Double Free-muscle Transfer to Restore Prehension Following Complete Brachial Plexus Avulsion Kazuteru Doi, MD, Kazuhiro Sakai, MD, Noriyuki Kuwata, MD, Koichiro Ihara, MD, ShinyaKawai, MD, Ube, Japan Restoration of finger flexion and extension as well as elbow flexion and extension with a double free-muscle and multiple nerve transfers following complete avulsion of the brachial plexus (nerve roots C5 to T1) is reported. The procedure combines (1) free-muscle transfer with reinnervation by the spinal accessory nerve to achieve elbow flexion and finger exten- sion, (2) free-muscle transfer with reinnervation by the fifth and sixth intercostal nerves to restore finger flexion, (3) third and fourth intercostal motor nerve transfer to the triceps brachi to extend and stabilize the elbow, (4) nerve transfer of the supraclavicular nerve or nerve transfer of the sensory rami of the intercostal nerves to the median nerve to restore hand sen- sibility, and (5) glenohumeral arthrodesis. Seven of 10 patients recovered elbow function and finger flexion and extension. Five patients reported use of their hand in activities of daily liv- ing. (J Hand Surg 1995;20A:408-414.) We have previously reported restoration of elbow and finger flexion using free-muscle and nerve trans- fers following complete avulsion of the brachial plexus. 1 In these patients, inability to achieve finger extension limited hand use in activities of daily life. We now report a second surgery in patients with complete avulsion injuries of the brachial plexus with a free-muscle transfer to the extensor tendons of the forearm to provide active finger extension. Materials and Methods Clinical Materials Fifteen patients have undergone restoration of fin- ger and elbow flexion and extension by double free- muscle transfer. This report is based on the 10 patients in whom the second free-muscle transfer was performed more than 12 months ago. From the Department of Orthopaedic Surgery, Yamaguchi University Schoolof Medicine, Ube, 755, Japan. Received for publicationAug. 14, 1992; accepted in revised form Sept. 20, 1994. No benefits in any form havebeenreceived or willbe receivedfroma commercial party related directly or indirectly to the subject of this article. Reprint requests: Kazuteru Doi. MD, Departmentof Orthopaedic Surgery, Yamaguchi University Schoolof Medicine, Ube, 755, Japan. Intraoperative spinal-evoked potentials were used to diagnose the nature of the plexus injury in eight of the patients. The other two cases were diagnosed by myel- ography and intraoperative macroscopic findings. Three patients had suffered complete preganglionic avulsion of the C5 to T1 nerve roots. Three patients had a postganglionic rupture injury of the C5 nerve root and a preganglionic avulsion of C6 to T1 nerve roots. Four patients had a combined lesion of the C5 nerve root and a preganglionic avulsion of C6 to T1 nerve roots (Table 1). Postoperative followup ranged from 15 to 38 months following the first free-muscle transfer and from 13 to 34 months following the second. For the first free-muscle transfer, the gracilis mus- cle was used in seven cases. The contralateral latis- simus dorsi muscle was used in the remaining three cases. In four patients, the supraclavicular nerve was connected to the median nerve component of the lat- eral cord at the same surgery. The second surgery was performed 2-6 months following the first surgery. The gracilis muscle was transferred in eight patients. The ipsilateral latis- simus dorsi muscle was transferred in two patients. In six patient the motor branch of the transferred gra- cilis muscle was connected to the fifth and sixth 408 The Journal of Hand Surgery