At Penn Medicine, a multidisciplinary team of surgeons from the Departments of Neurosurgery and Orthopaedic Surgery and the Division of Plastic Surgery are performing gracilis functional free muscle transfers (FFMT) to restore upper extremity movement to patients with brachial plexus injuries (such as avulsion, laceration or contusion).
Brachial plexus injuries are typically traumatic in origin and are marked by paralysis and other functional upper extremity deficits. If initiated within six to nine months of injury, nerve grafting and nerve transfers (also known as neurotization) can restore function to patients with brachial plexus injuries. For patients with brachial plexus denervation exceeding this timespan, gracilis FFMT has the potential to restore movement to the shoulder and elbow.
Located on the medial aspect of the thigh, the gracilis muscle has the advantages of a rich blood supply and reliable motor innervation. Gracilis FFMT surgery involves minimal donor site morbidity and little to no impairment of leg function. Once transferred to the upper arm, the gracilis has the capacity to mimic the function of the biceps and brachialis muscles. Neurotization and vascular anastomosis of the muscle at the recipient site are achieved through microsurgery. The reported success rate for gracilis FFMT in patients with brachial plexus avulsion is approximately 70%.
Case Study
RL, a 28-year-old man, was referred to the Department of Neurosurgery at Penn Medicine for restoration of movement in his paralyzed right arm. Two years prior, RL had a motorcycle accident resulting in spinal injury and complete right brachial plexus avulsion. Following the injury, he had rehabilitative therapy, including range of motion exercises, which maintained flexibility but did not restore function in the right arm.
Since direct nerve repair was no longer an option, a functioning gracilis muscle in his left leg and donor nerves that could serve to reinnervate the muscle transfer were selected. At Penn, gracilis FFMT surgery proceeds in phases and involves coordinated teams of surgeons from Neurosurgery, Orthopaedics and Plastic Surgery. At the start of surgery, neurosurgeons first explored the brachial plexus to identify viable donor nerve sites.
The spinal accessory nerve was selected as a functional donor nerve, maintaining several branches to the trapezius muscle to avoid loss of upper shoulder function. The orthopaedic and plastic surgery teams prepared the recipient site at the upper arm; the gracilis muscle, obturator nerve, blood vessels and a skin paddle were harvested from RL’s left leg. This tissue was then positioned within the recipient site and the gracilis secured via the clavicle and biceps tendons.
With the completion of microvascular repair to the arteries and veins, microdoppler probes were applied to ensure vessel patency and to measure blood flow. The neurosurgical team then returned to attach the obturator nerve of the gracilis muscle to the donor spinal accessory nerve. After five days in the hospital for observation, RL was discharged home and had an unremarkable recovery. He is currently participating in daily range of motion rehabilitative therapy.
Team of Faculty
Penn Medicine is involved in the management of the entire spectrum of surgically treated disorders and injuries of the nervous system. These conditions include brain tumors and aneurysms, spinal column lesions and peripheral nerve disorders, as well as traumatic injuries to the brain, spinal column and peripheral nervous system. Patients are often managed by a collaborative effort involving neurosurgeons, orthopaedic surgeons, plastic surgeons, otorhinolaryngology- head and neck surgeons and other specialists in a multi-disciplinary and multi-modality approach.
Performing Gracilis Free Functional Muscle Transfer Surgery at Penn Medicine Neurosurgery
Eric L. Zager, MD, FACS
Professor of Neurosurgery
Orthopaedic Surgery
L. Scott Levin, MD, FACS
Chair, Department of Orthopaedic Surgery
Paul B. Magnuson Professor of Bone and Joint Surgery;
Professor of Surgery, Division of Plastic Surgery
Plastic Surgery
Stephen J. Kovach III, MD
Assistant Professor of Surgery
Access
Hospital of the University of Pennsylvania
Department of Neurosurgery
3 Silverstein
3400 Spruce Street
Philadelphia, PA 19104
Division of Plastic Surgery
Perelman Center for Advanced Medicine
East Pavilion 1st Floor
3400 Civic Center Boulevard
Philadelphia, PA 19104
Department of Orthopaedics
Hospital of the University of Pennsylvania
2 Silverstein
3400 Spruce Street
Philadelphia, PA 19104
To refer a patient and/or consult with a physician: Call 800-789-PENN (7366) or visit: PennMedicine.org/referral
Nerve Repair Research at Penn
At Penn Medicine, nerve repair and regeneration research occurs within the Center for Brain Injury and Repair. One of five research divisions within the Department of Neurosurgery, the Center has been in existence for more than 30 years and is among the most respected centers for head injury in the United States. The Center is currently engaged in the following investigations:
- Engineering Nerve Constructs for Clinical Application – A distinct approach to engineering an effective man-made nerve construct for nerve repair, this construct consists of numerous bundles of axons, which are embedded in a collagen gel and packaged in a biocompatible conduit. Sized to the length of the damaged nerve, axon bundles can be directly transplanted to provide a living and functional connection.
- Peripheral Nerve Transplant – A new concept in which living dorsal root ganglion neurons and mechanically stretch-grown axons are transplanted into a 12mm sciatic nerve gap in the rat for repair of significant lesions within the peripheral nervous system.
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