Kazuteru Doi

Restoration of prehension with the Double free muscle technique following complete avulsion of the brachial plexus : Indications and long-term results

Background: Recent interest in reconstruction of the upper limb following brachial plexus injuries has focused on the restoration of prehension following complete avulsion of the brachial plexus. Methods: Double free muscle transfer was performed in patients who had complete avulsion of the brachial plexus. After initial exploration of the brachial plexus and (if possible) repair of the fifth cervical nerve root, the first free muscle, used to restore elbow flexion and finger extension, is transferred and reinnervated by the spinal accessory nerve. The second free muscle, transferred to restore finger flexion, is reinnervated by the fifth and sixth intercostal nerves. The motor branch of the triceps brachii is reinnervated by the third and fourth intercostal nerves to restore elbow extension. Hand sensibility is restored by suturing of the sensory rami of the intercostal nerves to the median nerve or the ulnar nerve component of the medial cord. Secondary reconstructive procedures, such as arthrodesis of the carpometacarpal joint of the thumb, shoulder arthrodesis, and tenolysis of the transferred muscle and the distal tendons, may be required to improve the functional outcome. Results: The early results were evaluated in thirty-two patients who had had reconstruction with use of the double free muscle procedure. Twenty-six of these patients were followed for at least twenty-four months (mean duration, thirty-nine months) after the second free muscle transfer, and they were assessed with regard to the long-term outcome as well. Satisfactory (excellent or good) elbow flexion was restored in twenty-five (96 percent) of the twenty-six patients and satisfactory prehension (more than 30 degrees of total active motion of the fingers), in seventeen (65 percent). Fourteen patients (54 percent) could position the hand in space, negating simultaneous flexion of the elbow, while moving the fingers at least 30 degrees and could use the reconstructed hand for activities requiring the use of two hands, such as holding a bottle while opening a cap and lifting a heavy object. The results were analyzed to identify factors affecting the outcome. Conclusions: The double free muscle procedure can provide reliable and useful prehensile function for patients with complete avulsion of the brachial plexus.

FREE VASCULARIZED THIN CORTICOPERIOSTEAL GRAFT

This paper describes a new thin corticoperiosteal graft harvested from the medial condylar and supracondylar areas of the femur. It is based on the articular branch of the descending genicular artery and vein and consists of periosteum with a thin (0.5 to 1.0 mm) layer of outer cortical bone. By retaining the cortex, the cambium layer is preserved, and this is thought to have a better osteogenic capacity than vascularized periosteal grafts. This graft was used to treat six patients with fracture nonunion of the upper extremity in which conventional treatment had failed. Uneventful bony union was achieved in all patients within 10 weeks.

Double free-muscle transfer to restore prehension following complete brachial plexus avulsion

Restoration of finger flexion and extension as well as elbow flexion and extension with a double free-muscle and multiple nerve transfers following complete avulsion of the brachial plexus (nerve roots C5 to T1) is reported. The procedure combines (1) free-muscle transfer with reinnervation by the spinal accessory nerve to achieve elbow flexion and finger extension, (2) free-muscle transfer with reinnervation by the fifth and sixth intercostal nerves to restore finger flexion, (3) third and fourth intercostal motor nerve transfer to the triceps brachi to extend and stabilize the elbow, (4) nerve transfer of the supraclavicular nerve or nerve transfer of the sensory rami of the intercostal nerves to the median nerve to restore hand sensibility, and (5) glenohumeral arthrodesis. Seven of 10 patients recovered elbow function and finger flexion and extension. Five patients reported use of their hand in activities of daily living.

Reinnervated free muscle transplantation for extremity reconstruction

Reinnervated free muscle transplantation was used to rehabilitate severely impaired extremities in patients with brachial plexus palsy and for functional limb salvage in cases of traumatic muscle loss or radical excision of a malignant soft-tissue tumor. Fifty-eight reinnervated free muscle transplantations were implanted in 46 patients. Twenty-four patients had simultaneous reconstruction of two functions, such as finger and elbow flexion lost to brachial plexus palsy; 12 patients underwent double muscle transplantation; 15 patients received free muscle transplants for limb salvage after tumor excision in an extremity; 6 transplants replaced traumatic muscle loss; and 1 was used for reconstruction of finger flexion after poliomyelitis. Twenty-six latissimus dorsi, 25 gracilis, and 7 rectus femoris muscles were used as donors. All muscles survived. The postoperative follow-up ranged from 18 months to 4 years. The speed and extent of reinnervation of the transplanted muscle depended on the choice of recipient nerve, the patients age, and the occurrence of postoperative vascular complications. Neurotization by the spinal accessory nerve or the posterior interosseous nerve resulted in the most rapid recovery. The administration of postoperative chemotherapy did not delay recovery of function. Free muscle transplantation is consistently successful and provides a functional extremity in severely handicapped patients.

Reconstruction of finger and elbow function after complete avulsion of the brachial plexus

Simultaneous reconstruction of elbow and finger function with free muscle and nerve transfers after complete avulsion of the brachial plexus (nerve roots C5 to T1) and its long-term results are presented. The basic procedure combined free or vascular pedicle latissimus dorsi muscle transfer with reinnervation by the spinal accessory nerve to obtain elbow and finger flexion, intercostal nerve transfer of the radial nerve to activate elbow and wrist extensors, and suture of the supraclavicular nerve or intercostal sensory rami to the median nerve to restore hand sensibility. Six patients had some or all of these procedures. Postoperative follow-up ranged from 2 to 5 years. Elbow function was restored completely, and some finger flexion was achieved in all cases, although a dynamic splint was necessary to straighten the digits. Patients have continued to improve in grasp power and finger control. This procedure appears to be promising for the restoration of basic hand function in severely handicapped patients.

Recalcitrant posttraumatic nonunion of the humerus: 23 patients reconstructed with vascularized bone graft

We treated 23 patients with recalcitrant posttraumatic humeral shaft nonunion with vascularized bone grafts (fibula 10, femur 10 and scapula 3). 21/23 patients healed primarily. Venous thrombosis in the graft necessitated postoperative thrombectomy in 2 patients. Complications at the donor site were trivial. We used a vascularized fibular graft in patients with a large bone defect and with poor intrinsic stability of the nonunion site and a corticoperiosteal femoral graft in atrophic nonunion without a substantial bone defect. The scapula graft is easy to transfer to the surgical neck of the humerus on its pedicle.

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

&NA; 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 MO 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. (Plast. Reconstr. Surg. 100: 364, 1997.)

A comparison of vascularized and conventional sural nerve grafts

Long-term results of a randomized series of 27 vascularized and 22 conventional sural nerve grafts in patients with comparable upper extremity injuries are reported. Recovery speed and outcome depended on (1) whether or not there was an overlying skin defect, (2) how the defect was closed, and (3) which nerve was injured and at what level. Generally, a vascularized nerve graft is indicated when the nerve gap is more than 6 cm and is associated with a massive skin defect or the graft is performed after reimplantation. Otherwise, results achieved with a conventional graft are equally good.

Significance of shoulder function in the reconstruction of prehension with double free-muscle transfer after complete paralysis of the brachial plexus.

Reconstruction of shoulder stability and movement in cases with complete paralysis of the brachial plexus was performed to improve the outcomes for universal function of prehension after double free-muscle transfer (Doi’s procedure). In cases in which the C5 or C6 nerve root was available as a donor, neurotization of the supra-scapular nerve was performed with a nerve graft. If the C5 or C6 nerve root was not available, then the contralateral C7 nerve root was chosen as the donor motor nerve and was transferred to the suprascapular nerve by using a vascularized ulnar nerve graft. Seven cases with ipsilateral C4, C5, or C6 nerve root transfer to the suprascapular nerve and one with contralateral C7 transfer were evaluated, and the functional outcomes for the range of shoulder motion were compared with those for patients who had undergone arthrodesis of the humeroscapular joint or had undergone no procedures for shoulder function reconstruction. The patients who underwent supra-scapular nerve repair demonstrated statistically significantly better ranges of motion for flexion and abduction of the shoulder, compared with the other two groups. Shoulder function is important for achieving prehensile function among patients with complete paralysis of brachial function, when they undergo double free-muscle transfer.

Limb-sparing surgery with reinnervated free-muscle transfer following radical excision of soft-tissue sarcoma in the extremity.

Limb-sparing surgery is the preferred approach in the management of patients with high-grade soft-tissue sarcomas when local disease can be completely resected. However, conventional treatment focuses only on restoration of basic functions to the remnant limb. Lost functions are not restored to normal, leaving the patient with variable degrees of functional disabilities. This in turn may necessitate further massive reconstructive procedures. Transferred reinnervated free muscles were used to reconstruct functions lost after radical resection of malignant soft-tissue sarcoma of the extremities in 17 patients. The long-term functional outcome included survival of transplanted muscle, speed of neural recovery, and muscle strength and disabilities. All muscles survived. Postoperative follow-up ranged from 27 to 106 months. All muscles except those in a 75-year-old patient were successfully reinnervated. Powerful strength and almost normal limb functions were obtained. Functional scoring of the patients according to the rating system of the Musculoskeletal Tumor Society was 87 percent for the lower extremity and 93 percent for the upper extremity. All patients are presently disease-free. Use of the reinnervated free-muscle transfer in limb-sparing surgery after resection of soft-tissue sarcoma in the extremity may be indicated in the young adult when radical excision of the tumor will result in severe motor functional loss, provided adequate clearance can be obtained and that there is no presence of distant metastasis.