![Patient diagnosed preoperatively with level III brachial plexus injury [according to the classification of Chuang (Chuang DCC. Adult brachial plexus injuries. In: Mathes SJ, Hentz VR, eds. Plastic Surgery. 2nd ed. Philadelphia: Saunders Elsevier; 2006:515-538)] with shoulder and elbow palsies. Brachial plexus exploration with osteotomy of the clavicle was performed. Intraoperative findings showed the anterior division of the upper trunk still in continuity with the lateral cord without rupture. Rupture of the posterior divisions of the upper and middle trunks was reconstructed with nerve grafts.](https://www.researchgate.net/profile/Tommy-Nai-Jen-Chang/publication/322169569/figure/fig2/AS:579276898566144@1515121783865/Patient-diagnosed-preoperatively-with-level-III-brachial-plexus-injury-according-to-the_Q320.jpg)
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68e
Restoration of elbow flexion is always the first
priority in brachial plexus injury reconstruc-
tion. The relative success of brachial plexus
injury reconstruction is dependent on many fac-
tors, including the patient’s age, comorbidities,
severity of injury, length of time elapsed since
injury, surgical technique, quality of the donor
neurotizers, length of nerve grafts, and more.1–3
For an incomplete brachial plexus injury
involving the upper plexus (C5−6 with or without
C7) with intact C8−T1, according to the traditional
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.
Copyright © 2017 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000003935
Ching-Hsuan Hu, M.D.
Tommy Nai-Jen Chang, M.D.
Johnny Chuieng-Yi Lu, M.D.
Vincent G. Laurence, M.D.
David Chwei-Chin
Chuang, M.D.
Taoyuan, Taiwan
Background: Surgical strategy to treat incomplete brachial plexus injury with
palsies of the shoulder and elbow by using proximal nerve graft/transfer or
distal nerve transfer is still debated. The aim of this study was to compare both
strategies with respect to the recovery of elbow flexion.
Methods: One hundred forty-seven patients were enrolled: 76 patients underwent
reconstruction using proximal nerve graft/transfer, and 71 patients underwent
reconstruction using distal nerve transfer. All patients were evaluated preop-
eratively and postoperatively to assess the recovery rate and muscle strength of
elbow flexion. Shoulder abduction and hand grip power were also recorded to
assess any concomitant postoperative changes between the two methods.
Results: The best recovery rate for functional elbow flexion (p = 0.006) and the
fastest recovery to M3 strength (p < 0.001) were found in the double fascicular
transfer group. However, recovery of shoulder abduction with proximal nerve
graft/transfer was significantly better than with distal nerve transfer (80.3 per-
cent versus 66.2 percent in shoulder abduction ≥60 degrees; and 56.6 percent
versus 38.0 percent in shoulder abduction ≥90 degrees). A significant decrease
in grip strength between the operative and nonoperative hands was also found
in patients undergoing distal nerve transfer (p = 0.001).
Conclusions: Proximal nerve graft/transfer offers more accurate diagnosis
and proper treatment to restore shoulder and elbow function simultaneously.
Distal nerve transfer can offer more efficient elbow flexion. Combined, both
strategies in primary nerve reconstruction are especially recommended when
there is no healthy or not enough donor nerve available. (Plast. Reconstr. Surg.
141: 68e, 2018.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
From the Department of Plastic Surgery, Chang Gung
Memorial Hospital, Chang Gung Medical College and
University.
Received for publication October 22, 2016; accepted June
21, 2017.
Comparison of Surgical Strategies between
Proximal Nerve Graft and/or Nerve Transfer
and Distal Nerve Transfer Based on Functional
Restoration of Elbow Flexion: A Retrospective
Review of 147 Patients
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HAND/PERIPHERAL NERVE
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 141, Number 1 • Incomplete Brachial Plexus Injury
69e
strategy,1–3 the plexus would be explored and dis-
sected to the suspected zone of injury as indicated
by clinical examination and imaging studies until
healthy, grossly normal nerve tissues are encoun-
tered. This allows an accurate and thorough diag-
nosis to define the extent of injury and requirement
for reconstruction. Nerve grafts for connection of
the healthy proximal and distal stumps (such as C5
to C5, C6 to C6) or nerve transfers for reinnerva-
tion if C5 or C6 single root or both roots are either
completely avulsed and unavailable or unhealthy.
Nerve transfers may be either intraplexus nerve
transfers (e.g., C5 to C6, or C5 to the anterior
division of the upper trunk with nerve grafts) or
extraplexus nerve transfers (e.g., phrenic or spinal
accessory nerve as donor to C6, or to the muscu-
locutaneous nerve with nerve grafts). This surgical
strategy is here called proximal nerve graft and/or
nerve transfer technique. The use of spinal acces-
sory nerve (volar approach),3 contralateral C7,4 or
intercostal nerve5 as the donor for transfer is also
generally considered as a proximal nerve transfer
because of the distance between donor nerve and
muscle target.
Distal nerve transfer, although used since
19946 and described extensively in the litera-
ture,7–12 is nonetheless a newer reconstructive
technique, in which a physiologically intact
nerve, when sacrificed with minimal morbidity,
is intentionally divided and transferred to the
distal stump (by means of end-to-end or, in some
cases, end-to-side manner) of a more functionally
important severed nerve. As a rule, it should be a
close-target (muscle or skin) nerve transfer and
direct nerve repair without nerve grafts. Partial
ulnar or median nerve fascicle transfer (Oberlin
method6,7) and double fascicular transfer [fascicle
of ulnar nerve transfer to the biceps branch and
fascicle of median nerve transfer to the brachialis
branch simultaneously (Mackinnon method)8–10]
are examples of distal nerve transfer for elbow
flexion. Distal nerve transfer provides an exciting
alternative option for elbow flexion with charac-
teristics of nerve dissection in the healthy tissue
(no scar problem), direct nerve coaptation with-
out nerve graft, close to the target muscle, short
regeneration time, short rehabilitation, and quick
recovery. In the past two decades, a major shift
away from the traditional proximal nerve graft/
transfer option to the distal nerve transfer option
has occurred. Consequently, distal nerve transfer
has become part of the standard choices avail-
able to the reconstructive surgeon facing bra-
chial plexus injury or a high level of limb nerve
injury.11,12
Consensus regarding the optimal recon-
structive strategy for restoration of elbow flexion
remains elusive. The aim of this study was to com-
pare both strategies in acute brachial plexus injury
patients with shoulder and elbow palsies but with
preserved hand function (i.e., upper plexus inju-
ries), evaluating the strength and rate of recovery
of elbow flexion, and any concomitant effects on
hand grip strength and shoulder abduction.
PATIENTS AND METHODS
From September of 1985 to September of
2013, 1950 adult brachial plexus injury recon-
structions were performed by the senior author
(D.C.C.C.) at Linkou Chang-Gung Memorial
Hospital. To ensure consistency and maturity
of technique and because distal nerve transfer
was not performed in the earlier years, the first
1000 cases were excluded. Any cases of obstet-
rical brachial plexus palsy and brachial plexus
injury secondary to knife or gunshot injury,
tumor resection, or enterovirus infection were
excluded. Additional exclusion included preop-
erative elbow flexion strength ≥M2 (according to
the Medical Research Council classification) or
shoulder abduction (≥30 degrees), finger flex-
ion strength < M3, infraclavicular brachial plexus
injury, total root avulsion or complete brachial
plexus palsies, or reconstruction procedure by
neurolysis only. Cases with missing notes, missed
follow-up, and follow-up less than 4 years were
excluded. Cases in which there was contralateral
C7 transfer or intercostal nerve transfer were
also excluded because their transfer would cause
confusion in grouping. After applying the above
exclusion criteria, 147 patients remained for the
study.
Of the 147 patients, 124 were men and 23
were women. All were caused by motorcycle acci-
dents. The mean age of the cohort was 29.9 ±
12.5 years. The interval from injury to operation
was 4.3 ± 1.7 months (Table 1). Maximum strength
of elbow flexion and the recovery time to obtain
a strength greater than over equal to M3 were
recorded. A modified Medical Research Council
grading system was used with an additional sub-
class: M0, no contraction; M1, trace of contraction;
M2, contraction with elimination of gravity; M3,
contraction against gravity; M3+, contraction with
resistance against a finger (index) for less than
30 seconds; M4, contraction with resistance against
one finger for greater than 30 seconds; and M5,
full strength.13,14 A score of greater than over equal
to M3 defines functional recovery. Recovery time
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
70e
Plastic and Reconstructive Surgery • January 2018
was calculated from the date of surgery to the date
of the follow-up clinic visit at which the patient
first demonstrated functional recovery of elbow
flexion. Results were analyzed with respect to the
patient’s age, sex, duration from injury to opera-
tion, comorbidity, and method of reconstruction.
In addition, shoulder abduction was assessed in
both groups, and hand grip strength was assessed
in the distal nerve transfer group. Grip strength
was recorded for both operative and nonoperative
limbs, and the difference was compared to that
of a control group, a randomly selected group of
healthy individuals (n = 10).
Of the 147 patients, 76 underwent recon-
struction using proximal nerve graft/transfer,
with all neurotizers either ipsilateral intraplexus
or extraplexus nerves (Table 2). The remaining
71 patients underwent distal nerve transfer, with
all neurotizers close to the muscle target and no
nerve grafts used.
Operative Procedures
Proximal Nerve Graft/Transfer Technique
All of these patients had brachial plexus
exploration to establish the precise nature and
extent of lesions, determine whether the lesion
Table 1. Patient Demographic Data*
Nerve Repair Type
Proximal
Nerve Graft/
Transfer (%)
Distal Nerve Transfer
Total (%) p
Oberlin I
(%)† Mackinnon
(%)‡ Both (%)
No. of patients (%) 76 (51.7) 28 (19.0) 43 (29.3) 71 147 —
Sex
Male 61 23 40 63 124
Female 15 5 3 8 23 0.18
Mean age ± SD, yr 26.8 ± 10.7 34.1 ± 12.3 32.7 ± 14.2 33.3 ± 13.4 29.9 ± 12.5 0.03§
Mean time from injury to
operation ± SD, mo 3.9 ± 1.5 4.7 ± 1.9 4.7 ± 1.8 4.7 ± 1.8 4.3 ± 1.7 0.007§
Comorbidity
Smoke 15 (19.7) 11 (39.3) 16 (37.2) 27 (38.0) 42 (28.6) 0.01§
Diabetes 1 (1.3) 1 (3.6) 2 (4.7) 3 (4.2) 4 (2.7) 0.5
Associate injury (ipsilateral upper
extremity fracture) 32 (42.1) 11 (39.3) 21 (48.8) 32 (45.1) 64 (43.5) 0.6
*n = 147 patients.
†Fascicle of the ulnar nerve or fascicle of the median nerve to branch of the biceps muscle.
‡Fascicle of the ulnar nerve to branch of the biceps muscle plus fascicle of the median nerve to branch of the brachialis muscle.
§p < 0.05 = Proximal nerve neurotization group vs. all distal nerve transfer group.
Table 2. Proximal Nerve Graft/Transfer Group*
Type Target No. of Patients
No. of Patients
Achieving ≥M3
Function (%)
No. of Patients
Achieving ≥M4
Function (%)
Intraplexus donor C5† C5 3 3 (100) 2 (66.7)
C6 9 8 (88.9) 6 (66.7)
AD† 36 30 (83.3) 21 (58.3)
LC 3 3 (100) 3 (100)
MC 1 1 (100) 0 (0)
Total 52 45 (86.5) 32 (61.5)
C6 C6 2 1 (50) 1 (50)
AD 6 5 (83.3) 3 (50)
LC 3 2 (66.7) 1 (33.3)
MC 1 1 (100) 1 (100)
Total 12 9 (75) 6 (50)
C7 AD 2 2 (100) 2 (100)
UT LC 1 1 (100) 1 (100)
AD AD 2 2 (100) 2 (100)
MC 2 2 (100) 1 (50)
Total 7 7 (100) 6 (85.7)
Total 71 61 (85.9) 44 (62)
Extraplexus donor Ph or XI AD 5 4 (80.0) 2 (40.0)
Total (intraplexus plus extraplexus donor) 76 65 (85.5) 46 (60.5)
AD, anterior division of the upper trunk; LC, lateral cord; MC, musculocutaneous nerve; Ph, phrenic nerve, XI, spinal accessory nerve.
*Different nerve neurotizers with different functional elbow flexion recovery (M ≥ 3 and M ≥ 4).
†On subgroup analysis, there is no significant difference between C5-AD and distal nerve transfer for elbow flexion to M3 and M4.
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 141, Number 1 • Incomplete Brachial Plexus Injury
71e
was caused by rupture or avulsion, and locate
healthy portions of affected nerves proximally and
distally. The available neurotizer(s), either from
intraplexus nerves (including C5, C6, C7, upper
trunk, and anterior division of upper trunk) or
from extraplexus nerves (including phrenic and
spinal accessory nerves) were identified and con-
firmed by nerve stimulation, divided, and trans-
ferred (Table 2). Shoulder abduction was also
performed at this time, given the ideal time for
shoulder reconstruction, achieved by proximal
nerve graft/transfer to the suprascapular nerve,
posterior division of the upper trunk, or axillary
nerve, depending on intraoperative findings.
Distal Nerve Transfer
Patients in the distal nerve transfer group
might or might not have undergone brachial
plexus exploration. Distal nerve transfer was
either single-fascicle (either partial ulnar or partial
median, depending on which appeared stronger
and/or healthier) transfer to the biceps branch of
musculocutaneous nerve, or double-fascicle trans-
fer (partial ulnar and partial median to both biceps
and brachialis branches of the musculocutaneous
nerve). The donor ulnar (and/or median) and
musculocutaneous nerves were identified through
a medial arm incision. The biceps branch of the
musculocutaneous nerve was located, dissected in
a retrograde fashion (under microscope or loupe)
to a distance of 5 cm, transected, and transferred
to the nearby ulnar nerve. An intraneural dissec-
tion of the ulnar nerve was performed under oper-
ative microscopy, separating it into three fascicle
groups. Nerve stimulation was used to identify the
branch eliciting the greatest flexor carpi ulnaris
muscle contraction, and this was selected as the
neurotizer. The fascicle was transected distally
and transferred to the previously dissected biceps
branch of the musculocutaneous nerve. In cases
where the median nerve was used, an analogous
process was used, choosing the fascicle eliciting
the greatest flexor carpi radialis response.
For the double-fascicular transfer, the tech-
nique was similar, the only difference being that
the brachialis branch of the musculocutaneous
nerve was also dissected free of surrounding tis-
sues. Generally, the ulnar fascicle was coapted to
the biceps branch and the median fascicle to the
brachialis branch, but a good size match and a
tension-free coaptation were essential.
Statistical Analysis
Values were expressed as mean ± SD. Cate-
gorical and continuous variables were compared
with means and normal distribution using the
chi-square, Kruskal-Wallis, and Mann-Whitney
U tests. Values of p < 0.05 were considered statisti-
cally significant.
RESULTS
A number of demographic differences
were noted between the two groups. Patients
who underwent distal nerve transfer were sig-
nificantly older (p = 0.03), had a significantly
longer interval between injury and operation
(p = 0.007), and were significantly more likely to
have a smoking history (p = 0.01) than patients in
the group who underwent proximal nerve graft/
transfer (Table 1). Within the proximal nerve
graft/transfer group, patients with intraplexus
nerve grafts demonstrated somewhat better
recovery than those with extraplexus transfers,
but not to a statistically significant degree
(p = 0.5). C5 was the most common intraplexus
neurotizer, but there was no significant difference
in the recovery of elbow flexion between differ-
ent intraplexus donors. However, on subgroups
analysis, there is no significant difference between
C5 nerve grafting to the anterior division of the
upper trunk and distal nerve transfer for elbow
flexion to achieve M3 and M4 (Table 2). Extra-
plexus neurotization (phrenic and spinal acces-
sory nerves in this series) also provided functional
elbow flexion (≥M3) in 80 percent (four of five)
of patients, but there were too few patients to
assess significance (Table 2).
The best functional recovery (defined as
≥M3) of elbow flexion was seen in the group that
underwent double-fascicular distal nerve trans-
fer; 95.3 percent of these patients attained M3
or greater strength during the course of follow-
up (Table 3). The proximal nerve graft/transfer
group had the next best results, with 85.5 per-
cent of patients attaining M3 strength or greater.
However, the single-fascicular distal nerve trans-
fer group (Oberlin I group) had 67.9 percent
of patients meet this same standard (p = 0.006).
Similar results were noted with respect to patients
attaining greater than or equal to M4 strength:
83.7 percent for the Mackinnon method, 60.5 per-
cent for the proximal graft/transfer group, and
57.1 percent for the Oberlin I group (p = 0.016).
After advanced intragroup comparison, the sig-
nificant difference was between the Mackinnon
method group and the Oberlin I group, both for
greater than or equal to M3 and for greater than
or equal to M4 strength, and between the proxi-
mal graft/transfer group and the Oberlin I group,
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
72e
Plastic and Reconstructive Surgery • January 2018
but not between the Mackinnon method and the
proximal graft/transfer group for greater than or
equal to M3 strength. The significant difference
for greater than or equal to M4 strength is also
between the proximal graft/transfer group and
the Mackinnon method group (Table 3).
With respect to the length of time from sur-
gery to functional recovery of elbow flexion, the
best results were again seen with the Mackin-
non method, taking an average of 11.2 months
(range, 8.1 to 15.3 months) to attain greater than
or equal to M3 strength. In the proximal group,
there was an average of 16.7 months (range, 13.0
to 23.5 months), and for the Oberlin I group, 16.8
months (range, 11.5 to 22.1 months) (p < 0.001).
For those patients who eventually attained greater
than or equal to M4 strength, the Mac kinnon
group was again the fastest at an average of
17.6 months (range, 12.6 to 23.9 months), fol-
lowed by the proximal nerve graft/transfer group
at 21.3 months (range, 16.3 to 32.1 months), and
then the Oberlin I group at 26.0 months (range,
18.4 to 36.7 months; p = 0.013). The recovery time
was significant between the Mackinnon method
group and the Oberlin I group, both for greater
than or equal to M3 and for greater than or equal
to M4 strength, and between the proximal graft/
transfer group and the Mackinnon group, but not
between the Oberlin I group and the proximal
graft/transfer group.
Of the 147 patients in our study, 142 (96.6 per-
cent) underwent shoulder reconstruction simul-
taneously (Table 4). Overall, 108 patients (73.5
percent) achieved shoulder abduction greater
than or equal to 60 degrees and 70 (47.6 per-
cent) achieved shoulder abduction greater than
or equal to 90 degrees. Seventy-five of the patients
(98.7 percent) who underwent proximal nerve
graft/transfer for elbow flexion received shoulder
reconstruction, with 61 (80.3 percent) of them
achieving shoulder abduction greater than or
equal to 60 degrees and 43 patients (56.6 percent)
achieved greater than or equal to 90 degrees.
In the distal nerve transfer group, 67 patients
(94.3 percent) also underwent shoulder recon-
struction with proximal nerve transfer and/or
graft: 47 patients (66.2 percent) achieved greater
than or equal to 60 degrees, and 27 patients
(38.0 percent) achieved greater than or equal to
90 degrees. The difference in the percentage of
patients achieving 60 degrees and 90 degrees of
abduction between the proximal and distal nerve
groups was statistically significant (p = 0.05 and
p = 0.02, respectively), and there was also statisti-
cal significance between the proximal and distal
groups in the differing lengths of time required
to achieve 60 degrees of abduction (p = 0.003),
though not for 90 degrees of abduction.
Preoperative and postoperative grip strength
was evaluated in 36 of 71 patients (50.7 per-
cent) who underwent distal nerve transfer for
elbow flexion. The maximum postoperative grip
(mean, 17.2 ± 9.1 kg) strength was inferior to
preoperative grip (mean, 33.1 ± 8.2 kg) strength.
The difference was significant, with a value of
p < 0.001 (Fig. 1 and Table 5). Not a few patients
revealed permanent decreasing grip strength and
showed a positive Froment sign in the operative
limb. [See Video, Supplemental Digital Content
1, which shows the patient with right brachial
plexus injury of C5-C6 root avulsion managed
with the Oberlin I technique for elbow flexion 9
Table 3. Comparison of Two Groups Based on Elbow Recovery Rate and Speed of Elbow Flexion Recovery*
Nerve Repair Type Proximal Nerve
Graft/Transfer
Distal Nerve Transfer
Total pOberlin I (%)† Mackinnon (%)‡ Both
No. of patients achieving ≥M3 65 (85.5) 19 (67.9) 41 (95.3) 60 (84.5) 125 (85.0) 0.006§a
Recovery time, mo
Median 16.7 16.8 11.2 12.2 15.0 <0.001§b
No. of patients achieving ≥M4 46 (60.5) 16 (57.1) 36 (83.7) 52 (73.2) 98 (66.7) 0.016§c
Recovery time, mo
Median 21.3 26.0 17.6 19.8 20.4 0.013§d
*n = 147 patients.
†Fascicle of the ulnar nerve or fascicle of the median nerve to branch of the biceps muscle.
‡Fascicle of the ulnar nerve to branch of the biceps muscle plus fascicle of the median nerve to branch of the brachialis muscle.
§p < 0.05.
aPearson χ2 test followed by Bonferroni correction, significant difference between proximal and Oberlin, and Mackinnon and Oberlin.
bKruskal-Wallis test followed by post hoc Mann-Whitney multiple comparisons and Bonferroni correction. Significant difference between proxi-
mal and Mackinnon, and Mackinnon and Oberlin.
cPearson χ2 test follow by Bonferroni correction, significant difference between proximal and Mackinnon, and Mackinnon and Oberlin.
dKruskal-Wallis test followed by post hoc Mann-Whitney multiple comparisons and Bonferroni correction. Significant difference between proxi-
mal and Mackinnon, and Mackinnon and Oberlin.
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 141, Number 1 • Incomplete Brachial Plexus Injury
73e
years previously. The patient achieved M4 elbow
flexion but persistence of weak hand and finger
grip strength with a positive Froment sign (com-
pensation of the first web grip with flexor pol-
licis longus) on the operative hand, http://links.
lww.com/PRS/C502.] Reducing grip strength in
the injured limb compared with the noninjured
limb was noted after 4-year follow-up. The aver-
age difference in grip strength between operative
and nonoperative limbs is 59.1 percent with the
Oberlin I technique and 54.5 percent with the
Mackinnon technique. We also evaluated the grip
strength of 10 volunteers’ dominant and non-
dominant hands as the control group as an addi-
tional reference (Table 5). There is significant
grip strength difference between control and dis-
tal nerve transfer groups (p = 0.001) (Fig. 1 and
Table 5).
DISCUSSION
As noted above, there is no consensus
regarding the optimal reconstructive strategy
between proximal nerve graft/transfer and dis-
tal nerve transfer groups to obtain recovery of
elbow flexion. In our practice, brachial plexus
exploration has routinely been performed for
brachial plexus injuries, which provides the
most accurate diagnosis and helps determine
the optimal surgical treatment within the same
operative field. This was considered essential of
“no diagnosis, then no treatment.” With current
imaging technology, sensitivity is quite high,
but false-positives still exist. In our series, 14 of
147 cases (9.5 percent) were identified intra-
operatively as ruptured spinal nerves (C5, most
commonly), despite preoperative imaging indi-
cating complete root avulsion. Other benefits of
brachial plexus exploration are that the injury
is less severe (less than or equal to Sunderland
III injury15), the relative nerves are in continuity,
and neurolysis alone can result in the recovery
of elbow flexion (Figs. 2 and 3). This can avoid
iatrogenic injury by distal nerve transfer. In our
series, 14 patients with C5–7 nerve injury who
underwent only neurolysis achieved functional
recovery of elbow flexion spontaneously within
6 months. They were not included in the study.
Exploration of the proximal neck in the course
of exposing brachial plexus also provides easy
and convenient access to extraplexus neurotiz-
ers such as the phrenic nerve, spinal accessory
nerve, hypoglossal nerve, and cervical motor
branch, which can be used to restore shoulder
abduction. This would explain the results, with
significantly more patients gaining shoulder
abduction in the proximal nerve graft/transfer
group than in the distal nerve transfer group
(80.3 percent versus 66.2 percent in shoulder
abduction ≥ 60 degrees; 56.6 percent versus 38.0
percent in shoulder abduction ≥ 90 degrees; p =
0.05). For all of the reasons mentioned above,
we prefer to perform a thorough brachial plexus
exploration with proximal nerve graft/transfer
as indicated, before proceeding to distal nerve
transfer for elbow flexion. However, we recog-
nize the difficulty and time-consuming nature
of brachial plexus exploration, often with sur-
rounding dense scar tissue, that is fragile and
prone to easy bleeding. The other major draw-
backs of using a proximally based strategy are
that the distance between neurotizers and the
Table 4. Additional Result from Proximal Nerve Graft/Transfer Group and Distal Nerve Transfer Group:
Recovery of Shoulder Abduction*
Nerve Repair Type
Proximal Nerve
Graft/Transfer
Group (%)
Distal Nerve Transfer Group (n = 71)
Total pOberlin I (%)† Mackinnon (%)‡ Both (%)
No. 76 28 43
Patient received additional nerve
neurotization for shoulder abduction 75 (98.7) 27 (96.4) 40 (93.0) 67 (94.3) 142 (96.6) 0.2
Patient achieved shoulder abduction
≥60 degrees 61 (80.3) 16 (57.1) 31 (72.1) 47 (66.2) 108 (73.5) 0.05§
Recovery time, mo
Median 13.6 16.2 20.7 18.6 15.9 0.003§
No. of patients achieving shoulder
abduction ≥90 degrees 43 (56.6) 12 (42.9) 15 (34.9) 27 (38.0) 70 (47.6) 0.02§
Recovery time, mo
Median 18.5 31.8 20.7 20.8 19.6 0.3
*n = 147 patients.
†Fascicle of the ulnar nerve or fascicle of the median nerve to branch of the biceps muscle.
‡Fascicle of the ulnar nerve to branch of the biceps muscle plus fascicle of the median nerve to branch of the brachialis muscle.
§p < 0.05 = Proximal nerve graft/transfer group vs. distal nerve transfer group.
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
74e
Plastic and Reconstructive Surgery • January 2018
Fig. 1. There is signicant grip strength dierence between distal nerve transfer methods. (Above) Oberlin I method
group. (Center) Mackinnon method group. (Below) Control group at 4-year follow-up (p < 0.001). Post op, postoperatively.
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 141, Number 1 • Incomplete Brachial Plexus Injury
75e
target muscles is great, and interpositional nerve
grafts are almost always required, resulting in
both functional recovery that is uncertain and a
longer rehabilitation time.
Distal nerve transfers for elbow flexion involve
direct innervation of the branches to the biceps
and brachialis muscles, a short distance, and a
short rehabilitation. The technique was first intro-
duced by Oberlin (Oberlin I technique),6 who used
donor fascicles from the ulnar nerve to innervate
the biceps muscle. Oberlin I distal nerve transfer
for elbow flexion could achieve functional recov-
ery in a shorter period. However, the strength of
the biceps muscle may not be sufficient to provide
adequate power. Modification of this technique
includes adding an additional fascicle from the
median nerve to enhance the muscle strength,
introduced by Liverneaux et al.7 and Mackinnon
et al.,8 and has come to be known as the double
fascicular transfer. In our experience, the distal
nerve transfer technique is now used commonly
to restore elbow flexion in upper plexus injuries,
even when the injury extends to the C8 root, in
which longer rehabilitation is still required to
achieve functional recovery of elbow flexion. In
addition, if more than 6 months has elapsed after
injury, the use of distal nerve transfer may still be
able to provide functional recovery of elbow flex-
ion. This later timing for distal nerve transfer in
our series reflects its predominant use to date as a
salvage procedure, often made necessary because
of delayed referrals of patients to our clinic. The
simpler anatomy; clean, scar-free wound bed; and
consequent easier dissection, easier identification
of healthy donor nerve, and shorter operative
time are all other advantages of distal nerve trans-
fer. However, there has been a lack of or rather
a neglected area of reporting donor nerve mor-
bidities in the past studies.7,16,17 In our series, we
found that significant donor-site morbidities are
still numerous, and most are subclinical deficits.
Decreases in grip strength of an average of 59.1 per-
cent in the Oberlin procedure and 54.5 percent in
the Mackinnon procedure were noted. Numbness
of the fingers was also noted but was negligible.
Although most donor-site deficits are subclinical,
they may be prolonged or permanent. The pri-
mary liabilities of distal nerve transfers are that
they are usually performed without a diagnostic
Table 5. Average Grip Strength Decrease between the Operated Limb and Normal Limb after Distal Nerve
Transfer at 4-Year Follow-Up
Distal
Nerve
Transfer No.
Dominant
Hand
Involved
(%)
Preoperative
Grip Strength
of Operated
Limb (kg)
Postoperative
Maximum
Grip Strength
of Operated
Limb (kg)
Grip Strength
of Operated
Limb (kg)
Grip Strength
of Normal
Limb (kg)
Difference
in Grip
Strength (kg) Difference
Percentage
Oberlin I 13 7 (53.9) 34.0 ± 4.8 17 ± 10.0 14.7 ± 9.4 35.0 ± 5.8 20.7 ± 9.8 59.1
Mackinnon 23 16 (69.6) 32.6 ± 9.7 17.3 ± 8.7 16.3 ± 8.7 36.1 ± 10.1 19.7 ± 12.1 54.5
Sum 33.1 ± 8.2 17.2 ± 9.1
Grip Strength
of Dominant
Limb (kg)
Grip Strength of
Nondominant
Limb (kg)
Difference
in Grip
Strength (kg)
Difference
Percentage
Control
group 10 — — —
40 ± 6.0 33 ± 5.8 6.8 ± 2.1 17.0
p <0.001* <0.001† 0. 3 0.002† 0.001†
*Preoperative grip strength vs. postoperative maximum grip strength.
†p < 0.05 (control group vs. distal nerve transfer group).
Video. Supplemental Digital Content 1 shows the patient with
right brachial plexus injury of C5-C6 root avulsion managed
with the Oberlin I technique for elbow exion 9 years previ-
ously. The patient achieved M4 elbow exion but persistence of
weak hand and nger grip strength with a positive Froment sign
(compensation of the rst web grip with exor pollicis longus)
on the operative hand, http://links.lww.com/PRS/C502.
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
76e
Plastic and Reconstructive Surgery • January 2018
Fig. 2. Patient diagnosed preoperatively with level III brachial plexus
injury [according to the classication of Chuang (Chuang DCC. Adult
brachial plexus injuries. In: Mathes SJ, Hentz VR, eds. Plastic Surgery. 2nd
ed. Philadelphia: Saunders Elsevier; 2006:515–538)] with shoulder and
elbow palsies. Brachial plexus exploration with osteotomy of the clavi-
cle was performed. Intraoperative ndings showed the anterior division
of the upper trunk still in continuity with the lateral cord without rup-
ture. Rupture of the posterior divisions of the upper and middle trunks
was reconstructed with nerve grafts.
Fig. 3. Same patient as shown in Figure 2. Spontaneous recovery of elbow exion at 5
months postoperatively.
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 141, Number 1 • Incomplete Brachial Plexus Injury
77e
Fig. 4. An 18-year-old male subject had palsies of the right shoulder and elbow for 4
months after a motorcycle accident.
Fig. 5. Exploration of patient shown in Figure 4 revealed ruptured C5 with a good proximal
stump and C6 with a poor proximal stump. C5 nerve graft (5 × 3cm) plus C6 nerve graft
(5 × 1cm) to the suprascapular and posterior division of the upper trunk for the shoulder,
and the Mackinnon method for elbow restoration were performed.
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
78e
Plastic and Reconstructive Surgery • January 2018
exploration of the brachial plexus and therefore
may waste valuable proximal neurotizers.
Although the proximal nerve graft/transfer
strategy remains the primary means of brachial
plexus reconstruction in our hospital, in recent
years, we have performed more and more distal
nerve transfers for elbow flexion. In our experience,
the combination of use of both strategies, proximal
exploration of the brachial plexus with nerve graft
and/or transfer as needed for the restoration of
shoulder function, along with distal nerve transfer
for elbow flexion, has been very beneficial to patients
with upper plexus injuries (Figs. 4 through 6).
CONCLUSIONS
Proximal nerve graft/transfer and distal nerve
transfer are both strategies that clearly have a role
to play in nerve reconstruction, with advantages
and disadvantages. The combination of both strat-
egies provides the reconstructive surgeon more
options, allows greater flexibility, and ultimately
benefits patients with better restoration of shoul-
der and elbow function.
David Chwei-Chin Chuang, M.D.
Division of Reconstructive Microsurgery
Department of Plastic Surgery
Chang Gung Memorial Hospital
Chang-Gung University
No. 5, Fu-Hsing Street
Kuei-Shan, Taoyuan 333, Taiwan
dccchuang@gmail.com
PATIENT CONSENT
Patients provided written informed consent for the
use of their images.
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