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Background:. Nerve reconstruction following brachial plexus injury (BPI) is a time-sensitive procedure, and surgical delay may negatively impact muscle reinnervation and outcomes. This study investigated the impact of surgical timing on elbow flexion strength in patients with BPI undergoing nerve transfer to restore elbow flexion. Methods:. Following PRISMA guidelines, MEDLINE, Embase, and the Cochrane Library databases were systematically searched. English-language studies investigating the single fascicular transfer (SFT) or double fascicular transfer (DFT) to restore elbow flexion in BPI were included. Data were analyzed to identify the predictors of elbow flexion strength: surgery timing, age, injury level, and SFT versus DFT. Results:. The literature search identified 1051 articles. Studies (n = 31) reporting data of individual patients who underwent SFT (n = 341) or DFT (n = 67) were included; the mean age was 29.6 ± 11.2 years, time from injury to surgery was 6.5 ± 5.0 months, and follow-up was 27.1 ± 24.3 months. Good elbow flexion strength was found: Medical Research Council grade greater than or equal to 3 in 352 (86.3%) and Medical Research Council grade greater than or equal to 4 in 288 (70.6%). In the adjusted analysis, poorer motor recovery was associated with increased age (P = 0.02), surgical delay (P < 0.0001), C5-7 injuries (P < 0.01), and pan-plexus injuries (P < 0.0001). A 32% reduction in the odds of favorable motor recovery was observed with a 3-month delay to surgery. Patients who had a nerve transfer 6 months or earlier from injury had 2.4 times the odds of favorable motor recovery (P < 0.001). Conclusions:. SFT and DFT provide excellent elbow flexion strength in the majority of patients. Following nerve transfers in individuals with BPI, poorer motor recovery was observed with each 3-month delay to surgery.

Background:. Pediatric craniofacial surgery performed in tertiary care centers by dedicated teams is associated with high levels of safety and low rates of mortality. However, catastrophic and life-threatening events may occur as a result of surgical management of these complex patients. This study reviewed the incidence and acute outcomes of catastrophic and critical events during craniofacial surgery at a single high-volume center. Methods:. The data reviewed included the operative procedures of two senior craniofacial surgeons over an 18-year period at a tertiary care pediatric craniofacial center. Catastrophic or critical intraoperative events were defined as events requiring the activation of an emergency code during surgery. The operative details and acute outcomes were reviewed and analyzed. Results:. This study reviewed 7214 procedures performed between January 2002 and January 2019. There were 2072 (29%) cases classified as major craniofacial procedures (transcranial, mixed trans-and-extracranial, or major extracranial facial osteotomies), and code events occurred in 14 cases (0.67%; one in 148 patients): venous air embolism (n = 4), cardiac complications (n = 3), major hemorrhage (n = 3), trigeminocardiac reflex (n = 2), acute intracranial hypertension (n = 1), and acute airway obstruction (n = 1). Two cases (14%) experienced a critical event that was anesthesia-related. Cardiac arrest requiring compressions and/or defibrillation was necessary for eight patients. There were no mortalities. Surgery was curtailed in seven cases and successfully completed in seven patients. Conclusions:. Catastrophic life-threatening events during pediatric craniofacial surgery are, fortunately, rare. In our institution, experienced teams in the management of catastrophic and critical intraoperative events during major pediatric craniofacial procedures resulted in no mortalities.

Summary:. In this review, we present the current role of nerve transfers in the management of nerve injuries. The outcome of a literature review comparing the results of nerve graft versus nerve transfer and the experience of select surgical societies’ members regarding experience and adoption of nerve transfer are reported. Nerve transfer publications have increased more than nerve graft or repair articles. The surgeon survey revealed an increase in nerve transfers and that more motor nerve transfers have been adopted into practice compared to sensory nerve transfers. The meta-analyses and systematic reviews of motor nerve transfers for shoulder and elbow function presented variable outcomes related to donor nerve selection. Comprehensive patient assessment is essential to evaluate the immediate functional needs and consider future reconstruction that may be necessary. Optimal outcome following nerve injury may involve a combination of different surgical options and more than one type of reconstruction. Nerve transfer is a logical extension of the paradigm shift from nerve repair and nerve graft and offers a new rung on the reconstruction ladder.