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      Neurotization of free gracilis transfer with the brachialis branch of the musculocutaneous nerve to restore finger and thumb flexion in lower trunk brachial plexus injury: an anatomical study and case report

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          Abstract

          OBJECTIVE:

          To investigate the feasibility of using free gracilis muscle transfer along with the brachialis muscle branch of the musculocutaneous nerve to restore finger and thumb flexion in lower trunk brachial plexus injury according to an anatomical study and a case report.

          METHODS:

          Thirty formalin-fixed upper extremities from 15 adult cadavers were used in this study. The distance from the point at which the brachialis muscle branch of the musculocutaneous nerve originates to the midpoint of the humeral condylar was measured, as well as the length, diameter, course and branch type of the brachialis muscle branch of the musculocutaneous nerve. An 18-year-old male who sustained an injury to the left brachial plexus underwent free gracilis transfer using the brachialis muscle branch of the musculocutaneous nerve as the donor nerve to restore finger and thumb flexion. Elbow flexion power and hand grip strength were recorded according to British Medical Research Council standards. Postoperative measures of the total active motion of the fingers were obtained monthly.

          RESULTS:

          The mean length and diameter of the brachialis muscle branch of the musculocutaneous nerve were 52.66±6.45 and 1.39±0.09 mm, respectively, and three branching types were observed. For the patient, the first gracilis contraction occurred during the 4th month. A noticeable improvement was observed in digit flexion one year later; the muscle power was M4, and the total active motion of the fingers was 209°.

          CONCLUSIONS:

          Repairing injury to the lower trunk of the brachial plexus by transferring the brachialis muscle branch of the musculocutaneous nerve to the anterior branch of the obturator nerve using a tension-free direct suture is technically feasible, and the clinical outcome was satisfactory in a single surgical patient.

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          Outcomes of brachial plexus reconstruction in 204 patients with devastating paralysis.

          Marios Vekris, P Soucacos, Julia Terzis (1999)
          Thus far, devastating injuries of the adult brachial plexus have had a poor prognosis. This article presents the possible outcomes of aggressive microsurgical reconstruction in the largest series of patients in North America to date. It should change the pessimistic outlook that has surrounded these lesions. In this study, the outcomes of surgery were analyzed in relation to the type and level of injury, the age of the patient, and the denervation time; stronger donors for neurotization in relation to the various targets were delineated. The results were analyzed in 204 patients with adequate follow-up from a total of 263 patients who were operated on between 1978 and 1996. The mean age of the patients was 25.9 years, and the injuries were caused by high-velocity motor accidents involving avulsion in 55 percent of the patients. Nerve reconstruction included 577 nerve repairs (140 direct neurotizations and 437 cases of nerve grafting). Microneurolysis was performed in 89 cases. Vascularized nerve grafts were used in 120 repairs. Muscle transfers (29 pedicled and 78 free) were used to enhance function. The results were good or excellent in 75 percent of suprascapular nerve reconstructions, 40 percent of deltoid reconstructions, 48 percent of biceps reconstructions, 30 percent of triceps reconstructions, 35 percent of finger-flexion reconstructions, and 15 percent of finger-extension reconstructions. The majority of the patients had protective sensation and pain relief postoperatively.
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            Innervation ratio is an important determinant of force in normal and reinnervated rat tibialis anterior muscles.

            J Tötösy de Zepetnek, H V Zung, S Erdebil … (1992)
            1. The technique of glycogen depletion and periodic acid-Schiff (PAS) staining, which identifies glycogen-free muscle fibers, was used to directly count the number (N) and measure the cross-sectional area (CSA) of muscle fibers in single motor units (MUs) from normal and reinnervated tibialis anterior (TA) muscles. Indirect estimates, derived from the proportions of muscle fiber types to MU types, were also made, and force per unit area (or specific force, SF) was calculated. Previous results using direct and indirect approaches have been contradictory. To shed more light on this issue, the relative contributions of N, mean fiber area (A), and SF to muscle-unit force were determined by the use of both methods. 2. TA muscles were examined in experimental rats 3.5-10 mo after cutting and resuturing the common peroneal nerve in one hindlimb and in muscles in age-matched control rats. Ventral roots were dissected to isolate and characterize single MUs according to contraction speed, sag, and fatigability. One unit per muscle was selected for repetitive tetanic stimulation designed to deplete muscle fiber glycogen stores. Muscles were removed for identification of the unit with the PAS reaction and histochemical fiber typing by the use of modified standard techniques. 3. In the total population of MUs sampled, isometric tetanic force ranged from 5 to 441 mN in normal muscles and from 5 to 498 mN in reinnervated muscles, and the mean values were not significantly different. In the smaller sample of glycogen-depleted units from normal muscle, for a force range of 14-217 mN, N varied from 57 to 202, and A varied from 1,135 +/- 45 to 6,706 +/- 172 (SE) microns2. Within each unit the variation in fiber area is broad. After reinnervation, for a force range of 30-278 mN, N varied from 70 to 374, and A varied from 1,694 +/- 81 to 5,425 +/- 93 microns2. Mean fiber number was 153 +/- 18 in reinnervated muscle, which is significantly higher (P less than 0.01) than the normal value of 121 +/- 9. 4. The contribution of N and A to MU tetanic force was assessed by plotting each factor as a function of force on a log-log scale. N accounts for 39% and A for 49% of the variation in force in normal muscle. The contributions are changed after reinnervation where N, accounting for 65% of force, appears to compensate for the reduced range in A, which accounts for only 19% of the variation in force.(ABSTRACT TRUNCATED AT 400 WORDS)
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              Surgical treatment for total root avulsion type brachial plexus injuries by neurotization: A prospective comparison study between total and hemicontralateral C7 nerve root transfer

              Yuan-Kun Tu, Athena Tsai, Chih-Han Chang … (2013)
              Purpose: We conducted a clinical study to evaluate the effects of neurotization, especially comparing the total contralateral C7 (CC7) root transfer to hemi-CC7 transfer, on total root avulsion brachial plexus injuries (BPI). Methods: Forty patients who received neurotization for BPI were enrolled in this prospective study. Group 1 (n = 20) received hemi-CC7 transfer for hand function, while group 2 (n = 20) received total-CC7 transfer. Additional neurotization included spinal accessory, phrenic, and intercostal nerve transfer for shoulder and elbow function. The results were evaluated with an average of 6 years follow-up. Results: Group 1 had fewer donor site complications (15%) than group 2 (45%); group 2 had significantly better hand M3 and M4 motor function (65%) than group 1 (30%; P = 0.02). There was no difference in sensory recovery. Significantly, better shoulder function was obtained by simultaneous neurotization on both suprascapular and axillary nerves. Conclusions: Total-CC7 transfer had better hand recovery but more donor complications than hemi-CC7. Neurotization on both supra-scapular and axillary nerves improved shoulder recovery. © 2013 The Authors. Microsurgery published by Wiley Periodicals, Inc. Microsurgery 34:91–101, 2014.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Clinics (Sao Paulo)
                Journal ID (iso-abbrev): Clinics (Sao Paulo)
                Title: Clinics
                Publisher: Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
                ISSN (Print): 1807-5932
                ISSN (Electronic): 1980-5322
                Publication date (Electronic): April 2016
                Publication date (Print): April 2016
                Volume: 71
                Issue: 4
                Pages: 193-198
                Affiliations
                [I ]The First Affiliated Hospital of Sun Yat-sen University, Department of Microsurgery and Orthopedic Trauma, Guangzhou, China
                [II ]Naval-Hospital, Department of Orthopedic Trauma, Guangzhou, China
                [III ]The First Affiliated Hospital of Henan University of Science and Technology, Department of Orthopedic Surgery, Luoyang, China
                Author notes
                Article
                Publisher ID: cln_71p193
                DOI: 10.6061/clinics/2016(04)03
                PMC ID: 4825193
                PubMed ID: 27166768
                SO-VID: 1bf9e04f-a600-4163-b3e9-a210d37e6789
                Copyright © Copyright © 2016 CLINICS
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 19 October 2015
                Date revision received : 1 December 2015
                Date accepted : 28 January 2016
                Categories
                Subject: Clinical Science

                ScienceOpen disciplines: Medicine
                Keywords: inferior trunk of the brachial plexus injury,brachialis muscle branch of the musculocutaneous nerve,gracilis,muscle transfer
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: inferior trunk of the brachial plexus injury, brachialis muscle branch of the musculocutaneous nerve, gracilis, muscle transfer

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