Recent interest in reconstruction of the upper limb following brachial plexus injuries has focused on the restoration of prehension following complete avulsion of the brachial plexus. The authors use free muscle transfers for reconstruction of the upper limb to resolve the difficult problems in complete avulsion of the brachial plexus. This article describes the authors' updated technique-the double free muscle procedure. Reconstruction of prehension to achieve independent voluntary finger and elbow flexion and extension by the use of double free muscle and multiple nerve transfers following complete avulsion of the brachial plexus (nerve roots C5 to Tl) is presented. The procedure involves transferring the first free muscle, neurotized by the spinal accessory nerve for elbow flexion and finger extension, a second free muscle transfer reinnervated by the fifth and sixth intercostal nerves for finger flexion, and neurotization of the triceps brachii via its motor nerve by the third and fourth intercostal motor nerves to extend and stabilize the elbow. Restoration of hand sensibility is obtained via the suturing of sensory rami from the intercostal nerves to the median nerve. Secondary reconstruction, including arthrodesis of the carpometacarpal joint of the thumb and glenohumeral joint, and tenolysis of the transferred muscle and distal tendons, improve the functional outcome. Based on the long-term result, selection of the patient, donor muscle, and donor motor nerve were indicated.

Most patients were able to achieve prehensile functions such as holding a can and lifting a heavy box. This double free muscle transfer has provided prehension for patients with complete avulsion of the brachial plexus and has given them new hope to be able to use their otherwise useless limbs.