Free Muscle Transfer in Posttraumatic Plexopathies Part II: The Elbow

Abstract

The indications for free muscle transfer in brachial plexopathies are prolonged denervation time or inadequate upper extremity function after primary nerve reconstruction. The purpose of this study is to analyze the outcomes of free muscle transfer for elbow flexion and extension in brachial plexopathies in relation to the different muscles used and the respective motor donors. Seventy-three muscles were transferred for elbow flexion and ten for elbow extension. Latissimus dorsi (LD) was used in 37 cases, gracilis in 28, rectus femoris (RF) in seven, and vastus lateralis in one. Five LD and five gracilis were transferred for elbow extension. Patients younger than 15 years yielded better results than older patients for elbow flexion. When LD was transferred, the mean muscle grading (MG) was 3.33±0.25 when the neurotization was from intercostals; these outcomes were statistically significant when compared with outcomes of free gracilis transfer (MG 2.25±0.6). There was also a statistically significant difference when free LD was neurotized with three intercostals as compared with two intercostals nerves. RF yielded also good results when neurotized from contralateral C7 (cC7; MG 3.67±0.6). For elbow extension, the better outcomes of LD were not statistically significant. Among all the free muscle transfers for upper extremity reconstruction, elbow reanimation yielded the most rewarding outcomes. The selection of powerful muscle units was more important than the effect of neurotization which was not as strong as it was in muscle transfers for facial or hand reanimation.

Elbow flexion restoration using pedicled latissimus dorsi transfer in seven cases

“…In case of complete elbow flexion palsy, pectoralis major transfer [24] could be an interesting solution. Finally, several free and reinnervated muscle transfers were proposed including gracilis [25][26][27][28][29] and rectus femoris [25,27]. While some series give encouraging results with 79% of M4 quoted strength [28], others show overall grade inferior to M3 [27] and a failure rate reaching 15% [29].…”

Algorithm for bionic hand reconstruction in patients with global brachial plexopathies

“…In 53% of the described cohort of 34 patients, classic reconstructive techniques restored sufficient hand/arm function similar to that reported in the literature. 37,38 In the remaining 47%, the patients demonstrated dismal hand function attributable to poor or inadequate surgical management or extensive neural injury. For this patient group In ARAT, a maximum of 57 points is attainable.…”

“…sions, repair has been focused on restoration of shoulder stability and biceps function. 35,36,38 If the lower roots are avulsed, however, the return of hand function is hardly ever achieved due to limited axonal support, long denervation time of muscles located more distally, and accompanying joint stiffness. Even though bodily integrity is maintained, some patients refer to their hand as an insensate, useless appendage that they would rather have amputated.…”

Restoration of finger and thumb movement using one-stage free muscle transplantation

“…However, ethnic differences in the strength of the gracilis muscle may exist. Terzis and Kostopoulos [19] reported that the gracilis strength was inadequate to allow for sufficient elbow flexion in Caucasians, whereas, in studies on East Asians, using the gracilis muscle provided good results [16]. This discrepancy may be attributed to variations in body size between Caucasians and East Asians.…”