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Comparison Between Long Nerve Grafts and Nerve Transfers for Axillary Nerve Injuries
Scott W. Wolfe, MD; Parker Johnsen; Adele Mirbey; Joseph Feinberg, MD; Steve Lee, MD
Hospital for Special Surgery, New York, NY, USA
Introduction: Nerve grafts and nerve transfers are procedures utilized in the reconstruction of axillary nerve injuries. Traditionally, grafts longer than 7 cm have demonstrated worse outcomes than shorter grafts (1). A recent systematic review demonstrated superior outcomes of shoulder and elbow function in patients treated with nerve transfers than those treated with nerve grafts (2). The purpose of this investigation was to compare the functional and electromyographic outcomes of long nerve grafts to nerve transfers for complete axillary nerve palsy, performed by a single surgeon.
Methods: 11 consecutive patients treated with long nerve grafts (>7cm, range 9cm to 15cm) were compared with 14 consecutive patients treated with triceps to axillary nerve transfer over a 10 year period. Data was collected prospectively at regular intervals, beginning pre-operatively and continuing up to 11 years. Prior to intervention all patients demonstrated electromyographic evidence of complete denervation of the deltoid. Deltoid recovery (MRC grade), shoulder abduction (degrees), improvement in shoulder abduction (degrees) and electromyographic evidence of deltoid reinnervation were compared using generalized estimating equation (GEE) regression models (p<0.05).
Results: The average length of nerve graft was 13cm (range 9cm to 15cm). The average time from injury to surgery was 5 months (range 3 mos to 10 mos) for nerve grafts and 7 months (range 2 mos to 13 mos) for nerve transfers. Average shoulder abduction was 53o (range 10o to 150o) for transfers and 65o (range 30o to 130o) for grafts. Average increase in shoulder abduction measured 52o (range 0o to 150o) for transfers and 50o (range 0o to 90o) for grafts. 9/11 patients recovered M3 or greater strength in the graft group and 11/14 patients in the transfer group. For those patients with electromyographic data available >9 months post-op, 9 out of 9 had electromyographic recovery in the form of axonal regeneration in the graft group and 8 out of 8 in the transfer group. There were no statistically significant differences in shoulder abduction strength, range of motion or electromyographic recovery between graft and transfer cohorts.
Discussion and Conclusion: These data demonstrate that outcomes of long nerve grafts for axillary nerve palsy are comparable to those of modern nerve transfers, and question a widely held belief that long nerve grafts do poorly. When healthy donor roots or trunks are available, long nerve grafts should not be overlooked as an effective intervention for the treatment of axillary nerve injuries in adult brachial plexus injuries.
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