Free Functional Gracilis for Restoration of Elbow Flexion in Late Brachial Plexus Palsy | ||||
The Egyptian Journal of Plastic and Reconstructive Surgery | ||||
Article 5, Volume 48, Issue 3, July 2024, Page 197-204 PDF (780.36 K) | ||||
Document Type: Original Article | ||||
DOI: 10.21608/ejprs.2024.365329 | ||||
![]() | ||||
Authors | ||||
Mahmoud E Gouda* ; Mohammad R Ahmed* | ||||
The Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Zagazig University | ||||
Abstract | ||||
Background: Functional restoration of elbow flexion represents a major reconstructive challenge for post-traumatic adult brachial plexus injuries. Free functional muscle transfer (FFMT) is the only hope in patients with a lack of local donor tissues or delayed presentation. Objective: To study the outcome of free functional gracilis for restoration of elbow flexion in late brachial plexus palsy. Methods: A retrospective review of 15 patients who underwent free functioning muscle transfer for elbow flexion as part of their brachial plexus injury reconstruction with an average of 22-month follow-up period. Report of the clinical outcomes of flap viability and the degree of elbow flexion restoration by range of motion and British Medical Research Council (MRC) grade. Results: The average age was 37 years, and 60% were caused by Road Traffic Accidents. The flap survival rate reached 86.6% (n=13). The mean follow-up period was 22 months (range, 12-30 months). By the end of the follow-up period, 69% of the transfers had recovered MRC grade >M3 elbow flexion strength. They could lift an average of 2.7kg (range, 0.5-5kg). Conclusion: The use of FFMT using the gracilis muscle is a reliable procedure in the restoration of elbow flexion in patients with brachial plexus injuries beyond 12 months from the time of injury and in patients with complete root avulsion injuries. In the hands of an experienced team, good results can be achieved. | ||||
Keywords | ||||
Elbow flexion; Brachial Plexus; Free Functional Muscle Transfer | ||||
References | ||||
Al Sabbahi M.S., Abd El Aal M., Ali A.M., Ahmad M.H. and Abdel Azeem M.H.: Functional Outcomes of Primary Restoration of Elbow Flexion after Traumatic Brachial Plexus Palsy. Egypt J. Plast. Reconstr. Surg., Jan. 1; 43 (1): 7-11, 2019. 2- Chuang D.C.C.: Neurotization and free muscle transfer for brachial plexus avulsion injury. Hand Clin., Feb. 23 (1): 91-104, 2007. 3- Colbert S.H. and Mackinnon S.E.: Nerve transfers for brachial plexus reconstruction. Hand Clin., Nov. 24 (4): 341- 61, v, 2008. 4- Oberlin C., Durand S., Belheyar Z., Shafi M., David E. and Asfazadourian H.: Nerve transfers in brachial plexus palsies. Chir. Main., Feb. 28 (1): 1-9, 2009. 5- Cambon-Binder A., Walch A., Marcheix P.S. and Belkheyar Z.: Bipolar transfer of the pectoralis major muscle for restoration of elbow flexion in 29 cases. J. Shoulder Elbow Surg., Nov.27 (11): e330-6, 2018. Egypt, J. Plast. Reconstr. Surg., July 2024 203 6- Cambon-Binder A., Belkheyar Z., Durand S., Rantissi M. and Oberlin C.: Elbow flexion restoration using pedicled latissimus dorsi transfer in seven cases. Chir. Main., Dec. 31 (6): 324-30, 2012. 7- Bertelli J.A.: Free Reverse Gracilis Muscle Combined With Steindler Flexorplasty for Elbow Flexion Reconstruction After Failed Primary Repair of Extended Upper-Type Paralysis of the Brachial Plexus. J. Hand Surg., Feb. ;44 (2): 112-20, 2019. 8- Griepp D.W., Shah N.V., Scollan J.P., Horowitz E.H., Zuchelli D.M., Gallo V., et al.: Outcomes of gracilis freeflap muscle transfers and non-free-flap procedures for restoration of elbow flexion: A systematic review. J. Plast. Reconstr. Aesthet. Surg., Aug. 75 (8): 2625-36, 2022. 9- Hoang D., Chen V.W. and Seruya M.: Recovery of Elbow Flexion after Nerve Reconstruction versus Free Functional Muscle Transfer for Late, Traumatic Brachial Plexus Palsy: A Systematic Review. Plast. Reconstr. Surg. Apr. 141 (4): 949-59, 2018. 10- Oliver J.D., Beal C., Graham E.M., Santosa K.B. and Hu M.S.: Functioning Free Muscle Transfer for Brachial Plexus Injury: A Systematic Review and Pooled Analysis Comparing Functional Outcomes of Intercostal Nerve and Spinal Accessory Nerve Grafts. J. Reconstr. Microsurg., Oct. 36 (8): 567-71, 2020. 11- Venkatramani H., Bhardwaj P. and Sabapathy R.: Functioning Free Gracilis Muscle Transfer for Restoration of Elbow Flexion in Adult Brachial Plexus Palsy-The Ganga Hospital Approach. J Peripher Nerve Surg., Aug. 25; (Volume 1, No. 1, July 2017) 24-30, 2017. 12- Hinchcliff K.M., Kircher M.F., Bishop A.T., Spinner R.J. and Shin A.Y.: Factors Impacting the Success of Free Functioning Gracilis Muscle Transfer for Elbow Flexion in Brachial Plexus Reconstruction. Plast. Reconstr. Surg., May 1;149(5):921e–9e, 2022. 13- Armangil M., Ünsal S.Ş., Yıldırım T., Bezirgan U., Keremov A., Adıyaman S., et al.: Outcome of free gracilis muscle transfer for the restoration of elbow flexion in traumatic brachial plexus palsy. Jt. Dis. Relat. Surg., Nov. 19; 32 (3): 633-41, 2021. 14- Karamanos E., Julian B.Q. and Cromack D.: The Gracilis Muscle Flap, In p. 247-57, 2021. 15- Yi Lee T.M., Sechachalam S. and Satkunanantham M.: Systematic review on outcome of free functioning muscle transfers for elbow flexion in brachial plexus injuries. J. Hand Surg. Eur., Jul. 44 (6): 620-7, 2019. 16- Stevanovic M. and Sharpe F.: Functional free muscle transfer for upper extremity reconstruction. Plast. Reconstr. Surg., Aug. 134 (2): 257e–74e, 2014. 17- Hosseinian M.A. and Tofigh A.M.: Cross pectoral nerve transfer following free gracilis muscle transplantation for chronic brachial plexus palsy: A case series. Int. J. Surg., Apr. 1; 6 (2): 125-8, 2008. 18- Lanier S.T., Hill J.R., James A.S., Rolf L., Brogan D.M. and Dy C.J.: Approach to the Pan-brachial Plexus Injury: Variation in Surgical Strategies among Surgeons. Plast. Reconstr. Surg. Glob. Open, Nov. 24; 8 (11): e3267, 2020. 19- Ikuta Y., Yoshioka K. and Tsuge K.: Free muscle graft as applied to brachial plexus injury-case report and experimental study. Ann. Acad. Med. Singapore, Oct. 8 (4): 454- 8, 1979. 20- Coulet B., Boch C., Boretto J., Lazerges C. and Chammas M.: Free Gracilis muscle transfer to restore elbow flexion in brachial plexus injuries. Orthop. Traumatol. Surg. Res., Dec. 97 (8): 785-92, 2011. 21- Maldonado A.A., Kircher M.F., Spinner R.J., Bishop A.T. and Shin A.Y.: 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. J. Hand Surg., Apr. 1; 42 (4): 293.e1-293.e7, 2017. 22- Nicoson M.C., Franco M.J. and Tung T.H.: Donor nerve sources in free functional gracilis muscle transfer for elbow flexion in adult brachial plexus injury. Microsurgery, Jul. 37 (5): 377-82, 2017. 23- Texakalidis P., Hardcastle N., Tora M.S. and Boulis N.M.: Functional restoration of elbow flexion in nonobstetric brachial plexus injuries: A meta-analysis of nerve transfers versus grafts. Microsurgery, 40 (2): 261-7, 2020. 24- Martins-Filho F.V.F., do Carmo Iwase F., Silva G.B., Cho A.B., Wei T.H., de Rezende M.R., et al.: Do technical components of microanastomoses influence the functional outcome of free gracilis muscle transfer for elbow flexion in traumatic brachial plexus injury? Orthop. Traumatol. Surg. Res., Apr. 107 (2): 102827, 2021. 25- Kay S., Pinder R., Wiper J., Hart A., Jones F. and Yates A.: Microvascular free functioning gracilis transfer with nerve transfer to establish elbow flexion. J. Plast. Reconstr. Aesthet. Surg., Jul. 63 (7): 1142-9, 2010. 26- Seal A. and Stevanovic M.: Free Functional Muscle Transfer for the Upper Extremity. Clin. Plast. Surg., Oct. 38 (4): 561–75, 2011. 27- Terzis J.K. and Kostopoulos V.K.: Free Muscle Transfer in Posttraumatic Plexopathies Part II: The Elbow. Hand N Y N., Jun. 5 (2): 160-70, 2010. 28- Chidester J., Leland H., Navo P., Minneti M., Ghiassi A. and Stevanovic M.: Redefining the Anatomic Boundaries for Safe Dissection of the Skin Paddle in a Gracilis Myofasciocutaneous Free Flap: An Indocyanine Green Cadaveric Injection Study. Plast. Reconstr. Surg. Glob Open., Dec. 1; Latest Articles: 1, 2018. 29- Coquerel-Beghin D., Milliez P., Auquit-Auckbur I., Lemierre G. and Duparc F.: The gracilis musculocutaneous flap: Vascular supply of the muscle and skin components. Surg Radiol Anat SRA, Jan. 1; (28): 588-95, 2007. 30- Horner V.K., Schneider L.A., Leibig N., Zeller J., Kiefer J. and Eisenhardt S.U.: An Analysis of the Implantable Doppler Probe for Postoperative Free-Flap Monitoring and Risk Factor Analysis for Revision Surgery in Facial Reanimation Surgery. Facial Plast. Surg. Aesthetic Med., 24 (5): 345-51, 2022. 31- Doi K., Kuwata N., Muramatsu K., Hottori Y. and Kawai S.: Double muscle transfer for upper extremity reconstruction following complete avulsion of the brachial plexus. Hand Clin., Nov. 15 (4): 757-67, 1999. 204 Vol. 48, No. 3 / Free Functional Gracilis for Restoration of Elbow Flexion 32- Barrie Ka, Sp S,, Ay S,, Rj S. and At B.: Gracilis free muscle transfer for restoration of function after complete brachial plexus avulsion. Neurosurg Focus, May 15; 16 (5), 2004. 33- Estrella E.P. and Montales T.D.: Functioning free muscle transfer for the restoration of elbow flexion in brachial plexus injury patients. Injury, Nov. 47 (11): 2525-33, 2016. 34- Yang Y., Yang J.T., Fu G., Li X.M., Qin B.G., Hou Y., et al.: Functioning free gracilis transfer to reconstruct elbow flexion and quality of life in global brachial plexus injured patients. Sci. Rep., Mar. 3; (6): 22479, 2016. 35- Vekris M.D., Beris A.E. Lykissas M.G., Korompilias A.V., Vekris A.D. and Soucacos P.N.: Restoration of elbow function in severe brachial plexus paralysis via muscle transfers. Injury, Sep. 39 (Suppl 3): S15-22, 2008. 36- Akasaka Y., Hara T. and Takahashi M.: Free muscle transplantation combined with intercostal nerve crossing for reconstruction of elbow flexion and wrist extension in brachial plexus injuries. Microsurgery, 12 (5), 1991 | ||||
Statistics Article View: 33 PDF Download: 42 |
||||