From 1986 to 1994, 82 patients with brachial plexus root avulsion were operated on using a contralateral C7 nerve-root transfer. Forty-four patients underwent a one-stage procedure in which the distal end of the ulnar nerve was anastomosed to the contralateral C7 root, and the other 38 underwent a two-stage procedure (first phase: C7 root --> ulnar nerve; second phase: ulnar nerve --> recipient nerve). Twenty postoperative cases were followed-up for 2 years. Of them, the ulnar nerve was transferred to the musculocutaneous nerve in six cases, with recovery of the biceps up to M3 in four and S3 in five cases; the ulnar nerve was transferred to the median nerve in eight cases, with recovery of the wrist and finger flexors up to M3 in five and S3 in six cases; the ulnar nerve was transferred to the radial nerve in four cases, with recovery of the triceps up to M4 in two and S3 in three cases; and the ulnar nerve was transferred to the thoracodorsal nerve in two cases, with recovery of the latissimus dorsi to M4 in one case. The total muscle recovery rate (up to M3) of the series was 60 percent, and the sensory recovery rate (S3) was 78 percent. Outcomes were related to patient age, operative delay, and whether or not the ulnar nerve was used as a bridge for transfer.

Based on an anatomic study, a transfer of the brachialis muscle branch of the musculocutaneous nerve (BMBMCN) to finger flexor functional fascicles of the median nerve was designed. Preliminary results of clinical application of this new procedure are reported. Dissection of 32 cadaver upper limbs revealed that BMBMCN derives from the musculocutaneous nerve at the distal 1/3 upper arm level. Mostly it is of single-branch type, with an average dissectable length of 5.2 cm. At this level, functional fascicles of finger flexors are located at the posterior 1/3 of the median nerve. BMBMCN can be directly coapted to these finger flexion fascicles. In one case of brachial plexus lower trunk injury, this neurotization procedure was done. No impairment of elbow flexion and wrist flexion was found postoperatively. Recovery of finger and thumb flexion was seen 1 year postoperatively. This neurotization is safe and effective for treating lower trunk injuries.

We report a series of 164 patients who underwent phrenic neurotization to elements of the brachial plexus with root avulsion injuries. Recipient nerves included musculocutaneous nerve in 125 patients (78 direct neurotizations and 48 with intervening autograft), median nerve in 10 patients, and a variety of other nerves in 28 patients. Sixty-five patients presented a follow-up period of 2 or more years. Of this group, 55 patients (84.6%) achieved a recovery of M-3 or better. We observed no long-term deleterious effects on respiratory function.

Between February 1966 and February 1994, 400 cases of toe transplantation were analyzed, to evaluate toe-transfer procedures in thumb and finger reconstruction. Techniques utilized included single second-toe transfer, with and without the metatarsophalangeal joint (299): second- and third-toe transfer (28); second-toe and third proximal phalanx transfer (1); second-toe with flap transfers (66); and hallux nail flap with second toe or second and third toe transfer (6). There was a survival rate of 96.5 percent, with 386 cases surviving and 14 failing. A more than 2-year follow-up was possible in 240 cases. Excellent motor and sensory function (more than 90 percent of normal) was achieved in the reconstructed fingers and thumbs, as well as satisfactory function (between 86 and 91 percent of normal) in the donor foot.

Transfer of the contralateral C7 to the lower trunk proved to be a safe and feasible procedure. Compared with the traditional transfer of the contralateral C7 to the median nerve, it might help patients gain better restoration of wrist flexion, finger flexion, and hand sensation.