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American Association for Hand Surgery

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Optimal Techniques for Surgery in Isolated Radial Nerve Palsy: A Systematic Review and Pooled Analysis
Nirbhay S. Jain, MD1, Meaghan L Barr, MD2, Daniel Kim, BS3 and Neil Ford Jones, MD3, (1)University of California, Los Angeles, Los Angeles, CA, (2)University of California Los Angeles, Los Angeles, CA, (3)UCLA, Los Angeles, CA

Introduction:
Isolated radial nerve palsy is a debilitating injury treated with nerve grafts, tendon transfers, and nerve transfers. There is no consensus on the optimal technique for reconstruction. Therefore, we performed a systemic review and pooled analysis to determine which surgical intervention provides the best outcomes.

Methods:
A systemic review was conducted according to PRISMA guidelines. Twenty-four papers met inclusion criteria. Data extraction was performed. Grading scales were converted into a tripartite scoring system to compare outcomes between techniques. Pooled Chi-squared analyses with Bonferroni corrections were performed with tests of significant and a p-value < 0.05.

Results:
Three hundred seventy patients were analyzed. Tendon transfers resulted in the greatest percentage of good outcomes (86%) and the lowest percentage of poor outcomes (8%). This data was statistically significant (p = 0.000). Rates of poor outcomes after nerve transfer were statistically equivalent at the elbow, wrist, and fingers, but rates of good outcomes were superior more proximally (p = 0.031). Rates of good and poor outcomes were equivalent at all joint levels for tendon transfers and nerve grafts (p > 0.05). At the wrist, tendon transfers were superior to nerve grafts and nerve transfers (p = 0.000). Nerve grafts and nerve transfers provided equivalent outcomes at all three levels (p > 0.05).
After converting disparate grading scales into a uniform tripartite scoring system, analysis was performed by pooling together individual studies. There was no statistical difference in distribution of outcomes regardless of grading system. Although isolating patients evaluated on the MRC grading system suggested that all three techniques were equivalent, this analysis was biased by the small sample size of the tendon transfer patients represented in the data (n=13 of 245 tendon transfer patients, or 5%); in comparison, almost all nerve transfer and nerve grafting patients were included in this analysis likely skewing the data.

Conclusions:
Our study analyzed reported outcomes of nerve grafts, tendon transfers, and nerve transfers for reconstruction of isolated radial nerve palsy. Pooled analysis demonstrated that tendon transfers had higher rates of superior outcomes with similar rates of inferior outcomes as compared to nerve transfers and nerve grafts. Both tendon transfers and nerve transfers demonstrated good results at all reported anatomic levels, though nerve grafts and nerve transfers had worse outcomes distally. Our findings suggest that tendon transfers should always be considered for reconstruction of patients with isolated radial nerve palsy because nerve-based reconstruction is less reproducible


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