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.

PURPOSE: 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.

METHODS: 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).

RESULTS: 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.

CONCLUSIONS: 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.

TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.