Reconstruction Of Elbow Flexion Research Articles

Free muscle transplantation combined with intercostal nerve crossing for reconstruction of elbow flexion and wrist extension in brachial plexus injuries

Complete paralysis due to traumatic brachial plexus injury is extremely difficult to treat when the injury affects whole nerve roots and when motor function fails to show any signs of recovery. Seddon has suggested that arthrodesis of the shoulder and amputation at the humerus, combined with the use of a functional upper extremity prosthesis, was the most practical procedure available. Since 1965, in cases of irreparable lesions such as complete root avulsion type injuries, we have performed direct intercostal nerve crossing to the musculocutaneous nerve without free nerve graft to achieve elbow flexion. However, it is necessary to operate on the patient within 6 months following the injury to obtain good results. In the past there was no procedure for dealing with delayed cases of complete brachial plexus palsy. However, with the advent of microsurgical techniques, new approaches have become open to us. Since 1978, we have reconstructed the elbow flexor by the combined surgery of free muscle transplantation with intercostal nerve crossing in delayed cases of complete paralysis. This article introduces the operative technique and the results we have obtained.

Latissimus dorsi myocutaneous flap for breast reconstruction

THE ideal breast reconstruction following mastectomy should: be a one-stage procedure; restore deficient skin; replace the contour of the absent pectoralis major muscle; restore lost breast volume; replace the absent nipple-areolar complex; and match in a symmetrical and pleasing way the contour of the remaining breast. We believe that the first 3 of these objectives can be achieved in many patients by the use of a myocutaneous flap incorporating the latissimus dorsi muscle. The latissimus dorsi myocutaneous flap was first reported for chest wall reconstruction by d’Este (1912). It was used as a superiorly based flap of skin and muscle having its pedicle base in the axilla. The flap was used at the time of radical mastectomy to cover the remaining defect. David (1949) and Campbell (1950) used a superiorly based latissimus dorsi muscle flap to reconstruct extensive chest wall defects. The latissimus dorsi muscle has also been used for the reconstruction of elbow flexion and extension (Schottstaedt, 1955; zancolli, 1973). DesPrez (1971) included the latissimus dorsi in bilateral bipedicle flaps for the closure of a defect secondary to a myelomeningocele. Olivari (1976) reported using a latissimus dorsi myocutaneous flap for the reconstruction of a chest wall defect. His technique was almost identical to that used by d’Este. Increased understanding of the blood supply of the skin overlying muscle as discussed by Daniel and Williams (1973) has further widened the range of myocutaneous flaps. Orticochea (1972) and McGraw (1976) took advantage of the vascular interconnection of skin and muscle in using the gracilis myocutaneous flap for penile and vaginal reconstruction. Harii (1976) reported the first free myocutaneous flap transfer. He used the gracilis muscle and its overlying skin based on the superior vascular pedicle of the muscle, which receives its arterial blood supply from the profunda femoris artery, thus further demonstrating that the skin can survive on the muscular perforators. Blood is supplied to the latissimus dorsi muscle by the thoracodorsal artery which is the terminal branch of the subscapular artery. The muscle is innervated by the thoracodorsal nerve, a branch of the posterior cord of the brachial plexus (Fig. I). The entire muscle, based on its neurovascular pedicle, can be mobilised after the division of the muscular origin from the lower 4 ribs, the lower 6 thoracic vertebrae, the lumber vertebrae, the sacral vertebrae, the supraspinal ligament and the posterior crest of the ilium. It can then be transposed to cover defects of the chest wall, the shoulder, the lower neck and the upper arm. An island of skin may be left on the muscle and used as necessary for the reconstruction (Fig. 2). We report the use of such a myocutaneous flap in a 3 I-year-old woman who 4 years previously had a radical mastectomy, including removal of the pectoralis major, for a stage I carcinoma. necrosis and an atrophic scar resulted (Fig. 3).