Muscle transfers in brachial plexus lesions

Brachial Plexus Injuries - Review of the Anatomy and the Treatment Options

Brachial plexus injuries are still challenging for every surgeon taking part in treating patients with BPI. Injuries of the brachial plexus can be divided into injuries of the upper trunk, extended upper trunk, injuries of the lower trunk and swinging hand where all of the roots are involved in this type of the injury. Brachial plexus can be divided in five anatomical sections from its roots to its terminal branches: roots, trunks, division, cords and terminal branches. Brachial plexus ends up as five terminal branches, responsible for upper limb innervation, musculocutaneous, median nerve, axillary nerve, radial and ulnar nerve. According to the findings from the preoperative investigation combined with clinically found functional deficit, the type of BPI will be confirmed and that is going to determine which surgical procedure, from variety of them (neurolysis, nerve graft, neurotization, arthrodesis, tendon transfer, free muscle transfer, bionic reconstruction) is appropriate for treating the patient.

Electromyographic Findings in Gracilis Muscle Grafts Used to Augment Elbow Flexion in Traumatic Brachial Plexopathy

BACKGROUND

Gracilis muscle graft transplantation is one of the last resort surgical options to restore elbow flexion in patients with chronic traumatic upper-trunk brachial plexopathies.

METHODS

We retrospectively identified 34 patients who underwent surgeries between 1997 and 2014, and had postoperative follow-up for at least 12 months. Demographic, clinical, and electromyographic preoperative and postoperative data were analyzed.

RESULTS

The median age of injury was 30 years old. Most subjects had a complete loss of elbow flexion preoperatively (n = 28, 82.4%). Median time from injury to surgery was 20 months (range = 3-226 months). It did not correlate with the time to reinnervation on EMG (r = 0.35, 95% CI = 0.007-0.62) or with the time improvement in muscle strength (r = 0.35, 95% CI = 0.007-0.62). The mean postoperative follow-up interval was 22.35 months. During that period, 32 of 34 (94%) patients achieved reinnervation. Median times from surgery to graft innervation and to any improvement in elbow flexor muscle power were the same (8.5 months) with overlapping time to event curves.

CONCLUSION

Despite the long-standing and complete loss of elbow flexion in most of our patients, gracilis transfer surgeries have helped most of them to achieve reinnervation and start to regain function. Electromyography is a helpful tool, which along with the clinical examination, can predict postoperative improvement.

Treatment options for brachial plexus injuries

The incidence of brachial plexus injuries is rapidly growing due to the increasing number of high-speed motor-vehicle accidents. These are devastating injuries leading to significant functional impairment of the patients. The purpose of this review paper is to present the available options for conservative and operative treatment and discuss the correct timing of intervention. Reported outcomes of current management and future prospects are also analysed.

Complications of intercostal nerve transfer for brachial plexus reconstruction

PURPOSE

Although numerous publications discuss outcomes of intercostal nerve transfer for brachial plexus injury, few publications have addressed factors associated with intercostal nerve viability or the impact perioperative nerve transfer complications have on postoperative nerve function. The purposes of this study were to report the results of perioperative intercostal nerve transfer complications and to determine whether chest wall trauma is associated with damaged or nonviable intercostal nerves.

METHODS

All patients who underwent intercostal nerve transfer as part of a brachial plexus reconstruction procedure as a result of injury were identified. A total of 459 nerves in 153 patients were transferred between 1989 and 2007. Most nerves were transferred for use in biceps innervation, free-functioning gracilis muscle innervation, or a combination of the two. Patient demographics, trauma mechanism, associated injuries, intraoperative nerve viability, and perioperative complications were reviewed.

RESULTS

Complications occurred in 23 of 153 patients. The most common complication was pleural tear during nerve elevation, occurring in 14 of 153 patients. Superficial wound infection occurred in 3 patients, whereas symptomatic pleural effusion, acute respiratory distress syndrome, and seroma formation each occurred in 2 patients. The rate of complications increased with the number of intercostal nerves transferred. Nerves were harvested from previously fractured rib levels in 50 patients. Rib fractures were not associated with an increased risk of overall complications but were associated with an increased risk of lack of nerve viability. In patients with rib fractures, intraoperative nerve stimulation revealed 148 of 161 nerves to be functional; these were subsequently transferred. In patients with preoperative ipsilateral phrenic nerve palsy, the risk of increased complications was marginally significant.

CONCLUSIONS

Brachial plexus reconstruction using intercostal nerves can be challenging, especially if there is antecedent chest wall trauma. Complications were associated with increasing numbers of intercostal nerves transferred. Ipsilateral rib fracture was adversely associated with intercostal nerve viability; it was not significantly associated with complication risk and should not be considered a contraindication to transfer. Preoperative phrenic nerve palsy was marginally associated with the likelihood of complications but not postoperative respiratory dysfunction when associated with intercostal nerve transfer.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Novel strategies in brachial plexus repair after traumatic avulsion

Clinical trials in spinal cord injury (SCI) can be affected by many confounding variables including spontaneous recovery, variation in the lesion type and extend. However, the clinical need and the paucity of effective therapies has spawned a large number of animal studies and clinical trials for SCI. In this review, we suggest that brachial plexus avulsion injury, a longitudinal spinal cord lesion, is a simpler model to test methods of spinal cord repair. We explore reconstructive techniques currently explored for the repair of brachial plexus avulsion and focus on the use of olfactory ensheathing cell transplantation as an adjunct treatment in brachial plexus repair.

Transfer of the recovered biceps to the long flexors of the digits to restore grip function following complete traumatic brachial plexus palsy

Restoration of grip function was achieved through transfer of the recovered biceps tendon to the long digital flexors using a fascia lata graft in seven patients with complete brachial plexus palsy. Initial nerve repair was followed by biceps transfer with stabilising wrist and hand fusions. The biceps recovered to Medical Research Council (MRC) grade 4 in all cases. Patients were reviewed at a mean time of 26.7 (range 7-63) months after biceps transfer. After transfer, the total active movement of the digits averaged 55 (range 30-90)8. The strongest measurable grip strength was 6 kg. Patient satisfaction was high. The excellent excursion of the elbow provides a good basis for a transfer to power grip function, enabling a greater total active movement of the fingers to be achieved. We recommend this method as a useful adjunct to the treatment of the complete brachial plexus palsy.

Free Muscle Transfer in Posttraumatic Plexopathies Part II: The Elbow

The indications for free muscle transfer in brachial plexopathies are prolonged denervation time or inadequate upper extremity function after primary nerve reconstruction. The purpose of this study is to analyze the outcomes of free muscle transfer for elbow flexion and extension in brachial plexopathies in relation to the different muscles used and the respective motor donors. Seventy-three muscles were transferred for elbow flexion and ten for elbow extension. Latissimus dorsi (LD) was used in 37 cases, gracilis in 28, rectus femoris (RF) in seven, and vastus lateralis in one. Five LD and five gracilis were transferred for elbow extension. Patients younger than 15 years yielded better results than older patients for elbow flexion. When LD was transferred, the mean muscle grading (MG) was 3.33 ± 0.25 when the neurotization was from intercostals; these outcomes were statistically significant when compared with outcomes of free gracilis transfer (MG 2.25 ± 0.6). There was also a statistically significant difference when free LD was neurotized with three intercostals as compared with two intercostals nerves. RF yielded also good results when neurotized from contralateral C7 (cC7; MG 3.67 ± 0.6). For elbow extension, the better outcomes of LD were not statistically significant. Among all the free muscle transfers for upper extremity reconstruction, elbow reanimation yielded the most rewarding outcomes. The selection of powerful muscle units was more important than the effect of neurotization which was not as strong as it was in muscle transfers for facial or hand reanimation.

Upper limb functional restoration in old and complete brachial plexus paralysis

Nineteen patients with longstanding and permanent brachial plexus injuries underwent a three-staged surgical reconstruction. First, a sural nerve was grafted from the contralateral intact medial pectoral nerve to the paralyzed arm. One year later, a free gracilis muscle was transferred and neurotized by the grafted sural nerve. This procedure results in reanimation of elbow flexion. Finally, the biceps tendon was transferred to the finger flexors using a fascia bundle of tensor fascia lata muscle. Two of the gracilis muscle free transfers failed. In the remaining 17 patients, the overall result was evaluated as satisfactory in 11 patients and good in 6.

[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.

Late reconstruction for brachial plexus injury

Traumatic brachial plexus injuries are devastating and management is complex. Treatment involves a multidisciplinary approach. Primary reconstruction involves nerve repair, grafting, and transfer techniques. Secondary reconstruction includes microneurovascular free-functioning muscle transfer, tendon transfers, and arthrodesis to improve or restore function. These procedures are indicated when patients present more than 12 months from injury or when primary reconstruction procedures fail, and should focus on elbow flexion and shoulder stability. A free-functioning muscle transfer is often indicated for elbow flexion, with double free-functioning muscle transfers providing possible prehension. Shoulder reconstruction focuses on restoring stability to the glenohumeral joint and restoring abduction. This article outlines these techniques, their principles, and important details.

Technique of intercostal nerve harvest and transfer for various neurotization procedures in brachial plexus injuries

Brachial plexus palsy caused by traction injury, especially spinal nerve-root avulsion, represents a severe handicap for the patient. Despite recent progress in diagnosis and microsurgical repair, the prognosis in such cases remains unfavorable. Neurotization is the only possibility for repair in cases of spinal nerve-root avulsion. Intercostal neurotization is a well-established technique in the treatment of some severe brachial plexus lesions in adults. In this article, we describe our experience and technique of intercostal nerve harvest for transfer in various neurotization strategies in posttraumatic brachial plexus reconstruction. Intercostal nerve harvest is a technique requiring meticulous technique and careful dissection along with proper hemostasis. It is also very important to preserve the serratus anterior muscle insertion and keep soft tissue stripping to a minimal. We do not osteotomize the ribs and believe that this adds to the morbidity and length of the procedure. Neurotization using intercostal nerves is a very viable procedure in avulsion injuries of the brachial plexus; however, there is some concern that in the presence of ipsilateral phrenic nerve palsy, it may lead to a significant compromise of respiratory function. In our experience, this is negligible with good long-term results.

The Surgical Treatment of Brachial Plexus Injuries in Adults

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Evaluate clinically a patient with brachial plexus paralysis and define the appropriate electrophysiologic and radiographic studies. 2. Differentiate between preganglionic (root) avulsion and postganglionic lesions and identify appropriate motor donors and nerve grafts. 3. Describe various nerve reconstructive strategies and make appropriate selection of secondary procedures for shoulder stability, elbow flexion, and hand reanimation. 4. Anticipate the possible functional outcome.

Wrist arthrodesis after double free-muscle transfer in traumatic total brachial plexus palsy

Double free-muscle transfer is a technique used to treat patients with total brachial plexus palsy to restore hand prehension. It involves the reconstruction of shoulder stability, the transfer of 2 functioning gracilis muscles, and other complementary procedures to optimize the function of the transferred muscles. Wrist arthrodesis is one of these complementary procedures. Our technique of wrist arthrodesis in these patients is different from the standard technique. In this article, we describe our technique and experience of wrist arthrodesis in patients with complete brachial plexus palsy treated with double free-muscle transfer technique. In our procedure, the plate is fixed from the second metacarpal--and not the third as is the usual practice--to the radius to avoid friction with the extensor digitorum communis tendons. A very small bone graft, prepared from the removed Lister tubercle, is needed because of the very thin articular cartilage in these patients. A short arm splint is used for only 1 week postoperatively to avoid finger stiffness. There were no major complications such as pseudoarthrosis or metal failure in our patients because the affected limb is subjected only to mild stresses.

Rekonstruktion der Schulterabduktion durch Transfer des M. trapezius

INTRODUCTION

After brachial plexus injuries, shoulder function is frequently impaired or lost. For reconstruction of the most important functions muscle transfers are indicated. To restore abduction and external rotation of the shoulder the trapezius muscle transfer is mainly used.

PATIENTS AND METHODS

We demonstrate 16 patients with insufficient abduction of the shoulder joint. All patients were treated with the transfer of trapezius muscle (pars horizontalis). We used a modification of the technique of Saha. After the operation, the arm was immobilized in 80 degrees abduction for 6 weeks followed by 10 degrees adduction of the shoulder per week. Afterwards physiotherapy was started. Evaluation was done by the DASH score and Gilbert score.

RESULTS

In all cases, an improvement of shoulder mobility was seen, assessed clinically and individually by the patient. The average DASH score was 37.4. For ten patients the results of the operation were very good, good, or satisfactory. Active abduction increased from 15 degrees (0-30 degrees) to 54 degrees (35-80 degrees) postoperatively. The external rotation was 9 degrees (-20-40 degrees) preoperatively and 19 degrees (0-70 degrees ) postoperatively.

DISCUSSION

Trapezius muscle transfer for reconstruction of abduction is an easy and practicable method without serious complications. We achieved good stability and functionality of the shoulder. Intensive pre- and postoperative physiotherapy may provide greater improvement of mobility.

Functioning free-muscle transfer for brachial plexus injury

Functioning free-muscle transfers are now an important, even essential, tool in the current management of patients with brachial plexus injury. They are indicated for the restoration of elbow flexion in patients who delay presentation(those seen after 6 to 9 mo). Double free-muscle transfers provide the possibility of simple grasp function when combined with nerve transfers or grafts for restoration of shoulder motion, hand sensation, and triceps function.

Gracilis free muscle transfer for restoration of function after complete brachial plexus avulsion

Object

The authors report the functional outcomes after functioning free muscle transfer (FFMT) for restoration of the upper-extremity movement after brachial plexus injury (BPI).

Methods

The authors conducted a retrospective review of 36 gracilis FFMT procedures performed in 27 patients with BPI between 1990 and 2000. Eighteen patients underwent a single gracilis FFMT procedure for restoration of either elbow flexion (17 cases) or finger flexion (one case). Nine patients underwent a double free muscle transfer for simultaneous restoration of elbow flexion and wrist extension (first muscle) and finger flexion (second muscle), combined with direct triceps neurotization. The results obtained in 29 cases of FFMT in which the follow-up period was 1 year are reported.

Neurotization of the donor muscle was performed using the musculocutaneous nerve (one case), spinal accessory nerve (12 cases), or multiple intercostal motor nerves (16 cases). Two second-stage muscle flaps failed secondary to vascular insufficiency. Mean electromyography-measured reinnervation time was 5 months. At a minimum follow-up period of 1 year, five muscles achieved less than or equal to Grade M2, eight Grade M3, four Grade M4, and 12 Grade M5. Transfer for combined elbow flexion and wrist extension compared with elbow flexion alone lowered the overall results for elbow flexion strength. Seventy-nine percent of the FFMTs for elbow flexion alone (single transfer) and 63% of similarly innervated muscles transferred for combined motion achieved at least Grade M4 elbow flexion strength.

Conclusions

Functioning free muscle transfer is a viable reconstructive option for restoration of upper-extremity function in the setting of severe BPI. It is possible to achieve good to excellent outcomes in terms of muscle grades with the simultaneous reconstruction of two functions by one FFMT, making restoration of basic hand function possible. More reliable results are obtained when a single FFMT is performed for a single function.

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.

Significance of elbow extension in reconstruction of prehension with reinnervated free-muscle transfer following complete brachial plexus avulsion

Thirty-one patients with complete avulsion of the brachial plexus underwent reconstruction of elbow extension by intercostal nerve transfer following reconstruction of prehension with either a single or double free-muscle transfer. Long-term results of elbow extension were evaluated in 24 patients. Reinnervation of the triceps muscle took longer than that of the transferred muscle on serial electromyographic examinations, and the eventual strength of the triceps muscle was weak. None attained M5 grade, 2 achieved M4 grade, 4 achieved M3 grade, 8 achieved M2 grade, 5 achieved M1 grade, and another 5 achieved M0 grade. However, despite the weak recovery, 14 patients were able to obtain useful functional recovery of the triceps muscle, enabling it to stabilize the elbow joint against the transferred muscle, which acted as simultaneous elbow flexor and wrist or finger extensor. Elbow stability is imperative in order to obtain voluntary finger function following free-muscle transfer. Should the triceps muscle fail to recover following intercostal nerves neurotization, transferring the reinnervated infraspinatus to the triceps is an optional procedure to provide stabilization of the elbow.

Results of functioning free muscle transplantation for elbow flexion

Thirty-eight patients underwent functioning free muscle transplantation for restoration of elbow flexion. Thirty-five patients had sustained brachial plexus injury and 3 had traumatic loss of the biceps muscle. The gracilis muscle was used in 37 patients and the rectus femoris muscle in 4. The transferred muscle was reinnervated by the musculocutaneous (n = 3), intercostal (n = 31), and spinal accessory (n = 4) nerves. Results were assessed by the Medical Research Council grading system and success was defined as a muscle strength of M4. Reinnervation with the musculocutaneous nerve resulted in success in all cases (n = 3) within 1 year. Success was obtained in 78% of patients following transfer of 3 intercostal nerves (n = 23) with recovery in an average of 2 years. Using the spinal accessory nerve (n = 4), strength of only M2+ was achieved, probably on account of the need for interposition nerve grafts in those cases.

Restoring elbow flexion by pectoralis major transplantation in war-injured patients

In seven war victim patients, five with brachial plexus palsy, one with biceps brachii muscle loss and one with pure injury of the musculo-cutaneous nerve and atrophic muscle, we modified Carroll and Kleinman's original pectoralis major muscle technique and then adopted it for use in all seven patients to restore elbow flexion (Carroll and Kleinman, Journal of Hand Surgery, 4:501, 1979). The entire pectoralis major muscle with the rectus sheath was transplanted to the tendon of the biceps near the insertion. Motion and power were well restored in five patients, satisfactorily in one patient, and unknown in the other case because the patient was lost to follow-up.

Morphometric changes in free neurovascular latissimus dorsi flaps: an experimental study

This study was designed to investigate regeneration of reinnervated, free transplanted muscles. We used a rat model, consisting of eight rats per group, in which the latissimus dorsi muscle was transplanted orthotopically and then harvested and evaluated after 2 and 12 weeks. Age-matched control animals were used to oppose non-operated muscles. At date of removal the patency of the vascular anastomoses was checked clinically and histologically. Electrophysiological measurements were also performed and conventional and enzyme histochemical histological slides manufactured. Two weeks after the free neurovascular flap transfer the muscle was not yet innervated, and histologically a dissolved pattern of type 1 and type IIA muscle fibres was found. The muscle fibres demonstrated a decrease of more than 50% cross-sectional area. After 12 weeks the muscles were reinnervated again; muscle contraction was positive with electrical stimulation and the cross-sectional area had regained 80% of the activity of normal muscle fibres. With enzyme histochemical staining the typical type grouping of reinnervated muscles could be demonstrated.

Secondary surgery following brachial plexus injuries

The favourable treatment of post-traumatic brachial plexus lesions based on our experience of 362 cases over a 12 year period is reported. Twenty-five percent of the patients needed secondary operations. The spectrum of the latter consisted of arthrodesis, tenodesis, and musculotendinous transfer, including free neurovascular tissue transfer partially innervated by nerve transposition. Functionally, secondary tendon transfer can help to improve the effect of nerve repair techniques. To restore shoulder function the trapezius transfer (n = 22) has been used mainly; elbow flexion has been regained by pedicled latissimus dorsi translocation (n = 22), triceps-to-biceps transfer (n = 18), bipolar latissimus muscle transfer, and free neurovascular tissue transfer (n = 8). The Steindler flexorplasty was performed in four plexopathies, and finally a pedicled serratus muscle transfer was used. A unipolar latissimus dorsi transfer results in an ability to lift 10-15 kg, whilst the bipolar latissimus transfer and the triceps-to-biceps transfer produced a maximal strength of 5-8 kg. Epitrochlear flexor-pronator mass transfer produced a strength of 2-5 kg, whereas free neurovascular latissimus dorsi transfer developed a maximal muscular strength of 2-4 kg in the unipolar variation and 1-2 kg for the bipolar LD. In 97 secondary procedures to the lower arm and hand the following secondary operations were indicated: in 29 cases of radial nerve palsy transfers according to Merle d'Aubigne, a further 21 wrist tenodeses and 8 wrist arthrodeses were performed. To restore median nerve function, coupling tendon transfer (n = 4) and free neurovascular gracilis transfer (n = 3) were selected.(ABSTRACT TRUNCATED AT 250 WORDS)

Intercostal nerve transfer for brachial plexopathy

Thirteen patients with traumatic brachial plexopathy underwent intercostal nerve transfer to the biceps motor branch (9 patients) or combined gracilis muscle and intercostal nerve transfer (4 patients; 3 for elbow flexion and 1 for elbow extension). Follow-up time ranged from 12 to 48 months (mean, 25 months) on 12 patients. Useful elbow flexion or extension was obtained in a total of 9 patients. Comparison of pre- and postoperative spirometry in 4 patients demonstrated a mild decline in pulmonary function, although there was no subjective change in respiratory status. Intercostal nerve transfer and combined gracilis muscle and intercostal nerve transfer are viable, although technically demanding, alternatives for restoring active elbow motion in patients with irreparable brachial plexus lesions when conventional tendon transfers are not feasible. The morbidity of intercostal nerve harvest with respect to pulmonary function is minimal.