188 Timing of Nerve Reconstruction Surgery to Optimize Long-Term Recovery at the Elbow and Forearm in Neonatal Brachial Plexus Palsy

Abstract

INTRODUCTION: Restoration of elbow flexion is highly prioritized in nerve reconstruction for neonatal brachial plexus palsy (NBPP). Elbow extension and forearm supination are also frequently impacted in NBPP. Timing of surgical reconstruction for optimal outcomes at the elbow and forearm remains unknown. METHODS: We interrogated a prospectively collected database of all children with NBPP who underwent nerve reconstruction at a single center between 2005-2020. AROM was collected for elbow flexion and extension and forearm supination at every clinic visit and normalized between 0 and 1. The cohort was divided into those with surgery =6 months old, 6-9 months old, and >9 months old. We compared elbow and forearm AROM in local age windows between the groups using a regression model expressing the expected AROM as a linear function. Significant differences between the groups were identified using a Wald test. RESULTS: Of 99 included children 28 had surgery =6 months old, 46 had surgery between 6-9 months, and 25 had surgery >9 months. At ∼13 years follow up, there was no difference in recovery of AROM for elbow flexion between the groups. For elbow extension, mean normalized AROM was significantly worse when comparing the >9 month and =6 month group (0.41 vs 0.84, p < 0.001). For forearm supination, the =6 month group had significantly better AROM than the 6-9 month (0.57 vs 0.77, p = 0.02) and >9 month (0.46 vs 0.77, p < 0.001) groups. Children who presented earlier had surgery at a younger age. CONCLUSIONS: Earlier surgery may result in better long-term recovery of elbow extension and surgery =6 months of age may yield the best outcomes for forearm supination. Early referral may help optimize timing of nerve surgery.