Evaluating Elbow Flexion After Free Functional Gracilis Muscle Transfer in Adult Brachial Plexus Lnjury

‐ Study Overview This single‐arm prospective clinical trial evaluates the efficacy ofgracilis free functional muscle transfer (FFMT) for restoring elbow flexion inpatients with late‐presenting brachial plexus injuries (≥12 months post‐injury) orfailed prior reconstructive surgery. The gracilis muscle is the preferred donor dueto its reliable vascular pedicle, adequate excursion, long motor nerve, and minimaldonor‐site morbidity . ‐ Primary Objective To assess postoperative elbow flexion strength using the BritishMedical Research Council (BMRC) grading system following gracilis FFMT neurotized byintercostal nerves (ICN) or spinal accessory nerve (SAN). ‐ Secondary Objectives ‐ Evaluate active range of motion (AROM) ‐ Measure time to first detectable muscle contraction and time to maximum power ‐ Assess functional improvement via DASH scores ‐ Compare outcomes between ICN and SAN neurotization groups ‐ Compare outcomes between pediatric and adult patients ‐ Document complications, particularly elbow flexion contracture ‐ Key Inclusion Criteria ‐ Age 4‐50 years ‐ Elbow flexion loss or severe weakness for >12 months following brachial plexus injury (obstetric or traumatic) ‐ Weak ipsilateral latissimus dorsi and pectoralis major (50 years (diminished regenerative capacity) ‐ Presentation within 12 months of injury ‐ Reconstructable by local muscle or nerve transfer ‐ Elbow joint stiffness or contracture ‐ Uncontrolled comorbidities or inability to comply with rehabilitation ‐ InterventionGracilis FFMT harvested from the contralateral thigh with: ‐ **Neurotization:** ICNs (50%) or SAN (50%) ‐ **Vascular anastomosis:** Thoracoacromial artery (77%), thoracodorsal artery(13.6%), or subscapular artery (9.2%) ‐ **Muscle tensioning:** Elbow flexed 90‐110° during inset ‐ Primary Outcome Measure Postoperative elbow flexion power (BMRC grade) at 24‐month follow‐up ‐ Secondary Outcome Measures ‐ Active range of motion (goniometry) ‐ Time to first clinical contraction ‐ Time to maximum power achievement ‐ DASH score ‐ Complication rate (flap loss, flexion contracture, scarring) ‐ Sample Size 22 patients (17 male, 5 female; mean age 13.4±8.7 years) ‐ Statistical Considerations ‐ Paired t‐test for continuous outcomes ‐ Wilcoxon signed‐rank test for non‐parametric data ‐ Fisher's exact test for categorical comparisons ‐ Significance threshold: p<0.05 ‐ Expected Outcomes Based on existing literature, 68‐76% of patients achieve functionally useful elbow flexion (≥M3) following gracilis FFMT, with significant improvements in AROM and DASH scores . ICN neurotization may offer faster recovery to maximum power (approximately 9 months vs. 14 months for SAN) without compromising final strength . ‐ Trial Registration:** Not reported (retrospective/prospective case series design)