At Penn Medicine, a multidisciplinary team of surgeons from the Penn Nerve Center are performing gracilis functional free muscle transfers (FFMT) to restore upper extremity movement to patients with brachial plexus injuries (including avulsion, laceration and contusion).
Brachial plexus injuries are typically traumatic in origin and are marked by paralysis and other functional upper extremity deficits. Restoration of shoulder and elbow function is considered a vital necessity for patients with these injuries, and can be achieved if initiated within six to nine months of injury by nerve grafting and nerve transfers (neurotization). For individuals with brachial plexus nerve injuries that exceed this timespan, gracilis FFMT has the potential to restore movement to the shoulder and elbow.
Gracilis FFMT surgery involves transferring the gracilis muscle, located on the medial aspect of the thigh, to the upper arm (Figure 1). The gracilis muscle has the advantages of a rich blood supply and reliable motor innervation, and FFMT surgery involves minimal donor site morbidity and little to no impairment of leg function.
Once transferred to the upper arm, the gracilis has the capacity to mimic the function of the biceps and brachialis muscles. Neurotization and vascular anastomosis of the muscle at the recipient site are achieved through microsurgery. The reported success rate for gracilis FFMT in patients with brachial plexus avulsion is approximately 70%.1
Figure 1: Gracilis functional free muscle transfer surgery involves transferring the gracilis muscle from the medial thigh to the upper arm to restore function in patients with brachial plexus injuries. The gracilis offers a rich source of vascular and nervous tissue and its transfer results in minimal morbidity and function loss at the donor site.
Clinical Case Study
RL, a 28-year-old man, was referred to the Penn Nerve Center for restoration of movement in his paralyzed right arm. Two years prior, RL had a motorcycle accident resulting in spinal injury and complete right brachial plexus avulsion. Following the injury, he had rehabilitative therapy, including range of motion exercises, which maintained flexibility but did not restore function in the right arm. Since direct nerve repair was no longer an option, a functioning gracilis muscle in RL’s left leg and donor nerves that could serve to re-innervate the muscle transfer were selected.
At Penn, gracilis FFMT surgery proceeds in phases and involves coordinated teams of surgeons from Neurosurgery, Orthopaedics and Plastic Surgery. At the start of surgery, neurosurgeons first explored the brachial plexus to identify viable donor nerve sites. The spinal accessory nerve was selected as a functional donor nerve, maintaining several branches to the trapezius muscle to avoid loss of upper shoulder function.
The orthopaedic and plastic surgery teams prepared the recipient site at the upper arm; the gracilis muscle, obturator nerve, blood vessels and a skin paddle were harvested from RL’s left leg. This tissue was then positioned within the recipient site and the gracilis secured via the clavicle and biceps tendons. With the completion of microvascular repair to the arteries and veins, micro-doppler probes were applied to ensure vessel patency and to measure blood flow.
The neurosurgical team then returned to attach the obturator nerve of the gracilis muscle to the donor spinal accessory nerve. After five days in the hospital for observation, RL was discharged home and had an unremarkable recovery. He is currently participating in daily range of motion rehabilitative therapy.
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Published on: June 15, 2021
References
1. Ali ZS, Heuer GG, Faught RWF, at al. Upper brachial plexus injury in adults: comparative effectiveness of different repair techniques. J Neurosurg 2015;122:195-201.
About the Penn Nerve Center
The Penn Nerve Center offers expert diagnosis and cutting edge treatment for a wide range of nerve conditions including traumatic nerve injuries such as brachial plexus, nerve entrapment, nerve compression, and nerve tumors. We offer a multidisciplinary surgical and medical team consisting of neurosurgeons, orthopaedic surgeons, plastic surgeons, neurologists, physiatrists, physical therapists, and other specialists. As an academic medical center, we conduct extensive nerve research and provide access to clinical trials. Our goal is to provide hope to our patients by creating individualized treatment plans to alleviate their symptoms and ultimately improve their quality of life.
Penn Faculty Team
Chief of Neurosurgery, Penn Presbyterian Medical Center
Vice Chair, Clinical Operations and Quality Improvement
Co-Director, Penn Nerve Center
Associate Professor of Neurosurgery at the Presbyterian Medical Center of Philadelphia
Associate Professor of Orthopaedic Surgery
Chief, Hand Surgery
Chief, Orthopaedic Surgery at Penn Presbyterian Medical Center
Professor of Orthopaedic Surgery at the Hospital of the University of Pennsylvania
Chief, Shoulder and Elbow Division
Associate Professor of Orthopaedic Surgery at the Hospital of the University of Pennsylvania
Co-Director, Penn Orthoplastic Limb Salvage Center
Director, Microsurgery Fellowship
Herndon B. Lehr, M.D. Endowed Professor in Plastic Surgery
Associate Professor of Surgery in Dermatology
Associate Professor of Surgery in Orthopaedic Surgery
Chair Emeritus, Department of Orthopaedic Surgery
Co-Director, Penn Nerve Center
Professor of Orthopaedic Surgery
Professor of Plastic Surgery in Surgery
Associate Professor of Surgery at the Hospital of the University of Pennsylvania and the Children's Hospital of Philadelphia
Associate Professor of Surgery in Orthopaedic Surgery
Associate Director, Orthopaedic Residency Program
Clinical Assistant Professor of Orthopaedic Surgery
Director, Hand & Upper Extremity Fellowship
Education Officer, Department of Orthopaedic Surgery
Professor of Orthopaedic Surgery at the Hospital of the University of Pennsylvania
Neurosurgical Professor in Academic Excellence