Maldonado Andrés A, Kircher Michelle F, Spinner Robert J, Bishop Allen T, Shin Alexander Y
Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic, Rochester, MN; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN.
Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic, Rochester, MN.
J Hand Surg Am. 2017 Apr;42(4):293.e1-293.e7. doi: 10.1016/j.jhsa.2017.01.014. Epub 2017 Feb 27.
After complete 5-level root avulsion brachial plexus injury, the free-functioning muscle transfer (FFMT) and the intercostal nerve (ICN) to musculocutaneous nerve (MCN) transfer are 2 potential reconstructive options for restoration of elbow flexion. The aim of this study was to determine if the combination of the gracilis FFMT and the ICN to MCN transfer provides stronger elbow flexion compared with the gracilis FFMT alone.
Sixty-five patients who underwent the gracilis FFMT only (32 patients) or the gracilis FFMT in addition to the ICN to MCN transfer (33 patients) for elbow flexion after a pan-plexus injury were included. The 2 groups were compared with respect to postoperative elbow flexion strength according to the modified British Medical Research Council grading system as well as preoperative and postoperative Disability of the Arm, Shoulder, and Hand scores. Two subgroup analyses were performed for the British Medical Research Council elbow flexion strength grade: FFMT neurotization (spinal accessory nerve vs ICN) and the attachment of the distal gracilis tendon (biceps tendon vs flexor digitorum profundus/flexor pollicis longus tendon).
The proportion of patients reaching the M3/M4 elbow flexion muscle grade were similar in both groups (FFMT vs FFMT + ICN to MCN transfer). Statistically significant improvement in postoperative Disability of the Arm, Shoulder, and Hand score was found in the FFMT + ICN to MCN transfer group but not in the FFMT group. There was a significant difference between gracilis to biceps (M3/M4 = 52.6%) and gracilis to FDP/flexor pollicis longus (M3/M4 = 85.2%) tendon attachment.
The use of the ICN to MCN transfer associated with the FFMT does not improve the elbow flexion modified British Medical Research Council grade, although better postoperative Disability of the Arm, Shoulder, and Hand scores were found in this group. The more distal attachment of the gracilis FFMT tendon may play an important role in elbow flexion strength.
TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.
在完全性5级根性撕脱性臂丛神经损伤后，游离功能性肌肉转移（FFMT）和肋间神经（ICN）至肌皮神经（MCN）转移是恢复肘关节屈曲的两种潜在重建选择。本研究的目的是确定股薄肌FFMT与ICN至MCN转移相结合是否比单纯股薄肌FFMT能提供更强的肘关节屈曲。
纳入65例因全臂丛神经损伤后接受单纯股薄肌FFMT（32例患者）或股薄肌FFMT联合ICN至MCN转移（33例患者）以恢复肘关节屈曲的患者。根据改良的英国医学研究委员会分级系统比较两组术后肘关节屈曲力量，以及术前和术后的手臂、肩部和手部功能障碍评分。对英国医学研究委员会肘关节屈曲力量分级进行了两项亚组分析：FFMT神经支配（副神经与ICN）和股薄肌远端肌腱的附着（肱二头肌肌腱与指深屈肌/拇长屈肌肌腱）。
两组中达到M3/M4肘关节屈曲肌肉分级的患者比例相似（FFMT组与FFMT + ICN至MCN转移组）。在FFMT + ICN至MCN转移组中发现术后手臂、肩部和手部功能障碍评分有统计学意义的改善，而在FFMT组中未发现。股薄肌至肱二头肌（M3/M4 = 52.6%）和股薄肌至指深屈肌/拇长屈肌（M3/M4 = 85.2%）肌腱附着之间存在显著差异。
尽管该组术后手臂、肩部和手部功能障碍评分更好，但FFMT联合ICN至MCN转移并未改善肘关节屈曲的改良英国医学研究委员会分级。股薄肌FFMT肌腱更靠远端的附着可能在肘关节屈曲力量中起重要作用。
研究类型/证据水平：治疗性IV级。
