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Kimberly A. Barrie, Scott P. Steinmann, Alexander Y. Shin, Robert J. Spinner and Allen T. Bishop


The authors report the functional outcomes after functioning free muscle transfer (FFMT) for restoration of the upper-extremity movement after brachial plexus injury (BPI).


The authors conducted a retrospective review of 36 gracilis FFMT procedures performed in 27 patients with BPI between 1990 and 2000. Eighteen patients underwent a single gracilis FFMT procedure for restoration of either elbow flexion (17 cases) or finger flexion (one case). Nine patients underwent a double free muscle transfer for simultaneous restoration of elbow flexion and wrist extension (first muscle) and finger flexion (second muscle), combined with direct triceps neurotization. The results obtained in 29 cases of FFMT in which the follow-up period was 1 year are reported.

Neurotization of the donor muscle was performed using the musculocutaneous nerve (one case), spinal accessory nerve (12 cases), or multiple intercostal motor nerves (16 cases). Two second-stage muscle flaps failed secondary to vascular insufficiency. Mean electromyography-measured reinnervation time was 5 months. At a minimum follow-up period of 1 year, five muscles achieved less than or equal to Grade M2, eight Grade M3, four Grade M4, and 12 Grade M5. Transfer for combined elbow flexion and wrist extension compared with elbow flexion alone lowered the overall results for elbow flexion strength. Seventy-nine percent of the FFMTs for elbow flexion alone (single transfer) and 63% of similarly innervated muscles transferred for combined motion achieved at least Grade M4 elbow flexion strength.


Functioning free muscle transfer is a viable reconstructive option for restoration of upper-extremity function in the setting of severe BPI. It is possible to achieve good to excellent outcomes in terms of muscle grades with the simultaneous reconstruction of two functions by one FFMT, making restoration of basic hand function possible. More reliable results are obtained when a single FFMT is performed for a single function.

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Marie-Noëlle Hébert-Blouin, Bahram Mokri, Alexander Y. Shin, Allen T. Bishop and Robert J. Spinner

(nausea, emesis, visual changes, and others) is not unusual and has been well described. 8 , 9 The pathophysiology of preganglionic BPI can provide a direct explanation for the association between CSF volume–depletion headaches and traumatic BPIs. In BPI, forceful distraction of the arm away from the body can stretch nerves, leading to nerve root avulsions. In some cases, rents in the dura and/or arachnoid occur at one or more levels, with subsequent formation of nerve root pseudomeningoceles. Given the exponential relationship between CSF volume and CSF pressure, 6

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Harvey Chim, Michelle F. Kircher, Robert J. Spinner, Allen T. Bishop and Alexander Y. Shin

, Xu L , Fu Y : Contralateral C7 transfer for the treatment of brachial plexus root avulsions in children—a report of 12 cases . J Hand Surg Am 32 : 96 – 103 , 2007 7 Domínguez-Páez M , Socolovsky M , Di Masi G , Arráez-Sánchez MA : [Isolated traumatic injuries of the axillary nerve. Radial nerve transfer in four cases and literatura review] . Neurocirugia (Astur) 23 : 226 – 233 , 2012 . (Span) 8 Garg R , Merrell GA , Hillstrom HJ , Wolfe SW : Comparison of nerve transfers and nerve grafting for traumatic upper plexus palsy

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Liselotte F. Bulstra, Nadia Rbia, Michelle F. Kircher, Robert J. Spinner, Allen T. Bishop and Alexander Y. Shin

restoration of function after complete brachial plexus avulsion . Neurosurg Focus 16 ( 5 ): E8 , 2004 10.3171/foc.2004.16.5.9 15174828 4 Bertelli JA : Lower trapezius muscle transfer for reconstruction of elbow extension in brachial plexus injuries . J Hand Surg Eur Vol. 34 : 459 – 464 , 2009 10.1177/1753193408101466 5 Dodakundi C , Doi K , Hattori Y , Sakamoto S , Fujihara Y , Takagi T , : Outcome of surgical reconstruction after traumatic total brachial plexus palsy . J Bone Joint Surg Am 95 : 1505 – 1512 , 2013 10.2106/JBJS.K.01279