The Inverted Free Functioning Gracilis Muscle Transfer for Restoration of Elbow Flexion following Delayed Presentation or Failed Primary Nerve Reconstruction of Upper Trunk Injuries

Free functional gracilis transfer is a well-established technique for restoring active elbow flexion in brachial plexus injuries following delayed presentation or failed nerve reconstruction procedures. In cases of delayed presentation or failed nerve reconstruction following upper trunk injuries, the lower trunk intraplexal median and ulnar nerves are spared, thereby making them available to reinnervate the transferred gracilis. Therefore, we have inverted the conventional free functional gracilis orientation so as to orient the flap's recipient nerve in closer proximity to donor median or ulnar nerve fascicles to enable a short, tension-free coaptation in the middle to distal arm. Herein is our descriptive surgical technique for performing an inverted free functional gracilis muscle transfer in order to restore elbow flexion in the setting of an upper trunk injury.