Advancement of the insertion of the biceps brachii muscle: a technique for increasing elbow flexion force

Tendon transfers to restore elbow flexion

Elbow flexion paralysis is one of most significant deficiencies in the upper limb. When secondary to brachial plexus palsy or nerve trunk lesions, restoration of elbow flexion by means of early nerve surgery or palliative transfers should be part of a comprehensive treatment plan. Tendon transfers are indicated in long-standing palsies, in those who are poor candidates for nerve surgery or when the results of nerve surgery are inadequate. A regional pedicled muscle transfer is performed if available. In this case, a "strong" donor is preferred (pectoralis major with pectoralis minor transfer, triceps brachii to biceps brachii transfer, or bipolar latissimus dorsi transfer). A "weak" transfer is indicated in patients who have incomplete recovery of elbow flexion (MRC 2 strength): isolated pectoralis minor transfer, medial epicondylar muscle transfer according to Steindler technique, or advancement of biceps brachii tendon on forearm. When no donor muscle is available, a free reinnervated muscle transfer may be indicated if age and nerve regeneration conditions are favorable.

Effects of humeral shortening on the three-dimensional configuration of the brachial plexus: a cadaveric study

This study reports the gains in length of nerves after three different humeral shortenings. Ten brachial plexuses were dissected. The lengths of the different parts of the brachial plexus were measured using a three-dimensional digitizing system after humeral shaft shortenings of 2, 4 and 6 cm and after a standardized force of 0.588 N was used to apply tension to the plexus. The feasibility of nerve suturing was studied. Humeral shortening allowed for significant gains in lengths of the musculocutaneous (42 mm), median (41 mm), ulnar (29 mm) and radial nerves (15 mm). A 2 cm humeral shortening allowed a 2 cm nerve gap to be directly sutured in 70% to 90% of cases. This study suggests that humeral shortening could allow direct suture of nerve defects, or shorten the length of nerve grafts required to bridge a gap.

Free Reverse Gracilis Muscle Combined With Steindler Flexorplasty for Elbow Flexion Reconstruction After Failed Primary Repair of Extended Upper-Type Paralysis of the Brachial Plexus

PURPOSE

To report the clinical outcomes of elbow flexion reconstruction using a reverse free gracilis muscle flap plus Steindler flexorplasty in patients with previously failed reconstruction of extended upper-type brachial plexus paralysis.

METHODS

Twenty-four male patients were reoperated upon an average of 45 months (SD, ± 45 months) after brachial plexus repair. The gracilis tendon was secured to the acromion, and the muscle belly was sutured to the biceps distal tendon. Vascular repair was performed preferentially end to end to the radial artery and cephalic vein. Nerve repair was achieved by coapting the nerve to the gracilis to motor fascicles of the median or ulnar nerve. The medial epicondyle was osteotomized, proximally advanced by 4 to 5 cm and secured to the anterior side of the humerus.

RESULTS

Active elbow flexion was restored in 23 of 24 patients. Sixteen patients ultimately achieved M4 strength, among whom 6 had full range of motion (ROM), and the remaining 10 recovered an average of 110° (95% confidence interval [95% CI], 100°-120°) of elbow flexion. Seven patients exhibited M3 elbow flexion strength recovery, which was associated with weaker hands and incomplete ROM, averaging 94° (95% CI, 86°-102°). There was, on average, a 10° (95% CI, 4.4°-15.6°). elbow flexion contracture. Among the 16 patients with M4 level recovery of elbow flexion, supination was partially restored in 12.

CONCLUSIONS

In patients previously operated upon, using a reversed free gracilis muscle flap in association with a Steindler procedure is effective as salvage surgery to restore elbow flexion and partial supination.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The effect of humerus diaphyseal shortening on brachial plexus tension: a cadaver study

PURPOSE

To assess the extent to which diaphyseal shortening of the humerus can allow direct suture in case of rupture or transection injuries of the brachial plexus.

METHODS

The use of 3 fresh cadaver specimens allowed for the study of 6 brachial plexuses. Distance measurements were made between reference points placed on the clavicle and on different parts of the plexus. Those measurements were repeated after shortening the humerus by 2, 4, and 6 cm.

RESULTS

None of the dissected plexuses had classic anatomy. A humeral shortening of 6 cm allowed for a statistically significant reduction of length between the supraclavicular part of the plexus and the terminal branches, which did not exceed 17 mm on average. The difference of length was much greater for the specimen in which the musculocutaneous nerve did not pierce the coracobrachialis muscle proximally.

CONCLUSIONS

In clinical situations, nerve defects are usually larger than the gain observed when doing a 6-cm humeral shortening. Moreover, this procedure implies a large dissection, a functional loss of certain muscles, and a risk of humeral nonunion.

CLINICAL RELEVANCE

In the absence of extensive nerve dissection, the observed change of length is insufficient in the most brachial plexus disruptions to allow for a direct suture instead of long nerve grafts.