Free Reverse Gracilis Muscle Combined With Steindler Flexorplasty for Elbow Flexion Reconstruction After Failed Primary Repair of Extended Upper-Type Paralysis of the Brachial Plexus

Purpose To report the clinical outcomes of elbow flexion reconstruction using a reverse free gracilis muscle flap plus Steindler flexorplasty in patients with previously failed reconstruction of extended upper-type brachial plexus paralysis. Methods Twenty-four male patients were reoperated upon an average of 45 months (SD, +/- 45 months) after brachial plexus repair. The gracilis tendon was secured to the acromion, and the muscle bellywas sutured to the biceps distal tendon. Vascular repairwas performed preferentially end to end to the radial artery and cephalic vein. Nerve repair was achieved by coapting the nerve to the gracilis to motor fascicles of the median or ulnar nerve. The medial epicondyle was osteotomized, proximally advanced by 4 to 5 cm and secured to the anterior side of the humerus. Results Active elbow flexion was restored in 23 of 24 patients. Sixteen patients ultimately achieved M4 strength, among whom 6 had full range of motion (ROM), and the remaining 10 recovered an average of 110 degrees (95% confidence interval [95% CI], 100 degrees-120 degrees) of elbow flexion. Seven patients exhibited M3 elbow flexion strength recovery, which was associated with weaker hands and incomplete ROM, averaging 94 degrees (95% CI, 86 degrees-102 degrees). There was, on average, a 10 degrees (95% CI, 4.4 degrees-15.6 degrees). elbow flexion contracture. Among the 16 patients with M4 level recovery of elbow flexion, supination was partially restored in 12. Conclusions In patients previously operated upon, using a reversed free gracilis muscle flap in association with a Steindler procedure is effective as salvage surgery to restore elbow flexion and partial supination. Copyright (C) 2019 by the American Society for Surgery of the Hand. All rights reserved.