Functioning free muscle transplantation

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Functioning free muscle transplantation (FFMT) describes the transfer of a muscle using microvascular anastomoses for revascularization and subsequent neurorraphy of the muscle's motor nerve to a recipient motor nerve for reinnervation. The use of FFMT in brachial plexus reconstruction is another example of the application of neurotization and it has been shown to be effective and has become increasingly popular. The gracilis myocutaneous FFMT is the best choice for the donor muscle in brachial plexus reconstruction [26-28]. The most common extraplexus donor nerves include the XI, the IC, and the CC7, which all require a two-stage procedure: elongation with a nerve graft (cable nerve grafts or vascularized ulnar nerve graft) at the first stage followed by an FFMT at the second stage [26-30]. The Ph nerve can be also used as a neurotizer. Intraplexus donor nerves include part of the ulnar nerve, part of the median nerve, or more proximally from the infraclavicular or suprascapular nerves, which require nerve elongation and FFMT in a two-stage procedure. The results from FFMT are more satisfactory than those provided by local muscle transfer (Fig. 6A-C), and it is especially useful for restoration of elbow and hand function in the global plexopathy. Since Doi [24] described across elbow FFMT for finger extension or flexion reconstruction in 1995, the technique of simultaneous reconstruction of two functions by the transfer of a single long muscle has developed further to become an accepted and reliable procedure in BPI reconstruction. Before 1995, the author performed about 10 cases a year of FFMT, but subsequent to 2000 this has increased up to 50 or more cases a year. The author has performed 647 FFMTs for a number of different purposes between 1985 and 2003, nearly half of them were for BPI.

FFMT is technically demanding. Indications for FFMT in BPI include acute or chronic root avulsion where no nerve reconstruction has been performed before, root injuries with failed nerve transfer (muscle strength less than M3), or BPI associated with Volkmann's contracture of the forearm. Doi's FFMT across the elbow and a below-elbow pulley for hand reconstruction performed for the proven acute root avulsion case is a kind of '' distal to proximal '' reconstruction strategy that is different from the traditional ''proximal to distal'' reconstruction. The author prefers multiple nerve transfers, including CC7 in the acute total root avulsion [5-7] as a one-stage complete reconstruction. FFMT in my series is predominantly an adjuvant palliative reconstruction to enhance the results in the late

Fig. 6. A patient with infraclavicular BPI underwent axillary and musculocutaneous nerve repair with cable nerve grafts, and radial and median nerve repair with a C-loop vascularized ulnar nerve graft in the primary reconstruction. The patient achieved good shoulder elevation and elbow, wrist, and finger flexion 2 years postoperatively. However, he was still unable to extend his fingers and wrist (A, B). He achieved good MCP joint extension and PIP joint extension with the help of an MP block splint 1 year following a gracilis myocutaneous FFMT as a second-stage reconstruction, innervated with the XI nerve (C).

Fig. 6. A patient with infraclavicular BPI underwent axillary and musculocutaneous nerve repair with cable nerve grafts, and radial and median nerve repair with a C-loop vascularized ulnar nerve graft in the primary reconstruction. The patient achieved good shoulder elevation and elbow, wrist, and finger flexion 2 years postoperatively. However, he was still unable to extend his fingers and wrist (A, B). He achieved good MCP joint extension and PIP joint extension with the help of an MP block splint 1 year following a gracilis myocutaneous FFMT as a second-stage reconstruction, innervated with the XI nerve (C).

stage (see Fig. 6A-B). FFMT in acute injuries is not indicated for patients with poor understanding or cooperation (Fig. 7A, B).

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