Microsurgical Transfer of the Gracilis Muscle for Elbow Flexion in Brachial Plexus Injury in Adults: Retrospective Study of Eight Cases

Abstract

Objective: Treating brachial plexus injuries is a major challenge, especially lesions that are presented late, with more than 12 months of evolution. We retrospectively analyzed patients who underwent one of the possibilities for attempting to restore the function of upper limbs affected under such conditions: microsurgical transfer of the gracilis muscle for elbow flexion. Methods: Eight patients were included, divided into two groups: one in which the procedure consisted of neurorrhaphy of the muscle flap with sural nerve grafting and anastomosis more distally; and the other, in which the neurorrhaphy was performed directly on the spinal accessory nerve, with anastomosis in thoracoacromial vessels. Results: We found a significant difference between the groups. A greater number of satisfactory results (75% M4) were found among patients who underwent direct neurorrhaphy, whereas the procedure using grafts for neurorrhaphy was less successful (25% M4). Conclusion: Patients who underwent microsurgical functional transfer of the gracilis muscle in which vascular anastomoses were performed in thoracoacromial vessels presented better functional outcomes than shown by those whose anastomoses were in the brachial artery with subsequent use of a nerve graft.

Gracilis Muscle Transfer to Elbow Flexion in Brachial Plexus Injuries

“…4 When treatment is delayed or the surgical treatment fails in the acute phase -and there are no muscles strong enough for muscle transfer -the alternative to recover elbow flexion is free functional muscle transplant with intraplexual or extra-plexual nerve transfer, depending on the severity of the brachial plexus injury. [4][5] Opting for free functional muscle transfer, a donor motor nerve for the transferred muscle must be selected. Total brachial plexus injuries commonly uses the accessory nerve and the intercostal nerves.…”

“…( 4 When treatment is delayed or the surgical treatment fails in the acute phase - and there are no muscles strong enough for muscle transfer - the alternative to recover elbow flexion is free functional muscle transplant with intraplexual or extra-plexual nerve transfer, depending on the severity of the brachial plexus injury. ( 4 )- ( 5 …”

Outcome of free gracilis muscle transfer for the restoration of elbow flexion in traumatic brachial plexus palsy

“…Providing elbow flexion strength in patients with complete TBPP provides a stable and controlled limb that does not remain in swing while walking and prevents balance. [19] Doi [20] described the use of extensor digitorum communis tendons as tendon insertions to achieve simultaneous elbow flexion and finger extension. Some authors preferred the biceps tendon, flexor digitorum profundus, extensor digitorum communis and extensor pollicis longus as distal insertions.…”

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

“…The gracilis flap was then attached to two to three anchors placed at the acromion and lateral portion of the clavicle and microvascular anastomosis followed by nerve transfer were performed (Figures and ). The tendon of the gracilis muscle was sutured to the insertion of the biceps tendon at a tension sufficient to keep the elbow flexed at about 20 to 30° (Bishop, ; Kimura et al, ). The patient was allowed to ambulate unassisted at the first postoperative day.…”

“…However, patients that are evaluated late (interval between trauma and surgery longer than 12–18 months) progress with degeneration of the neuro‐muscular junction in the upper limb muscles, an irreversible alteration that makes reconstruction and nerve transfers that target this musculature unreliable (Azze, Mattar Jr., Ferreira, Starck, & Canedo, ; Bishop, ). The alternative to restore elbow flexion when treatment is delayed or when surgery fails in the acute phase—and there are no sufficiently strong muscles to perform muscle transfers—is free functional muscle transfer innervated by intra or extra plexus nerve transfers, depending on the level of brachial plexus injury (Bishop, ; Kimura et al, ).…”