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Modified Oberlin double fascicular nerve transfer for elbow flexion- FCR fascicle to motor branch to biceps and FCU fascicle to motor branch to brachialis

    Overview

    Learn the Modified Oberlin double fascicular nerve transfer for elbow flexion: FCR fascicle to motor branch to biceps and FCU fascicle to motor branch to brachialis surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Modified Oberlin double fascicular nerve transfer for elbow flexion: FCR fascicle to motor branch to biceps and FCU fascicle to motor branch to brachialis surgical procedure.
    Christophe Oberlin popularised the technique of nerve transfer for restoration of elbow flexion after upper brachial plexus palsy. The original technique involved highly selective fascicle transfer of a predominant flexor carpi ulnaris fascicle from the ulnar nerve to the motor branch to biceps. The technique enabled reliable and rapid re-innervation of biceps and superior results to nerve grafting for upper trunk ruptures. Modifications have included a double transfer technique using fascicles from both median and ulnar nerves transferred to the motor branches to biceps and to brachialis. I use a double technique in cases of complete elbow flexion paralysis with loss of biceps, brachialis and brachioradialis such as that resulting from a C5/6 avulsion injury or delayed presentation following rupture of the upper trunk. In cases of isolated musculocutaneous injury, proximal reconstruction for biceps can be combined with a single distal transfer to the brachialis from the ulnar nerve. The technique can also be used to salvage late presenting upper trunk or lateral cord ruptures where the time-distance phenomenon dictates that late nerve graft of a proximal rupture is unlikely to be successful or cases where proximal reconstruction has failed to provide functional elbow flexion by 9 months following injury.


    Indications

    INDICATIONS:
    The musculocutaneous nerve (MCuN) arises from the lateral cord and contains fascicles from the anterior division of the upper trunk (C5/6). The musculocutaneous nerve supplies coracobrachialis and then passes under that muscle’s tendon 4cm inferior to the coracoid and enters the arm lying in the upper arm in the interval between the short head of biceps and coracobrachialis and at the mid-arm level in the interval between biceps and triceps. The motor branch to biceps (MBrBi) arises approximately 5cm (three finger breadths) below the anterior axillary fold and enters the medial undersurface of the muscle with a vascular pedicle. The musculocutaneous nerve continues in the interval between biceps and brachialis with a posterior and slightly lateral branch to brachialis (6 finger breadths below the anterior axillary fold) and the more anterior and medially placed lateral cutaneous nerve of the forearm. The anatomy is variable and there may be more than one branch to each muscle or a direct take off of the MBrBi may be seen from a low lying lateral cord.
    The ulnar nerve (C8/T1) lies in the posterior and medial part of the interval between biceps and brachialis until the mid-arm level when it obliquely pierces the medial intermuscular septum to lie in the posterior compartment of the arm. The ulnar is difficult to identify at this level because of its intra-septal course. The first branch identified in this region is usually the medial cutaneous nerve of forearm (MCNF) from the medial cord and the ulnar nerve will be posterior to this branch. The MCNF is smaller in diameter than the ulnar nerve and has no motor action on nerve stimulation.
    The median nerve (C5-T1) lies immediately adjacent to the musculocutaneous nerve at the mid-humeral level and is anterior to the brachial artery.
    The Oberlin transfers are useful for reinnervation of the biceps and brachialis in C5/6 avulsion injuries when there is a complete loss of elbow flexion (ie brachioradialis is also denervated) or when recovery is poor following nerve grafting of upper trunk, lateral cord or musculocutaneous nerve ruptures or neuromata in continuity. An isolated nerve transfer to brachialis may be used when there is recovery expected to biceps but the time-distance phenomenon renders the more distally placed brachialis recovery potential limited.
    The Oberlin nerve transfer to the biceps or brachialis can be successfully accomplished up to 9 months from injury. In cases of early diagnosis of avulsion of C5/6 the transfers may be completed in the first few weeks after injury as long as the donor median and ulnar nerve function is normal. When these latter nerves have sustained low grade continuity partial axonopathy injury it may be sensible to wait until the lower plexus recovery is established beyond doubt before undertaking salvage intra-plexal highly selective fascicle transfer. Reinnervation distances are short and the earliest signs of reinnervation should be seen at 2-3 months post surgery. The first sign is muscle tenderness on squeezing the recipient muscle, twitches follow with donor potentiation from 3 months with volitional control at 6-12 months. Further strengthening will occur for 2-3 years after transfer.
    SYMPTOMS & ASSESSMENT:
    There is loss of elbow flexion following injury to the C5 and C6 nerve roots, the upper trunk, the lateral cord or the musculocutaneous nerve. wasting of the biceps and brachialis is usually obvious, however in cases of isolated lateral cord or musculocutaneous nerve injury there may be a functional (albeit weak) preservation of elbow flexion through the brachioradialis innervated through the posterior division of the upper trunk and the posterior cord.
    There is sensory loss in the cutaneous territory dictated by the level of nerve lesion. In a case of isolated musculocutaneous nerve injury the sensory loss is limited to the lateral cutaneous nerve of the forearm. In a C5 and C6 root avulsion or an upper trunk rupture there is more widespread sensory loss involving the lateral arm and volar and dorsal aspects of the radial forearm and hand. There may be dry skin and erythema due to vasodilatation due to loss of autonomic sudomotor and vasomotor function as a result of axonopathy of the affected nerves.
    Careful assessment for a non-progressive Tinel at Erb’s point in the posterior triangle of the neck can confirm a non-regenerating lesion of prompt suspicion of rupture of the upper trunk. In a case of C5 ad C6 root avulsion there is no Tinel’s sign at Erb’s point due to the pre-ganglionic nature of the nerve injury. A Tinel’s sign over the infra-clavicular brachial plexus may be elicited over the lateral cord radiating to the hand or the musculocutaneous nerve radiating to the lateral forearm. A common sit eof tether and rupture of the musculocutaneous nerve is as it pierces the coracobrachialis tendon inferior to the coracoid process.
    Potential donor nerves should be examined prior to consideration of nerve transfer as they may have been injured by the index accident. Thorough assessment should include MRC muscle grading of the flexor carpi ulnaris (FCU) innervated through the ulnar nerve and the flexor carpi radialis (FCR) innervated through the median nerve.
    INVESTIGATION:
    Imaging studies may be used to confirm a nerve root avulsion. MRI or the cervical spine and brachial plexus is useful in such cases. Ultrasound of the upper trunk can demonstrate a rupture or a neuroma-in-continuity in some cases and may be useful in obstetric brachial plexus injury cases.
    Neurophysiological studies including electromyography of the biceps, brachialis and brachioradialis can confirm denervation with fibrillation. Evidence of reinnervation with polyphasia could indicate that there is some further recovery potential and an interval review may be warranted as long as the denervation is less than 9 months duration. Successful reinnervation through nerve transfers requires surgery to be completed by 9 months from injury otherwise there is irreversible loss of the intra-muscular neural plexus.
    Potential donor muscles can be examined with electromyography to confirm useful function and full reinnervation if there was a concomitant involvement of the lower plexus with a continuity mixed or low grade axonal injury. This may be useful early on to plan reconstruction when there is a pan-plexus injury with a flail arm at presentation with suspicion of predominant conduction block injury of the lower plexus. However this is usually not necessary and clinical examination prior to transfer can usually confirm acceptable function and predict useful recovery from a motor nerve ransfer to the biceps or the brachialis from the median nerve, ulnar nerve or double fascicle transfer from both nerves.
    OPERATIVE ALTERNATIVES:
    In a rupture of the upper trunk, autologous nerve grafting can be performed to restore elbow flexion function. The distance for reinnervation is such that early surgery may restore useful biceps but the additional reinnervation distance to the nerve to brachialis means that functional recovery of the latter muscle is unpredictable. Grafting may be performed in conjunction with a nerve transfer to the more distally-placed brachialis muscle.
    There are muscle-tendon transfer options in partial plexus injuries. The pectoralis major or latissimus dorsi can be transferred to restore elbow flexion although function is usually limited due to amplitude or excursion mis-match. In a patient with a weak elbow flexion from a poor continuity nerve lesion recovery the functioning common flexor muscle mass at the medial epicondyle may be transferred to the anterior aspect of the distal humerus creating a fixed flexion deformity of the elbow but allowing flexios of the elbow to be augmented by these wrist and finger flexors. This is known as a Steindler fleroplasty. Function is severely limited but it may salvage an otherwise non-functional elbow.
    Late presentation of failed primary surgery can be managed with a free functioning muscle transfer using the gracilis muscle. This muscle may be anchored on the lateral clavicle and anastomosed to the thoraco-accromial vessels and reinnervated with a nerve in the vicinity, typically either a fascicle from the ulnar nerve of the medial pectoral nerve. The tendon of the gracilis can be sutured to the biceps tendon or routed to the forearm for a combined functional gain (for example elbow flexion and finger flexion; elbow flexion and wrist extension).
    NON-OPERATIVE ALTERNATIVES:
    There is growing interest in the use of robotic exo-skeleton devices that can be used to position the limb as an assist arm. These are most useful when there is useful retained hand function and the device improves function by allowing arm positioning in the upper limb working space. The only alternative is a flail arm orthotic device that allows locking and unlocking of the elbow joint with limited positioning options.
    CONTRAINDICATIONS:
    Nerve transfer should not be contemplated when there has been muscle denervation for more than 9 months or when the donor muscles are too weak to risk sacrifice of a fascicle in the ulnar or median nerves. If there is stiffness of the elbow or heterotopic bone then it is not advisable to undertake reanimation of the elbow as it will most likely fails unless there is first restoration of a full passive elbow range of motion through therapy and surgical releases.

    Setup

    General anaesthesia without neuromuscular blockade is required.
    Use the supine position with arm table support and abduction of the shoulder to facilitate access to the medial arm. A lead hand will maintain forearm supination and elbow extension. Skin preparation should be used for the whole arm to allow visualization of the hand and wrist during nerve stimulation to ensure that no critical nerve function is at risk during fascicle selection.
    A nerve stimulator, stimulator needle and electrode circuit is required to assess function in the nerves to biceps and brachialis plus for the selection of the most appropriate fascicle from the median and ulnar nerves for transfer.
    Microsurgical instruments, an operating microscope and 9’0 nylon sutures are required for the dissection and nerve co-aptation.
    I use Tisseel fibrin glue (Baxter) for the co-aptation to minimise sutures at the neurorraphy.

    Operation – 1

    The arm is prepped and draped with the forearm and hand positioned in supination in a lead hand on an operating side table with the shoulder abducted to 7-90 degrees to afford access to the axilla and medial arm.

    Three finger breadths below the axilla mark the level for the origin of the motor branch to the biceps at the biceps motor point.

    Three finger breadths below this mark the level for the motor point to brachialis.

    Mark the line of the surgical incision in the interval between biceps anteriorly and tricpes posteriorly along the course of the neurovascular bundle on the medial aspect of the arm.
    Make a 10cm longitudinal incision on the medial arm along this line between the two transverse lines.
    The proximal incision should start 3 finger breadths below the anterior axillary fold and extend to the junction of the upper 2/3 and lower 1/3 of the upper arm.

    Open the skin taking care to avoid damage to the cutaneous nerve branches from the medial cutaneous nerve of the arm (MCNA) and incise the deep fascia.

    Using gentle digital dissection to expose the interval between biceps and triceps.
    In the upper part of the wound the interval is less distinct because of the insertion of the coracobrachialis.
    In the distal part of the incision the interval between biceps and triceps forms the superficial part of the dissection and then later the deeper dissection is between the biceps and brachialis muscles.

    The biceps muscle is seen anteriorly with fat around the neurovascular bundle posterior to it. the musculocutaneous nerve and the motor branch to biceps will lie within this fat with a vascular pedicle to the biceps muscle from the brachial artery.

    Use a retractor under the distal biceps muscle belly to elevate biceps and identify the motor branch entering the undersurface proximally. Take great care when placing this retractor to avoid direct or tractional damage to the motor branch to the biceps muscle.

    The motor branch to biceps is identified in the proximal wound deep to biceps. It is intimately related to the vascular pedicle to the biceps muscle which may need retracting to identify the nerve.
    A fine-tipped 90 degree mixter forceps is passed deep to the motor branch to biceps (MBrBi) to facilitate passage of a surgical rubber loop.

    The motor branch is small and delicate and care should be taken to avoid inadvertent injury to the nerve through crush between the mixter jaws or through traction.

    A white surgical rubber loop is passed into the jaws of the mixter using DeBakey forceps and grasped so that the tip is held firmly and won’t sag on delivery deep to the MBrBi on withdrawal of the mixter.

    The white sloop is positioned around the motor branch to biceps from the musculocutaneous nerve.

    Nerve stimulation is used to confirm that there is no contraction f the biceps muscle. A normal nerve in a patient under general anaesthesia without neuromuscular blockade and no tourniquet should stimulate with strong visible contraction at 0.1mA with evidence of increasing recruitment as the stimulation threshold is increased to 0.5mA. The threshold for stimulation may depend on the position of the stimulator needle which should be placed flat against the epineurium.

    Develop the interval posterior to biceps to identify the musculocutaneous nerve, the median nerve and the brachial artery.

    Follow the MBrBi proximally to the take-off from the musculocutaneous nerve and then use a surgical loop to lift the MCuN and trace distally for 5cm.
    The musculocutaneous nerve lies between biceps and the neurovascular bundle (median nerve and brachial artery).
    Identify the point where the lateral cutaneous nerve of forearm (LCuNF) continues between biceps and brachialis.
    The more medially positioned LCuNF overlies the smaller and deeper Motor branch to brachialis (MBrBra)


    Expose the median nerve immediately medial to the MCuN and lying anterior to the brachial artery at the level of the MBrBi.

    The blue sloop is placed around the combined lateral cutaneous nerve of the forearm and the motor branch to brachialis distal to the take-off of the motor branch to biceps.

    Develop the plane between the LCuNF and the MBrBra so that a mixter may be passed through this interval to place sloops around each of these structures.


    A yellow sloop is passed around the LCuNF which is retracted medially. This will expose the motor branch to brachialis (MBrBr) entering the upper part of the brachialis muscle.


    A mixter is positioned deep to the nerve to brachialis facilitate passage of a surgical loop.

    A red sloop is placed around the MBrBra. Using gentle traction on the surgical loops undertake a limited external neurolysis of both the MBrBi and the MBrBra by splitting along the fascicle groups with microscissors to gain sufficient length for nerve transfer.

    In this case the LCuNF is identified distal to the biceps vascular pedicle to facilitate exposure of the nerve to brachialis as it enters that muscle to confirm the anatomy and allow completion of the neurolysis of the individual branches.

    The yellow sloop is repositioned around the LCuNF in the distal part of the interval between biceps and brachialis.

    Gentle retraction of the LCuNF in the yellow sloop facilitates exposure of the distal part of the motor branch to brachialis.

    The motor branch to brachialis is exposed as it enters the brachialis muscle. It usually branches into 2-3 terminal motor branches at this point. care should be taken to avoid injury to these delicate branches.

    Operation – 2

    The red sloop is repositioned around the distal motor branch to brachialis.

    In the red sloop the terminal branching anatomy of the motor branch to brachialis can be seen. Take great care to ensure that the assistant doesn’t place the retractor on the nerves as they enter biceps and brachialis. I would normally place a self-retaining retractor in the more superficial part of the biceps muscle and avoid using Langenbeck retractors because the assistant doesn’t have a clear view of the surgery site and iatrogenous injury to the delicate nerve branches would result in no functional recovery and failure f the selective nerve transfer procedure.

    Nerve stimulation is used to confirm absence of contraction of the motor branch to brachialis with increasing stimulation threshold to 5mA. Normal stimulation thresholds for an intact nerve are 0.1mA. use of these high thresholds confirms that there is no early partial reinnervation and is necessary before determining to proceed with the nerve transfer procedure.

    The absence of stimulation to the motor branch to biceps in the white sloop is confirmed once again at a threshold gradually increasing from 0.1 to 5mA. Nerve stimulation should be used to confirm the absence of contraction in each of the potential recipients (MBrBi and MBrBra). A decision must be made whether transfer is required to biceps or brachialis in isolation or a double nerve transfer to both muscles. The decision depends on whether there is any residual function or anticipated functional recovery in the proximally placed biceps muscle and whether there are sufficient donor nerve options available. The rational will be discussed later.
    White: Motor branch to biceps
    Blue: Musculocutaneous nerve distal to MBrBi
    Red: Motor branch to brachialis
    Yellow: Lateral cutaneous nerve of forearm

    The median nerve is exposed posterior to the musculocutaneous nerve and overlying the brachial artery.

    A second white sloop is passed around the median nerve using the mixter forceps.
    MN: Median nerve

    The median nerve is isolated in the white sloop.

    Using DeBakey forceps and Jamieson scissors gently expose the tissues dorsal to the median nerve and the brachial artery to look for the medial cutaneous nerve of the forearm (MCNF). This is superficial and anterior to the ulnar nerve at the mid point of the humerus.

    Retract the posterior skin flap at the level of the MBrBr and identify the medial cutaneous nerve of forearm.

    Mobilise the MCNF and then incise the medial intermuscular septum to expose the ulnar nerve in the posterior compartment of the arm.


    Free the ulnar nerve through the septum.


    Pass the fine tipped mixter forceps under the ulnar nerve.

    The ulnar nerve is lifted from its bed with the mixter forceps.

    Place a red sloop in the tip of the mixter forceps and pass it deep to the ulnar nerve carefully, making sure that it doesn’t snag. The ulnar nerve is now isolated in a red sloop.

    Nerve stimulation of the ulnar nerves confirms normal stimulation thresholds at 0.1mA. The surface of the ulnar nerve can be mapped topographically to identify a region with strong wrist flexion (FCU) and little finger flexion or intrinsic function. This will be the initial target area for a selective fascicle harvest.

    During the stimulation of the ulnar nerve the forearm, wrist and hand must be observed to identify muscle recruitment.

    Next the median nerve in the white sloop is mapped in the same manner, confirming normal function at 0.1mA stimulation threshold and mapping the surface of the nerve to identify a zone with predominant FCR function.

    1. Median fascicle (FCR) transfer to MBrBi:
    The original description by Oberlin used an ulnar nerve (UN) fascicle (reliable C8/T1 function in isolated upper plexus C5/6 avulsions) to transfer to biceps. This requires mobilization of 3-4 cm of donor fascicle from the UN. A lengthy dissection can be avoided by using a median donor adjacent to the MBrBi. The median nerve should only be used where there is normal C7/8 T1 function. Map the surface of the median nerve using a nerve stimulation of approximately 1mA. Identify a region of the nerve (usually anteromedial) with strong wrist and pronation contraction. Under the operating microscope make a longitudinal epineurotomy and expose the fascicles in that segment of nerve. Stimulate at 0.2mA and identify a brisk wrist flexion response without significant intrinsic or finger flexion. Gentle mobilize the selected fascicle and pass a microsurgical loop under this fascicle and restimulate at 0.05-0.1mA. If there is still good contraction then this fascicle should be selected. If not then continue with the same technique on an adjacent fascicle.

    The median nerve is exposed and the loose connective tissue adjacent to the epineurium is cleared.

    The fascicle group pre-selected through stimulation is exposed using initial interfasciccular dissection by gently spreading the tips of the Jamieson scissors. The epineurium may need incising with a scalpel to create a small window adjacent to the fascicle of interest.

    The anterior spect of the median nerve has two main fascicle groups that are being separated. The aim is to use intermittent low threshold stimulation to confirm target fascicle selection without cross stimulation to other fascicles. Inside the nerve direct fascicle stimulation can be achieved with small thresholds as little as 0.04mA. Excess dissection creates a temporary conduction block which should be avoided. The target fascicle is then isolated in a sloop and confirmed as the one of choice with further stimulation before proceeding with intrafascicular neurolysis.

    An anterior and centrally placed fascicle is initially targeted as selected through stimulation. This seems to involve mainly wrist flexion (FCR and some pronation) on stimulation.

    The fascicle is separated from the rest of the median nerve using the fine tipped mixter forceps.

    A white sloop is placed around the selected donor fascicle within the median nerve. Stimulation confirms that this is the donor of choice. Minimal intraneural dissection has been undertaken and this prevents the risk of inadvertent injury, scar formation and sensory disturbance in the hand. The median nerve has a major sensory component and the risk with a double Oberlin transfer utilising fascicles from both the ulnar and median nerves is this sensory sensitisation of the median nerve. Therefore in a case for a single nerve transfer I would use the ulnar nerve in isolation as a donor.

    The ulnar nerve surface is now mapped prior to epineurial windowing. Note that the median nerve selected fascicle has not undergone neurolysis yet for length for transfer. However a blue sloop has been placed around the remaining median nerve so that the target fascicle can be rapidly identified under the operating microscope and with gentle traction on the blue (median nerve) and white (selected FCR fascicle) an intraneural neurolysis can be undertaken later.

    Surgical loupes with at least 3.5x magnification are used in the initial dissection and then the operating microscope is used for the intraneural dissection once the main fascicle group is identified. The microscop is positioned in the axilla so that the operator and assistant have a clear view. the surgeon is seated. Note that there is a monitor screen so that the scrub team can watch the procedure and anticipate the steps and instruments required.

    Operation – 3

    The surgeon is on the left facing the axilla.

    2. Ulnar fascicle (FCU) transfer to MBrBr:
    The ulnar nerve lies more posteriorly and generally requires less mobilization for co-aptation to the MBrBr than for the original description of transfer to the MBrBr. Mobilise the MBrBr and section proximally and reflect distally and ulnarwards to meet the distally sectioned FCU fascicle from the UN. Typically only 1-2 cm of ulnar nerve fascicle mobilization is needed for this technique compared to 3-4cm if the target is the MBrBiceps. Direct co-aptation without tension is performed as for the fascicle transfer to MBrBi.
    Here a fascicle is selected in the ulnar nerve an a red sloop placed beneath it.

    Nerve stimulation directly on this fascicle confirms that it is the fascicle of choice with predominant FCU function. This fascicle is typically situated in the anterior and medial part of the ulnar nerve.

    Stimulation of the residual ulnar nerve confirms that there is FCU, FDP and intrinsic function preserved in the nerve outside of the selected fascicle.

    The upper white sloop is the target motor branch to biceps and the lower white sloop the selected predominant FCR fascicle of the median nerve.

    Neurolysis is performed of the Motor branch to bicpes from the rest of the musculocutaneous nerve using gentle sloop retraction and serrated curved microscissors to split the loose intrafascicular epineurium. This is a natural cleavage plane and 3-4cm of length can be readily obtained.

    Under the microscope with gentle sloop retraction separate the donor motor fascicle (FCR) of the median nerve from the remainder of the median nerve. Look for crossing intrafascicular branches are identified and must be preserved. These branches can limit the length of donor nerve fascicle available. The final sectioning os the donor and recipient should wait until the intraneural dissection is complete.
    Section the MBrBi proximally and reflect distally and then section the donor median fascicle distally and reflect proximally. The two nerve stumps should reach without tension with the shoulder in abduction and the elbow extended.
    A microsurgical background has been positioned under the recipient motor branch to biceps to assist with co-aptation.

    The donor fascicle is sectioned distally with scissors.

    The donor fascicle is small is comparison to the recipient, however there is loss connective tissue around the motor branch to biceps which can be trimmed and the size mismatch will be less apparent.

    Next the motor branch to brachialis is sectioned proximally.

    The selected fascicle from the ulnar nerve (FCU) is sectioned distally. A second sheet of microsurgical background material is placed under the recipient motor branch to brachialis.

    Principles:
    Minimise dissection in the donor nerve
    Section the recipient proximally and the donor distally
    Aim for a tension free co-aptation
    Excess redundancy should be managed with shortening of the recipient stump to allow co-aptation to be closer to the target muscle, thereby shortening the reinnervation time

    Suture the two nerve ends under the operating microscope with 2-3 well placed 9’0 nylon sutures.


    Note the size mismatch is less apparent after trimming excess connective tissue. Fine suture placement allows tension free approximation of the fascicles under the operating microscope.

    Complete the second neurorraphy for ulnar FCU fascice to motor branch to brachialis. Typically the co-aptation and therefore the reinnervation distance is approximately 2-3cm from the target muscle motor point.

    The completed double fascicular transfer.

    Complete a neurorraphy using 9’0 nylon sutures and an operating microscope. 2-3 sutures should suffice and the neurorraphy may be supported with Tisseel fibrin glue. An alternative method is to use a collagen nerve connector (2-3mm) to approximate the nerve transfer with remote sutures between the connector and the epineurium. Minimizing sutures at the co-aptation site reduces fascicle distortion, nerve ischaemia and scar formation. The nerve transfer should be tension free and remain tension free throughout a full passive range of shoulder and elbow motion.

    Tisseel (Baxter) is placed around the co-aptation site and then the microsurgical background material can be rolled and held with DeBakey forceps to achieve circumferential support from Tisseel fibrin glue at the neurorraphy site.

    Tisseel can be used after background material removal to secure the nerve transfers to the surgery bed to prevent displacement from inadvertent excessive tension during the initial two week rehabilitation phase.

    Deep interupted vicryl 3’0 sutures are placed in the superficial fascia.

    The wound is closed with a subcuticular 3’0 Monacril suture.

    Local anaesthetic is infiltrated to the wound edges. No local anaesthetic is placed deeply in the wound because it is important to assess and document residual intact motor function in the median and ulnar nerves in the recovery room.

    Steristrips are applied to the wound edges after subcuticular closure.

    A waterproof occlusive dressing is applied to the wound.

    Post Operative

    This procedure may be performed in combination with spinal accessory to suprascapular nerve transfer and nerve transfers to deltoid and teres minor from the radial nerve for C5 nerve root injuries. These procedures will be featured elsewhere in OrthOracle.
    A waterproof dressing with absorbent pad is applied to the wound. The wound should be kept clean and dry for 7 days after which the patient can shower then replace the dressing. A polysling is applied to the upper limb with a torso strap around the waist before the patient wakes from surgery. The polysling and torso strap should be maintained for 3 weeks to prevent excessive passive movement at the shoulder.
    During this phase the patient is encouraged to maintain isometric contraction of the donor muscles in the sling and to visualise the combination of wrist flexion and elbow flexion.
    Nerve transfer rehabilitation involves a 6-phase programme of activity developed at the Centre for Nerve Injury and Paralysis, Birmingham, UK.
    Phase 1 – Pre-operative phase: Education and donor optimisation. Introduction to trophic stimulation and the concept for functional electrical stimulation (FES).
    Phase 2 – Protection phase: During the immediate post-operative period the nerve transfer is protected from inadvertent injury with the arm immobilised. Isometric contraction of the donor and visualisation of the combination donor-recipient action is performed during this period which typically lasts 3 weeks.
    Phase 3 – Prevention phase: During this phase the arm is mobilised and neural gliding is commenced. Joint range of motion exercises (active and passive) are commenced to prevent joint contractures developing. The isometric exercises are continued and isotonic and eccentric exercises are commenced for the donor muscle to maintain function and restore strength. Functional stimulation can be commenced on the donor muscle. Trophic stimulation can be maintained on the recipient muscle.
    Phase 4 – Power phase: During this period the donor muscle is strengthened and the recipient muscle starts to respond. Typically the first sign of reinnervation is a tender muscle squeeze sign due to small fibre reinnervation. Typically this is 3 months following transfer but is affected by the distance of the co-aptation from the recipient motor point.Visible flickers of contraction follow within 6 weeks and donor activation potentiate the recipient response. FES continues and the phase lasts for approximately 6-12 months during which useful motor grade returns: Medical Research Council – (MRC) Grade 3-4.
    Phase 5 – Plasticity: During this phase the patient works on activation of the recipient muscle without activation of the donor. This phase can overlap with phase 4 and is guided by a therapist specialised in nerve transfer rehabilitation.
    Phase 6 – Purpose: During this phase the patient introduces function tasks discussed as objectives during the pre-operative phase. This period of training is tailored to the individual and includes work hardening. Improvements are typically found in power and functional performance for at least 2 years following nerve transfer surgery.
    Outcomes assessment can be with MRC scales but because of the huge functional variation within MRC Grade 4, I prefer absolute muscle testing with digital myometry and comparison with the contralateral limb. In addition fatigue testing and functional scores are important. The EQ5D, DASH and the BrAT scores are in common use in assessing upper limb function after brachial plexus injury. The Canadian Occupational Performance Measure (COPM) is an ideally suited tool to assess patient specific objectives and outcomes.

    Recommended Reading

    History of the Oberlin nerve transfer procedure:
    Adolf Stoffel described the technique of triceps to musculocutaneous nerve transfer via an anterior approach in 1911 in a textbook of orthopaedic surgery “Orthopadische Operationslhere” published in 1913. This text was never translated from German and the technique did not receive wide uptake.
    Christophe Oberlin described the technique of ulnar nerve fascicle transfer in 1994 with a follow-up series in 1997. In 2002 Oberlin wrote a technical description of the procedure and it gained in popularity.In 2005 Susan Mackinnon published a technique of double nerve transfer for elbow flexion and this was followed by a paper from Oberlin in 2006 detailing the same technique. Bertelli in 2010 wrote about the role of adjunctive distal nerve transfer after proximal nerve repair or graft. The current practice is for a single FCU fascicle to biceps or in a double transfer to use the FCU fascicle for brachialis and the FCR fascicle to biceps in my practice. In caes of anticipated biceps recovery from proximal surgery I undertake a distal concomitant nerve transfer FCU to brachialis in keeping with the rational described by Jayme Bertelli.
    Author’s note:
    Double nerve transfer at the shoulder for abduction (deltoid and supraspinatus) and for external rotation (infraspinatus and teres minor) confers superior results in terms of brachiothoracic motion and strength with MRC grade 4 shoulder abduction in approximately 80% of patients compared to around 80% MRC grade 3+ with a single transfer for each function. The benefit of the second transfer at the elbow is less clear with approximately 70% achieving MRC grade 4 after a single transfer and 90% MRC grade 4 after a double transfer. This is based on the author’s own series of nerve transfers around the shoulder and elbow and is supported by the published literature. The single transfer should use the UN as fascicle donor. The added benefit of 20% increase MRC grade 4 should be weighed against the risk of sensory compromise to the hand and reduction in wrist flexion strength when the median nerve is used as a second donor.
    Avoid dissection in the donor nerve by surface mapping of the topography using the nerve stimulator and exposing only the target area. Do not undertake intra-fscicle dissection until a donor is identified and consider minimizing the length of the intra-fascicle dissection by using FCU fascicle to brachialis and FCR fascicle to biceps when a double transfer is selected (MacKinnon modification).
    Use caution when there is C7 involvement as the FCR will not be of sufficient strength for a reliable double transfer technique and I would recommend a single FCU fascicle to the MBrBi as the preferred choice in such cases. The rationale here is that as the injured is more extensive there are fewer donors available and more potential targets and so a pragmatic approach to reconstruction is required and it should be accepted that the outcome is likely to be inferior to that following isolated C5/6 avulsion injury.
    References:
    Orthopadische Operationslhere. “Operationen am nervensystem” Oskar Vulpius and Adolf Stoffel. Publshed by Ferdinand Enke, Stuttgart, 1913
    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.
    Oberlin C, Béal D, Leechavengvongs S, Salon A, Dauge MC, Sarcy JJ.
    J Hand Surg Am. 1994 Mar;19(2):232-7.
    Ulnar nerve fascicle transfer onto to the biceps muscle nerve in C5-C6 or C5-C6-C7 avulsions of the brachial plexus. Eighteen cases].
    Loy S, Bhatia A, Asfazadourian H, Oberlin C.
    Ann Chir Main Memb Super. 1997;16(4):275-84. French.
    Restoration of elbow flexion in brachial plexus injury by transfer of ulnar nerve fascicles to the nerve to the biceps muscle.
    Oberlin C, Ameur NE, Teboul F, Beaulieu JY, Vacher C.
    Tech Hand Up Extrem Surg. 2002 Jun;6(2):86-90
    Preliminary results of double nerve transfer to restore elbow flexion in upper type brachial plexus palsies.
    Liverneaux PA, Diaz LC, Beaulieu JY, Durand S, Oberlin C.
    Plast Reconstr Surg. 2006 Mar;117(3):915-9.
    Results of reinnervation of the biceps and brachialis muscles with a double fascicular transfer for elbow flexion.
    Mackinnon SE, Novak CB, Myckatyn TM, Tung TH.
    J Hand Surg Am. 2005 Sep;30(5):978-85.
    Double fascicular nerve transfer to the biceps and brachialis muscles after brachial plexus injury: clinical outcomes in a series of 29 cases.
    Ray WZ, Pet MA, Yee A, Mackinnon SE.
    J Neurosurg. 2011 Jun;114(6):1520-8. doi: 10.3171/2011.1.JNS10810.
    Nerve root grafting and distal nerve transfers for C5-C6 brachial plexus injuries.
    Bertelli JA, Ghizoni MF.

    Reference

    • orthoracle.com

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