Selection of Grip Function in Double Free Gracilis Transfer Procedures After Complete Paralysis of the Brachial Plexus

Abstract

Double free gracilis transfer (DFGT) procedures introduced by Doi et al have resulted in significant improvement in maintaining functional prehensile hand after total brachial plexus injury (TBPI). However, not all patients with satisfactory recovery of finger motion could improve their prehensile function. The use of reconstructed hand in daily activities was examined retrospectively to plan individual grip function, depending on the patient's own demand. Thirty patients who had had reconstruction with DFGT procedures were evaluated retrospectively according to total active motion (TAM), power grip, hook grip, and pinch function. Power grip was evaluated by holding a bottle and hook grip by lifting a weight. Only 11 patients (36%) had very light pulp-to-pulp pinch, 11 (36%) had power grip, and 25 (83%) had hook grip. The mean weight that could be carried by hook grip was 1.3 kg. The mean TAM was 43 degrees. Pain sensation was the only encouraging sensation recovery, radiating to the chest. Fine movements of the hand like pinching require well-developed exquisite control of movements. TBPI patients have the contralateral normal limb, which they always prefer, only using their reconstructed hand when the activity requires both hands, such as when holding a bottle to open its cap or lifting bags when the contralateral normal hand is already engaged. For performance of these actions, hook grip and power grip are the useful prehensile hand functions that can be obtained after DFGT. Selection of grip functions should be done according to patient needs, and the late-stage reconstructive hand operations should be decided according to preferred grip function.

The Surgical Treatment of Brachial Plexus Injuries in Adults

“…For hand reanimation, the gracilis muscle can be transferred to the forearm, for finger flexion or extension, or intrinsic substitution (single muscle function), 84,87 or it can be transferred to substitute simultaneously for finger extension and elbow flexion (double muscle function). 85,97 PAIN Pain in brachial plexus injuries is associated with interruption of afferent nerve signals (deafferentation pain). The incidence varies from study to study.…”

Wrist Fusion in Posttraumatic Brachial Plexus Palsy

“…11-14,36,48 -50 Mackenzie,12 in 1960, reported on the indication of wrist arthrodesis in brachial plexus palsy and performed it in 17 patients, improving both function and appearance of the upper extremity, using bone graft from the distal ulna. Authors such as Sorial et al, 36 Monreal, 49 Bentolila et al, 50 Takka et al, 52 Brunelli et al, 53 Anderson and Thomas, 54 and others have documented the use of wrist stabilization in patients with upper extremity deficit. Addosooki et al 10 showed their technique for wrist fusion in 18 patients, placing the rigid plate between the radius and the second metacarpal.…”

“…In addition, it is important for aesthetic improvement of the arm, and a stable wrist with a hooked hand enables the patient to carry small objects. [52][53][54][55] Generally, carpus union is indicated in multiple root avulsions and flaccid wrist or in cases with wrist flexors and extensors but no finger movers. If adequate wrist flexors and extensors are not available and the stabilizing effect of the carpus is lost, reconstruction of hand function needs some sort of wrist stabilization.…”

Hand prehension recovery after brachial plexus avulsion injury by performing a full-length phrenic nerve transfer via endoscopic thoracic surgery

“…12,32 Considering that synchronous movement with the unaffected side is required, 23 useful hand prehension has failed in a large portion of patients. 37 Doi and associates 6,35 have advised using free muscle transfer to provide reliable and powerful motor recovery of finger function, because the neuromotor units of the free muscle are in the upper arm and the nerve to the muscle is purely motor. However, there are some disadvantages, such as being more traumatic and involving the risk of flap necrosis.…”