Staged Phrenic Nerve Elongation and Free Functional Gracilis Muscle Transplantation-A Possible Option for Late Reconstruction in Chronic Brachial Plexus Injury

J Hand Surg Am. 2023 Oct;48(10):1058.e1-1058.e9. doi: 10.1016/j.jhsa.2022.03.006. Epub 2022 May 7.


Purpose: In patients with late brachial plexus birth injuries, sequelae after acute flaccid myelitis, or chronic adult brachial plexus injury, donor nerves for functioning muscle transplantation are often scarce. We present the results of a potential strategy using the phrenic nerve with staged free gracilis transplantation for upper extremity reanimation in these scenarios.

Methods: A retrospective review was performed on an institutional database of brachial plexus injury or patients with palsy. All patients underwent a staged reconstruction in which the ipsilateral phrenic nerve was extended by an autogenous nerve graft (PhNG), followed by free-functioning gracilis transplantation (PhNG-gracilis).

Results: Nine patients (6 cases of late brachial plexus birth injuries, 2 of acute flaccid myelitis, and 1 of adult chronic brachial plexus injury) were included in this study. The median follow-up period following the PhNG-gracilis procedure was 27 months (range, 12-72 months). The goals of the staged PhNG and PhNG-gracilis were primarily finger extension or finger flexion. In some patients, the technique was used to improve both elbow and finger function, tunneling the muscle through the flexor compartment of the upper arm and under the mobile wad at the elbow. All patients exhibited improvement of muscle strength, including in finger extension (4 patients) from M0 to M2; finger flexion (3 patients) from M0 to M3; elbow extension (1 patient) from M0 to M2; and elbow flexion (1 patient) from M2 to M4.

Conclusions: A 2-stage PhNG-gracilis may restore or enhance the residual elbow and/or finger paralysis in chronic brachial plexus injuries. A minimum follow-up period of 3 years is recommended. This technique may remain useful as one of the last reconstructive options to increase power in patients with scarce donor nerves.

Type of study/level of evidence: Therapeutic V.

Keywords: Brachial plexus injuries; gracilis; nerve graft; phrenic.

MeSH terms

  • Adult
  • Birth Injuries* / surgery
  • Brachial Plexus Neuropathies* / surgery
  • Brachial Plexus* / injuries
  • Elbow Joint* / surgery
  • Free Tissue Flaps* / innervation
  • Gracilis Muscle* / transplantation
  • Humans
  • Nerve Expansion*
  • Nerve Transfer* / methods
  • Phrenic Nerve / injuries
  • Phrenic Nerve / surgery
  • Range of Motion, Articular / physiology
  • Recovery of Function / physiology
  • Retrospective Studies
  • Treatment Outcome

Supplementary concepts

  • acute flaccid myelitis