Free Functional Gracilis Muscle Transfer Research Articles

Comparison of Outcomes of Facial Reanimation Between the Use of Cross-facial Nerve Graft and the Masseteric Nerve as the Donor Nerve for Reinnervation of Gracilis Muscle Flap Transfer.

In patients with facial paralysis, the free functional gracilis muscle transfer is preferred for facial reanimation. The choice of an adequate motor nerve to innervate the transplanted gracilis muscle is one of the procedure's key components. We present a comparative study between cross-facial nerve graft (CFNG) and masseteric nerve as donor nerves for reinnervated gracilis flap transfer in patients with complete facial paralysis. Retrospective analysis was performed on all patients with complete facial paralysis who had a free functional gracilis muscle transfer for facial reanimation between January 2014 and December 2021. Only those who received gracilis transfer reinnervated by either CFNG or masseteric nerve were included in this study. The smile excursion and lip angle were measured for evaluating the outcomes postoperatively. The inclusion criteria were met by a total of 21 free functional gracilis muscle transfers, of which 11 were innervated by CFNG and 10 by the masseteric nerve. Both surgical procedures resulted in a highly considerable smile excursion of the reanimated side and postoperative improvement of static or dynamic lip angle. Masseteric nerve coaptation led to greater smile excursion and more significant improvement of dynamic lip angle than CFNG. For patients who have complete facial paralysis, face reanimation can be successfully accomplished by free gracilis transfer reinnervated by the CFNG or the masseteric nerve. In particular, the masseteric nerve is a reliable choice for dynamic smile reanimation.

Age-related outcomes of facial reanimation surgery using gracilis free functional muscle transfer innervated by the masseteric nerve: A retrospective cohort study

The free functional muscle gracilis transfer is an established approach in facial reanimation surgery; however, the significance of its neurotization and the patient's age is still inconclusive. Several donor nerves are available for facial reanimation using the free functional gracilis muscle transfer. This retrospective cohort study investigates whether the masseteric nerve is an equally reliable donor nerve in both older and younger patients. We included 46 patients (13-71 years, male and female) who underwent nerve-to-masseter (NTM)-driven free functional muscle transfer (FFMT) between January 2008 and December 2019. Patients were distributed into three cohorts according to their age at surgery. We assessed the facial symmetry before and after surgery using the pupillo-modiolar angle. Commissure height and excursion deviation were measured with the Emotrics software. Patient-reported outcome measurements were taken using the Facial Clinimetric Examination (FaCE) scale. All patients had successful flap innervation, except for one patient in the middle-aged cohort (31-51 years). The postoperative facial symmetry at rest, smiling, and laughing was analyzed with the pupillo-modiolar angle and the Emotrics software and showed similar results between all cohorts. The FaCE scale showed similar scores for the middle-aged (31-51 years) cohort and the senior cohort (52-71 years). The social function score in the senior cohort was higher than in the middle-aged cohort, without statistical significance. One patient in the middle-aged (31-51 years) cohort and the senior cohort (52-71 years), respectively, underwent emergency revision due to impaired flap perfusion and could be salvaged. NTM-driven FFMT for facial reanimation is a safe and reliable procedure across all age groups of patients.

D32. Long-term Outcomes Comparing Between Single Versus Dual Innervated Free Functional Gracilis Muscle Transfer in Longstanding Facial Paralysis Patients

PURPOSE: Comparing long-term outcomes between single versus dual innervated free functional muscle transfer (FFMT) in patients with longstanding facial paralysis. METHODS: Included were longstanding flaccid facial palsy patients between 2013-2020 treated with a FFMT innervated either by a nerve-to-masseter (single innervation group - SIG) or by nerve-to-masseter and cross-facial-nerve graft (dual innervation group - DIG). One year minimal follow up was required. Outcome measures, based on professional standardized photos, included excursion, smile angle, teeth exposure in repose and in closed and open teeth smile preoperatively, and at 3 months, 1-year, 3-years, and 5-years postoperatively as available. Emotrics software (Massachusetts Eye and Ear Infirmary, Boston, MA) and ImageJ (Rasband, W.S., ImageJ, U.S, National Institutes of Health, Bethesda, MD) were used for all measurements. Between group and within group longitudinal comparisons at each timepoint were analyzed using Wilcoxon Two-Sample Testing. RESULTS: Preoperatively (SIG=33, DIG=14) and 3-months-postoperatively (SIG=28, DIG=14) parameters were similar between groups. At one-year (SIG=32, DIG=13) modiolus angle in repose was increased in the DIG (SIG=99.245 degrees, DIG=105.91 degrees, p=0.0146). At three years (SIG=24, DIG=13),significance was found in modiolus position (SIG=26.42mm, DIG=31.51mm, p=0.0001), commissure excursion with open mouth smile (SIG=31.21mm, DIG=30.915mm, p=0.0005), modiolus angle in repose (SIG=98.14 degrees, DIG=105.06 degrees, p=0.0344), and modiolus angle with open mouth smile(SIG=111.025 degrees, DIG=99.47 degrees, p=0.0001). Midface parameters at 5-year follow up (SIG=14, DIG=6) were similar between groups. CONCLUSION: Dually innervated FFMT did not reveal any clear long-term measurable benefit for midface reanimation albeit synchrony and spontaneity were not assessed.

Results of Free Functioning Gracilis Muscle Transfer in Severe Volkman’s Ischemic Contracture of The Forearm in Children

Results of Free Functioning Gracilis Muscle Transfer in Severe Volkman’s Ischemic Contracture of The Forearm in Children

Restoration of Grasp after Single-Stage Free Functioning Gracilis Muscle Transfer in Traumatic Adult Pan-Brachial Plexus Injury.

A variety of approaches have been described to obtain rudimentary grasp after traumatic pan-brachial plexus injury in adults. The aim of this study is to evaluate hand prehension after a gracilis single-stage free functioning muscle transfer. Twenty-seven patients who underwent gracilis single-stage free functioning muscle transfer for elbow flexion and hand prehension after a pan-plexus injury were included. All patients presented with a minimum of 2 years of follow-up. Postoperative finger flexion, elbow flexion strength, preoperative and postoperative Disability of the Arm, Shoulder, and Hand questionnaire scores, secondary hand procedures, complications, and demographic characteristics were analyzed. Twenty patients (74%) demonstrated active finger pull-through. Only six patients (25%) considered their hand function useful for daily activities. Disability of the Arm, Shoulder, and Hand score improved by 13.1 ± 13.7 ( P < 0.005). All patients were expected to require one secondary procedure (wrist fusion, thumb carpometacarpal fusion, and/or thumb interphalangeal fusion) because no extensor reconstruction was performed. These were performed in 89%, 78%, and 74% of patients, respectively. Four postoperative complications (hematoma, seroma, wound dehiscence, and skin paddle loss) occurred. No flap loss occurred. In pan-plexus injuries, the use of a gracilis single-stage free functioning muscle transfer is an alternative to the double free functioning muscle transfer procedure and contralateral C7 transfer, especially for patients who are unable to undergo two to three important operations in a short period of time. Further research and studies are required to improve hand function in these patients. Therapeutic, IV.

CORR Insights®: What is the Elbow Flexion Strength After Free Functional Gracilis Muscle Transfer for Adult Traumatic Complete Brachial Plexus Injuries?

CORR Insights®: What is the Elbow Flexion Strength After Free Functional Gracilis Muscle Transfer for Adult Traumatic Complete Brachial Plexus Injuries?

Functional Outcome Comparison of Free Gracilis Muscle Anchoring Methods in Patients with Facial Paralysis: Upper Lip Red Line Incision versus Facelift Incision Approach.

The greatest challenge of a free-muscle transfer in facial reanimation surgery is anchoring muscle to perioral soft tissue. An additional incision provides a better way to anchor the transferred muscle but leaves a visible scar. Herein, we compared the functional and aesthetic outcomes in a conventional facelift incision approach with and without the addition of a red line incision. This study included patients experiencing unilateral facial paralysis who underwent free gracilis transfer between December 2016 and December 2018. Anchoring through facelift incision with extended neck incision was performed in the control group, while a red line incision was added in the red line group by avoiding extended neck incision. Oral commissure excursion, upper lip and commissure height differences, and symmetry were measured. A total of 24 patients met the criteria and were included in this study. Of these, 10 patients were assigned to the red line group and 14 to the control group. The red line and control groups demonstrated a similar symmetry index in both resting (0.96 ± 0.18 and 0.92 ± 0.10, respectively; p = 0.435) and smiling (0.94 ± 0.12 and 0.91 ± 0.10, respectively; p = 0.314). However, the upper lip height difference demonstrated greater postoperative improvement (resting: 2.12 ± 1.13 vs. 3.92 ± 1.41 mm, p = 0.002, and smiling: 1.68 ± 0.88 vs. 3.41 ± 1.69 mm, p = 0.004, respectively). A scar could be easily concealed on the mucocutaneous line of the lip. This novel method for muscle anchoring in facial reanimation surgery allows surgeons to approach perioral muscle more directly. This leads to improved surgical results by securely anchoring the transferred muscles using a fixation point that is more medially located than in other approaches. Our method is effective and offers an improved surgical outcome for the free functional gracilis muscle transfer.

Factors Impacting the Success of Free Functioning Gracilis Muscle Transfer for Elbow Flexion in Brachial Plexus Reconstruction.

Free functioning muscle transfer is a reconstructive option to restore elbow flexion in brachial plexus injuries. The authors determined the impact of body mass index, age, and location of distal tendon attachment on elbow flexion strength after free functioning muscle transfer in traumatic brachial plexus injury patients. A retrospective review of patients who underwent free functioning muscle transfer for elbow flexion as part of their brachial plexus injury reconstruction with a minimum 2-year follow-up were evaluated. Outcomes assessed included elbow flexion strength (British Medical Research Council grade) and change in Disabilities of the Arm, Shoulder and Hand questionnaire and visual analogue scale pain scores. One hundred six patients met inclusion criteria. The average age was 32 years, and the average body mass index was 27.1 kg/m2; 56.5 percent of patients achieved M3 or greater muscle grade using the authors' strict modification of the British Medical Research Council scale. Disabilities of the Arm, Shoulder and Hand questionnaire scores improved from 45.7 to 38.8 (p < 0.05). Visual analogue scale pain scores decreased, but this trend did not obtain significance. Age and body mass index both had a significant negative impact on final free functioning muscle transfer grade (p < 0.05). Use of a distal tendon insertion led to improved muscle grade outcomes, with targeting of wrist extension being superior to finger flexion (p < 0.05). Simultaneous musculocutaneous nerve grafting did not significantly alter final elbow flexion strength. Increasing age and body mass index both imparted a deleterious effect on free functioning muscle transfer muscle grade. Distal muscle targets had better strength outcomes than when the biceps tendon was used. Risk, III.

Dynamic Reconstruction of the Lower Lip With Free Functioning Gracilis Muscle Transfer.

The restoration of large full-thickness lip defects still remains a formidable challenge for the reconstructive surgeons. Traumatic injuries, infections and tumors (primarily squamous cell carcinoma) are the most common source of the lip defects. Lower lips are more important in providing oral competence, unfortunately throughout the life-time they are significantly more exposed to ultraviolet radiation and thus are the most common site for the lip cancers (89%). This type of defect requires a complex reconstruction of an adequate sphincter function, defined vermilion, proper oral lining and sufficient mouth opening. To maintain the oral competence, it is of paramount importance to restore the function of orbicularis oris, which principally composes the body of the lip. Currently, the dynamic reconstructions are gaining considerable interest. They enables not only improvement of appearance but also a restoration of function and preservation of health-related quality of life. The use of the free gracilis muscle transfer to reconstruct the lower lip and its dynamic character in contrast to other, static reconstructions can provide the sufficient movement of the lower lip, which does not depend on function of other mimic muscles as it becomes an independent motor unit with its own neurotization. In our opinion the free functioning gracilis muscle flap, due to its anatomic and functional features as well as low-rate donor-site morbidity is the worth considering option for a lower lip reconstruction.

Technical considerations and outcome of free functioning gracilis muscle transfer for finger flexion in patients with Volkmann's Ischemic Contracture

IntroductionSevere Volkmann's Ischemic Contracture (VIC) is a reconstructive challenge for the surgeon because of the loss of entire flexor muscle mass and lack of powerful wrist extensors for restoration of finger flexion. In such cases, free functioning muscle transfer (FFMT) using gracilis is our choice. We herein summarize the technical considerations to achieve a successful outcome and report functional outcome achieved in our series. Patients and MethodBetween 2007-2018, 22 patients of VIC underwent gracilis FFMT for restoration of finger flexion. FFMT was done as a second stage following an initial stage of neurolysis/excision of fibrotic flexor muscles/contracture release/flap cover in these patients. Cases were retrospectively reviewed and their functional outcome at a minimum of one-year follow up was analyzed. Follow-up duration ranged from 2-13 years (average-4 years). At the final follow up, the motor and sensory recovery was evaluated using the Medical Research Council Grading and their function using Disabilities of the Arm, Shoulder, and Hand (DASH) score. ResultsThe average age at surgery ranged from 3-45 years (average-18.4 years). All the transferred muscles survived. Secondary procedures to further improve the hand function were done in nine patients. The motor recovery for finger flexion was graded as M2 in two, M3 in nine and M4 in 11 cases. These 20/22 patients who recovered M3/M4 finger flexion expressed high satisfaction with the operation while other two also felt that they were better after the surgery. DASH score was available for 13 patients and it averaged 13.21 (Range-1.8-34.5). Grip strength was available for 10/22 patients and it averaged 10.5 kg (range-0-21kg) amounting to 24% of the normal side. The sensory recovery was graded as S4 in two, S3 in 17 and S2 in three cases. ConclusionGracilis FFMT is a reliable option for restoration of finger flexion in patients with severe VIC. Outcome is better when done after an early preliminary stage of excision of fibrosed muscles and neurolysis which allows recovery of intrinsic function and sensation. FFMT is best carried out 3-6 months after the first stage with supple skin and good passive range of movement in the fingers.

Les variations techniques des micro-anastomoses influencent-elles les résultats fonctionnels du transfert musculaire libre de gracilis pour la flexion du coude dans les lésions traumatiques du plexus brachial ?

IntroductionThe traumatic lesions of the brachial plexus in adults are devastating injuries causing continuous severe functional impairment for both work and daily living activities. The restoration of elbow flexion is one of the most important movements for patient recovery to previous activities. Free gracilis muscle transfer has good outcomes for cases with late presentation or as a rescue surgery to regain elbow flexion, however, bad results are present in all cohorts with insufficient recovery of muscle strength for elbow flexion. A number of hypotheses can be postulate to explain the fair results observed in some cases of free gracilis muscle transfer for elbow flexion. Most studies in the current literature compare the choice of the donor nerve used in neurotisation and nerve grafts. The aim of this study is to evaluate if technical components of microvascular anastomosis could influence the functional outcome of free functional muscle transfer for elbow flexion in adult patients with traumatic brachial plexus injury. Material and methodsIncluded all adult patients with traumatic brachial plexus injury submitted to free functional gracilis muscle transfer for elbow flexion. The complications and functional results according to British Medical Research Council (BMRC) score were recorded. ResultsWe assessed 26 patients with mean age of 32,8 years. The most common donor nerve for gracilis muscle was the accessory nerve in 18 patients. Eighteen patients presented with good result (M3/M4). The mean ischemia time was higher for patients with bad results (132minutes) comparing with patients with good results (122minutes). Patients with only one venous anastomosis had 41% of poor functional outcome compared with 22% of cases with two venous anastomoses. No statistically significant difference in the ischemia time of the cases with good or poor functional outcome was observed (p=0.657), as for the number of venous anastomoses (p=0.418). ConclusionOur study observes that patients with only one venous anastomoses for drainage of free gracilis and those with longer intraoperative ischemia time had higher incidence of poor functional outcome of free gracilis muscle transfer for elbow flexion, but not statistically significant. Level of proofII; prospective cross-sectional study.

Movement Restricting Heterotopic Ossification After Free Functioning Gracilis Muscle Transfer to the Elbow: A Case Report

Movement Restricting Heterotopic Ossification After Free Functioning Gracilis Muscle Transfer to the Elbow: A Case Report

Do technical components of microanastomoses influence the functional outcome of free gracilis muscle transfer for elbow flexion in traumatic brachial plexus injury?

IntroductionThe traumatic lesions of the brachial plexus in adults are devastating injuries causing continuous severe functional impairment for both work and daily living activities. The restoration of elbow flexion is one of the most important movements for patient recovery to previous activities. Free gracilis muscle transfer has good outcomes for cases with late presentation or as a rescue surgery to regain elbow flexion, however, bad results are present in all cohorts with insufficient recovery of muscle strength for elbow flexion. A number of hypotheses can be postulate to explain the fair results observed in some cases of free gracilis muscle transfer for elbow flexion. Most studies in the current literature compare the choice of the donor nerve used in neurotization and nerve grafts. The aim of this study is to evaluate if technical components of microvascular anastomosis could influence the functional outcome of free functional muscle transfer for elbow flexion in adult patients with traumatic brachial plexus injury. Material and methodsIncluded all adult patients with traumatic brachial plexus injury submitted to free functional gracilis muscle transfer for elbow flexion. The complications and functional results according to British Medical Research Council (BMRC) score were recorded. ResultsWe assessed 26 patients with mean age of 32.8 years. The most common donor nerve for gracilis muscle was the accessory nerve in 18 patients. Eighteen patients presented with good result (M3/M4). The mean ischemia time was higher for patients with bad results (132 minutes) comparing with patients with good results (122 minutes). Patients with only one venous anastomosis had 41% of poor functional outcome compared with 22% of cases with two venous anastomoses. No statistically significant difference in the ischemia time of the cases with good or poor functional outcome was observed (p=0.657), as for the number of venous anastomoses (p=0.418). ConclusionOur study observes that patients with only one venous anastomoses for drainage of free gracilis and those with longer intraoperative ischemia time had higher incidence of poor functional outcome of free gracilis muscle transfer for elbow flexion, but not statistically significant. Level of proofII; prospective cross-sectional study.

Restoration of Elbow Flexion With a Free Functional Gracilis Muscle Transfer in an Arthrogrypotic Patient Using a Motor Nerve to Pectoralis Major.

Background: Patients with arthrogryposis may exhibit inability to flex the elbow. A free functional gracilis muscle transfer (FFGMT) can be used to restore elbow flexion. In our search of the available literature, we have not seen any descriptions of using a motor branch to the pectoralis major as a donor nerve to establish elbow flexion. Methods: We performed an FFGMT for restoration of elbow flexion in an arthrogrypotic patient with no active elbow flexion, who had a Medical Research Council (MRC) muscle grade of 0. Results: We report our 4.5-year outcomes. After undergoing an FFGMT for elbow flexion, our patient was able to gain an MRC grade 4 and achieve an arc of motion of 25° to 140°. Conclusion: An FFGMT for elbow flexion may be performed successfully using a motor branch to the pectoralis major.

Reoperation Rate and Indication for Reoperation after Free Functional Muscle Transfers in Traumatic Brachial Plexus Injury.

Free functional gracilis muscle transfers (FFGT) are an option for reconstruction after traumatic brachial plexus injury. Few studies report the rate of revision surgeries following free functional muscle transfers. We examined the reoperation rate and indication for reoperation after primary reconstruction of upper extremity function with a free gracilis transfer after brachial plexus injury. From 2003-2016, we identified 25 patients who underwent a free functional gracilis muscle transfer for restoration of upper extremity function. We reviewed their medical charts to record patient, injury, and treatment characteristics. Indication for reoperation and reoperative procedure were also identified. Fourteen out of 25 patients (56%) had a reoperation after FFGT. Four flaps were re-explored for vascular compromise, but there were no flap failures. The majority of reoperations involved adjustment of tendon excursion (8/14) which demonstrated that tenolysis was the main procedure. Despite promising results of free functional gracilis transfers, reoperation is relatively common and should be discussed with the patient as a preoperative strategy. Early exploration of vascular compromise may decrease the flap failure. Poor tendon excursion is a common unpredicted consequence after FFMT and is the main indication for reoperation.

The Inverted Free Functioning Gracilis Muscle Transfer For Restoration of Elbow Flexion Following Delayed Presentation or Failed Primary Nerve Reconstruction of Upper Trunk Injuries.

Free functional gracilis transfer is a well-established technique for restoring active elbow flexion in brachial plexus injuries following delayed presentation or failed nerve reconstruction procedures. In cases of delayed presentation or failed nerve reconstruction following upper trunk injuries, the lower trunk intraplexal median and ulnar nerves are spared, thereby making them available to reinnervate the transferred gracilis. Therefore, we have inverted the conventional free functional gracilis orientation so as to orient the flap's recipient nerve in closer proximity to donor median or ulnar nerve fascicles to enable a short, tension-free coaptation in the middle to distal arm. Herein is our descriptive surgical technique for performing an inverted free functional gracilis muscle transfer in order to restore elbow flexion in the setting of an upper trunk injury.

Comparison between donor nerves to motorize the free functional gracilis muscle transfer for elbow flexion: Retrospective study of 38 consecutive cases in traumatic adult brachial plexus injuries.

Elbow flexion deficit is a frequent problem in traumatic brachial plexus injuries and reestablishment of this function is the primary treatment goal. When management is delayed, or the initial acute approach fails, free functional transfer of the gracilis muscle for elbow flexion is the treatment of choice. In this report, the authors present the results of a comparison study on different donor nerves (spinal accessory and ulnar) in elbow flexion reconstruction with gracilis flap for traumatic adult brachial plexus injuries. Retrospective analysis of patients with both total or partial traumatic brachial plexus injuries was carried out. Of the 38 patients enrolled, 37 were male (97.4%) with a mean age of 28.3 years. The mean follow-up period was 25 months. Postoperative function of the gracilis muscle flap was recorded and patients were divided into two groups according to donor nerve: spinal accessory nerve (SAN) (18 cases), and motor fascicles of the ulnar (ULNAR) (20 cases). Twenty-six cases obtained elbow flexion strength M3 or M4 (68.4%): 0 M0 (0.0%), 4 M1 (10.5%), 8 M2 (21.1%), 9 M3 (23.7%) and 17 M4 (44.7%). The mean interval to first recorded M3 muscular strength was 12.4 months. Functional elbow flexion strength (≥ M3) had the following distribution: SAN 83.3% (15/18) and ULNAR 55.0% (11/20) (p = .086). No statistical difference for final muscle strength was found between donor nerve groups.

Abstract: Enhancement of Voluntary Elbow Movement with a Myoelectric Orthotic Device: Long Term Follow Up of a Novel Application of a Post-Cva Assistive Rehabilitation Orthotic Device

INTRODUCTION: Free functioning muscle transfers (FFMTs), nerve grafting and nerve transfers have led to improved functional outcomes in brachial plexus injury (BPI) patients. Reports have shown that 39% of FFMTs and 26% of nerve transfers for elbow flexion achieve ≥ M4 elbow flexion strength.1 However, there remains a substantial number of patients with less favorable functional outcomes that need to be addressed further. The MyoPro (Myomo Inc., Cambridge, MA, USA) is a FDA-cleared myoelectric elbow-wrist-hand orthosis that uses surface EMG signals from affected muscle groups to control a powered orthosis to assist with the movement of a paretic upper limb. We describe the application of this orthosis for enhancement of elbow flexion and extension in patients with incomplete recovery from BPI. METHODS: Two patients from a single-surgeon practice have been evaluated for suitability of the myoelectric functional orthotic device. Both patients are 37 year-old men with 14 and 17 years history of left and right BPIs. Patient-1 initially had BP reconstruction by nerve transfers and secondarily a FFMT for restoration of elbow flexion and finger extension. Patient-2 underwent brachial plexus exploration and neurolysis only. Both patients failed to regain voluntary elbow movement. Evaluation showed 0–130 degree elbow passive range of motion in flail arms. Both patients had detectable EMG signals in the biceps or gracilis, and triceps muscles. Patients underwent 30 minutes of training with the device, which provides powered assistance for elbow flexion and extension via motors attached to the exterior of the orthosis. After the training, patients were asked to perform voluntary assisted elbow flexion and extension. Patients were then referred to receive custom orthotic devices. Functional assessment was performed using disabilities of the arm, shoulder and hand (DASH) questionnaire. RESULTS: Both patients demonstrated voluntary active elbow flexion and extension from 0 to 115 degrees using EMG control signals from the gracilis and triceps in Patient-1, and from the biceps and triceps muscles in Patient-2. Patient-1 quitted before getting the custom device. Patient-2 had DASH scores of 44.17 before and 36.6 after 6 months of using the orthotic device. CONCLUSION: Given the limited options available after definitive reconstruction, this myoelectric orthosis is a valuable option to improve the functional outcome in patients with BPI and poor return of voluntary elbow movement following reconstruction. Reference Citations: 1. Maldonado AA, Kircher MF, Spinner RJ, Bishop AT, Shin AY. Free Functioning Gracilis Muscle Transfer versus Intercostal Nerve Transfer to Musculocutaneous Nerve for Restoration of Elbow Flexion after Traumatic Adult Brachial Pan-Plexus Injury. Plast Reconstr Surg. 2016 Sep;138(3):483e-8e.

Free Functioning Gracilis Muscle Transfer With and Without Simultaneous Intercostal Nerve Transfer to Musculocutaneous Nerve for Restoration of Elbow Flexion After Traumatic Adult Brachial Pan-Plexus Injury

After complete 5-level root avulsion brachial plexus injury, the free-functioning muscle transfer (FFMT) and the intercostal nerve (ICN) to musculocutaneous nerve (MCN) transfer are 2 potential reconstructive options for restoration of elbow flexion. The aim of this study was to determine if the combination of the gracilis FFMT and the ICN to MCN transfer provides stronger elbow flexion compared with the gracilis FFMT alone. Sixty-five patients who underwent the gracilis FFMT only (32 patients) or the gracilis FFMT in addition to the ICN to MCN transfer (33 patients) for elbow flexion after a pan-plexus injury were included. The 2 groups were compared with respect to postoperative elbow flexion strength according to the modified British Medical Research Council grading system as well as preoperative and postoperative Disability of the Arm, Shoulder, and Hand scores. Two subgroup analyses were performed for the British Medical Research Council elbow flexion strength grade: FFMT neurotization (spinal accessory nerve vs ICN) and the attachment of the distal gracilis tendon (biceps tendon vs flexor digitorum profundus/flexor pollicis longus tendon). The proportion of patients reaching the M3/M4 elbow flexion muscle grade were similar in both groups (FFMT vs FFMT+ ICN to MCN transfer). Statistically significant improvement in postoperative Disability of the Arm, Shoulder, and Hand score was found in the FFMT+ ICN to MCN transfer group but not in the FFMT group. There was a significant difference between gracilis to biceps (M3/M4= 52.6%) and gracilis to FDP/flexor pollicis longus (M3/M4= 85.2%) tendon attachment. The use of the ICN to MCN transfer associated with the FFMT does not improve the elbow flexion modified British Medical Research Council grade, although better postoperative Disability of the Arm, Shoulder, and Hand scores were found in this group. The more distal attachment of the gracilis FFMT tendon may play an important role in elbow flexion strength. Therapeutic IV.

Donor nerve sources in free functional gracilis muscle transfer for elbow flexion in adult brachial plexus injury.

With complete plexus injuries or late presentation, free functional muscle transfer (FFMT) becomes the primary option of functional restoration. Our purpose is to review cases over a 10-year period of free functioning gracilis muscle transfer after brachial plexus injury to evaluate the effect of different donor nerves used to reinnervate the FFMT on functional outcome. A retrospective study from April 2001 to January 2011 of a single surgeon's practice was undertaken. During this time period 22 patients underwent FFMT at Washington University in St Louis, Missouri for elbow flexion. Thirteen patients for whom FFMT was performed for elbow flexion met all of the requirements for inclusion in this study. Average time from injury to first operation was 12.8 months (range 4-60), and average time from injury to FFMT was 29 months (range 8-68). Average follow-up was 31.8 months (range 11-84). The nerve donors utilized included the distal accessory nerve, intercostal with or without rectus abdominis nerves, medial pectoral nerves, thoracodorsal nerve, and flexor carpi ulnaris fascicle of ulnar nerve. Functional recovery of elbow flexion was measured using the MRC grading system which showed 1 M5/5, 5 M4, 4 M3, and 3 M2 outcomes. Intraplexal donor motor nerves if available will provide better transferred muscle function because they are higher quality donors closer to the muscle and can be done in one stage without a nerve graft. Otherwise, intercostal, rectus abdominis, or the distal accessory nerve should be used in a staged fashion. © 2016 Wiley Periodicals, Inc. Microsurgery 37:377-382, 2017.