Rev. bras. ortop. vol.50 número6

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w w w . r b o . o r g . b r

Original

Article

Evaluation

of

elbow

flexion

following

free

muscle

transfer

from

the

medial

gastrocnemius

or

transfer

from

the

latissimus

dorsi,

in

cases

of

traumatic

injury

of

the

brachial

plexus

夽

Frederico

Barra

de

Moraes

∗

_,

_Mário

_Yoshihide

_Kwae,

_Ricardo

_Pereira

_da

_Silva,

Celmo

Celeno

Porto,

Daniel

de

Paiva

Magalhães,

Matheus

Veloso

Paulino

DepartmentofOrthopedicsandTraumatology,FaculdadedeMedicina,UniversidadeFederaldeGoiás(UFG),Goiânia,GO,Brazil

a

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t

i

c

l

e

i

n

f

o

Articlehistory:

Received24March2014 Accepted21October2014 Availableonline20October2015

Keywords:

Brachialplexus/surgery Muscle/transplant

Reconstructivesurgicalprocedures

a

b

s

t

r

a

c

t

Objective:Tocomparethegaininelbowflexioninpatientswithtraumaticinjuryofthe brachialplexusfollowingmuscletransferfromlatissimusdorsiwiththegainfollowingfree muscletransferfromthemedialbellyofthegastrocnemius.

Methods:Thiswasaretrospectivestudyinwhichthemedicalfilesofaconvenience sam-pleof13patientsoperatedbetween2000and2010werereviewed.Group1comprisedseven patientswhounderwenttransfersfromthegastrocnemiusandgroup2(controls)comprised sixpatientswhounderwenttransfersfromthelatissimusdorsi.Thefollowingfunctions wereevaluated:(1)rangeofmotion(ROM)ofelbowflexion,indegrees,usingmanual goniom-etryand(2)gradeofelbowflexionstrength,usingamusclestrength scale.Satisfactory resultsweredefinedas:(1)elbowflexionROM≥80◦_and₍₂₎_elbow_flexion_strength

≥M3.The

FisherexactandKruskal–Wallistestswereused(p<0.05).

Results:Thepatients’meanagewas32years(range:17–56)and72%hadbeeninvolvedin motorcycleaccidents.Elbowflexionstrength≥M3wasobservedinsevenpatients(100%)

ingroup1andinfivepatients(83.3%)ingroup2(p=0.462).Noneofthepatientspresented M5,andonepatient(16.7%)ingroup2hadapoorresult(M2).ElbowflexionROMwitha gain≥80◦

(dailyfunctions)wasfoundinsixpatients(86%)ingroup1andinthreepatients (50%)ingroup2(p=0.1).

Conclusion:Thepatientsingroup1hadgreatergainsinstrengthandROMthandidthosein group2,butwithoutstatisticalsignificance.Thus,transfersfromthegastrocnemiusbecome anewsurgicaloption,ifothertechniquescannotbeused.

夽

StudycarriedoutatHandandMicrosurgeryService,HospitaldasClínicas,UniversidadeFederaldeGoiás(UFG),Goiânia,GO,Brazil.

∗ _{Corresponding}_author_.

E-mail:[email protected](F.B.deMoraes).

http://dx.doi.org/10.1016/j.rboe.2015.09.007

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Avaliac¸ão

da

flexão

do

cotovelo

após

transferência

muscular

livre

do

gastrocnêmio

medial

ou

transferência

do

latíssimo

do

dorso

na

lesão

traumática

do

plexo

braquial

Palavras-chave:

Plexobraquial/cirurgia Músculo/transplante Procedimentoscirúrgicos reconstrutivos

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e

s

u

m

o

Objetivo: Compararoganhodeflexãodocotoveloempacientescomlesãotraumáticado plexobraquialapóstransferênciamusculardolatíssimodorsal(TMLD)comatransferência muscularlivredoventremedialdogastrocnêmio(TMLGM).

Metódos: Estudoretrospectivo,revisãodeprontuários,amostradeconveniência,com13 pacientesoperados,entre2000e2010.Grupo1(TMLGM)comsetepacientesegrupo2ou controle(TMLD)comseis.Funçãoavaliada:1)amplitudedemovimento(ADM)emgraus da flexãodocotovelo,goniometriamanual; 2)graude forçadeflexão docotovelo,por escaladeforçamuscular.Satisfatórios:1)ADM:flexãodocotovelo≥80◦

;2)Forc¸a:flexão docotovelo≥M3.TestesexatodeFishereKruskal–Wallis(p<0,05).

Resultados:Médiadeidadefoide32anos(17a56).Acidentedemotoem72%.Forc¸adeflexão docotovelo≥M3nogrupo1emsetepacientes(100%)eogrupo2emcinco(83,3%)(p=0,462).

NãotivemosM5eogrupo2apresentouumpaciente(16,7%)comresultadoruimM2.ADM naflexãodocotovelocomganho≥80◦

(func¸õesdiárias)foramencontradosnogrupo1em seispacientes(86%)enogrupo2emtrês(50%)(p=0,1).

Conclusão:Pacientesdogrupo1tiveramumganhomaiordeforc¸aeADM,quando compara-doscomosdogrupo2,semsignificadoestatístico.Assim,TMLGMsetornaumanovaopc¸ão cirúrgica,casonãopossamseraplicadasoutrastécnicas.

Introduction

Traumaticbrachialplexusinjuries(BPIs)canhindertheelbow flexion function and thus dramatically alter the quality of lifeofindividuals.Veryoften,theinitialmicroneurosurgery cannotappropriatelyrestoremovementinthisjoint.Inolder injuries,nerverepairsurgeriesarenotrecommended,asthere isdefiniteatrophyandclassicmuscletransfers(MT)are pos-sible only in partial lesions. Thus, some patients require complementary interventions for functional gain of elbow flexion.Theseprocedures arerelated toMTorfreemuscle transfer(FMT).1

The MTs were the first techniques described. Steindler flexorplastyanduseofthelatissimusdorsi,pectoralismajor and triceps were the main types.2 _The _FMTs _are _newer and exhibit higher technicaldifficulty, due to the need to perform the neurovascular microanastomosis between the transplantedmuscle pedicleand the vesselsandnerves of the injurysite. Inthe upperlimb,and morespecifically to gainelbowflexion,thetechniquesusedaretheFMTofthe contralaterallatissimusdorsi(LD),rectusfemorisandgracilis muscles.1,3

Theliteraturehasonlythreestudiesconcerningthemedial gastrocnemius(MG)usedintheupperlimbforFMT,inorder torecoverthefunctionofaninjuredmusclegroup.Liuetal.4 useditforVolkmann’sischemiccontractureintheforearm, withgoodfunctionalresults.Serafin5_proposed_that_the_MG wouldhavesignificantpotentialtorestoreelbowflexionor extension.Kwaeetal.6_described_the_FMT_of_the_MG_to_gain elbowflexioninpatientswithtraumaticBPI.

Theaimofthisstudywastocomparethegaininelbow flexioninpatientswithtraumaticBPIafterstandardsurgical procedureofMToftheLD(controlgroup)withFMToftheMG (studygroup).

Method

Retrospective study carried out by the review of medical recordsfromaconveniencesampleconsistingof13patients withtraumaticBPIthatwereconsecutivelysubmittedto sur-gicalprocedurefromDecember2000toDecember2010atthe HandandMicrosurgeryService.Thesepatientsweredivided intotwogroups.Group1orstudyconsistedofsevenpatients submittedtoFMToftheMGandgroup2orcontrolconsisted ofsixpatientssubmittedtoMToftheLD.

Patientsthatwereincludedinthetwogroupshadmuscle strengthequaltoM0(withoutstrength)anddegreeofelbow flexionbetween0and10◦ _(no_movement),_who_had_already

beensubmittedtosurgerywithothertechniques,but with-outsuccess,orthosethathadtheplexusinjuryforabouta yearandhadnotbeentreatedsurgically,withoutthe possi-bilityofapreviousneuralsurgery.Also,asinclusioncriteria, patientswithpreoperativeLDmuscleactivity≥M4were

cho-senfortheLDcontrolgroup,whilefortheMGstudygroup, patientswithLDstrength≤M3wereselected,asLDtransfer

wouldbecontraindicatedinthissituation.

Weexcluded patientsthathad incomplete dataintheir medicalrecords,orpreoperativestrength≥M1andelbow

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Thedatacollectedfrommedicalrecordsconsistedofage, timeof injuryin months,neural injury level, typeof neu-raldamage,typeofmuscletransfer,typeofprevioussurgery, elbowflexionstrengthandrangeofmotionforbothpre-and postoperativeperiods.

Thelevel and type ofneurologic injurywere diagnosed bypreoperativeelectromyography.Asforelbowflexion,the degreeofmusclestrengthwasmeasuredbytheBritish Med-icalCouncil scale (M0=no movement;M1=onlya trace or flicker of movement is seen or felt, or fasciculations are observed;M2=musclecanonlymoveifresistanceofgravity isremoved;M3=jointcanbemovedonlyagainstgravitywith examiner’s resistance completely removed; M4=strength reduced,but contraction canstill movejoint against resis-tance;M5=normalstrength)andamanualgoniometerwas usedtomeasurerangeofmotion(ROM),startingfromzero degrees in total elbow extension to the maximum angle achievedandmaintainedbythepatient,oneyearafter mus-culartransfersurgery.

Ingroup1,theMGFMTwasperformedwiththe follow-ingsteps:(1)mediancurvilinearlongitudinalincision,which starts8cmproximaltothepoplitealcrease,extendsdistally upto10cmproximaltothemedialmalleolus;(2)dissection oftheintermuscularseptumbetweenthetwogastrocnemius bellies,laterallydisplacingthesmallsaphenousveinandthe sural nerve, individualizing the muscle and neurovascular structuresofthepoplitealfossa;(3)theoriginoftheMGisthen severedfromthefemoralmedialcondyleandthemedialsural neurovascularbundleisdissectedandclampedforresection, initslongestextension,1cmproximaltothejoint;(4) identifi-cationofthesciatic,medialpoplitealandtibialnerve(fromthe rootsofL4–L5/S1–S3ofthelumbosacralplexus),fromwhich thebranch totheMGoriginates, calledmedialsuralnerve (MSN),accordingtotheanatomicalmodeldescribedbyMoraes etal.7₍₅₎_{identification}_of_the_number_of_arterial_and_venous branchesthatarriveattheMGpedicle,aswellasthecrossing ofthesmallsaphenousveinovertheMSN,whichmay hin-deritsdissection;(6)deltopectoralincisionandsubcutaneous dissectionintheupperlimbtowhereoneintendsto trans-fertheMGforbicepsfunctionwithdissectionoftheartery, thethoracodorsalveinandthecephalicvein;(7)MGFMTfor elbowflexion,withfixationoftheproximalventralregionat theproximalendofthehumerusthroughthebonewindow andfixationwithcorticalscrewsinthedistalregionofthe distalstumpofthebicepstendon;(8)microanastomosisofthe arterialbranchoftheMGinthethoracodorsalartery;theveins wereattached,oneinthethoracodorsalveinandanotherin thecephalicvein;(9)themicroanastomosisoftheMGMSN wascarriedoutindifferentperipheralbranches,with neuro-tizationstothemusculocutaneousfromtheulnar,intercostal oraccessorynerves.1,8,9

Oneofthe principlesof surgicalreconstructionof trau-matic BPIs is the recovery of elbow flexion. Thus, the following parameters are considered satisfactory: (1) ROM: elbowflexion≥80◦and(2)strength:elbowflexion≥M3.Group

2 consisted of patients submitted to ipsilateral latissimus dorsitransfer,whichwasperformedaspreviouslydescribed inliterature.1,2

Data were collected and stored in Excel for Windows andanalyzedusingthestatisticalsoftwareprogramSPSSfor

Windows,version13.0.AllsampleswereevaluatedbyFisher’s exacttestforparametricdataandKruskal–Wallistestfor non-parametricdata.Statisticalsignificancewassetatp≤0.05.

Results

Ofthe13patientsassessedtoimproveelbowflexionfunction aftertraumaticBPI,seven(54%)wereingroup1(free mus-cletransferofthemedialgastrocnemius),withameanlesion timeof18.4months(10–30),andsix(46%)ingroup2orcontrol (latissimusdorsitransfer),withameantimeoflesionof22.3 months(12–36).Allpatientsweremales.

Meanagewas32years(17–56).Therightsidewasaffected in seven(54%)casesand the left insix(46%). Sevencases (54%)werefromGoiâniaandsix(46%)fromthestateofGoiás countryside.Regardingwork,twopatients(15%)were unem-ployed,five(39%)didmanualworkandsix(46%)workedinthe administrativearea.

Motorcycle accidentwasthe causeoftheinjury innine patients(70%)(p<0.05);one(7.5%)casewasduetoautomobile accident,one(7.5%)casewashit byacar,one(7.5%)hada work-relatedaccidentandone(7.5%)wasduetofirearminjury. The clinical characteristics of patients in group 1 (MG) relatedtothetypeofbrachialplexusinjuryanditsevolution aftertreatmentareshowninTable1andthoseofgroup2(GD) areshowninTable2.

Regardinggainofstrengthinelbowflexion,weobserved thatbothgroupshadsatisfactoryresultswithagainequalto oraboveM3,group1withsevenpatients(100%)andgroup2 withfive(83.3%),butnosignificantdifference(p=0.462).There were noresultswithgainM5and group2hadonepatient (16.7%)withpoorresultsintermsofstrengthgain,whichonly achievedM2(Fig.1).

Regarding the rangeofmotiongainindegreesofelbow flexion,weobservedthatsatisfactoryresultswithgains>80◦

indailyfunctionswerefoundingroup1insixpatients(86%) andingroup2inthree(50%),butwithnosignificantdifference (p=0.1).Therewerenoresultswithgain>150◦_._Regarding_the

resultsinwhichflexionwasonlyachievedupto60◦_,_there_was

onlyonepatient(14.3%)ingroup1andthreepatientsingroup 2(50%)(Fig.2).

57%

43%

16.7% 16.7%

66.6%

Group 1

Group 2 Gain in elbow strength 4.5

3.5

2.5

1.5

0.5 4

3

2

1

0

Patients

M0-M2 M0-M3 M0-M4

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Table1–Clinicalcharacteristicsofpatientssubmittedtofreetransferfromthemedialgastrocnemiusmuscleforgainin elbowflexion(group1).

P Age Timeof

lesion (months)

Neural lesionlevel

Typeofneural lesion

Previous surgery

Pre-op flexion strength

Pre-op ROM

Post-op flexion strength

Post-op ROM

1 42 30 C5C6C7C8 Axonotmesis Neurolysis

neurotization AC>SE

MO 0–10◦ _M3 _0–90◦

neurotization AC<SE+sural graft

MO 0–10◦ _M3 _0–80◦

3 36 20 C5C6C7C8 Neurotmesis Neurorrhaphy

C5C6+sural graft

MO 0–10◦ _M3 _0–80◦

4 31 11 C5C6C7 Axonotmesis Nosurgery MO 0–10◦ _M4 _0–60◦

5 21 10 C5C6C7C8 Axonotmesis Nosurgery MO 0–10◦ _M4 _0–90◦

MO 0–10◦ _M4 _0–90◦

7 23 12 C5C6C7C8 Neuropraxis Nosurgery MO 0–0◦ _M4 _0–90◦

Table2–Clinicalcharacteristicsofpatientssubmittedtomuscletransferfromlatissimusdorsiforelbowflexiongain (group2).

P Age Timeof

lesion (months)

Neural lesionlevel

Typeofneural lesion

Previous surgery

Pre-op flexion strength

Pre-op ROM

Post-op flexion strength

Post-op ROM

1 32 36 C5C6 Axonotmesis Neurolysis

MO 0–10◦ _M3 _0–90◦

2 56 23 C5C6 Neurotmesis Neurolysis

neurotization AC<SE+sural graft+oberain

MO 0–10◦ _M2 _0–30◦

3 23 18 C5C6C7 Neurotmesis Nosurgery MO 0–10◦ _M3 _0–80◦

neurotization AC<SE+sural graftoberain

MO 0–10◦ _M3 _0–60◦

5 39 12 C5C6 Axonotmesis NeurolysisC5C6 MO 0–10◦ _M4 _0–120◦

6 31 26 C5C6 Axonotmesis Neurolysis

neurotization AC<SE+sural graft+oberain

MO 0–10◦ _M3 _0–60◦

Discussion

Elbowflexionimprovementinpatients withtraumaticBPIs providesanimportantgainintheinjuredlimbfunctionand anelbowconsideredadequateistheonewithstrength≥ M3,

ideally≥M4and withmorethan 80◦ ofactiveflexion.2 The

MTsaremainlyindicatedincaseswherethepatienthashad apartialinjuryoronlyintheuppertrunk(C5C6)orshowsgood handandwristfunction.

TheFMThaveawiderrangeofpossibilities,butwithfar greatertechnicaldifficulties.Forthehandtoworkadequately, theshouldermustbestableandtheelbowmusthave ade-quateflexion–extensionactivity,topositionitinthespace.9 Otherwisethelimbwillbecomenonfunctional.Bothinthe

MTorFMTforelbowrecovery,regardlessofthechosen tech-nique,theelbowjointcannotbeankylosedorcontractedand thechosenmusclemusthaveM4orM5strength.

TheMT from the tricepsto thebiceps isconsidered by Steindler10_as_{unsatisfactory,}_as_it_can_affect_elbow_extension. Thetricepshasanimportantfunctionintheupperlimband, therefore,theMTshouldbeusedonlyasalastresort. Accord-ingtosomeauthors,suchasPardinietal.11_they_use_it_due_to thetechnicalsimplicity,aswellasbecausethisMTisableto allowthepatienttomovethehandtotheheadandmouth withsatisfactoryflexionofaround120◦_and_provides_muscle

strengthtosupportuptothreeandahalfkilograms.

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4.5

4

3

2

1 3.5

2.5

1.5

0.5

0

Group 1 Group 2

Patients

0-30 degrees 0-60 degrees 0-80 degrees

0-90 degrees 0-120 degrees

57%

28.7%

14.3% 16.7%

33.2%

16.7%

16.7% 16.7%

Gain in elbow range of motion

Fig.2–Assessmentofgaininelbowflexionrangeof motionbetweenthegroups.

portions are used. Itsmain contraindication in relation to other MTs is damageto the axillaryartery, which impairs thethoracoacromialartery.However,itisnotthefirstoption either,asthepectoralismajorispartoftheshouldergirdle andmaybeusedforshoulderrecoveryanditsresultsarenot satisfactoryformostpatients,whoendupattainingonly60◦

ofelbowflexioninaverageandwithlittlestrength.12 Steindlerflexorplasty10 _was_the _first _procedure_used _for rehabilitationoftheparalyzedelbow.Itwasinitiallyapplied inpatientswithpoliosequelae,obstetricalandarthrogrypotic paralysis and onlylater in traumatic BPI. That MT is per-formedbyfreeing the medialelbowepicondylealong with flexor–pronatormusclesoftheforearm(pronatorteres,flexor carpiradialis,palmarislongus,flexordigitorumsuperficialis and flexorcarpi ulnaris)and thensubsequently fixation to amoreproximalportionofthehumerus.Itiscurrentlyone ofthemostwidelyusedtechniques, asitissimpleto per-formandcanattainmorethan100◦ _of_elbow_flexion_in_70%

ofpatients.However,itsdisadvantagesareadecreaseinthe flexingstrengthofthehandandwrist;objectscanberaised onlyiftheyweightuptotwokilogramsandthecontractureof elbowjoint.13

However,it isthemainMTusedforelbowrecoveryand from the latissimus dorsi to the ipsilateral biceps, where the results can reach over 100◦ _of _active _elbow _flexion

and M4 strength. The latissimus dorsi can be transferred inunipolar or bipolar mannerand the main contraindica-tion isthelackofanadequate postoperativerehabilitation program.14

AsfortheFMT,themostoftenusedmuscleisthe contralat-erallatissimusdorsi15–17_followed_by_the_gracilis_(GD)_from_the lowerlimb,andrarelytherectusfemoris.1_The_indication_for aFMTcomesfromtheneedtorestoreelbowflexionfunction intraumaticBPIs,evenafterneurosurgicalproceduresinthe plexus,orincasesthatarereferredfortreatmentafterone year.TheFMTwillnotbenecessarywhenscienceisableto maintainthe morphologyand ultrastructureofdenervated musclemakeneuralgraftsdirectlyontothespinalcordand acceleratetheneuronalregenerationvelocity.18

ThegracilisFMTcanbeperformedasasingleprocedure togainelbowflexionfunctionorasdualproceduretoattain elbowflexionandatthesametimeimprovehandfunction and shoulder stability. When it isused onlytogain elbow flexion, approximately 80% of patients reach M4 strength, but when usedasdualfunction, this numberdecreases to 60%.19–21

Accordingtotheliterature,22–26_the_MG_has_attractive fea-turesforFMT,suchas:length,excursioncapacity,contraction forceproportionaltothesectionalarea,longinsertional ten-don, adequate neurovascular bundle(blood supply classI), puremotorbranchoftheMSNfromthemedialpoplitealnerve (95%singlebranch).

Otheradvantagesare:resectionofonlyonegastrocnemius belly,whichdoesnotaffecttheplantflexionfunctionanddoes notcausemajordeformity.ThescarleftbytheMGremoval is cosmeticallyacceptable, especiallyin men. Moreover,in patientsthatmaybesubmittedtolocaltransfers,theMGFMT hastheadvantageofaddinganothermusclegrouptoa weak-enedupperlimb,aimingatbetterfunction.Thedisadvantages are: thescars inwomen; thesupineposition makesit dif-ficulttodissectatthedonorsite(poplitealfossa)inFMTto upperlimb.Optionally,theprocedurecanbeperformedwith thepatientinthelateraldecubitusposition.

WebelievethattheanastomosisoftheMSNwithpartof theulnarshowedbetterperformancethanwiththeintercostal nerve,duetotheshorterreinnervationdistance.However,the useoftheintercostalnervecanbeconsideredanoptionifthe ulnarisnotavailable.

TheMGFMTtobicepshadnotbeenperformed,untilthen, forthispurpose.ThusKuwaeetal.6_described_in_two_cases_the MGFMTforelbowflexionfunctionrecoveryinpatientswith traumaticBPIs.Inourstudy,weobservedgoodresults≥M3in

100%ofMGFMTand85.6%inGDMTandexcellentresults withM4in57%oftheMGFMTand29%inGDMT,butwithout significantdifference.Regardingtheelbowrangeofmotion, flexionexceeded80◦_in_85.6%_of_patients_undergoing_MG_FMT

andin57%ofpatientssubmittedtoGDMT.Thisdifference wasnotsignificantbetweenthegroups.

Whencomparingtheresultsofthetwogroups,therewas nodifferenceinelbowflexiongain.Patientssubmittedtofree transferofthemedialgastrocnemiusmusclehadahighergain instrengthandROMwhencomparedwiththecontrolgroup submittedtolatissimusdorsitransfer,butwithoutstatistical significance.Thus,MGFMTcanbeconsideredatechniqueof whichresultsarenotinferiortothoseoftheLDMTstandard techniqueand becomesaviableoptionifother techniques cannotbeapplied.

Conclusion

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Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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