Steindler and pectoralis major flexorplasty: a comparative analysis

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.

The failed adult traumatic brachial plexus reconstruction

Traumatic adult brachial plexus injuries typically cause immediate loss of upper limb function. Timely multidisciplinary treatment in specialized centres often results in a useful helper arm. Both the patient and the surgical team can benefit from an open discussion to set realistic expectations. Surgical reconstruction is customized for each patient, considering their injury factors and functional objectives. Optimizing pain control, adherence to procedure indications and using meticulous surgical techniques help minimize the risk of failing to meet the patient's goals. The need for potential alternative treatment(s) if the desired result is not achieved should be detailed before the initial reconstruction. This review discusses late treatment options, including tendon transfers, joint fusions, free functioning muscle transfers and prosthetics, for managing the failed primary reconstruction of the traumatic adult brachial plexus.

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.

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.

Steindler Flexorplasty: A Description of Current Technique and Case Series

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.

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 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.

The role of elective amputation in patients with traumatic brachial plexus injury

BACKGROUND AND AIM

Despite undergoing complex brachial plexus, surgical reconstructions, and rehabilitation, some patients request an elective amputation. This study evaluates the role of elective amputation after brachial plexus injury.

METHODS

A retrospective chart review was performed for all the 2140 patients with brachial plexus injuries treated with elective amputation between 1999 and 2012 at a single institution. Analysis was conducted on the potential predisposing factors for amputation, amputation level, and postamputation complications. Patients were evaluated using pre- and postamputation Disabilities of the Shoulder, Arm, and hand scores in addition to visual analog pain scores.

RESULTS

The following three conditions were observed in all nine patients who requested an elective amputation: (1) Pan-plexus injury; (2) non-recovery (mid-humeral amputation) or elbow flexion recovery only (forearm amputation) 1 year after all other surgical options were performed; and (3) at least one chronic complication (chronic infection, nonunion fractures, full-thickness burns, chronic neck pain with arm weight, etc.). Pain improvement was found in five patients. Subjective patient assessments and visual analog pain scores before and after amputation did not show a statistically significant improvement in Disabilities of the Shoulder, Arm, and Hand Scores. However, four patients reported that their shoulder pain felt "better" than it did before the amputation, and two patients indicated they were completely cured of chronic pain after surgery.

CONCLUSIONS

Elective amputation after brachial plexus injury should be considered as an option in the above circumstances. When the informed and educated decision is made, patients can have satisfactory outcomes regarding amputation.

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.

Avaliação do ganho funcional do cotovelo com a cirurgia de Steindler na lesão do plexo braquial

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.

[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.

Immediate active range of motion after modified 2-incision repair in acute distal biceps tendon rupture

BACKGROUND

Different rehabilitation protocols have been used after repair of distal biceps ruptures.

PURPOSE

This study investigates the safety of immediate active range of motion protocol after modified 2-incision distal biceps tendon repair in acute ruptures.

STUDY DESIGN

Case series; Level of evidence, 4.

MATERIALS AND METHODS

Twenty-one patients with a minimum follow-up of 2 years were participants in this study. After repair, the upper extremities were placed in a sling for 1 to 2 days and then immediate active range of motion was started. For the first 6 weeks, the elbow was allowed activities of daily living as tolerated by the patient with a 1-lb weight-lifting restriction. Elbow range of motion, isometric and dynamic flexion, and supination strengths were recorded and Disabilities of the Arm, Shoulder and Hand (DASH) scores were obtained.

RESULTS

Mean follow-up extension was 0 degrees and mean follow-up flexion was 141 degrees on the operated side, with supination of 74 degrees and pronation of 75 degrees. The mean DASH score for 21 patients was 3.6 +/- 3.6 (range, 0-11.4). The mean follow-up isometric flexion strength was found to be 5% (P = .411), and the power (dynamic strength) of flexion was 12% greater on the operated side (P = .046). However, follow-up isometric supination strength was 9% less on the involved side than on the noninvolved side (P = .030), and the power of supination was 11% less on the operated side (P = .007). There were no tendon reruptures at follow-up, determined by physical examination.

CONCLUSION

A modified 2-incision distal biceps repair allows a safe immediate active range of motion protocol with early return of nearly full range of motion and strength, without any clinically significant disability.

Surgical technique of pedicled bipolar pectoralis major transfer for reconstruction of elbow flexion in brachial plexus palsy

In Erb (C5-C6) type of palsy due to traumatic brachial plexus injury, function is dependent upon the ability of the arm to maneuver and stabilize the hand for action. Complete loss of power of elbow flexion after brachial plexus injuries is a severe disability. If there is control of the shoulder, elbow flexion is of major importance. Various types of procedures have been described to recover or reanimate elbow flexion for chronic or failed upper type paralysis, including free muscle transfer, unipolar and bipolar pedicled muscle transfer, and various tendon transfers. In this article, we describe the surgical technique of bipolar pectoralis major transfer and our experience with this type of transfer, wherein we prefer to transfer all components of the pectoralis major muscle including the sternocostal and clavicular origins and humeral insertion without a fascial graft by the inclusion of a strip of the rectus abdominis fascia along with the flap.

A one-stage shoulder arthrodesis and Brooks Seddon pectoralis major to biceps tendon transfer for upper brachial plexus injuries

Reconstructive procedures to optimise the function of patients with upper brachial plexus injuries are well described. From 1999 to 2005, nine patients underwent a single stage Brooks Seddon pectoralis major to biceps tendon transfer with a glenohumeral arthrodesis for restoration of elbow flexion and shoulder stability. All of these patients had sustained traumatic upper trunk brachial plexus injuries which had not responded to nerve repair, grafting or neurotisation or had a delayed presentation. Results were assessed using a goniometer and the Medical Research Council strength grading. At follow-up of 28.5 months, the average arc of elbow flexion was 103 degrees and eight had good elbow flexion power. There was one failure. We had two complications, both related to humerus fractures below the arthrodesis plate. Both united with conservative treatment. Our experience has given encouraging results with a high level of patient satisfaction. Our indications, operative technique and results are presented.

Modified Steindler procedure for the treatment of brachial plexus injuries

A retrospective follow-up study was completed on ten patients who suffered from a brachial plexus injury that was treated with a modified Steindler procedure. The mean postoperative period was 6.8 years. The postoperative elbow joint range of motion was -42 degrees of extension (range -5 degrees to -65 degrees ) and 107 degrees of flexion (range 90 degrees -130 degrees ). Manual muscle testing showed grade 4 or 5 in eight patients and grade 3 in two patients. In the subjective assessment, the patients scored 20 out of 30 points and were able to perform almost all activities with the exception of shoulder elevation. Innervation of the musculocutaneous nerve was evaluated by electromyography and no correlation was seen between preoperative and postoperative amplitude of the biceps brachii by electromyogram. Based on these results, we concluded that a modified Steindler procedure is useful for reconstruction of upper brachial plexus injuries, and recovery of the biceps brachii was difficult to predict by an electromyogram.

Elbow flexion reconstruction by Steindler flexorplasty in obstetric brachial plexus palsy

The results of Steindler flexorplasty in nine patients with obstetric brachial plexus palsy are reported. There were 5 girls and 4 boys with a mean age of 6 (range 2-13) years. Selection criteria for the procedure included strong (at least M4) grip strength and wrist and elbow extension, as well as the presence of the "Steindler effect". Pre-operatively, elbow flexion was rated as M0 or M1 in three patients and M2 in the remaining six patients. Intra-operatively, the detached common flexor origin was advanced 5 to 7 cm and fixation was done to the anterior humerus either with direct suture to the periosteum (in younger children) or suturing into a drill hole in the humerus (in older children). Postoperatively, the elbow was immobilized in flexion and supination for 6 weeks. At a mean follow-up of 5 years, the results in eight patients were good with mean active elbow flexion against resistance of 110 degrees and a mean elbow flexion contracture of 35 degrees. The result in the remaining patient was poor (unsuccessful transfer). It is concluded that the results of the Steindler flexorplasty in obstetric brachial plexus palsy patients are good and reliable, provided patient selection is careful.

Patient-oriented functional outcome after repair of distal biceps tendon ruptures using a single-incision technique

Using a patient-oriented outcome questionnaire, in addition to standard outcome measures, we sought to determine the outcome of patients who had repair of a complete rupture of the distal biceps tendon via a single anterior incision technique with suture anchors. We identified 62 patients who were treated operatively by a single surgeon over an 8-year period for a diagnosis of complete rupture of the distal biceps tendon. Of the patients, 9 could not be located for final follow-up, and 53 of 62 (85%) participated in the study. All patients were men, and their mean age was 42 years. All repairs were performed via a single anterior incision by use of 2 suture anchors in the bicipital tuberosity on an outpatient basis. There were 4 complications (4/53 [7.5%]): 1 wound infection, 2 transient paresthesias in the lateral cutaneous nerve distribution, and 1 posterior interosseous nerve palsy that resolved in 6 weeks (no reoperations). There were no reruptures, and no patient lost more than 5 degrees of elbow flexion- extension or forearm rotation. All patients completed the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. The mean DASH score was 8.2 +/- 11.6 (95% CI, 5.2 to 11.9), which was similar to the mean DASH score in population controls of 6.2 (DASH User Manual). The strengths of our study include the consistent surgical technique by a single surgeon, the large number of patients, and the use of a patient-oriented outcome measure. Distal biceps tendon rupture repair via a single-incision technique with suture anchors was effective in restoring injured arms to normal, as measured by limb-specific patient-oriented measures, with minimal morbidity and a low complication rate.

[The brachial plexus lesion. Management, consequences of palsy and reconstructive operations]

The treatment of traumatic brachial plexus lesions follows sequential steps. After acute therapy (phase I), neurological diagnostics (phase II), neurosurgery and postoperative treatment (phase III/IV), reconstructive operations (phase V) can be indicated and performed. In most cases an insufficient grade of muscle power remains. Within 6 months after injury, neurosurgery must be performed in patients with brachial plexus palsy. After malfunction of the muscles, taking into account the individual neuromuscular defects, passive joint function and bony deformities, different procedures such as muscle transposition, arthrodesis and corrective osteotomy can be performed to improve the function of the upper extremity. The treatment of patients suffering from brachial plexus lesion requires interdisciplinary teamwork.

The Steindler flexorplasty for the arthrogrypotic elbow

PURPOSE

The arthrogrypotic elbow often lacks active flexion. If active elbow flexion can be provided by muscle transfer, patient independence increases and the patient can function in a less conspicuous manner by avoiding adaptive mechanisms. The purpose of this article is to review the outcome of patients with arthrogryposis treated with the Steindler flexorplasty to obtain active elbow flexion.

METHODS

Seventeen elbows in 10 patients with an average age of 7 years were treated surgically with the Steindler flexorplasty procedure. Before surgery none of the patients was able to flex actively the elbow against gravity. All of the patients had at least 70 degrees of passive elbow flexion. Upper-extremity active and passive range of motion, strength of flexion, functional outcome, and patient satisfaction were assessed at an average of 5 years after surgery (range, 2-9 years).

RESULTS

After surgery all patients obtained active elbow flexion against gravity averaging 85 degrees (range, 30 degrees -120 degrees ); patients were able to lift an average of 1 kg through their entire arc of elbow flexion. At last follow-up evaluation patients lost an average of 27 degrees of elbow extension. Patients lost forearm rotation but did not lose wrist or finger range of motion. Subjectively, 9 of the 10 patients were satisfied with the outcome of the surgery and would recommend the surgery to others.

CONCLUSIONS

The Steindler flexorplasty provides improved elbow flexion strength and patient function and should be considered for children with arthrogryposis.

Effect of humeral condylar resection on strength and functional outcome after semiconstrained total elbow arthroplasty

BACKGROUND

Under certain conditions it is standard practice to excise ununited humeral condyles during insertion of a semiconstrained total elbow prosthesis. Since the osseous origins of the common extensors and flexor-pronator muscles are lost, it has been postulated that this excision has a negative effect on strength. We are not aware of any previous study in which this issue has been investigated with use of standardized, objective testing of muscle strength.

METHODS

We used objective testing to determine the effect of condylar resection on the muscle strength of the elbow, forearm, wrist, and hand in thirty-two patients who had undergone total elbow arthroplasty. To eliminate bias, the normal, contralateral limb served as the control, and all strength values are given as a percentage of the normal side. The humeral condyles were intact in sixteen patients and had been resected in the other sixteen. Patient demographics were similar in the two groups.

RESULTS

There were no significant differences between the two groups with regard to strength of pronation (103% of the normal side in the group with intact condyles compared with 89% in the group with resection of the condyles; p = 0.40), supination (68% compared with 89%; p = 0.49), wrist flexion (66% compared with 56%; p = 0.46), wrist extension (75% compared with 65%; p = 0.40), or grip strength (83% compared with 72%; p = 0.40). There was also no difference between the two groups with regard to the Mayo Elbow Performance Score (79 points in the group with intact condyles compared with 77 points in the group with resection of the condyles; p = 0.67).

CONCLUSIONS

Condylar resection has a minimal, clinically irrelevant effect on forearm, wrist, and hand strength and no effect on the Mayo Elbow Performance Score following total elbow arthroplasty. Thus, the findings of our study support the practice of condylar resection, which simplifies total elbow arthroplasty for many conditions.

Transposition of local muscles to restore elbow flexion in brachial plexus palsy

Between 1994 and 2001, triceps to biceps transfers were done in 10 men and a transfer of the forearm flexors and extensors (Steindler procedure) in nine. All had suffered from a post-traumatic lesion of their brachial plexus, resulting in loss of elbow flexion. Their mean age at the time of the original accident was 27 years (range 16-50 years) and at the time of muscle transfer 35 years (range 22-56 years), with a mean observation period of 20 months (range 6-51 months). In 16 patients, a neurosurgical procedure had been performed after the trauma, and in 22 patients other reconstructive operations had been done. Transfer of the forearm flexors and extensors resulted in active elbow flexion with a mean of 94 degrees (range 70-130 degrees ). After triceps to biceps transposition a mean of 109 degrees (range 70-140 degrees ) was reached. A mean deficit of passive extension of 12 degrees (range 0-30 degrees ) remained after the Steindler procedure, and of 5 degrees (range 0-10 degrees ) after triceps to biceps transposition. Two complications occurred with the Steindler procedure. The transfer of the triceps muscle to the tendon of the biceps and the transfer of the forearm flexors or extensors on loss of elbow flexion, therefore, resulted in adequate movement and strength. Both procedures involve operating close to the elbow joint and had minimal complications. The triceps to biceps transfer is particularly suitable for co-contraction of triceps and biceps.

Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach

BACKGROUND

While surgical repair is considered the standard of care of displaced intra-articular distal humeral fractures, most investigators have assessed its results with use of surgeon-based and/or radiograph-based outcome measures. The purpose of our study was to determine the functional outcome of fixation of displaced intra-articular distal humeral fractures with use of a standardized evaluation methodology consisting of objective testing of muscle strength and use of patient-based questionnaires (both limb-specific and general health-status questionnaires).

METHODS

We identified twenty-five patients (fourteen male and eleven female), with a mean age of forty-seven years, who had an isolated, closed, displaced, intercondylar, intra-articular fracture of the distal part of the humerus repaired operatively through a posterior approach and fixed with plates on both the medial and the lateral column. All patients returned for follow-up that included recording of a complete history, physical examination, radiographic examination, completion of both a limb-specific questionnaire (Disabilities of the Arm, Shoulder and Hand [DASH]) and a general health-status questionnaire (Short Form-36 [SF-36]), and objective muscle-strength testing.

RESULTS

The mean duration of follow-up was thirty-seven months (range, eighteen to seventy-five months). The mean flexion contracture was 25 degrees (range, 5 to 65 degrees), and the mean arc of flexion-extension was 108 degrees (range, 55 to 140 degrees). Significant decreases in mean muscle strength compared with that on the normal side were seen in both elbow flexion measured at 90 degrees (74 percent of normal, p = 0.01) and elbow extension measured at 45 degrees (76 percent of normal, p = 0.01), 90 degrees (74 percent of normal, p = 0.01), and 120 degrees (75 percent of normal, p = 0.01). The mean DASH score was 20 points, indicating mild residual impairment. The SF-36 scores revealed minor but significant decreases in the role-physical and physical function scores (p = 0.01 and 0.03, respectively) but no alteration of the mental component or mean scores. Six patients (24 percent) had a reoperation; three of them had removal of prominent hardware used to fix the site of an olecranon osteotomy.

CONCLUSIONS

The surgical repair of an intra-articular distal humeral fracture is an effective procedure that reliably maintains general health status as measured by patient-based questionnaires. Our study quantified a decrease in the range of motion and muscle strength of these patients, which may help to explain the mild residual physical impairment detected by the limb-specific outcome measures and physical function components of the general health-status measures.

The surgical treatment of brachial plexus injuries in adults

Posttraumatic brachial plexus palsy is a severe injury primarily affecting young individuals at the prime of their life. The devastating neurological dysfunction inflicted in those patients is usually lifelong and creates significant socioeconomic issues. During the past 30 years, the surgical repair of these injuries has become increasingly feasible. At many centers around the world, leading surgeons have introduced new microsurgical techniques and reported a variety of different philosophies for the reconstruction of the plexus. Microneurolysis, nerve grafting, recruitment of intraplexus and extraplexus donors, and local and free-muscle transfers are used to achieve optimal outcomes. However, there is yet no consensus on the priorities and final goals of reconstruction among the various centers.

Effect of the Steindler procedure on the median nerve branches to the medial epicondylar muscles

Usually the median nerve gives off six branches to the muscles arising from the medial epicondyle, which could be tightened during Steindler's procedure. We studied these branches before and after Steindler's procedure in 20 fresh cadavers and observed a considerable variation in the origin of the branches. The muscular branches arising from the median nerve did not seem to limit the mobilization of the medial epicondyle when performing Steindler's transfer. The limitation of the flexion observed after Steindler's procedure was mainly related to the tension of the transferred forearm flexor muscles. The variability of the origin of the branch to the flexor digitorum superficialis muscle could explain a lesion of this branch when Steindler's procedure is carried out with Brunelli's modification. The lateral transfer and the anterior transfer on to the humeral shaft did not influence the limitation of elbow flexion or result in tightness in any nerve branch to the transferred muscles.