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The Efficacy of Different Nerve Transfers to Restore Elbow Flexion in Adults Following Brachial Plexus Injury: A Systematic Review and Meta-Analysis
Chung Yan Vernon Lee, MBBS1; Elliot Cochrane, MBChB BSc MRCSEd2; Misha Chew, MBBS1; Robert D Bains, MBChB BSc FRCS(Plast)1; Gráinne Bourke, MB BCh BAO FRCSI FRCS(Plast)1; Ryckie George Wade, MBBS MSc MClinEd MRCS FHEA GradStat PhD3
1Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom; 2Leeds Teaching Hospitals, Leeds, United Kingdom; 3Department of Plastic and Reconstructive Surgery, University of Leeds, Leeds, United Kingdom

Introduction: Restoration of elbow flexion is an important goal in the treatment of patients with traumatic brachial plexus injury (BPI). Numerous studies have described various nerve transfers to neurotise the musculocutaneous nerve (or its motor branches), but there is uncertainty over the efficacy of each method. The aim of this study was to summarise the published evidence in adults with traumatic BPI.
Methods: Medline, Embase, medRxiv and bioRxiv were systematically searched from inception to 12th April 2021. We included studies reporting the outcomes of nerve transfers to restore elbow flexion in adults. The primary outcome was ?M4 elbow flexion on the British Medical Research Council (BMRC) scale. Data were pooled using random-effects meta-analyses and heterogeneity was explored using meta-regression. Confidence intervals (CI) were generated to the 95% level.
Results: We included 64 articles, describing 13 different nerve transfers. There were 1335 adults with 813 (61%) partial and 522 (39%) pan plexus injuries. Overall, 75% of patients with partial BPIs achieved ?M4 (CI 69%-80%, Figure 1) and the choice of donor nerve was associated with clinically meaningful differences in the outcome. For patients with pan plexus injuries, 45% achieved ?M4 (CI 31%-60%, Figure 2) and each month delay from injury to reconstruction reduced the probability of achieving ?M4 by 7% (CI 1%-12%, Figure 3).
Conclusions: The choice of donor nerve affects the chance of attaining BMRC ?4 in upper trunk reconstruction. For patients with pan plexus injuries, delay to neurotisation appears to be detrimental to motor outcome. This information may help in the design of future research, and allow clinicians and patients reach shared decisions about surgical timing and donor nerve(s).
Registration: PROSPERO ID CRD42019142880



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