Download PDF
J Reconstr Microsurg 2023; 39(05): 361-366
DOI: 10.1055/s-0042-1757750
Original Article

Outcomes of Functioning Free Gracilis Muscle Transplantation to Restore Elbow Flexion in Late Brachial Plexus Birth Injury

Nicole A. Zelenski
1   Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
2   Department of Plastic and Reconstructive Surgery, Division of Reconstructive Microsurgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
,
Anthony L. Karzon
1   Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
,
Tommy Nai-Jen Chang
2   Department of Plastic and Reconstructive Surgery, Division of Reconstructive Microsurgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
,
David Chwei-Chin Chuang 
2   Department of Plastic and Reconstructive Surgery, Division of Reconstructive Microsurgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
,
Johnny Chuieng-Yi Lu
2   Department of Plastic and Reconstructive Surgery, Division of Reconstructive Microsurgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
› Author Affiliations Funding None.
› Further Information
    Permissions and Reprints

Abstract

Background Restoring elbow function is challenging after late presenting brachial plexus birth injury (BPBI). Free functioning muscle transplantation (FFMT) using the gracilis muscle is a reliable procedure to restore elbow flexion in patients with impaired function after spontaneous recovery or failed surgical reconstruction.

Methods A retrospective review was performed on BPBI patients more than 2 years of age who received a FFMT between January 1993 and January 2018, with the aim of improving elbow flexion as the primary or secondary functional goal. Patients with preoperative elbow flexion Medical Research Council (MRC) grades less than 3 with more than or equal to 18 months of follow-up duration were included in the analysis. Patient demographic information and pre/postoperative clinical parameters including elbow flexion MRC scale, passive elbow range of motion, and complications were recorded. Surgical data including donor nerve choice, site of the FFMT tendon attachment, and necessity of concomitant procedures or reoperation were also analyzed.

Results Fifty-six FFMTs were performed for the primary (29 patients) or secondary (26 patients) objective of restoring elbow flexion. The mean age at the time of the procedure was 9.6 years (standard deviation [SD] = 6.29, R = 3-35). Mean follow-up was 7.9 years (SD = 5.2). Elbow flexion improved from a median MRC grade 2 to 4 after a FFMT (p < 0.05). Patients who had a FFMT to restore two functions had 86% lower elbow flexion MRC grades than those who had a FFMT to restore flexion only (p < 0.05). Patients less than 12 years old at the time of surgery had more complications, reoperations, and rates of a flexion contracture more than or equal to 30 degrees than those aged more than 12 years (p < 0.05).

Conclusion FFMT is a reliable option for upper extremity reanimation. Patients aged less than 12 years old at the time of FFMT had significantly more complications, reoperations, and rates of postoperative elbow flexion contracture more than or equal to 30 degrees, but equivalent elbow flexion MRC grades.

Level of Evidence III

Keywords

brachial plexus birth palsy - obstetric brachial plexus palsy - free functioning muscle transplantation - muscle transfer - elbow flexion

Ethical Approval

Ethical approval for this study was obtained from Chang Gung Memorial Hospital Institutional Review Board.


Informed Consent

Written informed consent was obtained from all subjects before the study.


Authors' Contributions

N.A.Z. performed chart review, data analysis, and wrote the first and final draft of the manuscript. A.L.K. assisted in data analysis, writing, and editing of the manuscript. D.C.C.C. devised the original concept and was the senior author responsible for the surgeries performed in this study. D.C.C.C. and T.N.J.C. edited the first draft of the manuscript. J.L. edited and approved the final draft of the manuscript. All authors were involved in the design and data analysis of the study.




Publication History

Received: 12 April 2022

Accepted: 14 August 2022

Article published online:
19 October 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Hoeksma AF, ter Steeg AM, Nelissen RG, van Ouwerkerk WJ, Lankhorst GJ, de Jong BA. Neurological recovery in obstetric brachial plexus injuries: an historical cohort study. Dev Med Child Neurol 2004; 46 (02) 76-83
    CrossrefPubMedGoogle Scholar
  • 2 Vekris MD, Papadopoulos DV, Gelalis ID. et al. Secondary procedures for restoration of upper limb function in late cases of neonatal brachial plexus palsy. Eur J Orthop Surg Traumatol 2019; 29 (02) 329-336
    CrossrefPubMedGoogle Scholar
  • 3 Terzis JK, Kokkalis ZT. Outcomes of hand reconstruction in obstetric brachial plexus palsy. Plast Reconstr Surg 2008; 122 (02) 516-526
    CrossrefPubMedGoogle Scholar
  • 4 Foad SL, Mehlman CT, Ying J. The epidemiology of neonatal brachial plexus palsy in the United States. J Bone Joint Surg Am 2008; 90 (06) 1258-1264
    CrossrefPubMedGoogle Scholar
  • 5 Laurent JP, Lee R, Shenaq S, Parke JT, Solis IS, Kowalik L. Neurosurgical correction of upper brachial plexus birth injuries. J Neurosurg 1993; 79 (02) 197-203
    CrossrefPubMedGoogle Scholar
  • 6 Terzis JK, Kokkalis ZT. Secondary procedures for elbow flexion restoration in late obstetric brachial plexus palsy. Hand (N Y) 2010; 5 (02) 125-134
    CrossrefPubMedGoogle Scholar
  • 7 Pondaag W, Malessy MJ, van Dijk JG, Thomeer RT. Natural history of obstetric brachial plexus palsy: a systematic review. Dev Med Child Neurol 2004; 46 (02) 138-144
    CrossrefPubMedGoogle Scholar
  • 8 Narakas AO. [Injuries of the brachial plexus and neighboring peripheral nerves in vertebral fractures and other trauma of the cervical spine]. Orthopade 1987; 16 (01) 81-86
    PubMedGoogle Scholar
  • 9 Waters PM, Bae DS. The early effects of tendon transfers and open capsulorrhaphy on glenohumeral deformity in brachial plexus birth palsy. Surgical technique. J Bone Joint Surg Am 2009; 91 (Suppl. 02) 213-222
    CrossrefPubMedGoogle Scholar
  • 10 Hale HB, Bae DS, Waters PM. Current concepts in the management of brachial plexus birth palsy. J Hand Surg Am 2010; 35 (02) 322-331
    CrossrefPubMedGoogle Scholar
  • 11 Chuang DCC. Brachial plexus injuries: Adult and Pediatric, Neligan P (ed.) Plastic Surgery. Vol. 6, 4th edition. London: Saunders Elsevier; 2017
    Google Scholar
  • 12 Chuang DCC, Hattori Y, Ma And HS, Chen HC. The reconstructive strategy for improving elbow function in late obstetric brachial plexus palsy. Plast Reconstr Surg 2002; 109 (01) 116-126 , discussion 127–129
    CrossrefPubMedGoogle Scholar
  • 13 Chuang DCC, Ma HS, Borud LJ, Chen HC. Surgical strategy for improving forearm and hand function in late obstetric brachial plexus palsy. Plast Reconstr Surg 2002; 109 (06) 1934-1946
    CrossrefPubMedGoogle Scholar
  • 14 Hattori Y, Doi K, Ikeda K, Pagsaligan JM, Watanabe M. Restoration of prehension using double free muscle technique after complete avulsion of brachial plexus in children: a report of three cases. J Hand Surg Am 2005; 30 (04) 812-819
    CrossrefPubMedGoogle Scholar
  • 15 Gilbert A, Brockman R, Carlioz H. Surgical treatment of brachial plexus birth palsy. Clin Orthop Relat Res 1991; (264) 39-47
    PubMedGoogle Scholar
  • 16 El-Gammal TA, El-Sayed A, Kotb MM. et al. Free functioning gracilis transplantation for reconstruction of elbow and hand functions in late obstetric brachial plexus palsy. Microsurgery 2015; 35 (05) 350-355
    CrossrefPubMedGoogle Scholar
  • 17 Mersa B, Aydin A, Ozkan T. Obstetrical brachial plexus palsy: the Istanbul experience. Semin Plast Surg 2004; 18 (04) 347-358
    Article in Thieme ConnectPubMedGoogle Scholar
  • 18 Mulcahey MJ, Lutz C, Kozin SH, Betz RR. Prospective evaluation of biceps to triceps and deltoid to triceps for elbow extension in tetraplegia. J Hand Surg Am 2003; 28 (06) 964-971
    CrossrefPubMedGoogle Scholar
  • 19 Chim H, Kircher MF, Spinner RJ, Bishop AT, Shin AY. Free functioning gracilis transfer for traumatic brachial plexus injuries in children. J Hand Surg Am 2014; 39 (10) 1959-1966
    CrossrefPubMedGoogle Scholar
  • 20 Waters PM. Obstetric brachial plexus injuries: evaluation and management. J Am Acad Orthop Surg 1997; 5 (04) 205-214
    CrossrefPubMedGoogle Scholar
  • 21 Socolovsky M, Paez MD. A literature review of intercostal-to-musculocutaneous-nerve transfers in brachial plexus injury patients: Does body mass index influence results in Eastern versus Western countries?. Surg Neurol Int 2013; 4: 152 DOI: 10.4103/2152-7806.122233.
    CrossrefPubMedGoogle Scholar
  • 22 Dy CJ, Brogan DM, Rolf L, Ray WZ, Wolfe SW, James AS. A qualitative study of life satisfaction after surgery for adult traumatic brachial plexus injury. Bone Jt Open 2021; 2 (01) 9-15
    CrossrefPubMedGoogle Scholar