We have described five operations based on nerve grafting, nerve transfers, tendon transfer, and free muscle transfer that have completely changed the prognosis and recovery of different brachial plexus injuries. However, to offer the entire spectrum of reconstructive options and possibly achieve the best outcomes, it is important to critically evaluate patients as soon as possible by a multidisciplinary team of surgeons. Although new techniques may continue to be developed and new therapies (such as tissue engineering and stem cell technology) may emerge as future options, the five operations described (some new and some old) have given consistently good outcomes and have made significant changes in the lives of our patients.
1. Shin AY, Spinner RJ, Steinmann SP, Bishop AT. Adult traumatic brachial plexus injuries. J Am Acad Orthop Surg. 2005;13:382–396.
2. Oberlin C, Béal D, Leechavengvongs S, Salon A, Dauge MC, Sarcy JJ. Nerve transfer to biceps muscle using a part of ulnar nerve for C5-C6 avulsion of the brachial plexus: Anatomical study and report of four cases. J Hand Surg Am. 1994;19:232–237.
3. Tsai YJ, Su FC, Hsiao CK, Tu YK. Comparison of objective muscle strength in C5-C6 and C5-C7 brachial plexus injury patients after double nerve transfer. Microsurgery 2015;35:107–114.
4. Mackinnon SE, Novak CB, Myckatyn TM, Tung TH. Results of reinnervation of the biceps and brachialis muscles with a double fascicular transfer for elbow flexion. J Hand Surg Am. 2005;30:978–985.
5. Carlsen BT, Kircher MF, Spinner RJ, Bishop AT, Shin AY. Comparison of single versus double nerve transfers for elbow flexion after brachial plexus injury. Plast Reconstr Surg. 2011;127:269–276.
6. Martins RS, Siqueira MG, Heise CO, Foroni L, Teixeira MJ. A prospective study comparing single and double fascicular transfer to restore elbow flexion after brachial plexus injury. Neurosurgery 2013;72:709–714; discussion 714–715.
7. Brandt KE, Mackinnon SE. A technique for maximizing biceps recovery in brachial plexus reconstruction. J Hand Surg Am. 1993;18:726–733.
8. Leechavengvongs S, Witoonchart K, Uerpairojkit C, Thuvasethakul P. Nerve transfer to deltoid muscle using the nerve to the long head of the triceps: Part II. A report of 7 cases. J Hand Surg Am. 2003;28:633–638.
9. Garg R, Merrell GA, Hillstrom HJ, Wolfe SW. Comparison of nerve transfers and nerve grafting for traumatic upper plexus palsy: A systematic review and analysis. J Bone Joint Surg Am. 2011;93:819–829.
10. Lee JY, Kircher MF, Spinner RJ, Bishop AT, Shin AY. Factors affecting outcome of triceps motor branch transfer for isolated axillary nerve injury. J Hand Surg Am. 2012;37:2350–2356.
11. Steinmann SP, Moran EA. Axillary nerve injury: Diagnosis and treatment. J Am Acad Orthop Surg. 2001;9:328–335.
12. Wolfe SW, Johnsen PH, Lee SK, Feinberg JH. Long-nerve grafts and nerve transfers demonstrate comparable outcomes for axillary nerve injuries. J Hand Surg Am. 2014;39:1351–1357.
13. Maldonado AA, Howe BM, Lawton R, Bishop AT, Shin AY, Spinner RJ. Anatomical study of the axillary nerve: Description of a surgical blind zone. Plast Reconstr Surg. 2016;138:419–426.
14. Maldonado AA, Spinner RJ, Bishop AT, Shin AY, Elhassan BT. Effectiveness of the extended surgical approach to visualize the axillary nerve in the blind zone in an arthroscopic axillary nerve injury model. J Plast Reconstr Aesthet Surg. 2016;69:1697–1703.
15. Baltzer HL, Kircher MF, Spinner RJ, Bishop AT, Shin AY. A comparison of outcomes of triceps motor branch-to-axillary nerve transfer or sural nerve interpositional grafting for isolated axillary nerve injury. Plast Reconstr Surg. 2016;138:256e–264e.
16. Brophy RH, Wolfe SW. Planning brachial plexus surgery: Treatment options and priorities. Hand Clin. 2005;21:47–54.
17. Chuang DC, Lee GW, Hashem F, Wei FC. Restoration of shoulder abduction by nerve transfer in avulsed brachial plexus injury: Evaluation of 99 patients with various nerve transfers. Plast Reconstr Surg. 1995;96:122–128.
18. Chuang DC, Yeh MC, Wei FC. Intercostal nerve transfer of the musculocutaneous nerve in avulsed brachial plexus injuries: Evaluation of 66 patients. J Hand Surg Am. 1992;17:822–828.
19. Krakauer JD, Wood MB. Intercostal nerve transfer for brachial plexopathy. J Hand Surg Am. 1994;19:829–835.
20. Merrell GA, Barrie KA, Katz DL, Wolfe SW. Results of nerve transfer techniques for restoration of shoulder and elbow function in the context of a meta-analysis of the English literature. J Hand Surg Am. 2001;26:303–314.
21. Barrie KA, Steinmann SP, Shin AY, Spinner RJ, Bishop AT. Gracilis free muscle transfer for restoration of function after complete brachial plexus avulsion. Neurosurg Focus 2004;16:E8.
22. Akasaka Y, Hara T, Takahashi M. Free muscle transplantation combined with intercostal nerve crossing for reconstruction of elbow flexion and wrist extension in brachial plexus injuries. Microsurgery 1991;12:346–351.
23. Berger A, Flory PJ, Schaller E. Muscle transfers in brachial plexus lesions. J Reconstr Microsurg. 1990;6:113–116.
24. Doi K. New reconstructive procedure for brachial plexus injury. Clin Plast Surg. 1997;24:75–85.
25. Doi K, Muramatsu K, Hattori Y, et al. Restoration of prehension with the double free muscle technique following complete avulsion of the brachial plexus: Indications and long-term results. J Bone Joint Surg Am. 2000;82:652–666.
26. Doi K, Sakai K, Fuchigami Y, Kawai S. Reconstruction of irreparable brachial plexus injuries with reinnervated free-muscle transfer: Case report. J Neurosurg. 1996;85:174–177.
27. Doi K, Kuwata N, Muramatsu K, Hottori Y, Kawai S. Double muscle transfer for upper extremity reconstruction following complete avulsion of the brachial plexus. Hand Clin. 1999;15:757–767.
28. Doi K, Sakai K, Kuwata N, Ihara K, Kawai S. Reconstruction of finger and elbow function after complete avulsion of the brachial plexus. J Hand Surg Am. 1991;16:796–803.
29. Doi K, Shigetomi M, Kaneko K, et al. Significance of elbow extension in reconstruction of prehension with reinnervated free-muscle transfer following complete brachial plexus avulsion. Plast Reconstr Surg. 1997;100:364–372; discussion 373–374.
30. Estrella EP, Montales TD. Functioning free muscle transfer for the restoration of elbow flexion in brachial plexus injury patients. Injury 2016;47:2525–2533.
31. Garcia RM, Ruch DS. Free flap functional muscle transfers. Hand Clin. 2016;32:397–405.
32. Terzis JK, Kostopoulos VK. Free muscle transfer in posttraumatic plexopathies part II: The elbow. Hand (N Y) 2010;5:160–170.
33. Terzis JK, Vekris MD, Soucacos PN. Outcomes of brachial plexus reconstruction in 204 patients with devastating paralysis. Plast Reconstr Surg. 1999;104:1221–1240.
34. Wei CY, Chuang DC, Chen HC, Lin CH, Wong SS, Wei FC. The versatility of free rectus femoris muscle flap: An alternative flap. Microsurgery 1995;16:698–703.
35. Doi K, Sakai K, Ihara K, Abe Y, Kawai S, Kurafuji Y. Reinnervated free muscle transplantation for extremity reconstruction. Plast Reconstr Surg. 1993;91:872–883.
36. Chung DC, Carver N, Wei FC. Results of functioning free muscle transplantation for elbow flexion. J Hand Surg Am. 1996;21:1071–1077.
37. de Moraes FB, Kwae MY, da Silva RP, Porto CC, de Paiva Magalhães D, Paulino MV. Evaluation of elbow flexion following free muscle transfer from the medial gastrocnemius or transfer from the latissimus dorsi, in cases of traumatic injury of the brachial plexus. Rev Bras Ortop. 2015;50:660–665.
38. Adams JE, Kircher MF, Spinner RJ, Torchia ME, Bishop AT, Shin AY. Complications and outcomes of functional free gracilis transfer in brachial plexus palsy. Acta Orthop Belg. 2009;75:8–13.
39. Giuffre JL, Bishop AT, Shin AY. Harvest of an entire gracilis muscle and tendon for use in functional muscle transfer: A novel technique. J Reconstr Microsurg. 2012;28:349–358.
40. Maldonado AA, Romero-Brufau S, Kircher MF, Spinner RJ, Bishop AT, Shin AY. Free functioning gracilis muscle transfer for elbow flexion reconstruction after traumatic adult brachial pan-plexus injury: Where is the optimal distal tendon attachment for elbow flexion? Plast Reconstr Surg. 2017;139:128–136.
41. Maldonado AA, Kircher M, Spinner RJ, Bishop AT, Shin AY. Free functioning gracilis muscle transfer versus intercostal nerve transfer to musculocutaneous nerve for restoration of elbow flexion after traumatic adult brachial pan-plexus injury. Plast Reconstr Surg. 2016;138:483e–488e.
42. Oberlin C, Chino J, Belkheyar Z. Surgical treatment of brachial plexus posterior cord lesion: A combination of nerve and tendon transfers, about nine patients. Chir Main 2013;32:141–146.
43. Jones NF, Machado GR. Tendon transfers for radial, median, and ulnar nerve injuries: Current surgical techniques. Clin Plast Surg. 2011;38:621–642.
44. Giuffre JL, Bishop AT, Spinner RJ, Shin AY. The best of tendon and nerve transfers in the upper extremity. Plast Reconstr Surg. 2015;135:617e–630e.
45. Ropars M, Dréano T, Siret P, Belot N, Langlais F. Long-term results of tendon transfers in radial and posterior interosseous nerve paralysis. J Hand Surg Br. 2006;31:502–506.
46. Ray WZ, Mackinnon SE. Clinical outcomes following median to radial nerve transfers. J Hand Surg Am. 2011;36:201–208.
47. Erb W. Über eine eigentümliche Lokalisation von Lähmungen im Plexusbrachialis. Naturhist Med Verh Heidelberg Verh. 1874;2:130–136.
48. Franz RW, Skytta CK, Shah KJ, Hartman JF, Wright ML. A five-year review of management of upper-extremity arterial injuries at an urban level I trauma center. Ann Vasc Surg. 2012;26:655–664.
49. Lin KY, Posnick JC, al-Qattan MM, Vajsar J, Becker LE. Fetal nerve healing: An experimental study. Plast Reconstr Surg. 1994;93:1323–1333.
50. Butler PE, Sims CD, Randolph MA, Menkes D, Onorato J, Lee WP. A comparative study of nerve healing in adult, neonatal, and fetal rabbits. Plast Reconstr Surg. 1999;104:1386–1392.
51. Gilbert A, Pivato G, Kheiralla T. Long-term results of primary repair of brachial plexus lesions in children. Microsurgery 2006;26:334–342.