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J Reconstr Microsurg 2023; 39(04): 279-287
DOI: 10.1055/s-0042-1755612
Review Article

Long-Term Outcome of 118 Acute Total Brachial Plexus Injury Patients Using Free Vascularized Ulnar Nerve Graft to Innervate the Median Nerve

Jennifer An-Jou Lin
1   Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
,
Johnny Chuieng-Yi Lu 
1   Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
,
Tommy Nai-Jen Chang
1   Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
,
Ahmet Hamdi Sakarya 
1   Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
,
David Chwei-Chin Chuang 
1   Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
› Author Affiliations Funding This study was funded by Chang Gung Memorial Hospital under the grant number CORPG3H0111.
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Abstract

Background The restoration of finger movement in total brachial plexus injuries (BPIs) is an ultimate challenge. Pedicled vascularized ulnar nerve graft (VUNG) connecting a proximal root to distal target nerves has shown unpredictable outcomes. We modified this technique by harvesting VUNG as a free flap to reinnervate median nerve (MN). We analyzed the long-term outcomes of these methods.

Methods From years 1998 to 2015, 118 acute total brachial plexus patients received free VUNG to innervate the MN. Patients were followed up at least 5 years after the initial surgery. Donor nerves included the ipsilateral C5 root (25 patients) or contralateral C7 root (CC7 = 93 patients). Recovery of finger and elbow flexion was evaluated with the modified Medical Research Council system. Michigan Hand Score and Quick-DASH were used to represent the patient-reported outcomes.

Results For finger flexion, ipsilateral C5 transfer to MN alone yielded similar outcomes to MN + MCN (musculocutaneous nerve), while CC7 had significantly better finger flexion when coapted to MN alone than to MN + MCN. Approximately 75% patients were able to achieve finger flexion with nerve transfer alone. For elbow flexion, best outcome was seen in the ipsilateral C5 to MCN and MN.

Conclusion In acute total BPI, the priority is to identify the ipsilateral C5 root to innervate MN, with concomitant innervation of MCN to establish the best outcomes for finger and elbow flexion. CC7 is more reliable when used to innervate one target (MN).

Level of evidence: III.

Keywords

free vascularized ulnar nerve graft - total brachial plexus injury - contralateral C7 - ipsilateral C5

Ethical Approval

Ethical approval to report these cases was obtained from the Institutional Review Board in Chang Gung Memorial Hospital under the given certification number “202001873B0.”


Informed Consent

Written informed consent was obtained from the patient(s) for their anonymized information to be published in this article.


Author Contributions

J.A.L. wrote the first draft of the manuscript. J.A.L. and A.H.S. were involved in data collection and data analysis. J.C.L. and D.C.C. were involved with the study design. D.C.C., T.N.C., and J.C.L. were the operating surgeons for the brachial plexus surgeries, and helped revised the final manuscript. All authors reviewed and approved the final version of the manuscript.




Publication History

Received: 14 March 2022

Accepted: 23 June 2022

Article published online:
03 October 2022

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