Ersatzoperationen bei Ausfall motorischer Funktionen an der Hand

[Secondary surgical procedures following motor nerve injuries]

BACKGROUND

The functional deficits that develop after a peripheral nerve injury mean a considerable reduction in the quality of life for the affected patients. However, interventions on the injured nerve are not always possible or effective. In this case, secondary procedures, e.g. tendon transfers, are a feasible option for functional reconstruction.

OBJECTIVES

An overview of the most common secondary surgical procedures for functional reconstruction after peripheral nerve injuries.

METHODS

Presentation and discussion of the most common secondary surgical procedures with emphasis on tendon transfers. Illustration of the primary functions that need to be reconstructed depending on the respective nerve lesion.

RESULTS

The basic principle of secondary surgical procedures after nerve injuries is the transposition of a healthy tendomuscular unit to replace a lost function following a loss of muscle or tendon or if an intervention on the nerve is not promising. For example, by transferring flexor forearm muscles, wrist, finger and thumb extension can be reconstructed after radial nerve injury. By transposing the tibialis posterior muscle, dorsiflexion in the talocrural joint can be restored to enable the affected patient to walk safely without an orthosis.

CONCLUSIONS

Secondary surgical procedures are a valuable option for functional reconstruction after nerve injury.

Transfer of the nerve to the brachioradialis muscle to the anterior interosseous nerve for treatment for lower brachial plexus lesions: case report

In lower lesions of the brachial plexus (C8-T1) there is good function of the shoulder, elbow, and wrist, although that of the hand is impaired. Reconstruction of finger flexion is generally obtained by tendon transfer. We present a case report involving transfer of the motor nerve branch of the brachioradialis muscle to the anterior interosseous nerve to restore finger flexion in acute lower brachial plexus lesion.

[Proximal radial nerve palsy resulting from acute Epstein-Barr virus infection]

Irreparable peripheral nerve palsies rarely present as neurological complications in infectious mononucleosis. A case of isolated proximal radial nerve palsy resulting from an acute infection with Epstein-Barr virus is reported. The hand function was restored by multiple tendon transfer surgery.

[Restoration of active elbow flexion by muscle transfer of the latissimus dorsi]

OBJECTIVE

Reconstruction of active elbow flexion against gravity (strength grade > or =M(3)) by transfer of the latissimus dorsi muscle in order to improve the functionality of the upper extremity.

INDICATIONS

Irreparable lesions of the musculocutaneous nerve (C(5)/6). Failure of regeneration after peripheral nerve reconstruction for the musculocutaneous nerve (neurolysis, suture, nerve grafting). Brachial plexus injury (lesions to the upper part, C(5)/6). Loss of biceps function due to trauma, ischemia, poliomyelitis or tumor.

CONTRAINDICATIONS

Possible recovery of biceps function by reinnervation, spontaneously or after nerve reconstruction. Weakness of the latissimus dorsi muscle (strength grade < M(4)). Insufficient passive range of motion of the elbow joint (osteoarthritis, contracture). Lack of motivation, reliability, and cooperation of the patient in postoperative rehabilitation program.

SURGICAL TECHNIQUE

The intact latissimus dorsi muscle is transferred with its origin and insertion ventrally and sutured with its thoracic aponeurosis into the insertion of the biceps tendon in order to act as an elbow flexor.

POSTOPERATIVE MANAGEMENT

Following postoperative immobilization in an upper-arm Gilchrist bandage at 100 degrees flexion and supination (or neutral position, but not pronation) of the forearm for 6 weeks, passive motion exercises of the elbow are started. Active flexion and extension exercises begin at 8-10 weeks postoperatively. To prevent the deleterious effect of muscle and tendon elongation, an orthosis is used during the night to keep the elbow flexed at 90 degrees for 6 months.

RESULTS

According to the authors' experience and the results reported in the literature, bipolar latissimus dorsi muscle transfer is a reliable method to restore functional elbow flexion regarding range of motion (> 90 degrees elbow flexion) and strength (at least antigravity strength, > or =M(3)) with acceptable donor morbidity and complication rate.