A novel dual nerve transfer for restoration of shoulder function and sensory recovery of the hand, in patients with C567 traumatic root avulsion of the brachial plexus.

OBJECTIVE: The objective of our study is to determine the anatomical viability in cadavers of a novel doble nerve transfer technique for simultaneous reanimation of shoulder abduction and sensory recovery of the hand, in patients with brachial plexus injuries sustaining a C5-C6-C7 roots avulsion. These new transfers should be complemented in the clinical setting with other classic nerve transfers, i.e.: (1) a spinal accessory to suprascapular for shoulder abduction and stability, (2) ulnar nerve fascicles to the biceps branches of the musculocutaneous for elbow flexion, and (3) intercostal to triceps branches for elbow extension. METHODS: The proposed surgical technique includes (1) transferring motor fascicles of the median nerve (MNF), as donors to the axillary nerve (AN), and (2) the whole medial antebrachial cutaneous nerve (MACN) to the lateral contribution (sensory) of the median nerve (LCMN), both without the use of interposed nerve grafts. These techniques were performed in eight cadaveric upper extremities. Analyzed variables were: donor and receptor nerves diameter, length and distance of donor and receptors nerves, and axonal count. RESULTS: The mean distance between the MNF and its point of coaptation to the AN was 19 mm. The average length of each one of the MNF, after distal dissection, was 46.5 mm. The average diameter of each fascicle of the median nerve at its coaptation point with the axillary nerve was 0.8 mm, while the average diameter of the latter was 3.9 mm. The average distance between the MACN and its point of coaptation to the LCMN, was 16.5 mm. The average diameter of the MACN and the LCMN at their point of coaptation, were 2.7 mm and 3.5 mm, respectively. CONCLUSION: These nerve transfers are anatomically viable and could be a complement for other currently used techniques that can be employed in severely injured C567 brachial plexus patients.

Defining the relative impact of muscle versus Schwann cell denervation on functional recovery after delayed nerve repair.

Functional recovery following peripheral nerve injury worsens with increasing durations of delay prior to repair. From the time of injury until re-innervation occurs, denervated muscle undergoes progressive atrophy that limits the extent to which motor function can be restored. Similarly, Schwann cells (SC) in the distal nerve lacking axonal interaction progressively lose their capacity to proliferate and support regenerating axons. The relative contributions of these processes to diminished functional recovery is unclear. We developed a novel rat model to isolate the effects of SC vs. muscle denervation on functional recovery. Four different groups underwent the following interventions for 12 weeks prior to nerve transfer: 1) muscle denervation; 2) SC denervation; 3) muscle + SC denervation (negative control); 4) no denervation (positive control). Functional recovery was measured weekly using the stimulated grip strength testing (SGST). Animals were sacrificed 13 weeks post nerve transfer. Retrograde labeling was used to assess the number of motor neurons that regenerated their axons. Immunofluorescence was performed to evaluate target muscle re-innervation and atrophy, and to assess the phenotype of the SC within the distal nerve segment. Functional recovery in the muscle denervation and SC denervation groups mirrored that of the negative and positive control groups, respectively. The SC denervation group achieved better functional recovery, with a greater number of reinnervated motor endplates and less muscle atrophy, than the muscle denervation group. Retrograde labeling suggested a higher number of neurons contributing to muscle reinnervation in the muscle denervation group as compared to SC denervation (p > 0.05). The distal nerve segment in the muscle denervation group had a greater proportion of SCs expressing the proliferation marker Ki67 as compared to the SC denervation group (p < 0.05). Conversely, the SC denervation group had a higher percentage of senescent SCs expressing p16 as compared to the muscle denervation group (p < 0.05). The deleterious effects of muscle denervation are more consequential than the effects of SC denervation on functional recovery. The effects of 12 weeks of SC denervation on functional outcome were negligible. Future studies are needed to determine whether longer periods of SC denervation negatively impact functional recovery.

Contralateral C7 transfer to axillary and median nerves in rats with total brachial plexus avulsion.

BACKGROUND: Contralateral cervical 7 nerve (cC7) was used to repair two recipient nerves simultaneously for patients with total brachial plexus avulsion (TBPA). OBJECTIVE: To evaluate the effect of cC7 transfer to axillary and median nerves in rats with TBPA. METHODS: Eighty S-D rats were divided into 4 groups randomly on average. Group A: cC7-median nerve, Group B: cC7-axillary nerve, Group C: cC7-median and axillary nerves, Group D: TBPA without repair. The evaluation tools included behavioral tests, electromyogram (EMG), measurement of cross-sectional area of muscle fiber, nerve fiber count and gene expression assay. RESULTS: The effective rates of EMG were 90 and 70% in Flexor Carpi Radialis (FCR) in Group A and C, while 70 and 60% in deltoid (DEL) in Group B and C, respectively. In behavioral test, the differences of effective rates between groups were not significant. The mean cross-sectional area of FCR in Group A or C was significantly larger than that in Group D. Either the number of median or axillary nerve fibers in Group A, B or C was statistically more than that in Group D. No matter for FCR or DEL, there were no significant differences in the ratios of relative expression of Muscle Atrophy F-box(MAFBOX)and Muscle RING Finger 1(MURF1)among these groups. CONCLUSION: Compared with cC7 transfer to median nerve, cC7 transfer to both median and axillary nerves did not affect median nerve recovery. The deltoid muscle also could be restored. The recovery proportion of axillary nerve was less than that of median nerve.

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.

Case Report: Double Oberlin Nerve Transfer to Restore Elbow Flexion Following C5-C6 Avulsion Injury.

BACKGROUND AND IMPORTANCE: The use of nerve transfers to restore nerve function following traumatic avulsion injuries has been described, though there is still a paucity in the literature documenting technique and long-term outcomes for these procedures. The double Oberlin nerve transfer involves transferring fascicles from the median and ulnar nerves to the musculocutaneous nerve to restore elbow flexion in patients with a C5-C6 avulsion injury. The purpose of this case report is to present our indications and technique for a double Oberlin transfer in addition to exhibiting video footage at follow-up time points documenting the incremental improvement in elbow flexion following the injury. CLINICAL PRESENTATION: The patient is a 25-yr old, left-hand dominant male who presented 5 mo following a motor vehicle accident. He had 0/5 biceps muscle strength on the left with a computed tomography myelogram that demonstrated pseudomeningoceles from C2-C3 to C7-T1 with root avulsions of C5 and C6. He was subsequently indicated for a double Oberlin nerve transfer to restore elbow flexion. CONCLUSION: In this case report, we present our technique and outcomes for a double Oberlin transfer with restoration of elbow flexion at 1-yr follow-up for a patient with traumatic brachial plexus injury. We believe that the double Oberlin transfer serves as a safe and effective method to restore elbow flexion in this patient population.

Distal nerve transfer from the median nerve lumbrical fibers to the distal ulnar nerve motor branches in the palm: An anatomical cadaveric study.

BACKGROUND: The aim of the current study is to investigate the first and second lumbrical nerves as potential fibers donors to the deep motor branch of the ulnar nerve to avoid intrinsic atrophy in high ulnar nerve injuries. METHODS: Sixteen fresh frozen cadaveric hands were dissected, the radial lumbrical nerves accessed, and a coaptation, either in reverse end-to-side or in double end-to-side through a bridge nerve graft, was created to the deep motor branch of ulnar nerve. Semithin sections were taken from samples of donor and recipient nerves for qualitative (nerve architecture) and quantitative studies (fiber count and donor/recipient ratio). RESULTS: The first lumbrical showed a robust trunk and a superior axon density (9,126.50 ± 2,923.41 axons/mm2 ) to the ulnar motor branch (7,506.50 ± 1,137.50 axons/mm2 distal to the opponens tunnel and 7,947.75 ± 1,741.24 axons/mm2 before its terminal branching); the ulnar motor branch showed a higher axon number (2,633.51 ± 410.00 distal to the opponens tunnel and 2,345.75 ± 2,101.56 before its terminal branching) than the first lumbrical (1,410.56 ± 823.89); section areas occupied by axons were higher in proximal (0.20 ± 0.16) and distal (0.26 ± 0.20) ulnar samples than the first lumbrical (0.17 ± 0.16). Donor/recipient ratio first lumbrical/deep motor branch of the ulnar nerve were 1:1.86 (distal to the opponens tunnel) and 1:1.67 (at its terminal branching); data about the second lumbrical were ruled out because of bias. CONCLUSIONS: A transfer from the first lumbrical nerve to the deep motor branch of the ulnar nerve in palm is suitable to avoid intrinsic atrophy.

Restoration of Elbow Flexion in Traumatic Upper Brachial Plexus Palsy in Adults: Outcome with Intraplexus Distal Nerve Transfers in 78 Patients

Objective To present the functional outcomes of distal nerve transfer techniques for restoration of elbow flexion after upper brachial plexus injury. Method The files of 78 adult patients with C5, C6, C7 lesions were reviewed. The attempt to restore elbow flexion was made by intraplexus distal nerve transfers using a fascicle of the ulnar nerve (group A, n » 43), or a fascicle of themedian nerve (group B, n » 16) or a combination of both (group C, n » 19). The result of the treatment was defined based on the British Medical Research Council grading system: muscle strength < M3 was considered a poor result. Results The global incidence of good/excellent results with these nerve transfers was 80.7%, and for different surgical techniques (groups A, B, C), it was 86%, 56.2% and 100% respectively. Patients submitted to ulnar nerve transfer or double transfer (ulnar þ median fascicles transfer) had a better outcome than those submitted to median nerve transfer alone (p < 0.05). There was no significant difference between the outcome of ulnar transfer and double transfer. Conclusion In cases of traumatic injury of the upper brachial plexus, good and excelent results in the restoration of elbow flexion can be obtained using distal nerve transfers.

Future Perspectives in the Management of Nerve Injuries.

AIM: The author presents a solicited "white paper" outlining her perspective on the role of nerve transfers in the management of nerve injuries. METHODS: PubMed/MEDLINE and EMBASE databases were evaluated to compare nerve graft and nerve transfer. An evaluation of the scientific literature by review of index articles was also performed to compare the number of overall clinical publications of nerve repair, nerve graft, and nerve transfer. Finally, a survey regarding the prevalence of nerve transfer surgery was administrated to the World Society of Reconstructive Microsurgery (WSRM) results. RESULTS: Both nerve graft and transfer can generate functional results and the relative success of graft versus transfer depended on the function to be restored and the specific transfers used. Beginning in the early 1990s, there has been a rapid increase from baseline of nerve transfer publications such that clinical nerve transfer publication now exceeds those of nerve repair or nerve graft. Sixty-two responses were received from WSRM membership. These surgeons reported their frequency of "usually or always using nerve transfers for repairing brachial plexus injuries as 68%, radial nerves as 27%, median as 25%, and ulnar as 33%. They reported using nerve transfers" sometimes for brachial plexus 18%, radial nerve 30%, median nerve 34%, ulnar nerve 35%. CONCLUSION: Taken together this evidence suggests that nerve transfers do offer an alternative technique along with tendon transfers, nerve repair, and nerve grafts.

The First Experience of Triple Nerve Transfer in Proximal Radial Nerve Palsy.

BACKGROUND: Injury to distal portion of posterior cord of brachial plexus leads to palsy of radial and axillary nerves. Symptoms are usually motor deficits of the deltoid muscle; triceps brachii muscle; and extensor muscles of the wrist, thumb, and fingers. Tendon transfers, nerve grafts, and nerve transfers are options for surgical treatment of proximal radial nerve palsy to restore some motor functions. Tendon transfer is painful, requires a long immobilization, and decreases donor muscle strength; nevertheless, nerve transfer produces promising outcomes. We present a patient with proximal radial nerve palsy following a blunt injury undergoing triple nerve transfer. CASE DESCRIPTION: The patient was involved in a motorcycle accident with complete palsy of the radial and axillary nerves. After 6 months, on admission, he showed spontaneous recovery of axillary nerve palsy, but radial nerve palsy remained. We performed triple nerve transfer, fascicle of ulnar nerve to long head of the triceps branch of radial nerve, flexor digitorum superficialis branch of median nerve to extensor carpi radialis brevis branch of radial nerve, and flexor carpi radialis branch of median nerve to posterior interosseous nerve, for restoration of elbow, wrist, and finger extensions, respectively. CONCLUSIONS: Our experience confirmed functional elbow, wrist, and finger extensions in the patient. Triple nerve transfer restores functions of the upper limb in patients with debilitating radial nerve palsy after blunt injuries.

Distal nerve transfer versus supraclavicular nerve grafting: comparison of elbow flexion outcome in neonatal brachial plexus palsy with C5-C7 involvement.

PURPOSE: Ulnar and median nerve transfers to arm muscles have been used to recover elbow flexion in infants with neonatal brachial plexus palsy, but there is no direct outcome comparison with the classical supraclavicular nerve grafting approach. METHODS: We retrospectively analyzed patients with C5-C7 neonatal brachial plexus palsy submitted to nerve surgery and recorded elbow flexion recovery using the active movement scale (0-7) at 12 and 24 months after surgery. We compared 13 patients submitted to supraclavicular nerve grafting with 21 patients submitted to distal ulnar or median nerve transfer to biceps motor branch. We considered elbow flexion scores of 6 or 7 as good results. RESULTS: The mean elbow flexion score and the proportion of good results were better using distal nerve transfers than supraclavicular grafting at 12 months (p < 0.01), but not at 24 months. Two patients with failed supraclavicular nerve grafting at 12 months showed good elbow flexion recovery after ulnar nerve transfers. CONCLUSION: Distal nerve transfers provided faster elbow flexion recovery than supraclavicular nerve grafting, but there was no significant difference in the outcome after 24 months of surgery. Patients with failed supraclavicular grafting operated early can still benefit from late distal nerve transfers. Supraclavicular nerve grafting should remain as the first line surgical treatment for children with neonatal brachial plexus palsy.

Nerve Transfer Versus Nerve Graft for Reconstruction of High Ulnar Nerve Injuries.

PURPOSE: To assess the efficacy of nerve transfer versus nerve grafting in restoring motor and sensory hand function in patients with complete, isolated high ulnar nerve injuries. METHODS: A retrospective chart review was performed, at a minimum 2 years of follow-up, of 52 patients suffering complete, isolated high ulnar nerve injury between January 2006 and June 2013 in one specialized hand surgery unit. Twenty-four patients underwent motor and sensory nerve transfers (NT group). Twenty-eight patients underwent sural nerve grafting (NG group). Motor recovery, return of sensibility and complications were examined as outcome measures. The Medical Research Council scale was applied to evaluate sensory and motor recovery. Grip and pinch strengths of the hand were measured. RESULTS: Twenty of 24 patients (83.33%) in the NT group regained M3 grade or greater for the adductor pollicis, the abductor digiti minimi, and the medial 2 lumbricals and interossei, compared with only 16 of 28 patients (57.14%) in the NG group. Means for percentage recovery of grip strengths compared with the other healthy hand were significantly higher for the NT group than the NG group. Sensory recovery of S3 or greater was achieved in more than half of each group with no significant difference between groups. CONCLUSIONS: Nerve transfer is favored over nerve grafting in managing high ulnar nerve injuries because of better improvement of motor power and better restoration of grip functions of the hand. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Analyzing cost-effectiveness of ulnar and median nerve transfers to regain forearm flexion.

OBJECTIVE Peripheral nerve transfers to regain elbow flexion via the ulnar nerve (Oberlin nerve transfer) and median nerves are surgical options that benefit patients. Prior studies have assessed the comparative effectiveness of ulnar and median nerve transfers for upper trunk brachial plexus injury, yet no study has examined the cost-effectiveness of this surgery to improve quality-adjusted life years (QALYs). The authors present a cost-effectiveness model of the Oberlin nerve transfer and median nerve transfer to restore elbow flexion in the adult population with upper brachial plexus injury. METHODS Using a Markov model, the authors simulated ulnar and median nerve transfers and conservative measures in terms of neurological recovery and improvements in quality of life (QOL) for patients with upper brachial plexus injury. Transition probabilities were collected from previous studies that assessed the surgical efficacy of ulnar and median nerve transfers, complication rates associated with comparable surgical interventions, and the natural history of conservative measures. Incremental cost-effectiveness ratios (ICERs), defined as cost in dollars per QALY, were calculated. Incremental cost-effectiveness ratios less than $50,000/QALY were considered cost-effective. One-way and 2-way sensitivity analyses were used to assess parameter uncertainty. Probabilistic sampling was used to assess ranges of outcomes across 100,000 trials. RESULTS The authors' base-case model demonstrated that ulnar and median nerve transfers, with an estimated cost of $5066.19, improved effectiveness by 0.79 QALY over a lifetime compared with conservative management. Without modeling the indirect cost due to loss of income over lifetime associated with elbow function loss, surgical treatment had an ICER of $6453.41/QALY gained. Factoring in the loss of income as indirect cost, surgical treatment had an ICER of -$96,755.42/QALY gained, demonstrating an overall lifetime cost savings due to increased probability of returning to work. One-way sensitivity analysis demonstrated that the model was most sensitive to assumptions about cost of surgery, probability of good surgical outcome, and spontaneous recovery of neurological function with conservative treatment. Two-way sensitivity analysis demonstrated that surgical intervention was cost-effective with an ICER of $18,828.06/QALY even with the authors' most conservative parameters with surgical costs at $50,000 and probability of success of 50% when considering the potential income recovered through returning to work. Probabilistic sampling demonstrated that surgical intervention was cost-effective in 76% of cases at a willingness-to-pay threshold of $50,000/QALY gained. CONCLUSIONS The authors' model demonstrates that ulnar and median nerve transfers for upper brachial plexus injury improves QALY in a cost-effective manner.

Nerve grafts bridging the thenar branch of the median nerve to the ulnar nerve to enhance nerve recovery: a report of three cases.

We report a nerve graft procedure bridging the thenar branch of the median nerve to the ulnar nerve in three patients with ulnar nerve transection and defect at the mid-forearm. Ulnar nerve function was evaluated with electroneurography and quantitative sensory-motor testing before and after surgery, and at a 6-year follow-up. After surgery all patients showed electroneurographic evidence of median nerve innervation of the intrinsic muscles normally innervated by the ulnar nerve. The average strength was Grade 4 in the intrinsic muscles originally supplied by the ulnar nerve at the final follow-up. Our results indicate that the thenar branch of the median nerve may support ulnar nerve regeneration and so help prevent intrinsic muscles from irreversible atrophy, but our report is preliminary. This procedure should be validated by future clinical data, especially those with complete ulnar nerve transection at or above the elbow. LEVEL OF EVIDENCE: IV.

[METABOLIC CHANGES OF SKELETAL MUSCLES IN TRAUMATIC INJURY OF PERIPHERAL NERVE AND AUTOPLASTY IN EXPERIMENT].

The changes in metabolism of the amine acids, enzymes, electrolytes, fat acids (FA) in skeletal muscles of anterior and posterior extremities of rats in significant defects of peripheral nerve and its autoplasty were studied in experimental investigation. Metabolic changes in skeletal muscles are accompanied by significant intensity of proteolysis, lowering of the enzymes activity, energetic metabolism and in a less extent of the electrolytes balance and the FA metabolism. After autoplasty of big defects in the traumatized nerve the proteins' synthesis and restoration of activity of lactate dehydrogenase and creatine phosphokinase constitute the markers of muscular tissue restoration. Surgical restoration of the nerve is accompanied by a protein synthesis activation in muscles, but normalization of the enzyme systems indices, the lipids metabolism and the electrolytes balance was not observed. Metabolic dysbalance needs a certain pharmacological correction and prevention of a progress of pathological process in skeletal muscles.

Comparative study of the efficacy of decellularization treatment of allogenic and xenogeneic nerves as nerve conduits.

The objective of this study was to compare the results of allogenic and xenogeneic nerve grafts that were treated using decellularization. The sciatic nerves of Sprague-Dawley rats and the median nerves of Japanese white rabbits were decellularized with sodium dodecyl sulfate and Triton X-100 and examined with a scanning electron microscope and immunofluorescence staining. A bridge-graft into the sciatic nerve in Wistar rats was performed with the decellularized nerves (10 mm in length for short-term evaluation; 15 mm in length for long-term evaluation). As a control, an isograft was performed. The specimens were harvested at 4 weeks postoperatively and prepared for immunohistochemistry. Function, electrophysiological and histomorphological analyses were performed to evaluate nerve recovery at 24 weeks postoperatively. The 3-dimensional structure of the basal lamina column, on which the cell adhesion molecules were integrated, was preserved through the decellularization protocols. Limited ED1-positive macrophage invasion was observed, and abundant NF 160-positive axons, which were accompanied by S-100-positive Schwann cells, penetrated through the implanted nerves. The sciatic nerve function and electrophysiological and histomorphological analyses suggest that the xenogeneic nerve graft was statistically indistinguishable from the allogenic nerve graft but slightly inferior to the isograft in supporting the axonal regeneration and functional recovery.

Optimal axon counts for brachial plexus nerve transfers to restore elbow flexion.

BACKGROUND: Nerve transfer surgery has revolutionized the management of traumatic brachial plexus injures. However, the optimal size ratio of donor to recipient nerve has yet to be elucidated. The authors investigated the axon count ratios of ulnar and median fascicular transfers to restore elbow flexion. The authors hypothesized that donor nerve axon counts would be correlated with historical success of various nerve transfers used to restore elbow flexion. METHODS: Ten cadaveric specimens were used for a histomorphologic analysis of fascicular nerve transfers. Review of previously published axon counts and clinical results following transfer to the musculocutaneous nerve to restore elbow flexion was performed for the following donor nerves: medial pectoral, spinal accessory, intercostal, thoracodorsal, ulnar, and median fascicular. RESULTS: The average number of fascicles identified was 7.9 in the ulnar nerve and 8.0 in the median nerve. The mean fascicular axon count was 1318 for the ulnar nerve and 1860 for the median nerve. Mean recipient nerve axon count was 1826 for the musculocutaneous biceps branch and 1840 for the brachialis branch. A significant correlation between axon count and clinical results of transfers to restore elbow flexion was observed. Donor-to-recipient nerve axon count ratios below 0.7:1 were associated with a decreased likelihood of a successful outcome. CONCLUSIONS: In nerve transfers to restore elbow flexion, an appropriate size match between donor and recipient nerves appears to be a factor affecting clinical success. These data support a donor-to-recipient axon count ratio greater than 0.7:1 as the goal for brachial plexus nerve transfers to restore elbow flexion.

Median nerve fascicle transfer versus ulnar nerve fascicle transfer to the biceps motor branch in C5-C6 and C5-C7 brachial plexus injuries: nonrandomized prospective study of 23 consecutive patients.

The purpose of this study was to observe whether the results of the median nerve fascicle transfer to the biceps are equivalent to the classical ulnar nerve fascicle transfer, in terms of elbow flexion strength and donor nerve morbidity. Twenty-five consecutive patients were operated between March 2007 and July 2013. The patients were divided into two groups. In Group 1 (n = 8), the patients received an ulnar nerve fascicle transfer to the biceps motor branch. In Group 2 (n = 15), the patients received a median nerve fascicle transfer to the biceps motor branch. Two patients with follow-up less than six months were excluded. Both groups were similar regarding age (P = 0.070), interval of injury (P = 0.185), and follow-up period (P = 0.477). Elbow flexion against gravity was achieved in 7 of 8 (87.5%) patients in Group 1, versus 14 of 15 (93.3%) patients in Group 2 (P = 1.000). The level of injury (C5-C6 or C5-C7) did not affect anti-gravity elbow flexion recovery in both the groups (P = 1.000). It was concluded that the median nerve fascicle transfer to the biceps is as good as the ulnar nerve fascicle transfer, even in C5-C7 injuries.

Median nerve to biceps nerve transfer to restore elbow flexion in obstetric brachial plexus palsy.

Median nerve to biceps nerve transfer in the arm has been reported only in adults. The following paper reports on 10 cases of this transfer in obstetric brachial plexus palsy. All patients had upper palsy (ERb's or extended ERb's palsy) and presented to the author late (13-19 months of age) with poor or no recovery of elbow flexion. Following the nerve transfer, nine children recovered elbow flexion (a score of 6 in one child and a score of 7 in eight children by the Toronto scale). The remaining child did not recover elbow flexion.

Nerve transfers from branches to the flexor carpi radialis and pronator teres to reconstruct the radial nerve.

PURPOSE: To present our method and results for transferring branches of the median nerve for radial nerve palsy or posterior cord lesions. METHODS: We transferred 1 branch to the pronator teres to the branch to the extensor carpi radialis longus muscle and transferred the branch to the flexor carpi radialis to the posterior interosseous nerve. We carried out these transfers in 6 patients with radial nerve palsy or posterior cord lesions. We reviewed functional outcomes, Disabilities of the Arm, Shoulder and Hand scores, and Patient Evaluation Measure scores. RESULTS: After 20 months of follow-up evaluation, all patients had recovered extensor carpi radialis longus activity of M4. Activity of the extensor carpi ulnaris was M3 in 2 patients and M4 in 4 patients. Extensor pollicis longus activity was M4 in all 6 cases. Metacarpophalangeal extension was M4 in 4 cases and M3 in 2 cases. The mean Disabilities of the Arm, Shoulder, and Hand score was 26 (range, 7-43), and the mean Patient Evaluation Measure score was 34 (range, 24-53). CONCLUSIONS: Selective independent synergistic transfer of median nerve fascicles to the radial nerve branches has shown excellent results in the treatment of severe lesions of the radial nerve. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.