Reconstruction of Forearm Muscle Loss with Innervated Gracilis Transfer: Experience with Modifications in Indications and Technique

The authors reported on their experience with microvascular innervated gracilis muscle transfer for reconstruction of the forearm musculature in 20 patients. A total of 21 muscles were transferred in this group. There was one flap loss due to vascular compromise (4.7%) of 21 muscles transferred. The average age of this group was 33 years (range: 3–47 years). All but one of the patients were males. There was one death in the series in a patient with psychiatric disorders who drowned in a hot tub after an overdose at 8 months postoperatively. Sixteen muscles were transferred to the flexor side of the forearm and 5 to the extensor side. Twelve patients had direct traumatic muscle injury or loss, 5 patients had established Volkmann's ischemic contracture, 2 patients had long-standing nerve injuries, and 1 patient had muscle excision for tumor removal. In the traumatic injury group, 8 patients had grafting of the median and/or ulnar nerve at the time of gracilis muscle transfer.

With the exception of the failed transfer, all patients had return of motor function of the innervated muscle. The quality of function of the transferred muscle was dependent on a number of factors, including site of tendon re-attachment and other deficits in the injured arm. The authors believe that innervated gracilis transfer provides an excellent reconstruction of wrist and finger motion. While standard teaching has given parameters for the safe performance of this procedure, they believe that some modifications can be made to these parameters. With severe muscle loss and forearm scarring, innervated gracilis transfer may be superior to standard tendon transfers. Obtaining adequate cover prior to gracilis transfer is not always necessary. While intact sensation remains one of the absolute necessities for a functional hand, nerve repair and/or grafting can be safely done at the time of gracilis transfer. They propose a one-stage reconstruction in patients with severe injury to the forearm incorporating innervated graciliis muscle transfer.