Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. www.PRSJournal.com 128 E lbow fexion is widely accepted as the most important function to restore after a pan- plexus injury. 1,2 Free functioning muscle transfer has been recommended to restore elbow function, especially when the time from injury to surgery is greater than 9 to 12 months. Use of the free functioning muscle transfer in patients less than 6 months after injury has been advocated to obtain grasp or to potentially improve outcomes of Disclosure: The authors have no financial interest to declare in relation to the content of this article. No external funding was secured for this study. Copyright © 2016 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000002864 Andrés A. Maldonado, M.D., Ph.D. Santiago Romero-Brufau, M.D. Michelle F. Kircher, R.N. Robert J. Spinner, M.D. Allen T. Bishop, M.D. Alexander Y. Shin, M.D. Rochester, Minn. Background: Reconstruction after pan-plexus root avulsions often includes gracilis free functioning muscle transfer. For elbow fexion reconstruction, the free func- tioning muscle transfer distal tendon is inserted into the biceps tendon or more distally (i.e., fexor digitorum profundus/fexor pollicis longus tendons) for com- bined elbow and fnger fexion; the theoretical drawback of the latter approach is weaker elbow fexion. The authors compared elbow fexion strength with a biceps tendon versus a fexor digitorum profundus/fexor pollicis longus tendon attachment to determine which insertion point resulted in better elbow fexion. Methods: Thirty-nine patients underwent free functioning muscle transfer with either a biceps tendon or a distal attachment. Groups were compared on post- operative elbow fexion strength, preoperative and postoperative Disabilities of the Arm, Shoulder, and Hand questionnaire scores, range of motion, and other surgical and demographic characteristics. A biomechanical analysis simu- lating different tendon attachments determined which reconstruction resulted in optimal elbow fexion mechanics. Results: Distal tendon attachment was associated with M3 or M4 elbow fex- ion and greater range of motion compared with the biceps tendon attachment (p < 0.05). There were no statistically signifcant improvements in Disabilities of the Arm, Shoulder, and Hand questionnaire scores. Biomechanical analysis dem- onstrated that all distal tendon attachments studied generated a 15 to 30 percent greater torque compared with the biceps tendon attachment; this was true for attachments either at the fexor digitorum profundus/fexor pollicis longus ten- don, or directly at the radius at 10 cm or 15 cm from the elbow axis of rotation. Conclusions: The fexor digitorum profundus/fexor pollicis longus tendon attachment of the gracilis free functioning muscle transfer distal tendon was superior in achieving elbow fexion strength. Patients with only elbow fexion reconstruction may also beneft from a fexor digitorum profundus/fexor pollicis longus tendon attachment or from a more distal attachment to the radius. (Plast. Reconstr. Surg. 139: 128, 2017.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III. From the Department of Orthopedic Surgery, Division of Hand Surgery, the Department of Neurologic Surgery, and the Center for Innovation, Mayo Clinic. Received for publication May 9, 2016; accepted August 9, 2016. Free Functioning Gracilis Muscle Transfer for Elbow Flexion Reconstruction after Traumatic Adult Brachial Pan-Plexus Injury: Where Is the Optimal Distal Tendon Attachment for Elbow Flexion? cpt HAND/PERIPHERAL NERVE