- This database review explored the rate and indications of reoperation among 25 adults who underwent free functional gracilis transfer (FFGT) to restore upper extremity function after traumatic brachial plexus injury
- 14 patients (56%) required an unplanned reoperation
- Poor tendon excursion was the main reason for reoperation (eight of 14 reoperations, 57%)
- All muscle flaps survived
- Patients with traumatic brachial plexus injury should be counseled preoperatively about the high potential for reoperation after FFGT when the intention is to restore upper extremity function
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For patients with traumatic brachial plexus injuries (BPI), free functional muscle transfer using the gracilis muscle (FFGT) can restore upper extremity function. The technique is particularly useful for patients with delayed presentation, those ineligible for nerve grafts or transfers and those who underwent prior surgery with unsatisfactory outcomes.
Published information conflicts about the frequency of revision surgery after FFGT. In The Archives of Bone & Joint Surgery, Pichitchai Atthakomol, MD, of Chiang Mai University, and Sang-Gil Lee, MD, hand and upper extremity surgeon of the Department of Orthopaedic Surgery at Massachusetts General Hospital, and colleagues report a reoperation rate of 56%, with poor tendon excursion being the most common indication.
The team reviewed a research database of two tertiary-level hospitals in the Boston area. They identified 550 adults who underwent FFGT after traumatic BPI between 2002 to 2016, of whom 25 (average age 36) had the surgery for restoration of upper extremity function. All BPIs were closed traction injuries.
Reoperation was defined as an unplanned operation performed after a first- or second-stage FFGT, excluding arthrodesis and tenodesis involving the wrist. The average length of follow-up was 42 months.
Fourteen of 25 patients (56%) had at least one reoperation after the FFGT. There was no association between the occurrence of reoperation and any patient, injury or treatment characteristic.
Indications for Reoperation
All muscle flaps survived. The indications and timing for the 14 reoperations were:
- Wound complications—two of the 14 reoperations (14%): reoperation was performed two days after the index procedure
- Compromised perfusion—four (29%): reoperation was performed one day after
- Poor tendon excursion—eight (57%): reoperation was performed a median of 25 days after
Four patients (29%) had a second reoperation: for skin deformity (n=1), wound complications (n=1) or poor muscle function (n=2). Two patients required a third reoperation, for scar contracture release.
Implications for the Clinic
The high potential for reoperation should be discussed with patients prior to FFGT for the restoration of upper extremity function. Close monitoring is vital in order to rapidly identify any vascular compromise of the flap and intervene to decrease the risk of flap failure.
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