The Effectiveness of Different Nerve Transfers in the Restoration of Elbow Flexion in Adults Following Brachial Plexus Injury: A Systematic Review and Meta-Analysis.

ABSTRACT

PURPOSE: Restoration of elbow flexion is an important goal in the treatment of patients with traumatic brachial plexus injury. Numerous studies have described various nerve transfers for neurotization of the musculocutaneous nerve (or its motor branches); however, there is uncertainty over the effectiveness of each method. The aim of this study was to summarize the published evidence in adults with traumatic brachial plexus injury. METHODS: Medline, Embase, medRxiv, and bioRxiv were systematically searched from inception to April 12, 2021. We included studies that reported the outcomes of nerve transfers for the restoration of elbow flexion in adults. The primary outcome was elbow flexion of grade 4 (M4) or higher on the British Medical Research Council scale. Data were pooled using random-effects meta-analyses, and heterogeneity was explored using metaregression. Confidence intervals (CIs) were generated to the 95% level. RESULTS: We included 64 articles, which described 13 different nerve transfers. There were 1,335 adults, of whom 813 (61%) had partial and 522 (39%) had pan-plexus injuries. Overall, 75% of the patients with partial brachial plexus injuries achieved ≥M4 (CI, 69%-80%), and the choice of donor nerve was associated with clinically meaningful differences in the outcome. Of the patients with pan-plexus injuries, 45% achieved ≥M4 (CI, 31%-60%), and overall, each month delay from the time of injury to reconstruction reduced the probability of achieving ≥M4 by 7% (CI, 1%-12%). CONCLUSIONS: The choice of donor nerve affects the chance of attaining a British Medical Research Council score of ≥4 in upper-trunk reconstruction. For patients with pan-plexus injuries, delay in neurotization may be detrimental to motor outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.