Abstract
We report the case of a 34-year-old man with a total brachial plexus injury that was treated by free functional muscle transplantation to restore simultaneously elbow flexion and finger extension. The muscle had a very large muscle belly (12 cm width), which was considered anatomically to be a fusion of the gracilis and the adductor longus muscles. Although the muscle possessed two major vascular pedicles with almost equal diameters, only the proximal vascular pedicle was anastomosed to the recipient vessels during the transplantation surgery, resulting in partial necrosis of the muscle. Several authors have reported on the successful simultaneous transplantation of the gracilis and adductor longus muscles, because they are supplied generally by a single common vascular pedicle. However, the present study suggests that when a surgeon encounters an aberrant femoral adductor with a very large muscle belly that can be considered to be a fusion of these muscles, the surgeon should assess intraoperatively the vascularity of the muscle using Doppler sonography, indocyanine green fluorescence injection, or other techniques.
Highlights
The gracilis muscle has been used often for free functional muscle transplantation (FFMT) because of its long tendinous portion, its reliable vascularity with anatomical consistency, and the location of the nutrient vessels and innervating nerve in the terminal portion
The dominant pedicle of the gracilis muscle is usually located about 10 cm caudal to the pubic tubercle [4,5,10], and the entire gracilis muscle is nourished by this dominant pedicle alone [9,11]
Sananpanich et al [7] studied the vascular anatomy of the gracilis and adductor longus muscles in cadaveric specimens, and found that in 98% of cadaveric specimens both muscles were nourished by a single common vascular pedicle
Summary
The gracilis muscle has been used often for free functional muscle transplantation (FFMT) because of its long tendinous portion, its reliable vascularity with anatomical consistency, and the location of the nutrient vessels and innervating nerve in the terminal portion. We report the case of a patient with an aberrant muscle that was considered to be a fusion of the gracilis and adductor longus muscles. The deep femoral artery was exposed by retracting the large muscle medially (Figure 1) Based on this anatomical situation, we considered it probable that the very large muscle represented a fusion of the gracilis and adductor longus muscles (Figure 2). Because several authors [6,7] have described the successful simultaneous transfer of the gracilis and adductor longus muscles with a common vascular pedicle, the distal vascular pedicle was ligated and the proximal pedicle was sutured to the left thoracoacromial vessels (one artery and one vein). At the latest follow up, two years after the second FFMT, the patient has obtained
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