Reconstruction Of Elbow Flexion Research Articles

Functional reconstruction of elbow flexion with latissimus dorsi muscle rotational transfer: two case reports

BackgroundWe report two cases of biceps brachii and brachialis paralysis due to musculocutaneous nerve injury in which elbow joint flexion was reconstructed using rotational transfer of the latissimus dorsi muscle with sutures to the radial and ulnar tuberosities, thereby enabling flexion by simultaneous activation of the humeroradial and humeroulnar joints. In cases of associated brachialis paralysis, weaker flexion strength can be expected when the forearm is in a pronated position than when it is in a supinated state. To the best of our knowledge, no previous study has reported the rotational position of the forearm during elbow joint flexion reconstruction.Case presentationCase 1 involved a 30-year-old Asian male who presented with a rupture of the musculocutaneous, median, radial, and ulnar nerves. Reconstruction was performed by rotational transfer of the latissimus dorsi muscle. In this case, the supination and pronation flexion forces were equal. Case 2 involved a 50-year-old Asian man who presented with partial loss of the musculocutaneous nerve, biceps brachii, and pectoralis major due to debridement. Reconstruction was performed by rotational transfer of the latissimus dorsi muscle. In this case, supination and pronation flexion strengths were demonstrated to be equal. Our reconstruction method used the rotational transfer of the latissimus dorsi muscle; the distal muscle flap was divided into radial and ulnar sides to allow elbow joint flexion by simultaneously activating the humeroradial and humeroulnar joints. These sides were then fixed to the anchors at the radial and ulnar tuberosities. Finally, they were wrapped around the myotendinous junction of the biceps brachii or brachialis and secured using sutures.ConclusionsAlthough larger studies are required to verify these methods, this case study successfully demonstrates the following: (1) the flexion strength in the supinated position was equal to that in the pronated position; (2) the stability of the humeroradial and humeroulnar joints was unaffected by the forearm's rotational position; and (3) a satisfactory range of motion of the elbow joint was obtained, with no complications.

Clinical Outcome of the Latissimus Dorsi Muscle Flap in Orthopedic Reconstruction

Introduction. The latissimus dorsi muscle has been the “workhorse” of reconstructive surgery because of its predictable neurovascular anatomy and ability to perform both wound coverage and restoration of function.Objectives. We determined the flap viability, complications, and muscle function (if used as muscle transfer) of our latissimus dorsi flaps for orthopedic reconstruction.Methods. This is a retrospective review of all cases done in the Microsurgery Unit of the Philippine General Hospital and The Medical City from January 2005 to present using the latissimus dorsi muscle for reconstructive surgery. All patients were followed-up for six months.Results. There were 14 patients who had reconstructive surgeries using the latissimus dorsi muscle. Three patients had traumatic brachial plexus injuries where the latissimus dorsi muscle was used for the reconstruction of elbow flexion. Eleven patients required coverage of a large defect, where seven were secondary to tumor resection and four were secondary to trauma. Of the fourteen patients, nine were pedicled flaps and five were free flaps. We had one failure (free flap group/tumor resection). The rest of the flaps survived completely. The smallest flap was 10 x 8 cm, and the largest flap was 28 x 24 cm.Conclusion. The latissimus dorsi muscle remains to be a versatile muscle in the field of orthopedic reconstructive surgery.
 
 
 

Virtual Rehabilitation of Elbow Flexion Following Nerve Transfer Reconstruction for Brachial Plexus Injuries Using the Single-Joint Hybrid Assisted Limb

PurposeThe upper limb single-joint hybrid assistive limb (HAL), a wearable robot that can support elbow flexion and extension motions, was originally used to rehabilitate patients with stroke. We report the preliminary outcomes of serial HAL use for rehabilitation following nerve transfer (NT) for elbow flexion reconstruction in brachial plexus injuries.MethodsHybrid assistive limb training consisted of virtual and power training courses. Virtual training was started before HAL picked up motor unit potentials (MUPs) from the target muscle through electrodes attached to the skin overlying the original donor muscles. Power training was started after the maturation of MUPs, the stage where the MUPs were strong to be recognized to arise from the target muscles. Hybrid assistive limb assist at this stage was carried out by decreasing the settings in an inversely proportionate manner to the increase in target muscle strength. Fourteen patients underwent HAL training following NT. Eight patients had the intercostal nerve to musculocutaneous nerve (ICN-MCN) transfer, and their postoperative functional outcomes and rehabilitation performance were compared to 50 patients with ICN-MCN transfer who underwent conventional postoperative rehabilitation with electromyographic biofeedback (EMG-BF) techniques.ResultsComparison of the long-term results following ICN-MCN transfer between EMG-BF and HAL groups showed similar follow-up times, elbow flexion range of motion, or power of elbow flexion assessed using the British Medical Council grade, and quantitative measurement using Kin-Com dynamometer. However, the number of rehabilitation sessions was significantly fewer in the HAL than EMG-BF group.ConclusionHAL training accelerated patients’ learning to convert the original muscle function into elbow flexion following NT by replicating elbow flexion during the pre-MUP detection stage and shortening the rehabilitation time.Type of study/level of evidenceTherapeutic IV.

Paediatric Elbow Flexion Reconstruction with the Latissimus Dorsi Muscle Flap, Case Report and Literature Review

We have conducted two latissimus dorsi transfers for elbow function reconstruction in paediatric patients at Chris Hani Baragwanath Academic Hospital. The first patient was a four-year-old girl with distal, asymmetric arthrogryposis, involving the shoulder, elbow, and wrist. The second patient was a five-year-old boy with paediatric brachial plexus injury, with C5 and C6 root avulsions with an inability to flex the elbow, as well as a glenohumeral contracture. He presented following a rotational humerus osteotomy. We performed a unipolar latissimus dorsi transfer in both patients with good results. We also performed a literature review to compare the available methods of elbow flexion reconstruction, especially in paediatric cases. We believe that the latissimus dorsi transfer is the preferred muscle transfer for reconstructing elbow function and the literature review supports this assertion.

Elbow Flexion Reconstruction in Brachial Plexus Avulsion Injuries - Results with Intercostal Nerve and Distal Nerve Transfers.

Background: The neural surgical options for reconstruction of elbow flexion in brachial plexus injuries depend on the availability of nerve donors. In upper-type avulsion injuries, the ulnar or median nerves, when intact, are reliable intra-plexal donor nerves for transfers to the biceps muscle. In complete avulsion injuries, donors are limited to extra-plexal sources, such as intercostal nerves (ICNs). Methods: We reviewed our results of ICN and partial distal nerve (ulnar or median) transfers for elbow flexion reconstruction in patients with brachial plexus avulsion injuries. The time taken for recovery of elbow flexion strength to M3 and the final motor outcome at 2 years were compared between both groups. Results: 38 patients were included in this study. 27 had ICN transfers to the musculocutaneous nerve (MCN), 8 had partial ulnar nerve transfers and 3 had partial median nerve transfers to the MCN's biceps motor branch. The mean time interval from injury to surgery was 3.6 months. Recovery of elbow flexion was observed earlier in the distal nerve transfer group (p < 0.05). Overall, success rates were higher in patients with distal nerve transfers (100%), compared to ICN transfers (63%) at 2 years (p = 0.018). Patients with distal nerve transfers achieved a higher final median strength of M4.0 [Interquartile range (IQR) 3.5-4.5], compared to M3.5 (IQR 2.0-4.0) in the ICN group (p = 0.031). In the subgroup of patients with upper-type brachial plexus injuries, there were no significant differences in motor outcomes between the ICN versus distal nerve transfers group. Conclusions: In our entire cohort, patients with distal nerve transfers had faster motor recovery and better elbow flexion power than patients with ICN transfers. In patients with partial brachial plexus injuries, outcomes of ICN transfers were not inferior to distal nerve transfers.

Elbow flexion reconstruction after arm-sparing excision for high-grade triton sarcoma: a case report

BackgroundSoft tissue sarcomas affecting the root of an upper extremity raise the question of limb amputation depending on their location, size, and malignancy. Malignant triton tumors are a rare subtype of neurofibrosarcomas that have been poorly reported in the literature. We report the case of a challenging reconstruction of the upper extremity using a pedicled latissimus dorsal flap.Case presentationA 25-year-old Occidental man was referred to our sarcoma unit for the management of a large, high-grade malignant peripheral nerve sheath tumor with no regional or distant extension and very fast progression. He was treated first by concomitant neoadjuvant radiotherapy and chemotherapy. Carcinologic excision was performed “en bloc” including the skin, the tumor, and the flexor muscles of our patient’s elbow. Coverage of the skin defect and elbow flexion restoration were achieved by using a homolateral pedicled musculocutaneous latissimus dorsi flap. Histological analysis showed an R0 resection. The reconstruction process recovered a complete bending of his elbow. He is still in remission at 26 months follow-up.ConclusionsA malignant triton tumor is a rare, aggressive, and high-grade sarcoma. It was successfully treated and this case report describes an effective treatment modality. Reconstructive surgery, allowing large, complete tumor removal, is indispensable after neoadjuvant chemotherapy and radiotherapy.

Neurophysiological signals for estimation of the result of latissimus dorsii muscle transfer to biceps brachii in patients with arthrogryposis

Background. One of the leading causes of restriction in daily-living activities in patients with arthrogryposis is severe hypoplasia (or aplasia) of the biceps brachii. Latissimus dorsii muscle transfer to the biceps brachii is one of the most used methods for the reconstruction of active elbow flexion in patients with arthrogryposis.&#x0D; Aim. The aim of the study is to identify neurophysiological correlates for evaluating the result of the transposition of the latissimus dorsii muscle to the biceps in patients with multiple congenital arthrogryposis.&#x0D; Materials and methods. From 2011 to 2018, we performed monopolar latissimus dorsii muscle transfer to the biceps for the restoration of active elbow flexion in 30 patients with arthrogryposis (44 upper extremities). The follow-up results were studied in 14 cases. For this purpose, we used clinical examination, surface electromyography (sEMG), and statistical analysis. The patients were examined before and from 1 month to 96 months (7 months; 224.5 months) after the surgery. The age of patients was from 1 to 10 years at the time of surgery (4.89 2.42 years).&#x0D; Results. Our study showed that the age of the child at the time of surgery does not significantly change the index of activation of the latissimus dorsii muscle. A decrease of coactivation of the latissimus dorsii muscle in the long term after surgery correlates with an increase in the strength of the displaced latissimus dorsii muscle, and an improvement in active flexion in the elbow. If the value of the index of coactivation of the latissimus dorsii muscle is less 42%, the muscle strength after surgery reaches 4 points. It was found that the index of coactivation of the latissimus dorsii muscle does not depend on the level of segmental damage to the spinal cord. However, the strength of the muscle depends on the level of spinal cord damage.&#x0D; Conclusion. The determination of the index coactivation of the latissimus dorsii muscle after surgery can be used to evaluate the results of the latissimus dorsii muscle transfer to the biceps in patients with arthrogryposis. The index of activation of the latissimus dorsii muscle must be less than 42% for effective elbow active flexion.

Finger sensory impairment after elbow flexion reconstruction using concomitant nerve transfer from the median and ulnar nerves

Purpose Single and double fascicular nerve transfer using the ulnar or median nerve is performed to restore elbow flexion following injuries to the brachial plexus or nerve root. However, little is known regarding the postoperative changes involved in the sensory alteration of the hand after a single and double fascicular nerve transfer. We evaluated the sensory alteration of the hand in patients who underwent single and double fascicular nerve transfer for two years. Methods A total of five patients that underwent single or double fascicular nerve transfer participated in this study. The injury mechanism was avulsion (n = 2), stretching (n = 1), open injury (n = 1), and compression (n = 1). The touch sensation of the index and the little fingers before surgery at 6 months, 1 year, and 2 years after nerve transfer was evaluated using the Semmes-Weinstein monofilaments test (SWM-t). Muscle strength of the elbow flexion and the wrist flexion was evaluated. Results The touch sensation of the index finger at 24 months was equal to the preoperative evaluation. On the other hand, the touch sensation of the little finger at 24 months slightly improved compared to what it had been at the preoperative evaluation. Moreover, the median of the SWM-t score in the index and little finger at 24 months after surgery was beyond 3.61 that mean diminished light touch level. Conclusions The results of this study indicate that the touch sensory deficit of the index and little fingers persist for up to 2 years after nerve transfer.

Elbow flexion strength and contractile activity after partial ulnar nerve or intercostal nerve transfers for brachial plexus injuries

We compared the outcomes of 23 partial ulnar nerve and 15 intercostal nerve transfers for elbow flexion reconstruction in patients with C56 or C567 brachial plexus injuries using manual muscle power, dynamometric measurements of elbow flexion strength and electromyography. The range of elbow flexion and muscle strength recovery to Grade 3 or 4 were comparable between the two groups. The patients with C567 injuries had significantly stronger eccentric contraction after the partial ulnar nerve transfer than after the intercostal nerve transfer (p < 0.05). Electromyography of individual muscles demonstrated that the patients with partial ulnar nerve transfers were unable to voluntarily isolate biceps contraction and recruited forearm flexors and extensors. The patients after partial ulnar nerve transfer had significantly more activity of the forearm muscles during concentric elbow flexion than after intercostal nerve transfers (p < 0.05). We conclude that partial ulnar nerve transfers were superior to intercostal nerve transfers when assessed quantitatively with the dynamometer to evaluate elbow flexion, although simultaneous recruitment of forearm muscles may have contributed to the increased elbow flexion strength in the patients with the partial ulnar nerve transfer.Level of evidence: III.

Independent elbow flexion and extension by isolated long head of triceps transfer for reconstruction of elbow flexion in old upper brachial plexus palsy

Independent elbow flexion and extension by isolated long head of triceps transfer for reconstruction of elbow flexion in old upper brachial plexus palsy

Reconstruction of elbow flexion with a modified Oberlin procedure: A comparative study

IntroductionIn upper brachial plexus injuries (C5-C6-C7), selective nerve transfers appear as a favourable technique. For this purpose, transfer of an ulnar nerve fascicle to the biceps motor branch (Oberlin's procedure) is often used. In this paper we present our modified Oberlin technique, as well as a comparison of this method with the classic Oberlin procedure. Materials and MethodsWe present two groups of patients that where operated by two different surgeons. The first group, consisting of 16 patients was treated with the classic Oberlin procedure. The second group included 5 patients treated with a modified Oberlin procedure, where two fascicles from the ulnar nerve were transferred to both the motor branch of the biceps and the motor branch of the brachialis muscles. ResultsIn the last follow-up of the 16 patients from the first group with the classic Oberlin procedure, 15 patients (93.75%) had Medical Research Council (MRC) grade of biceps strength 4 and 1 patient (6.25%) had MRC grade 3, whereas in the group where the modified Oberlin procedure was used the muscle strength was very durable with 4 out of 5 the patients reached MRC grade of 4+ and one MRC grade of 4, and with a mean elbow strength at 5.4 kg (3–8 kg). No sensitivity or motor problems were encountered on the ulnar territories for both groups. ConclusionWith the modified Oberlin technique, the median nerve is reserved and both elbow flexors are innervated. The results of this technique compare favourably with those of other methods. Thus, we propose using the double fascicle transfer from the ulnar nerve to both elbow flexors in order to restore a strong elbow flexion in patients with upper brachial plexus injuries.

Comparison between donor nerves to motorize the free functional gracilis muscle transfer for elbow flexion: Retrospective study of 38 consecutive cases in traumatic adult brachial plexus injuries.

Elbow flexion deficit is a frequent problem in traumatic brachial plexus injuries and reestablishment of this function is the primary treatment goal. When management is delayed, or the initial acute approach fails, free functional transfer of the gracilis muscle for elbow flexion is the treatment of choice. In this report, the authors present the results of a comparison study on different donor nerves (spinal accessory and ulnar) in elbow flexion reconstruction with gracilis flap for traumatic adult brachial plexus injuries. Retrospective analysis of patients with both total or partial traumatic brachial plexus injuries was carried out. Of the 38 patients enrolled, 37 were male (97.4%) with a mean age of 28.3 years. The mean follow-up period was 25 months. Postoperative function of the gracilis muscle flap was recorded and patients were divided into two groups according to donor nerve: spinal accessory nerve (SAN) (18 cases), and motor fascicles of the ulnar (ULNAR) (20 cases). Twenty-six cases obtained elbow flexion strength M3 or M4 (68.4%): 0 M0 (0.0%), 4 M1 (10.5%), 8 M2 (21.1%), 9 M3 (23.7%) and 17 M4 (44.7%). The mean interval to first recorded M3 muscular strength was 12.4 months. Functional elbow flexion strength (≥ M3) had the following distribution: SAN 83.3% (15/18) and ULNAR 55.0% (11/20) (p = .086). No statistical difference for final muscle strength was found between donor nerve groups.

Outcomes of Elbow Flexion Reconstruction in Patients Older than 50 with Traumatic Brachial Plexus Injury.

There is controversy regarding the effectiveness of brachial plexus reconstruction for elbow function in older patients, as reported outcomes are generally poor. The purpose of this study was to evaluate elbow function outcomes in patients older than 50. Fifty-eight patients older than 50 years underwent nerve grafting, transfers, or free functioning muscle transfer to improve elbow function after traumatic brachial plexus injury. Patients were evaluated preoperatively and postoperatively for elbow flexion strength and range of motion; Disabilities of the Arm, Shoulder and Hand scores; pain; concomitant trauma; severity of trauma; and type of reconstruction. The average age of the patients was 57.8 years, and the average follow-up was 24.0 months. The average modified British Medical Research Council elbow flexion grade improved significantly from 0.26 to 2.63. Thirty-three patients (60 percent) achieved functional flexion greater than or equal to M3 postoperatively, compared to zero patients preoperatively. There was no correlation between age and modified British Medical Research Council grade. Active elbow range of motion improved significantly postoperatively, with no effect of age on flexion motion. More patients achieved greater than or equal to M3 flexion with nerve transfers (69 percent) compared to free functioning muscle transfer (43 percent). Patients had worse outcomes with high-energy injuries. The mean Disabilities of the Arm, Shoulder and Hand score decreased from 51.5 to 49.6 postoperatively, and the average pain score decreased from 5.0 to 4.3. Brachial plexus reconstruction for elbow function in patients older than 50 can yield useful flexion. Therapeutic, IV.

Free Reverse Gracilis Muscle Combined With Steindler Flexorplasty for Elbow Flexion Reconstruction After Failed Primary Repair of Extended Upper-Type Paralysis of the Brachial Plexus

To report the clinical outcomes of elbow flexion reconstruction using a reverse free gracilis muscle flap plus Steindler flexorplasty in patients with previously failed reconstruction of extended upper-type brachial plexus paralysis. Twenty-four male patients were reoperated upon an average of 45 months (SD, ± 45 months) after brachial plexus repair. The gracilis tendon was secured to the acromion, and the muscle belly was sutured to the biceps distal tendon. Vascular repair was performed preferentially end to end to the radial artery and cephalic vein. Nerve repair was achieved by coapting the nerve to the gracilis to motor fascicles of the median or ulnar nerve. The medial epicondyle was osteotomized, proximally advanced by 4 to 5 cm and secured to the anterior side of the humerus. Active elbow flexion was restored in 23 of 24 patients. Sixteen patients ultimately achieved M4 strength, among whom 6 had full range of motion (ROM), and the remaining 10 recovered an average of 110° (95% confidence interval [95% CI], 100°-120°) of elbow flexion. Seven patients exhibited M3 elbow flexion strength recovery, which was associated with weaker hands and incomplete ROM, averaging 94° (95% CI, 86°-102°). There was, on average, a 10° (95% CI, 4.4°-15.6°). elbow flexion contracture. Among the 16 patients with M4 level recovery of elbow flexion, supination was partially restored in12. In patients previously operated upon, using a reversed free gracilis muscle flap in association with a Steindler procedure is effective as salvage surgery to restore elbow flexion and partial supination. Therapeutic IV.

A newly developed upper limb single-joint HAL in a patient with elbow flexion reconstruction after traumatic brachial plexus injury: A case report

Abstract We report a case in which elbow flexion exercises using the upper limb single-joint Hybrid Assistive Limb (upper limb HAL-SJ) were implemented in a patient 13 months postoperatively following elbow flexion reconstruction with intercostal nerve transfer after a traumatic brachial plexus injury. Treatment using the upper limb HAL-SJ was administered once a week for 10 sessions from 13 to 16 months after surgery. Exercises using the upper limb HAL-SJ supported elbow motion by detecting bioelectric signals through surface electrodes on the biceps and triceps brachii. No adverse events were observed during treatment with the upper limb HAL-SJ. Improvements in elbow flexion strength were observed during treatment. Treatment with the upper limb HAL-SJ can be performed safely and effectively following elbow flexion reconstruction by intercostal nerve transfer after a traumatic brachial plexus injury.

Free Functioning Gracilis Muscle Transfer for Elbow Flexion Reconstruction after Traumatic Adult Brachial Pan-Plexus Injury: Where Is the Optimal Distal Tendon Attachment for Elbow Flexion?

Reconstruction after pan-plexus root avulsions often includes gracilis free functioning muscle transfer. For elbow flexion reconstruction, the free functioning muscle transfer distal tendon is inserted into the biceps tendon or more distally (i.e., flexor digitorum profundus/flexor pollicis longus tendons) for combined elbow and finger flexion; the theoretical drawback of the latter approach is weaker elbow flexion. The authors compared elbow flexion strength with a biceps tendon versus a flexor digitorum profundus/flexor pollicis longus tendon attachment to determine which insertion point resulted in better elbow flexion. Thirty-nine patients underwent free functioning muscle transfer with either a biceps tendon or a distal attachment. Groups were compared on postoperative elbow flexion strength, preoperative and postoperative Disabilities of the Arm, Shoulder, and Hand questionnaire scores, range of motion, and other surgical and demographic characteristics. A biomechanical analysis simulating different tendon attachments determined which reconstruction resulted in optimal elbow flexion mechanics. Distal tendon attachment was associated with M3 or M4 elbow flexion and greater range of motion compared with the biceps tendon attachment (p < 0.05). There were no statistically significant improvements in Disabilities of the Arm, Shoulder, and Hand questionnaire scores. Biomechanical analysis demonstrated that all distal tendon attachments studied generated a 15 to 30 percent greater torque compared with the biceps tendon attachment; this was true for attachments either at the flexor digitorum profundus/flexor pollicis longus tendon, or directly at the radius at 10 cm or 15 cm from the elbow axis of rotation. The flexor digitorum profundus/flexor pollicis longus tendon attachment of the gracilis free functioning muscle transfer distal tendon was superior in achieving elbow flexion strength. Patients with only elbow flexion reconstruction may also benefit from a flexor digitorum profundus/flexor pollicis longus tendon attachment or from a more distal attachment to the radius. Therapeutic, III.

Single-stage Reconstruction of Elbow Flexion Associated with Massive Soft-Tissue Defect Using the Latissimus Dorsi Muscle Bipolar Rotational Transfer.

Our data base was queried for all patients undergoing a rotational latissimus dorsi muscle transfer for simultaneous soft-tissue coverage and functional reconstruction of elbow flexion. Four patients were identified. A chart review documented the mechanism of injury, associated injuries, soft-tissue defect size, number of surgical procedures, length of follow-up, last elbow range of motion, and flexion strength. Four patients with loss of elbow flexion due to traumatic loss of the anterior compartment muscles and the overlying soft tissue underwent simultaneous soft-tissue coverage and elbow flexorplasty using the ipsilateral latissimus dorsi as a bipolar muscle rotational tissue transfer. All flaps survived and had a recovery of Medical Research Council Grade 4/5 elbow flexion strength. No additional procedures were required for elbow flexion. The surgical technique is described and supplemented with surgical technique video and patient outcome. This patient series augments the data provided in other series supporting the safety and efficacy of this procedure which provides both soft-tissue coverage and functional restoration of elbow flexion as a single-stage procedure in the setting of massive traumatic soft-tissue loss of the arm.

Elbow Flexion Reconstruction by End-to-Side Neurorrhaphy in Phrenic Nerve Transfer

Purpose: Phrenic nerve transfer (PNT) has proven to be an effective approach for the treatment of brachial plexus avulsion injuries (BPAI). But there have been major concerns about the possibility of deterioration of the pulmonary and diaphragm functions after PNT. In the current study, we performed end-to-side neurorrhaphy in PNT for BPAI patients while minimizing the potential damage to the diaphragm function. We prospectively assessed the efficacy of end-to-side neurorrhaphy for PNT in reconstructing the elbow flexion by regenerating the anterior division of the upper trunk (ADUT) or the musculocutaneous nerve (McN) in a series of 5 patients. Methods: From January to June 2008, 5 patients with BPAI underwent PNT with an end-to-side fashion, to regenerate the ADUT (3 patients) or the McN (2 patients). The operative delay after injury was from 1 to 6 months (mean, 2.5 months). The follow-up duration was 24 months. The regeneration outcomes of ADUT or McN were evaluated with an electromyography (EMG) test. The recovery of elbow flexion power was recorded according to the British Medical Research Council (MRC) grading system. Pulmonary function tests (PFTs) were used to assess the respiratory function. Chest fluoroscopy and phrenic nerve conduction studies were performed in the evaluation of phrenic nerve and diaphragm functions. Results: At the final visits after 2 years, all patients regained various degrees of biceps strength (M4 in 2 patients, M3 in 1 patient, M2 in 1 patient, and M1 in 1 patient). At 24 months after surgery, the average prolongation of latency of PN was 2.88 seconds, and the average decrease in amplitude from before the operation was 32.4%. The diaphragm function and PFTs were normal in all patients. Conclusions: PNT with end-to-side neurorrhaphy could provide functional biceps recovery in a majority of patients, with preservation of donor nerve function.

Expression of MuRF1 and MAFbx in Donor and Recipient Muscles after Musculocutaneous Nerve Transection and Partial Pectoralis Major Muscle Transfer for Reconstruction of Elbow Flexion in Rats

La expresion de MuRF1 y MAFbx en un musculo denervado ha sido estudiada previamente. Sin embargo, la expresion de MuRF1 y MAFbx en los musculos receptores y donantes despues de la transferencia del musculo para la reconstruccion de la funcion articular no se ha investigado lo suficiente. Cuarenta y dos ratas adultas Sprague-Dawley fueron divididas en 7 grupos: normales, 1 semana post-, 2 semanas post- y 4 semanas post-transeccion del nervio musculocutaneo; y 1 semana post-, 2 semanas post-, y 4 semanas post-reconstruccion de la flexion del codo. Se evaluo el peso de los musculos humedos, y las expresiones de MuRF1 y MAFbx mRNA fueron detectadas a traves de reaccion en cadena de la polimerasa. La longitud de la parte oblicua del musculo pectoral mayor de una rata Sprague-Dawley es suficiente para realizar la sutura en la insercion del tendon de musculo biceps braquial. El peso humedo del musculo biceps braquial y su tasa de retencion siguieron disminuyendo despues de la seccion del nervio musculocutaneo y un aumento gradual se observo despues de la transferencia de la parte oblicua del musculo pectoral mayor para la reconstruccion de la flexion del codo. La parte oblicua del musculo pectoral mayor mostro una disminucion de solo 2-6%. La expresion regulada por incremento de MuRF1 y MAFbx en el biceps braquial alcanzo un peak 2 semanas despues de la denervacion y 1 semana despues de la reconstruccion de la flexion del codo, con un incremento del 15% y el 4%, respectivamente. Esto fue seguido por un regulacion en baja. Sin embargo, la expresion no se normalizo en el postoperatorio de las 4 semanas. El aumento de la expresion de MuRF1 (17%) y MAFbx (1%) en la parte oblicua del musculo pectoral fue mayor en el postoperatorio de 1 semana, mientras que se encontro por debajo de los niveles normales en el postoperatorio de 4 semanas. La transferencia de la parte oblicua del musculo pectoral mayor para la reconstruccion de la flexion del codo despues de la seccion del nervio musculocutaneo puede regular a la baja la expresion de MuRF1 y MAFbx en el musculo receptor y provocar solo un dano transitorio en el musculo donado en ratas.

Lesiones altas del plexo braquial. Reconstrucción con técnicas combinadas de neurotización e injertos nerviosos.

&lt;p&gt;Las lesiones altas del plexo braquial son reconstruidas con neurotización e injerto nervioso. El nervio espinal accesorio, la raíz C7, ramas del tríceps, y el nervio mediano y cubital son los más usados para transferencias.&lt;/p&gt;&lt;p&gt;Se muestra la experiencia con neurotización de la rama inferior del nervio espinal accesorio (NEA) al nervio supraescapular (NSE), transferencia nerviosa de fascículos del nervio cubital o del mediano, y en ocasiones injertos nervioso hacia el nervio musculocutáneo y al tronco posterior, y reconstrucción del nervio axilar en algunos casos.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Materiales y métodos&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;Se revisan 42 pacientes con lesiones altas de plexo braquial, operados mediante combinación de neurotización e injertos nerviosos. Seguimiento mínimo de 15 meses.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Resultados &lt;/strong&gt;&lt;/p&gt;&lt;p&gt;40 pacientes fueron por accidente en moto. En 22 se transfirió únicamente el NSE con el NEA, recuperando abducción de hombro de 33º En 8 pacientes que se combinó con reparación del axilar, mejoró la abducción a 81º.&lt;/p&gt;&lt;p&gt;En 30 pacientes con neurotización del nervio cubital o mediano para el bíceps, se obtuvo respuesta entre 3 y 4 meses. Al final flexión del codo de 116º y M4.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Discusión&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;Los mejores resultados en hombro fueron con la combinación de NSE y del nervio axilar, logrando 81º de abducción. La rotación externa mejoro en 28.5% de los pacientes, siendo una respuesta tardía&lt;/p&gt;&lt;p&gt;La neurotización del bíceps con fascículos del cubital consiguió una flexión de 116º, muy comparable con otras series. Hoy esta técnica es el &lt;em&gt;gold estándar&lt;/em&gt; para la reconstrucción de flexión del codo. &lt;/p&gt;