Thoracodorsal Vessels as Recipient for Gracilis Free Functional Muscle Transfer after Neurologic Surgery of Brachial Plexus without Elbow Flexion Recover. Report of 2 Clinical Cases

Introduction: Since it first description by IKUTA 1979, gracilis free functional muscle transfer (FFMT) for biceps in brachial plexus injury (BPI) is as reliable alternative achieve elbow flexion. DOI 1994 described staged double transfer. First stage for elbow flexion and finger extension and second one for finger flexion. The Rambo procedure (derived from lambeau) is nowadays modified by DOI with acute neurologic reconstruction for shoulder and elbow extension. We have indicated FFMT on total BPI where deadline for neurologic reconstruction is over (9 months post trauma) and no orthopedics alternatives are possible for elbow flexion. Or when no recover for elbow flexion was achieved after neurologic surgery. We follow BISHOP's (Mayo Clinics) routine with thoracoacromial artery is our main recipient vessel. We fix gracilis on lateral part of clavicle. We have re-operated 2 cases with previous extensive approach for neurologic reconstruction. Thoraco acromial vessels dissection was unsuitable. We´ve transferred thoracodorsal vessels (latissimo dorsi muscle pedicle) to the axila as recipient vessels. Methodology and Material: Fist patient is a 24 year old man previously operated on another institution by upper trunk lesion under extensive Narakas approach coming with a surgical description of medial pectoral nerve intraplexual neurotization to musculocutaneous nerve without no flexion recover. We´ve indicated a FFMT. Thoaracoacromial artery was on fibrosis and friable. Region was considered unsuitable for vessel dissection. We´ve transferred thoracodorsal artery. Second patient is a 17 year boy that achieved previous bike vs. auto accident. He has sustained total BPI. He was first operated with phrenic neurotization to supraescapular nerve, C5 grafted to musculocutaneous and c6 grafted to axilar nerve. There were shoulder abduction recover but M0 biceps contraction. After 24 months we've gone straight to thoracodorsal artery with uneventful successful transfer. Results: First patient developed post-operative venous congestion at night. Surgical re-exploration showed venous thrombosis. Safena magna interposition graft to re-routed external jugular saved the flap. He has M3 elbow flexion recover. Second patient surgery was uneventful. He developed retraction scar on axilla early treated with hand therapy. He has M4 plus elbow flexion recover. Conclusions: In both cases presented transfer of thoracodorsal vessels for late FFMT were at first look reliable and successful. Of course we do not have strong evidence with only 2 clinical cases. Anyway we strongly advice do not look for thoracoacromial vessels if approach on its anatomical site was previously realized. It spares time and surgeons energy. Once latissimu dorsi muscle is denervated, muscle atrophy is unavoidable. In both cases, we have observed, vessels were also smaller and with small blood flow. So do not wait for so long for a FFMT after total BPI. Although surgeries were successful in achieving elbow flexion (including case 2 with post-operative re-exploration that saved the muscle but achieved only M3 BCR flexion force) DOI FFMT 1st stage procedure in acute neurologic surgical phase one shot appears to be a more reliable approach than working on late fibrosis. The authors are still not convinced about DOI 2nd stage procedure for total BPI hand real function.