoration of elbow flexion is widely accepted as the reconstructive priority. A gracilis free functioning muscle transfer (FFMT) can be used to restore elbow flexion alone with insertion into the biceps brachii (BIC) or brachioradialis (BRD) tendons or restore combined elbow and finger flexion with a more distal insertion into the flexor digitorum profundus (FDP) tendons. Using cadaveric experiments, we determined the peak instantaneous moment arm for each insertion option.

METHODS

Six simulated gracilis transfer surgeries were performed using both arms of three fresh-frozen full body cadaveric specimens (age: 79 + 10 years. 2 female). The gracilis muscles from both legs were harvested and transferred to the contralateral upper extremity. The elbow was manually moved through three flexion-extension cycles while the instantaneous moment arm was calculated from measurements of gracilis excursion and elbow joint angle for the three distal insertion sites.

RESULTS

Peak instantaneous moment arm for all three insertions occurred at an elbow angle between 83° to 92° with a magnitude ranging from 33 mm to 54 mm. The more distal (FDP/BRD) insertions produced a significantly greater (∼1.5 times) peak elbow flexion instantaneous moment arm compared to the BIC insertion.

CONCLUSIONS

Based on the instantaneous moment arm, the gracilis FFMT distal insertion locations could result in greater reconstructed elbow flexion strength. In addition, direct measurement of the shape and magnitude of the moment arm curve for differing insertion sites allows high resolution surgical planning and model testing.

CLINICAL RELEVANCE

This study presents the first direct experimental quantification of the gracilis FFMT instantaneous moment arm. The experimental evidence supports the use of FDP/BRD insertion locations by providing a quantitative explanation for the increased elbow flexion torque observed clinically in patients with a gracilis FFMT and distal FDP insertion.

Shear wave elastography characterizes passive and active mechanical properties of biceps brachii muscle in vivo

Mechanical characterization of individual muscles in their in vivo environment is not well studied. Shear wave elastography (SWE) as a non-invasive technique was shown to be promising in quantifying the local mechanical properties of skeletal muscles. This study aimed to investigate the mechanics of the biceps brachii muscle (BB) derived from SWE in relation to elbow joint position and contraction intensity during isometric contraction. 14 healthy, young subjects participated in the study and five different joint positions (60°-180° elbow angle) were investigated. Shear elastic modulus and surface electromyography (sEMG) of the BB and elbow torque were measured simultaneously, both in passive (i.e., resting) and active states during slow, sub-maximal isometric ramp contractions up to 25%, 50%, and 75% of the maximum voluntary contraction. At passive state, the shear elastic modulus of the BB increased with increasing elbow angle (p < 0.001). Maximum elbow flexion torque was produced at 60° and it decreased with increasing elbow angle (p = 0.001). During sub-maximal contractions, both elbow angle (p < 0.001) and contraction intensity (p < 0.001) had significant effects on the shear elastic modulus but only contraction intensity (p < 0.001) affected sEMG amplitude of the BB. Although torque was decreased at extended elbow positions (150°, 180°), higher active shear elastic modulus of BB muscle was found compared to flexed positions (60°, 90°). Linear regression of the BB sEMG amplitude over elbow torque showed good agreement for all joint positions (R² between 0.69 and 0.89) while the linear agreement between shear elastic modulus of BB and elbow torque differed between flexed (R² = 0.70 at 60° and R² = 0.79 at 90°) and extended positions (with the lowest R² = 0.57 at 150°). We conclude that using SWE, we can detect length-dependent mechanical changes of BB both in passive and active states. More importantly, SWE can be used to characterize active muscle properties in vivo. The present findings have critical importance for developing muscle stiffness as a measure of individual muscle force to validate muscle models and using SWE in clinical diagnostics.

A cadaveric study of ulnar nerve strain at the elbow associated with cubitus valgus/varus deformity

Background

Cubital tunnel syndrome can be caused by overtraction and dynamic compression in elbow deformities. The extent to which elbow deformities contribute to ulnar nerve strain is unknown. Here, we investigated ulnar nerve strain caused by cubitus valgus/varus deformity using fresh-frozen cadavers.

Methods

We used six fresh-frozen cadaver upper extremities. A strain gauge was placed on the ulnar nerve 2 cm proximal to the medial epicondyle of the humerus. For the elbow deformity model, osteotomy was performed at the distal humerus, and plate fixation was performed to create cubitus valgus/varus deformities (10°, 20°, and 30°). Ulnar nerve strain caused by elbow flexion (0–125°) was measured in both the normal and deformity models. The strains at different elbow flexion angles within each model were compared, and the strains at elbow extension and at maximum elbow flexion were compared between the normal model and each elbow deformity model. However, in the cubitus varus model, the ulnar nerve deflected more than the measurable range of the strain gauge; elbow flexion of 60° or more were considered effective values. Statistical analysis of the strain values was performed with Friedman test, followed by the Williams’ test (the Shirley‒Williams’ test for non-parametric analysis).

Results

In all models, ulnar nerve strain increased significantly from elbow extension to maximal flexion (control: 13.2%; cubitus valgus 10°: 13.6%; cubitus valgus 20°: 13.5%; cubitus valgus 30°: 12.2%; cubitus varus 10°: 8.3%; cubitus varus 20°: 8.2%; cubitus varus 30°: 6.3%, P < 0.001). The control and cubitus valgus models had similar values, but the cubitus varus models revealed that this deformity caused ulnar nerve relaxation.

Conclusions

Ulnar nerve strain significantly increased during elbow flexion. No significant increase in strain 2 cm proximal to the medial epicondyle was observed in the cubitus valgus model. Major changes may have been observed in the measurement behind the medial epicondyle. In the cubitus varus model, the ulnar nerve was relaxed during elbow extension, but this effect was reduced by elbow flexion.

Upper extremity nerve transfers for acute flaccid myelitis: a systematic literature review

BACKGROUND

Acute flaccid myelitis (AFM) is a rare disease that commonly affects young children. AFM's pathophysiology involves loss of lower motor neurons following a viral infection and induces acute asymmetric flaccid paralysis most commonly in the upper extremities. Nerve transfers have emerged as a treatment option for these patients with permanent motor deficits.

OBJECTIVE

To summarize the literature and report safety and efficacy outcomes following nerve transfers for recovery of shoulder abduction and external rotation, and elbow flexion and extension in pediatric patients with AFM. Recovery of at least antigravity function was defined as a successful outcome. This systematic review was performed according to the PRISMA guidelines. The PubMed, Embase and Cochrane databases were utilized.

RESULTS

Five studies comprising 44 patients (median age 2.95 years; 71% male), and 93 upper extremity nerve transfers were included. Thirty-eight patients received 65 nerve transfer procedures aiming for recovery of shoulder abduction and/or external rotation with a transfer to the axillary and/or suprascapular nerve. The recovery of shoulder abduction and external rotation was achieved in 40.7% (n = 11/27) and 60% (n = 6/10) of patients, respectively. Time from injury to surgery showed an inverse relationship with the odds for successful recovery (OR: 0.81; 95% CI: 0.64-1.02; p = 0.07); however, statistical significance was not reached. Successful recovery of elbow flexion with a transfer to the musculocutaneous was reported at a rate of 92.3% (n = 12/13). Successful re-innervation of the radial nerve with recovery of elbow extension was found in 75% (n = 6/8) of patients. No complications were reported.

CONCLUSIONS

Upper extremity nerve transfers appear to be promising and safe for AFM patients. Shoulder abduction is the most challenging upper extremity function to recover. Further studies are warranted to identify whether nerve transfers are associated with superior outcomes when performed earlier.

Do technical components of microanastomoses influence the functional outcome of free gracilis muscle transfer for elbow flexion in traumatic brachial plexus injury?

INTRODUCTION

The traumatic lesions of the brachial plexus in adults are devastating injuries causing continuous severe functional impairment for both work and daily living activities. The restoration of elbow flexion is one of the most important movements for patient recovery to previous activities. Free gracilis muscle transfer has good outcomes for cases with late presentation or as a rescue surgery to regain elbow flexion, however, bad results are present in all cohorts with insufficient recovery of muscle strength for elbow flexion. A number of hypotheses can be postulate to explain the fair results observed in some cases of free gracilis muscle transfer for elbow flexion. Most studies in the current literature compare the choice of the donor nerve used in neurotization and nerve grafts. The aim of this study is to evaluate if technical components of microvascular anastomosis could influence the functional outcome of free functional muscle transfer for elbow flexion in adult patients with traumatic brachial plexus injury.

MATERIAL AND METHODS

Included all adult patients with traumatic brachial plexus injury submitted to free functional gracilis muscle transfer for elbow flexion. The complications and functional results according to British Medical Research Council (BMRC) score were recorded.

RESULTS

We assessed 26 patients with mean age of 32.8 years. The most common donor nerve for gracilis muscle was the accessory nerve in 18 patients. Eighteen patients presented with good result (M3/M4). The mean ischemia time was higher for patients with bad results (132 minutes) comparing with patients with good results (122 minutes). Patients with only one venous anastomosis had 41% of poor functional outcome compared with 22% of cases with two venous anastomoses. No statistically significant difference in the ischemia time of the cases with good or poor functional outcome was observed (p=0.657), as for the number of venous anastomoses (p=0.418).

CONCLUSION

Our study observes that patients with only one venous anastomoses for drainage of free gracilis and those with longer intraoperative ischemia time had higher incidence of poor functional outcome of free gracilis muscle transfer for elbow flexion, but not statistically significant.

LEVEL OF PROOF

II; prospective cross-sectional study.

The results of decompression of the musculocutaneous nerve entrapment in children with obstetric brachial plexus palsy

PURPOSE

Elbow flexion is a key indicator of functional recovery in obstetric brachial plexus palsy (OBPP). However, lack of flexion could be a result of an entrapped musculocutaneous nerve during the healing period. The purpose of this study was to investigate the possible compression of the musculocutaneous nerve and outcomes of decompression.

METHODS

The study included 11 children aged with a mean age of 10.9 ± 2.7 months (range, 8-16 months) with Narakas 2 involvement OBPP, who had insufficient elbow flexion but had satisfactory shoulder abduction. Prior to surgery, magnetic resonance imaging (MRI) was performed to identify the entrapment. The children were evaluated pre-operatively and at 3 and 12 months postoperatively using the Active Movement Scale and Faradic Excitability Test. The musculocutaneous nerve was explored and decompressed in all the children. Regular physiotherapy and a home exercise programme were prescribed after surgery.

RESULTS

The MRI findings were consistent with the surgical exploration in all the infants. Statistical analyses showed that decompression of the musculoskeletal nerve improved active movement scale scores on elbow flexion and faradic excitability test values of biceps brachii within 3 months after surgery.

CONCLUSION

Children with delayed elbow flexion and satisfactory shoulder abduction may have an entrapped musculocutaneous nerve in the proximal arm and decompression of the nerve improves elbow function.

Changes in muscle activity during the flexion and extension phases of arm cycling as an effect of power output are muscle-specific

Arm cycling is commonly used in rehabilitation settings for individuals with motor impairments in an attempt to facilitate neural plasticity, potentially leading to enhanced motor function in the affected limb(s). Studies examining the neural control of arm cycling, however, typically cycle using a set cadence and power output. Given the importance of motor output intensity, typically represented by the amplitude of electromyographic (EMG) activity, on neural excitability, surprisingly little is known about how arm muscle activity is modulated using relative workloads. Thus, the objective of this study was to characterize arm muscle activity during arm cycling at different relative workloads. Participants (n = 11) first completed a 10-second maximal arm ergometry sprint to determine peak power output (PPO) followed by 11 randomized trials of 20-second arm cycling bouts ranging from 5–50% of PPO (5% increments) and a standard 25 W workload. All submaximal trials were completed at 60 rpm. Integrated EMG amplitude (iEMG) was assessed from the biceps brachii, brachioradialis, triceps brachii, flexor carpi radialis, extensor carpi radialis and anterior deltoid of the dominant arm. Arm cycling was separated into two phases, flexion and extension, relative to the elbow joint for all comparisons. As expected, iEMG amplitude increased during both phases of cycling for all muscles examined. With the exception of the triceps brachii and extensor carpi radialis, iEMG amplitudes differed between the flexion and extension phases. Finally, there was a linear relationship between iEMG amplitude and the %PPO for all muscles during both elbow flexion and extension.

Partial ulnar nerve transfer to the branch of the long head of the triceps to recover elbow extension in C5, C6 and C7 brachial plexus palsy

Elbow flexion is the first goal in upper partial brachial plexus palsy treatment. However, elbow extension is essential for daily living activities. To recover this function, one fascicle of ulnar nerve can be transferred to the branch of the long head of the triceps, but this procedure has been previously published in only two patients. The goal of our study is to assess a larger series of transfers of one fascicle of ulnar nerve to the branch of the long head of the triceps to help patients recover elbow extension. Ten male patients with C5, C6 and C7 brachial plexus injuries underwent operation. For shoulder recovery, we transferred the spinal accessory nerve and rhomboid nerve. For elbow flexion, one fascicle of median nerve was transferred to the nerve of the biceps. For elbow extension, we transferred one fascicle of ulnar nerve to the branch of the long head of the triceps. Tendon transfers were performed for wrist and finger extension. Nine patients recovered M4 elbow flexion and extension. One patient had M3 elbow extension and flexion. Average active shoulder elevation was 85° and average active shoulder external rotation was 65° All patients recovered finger and wrist extension. The classical techniques of grafts or phrenic or intercostal nerve transfers to recover elbow extension are not always reliable, according to the literature. Because the harvested ulnar nerve motor fascicle is close to the branch of the long head of the triceps, the recovery time for this procedure is shorter than that of other described nerve transfers. The isolated recovery of the reinnervated long head of the triceps muscle excludes spontaneous recovery occasionally noted in upper root plexus injuries. The transfer of one fascicle of ulnar nerve to the branch of the long head of the triceps is reliable for active elbow extension recovery in C5, C6 and C7 brachial plexus palsies.

Reconstruction of elbow flexion with a modified Oberlin procedure: A comparative study

INTRODUCTION

In upper brachial plexus injuries (C5-C6-C7), selective nerve transfers appear as a favourable technique. For this purpose, transfer of an ulnar nerve fascicle to the biceps motor branch (Oberlin's procedure) is often used. In this paper we present our modified Oberlin technique, as well as a comparison of this method with the classic Oberlin procedure.

MATERIALS AND METHODS

We present two groups of patients that where operated by two different surgeons. The first group, consisting of 16 patients was treated with the classic Oberlin procedure. The second group included 5 patients treated with a modified Oberlin procedure, where two fascicles from the ulnar nerve were transferred to both the motor branch of the biceps and the motor branch of the brachialis muscles.

RESULTS

In the last follow-up of the 16 patients from the first group with the classic Oberlin procedure, 15 patients (93.75%) had Medical Research Council (MRC) grade of biceps strength 4 and 1 patient (6.25%) had MRC grade 3, whereas in the group where the modified Oberlin procedure was used the muscle strength was very durable with 4 out of 5 the patients reached MRC grade of 4+ and one MRC grade of 4, and with a mean elbow strength at 5.4 kg (3-8 kg). No sensitivity or motor problems were encountered on the ulnar territories for both groups.

CONCLUSION

With the modified Oberlin technique, the median nerve is reserved and both elbow flexors are innervated. The results of this technique compare favourably with those of other methods. Thus, we propose using the double fascicle transfer from the ulnar nerve to both elbow flexors in order to restore a strong elbow flexion in patients with upper brachial plexus injuries.

Elbow flexion in neonatal brachial plexus palsy: a meta-analysis of graft versus transfer

BACKGROUND

Functional elbow flexion recovery is one of the main goals of neonatal brachial plexus palsy (NBPP) reconstruction. The current neurosurgical treatment options include nerve grafting and nerve transfer.

OBJECTIVE

The present study sought to examine the literature for comparison of functional elbow flexion recovery in NBPP following nerve grafting or nerve transfer. We conducted a systematic literature review and meta-analysis according to PRISMA guidelines. A search was conducted on Pubmed/Medline and Cochrane for eligible studies published until November of 2018. Odd ratios (OR) and 95% confidence intervals (CI) were calculated to compare functional elbow flexion outcomes between nerve graft and nerve transfer. A random effects model meta-analysis was conducted. A Medical Research Council (MRC) score ≥ 3 or Active Movement Scale (AMS) ≥ 5 was considered a functional recovery of elbow flexion.

RESULTS

The present study included 194 patients from 1990 to 2015 across five observational trials. Only pediatric patients with obstetric brachial plexus injury were included. The mean patient age at surgery varied between studies from 5.7 months to 11.9 months and mean follow-up from 12 to 70 months. No complications or cases of donor site morbidity were reported. From the included studies, 118 patients were reported with MRC or AMS scoring usable for odd ratio comparison. Functional recovery occurred with nerve transfer in 95.2% of patients (n = 59/62) and with nerve grafting in 96.4% of patients (n = 54/56). Overall, the outcomes for elbow flexion between the groups appeared similar (OR 1.15, 95% CI 0.19-7.08, I² 2.9%).

CONCLUSION

Comparing nerve grafting and nerve transfer for NBPP, there is no statistically significant difference in functional elbow flexion recovery.

Muscle fatigue in response to low-load blood flow-restricted elbow-flexion exercise: are there any sex differences?

PURPOSE

This study aimed to determine whether men and women display a different magnitude of muscle fatigue in response to high-load (HL) and low-load blood flow-restricted (LLBFR) elbow-flexion exercise. We also explored to which extent both exercise protocols induce similar levels of muscle fatigue (i.e., torque decrement).

METHODS

Sixty-two young participants (31 men and 31 women) performed dynamic elbow flexions at 20 and 75% of one-repetition maximum for LLBFR and HL exercise, respectively. Maximum voluntary isometric contractions were performed before and after exercise to quantify muscle fatigue.

RESULTS

Men and women exhibited similar magnitude of relative torque decrement after both exercise protocols (p > 0.05). HL was more fatiguing (∆ torque output: 11.9 and 23 N.m in women and men, respectively) than LLBFR resistance exercise (∆ torque output: 8.3 and 15.4 N.m in women and men, respectively) in both sexes, but this was largely attenuated after controlling for the differences in volume load between protocols (p > 0.05).

CONCLUSIONS

These data show that torque decrement in response to LLBFR and HL dynamic elbow-flexion exercise does not follow a sexually dimorphic pattern. Our data also indicate that, if performed in a multiple-set fashion and prescribed for a given volume load, elbow-flexion LLBFR exercise induces similar levels of fatigue as HL acute training. Importantly, this occurs similarly in both sexes.

The Role of the Muscle Brachioradialis in Elbow Flexion: An Electromyographic Study

BACKGROUND

In the classical conception, the brachioradialis is a forearm supinator. The hypothesis of this study was that, at least in certain positions of elbow flexion and forearm rotation, the brachioradialis is, along with the biceps and brachialis, one of the main elbow flexors.

METHODS

Fifteen young healthy male volunteers participated in this research. The activities of the biceps, brachialis and brachioradialis muscles were studied using surface electromyography, while the subjects were performing elbow flexions/extensions with as much strength as possible, forearm in neutral position, then in full pronation, then in full supination. The elbow flexion torques were isokinetically measured at 60°/sec for an arc of 120°.

RESULTS

The biceps, brachialis and brachioradialis muscles were electromyographically very active throughout resisted elbow flexion, in all three investigated positions of forearm rotation. At certain positions, the electromyographic activities were much higher than the maximal voluntary contraction signal. For what concerns specifically the brachioradialis, in all three forearm rotation investigated positions, the activity curve demonstrated a slow increase during the first part of elbow flexion, reaching in 73.3% of subjects its peak at the end of flexion; in the remaining 26.7%, the brachioradialis had a flat activity without significant peak. The activity was slightly higher in supination.

CONCLUSIONS

This study indirectly supports the idea that the brachioradialis is one of the main elbow flexors, especially when the elbow flexion is done with the forearm in supination. This observation could be important in clinical elbow and wrist surgical practice.

Comparative study of phrenic and partial ulnar nerve transfers for elbow flexion after upper brachial plexus avulsion: A retrospective clinical analysis

The widely used nerve transfer sources for elbow flexion in patients with upper brachial plexus avulsion (UBPA) include partial ulnar nerve, phrenic nerve, and intercostal nerves. A retrospective review of 21 patients treated with phrenic and partial ulnar nerve transfers for elbow flexion after UBPA was carried out. In the phrenic nerve transfer group, the phrenic nerve was transferred to the anterolateral bundle of the anterior division of the upper trunk; in the partial ulnar nerve transfer group, one fascicle of the ulnar nerve was transferred to the biceps branch. The British Medical Research Council (MRC) grading system, angle of elbow flexion, electromyography (EMG), and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire scoring were used to evaluate the recovery of elbow flexion at least 3 years postoperatively. The efficiency of motor function in phrenic nerve transfer group was 82%, whereas it was 80% in partial ulnar nerve transfer group. The outstanding rates of angle of elbow flexion were 64% and 70% in phrenic and partial ulnar nerve transfer groups, respectively. The DASH scores after surgery were significantly lower than those before surgery in the two groups. There was no statistical difference between the two groups in the changes of DASH scores before and after surgery. Both of phrenic and partial ulnar nerve transfers had good prognosis for elbow flexion in patients with UBPA.

Quantitative assessment for flexed-elbow deformity during gait following botulinum toxin A treatment

BACKGROUND

The effect of botulinum toxin A (BoNTA) injection on flexed-elbow deformity is usually evaluated using the Modified Ashworth Scale (MAS), but only with the muscle tone at rest. Some patients show the flexed-elbow deformity during gait despite low muscle tone at rest.

OBJECTIVE

This study aimed to evaluate the effect of BoNTA injection on flexed-elbow deformity during gait using a three-dimensional motion analysis system.

METHODS

Twenty stroke patients with spastic flexed-elbow deformity during gait received BoNTA injections into the upper limb muscles. The MAS score of the elbow flexors, passive elbow range of motion, comfortable overground gait velocity, and elbow flexion angle during treadmill gait were evaluated just before and 2, 6, and 12 weeks after the injection. Twenty-five healthy subjects were also recruited to provide a normal reference of the elbow flexion angle.

RESULTS

The MAS scores at 2, 6 and 12 weeks after the injection were significantly lower than that before the injection. Some patients showed no spasticity at rest but an obviously flexed elbow during gait. The elbow flexion angles during gait at 2 and 6 weeks after the injection were significantly lower than that before the injection.

CONCLUSIONS

BoNTA injections to the upper limb muscles reduced muscle tone at rest and flexed-elbow deformity during gait. However, the elbow flexion angle during gait returned to its pre-injection level sooner than the muscle tone at rest. We strongly recommend evaluating muscle tone during motion and at rest, preferably using three-dimensional motion analysis since it can objectively detect small changes.

Pectoralis minor transfer for elbow flexion restoration in late obstetric brachial plexus palsy

PURPOSE

Obstetric brachial plexus palsy (OBPP) may result in a severe impairment of upper limb function, especially when major motor functions do not recover with or without early microsurgical reconstruction. Various methods to restore elbow flexion have been described. The aim of this study was to report the results after pectoralis minor transfer for elbow flexion restoration in late OBPP.

METHODS

Nineteen patients were included. Mean age at surgery was six years (range, 2.3-12.8). The mean follow-up period was four years (range, 1-15). Shoulder function was evaluated by the Mallet classification and hand function by the Raimondi scale. We used the "active movement scale" (AMS) to evaluate elbow flexion function.

RESULTS

Eighteen of the 19 patients had improvement in their elbow active flexion. There was significant improvement in biceps muscle power according to the BMRC grading system, from an average grading of 1.7 (range, 1-3) pre-operatively to 3 (range, 1-4) post-operatively (P < 0.05). The average active elbow flexion was significantly improved from a mean of 81° (range, 0-120; SD = 44) pre-operatively, most of them gravity eliminated, to a mean of 111° (range, 0-140; SD = 33) post-operatively (P < 0.05). According to the AMS, 12 patients (63%) had a good result, 4 (21%) a fair result and 5 (26%) a poor result. Poor results were significantly correlated with a low pre-operative AMS score (P < 0.05).

CONCLUSIONS

The pectoral minor transfer can be a reliable technique for elbow flexion improvement in late OBPP by strengthening an already existing but inadequate active flexion.

LEVEL OF EVIDENCE

IV.

The relation between elbow range of motion and patient satisfaction after open release of stiff elbow

Objective

The aim of this retrospective study was to find out whether a cut off value existed for elbow flexion and extension after open surgical release of elbow contracture that would correlate with subjective patient satisfaction.

Methods

The study enrolled 77 patients (53 males and 24 females with a mean age of 35.1 (18–77) years at the time of operation) with elbow contracture who attended regular follow-up appointments for more than 12 months. The mean follow up period was 44.2 months (12–186). The preoperative and postoperative modified MAYO elbow scores, objective parameters of increase in both flexion and extension end point measurements and improvement in total ROM were compared in order to determine the cut off degree of ROM in both flexion and extension that significantly correlated with patient satisfaction.

Results

Of the 77 participating patients, 26 patients had an extrinsic (33.8%) and 51 patients had an intrinsic elbow contracture (66.2%). Surgeries performed involved 40 cases of lateral release and 37 cases of both lateral and medial (progressive) release. The median preoperative total flexion-extension arch (ROM) was 45° (20°–65°). The median postoperative total flexion-extension arch (ROM) was 110° (97.5°–125°). The modified MAYO elbow score improved from 60 to 85 points postoperatively. The postoperative flexion cut off value was 115° for an excellent or good postoperative modified MAYO elbow score.

Conclusion

Post-operative flexion cut off value was 115° and had a positive effect on the postoperative patient satisfaction. The cut off value for postoperative extension was 20° but it was not a significant variable on patient satisfaction as was the total increase in ROM.

Level of significance

Level IV Therapeutic Study.

Restoration of Elbow Flexion

Active elbow flexion is required to position the hand in space, and loss of this function is debilitating. Nerve transfers or nerve grafts to restore elbow flexion may be options when the target muscle is viable, but in delayed reconstruction when the biceps and brachialis are atrophied or damaged, muscle transfer options should be considered. Muscle transfer options are discussed with attention to the advantages and disadvantages of each transfer option.

Isolated Muscle Transfer to Restore Elbow Flexion in Children with Arthrogryposis

BACKGROUND

Arthrogryposis is the general term given to conditions characterized by multiple joint contractures resulting in substantial disability most frequently involving a child. Early muscle transfer reconstructive surgery reliably restores elbow flexion. In the present study, we aimed to determine which preoperative condition is best able to restore elbow flexion in patients with arthrogryposis.

METHODS

We retrospectively reviewed five children (seven cases) who underwent elbow flexor reconstruction (Steindler flexorplasty, four cases; latissimus dorsi transfer, two cases; pectoralis major transfer, one case). Upper-extremity function was assessed on the basis of range of elbow extension and flexion and elbow flexor muscle power pre- and postoperatively.

RESULTS

The mean postoperative active flexion and extension range of motion was 82.1° (60° to 100°) and -15.0° (-40° to 0°) respectively. Mean postoperative elbow flexor muscle power was graded as a 3.4 (2 to 4) as measured with the Medical Research Council (MRC) scale. The preoperative passive elbow flexion angle was found to correlate with postoperative muscle power (MRC) (r = 0.830, p = 0.042) and postoperative active elbow flexion angle (r = 0.902, p = 0.027). Age at operation was not found to correlate with postoperative muscle power (MRC) (r = -0.063, p = 0.878) or active elbow flexion angle (r = -0.134, p = 0.743).

CONCLUSIONS

We found a positive correlation between preoperative passive elbow flexion/range of elbow motion and postoperative results including active range of motion and transferred muscle power. Diminished preoperative elbow flexion appeared to correlate with having a poor outcome. The present results suggest that choosing another muscle, such as the gracilis, may be beneficial for muscle transfer in more severe cases of arthrogryposis.

Biomechanical differences of the anterior and posterior bands of the ulnar collateral ligament of the elbow

PURPOSE

The main purpose of this study was to examine the functional characteristics of the anterior and posterior bands of the anterior bundle of the ulnar collateral ligament (UCL).

METHODS

Six cadaveric elbows were tested using a digital tracking system to measure the strain in the anterior band and posterior band of the anterior bundle of the UCL throughout a flexion/extension arc. The specimens were then placed in an Instron materials testing machine and loaded to failure to determine yield load and ultimate load of the UCL.

RESULTS

The posterior band showed a linear increase in strain with increasing degrees of elbow flexion while the anterior band showed minimal change in strain throughout. The bands showed similar strain at yield load and ultimate load, demonstrating similar intrinsic properties.

CONCLUSION

The anterior band of the anterior bundle of the UCL shows an isometric strain pattern through elbow range of motion, while the posterior band shows an increasing strain pattern in higher degrees of elbow flexion. Both bands show similar strain in a load to failure model, indicating insertion point, not intrinsic differences, of the bands determine the function of the anterior bundle of the UCL. This demonstrates a biomechanical rationale for UCL reconstructions using single point anatomical insertion points.

Nerve Transfers to Restore Elbow Function

The purpose of this article is to provide an overview of the various nerve transfer options for restoration of elbow function. This article describes nerve transfer strategies for elbow flexion and extension including the indications, limitations, and expected outcomes based on current literature.

Comparison of upper body strength gains between men and women after 10 weeks of resistance training

Resistance training (RT) offers benefits to both men and women. However, the studies about the differences between men and women in response to an RT program are not conclusive and few data are available about upper body strength response. The aim of this study was to compare elbow flexor strength gains in men and women after 10 weeks of RT. Forty-four college-aged men (22.63 ± 2.34 years) and forty-seven college-aged women (21.62 ± 2.96 years) participated in the study. The RT program was performed two days a week for 10 weeks. Before and after the training period, peak torque (PT) of the elbow flexors was measured with an isokinetic dynamometer. PT values were higher in men in comparison to women in pre- and post-tests (p < 0.01). Both males and females significantly increased elbow flexor strength (p < 0.05); however, strength changes did not differ between genders after 10 weeks of RT program (11.61 and 11.76% for men and women, respectively; p > 0.05). Effect sizes were 0.57 and 0.56 for men and women, respectively. In conclusion, the present study suggests that men and women have a similar upper body strength response to RT.

Comparative study of phrenic and intercostal nerve transfers for elbow flexion after global brachial plexus injury

BACKGROUND

Global brachial plexus injuries (BPIs) are devastating events frequently resulting in severe functional impairment. The widely used nerve transfer sources for elbow flexion in patients with global BPIs include intercostal and phrenic nerves.

OBJECTIVE

The aim of this study was to compare phrenic and intercostal nerve transfers for elbow flexion after global BPI.

METHODS

A retrospective review of 33 patients treated with phrenic and intercostal nerve transfer for elbow flexion in posttraumatic global root avulsion BPI was carried out. In the phrenic nerve transfer group, the phrenic nerve was transferred to the anterolateral bundle of the anterior division of the upper trunk (23 patients); in the intercostal nerve transfer group, three intercostal nerves were coapted to the anterolateral bundles of the musculocutaneous nerve. The British Medical Research Council (MRC) grading system, angle of elbow flexion, and electromyography (EMG) were used to evaluate the recovery of elbow flexion at least 3 years postoperatively.

RESULTS

The efficiency of motor function in the phrenic nerve transfer group was 83%, while it was 70% in the intercostal nerve transfer group. The two groups were not statistically different in terms of the MRC grade (p=0.646) and EMG results (p=0.646). The outstanding rates of angle of elbow flexion were 48% and 40% in the phrenic and intercostal nerve transfer groups, respectively. There was no significant difference of outstanding rates in the angle of elbow flexion between the two groups.

CONCLUSION

Phrenic nerve transfer had a higher proportion of good prognosis for elbow flexion than intercostal nerve transfer, but the effective and outstanding rate had no significant difference for biceps reinnervation between the two groups according to MRC grading, angle of elbow flexion, and EMG.

[Recovery of elbow flexion in post-traumatic C5-C6 and C5-C6-C7 palsy: retrospective dual-center study comparing single and double nerve transfer]

Twenty-nine patients underwent single (n=15) or double (n=14) nerve transfer for post-traumatic elbow flexion palsy. Patients averaged 30.2 years, with a mean preoperative delay of six months and postoperative follow-up of 34.2 months. Sixty per cent of the single transfer patients recovered to BMRC grade M4 after an average of follow-up of 13.2 months. Eighty-five percent of double nerve transfer patients reached grade M4 after an average follow-up of 11 months. There were no significant differences between groups. Clinical assessment revealed motor or sensory deficit in seven cases, which did not cause any impairment. Patients with a C5-C6 injury had shorter recovery times and better strength in comparison with those with C5-C6-C7 injury. By restoring shoulder function, elbow flexion will be indirectly improved. This improvement can be partially attributed to the base of the arm being more stable.

Comparative study of phrenic nerve transfers with and without nerve graft for elbow flexion after global brachial plexus injury

BACKGROUND

Nerve transfer is a valuable surgical technique in peripheral nerve reconstruction, especially in brachial plexus injuries. Phrenic nerve transfer for elbow flexion was proved to be one of the optimal procedures in the treatment of brachial plexus injuries in the study of Gu et al.

OBJECTIVE

The aim of this study was to compare phrenic nerve transfers with and without nerve graft for elbow flexion after brachial plexus injury.

METHODS

A retrospective review of 33 patients treated with phrenic nerve transfer for elbow flexion in posttraumatic global root avulsion brachial plexus injury was carried out. All the 33 patients were confirmed to have global root avulsion brachial plexus injury by preoperative and intraoperative electromyography (EMG), physical examination and especially by intraoperative exploration. There were two types of phrenic nerve transfers: type1 - the phrenic nerve to anterolateral bundle of anterior division of upper trunk (14 patients); type 2 - the phrenic nerve via nerve graft to anterolateral bundle of musculocutaneous nerve (19 patients). Motor function and EMG evaluation were performed at least 3 years after surgery.

RESULTS

The efficiency of motor function in type 1 was 86%, while it was 84% in type 2. The two groups were not statistically different in terms of Medical Research Council (MRC) grade (p=1.000) and EMG results (p=1.000). There were seven patients with more than 4 month's delay of surgery, among whom only three patients regained biceps power to M3 strength or above (43%). A total of 26 patients had reconstruction done within 4 months, among whom 25 patients recovered to M3 strength or above (96%). There was a statistically significant difference of motor function between the delay of surgery within 4 months and more than 4 months (p=0.008).

CONCLUSION

Phrenic nerve transfers with and without nerve graft for elbow flexion after brachial plexus injury had no significant difference for biceps reinnervation according to MRC grading and EMG. A delay of the surgery after the 4 months might imply a bad prognosis for the recovery of the function.

Bipolar latissimus transfer for restoration of elbow flexion

BACKGROUND

Elbow flexion is often lacking in patients with brachial plexus palsy or anterior arm trauma. Restoring elbow flexion helps position the functioning hand for activity and nonfunctioning hand for stabilization. Bipolar latissimus transfer is one method of improving elbow flexion.

METHODS

A clinical case of bipolar latissimus transfer is presented. Additionally, results of a literature search are incorporated.

RESULTS

Bipolar latissimus can effectively improve elbow function, however residual deficits are to be expected. Additional transfers include unipolar latissimus, triceps, sternocleidomastoid, and pectoralis. Other methods include primary nerve transfer, Steindler flexorplasty, free muscle transfer, and elbow fusion.

CONCLUSION

Elbow flexion can be improved through various techniques. Each individual's clinical picture should be examined by an experienced clinician when choosing which technique to apply.