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

• Published in: Clinical orthopaedics and related research 2022-12, Vol.480 (12), p.2392-2405
• Main Authors: Steendam, Tawatha C., Nelissen, Rob G. H. H., Malessy, Martijn J. A., Basuki, Mohammad H., Sihotang, Airlangga B. P., Suroto, Heri
• Format: Article
• Language: English
• Subjects: Accessory nerve; Adult; Brachial plexus; Brachial Plexus - injuries; Clinical Research; Elbow; Elbow Joint - surgery; Female; Gracilis Muscle - transplantation; Humans; Injuries; Innervation; Intercostal Nerves - transplantation; Male; Medical research; Muscle strength; Necrosis; Nerve Transfer - methods; Nerves; Orthopedics; Pain; Patients; Phrenic nerve; Range of Motion, Articular - physiology; Recovery of Function; Rehabilitation; Shoulder; Trauma; Treatment Outcome; Wrist; Young Adult
• ISSN: 0009-921X; 1528-1132; 1528-1132
• DOI: 10.1097/CORR.0000000000002311

Traumatic brachial plexus injuries (BPIs) in the nerve roots of C5 to T1 lead to the devastating loss of motor and sensory function in the upper extremity. Free functional gracilis muscle transfer (FFMT) is used to reconstruct elbow and shoulder function in adults with traumatic complete BPIs. The question is whether the gains in ROM and functionality for the patient outweigh the risks of such a large intervention to justify this surgery in these patients. (1) After FFMT for adult traumatic complete BPI, what is the functional recovery in terms of elbow flexion, shoulder abduction, and wrist extension (ROM and muscle grade)? (2) Does the choice of distal insertion affect the functional recovery of the elbow, shoulder, and wrist? (3) Does the choice of nerve source affect elbow flexion and shoulder abduction recovery? (4) What factors are associated with less residual disability? (5) What proportion of flaps have necrosis and do not reinnervate? We performed a retrospective observational study at Dr. Soetomo General Hospital in Surabaya, Indonesia. A total of 180 patients with traumatic BPIs were treated with FFMT between 2010 and 2020, performed by a senior orthopaedic hand surgeon with 14 years of experience in FFMT. We included patients with traumatic complete C5 to T1 BPIs who underwent a gracilis FFMT procedure. Indications were total avulsion injuries and delayed presentation (>6 months after trauma) or after failed primary nerve transfers (>12 months). Patients with less than 12 months of follow-up were excluded, leaving 130 patients eligible for this study. The median postoperative follow-up period was 47 months (interquartile range [IQR] 33 to 66 months). Most were men (86%; 112 of 130) who had motorcycle collisions (96%; 125 patients) and a median age of 23 years (IQR 19 to 34 years). Orthopaedic surgeons and residents measured joint function at the elbow (flexion), shoulder (abduction), and wrist (extension) in terms of British Medical Research Council (MRC) muscle strength scores and active ROM. A univariate analysis of variance test was used to evaluate these outcomes in terms of differences in distal attachment to the extensor carpi radialis brevis (ECRB), extensor digitorum communis and extensor pollicis longus (EDC/EPL), the flexor digitorum profundus and flexor pollicis longus (FDP/FPL), and the choice of a phrenic, accessory, or intercostal nerve source. We measured postoperative function with the DASH score and pain at rest with the VAS s