Technical considerations and outcome of free functioning gracilis muscle transfer for finger flexion in patients with Volkmann's Ischemic Contracture

Introduction: Severe Volkmann's Ischemic Contracture (VIC) is a reconstructive challenge for the surgeon because of the loss of entire flexor muscle mass and lack of powerful wrist extensors for restoration of finger flexion. In such cases, free functioning muscle transfer (FFMT) using gracilis is our choice. We herein summarize the technical considerations to achieve a successful outcome and report functional outcome achieved in our series. Patients and Method: Between 2007-2018, 22 patients of VIC underwent gracilis FFMT for restoration of finger flexion. FFMT was done as a second stage following an initial stage of neurolysis/excision of fibrotic flexor muscles/contracture release/flap cover in these patients. Cases were retrospectively reviewed and their functional outcome at a minimum of one-year follow up was analyzed. Follow-up duration ranged from 2-13 years (average-4 years). At the final follow up, the motor and sensory recovery was evaluated using the Medical Research Council Grading and their function using Disabilities of the Arm, Shoulder, and Hand (DASH) score. Results: The average age at surgery ranged from 3-45 years (average-18.4 years). All the transferred muscles survived. Secondary procedures to further improve the hand function were done in nine patients. The motor recovery for finger flexion was graded as M2 in two, M3 in nine and M4 in 11 cases. These 20/22 patients who recovered M3/M4 finger flexion expressed high satisfaction with the operation while other two also felt that they were better after the surgery. DASH score was available for 13 patients and it averaged 13.21 (Range-1.8-34.5). Grip strength was available for 10/22 patients and it averaged 10.5 kg (range-0-21kg) amounting to 24% of the normal side. The sensory recovery was graded as S4 in two, S3 in 17 and S2 in three cases. Conclusion: Gracilis FFMT is a reliable option for restoration of finger flexion in patients with severe VIC. Outcome is better when done after an early preliminary stage of excision of fibrosed muscles and neurolysis which allows recovery of intrinsic function and sensation. FFMT is best carried out 3-6 months after the first stage with supple skin and good passive range of movement in the fingers.