A. Berger, R-J. Flory, and E. Schaller
MUSCLE TRANSFERS IN BRACHIAL PLEXUS LESIONS ABSTRACT
Over the last two decades, the treatment of brachial plexus lesions has been expanded by the development of reconstructive surgery of the nerves by microsurgical methods. It has become possible to achieve useful function in the paralyzed arm, even in cases with complete palsy. We found however that the use of only a nerve repair limited what could be accomplished.12 Therefore, the use of additional muscle and tendon transfers, tenodesis, and arthrodesis are necessary for optimal functional results. An integrated concept currently is necessary to obtain the most successful result for the patient, and techniques must be included for the late phases of this program. In our clinic, the first step in the treatment of brachial plexus lesions is nerve repair by neurolysis, nerve grafting, or nerve transfer. These procedures are performed between six weeks and six months after the initial injury. As a second step, intensive physiotherapy is prescribed for the patient in cooperation with his family physician. Our patients are examined in the clinic every three months. The recovery of sensory and motor function is documented, especially the progress of the Tinel sign. During these examinations, patients are encouraged to perform intensive active and passive exercises
of the paralyzed joints to prevent contractures. Patients have already been informed about the possibility and potential use of secondary operations. If orthopedic splints are necessary, they are prescribed as well. If a muscle transfer is planned, a special training regimen of the donor muscle is also initiated. After the nerve repair, we wait at least one-and-a-half to two years until a secondary operation takes place. At this time, a very critical part of final nerve regeneration is possible. The first question in planning a secondary operation is: Which function does the patient need most in his daily life? A routine management program is not possible; each patient has to be treated individually. Even in patients with reinnervated muscles after nerve repair, the diminished power of these muscles must be considered. Exact neurologic status, including EMG evaluation, is determined preoperatively. After producing the maximal result of our nerve repair but still not obtaining sufficient function, we use a new concept that consists of employing one muscle for two major functions.2 This is a method that can result in elbow flexion and mass grip of the fingers. For patients lacking movement at the elbowfinger-wrist levels, the first problem is to find a useful muscle for the desired function. If the ipsilateral latissi-
Clinic of Plastic, Hand, and Reconstructive Surgery, Medical School of Hannover Reprint requests-. Dr. Berger, Director, Clinic of Plastic, Hand, and Reconstructive Surgery, Medical School of Hannover, Podbielskistr. 380, D-3000, Hannover 51, West Germany Accepted for publication October 19, 1989 Copyright © 1990 by Thieme Medical Publishers, Inc., 381 Park. Avenue South, New York, NY 10016. All rights reserved.
Downloaded by: National University of Singapore. Copyrighted material.
The concept of reconstruction to regain lost function after brachial plexus lesions has to be as broad and complex as possible. We have been exploring wider and more novel clinical concepts at the Clinic of Plastic, Hand, and Reconstructive Surgery at the Medical School of Hannover. Our ideas are supported by experience in 160 patients. We have attempted to combine the use of a vascularized nerve graft and a microvascularly-transferred autologous muscle. Patients undergoing the procedures have included those with late complete root avulsions and no functional return, as well as previously operated cases with poor recovery of biceps, wrist, and forearm function. The surgery is divided into two stages. In the first stage, the ulnar nerve is prepared as a vascularized nerve graft and is sutured to intercostal nerves 3 to 5 or 6. In stage 2, when the Tinel sign reaches the distal ends of the ulnar nerve graft (about six to eight months later), the latissimus dorsi muscle is harvested. The muscle is then placed as far distally as possible in the forearm and sutured to the deep finger flexors and flexor pollicis Iongus. Proximally, the insertion is performed similarly to Steindler's method. The vessels are connected to the brachial artery and vein and the thoracodorsal nerve is sutured to the graft. This method provides flexion of both the fingers and the elbow.
13
APRIL 1990
mus dorsi is available and powerful enough, then the above described stage is sufficient. In this case, a tenodesis of the wrist extensors is done and an opponensplasty of the thumb is performed. The tenodesis is done in a neutral position, placing the radial extensor tendons through a drill hole in the radius. Opposition of the thumb is obtained by arthrodesis of the first and second metacarpal bones with an AO screw (Fig. 1). The latissimus dorsi muscle is then freed by carefully preserving the neurovascular pedicle. The insertion is cut and the muscle advanced to the middle of the humerus. The next step is crucial: the flexor carpi radialis or ulnaris is transected distally and placed over the latissimus dorsi now in the forearm (Fig. 2). The distal end of the latissimus dorsi is then carefully sutured in different layers to the flexor pollicis longus3 and deep finger flexors in a tight position. This enables flexion of the elbow joint and, at the same time or after even better training, also produces independent closing of the fingers for keeping larger items in the hand (Fig. 3). In cases without available ipsilateral muscles, a second method can be used. This is more complicated because a free muscle transfer will be necessary and, in addition, the motor nerve supply must be restored. The procedure is divided into two sections.2 In the first, the ulnar nerve is used when possible 4 as a vascularized
Figure 2. Diagram of the muscle transposition. Left arrow shows simultaneous two-joint function (EC.R.); right arrow indicates latissimus dorsi muscle.
14
Figure 1. Arthrodesis from MC I to MC II with an AO screw, bringing the thumb in opposition.
nerve graft, to provide motor innervation for the final stage (Fig. 4). The ulnar nerve is dissected, leaving the vascular pedicle intact on its whole length. Proximally, the graft is sutured either to a cervical motor nerve, the spinal accessory nerve, or to intercostal nerves 3 or 4. Distally, the ulnar nerve is cut. The Tinel sign is watched closely and about six months later, a further stage can begin. Also in the first procedure, all necessary tendon transfers, opponens-plasties, and tenodeses are done, as mentioned above. After six months on average have passed, the lower and upper arm is reopened (Fig. 5). The contralateral latissimus dorsi is harvested and transferred to the affected upper and lower arm. The vessels are anastomosed end-to-side to the major arm vessels and the thoracodorsal nerve to the vascularized, reinnervated ulner nerve graft. Again, the flexor carpi radialis or ulnaris is used for a two-joint function (Fig. 2), making it possible for a sufficient force to be applied for both elbow and finger flexion. Postoperatively, the arm is protected by a cast that should be in 90 degree elbow flexion and 120 degree wrist flexion until signs of early reinnervation are detected. Care must be taken not to stretch the transplanted muscle too early.
Downloaded by: National University of Singapore. Copyrighted material.
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 6, NUMBER 2
BRACHIAL PLEXUS LESIONS/BERGER, FLORY, SCHALLER
Downloaded by: National University of Singapore. Copyrighted material.
Figure 4. Vascularized ulnar nerve graft sutured to intercostals 2,3, and 4. Intercostals 5 and 6 are sutured to the median nerve for sensible reinnervation.
o
Figure 3. A, A 21-year-old male patient; upper arrow indicates insertion of the latissimus dorsi muscle; lower arrow shows the dual function of the single muscle transfer. B, A 25-year-old male patient, two years postoperatively. The latissimus dorsi muscle functions well and the patient is also able to hold larger items in his hand. Figure 5. Microvascularly transferred latissimus dorsi muscle for elbow and finger flexion.
RESULTS Since 1986,18 patients have undergone these procedures. In four cases, the first method only was used with good subsequent results. Fourteen patients have already undergone the first stage of the second method (i.e., a vascularized ulnar nerve graft in position). In six
115
APRIL 1990
Figure 6. A 20-year-old male two years postoperatively, demonstrating the entire concept of two-joint function single muscle transfers.
cases, free muscle transposition has already been performed (Fig. 6); in five of these patients, useful function is expected to be obtained.
procedures and possibly newer concepts that combine nerve surgery, classic tendon transfers, arthrodesis, and our two-joint function muscle transfers.
DISCUSSION
REFERENCES
We have presented an additional possibility for patients suffering a brachial plexus lesion without any regained function. The one-muscle transfer for two functions is a new concept for patients who have undergone nerve surgery with results that have not produced a functional elbow and hand. It is also useful for late cases, when nerve surgery is no longer possible 2,4,5,6 j n Spite of the fact that only mass movement in limited extension and power can be gained, these methods used in cooperative patients provide additional chances for improvement of function in upperarm palsies. We believe we can achieve better function than can be provided with the use of a prosthesis. A postoperative training regimen with special orthesis gives additional and early function to these extremities. We hope in the near future that more centers dealing with these patients can validate the reported 16
Berger A, Meissl G, Millesi H, Piza H: Brachial plexus injuries: An integrated therapeutical concept. Proceedings of the International Congress of Emergency Surgery, 1975, p p 382-392
Berger A, Mailaender P, Schaller E. Simultaneous reconstruction of finger flexors and elbow flexion by microsurgical muscle transfer. Program Abstracts of the Mt. Fuji Microsurgery Sympo-
sium, 1988, p 49 Manktelow RT, Zuker RM: The principles of functioning muscle transplantation: Applications to the upper arm. Am I Plast Surg 22:275, 1989 Breidenbach W, Terzis I: The anatomy of free vascularized nerve grafts. Clin Plast Surg 11:65, 1984 Millesi H: Indikation und Auswahl der Operationstechnik im Rahmen der chirurgischen Behandlung von Laesionen des Plexus brachialis. In Hase U, Reulen HJ (eds.): Laesionen des Plexus brachialis. Berlin, New York: de Gruyter, 1985, pp 89105 Doi K, Kawai S, Sasabi K, Kuwata N: Further applications of pedicle of free latissimus dorsi musculocutaneous flap to restore finger function in severely paralyzed upper extremities. Program Abstracts of the Mt. Fuji Microsurgery Symposium,
1988, p 13
Downloaded by: National University of Singapore. Copyrighted material.
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 6, NUMBER 2
MUSCLE TRANSFERS IN BRACHIAL PLEXUS LESIONS ABSTRACT
Over the last two decades, the treatment of brachial plexus lesions has been expanded by the development of reconstructive surgery of the nerves by microsurgical methods. It has become possible to achieve useful function in the paralyzed arm, even in cases with complete palsy. We found however that the use of only a nerve repair limited what could be accomplished.12 Therefore, the use of additional muscle and tendon transfers, tenodesis, and arthrodesis are necessary for optimal functional results. An integrated concept currently is necessary to obtain the most successful result for the patient, and techniques must be included for the late phases of this program. In our clinic, the first step in the treatment of brachial plexus lesions is nerve repair by neurolysis, nerve grafting, or nerve transfer. These procedures are performed between six weeks and six months after the initial injury. As a second step, intensive physiotherapy is prescribed for the patient in cooperation with his family physician. Our patients are examined in the clinic every three months. The recovery of sensory and motor function is documented, especially the progress of the Tinel sign. During these examinations, patients are encouraged to perform intensive active and passive exercises
of the paralyzed joints to prevent contractures. Patients have already been informed about the possibility and potential use of secondary operations. If orthopedic splints are necessary, they are prescribed as well. If a muscle transfer is planned, a special training regimen of the donor muscle is also initiated. After the nerve repair, we wait at least one-and-a-half to two years until a secondary operation takes place. At this time, a very critical part of final nerve regeneration is possible. The first question in planning a secondary operation is: Which function does the patient need most in his daily life? A routine management program is not possible; each patient has to be treated individually. Even in patients with reinnervated muscles after nerve repair, the diminished power of these muscles must be considered. Exact neurologic status, including EMG evaluation, is determined preoperatively. After producing the maximal result of our nerve repair but still not obtaining sufficient function, we use a new concept that consists of employing one muscle for two major functions.2 This is a method that can result in elbow flexion and mass grip of the fingers. For patients lacking movement at the elbowfinger-wrist levels, the first problem is to find a useful muscle for the desired function. If the ipsilateral latissi-
Clinic of Plastic, Hand, and Reconstructive Surgery, Medical School of Hannover Reprint requests-. Dr. Berger, Director, Clinic of Plastic, Hand, and Reconstructive Surgery, Medical School of Hannover, Podbielskistr. 380, D-3000, Hannover 51, West Germany Accepted for publication October 19, 1989 Copyright © 1990 by Thieme Medical Publishers, Inc., 381 Park. Avenue South, New York, NY 10016. All rights reserved.
Downloaded by: National University of Singapore. Copyrighted material.
The concept of reconstruction to regain lost function after brachial plexus lesions has to be as broad and complex as possible. We have been exploring wider and more novel clinical concepts at the Clinic of Plastic, Hand, and Reconstructive Surgery at the Medical School of Hannover. Our ideas are supported by experience in 160 patients. We have attempted to combine the use of a vascularized nerve graft and a microvascularly-transferred autologous muscle. Patients undergoing the procedures have included those with late complete root avulsions and no functional return, as well as previously operated cases with poor recovery of biceps, wrist, and forearm function. The surgery is divided into two stages. In the first stage, the ulnar nerve is prepared as a vascularized nerve graft and is sutured to intercostal nerves 3 to 5 or 6. In stage 2, when the Tinel sign reaches the distal ends of the ulnar nerve graft (about six to eight months later), the latissimus dorsi muscle is harvested. The muscle is then placed as far distally as possible in the forearm and sutured to the deep finger flexors and flexor pollicis Iongus. Proximally, the insertion is performed similarly to Steindler's method. The vessels are connected to the brachial artery and vein and the thoracodorsal nerve is sutured to the graft. This method provides flexion of both the fingers and the elbow.
13
APRIL 1990
mus dorsi is available and powerful enough, then the above described stage is sufficient. In this case, a tenodesis of the wrist extensors is done and an opponensplasty of the thumb is performed. The tenodesis is done in a neutral position, placing the radial extensor tendons through a drill hole in the radius. Opposition of the thumb is obtained by arthrodesis of the first and second metacarpal bones with an AO screw (Fig. 1). The latissimus dorsi muscle is then freed by carefully preserving the neurovascular pedicle. The insertion is cut and the muscle advanced to the middle of the humerus. The next step is crucial: the flexor carpi radialis or ulnaris is transected distally and placed over the latissimus dorsi now in the forearm (Fig. 2). The distal end of the latissimus dorsi is then carefully sutured in different layers to the flexor pollicis longus3 and deep finger flexors in a tight position. This enables flexion of the elbow joint and, at the same time or after even better training, also produces independent closing of the fingers for keeping larger items in the hand (Fig. 3). In cases without available ipsilateral muscles, a second method can be used. This is more complicated because a free muscle transfer will be necessary and, in addition, the motor nerve supply must be restored. The procedure is divided into two sections.2 In the first, the ulnar nerve is used when possible 4 as a vascularized
Figure 2. Diagram of the muscle transposition. Left arrow shows simultaneous two-joint function (EC.R.); right arrow indicates latissimus dorsi muscle.
14
Figure 1. Arthrodesis from MC I to MC II with an AO screw, bringing the thumb in opposition.
nerve graft, to provide motor innervation for the final stage (Fig. 4). The ulnar nerve is dissected, leaving the vascular pedicle intact on its whole length. Proximally, the graft is sutured either to a cervical motor nerve, the spinal accessory nerve, or to intercostal nerves 3 or 4. Distally, the ulnar nerve is cut. The Tinel sign is watched closely and about six months later, a further stage can begin. Also in the first procedure, all necessary tendon transfers, opponens-plasties, and tenodeses are done, as mentioned above. After six months on average have passed, the lower and upper arm is reopened (Fig. 5). The contralateral latissimus dorsi is harvested and transferred to the affected upper and lower arm. The vessels are anastomosed end-to-side to the major arm vessels and the thoracodorsal nerve to the vascularized, reinnervated ulner nerve graft. Again, the flexor carpi radialis or ulnaris is used for a two-joint function (Fig. 2), making it possible for a sufficient force to be applied for both elbow and finger flexion. Postoperatively, the arm is protected by a cast that should be in 90 degree elbow flexion and 120 degree wrist flexion until signs of early reinnervation are detected. Care must be taken not to stretch the transplanted muscle too early.
Downloaded by: National University of Singapore. Copyrighted material.
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 6, NUMBER 2
BRACHIAL PLEXUS LESIONS/BERGER, FLORY, SCHALLER
Downloaded by: National University of Singapore. Copyrighted material.
Figure 4. Vascularized ulnar nerve graft sutured to intercostals 2,3, and 4. Intercostals 5 and 6 are sutured to the median nerve for sensible reinnervation.
o
Figure 3. A, A 21-year-old male patient; upper arrow indicates insertion of the latissimus dorsi muscle; lower arrow shows the dual function of the single muscle transfer. B, A 25-year-old male patient, two years postoperatively. The latissimus dorsi muscle functions well and the patient is also able to hold larger items in his hand. Figure 5. Microvascularly transferred latissimus dorsi muscle for elbow and finger flexion.
RESULTS Since 1986,18 patients have undergone these procedures. In four cases, the first method only was used with good subsequent results. Fourteen patients have already undergone the first stage of the second method (i.e., a vascularized ulnar nerve graft in position). In six
115
APRIL 1990
Figure 6. A 20-year-old male two years postoperatively, demonstrating the entire concept of two-joint function single muscle transfers.
cases, free muscle transposition has already been performed (Fig. 6); in five of these patients, useful function is expected to be obtained.
procedures and possibly newer concepts that combine nerve surgery, classic tendon transfers, arthrodesis, and our two-joint function muscle transfers.
DISCUSSION
REFERENCES
We have presented an additional possibility for patients suffering a brachial plexus lesion without any regained function. The one-muscle transfer for two functions is a new concept for patients who have undergone nerve surgery with results that have not produced a functional elbow and hand. It is also useful for late cases, when nerve surgery is no longer possible 2,4,5,6 j n Spite of the fact that only mass movement in limited extension and power can be gained, these methods used in cooperative patients provide additional chances for improvement of function in upperarm palsies. We believe we can achieve better function than can be provided with the use of a prosthesis. A postoperative training regimen with special orthesis gives additional and early function to these extremities. We hope in the near future that more centers dealing with these patients can validate the reported 16
Berger A, Meissl G, Millesi H, Piza H: Brachial plexus injuries: An integrated therapeutical concept. Proceedings of the International Congress of Emergency Surgery, 1975, p p 382-392
Berger A, Mailaender P, Schaller E. Simultaneous reconstruction of finger flexors and elbow flexion by microsurgical muscle transfer. Program Abstracts of the Mt. Fuji Microsurgery Sympo-
sium, 1988, p 49 Manktelow RT, Zuker RM: The principles of functioning muscle transplantation: Applications to the upper arm. Am I Plast Surg 22:275, 1989 Breidenbach W, Terzis I: The anatomy of free vascularized nerve grafts. Clin Plast Surg 11:65, 1984 Millesi H: Indikation und Auswahl der Operationstechnik im Rahmen der chirurgischen Behandlung von Laesionen des Plexus brachialis. In Hase U, Reulen HJ (eds.): Laesionen des Plexus brachialis. Berlin, New York: de Gruyter, 1985, pp 89105 Doi K, Kawai S, Sasabi K, Kuwata N: Further applications of pedicle of free latissimus dorsi musculocutaneous flap to restore finger function in severely paralyzed upper extremities. Program Abstracts of the Mt. Fuji Microsurgery Symposium,
1988, p 13
Downloaded by: National University of Singapore. Copyrighted material.
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 6, NUMBER 2
