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Gatskiy AA, Tretyak IB, Bahm J, Tsymbaliuk VI, Tsymbaliuk YV. Redefining the Inclusion Criteria for Successful Steindler Flexorplasty Based on the Outcomes of a Case Series in Eight Patients. J Brachial Plex Peripher Nerve Inj 2023; 18:e32-e41. [PMID: 37829766 PMCID: PMC10567141 DOI: 10.1055/s-0043-1767672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 02/03/2023] [Indexed: 10/14/2023] Open
Abstract
Background (rationale) Steindler flexorplasty (SF) is aimed at restoring independent elbow flexion in the late stages of dysfunction of the primary elbow flexors. Selection criteria for successful SF have been defined. Objectives The purpose of this study was to redefine the inclusion criteria for successful SF based on functional outcomes. Methods Eight patients received SF after an average of 50.8 months after injury or dysfunction. Three patients (37.5%) met all five Al-Qattan inclusion criteria (AQIC), and another five patients (62.5%) met four or less AQIC. Patients were followed up for at least 9 months, and the maximum range of active elbow flexion (REF) was measured. Functional results of SF were assessed using the Al-Qattan scale (in accordance with Al-Qattan's scale). Results The mean maximum REF was 100 degrees (70 to 140 degrees). Five patients reached REF greater than 100 degrees. One patient had a poor outcome, two patients (25%) had a fair outcome, three patients (37.5%) had a good outcome, and two patients (25%) had an excellent outcome of SF on the Al-Qattan scale. The impact of each AQIC on functional outcome has been critically reviewed from a biomechanical point of view. Conclusions The sufficient number of inclusion criteria required for successful SF can be reduced from five (according to AQIC) to two; Normal or near-normal function (M4 or greater on the MRC scale) of the muscles of the flexor-pronator mass should be considered an obligatory inclusion criterion, while primary wrist extensors may be considered an optional inclusion criterion.
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Affiliation(s)
- Alexander A. Gatskiy
- Restorative Neurosurgery Department, Romodanov Neurosurgery Institute, Kyiv, Ukraine
| | - Ihor B. Tretyak
- Restorative Neurosurgery Department, Romodanov Neurosurgery Institute, Kyiv, Ukraine
| | - Jörg Bahm
- Klinik für Plastische Chirurgie, Hand- und Verbrennungschirurgie, Sektion Plexuschirurgie in der Uniklinik RWTH Aachen, Aachen, Deutschland
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Outcomes of gracilis free-flap muscle transfers and non-free-flap procedures for restoration of elbow flexion: A systematic review. J Plast Reconstr Aesthet Surg 2022; 75:2625-2636. [PMID: 35644885 DOI: 10.1016/j.bjps.2022.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 08/14/2021] [Accepted: 04/12/2022] [Indexed: 11/22/2022]
Abstract
PURPOSE Elbow flexion is one of the most important functions to restore following brachial plexus damage. The authors sought to systematically review available evidence to summarize outcomes of free gracilis and non-free muscle transfers in restoring elbow flexion. METHODS MEDLINE, EMBASE, and Cochrane were searched to identify articles reporting on elbow flexion reanimation in terms of transfer failure rates, strengths, range of motion (ROM), and/or Disabilities of the Arm, Shoulder and Hand (DASH) scores. A systematic review was chosen to select studies and reported according to PRISMA guidelines. RESULTS Forty-six studies met the inclusion criteria for this study. A total of 432 cases were gracilis free-flap muscle transfers (FFMT), and 982 cases were non-free muscle transfers. FFMT were shown to have higher Medical Research Council (MRC) strength scores than non-free muscle transfer groups. However, 42 studies, totaling 1,266 cases, were useful in evaluating graft failure, showing failure (MRC<3) in 77/419 (∼18.4%) of gracilis free-flap transfers and 215/847 (∼25.4%) of non-free muscle transfers. Sixteen articles, 285 cases, were useful to evaluate ROMs (total range: 0-140°), and eight articles, 215 cases, provided DASH scores (total range: 8-90.8). CONCLUSIONS Of patients who underwent gracilis FFMT procedures, higher mean strength scores and lower failure rates were observed when compared with non-free muscle transfers. Articles reporting non-free muscle transfer procedures (pectoralis, pedicled, Steindler, vascularized ulnar nerve grafts, Oberlin, single/double nerve transfers) provided comprehensive insight into outcomes and indicated that they may result in pooerer poorer DASH scores and ROM.
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Alshammari SM, Alghamdi AA, Almarzouq SF, Shash HA. Successful Elbow Flexion Reconstruction Using Latissimus Dorsi Muscle Transfer Following a Road Traffic Accident and Upper Limb Trauma. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e933374. [PMID: 34686648 PMCID: PMC8552418 DOI: 10.12659/ajcr.933374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Several surgical procedures to restore elbow flexion have been reported in the literature. Multiple factors direct the selection of appropriate procedures for each patient, including hand dominance, neurovascular injury, and comorbidities. Traumatic damage to the anterior compartment of the arm is an indication for latissimus dorsi transfer, which can restore elbow flexion. Bipolar pedicled latissimus dorsi (LD) flap is a design used very rarely to simultaneously reconstruct biceps brachii soft-tissue defects and regain complete flexion function. We report the case of a 30-year-old man who underwent successful elbow flexion reconstruction using latissimus dorsi muscle transfer following a road traffic accident and upper limb trauma. CASE REPORT A 30-year-old man presented with acute compartment syndrome caused by a road traffic accident and impact trauma to the left arm. The surgical evaluation revealed proximal biceps tendons rapture; therefore, immediate repair and therapeutic fasciotomy were done. Subsequently, unsuccessful repair resulted in total necrosis of the biceps muscle, which necessitated debridement of the biceps muscle. Delayed reconstruction with an LD flap was successfully done after stabilization of the patient's condition. The flap was harvested as free-pedicled, then modified into a tube-like shape to resemble the biceps muscle. CONCLUSIONS This report has shown that the surgical procedure of latissimus dorsi muscle transfer can successfully restore elbow function following upper limb trauma; however, preoperative planning and postoperative follow-up are crucial for functional reconstruction of the upper extremity. In addition, carefully selecting reconstructive surgery considering patient factors, degree of injury, and the institution's capacity are essential factors in achieving optimal function restoration with minimal complications.
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Affiliation(s)
- Salem Mohammad Alshammari
- Department of General Surgery, Plastic and Reconstructive Surgery Unit, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Abdulrahman Abdulaziz Alghamdi
- Department of General Surgery, Plastic and Reconstructive Surgery Unit, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Sawsan Fahad Almarzouq
- Department of General Surgery, Plastic and Reconstructive Surgery Unit, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Hani Ali Shash
- Department of General Surgery, Plastic and Reconstructive Surgery Unit, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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Abstract
This year marks the 100th anniversary of Dr Steindler's original report of a proximal transfer of the flexor pronator mass to restore elbow flexion. The authors present their updated surgical technique to perform the Steindler flexorplasty. In this procedure, the flexor-pronator mass origin on the medial epicondyle is transferred proximally to the anterior humerus to restore elbow flexion. They also report a retrospective case series of patients from 2007 to 2017 who underwent a Steindler flexorplasty at their institution to restore elbow flexion. In the series, 8 of 9 patients achieved at least 90 degrees of active antigravity (M3) or greater elbow flexion. Outcomes following the Steindler flexorplasty have been reported in the literature over the course of the past 100 years. Although alternative techniques to improve elbow flexion have been developed and performed over the last century, this time tested procedure remains a powerful reconstructive option.
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Affiliation(s)
- Neil V Shah
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York
| | - John J Kelly
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York.,School of Medicine, SUNY Upstate Medical University, Syracuse, New York
| | - Aakash M Patel
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York.,Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, Illinois
| | - Colin M White
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York
| | - Michael R Hausman
- Leni & Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven M Koehler
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York
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Cambon-Binder A, Walch A, Marcheix PS, Belkheyar Z. Bipolar transfer of the pectoralis major muscle for restoration of elbow flexion in 29 cases. J Shoulder Elbow Surg 2018; 27:e330-e336. [PMID: 30195620 DOI: 10.1016/j.jse.2018.06.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 06/18/2018] [Accepted: 06/23/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study evaluated the functional outcomes of bipolar pedicled pectoralis major (PM) transfer to restore elbow flexion. METHODS We retrospectively reviewed 29 transfers in 28 patients with a mean age of 31.2 years (range, 5-65 years). The loss of elbow flexion was due to brachial plexus palsy in 24 patients, elbow flexors necrosis in 4, and poliomyelitis in 1. The entire PM muscle was mobilized and fixed proximally to the coracoid process. Intraoperative positioning and postoperative immobilization of the shoulder and the elbow flexed at 60° and 120°, respectively, allowed direct distal fixation of the muscle to the biceps brachii tendon. RESULTS At the last follow-up (mean, 13 months; range, 4-37 months), 41% of the transfers (n = 12) recovered grade 4 elbow flexion strength and were able to lift 2.2 kg on average (range, 0.5-5 kg), 52% (n = 15) recovered grade 3 strength, and 7% (n = 2) had a poor result (ie, grade 2 elbow flexion). The mean active elbow flexion was 100° (ranging, 30°-150°), and the patients had 0° to 10° elbow flexion contracture. CONCLUSIONS Our results indicate that bipolar PM transfer is a reliable and effective procedure to restore elbow flexion. Flexion of the shoulder and elbow allowed the transfer to reach the elbow fold and avoided an interposition graft between the distal PM and the biceps brachii tendon.
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Affiliation(s)
- Adeline Cambon-Binder
- Department of Orthopaedic and Hand Surgery, Saint-Antoine Hospital, Sorbonne Université, Paris, France.
| | - Arnaud Walch
- Hand and Upper Limb Surgery Department, Edouard Herriot Hospital, Lyon, France
| | - Pierre-Sylvain Marcheix
- Orthopaedic and Trauma Department, Centre Hospitalier Universitaire Dupuytren, Limoges, France
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Chang KWC, Wilson TJ, Popadich M, Brown SH, Chung KC, Yang LJS. Oberlin transfer compared with nerve grafting for improving early supination in neonatal brachial plexus palsy. J Neurosurg Pediatr 2018; 21:178-184. [PMID: 29219789 DOI: 10.3171/2017.8.peds17160] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The use of nerve transfers versus nerve grafting for neonatal brachial plexus palsy (NBPP) remains controversial. In adult brachial plexus injury, transfer of an ulnar fascicle to the biceps branch of the musculocutaneous nerve (Oberlin transfer) is reportedly superior to nerve grafting for restoration of elbow flexion. In pediatric patients with NBPP, recovery of elbow flexion and forearm supination is an indicator of resolved NBPP. Currently, limited evidence exists of outcomes for flexion and supination when comparing nerve transfer and nerve grafting for NBPP. Therefore, the authors compared 1-year postoperative outcomes for infants with NBPP who underwent Oberlin transfer versus nerve grafting. METHODS This retrospective cohort study reviewed patients with NBPP who underwent Oberlin transfer (n = 19) and nerve grafting (n = 31) at a single institution between 2005 and 2015. A single surgeon conducted intraoperative exploration of the brachial plexus and determined the surgical nerve reconstruction strategy undertaken. Active range of motion was evaluated preoperatively and postoperatively at 1 year. RESULTS No significant difference between treatment groups was observed with respect to the mean change (pre- to postoperatively) in elbow flexion in adduction and abduction and biceps strength. The Oberlin transfer group gained significantly more supination (100° vs 19°; p < 0.0001). Forearm pronation was maintained at 90° in the Oberlin transfer group whereas it was slightly improved in the grafting group (0° vs 32°; p = 0.02). Shoulder, wrist, and hand functions were comparable between treatment groups. CONCLUSIONS The preliminary data from this study demonstrate that the Oberlin transfer confers an advantageous early recovery of forearm supination over grafting, with equivalent elbow flexion recovery. Further studies that monitor real-world arm usage will provide more insight into the most appropriate surgical strategy for NBPP.
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Affiliation(s)
| | - Thomas J Wilson
- 2Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | | | | | - Kevin C Chung
- 4Plastic Surgery, University of Michigan, Ann Arbor, Michigan; and
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Costil V, Romana C, Fitoussi F. Pectoralis minor transfer for elbow flexion restoration in late obstetric brachial plexus palsy. INTERNATIONAL ORTHOPAEDICS 2017; 42:1137-1141. [PMID: 29285664 DOI: 10.1007/s00264-017-3725-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 12/10/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE Obstetric brachial plexus palsy (OBPP) may result in a severe impairment of upper limb function, especially when major motor functions do not recover with or without early microsurgical reconstruction. Various methods to restore elbow flexion have been described. The aim of this study was to report the results after pectoralis minor transfer for elbow flexion restoration in late OBPP. METHODS Nineteen patients were included. Mean age at surgery was six years (range, 2.3-12.8). The mean follow-up period was four years (range, 1-15). Shoulder function was evaluated by the Mallet classification and hand function by the Raimondi scale. We used the "active movement scale" (AMS) to evaluate elbow flexion function. RESULTS Eighteen of the 19 patients had improvement in their elbow active flexion. There was significant improvement in biceps muscle power according to the BMRC grading system, from an average grading of 1.7 (range, 1-3) pre-operatively to 3 (range, 1-4) post-operatively (P < 0.05). The average active elbow flexion was significantly improved from a mean of 81° (range, 0-120; SD = 44) pre-operatively, most of them gravity eliminated, to a mean of 111° (range, 0-140; SD = 33) post-operatively (P < 0.05). According to the AMS, 12 patients (63%) had a good result, 4 (21%) a fair result and 5 (26%) a poor result. Poor results were significantly correlated with a low pre-operative AMS score (P < 0.05). CONCLUSIONS The pectoral minor transfer can be a reliable technique for elbow flexion improvement in late OBPP by strengthening an already existing but inadequate active flexion. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Vanessa Costil
- Department of Pediatric Orthopaedic and Reconstructive Surgery, Trousseau Hospital, Paris 6 University, Paris, France
| | - Claudia Romana
- Department of Pediatric Orthopaedic and Reconstructive Surgery, Trousseau Hospital, Paris 6 University, Paris, France
| | - Frank Fitoussi
- Department of Pediatric Orthopaedic and Reconstructive Surgery, Trousseau Hospital, Paris 6 University, Paris, France.
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de Moraes FB, Kwae MY, da Silva RP, Porto CC, de Paiva Magalhães D, Paulino MV. Evaluation of elbow flexion following free muscle transfer from the medial gastrocnemius or transfer from the latissimus dorsi, in cases of traumatic injury of the brachial plexus. Rev Bras Ortop 2016; 50:660-5. [PMID: 27218077 PMCID: PMC4867918 DOI: 10.1016/j.rboe.2015.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 10/21/2014] [Indexed: 11/14/2022] Open
Abstract
Objective To compare the gain in elbow flexion in patients with traumatic injury of the brachial plexus following muscle transfer from latissimus dorsi with the gain following free muscle transfer from the medial belly of the gastrocnemius. Methods This was a retrospective study in which the medical files of a convenience sample of 13 patients operated between 2000 and 2010 were reviewed. Group 1 comprised seven patients who underwent transfers from the gastrocnemius and group 2 (controls) comprised six patients who underwent transfers from the latissimus dorsi. The following functions were evaluated: (1) range of motion (ROM) of elbow flexion, in degrees, using manual goniometry and (2) grade of elbow flexion strength, using a muscle strength scale. Satisfactory results were defined as: (1) elbow flexion ROM ≥ 80° and (2) elbow flexion strength ≥ M3. The Fisher exact and Kruskal–Wallis tests were used (p < 0.05). Results The patients’ mean age was 32 years (range: 17–56) and 72% had been involved in motorcycle accidents. Elbow flexion strength ≥ M3 was observed in seven patients (100%) in group 1 and in five patients (83.3%) in group 2 (p = 0.462). None of the patients presented M5, and one patient (16.7%) in group 2 had a poor result (M2). Elbow flexion ROM with a gain ≥ 80° (daily functions) was found in six patients (86%) in group 1 and in three patients (50%) in group 2 (p = 0.1). Conclusion The patients in group 1 had greater gains in strength and ROM than did those in group 2, but without statistical significance. Thus, transfers from the gastrocnemius become a new surgical option, if other techniques cannot be used.
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Affiliation(s)
- Frederico Barra de Moraes
- Department of Orthopedics and Traumatology, Faculdade de Medicina, Universidade Federal de Goiás (UFG), Goiânia, GO, Brazil
| | - Mário Yoshihide Kwae
- Department of Orthopedics and Traumatology, Faculdade de Medicina, Universidade Federal de Goiás (UFG), Goiânia, GO, Brazil
| | - Ricardo Pereira da Silva
- Department of Orthopedics and Traumatology, Faculdade de Medicina, Universidade Federal de Goiás (UFG), Goiânia, GO, Brazil
| | - Celmo Celeno Porto
- Department of Orthopedics and Traumatology, Faculdade de Medicina, Universidade Federal de Goiás (UFG), Goiânia, GO, Brazil
| | - Daniel de Paiva Magalhães
- Department of Orthopedics and Traumatology, Faculdade de Medicina, Universidade Federal de Goiás (UFG), Goiânia, GO, Brazil
| | - Matheus Veloso Paulino
- Department of Orthopedics and Traumatology, Faculdade de Medicina, Universidade Federal de Goiás (UFG), Goiânia, GO, Brazil
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Socolovsky M, Costales JR, Paez MD, Nizzo G, Valbuena S, Varone E. Obstetric brachial plexus palsy: reviewing the literature comparing the results of primary versus secondary surgery. Childs Nerv Syst 2016; 32:415-25. [PMID: 26615411 DOI: 10.1007/s00381-015-2971-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 11/20/2015] [Indexed: 11/27/2022]
Abstract
Obstetric brachial plexus injuries (OBPP) are a relatively common stretch injury of the brachial plexus that occurs during delivery. Roughly 30 % of patients will not recover completely and will need a surgical repair. Two main treatment strategies have been used: primary surgery, consisting in exploring and reconstructing the affected portions of the brachial plexus within the first few months of the patient's life, and secondary procedures that include tendon or muscle transfers, osteotomies, and other orthopedic techniques. Secondary procedures can be done as the only surgical treatment of OBPP or after primary surgery, in order to minimize any residual deficits. Two things are crucial to achieving a good outcome: (1) the appropriate selection of patients, to separate those who will spontaneously recover from those who will recover only partially or not at all; and (2) a good surgical technique. The objective of the present review is to assess the published literature concerning certain controversial issues in OBPP, especially in terms of the true current state of primary and secondary procedures, their results, and the respective roles each plays in modern-day treatment of this complex pathology. Considerable published evidence compiled over decades of surgical experience favors primary nerve surgery as the initial therapeutic step in patients who do not recover spontaneously, followed by secondary surgeries for further functional improvement. As described in this review, the results of such treatment can greatly ameliorate function in affected limbs. For best results, multi-disciplinary teams should treat these patients.
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Affiliation(s)
- Mariano Socolovsky
- Department of Neurosurgery, Peripheral Nerve & Brachial Plexus Unit, University of Buenos Aires School of Medicine, La Pampa 1175 5 A, 1428, Buenos Aires, Argentina.
| | | | | | - Gustavo Nizzo
- Department of Orthopedic Surgery, Peripheral Nerve & Brachial Plexus Unit, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Sebastian Valbuena
- Department of Orthopedic Surgery, Hospital de Alta Complejidad en Red El Cruce, Buenos Aires, Argentina
| | - Ernesto Varone
- Department of Orthopedic Surgery, Hospital Ricardo Gutierrez, Buenos Aires, Argentina
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Avaliação da flexão do cotovelo após transferência muscular livre do gastrocnêmio medial ou transferência do latíssimo do dorso na lesão traumática do plexo braquial. Rev Bras Ortop 2015. [DOI: 10.1016/j.rbo.2015.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Suh N, Wagner ER, Spinner RJ, Bishop AT, Shin AY. Trick elbow motions in patients with brachial plexus injuries. J Hand Surg Am 2014; 39:2312-4. [PMID: 24908554 DOI: 10.1016/j.jhsa.2014.04.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 04/21/2014] [Accepted: 04/29/2014] [Indexed: 02/02/2023]
Affiliation(s)
- Nina Suh
- Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic, Rochester, MN; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Eric R Wagner
- Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic, Rochester, MN; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Robert J Spinner
- Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic, Rochester, MN; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Allen T Bishop
- Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic, Rochester, MN; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic, Rochester, MN; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN.
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Gilbert A, Valbuena S, Posso C. Obstetrical brachial plexus injuries: late functional results of the Steindler procedure. J Hand Surg Eur Vol 2014; 39:868-75. [PMID: 24893931 DOI: 10.1177/1753193414537203] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We reviewed late functional results of a modified Steindler procedure in patients with obstetrical brachial plexus palsy and poor active elbow flexion. From 1982 to 2005, we reviewed final functional results and complications of 27 cases with flexion weakness of the elbow secondary to obstetrical brachial plexus injury, treated with a modified Steindler procedure. At the end of the follow-up, the mean active elbow flexion was 97° and the mean extensor lag was 10°. In the long-term follow-up, the modified Steindler procedure maintained good results in 67% of the cases in our series, and this percentage raised by 82% when the wrist extensor was present or restored before the Steindler procedure. There were poor results in 19% of the patients, but no major complications.
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Affiliation(s)
- A Gilbert
- Institut de la Main (Clinique Jouvenet), Paris, France
| | | | - C Posso
- Plastic and Reconstructive Surgery Service, University of Antioquia, Medellín, Colombia
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Cambon-Binder A, Belkheyar Z, Durand S, Rantissi M, Oberlin C. Elbow flexion restoration using pedicled latissimus dorsi transfer in seven cases. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.main.2012.10.169] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Rezende MRD, Massa BSF, Furlan FC, Mattar Junior R, Paula EJLD, Santos SSE, Freitas MC. Avaliação do ganho funcional do cotovelo com a cirurgia de Steindler na lesão do plexo braquial. ACTA ORTOPEDICA BRASILEIRA 2011. [DOI: 10.1590/s1413-78522011000300008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJETIVO: Avaliar ganho de força e amplitude de movimento do cotovelo após cirurgia de Steindler Modificada em pacientes com lesão do tronco superior do plexo braquial. MÉTODO: Foram acompanhados de 1998 a 2007 onze pacientes com lesão traumática fechada do tronco superior do plexo braquial. Todos apresentavam evolução de pelo menos 1 ano da lesão e grau de força de flexão do cotovelo que variou de M1 a M3. Os pacientes foram submetidos à cirurgia de Steindler modificada e seguidos por período mínimo de 6 meses. Realizadas avaliações pré e pós-operatórias do ganho de força muscular, amplitude de movimento do cotovelo e pontuação conforme escala DASH. RESULTADOS: Dos onze pacientes analisados, nove (82%) atingiram nível de força igual ou maior a M3 (MRC). Dois (18%) chegaram ao nível de força M2(MRC). Observamos que os pacientes apresentaram ganho médio de amplitude de movimento do cotovelo pós-operatória de 43,45 graus. A média de flexão do cotovelo pós-operatória foi de 88 graus. Houve melhora da função do cotovelo demonstrada na Escala DASH em 81% dos pacientes do estudo. CONCLUSÃO: A cirurgia de Steindler Modificada mostrou-se eficaz no tratamento dos pacientes com lesão de tronco superior de plexo braquial, com ganho estatisticamente significativo de amplitude de movimento. Em todos os casos algum grau de ganho de força e amplitude de flexão do cotovelo, sendo tanto maior quanto maior a força muscular inicial. Nível de Evidência: Nível II, ensaio clínico prospective.
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Terzis JK, Kokkalis ZT. Secondary procedures for elbow flexion restoration in late obstetric brachial plexus palsy. Hand (N Y) 2010; 5:125-34. [PMID: 19430848 PMCID: PMC2880668 DOI: 10.1007/s11552-009-9198-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2009] [Accepted: 04/01/2009] [Indexed: 11/25/2022]
Abstract
Even though total absence of elbow flexion in obstetric brachial plexus palsy (OBPP) is rare, weakness is a frequent problem. Numerous procedures for elbow flexion restoration in late obstetric brachial plexus palsy have been described. In this study, children with OBPP who underwent secondary reconstruction for elbow flexion restoration were studied. A retrospective review of 15 patients (16 elbows) who underwent 16 pedicled and eight free-muscle transfers for elbow flexion restoration was conducted. The mean follow-up period was 8.4 ± 2.9 years (range, 25 months to 12.2 years). The mean age at operation (elbow surgery) was 5.4 ± 1.9 years. The total arc of elbow motion was the result of the active elbow flexion less the flexion contracture. There was significant improvement in biceps muscle power from an average grading of 2.49 ± 0.80 preoperatively to 3.64 ± 0.46 postoperatively (p < 0.001). Thirteen of 16 elbows (81%) achieved good and excellent results (≥M3+); and three elbows (19%) fair results (M3- or M3). The average arc of motion was significantly improved from 36° ± 25° preoperatively to 94° ± 26° postoperatively (p < 0.001). The preoperative and postoperative average elbow flexion contracture was 10.9° ± 8.9° and 20° ± 12.2°, respectively. Pedicled and/or free-muscle transfers can significantly improve elbow flexion in late obstetric brachial plexus palsy. Choice of the procedure should be individualized and determined on the basis of the type of paralysis, availability of donor muscles, previous reconstruction, and experience of the surgeon.
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Affiliation(s)
- Julia K. Terzis
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Eastern Virginia Medical School (EVMS), 700 Olney Road, LH 2055, Norfolk, VA 23501 USA
| | - Zinon T. Kokkalis
- Microsurgery Program, Department of Surgery, Eastern Virginia Medical School, Norfolk, VA USA
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Al-Qattan MM. An obstetric brachial plexus data sheet. J Hand Microsurg 2009; 1:32-8. [PMID: 23129929 DOI: 10.1007/s12593-009-0005-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Accepted: 03/15/2009] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Several reputed obstetric brachial plexus clinics use their own protocols and indications for surgery. This study is to present and explain the obstetric brachial plexus data sheet used at our institution. METHODS The data sheet is composed of 5 main parts: (1) the basic database which includes the name, age, type and side of palsy, maternal history, birth history and other complications of the traumatic delivery; (2) motor assessment of the limb; (3) preoperative investigations; (4) description of intraoperative brachial plexus findings and type of nerve procedure performed; and (5) secondary surgery to the shoulder, elbow, forearm, wrist and hand. RESULTS The data sheet was found useful in documenting the assessment and events in infants and older children. CONCLUSION An obstetric brachial plexus data sheet is presented and it may be modified and used by other centers.
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Krishnan KG, Martin KD, Schackert G. TRAUMATIC LESIONS OF THE BRACHIAL PLEXUS. Neurosurgery 2008; 62:873-85; discussion 885-6. [DOI: 10.1227/01.neu.0000318173.28461.32] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
AbstractOBJECTIVETo analyze retrospectively the outcomes of primary as well as secondary functional reconstructions in 49 patients with traumatic brachial plexus lesions from a single service. Guidelines for treatment might be extracted from this analysis.METHODSAmong 152 cases of traumatic lesion of the brachial plexus presented to our clinic, 58 underwent primary brachial plexus reconstructive surgery. On exploration, all patients showed stretching and scarring of plexus elements; root avulsions were found in 28 patients (48%). Outcome evaluation was carried out in 49 of these patients with a follow-up period of 1 year or longer (mean follow-up, 27.9 mo; range, 12–72 mo). A total of 43 secondary reconstructive procedures to improve functionality of the involved arm were performed at a later stage in 25 of 58 patients. Outcomes of the secondary functional restorative procedures were evaluated (mean follow-up, 11.5 mo; range, 3–60 mo in 43 procedures).RESULTSPatients with neurolysis as a stand-alone procedure (11 patients) showed an outcome grade of 4 or 5. The average outcome of the 19 patients with C5, C6, and C7 grafting was Grade 3, the same as in patients with nerve transfers to the upper plexus elements (C5–C6 root avulsions, 13 patients). Patients with multiple root avulsions (five cases) showed an overall poor outcome (Grades 0–2). Secondary functional restorative surgery was performed in 43% of the patients and helped improve individual outcomes, providing a favorable effect on the general functionality of the arm. Among the restorative operations performed, the Steindler procedure, wrist extension restoration, claw hand correction, and free functional muscle flap transfer to the arm and forearm were the most rewarding.CONCLUSIONA combination of primary brachial plexus reconstruction and carefully evaluated, selected, and planned function-restorative secondary procedures might offer favorable outcomes in patients with partial or total brachial plexus lesions.
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Affiliation(s)
- Kartik G. Krishnan
- Department of Neurological Surgery, Carl Gustav Carus University Hospital, Dresden University of Technology, Dresden, Germany
| | - K. Daniel Martin
- Department of Neurological Surgery, Carl Gustav Carus University Hospital, Dresden University of Technology, Dresden, Germany
| | - Gabriele Schackert
- Department of Neurological Surgery, Carl Gustav Carus University Hospital, Dresden University of Technology, Dresden, Germany
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