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Free-Functioning Muscle Transfer for Management of Elbow Flexion

March 01, 2019

Contributors: Jamie P. Levine, MD; Shreya Sanjay Veera, BS; Jacques Henri Hacquebord, MD, FAAOS; Jacques Henri Hacquebord, MD, FAAOS

Free-functioning muscle transfers are effective for the reconstruction of elbow flexion in patients with severe brachial plexus injury. This video discusses the treatment of a 52-year-old man who sustained a brachial plexus injury and an extended trunk injury in a motor vehicle collision that occurred 2.5 years ago. The patient underwent transfer of the third through seventh intercostal nerves to the axillary and musculocutaneous nerves and transfer of the spinal accessory nerve to the suprascapular nerve 16 months prior to presentation. He reported no elbow or shoulder function. Evaluation confirmed left arm brachial plexopathy with no regained function after nerve transfer. Electromyographic studies were consistent with an extended upper trunk injury. Electromyographic studies also were conducted to identify potential nerve donors for free-functioning muscle transfer neurotization. Although considerable denervation of the medial pectoral fascicles was present, the median and ulnar nerves to the flexor carpi radialis and flexor carpi ulnaris muscles, respectively were near normal. Free-functioning muscle transfer using the ipsilateral gracilis was indicated for reconstruction of elbow flexion. The median and ulnar nerves were identified and stimulated to assess their function and viability. The ipsilateral gracilis muscle was harvested with a skin paddle. The recipient site was dissected, with vessels and donor nerves made available for muscle transfer. The gracilis was inset into the saucerized distal biceps tendon, and anastomoses and neurotization were completed via microsurgery. The earliest evidence of recovery consists of pain of the gracilis on palpitation. Clinically significant gracilis contracture requires a minimum of several months.

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