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Current Procedure of Double Free Muscle Transfer for Traumatic Total Brachial Plexus Palsy
Kazuteru Doi, MD, PhD1; Yasunori Hattori, MD, PhD1; Sotetsu Sakamoto, MD1; Chaitanya Dodakundi, MBBS, MS(Orth)1; Nilesh G. Satbhai, MS, MCh1; Tristram Montales, MD1
1 Department of Orthopaedics, Ogori Daiichi General Hospital, 862-3 Shimogo-Ogori, Yamaguchi 754-0002, Japan. E-mail address for K. Doi: doimicro@saikyo.or.jp
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Based on an original article: J Bone Joint Surg Am. 2013 Aug 21;95(16):1505-12

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
JBJS Essential Surgical Techniques, 2013 Aug 28;3(3):e16 1-11. doi: 10.2106/JBJS.ST.M.00010
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We describe the current procedure of not only double free muscle transfer but also supplemental techniques including nerve transfer for shoulder and elbow reconstruction and secondary surgery for the wrist and fingers to improve prehensile function following traumatic total brachial plexus palsy1-4.

Step 1: Preoperative Planning

Coronal and transverse MRIs and intraoperative electrical stimulation are useful for nerve-root evaluation.

Step 2: Reconstruction of Shoulder Function (Stage I)

If the nerve gap is <10 cm, use the sural nerve as an interpositional graft; if the nerve gap is >15 cm, use a vascularized ulnar or radial nerve graft from the ipsilateral forearm; if the ipsilateral nerve roots are not available, explore the contralateral plexus.

Step 3: First Free Innervated Muscle Transfer for Elbow Flexion and Finger Extension (Stage II)

Prepare the recipient site, harvest the gracilis muscle, and transfer the muscle graft.

Steps 4 and 5 (Stage III): Nerve Transfer for Elbow Extension and Sensory Restoration (Step 4) and Second Free Innervated Muscle Transfer for Elbow Flexion and Finger Flexion (Step 5)

Repair the long-head branches of the triceps brachii muscle of the radial nerve by using the third and fourth intercostal nerves, and the median nerve by using the sensory branch of the the second and third intercostal nerves; then transfer the second free muscle.

Step 6: Postoperative Management

Immobilize the upper limb for eight weeks, and start early passive mobilization at one week.

Step 7: Secondary Procedures (Stage IV)

Secondary procedures include wrist fusion, correction of intrinsic minus deformity, etc.


From 2002 to 2008, thirty-six patients underwent reconstruction with the double free muscle technique to treat a total brachial plexus palsy5.

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    Video 1: Nerve suture between the motor branch of the gracilis muscle and the terminal branch of the spinal accessory nerve

    Running Time: 2:36

    Video 2: Tension adjustment at the tendon suture between the gracilis muscle and the extensor digitorum communis tendon

    Running Time: 0:18

    Video 3: Nerve suture between the intercostal nerves and the long-head branches of the triceps muscle of the radial nerve

    Running Time: 3:17

    Video 4: Patient follow-up

    Running Time: 0:52


    Accreditation Statement
    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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