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The results of functioning free muscle transfers to the upper extremity have been quite rewarding. The authors have experience in 30 forearm reconstructions and 13 transfers to the upper arm. Muscle contraction generally begins approximately 2 months after surgery, although improvement may be seen up to 1.5 years after surgery.

In the forearm, the main benefit has been that of finger and thumb flexion as well as consequent improvement in grip strength (Fig. 14). More than half of these patients were able to make a fist

Diabetic Prayer Hands
Fig. 14. (A) Postoperative view with full wrist and finger extension. (B) Postoperative view with good finger excursion and thumb flexion. Note the lag in thumb flexion. (C) Postoperative view demonstrates bulk of the gracilis.

completely. In adults, the distal palmar crease-to-fingertip distance ranged from 0.5 to 4 cm, whereas it was not quite as good in children. Grip strength in the adult group was 38% of the normal side but only 25% in children. This may reflect testing techniques or compliance with the rehabilitation program.

It is interesting that all patients who had transfers to the extensor surface achieved close to full finger and thumb extension.

In functioning free muscle transfers, one can anticipate complete viability and function of the transferred muscle. One can expect an excellent range of finger flexion with proper positioning of the muscle and, hopefully, a distal palmar crease-to-finger pulp distance of less than 3 cm [11]. It is not realistic to expect a perfectly coordinated grip when the muscle transfer is used for finger and thumb flexion. This can be separated, at least to a partial extent, still using only a single gracilis muscle, which is split in its distal segment. This provides a degree of separation of finger and thumb flexion. It is important that the thumb not flex in advance of the fingers, and thus interfere with grip.

The results of functioning free muscle transfer for biceps reconstruction have been gratifying. Four of the authors' five patients had full elbow flexion and were able to flex their elbows with a 5-kg weight in each hand.

The results of functioning free muscle transfers in deltoid reconstruction have been equally satisfying. Seven of the authors' eight patients had useful shoulder flexion, which varied from 90° to 170°. There was one failure in this group in a patient who did not develop any active muscle contraction. Importantly, however, the four patients who had chronic subluxation of the shoulder noted a significant decrease in shoulder pain after their muscle transfer procedure.

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