Microvascular free functioning gracilis transfer with nerve transfer to establish elbow flexion

The loss of elbow flexion is an uncommon, but devastating consequence of injury to the upper limb and a complex problem to manage. This paper describes our experience with free functioning gracilis muscle transfer (FFGMT) to the upper limb for elbow flexion. 33 patients were followed up after FFGMT for elbow flexion. 26 patients were male, and 20 were children. Indications for FFGMT included obstetric brachial palsy (n=13) and adult brachial plexus injury (n=12), arthrogryposis (n=4), sarcoma, polio and radial dysplasia. Seventy percent (n=23) of patients had a successful outcome. Power comparable to the other side (M5) was recorded in two patients, 19 patients scored M4, and three scored M3. FFGMT in the OBP group alone (n=13) was the most successful; all had a pre-operative score of M2 or less and post-operatively 12 (92%) achieved a score of M4 or greater. A greater increase in Medical Research Council (MRC) grade for elbow flexion was achieved when intercostal nerves (ICN) were transferred to innervate the gracilis flap (mean gain three points, SD1.3), than ulnar fascicles (mean gain 1.75 points, SD2.3), P=0.05. With a multidisciplinary team approach involving experienced surgeons, theatre staff and therapists, a significant, reproducible and measurable improvement in elbow flexion can be achieved by FFGMT.