Brachial Plexus Injury, Brachial Plexus Palsy
Conditions
Keywords
Brachial plexus palsy, Tendon transfer, Finger flexion reconstruction, Brachial plexus injury, secondary reconstruction
Brief summary
This study is a prospective single-arm surgical protocol evaluating biceps-to-flexor digitorum superficialis (FDS) tendon transfer using a tensor fascia lata graft for restoration of finger flexion in patients with traumatic pan-brachial plexus injury (pan-BPI). Finger flexion reconstruction in intrinsic-minus hands remains challenging, as conventional flexor digitorum profundus (FDP)-based reconstructions may result in clawing and ineffective grasp. The proposed technique aims to improve metacarpophalangeal and proximal interphalangeal joint flexion to enhance functional grasp. Eligible patients are those with pan-BPI who previously underwent nerve transfer and achieved elbow flexion strength of at least Medical Research Council (MRC) grade 4. Patients with significant joint stiffness, severe forearm soft tissue injury, or insufficient elbow flexion strength are excluded. The procedure consists of staged reconstruction followed by tendon transfer with tensor fascia lata graft interposition. Postoperative management includes 4 weeks of immobilization and progressive rehabilitation. The primary outcome is functional finger flexion, while secondary outcomes include complications and reoperation rates.
Detailed description
Traumatic pan-brachial plexus injury (pan-BPI) results in severe upper limb dysfunction, with finger flexion restoration remaining challenging. FDP-based reconstructions often produce clawing and ineffective grasp in intrinsic-minus hands. This study proposes biceps-to-FDS tendon transfer using a tensor fascia lata graft to improve MCP and PIP flexion and enhance grasp. This is a prospective single-arm surgical protocol. Eligible patients include those with pan-BPI who have undergone nerve transfer and achieved elbow flexion at least MRC grade 4. Patients with joint stiffness, severe forearm soft tissue injury, or inadequate elbow strength are excluded. The procedure involves staged reconstruction, followed by tendon transfer with graft interposition. Postoperatively, immobilization is maintained for 4 weeks, with gradual rehabilitation. Primary outcome is functional finger flexion. Secondary outcomes include complications and reoperation.
Interventions
PROCEDUREBiceps to FDS tendon transfer
All procedures were performed under general anesthesia. An S-shaped incision was made over the anterior elbow to identify and mobilize the biceps tendon to its insertion at the radial tuberosity, followed by division of the bicipital aponeurosis. A second incision was made in the distal forearm to identify the flexor digitorum superficialis (FDS) tendon. The tendon gap was measured to determine graft length. A tensor fascia lata graft was harvested from the lateral thigh, tubularized, and used as an interposition tendon graft. The graft was attached to the biceps tendon using the Pulvertaft technique with nonabsorbable sutures, then passed through a subfascial tunnel to the distal forearm to prevent bowstringing. With the elbow flexed at 90° and fingers in full flexion, the distal graft was woven into the FDS tendons using the Pulvertaft technique. Transfer tension was confirmed by assessing the tenodesis effect.
Sponsors
Siriraj Hospital
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Brachial plexus injury patients with successful nerve transfer surgery for elbow flexion * Elbow flexion motor power at least grade 4
Exclusion criteria
* Stiffness of proximal interphalangeal (PIP) joint * Stiffness of metacarpophalangeal (MCP) joint * Severe soft tissue injury around the forearm
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Finger flexion motor power | From enrollment to at least 3 months after surgery | Finger flexion motor power was assessed using the Medical Research Council (MRC) grading system at postoperative follow-up visits for a minimum of 3 months after surgery. Motor strength was graded on a scale from M0 to M5, where M0 indicates no visible muscle contraction and M5 indicates normal muscle strength against full resistance. Functional finger flexion strength during grasp was evaluated clinically by the treating surgeon. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Elbow flexion motor power | From enrollment to at least 3 months after surgery | Elbow flexion motor power was assessed using the Medical Research Council (MRC) grading system at postoperative follow-up visits for a minimum of 3 months after surgery. Motor strength was graded on a scale from M0 to M5, where M0 indicates no visible muscle contraction and M5 indicates normal muscle strength against full resistance. Elbow flexion strength was evaluated clinically by the treating surgeon. |
| Tendon rupture | From enrollment to at least 3 months after surgery | Tendon rupture was assessed as a postoperative complication during follow-up visits for a minimum of 3 months after surgery. Tendon rupture was diagnosed clinically based on loss of active finger flexion or loss of previously achieved motor function at the tendon transfer site, with additional imaging performed when clinically indicated. The incidence of tendon rupture and the need for reoperation were recorded. |
| Finger stiffness | From enrollment to at least 3 months after surgery | Finger stiffness related to excessive tension of the tendon transfer was assessed as a postoperative complication during follow-up visits for a minimum of 3 months after surgery. The complication was defined as limitation of passive and/or active finger motion associated with excessive tightness of the tendon transfer, resulting in impaired hand opening or functional finger movement. Clinical evaluation was performed by the treating surgeon, and the incidence of stiffness and requirement for additional intervention were recorded. |
Countries
Thailand
Contacts
PRINCIPAL_INVESTIGATORPanai Laohaprasitiporn, MD
Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University
Outcome results
None listed