Abstract
Background: Recent interest in reconstruction
of the upper limb following brachial plexus injuries has focused
on the restoration of prehension following complete avulsion of
the brachial plexus.
Methods: Double free muscle transfer was performed
in patients who had complete avulsion of the brachial plexus. After
initial exploration of the brachial plexus and (if possible) repair
of the fifth cervical nerve root, the first free muscle, used to
restore elbow flexion and finger extension, is transferred and reinnervated
by the spinal accessory nerve. The second free muscle, transferred
to restore finger flexion, is reinnervated by the fifth and sixth intercostal
nerves. The motor branch of the triceps brachii is reinnervated
by the third and fourth intercostal nerves to restore elbow extension.
Hand sensibility is restored by suturing of the sensory rami of
the intercostal nerves to the median nerve or the ulnar nerve component
of the medial cord. Secondary reconstructive procedures, such as
arthrodesis of the carpometacarpal joint of the thumb, shoulder
arthrodesis, and tenolysis of the transferred muscle and the distal
tendons, may be required to improve the functional outcome.
Results: The early results were evaluated in
thirty-two patients who had had reconstruction with use of the double
free muscle procedure. Twenty-six of these patients were followed
for at least twenty-four months (mean duration, thirty-nine months)
after the second free muscle transfer, and they were assessed with
regard to the long-term outcome as well. Satisfactory (excellent
or good) elbow flexion was restored in twenty-five (96 percent)
of the twenty-six patients and satisfactory prehension (more than
30 degrees of total active motion of the fingers), in seventeen
(65 percent). Fourteen patients (54 percent) could position the
hand in space, negating simultaneous flexion of the elbow, while
moving the fingers at least 30 degrees and could use the reconstructed
hand for activities requiring the use of two hands, such as holding
a bottle while opening a cap and lifting a heavy object. The results
were analyzed to identify factors affecting the outcome.
Conclusions: The double free muscle procedure
can provide reliable and useful prehensile function for patients with
complete avulsion of the brachial plexus.
The restoration of prehension following complete avulsion of
the brachial plexus has been the focus of recent interest in reconstruction
of the upper limb following brachial plexus injuries. Transfer of
the intercostal nerves to the median nerve to restore finger function15,20 has failed because the distance
between the site of nerve anastomosis and the neuromuscular junction of
the forearm muscles is too great; it took more than one and a half
to two years after the nerve transfer for the regenerating axons
to reach the muscle, resulting in muscular atrophy. Furthermore,
misdirection of the regenerating axons frequently occurred. Hence,
simple nerve transfer should not be attempted to restore finger
function following brachial plexus injury, but it can be used to
achieve shoulder stability and active elbow flexion17.
Free muscle transfer can provide reliable and powerful motor
recovery for finger function, as the neuromotor units of the free
muscle are in the upper arm and the nerve to the muscle is purely
motor5. Following brachial plexus
injury, free muscle transfer combined with multiple transfers of
the spinal accessory nerve and the intercostal nerves can be used
to restore prehensile function.
Akasaka et al.1 and Berger
et al.2 restored wrist extension
with use of free muscle transfers reinnervated with intercostal
nerves and restored pinch with use of tenodesis of the finger flexors15,19. However, the weak key pinch
that was achieved was not useful, and the synergistic action16 was troublesome and inconvenient
for patients with a brachial plexus injury who had a normal contralateral
upper limb. Furthermore, those authors did not restore elbow extension
and their patients had to use the contralateral hand for positioning
the hand in space while moving the fingers.
One of us (K. D.) and colleagues6,7,9 reported
the interim results of double free muscle and multiple nerve transfers
(the so-called double free muscle technique) to restore prehension.
Although the powerful grip that was achieved was associated with
clawing of the fingers, grip, together with good prehension, are
the most essential and useful functions for such patients. In the current
report, we describe the long-term results of the double free muscle
technique that was originally described by one of us (K. D.) and
colleagues and was subsequently modified6,7,9.
Patients
The results in a consecutive series of patients who had undergone
the double free muscle transfer procedure for the restoration of
prehension following complete avulsion of the brachial plexus between
August 1, 1990, and October 31, 1996, were reviewed retrospectively.
The patients had given informed consent after discussions concerning
the procedure, the rehabilitation program, and the prognosis before
the initial operation.
There were thirty-two patients, thirty of whom were male and
two of whom were female (Table I). At the time of the operation,
the patients' ages ranged from fifteen to forty-five years (mean, twenty-two
years). Three patients had had an unsuccessful intercostal-to-musculocutaneous
nerve transfer done by other surgeons. Two patients had had an injury
of the subclavian artery, which had been repaired but the artery
had become thrombosed. One patient had had an associated spinal cord
and spinal accessory nerve injury on the ipsilateral side but had
recovered by the time of the operation. The interval between the
injury and the first free muscle transfer ranged from two to 113 months
(mean, 8.8 months).
Myelography was performed preoperatively with use of metrizamide
(Amipaque). During the operation, the brachial plexus was exposed
and the involved root was identified and electrically stimulated.
The spinal evoked potentials were recorded from an epidural electrode,
which was placed preoperatively, to assess the quality of the continuity
of the root with the spinal cord.
Myelography and intraoperative monitoring of spinal evoked potentials
established that nine patients had a postganglionic rupture of the
fifth cervical nerve root and a preganglionic avulsion of the sixth
cervical to the first thoracic nerve root. The remaining seventeen
patients were classified as having a complete preganglionic avulsion
of the fifth cervical to the first thoracic nerve root, although
five showed low but positive spinal evoked potential waves.
Operative Procedures
The double free muscle technique described previously by one
of us (K. D.) and colleagues6,7,9 consisted
of five established but modified reconstructive procedures (Fig. 1): (1) surgical
exploration of the brachial plexus, intraoperative monitoring of
the spinal evoked potentials, and repair of the disrupted motor
nerves when possible; (2) the first free muscle transfer, neurotized
by the spinal accessory nerve, to restore elbow flexion and finger
extension (Fig. 2);
(3) the second free muscle transfer, neurotized by the fifth and
sixth intercostal nerves, to restore finger flexion (Fig. 3); (4) transfer
of the third and fourth intercostal nerves to the motor branch of
the triceps brachii muscle (done concomitantly with the second muscle
transfer), to restore elbow extension (Fig. 4); and (5) transfer of the supraclavicular
nerves or the intercostal sensory rami to the median nerve or the
ulnar nerve component of the medial cord of the brachial plexus
(done concomitantly with the second muscle transfer), to restore
hand sensibility. All thirty-two patients had the first three procedures,
twenty-eight patients also had the fourth procedure, and twenty-six
patients also had the fifth procedure.
Eight patients with a normal amplitude of the fifth cervical
nerve root identified on spinal evoked potential monitoring at the
first operation, three with a low amplitude, and one patient who
had no amplitude underwent repair of the fifth cervical nerve root
to the suprascapular nerve, the axillary nerve, the musculocutaneous
nerve, or the posterior cord individually with use of a sural nerve
graft. In two patients, the thrombosed subclavian artery that was
diagnosed on the preoperative angiogram was repaired with a saphenous
vein graft at the first operation.
For the first free muscle transfer, the gracilis muscle was used
in twenty-seven patients; the contralateral latissimus dorsi muscle,
in four; and the ipsilateral rectus femoris muscle, in one patient.
In six patients, the supraclavicular nerves were anastomosed to
the median nerve component of the lateral cord during the same surgery.
The second free muscle transfer was performed two to six months
following the first procedure. The gracilis muscle was used in twenty-six
patients and the ipsilateral latissimus dorsi, in five. One patient
had a transfer of the ipsilateral rectus femoris muscle. In twenty-eight
patients, the third and fourth intercostal nerves were anastomosed
to the motor branch of the triceps brachii muscle in the axillary
region. In twenty patients, the sensory rami of the intercostal
nerves were anastomosed to the median nerve or the ulnar nerve component
of the medial cord.
Postoperative Management
The upper limb was immobilized without tension on the transferred
muscles, the motor nerves, or the nutrient vessels for four weeks
after each free muscle transfer. Gentle passive exercises for the elbow
and the metacarpophalangeal joints were then started. During the
early postoperative period, a plastic static splint was used to
maintain the wrist in a neutral position and the proximal and distal
interphalangeal joints in extension to allow these joints to stiffen
in these positions.
Following electromyographic documentation of reinnervation of
the transferred muscle, usually performed between three and eight
months postoperatively, electromyographic biofeedback techniques
were started to train the transferred muscles to move the elbow
and fingers. After recovery of active elbow and finger movements,
electromyographic biofeedback to train for independent finger flexion
and extension was commenced. The patients were then started on skilled
activities, such as lifting, holding, carrying, and pinching.
Six patients did not undergo postoperative rehabilitation. The
remaining twenty-six patients had rehabilitation at our hospital
or at other rehabilitation centers at least twice a week for a mean
of twenty months postoperatively, and all twenty-six completed the
rehabilitation program. Patients who were covered by workplace insurance
continued the rehabilitation program for a longer period than did
those who were not covered (mean, thirty-two compared with fourteen months).
Secondary Reconstruction
Tenolysis was done on the first free muscle (finger extensor)
in nine patients and on the second free muscle (finger flexor) in
six (Table II).
Arthrodesis of the glenohumeral joint was done with use of four
large cancellous screws and iliac-crest bone graft in nine patients,
and arthrodesis of the carpometacarpal joint of the thumb was performed
in eight. Three patients had arthrodesis of the proximal and distal
interphalangeal joints with percutaneous Kirschner wires. The reinnervated infraspinatus
muscle was transferred to the triceps brachii in two patients when
the latter muscle failed to recover sufficiently. One patient had
neurolysis of the spinal accessory nerve because reinnervation was
delayed.
Assessment of Results
Early results: All thirty-two patients were
evaluated for survival of the transferred muscles and electromyographic evidence
of reinnervation of the transferred muscles and the triceps brachii
(Table II).
Long-term results: Twenty-six of the thirty-two
patients had long-term evaluation at least twenty-four months after the
second free muscle transfer (Table II and Table III). The parameters that were evaluated
included the strength of the transferred muscles and the triceps brachii,
the range of active motion of the elbow and finger joints, sensory
recovery, the ability to perform activities of daily living, and
restoration of prehension.
Functional Outcome
Motor evaluation: The modified grading system
of Highet4,14 and that of one
of us (K. D.) and colleagues6 were
used to evaluate the results of elbow flexion (Table IV). Elbow-flexion
power of more than grade 5 (according to the modified Highet scale)
was classified as excellent; grade 3 or 4, as good; grade 1 or 2,
as fair; and grade 0, as poor. The final outcome of finger motion
was graded according to the total active motion of the fingers,
with 60 degrees or more classified as excellent; 30 to 55 degrees,
as good; 5 to 25 degrees, as fair; and 0 degrees, as poor. The final
outcome of prehension following double free muscle transfer depends
not only on finger motion but also on more proximal function, such
as elbow flexion and dynamic elbow stability, which were assessed
according to the patient's ability to position the hand in space
while moving the fingers.
Sensory evaluation: Tinel's sign was checked
periodically in all patients, and sensibility in the corresponding
distribution of the repaired nerve in the hand was evaluated. Sensation
of vibration was tested with a tuning fork; pain, with pin-prick;
sensation of moving touch, with cotton wool; and cutaneous pressure
thresholds, with Semmes-Weinstein monofilaments. All tests were
performed by an experienced hand therapist, and the results of sensory recovery
were classified according to the modified Highet scale (Table IV)4,14.
Pain (causalgia): Ten-point visual analog scales
were used to define the severity of pain, with 5 points or less
indicating mild pain and more than 5 points, severe pain.
Functional ability: Functional ability was assessed
with use of patient-based outcome measures, including the weight
of a book that could be held between the arm and the trunk, the
weight of a bag that could be lifted with the forearm, the weight
of a bottle that could be held, the weight of a box that could be
lifted, and the height to which the box could be lifted with use
of a hook grip and with both hands.
Statistical analysis: The paired t test for
paired continuous variables was used. Spearman rank correlations
were calculated for the comparison of two-scaled variables. The
level of significance was set at p < 0.05.
Early Results
Three free muscles had a thrombosis postoperatively (Table II). Two of them
were revised successfully after exploration. Ischemic necrosis developed
in the third muscle, and another free muscle transfer was needed.
All transferred muscles were successfully reinnervated, as detected
electromyographically between three and ten months following the
surgery, depending on the donor motor nerve that had been used.
Muscles that were reinnervated by the spinal accessory nerve recovered
significantly earlier (mean, 3.9 months) than did those that were
reinnervated by the intercostal nerves (mean, 4.8 months) (p < 0.05).
Voluntary contraction occurred approximately two months later on
the average. The triceps brachii muscles recovered even later (mean,
8.2 months) than did the transferred muscles that were reinnervated
by the intercostal nerves (p < 0.001).
Long-Term Results
Twenty-six patients were followed for at least twenty-four months
(maximum, eighty-one months; mean, thirty-nine months) after the
second transfer. The mean age at the time of the operation was twenty-two
years (range, fifteen to forty-five years) (Table I). The mean
interval from the time of the injury to the first operation was
9.8 months (range, two to 113 months).
Elbow Function
Active elbow flexion ranged from 50 to 145 degrees (mean, 112
degrees). The strength of elbow flexion was measured isokinetically
with a computerized dynamometer (KinCom; Chattanooga Group, Hixson,
Tennessee). Peak torque at a slow speed of movement (30 degrees
per second), measured in ten patients, averaged 5.8 ± 2.7 newton-meters (concentric flexion) and 10.2 ± 4.3 newton-meters (eccentric flexion). These values
averaged 14 and 19 percent of those for the contralateral, normal
elbow. According to the modified Highet scale4,14 (Table IV), fourteen
patients (54 percent) had an excellent result; eleven (42 percent),
a good result; and one (4 percent), a fair result. In two patients,
elbow flexion was assisted by the biceps brachii after it had been
successfully reinnervated by the fifth cervical nerve root with
use of nerve graft. There were no significant differences in the
ranges of elbow flexion resulting from the different combinations
of transferred muscles; the mean flexion for the gracilis-gracilis
combination was 110 degrees, and that for the gracilis-latissimus
dorsi and the gracilis-rectus femoris combinations was 115 degrees.
All twenty-six patients could flex the elbow at least 90 degrees.
The exceptional patient was a forty-five-year-old man who had only
50 degrees of elbow flexion.
Voluntary extension of the elbow was limited by postoperative
contracture. The mean range of elbow extension was -36 degrees (range,
0 to -65 degrees), and the mean power of elbow extension according
to the modified Highet scale was 1.8 (range, 0 to 5). In twenty-one
patients, voluntary extension of the elbow was recovered, but only sixteen
patients could voluntarily position the hand in space, negating
the tendency of elbow flexion while moving the fingers. Two of these
patients achieved this function.
Finger Function
The total active motion of the fingers ranged from 0 to 110 degrees
(mean, 35 degrees). Four patients (15 percent) had an excellent
result; thirteen (50 percent), a good result; four (15 percent),
a fair result; and five (19 percent), a poor result. As mentioned,
sixteen patients could position the hand in space while moving the
fingers. The most powerful finger flexion was obtained with the
elbow in extension when the fingers were not extended (Fig. 5-A and Fig. 5-B). When the
elbow was flexed and the fingers were extended, the power of finger
flexion decreased slightly (Fig. 5-C and Fig. 5-D). In contrast to the elbow, there
were significant differences in the total active ranges of finger
motion resulting from the different combinations of transferred
muscles; the best range of motion was achieved with use of the gracilis-gracilis
combination (mean, 43.6 degrees), whereas the gracilis-latissimus
dorsi and the gracilis-rectus femoris combinations were associated
with a mean of only 15.6 degrees (p < 0.01).
Nine patients who had had a tenolysis of the gracilis to the
finger flexors or extensors had improvement in the total active
motion of the fingers, ranging from 20 to 60 degrees. However, tenolysis of
the latissimus dorsi or the rectus femoris did not improve the range
of active finger motion.
Shoulder Function
Six patients underwent arthrodesis of the glenohumeral joint
because of shoulder instability. Twelve patients could stabilize
the glenohumeral joint and hence did not need an arthrodesis. The latter
patients all had a grade of M2 or better for the triceps brachii
or the infraspinatus muscle, or both. Stability of the glenohumeral
joint can be achieved by the two reinnervated free muscles, the triceps
brachii muscle, or the supraspinatus and infraspinatus muscles.
Eighteen patients achieved a mean of 25 degrees of shoulder flexion
and -24 degrees of external rotation. The remaining eight patients
had contracture and mild instability of the glenohumeral joint;
however, they did not want to undergo arthrodesis. Four of these
eight patients achieved shoulder flexion, ranging from 10 to 20 degrees,
and the other four could not move the shoulder.
Shoulder flexion was achieved either with the muscle used for
the first free muscle transfer or, in the patients who had had a
glenohumeral arthrodesis, with the trapezius; external rotation
was achieved either with the recovered triceps brachii or the infraspinatus
muscle or, in the patients who had had an arthrodesis, with the
trapezius or the rhomboid muscles.
Sensory Recovery
The Tinel sign advanced at a mean rate of 1.3 millimeters per
day (range, 0.5 to 2.0 millimeters per day) in twenty-one patients.
In two patients who had intercostal nerve-crossing, the Tinel sign
never progressed beyond the forearm. The mean interval between the
surgery and the initial recovery of sensibility in the palm was
twenty-two months (range, fourteen to thirty-two months).
Limited sensibility in the cutaneous distribution of the repaired
median or ulnar nerve was achieved in twenty-one patients. The recovered
sensibility was the most sensitive in the palm, whereas only five patients
felt sensation in the fingertips. All twenty-one patients had referred
sensibility only to the clavicle or the chest after supraclavicular
or intercostal nerve reconstruction, respectively. Six patients
had double sensation in the cutaneous distribution of both the repaired
nerve of the hand in situ and that of the recipient
sensory nerve.
According to the modified Highet scale4,14,
sensation recovered to S2+ in seven patients, to S2 in nine, and
to S1 in four; in the two remaining patients, there was no recovery
of sensibility (S0). There was no significant difference in the
recovery of sensibility between the supraclavicular nerve and the
intercostal nerve.
Pain
During the follow-up period, sixteen patients had causalgia.
Five of these patients had complained of causalgia preoperatively,
but in the other patients the pain developed during the postoperative
rehabilitation. At the time of the final follow-up examination,
according to the visual analog scales only two patients complained
of moderate pain that interfered with their activities; the other
fourteen patients had mild, intermittent pain, which was relieved
with medication and did not seriously interfere with activities.
The remaining ten patients did not have causalgia at any time.
Ability to Hook or Hold Objects
All twenty-six patients could hold an object such as a book weighing
more than one kilogram between the arm and the trunk with use of
the reinnervated second free muscle and the triceps brachii and
assisted by the rhomboid muscles. All but one patient could lift
an object such as a bag weighing a mean of 4.8 kilograms with the
forearm. No patient had key pinch since the carpometacarpal joint
of the thumb had been immobilized in opposition either with an arthrodesis
or a splint. However, eleven patients were able to grasp a light
object such as a bottle weighing 300 grams. Nineteen patients were
able to lift a bag weighing between 0.5 and five kilograms with a
hook grip and to lift a box weighing two to thirteen kilograms with
use of both hands up to the level of the middle of the thigh (twelve
patients) or to the pubic symphysis (seven patients). These nineteen
patients could use the reconstructed hand well in daily activities
for lifting and carrying light objects with one hand and heavy objects
with both hands (Fig. 5-F. Eleven of these patients also
could hold a bottle with the reconstructed hand while opening its
cap with the contralateral, normal hand (Fig. 5-E).
Prehensile Recovery
A satisfactory (excellent or good) result was obtained in seventeen
(65 percent) of the twenty-six patients, according to our evaluation
system. Fourteen patients (54 percent) could achieve more than 90
degrees of elbow flexion, position the hand in space while moving
the fingers more than 30 degrees voluntarily, and use the reconstructed
hand for two-handed activities such as holding a bottle while opening
a cap and lifting a heavy object. All of these patients were thirty-two
years old or less and had had a short interval (eight months or
less) between the injury and the surgery, a long duration (more
than fifty-five months) of follow-up, and no associated injuries
of the subclavian artery, the spinal accessory nerve, or the spinal
cord.
Donor-Site Sequelae
There were no functional complications related to the donor site,
although some patients complained about the presence of a long scar
that they considered to be cosmetically unacceptable.
The double free muscle procedure after complete avulsion of the
brachial plexus reliably provided prehension involving the basic
grasping function of the hand, as well as voluntary motion and stability
of the shoulder and elbow, in more than half of the twenty-six patients
who had long-term follow-up. Nineteen patients could use the reconstructed hand
for two-handed activities such as holding or lifting an object,
despite having a limited total range of active finger motion.
Fourteen patients with excellent or good prehension had a mean
total range of active finger motion of 52 degrees (range, 30 to
110 degrees). Approximately half of the patients failed to obtain
useful prehension, due mainly to lack of active elbow extension
as well as adhesion of the transferred muscles. However, they achieved
good elbow function. Hence, even though prehension was not achieved,
the elbow flexion that was restored was more reliable than that
achieved with conventional nerve-transfer procedures, which have
yielded a higher grade of elbow flexion than M3 in 80 percent of
patients17.
In the current series, the latissimus dorsi, gracilis, and rectus
femoris muscles were used as donor muscles. The latissimus dorsi
did not provide satisfactory finger function because of adhesion
of the muscle to the pulley system and also because of rupture of
its tendon due to ischemic necrosis of the portion distal to the
pulley. The rectus femoris muscle was also unsatisfactory due to
poor muscle excursion with resulting poor finger function. The gracilis
is the donor muscle of choice.
Tenolysis was indicated when active finger function was not achieved
despite strong contraction of the transferred muscle. Nine finger
extensors and six finger flexors had tenolysis from the proximal musculotendinous
junction to the fingers. However, in four patients with a latissimus
dorsi transfer and in one with a rectus femoris transfer, tenolysis failed
to improve the range of motion postoperatively as there was recurrence
of adhesion. Nine patients who had a gracilis transfer had an improved
range of finger motion, ranging from 20 to 60 degrees, postoperatively.
The spinal accessory nerve and the third to sixth intercostal
nerves were used in our series. There were significant differences
between the two sources of donor nerves with regard to the time that
it took for reinnervation of the transferred muscle (p < 0.05)22; however, the final muscle power
was not significantly different. The phrenic nerve and the contralateral
seventh cervical nerve root also may be used as donor nerves3,11,18,21, but we did not use these
nerves because of the possible risks.
The double free muscle technique utilizes the simultaneous movement
of multiple joints with a limited number of donor motor nerves;
for example, the first free muscle reinnervated by the spinal accessory
nerve works to extend the fingers and flex the elbow simultaneously.
After recovery of the triceps brachii as an antagonist of the elbow flexor,
the patients could position the hand in space while extending the
fingers.
Multiple intercostal nerve-crossing from the ipsilateral side,
such as crossing of the second free muscle with the fifth and sixth
intercostal nerves and crossing of the triceps brachii with the
third and fourth intercostal nerves, might have produced paradoxical
movements, such as simultaneous contraction of the elbow flexor
(the second free muscle transfer) and the elbow extensor (the triceps
brachii). Electromyography with use of multichannel electrodes showed
that the second free muscle and the triceps brachii were contracting
at the same time, although the amplitude of the compound motor-action
potential was different depending on the phase of elbow and finger movement.
However, the second free muscle acted as a supplemental elbow flexor
since it was not placed in the flexion-extension plane of the elbow. The
first free muscle acted as the main elbow flexor. Subsequently,
the patients could flex the elbow to overcome the antagonist.
The most powerful finger flexion was obtained with the elbow
in extension while finger extension was not operative, and the power
of finger flexion decreased slightly when the elbow was flexed.
In nineteen patients, the triceps brachii was reinnervated as
demonstrated electromyographically, but only sixteen patients could
voluntary stabilize the elbow joint when they moved the fingers.
The time until the triceps brachii was reinnervated following nerve-crossing
was longer than the time until reinnervation of the second free
muscle reinnervated by the intercostal nerves. The final power that
was achieved was weaker and the results were less reliable than
those of conventional nerve-crossing to the biceps brachi. This
may be due to the difficulty in identifying the motor fascicles
in the nerve stump and the delay between the time of injury and
the procedure. However, even if the power of the triceps brachii
was weak (M2), it could contribute to stability of the elbow with
the aid of gravity. If reinnervation of the triceps brachii fails,
secondary reconstruction (for example, transfer of the reinnervated
infraspinatus to the triceps brachii) may be an option for restoring elbow
stability8. Two patients obtained
elbow extension powerful enough to negate the simultaneous elbow
flexion while moving the fingers.
Stability of the glenohumeral joint can be achieved by the reinnervated
free muscle, the triceps brachii, and the shoulder-girdle muscles
without arthrodesis. During exploration of the brachial plexus,
if the fifth cervical nerve root is available8 it
should be crossed to the suprascapular nerve with use of nerve-grafting,
not only to improve shoulder function but also to reinnervate paralyzed muscles
for use as possible donor muscles for transfer if the triceps brachii
does not recover. If the glenohumeral joint remains unstable even
after recovery of these muscles, glenohumeral arthrodesis can be
done, although this will limit several activities, such as turning
over during sleep. Care must be taken to prevent fracture of the
proximal part of the humerus; in the current series, one humeral
fracture occurred postoperatively.
Restoration of basic functions such as protective sensation and
position sense is imperative when prehensile function is restored
after irreparable brachial plexus injury. Sixteen patients achieved sensibility
of the hand that was at least S2, had adequate position sense, and
never had a minor injury, such as a burn, in the reconstructed hand. Intercostal
nerve-crossing has been reported to provide a better outcome with
regard to sensory restoration12.
However, in the current series, there were no significant differences
in sensibility between the patients in whom the suprascapular nerve
had been used as the donor nerve and those in whom the intercostal
nerves had been used.
In contrast to series reported in the literature13,19, we had no patients with severe
postoperative causalgia that could not be relieved with the usual analgesics.
Ten patients had never had causalgia. This finding is difficult
to explain, but perhaps these patients had some inborn genetic means
of inhibiting pain. Parry19 noted
that Oriental patients rarely reported pain in association with
traction lesions of the brachial plexus. Sensory restoration with
transfer of the intercostal or supraclavicular nerves to the median or
ulnar nerve might have modulated pathogenesis of the deafferentation
pathway of causalgia, and the patients' high motivation for surgical
reconstruction and rehabilitation might have helped them to tolerate
the pain better.
Postoperatively, fifteen patients returned to their former occupation
or to school and five of them modified their work. Three patients
were employed in a sheltered workshop, and six patients changed
their work following vocational retraining. Two patients were unemployed
despite their ability to return to work. The twenty patients who had
been employed or attending school before the injury were able to
return to work or to school after a mean of twenty-two months (range,
six to fifty months).
Ten patients had an unsatisfactory result. One patient (Case
9), a forty-five-year-old man in whom a previous intercostal nerve-crossing
to the musculocutaneous nerve had failed, ultimately achieved only
50 degrees of elbow flexion and had no prehensile function after
reconstruction with the latissimus dorsi and the gracilis. The first
free muscle, the latissimus dorsi, was successfully reinnervated by
the accessory nerve. The second free muscle, the gracilis, was reinnervated
by the previously crossed third and fourth intercostal nerves, but
it did not ultimately provide prehension or elbow flexion of more
than 90 degrees. Factors that contributed to the poor result were
the patient's age, the use of the latissimus dorsi as the donor
muscle, and the use of intercostal nerves that had been used previously
for nerve-crossing.
Another patient (Case 22), a twenty-three-year-old man, had sustained
an injury of the spinal cord and the ipsilateral accessory nerve
from which he had recovered at the time of the operation. The first free
muscle had subsequent neurotization by the previously paralyzed
spinal accessory nerve because intraoperative biochemical assay
of catecholamine anhydrase showed activity of the donor motor nerve.
Although electromyographic studies showed the muscle to have been
reinnervated successfully, it did not provide useful elbow flexion or
finger flexion strength. The patient was able to flex the elbow
only with the second free muscle. The use of a previously injured
nerve or a transferred nerve should be strictly avoided.
Although an associated major vascular injury was successfully
repaired in two patients, free muscle transfer was difficult in
these patients because of the paucity of donor vessels for anastomoses.
Even when these vessels were present, they usually were injured
or were surrounded by a severely scarred bed. The presence of an
associated subclavian artery injury is a contraindication to the
double free muscle technique.
The presence of elbow stability with a functioning triceps brachii
muscle is imperative in order to obtain satisfactory function. Because
of severe muscular atrophy of the triceps with consequent incomplete
recovery leading to loss of elbow stability, no patient who had
nerve-crossing to the triceps muscle more than one year after the
injury had restoration of useful prehension. It is recommended that
this procedure be performed within eight months following the injury.
To maximize recovery following the double free muscle technique,
patients need to participate in an intensive rehabilitation program,
preferably every day or, at a minimum, twice a week for one year, as
an inpatient for four months and as an outpatient for the next six
months; this should be followed by a home program of rehabilitation
for another year after the patient returns to work. Six patients
in our series could not continue with the rehabilitation program
regularly because of lack of motivation or financial support or
for unknown reasons.
Not all patients who have a complete avulsion of the brachial
plexus are candidates for double free muscle transfer. Suitable
patients are younger than forty years old and have sustained the
injury within the preceding eight months; have no major vessel injury
(for example, of the subclavian or axillary artery); have no injury
or history of surgery involving the donor motor nerve (for example,
the spinal accessory or the intercostal nerves); and are motivated,
and have financial and emotional support, to participate in a prolonged
postoperative rehabilitation program.
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