Restoration of Prehension with the

Double Free Muscle Technique Following

Complete Avulsion of the Brachial Plexus
INDICATIONS AND LONG-TERM RESULTS*
BY KAZUTERU DOI, M.D.†, KEIICHI MURAMATSU, M.D.†, YASUNORI HATTORI, M.D.†,
KEN OTSUKA, M.D.†, SOO-HEONG TAN, M.D.‡, VIPUL NANDA, M.D.†,
AND MASAO WATANABE, O.T.R.†

Investigation performed at the Departments of Orthopedic Surgery, Ogori Daiichi General Hospital, Ogori,
and Yamaguchi University School of Medicine, Ube, Yamaguchi-ken, Japan

Abstract prehension (more than 30 degrees of total active mo-

Background: Recent interest in reconstruction of
the upper limb following brachial plexus injuries has fo-
cused on the restoration of prehension following com-
plete avulsion of the brachial plexus.
Methods: Double free muscle transfer was per-
formed in patients who had complete avulsion of the
brachial plexus. After initial exploration of the brachial
plexus and (if possible) repair of the fifth cervical nerve
root, the first free muscle, used to restore elbow flexion
and finger extension, is transferred and reinnervated by
the spinal accessory nerve. The second free muscle,
transferred to restore finger flexion, is reinnervated by
the fifth and sixth intercostal nerves. The motor branch
of the triceps brachii is reinnervated by the third and
fourth intercostal nerves to restore elbow extension.
Hand sensibility is restored by suturing of the sensory
rami of the intercostal nerves to the median nerve or
the ulnar nerve component of the medial cord. Second-
ary reconstructive procedures, such as arthrodesis of
the carpometacarpal joint of the thumb, shoulder ar-
throdesis, and tenolysis of the transferred muscle and
the distal tendons, may be required to improve the
functional outcome.
Results: The early results were evaluated in thirty-
two patients who had had reconstruction with use of the
double free muscle procedure. Twenty-six of these pa-
tients were followed for at least twenty-four months
(mean duration, thirty-nine months) after the second
free muscle transfer, and they were assessed with regard
to the long-term outcome as well. Satisfactory (excel-
lent or good) elbow flexion was restored in twenty-five
(96 percent) of the twenty-six patients and satisfactory
*No benefits in any form have been received or will be received
from a commercial party related directly or indirectly to the subject
of this article. No funds were received in support of this study.
†Department of Orthopedic Surgery, Ogori Daiichi General Hos-
pital, Shimogo 862-3, Ogori, Yamaguchi-ken 754-0002, Japan. E-mail
address for Kazuteru Doi: doimac@ca.mbn.or.jp.
‡Department of Orthopedic Surgery, Yamaguchi University School
of Medicine, Ube, Yamaguchi-ken, 755-8505, Japan.
Copyright 2000 by The Journal of Bone and Joint Surgery, Incorporated
tion of the fingers), in seventeen (65 percent). Fourteen
patients (54 percent) could position the hand in space,
negating simultaneous flexion of the elbow, while mov-
ing the fingers at least 30 degrees and could use the re-
constructed hand for activities requiring the use of two
hands, such as holding a bottle while opening a cap and
lifting a heavy object. The results were analyzed to
identify factors affecting the outcome.
Conclusions: The double free muscle procedure can
provide reliable and useful prehensile function for pa-
tients with complete avulsion of the brachial plexus.
The restoration of prehension following complete
avulsion of the brachial plexus has been the focus of
recent interest in reconstruction of the upper limb fol-
lowing brachial plexus injuries. Transfer of the inter-
costal nerves to the median nerve to restore finger
function15,20 has failed because the distance between the
site of nerve anastomosis and the neuromuscular junc-
tion of the forearm muscles is too great; it took more
than one and a half to two years after the nerve transfer
for the regenerating axons to reach the muscle, resulting
in muscular atrophy. Furthermore, misdirection of the
regenerating axons frequently occurred. Hence, simple
nerve transfer should not be attempted to restore finger
function following brachial plexus injury, but it can be
used to achieve shoulder stability and active elbow
flexion17.
Free muscle transfer can provide reliable and pow-
erful motor recovery for finger function, as the neuro-
motor units of the free muscle are in the upper arm and
the nerve to the muscle is purely motor5. Following bra-
chial plexus injury, free muscle transfer combined with
multiple transfers of the spinal accessory nerve and the
intercostal nerves can be used to restore prehensile
function.
Akasaka et al.1 and Berger et al.2 restored wrist ex-
tension with use of free muscle transfers reinnervated
with intercostal nerves and restored pinch with use of
tenodesis of the finger flexors15,19. However, the weak
key pinch that was achieved was not useful, and the syn-

652 THE JOURNAL OF BONE AND JOINT SURGERY

 RESTORATION OF PREHENSION WITH THE DOUBLE FREE MUSCLE TECHNIQUE 653

TABLE I
DEMOGRAPHIC AND OPERATIVE DATA*

C5 Nerve-Root Lesion Reconstruction

Time from
Injury to Myelographic Spinal Donor Muscle‡ Nerve-Crossing
Gender, Previous 1st Muscle Classification18 Evoked Nerve 1st Muscle 2nd Muscle To Triceps Sensory
Case Age Operation Transfer (Level of Injury) Potentials10† Repair Transfer Transfer Brachii Restoration
(yrs.) (mos.)
1 M, 24 No 3 A2 (pregang.) – No Gracilis Gracilis ICN (3,4) SCN-MN
2 M, 17 No 5 A2 (pregang.) – No Gracilis Gracilis ICN (3,4) SCN-MN
3 F, 32 No 5 A1 (pregang.) Not tested No Gracilis Gracilis ICN (3,4) SCN-MN
4 M, 16 No 10 A1 (pregang.) – No Gracilis Latissimus ICN (3,4) SCN-MN
dorsi
5 M, 17 No 7 A1 (pregang.) ± No Gracilis Latissimus No No
dorsi
6 M, 20 No 2 A1 (pregang.) ± No Latissimus Gracilis ICN (3,4) ICN (3,4)-MN
dorsi
7 F, 20 No 2 A1 (postgang.) + Nerve graft, Gracilis Latissimus ICN (3,4) SCN-MN
C5-MCN dorsi
8 M, 32 ICN (3,4)- 113 Not tested Not tested No Latissimus Gracilis No No
MCN (unknown) dorsi
9 M, 45 ICN (3,4)- 5 A1 (pregang.) ± Nerve graft, Latissimus Gracilis ICN (3,4) No
MCN C5-SSN dorsi
10 M, 24 Fx, 3 A1 (postgang.) + Nerve graft, Gracilis Gracilis ICN (3,4) ICN (3,4)-MN
forearm C5-SSN
11 M, 22 No 3 A1 (postgang.) + Nerve graft, Gracilis Gracilis ICN (3,4) ICN (3,4)-MN
C5-SSN
12 M, 21 Fx., 3 A1 (postgang.) + Nerve graft, Gracilis Latissimus ICN (3,4) ICN (3,4)-MN
femur C5-MCN dorsi
13 M, 21 No 2 A1 (postgang.) ± Nerve graft, Gracilis Gracilis ICN (3,4) ICN (2)-MN
C5-AX
14 M, 23 No 3 A1 (pregang.) – No Gracilis Gracilis ICN (3,4) ICN (3,4)-UN
15 M, 19 No 7 A2 (pregang.) – No Gracilis Gracilis ICN (3,4) ICN (3,4)-UN
16 M, 30 No 5 A2 (pregang.) – No Gracilis Gracilis ICN (3,4) ICN (3,4)-UN
17 M, 17 No 4 A1 (pregang.) ± No Gracilis Rectus ICN (3,4) No
femoris
18 M, 22 No 2 A1 (postgang.) + Nerve graft, Gracilis Gracilis ICN (3,4) ICN (2,3,4)-MN
C5-SSN
19 M, 20 Fx, 3 A1 (postgang.) + Nerve graft, Gracilis Gracilis ICN (3,4) ICN (2,3,4)-MN
humerus C5-SSN
20 M, 15 No 7 A2 (pregang.) – No Gracilis Gracilis ICN (3,4) ICN (2)-UN
21 M, 20 No 2 A1 (pregang.) ± Nerve graft, Gracilis Gracilis ICN (3,4) ICN (2)-UN
C5-SSN
22 M, 23 ICN (3,4)- 31 Not tested Not tested No Gracilis Gracilis No No
MCN
23 M, 22 No 8 D (pregang.) – No Gracilis Gracilis ICN (3,4) ICN (2)-UN
24 M, 19 Subclavian 10 A1 (pregang.) – No Gracilis Gracilis ICN (3,4) ICN (3,4)-UN
artery
rupture,
disloc.
25 M, 21 No 4 M (pregang.) – No Gracilis Gracilis ICN (3,4) ICN (3,4)-UN
26 M, 15 No 5 A1 (postgang.) + Nerve graft, Gracilis Gracilis No ICN (3,4)-UN
C5-post.
cord
Mean ± 22 ± 6.4 9.8 ± 22
s.d.
27 M, 24 No 2 A1 (postgang.) + Nerve graft, Gracilis Gracilis ICN (3,4) SCN-MN,
C5-SSN ICN (4)-UN
28 M, 20 No 4 A2 (pregang.) – Nerve graft, Gracilis Gracilis ICN (3,4) ICN (2)-MN
C5-AX
29 M, 21 Subclavian 5 A1 (pregang.) – No Gracilis Gracilis ICN (3,4) ICN (2)-UN
artery
rupture
30 M, 22 No 6 A2 (unknown) Not tested No Gracilis Latissimus ICN (3,4) ICN-MN
dorsi
31 M, 25 No 5 A1 (unknown) Not tested No Latissimus Gracilis ICN (3,4) No
dorsi
32 M, 24 No 5 A1 (unknown) Not tested No Rectus Gracilis ICN (3,4) ICN (3,4)-MN
femoris
Mean ± 22 ± 5.8 8.8 ± 20
s.d.

*ICN = intercostal nerve, SCN = supraclavicular nerve, MN = median nerve, MCN = musculocutaneous nerve, SSN = suprascapular nerve, fx = fracture, AX = axillary
nerve, and UN = ulnar nerve.
†– sign = no wave, ± sign = lower amplitude but recordable, and + sign = same wave as from normal fourth cervical nerve root.
‡The spinal accessory nerve was used as the donor motor nerve for all of the first free muscle transfer procedures and the fifth and sixth intercostal nerves, for all of
the VOL.
second 82-A, NO. transfer
free muscle 5, MAY 2000
procedures.
654 KAZUTERU DOI ET AL.

FIG. 1
Treatment algorithm. BP = brachial plexus, SSN = suprascapular nerve, MCN = musculocutaneous nerve, SAN = spinal accessory nerve,
MN = median nerve, SCN = supraclavicular nerve, ICN = intercostal nerve, UN = ulnar nerve, CMJ = carpometacarpal joint, and GH = gle-
nohumeral joint.

ergistic action16 was troublesome and inconvenient for
patients with a brachial plexus injury who had a normal
contralateral upper limb. Furthermore, those authors
did not restore elbow extension and their patients had
to use the contralateral hand for positioning the hand in
space while moving the fingers.
One of us (K. D.) and colleagues6,7,9 reported the in-
terim results of double free muscle and multiple nerve
transfers (the so-called double free muscle technique)
to restore prehension. Although the powerful grip that
was achieved was associated with clawing of the fingers,
grip, together with good prehension, are the most es-
sential and useful functions for such patients. In the
current report, we describe the long-term results of the
double free muscle technique that was originally de-
scribed by one of us (K. D.) and colleagues and was
subsequently modified6,7,9.
Materials and Methods
Patients
The results in a consecutive series of patients who
had undergone the double free muscle transfer proce-
dure for the restoration of prehension following com-
plete avulsion of the brachial plexus between August 1,
1990, and October 31, 1996, were reviewed retrospec-
tively. The patients had given informed consent after
discussions concerning the procedure, the rehabilitation
program, and the prognosis before the initial operation.
There were thirty-two patients, thirty of whom were
male and two of whom were female (Table I). At the
time of the operation, the patients’ ages ranged from
fifteen to forty-five years (mean, twenty-two years).
Three patients had had an unsuccessful intercostal-to-
musculocutaneous nerve transfer done by other sur-
geons. Two patients had had an injury of the subclavian
artery, which had been repaired but the artery had be-
come thrombosed. One patient had had an associated
spinal cord and spinal accessory nerve injury on the ip-
silateral side but had recovered by the time of the oper-
ation. The interval between the injury and the first free
muscle transfer ranged from two to 113 months (mean,
8.8 months).
Myelography was performed preoperatively with use
of metrizamide (Amipaque). During the operation, the
brachial plexus was exposed and the involved root was
identified and electrically stimulated. The spinal evoked
potentials were recorded from an epidural electrode,
which was placed preoperatively, to assess the quality of
the continuity of the root with the spinal cord.
Myelography and intraoperative monitoring of spi-
nal evoked potentials established that nine patients had
a postganglionic rupture of the fifth cervical nerve root
and a preganglionic avulsion of the sixth cervical to the
first thoracic nerve root. The remaining seventeen pa-
tients were classified as having a complete preganglionic
avulsion of the fifth cervical to the first thoracic nerve
root, although five showed low but positive spinal
evoked potential waves.
Operative Procedures
The double free muscle technique described previ-
ously by one of us (K. D.) and colleagues6,7,9 consisted of
five established but modified reconstructive procedures
(Fig. 1): (1) surgical exploration of the brachial plexus,

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 RESTORATION OF PREHENSION WITH THE DOUBLE FREE MUSCLE TECHNIQUE
FIG. 2
Illustration showing the first free muscle transfer, performed to re-
store finger extension and elbow flexion simultaneously. The trans-
ferred muscle is placed on the anterior surface of the upper arm. The
nutrient vessels are anastomosed to the thoracoacromial artery and
the cephalic vein, and the motor nerve is anastomosed to the spinal
accessory nerve. The muscle is anchored to the acromion and the lat-
eral aspect of the clavicle proximally, passed underneath the pulley of
the brachioradialis and the wrist extensors, and sutured distally to the
extensor digitorum communis tendon in the forearm. a = spinal acces-
sory nerve, b = motor branch of muscle transplant, c = thoracoacro-
mial artery and branches of cephalic vein, d = nutrient artery and
veins of muscle transplant, e = muscle transplant, f = brachioradialis
and wrist extensors serving as pulley, and g = extensor digitorum
communis tendon.
intraoperative monitoring of the spinal evoked poten-
tials, and repair of the disrupted motor nerves when
possible; (2) the first free muscle transfer, neurotized by
the spinal accessory nerve, to restore elbow flexion and
finger extension (Fig. 2); (3) the second free muscle
transfer, neurotized by the fifth and sixth intercostal
nerves, to restore finger flexion (Fig. 3); (4) transfer of
the third and fourth intercostal nerves to the motor
branch of the triceps brachii muscle (done concomi-
tantly with the second muscle transfer), to restore elbow
extension (Fig. 4); and (5) transfer of the supraclavicular
nerves or the intercostal sensory rami to the median
nerve or the ulnar nerve component of the medial cord
of the brachial plexus (done concomitantly with the
second muscle transfer), to restore hand sensibility. All
thirty-two patients had the first three procedures,
twenty-eight patients also had the fourth procedure, and
twenty-six patients also had the fifth procedure.
Eight patients with a normal amplitude of the fifth
cervical nerve root identified on spinal evoked potential
monitoring at the first operation, three with a low ampli-
VOL. 82-A, NO. 5, MAY 2000
655
tude, and one patient who had no amplitude underwent
repair of the fifth cervical nerve root to the suprascap-
ular nerve, the axillary nerve, the musculocutaneous
nerve, or the posterior cord individually with use of a
sural nerve graft. In two patients, the thrombosed sub-
clavian artery that was diagnosed on the preoperative
angiogram was repaired with a saphenous vein graft at
the first operation.
For the first free muscle transfer, the gracilis muscle
was used in twenty-seven patients; the contralateral
latissimus dorsi muscle, in four; and the ipsilateral rectus
femoris muscle, in one patient. In six patients, the su-
praclavicular nerves were anastomosed to the median
nerve component of the lateral cord during the same
surgery.
The second free muscle transfer was performed two
to six months following the first procedure. The gracilis
muscle was used in twenty-six patients and the ipsilat-
eral latissimus dorsi, in five. One patient had a transfer
of the ipsilateral rectus femoris muscle. In twenty-eight
patients, the third and fourth intercostal nerves were
anastomosed to the motor branch of the triceps brachii
muscle in the axillary region. In twenty patients, the sen-
sory rami of the intercostal nerves were anastomosed to
the median nerve or the ulnar nerve component of the
medial cord.
Postoperative Management
The upper limb was immobilized without tension on
the transferred muscles, the motor nerves, or the nutri-
ent vessels for four weeks after each free muscle trans-
fer. Gentle passive exercises for the elbow and the
FIG. 3
Illustration showing the second free muscle transfer, performed to
restore finger flexion. The transferred muscle is placed on the medial
surface of the upper arm. The nutrient vessels are anastomosed to the
thoracodorsal artery and vein, and the motor nerve is anastomosed to
the fifth and sixth intercostal nerves. The muscle is anchored to the
second and third ribs proximally and to the flexor digitorum profun-
dus tendons distally, passing beneath the pulley of the pronator teres
and the wrist flexors. a = muscle transplant, b = flexor tendons of long
finger, c = pronator teres and wrist flexors serving as pulley, d = tho-
racodorsal artery and vein, e = nutrient artery and veins of muscle
transplant, f = second and third ribs, g = fifth and sixth intercostal
nerves, and h = motor branch of muscle transplant.
 656 KAZUTERU DOI ET AL.

TABLE
RESULTS OF THEFREE

Long-Term
Early Results Elbow Function
Secondary Reconstruction Isokinetic
Time to EMG
Reinnerv. Arthrod., Other Durat Flexion Measurements Extension
(1st Transfer/ Gleno- Arthrod., Secondary of (Degrees/ (Concen./Eccen.) (Degrees/
Vasc. 2nd Transfer/ humeral Thumb Proce- Follow- MMT6 (Nm) MMT6
Case Comp.† Triceps Brachii) Joint Tenolysis CMJ dures up† Grade) Involved Normal Outcome Grade)
(mos.) (mos.)
1 No/no 4/6.5/8 Yes No Yes No 58/54 100/5 9/13 48/63 Exc. –30/3
2 No/no 4/5/no Yes No No No 27/25 100/5 — — Exc. –40/0
3 No/no 3/3/4 No No Yes No 65/60 110/5 — — Exc. –15/3

4 No/no 4/6/10 No No No No 32/34 120/4 — — Good –20/1

5 No/no 3/4/no No No No No 50/46 145/5 — — Exc. –50/0
6 No/no 8/4/18 No EDC No Neuroly- 84/81 100/4 — — Good –20/4
sis, ACC
7 No/no 4/3/12 No EDC, Yes Arthrod., 80/77 130/5 5/8 40/49 Exc. –30/2
FDP PIP,
DIP
8 No/no 3.5/2.5/no No EDC, Yes No 60/59 120/5 — — Exc. –15/0
FDP
9 No/no 4.5/10/12 Yes EDC No No 32/28 50/2 — — Fair 0/2
(fx)
10 No/no 4/4.5/8 Yes FDP Yes IS transfer 40/38 120/5 6/14 53/76 Exc. –25/3

11 No/no 4/4/no Yes No Yes IS transfer 46/40 120/5 — — Exc. –25/3

12 Thromb./ 8/5/no No EDC No No 59/55 140/5 12/16 60/68 Exc. –40/0
no‡
13 No/no 4/5/no No No No Arthrod., 33/30 120/4 10/18 59/64 Good –50/2
PIP,
DIP
14 No/no 4/4/12 No EDC No No 36/30 120/5 — — Exc. –60/1

15 No/no 4/5/13 Yes EDC No No 45/43 125/5 5/8 40/49 Exc. –35/2
(splint)
16 No/no 3/4/6 No No No No 30/27 100/4 6/9 33/40 Good –45/2

17 No/no 3/4/4 No FDP No No 28/24 115/5 7/9 38/42 Exc. –65/1

18 No/no 2.5/3.5/9 No No No No 54/52 120/5 — — Exc. –45/3
(splint)
19 No/no 3/5/5 No EDC No No 35/32 110/4 — — Good –45/2
20 No/no 3/3/6 No FDP No No 28/25 90/4 — — Good –40/2
(splint)

21 No/no 3.5/4/5 No No No No 27/24 110/4 — — Good –40/1

22 No/no 5/4/did not test No No No No 27/24 100/3 2/6 40/53 Good –45/0
23 No/no 5/7/7 No No No No 26/24 120/5 8/12 40/53 Exc. –50/2
(splint)

24 No/no Did not test/4/4 No No No No 27/24 100/3 — — Good –30/2

(splint)

25 No/no 5/5/7 No EDC, Yes Arthrod., 26/24 110/4 — — Good —/3

FDP PIP,
DIP
26 No/no 3/4/6 No No Yes No 28/26 110/4 — — Good –30/2

Mean ± 4.0 ± 1.4/ 42/39 112 ± 18/ 7 ± 0/ 45 ± 3/ 36 ± 14/

s.d. 4.6 ± 1.5/8.2 ± 3.8 4.4 ± 0.8 11 ± 1.2 56 ± 3.7 1.8 ± 1.1
P value 0.09

*EMG = electromyographic, CMJ = carpometacarpal joint, MMT = manual muscle-testing, fx = fracture, TAM = total active motion, EDC = extensor digitorum com-
munis, ACC = spinal accessory nerve, FDP = flexor digitorum profundus, PIP = proximal interphalangeal joint, DIP = distal interphalangeal joint, IS = infraspinatus, BB =
biceps brachii, and D = deltoid.
†Values are given for the first transfer/second transfer.
‡Revision of the anastomosed vessel was successful, but the muscle became necrotic and a second free muscle transfer was performed.
§Patients who had an unstable glenohumeral joint were excluded from this calculation.

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 RESTORATION OF PREHENSION WITH THE DOUBLE FREE MUSCLE TECHNIQUE 657

II
MUSCLE TRANSFER PROCEDURES*

Results
Shoulder Function

Finger Function Ext. Muscle Sensory Recovery

Flexion Rotation Reinner-
Abil. to (Degrees/ (Degrees/ vated from Location Modified Interval
Flex. Position MMT14 MMT14 Repaired C5 (Radiating Highet to
TAM Power6 Outcome Hand Grade) Grade) Nerve Root Stability Site) Scale14 Recovery Pain
(degrees) (stage) (mos.) (grade)
90 5 Exc. Yes 30/2 0/2 — Yes Palm (in situ) S1 24 Mod.
30 3 Good No 10/2 –50/2 — Yes Palm (in situ) S1 22 Mild
110 5 Exc. Yes 30/2 0/2 — Yes Fingertip S2+ 14 No
(shoulder)
45 3 Good No 0/0 –20/0 — No Palm (in situ) S1 23 Mild
0 0 Poor No 10/2 –10/2 — Yes No S0 — No
20 2 Fair Yes 30/3 –50/2 — Yes Fingertip S2+ 16 Mild
(chest)
40 3 Good Yes 10/2 –10/2 BB Yes Palm (rad. S2+ 18 No
aspect of
forearm)
20 2 Fair No 0/0 –30/0 — No No S0 — Mild

0 1 Poor No 10/2 –50/2 IS Yes No S0 — Mod.

60 4 Exc. Yes 30/2 0/1 IS Yes Little finger S2+ 22 Mild

(chest)
35 3 Good Yes 20/2 –30/2 IS Yes Palm (chest) S2 25 Mild
0 3 Poor No 50/2 –30/2 BB Yes Fingertip S2+ 32 Mild
(in situ)
30 2 Good Yes 20/2 –30/2 D Yes Palm (chest) S1 24 No

20 3 Fair No 30/2 0/2 — Yes Fingertip S2+ 16 Mild

(chest)
40 4 Good Yes 20/2 –20/2 — Yes Palm (in situ) S2 18 Mild

30 3 Good Yes 20/0 –40/0 — No Forearm S0 — Mild

(chest)
0 0 Poor No 10/2 –50/2 — Yes No S0 — Mild
80 4 Exc. Yes 20/2 –50/2 IS Yes Fingertip S2+ 24 Mild
(in situ)
50 3 Good Yes 20/2 –30/2 IS Yes Palm (chest) S2 26 No
30 2 Good Yes 30/1 –10/1 — No Ulnar aspect S2 24 No
of palm
(upper arm)
30 3 Good No 20/2 –50/2 IS Yes Palm (med. S2 22 No
aspect of
upper arm)
0 0 Poor No 0/0 –50/0 — No No S0 — No
40 3 Good Yes 30/2 –60/2 — Yes Ulnar aspect S2 18 Mild
of palm
(med. aspect
of upper arm)
20 3 Fair Yes 0/2 –20/0 — Yes Little finger S2 22 Mild
(med. aspect
of upper arm)
50 3 Good Yes 20/2 –20/0 — No Little finger S2 22 No
(med. aspect
of upper arm)
40 3 Good Yes 30/2 –20/2 IS Yes Forearm (med. S2 26 No
aspect of
upper arm)
40 ± 28 25 ± 2.3§/ –24 ± 5.1/ 22 ± 4.2
1.7 ± 0.8 1.5 ± 0.9

metacarpophalangeal joints were then started. During proximal and distal interphalangeal joints in extension
the early postoperative period, a plastic static splint was to allow these joints to stiffen in these positions.
used to maintain the wrist in a neutral position and the Following electromyographic documentation of rein-

VOL. 82-A, NO. 5, MAY 2000

658 KAZUTERU DOI ET AL.

nervation of the transferred muscle, usually performed

between three and eight months postoperatively, elec-
tromyographic biofeedback techniques were started to
train the transferred muscles to move the elbow and
fingers. After recovery of active elbow and finger move-
ments, electromyographic biofeedback to train for inde-
pendent finger flexion and extension was commenced.
The patients were then started on skilled activities, such
as lifting, holding, carrying, and pinching.
Six patients did not undergo postoperative rehabili-
tation. The remaining twenty-six patients had rehabili-
tation at our hospital or at other rehabilitation centers
at least twice a week for a mean of twenty months post-
operatively, and all twenty-six completed the rehabili-
tation program. Patients who were covered by work-
place insurance continued the rehabilitation program
for a longer period than did those who were not covered
(mean, thirty-two compared with fourteen months).

Secondary Reconstruction
Tenolysis was done on the first free muscle (finger ex-
tensor) in nine patients and on the second free muscle
(finger flexor) in six (Table II). Arthrodesis of the gleno-
humeral joint was done with use of four large cancellous
screws and iliac-crest bone graft in nine patients, and ar-
throdesis of the carpometacarpal joint of the thumb was
performed in eight. Three patients had arthrodesis of the
proximal and distal interphalangeal joints with percuta-
neous Kirschner wires. The reinnervated infraspinatus
muscle was transferred to the triceps brachii in two pa-
tients when the latter muscle failed to recover sufficiently.
One patient had neurolysis of the spinal accessory nerve
because reinnervation was delayed.
Assessment of Results
Early results: All thirty-two patients were evaluated
for survival of the transferred muscles and electromy-
ographic evidence of reinnervation of the transferred
muscles and the triceps brachii (Table II).
Long-term results: Twenty-six of the thirty-two pa-
tients had long-term evaluation at least twenty-four
months after the second free muscle transfer (Tables II
and III). The parameters that were evaluated included
the strength of the transferred muscles and the triceps
brachii, the range of active motion of the elbow and
finger joints, sensory recovery, the ability to perform ac-
tivities of daily living, and restoration of prehension.
Functional Outcome
Motor evaluation: The modified grading system of
Highet4,14 and that of one of us (K. D.) and colleagues6
were used to evaluate the results of elbow flexion (Table
IV). Elbow-flexion power of more than grade 5 (accord-
ing to the modified Highet scale) was classified as ex-
cellent; grade 3 or 4, as good; grade 1 or 2, as fair; and
grade 0, as poor. The final outcome of finger motion was
graded according to the total active motion of the fin-
FIG. 4
Illustration showing transfer of the third and fourth intercostal
nerves to the motor branch of the triceps brachii muscle, performed
to restore elbow extension and stability. This procedure is done at the
time of the second free muscle transfer. a = third and fourth intercos-
tal nerves, b = motor branch of triceps brachii, and c = triceps brachii.
gers, with 60 degrees or more classified as excellent; 30
to 55 degrees, as good; 5 to 25 degrees, as fair; and 0 de-
grees, as poor. The final outcome of prehension follow-
ing double free muscle transfer depends not only on
finger motion but also on more proximal function, such
as elbow flexion and dynamic elbow stability, which
were assessed according to the patient’s ability to posi-
tion the hand in space while moving the fingers.
Sensory evaluation: Tinel’s sign was checked period-
ically in all patients, and sensibility in the corresponding
distribution of the repaired nerve in the hand was eval-
uated. Sensation of vibration was tested with a tuning
fork; pain, with pin-prick; sensation of moving touch,
with cotton wool; and cutaneous pressure thresholds,
with Semmes-Weinstein monofilaments. All tests were
performed by an experienced hand therapist, and the
results of sensory recovery were classified according to
the modified Highet scale (Table IV)4,14.
Pain (causalgia): Ten-point visual analog scales were
used to define the severity of pain, with 5 points or less
indicating mild pain and more than 5 points, severe
pain.
Functional ability: Functional ability was assessed
with use of patient-based outcome measures, including
the weight of a book that could be held between the arm
and the trunk, the weight of a bag that could be lifted
with the forearm, the weight of a bottle that could be

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 RESTORATION OF PREHENSION WITH THE DOUBLE FREE MUSCLE TECHNIQUE 659

TABLE III
LONG-TERM RESULTS: ACTIVITIES OF DAILY LIVING AND WORK*
Lifting Object with Lifting Object with Durat. Until
Lifting Pulp Pinch Hook Grip Both Hands Vocation Return to
Object with (Light [50-g] Holding Can Height Can Height Before/After Work or
Case Forearm (kg) Object) 300-g Bottle Lift (kg) Lifted† Lift (kg) Lifted† Reconstruct. School
(level) (level) (mos.)
1 Yes (6) Yes Yes Yes (5) 2 Yes (13) 2 Auto. builder/ 36
farmer.
2 Yes (5) No No No — No — Auto. builder/ 14
salesperson
3 Yes (5) Yes Yes Yes (3) 2 Yes (5) 2 Homemaker/ 6
homemaker
4 Yes (3) No No Yes (0.5) 1 Yes (2) 1 Student/ 12
salesperson
5 Yes (5) No No No — No — Construct./ 10
carpenter
6 Yes (5) No No Yes (2) 2 Yes (5) 2 Construct./ 50
construct.
7 Yes (5) No No Yes (0.5) 1 Yes (3) 1 Public officer/ 30
manager
8 Yes (5) No No Yes (0.5) 1 Yes (2) 1 Police officer/ 14
manager
9 No No No No — No — Masseur/ 24
masseur
10 Yes (6) Yes Yes Yes (1) 2 Yes (3) 2 Auto. builder/ 41
clerk
11 Yes (6) Yes Yes Yes (0.5) 1 Yes (2) 1 Student/student 35
12 Yes (6) No No No — No — Student/student 47
13 Yes (8) Yes Yes Yes (0.5) 1 Yes (2) 1 Student/officer 10
14 Yes (5) No No No — No — Designer/ 15
computer
programmer
15 Yes (5) Yes Yes Yes (1) 1 Yes (2.5) 1 Student/clerk 27
16 Yes (5) Yes Yes Yes (0.5) 1 Yes (2) 1 Designer/clerk 14
17 Yes (6) No No No — No — Student/ —
unemployed
18 Yes (6) Yes Yes Yes (1) 2 Yes (5) 2 Student/ 23
salesperson
19 Yes (5) No No Yes (1) 2 Yes (5) 2 Auto. builder/ 38
contruct.
20 Yes (1.5) Yes No Yes (0.5) 1 Yes (3) 1 Student/student 10
21 Yes (4) No No Yes (0.5) 1 Yes (3) 1 Student/computer 12
programmer
22 Yes (2) No No No — No — Student/student 24
23 Yes (5) Yes Yes Yes (1.5) 1 Yes (3) 1 Guard/guard 21
24 Yes (3) Yes Yes Yes (0.5) 1 Yes (2) 1 Student/student 12
25 Yes (3) Yes Yes Yes (0.5) 1 Yes (3) 1 Auto. builder/ —
unemployed
26 Yes (3) No No Yes (2) 2 Yes (5) 2 Student/student 12
Mean ± 4.8 ± 2.7 22 ± 2.6
s.d.
*All patients were able to lift a book weighing from one to three kilograms.
†Level 1 = to middle of thigh, and level 2 = to pubic symphysis.

held, the weight of a box that could be lifted, and the
height to which the box could be lifted with use of a
hook grip and with both hands.
Statistical analysis: The paired t test for paired con-
tinuous variables was used. Spearman rank correlations
were calculated for the comparison of two-scaled vari-
ables. The level of significance was set at p < 0.05.
Results
Early Results
Three free muscles had a thrombosis postoperatively
(Table II). Two of them were revised successfully after

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660 KAZUTERU DOI ET AL.

FIG. 5-A FIG. 5-B

Figs. 5-A through 5-F: Photographs of Case 10, a twenty-four-year-old man who sustained a complete avulsion of the left brachial plexus and
underwent the double free muscle procedure.
Figs. 5-A and 5-B: Finger flexion (Fig. 5-A) and extension (Fig. 5-B) with the elbow in extension. The patient had 60 degrees of total active
motion of the fingers.

exploration. Ischemic necrosis developed in the third

muscle, and another free muscle transfer was needed.
All transferred muscles were successfully reinner-
vated, as detected electromyographically between three
and ten months following the surgery, depending on
the donor motor nerve that had been used. Muscles
that were reinnervated by the spinal accessory nerve
recovered significantly earlier (mean, 3.9 months) than
did those that were reinnervated by the intercostal
nerves (mean, 4.8 months) (p < 0.05). Voluntary con-
traction occurred approximately two months later on
the average. The triceps brachii muscles recovered
even later (mean, 8.2 months) than did the transferred
muscles that were reinnervated by the intercostal FIG. 5-C
nerves (p < 0.001).

Long-Term Results
Twenty-six patients were followed for at least twenty-
four months (maximum, eighty-one months; mean, thirty-
nine months) after the second transfer. The mean age at
the time of the operation was twenty-two years (range,
fifteen to forty-five years) (Table I). The mean interval
from the time of the injury to the first operation was 9.8
months (range, two to 113 months).

Elbow Function
FIG. 5-D
Active elbow flexion ranged from 50 to 145 de- Finger flexion (Fig. 5-C) and extension (Fig. 5-D) with the elbow in
grees (mean, 112 degrees). The strength of elbow flexion.

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 RESTORATION OF PREHENSION WITH THE DOUBLE FREE MUSCLE TECHNIQUE 661

FIG. 5-E
The patient is shown unscrewing a bottle cap with both hands.

flexion was measured isokinetically with a computer-

ized dynamometer (KinCom; Chattanooga Group,
Hixson, Tennessee). Peak torque at a slow speed of
movement (30 degrees per second), measured in ten
patients, averaged 5.8 ± 2.7 newton-meters (concen-
tric flexion) and 10.2 ± 4.3 newton-meters (eccentric
flexion). These values averaged 14 and 19 percent of
those for the contralateral, normal elbow. According
to the modified Highet scale4,14 (Table IV), fourteen
patients (54 percent) had an excellent result; eleven
(42 percent), a good result; and one (4 percent), a fair
result. In two patients, elbow flexion was assisted by
the biceps brachii after it had been successfully rein-
nervated by the fifth cervical nerve root with use of
nerve graft. There were no significant differences in
the ranges of elbow flexion resulting from the differ-
ent combinations of transferred muscles; the mean
flexion for the gracilis-gracilis combination was 110
degrees, and that for the gracilis-latissimus dorsi and
the gracilis-rectus femoris combinations was 115 de-
grees. All twenty-six patients could flex the elbow at
least 90 degrees. The exceptional patient was a forty-
five-year-old man who had only 50 degrees of elbow
flexion.
Voluntary extension of the elbow was limited by
postoperative contracture. The mean range of elbow
extension was –36 degrees (range, 0 to –65 degrees),
and the mean power of elbow extension according to
the modified Highet scale was 1.8 (range, 0 to 5). In
twenty-one patients, voluntary extension of the elbow FIG. 5-F
was recovered, but only sixteen patients could volun- The patient is shown lifting a five-kilogram container with both
tarily position the hand in space, negating the tendency hands at thirty-six months postoperatively.

VOL. 82-A, NO. 5, MAY 2000

662 KAZUTERU DOI ET AL.
*
TABLE IV
MODIFIED HIGHET SCALE4,14 FOR END-RESULT EVALUATION
Description
Sensory recovery
(stage)
S0 Absence of sensibility in
autonomous area of nerve
S1 Recovery of deep cutaneous
pain sensibility distinguish-
able with number 20 (red)
on Semmes-Weinstein
monofilament test within
autonomous area
Return of some degree of
S2
superficial cutaneous pain
and tactile sensibility within
autonomous area
S2+ Return of sensibility as in stage 2;
in addition, some recovery (11
to 15 mm) of 2-point discrimi-
nation within autonomous
area or distinguishable with
number 10 (yellow) on Semmes-
Weinstein monofilament test,
or both
S3 Return of superficial cutaneous
pain and tactile sensibility
throughout autonomous area,
with disappearance of any
previous overresponse
S3+ Return of sensibility as in stage 3;
in addition, some recovery (6
to 10 mm) of 2-point discrim-
ination within autonomous
area or distinguishable with
number 6 (blue) on Semmes-
Weinstein monofilament test,
or both
S4 Complete recovery (2 to 6 mm)
of 2-point discrimination or
distinguishable with number 4
(green) on Semmes-Weinstein
monofilament test, or both
Elbow flexion
(grade)
M0 No contraction (on electro-
myography)
M1 Return of perceptible contraction
in biceps brachii muscle
(transplanted muscle)
M2 Return of some degree of elbow
flexion while negating gravity
M3 Return of elbow function sufficient
to act against gravity
M4 Return of elbow function sufficient
to act against some resistance
M5 Complete recovery
Free muscle
transplant
M0-M2 Same as above
M3 Range of active elbow flexion
(>30 degrees)
M4 Range of active elbow flexion
(>60 degrees)
M5 Range of active elbow flexion
(>90 degrees)
*
*
of elbow flexion while moving the fingers. Two of these
patients achieved this function.
Finger Function
The total active motion of the fingers ranged from 0
to 110 degrees (mean, 35 degrees). Four patients (15 per-
cent) had an excellent result; thirteen (50 percent), a
good result; four (15 percent), a fair result; and five (19
percent), a poor result. As mentioned, sixteen patients
could position the hand in space while moving the fin-
gers. The most powerful finger flexion was obtained with
the elbow in extension when the fingers were not ex-
tended (Figs. 5-A and 5-B). When the elbow was flexed
and the fingers were extended, the power of finger flex-
ion decreased slightly (Figs. 5-C and 5-D). In contrast to
the elbow, there were significant differences in the to-
tal active ranges of finger motion resulting from the
different combinations of transferred muscles; the best
range of motion was achieved with use of the gracilis-
gracilis combination (mean, 43.6 degrees), whereas the
gracilis-latissimus dorsi and the gracilis-rectus femoris
combinations were associated with a mean of only 15.6
degrees (p < 0.01).
Nine patients who had had a tenolysis of the gracilis
to the finger flexors or extensors had improvement in
the total active motion of the fingers, ranging from 20 to
60 degrees. However, tenolysis of the latissimus dorsi or
the rectus femoris did not improve the range of active
finger motion.
Shoulder Function
Six patients underwent arthrodesis of the gleno-
humeral joint because of shoulder instability. Twelve pa-
tients could stabilize the glenohumeral joint and hence
did not need an arthrodesis. The latter patients all had a
grade of M2 or better for the triceps brachii or the
infraspinatus muscle, or both. Stability of the gleno-
humeral joint can be achieved by the two reinnervated
free muscles, the triceps brachii muscle, or the supra-
spinatus and infraspinatus muscles. Eighteen patients
achieved a mean of 25 degrees of shoulder flexion and
–24 degrees of external rotation. The remaining eight
patients had contracture and mild instability of the gle-
nohumeral joint; however, they did not want to undergo
arthrodesis. Four of these eight patients achieved shoul-
der flexion, ranging from 10 to 20 degrees, and the other
four could not move the shoulder.
Shoulder flexion was achieved either with the muscle
used for the first free muscle transfer or, in the patients
who had had a glenohumeral arthrodesis, with the trape-
zius; external rotation was achieved either with the recov-
ered triceps brachii or the infraspinatus muscle or, in the
patients who had had an arthrodesis, with the trapezius or
the rhomboid muscles.
Sensory Recovery
The Tinel sign advanced at a mean rate of 1.3 milli-
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 RESTORATION OF PREHENSION WITH THE DOUBLE FREE MUSCLE TECHNIQUE
meters per day (range, 0.5 to 2.0 millimeters per day) in
twenty-one patients. In two patients who had inter-
costal nerve-crossing, the Tinel sign never progressed
beyond the forearm. The mean interval between the
surgery and the initial recovery of sensibility in the
palm was twenty-two months (range, fourteen to thirty-
two months).
Limited sensibility in the cutaneous distribution of
the repaired median or ulnar nerve was achieved in
twenty-one patients. The recovered sensibility was the
most sensitive in the palm, whereas only five patients
felt sensation in the fingertips. All twenty-one patients
had referred sensibility only to the clavicle or the chest
after supraclavicular or intercostal nerve reconstruc-
tion, respectively. Six patients had double sensation in
the cutaneous distribution of both the repaired nerve
of the hand in situ and that of the recipient sensory
nerve.
According to the modified Highet scale4,14, sensation
recovered to S2+ in seven patients, to S2 in nine, and to
S1 in four; in the two remaining patients, there was no
recovery of sensibility (S0). There was no significant
difference in the recovery of sensibility between the
supraclavicular nerve and the intercostal nerve.
Pain
During the follow-up period, sixteen patients had
causalgia. Five of these patients had complained of
causalgia preoperatively, but in the other patients the
pain developed during the postoperative rehabilita-
tion. At the time of the final follow-up examination,
according to the visual analog scales only two patients
complained of moderate pain that interfered with their
activities; the other fourteen patients had mild, inter-
mittent pain, which was relieved with medication and
did not seriously interfere with activities. The remain-
ing ten patients did not have causalgia at any time.
Ability to Hook or Hold Objects
All twenty-six patients could hold an object such as
a book weighing more than one kilogram between the
arm and the trunk with use of the reinnervated second
free muscle and the triceps brachii and assisted by the
rhomboid muscles. All but one patient could lift an ob-
ject such as a bag weighing a mean of 4.8 kilograms
with the forearm. No patient had key pinch since the
carpometacarpal joint of the thumb had been immobi-
lized in opposition either with an arthrodesis or a
splint. However, eleven patients were able to grasp a
light object such as a bottle weighing 300 grams. Nine-
teen patients were able to lift a bag weighing between
0.5 and five kilograms with a hook grip and to lift a box
weighing two to thirteen kilograms with use of both
hands up to the level of the middle of the thigh (twelve
patients) or to the pubic symphysis (seven patients).
These nineteen patients could use the reconstructed
hand well in daily activities for lifting and carrying
VOL. 82-A, NO. 5, MAY 2000
663
light objects with one hand and heavy objects with
both hands (Fig. 5-F). Eleven of these patients also
could hold a bottle with the reconstructed hand while
opening its cap with the contralateral, normal hand
(Fig. 5-E).
Prehensile Recovery
A satisfactory (excellent or good) result was ob-
tained in seventeen (65 percent) of the twenty-six pa-
tients, according to our evaluation system. Fourteen
patients (54 percent) could achieve more than 90 de-
grees of elbow flexion, position the hand in space while
moving the fingers more than 30 degrees voluntarily,
and use the reconstructed hand for two-handed activi-
ties such as holding a bottle while opening a cap and lift-
ing a heavy object. All of these patients were thirty-two
years old or less and had had a short interval (eight
months or less) between the injury and the surgery, a
long duration (more than fifty-five months) of follow-
up, and no associated injuries of the subclavian artery,
the spinal accessory nerve, or the spinal cord.
Donor-Site Sequelae
There were no functional complications related to
the donor site, although some patients complained about
the presence of a long scar that they considered to be
cosmetically unacceptable.
Discussion
The double free muscle procedure after complete
avulsion of the brachial plexus reliably provided pre-
hension involving the basic grasping function of the
hand, as well as voluntary motion and stability of the
shoulder and elbow, in more than half of the twenty-six
patients who had long-term follow-up. Nineteen pa-
tients could use the reconstructed hand for two-handed
activities such as holding or lifting an object, despite
having a limited total range of active finger motion.
Fourteen patients with excellent or good prehension
had a mean total range of active finger motion of 52
degrees (range, 30 to 110 degrees). Approximately half
of the patients failed to obtain useful prehension, due
mainly to lack of active elbow extension as well as adhe-
sion of the transferred muscles. However, they achieved
good elbow function. Hence, even though prehension
was not achieved, the elbow flexion that was restored was
more reliable than that achieved with conventional
nerve-transfer procedures, which have yielded a higher
grade of elbow flexion than M3 in 80 percent of patients17.
In the current series, the latissimus dorsi, gracilis,
and rectus femoris muscles were used as donor muscles.
The latissimus dorsi did not provide satisfactory finger
function because of adhesion of the muscle to the pulley
system and also because of rupture of its tendon due to
ischemic necrosis of the portion distal to the pulley. The
rectus femoris muscle was also unsatisfactory due to
poor muscle excursion with resulting poor finger func-
664 KAZUTERU DOI ET AL.
tion. The gracilis is the donor muscle of choice.
Tenolysis was indicated when active finger function
was not achieved despite strong contraction of the
transferred muscle. Nine finger extensors and six finger
flexors had tenolysis from the proximal musculotendi-
nous junction to the fingers. However, in four patients
with a latissimus dorsi transfer and in one with a rectus
femoris transfer, tenolysis failed to improve the range of
motion postoperatively as there was recurrence of ad-
hesion. Nine patients who had a gracilis transfer had an
improved range of finger motion, ranging from 20 to 60
degrees, postoperatively.
The spinal accessory nerve and the third to sixth in-
tercostal nerves were used in our series. There were sig-
nificant differences between the two sources of donor
nerves with regard to the time that it took for reinner-
vation of the transferred muscle (p < 0.05)22; however, the
final muscle power was not significantly different. The
phrenic nerve and the contralateral seventh cervical
nerve root also may be used as donor nerves3,11,18,21, but we
did not use these nerves because of the possible risks.
The double free muscle technique utilizes the simul-
taneous movement of multiple joints with a limited
number of donor motor nerves; for example, the first
free muscle reinnervated by the spinal accessory nerve
works to extend the fingers and flex the elbow simulta-
neously. After recovery of the triceps brachii as an an-
tagonist of the elbow flexor, the patients could position
the hand in space while extending the fingers.
Multiple intercostal nerve-crossing from the ipsilat-
eral side, such as crossing of the second free muscle with
the fifth and sixth intercostal nerves and crossing of the
triceps brachii with the third and fourth intercostal
nerves, might have produced paradoxical movements,
such as simultaneous contraction of the elbow flexor
(the second free muscle transfer) and the elbow exten-
sor (the triceps brachii). Electromyography with use of
multichannel electrodes showed that the second free
muscle and the triceps brachii were contracting at the
same time, although the amplitude of the compound
motor-action potential was different depending on the
phase of elbow and finger movement. However, the sec-
ond free muscle acted as a supplemental elbow flexor
since it was not placed in the flexion-extension plane of
the elbow. The first free muscle acted as the main elbow
flexor. Subsequently, the patients could flex the elbow
to overcome the antagonist.
The most powerful finger flexion was obtained with
the elbow in extension while finger extension was not
operative, and the power of finger flexion decreased
slightly when the elbow was flexed.
In nineteen patients, the triceps brachii was reinner-
vated as demonstrated electromyographically, but only
sixteen patients could voluntary stabilize the elbow joint
when they moved the fingers. The time until the triceps
brachii was reinnervated following nerve-crossing was
longer than the time until reinnervation of the second
free muscle reinnervated by the intercostal nerves. The
final power that was achieved was weaker and the results
were less reliable than those of conventional nerve-
crossing to the biceps brachi. This may be due to the dif-
ficulty in identifying the motor fascicles in the nerve
stump and the delay between the time of injury and the
procedure. However, even if the power of the triceps
brachii was weak (M2), it could contribute to stability of
the elbow with the aid of gravity. If reinnervation of the
triceps brachii fails, secondary reconstruction (for exam-
ple, transfer of the reinnervated infraspinatus to the tri-
ceps brachii) may be an option for restoring elbow
stability8. Two patients obtained elbow extension power-
ful enough to negate the simultaneous elbow flexion
while moving the fingers.
Stability of the glenohumeral joint can be achieved
by the reinnervated free muscle, the triceps brachii, and
the shoulder-girdle muscles without arthrodesis. During
exploration of the brachial plexus, if the fifth cervical
nerve root is available8 it should be crossed to the supra-
scapular nerve with use of nerve-grafting, not only to
improve shoulder function but also to reinnervate para-
lyzed muscles for use as possible donor muscles for
transfer if the triceps brachii does not recover. If the gle-
nohumeral joint remains unstable even after recovery
of these muscles, glenohumeral arthrodesis can be done,
although this will limit several activities, such as turning
over during sleep. Care must be taken to prevent frac-
ture of the proximal part of the humerus; in the current
series, one humeral fracture occurred postoperatively.
Restoration of basic functions such as protective
sensation and position sense is imperative when pre-
hensile function is restored after irreparable brachial
plexus injury. Sixteen patients achieved sensibility of the
hand that was at least S2, had adequate position sense,
and never had a minor injury, such as a burn, in the re-
constructed hand. Intercostal nerve-crossing has been
reported to provide a better outcome with regard to
sensory restoration12. However, in the current series,
there were no significant differences in sensibility be-
tween the patients in whom the suprascapular nerve had
been used as the donor nerve and those in whom the in-
tercostal nerves had been used.
In contrast to series reported in the literature13,19, we
had no patients with severe postoperative causalgia that
could not be relieved with the usual analgesics. Ten pa-
tients had never had causalgia. This finding is difficult to
explain, but perhaps these patients had some inborn ge-
netic means of inhibiting pain. Parry19 noted that Orien-
tal patients rarely reported pain in association with
traction lesions of the brachial plexus. Sensory restora-
tion with transfer of the intercostal or supraclavicular
nerves to the median or ulnar nerve might have modu-
lated pathogenesis of the deafferentation pathway of
causalgia, and the patients’ high motivation for surgical
reconstruction and rehabilitation might have helped
them to tolerate the pain better.
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 RESTORATION OF PREHENSION WITH THE DOUBLE FREE MUSCLE TECHNIQUE 665

Postoperatively, fifteen patients returned to their nerve should be strictly avoided.

former occupation or to school and five of them modi-
fied their work. Three patients were employed in a
sheltered workshop, and six patients changed their work
following vocational retraining. Two patients were un-
employed despite their ability to return to work. The
twenty patients who had been employed or attending
school before the injury were able to return to work or
to school after a mean of twenty-two months (range, six
to fifty months).
Ten patients had an unsatisfactory result. One pa-
tient (Case 9), a forty-five-year-old man in whom a
previous intercostal nerve-crossing to the musculocuta-
neous nerve had failed, ultimately achieved only 50 de-
grees of elbow flexion and had no prehensile function
after reconstruction with the latissimus dorsi and the
gracilis. The first free muscle, the latissimus dorsi, was
successfully reinnervated by the accessory nerve. The
second free muscle, the gracilis, was reinnervated by the
previously crossed third and fourth intercostal nerves,
but it did not ultimately provide prehension or elbow
flexion of more than 90 degrees. Factors that contrib-
uted to the poor result were the patient’s age, the use of
the latissimus dorsi as the donor muscle, and the use of
intercostal nerves that had been used previously for
nerve-crossing.
Another patient (Case 22), a twenty-three-year-old
man, had sustained an injury of the spinal cord and the
ipsilateral accessory nerve from which he had recov-
ered at the time of the operation. The first free muscle
had subsequent neurotization by the previously para-
lyzed spinal accessory nerve because intraoperative
biochemical assay of catecholamine anhydrase showed
activity of the donor motor nerve. Although electro-
myographic studies showed the muscle to have been
reinnervated successfully, it did not provide useful el-
bow flexion or finger flexion strength. The patient was
able to flex the elbow only with the second free muscle.
The use of a previously injured nerve or a transferred
Although an associated major vascular injury was
successfully repaired in two patients, free muscle trans-
fer was difficult in these patients because of the paucity
of donor vessels for anastomoses. Even when these ves-
sels were present, they usually were injured or were sur-
rounded by a severely scarred bed. The presence of an
associated subclavian artery injury is a contraindication
to the double free muscle technique.
The presence of elbow stability with a functioning
triceps brachii muscle is imperative in order to obtain
satisfactory function. Because of severe muscular atro-
phy of the triceps with consequent incomplete recovery
leading to loss of elbow stability, no patient who had
nerve-crossing to the triceps muscle more than one year
after the injury had restoration of useful prehension. It is
recommended that this procedure be performed within
eight months following the injury.
To maximize recovery following the double free mus-
cle technique, patients need to participate in an intensive
rehabilitation program, preferably every day or, at a min-
imum, twice a week for one year, as an inpatient for four
months and as an outpatient for the next six months; this
should be followed by a home program of rehabilitation
for another year after the patient returns to work. Six pa-
tients in our series could not continue with the rehabilita-
tion program regularly because of lack of motivation or
financial support or for unknown reasons.
Not all patients who have a complete avulsion of the
brachial plexus are candidates for double free muscle
transfer. Suitable patients are younger than forty years
old and have sustained the injury within the preceding
eight months; have no major vessel injury (for example,
of the subclavian or axillary artery); have no injury or
history of surgery involving the donor motor nerve (for
example, the spinal accessory or the intercostal nerves);
and are motivated, and have financial and emotional
support, to participate in a prolonged postoperative re-
habilitation program.

References
1. Akasaka, Y.; Hara, T.; and Takahashi, M.: Free muscle transplantation combined with intercostal nerve crossing for reconstruction of el-
bow flexion and wrist extension in brachial plexus injuries. Microsurgery, 12: 346-351, 1991.
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