Functioning Free Muscle Transfer for Brachial Plexus Injury: A Systematic Review and Pooled Analysis Comparing Functional Outcomes of Intercostal Nerve and Spinal Accessory Nerve GraftsFunding None.
Background The aim of this study was to compare postoperative elbow flexion outcomes in patients receiving functioning free muscle transplantation (FFMT) innervated by either intercostal nerve (ICN) or spinal accessory nerve (SAN) grafts.
Methods A comprehensive systematic review on FFMT for brachial plexus reconstruction was conducted utilizing Medline/PubMed database. Analysis was designed to compare functional outcomes between (1) nerve graft type (ICN vs. SAN) and (2) different free muscle graft types to biceps tendon (gracilis vs. rectus femoris vs. latissimus dorsi).
Results A total of 312 FFMTs innervated by ICNs (169) or the SAN (143) are featured in 10 case series. The mean patient age was 28 years. Patients had a mean injury to surgery time of 31.5 months and an average follow-up time of 39.1 months with 18 patients lost to follow-up. Muscles utilized included the gracilis (275), rectus femoris (28), and latissimus dorsi (8). After excluding those lost to follow-up or failures due to vascular compromise, the mean success rates of FFMTs innervated by ICNs and SAN were 64.1 and 65.4%, respectively.
Conclusion This analysis did not identify any difference in outcomes between FFMTs via ICN grafts and those innervated by SAN grafts in restoring elbow flexion in traumatic brachial plexus injury patients.
Received: 12 December 2019
Accepted: 20 April 2020
11 June 2020 (online)
Thieme Medical Publishers
333 Seventh Avenue, New York, NY 10001, USA.
- 1 Shin AY, Spinner RJ, Steinmann SP, Bishop AT. Adult traumatic brachial plexus injuries. J Am Acad Orthop Surg 2005; 13 (06) 382-396
- 2 Moran SL, Steinmann SP, Shin AY. Adult brachial plexus injuries: mechanism, patterns of injury, and physical diagnosis. Hand Clin 2005; 21 (01) 13-24
- 3 Brophy RH, Wolfe SW. Planning brachial plexus surgery: treatment options and priorities. Hand Clin 2005; 21 (01) 47-54
- 4 Ruch DS, Friedman A, Nunley JA. The restoration of elbow flexion with intercostal nerve transfers. Clin Orthop Relat Res 1995; (314) 95-103
- 5 Friedman AH, Nunley II JA, Goldner RD, Oakes WJ, Goldner JL, Urbaniak JR. Nerve transposition for the restoration of elbow flexion following brachial plexus avulsion injuries. J Neurosurg 1990; 72 (01) 59-64
- 6 Chuang DC, Yeh MC, Wei FC. Intercostal nerve transfer of the musculocutaneous nerve in avulsed brachial plexus injuries: evaluation of 66 patients. J Hand Surg Am 1992; 17 (05) 822-828
- 7 Akasaka Y, Hara T, Takahashi M. Restoration of elbow flexion and wrist extension in brachial plexus paralyses by means of free muscle transplantation innervated by intercostal nerve. Ann Chir Main Memb Super 1990; 9 (05) 341-350
- 8 Bishop AT. Functioning free-muscle transfer for brachial plexus injury. Hand Clin 2005; 21 (01) 91-102
- 9 Maldonado AA, Kircher MF, Spinner RJ, Bishop AT, Shin AY. Free functioning gracilis muscle transfer versus intercostal nerve transfer to musculocutaneous nerve for restoration of elbow flexion after traumatic adult brachial pan-plexus injury. Plast Reconstr Surg 2016; 138 (03) 483e-488e
- 10 Doi K, Sakai K, Ihara K, Abe Y, Kawai S, Kurafuji Y. Reinnervated free muscle transplantation for extremity reconstruction. Plast Reconstr Surg 1993; 91 (05) 872-883
- 11 Ikuta Y, Yoshioka K, Tsuge K. Free muscle graft as applied to brachial plexus injury-case report and experimental study. Ann Acad Med Singapore 1979; 8 (04) 454-458
- 12 Moneim MS, Omer GE. Latissimus dorsi muscle transfer for restoration of elbow flexion after brachial plexus disruption. J Hand Surg Am 1986; 11 (01) 135-139
- 13 Yang Y, Yang JT, Fu G. , et al. Functioning free gracilis transfer to reconstruct elbow flexion and quality of life in global brachial plexus injured patients. Sci Rep 2016; 6: 22479
- 14 Kay S, Pinder R, Wiper J, Hart A, Jones F, Yates A. Microvascular free functioning gracilis transfer with nerve transfer to establish elbow flexion. J Plast Reconstr Aesthet Surg 2010; 63 (07) 1142-1149
- 15 Waikakul S, Wongtragul S, Vanadurongwan V. Restoration of elbow flexion in brachial plexus avulsion injury: comparing spinal accessory nerve transfer with intercostal nerve transfer. J Hand Surg Am 1999; 24 (03) 571-577
- 16 Giuffre JL, Kakar S, Bishop AT, Spinner RJ, Shin AY. Current concepts of the treatment of adult brachial plexus injuries. J Hand Surg Am 2010; 35 (04) 678-688 , quiz 688
- 17 Barrie KA, Steinmann SP, Shin AY, Spinner RJ, Bishop AT. Gracilis free muscle transfer for restoration of function after complete brachial plexus avulsion. Neurosurg Focus 2004; 16 (05) E8
- 18 Chung DC, Carver N, Wei FC. Results of functioning free muscle transplantation for elbow flexion. J Hand Surg Am 1996; 21 (06) 1071-1077
- 19 Coulet B, Boch C, Boretto J, Lazerges C, Chammas M. Free gracilis muscle transfer to restore elbow flexion in brachial plexus injuries. Orthop Traumatol Surg Res 2011; 97 (08) 785-792
- 20 Kimura LK, do Nascimento AT, Capócio R. , et al. Microsurgical transfer of the gracilis muscle for elbow flexion in brachial plexus injury in adults: retrospective study of eight cases. Rev Bras Ortop 2015; 46 (05) 534-539
- 21 Maldonado AA, Kircher MF, Spinner RJ, Bishop AT, Shin AY. 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 Am 2017; 42 (04) 293.e1-293.e7
- 22 Nicoson MC, Franco MJ, Tung TH. Donor nerve sources in free functional gracilis muscle transfer for elbow flexion in adult brachial plexus injury. Microsurgery 2017; 37 (05) 377-382