Results of biceps brachii neurotization using ulnar median and intercoastal nerves.

INTRODUCTION: Imagine waking up to realize that your hand simply stops following your command. In a nut shell this is what happens in brachial plexus injuries. Absence of functionality is one of the devastating effects of brachial plexus injuries. Apart from it brachial plexus injury also results in loss of sensation in the affected limb. The affected person also undergoes a period of depression. Many affected persons never return to their normal life. Brachial plexus injury has plagued human species for a long time. It was only at the beginning of this century people started treating brachial plexus injuries. Only in the preceding thirty to forty years advances were made in treatment of brachial plexus injuries. Treatment of brachial plexus injury is multi-staged. Separate operations are required for shoulder, elbow and finger re2 animation. Physiotherapy plays an integral role in treatment of brachial plexus injuries. Regular physical rehabilitation before and after surgery is necessary. Patients should be informed about the expected outcome and the need for regular physiotherapy. AIM AND OBJECTIVES: 1. To analyze the elbow restoration techniques in brachial plexus injuries. 2. To compare functional outcomes of the procedures. 3. To compare patients perspective of the procedures. 4. To assess the complication rates of the procedures. MATERIALS AND METHODS: A clinical study was conducted in the department of Plastic Reconstructive and Maxillofacial Surgery, Madras Medical College and Rajiv Gandhi Government Hospital over a period of 28 months from October 2011 to January 2013. Study Population: The study populations in the present study were the people who visited the hospital for brachial plexus injury treatment. Inclusion Criteria: Patients with brachial plexus injury where Direct neurotization is done. Post-operatively Grade 3 – Elbow Flexion is present Age between 19 – 45 Exclusion Criteria: • Patients with nerve grafts • Patients with muscle power less than Grade 3 Ethical Clearance: The ethical clearance was given by the Institutional ethics Committee of Madras Medical College. Informed Written Consent: Informed and written consent was obtained from all the patients prior to the start of the study. Sample Size: A sample size of 43 patients underwent treatment for brachial plexus injury in this study. Collection of Data: The data was collected with a proforma regarding patient’s injuries and treatment parameters. The time of injury, mode of injury, the type of surgery done, the distance from coapted site to the neuromuscular junction, the number of days patient remained in hospital post operatively, the severity of the pain experienced by the patient, the number of days required to achieve grade III muscle power are noted. OBSERVATION AND RESULTS: A total of 43 patients were included in this study over a period of 28 months between October 2011 and January 2014. Patient related, injury related and treatment related parameters were collected. Age in years, gender and co-morbid illness were noted as patient parameters. The time, etiology are noted as injury related parameters. The type of surgery, complications and number of days required to achieve Grade III are noted as treatment related parameters. Conclusion : • In our study it was found that the number of days required to achieve muscle power Grade III was significantly lesser in the ulnar nerve transfer group. • The number of days required to achieve muscle power Grade III was maximum in intercostal nerve transfer group. The possible reasons for this are 1. Shorter neuromuscular junction to coaptation site distance 2. The sensory fascicle contamination is less in case of ulnar and median nerve transfers. • The post-operative complications are more in intercostal nerve transfers because of the long incision and extensive tissue handling. Patients should be highly motivated and should understand the procedure. They should be ready to do regular physiotherapy. They should realize that elbow reanimation is one step in the multi-staged brachial plexus repair. To sum up, transfer of well vascularized nerves containing pure motor fascicles gives superior results