Elbow flexion restoration using pedicled latissimus dorsi transfer in seven cases

Reconstruction of elbow flexion after sarcoma excision by a unipolar pedicled latissimus dorsi flap

INTRODUCTION

The latissimus dorsi flap is widely used in plastic surgery for covering the upper limb but also for reconstruction the function of the elbow or shoulder. We describe a case of a sarcoma of the anterior compartment of the arm, the surgical removal then the covering and reconstruction of the elbow flexion. This case was carried out by a unipolar pedicled flap of the latissimus dorsi.

MATERIAL AND METHODS

Three steps were performed (excision, flap preparation and flap fixation). The functional results (muscle strength, MRC scale) and range of motion (ROM) were analyzed. We performed a small literature review to compare the results.

RESULTS

A complete excision (R0) was carried out with a good vitality of the latissimus dorsi flap. A rapid scarring was obtained, allowing an early start of adjuvant radiotherapy. Muscular strength was 33% less compared to preoperative, MRC scale was classified 4. ROM of the elbow was rated at -10/0/130. One year after the operation, the patient is still in remission.

CONCLUSION

Our functional results are comparable to those found in the literature. The muscle strength in our case appears to be superior, probably linked to a brachio-radialis muscle still functional. No difference in function has been found in the literature between a unipolar or a bipolar transfer of the latissimus dorsi. This case report confirms the reliable and effective nature of the latissimus dorsi flap. The use of this flap for reconstruction after sarcoma surgery has only few reports in the literature.

Triceps-to-Biceps Tendon Transfer for Restoration of Elbow Flexion in Brachial Plexus Injury

PURPOSE

Restoring elbow flexion is a reconstructive priority in patients with brachial plexus injuries. This study aimed to evaluate the results and assess factors contributing to outcomes of triceps-to-biceps tendon transfer in patients presenting with delayed or chronic upper brachial plexus injury.

METHODS

Patients with traumatic brachial plexus injuries undergoing triceps-to-biceps tendon transfer at a single institution's multidisciplinary brachial plexus center between 2001 and 2021 were retrospectively reviewed. The entire triceps tendon was transferred around the lateral aspect of the arm, secured to the radius with a tenodesis button, and reinforced with a side-to-side tendon transfer to the biceps tendon. Primary outcomes include the modified British Medical Research Council (mBMRC) elbow flexion strength and active elbow range of motion.

RESULTS

Twelve patients (eight men and four women; mean age, 45.2 years) were included. The mean follow-up was 10.4 (range, 5-34) months. Nine patients achieved mBMRC ≥3. Five patients achieved mBMRC 4. Average active elbow flexion was 119°, with average extension deficit of 11°. There were three patients with unsatisfactory results, achieving mBMRC 2 elbow flexion.

CONCLUSIONS

Triceps-to-biceps tendon transfer is an excellent tendon transfer option for restoring elbow flexion in certain patients with an adequately functioning triceps muscle, who present with a delayed or chronic brachial plexus injury. Although most patients achieved mBMRC ≥3 elbow flexion, there was an expected permanent loss of elbow active extension with a residual elbow flexion contracture.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Bipolar Pedicled Latissimus Dorsi Flap for Soft-Tissue Coverage and Restoration of Elbow Function

Bipolar latissimus dorsi transfer has been considered a viable option for the restoration of elbow flexion in patients with large traumatic defects of the anterior arm compartment. Advantages of bipolar transfer of the latissimus include stabilization of the anterior shoulder joint in addition to recreating the biceps for a direct line of pull in restoring elbow flexion with minimal donor site morbidity. Previous literature in bipolar latissimus transfer has demonstrated good outcomes in elbow flexion against gravity, range of motion, and patient satisfaction. We present a step-by-step demonstration of a bipolar pedicled latissimus dorsi transfer for restoration of elbow function and soft-tissue coverage for large traumatic defects to the anterior compartment of the arm.

Elbow Flexion Reconstruction after Traumatic Amputation Using Hinged External Fixator and Muscle Transfer: A Case Report

CASE

A 40-year-old man sustained a traumatic elbow disarticulation without any fracture, accompanied by severe damage of the biceps and brachialis. After replantation, passive elbow motion was used with a hinged external fixator to facilitate elbow joint reduction and mobility. Eight months after the injury, a functional latissimus dorsi transfer for elbow flexion restoration was performed. Ten years postoperatively, he achieved antigravity elbow flexion and 120° of flexion and -15° extension of the elbow.

CONCLUSION

This reconstruction technique was useful for reconstructing elbow flexion after traumatic elbow disarticulation.

Functional reconstruction of elbow flexion with latissimus dorsi muscle rotational transfer: two case reports

BACKGROUND

We report two cases of biceps brachii and brachialis paralysis due to musculocutaneous nerve injury in which elbow joint flexion was reconstructed using rotational transfer of the latissimus dorsi muscle with sutures to the radial and ulnar tuberosities, thereby enabling flexion by simultaneous activation of the humeroradial and humeroulnar joints. In cases of associated brachialis paralysis, weaker flexion strength can be expected when the forearm is in a pronated position than when it is in a supinated state. To the best of our knowledge, no previous study has reported the rotational position of the forearm during elbow joint flexion reconstruction.

CASE PRESENTATION

Case 1 involved a 30-year-old Asian male who presented with a rupture of the musculocutaneous, median, radial, and ulnar nerves. Reconstruction was performed by rotational transfer of the latissimus dorsi muscle. In this case, the supination and pronation flexion forces were equal. Case 2 involved a 50-year-old Asian man who presented with partial loss of the musculocutaneous nerve, biceps brachii, and pectoralis major due to debridement. Reconstruction was performed by rotational transfer of the latissimus dorsi muscle. In this case, supination and pronation flexion strengths were demonstrated to be equal. Our reconstruction method used the rotational transfer of the latissimus dorsi muscle; the distal muscle flap was divided into radial and ulnar sides to allow elbow joint flexion by simultaneously activating the humeroradial and humeroulnar joints. These sides were then fixed to the anchors at the radial and ulnar tuberosities. Finally, they were wrapped around the myotendinous junction of the biceps brachii or brachialis and secured using sutures.

CONCLUSIONS

Although larger studies are required to verify these methods, this case study successfully demonstrates the following: (1) the flexion strength in the supinated position was equal to that in the pronated position; (2) the stability of the humeroradial and humeroulnar joints was unaffected by the forearm's rotational position; and (3) a satisfactory range of motion of the elbow joint was obtained, with no complications.

Unipolar Latissimus Dorsi Transfer for Restoration of Elbow Flexion in Residual Post-traumatic Brachial Plexus Palsy Associated with Distal Humeral Fractures

Introduction  Elbow flexion is indispensable for both functioning and nonfunctioning hands. It is well perceived that restoration of elbow function is the first reconstructive priority in cases of brachial plexus injuries. The authors assessed the impact of associated distal humeral fractures on the functional outcome after unipolar latissimus dorsi transfer (ULDT) for restoration of elbow flexion in patients with residual brachial plexus palsy (BPP). Patients and Methods  Twenty-three patients operated for restoring elbow flexion after residual post-traumatic BPP (with or without distal humeral fracture) by unipolar latissimus dorsi transfer (ULDT) were reviewed for a retrospective study. Patients were divided into two groups; associated distal humeral fracture group (HF-group; 10 patients) and non-associated distal humeral fracture group (NHF-group; 13 patients). Elbow flexion active range of motion (AROM), flexion deformity in addition to Mayo Elbow Performance Score (MEPS) were assessed. Results  In both groups there were statistically better postoperative MEPS grading ( p  = 0.007, p  = 0.001 , respectively) and scoring with a mean of 81 ± 16.1 and 90 ± 4.6, respectively ( p < 0.001). The mean postoperative elbow flexion AROM was statistically better in both groups. The mean supination AROM was better in NHF group ( p  = 0.057). Conclusion  The use of ULDT in residual post-traumatic BPP is an efficient procedure in regaining functional flexion and supination. An associated distal humeral fracture does not significantly affect the final functional outcome. Level of Evidence  Level IV.

Outcomes of gracilis free-flap muscle transfers and non-free-flap procedures for restoration of elbow flexion: A systematic review

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.

Successful Elbow Flexion Reconstruction Using Latissimus Dorsi Muscle Transfer Following a Road Traffic Accident and Upper Limb Trauma

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.

Clinical outcomes report in different brachial plexus injury surgeries: a systematic review

Brachial plexus injury is a lesion that results in loss of function of the arm, and there are multiple ways of surgically approaching its treatment. Controlled trials that compare all surgical repair strategies and their clinical outcomes have not been performed. A systematic review was conducted to identify all articles that reported clinical outcomes in different surgeries (nerve transfer, nerve graft, neurolysis, end-to-end, multiple interventions, and others). Advanced search in PubMed was performed using the Mesh terms "brachial plexus injury" as the main topic and "surgery" as a subtopic, obtaining a total of 2153 articles. The clinical data for eligibility extraction was focused on collecting motor, sensory, pain, and functional recovery. A statistical analysis was performed to find the superior surgical techniques in terms of motor recovery, through the assessment of heterogeneity between groups, and of relationships between surgery and motor recovery. The frequency and the manner in which clinical outcomes are recording were described. The differences that correspond to the demographics and procedural factors were not statistically significant among groups (p > 0.05). Neurolysis showed the highest proportion of motor recovery (85.18%), with significant results between preoperative and post-operative motor assessment (p = 0.028). The proportion of motor recovery in each group according to the surgical approach differed significantly (X² = 82.495, p = 0.0001). The motor outcome was the most reported clinical outcome (97.56%), whereas the other clinical outcomes were reported in less than 15% of the included articles. Unexpectedly, neurolysis, a technique displaced by new surgical alternatives such as nerve transfer/graft, demonstrated the highest proportion of motor recovery. Clinical outcomes such as pain, sensory, and functional recovery were infrequently reported. These results introduce the need to re-evaluate neurolysis through comparative clinical trials, as well as to standardize the way in which clinical outcomes are reported.

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.

A review of functional latissimus dorsi transfers for absent elbow flexion and supination

AIMS

To review patients treated with a functional latissimus dorsi flap for congenital and acquired elbow flexion deficits.

METHODS

Retrospective review of functional latissimus dorsi flaps performed in one regional unit. Patient notes were reviewed to determine aetiology, pre-op deficits and function, surgical technique, complications and outcomes.

RESULTS

A total of six functional latissimus dorsi transfers were performed on four patients. Two patients had bilateral latissimus dorsi transfers for congenital defects. The remaining two procedures were for traumatic defects. Post-operatively both children had excellent outcomes with full range of active movement allowing them to perform key activities of daily living.

SURGICAL TECHNIQUE

Epimysium of latissimus dorsi folded to form a pseudo-tendon, tunnelled subcutaneously and either attached to a remnant of biceps tendon or secured to the radius. Congenital patients achieved better outcomes; pre-operatively, there was no active elbow flexion in all four elbows but 90-100 of passive flexion.

COMPLICATIONS

One latissimus dorsi dehiscence which required revision surgery. Two donor-site seromas.

CONCLUSIONS

Functional latissimus dorsi transfer has been shown to achieve excellent elbow flexion in patients with congenital absence of biceps and brachialis muscles. Outcomes in older patients with traumatic injuries have been less successful in achieving a full range of active flexion.

Engineering skeletal muscle: Building complexity to achieve functionality

Volumetric muscle loss (VML) VML is defined as the loss of a critical mass of skeletal muscle that overwhelms the muscle's natural healing mechanisms, leaving patients with permanent functional deficits and deformity. The treatment of these defects is complex, as skeletal muscle is a composite structure that relies closely on the action of supporting tissues such as tendons, vasculature, nerves, and bone. The gold standard of treatment for VML injuries, an autologous muscle flap transfer, suffers from many shortcomings but nevertheless remains the best clinically available avenue to restore function. This review will consider the use of composite tissue engineered constructs, with multiple components that act together to replicate the function of an intact muscle, as an alternative to autologous muscle flaps. We will discuss recent advances in the field of tissue engineering that enable skeletal muscle constructs to more closely reproduce the functionality of an autologous muscle flap by incorporating vasculature, promoting innervation, and reconstructing the muscle-tendon boundary. Additionally, our understanding of the cellular composition of skeletal muscle has evolved to recognize the importance of a diverse variety of cell types in muscle regeneration, including fibro/adipogenic progenitors and immune cells like macrophages and regulatory T cells. We will address recent advances in our understanding of how these cell types interact with, and can be incorporated into, implanted tissue engineered constructs.

Arm reconstruction

The arm is less often concerned by reconstructive surgeries than more distal parts of the upper extremity. However, when affected, the arm is frequently part of complex mutilating injuries involving composite defects. For a given traumatic or oncologic defect, there are several reconstructive options and choosing the right sequence may pose a challenge even to the most experienced surgeon. The latter must integrate not only functional and esthetic requirements, but also the surgeon's habits, especially in situations of emergency. Once life-threatening conditions are averted, wound debridement, bony stabilization, neurovascular, and cutaneous reconstruction tailored to the defects should be performed in a single-stage procedure. Functionally, prompt bony stabilization is necessary to allow early mobilization. Diaphyseal shortening of the humerus can be a salvage procedure to avoid nerve and vascular grafting, with good biomechanical tolerance up to 5cm. Restoration of adequate elbow motion sometimes requires muscle transfer and should be a main concern, as proper positioning of the hand during daily activities demands a functional elbow joint. Esthetically, the surgeon must choose the most cosmetic skin coverage option whilst limiting morbidity of the donor site area. The flaps vascularized by the sub- scapular or thoraco-dorsal vessels are the most useful flaps for arm reconstruction. This paper discusses the reconstructive sequence of complex defects of the arm and provides a review of commonly used reconstructive techniques supported with illustrative cases.

Bipolar transfer of the pectoralis major muscle for restoration of elbow flexion in 29 cases

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.

Restoration of elbow active flexion via latissimus dorsii transfer in patients with arthrogryposis

Background. Severe hypoplasia (or aplasia) of the biceps brachii is a primary cause of restriction in activities of daily living in patients with arthrogryposis. Aim. To estimate the possibility of restoring elbow active flexion via a latissimus dorsii transfer in patients with arthrogryposis. Materials and methods. From 2011 to 2018, we restored active flexion of the elbow via a latissimus dorsi transfer to the biceps brachii in 30 patients with arthrogryposis (44 upper limbs). We used different regimes including clinical examinations, EMG donor and recipient sites, and CT of the chest wall and shoulder. Results. The mean age of the patients was 4.0 ± 2.4 years, and the follow-up period was 3.2 ± 1.9 months. Follow-up results were available for 26 patients (30 upper limbs). The active postoperative elbow motion was 90.5 ± 14.9°. Elbow extension limitation occurred in 51% of cases (12.8 ± 4.3°) without any problems in activities of daily living. In total, 55.6% of patients had good results, 33.3% had satisfactory results, and 11.1% had poor results. Discussion. Our latissimus dorsi transfer results were comparable with those of other authors. Transposition of the latissimus dorsi to the biceps brachii restores sufficient flexion of the elbow without severe elbow flexion contractures. Conclusions. We suggest pedicle monopolar latissimus dorsi transfer as a reliable therapeutic option to restore active elbow flexion in patients with arthrogryposis having passive elbow flexion of 90° or higher before operation and donor muscle strain grade 4 or higher.

Surgical strategy in extensive proximal brachial plexus palsies

PURPOSE

To describe and assess an overall surgical strategy addressing extensive proximal brachial plexus injuries (BPI).

METHODS

Forty-five consecutive patients' charts with C5-C6-C7 and C5-C6-C7-C8 BPI were reviewed. Primary procedures were nerve transfers to restore elbow function and grafts to restore shoulder function when a cervical root was available; when nerve surgery was not possible or had failed, tendon transfers were conducted at the elbow while addressing shoulder function with glenohumeral arthrodesis or humeral osteotomy. Tendon transfers were used to restore finger extension.

RESULTS

Forty-one patients underwent elbow flexion reanimation: thirty-eight had nerve transfers and eight received tendon transfers, including five cases secondary to nerve surgery failure; grade-3 strength or greater was reached in thirty-seven cases (90%). Twenty-nine patients had nerve transfers to restore elbow extension: twenty-five recovered grade-3 or grade-4 strength (86%). Forty-one patients underwent shoulder surgery: fourteen had nerve surgery and thirty-one received palliative procedures, including four cases secondary to nerve surgery failure; thirty patients recovered at least 60° of abduction and rotation (73%). Distal reconstruction was performed in thirty-seven patients, providing finger full extension in all cases but two (95%).

CONCLUSIONS

A standardized strategy may be used in extensive proximal BPI, providing overall satisfactory outcomes.

Bipolar Transfer of Latissimus Dorsi Myocutaneous Flap for Restoration of Elbow Flexion in Late Traumatic Brachial Plexus Injury: Evaluation of 13 Cases

BACKGROUND

Restoration of elbow flexion following traumatic brachial plexus injury represents a great challenge to the reconstructive surgeons. Functional muscle transfers come next to the sophisticated types of nerve surgery in this area. Many transfers are well known for restoration of elbow flexion; bipolar or unipolar latissimus dorsi, triceps brachii, sternocleidomastoid, pectoralis major, and Steindler flexorplasty.

OBJECTIVE

Evaluation of the outcome of bipolar transfer of latissimus dorsi myocutaneous flap when used to restore elbow flexion in late traumatic brachial plexus injury.

PATIENTS AND METHODS

Thirteen patients were included in this case series with careful evaluation both preoperatively and postoperatively both clinically and using electromyography.

RESULTS

Almost 84.6% of patients (11 of 13) developed G3-4 on the Medical Research Council grading with relatively minimal both donor-site and recipient-site morbidity.

CONCLUSIONS

Bipolar transfer of latissimus dorsi myocutaneous flap is a reliable method for restoration of elbow flexion in patients suffering from late sequelae of traumatic brachial plexus injury.

Triceps to biceps transfer for restoration of elbow flexion following upper brachial plexus injury

INTRODUCTION

Upper brachial plexus injury in adults causes loss of elbow fl exion; when the primary nerve surgery has failed or the patient seeks treatment after 12 months of injury and pedicled muscle transfers are required. Most commonly, the latissimus dorsi or the Steindler flexorplasty is used.

MATERIAL AND METHODS

We have transferred one of the heads of triceps muscle to restore the elbow flexion in such cases. In addition to return of elbow flexion, extension of elbow following surgery is retained. Ten patients suffering from upper brachial plexus injuries underwent transfer of one head of triceps to biceps tendon between December 2011 and August 2015.

RESULTS

The recovery of elbow flexion was Grade 5 in 1, Grade 4 in 4 and Grade 3 in 2; only three of the ten patients had no functionally useful elbow flexion. Seven of the ten patients had an adequate elbow extension following the procedure.

Single-stage Reconstruction of Elbow Flexion Associated with Massive Soft-Tissue Defect Using the Latissimus Dorsi Muscle Bipolar Rotational Transfer

In the upper extremity, the latissimus dorsi muscle can be used as an ipsilateral rotational muscle flap for soft-tissue coverage or functional reconstruction of arm and elbow. Patients who have both major soft-tissue loss and functional deficits can be successfully treated with a single-stage functional latissimus dorsi rotational muscle transfer that provides simultaneous soft-tissue coverage and functional reconstruction.

METHODS

Our data base was queried for all patients undergoing a rotational latissimus dorsi muscle transfer for simultaneous soft-tissue coverage and functional reconstruction of elbow flexion. Four patients were identified. A chart review documented the mechanism of injury, associated injuries, soft-tissue defect size, number of surgical procedures, length of follow-up, last elbow range of motion, and flexion strength.

RESULTS

Four patients with loss of elbow flexion due to traumatic loss of the anterior compartment muscles and the overlying soft tissue underwent simultaneous soft-tissue coverage and elbow flexorplasty using the ipsilateral latissimus dorsi as a bipolar muscle rotational tissue transfer. All flaps survived and had a recovery of Medical Research Council Grade 4/5 elbow flexion strength. No additional procedures were required for elbow flexion. The surgical technique is described and supplemented with surgical technique video and patient outcome.

CONCLUSIONS

This patient series augments the data provided in other series supporting the safety and efficacy of this procedure which provides both soft-tissue coverage and functional restoration of elbow flexion as a single-stage procedure in the setting of massive traumatic soft-tissue loss of the arm.

Restoration of Elbow Flexion

Active elbow flexion is required to position the hand in space, and loss of this function is debilitating. Nerve transfers or nerve grafts to restore elbow flexion may be options when the target muscle is viable, but in delayed reconstruction when the biceps and brachialis are atrophied or damaged, muscle transfer options should be considered. Muscle transfer options are discussed with attention to the advantages and disadvantages of each transfer option.

Plastic surgery for the oncological patient

The therapy of oncological patients has seen tremendous progress in the last decades. For most entities, it has been possible to improve the survival as well as the quality of life of the affected patients. To supply optimal cancer care, a multidisciplinary approach is vital. Together with oncologists, radiotherapists and other physicians, plastic surgeons can contribute to providing such care in all stages of treatment. From biopsies to the resection of advanced tumors, the coverage of the resulting defects and even palliative care, plastic surgery techniques can help to improve survival and quality of life as well as mitigate negative effects of radiation or the problems arising from exulcerating tumors in a palliative setting. This article aims to present the mentioned possibilities by illustrating selected cases and reviewing the literature. Especially in oncological patients, restoring their quality of life with the highest patient safety possible is of utmost importance.

Obstetrical brachial plexus injuries: late functional results of the Steindler procedure

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.

Bipolar latissimus transfer for restoration of elbow flexion

BACKGROUND

Elbow flexion is often lacking in patients with brachial plexus palsy or anterior arm trauma. Restoring elbow flexion helps position the functioning hand for activity and nonfunctioning hand for stabilization. Bipolar latissimus transfer is one method of improving elbow flexion.

METHODS

A clinical case of bipolar latissimus transfer is presented. Additionally, results of a literature search are incorporated.

RESULTS

Bipolar latissimus can effectively improve elbow function, however residual deficits are to be expected. Additional transfers include unipolar latissimus, triceps, sternocleidomastoid, and pectoralis. Other methods include primary nerve transfer, Steindler flexorplasty, free muscle transfer, and elbow fusion.

CONCLUSION

Elbow flexion can be improved through various techniques. Each individual's clinical picture should be examined by an experienced clinician when choosing which technique to apply.