Purpose: Upper extremity neuromuscular injuries can lead to severe morbidity with limited options for reconstruction. Shoulder dislocation, brachial plexus stretch and avulsion damage and biceps tendon tears are just a few examples of such injuries that will result in instability, chronic pain, severe weakness, and lack of elbow flexion while in a supinated position. The problem with proximal injuries is the inability to bring a functional hand into a useful position. Muscle transfer procedures have been described, but are limited in scope and can give only partial range of motion and strength. However, free tissue transfer allows functional biceps reconstruction without relying on the limited available local tissue. We prefer to use the Tensor Fascia Lata (TFL) for biceps reconstruction since it offers excellent size match for the biceps muscle and has the appropriate strength, and sufficient excursion, to meet the functional needs of the upper extremity. Choice of nerve for rennervation of the free TFL depends largely on the original mechanism of injury and is factored into our decision-making paradigm. We present our therapeutic strategy, nerve selection process and experience using the free innervated TFL fasciocutaneous flap for biceps reconstruction.

Materials and Methods: From September 1998 to May 2001, three patients underwent biceps reconstruction using innervated free TFL. Two of the patients had complete loss of the biceps muscle due to trauma and both underwent delayed reconstruction. The third patient underwent biceps resection during surgical ablation of a pleomorphic fibrous histiocytoma of the left biceps and had immediate reconstruction. The musculocutaneous nerve was used in two of these patients. The thoracodorsal nerve was used in the third patient who had previously undergone a left shoulder arthrodesis and unipolar latissimus dorsi transfer. Flap anatomy, harvest and donor site management are described.

Results: The overall outcome of all three patients was excellent. There were no flap losses, or other major complications. One patient developed a seroma that required drainage. All three patients who underwent biceps reconstruction developed 5/5 strength and were able to complete activities of daily living. Two patients had flexion from 0-135°. The third patient had flexion of only 15-120° and returned one year later for biceps tendon shortening to increase the degree of proximal flexion excursion.

Discussion: The problem of neuromuscular biceps loss is complex. Reconstructive techniques must restore muscle bulk, as well as maximize power and degree of flexion. The free TFL flap surpasses traditional treatments in doing so. All three patients who underwent biceps reconstruction with the TFL developed improved strength and range of motion. Compared with traditional methods, the TFL flap does require a longer operative time but offers great results with minimal morbidity. Proper classification of a given injury will assist in choosing the best reconstruction for a patient. Our decision-making paradigm and rationale for nerve selection is offered.
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