Background: After complete five-level root brachial plexus injury, free functional muscle transfer and intercostal nerve transfer to the musculocutaneous nerve are two potential reconstructive options for elbow flexion. The aim of this study was to determine the outcomes of free functional muscle transfer versus intercostal nerve-to-musculocutaneous nerve transfers with respect to strength. Methods: Sixty-two patients who underwent free functional muscle transfer reconstruction or intercostal nerve-to-musculocutaneous nerve transfer for elbow flexion following a pan-plexus injury were included. The two groups were compared with respect to postoperative elbow flexion strength according to the British Medical Research Council grading system; preoperative and postoperative Disabilities of the Arm, Shoulder, and Hand questionnaire scores. Results: In the free functional muscle transfer group, 67.7 percent of patients achieved M3 or M4 elbow flexion. In the intercostal nerve-to-musculocutaneous nerve transfer group, 41.9 percent of patients achieved M3 or M4 elbow flexion. The difference was statistically significant (p < 0.05). Changes in Disabilities of the Arm, Shoulder, and Hand questionnaire scores were not statistically significant. Average time from injury to surgery was significantly different (p < 0.01) in both groups. The number of intercostal nerves used for the musculocutaneous nerve transfer did not correlate with better elbow flexion grade. Conclusions: Based on this study, gracilis free functional muscle transfer reconstruction achieves better elbow flexion strength than intercostal nerve-to-musculocutaneous nerve transfer for elbow flexion after pan-plexus injury. The role of gracilis free functional muscle transfer should be carefully considered in acute reconstruction.
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