Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and Chang Gung University, Taipei, Taiwan.
Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and Chang Gung University, Taipei, Taiwan.
J Hand Surg Am. 2023 Oct;48(10):1058.e1-1058.e9. doi: 10.1016/j.jhsa.2022.03.006. Epub 2022 May 7.
In patients with late brachial plexus birth injuries, sequelae after acute flaccid myelitis, or chronic adult brachial plexus injury, donor nerves for functioning muscle transplantation are often scarce. We present the results of a potential strategy using the phrenic nerve with staged free gracilis transplantation for upper extremity reanimation in these scenarios.
A retrospective review was performed on an institutional database of brachial plexus injury or patients with palsy. All patients underwent a staged reconstruction in which the ipsilateral phrenic nerve was extended by an autogenous nerve graft (PhNG), followed by free-functioning gracilis transplantation (PhNG-gracilis).
Nine patients (6 cases of late brachial plexus birth injuries, 2 of acute flaccid myelitis, and 1 of adult chronic brachial plexus injury) were included in this study. The median follow-up period following the PhNG-gracilis procedure was 27 months (range, 12-72 months). The goals of the staged PhNG and PhNG-gracilis were primarily finger extension or finger flexion. In some patients, the technique was used to improve both elbow and finger function, tunneling the muscle through the flexor compartment of the upper arm and under the mobile wad at the elbow. All patients exhibited improvement of muscle strength, including in finger extension (4 patients) from M0 to M2; finger flexion (3 patients) from M0 to M3; elbow extension (1 patient) from M0 to M2; and elbow flexion (1 patient) from M2 to M4.
A 2-stage PhNG-gracilis may restore or enhance the residual elbow and/or finger paralysis in chronic brachial plexus injuries. A minimum follow-up period of 3 years is recommended. This technique may remain useful as one of the last reconstructive options to increase power in patients with scarce donor nerves.
TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.
在迟发性臂丛神经产伤、急性弛缓性脊髓炎或慢性成人臂丛神经损伤的患者中，用于功能性肌肉移植的供体神经往往较为缺乏。我们提出了一种潜在策略的结果，即使用膈神经，并分期游离股薄肌移植，以实现这些情况下的上肢再神经支配。
我们对机构数据库中臂丛神经损伤或神经麻痹患者进行了回顾性研究。所有患者均接受分期重建，即同侧膈神经通过自体神经移植物（PhNG）延长，然后进行游离股薄肌移植（PhNG-股薄肌）。
本研究共纳入 9 例患者（6 例迟发性臂丛神经产伤、2 例急性弛缓性脊髓炎和 1 例成人慢性臂丛神经损伤）。PhNG-股薄肌手术后的中位随访时间为 27 个月（范围 12-72 个月）。分期 PhNG 和 PhNG-股薄肌的主要目标是手指伸展或手指弯曲。在一些患者中，该技术用于改善肘部和手指功能，将肌肉通过上臂的屈肌间隙并在肘部活动的腱膜下方隧道化。所有患者的肌肉力量均得到改善，包括 4 例手指伸展（从 M0 到 M2）、3 例手指弯曲（从 M0 到 M3）、1 例肘部伸展（从 M0 到 M2）和 1 例肘部弯曲（从 M2 到 M4）。
分期 PhNG-股薄肌可能恢复或增强慢性臂丛神经损伤中残留的肘部和/或手指瘫痪。建议至少随访 3 年。在供体神经稀少的患者中，作为增加力量的最后重建选择之一，该技术可能仍然有用。
研究类型/证据水平：治疗性 V 级。
