Factors Affecting Outcome of Triceps Motor Branch Transfer for Isolated Axillary Nerve Injury.

Department of Orthopedic Surgery, St. Vincent's Hospital, the Catholic University of Korea, Seoul, Korea
The Journal of hand surgery (Impact Factor: 1.33). 10/2012; DOI: 10.1016/j.jhsa.2012.07.030
Source: PubMed

ABSTRACT PURPOSE: Triceps motor branch transfer has been used in upper brachial plexus injury and is potentially effective for isolated axillary nerve injury in lieu of sural nerve grafting. We evaluated the functional outcome of this procedure and determined factors that influenced the outcome. METHODS: A retrospective chart review was performed of 21 patients (mean age, 38 y; range, 16-79 y) who underwent triceps motor branch transfer for the treatment of isolated axillary nerve injury. Deltoid muscle strength was evaluated using the modified British Medical Research Council grading at the last follow-up (mean, 21 mo; range, 12-41 mo). The following variables were analyzed to determine whether they affected the outcome of the nerve transfer: the age and sex of the patient, delay from injury to surgery, body mass index (BMI), severity of trauma, and presence of rotator cuff lesions. The Spearman correlation coefficient and multiple linear regression were performed for statistical analysis. RESULTS: The average Medical Research Council grade of deltoid muscle strength was 3.5 ± 1.1. Deltoid muscle strength correlated with the age of the patient, delay from injury to surgery, and BMI of the patient. Five patients failed to achieve more than M3 grade. Among them, 4 patients were older than 50 years and 1 was treated 14 months after injury. In the multiple linear regression model, the delay from injury to surgery, age of the patient, and BMI of the patient were the important factors, in that order, that affected the outcome of this procedure. CONCLUSIONS: Isolated axillary nerve injury can be treated successfully with triceps motor branch transfer. However, outstanding outcomes are not universal, with one fourth failing to achieve M3 strength. The outcome of this procedure is affected by the delay from injury to surgery and the age and BMI of the patient. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

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    ABSTRACT: To compare the functional and EMG outcomes of long-nerve grafts to nerve transfers for complete axillary nerve palsy. Over a 10-year period at a single institution, 14 patients with axillary nerve palsy were treated with long-nerve grafts and 24 patients were treated with triceps-to-axillary nerve transfers by the same surgeon (S.W.W.). Data were collected prospectively at regular intervals, beginning before surgery and continuing up to 11 years after surgery. Prior to intervention, all patients demonstrated EMG evidence of complete denervation of the deltoid. Deltoid recovery (Medical Research Council [MRC] grade), shoulder abduction (°), improvement in shoulder abduction (°), and EMG evidence of deltoid reinnervation were compared between cohorts. There were no significant differences between the long-nerve graft cohort and the nerve transfer cohort with respect to postoperative range of motion, deltoid recovery, improvement in shoulder abduction, or EMG evidence of deltoid reinnervation. These data demonstrate that outcomes of long-nerve grafts for axillary nerve palsy are comparable with those of modern nerve transfers and question a widely held belief that long-nerve grafts do poorly. When healthy donor roots or trunks are available, long-nerve grafts should not be overlooked as an effective intervention for the treatment of axillary nerve injuries in adults with brachial plexus injuries. Therapeutic III.
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    ABSTRACT: Background Nerve transfer to the deltoid muscle using the nerve to the long head of the triceps is a reliable method for restoration of deltoid function. The aim of this retrospective study was to report the results of nerve transfer to the deltoid muscle using the nerve to the long head of the triceps procedure using a robot. Methods Our series included six patients (mean age 36.3 years) with total deltoid muscle paralysis. A da Vinci-S robot was placed in position. After dissection of the quadrilateral and triangular spaces, the anterior branch of the axillary nerve and the branch to the long head of the triceps were transected, and then robotically sutured with two 10-0 nylon stiches. In two cases, an endoscopic procedure was tried under carbon dioxide (CO2) insufflation. Results In all patients except one, deltoid function against resistance (M4) was obtained at the last follow-up evaluation. The average shoulder abduction was 112 degrees. No weakness of elbow extension was observed. In two cases with the endoscopic technique, vision was blurred and conversion to open technique was performed. Conclusion The advantages of robotic microsurgery are motion scaling and disappearance of physiological tremor. Reasons for failure of the endoscopic technique could be explained by insufficient pressure. We had no difficulty using the robot without the sensory feedback. The robot-assisted nerve transfer to deltoid muscle using the nerve to the long head of the triceps was a feasible application for restoration of shoulder abduction after brachial plexus or axillary nerve injury.Therapeutic Study.Level of Evidence IV.
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    ABSTRACT: Object Axillary nerve palsy, isolated or as part of a more complex brachial plexus injury, can have profound effects on upper-extremity function. Radial to axillary nerve neurotization is a useful technique for regaining shoulder abduction with little compromise of other neurological function. A combined experience of this procedure used in children is reviewed. Methods A retrospective review of the authors' experience across 3 tertiary care centers with brachial plexus and peripheral nerve injury in children (younger than 18 years) revealed 7 cases involving patients with axillary nerve injury as part of an overall brachial plexus injury with persistent shoulder abduction deficits. Two surgical approaches to the region were used. Results Four infants (ages 0.6, 0.8, 0.8, and 0.6 years) and 3 older children (ages 8, 15, and 17 years) underwent surgical intervention. No patient had significant shoulder abduction past 15° preoperatively. In 3 cases, additional neurotization was performed in conjunction with the procedure of interest. Two surgical approaches were used: posterior and transaxillary. All patients displayed improvement in shoulder abduction. All were able to activate their deltoid muscle to raise their arm against gravity and 4 of 7 were able to abduct against resistance. The median duration of follow-up was 15 months (range 8 months to 5.9 years). Conclusions Radial to axillary nerve neurotization improved shoulder abduction in this series of patients treated at 3 institutions. While rarely used in children, this neurotization procedure is an excellent option to restore deltoid function in children with brachial plexus injury due to birth or accidental trauma.
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