21: Steindler Flexorplasty

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Procedure 21 Steindler Flexorplasty

Pao-Yuan Lin, Sandeep J. Sebastin, Kevin C. Chung

Indications

image Late presentation of upper trunk brachial plexus palsy (C5-C6; C5-C6-C7) without recovery of elbow flexion.

• Steindler procedure is preferred to a pedicled latissimus dorsi (LD) transfer or free functioning muscle transfer, if the patient has good function of the wrist and finger flexors.
• A pedicled LD transfer or free functioning muscle transfer can be considered if the wrist flexors are weak.
• A pectoralis major–biceps transfer can be considered in patients who have a weak biceps (partial recovery). The pectoralis major cannot replace the function of the biceps but can augment it.

image Arthrogryposis patients lacking elbow flexion.

Examination/Imaging

Clinical Examination

image The patients should have adequate strength in the flexor pronator mass, especially the wrist flexors [flexor carpi radialis (FCR) and flexor carpi ulnaris (FCU)]. This can be assessed by asking the patient to flex the wrist against resistance.

image The patient should have good wrist extension to counteract the possible development of a wrist flexion contracture.

image The patients should have adequate passive flexion of the elbow. If passive flexion of the elbow is limited owing to a tight triceps, then triceps lengthening may be necessary to increase passive range of motion.

Imaging

image Plain radiograph of the elbow should reveal normal elbow articulation.

Surgical Anatomy

image The common flexor-pronator muscles originate from the medial epicondyle. The following muscles are elevated during this procedure: pronator teres, FCR, palmaris longus, FCU, and flexor digitorum superficialis (Fig. 21-1). The flexor digitorum profundus is left in situ (see Fig. 21-1).

image The ulnar nerve must be protected during elevation of the flexor-pronator mass. It may be transposed anteriorly in the submuscular plane.

image The medial (ulnar) collateral ligament of the elbow should be protected during elevation of the flexor-pronator mass. It originates at the posterior distal aspect of the medial epicondyle and inserts into the base of the coronoid process of ulna. It is composed of three bands: anterior, posterior, and transverse (Fig. 21-2).

image

FIGURE 21-1

image

FIGURE 21-2

Positioning

image The patient is positioned supine with the affected extremity on a hand table. The procedure is performed under general or regional anesthesia, and a sterile tourniquet is placed as high up the arm as possible.

Exposures

image A 10-cm longitudinal curvilinear incision centered over the medial epicondyle is made (Fig. 21-3).

image A skin flap is elevated while protecting the medial antebrachial cutaneous nerve. After elevation of the skin flap, one will see the flexor-pronator mass attaching to the medial epicondyle (Fig. 21-4).

image The ulnar nerve is protected, and a vessel loop is placed around the nerve for identification and gentle traction (Fig. 21-5).

image Lateral to the flexor-pronator mass, the brachial artery and median nerve are seen entering the arch over the superficialis muscles (Fig. 21-6).

image

FIGURE 21-3

image

FIGURE 21-4

image

FIGURE 21-5

image

FIGURE 21-6

Procedure

Step 1

image The index finger is placed under the flexor-pronator mass to develop an interval plane between the median nerve and the entire flexor-pronator mass (Fig. 21-7). The ulnar head of FCU is dissected from the ulna.

image

FIGURE 21-7

Step 1 Pearls

Passing a finger around the flexor-pronator mass will define the dissection plane and make harvesting of the osteomuscular flap easier (see Fig. 21-7).

Step 1 Pitfalls

One must be careful to preserve the small nerve branches from the median nerve and ulnar nerve that innervate the flexor muscles.

Step 2

image An osteotome is used to elevate the common pronator-flexor origin along with a segment of bone measuring about 2 × 2 × 1 cm (Fig. 21-8).

image

FIGURE 21-8

Step 2 Pitfalls

The ulnar collateral ligament of the elbow must be protected while performing the osteotomy of the medial epicondyle.

Step 3

image The common flexor-pronator origin is separated from the anterior surface of the joint.

Step 3 Pitfalls

The ulnar nerve must be fully mobilized before elevation of the flexor-pronator mass to prevent traction and injury to the nerve (Fig. 21-9).

image

FIGURE 21-9

Step 4

image A cortical window is developed between the biceps and brachialis muscles to provide a bone attachment site for the osteotomized medial epicondyle. The fixation site of the new common pronator-flexor origin is about 5 to 7 cm proximal on the humerus, creating 130 degrees of elbow flexion.

Step 4 Pearls

• A bur is used to core out a trough on the humerus so that the medial epicondyle can be seated within the trough (Fig. 21-10).

image

FIGURE 21-10

Step 5

image The medial epicondyle can be provisionally fixed to the trough created in the distal humerus and secured using a towel clip.

image Secure fixation to the humerus is achieved by passing a 3.5-mm cortical screw over a washer through the medial epicondyle. A 2.5-mm drill bit and a 3.5-mm tap are used for this purpose (Fig. 21-11).

image After securing the bone, the ulnar nerve is then transposed anteriorly under the flexor-pronator mass. The muscle is then closed over the native medial epicondyle using 2-0 Vicryl sutures.

image

FIGURE 21-11

Step 5 Pitfalls

• The median nerve and brachial artery should be inspected carefully after fixation to ensure that there is compression, or entrapment.

Postoperative Care and Expected Outcomes

image The elbow is splinted at 90 degrees for 6 weeks to allow fusion of the osteotomized medial epicondyle to the humerus. After 2 weeks, the sutures are removed, and a thermoplastic splint is made to immobilize the elbow at 90 degrees of flexion for another 4 weeks. During the first 6 weeks, the patient should move the fingers to prevent contracture. After 6 weeks, the patient is started on gentle gravity-assisted extension of the elbow while initiating elbow flexion exercises. After 12 weeks, resisted flexion is started.

image It is not advisable for the patient to stretch to achieve full extension of the elbow because the purpose of this operation is to achieve sufficient elbow flexion, which is more beneficial to the patients. The patient can be expected to achieve an arc of flexion of 30 to 100 degrees that will reach to the mouth.

Evidence

Chen WS. Restoration of elbow flexion by modified Steindler flexorplasty. Int Orthop. 2000;24:43-46.

A retrospective review of eight patients who underwent modified Steindler flexorplasty was conducted. Union between the humerus and transferred bone block was achieved at 3 months. The maximum flexion achieved ranged from 110 to 130 degrees. (Level IV evidence)

Dutton RO, Dawson EG. Elbow flexorplasty: an analysis of long-term results. J Bone Joint Surg [Am]. 1981;63:1064-1069.

A retrospective review of 25 patients who underwent Steindler elbow flexorplasty between 1952 and 1976 was conducted. The mean length of the follow-up was 9.3 years. The mean arc of active flexion after flexorplasty was 95 degrees. The postoperative loss of elbow extension averaged 36 degrees. The mean postoperative active pronation and supination were 79 degrees and 51 degrees, respectively. At final evaluation, 14 patients were judged to have excellent; 6, good; 4, fair; and 1, poor function. (Level IV evidence)

Goldfarb CA, Burke MS, Manske PR, et al. The Steindler flexorplasty for the arthrogrypotic elbow. J Hand Surg [Am]. 2004;29:462-469.

A retrospective review of 17 elbows in 10 patients with an average age of 7 years being treated surgically with the Steindler flexorplasty procedure was conducted. The mean follow-up period was 5 years. All patients obtained active elbow flexion against gravity averaging 85 degrees (range, 30 to 120 degrees); patients were able to lift an average of 1 kg through their entire arc of elbow flexion postoperatively. Subjectively, 9 of the 10 patients were satisfied with the outcome of the surgery. (Level IV evidence)

Liu TK, Yang RS, Sun JS. Long-term results of the Steindler flexorplasty. Clin Orthop Relat Res. 1993;296:104-108.

A retrospective review of 71 consecutive patients who were treated with a modified Steindler flexorplasty from 1970 to 1987 was conducted. The average clinical follow-up was 8.2 years. The outcome was excellent in 32%, good in 47%, fair in 13%, and poor in 8%. The mean arc of active elbow flexion was 114 degrees; the average elbow extension loss, 28 degrees; the mean active pronation, 74 degrees; and supination, 30 degrees, postoperatively. (Level IV evidence)

Monreal R. Steindler flexorplasty to restore elbow flexion in C5-C6-C7 brachial plexus palsy type. J Brachial Plex Peripher Nerve Inj. 2007;2:15.

A retrospective follow-up study of 12 patients who had undergone surgical reconstruction of the flail upper limb by Steindler flexorplasty and wrist arthrodesis to restore elbow flexion was conducted. The etiology of elbow weakness was in all patients brachial plexus palsy (C5-C6-C7 deficit). The average duration of clinical follow-up was 28 months. Eleven patients were found to have very good or good function of the transferred muscles. (Level IV evidence)

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