Unipolar pedicled latissimus dorsi transfer for elbow reanimation in traumatic brachial plexus injuries

Abstract

Background: Brachial plexus injuries are troubling for the patients socially, economically and emotionally. Elbow joint being a large and vital joint needs to be reanimated so that the patient can carry out his routine work and bring the hand to the mouth. Number of procedures have been defined but latissimus dorsi being a large muscle is the muscle of choice for transfer in cases who present late. Bipolar latissimus dorsi transfers have often been reported but unipolar latissimus dorsi transfer has also been described. Authors have studied the unipolar muscle transfer, it’s surgical technique and results.Methods: In this study 18 patients were studied for demographic data, pre- and post-operative flexion of the elbow and the MRC grade of the corresponding movements. Diagnostic work up in the form of nerve conduction velocity, electromyography and magnetic resonance imaging were carried out and evaluated for their significance in traumatic brachial plexus injuries.Results: In this study 13 patients had avulsion of the C5-6 roots on magnetic resonance imaging. The patients presented after a period of 128.83±56.76 days. Substantial time elapsed and ruled out primary brachial plexus reconstruction or nerve transfers. The average elbow flexion improved from 6.67±5.69 degrees (range: 0-20 degrees) to 86.94±12.38 degrees (range: 65-110 degrees) following unipolar latissimus dorsi transfer. 12 patients (66.67%) developed M4 or M4+ power.Conclusions: Unipolar latissimus dorsi muscle transfer is a reliable method and most of the patients develop adequate strength and satisfactory function at the elbow joint.

Unipolar Latissimus Dorsi Transfer for Restoration of Elbow Flexion in Residual Post-traumatic Brachial Plexus Palsy Associated with Distal Humeral Fractures

“…4 5 8 Despite the fact that pedicled functional LD flap could be used for restoration of elbow flexion in different patterns; unipolar, bipolar, muscular, or myocutaneous, few studies have investigated the use of ULDT for such indication. 6 7 The authors preferred to use ULDT due to many reasons; both operating surgeons have long time experience with ULDT for various indications including soft tissue coverage and functional reconstruction of the upper extremity. 9 18 Second, ULDT provides adequate length (up to 6–8 cm distal to the elbow) 18 19 which is optimal for distal attachment to the biceps tendon or aponeurosis.…”

“…On the other hand, all patients with C7 injury, totally stiff elbow, skin contractures, or evident infection were excluded. Although 38 patients were reviewed, only 23 patients were eligible for the study (stiff elbow [6], lost follow-up [9]). All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.…”

“…Patients fulfilling the following inclusion criteria at the time of index surgery were included: (1) inability of active elbow flexion; (2) BPP cases presenting at least 9 months after injury; (3) BPP cases that failed prior exploration and reconstruction with no evidence of clinical or electrophysiological recovery for at least 1 year; (4) intact C7 root at time of reconstruction; (5) stable shoulder (whether initially or secondary to shoulder arthrodesis prior to elbow recon-struction); (6) cases with history of distal humeral fractures that were managed at the time of initial injury or on later stage but prior to ULDT procedure; and (7) minimum followup period of 24 months.…”

“…In those cases, the surgical technique entailed a posterior distal humeral approach to enable the surgeon to achieve intraarticular reduction and fixation (single columnar plating/double plating) with or without supplemental bone grafting (►Fig. 6).…”

“…However, this is limited by the time frame since injury with the possible need of interpositioning nerve grafts. [1][2][3][4][5] In cases of late presenting, neglected or residual UBP palsy after failed primary reconstruction, other reconstructive procedures have been proposed including muscle transfers of either triceps, pectoralis major, sternocleidomastoid, unipolar 6 or bipolar [7][8][9][10] latissimus dorsi (LD), ending with free functioning muscle transfer as the top of the reconstruction ladder. 1 Steindler flexorplasty has been also advocated as a salvage procedure to restore some elbow flexion provided that the forearm wrist and finger flexors are strong enough.…”