754 THE JOURNAL OF BONE AND JOINT SURGERY N. Ochiai, MD, Director Department of Orthopaedic Surgery, Kanto Teishin Hospital, 5-9-22 Higa- shi Gotanda Shinagawa-ku, Tokyo, Japan. A. Nagano, MD, Associate Professor H. Sugioka, MD, Clinical Fellow Department of Orthopaedic Surgery, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo Bunkyo-ku, Tokyo, Japan. T. Hara, MD, Director Ebara Municipal Hospital, 4-5-10 Higashi Yukigaya Oota-ku, Tokyo, Japan. Correspondence should be sent to Dr N. Ochiai. ©1996 British Editorial Society of Bone and Joint Surgery 0301-620X/96/41219 $2.00 NERVE GRAFTING IN BRACHIAL PLEXUS INJURIES RESULTS OF FREE GRAFTS IN 90 PATIENTS NAOYUKI OCHIAI, AKIRA NAGANO, HIROSHI SUGIOKA, TETSUYA HARA From the University of Tokyo and Hiroo Municipal Hospital, Tokyo, Japan W e have assessed the efficacy of free nerve grafts in 90 cases of brachial plexus injury. Relatively good recovery of the elbow flexor and extensor muscles and of those of the shoulder girdle was found but recovery of the flexors and extensors of the forearm and of the intrinsic muscles of the hand was extremely poor. Poor results were found when spinal nerve roots seemed normal to the touch and appeared intact but had abnormal somatosensory evoked potentials or myelography. Recovery of the deltoid and infraspinatus muscles was better when injury had occurred to the circumflex and suprascapular nerves rather than to the plexus itself, perhaps because these nerves were explored in their entirety to determine the presence of multiple lesions. It is important to visualise the entire nerve thoroughly to assess the overall condition. Thorough exploration of the plexus and the use of intraoperative recording of somatosensory evoked potentials are essential. J Bone Joint Surg [Br] 1996;78-B:754-8. Received 3 November 1995; Accepted after revision 6 February 1996 Despite the major progress which has been made over the last decade in both diagnostic procedures (Landi et al 1980; Sugioka et al 1982; Nagano et al 1989) and microsurgical techniques (Millesi 1977), the surgical management of brachial plexus injuries remains a challenge. Repair may be accomplished by nerve transfer and by reconstruction, usually using autologous free nerve grafts. The results, however, are still far from satisfactory. Our aim was to focus on the results of nerve grafting in brachial plexus injuries in terms of muscle recovery itself and to describe what should be expected from nerve graft- ing and what could be improved upon. PATIENTS AND METHODS We have reviewed 90 patients with brachial plexus injury who were operated on using free nerve grafting and fol- lowed up for more than 18 months at the Departments of Orthopaedics of the University of Tokyo and Hiroo Munici- pal Hospital between 1981 and 1993. Patients with com- plete avulsion of all five roots were excluded. The average age at injury was 20.9 years (5 to 49) and there were 85 males and five females. The cause of injury was a road- traffic accident in 85 cases, resection of a tumour in one, a conveyor-belt accident in one, a rope-lift accident in one, a dog-bite injury in one, and a sports injury in one. We explored the brachial plexus to evaluate the level of the lesions using intraoperative recordings of somatosen- sory evoked potentials (SEPs) induced by direct nerve-root stimulation and recorded at the scalp (C3 or C4, 10 to 20 system and Fz, reference electrode) (Sugioka et al 1982). The active electrode was on the parietal somatosensory cortex and the reference electrode on the midfrontal cortex. Recordings were taken at least twice from each root for reproducibility. As a control, we measured the SEPs induced by stimulating the ipsilateral intact roots or the contralateral median nerve. We also assessed the myelo- graphic findings (Nagano et al 1989) to decide whether the injured nerve roots were suitable for use as recipients for a nerve graft. From a therapeutic viewpoint we classified patients into two groups, a brachial plexus injury (BPI) group and an axillary/suprascapular nerve injury group (AX+SS). In the latter, functional impairment was limited to, or was most severe in the deltoid, supraspinatus and infraspinatus mus- cles (Ochiai et al 1988). The BPI group included both supra- and infraclavicular lesions. For recording SEPs the BPI patients were positioned on their back and the plexus approached through a zig-zag incision along the posterior border of the sternomastoid muscle, the clavicle and the deltopectoral groove to the upper arm. Recently, we have explored the supraclavicular
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