Use of a Pedicled Vascularized Ulnar Nerve as a Long Graft for Complete Brachial Plexus Palsy in Adults to Restore Elbow Flexion: Should this Practice Continue?

Abstract

Restoring elbow flexion is a priority in adults with complete brachial plexus palsy. If the nerve root is not avulsed, a graft can be placed between the existing root and the musculocutaneous nerve. The aim of this study was to evaluate the outcomes of using vascularized ulnar nerve grafts in this context. Our case series consisted of 17 male and 3 female patients (mean age of 31 years) presenting complete brachial plexus palsy after a motorcycle accident. A graft at the C5 or C6 root on the musculocutaneous nerve was done in all patients using a pedicled vascularized ulnar nerve to restore elbow flexion at a mean of 5 months after the accident. At a mean follow-up of more than 3 years, elbow flexion was graded as M4 in six patients and between M0 and M2 in the other 14 patients on the Medical Research Council scale. None of the patients had M3 strength. While the results of long grafts using a vascularized ulnar nerve are disappointing in this case series, they are consistent with previous publications. Encouraging results have only been reported with short grafts (<10 cm), which can rarely be used with supraclavicular lesions. For this reason, we currently prefer using a sural nerve graft or nerve transfer, when possible, to restore elbow flexion in adult patients with brachial plexus injuries.

Keywords

brachial plexus - nerve graft - vascularized ulnar nerve - allograft

Publikationsverlauf

Eingereicht: 14. April 2025

Angenommen: 03. September 2025

Artikel online veröffentlicht:
22. September 2025

• References

• 1 Taylor GI, Ham FJ. The free vascularized nerve graft. A further experimental and clinical application of microvascular techniques. Plast Reconstr Surg 1976; 57 (04) 413-426
• 2 Čebron U, Mayer JA, Lu C, Daigeler A, Prahm C, Kolbenschlag J. Treatment trends of adult brachial plexus injury: a bibliometric analysis. Plast Reconstr Surg Glob Open 2021; 9 (09) e3803
• 3 Muangsanit P, Shipley RJ, Phillips JB. Vascularization strategies for peripheral nerve tissue engineering. Anat Rec (Hoboken) 2018; 301 (10) 1657-1667
• 4 Bertelli JA, Ghizoni MF. Results of c5 root grafting to the musculocutaneous nerve using pedicled, vascularized ulnar nerve grafts. J Hand Surg Am 2009; 34 (10) 1821-1826
• 5 Birch R, Dunkerton M, Bonney G, Jamieson AM. Experience with the free vascularized ulnar nerve graft in repair of supraclavicular lesions of the brachial plexus. Clin Orthop Relat Res 1988; (237) 96-104
• 6 Lin JA, Lu JC, Chang TN. et al. Long-term outcome of 118 acute total brachial plexus injury patients using free vascularized ulnar nerve graft to innervate the median nerve. J Reconstr Microsurg 2022
• 7 Goubier J, Teboul F. Grading of nerve injuries. In: Tubbs S. ed. Nerve and Nerve Injuries. Elsevier; 2015: 609
• 8 Lanaras TI, Schaller HE, Sinis N. Brachial plexus lesions: 10 years of experience in a center for microsurgery in Germany. Microsurgery 2009; 29 (02) 87-94
• 9 Birch R. Timing of surgical reconstruction for closed traumatic injury to the supraclavicular brachial plexus. J Hand Surg Eur Vol 2015; 40 (06) 562-567
• 10 Bertelli JATM, Taleb M, Mira JC, Ghizoni MF. Functional recovery improvement is related to aberrant reinnervation trimming. A comparative study using fresh or predegenerated nerve grafts. Acta Neuropathol 2006; 111 (06) 601-609
• 11 Bertelli JAGM, Ghizoni MF. Concepts of nerve regeneration and repair applied to brachial plexus reconstruction. Microsurgery 2006; 26 (04) 230-244
• 12 Doi K, Kuwata N, Kawakami F, Tamaru K, Kawai S. The free vascularized sural nerve graft. Microsurgery 1984; 5 (04) 175-184
• 13 Shafi M, Hattori Y, Doi K. Surgical technique of harvesting vascularized superficial radial nerve graft. J Hand Surg Am 2010; 35 (02) 312-315
• 14 Peters BR, Wood MD, Hunter DA. et al. Acellular nerve allografts in major peripheral nerve repairs: an analysis of cases presenting with limited recovery. Hand (N Y) 2023; 18 (02) 312-315