IMAGE Double Functioning Free Muscle Transfer as a Salvage Procedure for Brachial Plexus Injury After Failed Nerve Transfer

A 29-year-old male suffered from total loss of function of his left shoulder and upper limb after a traffic accident while riding a motorcycle. He was treated by a brachial plexus specialist at another hospital and managed surgically under the impression of total root avulsion. He was treated initially with distal nerve transfer, using spinal accessory nerve to suprascapular nerve for shoulder abduction, and intercostal nerves T3, T4, and T5 to musculocutaneous nerve for elbow flexion. Four months later, he received contralateral C7 transfer to median nerve with a vascularized ulnar nerve graft for hand flexion and sensation. However, there was no recovery of elbow or finger contraction two years after the initial operation. He then received functioning free muscle transplantation as a salvage procedure using gracilis muscle for elbow flexion, with the reuse of T3 and T4 intercostal nerves as neurotizers. The ipsilateral neck and the supraclavicular brachial plexus were never explored in any of these surgeries. Unfortunately, the free functioning muscle transfer (FFMT) was unsuccessful and the muscle power of the gracilis remained at M1 status without any progression. He then came to our unit for help. The patient showed weak elbow flexion, with no finger flexion, but some recovery of median nerve sensation. Due to the lack of extraplexus donors, we arranged MRI of the left neck to search for viable roots, and surprisingly it showed ruptured C5 and C6 roots without avulsion. Thus, we planned for a two-staged surgery. At the first stage, we identified viable stumps of C5 and C6 roots. We harvested two sural nerve grafts as extension cables of the C5 and C6 roots, and passed the distal ends under clavicle, pectoralis minor and major muscles to be buried in the dermis of the left axilla region. The second stage of surgery was done 11 months later after the tinel signs reached the axillary destination. Tensor fascia lata was first harvested and attached to the clavicle for muscle elongation. Both gracilis and adductor longus muscle were harvested with common pediFigure 2. The proximal end of the FFMT was attached to the tensor fascia lata, while the distal end of the gracilis and adductor longus were attached to the flexor digitorum profundus and the distal biceps respectively. FFMT, free functioning muscle transfer.


IMAGE Double Functioning Free Muscle Transfer as a Salvage Procedure for Brachial Plexus Injury After Failed Nerve Transfer
Jerry Tsung-Kai Lin, MD; Johnny Chuieng-Yi Lu, MD * ; Tommy Nai-Jen Chang, MD; David Chwei-Chin Chuang, MD Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan A 29-year-old male suffered from total loss of function of his left shoulder and upper limb after a traffic accident riding a motorcycle.He was treated by a brachial plexus specialist at another hospital and managed surgically under the impression of total root avulsion.
He was treated initially with distal nerve transfer, using spinal accessory nerve to suprascapular nerve for shoulder abduction, and intercostal nerves T3, T4, and T5 to musculocutaneous nerve for elbow flexion.Four months later, he received contralateral C7 transfer to median nerve with a vascularized ulnar nerve graft for hand flexion and sensation.However, there was no recovery of elbow or finger contraction two years after the initial operation.He then received functioning free muscle transplantation as a salvage procedure using gracilis muscle for elbow flexion, with the reuse of T3 and T4 intercostal nerves as neurotizers.
The ipsilateral neck and the supraclavicular brachial plexus were never explored in any of these surgeries.
Unfortunately, the free functioning muscle transfer (FFMT) was unsuccessful and the muscle power of the gracilis remained at M1 status without any progression.He then came to our unit for help.The patient showed weak elbow flexion, with no finger flexion, but some recovery of median nerve sensation.Due to the lack of extraplexus donors, we arranged MRI of the left neck to search for viable roots, and surprisingly it showed ruptured C5 and C6 roots without avulsion.Thus, we planned for a two-staged surgery.At the first stage, we identified viable stumps of C5 and C6 roots.We harvested two sural nerve grafts as extension cables of the C5 and C6 roots, and passed the distal ends under clavicle, pectoralis minor and major muscles to be buried in the dermis of the left axilla region.The second stage of surgery was done 11 months later after the tinel signs reached the axillary destination.Tensor fascia lata was first harvested and attached to the clavicle for muscle elongation.Both gracilis and adductor longus muscle were harvested with common pedi-  cle vessels, but with two different innervating nerves, and their proximal ends were sutured to the elongated tensor fascia lata (Figure 1).The distal end of gracilis tendon was sutured to the tendon of flexor digitorum profundus in an end-to-end fashion, while that of adductor longus was sutured to distal biceps tendon under appropriate tension (Figure 2).The anterior circumflex humeral arteries and basilar veins were anastomosed to the common pedicle of the two functioning free muscles (Figure 3).

Figure 2 .
Figure 2. The proximal end of the FFMT was attached to the tensor fascia lata, while the distal end of the gracilis and adductor longus were attached to the flexor digitorum profundus and the distal biceps respectively.FFMT, free functioning muscle transfer.

Figure 3 .
Figure 3.The anterior circumflex humeral arteries and basilar veins were anastomosed to the common pedicle of the two functioning free muscles.

Figure 1 .
Figure 1.A scheme of the harvested double functional free muscle.The two muscles are based on a common vascular pedicle, but with two different innervating nerves.

Figure 4 .
Figure 4.The scheme regarding the coaptation of the nerves.The sural nerve grafts were used as extension cables of the C5 and C6 roots, and were coapted separately to the innervating nerves of the adductor and gracilis muscles.

Figure 5 .
Figure 5.The divisions of the obturator nerve.The branch innervating the adductor longus and the gracilis muscles both account for the anterior division of the obturator nerve.