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Functional Outcomes of Nerve Grafting and Triple Nerve Transfers For Upper Trunk Obstetrical Brachial Plexus Injuries
Kathleen O'Grady, MD1; Hollie Power, MD2; Jaret Olson, MD2; Michael Morhart, MD, FRCSC2; Rob Harrop3; Joe Watt2; K. Ming Chan, MD, FRCPC2
1Glenrose Rehabilitation Hospital, Edmonton, AB, Canada; 2University of Alberta, Edmonton, AB, Canada; 3University of Calgary, Calgary, AB, Canada

Purpose: Upper trunk obstetrical brachial plexus injury (OBPI) can cause profound shoulder and elbow dysfunction. Neuroma excision with interpositional sural nerve grafting is the current gold standard surgical treatment. However, distal nerve transfers have potential advantages including reduced distance to reinnervation, motor-to-motor coaptation, and shorter recovery time. The goal of this study was to compare the clinical outcomes and healthcare costs between nerve grafting and distal nerve transfers in children with upper trunk OBPI.

Methods: In this prospective cohort study, children who received the triple nerve transfer procedure (spinal accessory to suprascapular nerve, radial to axillary nerve and ulnar to musculocutaneous nerve) were evaluated with the Active movement scale (AMS) at regular intervals for a minimum of 2 years. Their outcomes were compared to children with underwent nerve graft reconstruction. To evaluate healthcare utilization, a direct cost analysis was also performed.

Results: Twelve patients who underwent nerve grafting were compared to 14 patients who underwent triple nerve transfers. Both groups had similar baseline characteristics and showed improved shoulder and elbow function following surgery, with the nerve transfer group displaying significantly better shoulder external rotation (AMS 2 years post-op= 4.3+0.5 (mean+SD) for transfers vs. 2.9+0.6 for graft, p<0.05), elbow flexion (6.1+0.5 for transfers vs. 5.5+0.2 for graft, p<0.05) and forearm supination (5.6+1.0 for transfers vs. 4.4+0.6 for graft, p<0.05) 2 years post-surgery. Nerve transfer donors had no loss of strength post-operatively. The operative time (2h19m+25m vs. 8h15m+1h31m), length of hospital stay (1.1+0.4 vs. 3.4+0.5 days) were significantly lower and overall cost was ~50% less in the nerve transfer group.

Conclusions: Triple nerve transfers for upper trunk OBPI is a feasible option with functional outcomes at least equivalent to that of traditional nerve grafting for shoulder flexion and abduction and faster recovery and better outcomes for shoulder external rotation, elbow flexion and forearm supination. Furthermore, nerve transfers are significantly less expensive than nerve graft reconstruction in this patient population.


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