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DOI: 10.1055/s-0042-1755612
Long-Term Outcome of 118 Acute Total Brachial Plexus Injury Patients Using Free Vascularized Ulnar Nerve Graft to Innervate the Median Nerve
Funding This study was funded by Chang Gung Memorial Hospital under the grant number CORPG3H0111.![](https://www.thieme-connect.de/media/jrm/202304/lookinside/thumbnails/10-1055-s-0042-1755612_220082-1.jpg)
Abstract
Background The restoration of finger movement in total brachial plexus injuries (BPIs) is an ultimate challenge. Pedicled vascularized ulnar nerve graft (VUNG) connecting a proximal root to distal target nerves has shown unpredictable outcomes. We modified this technique by harvesting VUNG as a free flap to reinnervate median nerve (MN). We analyzed the long-term outcomes of these methods.
Methods From years 1998 to 2015, 118 acute total brachial plexus patients received free VUNG to innervate the MN. Patients were followed up at least 5 years after the initial surgery. Donor nerves included the ipsilateral C5 root (25 patients) or contralateral C7 root (CC7 = 93 patients). Recovery of finger and elbow flexion was evaluated with the modified Medical Research Council system. Michigan Hand Score and Quick-DASH were used to represent the patient-reported outcomes.
Results For finger flexion, ipsilateral C5 transfer to MN alone yielded similar outcomes to MN + MCN (musculocutaneous nerve), while CC7 had significantly better finger flexion when coapted to MN alone than to MN + MCN. Approximately 75% patients were able to achieve finger flexion with nerve transfer alone. For elbow flexion, best outcome was seen in the ipsilateral C5 to MCN and MN.
Conclusion In acute total BPI, the priority is to identify the ipsilateral C5 root to innervate MN, with concomitant innervation of MCN to establish the best outcomes for finger and elbow flexion. CC7 is more reliable when used to innervate one target (MN).
Level of evidence: III.
Keywords
free vascularized ulnar nerve graft - total brachial plexus injury - contralateral C7 - ipsilateral C5Ethical Approval
Ethical approval to report these cases was obtained from the Institutional Review Board in Chang Gung Memorial Hospital under the given certification number “202001873B0.”
Informed Consent
Written informed consent was obtained from the patient(s) for their anonymized information to be published in this article.
Author Contributions
J.A.L. wrote the first draft of the manuscript. J.A.L. and A.H.S. were involved in data collection and data analysis. J.C.L. and D.C.C. were involved with the study design. D.C.C., T.N.C., and J.C.L. were the operating surgeons for the brachial plexus surgeries, and helped revised the final manuscript. All authors reviewed and approved the final version of the manuscript.
Publication History
Received: 14 March 2022
Accepted: 23 June 2022
Article published online:
03 October 2022
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References
- 1 Chuang DC. Management of traumatic brachial plexus injuries in adults. Hand Clin 1999; 15 (04) 737-755 , x
- 2 Chuang DCC. Brachial Plexus Injuries: Adult and Pediatric. Vol 6. 4 ed. London: Saunders Elsevier; 2017
- 3 Gu YD, Zhang GM, Chen DS, Yan JG, Cheng XM, Chen L. Seventh cervical nerve root transfer from the contralateral healthy side for treatment of brachial plexus root avulsion. J Hand Surg [Br] 1992; 17 (05) 518-521
- 4 Wang SF, Li PC, Xue YH, Yiu HW, Li YC, Wang HH. Contralateral C7 nerve transfer with direct coaptation to restore lower trunk function after traumatic brachial plexus avulsion. J Bone Joint Surg Am 2013; 95 (09) 821-827 , S1–S2
- 5 Doi K, Sakai K, Kuwata N, Ihara K, Kawai S. Double free-muscle transfer to restore prehension following complete brachial plexus avulsion. J Hand Surg Am 1995; 20 (03) 408-414
- 6 Bertelli JA, Ghizoni MF. Results of c5 root grafting to the musculocutaneous nerve using pedicled, vascularized ulnar nerve grafts. J Hand Surg Am 2009; 34 (10) 1821-1826
- 7 Songcharoen P, Wongtrakul S, Mahaisavariya B, Spinner RJ. Hemi-contralateral C7 transfer to median nerve in the treatment of root avulsion brachial plexus injury. J Hand Surg Am 2001; 26 (06) 1058-1064
- 8 Sammer DM, Kircher MF, Bishop AT, Spinner RJ, Shin AY. Hemi-contralateral C7 transfer in traumatic brachial plexus injuries: outcomes and complications. J Bone Joint Surg Am 2012; 94 (02) 131-137
- 9 Terzis JK. The Anatomy of Free Vascularized Nerve Grafts. Philadelphia, PA: W.B. Saunders; 1987
- 10 Chuang DC. Contralateral C7 transfer (CC-7T) for avulsion injury of the brachial plexus. Tech Hand Up Extrem Surg 1999; 3 (03) 185-192
- 11 Strange FG. An operation for nerve pedicle grafting; preliminary communication. Br J Surg 1947; 34 (136) 423-425
- 12 Millesi H. Surgical management of brachial plexus injuries. J Hand Surg Am 1977; 2 (05) 367-378
- 13 Gu YD, Zhang GM, Chen DS. et al. Cervical nerve root transfer from contralateral normal side for treatment of brachial plexus root avulsions. Chin Med J (Engl) 1991; 104 (03) 208-211
- 14 Chuang DC, Wei FC, Noordhoff MS. Cross-chest C7 nerve grafting followed by free muscle transplantations for the treatment of total avulsed brachial plexus injuries: a preliminary report. Plast Reconstr Surg 1993; 92 (04) 717-725 , discussion 726–727
- 15 Narakas A. Neurotization or nerve transfer for brachial plexus lesions. Ann Chir Main 1982; 1 (02) 101-118
- 16 Chuang DC, Cheng SL, Wei FC, Wu CL, Ho YS. Clinical evaluation of C7 spinal nerve transection: 21 patients with at least 2 years' follow-up. Br J Plast Surg 1998; 51 (04) 285-290
- 17 Chung KC, Pillsbury MS, Walters MR, Hayward RA. Reliability and validity testing of the Michigan Hand Outcomes Questionnaire. J Hand Surg Am 1998; 23 (04) 575-587
- 18 Liang HW, Wang HK, Yao G, Horng YS, Hou SM. Psychometric evaluation of the Taiwan version of the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire. J Formos Med Assoc 2004; 103 (10) 773-779
- 19 Chuang DC, Yeh MC, Wei FC. Intercostal nerve transfer of the musculocutaneous nerve in avulsed brachial plexus injuries: evaluation of 66 patients. J Hand Surg Am 1992; 17 (05) 822-828
- 20 Chuang DC, Hernon C. Minimum 4-year follow-up on contralateral C7 nerve transfers for brachial plexus injuries. J Hand Surg Am 2012; 37 (02) 270-276
- 21 Boyes JH. Bunnell's surgery of the hand. Acad Med 1964; 39 (09) 871
- 22 Yeow Y-J, Yeow K-M, Su I-H. et al. Predicting healthy C5 spinal nerve stumps eligible for grafting with MRI, tinel test, and rhomboid electromyography: a retrospective study of 295 consecutive brachial plexus surgeries. Radiology 2021; 300 (01) 141-151
- 23 Chuang DC. Neurotization and free muscle transfer for brachial plexus avulsion injury. Hand Clin 2007; 23 (01) 91-104
- 24 Gao K, Lao J, Zhao X, Gu Y. Outcome of contralateral C7 transfer to two recipient nerves in 22 patients with the total brachial plexus avulsion injury. Microsurgery 2013; 33 (08) 605-611
- 25 Liu Y, Yang X, Gao K. et al. Outcome of contralateral C7 transfers to different recipient nerves after global brachial plexus avulsion. Brain Behav 2018; 8 (12) e01174
- 26 Brushart T. Clinical Nerve Repair and Grafting. New York, NY: Oxford University Press; 2011
- 27 Lu JCT, Chuang D. Steal Phenomenon in Nerve Transfer: An Experimental Rat Study. Hawaii: American Society of Reconstructive Microsurgery; 2017
- 28 Birch R. Brachial plexus injuries. J Bone Joint Surg Br 1996; 78 (06) 986-992