Functional outcome of contralateral C7 nerve transfer combined with free functional gracilis transplantation to repair total brachial plexus avulsion: a report of thirty-nine cases

PURPOSE: Treatment of total brachial plexus avulsion (TBPA) is a challenge in the clinic, especially the restoration of hand function. The current main surgical order is from proximal to distal joints. The purpose of this study was to demonstrate the outcomes of “distal to proximal” surgical method. METHODS: Thirty-nine patients underwent contralateral C7 (CC7) nerve transfer to directly repair the lower trunk (CC7-LT) and phrenic nerve transfer to the suprascapular nerve (PN-SSN) during the first stage, followed by free functional gracilis transplantation (FFGT) for elbow flexion and finger extension. Muscle strength of upper limb, degree of shoulder abduction and elbow flexion, and Semmes–Weinstein monofilament test and static two-point discrimination of the hand were examined according to the modified British Medical Research Council (mBMRC) scoring system. RESULTS: The results showed that motor recovery reached a level of M3 + or greater in 66.7% of patients for shoulder abduction, 87.2% of patients for elbow flexion, 48.7% of patients for finger extension, and 25.6% of patients for finger flexion. The mean shoulder abduction angle was 45.5° (range 0–90°), and the average elbow flexion angle was 107.2° (range 0–142°), with 2.5 kg average flexion strength (range 0.5–5 kg). In addition, protective sensibility (≥ S2) was found to be achieved in 71.8% of patients. CONCLUSION: In reconstruction of TBPA, CC7 transfer combined with free functional gracilis transplantation is an available treatment method. It could help patients regain shoulder joint stability and the function of elbow flexion and finger extension and, more importantly, provide finger sensation and partial finger flexion function. However, the pick-up function was unsatisfied, which needed additional surgery.