Gracilis Free Flap Technique for Elbow Flexion Reconstruction

Area of Science:

• Microsurgery
• Orthopedic Surgery
• Reconstructive Surgery

Background:

• Brachial plexus injuries (BPI) cause significant physical, psychological, and socioeconomic distress.
• Pan-plexus injuries result in a flail extremity and loss of function, with elbow flexion restoration being a priority.
• Nerve transfers are not always viable, making free functioning muscle transfers a key reconstructive option.

Purpose of the Study:

• To present a detailed video guide on performing a gracilis free flap for elbow flexion reconstruction in complex BPI.
• To provide educational operative pearls for each step of the procedure, from markings to inset.
• To highlight the utility of gracilis transfer in cases where intra-plexal nerve donors are unavailable.

Main Methods:

• Harvesting the gracilis muscle as a type-II free functioning muscle transfer, preserving its pedicle and nerve.
• Transferring the muscle to the upper extremity, anchoring its origin to the clavicle and inserting its tendon into the biceps tendon.
• Performing microsurgical vascular anastomoses and innervating the muscle with the spinal accessory nerve.

Main Results:

• Gracilis free flap transfer is a reliable option for restoring functional elbow flexion in severe BPI.
• Studies report significant functional improvements, with a high percentage of patients achieving M3 or M4 muscle strength.
• Patients experience meaningful elbow flexion restoration, improved range of motion, and enhanced quality of life.

Conclusions:

• Free gracilis muscle transfer is a dependable and effective reconstructive approach for elbow flexion in complete BPI.
• This technique offers consistent outcomes and active elbow flexion, crucial for functional independence.
• The gracilis muscle's characteristics make it an ideal choice for this complex reconstructive procedure.