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.
What to Watch For
Pitfalls & Challenges