title: 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.
abstract: OBJECTIVE
  After complete 5-level root avulsion brachial plexus injury, the free-functioning muscle transfer (FFMT) and the intercostal nerve (ICN) to musculocutaneous nerve (MCN) transfer are 2 potential reconstructive options for restoration of elbow flexion. The aim of this study was to determine if the combination of the gracilis FFMT and the ICN to MCN transfer provides stronger elbow flexion compared with the gracilis FFMT alone.
  
  
  METHODS
  Sixty-five patients who underwent the gracilis FFMT only (32 patients) or the gracilis FFMT in addition to the ICN to MCN transfer (33 patients) for elbow flexion after a pan-plexus injury were included. The 2 groups were compared with respect to postoperative elbow flexion strength according to the modified British Medical Research Council grading system as well as preoperative and postoperative Disability of the Arm, Shoulder, and Hand scores. Two subgroup analyses were performed for the British Medical Research Council elbow flexion strength grade: FFMT neurotization (spinal accessory nerve vs ICN) and the attachment of the distal gracilis tendon (biceps tendon vs flexor digitorum profundus/flexor pollicis longus tendon).
  
  
  RESULTS
  The proportion of patients reaching the M3/M4 elbow flexion muscle grade were similar in both groups (FFMT vs FFMT + ICN to MCN transfer). Statistically significant improvement in postoperative Disability of the Arm, Shoulder, and Hand score was found in the FFMT + ICN to MCN transfer group but not in the FFMT group. There was a significant difference between gracilis to biceps (M3/M4 = 52.6%) and gracilis to FDP/flexor pollicis longus (M3/M4 = 85.2%) tendon attachment.
  
  
  CONCLUSIONS
  The use of the ICN to MCN transfer associated with the FFMT does not improve the elbow flexion modified British Medical Research Council grade, although better postoperative Disability of the Arm, Shoulder, and Hand scores were found in this group. The more distal attachment of the gracilis FFMT tendon may play an important role in elbow flexion strength.
  
  
  METHODS
  Therapeutic IV.
authors.affiliation: Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic, Rochester, MN; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN.
authors.forename: Andrés A
authors.initials: AA
authors.lastname: Maldonado
authors.affiliation: Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic, Rochester, MN.
authors.forename: Michelle F
authors.initials: MF
authors.lastname: Kircher
authors.affiliation: Department of Neurologic Surgery, Mayo Clinic, Rochester, MN.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Spinner
authors.affiliation: Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic, Rochester, MN.
authors.forename: Allen T
authors.initials: AT
authors.lastname: Bishop
authors.affiliation: Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic, Rochester, MN. Electronic address: shin.alexander@mayo.edu.
authors.forename: Alexander Y
authors.initials: AY
authors.lastname: Shin
mesh_terms: D000293:Adolescent; D000328:Adult; D020516:Brachial Plexus Neuropathies / Q000209:etiology / Q000601:surgery*; D004551:Elbow Joint / Q000294:innervation* / Q000503:physiopathology; D000071976:Gracilis Muscle / Q000637:transplantation*; D006801:Humans; D007367:Intercostal Nerves / Q000637:transplantation*; D008297:Male; D008875:Middle Aged; D053580:Muscle Strength; D009138:Musculocutaneous Nerve / Q000601:surgery*; D016067:Nerve Transfer / Q000379:methods*; D059348:Peripheral Nerve Injuries / Q000601:surgery*; D016059:Range of Motion, Articular; D020127:Recovery of Function; D012189:Retrospective Studies; D055815:Young Adult
keywords: Free muscle transfer; elbow flexion reconstruction; gracilis tendon attachment; intercostal nerve transfer; pan-plexus injury