Objective: The total brachial plexus avulsion injury (BPAI) patients were treated in many organizations in the world, but the results reported differ significantly regarding different surgical strategy. Thus, this study aimed to evaluate the outcomes of different methods of nerve transfer and to determine a relatively optimal surgical strategy for treatment of total BPAI patients. Methods: A retrospective review was conducted on 73 patients with total BPAI who were treated with nerve transfer. The elbow flexion was reconstructed in 73 patients with phrenic nerve (PN) or intercostal nerves (ICNs) or contralateral C7 (cC7) transfer. The shoulder abduction was reconstructed in 73 patients with spinal accessory nerve (SAN) or ICNs transfer or both. Elbow extension was reconstructed in 35 patients with ICNs or cC7 transfer. Wrist and finger flexion were reconstructed in 73 patients with cC7 transfer. Wrist and finger extension were reconstructed in 31 patients with ICNs transfer. The mean follow-up period was 7.3 years. Results: The effective recovery rate were 79.5% in elbow flexion, 76.7% in shoulder abduction, 45.7% in elbow extension, 54.8% in wrist and finger flexion, 57.5% in median nerve area sensation, and 38.7% in wrist and finger extension. No significant difference was found in elbow flexion recovery between the patients with PN, ICN, or cC7 transfer. Shoulder abduction was significantly better in patients with SAN combined with ICNs transfer while no significant difference was found between the patients with anterior or posterior approach SAN transfer. Elbow extension was significantly better in patients with ICNs transfer. Entire cC7 transfer achieved significantly better recovery in wrist and finger flexion than partial cC7 transfer. Conclusion: For the treatment of total BPAI patients, we recommend PN transfer for elbow flexion, SAN combined with ICNs transfer for shoulder abduction, ICNs transfer for elbow extension, entire cC7 transfer for wrist and finger flexion, and ICNs transfer for finger extension, whereas for the elder or PN-injured patients, we recommend SAN combined with ICNs transfer for shoulder abduction, entire cC7 transfer for elbow flexion and wrist and finger flexion, and ICNs transfer for elbow extension and wrist and finger extension.
