Elbow flexion restoration using pedicled latissimus dorsi transfer in seven cases

Abstract

Purpose

The aim of this study is to analyse the results of a series of pedicled latissimus dorsi transfers to restore elbow flexion. Moreover, we describe a new technique of distal fixation of the muscle to the proximal third of the ulnar diaphysis to increase the lever arm and improve strength.

Methods

We retrospectively reviewed seven patients aged from 18 to 49 years. Elbow flexion paralysis was secondary to destruction of the anterior arm compartment in four cases and to brachial plexus palsy in three cases. The humeral insertion of the latissimus dorsi was relocated on the coracoid process in five cases and not relocated in two cases. The patients were assessed using the Medical Research Council grading system, the maximum weight lifted by the wrist and the active elbow range of motion.

Results

At the last follow-up (mean 26.6 months), five patients recovered M4 elbow flexion strength (0.5 to 8 kg), one patient recovered M3 strength and the last transfer failed because of triceps brachii co-contractions. The mean active elbow flexion was 91° (range, 45 to 130°). Patients with destruction of the anterior arm compartment and particularly whose forearm was not paralyzed had better strength than patients with a brachial plexus palsy (3.25 versus 1 kg). A skin island with the latissimus dorsi muscle flap was particularly useful in case of arm soft tissue defect.

Discussion

A destroyed anterior compartment of the arm is a good indication for latissimus dorsi transfer to restore elbow flexion. The muscle is usually too weak in high brachial plexus palsy. Finally, the latissimus dorsi needs an objective, reproducible and reliable preoperative evaluation.

Level of evidence

Level IV.

Résumé

Objectif

Le but de l’étude était d’analyser les résultats d’une série de transferts pédiculés du latissimus dorsi pour restaurer la flexion du coude. De plus, nous décrivons une nouvelle technique de fixation distale du muscle au tiers supérieur de la diaphyse ulnaire afin d’augmenter le bras de levier ainsi que la force développée.

Méthodes

Nous avons revu rétrospectivement sept patients âgés de 18 à 49 ans. La paralysie de flexion du coude était secondaire à une destruction de la loge antérieure du bras dans quatre cas et à une paralysie du plexus brachial dans trois cas. L’insertion humérale du latissimus dorsi était transférée sur la coracoïde dans cinq cas, et laissée en place dans deux cas. L’évaluation des patients a porté sur la force de flexion du coude mesurée selon le score Medical Research Council, sur le poids maximum soulevé au poignet et sur les mobilités actives du coude.

Résultats

Au recul moyen de 26,6 mois, cinq patients ont récupéré une force de flexion du coude de grade M4 (0,5 à 8 kg), un patient a récupéré une flexion de grade M3 et le dernier transfert a échoué du fait de co-contractions du triceps brachial. La flexion active moyenne du coude était de 91° (de 45° à 130°). Les patients ayant eu une destruction de la loge antérieure du bras, et particulièrement ceux dont l’avant-bras n’était pas paralysé avaient une force plus importante que ceux ayant une paralysie plexique (3,25 versus 1 kg). Une palette cutanée combinée au muscle était utile en cas de perte de substance associée des parties molles du bras.

Discussion

La destruction de la loge antérieure du bras est une bonne indication au transfert de latissimus dorsi pour réanimer la flexion du coude. Le muscle est régulièrement trop faible dans les paralysies plexiques hautes. Enfin, nous ne disposons pas pour l’instant de procédé d’évaluation préopératoire objectif, fiable et reproductible du latissimus dorsi.

Niveau de preuve

IV.

Introduction

Flexion of the elbow is a vital function in daily living particularly for bringing the hand to the mouth and dressing oneself. Biceps brachii and brachialis muscles are the primary elbow flexors. Elbow flexion insufficiency is caused by either paralysis of the flexor muscles (by brachial plexus palsy or historically, poliomyelitis) or by destruction of the muscles (by trauma, infection or after tumour resection). Furthermore, the terminal vascularisation pattern of biceps brachii and brachial muscles makes them vulnerable to ischemic necrosis.

One of the most important aims in brachial plexus surgery is recovery of active elbow flexion, obtained by neurotisations or nerve grafts [1]. In cases of nerve surgery failure or impossibility, palliative transfers are used. Several transfers have been described: medial epitrochlear muscles transposition by Steindler, pectoralis major transfer, triceps brachii transfer, sternocleidomastoid transfer, and free muscle transfers like gracilis.

Following the use of latissimus dorsi transfer to restore elbow extension [2], elbow flexion transfer was developed by Schottstaedt et al. [3] and Hovnanian [4] without relocation of the humeral insertion. Zancolli and Mitre [5] described the bipolar technique that is presently most commonly employed.

The latissimus dorsi muscle is a wide flat muscle extending from dorsal and lumbosacral regions to the humeral shaft. It is triangular in shape, with its base at the spine and the apex at the axilla. Its blood supply comes from the thoracodorsal artery, a branch of the subscapular artery. The thoracodorsal nerve (roots C5 C6 C7) is responsible for the innervation of the muscle. It participates in arm adduction, retropulsion and internal rotation, but functional donor site morbidity is minimal except in patients participating in sports or paraplegics [6].

We present a series of seven patients with paralysis of elbow flexion who had a pedicled latissimus dorsi transfer. Moreover, we describe a new technique of distal fixation to the ulna.