Muscle Transfer to Restore Elbow Flexion Grant R. Lohse, MD, Donald H. Lee, MD, Jeffry T. Watson, MD THE PATIENT A 47-year-old right-handed salesman is referred 14 months following a motorcycle collision resulting in multiple injuries including a right brachial plexopathy. He has limited shoulder function and no active elbow flexion. His hand and wrist function well. Electrodiagnostic studies and computed tomography myelogram confirm C5 and C6 root avulsions. Manual muscle strength testing identifies grade M0 in the rotator cuff muscles, deltoid, biceps, and brachialis; at least M4 in the latissimus and pectoralis major; and M5 in the triceps, forearm, and hand muscles. He spends most of his time working at a computer and inquires about options for improving elbow flexion. THE QUESTION What is the best operation for restoring elbow flexion in an adult with an established upper trunk brachial plexopathy? CURRENT OPINION More than 6 months after root avulsions, muscle atrophy and loss of motor endplate reinnervation potential leave muscle transfer the only viable option.1e3 The transfer recommended depends upon the extent of plexus injury, strength of available donors, patient goals, and surgeon preference. THE EVIDENCE Steindler flexorplasty Liu et al4 described 71 consecutive patients treated with a modified Steindler flexorplasty (transfer of the
From the Colorado Springs Orthopaedic Group, Colorado Springs, CO. Received for publication December 21, 2013; accepted in revised form December 31, 2013. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Jeffry T. Watson, MD, 1231 Castle Hills Pl., Colorado Springs, CO 80921; e-mail: [email protected]. 0363-5023/14/3904-0026$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.12.029
flexor-pronator origin to a more midline and proximal position), 58 for brachial plexopathy and 14 for poliomyelitis. An average of 8 years after the procedure, 80% achieved a “good or excellent” result. Mean arc of elbow motion against gravity was from a 28 flexion contracture to 142 flexion, the average pronation was 74 , and the average supination was 30 . Among the 32 patients with strength testing, 25 (78%) could lift a 2-kg weight and the other 7 a 1-kg weight to at least 90 of elbow flexion. Loss of supination and elbow extension were adverse outcomes acknowledged by the authors. Marshall et al5 described 23 patients with an average active elbow flexion arc of 84 . Pronation contracture was again a problem, with only 7 of 23 achieving full active supination. The authors reported transient ulnar neuritis in 1 patient and recommended routine ulnar nerve decompression at the time of transfer. More recently, Chen6 described 5 patients an average of 8 years after transfer. Active elbow range of motion (ROM) on final evaluation was from a 34 flexion contracture to 116 flexion. Supination averaged 57 . Patients were noted to have good strength lifting an average of 3.3 kg. Chen6 stressed the importance of preoperative flexor-pronator strength assessment citing weakness as a cause for failure. Triceps to biceps transfer Berger and Brenner7 described 18 patients who achieved an average maximum elbow flexion strength of 5.8 kg after triceps to biceps transfer. ROM was not reported. Ruhmann et al8 reported good and excellent results in 8 of 10 patients who underwent triceps to biceps transfer. Average ROM was from 5 flexion contracture to 109 flexion, and strength fell between grades M3 and M5. The authors indicated that preoperative co-contraction of the biceps and triceps resulted in favorable postoperative outcomes. In one of the few studies publishing both objective strength and ROM data, Hoang and colleagues9 found ROM averaged from 13 flexion contracture to 123 flexion. Patients could lift an average of 3.3 kg to 90 of flexion. The authors highlighted that patient
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
761
Evidence-Based Medicine
EVIDENCE-BASED MEDICINE
762
MUSCLE TRANSFER TO RESTORE ELBOW FLEXION
Evidence-Based Medicine
dependence on the upper limbs for weight bearing may be a contraindication to this transfer.
Preoperative pectoralis weakness was felt to be the primary etiology.
Latissimus, pedicled Berger et al7 published the largest series of pedicled latissimus transfers, reporting 22 unipolar and 6 bipolar procedures. Although no statistical analysis was performed, superior elbow flexion strength was noted in the unipolar (10e15 kg) versus the bipolar (5e8 kg) transfers. Kawamura and colleagues10 reported 7 bipolar and 3 unipolar transfers. Both transfer types achieved approximately 110 of active motion with M4 strength noted in 8 patients, M3 in 2. Reoperation rate was high, with 5 of 10 patients requiring muscle retensioning. The importance of preoperative latissimus strength assessment was stressed by Hirayama et al.11 Three of 9 patients had “unsatisfactory” results attributed to an overestimation of preoperative muscle strength. Stern and Carey12 reported 5 of 6 successful bipolar latissimus transfers with average ROM from 5 flexion contracture to 115 flexion and strength grade M3þ to M4.
Microvascular gracilis transfer Innervated free gracilis transfer has been used to restore elbow flexion since the late 1970s.17 Since then, the gracilis, rectus femoris, and latissimus dorsi have become the most commonly used free muscle transfers.7,18e28 Terzis and Kostopoulos27 reported the largest series of free innervated gracilis transfers for brachial plexopathies. In these 28 patients, average elbow flexion strength was increased from grade M1.1 before surgery to M2.8. The authors felt the gracilis was best utilized to augment weak baseline elbow flexion. Doi et al25 used free gracilis in a dual role to restore elbow flexion and finger extension in 23 patients. Average elbow ROM was 38 to 115 with strength, in the 10 patients tested, averaging 14% to 19% of the contralateral limb. In their series of 25 patients, Barrie and colleagues20 identified that gracilis transferred for restoration of elbow flexion alone yielded better results than when utilized for elbow flexion and wrist extension.
Pectoralis major The pectoralis major muscle can be used to restore elbow flexion by bipolar,13 unipolar,14 and tendon interposition type transfers.15 These techniques have not been directly compared. The pectoralis major receives its innervation from C5eC8 and can be denervated in brachial plexus injuries. Beaton et al15 used fascia lata between the pectoralis and the biceps tendons in 5 patients. Postoperative strength was reported to be M4þ, specifically 16% of the contralateral side, with ROM from 25 flexion contracture to 116 flexion. The authors acknowledged the indirect line of pull with this technique and the subsequent internal rotation force imparted to the shoulder. Shoulder instability is a potential complication of pectoralis transfer. All patients underwent shoulder fusion at the time of transfer. Botte and colleagues16 utilized a bipolar transfer technique. All 4 patients achieved M3þ to M4 strength and ROM of 25 to 125 . The authors commented that significant deformity of the anterior chest wall results from this procedure and alternatives should be considered in young women. In the largest published series to date, Marshall et al5 reported “disappointing” results. Eleven patients averaged postoperative active elbow flexion of just 34 and only 4 achieved antigravity strength.
Microvascular latissimus transfer Vekris et al29 reported the results of 10 free latissimus transfers for elbow flexion reanimation. Active flexion was not seen until 6 to 8 months after surgery. Eight patients ultimately achieved grade M3 or M4 strength. Failures were felt to be related to improper muscle tensioning. In the largest published series of free latissimus transfers, Terzis and colleagues27 reported good results in 30 patients with an average elbow flexion strength of grade M3.25. Latissimi transfers were significantly stronger (P ¼ .047) when neurotized with 3 versus 2 intercostal nerves.
J Hand Surg Am.
Microvascular rectus transfer Akasaka et al18 reported grade M3þ strength with greater than 80 flexion in 8 of 11 patients after innervated microvascular transfer of the rectus femorus. Donor site morbidity was not noted to be an issue. Outcome comparison Berger and Brenner7 reported postoperative elbow flexion strength of six muscle transfers: pedicled unipolar latissimus, 10 to 15 kg; pedicled bipolar latissimus, 5 to 8 kg; triceps to biceps, 5 to 8 kg; Steindler, 2 to 5 kg; and free latissimus, 2 kg. No statistical analysis was performed. Preoperative strength was not provided. r
Vol. 39, April 2014
Terzis et al27 compared the strength of gracilis, latissimus, and rectus femoris free muscle transfers. The latissimus group (grade M3.33) was significantly (P ¼ .045) stronger than the gracilis group (M2.25) but similar to the rectus, although no statics were reported. Steindler flexorplasty and pedicled pectoralis major transfers were compared by Beaton et al.15 Whereas both transfers achieved a statistically significant improvement in elbow flexion strength, no statistically significant strength difference was detected between the two transfers. However, the authors expressed a preference for pectoralis major transfer. Marshall and colleagues5 compared triceps with biceps, Steindler, pectoralis major, bipolar pedicled latissimus, and pectoralis minor transfers via objective and subjective measures. They concluded that triceps and latissimus transfers were most reliable, although no statistical analysis was performed. Eggers et al30 reached a similar conclusion. We attempted to compile then subsequently compare ROM and strength data from over two dozen studies.4e12,15,16,19,20,22,25,27,29e38 Heterogeneity substantially limits the validity of such a comparison and prevents statistical analysis. With these limitations in mind, we did observe some trends. Triceps to biceps and unipolar latissimus transfers seemed to yield the greatest elbow ROM and strength.
should probably address upper extremityespecific disability. A large multicenter prospective cohort study comparing preoperative and postoperative objective ROM and strength data, as well as disability and complications, would be helpful. OUR CURRENT CONCEPTS FOR THIS PATIENT If this patient had co-contraction of the biceps/triceps and was ambulatory on normal lower extremities, we would consider triceps to biceps transfer. If active elbow flexion is present but weak, Steindler flexorplasty can offer meaningful functional gains with relatively little morbidity. The pronation contracture that commonly develops may be well tolerated by an office worker. We avoid pectoralis transfer in women because of the marked cosmetic deformity of the anterior chest wall, but it would be an option for a patient with a stiff (or fused) shoulder. Any muscle with weak baseline strength should not be transferred. The latissimus and pectoralis major are often partially denervated in upper trunk brachial plexus injuries and should be thoroughly tested prior to transfer. In the patient under consideration, if at least M4 latissimus strength is present, we would perform a pedicled unipolar latissimus transfer. If there is any question of prohibitive weakness, we would perform a microvascular transfer of the gracilis muscle. We select the gracilis because it has been the most thoroughly studied, results in low donor site morbidity, and has a reliable dominant pedicle and innervation.
SHORTCOMINGS OF THE EVIDENCE Brachial plexus injuries are difficult to study because they are relatively uncommon and highly variable. The current body of evidence is composed primarily of retrospective case series and case reports, with a few retrospective comparisons. There is no universally accepted outcome measure. Strength grading, particularly in the M4 range, can be highly subjective. Many studies make no mention of baseline elbow flexion. Little attention is given to the issues of donor site morbidity and transfer failure. The heterogeneity of the underlying pathology, surgical techniques, and outcome measures limit meaningful comparison of techniques for restoration of elbow flexion in late adult brachial plexopathies.
REFERENCES 1. Shin AY, Spinner RJ, Steinmann SP, Bishop AT. Adult traumatic brachial plexus injuries. J Am Acad Orthop Surg. 2005;13(6): 382e396. 2. Bishop AT. Functioning free-muscle transfer for brachial plexus injury. Hand Clin. 2005;21(1):91e102. 3. Ferrante MA. Electrodiagnostic assessment of the brachial plexus. Neurol Clin. 2012;30(2):551e580. 4. Liu TK, Yang RS, Sun JS. Long-term results of the Steindler flexorplasty. Clin Orthop Relat Res. 1993;296:104e108. 5. Marshall RW, Williams DH, Birch R, Bonney G. Operations to restore elbow flexion after brachial plexus injuries. J Bone Joint Surg Br. 1988;70(4):577e582. 6. Chen WS. Restoration of elbow flexion by modified Steindler flexorplasty. Int Orthop. 2000;24(1):43e46. 7. Berger A, Brenner P. Secondary surgery following brachial plexus injuries. Microsurgery. 1995;16(1):43e47. 8. Rühmann O, Schmolke S, Gossé F, Wirth CJ. Transposition of local muscles to restore elbow flexion in brachial plexus palsy. Injury. 2002;33(7):597e609. 9. Hoang PH, Mills C, Burke FD. Triceps to biceps transfer for established brachial plexus palsy. J Bone Joint Surg Br. 1989;71(2): 268e271. 10. Kawamura K, Yajima H, Tomita Y, Kobata Y, Shigematsu K, Takakura Y. Restoration of elbow function with pedicled latissimus dorsi myocutaneous flap transfer. J Shoulder Elbow Surg. 2007;16(1):84e90.
DIRECTIONS FOR FUTURE RESEARCH Ideally, appropriately powered prospective randomized control trials could help determine the advantages and disadvantages of various muscle transfers to restore elbow flexion in patients with brachial plexus injury. We need reliable objective measures of elbow flexion and strength, but the primary study question J Hand Surg Am.
763
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MUSCLE TRANSFER TO RESTORE ELBOW FLEXION
Evidence-Based Medicine
11. Hirayama T, Hada T, Katsuki M, Yoshida E. The pedicle latissimus dorsi transfer for reconstruction of the plexus brachialis and brachium. Clin Orthop Relat Res. 1994;309:201e207. 12. Stern PJ, Carey JP. The latissimus dorsi flap for reconstruction of the brachium and shoulder. J Bone Joint Surg Am. 1988;70(4):526e535. 13. Carroll RE, Kleinman WB. Pectoralis major transplantation to restore elbow flexion to the paralytic limb. J Hand Surg Am. 1979;4(6): 501e507. 14. Clark JM. Reconstruction of biceps brachii by pectoral muscle transplantation. Br J Surg. 1946;34(134):180. 15. Beaton DE, Dumont A, Mackay MB, Richards RR. Steindler and pectoralis major flexorplasty: a comparative analysis. J Hand Surg Am. 1995;20(5):747e756. 16. Botte MJ, Wood MB. Flexorplasty of the elbow. Clin Orthop Relat Res. 1989;245:110e116. 17. Ikuta Y, Yoshioka K, Tsuge K. Free muscle graft as applied to brachial plexus injury-case report and experimental study. Ann Acad Med Singapore. 1979;8(4):454e458. 18. Akasaka Y, Hara T, Takahashi M. Free muscle transplantation combined with intercostal nerve crossing for reconstruction of elbow flexion and wrist extension in brachial plexus injuries. Microsurgery. 1991;12(5):346e351. 19. Chuang DC, Eptstein MD, Yeh M, Wei F. Functional restoration of elbow flexion in brachial plexus injuries: results in 167 patients (excluding obstetric brachial plexus injury). J Hand Surg Am. 1993;18(2):285e291. 20. Barrie KA, Steinmann SP, Shin AY, Spinner RJ, Bishop AT. Gracilis free muscle transfer for restoration of function after complete brachial plexus avulsion. Neurosurg Focus. 2004;16(5):1e9. 21. Chuang DC. Functioning free muscle transplantation for brachial plexus injury. Clin Orthop Relat Res. 1995;314:104e111. 22. Chung DC, Carver N, Wei FC. Results of functioning free muscle transplantation for elbow flexion. J Hand Surg Am. 1996;21(6): 1071e1077. 23. Doi K. Significance of shoulder function in the reconstruction of prehension with double free-muscle transfer after complete paralysis of the brachial plexus. Plast Reconstr Surg. 2003;112(6):1596e1603. 24. Doi K, Kuwata N, Muanmatsu K, Hottori Y, Kawai S. Double muscle transfer for upper extremity reconstruction following complete avulsion of the brachial plexus. Hand Clin. 1999;15(4):757e767. 25. Doi K, Muramatsu K, Hattori Y, et al. Restoration of prehension with the double free muscle technique following complete avulsion of the
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27. 28.
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31.
32. 33.
34.
35.
36.
37.
38.
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brachial plexus. Indications and long-term results. J Bone Joint Surg Am. 2000;82(5):652e666. Doi K, Sakai K, Kuwata N, Ihara K, Kawai S. Reconstruction of finger and elbow function after complete avulsion of the brachial plexus. J Hand Surg Am. 1991;16(5):796e803. Terzis JK, Kostopoulos VK. Free muscle transfer in posttraumatic plexopathies part II: the elbow. Hand. 2010;5(2):160e170. Wei CY, Chuang DC, Chen HC, Lin CH, Wong SS, Wei FC. The versatility of free rectus femoris muscle flap: an alternative flap. Microsurgery. 1995;16(10):698e703. Vekris MD, Beris AE, Lykissas MG, Korompilias AV, Vekris AD, Soucacos PN. Restoration of elbow function in severe brachial plexus paralysis via muscle transfers. Injury. 2008;39(Suppl 3): S15eS22. Eggers IM, Mennen U, Matime AM. Elbow flexorplasty: a comparison between latissimus dorsi transfer and Steindler flexorplasty. J Hand Surg Br. 1992;17(5):522e525. Thatte MR, Babhulkar S, Hiremath A. Brachial plexus injury in adults: diagnosis and surgical treatment strategies. Ann Indian Acad Neurol. 2013;16(1):26e33. Steindler A. Orthopaedic reconstruction work on hand and forearm. N Y Med J. 1918;108:1117e1119. Cambon-Binder A, Belkheyar Z, Durand S, Rantissi M, Oberlin C. Elbow flexion restoration using pedicled latissimus dorsi transfer in seven cases. Chir Main. 2012;31(6):324e330. Haninec P, Dubovy P, Samal F. Reconstruction of elbow flexion, wrist and finger extension by transposition of pedicled latissimus dorsi muscle and flexor carpi ulnaris muscle. Acta Chir Plast. 2001;43(3):80e85. Moneim MS, Omer GE. Latissimus dorsi muscle transfer for restoration of elbow flexion after brachial plexus disruption. J Hand Surg Am. 1986;11(1):135e139. Zancolli E, Mitre H. Latissimus dorsi transfer to restore elbow flexion. An appraisal of eight cases. J Bone Joint Surg Am. 1973;55(6):1265e1275. Akasaka Y, Hara T, Takahashi M. Restoration of elbow flexion and wrist extension in brachial plexus paralyses by means of free muscle transplantation innervated by intercostal nerve. Ann Chir Main Memb Super. 1990;9(5):341e350. Nagano A, Ochiai N, Okinaga S. Restoration of elbow flexion in root lesions of brachial plexus injuries. J Hand Surg Am. 1992;17(5): 815e821.
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From the Colorado Springs Orthopaedic Group, Colorado Springs, CO. Received for publication December 21, 2013; accepted in revised form December 31, 2013. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Jeffry T. Watson, MD, 1231 Castle Hills Pl., Colorado Springs, CO 80921; e-mail: [email protected]. 0363-5023/14/3904-0026$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.12.029
flexor-pronator origin to a more midline and proximal position), 58 for brachial plexopathy and 14 for poliomyelitis. An average of 8 years after the procedure, 80% achieved a “good or excellent” result. Mean arc of elbow motion against gravity was from a 28 flexion contracture to 142 flexion, the average pronation was 74 , and the average supination was 30 . Among the 32 patients with strength testing, 25 (78%) could lift a 2-kg weight and the other 7 a 1-kg weight to at least 90 of elbow flexion. Loss of supination and elbow extension were adverse outcomes acknowledged by the authors. Marshall et al5 described 23 patients with an average active elbow flexion arc of 84 . Pronation contracture was again a problem, with only 7 of 23 achieving full active supination. The authors reported transient ulnar neuritis in 1 patient and recommended routine ulnar nerve decompression at the time of transfer. More recently, Chen6 described 5 patients an average of 8 years after transfer. Active elbow range of motion (ROM) on final evaluation was from a 34 flexion contracture to 116 flexion. Supination averaged 57 . Patients were noted to have good strength lifting an average of 3.3 kg. Chen6 stressed the importance of preoperative flexor-pronator strength assessment citing weakness as a cause for failure. Triceps to biceps transfer Berger and Brenner7 described 18 patients who achieved an average maximum elbow flexion strength of 5.8 kg after triceps to biceps transfer. ROM was not reported. Ruhmann et al8 reported good and excellent results in 8 of 10 patients who underwent triceps to biceps transfer. Average ROM was from 5 flexion contracture to 109 flexion, and strength fell between grades M3 and M5. The authors indicated that preoperative co-contraction of the biceps and triceps resulted in favorable postoperative outcomes. In one of the few studies publishing both objective strength and ROM data, Hoang and colleagues9 found ROM averaged from 13 flexion contracture to 123 flexion. Patients could lift an average of 3.3 kg to 90 of flexion. The authors highlighted that patient
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
761
Evidence-Based Medicine
EVIDENCE-BASED MEDICINE
762
MUSCLE TRANSFER TO RESTORE ELBOW FLEXION
Evidence-Based Medicine
dependence on the upper limbs for weight bearing may be a contraindication to this transfer.
Preoperative pectoralis weakness was felt to be the primary etiology.
Latissimus, pedicled Berger et al7 published the largest series of pedicled latissimus transfers, reporting 22 unipolar and 6 bipolar procedures. Although no statistical analysis was performed, superior elbow flexion strength was noted in the unipolar (10e15 kg) versus the bipolar (5e8 kg) transfers. Kawamura and colleagues10 reported 7 bipolar and 3 unipolar transfers. Both transfer types achieved approximately 110 of active motion with M4 strength noted in 8 patients, M3 in 2. Reoperation rate was high, with 5 of 10 patients requiring muscle retensioning. The importance of preoperative latissimus strength assessment was stressed by Hirayama et al.11 Three of 9 patients had “unsatisfactory” results attributed to an overestimation of preoperative muscle strength. Stern and Carey12 reported 5 of 6 successful bipolar latissimus transfers with average ROM from 5 flexion contracture to 115 flexion and strength grade M3þ to M4.
Microvascular gracilis transfer Innervated free gracilis transfer has been used to restore elbow flexion since the late 1970s.17 Since then, the gracilis, rectus femoris, and latissimus dorsi have become the most commonly used free muscle transfers.7,18e28 Terzis and Kostopoulos27 reported the largest series of free innervated gracilis transfers for brachial plexopathies. In these 28 patients, average elbow flexion strength was increased from grade M1.1 before surgery to M2.8. The authors felt the gracilis was best utilized to augment weak baseline elbow flexion. Doi et al25 used free gracilis in a dual role to restore elbow flexion and finger extension in 23 patients. Average elbow ROM was 38 to 115 with strength, in the 10 patients tested, averaging 14% to 19% of the contralateral limb. In their series of 25 patients, Barrie and colleagues20 identified that gracilis transferred for restoration of elbow flexion alone yielded better results than when utilized for elbow flexion and wrist extension.
Pectoralis major The pectoralis major muscle can be used to restore elbow flexion by bipolar,13 unipolar,14 and tendon interposition type transfers.15 These techniques have not been directly compared. The pectoralis major receives its innervation from C5eC8 and can be denervated in brachial plexus injuries. Beaton et al15 used fascia lata between the pectoralis and the biceps tendons in 5 patients. Postoperative strength was reported to be M4þ, specifically 16% of the contralateral side, with ROM from 25 flexion contracture to 116 flexion. The authors acknowledged the indirect line of pull with this technique and the subsequent internal rotation force imparted to the shoulder. Shoulder instability is a potential complication of pectoralis transfer. All patients underwent shoulder fusion at the time of transfer. Botte and colleagues16 utilized a bipolar transfer technique. All 4 patients achieved M3þ to M4 strength and ROM of 25 to 125 . The authors commented that significant deformity of the anterior chest wall results from this procedure and alternatives should be considered in young women. In the largest published series to date, Marshall et al5 reported “disappointing” results. Eleven patients averaged postoperative active elbow flexion of just 34 and only 4 achieved antigravity strength.
Microvascular latissimus transfer Vekris et al29 reported the results of 10 free latissimus transfers for elbow flexion reanimation. Active flexion was not seen until 6 to 8 months after surgery. Eight patients ultimately achieved grade M3 or M4 strength. Failures were felt to be related to improper muscle tensioning. In the largest published series of free latissimus transfers, Terzis and colleagues27 reported good results in 30 patients with an average elbow flexion strength of grade M3.25. Latissimi transfers were significantly stronger (P ¼ .047) when neurotized with 3 versus 2 intercostal nerves.
J Hand Surg Am.
Microvascular rectus transfer Akasaka et al18 reported grade M3þ strength with greater than 80 flexion in 8 of 11 patients after innervated microvascular transfer of the rectus femorus. Donor site morbidity was not noted to be an issue. Outcome comparison Berger and Brenner7 reported postoperative elbow flexion strength of six muscle transfers: pedicled unipolar latissimus, 10 to 15 kg; pedicled bipolar latissimus, 5 to 8 kg; triceps to biceps, 5 to 8 kg; Steindler, 2 to 5 kg; and free latissimus, 2 kg. No statistical analysis was performed. Preoperative strength was not provided. r
Vol. 39, April 2014
Terzis et al27 compared the strength of gracilis, latissimus, and rectus femoris free muscle transfers. The latissimus group (grade M3.33) was significantly (P ¼ .045) stronger than the gracilis group (M2.25) but similar to the rectus, although no statics were reported. Steindler flexorplasty and pedicled pectoralis major transfers were compared by Beaton et al.15 Whereas both transfers achieved a statistically significant improvement in elbow flexion strength, no statistically significant strength difference was detected between the two transfers. However, the authors expressed a preference for pectoralis major transfer. Marshall and colleagues5 compared triceps with biceps, Steindler, pectoralis major, bipolar pedicled latissimus, and pectoralis minor transfers via objective and subjective measures. They concluded that triceps and latissimus transfers were most reliable, although no statistical analysis was performed. Eggers et al30 reached a similar conclusion. We attempted to compile then subsequently compare ROM and strength data from over two dozen studies.4e12,15,16,19,20,22,25,27,29e38 Heterogeneity substantially limits the validity of such a comparison and prevents statistical analysis. With these limitations in mind, we did observe some trends. Triceps to biceps and unipolar latissimus transfers seemed to yield the greatest elbow ROM and strength.
should probably address upper extremityespecific disability. A large multicenter prospective cohort study comparing preoperative and postoperative objective ROM and strength data, as well as disability and complications, would be helpful. OUR CURRENT CONCEPTS FOR THIS PATIENT If this patient had co-contraction of the biceps/triceps and was ambulatory on normal lower extremities, we would consider triceps to biceps transfer. If active elbow flexion is present but weak, Steindler flexorplasty can offer meaningful functional gains with relatively little morbidity. The pronation contracture that commonly develops may be well tolerated by an office worker. We avoid pectoralis transfer in women because of the marked cosmetic deformity of the anterior chest wall, but it would be an option for a patient with a stiff (or fused) shoulder. Any muscle with weak baseline strength should not be transferred. The latissimus and pectoralis major are often partially denervated in upper trunk brachial plexus injuries and should be thoroughly tested prior to transfer. In the patient under consideration, if at least M4 latissimus strength is present, we would perform a pedicled unipolar latissimus transfer. If there is any question of prohibitive weakness, we would perform a microvascular transfer of the gracilis muscle. We select the gracilis because it has been the most thoroughly studied, results in low donor site morbidity, and has a reliable dominant pedicle and innervation.
SHORTCOMINGS OF THE EVIDENCE Brachial plexus injuries are difficult to study because they are relatively uncommon and highly variable. The current body of evidence is composed primarily of retrospective case series and case reports, with a few retrospective comparisons. There is no universally accepted outcome measure. Strength grading, particularly in the M4 range, can be highly subjective. Many studies make no mention of baseline elbow flexion. Little attention is given to the issues of donor site morbidity and transfer failure. The heterogeneity of the underlying pathology, surgical techniques, and outcome measures limit meaningful comparison of techniques for restoration of elbow flexion in late adult brachial plexopathies.
REFERENCES 1. Shin AY, Spinner RJ, Steinmann SP, Bishop AT. Adult traumatic brachial plexus injuries. J Am Acad Orthop Surg. 2005;13(6): 382e396. 2. Bishop AT. Functioning free-muscle transfer for brachial plexus injury. Hand Clin. 2005;21(1):91e102. 3. Ferrante MA. Electrodiagnostic assessment of the brachial plexus. Neurol Clin. 2012;30(2):551e580. 4. Liu TK, Yang RS, Sun JS. Long-term results of the Steindler flexorplasty. Clin Orthop Relat Res. 1993;296:104e108. 5. Marshall RW, Williams DH, Birch R, Bonney G. Operations to restore elbow flexion after brachial plexus injuries. J Bone Joint Surg Br. 1988;70(4):577e582. 6. Chen WS. Restoration of elbow flexion by modified Steindler flexorplasty. Int Orthop. 2000;24(1):43e46. 7. Berger A, Brenner P. Secondary surgery following brachial plexus injuries. Microsurgery. 1995;16(1):43e47. 8. Rühmann O, Schmolke S, Gossé F, Wirth CJ. Transposition of local muscles to restore elbow flexion in brachial plexus palsy. Injury. 2002;33(7):597e609. 9. Hoang PH, Mills C, Burke FD. Triceps to biceps transfer for established brachial plexus palsy. J Bone Joint Surg Br. 1989;71(2): 268e271. 10. Kawamura K, Yajima H, Tomita Y, Kobata Y, Shigematsu K, Takakura Y. Restoration of elbow function with pedicled latissimus dorsi myocutaneous flap transfer. J Shoulder Elbow Surg. 2007;16(1):84e90.
DIRECTIONS FOR FUTURE RESEARCH Ideally, appropriately powered prospective randomized control trials could help determine the advantages and disadvantages of various muscle transfers to restore elbow flexion in patients with brachial plexus injury. We need reliable objective measures of elbow flexion and strength, but the primary study question J Hand Surg Am.
763
r
Vol. 39, April 2014
Evidence-Based Medicine
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MUSCLE TRANSFER TO RESTORE ELBOW FLEXION
Evidence-Based Medicine
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Vol. 39, April 2014
