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We sought to identify predictors of failed ulnar nerve fascicle (to flexor carpi ulnaris) to biceps motor branch transfer. A retrospective review of adult brachial plexus patients treated with flexor carpi ulnaris to biceps transfer with a minimum 1-year follow-up was performed. Failure, defined as modified British Medical Research Council grade <3 elbow flexion was compared with randomly selected controls (M ≥ 4-). Ninety-one patients, of which 80% regained >M3 flexion met criteria. Eighteen failures and 18 controls, with similar follow-up (20 vs 23 months) were evaluated. Preoperative flexor carpi ulnaris weakness (M < 5) was significantly more common in failures (78% vs 33%). The rate of flexor carpi ulnaris recovery after operation was significantly higher in controls (86% vs 7%). Increased failure risk can be expected with impaired preoperative flexor carpi ulnaris function. The challenge is how to identify which patients will regain near normal flexor carpi ulnaris strength as excellent outcomes can be obtained. Level of evidence: III.

We compared outcomes of primary vascularized ulnar nerve grafts from the C5 root neurotizing biceps and brachialis muscles, and gracilis functioning free muscle transfer neurotized by the distal spinal accessory nerve, as a primary or salvage procedure after complete brachial plexus injury. At 45 months, three of eight primary vascularized ulnar nerve graft patients regained grade 4 elbow flexion, while one regained grade 3. All 13 primary gracilis transfer patients regained grade 4 elbow flexion. Four patients with vascularized ulnar nerve grafts failed and subsequently had salvage functioning free muscle transfer procedures resulting in delayed recovery. Although vascularized ulnar nerve graft-based primary reconstructions can provide useful elbow flexion, this was achieved in less than half the cases. We consider primary gracilis functioning free muscle transfer neurotized by the distal spinal accessory nerve as the most reliable reconstruction for the restoration of elbow flexion in complete brachial plexus injury., Level of Evidence: IV.

Background: Tears of the ulnar collateral ligament (UCL) of the elbow are common injuries in overhead athletes that may be career-ending if left untreated., Purpose: The goal of this systematic review was to review all published reports of UCL reconstruction in overhead athletes, determine which techniques were associated with better outcomes, and assess the strengths and weaknesses of current data., Study Design: Systematic review., Methods: A systematic review of published studies evaluating reconstruction of the UCL in overhead athletes was performed using the Ovid Medline database. All studies with a cohort of athletes who underwent UCL reconstruction with a minimum of 1 year follow-up were included, resulting in a total of 8 Level III (retrospective cohort) studies. A database compiled variables of interest, including demographic variables, surgical techniques, Conway-Jobe ratings, and percentage and type of complications. Additionally, studies were evaluated for evidence of selection, performance, detection, and exclusion biases., Results: Demographic data were similar between studies. Overall, 83% of patients in all studies had an excellent result. There was an overall 10% complication rate, with the most common complication being postoperative ulnar neuropathy, which occurred in 6% of patients. Transition to the muscle-splitting approach was associated with better outcomes than detachment of the flexor-pronator mass, as there was only a 70% rate of excellent results and a 20% rate of postoperative ulnar neuropathy in patients treated with detachment of the flexor-pronator mass compared with 87% excellent results and a 6% rate of postoperative ulnar neuropathy in patients treated with a muscle-splitting approach. Abandoning obligatory ulnar nerve transposition was associated with better outcomes, as there was only a 75% rate of excellent results and a 9% rate of postoperative ulnar neuropathy in patients treated with obligatory ulnar nerve transposition compared with 89% excellent results and a 4% rate of postoperative ulnar neuropathy in patients who did not have obligatory ulnar nerve transposition. The docking technique was associated with better outcomes, as there was a 76% rate of excellent results and an 8% rate of ulnar neuropathy in patients treated with a figure-of-8 technique compared with 90% excellent results and a 3% rate of postoperative ulnar neuropathy in patients treated with the docking technique and 95% excellent results and a 5% rate of postoperative ulnar neuropathy in patients treated with a modified docking technique., Conclusion: The evolution in surgical techniques, most notably use of a muscle-splitting approach to the flexor-pronator mass, decreased handling of the ulnar nerve, and use of the docking technique, have resulted in improved outcomes and reduced complications. Although injury to the UCL was once a career-ending injury in overhead athletes, development and continued evolution of UCL reconstruction have made return to previous or higher level of athletic participation in sports highly likely. Future research should continue to utilize higher levels of evidence and compare new graft fixation techniques in an attempt to further improve the ability of overhead athletes to return to sports.