Objectives: In failed neurotization procedures or long-standing brachial plexus lesions functioning free muscle transplants are necessary to restore functions especially below the elbow.

Methods: In the past 5 years the author has used a free functioning muscle graft in 9 cases for neuromuscular reconstuction after irreparable brachial plexus injury or failed extraplexual neurotizations. Functional restoration is best accomplished by extraplexual neurotizations. In limited cases where no donor nerve or nerve transfer is available for direct end-to-end suture, intraplexual neurotization by end-to-side neurorraphy was performed. Intraoperative electric stimulqtion (SEP and evoked muscle response) was routinely used to help clarify the extend of injury. A functioning free gracilis muscle graft was innervated by intercostal nerve tansfer in 6 cases, and by end-to-side neurorrhaphy in other 3 cases. In 5 cases the goal of reconstruction was restoration of elbow flexion, in 4 cases wrist and finger flexion. The age of the patient treated ranges from 10 to 46 years, the mean follow-up was 18.3 months.

Results: The 9 functioning muscle grafts showed - with exception of one case - good clinical results with a minimum of M3 for elbow flexion, and finger flexion 16 months postoperatively, respectively (range M3 to M4). All patients developed reinnervation through the end-to-side coaptation site. Axonal regeneration could be documented electrophysiologically and later on clinically respectively. No downgrading of the 'donor' nerve (or root) or muscle function respectively, occurred in all clinical cases.

Conclusion: To gain a prospect of success or improved results in brachial plexus reconstructions neuromuscular reconstructions using functioning free muscle transplants or new additional rechniques, like end-to-side neurorrhaphy, have been introduced in the last few years. Overdimensioning seems to be useful in functional muscle transplantation, also in limited neural capacity situations. Synergic donor nerves should be preferred in end-to-side nerve repair.