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Restoration of Elbow Flexion by Nerve Transfer – Comparison between Proximal vs. Distal Nerve Transfer in 119 Acute Brachial Plexus Injuries
Ching-hsuan Hu, MD and David Chwei-Chin Chuang, MD
Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
Introduction Nerve transfer constitutes a major reconstruction in brachial plexus injury. Proximal and distal nerve transfers were both popularly utilized but with much controversy and debates. This study aimed to compare functional outcomes and speed of recovery of elbow flexion by these 2 strategies. Methods: We performed a retrospective review of 119 patients with proximal and distal nerve transfer for elbow flexion in acute brachial plexus injuries between 2000 and 2012. All data were collected and analyzed for recovery of the elbow flexion (M>3), and speed of this recovery. We also recorded the additional gain of shoulder abduction from proximal nerve transfer, and reduction of hand grip power in patient with distal nerve transfer. Results: In 119 patients with acute brachial plexus injury, 45 patients received proximal nerve transfer, 74 patients received distal nerve transfer for restoration of elbow flexion. It included Oberlin method (single fascicle transfer), 28 patients; Mackinnon method (double fascicles transfer), 20 patients; Intercostal nerve transfer, 26 patients. All had follow-up at least 2 years. Functional recovery of the elbow flexion showed proximal nerve transfer, 88.9%, and distal nerve transfer, Oberlin method: 64.3% and Mackinnon method, 95%, and intercostal nerve transfer, 80.8% of success rate with significant difference (p=0.026). The speed to achieve M>3 was Oberlin method, 16.4; Mackinnon method, 12.3, and intercostal nerve transfer, 16.2 and proximal nerve transfer, 15.4 in month. (p=0.018). Of the 45 patients who received proximal nerve transfer, 43 patients (95.6%) receive additional shoulder abduction restoration up to 60 degree. Significant decrease of grip strength between normal and operated hand were noted in patient received distal nerve transfer ( p<0.001) Discussion: Proximal nerve transfer is a traditional strategy which has benefits for both diagnosis and treatment. Proximal nerve exploration in the brachial plexus is worthy of C5 checking and applying the chance for simultaneous restore shoulder and elbow function. Distal nerve transfer is a new strategy with quick surgery time and quick result, however a significant decrease hand grip power was noted. Conclusion: We suggest combined proximal exploration and proximal nerve transfer for acute brachial plexus injury, and distal nerve transfer should only be applied selectively when appropriately
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