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Background A critical concept in brachial plexus reconstruction is the accurate assessment of functional outcomes. The current standard for motor outcome assessment is clinician-elicited, outpatient clinic-based, serial evaluation of range of motion and muscle power. However, discrepancies exist between such clinical measurements and actual patient-initiated use. We employed emerging technology in the form of accelerometry-based motion detectors to quantify real-world arm use after brachial plexus surgery. Objective To evaluate (1) the ability of accelerometry-based motion detectors to assess functional outcome and (2) the real-world arm use of patients after nerve transfer for brachial plexus injury, through a pilot study. Methods Five male patients who underwent nerve transfer after brachial plexus injury wore bilateral motion detectors for 7 d. The patients also underwent range-of-motion evaluation and completed multiple patient-reported outcome surveys. Results The average age of the recruits was 41 yr (±17 yr), and the average time from operation was 2 yr (±1 yr). The VT (time of use ratio) for the affected side compared to the unaffected side was 0.73 (±0.27), and the VM (magnitude ratio) was 0.63 (±0.59). VT strongly and positively correlated with shoulder flexion and shoulder abduction: 0.97 (P = .008) and 0.99 (P = .002), respectively. Conclusion Accelerometry-based activity monitors can successfully assess real-world functional outcomes after brachial plexus reconstruction. This pilot study demonstrates that patients after nerve transfer are utilizing their affected limbs significantly in daily activities and that recovery of shoulder function is critical.

Background Neonatal brachial plexus palsy (NBPP) results in reduced function of the affected arm with profound ramifications on quality of life. Advances in surgical technique have shown improvements in outcomes for appropriately selected patients. Patient selection, however, remains difficult. Objective To develop a decision algorithm that could be applied at the individual patient level, early in life, to reliably predict persistent NBPP that would benefit from surgery. Methods Retrospective review of NBPP patients was undertaken. Maternal and neonatal factors were entered into the C5.0 statistical package in R (The R Foundation). A 60/40 model was employed, whereby 60% of randomized data were used to train the decision tree, while the remaining 40% were used to test the decision tree. The outcome of interest for the decision tree was a severe lesion meeting requirements for surgical candidacy. Results A decision tree prediction algorithm was generated from the entered variables. Variables utilized in the final decision tree included presence of Horner's syndrome, presence of a pseudomeningocele, Narakas grade, clavicle fracture at birth, birth weight >9 lbs, and induction or augmentation of labor. Sensitivity of the decision tree was 0.71, specificity 0.96, positive predictive value 0.94, negative predictive value 0.79, and F1 score 0.81. Conclusion We developed a decision tree prediction algorithm that can be applied shortly after birth to determine surgical candidacy of patients with NBPP, the first of its kind utilizing only maternal and neonatal factors. This conservative decision tree can be used to offer early surgical intervention for appropriate candidates.

Background Contralateral C7 (CC7) transfer has been used for treating traumatic brachial plexus injury. However, the effectiveness of the procedure remains a subject of debate. The authors performed a systematic review to study the overall outcomes of CC7 transfer to different recipient nerves in traumatic brachial plexus injuries. Methods A literature search was conducted using PubMed and EMBASE databases to identify original articles related to CC7 transfer for traumatic brachial plexus injury. The data extracted were study/patient characteristics, and objective outcomes of CC7 transfer to the recipient nerves. The authors normalized outcome measures into a Medical Research Council-based (MRC) outcome scale. Results Thirty-nine studies were identified. The outcomes were categorized based on the major recipient nerves: median, musculocutaneous, and radial/triceps. Regarding overall functional recovery, 11 percent of patients achieved MRC grade M4 wrist flexion and 38 percent achieved MRC grade M3. Grade M4 finger flexion was achieved by 7 percent of patients, whereas 36 percent achieved M3. Finally, 56 percent achieved greater than or equal to S3 sensory recovery in the median nerve territories. In the musculocutaneous nerve group, 38 percent regained to M4 and 37 percent regained to M3. In the radial/triceps nerve group, 25 percent regained elbow or wrist extension strength to a MRC grade M4 and to M3, respectively. Conclusions Outcome measures in the included studies were not consistently reported to uncover true patient-related benefits from the CC7 transfer. Reliable and validated outcome instruments should be applied to critically evaluate patients undergoing CC7 transfer.

Although contralateral C7 (CC7) transfer has been widely used for treating traumatic brachial plexus injury, the safety of the procedure is questionable. The authors performed a systematic review to investigate the donor-site morbidity, including sensory abnormality and motor deficit, to guide clinical decision-making.A systematic review on (CC7) transfer for traumatic brachial plexus injury was performed for original articles in the PubMed and Embase databases. Patient demographic data and donor-site morbidity of (CC7) transfer, including incidence, recovery rate, and recovery time were extracted. The sensory abnormality areas and muscles involved in motor weakness were also summarized.A total of 904 patients from 27 studies were reviewed. Overall, 74 percent of patients (668 of 897) experienced sensory abnormalities, and 98 percent (618 of 633) recovered to normal; the mean recovery time was 3 months. For motor function, 20 percent (118 of 592) had motor deficit after (CC7) transfer and 91 percent (107 of 117) regained normal motor function; the mean recovery time was 6 months. Sensory abnormality mainly occurred in the area of the hand innervated by the median nerve, whereas motor deficit most often involved muscles innervated by the radial nerve. There were 19 patients with long-term morbidity of the donor site in the studies.The incidence of donor-site morbidity after (CC7) transfer was relatively high, and severe and long-term defects occurred occasionally. (CC7) transfer should be indicated only when other donor nerves are not available, and with a comprehensive knowledge of the potential risks.

Elective surgical management of neonatal brachial plexus palsy is complex, variable, and often individualized. Little is known about the medical decision-making process among adolescents with neonatal brachial plexus palsy and their families when faced with making complex treatment decisions. The experiences of these patients and their parents were analyzed to identify key factors in the decision-making process.Eighteen adolescents with residual neonatal brachial plexus palsy deficits between 10 and 17 years and their parents were included. Qualitative research design was used involving separate, 1-hour, in person, semistructured interviews, which were audio recorded and transcribed. Grounded theory was applied by two members of the research team to identify recurrent themes and create a codebook that was applied to the data.Medical decision-making among adolescents with neonatal brachial plexus palsy and their families is multifaceted and individualized, composed of both patient- and system-dependent factors. Four codes were identified: (1) knowledge acquisition, (2) multidisciplinary care, (3) adolescent autonomy, and (4) patient expectations and treatment desires. Overall, parental decision-making was heavily influenced by system-dependent factors, whereas adolescents largely based their decisions on individual treatment desires to improve function and/or aesthetics.There are many areas for improving the delivery of information and health care organization among adolescents with neonatal brachial plexus palsy and their families. The authors recommend the development of educational interdisciplinary programs and decision aids containing evidence-based management guidelines targeted toward primary care providers and patients. The authors believe that a computer-based learning module may provide the best avenue to achieve maximum penetrance and convenience of information sharing.Therapeutic, IV.

Nerve reconstruction for upper brachial plexus injury consists of nerve repair and/or transfer. Current literature lacks evidence supporting a preferred surgical treatment for adults with such injury involving shoulder and elbow function. We systematically reviewed the literature published from January 1990 to February 2011 using multiple databases to search the following: brachial plexus and graft, repair, reconstruction, nerve transfer, neurotization. Of 1360 articles initially identified, 33 were included in analysis, with 23 nerve transfer (399 patients), 6 nerve repair (99 patients), and 4 nerve transfer + proximal repair (117 patients) citations (mean preoperative interval, 6 ± 1.9 months). For shoulder abduction, no significant difference was found in the rates ratio (comparative probabilities of event occurrence) among the 3 methods to achieve a Medical Research Council (MRC) scale score of 3 or higher or a score of 4 or higher. For elbow flexion, the rates ratio for nerve transfer vs nerve repair to achieve an MRC scale score of 3 was 1.46 (P = .03); for nerve transfer vs nerve transfer + proximal repair to achieve an MRC scale score of 3 was 1.45 (P = .02) and an MRC scale score of 4 was 1.47 (P = .05). Therefore, for elbow flexion recovery, nerve transfer is somewhat more effective than nerve repair; however, no particular reconstruction strategy was found to be superior to recover shoulder abduction. When considering nerve reconstruction strategies, our findings do not support the sole use of nerve transfer in upper brachial plexus injury without operative exploration to provide a clear understanding of the pathoanatomy. Supraclavicular brachial plexus exploration plays an important role in developing individual surgical strategies, and nerve repair (when donor stumps are available) should remain the standard for treatment of upper brachial plexus injury except in isolated cases solely lacking elbow flexion.

Background Methodology rigor increases the quality of clinical research by encouraging freedom from the biases inherent in clinical studies. As randomized controlled studies (clinical trial design) are rarely applicable to surgical research, we address the commonly used observational study designs and methodologies by presenting guidelines for rigor.

Short-term results after proximal interphalangeal joint arthroplasty with pyrolytic carbon (pyrocarbon) implant have shown that this implant has high complication rates, but patient satisfaction is high. The authors evaluated the effectiveness of the implant for use in proximal interphalangeal joint at a minimum of 2 years of follow-up.Thirteen consecutive candidates who underwent 21 proximal interphalangeal joint arthroplasty procedures with pyrocarbon implant were evaluated prospectively. Functional measurements and the Michigan Hand Outcomes Questionnaire were administered preoperatively and at 12 months and intermediate term (2 years) postoperatively. Preoperative and intermediate-term mean data for all functional measures and questionnaire scores were compared.Thirteen patients were treated, with a mean follow-up of 44 months. Grip strength, key pinch strength, and active arc of motion demonstrated no statistical difference between preoperative and intermediate-term assessment. All domains of the Michigan Hand Outcomes Questionnaire showed improved large effect size at intermediate-term follow-up, especially pain and satisfaction. There were 10 complications in nine joints (complication rate, 42.9 percent). Patients without complications had better functional outcomes; however, there were no statistical differences in questionnaire scores between patients with and without complications, except for pain (p = 0.04).Proximal interphalangeal joint arthroplasty with pyrocarbon implant seems to be an effective way of reducing pain without sacrificing active arc of motion. Despite a high complication rate, patients were generally satisfied, especially with pain relief, and complications did not affect patients' satisfaction even when hand function was affected. Further decision-making analysis to compare arthroplasty and fusion for each finger may help surgeons to select the appropriate operative procedures.Therapeutic, IV.