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Long-Term Outcomes of Brachial Plexus Reconstruction with Sural Nerve Autograft for Brachial Plexus Birth Injury

Manske, M. Claire, M.D.; Bauer, Andrea S., M.D.; Hentz, Vincent R., M.D.; James, Michelle A., M.D.

Plastic and Reconstructive Surgery: May 2019 - Volume 143 - Issue 5 - p 1017e–1026e
doi: 10.1097/PRS.0000000000005557
Hand/Peripheral Nerve: Original Articles

Background: Infants with brachial plexus birth injury who do not recover motor function spontaneously in a timely manner are candidates for brachial plexus reconstruction with nerve autograft. Outcomes of this intervention are incompletely understood. The authors present the long-term outcomes of brachial plexus reconstruction with sural nerve autograft in infants with brachial plexus birth injury.

Methods: The authors retrospectively reviewed all infants with brachial plexus birth injury who underwent brachial plexus reconstruction with sural nerve autograft between 1992 and 2014 with a minimum 2-year follow-up. The authors used Active Movement Scale scores to determine the presence and timing of shoulder, elbow, and wrist recovery. They assessed recovery of hand function in infants with global brachial plexus birth injury with the Raimondi scale. The number and type of secondary reconstructive procedures were identified.

Results: Forty-three infants who underwent brachial plexus reconstruction at age 7 ± 2 months old were followed for 7 ± 5 years. Most infants recovered antigravity elbow flexion (91 percent) and shoulder abduction (67 percent), but fewer recovered antigravity shoulder external rotation (19 percent) and wrist extension (37 percent). Mean postoperative times until observed antigravity motor strength (Active Movement Scale score >5) at the shoulder, elbow, and wrist were all greater than 12 months; evidence of initial motor recovery (Active Movement Scale score >2) was observed earlier. The mean Raimondi score in infants with global brachial plexus birth injury was 2.2 (range, 0 to 5) at final follow-up. Thirty-three children underwent 2 ± 1.2 secondary reconstructive procedures.

Conclusions: Brachial plexus reconstruction with sural nerve autograft reliably results in recovery of shoulder abduction and elbow flexion, but recovery of shoulder external rotation and wrist extension is less predictable, and recovery often takes more than 1 year. Secondary procedures are often performed to optimize function.


Sacramento and Stanford, Calif.; and Boston, Mass.

From Shriners Hospital for Children–Northern California; Harvard Medical School, Boston Children’s Hospital; and the Robert A. Chase Center for Upper Limb Surgery, Stanford University.

Received for publication February 16, 2018; accepted September 25, 2018.

Disclosure:The authors have no financial interest to declare in relation to the content of this article.

M. Claire Manske, M.D., Shriners Hospital for Children–Northern California, 2425 Stockton Boulevard, Sacramento, Calif. 95817,

©2019American Society of Plastic Surgeons