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Nerve Transfer Versus Interpositional Nerve Graft Reconstruction for Posttraumatic, Isolated Axillary Nerve Injuries: a Systematic Review

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Nerve Transfer Versus Interpositional Nerve Graft Reconstruction for Posttraumatic, Isolated Axillary Nerve Injuries: a Systematic Review HAND/PERIPHERAL NERVE Nerve Transfer versus Interpositional Nerve Graft Reconstruction for Posttraumatic, Isolated Axillary Nerve Injuries: A Systematic Review John C. Koshy, M.D. Background: The purpose of this study was to compare functional outcomes Nikhil A. Agrawal, M.D. between nerve grafting and nerve transfer procedures in the setting of isolated, Mitchel Seruya, M.D. posttraumatic axillary nerve injuries. Houston, Texas; and Los Angeles, Calif. Methods: A systematic review was performed using the PubMed, Scopus, and Cochrane databases to identify all cases of isolated, posttraumatic axillary nerve injuries in patients aged 18 years or older. Patients who underwent axil- lary nerve reconstruction were included and categorized by technique: graft or transfer. Demographics were recorded, including age, time to operation, and presence of concomitant injuries. Functional outcomes were evaluated, including British Medical Research Council strength and range of motion for shoulder abduction. Results: Ten retrospective studies met criteria, for a total of 66 patients (20 nerve grafts and 46 nerve transfers). Median time from injury to operation was equivalent across the nerve graft and nerve transfer groups (8.0 months versus 7.0 months; p = 0.41). Postoperative follow-up was 24.0 months for nerve graft- 2017 ing versus 18.5 months for nerve transfer (p = 0.13). Clinically useful shoulder abduction, defined as British Medical Research Council grade M3 or greater, was obtained in 100 percent of nerve graft patients versus 87 percent of nerve trans- fer patients (p = 0.09). Grade M4 or better strength was obtained in 85 percent of nerve graft patients and 73.9 percent of nerve transfer patients (p = 0.32). Conclusions: Significant differences in functional outcomes between nerve graft and transfer procedures for posttraumatic axillary nerve injuries are not appar- ent at this time. Prospective outcomes studies are needed to better elucidate whether functional differences do exist. (Plast. Reconstr. Surg. 140: 953, 2017.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV. s our understanding of traumatic periph- to a single nerve coaptation, and bypass the zone eral nerve injuries has grown, methods for of injury.3–5 Presently, there remains little consen- Areconstructing nerve defects not amenable sus as to whether interpositional nerve grafting or to primary repair have evolved. Nerve grafting is nerve transfer procedures provide for better func- considered the standard of care1,2 and depends tional recovery. on neurotization from the donor to target nerve, The management of isolated axillary nerve two sites of nerve coaptation, and an adequate injuries can potentially provide some insight into vascular bed in the zone of injury. Nerve transfer this reconstructive dilemma. These injuries most techniques have recently gained momentum for commonly occur from fractures and dislocations their ability to reduce the neurotization distance of the proximal humerus, as the axillary nerve to the motor endplate target, focus microsurgery passes through the quadrangular space to inner- vate the deltoid muscle. Although initiation of From the Division of Plastic Surgery, Baylor College of Medi- abduction is preserved through the supraspinatus cine; and the Children’s Hospital of Los Angeles. muscle vis-à-vis the suprascapular nerve, overhead Received for publication February 3, 2017; accepted April reach is significantly limited in the absence of 4, 2017. deltoid function. Surgical intervention is typically Presented at Plastic Surgery The Meeting 2016, Annual Meeting of the American Society of Plastic Surgeons, in Los Angeles, California, September 23 through 27, 2016. Disclosure: The authors have no financial interest Copyright © 2017 by the American Society of Plastic Surgeons to declare in relation to the content of this article. DOI: 10.1097/PRS.0000000000003749 www.PRSJournal.com 953 Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Plastic and Reconstructive Surgery • November 2017 recommended in cases where axillary palsy per- who were operated on over 12 months from their sists 4 to 6 months after the injury. injury, (5) patients who had follow-up less than Interpositional nerve graft reconstruction of 12 months after their operation, and (6) studies the axillary nerve has long been performed with without any functional data for active shoulder reproducible success, with studies demonstrating abduction. 73 to 88 percent of patients regaining clinically Two authors independently screened the arti- useful strength.6–9 An alternative method for axil- cles based on review of title and abstract. Dupli- lary nerve reconstruction relies on nerve transfer, cates were next eliminated, and a full-text review which was first described in 1948 by Lurje and of the remaining articles was performed. The ref- based on the radial nerve branches to the triceps.10 erences of the remaining articles were scanned Since that time, nerve transfer methods using for additional relevant articles. When there was the long and medial head of the triceps, medial disagreement about the inclusion of a study or pectoral nerve, and spinal accessory nerve have data point, a consensus decision was determined been developed.11–16 As the majority of studies on with the assistance of the senior author (M.S.).19 nerve transfer reconstruction of the axillary nerve The final articles included in the study were have focused on patients with additional brachial then reviewed for both general study data and the plexus lesions, these studies have demonstrated presence of individual data points. General data varying results. Anywhere from 37 to 46 percent points included type of study, number of grafts of patients have been reported to achieve greater and transfers, and general cohort characteristics than or equal to British Medical Research Council (i.e., age, sex, concomitant injuries to the shoulder grade M4 strength.4,17 complex, time from injury to operation, descrip- Few studies have directly compared outcomes tion of reconstruction, active range of motion, between interpositional nerve grafting and nerve British Medical Research Council grade (Table 1) transfer reconstruction, largely because of the low for shoulder abduction both preoperatively and incidence of isolated axillary nerve injuries. In postoperatively, and follow-up time). this study, we sought to pool together the collec- To evaluate study quality and reporting bias, tive experience of the scientific community. The the Methodological Index for Non-Randomized purpose of this systematic review is to compare Studies criteria were applied.20 Each study was functional outcomes between nerve grafting and evaluated with a score of 0, 1, or 2 points for each nerve transfer procedures in the setting of post- of the applicable Methodological Index for Non- traumatic, isolated axillary nerve injuries. Randomized Studies criteria items. The scores were added and reported in percentages (of a PATIENTS AND METHODS possible 16 points for noncomparative studies and 24 for comparative studies) to allow for a review Literature Review of individual study quality. One hundred percent The study protocol followed the Preferred indicates a perfectly conducted study and 0 per- Reporting Items for Systematic Reviews and Meta- cent indicates the worst possible study design. Analyses guidelines.18 Search criteria, inclusion and exclusion criteria, and analytic methods were Data Analysis specified in advance. In July of 2015, two indepen- Individual data points were categorized based dent researchers queried the PubMed, Scopus, on type of surgical intervention (nerve graft versus and Cochrane databases using four distinct search transfer) and reviewed. Comparisons were made terms. The following search terms were used in between age (younger than 40 or 40 years of age various combinations for the review: “axillary nerve,” “trauma,” “traumatic,” “injury,” “deltoid,” “paralysis,” “palsy,” “repair,” “intervention,” “graft- Table 1. British Medical Research Council Motor ing,” “graft,” “transfer,” “nerve,” “brachial plexus,” Grading Scale “trauma,” “injury,” and “isolated axillary nerve Grade injury.” Inclusion criteria were studies in the Eng- of Motor lish language, published between 1940 and 2015, Recovery Clinical Examination Results and dealing with axillary nerve injuries treated by M0 No contraction M1 Visible contraction without movement nerve graft or transfer. Exclusion criteria were (1) M2 Active motion with gravity eliminated nontraumatic axillary nerve injuries, (2) axillary M3 Active motion sufficient to offset gravity nerve injuries with additional brachial plexopathy, M4 Active motion against some resistance (3) patients younger than 18 years, (4) patients M5 Muscle contracts normally against full resistance 954 Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Volume 140, Number 5 • Isolated Axillary Nerve Injuries or older),7 time to intervention (<6 months or ≥6 studies ranged from 25 to 75 percent, with a mean months),21 and functional outcome. Additional Methodological Index for Non-Randomized Stud- analyses were performed to look at differences in ies criteria score of 41.7 percent for nerve graft percentage of patients achieving grade M3 or bet- articles and 63.3 percent for nerve transfer arti- ter (clinically significant) and grade M4 or greater cles (p = 0.30). strength for shoulder
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