Wound Healing/Plastic SurgeryContralateral medial pectoral nerve transfer with free gracilis muscle transfer in old brachial plexus palsy
Introduction
Most brachial plexus injuries are in the form of the avulsion of the nerve root from the spinal cord with preganglionic injury.1, 2, 3, 4, 5 These patients have a very poor prognosis of regaining acceptable performance. Total brachial plexus palsy leads to severe and chronic disorders that require timely and long-term treatment. Neural injuries cause sensory and motor disorders, muscular atrophy, and deformation. Multiple surgical operations lead to many problems and lack of cooperation. In these cases, different specialists should contribute and cooperate to achieve the best result.
Nowadays, nerve transfer6 is usually done in acute injuries and those that have occurred in less than a year.7, 8, 9, 10, 11, 12 There is an ongoing attempt to increase the number of intra- and extraplexal donor nerves for nerve reconstruction in these patients. Traditionally, intraplexal nerves including medial pectoral, thoracodorsal (ipsilateral), and an ipsilateral C7 nerve were used for patients with partial brachial plexus injury, while the hypoglossal, phrenic, motor nerve of cervical plexus, platysma motor branch, spinal accessory, and intercostals nerves were used for cases with pan-plexus injuries.13, 14, 15, 16, 17, 18, 19, 20, 21
However, in cases who first visit 2 y since the injury, muscles are already atrophied and nerve transfer alone is not helpful. In these cases, alternative techniques can be used. In the most complete method, a motor nerve is transferred as a recipient nerve and also an appropriate muscle as a free functional muscle to induce elbow flexion alone or synchronous elbow and finger flexion in the affected limb.22, 23, 24
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Ethical statement
This study was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences, Tehran, Iran (IR.SBMU.MSP.REC.1396.421). A written informed consent was obtained from all the patients for participate in study and also surgery.
Patients
From December 2003 to 2015, we reviewed 68 patients who had previous brachial injury approximately more than 2 y ago and received no treatment or had undergone an ineffective nerve transfer surgery at least 1.5 y ago by another surgeon. In all the cases,
Results
Overall, 68 patients, comprising 64 (94.1%) men and 4 (5.9%) women, underwent this operation from December 2003 to 2015. The average age of the patients was 22.95 ± 5.35 y (ranging from 15 to 48 y). The brachial plexus was involved on the right and left sides in 25 (36.8%) and 43 (63.2%) patients, respectively. The mean length of the sural nerve grafts was 44.4 ± 2.2 cm.
In two patients, we had free flap failure. This was probably due to technical problems, but we observed arterial thrombosis in
Discussion
Ikuta et al. were the first to use free-functioning muscle transfer (FFMT) in brachial plexus reconstruction for elbow flexion in children with delayed referrals.26 Today, FFMT is used in many cases of brachial plexus injury, particularly in cases with delayed referrals or where previous surgeries have failed. Moreover, Manktelow et al.24 and Doi et al.26 conducted extensive research on fundamental science, anatomy, and FFMT.
There is an ongoing attempt and research to find more extraplexal
Conclusion
In summary, in old brachial plexus injuries with total palsy when no nerve on the affected side is available for the free transmission of muscle, the extraplexal nerve of the other side combined with sural graft can be successfully used as an alternative approach.
Acknowledgment
This article has been extracted from the thesis written by Mr Hormoz Mahmoudvand in School of Medicine Shahid Beheshti University of Medical Sciences. (Registration No. 198).
Authors' contributions: Study design was contributed by M.Y. and A. R.; experimental study was carried out by H.M. and S.N.; data were analyzed by H.M, and S.N.; article was written M.Y., H.M., and A.R.
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