Elbow Flexion Restoration in Brachial Plexus Injuries: What is the Optimal Nerve Transfer?
Natalia Fullerton, MD1,2; Eliana Saltzman, BA1; Emil Stefan Vutescu, MD3; Joseph Nguyen, MPH1; Anum Lalani, MPH1; Steve K Lee, MD1; Scott W Wolfe, MD4; (1)Hospital for Special Surgery, New York, NY, (2)Division of Plastic Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, (3)Columbia, New York, NY, (4)Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, NY
Following upper brachial plexus injury (BPI), one of the primary goals of reconstruction is reinnervation of elbow flexion. Various reconstruction techniques have been well described, including ulnar fascicular nerve and/or median fascicular nerve transfer to the musculocutaneous motor branch to biceps brachii and/or brachialis. However, no current study analyzes the efficacy of one set of transfers over the other. This study aims to identify whether ulnar fascicular nerve transfer to brachialis and median fascicular nerve transfer to biceps brachii motor branch (group 1) is superior to ulnar fascicular nerve transfer to biceps brachii and median fascicular nerve transfer to brachialis motor branch (group 2) for improving elbow flexion strength after upper BPI.
Data for twelve patients who sustained an upper BPI and underwent nerve transfer for elbow flexion reconstruction between 2005 and 2013was analyzed. Physical examination and electromyographic data were captured for an average follow-up time of 35 months. Data was evaluated using the proportion of patients in each group to achieve a British Medical Research Score (BMRC) grade 4 and a generalized estimating equation model, Alpha level was set at p<0.05.
A comparison of demographics for the 5 patients in group 1 and the 7 patients in group 2 demonstrated no differences. At 6, 9, and 24 months followup, there was a greater proportion of patients who achieved a BMRC grade of 4 for elbow flexion in group 1 when compared to group 2. Of note, elbow flexion strength equalized at 36 months between the 2 groups. Additionally, group 1 demonstrated an increased motor unit recruitment of the brachialis EMG at 12, 24 and 36 months (3 vs 2, p=0.011; 4.5 vs 2.5, p= 0.032; 5 vs 3, p=0.032, respectively).
The ulnar fascicular nerve transfer to brachialis and median fascicular nerve transfer to biceps brachii motor branch appear to have advantages in transfer technique, demonstrating an earlier BMRC grade 4 elbow flexion strength and increased motor unit recruitment on EMG.
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