Double free-muscle transfer to restore prehension following complete brachial plexus avulsion

Factors Affecting Outcomes After Free Functional Gracilis Muscle Transfer for Elbow Flexion in Brachial Plexus Injury: A Systematic Review and Meta-Analysis

PURPOSE

Free functional gracilis transfer (FFGT) is a useful option for reconstruction of elbow flexion following brachial plexus injury presenting late or with poor outcomes from previous nerve surgery. In this systematic review and meta-analysis, we aimed to investigate variables associated with superior outcomes. The efficacy of single versus double FFGT, where the first FFGT is performed to restore elbow flexion, and the choice of donor nerve for neurotization were evaluated.

METHODS

A meta-analysis was conducted, including studies that provided postoperative Medical Research Council (MRC) grade for elbow flexion, Disabilities of the Arm, Shoulder, and Hand and visual analog scale scores, quantitative elbow flexion strength, and range of motion. A random effects meta-regression analysis was performed to identify factors associated with improved outcomes.

RESULTS

Thirty-seven studies, with 1,607 patients, were analyzed. Single FFGT was reported in 34 studies (n = 1,398), and double FFGT was reported in 10 studies (n = 209). The mean follow-up duration was 37.3 ± 21.1 months. Following single FFGT, 75.4% and 48.9% achieved MRC grades ≥3 and ≥4, respectively. Following double FFGT, 100% achieved an MRC grade ≥3 and 62.7% ≥4. The likelihood of achieving M3 and M4 was significantly greater for double FFGT. Overall, FFGT innervated by the spinal accessory nerve had significantly better recovery of MRC grade ≥3. When comparing only single and double FFGT innervated by spinal accessory nerve, there was no significant difference in recovery of elbow flexion. The meta-regression analysis showed a significant negative correlation between the patient's age and the probability of achieving an MRC grade of ≥3 and 4.

CONCLUSIONS

In the overall analysis encompassing all innervating nerves, double FFGT was superior to single FFGT. Subgroup analysis of single and double FFGT innervated by the spinal accessory nerve showed no significant difference. Increasing age was a significant risk factor for poorer outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

A Novel Method of Spinal Accessory Nerve Banking Using Silicone Catheter for Functioning Free Muscle Transfer

In secondary brachial plexus reconstruction, exploring an area that has already been operated on is challenging and time-consuming for a surgeon, especially in centers with a single-team approach. Due to their inertness and lack of adverse effects, silicone Foley catheters were used successfully during the reconstruction of flexor tendons. Based on the concept, we have achieved an acceptable functional outcome by banking the spinal accessory nerve in a silicon catheter for gracilis reanimation, which permits smooth dissection, maintains the length, and shortens the operating time for subsequent reconstruction. Level of Evidence: Level V.

Treatment of Complete Brachial Plexus Injuries Using Double Free Muscle Transfer

PURPOSE

The purpose of this study was to examine the surgical outcomes of double free muscle transfer (DFMT) performed in patients with complete brachial plexus injury (BPI).

METHODS

We retrospectively analyzed the outcomes of DFMT for 12 patients with complete BPI who were followed up for more than 2 years after the final muscle transplantation. Their mean age was 29 years (range, 18-41). Three patients underwent contralateral C7 nerve root transfer before the DFMT. The range of motion (ROM) of the shoulder, elbow, and fingers was measured. Patient-reported outcome measures, including Disability of the Shoulder, Arm, and Hand (DASH) scores and visual analog scale (VAS) scores for pain, were also examined.

RESULTS

The mean shoulder ROM against gravity was 22° ± 8° in abduction and 33° ± 5° in flexion. Seven patients underwent phrenic nerve (PhN) transfer to the suprascapular nerves, and five exhibited asymptomatic lung impairment on spirography more than 2 years after PhN transfer. The mean elbow ROM against gravity was 111° ± 9° in flexion and -32° ± 7° in extension. All patients obtained elbow flexion >90° against a 0.5-kg weight. All patients obtained touch sensation and two recognized warm and cold sensations in the affected palm. The mean total active motion of the affected fingers was 44° ± 11°. All patients exhibited hook function of the hands. The mean preoperative and postoperative DASH scores were 70.3 ± 13.4 and 51.8 ± 15.9, respectively. The mean pain VAS score was 28 ± 31 at the final follow-up.

CONCLUSIONS

Double free muscle transfer provided patients with complete brachial plexus palsy with good elbow flexion and hand hook functions.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Free functional muscle transfer for lower extremity reconstruction

BACKGROUND

Free functional muscle transfer is a reconstructive strategy for the reconstruction of lost muscle units in the lower extremity after oncologic resection, trauma, compartment syndrome, or severe nerve injuries. Under appropriate circumstances, free functional muscle transfer may be the only suitable reconstructive option. This article reviews the underlying principles of free functional muscle transfer, its application to lower extremity reconstruction, appropriate patient selection, and surgical techniques.

METHODS

The underlying principles of free functional muscle transfer, its application to lower extremity reconstruction, appropriate patient selection, and surgical techniques are presented. Commonly used donor muscles appropriate for each type of functional defect are discussed. A review of recent publications on free functional muscle transfer in the lower extremity was also performed.

RESULTS

Good functional recovery with a Medical Research Council grade of up to 4/5 and full range of motion can be attained with free functional muscle transfer. Clinical outcomes and specific parameters for published case series in lower extremity free functional muscle transfer are presented and an illustrative case.

CONCLUSION

Free functional muscle transfer is a suitable treatment for the appropriate patient to restore essential functions and potentially regain ambulation. However, additional published clinical outcomes are needed and represent a major area for further investigation.

Phrenic Nerve as an Alternative Donor for Nerve Transfer to Restore Shoulder Abduction in Severe Multiple Root Injuries of the Adult Brachial Plexus

PURPOSE

Nerve transfer is the gold standard to restore shoulder abduction in acute brachial plexus injuries. The aim of this study was to compare the phrenic nerve (Ph) to the spinal accessory nerve (XI) as the donor nerve for this purpose.

METHODS

A retrospective chart review was performed on 136 patients with acute brachial plexus injuries who received a nerve transfer of the shoulder with either the Ph (94 patients) or XI (42 patients). Each group was divided into 3 subgroups based on the recipient nerve. The maximum degree of shoulder abduction was recorded after 2 years of postoperative follow-up. A generalized estimating equation model was performed to examine the variables affecting shoulder abduction over time.

RESULTS

The maximum degrees of shoulder abduction achieved were 61.9° ± 38.7° in patients with Ph and 51.1° ± 37.3° in patients with XI. More than M3 shoulder abduction was achieved by 67% of patients with Ph versus 59% of patients with XI. The regression analysis showed that the age at the time of surgery correlated more with the functional outcome over time than the choice of donor nerve.

CONCLUSIONS

In multiple root brachial plexus injuries, the Ph exhibited similar outcomes to the XI for shoulder abduction. Our routine exploration of the supraclavicular plexus exposes the Ph conveniently for nerve transfer. The phrenic nerve should be considered as an alternative when the XI is not available or is reserved for secondary reconstruction.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Long-Term Outcome of 118 Acute Total Brachial Plexus Injury Patients Using Free Vascularized Ulnar Nerve Graft to Innervate the Median Nerve

BACKGROUND

 The restoration of finger movement in total brachial plexus injuries (BPIs) is an ultimate challenge. Pedicled vascularized ulnar nerve graft (VUNG) connecting a proximal root to distal target nerves has shown unpredictable outcomes. We modified this technique by harvesting VUNG as a free flap to reinnervate median nerve (MN). We analyzed the long-term outcomes of these methods.

METHODS

 From years 1998 to 2015, 118 acute total brachial plexus patients received free VUNG to innervate the MN. Patients were followed up at least 5 years after the initial surgery. Donor nerves included the ipsilateral C5 root (25 patients) or contralateral C7 root (CC7 = 93 patients). Recovery of finger and elbow flexion was evaluated with the modified Medical Research Council system. Michigan Hand Score and Quick-DASH were used to represent the patient-reported outcomes.

RESULTS

 For finger flexion, ipsilateral C5 transfer to MN alone yielded similar outcomes to MN + MCN (musculocutaneous nerve), while CC7 had significantly better finger flexion when coapted to MN alone than to MN + MCN. Approximately 75% patients were able to achieve finger flexion with nerve transfer alone. For elbow flexion, best outcome was seen in the ipsilateral C5 to MCN and MN.

CONCLUSION

 In acute total BPI, the priority is to identify the ipsilateral C5 root to innervate MN, with concomitant innervation of MCN to establish the best outcomes for finger and elbow flexion. CC7 is more reliable when used to innervate one target (MN).

LEVEL OF EVIDENCE

 III.

Outcome of free gracilis muscle transfer for the restoration of elbow flexion in traumatic brachial plexus palsy

Objectives

The aim of this study was to evaluate the functional outcomes of patients with free gracilis muscle transfer (FGMT) for the restoration of elbow flexion.

Patients and methods

Between January 2012 and January 2019, a total of 16 patients (13 males, 3 females; mean age: 27.3±11.7 years; range: 18 to 53 years) who underwent FGMF to achieve elbow flexion after traumatic brachial plexus palsy (TBPP) were retrospectively analyzed. Data including demographic and clinical characteristics of the patients, etiology, affected side, injury level, accompanying injuries, time between injury and surgery, follow-up time, complications, whether nerve reconstruction and artery repair were performed previously, and details of the procedure were recorded. The outcome measures were elbow range of motion in degrees, muscle strength, and Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form-36 (SF-36) scores.

Results

The mean follow-up was 30±11.5 (range, 24 to 42) months. Two patients had C5-C8 injuries, two patients had C6-T1 injuries, and all other patients had injuries to the C5-T1 roots. Muscle strength was M3/M4 in 11 (68.8%) patients, M2 in two (12.5%) patients, and M0 in one (6.2%) patient. The median active range of motion of the elbow joint in patients with successful results (M3 and above) was measured as 75 (range, 30 to 100) degrees. A statistically significant improvement was observed in the pre- and postoperative DASH scores and in some SF-36 subscale scores of patients with successful results.

Conclusion

Free gracilis muscle flap is a reliable option in the restoration of elbow flexion in patients with TBPP. Although there is an improvement in functional results, disability, and quality of life, there may be no change in patients’ mental status and pain.

Distal Nerve Transfers to the Triceps Brachii Muscle: Surgical Technique and Clinical Outcomes

PURPOSE

To report the clinical outcomes and describe the surgical technique of triceps muscle reinnervation using 2 different distal nerve transfers: the flexor carpi ulnaris (FCU) fascicle of the ulnar nerve and the posterior branch of the axillary nerve (PBAN) to the triceps nerve branch.

METHODS

A retrospective review of patients undergoing FCU fascicle of ulnar nerve or PBAN to triceps nerve branch transfer was performed. Outcome measures included preoperative and postoperative modified British Medical Research Council (MRC) score, EMG results, and complications.

RESULTS

Between September 2003 and April 2017, 6 patients were identified. Four patients with a traumatic upper trunk and posterior cord palsy underwent ulnar nerve fascicle to triceps nerve transfer. Two patients with a recovering upper trunk following a pan-brachial plexus palsy underwent PBAN to triceps nerve branch transfer. The median age was 30.0 years (range, 18-68 years). Surgery was performed at a median of 6.9 months (range, 5.0-8.9 months) postinjury, with a median follow-up of 18.4 months (range, 7.6-176.3) months. Before surgery, 4 patients exhibited grade M0 and 2 patients exhibited grade M1 triceps strength. Four patients had M5 donor muscle strength and 2 had grade M4. Postoperatively, 4 patients regained MRC grade M4 triceps muscle strength, 1 regained M3, and 1 regained M2. There was no noticeable donor muscle weakness.

CONCLUSIONS

Nerve fascicles to the FCU and PBAN are viable options for obtaining meaningful triceps muscle recovery in a select group of patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Evaluation of Triple Neurotization Technique as a Single Procedure in Adult Traumatic Brachial Plexus Injury

INTRODUCTION

Brachial plexus injuries are common and result in significant disabilities. This study evaluated the outcome of triple neurotization as a single procedure for upper trunk brachial plexus injury.

PATIENTS AND METHODS

Some 25 adult consecutive patients with injured upper trunk brachial plexus who underwent microscopic reconstructive surgery using triple neurotization technique in the authors' institute were recruited in this study. Data on operative and functional outcomes were captured. Modified Narkas scale was used to evaluate the shoulder function in addition to Waikakul scale which was used to evaluate the elbow function. Data were analyzed with respect to short and long term with a median follow-up duration of two years.

RESULTS

Assessment of the recovered shoulder abduction was excellent in 48% (n=12), good in 24% (n=6), fair in 16% (n=4), and poor in 12% of cases (n=3). Shoulder external rotation recovery was excellent in 48% (n=12), good in 12% (n=3), fair in 12% (n=3), and poor in 28% of cases (n=7). Recovery of elbow flexion was excellent in 60% (n=15), good in 12% (n=3), fair in 12% (n=3), and poor in 16% of cases (n=4). The mean value of recovered shoulder abduction was 111.26 degrees (range: 70-150). The mean value of restored shoulder external rotation was 57.5 degrees (range: 45-70). The mean value of restored elbow flexion was 75 degrees (range: 55-120).

CONCLUSION

Triple neurotization technique can be effective to restore elbow flexion, shoulder abduction, and external rotation in adult patients with upper trunk brachial plexus injury.

Role of free functioning muscle transfer in improving the functional outcomes following replantation of crush avulsion amputations of the forearm

Replantation still remains the best form of reconstruction following major upper limb amputations. Regaining a functional limb is a challenge in avulsion amputations when there is entire loss of a compartment as it happens in proximal third of forearm amputations or when the avulsion occurs through the musculotendinous junction. In these circumstances, primary repair of the long flexors or extensors is not possible and options of secondary tendon transfers do not exist due to lack of donor tendons. These factors could weigh in negatively in making the decision for replantation at the time of presentation. We are presenting a series of 5 cases of avulsion amputation of the forearm wherein the functional outcome was enhanced by secondary Free Functional Muscle transfers (FFMT) using gracilis for finger flexion. Outcome scores improved from Chen IV to II in three patients and to III in two patients. The feasibility of gaining useful outcome through secondary procedures like FFMT should serve as an encouragement to extend the indications for replantation in avulsion amputations of the forearm.

Systematic review on outcome of free functioning muscle transfers for elbow flexion in brachial plexus injuries

Elbow flexion is widely regarded as the most important function to restore in brachial plexus injuries. Free functioning muscle transfer surgery is indicated in patients with delayed presentation or failure of other primary procedures. Results of the transfer surgeries have been reported in the form of case series, but no further studies are available. This systematic review aims to provide a deeper understanding of this complex surgery and consists of 19 articles that include 364 patients. Data on injury characteristics, surgical techniques, complications as well as outcome measures were analysed. Our results show that functional muscle transfer for elbow flexion enables 87% and 65% of patients to achieve a useful power grade of ≥ 3 and ≥ 4, respectively, although other important outcome factors should be considered.

Redefining the Anatomic Boundaries for Safe Dissection of the Skin Paddle in a Gracilis Myofasciocutaneous Free Flap: An Indocyanine Green Cadaveric Injection Study

The gracilis free flap remains a versatile option in the reconstructive ladder. The flap itself can be harvested with or without a skin paddle. The gracilis myocutaneous free flap, however, is known for partial skin flap necrosis, especially in the distal one-third of the skin island. The gracilis myofasciocutaneous flap has been previously described as a technique to improve perfusion to the skin by harvesting surrounding deep fascia in a pedicled flap. However, limitations to this study required injection of multiple pedicles to demonstrate its perfusion. We demonstrate a novel technique using a cadaveric model that shows perfusion through injection via a single dominant pedicle (medial circumflex) with a large cutaneous paddle (average 770 cm²) with included deep fascia, using indocyanine green and near-infrared imaging. For comparison, we are also able to confirm the lack of perfusion to the distal cutaneous paddle when the fascia is not harvested, correlating with previous findings and ink injection studies. This novel technique is versatile, relatively inexpensive, and can demonstrate perfusion patterns via perforasomes that were otherwise not possible from previous techniques. Additionally, real-time imaging is possible, helping to elucidate the sequence of flow into the flap and potentially predict areas of flap necrosis.

Transfer of the triceps brachii to the finger and thumb extensors: Anatomical study and report on one case

Our aims were to study the anatomical feasibility of triceps brachii long head (TBLH) transfer to the extensor digitorum communis (EDC) and extensor pollicis longus (EPL) tendons through a medial route, and to report on its first clinical application. Dissections were conducted on 10 fresh-frozen cadaver specimens. Using a posteromedial approach, the TBLH was separated from the remaining triceps and extended distally with a fascia lata strip. This strip was then tunneled through a medial route and secured distally to the EDC and EPL tendons. The transfer tenodesis effect during elbow extension was assessed with metacarpophalangeal (MCP) joint motion of the thumb and index finger, and the distance between the thumb and index finger tips (TI distance). This transfer was performed in an eight-year-old boy with incomplete recovery of a right brachial plexus birth palsy; preoperatively, shoulder and elbow functions were recovered as well as active gripping distally, but he had no active wrist or finger extension. With the trapeziometacarpal and radiocarpal joints stabilized, 90° elbow extension provided a mean extension of the thumb and index finger MCP joints of 34 ± 5° and 90 ± 11°, respectively, with a mean TI distance of 116 ± 16 mm. Twelve months after surgery, the boy had full active MCP joint extension, independent from elbow extension. Transferring the TBLH to the EDC and EPL tendons is anatomically feasible. Larger clinical studies will be needed to assess more adequately its functional outcomes.

Spinal accessory nerve to triceps muscle transfer using long autologous nerve grafts for recovery of elbow extension in traumatic brachial plexus injuries

OBJECTIVE

Reconstructive options for brachial plexus lesions continue to expand and improve. The purpose of this study was to evaluate the prevalence and quality of restored elbow extension in patients with brachial plexus injuries who underwent transfer of the spinal accessory nerve to the motor branch of the radial nerve to the long head of the triceps muscle with an intervening autologous nerve graft and to identify patient and injury factors that influence functional triceps outcome.

METHODS

A total of 42 patients were included in this retrospective review. All patients underwent transfer of the spinal accessory nerve to the motor branch of the radial nerve to the long head of the triceps muscle as part of their reconstruction plan after brachial plexus injury. The primary outcome was elbow extension strength according to the modified Medical Research Council muscle grading scale, and signs of triceps muscle recovery were recorded using electromyography.

RESULTS

When evaluating the entire study population (follow-up range 12–45 months, mean 24.3 months), 52.4% of patients achieved meaningful recovery. More specifically, 45.2% reached Grade 0 or 1 recovery, 19.1% obtained Grade 2, and 35.7% improved to Grade 3 or better. The presence of a vascular injury impaired functional outcome. In the subgroup with a minimum follow-up of 20 months (n = 26), meaningful recovery was obtained by 69.5%. In this subgroup, 7.7% had no recovery (Grade 0), 19.2% had recovery to Grade 1, and 23.1% had recovery to Grade 2. Grade 3 or better was reached by 50% of patients, of whom 34.5% obtained Grade 4 elbow extension.

CONCLUSIONS

Transfer of the spinal accessory nerve to the radial nerve branch to the long head of the triceps muscle with an interposition nerve graft is an adequate option for restoration of elbow extension, despite the relatively long time required for reinnervation. The presence of vascular injury impairs functional recovery of the triceps muscle, and the use of shorter nerve grafts is recommended when and if possible.

Recovery of Elbow Flexion after Nerve Reconstruction versus Free Functional Muscle Transfer for Late, Traumatic Brachial Plexus Palsy: A Systematic Review

BACKGROUND

In late presentation of brachial plexus trauma, it is unclear whether donor nerves should be devoted to nerve reconstruction or reserved for free functional muscle transfer. The authors systematically reviewed recovery of elbow flexion after nerve reconstruction versus free functional muscle transfer for late, traumatic brachial plexus palsy.

METHODS

A systematic review was performed using the PubMed, Embase, and Cochrane databases to identify all cases of traumatic brachial plexus palsy in patients aged 18 years or older. Patients who underwent late (≥12 months) nerve reconstruction or free functional muscle transfer for elbow flexion were included. Age, time to operation, and level of brachial plexus injury were recorded. British Medical Research Council grade for strength and range of motion were evaluated for elbow flexion.

RESULTS

Thirty-three studies met criteria, for a total of 103 patients (nerve reconstruction, n = 53; free functional muscle transfer, n = 50). There were no differences across groups regarding surgical age (time from injury) and preoperative elbow flexion. For upper trunk injuries, 53 percent of reconstruction patients versus 100 percent of muscle transfer patients achieved grade M3 or greater strength, and 43 percent of reconstruction patients versus 70 percent of muscle transfer patients achieved grade M4 or greater strength. Of the total brachial plexus injuries, 37 percent of reconstruction patients versus 78 percent of muscle transfer patients achieved grade M3 or greater strength, and 16 percent of reconstruction patients versus 46 percent of muscle transfer patients achieved grades M4 or greater strength.

CONCLUSION

In late presentation of traumatic brachial plexus injuries, donor nerves should be reserved for free functional muscle transfer to restore elbow flexion.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Reliability of functioning free muscle transfer and vascularized ulnar nerve grafting for elbow flexion in complete brachial plexus palsy

We compared outcomes of primary vascularized ulnar nerve grafts from the C5 root neurotizing biceps and brachialis muscles, and gracilis functioning free muscle transfer neurotized by the distal spinal accessory nerve, as a primary or salvage procedure after complete brachial plexus injury. At 45 months, three of eight primary vascularized ulnar nerve graft patients regained grade 4 elbow flexion, while one regained grade 3. All 13 primary gracilis transfer patients regained grade 4 elbow flexion. Four patients with vascularized ulnar nerve grafts failed and subsequently had salvage functioning free muscle transfer procedures resulting in delayed recovery. Although vascularized ulnar nerve graft-based primary reconstructions can provide useful elbow flexion, this was achieved in less than half the cases. We consider primary gracilis functioning free muscle transfer neurotized by the distal spinal accessory nerve as the most reliable reconstruction for the restoration of elbow flexion in complete brachial plexus injury.

LEVEL OF EVIDENCE

IV.

Electromyographic Findings in Gracilis Muscle Grafts Used to Augment Elbow Flexion in Traumatic Brachial Plexopathy

BACKGROUND

Gracilis muscle graft transplantation is one of the last resort surgical options to restore elbow flexion in patients with chronic traumatic upper-trunk brachial plexopathies.

METHODS

We retrospectively identified 34 patients who underwent surgeries between 1997 and 2014, and had postoperative follow-up for at least 12 months. Demographic, clinical, and electromyographic preoperative and postoperative data were analyzed.

RESULTS

The median age of injury was 30 years old. Most subjects had a complete loss of elbow flexion preoperatively (n = 28, 82.4%). Median time from injury to surgery was 20 months (range = 3-226 months). It did not correlate with the time to reinnervation on EMG (r = 0.35, 95% CI = 0.007-0.62) or with the time improvement in muscle strength (r = 0.35, 95% CI = 0.007-0.62). The mean postoperative follow-up interval was 22.35 months. During that period, 32 of 34 (94%) patients achieved reinnervation. Median times from surgery to graft innervation and to any improvement in elbow flexor muscle power were the same (8.5 months) with overlapping time to event curves.

CONCLUSION

Despite the long-standing and complete loss of elbow flexion in most of our patients, gracilis transfer surgeries have helped most of them to achieve reinnervation and start to regain function. Electromyography is a helpful tool, which along with the clinical examination, can predict postoperative improvement.

Free Functional Muscle Transfer Tendon Insertion Secondary Advancement Procedure to Improve Elbow Flexion

One method of restoring elbow flexion in patients with brachial plexus injuries is through the use of free functional muscle transfer. Most of our patients achieve good outcome, resulting in improved usefulness of the affected limb. However, a minority of our patients have successful reinnervation of the transferred muscle but with a suboptimal strength and range of motion (ROM) of elbow flexion. In this subset of patients, we perform a secondary procedure to improve the moment arm of the muscle on the elbow joint. This involves advancing the transferred muscle distally along the radius. The technique of the advancement procedure is described. We also report on our initial series of 5 patients who underwent this advancement procedure. In one patient, there was improvement in strength alone. In another, there was improvement of the ROM alone. The remaining 3 patients had improvement of both strength and ROM.

Free Functional Muscle Transfers to Restore Upper Extremity Function

Free functional muscle transfer provides an option for functional restoration when nerve reconstruction and tendon transfers are not feasible. To ensure a successful outcome, many factors need to be optimized, including proper patient selection, timing of intervention, donor muscle and motor nerve selection, optimal microneurovascular technique and tension setting, proper postoperative management, and appropriate rehabilitation. Functional outcomes of various applications to the upper extremity and the authors' algorithm for the use of free functional muscle transfer are also included in this article.

Functional outcome and quality of life after traumatic total brachial plexus injury treated by nerve transfer or single/double free muscle transfers

Aims

Between 2002 and 2011, 81 patients with a traumatic total brachial plexus injury underwent reconstruction by double free muscle transfer (DFMT, 47 cases), single muscle transfer (SMT, 16 cases) or nerve transfers (NT, 18 cases).

Methods

They were evaluated for functional outcome and quality of life (QoL) using the Disability of Arm, Shoulder and Hand questionnaire, both pre- and post-operatively. The three groups were compared and followed-up for at least 24 months.

Results

The mean shoulder abduction and flexion were comparable in all groups, but external rotation was significantly better in the DFMT group as were range and quantitative power of elbow flexion. Patients who had undergone DFMT had reasonable total active finger movement and hook grip strength. All groups showed improvement in function at a level greater than a minimum clinically important difference. The DFMT group showed the greatest improvement.

Discussion

Patients in the DFMT group had a better functional outcome and QoL recovery than those in the NT and SMT groups. Take home message: Double free muscle transfer procedure is capable of restoring maximum function in patients of total brachial plexus palsy. Cite this article: Bone Joint J 2016;97-B:209–17.

MUSCLE TRANSFER FROM TRICEPS TO BICEPS IN PATIENTS WITH CHRONIC INJURY OF THE UPPER TRUNK OF THE BRACHIAL PLEXUS

Objective: To evaluate the results from transposition of the triceps for elbow flexion in patients with chronic and complete injury to the upper trunk of the brachial plexus. Methods: This was a retrospective study, including only patients who had biceps grade 0 and triceps grade 5, who underwent anterior transfer of the triceps muscle, performed between 1998 and 2005. The affected side, sex, type of accident, strength of elbow flexion, complications and patient satisfaction were investigated in 11 cases. Results: 10 patients were male; the age range was from 24 to 49 years, with a mean of 33.7 years. The minimum time between injury and surgery was 21 months (range 21-74 months). The left side was affected in eight cases, and the right only in three. Good results were obtained in 10 patients, who acquired elbow flexion strength of grade 3 (two cases) and grade 4 (eight cases), while one evolved unfavorably with grade 2 strength. Two cases had complications (initial compartment syndrome and insufficient tensioning). All the patients said that they were satisfied with the procedure. Conclusion: Anterior transposition of the triceps muscle provided patient satisfaction in all cases except one, attaining strength grade 4 in eight cases, grade 3 in two cases and grade 2 in one case.

Functional free muscle transfer for upper extremity reconstruction

BACKGROUND

Functional losses in the upper extremity that cannot be restored by nerve or tendon transfer present a treatment dilemma to the reconstructive surgeon. Common indications for functional free muscle transfer include late reconstruction of brachial plexus injuries, traumatic muscle loss, Volkmann ischemic contracture, loss resulting from oncologic resection, and congenital absence of motor function as seen in arthrogryposis.

METHODS

This article reviews the authors' experience in upper extremity reconstruction using functional free muscle transfer. The indications and technique for functional free muscle transfer in the upper extremity are reviewed. Surgical details for sites of reconstruction and the nuances of harvesting the main donor muscles are presented.

RESULTS

Specific cases and outcome reviews for several series of functional free muscle transfers are presented.

CONCLUSION

Functional free muscle transfer is the best and final option for restoring function in an otherwise nonreconstructible limb.

Treatment options for brachial plexus injuries

The incidence of brachial plexus injuries is rapidly growing due to the increasing number of high-speed motor-vehicle accidents. These are devastating injuries leading to significant functional impairment of the patients. The purpose of this review paper is to present the available options for conservative and operative treatment and discuss the correct timing of intervention. Reported outcomes of current management and future prospects are also analysed.

Free functional muscle transplantation of an anomalous femoral adductor with a very large muscle belly: a case report

We report the case of a 34-year-old man with a total brachial plexus injury that was treated by free functional muscle transplantation to restore simultaneously elbow flexion and finger extension. The muscle had a very large muscle belly (12 cm width), which was considered anatomically to be a fusion of the gracilis and the adductor longus muscles. Although the muscle possessed two major vascular pedicles with almost equal diameters, only the proximal vascular pedicle was anastomosed to the recipient vessels during the transplantation surgery, resulting in partial necrosis of the muscle. Several authors have reported on the successful simultaneous transplantation of the gracilis and adductor longus muscles, because they are supplied generally by a single common vascular pedicle. However, the present study suggests that when a surgeon encounters an aberrant femoral adductor with a very large muscle belly that can be considered to be a fusion of these muscles, the surgeon should assess intraoperatively the vascularity of the muscle using Doppler sonography, indocyanine green fluorescence injection, or other techniques.

Surgical treatment for total root avulsion type brachial plexus injuries by neurotization: a prospective comparison study between total and hemicontralateral C7 nerve root transfer

PURPOSE

We conducted a clinical study to evaluate the effects of neurotization, especially comparing the total contralateral C7 (CC7) root transfer to hemi-CC7 transfer, on total root avulsion brachial plexus injuries (BPI).

METHODS

Forty patients who received neurotization for BPI were enrolled in this prospective study. Group 1 (n = 20) received hemi-CC7 transfer for hand function, while group 2 (n = 20) received total-CC7 transfer. Additional neurotization included spinal accessory, phrenic, and intercostal nerve transfer for shoulder and elbow function. The results were evaluated with an average of 6 years follow-up.

RESULTS

Group 1 had fewer donor site complications (15%) than group 2 (45%); group 2 had significantly better hand M3 and M4 motor function (65%) than group 1 (30%; P = 0.02). There was no difference in sensory recovery. Significantly, better shoulder function was obtained by simultaneous neurotization on both suprascapular and axillary nerves.

CONCLUSIONS

Total-CC7 transfer had better hand recovery but more donor complications than hemi-CC7. Neurotization on both supra-scapular and axillary nerves improved shoulder recovery.

Brachial plexus injury in adults: Diagnosis and surgical treatment strategies

Adult post traumatic Brachial plexus injury is unfortunately a rather common injury in young adults. In India the most common scenario is of a young man injured in a motorcycle accident. Exact incidence figures are not available but of the injuries presenting to us about 90% invole the above combination This article reviews peer-reviewed publications including clinical papers, review articles and Meta analysis of the subject. In addition, the authors' experience of several hundred cases over the last 15 years has been added and has influenced the ultimate text. Results have been discussed and analysed to get an idea of factors influencing final recovery. It appears that time from injury and number of roots involved are most crucial.

Functional reconstruction of sarcoma defects utilising innervated free flaps

Soft-tissue reconstruction following preoperative radiotherapy and wide resection of soft tissue sarcoma remains a challenge. Pedicled and free tissue transfers are an essential part of limb sparing surgery. We report 22 cases of sarcoma treated with radiotherapy and wide excision followed by one-stage innervated free or pedicled musculocutaneous flap transfers. The resection involved the upper limb in 3 cases, the lower limb in 17, and the abdominal wall in 2. The flaps used for the reconstruction were mainly latissimus dorsi and gracilis. The range of motion was restored fully in 14 patients. The muscle strength of the compartment reconstructed was of grades 4 and 5 in all patients except one. The overall function was excellent in all the cases with functional scores of 71.2% in the upper limb and 84% in the lower limb. The only 2 major complications were flap necrosis, both revised with another flap, one of which was innervated with restoration of function. Innervated flaps are valuable alternatives for reconstruction after sarcoma resection in the extremity and in the abdominal wall. The excellent functional results are encouraging, and we believe that innervated muscle reconstruction should be encouraged in the treatment of sarcoma after radiotherapy and wide resection.

Minimum 4-year follow-up on contralateral C7 nerve transfers for brachial plexus injuries

PURPOSE

Contralateral C7 (CC7) transfer for brachial plexus injuries (BPI) can benefit finger sensation but remains controversial regarding restoration of motor function. We report our 20-year experience using CC7 transfer for BPI, all of which had at least 4 years of follow-up.

METHODS

A total of 137 adult BPI patients underwent CC7 transfer from 1989 to 2006. Of these patients, 101 fulfilled the inclusion criteria for this study. A single surgeon performed all surgeries. A vascularized ulnar nerve graft, either pedicled or free, was used for CC7 elongation. The vascularized ulnar nerve graft was transferred to the median nerve (group 1, 1 target) in 55 patients, and to the median and musculocutaneous nerves (group 2, 2 targets) in 23 patients. In another 23 patients (group 3, 2 targets, 2 stages), the CC7 was transferred to the median nerve (17 patients) or to the median and musculocutaneous nerve (6 patients) during the first stage, followed by functioning free muscle transplantation for finger flexion.

RESULTS

We considered finger flexion strength greater or equal to M3 to be a successful functional result. Success rates of CC7 transfer were 55%, 39%, and 74% for groups 1, 2, and 3, respectively. In addition, the success rate for recovery of elbow flexion (strength M3 or better) in group 2 was 83%.

CONCLUSIONS

In reconstruction of total brachial plexus root avulsion, the best option may be to adopt the technique of using CC7 transfer to the musculocutaneous and median nerve, followed by FFMT in the early stage (18 mo or less) for finger flexion. Such a technique can potentially improve motor recovery of elbow and finger flexion in a shorter rehabilitation period (3 to 4 y) and, more importantly, provide finger sensation to the completely paralytic limb.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Microsurgery of the upper extremity

In the past 50 years, hand surgeons have made considerable contributions to microsurgery. The unique demands of complex upper extremity care have driven many of the technical and scientific advances of this discipline, including functional muscle transfers, nerve transfers, and composite tissue allotransplantation. The purpose of this article was to review the current applications of microsurgery to the upper extremity.

Complications of intercostal nerve transfer for brachial plexus reconstruction

PURPOSE

Although numerous publications discuss outcomes of intercostal nerve transfer for brachial plexus injury, few publications have addressed factors associated with intercostal nerve viability or the impact perioperative nerve transfer complications have on postoperative nerve function. The purposes of this study were to report the results of perioperative intercostal nerve transfer complications and to determine whether chest wall trauma is associated with damaged or nonviable intercostal nerves.

METHODS

All patients who underwent intercostal nerve transfer as part of a brachial plexus reconstruction procedure as a result of injury were identified. A total of 459 nerves in 153 patients were transferred between 1989 and 2007. Most nerves were transferred for use in biceps innervation, free-functioning gracilis muscle innervation, or a combination of the two. Patient demographics, trauma mechanism, associated injuries, intraoperative nerve viability, and perioperative complications were reviewed.

RESULTS

Complications occurred in 23 of 153 patients. The most common complication was pleural tear during nerve elevation, occurring in 14 of 153 patients. Superficial wound infection occurred in 3 patients, whereas symptomatic pleural effusion, acute respiratory distress syndrome, and seroma formation each occurred in 2 patients. The rate of complications increased with the number of intercostal nerves transferred. Nerves were harvested from previously fractured rib levels in 50 patients. Rib fractures were not associated with an increased risk of overall complications but were associated with an increased risk of lack of nerve viability. In patients with rib fractures, intraoperative nerve stimulation revealed 148 of 161 nerves to be functional; these were subsequently transferred. In patients with preoperative ipsilateral phrenic nerve palsy, the risk of increased complications was marginally significant.

CONCLUSIONS

Brachial plexus reconstruction using intercostal nerves can be challenging, especially if there is antecedent chest wall trauma. Complications were associated with increasing numbers of intercostal nerves transferred. Ipsilateral rib fracture was adversely associated with intercostal nerve viability; it was not significantly associated with complication risk and should not be considered a contraindication to transfer. Preoperative phrenic nerve palsy was marginally associated with the likelihood of complications but not postoperative respiratory dysfunction when associated with intercostal nerve transfer.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Free Muscle Transfer in Posttraumatic Plexopathies Part II: The Elbow

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.

History of microsurgery

In the mid-1500s, the techniques of vascular ligature and vascular suture were developed sporadically by several pioneers in this field. However, vascular surgery became realistic experimentally as a result of the work by Carrel and Guthrie in the early 1900s, in which they performed replantations and transplantations of several composite tissues and organs, including amputated limbs, kidneys, and others using experimental animals. In contrast, the development of heparin by Howell and Holt in 1918 accelerated the rate of these types of operations being performed with increasing success in humans. Since the first use of a monocular microscope for ear surgery by Nylen in 1921 and a binocular microscope by Holmgren in 1923, in addition to the timely developments of the Zeiss operating microscope, microsurgical instruments, and suture materials, microsurgery was born in several surgical disciplines in the ensuing 50-year period. The application of microvascular surgery and microneurosurgery in the fields of hand, plastic, and reconstructive surgery resulted in revolutionary advances in clinical replantation and transplantation of composite tissues and more allotransplantations.

Late reconstruction for brachial plexus injury

Traumatic brachial plexus injuries are devastating and management is complex. Treatment involves a multidisciplinary approach. Primary reconstruction involves nerve repair, grafting, and transfer techniques. Secondary reconstruction includes microneurovascular free-functioning muscle transfer, tendon transfers, and arthrodesis to improve or restore function. These procedures are indicated when patients present more than 12 months from injury or when primary reconstruction procedures fail, and should focus on elbow flexion and shoulder stability. A free-functioning muscle transfer is often indicated for elbow flexion, with double free-functioning muscle transfers providing possible prehension. Shoulder reconstruction focuses on restoring stability to the glenohumeral joint and restoring abduction. This article outlines these techniques, their principles, and important details.

Restoration of active fingers flexion with tensor fascia lata transfer in total brachial plexus palsy

In total brachial plexus palsy, fingers flexion restoration is a real challenge. Nerve surgery can generally restore shoulder abduction and elbow flexion. However, results of nerve grafts or nerve transfers are generally poor for hand function. As a matter of fact, the long distance between nerve sutures and terminal nerve branches in muscles decreases the rate of reinnervation. When finger flexion occurs, strength is generally weak and function remains fair. Therefore, we proposed a new technique to restore fingers flexion. The tensor fascia lata tendon is harvested and sutured between the biceps and flexor digitorum profundus (FDP) tendons. When elbow is flexed, the biceps muscle contraction pulls FDP tendons resulting in a partial but strong hand occlusion. This technique is an alternative to free muscle transfers or nerve surgery with reliable results.

Measuring outcomes in adult brachial plexus reconstruction

The focus of this article is on evaluating the various outcome measures of surgical interventions for adult brachial plexus injuries. From a surgeon's perspective, the goals of surgery have largely focused on the return of motor function and restoration of protective sensation. From a patient's perspective, alleviation of pain, cosmesis, return to work, and emotional state are also important. The ideal outcome measure should be valid, reliable, responsive, unbiased, appropriate, and easy. The author outlines pitfalls and benefits of current outcome measures and offers thoughts on possible future measures.

Nerve transfers for brachial plexus reconstruction

Brachial plexus injuries result in devastating loss of function for patients and present incredible challenges for peripheral nerve surgeons. Recently, nerve transfers have produced superior results compared with traditional interposition nerve grafts for brachial plexus reconstruction. The authors present a review of current surgical options for treatment of partial and complete adult brachial plexus injuries using nerve transfers.

Free functional gracilis muscle transfer in children with severe sequelae from obstetric brachial plexus palsy

We present 4 children between 6 and 13 years suffering from severe sequelae after a total obstetric brachial plexus lesion resulting in a hand without functional active long finger flexion. They had successfully reanimated long finger flexion using a free functional gracilis muscle transfer. These children initially presented a total obstetric brachial plexus palsy without neurotisation of the lower trunk in an early microsurgical nerve reconstruction procedure.

We describe our indications for this complex microsurgical procedure, the surgical technique and the outcome.

Management of hand palsies in isolated C7 to T1 or C8, T1 root avulsions

Thirteen patients were operated on for hand palsies in cases of C7 to T1 or C8, T1 root avulsions. Finger flexion and intrinsic function were paralyzed in all patients. Finger extension was paralyzed in 12 patients. Wrist flexion and extension were present in all patients. Tendon transfers were performed to restore the different functions. The extensor carpi radialis longus was transferred to the flexor digitorum profundus. The brachioradialis tendon was transferred to the flexor pollicis longus tendon for thumb flexion, with a tendon translocation procedure in 6 patients. Intrinsic function was reanimated with passive capsulorrhaphy techniques or other equivalent techniques in 9 patients. Extensor tenodesis was performed to restore hand opening with active wrist flexion in all patients. Moreover, sensory neurotization was performed to restore sensation on the ulnar side of the hand. All patients recovered finger flexion with an average pulp-to-palm distance of 2 cm. Finger extension occurred in 30 degrees wrist flexion. The average Kapandji score was 3. Key pinch was present in all patients. The average grip strength was 8 kg; the average key pinch was 5 kg. All patients recovered a protective sensation with a mean time of 19.5 months. Injury with C7 to T1 or C8, T1 root avulsions is a rare entity. Motor nerve surgery is not possible in these cases. However, surgery remains a challenge and may greatly improve these patients. Therefore, we propose a new tendon transfer and sensory neurotization protocol.

Innovations in osteosynthesis and fracture care

Over the years giant steps have been made in the evolution of fracture fixation and the overall clinical care of patients. Better understanding of the physiological response to injury, bone biology, biomechanics and implants has led to early mobilisation of patients. A significant reduction in complications during the pre-operative and post-operative phases has also been observed, producing better functional results. A number of innovations have contributed to these improved outcomes and this article reports on the advances made in osteosynthesis and fracture care.