Ulnar Fascicular Transfer vs. Double Fascicular Transfer for Elbow Flexion After Traumatic Brachial Plexus Injury
Kevin T Rezzadeh, BA, New York University School of Medicine, New York, NY, Megan Donnelly, BS, NYU School of Medicine, New York, NY, David Daar, MD, New York University Langone Health, New York, NY and Jacques Hacquebord, MD, NYU Langone Medical Center, New York, NY
Double fascicular transfer is argued to result in improved elbow flexion compared to the traditional, single transfer Oberlin procedure because it reinnervates both the biceps and the brachialis. This study seeks to determine if double fascicular transfer should be preferred over Oberlin transfer to restore elbow flexion in patients with upper trunk brachial plexus injuries by analyzing the current database of literature on the topic.
A systematic review was conducted according to PRISMA guidelines. Inclusion criteria were studies reporting Medical Research Council (MRC) scores on individual patients undergoing Oberlin's transfer (ulnar nerve fascicle donor) and double fascicular transfer (ulnar and median nerve fascicle donors). Patients were excluded if: age <18 years old and follow-up <12 months. Demographics obtained include age, sex, extent of injury (C5-C6/C5-C7), preoperative interval, procedure type, and follow-up time. Outcomes collected include absolute MRC score, ability to achieve MRC score ≥3 and ability to achieve elbow flexion MRC score ≥4. Univariate and multivariate regression analyses were completed to evaluate predictors of postoperative outcomes.
19 studies with 188 patients were included for pooled analysis. Patients that underwent double fascicular transfer had a higher percentage of patients attain a MRC score ≥4 compared to Oberlin subjects (84.7% vs. 63.0%,p=0.003). Double fascicular transfer was a predictor of achieving high MRC scores (OR=3.264,p=0.004). Time before procedure (OR to ≥3: 0.893, p=0.005; OR to ≥4: 0.933, p=0.035) and extent of brachial plexus injury (OR to ≥3: 0.254, p=0.015; OR to ≥4: 0.512, p=0.039) were also predictors of ability to achieve MRC scores ≥3 and ≥4, respectively. Multivariate analysis showed that procedure type was the only significant predictor of ability to obtain MRC ≥4 (OR: 2.889, p=0.011).
This analysis demonstrates that double fascicular transfer is associated with superior postoperative outcomes. Double fascicular transfer should be performed for restoring elbow flexion when possible.
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