Nerve Grafting Procedures Research Articles

Salvaging mangled upper limbs with early soft tissue cover with flaps- A case series

Mutilating upper limb injuries present complex challenges to both patients and surgeons, necessitating prompt and effective management strategies to achieve favorable outcomes. This retrospective study examines the cases of five consecutive patients with mangled upper limbs resulting from blunt trauma, evaluating demographics, injury mechanisms, injury patterns, and 60-day limb salvage outcomes. Among 2128 admissions between January and December 2022, five patients were identified with mangled upper limbs and open fractures, with an average age of 40.2 years and a notable male predominance (80%). The dominant hand was affected in 60% of cases, primarily due to blunt high-velocity road traffic accidents. The mean Mangled Extremity Severity Score (MESS) was 7.2, and the Ganga Hospital Open Injury Score averaged 16, indicating substantial injury severity without limb ischemia or compartment syndrome. All patients underwent definitive surgery within 48 hours, with various soft tissue reconstruction techniques employed, including free flaps, pedicle flaps, and local muscle mobilization, along with nerve grafting procedures. At the 60-day follow-up, successful limb salvage was achieved in all cases, with no instances of surgical site infection and excellent acceptance of skin grafted areas exceeding 95%. The findings underscore the importance of timely surgical intervention and comprehensive soft tissue coverage in achieving successful limb salvage outcomes in patients with mutilating upper limb injuries, emphasizing the critical role of early intervention and multidisciplinary collaboration.

Median and Ulnar Nerve Repair Using Sural Nerve Graft: A Case Report

Abstract: Most peripheral nerve injuries (PNI) are caused by trauma. Upper extrimities are most likely to get injured, and the radial nerve is the most common part in upper extrimites to be affected. There are different surgical options available to repair PNI. We reported a 48-years-old male consulted to the Neurosurgery Department for right upper limb weakness and numbness. He had history of laceration due to iron sheeting in the right arm. There was an irregular scar, weakness on right lower arm with hypesthesia, but no neurovascular distal (NVD) abnormalities were found. Further examination showed claw hand. EMG examination revealed total lesion of the right median and ulnar nerve, partial lesion of the right radial nerve with the lesion at wrist level, possibly neurotmesis according to Seddon Classification. Initial debridement, suturing, and repairing of radial artery and flexor carpi ulnar tendon were performed. The patient was then diagnosed as total lesion of the right median and ulnar nerve, partial lesion of the right radial nerve, post repair right ulnar and radial artery and flexor carpi ulnar tendon repair with the planning of nerve graft with no complication under monitoring. The patient was scheduled for sural nerve graft procedure. Early nerve repair or reconstruction is needed even though it only results in incomplete recovery for months to years. The sural nerve is great either in diameter or length which can be a huge source for the grafting of nerve and revealed good outcomes. Recent study showed incomplete recovery especially seen when the patient could not fully clench his hand and his thumb did not move properly during the movement. In conclusion, sural nerve graft is an appropriate choice for peripheral nerve injuries with more benefits included. Prognosis depends on how early the treatment performed and how severe the lesion is. Keywords: median nerve; sural nerve; peripheral nerve injury; nerve repair; nerve grafting

Muscle activation for targeted elbow force production following surgical reconstruction in adults with brachial plexus injury.

Nerve transfer or grafting surgery to restore elbow flexion in peripheral nerve injuries has been an effective technique, but alters neuromuscular control compared with healthy individuals. This study compared neuromuscular control in the elbow flexors of 11 unimpaired control subjects and 11 adult patients with traumatic brachial plexus injury who underwent a nerve transfer or grafting procedure to the biceps motor branch to restore elbow flexion. The subjects performed a series of trials to generate a specific percentage of their maximum elbow torque. Each trial had an increasing and decreasing stairstep torque pattern that the subjects were asked to match. The amount of time that the subject's elbow torque was maintained within 5% of the target torque was calculated. The hypothesis was that there was a significant difference in the neuromuscular control between the two groups during elbow isometric torque generation. A secondary hypothesis was that a relationship existed between the neuromuscular control and the torque level for each group. The results demonstrated that neuromuscular control was different between the groups and there were significant differences in how torque levels are generated. The control group more easily modulated their myoelectric activation and achieved greater neuromuscular control variability with varying torque demand. The nerve transfer or grafting group could not modulate their myoelectric activation with changing torque demands. Further studies focusing on the improvement of neuromuscular control are needed to optimize functional outcomes in nerve injury patients.

Reverse End-to-Side Transfer to Ulnar Motor Nerve: Evidence From Preclinical and Clinical Studies.

The disappointing outcomes of conventional nerve repair or grafting procedures for proximal ulnar nerve injuries have led the scientific community to search for better alternatives. The pronator quadratus branch of the anterior interosseous nerve has been transferred to the distal ulnar motor branch in a reverse end-to-side fashion with encouraging results. This transfer is now becoming commonly used as an adjunct to cubital tunnel decompression in patients with compressive ulnar neuropathy, underscoring the need for this knowledge transfer to the neurosurgical community. However, the mechanism of recovery after these transfers is not understood completely. We have reviewed the existing preclinical and clinical literature relevant to this transfer to summarize the current level of understanding of the underlying mechanisms, define the indications for performing this transfer in the clinic, and identify the complications and best practices with respect to the operative technique. We have also attempted to identify the major deficiencies in our current level of understanding of the recovery process to propose directions for future research.

Brachial Plexus Birth Injury: Trends in Early Surgical Intervention over the Last Three Decades.

A systematic review was performed through MEDLINE (PubMed) identifying studies limited to the early surgical management of BPBI from 1990 to current. Patients treated after 1 year of age (ie, tendon transfers and secondary reconstructive efforts) were excluded. Diagnostic tests, age of intervention, surgical treatment modalities, and outcome scoring systems were extrapolated and compared so as to determine trends in management over time. Seventeen studies met criteria, summating a total of 883 patients. The most commonly reported physical examination classifications were the Mallet and AMS scoring systems. Most patients underwent neuroma excision and sural nerve autografting (n = 618, 70%) when compared with primary nerve transfers (148, 16.8%), primary nerve transfer with autografting combinations (59, 6.7%), or neurolysis alone (58, 6.6%). There was no significant change in the proportion of patients treated with sural nerve grafting, combination graft and transfer procedures, or isolated neurolysis over time. However, there has been a significant increase in the proportion of patients treated with primary nerve transfer procedures (τ b = 0.668, P < 0.01) over time. Although neuroma excision and sural nerve autografting has been the historic gold-standard treatment for brachial plexus birth injury, peripheral nerve transfers have become increasingly utilized for surgical management.

Microanatomy of the Frontal Branch of the Facial Nerve: The Role of Nerve Caliber and Axonal Capacity.

A commonly seen issue in facial palsy patients is brow ptosis caused by paralysis of the frontalis muscle powered by the frontal branch of the facial nerve. Predominantly, static methods are used for correction. Functional restoration concepts include the transfer of the deep temporal branch of the trigeminal nerve and cross-facial nerve grafts. Both techniques can neurotize the original mimic muscles in early cases or power muscle transplants in late cases. Because axonal capacity is particularly important in cross-facial nerve graft procedures, the authors investigated the microanatomical features of the frontal branch to provide the basis for its potential use and to ease intraoperative donor nerve selection. Nerve biopsy specimens from 106 fresh-frozen cadaver facial halves were obtained. Histologic processing and digitalization were followed by nerve morphometric analysis and semiautomated axon quantification. The frontal branch showed a median of three fascicles (n = 100; range, one to nine fascicles). A mean axonal capacity of 1191 ± 668 axons (range, 186 to 3539 axons; n = 88) and an average cross-sectional diameter of 1.01 ± 0.26 mm (range, 0.43 to 1.74 mm; n = 67) were noted. In the linear regression model, diameter and axonal capacity demonstrated a positive relation (n = 57; r2 = 0.32; p < 0.001). Based on that equation, a nerve measuring 1 mm is expected to carry 1339 axons. The authors' analysis on the microanatomy of the frontal branch could promote clinical use of cross-facial nerve graft procedures in frontalis muscle neurotization and free muscle transplantations.

Accelerated outgrowth in cross-facial nerve grafts wrapped with adipose-derived stem cell sheets.

In this study, we devised a novel cross-facial nerve grafting (CFNG) procedure using an autologous nerve graft wrapped in an adipose-derived stem cell (ADSC) sheet that was formed on a temperature-responsive dish and examined its therapeutic effect in a rat model of facial palsy. The rat model of facial paralysis was prepared by ligating and transecting the main trunk of the left facial nerve. The sciatic nerve was used for CFNG, connecting the marginal mandibular branch of the left facial nerve and the marginal mandibular branch of the right facial nerve. CFNG alone, CFNG coated with an ADSC suspension, and CFNG wrapped in an ADSC sheet were transplanted in eight rats each, designated the CFNG, suspension, and sheet group, respectively. Nerve regeneration was compared histologically and physiologically. The time to reinnervation, assessed by a facial palsy scoring system, was significantly shorter in the sheet group than in the other two groups. Evoked compound electromyography showed a significantly higher amplitude in the sheet group (4.2 ± 1.3 mV) than in the suspension (1.7 ± 1.2 mV) or CFNG group (1.6 ± 0.8 mV; p < .01). Toluidine blue staining showed that the number of myelinated fibers was significantly higher in the sheet group (2,450 ± 687) than in the suspension (1,645 ± 659) or CFNG group (1,049 ± 307; p < .05). CFNG in combination with ADSC sheets, prepared using temperature-responsive dishes, promoted axonal outgrowth in autologous nerve grafts and reduced the time to reinnervation.

Assessment of the Effects of Swimming as a Postoperative Rehabilitation on Nerve Regeneration of Wistar Rats Submitted to Grafting of Autologous Nerves after Injury to the Sciatic Nerve.

Objective To evaluate the effects of swimming on nerve regeneration after sciatic nerve injury in Wistar rats. Methods A total of 30 Wistar rats was divided into 3 groups: Sham + Nat group animals that were not submitted to graft surgery and were submitted to swimming ( n = 10); Graft group: animals submitted to autologous sciatic nerve graft ( n = 10); and Graft + Nat group: animals submitted to autologous sciatic nerve graft surgery and to swimming ( n = 10). The results were analyzed on the software (GraphPad Software, San Diego, CA, USA). Results In the first evaluation, all sciatic functional index (SFI) values were similar ( p = 0.609). Thirty days after the surgical procedure, we observed differences between all the comparisons: Sham + Nat (−34.64 ± 13.89) versus Graft (−145.9 ± 26.06); Sham + Nat versus Graft + Nat (−89.40 ± 7.501); Graft (−145.9 ± 26.06) versus Graft + Nat (−89.40 ± 7.501). In the measurements (60 and 90 days), there was no statistical difference between the Graft and Graft + Nat groups, with significantly lower values in relation to the control group ( p < 0.001). The number of motor neurons presented differences in the comparisons between the Sham + Nat and Graft groups (647.1 ± 16.42 versus 563.4 ± 8.07; p < 0.05), and between the Sham + Nat and Graft + Nat groups (647.1 ± 16.42 versus 558.8 ± 14.79; p < 0.05). There was no difference between the Graft and Graft + Nat groups. Conclusion Animals submitted to the swimming protocol after the sciatic nerve grafting procedure did not present differences in the SFI values and motor neuron numbers when compared to the control group. Therefore, this type of protocol is not efficient for the rehabilitation of peripheral nerve lesions that require grafting. Therefore, further studies are needed.

A Rapid Protocol for Intraoperative Assessment of Peripheral Nerve Myelinated Axon Count and Its Application to Cross-Facial Nerve Grafting.

Donor nerve myelinated axon counts correlate with functional outcomes in reanimation procedures; however, there exists no reliable means for their intraoperative quantification. In this article, the authors report a novel protocol for rapid quantification of myelinated axons from frozen sections, and demonstrate its applicability to surgical practice. The impact of various fixation and FluoroMyelin Red staining strategies on resolved myelin sheath morphology from cryosections of rat and rabbit femoral and sciatic nerves was assessed. A protocol comprising fresh cryosection and rapid staining was developed, and histomorphometric results were compared against conventional osmium-postfixed, resin-embedded, toluidine blue-stained sections of rat sciatic nerve. The rapid protocol was applied for intraoperative quantification of donor nerve myelinated axon count in a cross-facial nerve grafting procedure. Resolution of myelinated axon morphology suitable for counting was realized within 10 minutes of tissue harvest. Although mean myelinated axon diameter appeared larger using the rapid fresh-frozen as compared to conventional nerve processing techniques (mean ± SD; rapid, 9.25 ± 0.62 μm; conventional, 6.05 ± 0.71 μm; p < 0.001), no difference in axon counts was observed on high-power fields (rapid, 429.42 ± 49.32; conventional, 460.32 ± 69.96; p = 0.277). Whole nerve myelinated axon counts using the rapid protocol herein (8435.12 ± 1329.72) were similar to prior reports using conventional osmium processing of rat sciatic nerve. A rapid protocol for quantification of myelinated axon counts from peripheral nerves using widely available equipment and techniques has been described, rendering possible intraoperative assessment of donor nerve suitability for reanimation.

The Great Auricular Nerve: Anatomical Study with Application to Nerve Grafting Procedures

When it comes to autogenous nerve grafting, the sural and great auricular nerve (GAN) are the 2 nerves predominately used for trigeminal and facial nerve repair. Arising from the second and third cervical ventral rami, the GAN emerges from the posterior border of the sternocleidomastoid coursing superiorly and anteriorly toward the ear. Eleven sides from 5 Caucasian and 1 Asian cadaveric heads (all fresh-frozen) were used. One man and 5 women were used with an age at death ranging from 57 to 91 years, with a mean of 80.3 years. Measurements were made from the inferior border of the ear to the GAN, the GAN to the external jugular vein, and the inferior border of the mastoid process to the GAN; the proximal, medial, and distal diameters of the GAN and the length of the GAN that was obtained from this exposure were also measured. The mean distance from the inferior border of the mastoid process to the GAN, inferior border of the ear to the GAN, and GAN to the external jugular vein was 27.71, 31.03, and 13.28 mm, respectively. The mean length of the GAN was 74.86 mm. The mean diameter of its distal, middle, and proximal portions was 1.51, 1.38, and 1.58 mm, respectively. The GAN is an excellent option for use in nerve grafting for repair of, for example, facial dysfunction. In this study, we review our measurements, techniques for identification, and dissecting techniques for the GAN. The proximity to the operative area and minimal complications associated with GAN grafting might contribute to improved patient satisfaction and better outcomes regarding functional restoration.

Anatomic variations of the extrathoracic course of the intercostobrachial nerve and its clinical significance

Background: The intercostobrachial nerve (ICBN) can present anatomic alterations in its course, but in general it originates as a lateral branch of the second intercostal nerve and penetrates the axilla, in the mid axillary line. Its communication with brachial plexus (BP) is of clinical importance. Neurotization and nerve grafting procedures have renewed interest in the communications of peripheral nerves, like that of between BP and ICBN. Aims and Objective: The current study was conducted with an aim to observe the variation in the origin of extra thoracic course of the ICBN and its connection with the components of BP.Materials and Methods: One hundred thirty hemi-thoraxes of 65 adult cadavers (35male &amp; 30 female) of Indian origin were dissected. After removal of the skin and superficial fascia, the ICBN was identified from its origin. The point of emergence from the intercostal space and its communication with BP was noted and photographed.Results: Extrathoracically, ICBN originated from the 2nd intercostals space in 100% specimens. Additionally ICBN originated from the 1st intercostals space in 3.8% specimens, from 3rd intercostals space in 20.7% cases. The ICBN communicated more frequently with medial cutaneous nerve of the arm (MCN) in 63% cases and with other BP branches in 44.6% cases.Conclusion: In the present study we observed ICBN and BP are coherently linked anatomically. The anatomical knowledge of ICBN origin and its variable communication with BP branchesis significant in the event of surgical treatment of breast cancers, lymph node clearance, anaesthetic nerve blocks and traction injuries to the brachial plexus.Asian Journal of Medical Sciences Vol.9(5) 2018 77-80

MP32-03 ERECTILE FUNCTION RESTORATION POST-RADICAL PROSTATECTOMY: UTILISATION OF A NEW NOVEL END-TO-SIDE NERVE GRAFTING PROCEDURE

You have accessJournal of UrologySexual Function/Dysfunction: Surgical Therapy II1 Apr 2018MP32-03 ERECTILE FUNCTION RESTORATION POST-RADICAL PROSTATECTOMY: UTILISATION OF A NEW NOVEL END-TO-SIDE NERVE GRAFTING PROCEDURE Christopher Coombs, Jeanette Reece, and David Dangerfield Christopher CoombsChristopher Coombs More articles by this author , Jeanette ReeceJeanette Reece More articles by this author , and David DangerfieldDavid Dangerfield More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1053AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Permanent erectile dysfunction (ED) is a common adverse side effect of radical prostatectomy (RP) that can significantly impact on health-related quality of life (HRQOL). We investigated the potential of our novel end-to-side sural nerve grafting technique to restore erectile function (EF) and improve HRQOL in a cohort of 11 men with permanent ED following RP. METHODS Eleven patients aged 58-70 years with moderate to severe ED, at least 2 years after nerve-sparing RP or 6 months after non-nerve-sparing RP, were candidates for novel nerve graft surgery to restore EF. The minimally invasive surgical technique involved two single bilateral end-to-side somatic-to-autonomic sural nerve grafts from the donor femoral nerve to the corpora cavernosa of the penis. EF outcomes were measured using the International Index of Erectile Function (IIEF5) and HRQOL outcomes were measured using the sexual domain of the Expanded Prostate Cancer Index Composite for clinical practice (EPIC-CP). Outcomes were assessed pre-RP, pre-nerve grafting and at 3-6 month intervals for 12-30 months following nerve grafting. All assessments were performed independently of the treating surgeons. RESULTS Pre-RP, all men had satisfactory EF (IIEF5 ≥ 17). Pre-nerve grafting, all men had ED insufficient to achieve and maintain sexual penetration (IIEF5 ≤ 11). Post-nerve grafting, EF recovery (IIEF5 ≥ 17) was observed in 9/11 (82%) men with confirmed ED following RP (3/4 men after non-nerve-sparing RP; 3/4 men after bilateral nerve-sparing RP and 3/3 men after unilateral nerve-sparing RP). EF recovery was observed in 4 men 6 months following nerve grafting and in 5 men 12 months following nerve grafting. Significant improvements in post-nerve grafting HRQOL summary, function and bother scores compared with pre-nerve grafting scores were observed in men with restored EF. Three patients could maintain spontaneous erections sufficient for sexual penetration without any penile rehabilitation therapy 12 months post-nerve grafting. Surgeries were performed in around 2.5 hours, followed by an overnight stay in hospital. There was one acute postoperative wound infection. CONCLUSIONS Our innovative end-to-side sural nerve grafting procedure offers a feasible treatment modality to restore EF in impotent men following nerve- or non-nerve sparing RP. EF restoration sufficient to achieve and maintain sexual penetration was observed in 82% of patients where prior to nerve grafting, the likelihood of EF recovery for these men was almost negligible. This minimally invasive nerve grafting technique also has the potential to significantly improve HRQOL. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e420-e421 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Christopher Coombs More articles by this author Jeanette Reece More articles by this author David Dangerfield More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Virtual Surgical Planning for Inferior Alveolar Nerve Reconstruction

The purpose of this study was to assess the outcomes after preoperative virtual surgical planning (VSP) for inferior alveolar nerve (IAN) reconstruction in ablative mandibular surgery. We performed a retrospective evaluation of consecutive surgical cases using standard VSP for hard tissue resection and reconstructive surgery in addition to IAN VSP performed simultaneously during surgery. Cases were assessed regarding the planning time, additional costs involved, surgeon's subjective impression of the process, accuracy of the prediction during surgery, and operative time during surgery compared with cases performed without VSP. The study sample was composed of 5 cases of mandibular resection for benign disease, with bony, soft tissue, and neural reconstruction with the use of VSP. The addition of IAN reconstruction to the VSP session added no additional expense to the planning session but resulted in an additional 22.5minutes (±7.5minutes) for the webinar session. From a subjective standpoint, IAN VSP provided the surgeon with a discreet plan for surgery. From an objective standpoint, IAN VSP provided the exactlength and diameter of nerve graft required for surgery, facilitated the surgeon's ability to visualize the actual nerve graft procedure, and limited the additional time required for simultaneous nerve reconstruction. Despite perceived prejudice against simultaneous IAN reconstruction with complex mandibular resection and reconstruction, the use of IAN VSP may facilitate the actual surgical procedure and result in considerably improved patient outcomes without considerable additional time or cost associated with this protocol.

Objective sensory and functional outcomes at the donor site following endoscopic-assisted sural nerve harvest

The sural nerve is a common choice for a nerve graft. Understanding the potential morbidity associated with its harvest is important. In this study, we describe the objective sensory and functional outcomes associated with endoscopic sural nerve harvest from a combined paediatric and adult population. Data were collected prospectively from patients attending for follow-up between August 2015 and January 2016, who had previously undergone an endoscopic sural nerve graft harvest. Sensory loss was evaluated using a 5.07 Semmes-Weinstein monofilament. The lower extremity functional scale was used to evaluate the patients' lower limb function. Statistical comparison was made using the Student's t-test. The outcomes from 46 sural nerve grafts were evaluated. The mean age of the patients was 18.1 years (range 4-45 years old). The mean time since surgery was 4.3 years. Those aged ≤18 years had a significantly smaller area of sensory loss (p=0.003), which was not related to a difference in foot size. Those who had undergone surgery >6 months previously had a significantly smaller area of sensory loss than those who had undergone surgery <6 months ago (p=0.0002). The mean lower extremity functional scale score was 78.7/80. We demonstrated a significantly reduced post-harvest sensory deficit among a paediatric population compared to that seen in adults. Furthermore, sensory loss reduces with time. Despite the sensory loss resulting from sural nerve graft harvest, there is minimal loss of function. As such, the sural nerve continues to be an excellent donor for a nerve graft procedure.

Thirty-Day Perioperative Adverse Outcomes After Peripheral Nerve Surgery: An Analysis of 2351 Patients in the American College of Surgeons National Surgical Quality Improvement Program Database

Because peripheral nerve surgery has become more common in recent years, the pressure to increase this procedure's health care safety and cost-effectiveness has increased. Given our limited understanding, we evaluated prospectively identified and randomly sampled patients who underwent peripheral nerve surgery from 2005 to 2014 through the American College of Surgeons National Surgical Quality Improvement Program database. We used bivariate testing and multivariate logistic regression analysis to identify patient- and surgery-related risk factors for postoperative complications and unplanned readmission in peripheral nerve surgery patients, and especially to estimate the impact of the nerve grafting procedure. Overall, 2351 patients underwent peripheral nerve surgery, 120 complications were identified in 100 patients (4.25%), and 103 patients (4.38%) received nerve grafting. Thirty-one of the 1593 patients (1.95%) underwent unplanned readmission. Nerve grafting procedures had noassociation with postoperative complications and unplanned readmission rates. Patients who experienced an inpatient procedure (odds ratio [OR], 2.54; P < 0.001), a longer operative time (OR, 1.00; P < 0.001), and worse wound classifications (OR, 1.83; P < 0.001) all had increased odds of postoperative complications. An inpatient procedure (OR, 2.74; P= 0.014) and any complications (OR, 24.43; P < 0.001) were significantly associated with unplanned readmission. Our study confirms that peripheral nerve surgery and nerve graft procedures can be safely performed with low complication risks and low unplanned readmission rates. We also identified the risks associated with perioperative adverse outcomes, and these data may be used as an adjunct for risk stratification for patients under consideration for peripheral nerve surgery. This approach may enable the improved targeting of the most costly and harmful complications of preventive measures.

Upper brachial plexus injury in adults: comparative effectiveness of different repair techniques

Adult upper trunk brachial plexus injuries result in significant disability. Several surgical treatment strategies exist, including nerve grafting, nerve transfers, and a combination of both approaches. However, no existing data clearly indicate the most successful strategy for restoring elbow flexion and shoulder abduction in these patients. The authors reviewed the literature to compare outcomes of the three surgical repair techniques listed above to determine the optimal approach to traumatic injury to the upper brachial plexus in adults. Both PubMed and EMBASE databases were searched for English-language articles containing the MeSH topic "brachial plexus" in conjunction with the word "injury" or "trauma" in the title and "surgery" or "repair" as a MeSH subheading or in the title, excluding pediatric articles and those articles limited to avulsions. The search was also limited to articles published after 1990 and containing at least 10 operated cases involving upper brachial plexus injuries. The search was supplemented with articles obtained through the "Related Articles" feature on PubMed and the bibliographies of selected publications. From the articles was collected information on the operation performed, number of operated cases, mean subject ages, sex distribution, interval between injury and surgery, source of nerve transfers, mean duration of follow-up, year of publication, and percentage of operative success in terms of elbow flexion and shoulder abduction of the injured limb. The recovery of elbow flexion and shoulder abduction was separately analyzed. A subanalysis was also performed to assess the recovery of elbow flexion following various neurotization techniques. As regards the restoration of elbow flexion, nerve grafting led to significantly better outcomes than either nerve transfer or the combined techniques (F = 4.71, p = 0.0097). However, separating the Oberlin procedure from other neurotization techniques revealed that the former was significantly more successful (F = 82.82, p < 0.001). Moreover, in comparing the Oberlin procedure to nerve grafting or combined procedures, again the former was significantly more successful than either of the latter two approaches (F = 53.14; p < 0.001). In the restoration of shoulder abduction, nerve transfer was significantly more successful than the combined procedure (p = 0.046), which in turn was significantly better than nerve grafting procedures (F = 5.53, p = 0.0044). According to data in this study, in upper trunk brachial plexus injuries in adults, the Oberlin procedure and nerve transfers are the more successful approaches to restore elbow flexion and shoulder abduction, respectively, compared with nerve grafting or combined techniques. A prospective, randomized controlled trial would be necessary to fully elucidate differences in outcome among the various surgical approaches.

Alternatives to sural nerve grafts in the upper extremity.

The sural nerve is the most common nerve graft donor despite requiring a second operative limb and causing numbness of the lateral foot. The purposes of this study were to review our experience using nerve autografts in upper extremity nerve reconstruction and develop recommendations for donor selection. A retrospective case series study was performed of all consecutive patients undergoing nerve grafting procedures for upper extremity nerve injuries over an 11-year period (2001-2012). Eighty-six patients received 109 nerve grafts over the study period. Mean patient age was 42.9 ± 18.3years; 57% were male. There were 51 median (59%), 26 ulnar (30%), 14 digital (13%), 13 radial (16%), and 3 musculocutaneous (4%) nerve injuries repaired with 99 nerve autografts (71 from upper extremity, 28 from lower extremity). Multiple upper extremity nerve autograft donors were utilized, including the medial antebrachial cutaneous nerve (MABC), third webspace branch of median, lateral antebrachial cutaneous nerve (LABC), palmar cutaneous, and dorsal cutaneous branch of ulnar nerve. By using an upper-extremity donor, a second operative limb was avoided in 58 patients (67%), and a second incision was avoided in 26 patients (30%). The frequency of sural graft use declined from 40% (n = 17/43) to 11% (n = 7/64). Our algorithm for selecting nerve graft material has evolved with our growing understanding of nerve internal topography and the drive to minimize additional incisions, maximize ease of harvest, and limit donor morbidity. This has led us away from using the sural nerve when possible and allowed us to avoid a second operative limb in two thirds of the cases.

Ultrasonographic Evaluation of Sural Nerve for Nerve Conduction Study

ObjectiveTo understand various morphologic types and locations of the sural nerve (SN) that are important for nerve conduction studies or nerve grafting procedures. The aim of this study was to describe the course and variations of the SN based on ultrasonographic findings for an adequate nerve conduction study.MethodsA total of 112 SNs in 56 volunteers with no history of trauma or surgery were examined by ultrasonography. The location and formation of the SNs in relation to the medial and lateral sural cutaneous nerve were investigated. We measured the horizontal distance between the SNs and the midline of the calf at the level of 14 cm from the lateral malleolus, and the distance between the SNs and the most prominent part of the lateral malleolus.ResultsSN variants was classified into four types according to the medial and lateral sural cutaneous nerve; type 1 (73.2%), type 2 (17.9%), type 3 (8.0%), and type 4 (0.9%). The mean distance between the SN and the midline of the calf was 1.02±0.63 cm, the SN and the most prominent part of the lateral malleolus was 2.14±0.15 cm.ConclusionVariations in the location and formation of the SN was examined by ultrasonography, and the results of this study would increase the accuracy of the SN conduction study.

Suprascapular nerve neurotization in obstetrical brachial plexus palsy using the spinal accessory nerve or the C5 root

ObjectiveTo evaluate the value of distal spinal accessory nerve (SAN) or 5th cervical (C5) root neurotization to the suprascapular nerve (SSN) in infants with obstetrical brachial plexus birth palsy.BackgroundSurgical treatment of obstetrical brachial plexus birth palsy in infants includes neurolysis, nerve repair directly, or the use of interposition nerve graft and neurotization procedures. Repair of SSN is the key to restoration of shoulder joint function.Materials and methodsOver a 3-year period, 30 infants with brachial plexus injuries were subjected to SSN repair, 18 infants by neurotization to the SAN and 12 infants by interposition nerve grafting to the C5 root as part of the primary surgical reconstruction. Operative and postoperative outcomes were evaluated with a minimum follow-up of 18 months.ResultsNeurotization of the SSN was performed by intraplexal neurotization using a nerve graft to C5 in 12 patients (40%) or extraplexal neurotization using SAN directly in 18 patients (60%). Nineteen infants were subjected to surgical reconstruction at less than 6 months of age and 11 were subjected to surgical reconstruction, age range 3 to 16 months, mean 5 months. At the latest follow-up, active shoulder movements were measured confirmed by review of videos. The outcome of nerve injury was assessed using the peripheral nerve injury unit scale. The results of neurotization and the use of an interpositional nerve graft were analyzed. SSN neurotization outcome by SAN showed 94.4% good outcome and 5.6% fair outcome, which were better than outcome by C5 root neurotization (66.7% good and 33.3% fair). Five patients developed a postoperative superficial wound infection.ConclusionAlthough both SAN and C5 root neurotization to the SSN nerve are reliable options for shoulder reinnervation in infants with obstetrical brachial plexus palsy, direct neurotization without an interpositional nerve graft yields better results.

Distal Nerve Transfers Are Effective in Treating Patients with Upper Trunk Obstetrical Brachial Plexus Injuries

Current surgical management of obstetrical brachial plexus injury is primary reconstruction with sural nerve grafts. Recently, the nerve-to-nerve transfer technique has been used to treat brachial plexus injury in adults, affording the benefit of distal coaptations that minimize regenerative distance. The purpose of this study was to test the hypothesis that nerve transfers are effective in reconstructing isolated upper trunk obstetrical brachial plexus injuries. Ten patients aged 10 to 18 months were treated with three nerve transfers: spinal accessory nerve to the suprascapular nerve for shoulder abduction and external rotation; a radial to axillary nerve for shoulder abduction; and ulnar or median nerve transfer to the musculocutaneous nerve for elbow flexion. Patients were assessed preoperatively and postoperatively using the Active Movement Scale. All patients were followed regularly for up to 2 years. Improvement in elbow and shoulder function was observed between 6 and 24 months. By 6 months, all patients passed the cookie test. At 24 months, shoulder abduction improved from 3.7 ± 0.6 to 5.0 ± 0.5, shoulder external rotation from 1.8 ± 0.4 to 4.3 ± 0.6, shoulder flexion from 3.7 ± 0.5 to 5.4 ± 0.5, elbow flexion from 3.7 ± 0.6 to 6.3 ± 0.2, and forearm supination from 2.1 ± 0.4 to 5.9 ± 0.2. There was no clinically appreciable donor-site morbidity. Nerve transfers reduced operative times compared with traditional nerve grafting procedures. Those patients showed significant gains in Active Movement Scale score by 24 months postoperatively, comparable to results achieved by nerve grafting. These findings support nerve transfers as a potential alternative treatment option for upper trunk obstetrical brachial plexus injuries. Therapeutic, IV.