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Factors affecting Outcomes after Free Functional Gracilis Muscle Transfer for Elbow Flexion in Brachial Plexus Injury: A Systematic Review and Meta-Analysis
Syeda Hoorulain Ahmed, MD
1; Ramin Shekouhi, MD
1; Yousef Husseiny, BS
2; Eddy Rios, BS
3; Maryam Sohooli, MD
4; Harvey Chim, MD
1
1University of Florida College of Medicine, Gainesville, FL; 2New Giza University, Giza, Upper Egypt, Egypt; 3University of Massachusetts Chan School of Medicine, Worcester, MA; 4University of Florida, Gainesville, FL
Purpose: Free functional gracilis muscle transfer (FFGT) is a valuable option for restoring elbow flexion in patients with brachial plexus injury (BPI), especially those presenting late or with poor outcomes from prior nerve surgeries. This systematic review and meta-analysis aim to identify variables associated with superior outcomes, comparing the efficacy of single versus double FFGT and evaluating the impact of the donor nerve choice for neurotization.
Methods: Meta-analysis was conducted, including studies that provided postoperative Medical Research Council (MRC) grade for elbow flexion, disabilities of the arm, shoulder, and hand (DASH) and visual analog scale (VAS) scores, quantitative elbow flexion strength, and range of motion (ROM). A random-effects meta-regression analysis identified factors linked to improved outcomes.
Results: 37 studies, with 1607 patients, were analyzed. Single FFGT was reported in 34 studies (n=1398), and double FFGT was reported in 10 studies (n=209). Following single FFGT, 75.4% and 48.9% achieved MRC grades
>3 and
>4, respectively. Following double FFGT, 100% achieved MRC grade
>3 and 62.7%
>4. Subgroup analysis showed a significant difference in MRC grade
>3 and
>4, favoring double FFGT over single FFGT (P<0.05). Overall, FFGT innervated by the spinal accessory nerve (SAN) had significantly better recovery of MRC grade
>3. When comparing only single and double FFGT innervated by SAN, there was no significant difference in recovery of elbow flexion. Meta-regression analysis showed a significant negative correlation between the patient's age and the probability of achieving an MRC grade of
> 3 and 4 (P<0.05). A random effects meta-analysis of 27 patients showed a significant improvement of postoperative DASH score from the preoperative score with a mean difference (MD) of -13.86 (95% CI [-23.57, -4.15]; P<0.05). A meta-analysis of 2 single FFGT studies comparing postoperative and preoperative VAS scores showed a significant improvement after the procedure (MD: -0.88, 95% CI [-1.55, -0.21]; P<0.05). Mean elbow flexion strength after single FFGT (n=4 studies, 210 patients) was analyzed to be 2.60 kg (95% CI [1.94,3.27]). The mean ROM of elbow flexion for patients undergoing single and double FFGT were 94.3 (95% CI: 87.8, 100.8), and 118.7 degrees (95% CI:113.6, 123.8), respectively, with significant subgroup differences between the two procedures (P<0.05).
Conclusion: In the overall analysis encompassing all innervating nerves, double FFGT was superior to single FFGT. Subgroup analysis of single and double FFGT innervated by the SAN showed no significant difference. Increasing age was a significant risk factor for poorer outcomes.
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