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Double Fascicular Transfer to Restore Elbow Flexion After Brachial Plexus Birth Injury: How Late is Too Late?
Abraham Zavala, MD, MSc; Wieslawa De Pawlikowski, MD, FACS
Instituto Nacional de Salud del Niņo - San Borja, Lima, Peru

Introduction. Microsurgical nerve reconstruction with grafts and/or proximal extraplexal nerve transfers has typically been recommended in patients with brachial plexus birth injuries (BPBI) between 3 and 9 months. However, some patients need to undergo indicated surgery after this period. In these cases, the use of distal transfers could enable us to move forward the traditional time thresholds for nerve reconstruction. While the double-fascicular transfer (DFT) has remained a popular intraplexal distal nerve transfer to restore elbow flexion, there is limited data on the efficacy of this technique in late-presenting BPBI patients. We analyzed outcomes of DFT performed after 12 months of age and discussed the indications and recovery of elbow flexion.
Materials and Methods. We performed a retrospective review of patients who presented after the age of 12 months with loss of elbow flexion due to upper BPBI (C5-C6/C5-C6-C7) and were treated with DFT. Patients were evaluated using Active Movement Scale (AMS) scores. We included patients with a minimum of thirty-six months of postoperative follow-up or achievement of an AMS score of 7/7 for elbow flexion (whichever was reached first). Recovery of elbow flexion was defined as an AMS score of >6, as previously standardized. Patients were allocated into three groups based on their age at surgery: group A (12 to 18 months); group B (19 to 24 months); group C (>24 months). We compared the AMS outcomes between groups using the Kruskal-Wallis test. To focus on the results of the DFT, only outcomes prior to secondary surgery were analyzed.
Results. We identified 24 patients (14 male; 10 female) with median follow-up of 62.3 months. Between-group comparisons found no differences in total preoperative AMS scores. Median age at surgery was 15.6 months. The 11 patients in group A (100%), 9 patients in group B (87%), and 1 patient in group C (33%) showed successful postoperative recovery of elbow flexion. Differences in postoperative AMS scores were significant between groups (p<0.01).
Conclusions. Overall, DFT in patients with upper BPBI between 12 and 24 months of age resulted in satisfactory recovery of elbow flexion. Patients beyond 24 months showed suboptimal postoperative outcomes. While longer series are required to corroborate these findings, our results suggest that this strategy may not be reliably effective after 24 months of age.


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