Loss of elbow flexion can be a devastating disability. Fortunately, the biceps muscle and the brachialis muscle are capable of performing this function. Thus, the direct loss of one or the other does not eliminate this function. The loss of both and the weakening of both can have significant functional consequences, however. In brachial plexus reconstruction, significant priority is given to elbow flexion. At their center, the authors have not had experience with this but have only performed surgery after localized trauma or
Fig. 13. (A) Preoperative view shows lack of digital and thumb extension. (B) Gracilis muscle to replace denervated muscle secondary to a nerve tumor is shown. (C) Postoperative view with full extension of fingers and thumb.
surgical resection in which the musculocutaneous nerve was available to reinnervate the transfer.
The operative procedure is again performed by two teams. The arm is prepared with an incision providing access to the acromion proximally, the brachial artery and the accompanying vein at the junction of the upper and middle thirds of the arm, and, finally, the distal biceps tendon and the bicipital aponeurosis inserting onto the ulna. The gracilis muscle is harvested and transplanted to the arm. It is secured proximally to the acromion, and the vascular and neural repairs are then performed. In the arm, end-to-side arterial repair and end-to-end venous repair are preferred. The musculocutaneous nerve is then coapted to the nerve to the gracilis. The muscle is placed under appropriate tension. This is accomplished by putting the elbow in full extension and then stretching the gracilis to its normal physiologically fully stretched position. The sites of tendon repair are marked, and a secure woven tendon repair is performed. The elbow can then be placed in flexion and maintained with a plaster slab until wound healing is complete.
After 3 weeks, passive extension of the elbow is begun. This is gradually increased over a 3-week period until full extension is achieved. When active muscle contraction begins, active exercises are started. Once again, improvement may occur for 1.5 years.
Functioning free muscle transfers can also be indicated for other important upper extremity functions. Specifically, the procedure can be used for triceps function and has potential for other aspects of shoulder stabilization. The principles outlined previously continue to be relevant and should be adhered to.
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