title: [Free functional gracilis muscle transplantation for reconstruction of active elbow flexion in posttraumatic brachial plexus lesions].
abstract: OBJECTIVE
  Reconstruction of powerful active elbow flexion. Reconstruction of missing muscle unit by neurovascular pedicled functional muscle transplantation.
  
  
  METHODS
  Treatment of last choice for --secondary reconstruction of active elbow flexion in case of complete lesion of the brachial plexus or musculocutaneous nerve (M0 muscle function = replacement indication), partial but incomplete lesion of the brachial plexus or musculocutaneous nerve (M1-(3) muscle function = augmentation indication); --replacement of the elbow flexor muscles in case of primary muscle loss (tumor, trauma).
  
  
  METHODS
  Concomitant lesions of the axillary artery. No adequate donor nerve. Relative: no sensibility at all at the forearm and hand.
  
  
  METHODS
  Free functional biarticular myocutaneous transplantation of gracilis muscle. A myocutaneous gracilis flap is raised at the thigh. At the upper arm the flap is fixed proximally to the coracoid process or the lateral clavicle. The distal insertion is sutured to the distal biceps tendon. Vascular anastomoses are carried out in end-to-side fashion with the brachial artery and vein. Nerval coaptation is done in end-to-end technique using the muculocutaneous nerve.
  
  
  METHODS
  Complete immobilization for 6 weeks. Dorsal upper arm splint until sufficient muscle power (M(4)). Progressive increase of active range of motion for another 6 weeks. Continuation of physiotherapy for 12-18 months. Postoperative standardized compression therapy, combined with scar therapy (silicone sheet).
  
  
  RESULTS
  Functionally useful results can be expected in 60-75% of patients, especially if there is some residual function (M1 or M2) left ("augmentation indication"). Early free functional muscle transplantation shows best results in patients with direct muscle defect, because all vascular and neuronal structures are still available, and no secondary changes such as fibrosis or joint stiffness are present yet. There are inconsistent results for patients with neurologic insufficiency (i.e., total brachial plexus palsy) or mixed neuromuscular insufficiency, such as compartment syndrome. Especially in complete brachial plexus lesion, free functional muscle transfer is often the only treatment option. Provided there is a good patient selection, satisfactory results can be achieved for elbow flexion. Whether a higher number of axons, as provided by the contralateral C7 transfer, will lead to better results is the topic of an ongoing study.
authors.affiliation: Klinik für Plastische, Hand- und Wiederherstellungschirurgie, Schwerverbranntenzentrum der Medizinischen Hochschule Hannover, Hannover, Germany.
authors.forename: Alfred
authors.initials: A
authors.lastname: Berger
authors.forename: Robert
authors.initials: R
authors.lastname: Hierner
mesh_terms: D020516:Brachial Plexus Neuropathies / Q000601:surgery*; D004551:Elbow Joint / Q000601:surgery*; D006801:Humans; D007592:Joint Diseases / Q000601:surgery*; D018482:Muscle, Skeletal / Q000637:transplantation*; D019651:Plastic Surgery Procedures / Q000295:instrumentation* / Q000379:methods*; D016896:Treatment Outcome; D000092464:Elbow Injuries
references.citation: J Hand Surg Am. 1996 May;21(3):387-90
references.pmid: 8724466
references.citation: Hand Clin. 1999 Nov;15(4):757-67
references.pmid: 10563274
references.citation: J Hand Surg Am. 1993 Mar;18(2):285-91
references.pmid: 8463596
references.citation: Plast Reconstr Surg. 2003 Nov;112(6):1596-603
references.pmid: 14578790
references.citation: Microsurgery. 1996;17(7):391-401
references.pmid: 9379888
references.citation: Plast Reconstr Surg. 1984 May;73(5):751-7
references.pmid: 6718573
references.citation: Ann Chir Main Memb Super. 1990;9(5):341-50
references.pmid: 1705130
references.citation: J Reconstr Microsurg. 2004 Apr;20(3):227-35
references.pmid: 15088207
references.citation: Plast Reconstr Surg. 1997 Aug;100(2):364-72; discussion 373-4
references.pmid: 9252603
references.citation: J Reconstr Microsurg. 1990 Apr;6(2):113-6
references.pmid: 2161927
references.citation: Ann Plast Surg. 1982 Nov;9(5):381-91
references.pmid: 7181426
references.citation: Handchir Mikrochir Plast Chir. 1994 Jan;26(1):51-4
references.pmid: 8150390
references.citation: J Bone Joint Surg Br. 1959 Feb;41-B(1):44-50
references.pmid: 13620705
references.citation: J Hand Surg Am. 1978 Jan;3(1):60-9
references.pmid: 340499
references.citation: J Hand Surg Am. 1995 May;20(3):408-14
references.pmid: 7642917
references.citation: J Reconstr Microsurg. 1993 Mar;9(2):111-8; discussion 118-9
references.pmid: 8468701
references.citation: Rev Chir Orthop Reparatrice Appar Mot. 1987;73(8):665-73
references.pmid: 3444946
references.citation: J Hand Surg Am. 2001 Jul;26(4):645-8
references.pmid: 11466638
references.citation: Neurosurg Focus. 2004 May 15;16(5):E8
references.pmid: 15174828
references.citation: J Bone Joint Surg Br. 1998 Jan;80(1):117-20
references.pmid: 9460966
references.citation: Clin Orthop Relat Res. 1989 Aug;(245):110-6
references.pmid: 2752610
references.citation: Plast Reconstr Surg. 1980 May;65(5):610-5
references.pmid: 7367503
references.citation: Hand Clin. 1997 May;13(2):279-89
references.pmid: 9136041
references.citation: Microsurgery. 1991;12(5):346-51
references.pmid: 1770864
references.citation: Chin J Traumatol. 2002 Aug;5(4):254-6
references.pmid: 12162907