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Restoration of Prehension with the Double Free Muscle Technique Following Complete Avulsion of the Brachial Plexus Indications and Long-Term Results*
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Investigation performed at the Departments of Orthopedic Surgery, Ogori Daiichi General Hospital, Ogori, and Yamaguchi University School of Medicine, Ube, Yamaguchi-ken, Japan
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
†Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Shimogo 862-3, Ogori, Yamaguchi-ken 754-0002, Japan. E-mail address for Kazuteru Doi: doimac@ca.mbn.or.jp.
‡Department of Orthopedic Surgery, Yamaguchi University School of Medicine, Ube, Yamaguchi-ken, 755-8505, Japan.

J Bone Joint Surg Am, 2000 May 01;82(5):652-652
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Background: Recent interest in reconstruction of the upper limb following brachial plexus injuries has focused on the restoration of prehension following complete avulsion of the brachial plexus.

Methods: Double free muscle transfer was performed in patients who had complete avulsion of the brachial plexus. After initial exploration of the brachial plexus and (if possible) repair of the fifth cervical nerve root, the first free muscle, used to restore elbow flexion and finger extension, is transferred and reinnervated by the spinal accessory nerve. The second free muscle, transferred to restore finger flexion, is reinnervated by the fifth and sixth intercostal nerves. The motor branch of the triceps brachii is reinnervated by the third and fourth intercostal nerves to restore elbow extension. Hand sensibility is restored by suturing of the sensory rami of the intercostal nerves to the median nerve or the ulnar nerve component of the medial cord. Secondary reconstructive procedures, such as arthrodesis of the carpometacarpal joint of the thumb, shoulder arthrodesis, and tenolysis of the transferred muscle and the distal tendons, may be required to improve the functional outcome.

Results: The early results were evaluated in thirty-two patients who had had reconstruction with use of the double free muscle procedure. Twenty-six of these patients were followed for at least twenty-four months (mean duration, thirty-nine months) after the second free muscle transfer, and they were assessed with regard to the long-term outcome as well. Satisfactory (excellent or good) elbow flexion was restored in twenty-five (96 percent) of the twenty-six patients and satisfactory prehension (more than 30 degrees of total active motion of the fingers), in seventeen (65 percent). Fourteen patients (54 percent) could position the hand in space, negating simultaneous flexion of the elbow, while moving the fingers at least 30 degrees and could use the reconstructed hand for activities requiring the use of two hands, such as holding a bottle while opening a cap and lifting a heavy object. The results were analyzed to identify factors affecting the outcome.

Conclusions: The double free muscle procedure can provide reliable and useful prehensile function for patients with complete avulsion of the brachial plexus.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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