Combined Hand Conference

Zachary Okhah PGY-5

March 20, 2018
 HPI
40 year-old female with a history of a C5-C7 brachial plexus root avulsion injury
sustained after being ejected off a motorcycle in 10/2016 presented to the office with
continued complaints of poor LEFT elbow flexion and supination.

The patient had undergone a double fascicular nerve transfer (median motor FCR
fascicle to biceps and ulnar FCU fascicle to brachialis) on 4/21/2016, but her 6-month
and one year post-op EMGs failed to demonstrate improved biceps function.

She has mildly improved elbow flexion but has plateaued. She has lack of supination,
and flexion of the elbow is via accessory elbow flexors and brachialis, minimal biceps
function, minimal use against gravity.
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 Past History
PMHx: Vitiligo

PSHx: multiple lower extremity operations for open tib/fib fx

Meds: Lyrica

Family Hx: non-contributory

Social Hx: occasional marijuana use; legally separated

 Exam
The patient is alert and in no acute distress. Tearful at times.
Respirations are normal.
Heart is regular for rate and rhythm
Pulses are intact in both upper extremities.
There is no rash present

Latissimus=weak
Deltoid=2+
Brachialis 3+ with flexion, diminished with gravity
Biceps= ? Weak/minimal function, no supination from BB
Triceps=mod
FDP=present
FPL=present
Wrist extensors=present
Finger extensors=weak/present, weakest index finger extension but mild
EPL=present
Thenar function=present
Intrinsics=present
MRI 11/3/2015
Electromyogram 1/2016
Electromyogram 3/2016
Pre-op
OR 4/2016
Double Fascicular Transfer
 Double Fascicular Transfer
Mackinnon et al developed the technique after noting that a small number of patients
who were operated on by Oberlin (transfer of an expendable FCU fascicle from the
ulnar nerve directly to the biceps branch to reconstruct elbow flexion) secondarily
required a Steindler flexorplasty in order to achieve satisfactory elbow flexion

Basic premise recognizes brachialis as primary elbow flexor while biceps makes mild
contribution and is more important in forearm supination
 Double Fascicular Transfer
Clinical evidence of reinnervation was noted at a mean of 5.5 months (SD, 1 month;
range, 3.5–7 mo) after surgery and the mean follow-up period was 20.5 months (SD,
11.2 mo; range, 13– 43 mo).

Reported M4 (movement against resistance) elbow flexion for all 6 patients in three
year series

No weakness in hand function was reported by any of the patients. On long-term

follow-up review there was no significant difference noted between the pre- operative
pinch (14 lb; SD, 6 lb) and grip strengths (47 lb; SD, 31 lb) and the postoperative pinch
(17 lb; SD, 8 lb) and grip strengths (52 lb; SD, 29 lb).
Chuang et al
Electromyogram 10/2016
6 months post-op
Electromyogram 7/2017
One year post-op
 OR 9/25/2017
Dissection of the patient's right leg was carried
down through skin and subcutaneous tissue until
the gracilis muscle was identified

It was followed distally first down to its tendinous

insertion, it was then followed proximally and the
segmental perforators were ligated using surgical
clips

The obturator nerve branch and the pedicle were

identified

The muscle was divided proximally and distally

leaving our nerve and vascular pedicle as the
team readied the arm
 OR 9/25/2017
The old incision was extended from the shoulder down to the elbow, exposing the underlying biceps

The medial antebrachial, median, ulnar, musculocutaneous nerves were identified and dissected from a
proximal to distal direction and then from distal to proximal, closing in on the area of our previous set
nerve transfers and scar tissue.

Careful lysis was performed of all scar tissue including median nerve, ulnar nerve, medial antebrachial
cutaneous nerve extensively mobilizing these.

In addition, we found the radial nerve in the proximal lateral upper arm and mobilized it.

We performed an intrafascicular dissections of the ulnar nerve, median nerve and radial nerve for best
planning of our transfers.
 OR 9/25/2017
Ulnar nerve still supplied the underlying brachialis, the decision was made not to move forward
with any ulnar nerve transfers.

The median and radial nerve were closely examinedunable to isolate or identify a distinct
fascicle to the brachioradialis.

Further dissection was then performed on the patient's median nerve isolating the flexors to FCR
and palmaris. It was extremely weak co-contraction of the superficialis to the middle finger, but
otherwise we were able to perform a lysis and through stimulation deemed this as our best
transfer.

Once this was performed, our muscle was then raised in the leg. The pedicle was transected and
the flap was then transferred up to the arm.

Prior to division of the muscle flap when harvesting, the appropriate resting length of the muscle
had been determined in 3cm intervals and sutures placed at these intervals.
 OR 9/25/2017
Two Mitek anchors were drilled into
the humerus proximally. The muscle
was then tied down to this in line
between the muscle fascicles of the old
biceps to set the appropriate
direction.

Once this was performed, we

performed our anastomosis of the
artery end to side followed by an end-
to-side vein followed by our nerve
repair followed by an end-to-end vein,
giving us 2 veins, 1 artery and our
nerve repair.
 OR 9/25/2017
The elbow was slightly flexed and we
measured between our stitches that
were sewn into the muscle at 3cm
intervals to ensure that we had the
muscle on full stretch. A Pulvertaft
weave was performed using
interrupted Ethibond sutures.
Retrospective review from April 2001-2011

13 patients for whom FFMT was performed for elbow flexion

Average time from injury to first operation was 12.8 months (range 4–60),

Average time from injury to FFMT was 29 months (range 8–68)

Average follow‐up was 31.8 months (range 11–84).

Functional recovery of elbow flexion was measured using the MRC grading system which showed 1 M5/5, 5 M4,
4 M3, and 3 M2 outcomes.
 References
Giuffre, J.L., Kakar, S., Bishop, A.T., Spinner, R.J. and Shin, A.Y., 2010. Current concepts of the
treatment of adult brachial plexus injuries. Journal of Hand Surgery, 35(4), pp.678-688.

Mackinnon, S.E., Novak, C.B., Myckatyn, T.M. and Tung, T.H., 2005. Results of reinnervation
of the biceps and brachialis muscles with a double fascicular transfer for elbow
flexion. Journal of Hand Surgery, 30(5), pp.978-985.

Chuang, D.C.C., 2009. Adult brachial plexus reconstruction with the level of injury: review
and personal experience. Plastic and reconstructive surgery, 124(6S), pp.e359-e369.

Nicoson, M.C., Franco, M.J. and Tung, T.H., 2017. Donor nerve sources in free functional
gracilis muscle transfer for elbow flexion in adult brachial plexus injury. Microsurgery, 37(5),
pp.377-382.

Hu, C.H., Chang, T.N.J., Lu, J.C.Y., Laurence, V.G. and Chuang, D.C.C., 2018. Comparison of
Surgical Strategies between Proximal Nerve Graft and/or Nerve Transfer and Distal Nerve
Transfer Based on Functional Restoration of Elbow Flexion: A Retrospective Review of 147
Patients. Plastic and reconstructive surgery, 141(1), pp.68e-79e.