Restoration of active pick-up function in patients with total brachial plexus avulsion injuries.

We designed multiple nerve transfers in one surgery to restore active pick-up function in patients with total brachial plexus avulsion injuries. Forty patients with total brachial plexus avulsion injuries first underwent multiple nerve transfers. These included transfer of the accessory nerve onto the suprascapular nerve to recover shoulder abduction, contralateral C7 nerve onto the lower trunk via the modified prespinal route with direct coaptation to restore lower trunk function and onto the musculocutaneous nerve with interpositional bridging by medial antebrachial cutaneous nerve arising from lower trunk to restore elbow flexion, and the phrenic nerve onto the posterior division of lower trunk to recover elbow and finger extension. At least three years after surgery, the patients who had a meaningful recovery were selected to perform secondary reconstruction to restore active pick-up function. Active pick-up function was successfully restored in ten patients after they underwent multiple nerve transfers combined with additional secondary functional hand reconstructions. LEVEL OF EVIDENCE: IV.

Direct Coaptation of the Phrenic Nerve With the Posterior Division of the Lower Trunk to Restore Finger and Elbow Extension Function in Patients With Total Brachial Plexus Injuries.

BACKGROUND: To overcome the mismatch in nerve sizes in phrenic nerve transfer to the radial nerve for elbow and finger extension reanimation for patients with total brachial plexus injuries (TBPI), a selective neurotization procedure was designed. OBJECTIVE: To investigate the long-term results of phrenic nerve transfer to the posterior division of the lower trunk with direct coaptation in restoring elbow and finger extension after TBPI. METHODS: Phrenic nerve was transferred to and directly coapted with the posterior division of the lower trunk in 27 patients with TBPI. Seven patients were <18 years old (adolescent group), and the remaining 20 patients ≥18 years (adult group). RESULTS: Postoperative mean follow-up period was 54 ± 9 months (range, 48-85 months). The motor function attained M3 or greater in 81.5% of patients for elbow extension and in 48% of patients for finger extension. The percentage of patients who regained M3 or greater muscle power of finger extension in the adolescent group and the adult group was 71.4%, and 40%, respectively. Meanwhile, 85.7% in the adolescent group and 80% in the adult group achieved M3 or greater muscle power of elbow extension. There were no significant differences between the 2 groups. The elbow extension and finger extension were synchronous contractions and did not become independent of respiratory effort. CONCLUSION: This procedure simultaneously and effectively restores the function of elbow and finger extension in patients after TBPI. However, the patients could not do elbow and finger extension separately.