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Comparative Outcomes of Nerve Graft, Nerve Transfer, and Combined Reconstruction in Brachial Plexus Birth Injury
Conner J McMains, MD, Ty Monty, BS, Gwendolyn Hoben, MD, PhD, Dustin Ragan, PhD; Patrick Hettinger, MD
Medical College of Wisconsin, Milwaukee, WI
Background/Purpose:
Brachial plexus birth injury (1.5 per 1,000 births) produces several patterns of upper extremity deficit that may persist without surgical intervention. Traditional autologous nerve grafts and more contemporary nerve transfers each aim to restore function, but direct comparisons are scarce. We compared shoulder abduction, shoulder external rotation, and elbow flexion on the active movement scale 36 months after nerve graft, nerve transfer, or combined procedures.
Methods:
We performed a retrospective cohort study of 113 children (63 graft, 18 transfer, 32 combined) treated from 2010-2020. Patients receiving only neurolysis, tendon transfers, or with missing procedure data were excluded. The primary outcomes were strength and range of shoulder abduction, shoulder external rotation, and elbow flexion on the Active Movement Scale (AMS). We used a mixed linear effects model to compare outcomes between the three groups. We used Spearman correlations to assess the influence of graft?length and age, and Mann-Whitney-U tests were used for demographic subgroup analyses.
Results:
61 females and 44 males were enrolled. The mean age at surgery was 12.2 months. Median time to first measurable improvement was 6 months for graft, transfer, and combined groups (p=0.42). Patients who received nerve transfer had AMS scores 2.9 points higher at their last follow-up for shoulder abduction (p < 0.001). External rotation scores were not statistically different between groups (p = 0.085). Patients who received nerve transfer had AMS scores 1.87 points higher at their last follow-up for elbow flexion (p = 0.002). Total graft length was inversely correlated with shoulder external?rotation grade at 36 months (? = -0.25, p = 0.01). Sex and age at surgery had no effect on outcome of shoulder abduction, external rotation, or elbow flexion (
p > 0.05)
Conclusions:
Combining nerve graft and transfer achieves superior shoulder abduction and external rotation without delaying initial recovery. Shorter graft spans enhance functional gains. These findings support a combined reconstructive strategy with attention to graft length in the management of obstetric brachial plexus palsy.
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