Restoration of elbow flexion

[Pectoralis major muscle transfer for reconstruction of elbow flexion in posttraumatic brachial plexus lesions]

OBJECTIVE

Active elbow flexion is necessary for bimanual tasks. Reconstruction of powerful active elbow flexion. Reconstruction of missing muscle unit by neurovascular pedicled functional muscle transposition.

INDICATIONS

Treatment of second choice (first choice bipolar latissimus dorsi transfer according to Zancolli & Mitre, transfer of the flexor/pronator muscle onto the distal humerus, or transposition of the triceps onto the biceps): --(Secondary) reconstruction of active elbow flexion in case of lesion of the brachial plexus or musculocutaneous nerve. --Replacement of the elbow flexor muscles in case of primary muscle loss (tumor, trauma).

CONTRAINDICATIONS

Ongoing spontaneous or postoperative nerve regeneration. Ankylosis of the elbow joint (in case of good shoulder and hand function, one should consider arthrolysis or even total joint replacement). Insufficient power of the pectoralis major muscle (< M(4)). Lesion of the axillary artery involving the thoracoacromial artery. Relative: concomitant lesion of the latissimus dorsi and teres major muscles (loss of glenohumeral adduction [thoracohumeral pinch].

SURGICAL TECHNIQUE

Distal muscle transposition: transposition of the origin--pars abdominalis, pars sternocostalis, pars clavicularis (unipolar or bipolar, partial or complete distal transfer): --Unipolar partial pectoralis major muscle transposition according to Clark. --Bipolar partial pectoralis major muscle transposition according to Schottstaedt et al. --Bipolar complete pectoralis major muscle transposition according to Dautry et al. and Carroll & Kleinmann, respectively, possibly in combination with transfer of the pectoralis minor muscle. --Myocutaneous flap in case of concomitant skin defect at the upper arm level. Proximal tendon transfer: transposition of the tendinous insertion at the humerus of the pectoralis major muscle.

POSTOPERATIVE MANAGEMENT

Immobilization for 6 weeks in a dorsal upper arm splint, a Gilchrist bandage or a thorax-arm abduction orthesis with the elbow in 90 degrees flexion and supination. Early passive motion depending on pain within the sector 90-140 degrees. Progressive increase of active range of motion after 6 weeks. Protected exercise from "out of the splint" with increasing elbow extension of 10 degrees per week. It is important, that there is still an extension lag of 30-40 degrees at 3 months after transfer, in order to protect the reinnervated muscle and avoid overstretching. Although complete elbow extension should be the aim after 1 year, most patients will keep an extension lag of 20-30 degrees. Physiotherapy must continue for 12-18 months. Postoperative standardized compression therapy, combined with scar therapy (silicone sheet).

RESULTS

Meta-analysis of the literature and personal results show functional (very good and good) results in 54-86% of patients. There are only few complications.

Medial and lateral pectoral nerves: Course and branches

During modified radical mastectomy or cosmetic surgery, denervation of the lower part of the pectoralis major frequently occurs and may reduce muscle spasm, with consequent better reconstruction of the breast. The aim of this study was to determine the relationship between the pectoral nerves and the pectoral muscles. Eight unembalmed female cadavers were dissected and vascular and radiologic studies performed. The lateral pectoral nerves showed a constant course, parallel to the thoraco-acromial vessels. They coursed for 55 +/- 7 mm inferomedially on the deep surface of pectoralis major, under its fascia. The medial pectoral nerves showed two main patterns of branching, which correlated with the extent of the costal attachments of the pectoralis minor muscles. In pattern A (56%), associated with costal attachments narrower than 6.0 cm, the nerve pierced the deep aspect of the pectoralis minor as a single trunk, ramified in the muscle, and gave some branches that appeared on the superficial aspect to enter the pectoralis major. In pattern B (44%), associated with costal attachments wider than 6.6 cm, the nerve divided before entering pectoralis minor and its branches passed through the muscle or round its lower border to reach pectoralis major. The most medial branch of the medial pectoral nerve directed to the pectoralis major muscle emerged from pectoralis minor at the third intercostal space in the midclavicular line, a mean of 10.3 cm lateral to the margin of the sternum. Knowledge of the relationship between the extent of the costal attachment of pectoralis minor and the two patterns of branching of the medial pectoral nerve may be useful when performing elective denervation of the major pectoralis muscle.

Restoration of elbow flexion 16 years after brachial plexus root avulsion

To restore elbow flexion in brachial plexus lesions or cervical root avulsions, surgical nerve reconstruction can be attempted after approximately 6 months. If the reconstruction is not successful or was not performed, tendon transfer may improve the function of a paralysed limb. The selection of the muscle for transfer can be influenced by strengthening potentially available muscles by a myo-feedback method.

Steindler and pectoralis major flexorplasty: a comparative analysis

Previously published studies on transfers to restore elbow flexion have rarely compared the outcomes among different techniques. We found no comparison between the Steindler procedure and pectoralis major tendon transfer. This study compared functional outcomes after these two types of elbow flexorplasty performed in conjunction with shoulder arthrodesis for patients with brachial plexus injuries. The same examiner assessed 14 patients who underwent shoulder fusion and elbow flexorplasty. Five had a pectoralis major tendon transfer, and nine underwent a modified Steindler procedure. All patients had brachial plexus lesions that were irreparable or had not responded to neurolysis, repair, or grafting. Average follow-up time was 60 months (range, 12 months-10 years). All patients completed a questionnaire (pain, function) and underwent an objective assessment of range of motion, isometric strength, isotonic power, grip, and pinch strength. The BTE Work Simulator (Baltimore Therapeutic Equipment, Hanover, MD) was used for muscle strength testing. Improvement was noted in daily activities including dressing and bilateral activities and was reflected in a significant improvement over preoperative function. No differences (at p = .05 level of significance) were found in objective tests between the pectoralis major transfer and the Steindler groups. In the patient requiring stabilization of the shoulder and flexorplasty, the pectoralis major tendon transfer was at least equivalent to the modified Steindler flexorplasty in terms of range of motion, strength, and subjective measures.

Muscle ultrasonography in arthrogryposis. Comparison with clinical, neuromyographic and histologic findings in 41 cases

We studied the ultrasonographic appearance of muscles in 41 patients with arthrogryposis multiplex congenita (AMC). The observations were compared to the findings in clinical testing, electroneuromyography, and histological examination. The strength of the muscles in AMC-patients did not always correspond to the ultrasonographic morphology of the muscles. In extension contractures of the elbow and in equinovarus adductus deformities of the foot there was a distribution of pathological changes in the muscles corresponding to the primary deformity. The sound transfer through the muscles was decreased, notably in the neurogenic form of AMC. Ultrasonography is an important complement to the clinical examination and it should always be done prior to surgery and muscle biopsy.

Compartment syndrome in transferred muscle: an unusual complication

It has been stated, but not reported, that compartment syndrome can occur in a transferred muscle (Bostwick, 1979). We report this unusual complication in two consecutive cases in which a latissimus dorsi muscle transfer had been done.

Technical considerations in pectoralis major transfer for treatment of the paralytic elbow

Modification of pectoralis major transfer as originally described by Clark in 1946 have not addressed concerns such as diminished strength and excursion of the transfer, along with obligatory supination of the forearm. Postoperative scarring from the long oblique chest incision further compounds the psychological impairment that accompanies brachial plexopathy. One hundred forty-three brachial plexopathies were seen over a five-year period. Seven pectoralis major transfers were done to restore elbow flexion in patients with C5-6 and C5-6-7 cord injuries. Mean age and follow-up were 26 years and 25 months respectively. The modifications of this transfer we use improve strength and range of motion by preserving dual innervation of the muscle, by tubularization of the transfer, and by restoration of the transverse aponeurosis as a fascial pulley. By transfer of the pectoralis insertion to the acromion, further anterior shoulder stability may be obtained. Aesthetics can also be improved by use of selected midline and deltopectoral incisions, along with preservation of the remaining pectoralis major and minor.

Restoration of Elbow Flexion by Complete Latissimus Dorsi Muscle Transposition

Flexor-plasty of the elbow has been performed using either a tubed complete latissimus dorsi muscle or musculocutaneous transposition in eight patients, six of whom had brachial plexus palsy and two traumatic loss of the anterior brachial musculature and overlying soft tissue. The range of follow-up was from one to eight years.

When the postoperative results were evaluated according to the criteria of Segal (1959), the results were excellent in four cases and good in three, with one failure. The indications, operative technique and results are discussed.

Pectoralis major transplantation to restore elbow flexion to the paralytic limb

In four patients, two with brachial plexus palsy and two with arthrogryposis, the entire pectoralis major muscle was transplanted to act as an elbow flexor, rotating it on its neurovascular pedicles and attaching the tendon to the acromion and the muscle origin to the tuberosity of the radius. Excellent motion and power was restored in three patients. One procedure failed due to fibrofatty degeneration of the transplanted muscle.