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

Abstract

Traumatic brachial plexus palsy (TBPP) is a devastating injury that significantly affects the upper extremity functions and results in serious disability. Surgical reconstruction is closely related to the severity of the injury and the time elapsed after the trauma. Microneural and/or free functional muscle transfer reconstruction can be performed in patients admitted in the early period. [1][2][3] Tendon transfers, pedicle or free muscle transfers are the treatment options in patients with delayed TBPP and reserved for cases where nerve repair or reconstruction fails. [1,4] Doi et al. [5] reported successful results using free muscle transfer to restore limb functions in TBPP patients in 1991. The same team defined double free muscle transfer in 1995. [6] Objectives: The aim of this study was to evaluate the functional outcomes of patients with free gracilis muscle transfer (FGMT) for the restoration of elbow flexion.Patients and methods: Between January 2012 and January 2019, a total of 16 patients (13 males, 3 females; mean age: 27.3±11.7 years; range: 18 to 53 years) who underwent FGMF to achieve elbow flexion after traumatic brachial plexus palsy (TBPP) were retrospectively analyzed. Data including demographic and clinical characteristics of the patients, etiology, affected side, injury level, accompanying injuries, time between injury and surgery, follow-up time, complications, whether nerve reconstruction and artery repair were performed previously, and details of the procedure were recorded. The outcome measures were elbow range of motion in degrees, muscle strength, and Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form-36 (SF-36) scores. Results:The mean follow-up was 30±11.5 (range, 24 to 42) months. Two patients had C5-C8 injuries, two patients had C6-T1 injuries, and all other patients had injuries to the C5-T1 roots. Muscle strength was M3/M4 in 11 (68.8%) patients, M2 in two (12.5%) patients, and M0 in one (6.2%) patient. The median active range of motion of the elbow joint in patients with successful results (M3 and above) was measured as 75 (range, 30 to 100) degrees. A statistically significant improvement was observed in the pre-and postoperative DASH scores and in some SF-36 subscale scores of patients with successful results. Conclusion:Free gracilis muscle flap is a reliable option in the restoration of elbow flexion in patients with TBPP. Although there is an improvement in functional results, disability, and quality of life, there may be no change in patients' mental status and pain.

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

“…Maldonado et al [ 21 ] concluded that distal attachment to the FDP/FPL achieves better elbow flexion strength and ROM than attachment to the biceps tendon. Although no studies, to our knowledge, have compared the effect of distal insertion on motor outcomes, other small case series have described some alternatives to distal attachment to the biceps, forearm extensor, or flexor tendons [ 3 , 17 ]. So far, the best results were achieved by Doi et al [ 9 ].…”

Redefining the Inclusion Criteria for Successful Steindler Flexorplasty Based on the Outcomes of a Case Series in Eight Patients

“…Since the first one is strongly adhered to the time factor, 7 the second one, which is aimed to restore independent EF, is not affected by the latter. 5 6 Since functional free muscle transfers 8 remain the prerogative of highly specialized microsurgical centers with a long history of successful utilization of the technique with low morbidity rate of the transferred myocutaneous flap, 9 approaches to the reconstruction of an effective EF remain dependent on the two abovementioned “classical” techniques, 3 4 5 6 available to most surgeons.…”