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Bertelli JA, Tuffaha S, Sporer M, Seltser A, Cavalli E, Soldado F, Hill E. Distal nerve transfers for peripheral nerve injuries: indications and outcomes. J Hand Surg Eur Vol 2024; 49:721-733. [PMID: 38296247 DOI: 10.1177/17531934231226169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Distal nerve transfer is a refined surgical technique involving the redirection of healthy sacrificable nerves from one part of the body to reinstate function in another area afflicted by paralysis or injury. This approach is particularly valuable when the original nerves are extensively damaged and standard repair methods, such as direct suturing or grafting, may be insufficient. As the nerve coaptation is close to the recipient muscles or skin, distal nerve transfers reduce the time to reinnervation. The harvesting of nerves for transfer should usually result in minimal or no donor morbidity, as any anticipated loss of function is compensated for by adjacent muscles or overlapping cutaneous territory. Recent years have witnessed notable progress in nerve transfer procedures, markedly enhancing the outcomes of upper limb reconstruction for conditions encompassing peripheral nerve, brachial plexus and spinal cord injuries.
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Affiliation(s)
- Jayme A Bertelli
- Department of Surgery, Federal University of Santa Catarina, Florianópolis, Brazil
- Department of Orthopedics and Traumatology, Governador Celso Ramos Hospital, Florianópolis, Santa Catarina, Brazil
| | - Sami Tuffaha
- Department of Plastic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Matthias Sporer
- Department of Plastic Surgery, Academic Teaching Hospital Feldkirch, Austria
| | - Anna Seltser
- Department of Hand Surgery and Microsurgery Unit, Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Ramat Gan, Israel
| | - Erica Cavalli
- Department of Plastic and Hand Surgery, IRCCS San Gerardo dei Tintori, Monza (MB), Italy
| | - Francisco Soldado
- Hospital Infantil Universitario Vall d'Hebron, Barcelona, Spain
- Hospital Infantil Universitario HM Nens, Barcelona, Spain
| | - Elspeth Hill
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
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2
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Miller C, Cross J, Power DM, Jerosch-Herold C. Development of a core outcome set for traumatic brachial plexus injury. J Hand Surg Eur Vol 2024; 49:554-563. [PMID: 37987677 PMCID: PMC11044516 DOI: 10.1177/17531934231212973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 09/29/2023] [Accepted: 10/20/2023] [Indexed: 11/22/2023]
Abstract
The aim of the present study was to reach international consensus on the minimum set of outcomes to measure and report in adult traumatic brachial plexus injury care and research. This would facilitate comparison of outcomes from different centres and meta-analysis in research. A list of outcomes was developed from a systematic review (n = 54) and patient interviews (n = 12). The outcomes were rated in a three-round online Delphi survey completed by international surgeons, patients and therapists. Two online consensus meetings with patients and clinicians ratified the final core outcome set. A total of 72 people (20 surgeons, 21 patients, 31 therapists) from 19 countries completed all survey rounds. Thirty-eight people from nine countries attended separate patient (n = 13) and clinician consensus (n = 25) meetings. Outcomes were included if recommended by more than 85% of contributors. Pain, voluntary movement and carrying out a daily routine are the core outcome domains that should be assessed and reported when treating and researching adults with a traumatic brachial plexus injury. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Caroline Miller
- School of Health Sciences, University of East Anglia, Norwich, UK
- Therapy Services, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham Foundation Trust, Birmingham, UK
| | - Jane Cross
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Dominic M. Power
- The Peripheral Nerve Injury Service, University Hospitals Birmingham Foundation Trust, Birmingham, UK
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Turner L, Duraku LS, Ramadan S, van der Oest M, Miller C, George S, Chaudhry T, Power DM. Versatility of the double fascicular transfer in reconstruction of elbow flexion paralysis: Intermediate term follow-up and patient-related outcome measures. J Plast Reconstr Aesthet Surg 2023; 87:494-501. [PMID: 37926608 DOI: 10.1016/j.bjps.2023.10.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 09/11/2023] [Accepted: 10/07/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVES The use of fascicle transfers in the reconstruction of traumatic brachial plexus injury is well established, but limited evidence is available regarding their use in atraumatic elbow flexion paralysis. This retrospective case review aimed to verify whether median and ulnar fascicle transfers are similarly effective in atraumatic versus traumatic elbow flexion paralysis when measured using the British Medical Research Council (MRC) scale, Brachial plexus Assessment Tool (BrAT) and Stanmore Percentage of Normal Elbow Assessment (SPONEA) scores at long-term follow-up. METHODS All median and ulnar fascicle transfer cases performed at the Queen Elizabeth Hospital Birmingham between August 2007 and November 2018 were reviewed to compare the outcomes of transfers performed for traumatic and atraumatic indications. Data on patient demographics, mechanism and nature of injury, date of injury or symptom onset, date of operation, and other nerve transfers performed were collected. Outcome measures collected included the British MRC scale and two patient-reported outcome measures (PROMs), BrAT and SPONEA. RESULTS In total, 34 patients with 45 median and ulnar fascicle transfers were identified. This included 27 traumatic and seven atraumatic brachial plexus insults. Thirty patients had sufficient follow-up to be included in MRC analysis and 17 patients had sufficient follow-up to be included in PROM analysis. No significant differences were found between traumatic and atraumatic subgroups for median MRC, BrAT, or SPONEA scores. CONCLUSIONS This study suggests that nerve transfers might be considered effective reconstructive options in atraumatic pathology and provides validation for further research on the subject.
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Affiliation(s)
- Lewis Turner
- The HaPPeN Research Group, Institute of Translational Medicine, Birmingham, UK.
| | - Liron S Duraku
- The HaPPeN Research Group, Institute of Translational Medicine, Birmingham, UK; Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam, the Netherlands
| | - Sami Ramadan
- The HaPPeN Research Group, Institute of Translational Medicine, Birmingham, UK; The Brachial Plexus and Peripheral Nerve Injury Service, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Mark van der Oest
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - Caroline Miller
- The HaPPeN Research Group, Institute of Translational Medicine, Birmingham, UK; The Brachial Plexus and Peripheral Nerve Injury Service, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Samuel George
- The HaPPeN Research Group, Institute of Translational Medicine, Birmingham, UK; The Brachial Plexus and Peripheral Nerve Injury Service, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Tahseen Chaudhry
- The HaPPeN Research Group, Institute of Translational Medicine, Birmingham, UK; The Brachial Plexus and Peripheral Nerve Injury Service, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Dominic M Power
- The HaPPeN Research Group, Institute of Translational Medicine, Birmingham, UK; The Brachial Plexus and Peripheral Nerve Injury Service, University Hospitals Birmingham NHS Foundation Trust, UK
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Vernon Lee CY, Cochrane E, Chew M, Bains RD, Bourke G, Wade RG. The Effectiveness of Different Nerve Transfers in the Restoration of Elbow Flexion in Adults Following Brachial Plexus Injury: A Systematic Review and Meta-Analysis. J Hand Surg Am 2023; 48:236-244. [PMID: 36623945 DOI: 10.1016/j.jhsa.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 11/22/2022] [Accepted: 11/22/2022] [Indexed: 01/09/2023]
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.
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Affiliation(s)
- Chung Yan Vernon Lee
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - Elliott Cochrane
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - Misha Chew
- James Cook University Hospital, South Tees Hospitals NHS Trust, Middlesbrough, United Kingdom
| | - Robert D Bains
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - Gráinne Bourke
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, United Kingdom; Leeds Institute for Medical Research, University of Leeds, Leeds, United Kingdom
| | - Ryckie G Wade
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, United Kingdom; Leeds Institute for Medical Research, University of Leeds, Leeds, United Kingdom.
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Abstract
PURPOSE OF THE REVIEW Traumatic brachial plexus injuries (BPI) are devastating life-altering events, with pervasive detrimental effects on a patient's physical, psychosocial, mental, and financial well-being. This review provides an understanding of the clinical evaluation, surgical indications, and available reconstructive options to allow for the best possible functional outcomes for patients with BPI. RECENT FINDINGS The successful management of patients with BPI requires a multidisciplinary team approach including peripheral nerve surgeons, neurology, hand therapy, physical therapy, pain management, social work, and mental health. The initial diagnosis includes a detailed history, comprehensive physical examination, and critical review of imaging and electrodiagnostic studies. Surgical reconstruction depends on the timing of presentation and specific injury pattern. A full spectrum of techniques including neurolysis, nerve grafting, nerve transfers, free functional muscle transfers, tendon transfers, and joint arthrodesis are utilized. SUMMARY Despite the devastating nature of BPI injuries, comprehensive care within a multidisciplinary team, open and practical discussions with patients about realistic expectations, and thoughtful reconstructive planning can provide patients with meaningful recovery.
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Affiliation(s)
| | - Robert J Spinner
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Estrella EP, Montales TD. Nerve Transfers for Elbow Reconstruction in Upper and Extended Upper-Type Brachial Plexus Injuries: A Case Series. Oper Neurosurg (Hagerstown) 2022; 23:367-373. [PMID: 36227251 DOI: 10.1227/ons.0000000000000369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 05/14/2022] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Nerve transfers for elbow flexion in brachial plexus injuries have been used with increasing frequency because of the higher rate of success and acceptable morbidity. This is especially true in upper and extended upper-type brachial plexus injuries. OBJECTIVE To present the clinical outcomes of nerve transfers for elbow flexion in patients with upper and extended upper-type brachial plexus injuries. METHODS A retrospective cohort review was done on all patients with upper and extended upper-type brachial plexus injuries from 2006 to 2017, who underwent nerve transfers for the restoration of elbow flexion. Outcome variables include Filipino version of the disability of the arm, shoulder, and hand (FIL-DASH) score, elbow flexion strength and range of motion, and pain. All statistical significance was set at P < .05. RESULTS Fifty-six patients with nerve transfers to restore elbow flexion were included. There was a significant improvement in FIL-DASH scores in 28 patients after the nerve transfer procedure. Patients with C56 nerve root injuries and those with more than 2 years' follow-up have a higher percentage of regaining ≥M4 elbow flexion strength. Those with double nerve transfers had a higher percentage of ≥M4 elbow flexion strength, greater range of elbow flexion, and better FIL-DASH scores compared with single nerve transfers, but this did not reach statistical significance. CONCLUSION Nerve transfer procedures improve FIL-DASH scores in upper and upper-type brachial plexus injuries. After nerve transfer, stronger elbow flexion can be expected in patients with C56 injuries, and those with longer follow-up.
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Affiliation(s)
- Emmanuel P Estrella
- Institute of Clinical Epidemiology, ASTRO Study Group, National Institutes of Health, University of the Philippines Manila, Manila, Philippines
- Microsurgery Unit, Department of Orthopedics, University of the Philippines, Manila Philippine General Hospital, Manila, Philippines
| | - Tristram D Montales
- Microsurgery Unit, Department of Orthopedics, University of the Philippines, Manila Philippine General Hospital, Manila, Philippines
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Miller C, Jerosch-Herold C, Cross J. Brachial plexus injury: living with uncertainty. Disabil Rehabil 2022:1-7. [PMID: 35722825 DOI: 10.1080/09638288.2022.2080287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE A traumatic brachial plexus injury (BPI) has life-changing consequences for patients and their families. Despite advancements in treatments final outcome is unpredictable depending on factors including time to treatment, injury severity, neural regeneration, and available interventions. The final outcome may not be seen for up to four years. This study aimed to explore the impact of uncertainty on people with a traumatic BPI. METHODS Secondary qualitative analysis was conducted on data from a study exploring outcomes important to patients with a traumatic BPI. Data from semi-structured interviews with adult traumatic BPI patients (n = 13) were analyzed using reflexive thematic analysis. RESULTS Three major themes were identified in the qualitative data: (i) "I don't know what happened to me," focused on uncertainty in diagnosis. (ii) "I went to work one day… and then it all changed" centered around uncertainty in the future. (iii) Coping with uncertainty. CONCLUSION The results illustrate that people with a traumatic BPI face uncertainty regarding diagnosis, prognosis, and surrounding their roles in the future. Individuals respond to uncertainty in different ways and this needs to be understood by health care professionals. IMPLICATIONS FOR REHABILITATIONHealth professionals should consider uncertainty in all their contacts with people who have experienced a traumatic brachial plexus injury.People with a traumatic brachial plexus injury experience uncertainty in different ways therefore education and information given may be optimized if tailored to the individual rather than generic.Increasing awareness of the injury and its presentation in non-specialist acute care clinicians may accelerate diagnosis and reduce initial uncertainty.Acknowledging the presence of uncertainty is important during the shared decision-making in brachial plexus injuries.
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Affiliation(s)
- Caroline Miller
- School of Health Sciences, University of East Anglia, Norwich, UK.,Therapy Services, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham, UK
| | | | - Jane Cross
- School of Health Sciences, University of East Anglia, Norwich, UK
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8
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Kuncoro J, Deapsari F, Suroto H. Clinical and functional outcome after different surgical approaches for brachial plexus injuries: Cohort study. Ann Med Surg (Lond) 2022; 78:103714. [PMID: 35620046 PMCID: PMC9127148 DOI: 10.1016/j.amsu.2022.103714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/26/2022] [Accepted: 05/01/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Brachial plexus injury (BPI) can result in complete loss of neurological function and reduces the quality of life. Nerve transfer, nerve grafting, external neurolysis, and free functional muscle transfer are several management options that determine the eventual outcomes. Despite various methods of treatment, hardly any literature compares directly the result of these treatment options. This study aimed to analyze differences in clinical and functional outcomes after a reconstructive surgery. Methods A cohort retrospective study was conducted on traumatic brachial plexus injured patients aged from 17 to 65 years at one hospital in Surabaya, Indonesia, from January 2009 to December 2019. All patients were divided into 4 groups depending on the types of surgery. The clinical outcomes were measured using elbow and shoulder muscle strength, elbow and shoulder range of motion (ROM), and pain level (measured using Visual Analog Scale/VAS); the functional outcomes were measured using the overall quality of life using the DASH (disabilities of the arms, shoulder, and hand) score. Results This study included 316 patients comprising of 256 males with an average age of 27.53 ± 11.37, an average time from injury to surgery of 17.74 ± 35.82 months, and average follow-up duration of 59.89 ± 37.68 months. Most cases were caused by road traffic accidents (77.22%) and most were total arm type of BPI injury (70.7%). There was no significant difference in the mean values of study parameters except in VAS (p = 0.042) as nerve grafting resulted in less pain than external neurolysis (2.27 ± 1.03 vs. 3.68 ± 1.93, respectively; p = 0.017). Besides, nerve transfer procedure also resulted in less pain compared to external neurolysis (2.99 ± 1.84 vs. 3.68 ± 1.93, respectively; p = 0.036). Conclusion We found no significant difference between types of surgery and the postsurgical outcome. A wider multicenter study was required to define the clinical and functional outcomes clearly.
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Affiliation(s)
- Jimmy Kuncoro
- Department of Orthopaedic & Traumatology, Faculty of Medicine, Universitas Airlangga/Dr. Soetomo General Hospital, Surabaya, 60132, Indonesia
| | - Fani Deapsari
- Cell and Tissue Bank-Regenerative Medicine, Dr Soetomo General Academic Hospital/ Faculty of Medicine, Universitas Airlangga, Surabaya, 60132, Indonesia
| | - Heri Suroto
- Department of Orthopaedic & Traumatology, Faculty of Medicine, Universitas Airlangga/Dr. Soetomo General Hospital, Surabaya, 60132, Indonesia
- Cell and Tissue Bank-Regenerative Medicine, Dr Soetomo General Academic Hospital/ Faculty of Medicine, Universitas Airlangga, Surabaya, 60132, Indonesia
- Master of Hospital Management, Universitas Muhammadiyah Yogyakarta, 55183, Indonesia
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Zhang D, Varadharajan V, Bhardwaj P, Venkatramani H, Sabapathy SR. Considerations in the Selection of Donor Nerves for Nerve Transfer for Reanimation of Elbow and Shoulder in Traumatic Brachial Plexus Injuries. J Hand Surg Asian Pac Vol 2022; 27:10-21. [PMID: 35193462 DOI: 10.1142/s242483552230002x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The advent of nerve transfers has revolutionised the treatment of brachial plexus and peripheral nerve injuries of the upper extremity. Nerve transfers offer faster reinnervation of a denervated muscle by taking advantage of a donor nerve, branch or fascicle close to the recipient muscle. A number of considerations in respect of donor selection for nerve transfers underlie their success. In this review article, we discuss the principles of donor selection for nerve transfers, the different options available and our considerations in choosing a suitable transfer in reanimating the elbow and the shoulder. We feel this will help nerve surgeons navigate the controversies in the selection of donor nerves and make appropriate treatment decisions for their patients. Level of Evidence: V (Therapeutic).
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Affiliation(s)
- Dafang Zhang
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Vigneswaran Varadharajan
- Department of Plastic, Hand and Reconstructive Microsurgery, Ganga Medical Center and Hospitals Pvt. Ltd., Coimbatore, Tamil Nadu, India
| | - Praveen Bhardwaj
- Department of Plastic, Hand and Reconstructive Microsurgery, Ganga Medical Center and Hospitals Pvt. Ltd., Coimbatore, Tamil Nadu, India
| | - Hari Venkatramani
- Department of Plastic, Hand and Reconstructive Microsurgery, Ganga Medical Center and Hospitals Pvt. Ltd., Coimbatore, Tamil Nadu, India
| | - S Raja Sabapathy
- Department of Plastic, Hand and Reconstructive Microsurgery, Ganga Medical Center and Hospitals Pvt. Ltd., Coimbatore, Tamil Nadu, India
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Management of Adult Brachial Plexus Injuries. J Hand Surg Am 2021; 46:778-788. [PMID: 34158206 DOI: 10.1016/j.jhsa.2021.05.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 03/23/2021] [Accepted: 05/07/2021] [Indexed: 02/02/2023]
Abstract
Adult brachial plexus injuries result in profound functional deficits, debilitating pain, substantial mental health implications, and extensive economic impacts. Their initial evaluation includes a detailed physical examination, electrodiagnostic studies, advanced imaging, and patient counseling. A team-based approach, led by a peripheral nerve surgeon and including hand therapists, electrodiagnosticians, mental health experts, and pain-management specialists, is used to provide optimal longitudinal care during the lengthy recovery process. The options for the surgical management of brachial plexus injuries include exploration, neurolysis, nerve grafting, nerve transfer, free functional muscle transfer, tendon transfer, arthrodesis, and amputation. When treated within 6 months, the outcomes are favorable for the restoration of essential shoulder and elbow function. Free functional muscle transfer is a powerful tool to address elbow flexion and rudimentary grasp in both primary and delayed settings. The restoration of hand function remains a challenge for patients with complete brachial plexus injury. The purpose of this review is to summarize foundational concepts in diagnosis and management, discuss current trends and controversial topics, and address areas for future investigation.
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Robinson LR, Binhammer P. Role of electrodiagnosis in nerve transfers for focal neuropathies and brachial plexopathies. Muscle Nerve 2021; 65:137-146. [PMID: 34331718 DOI: 10.1002/mus.27376] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 07/13/2021] [Accepted: 07/18/2021] [Indexed: 12/16/2022]
Abstract
Over the past 2 decades, the surgical treatment of brachial plexus and peripheral nerve injuries has advanced considerably. Nerve transfers have become an important surgical tool in addition to nerve repair and grafting. Electrodiagnosis has traditionally played a role in the diagnosis and localization of peripheral nervous system injuries, but a different approach is needed for surgical decision-making and monitoring recovery. When patients have complete or severe injuries they should be referred to surgical colleagues early after injury, as outcomes are best when nerve transfers are performed within the first 3 to 6 mo after onset. Patients with minimal recovery of voluntary activity are particularly challenging, and the presence of a few motor unit action potentials in these individuals should be interpreted on the basis of timing and evidence of ongoing reinnervation. Evaluation of potential recipient and donor muscles, as well as redundant muscles, for nerve transfers requires an individualized approach to optimize the chances of a successful surgical intervention. Anomalous innervation takes on new importance in these patients. Communication between surgeons and electrodiagnostic medicine specialists (EMSs) is best facilitated by a joint collaborative clinic. Ongoing monitoring of recovery post-operatively is critical to allow for decision making for continued surgical and rehabilitation treatments. Different electrodiagnostic findings are expected with resolution of neurapraxia, distal axon sprouting, and axonal regrowth. As new surgical techniques become available, EMSs will play an important role in the assessment and treatment of these patients with severe nerve injuries.
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Affiliation(s)
- Lawrence R Robinson
- Physical Medicine & Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Paul Binhammer
- Plastic & Reconstructive Surgery, University of Toronto, Toronto, Ontario, Canada
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Miller C, Cross J, O'Sullivan J, Power DM, Kyte D, Jerosch-Herold C. Developing a core outcome set for traumatic brachial plexus injuries: a systematic review of outcomes. BMJ Open 2021; 11:e044797. [PMID: 34330851 PMCID: PMC8327802 DOI: 10.1136/bmjopen-2020-044797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To identify what outcomes have been assessed in traumatic brachial plexus injury (TBPI) research to inform the development of a core outcome set for TBPI. DESIGN Systematic review. METHOD Medline (OVID), EMBASE, CINAHL and AMED were systematically searched for studies evaluating the clinical effectiveness of interventions in adult TBPIs from January 2013 to September 2018 updated in May 2021. Two authors independently screened papers. Outcome reporting bias was assessed. All outcomes were extracted verbatim from studies. Patient-reported outcomes or performance outcome measures were extracted directly from the instrument. Variation in outcome reporting was determined by assessing the number of unique outcomes reported across all included studies. Outcomes were categorised into domains using a prespecified taxonomy. RESULTS Verbatim outcomes (n=1491) were extracted from 138 studies including 32 questionnaires. Unique outcomes (n=157) were structured into 4 core areas and 11 domains. Outcomes within the musculoskeletal domain were measured in 86% of studies, physical functioning in 25%, emotional functioning in 25% and adverse events in 33%. We identified 63 different methods for measuring muscle strength, 16 studies for range of movement and 63 studies did not define how they measured movement. More than two-thirds of the outcomes were incompletely reported in prospective studies. CONCLUSION This review of outcome reporting in TBPI research demonstrated an impairment focus and heterogeneity. A core outcome set would ensure standardised and relevant outcomes are reported to facilitate future systematic review and meta-analysis. PROSPERO REGISTRATION NUMBER CRD42018109843.
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Affiliation(s)
- Caroline Miller
- School of Health Sciences, The Queens Building, University of East Anglia, Norwich, UK
- Physiotherapy Department, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Jane Cross
- School of Health Sciences, The Queens Building, University of East Anglia, Norwich, UK
- Physiotherapy Department, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Joel O'Sullivan
- Physiotherapy Department, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Dominic M Power
- The Birmingham Peripheral Nerve Injury Service, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Derek Kyte
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Christina Jerosch-Herold
- School of Health Sciences, The Queens Building, University of East Anglia, Norwich, UK
- Physiotherapy Department, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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13
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Ferris S, Alexander W. Ulnar and Median Fascicular Transfers for Elbow Flexion-Predicting Outcomes in a Heterogeneous Patient Group and Implications for Surgical Planning. Front Surg 2020; 7:567602. [PMID: 33344497 PMCID: PMC7746647 DOI: 10.3389/fsurg.2020.567602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 11/09/2020] [Indexed: 11/13/2022] Open
Abstract
Purpose: To measure the outcomes in patients undergoing nerve transfers for elbow flexion restoration, and compare patient outcomes based on the pre-operative fascicular transfer plan. Methods: Single surgeon series of 48 consecutive patients who underwent median and/or ulnar fascicular nerve transfers for elbow flexion restoration to treat palsies of the brachial plexus or musculocutaneous nerve. Outcomes measured were Medical Research Council (MRC) power grade, strength in kilograms, and time taken to recover function. Results: Overall, 96% of patients achieved MRC M4 or greater power. The subgroup who were planned for, and particularly those who then underwent, double as opposed to single fascicular transfer, had significantly better results. Conclusions: Overall results were excellent. Double fascicular transfers were superior, with no failures in this group. If pre-operatively a single fascicle transfer alone is planned due to a paucity of expendable donors, the predicted outcomes are worse and other treatment options should be considered.
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Affiliation(s)
- Scott Ferris
- Department of Plastic, Hand and Faciomaxillary Surgery, Alfred Health, Melbourne, VIC, Australia.,Victorian Plastic Surgery Unit, St. Vincent's Private Hospital, East Melbourne, VIC, Australia
| | - William Alexander
- Department of Plastic and Maxillofacial Surgery Unit, Royal Children's Hospital Melbourne, Parkville, VIC, Australia.,Victorian Hand Surgery Associates, Fitzroy, VIC, Australia
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