Plastic & Reconstructive Surgery:
Reconstruction of Elbow Flexion by End-to-Side Neurorrhaphy in Phrenic Nerve Transfer
Zheng, Mou-Xiong M.D.; Xu, Wen-Dong M.D., Ph.D.; Shen, Yun-Dong M.D., Ph.D.; Xu, Jian-Guang M.D., Ph.D.; Gu, Yu-Dong M.D.
Department of Hand Surgery, Hua-Shan Hospital, Fudan University, and, Shanghai Key Laboratory of Peripheral Nerve Microsurgery (Zheng)
Department of Hand Surgery, Hua-Shan Hospital, Fudan University, Shanghai Key Laboratory of Peripheral Nerve Microsurgery, and, State Key Laboratory of Medical Neurobiology, Fudan University (Xu)
Department of Hand Surgery, Hua-Shan Hospital, Fudan University, and, Shanghai Key Laboratory of Peripheral Nerve Microsurgery, Shanghai, People's Republic of China (Shen, Xu, Gu)
Correspondence to Dr. Xu, Department of Hand Surgery, Hua-Shan Hospital, Shanghai Medical College, Fudan University, 12 Wulumuqi Middle Road, Shanghai 200040, People's Republic of China email@example.com
Phrenic nerve transfer has been widely used in the treatment of brachial plexus avulsion injuries and has been one of the options for reconstruction of elbow flexion, with biceps strength of M3 or better at 84.6 percent recovery.1,2 However, concerns regarding potential pulmonary function problems have limited its popularization.3 Therefore, we considered balancing the restoration of the affected limb and preventing denervation of the ipsilateral diaphragm by end-to-side neurorrhaphy.
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In the current study, five consecutive patients (three male patients and two female patients) with brachial plexus avulsion injuries, aged from 6 to 36 years (mean, 18.6 years), were admitted to our hospital and underwent phrenic nerve transfer with end-to-side neurorrhaphy by neurotizing the anterior division of the upper trunk or the musculocutaneous nerve. The operative delay after injury was 1 to 6 months (mean, 2.5 months). In the surgical process, the distal end of the musculocutaneous nerve or anterior division of the upper trunk was sutured to the grafted sural nerve with end-to-end neurorrhaphy, and the other end of the graft was sutured to the side of the phrenic nerve in “helicoid fashion” at the level of the C6 nerve root using 9-0 polypropylene sutures. In the helicoid fashion, the proximal end of the graft was wrapped around the longitudinal axis of the phrenic nerve and sutured to the side of the phrenic nerve with an end-to-side neurorrhaphy, and the epineurium of the phrenic nerve was removed at the site of coaptation (Fig. 1). At the final visit at 2 years, all patients had regained various degrees of biceps strength (M4 in two patients, M3 in one patient, M2 in one patient, and M1 in one patient). The average prolongation of latency of the phrenic nerve was 2.88 msec, and the average decrease of amplitude from the preoperative value was 32.4 percent. However, compared with the preoperative status, none of these five patients suffered from diaphragm elevation or decreased diaphragm excursion. The pulmonary function test values forced vital capacity and forced expiratory volume in 1 second had all recovered to preoperative levels, and some values had even improved from preoperative values (Fig. 2).
Although the efficacy of end-to-side neurorrhaphy was reported lower than for end-to-end neurorrhaphy, the phrenic nerve could still provide motor recovery for elbow flexion even with an end-to-side neurorrhaphy.4 The phrenic nerve is composed mainly of myelinated motor nerve fibers and discharges spontaneous impulses that could be stimulated by deep breathing.5 These features might contribute to its superior regeneration capacity. Electrophysiologic studies suggested diaphragm elevation or excursion limitation. The suturing procedure or the winding technique might be the reason for abnormality of the phrenic nerve in the nerve conduction study. However, function of the diaphragm could be preserved. In conclusion, phrenic nerve transfer with end-to-side neurorrhaphy is capable of providing functional biceps recovery in a majority of patients, with preservation of diaphragm function (Table 1).
Mou-Xiong Zheng, M.D.
Department of Hand Surgery, Hua-Shan Hospital, Fudan University, and, Shanghai Key Laboratory of Peripheral Nerve Microsurgery
Wen-Dong Xu, M.D., Ph.D.
Department of Hand Surgery, Hua-Shan Hospital, Fudan University, Shanghai Key Laboratory of Peripheral Nerve Microsurgery, and, State Key Laboratory of Medical Neurobiology, Fudan University
Yun-Dong Shen, M.D., Ph.D.
Jian-Guang Xu, M.D., Ph.D.
Yu-Dong Gu, M.D.
Department of Hand Surgery, Hua-Shan Hospital, Fudan University, and, Shanghai Key Laboratory of Peripheral Nerve Microsurgery, Shanghai, People's Republic of China
This work was supported by Chinese National Basic Research Program grant no. 2003CB515300; “Dawn” Program of Shanghai Education Commission, China, grant no. 06SG04; and Program for New Century Excellent Talents in University, China, grant no. NCET-07-0209.
The authors have no conflicts of interest to disclose.
1. Gu YD, Wu MM, Zhen YL, et al.. Phrenic nerve transfer for brachial plexus neurotization. Microsurgery 1989;10:287–289.
2. Xu WD, Gu YD, Xu JG, Tan LJ. Full-length phrenic nerve transfer by means of video-assisted thoracic surgery in treating brachial plexus avulsion injury. Plast Reconstr Surg. 2002;110:104–109; discussion 110–111.
3. Chalidapong P, Sananpanich K, Kraisarin J, Bumroongkit C. Pulmonary and biceps function after intercostal and phrenic nerve transfer for brachial plexus injuries. J Hand Surg Br. 2004;29:8–11.
4. Wang M, Xu W, Zheng M, Teng F, Xu J, Gu Y. Phrenic nerve end-to-side neurotization in treating brachial plexus avulsion: An experimental study in rats. Ann Plast Surg. 2011;66:370–376.
5. Nail BS, Sterling GM, Widdicombe JG. Patterns of spontaneous and reflexly-induced activity in phrenic and intercostal motoneurons. Exp Brain Res. 1972;15:318–332.
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David H. Song, M.D., M.B.A. is the President-elect of the American Society of Plastic Surgeons (ASPS). He is a consultant with BioMet, Emmi Solutions, LLC, a consortium-member providing senior debt for Brava, and consultant with and investor in HealthEngine.com. He receives author royalties from Elsevier. Scot Glasberg, M.D. is the President of the American Society of Plastic Surgeons (ASPS). He is a consultant with LifeCell Corp and Mentor Corp and an investor with Strathspey Crown. The authors have no sources of funding to report related to the writing or submission of this discussion.
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