Anatomy

The pronator teres arises from two heads. The humeral head originates from the medial supracondylar ridge, the medial intermuscular septum, and the common flexor tendon. The smaller ulnar head arises from the coronoid process of the ulna. The median nerve enters the forearm between the two heads of the pronator teres. The flexor carpi radialis, palmaris longus, and humeral head of the flexor superficialis all originate from the common flexor tendon. The flexor carpi ulnaris arises from two heads: the humeral head originates from the common flexor tendon, and the ulnar head originates along the medial border of the olecranon and posterior border of the upper three fifths of the ulna. Branches originating from the medial surface of the median nerve supply the pronator teres (C6, C7), the flexor carpi radialis (C6, C7), the palmaris longus (C7, C8), and the humeral head of the flexor superficialis (C8 and T1). The flexor carpi ulnaris (C8 and T1) is innervated by two or three branches of the ulnar nerve, the first of which usually leaves the nerve just as it passes between the two heads of the muscle.

Technique (modified from Mayer and Green)

A sandbag is placed under the opposite hip (Fig. 71-4). A tourniquet usually is not used. The incision begins on the anterior aspect of the arm about 7.5 cm above the elbow and swings gently in a medial direction. At the elbow, it runs just posterior to the epicondyle. It then curves anteriorly, following the direction of the pronator teres, ending about 10 cm below the elbow. The ulnar nerve is isolated and freed distally to the branches of the flexor carpi ulnaris. Preserving these motor branches, the surgeon continues the dissection distally for 5 cm. The lacertus fibrosus is divided, and the median nerve is exposed above the elbow and dissected distally, exposing the motor branches (all of which leave the medial aspect of the nerve) to the common flexor-pronator muscle group. The common flexor-pronator muscle origin is then detached with a flake of epicondyle (cartilage in children and bone in adults). The flake of bone or cartilage is then grasped with a clamp, and while traction is exerted in distal and anterior directions, the muscles are stripped from the anterior surface of the joint and from the coronoid process of the ulna. As the ulnar head of the flexor carpi ulnaris is detached from the ulna with an elevator, the assistant puts gentle traction on the median and ulnar nerves, demonstrating the motor twigs that must be carefully avoided. Dissection is continued distally as far as the anatomic distribution of the nerves permits. The common tendon is then transfixed with a modified pull-out suture of No. 1 prolene. The elbow is flexed to 120 degrees, and traction is exerted on the transfer to determine how far above the elbow the transfer will reach. This is usually between 5 and 7.5 cm. The ulnar nerve often seems to have less tension on it if it is transferred anterior to the epicondyle. The atrophic fibers of the brachialis are slit longitudinally, the periosteum is incised, and the anterior humerus is exposed subperiosteally. An opening in the anterior cortex of the humerus nearer to the lateral than to the medial border is made at the point to which the transplant reaches when the elbow is flexed. Two small drill holes are made from anterior to posterior through this cortical window. The prolene suture ends are then threaded through the holes and out through the triceps muscle and skin. To be sure that they are not subjected to undue tension on twisting, the nerves are inspected as the transfer is pulled into the cortical window. The distal portion of the wound is closed, up to the bend in the elbow. The sutured ends are drawn tight with the elbow in maximal flexion and tied over a button under which a thick piece of felt has been placed. Several auxiliary sutures between the periosteum and the transplanted epicondylar tissues are placed, and the wound is closed with a drain.

FIGURE 71-4 Steindler’s flexorplasty.²²¹ A, The incision. B, The ulnar nerve is mobilized proximally and distally, and its motor branches to the flexor carpi ulnaris are identified and protected. C, The common flexor-pronator origin is detached with a flake of medial epicondyle. The motor branches of the median nerve to the flexor-pronator group are identified and protected. D, The detached flexor-pronator group is mobilized distally as far as the motor branches of the medial and ulnar nerves will permit. The brachialis muscle is divided. E, The distal humerus is prepared, and a prolene pull-out suture is used to anchor the transferred muscles to the anterolateral surface of the humerus 5 to 7.5 cm above the elbow.

(After Mayer, L., and Green, W.: Experiences with Steindler flexorplasty of the elbow. J. Bone Joint Surg. 36A:775, 1954.)

A posterior splint is then applied with the elbow in about 120 degrees’ flexion and the forearm in full supination. Four weeks after surgery, the pull-out suture is removed. A removable Orthoplast splint is applied, and active flexion and supination and extension exercises are begun. No special retraining is required because the muscles transferred functioned as an accessory elbow flexor before transfer.⁵⁸ Splinting is discontinued 6 to 8 weeks after surgery, the longer time being necessary for patients with normal triceps function. A dynamic extension splint is often useful if the patient has no triceps function (Fig. 71-5).

FIGURE 71-5 A and B, A dynamic flexion and extension elbow splint. The dynamic extension is particularly useful in patients who have Steindler’s flexorplasty but lack triceps function.

In patients with C5-7 palsy in which the wrist and finger extensors are weakened or paralyzed, the forearm flexor-pronators are strong but the triceps is not available or co-contracts with the biceps, the Steindler procedure should be complemented with wrist arthrodesis.¹⁷² Furthermore, success of the procedure relies on sufficient power of the flexor-pronator muscles.^{76,124,145,146,155,158}

Results

Published results of the Steindler flexorplasty reflect a high degree of success in achieving a functional range of elbow flexion against gravity. Most transfers reported have been performed for poliomyelitis. Steindler achieved 79.5% good results (flexion against gravity of not less than 90 degrees) in 39 cases.²²⁴ Fifteen good results (useful range of flexion with good to fair power) in 27 flexorplasties were reported by Carroll and Gartland.⁴² Using strict criteria for success, including subtracting from the total score for flexion contracture of more than 15 degrees and for supination of less than 45 degrees, Mayer and Green recorded 11 excellent results, five good, four fair, and two poor results among the 22 flexorplasties they followed up (Fig. 71-6).¹⁵⁸ Segal and associates compared the results of 13 Steindler flexorplasties (transplantation of both flexor and extensor origins) and 17 Clark pectoralis major transfers.²¹³ The flexorplasty results were better than the pectoralis transfers, but the average flexion contracture in the flexorplasty group was 60 degrees, whereas it rarely exceeded 15 degrees in the Clark transfer group. Kettelkamp and Larson, evaluating 15 flexorplasties using Mayer and Green’s scoring system, noted eight excellent or good results, six fair results, and one poor one.¹²⁴ They also measured the carry-lift strength (flexion against gravity, plus weight in 1-pound increments) and found that nine of the 14 patients who were able to flex the elbow 110 degrees or more against gravity were able to flex through this range with 1 pound or more. The maximum weight lifted was 6 pounds by one patient.

FIGURE 71-6 A, A 21-year-old man sustained a brachial plexus injury in a motorcycle accident. Steindler’s flexorplasty performed 16 months after injury restored excellent elbow flexion. Subsequent transfer of the flexor carpi ulnaris into the extensor carpi radialis brevis restored wrist extension, and finger and thumb extension were restored using the superficialis muscle of the middle and ring fingers. Shoulder arthrodesis was also performed. B, Fixed flexion deformity of 35 degrees was present after Steindler’s flexorplasty.

Nyholm¹⁸³ reported on 24 patients, six of whom achieved a normal degree of elbow flexion after flexorplasty. Five patients (three who had brachial plexus trauma and two polio) recovered some biceps function, which did not seem to be compromised by the previous flexorplasty. Nyholm noted that all of the patients except two preferred to flex the elbow with the forearm pronated and hand clenched.

Hoffer and Phipps¹¹³ reported on three Steindler flexorplasties in children with obstetric brachial plexus palsies (C5, C6). They achieved flexion strength M4 with 20 to 30 degrees of extension deficit.

One of the largest series of flexorplasties was reported by Lindholm and Einola,¹⁴⁵ who found that 50 of their 61 patients achieved a range of flexion of at least 90 degrees. Eleven were able to lift a weight heavier than 1 kg at right angles. Dutton and Dawson⁷⁶ noted that 20 patients had excellent or good function of the transferred muscles. Eighteen could lift at least 1 to 2 kg through an arc of full elbow motion.

Finally, several investigators have noted the beneficial effect of arthrodesis of the flail shoulder in patients who have had flexorplasties.^{76,124,145,223} Shoulder arthrodesis permits abduction at the scapulothoracic joint that decreases the gravitational forces that must be overcome by the transferred flexor-pronator muscle group. Stabilizing the humerus also maximizes the power of the transfer in preventing backward movement of the elbow, which diminishes the advantage of the flexion contracture by increasing the length of the arc through which the reconstructed flexor muscle must move the weight against gravity.¹²⁴

A retrospective review of 12 patients with C5-7 brachial plexus palsy and extremely weak elbow flexion (M2 or less) were treated by Steindler flexorplasty and wrist arthrodesis. Eleven patients were found to have good or very good outcomes based on the criteria established by Alnot and Abols,⁸ and one patient had mild active flexion of the elbow.¹⁷² These results emphasize that despite recent advances in neurolysis nerve grafting and neurotization procedures, a direct approach to the neurologic lesion can give incomplete results, and for this reason, tendon transfers still play an important role. Chen⁴⁹ reported results in eight patients, in four of whom one or several flexor-pronator tendons had been used in tendon transfer procedures to restore wrist and finger extension. The results after modified Steindler flexorplasty were not negatively affected by these previous procedures.

Liu and associates¹⁴⁶ reported on the largest cohort of 71 patients with a follow-up of 4 to 15 years. The mean range of motion during active flexion against gravity was 114 degrees (range: 80 to 140 degrees). A mean extension lag of 28 degrees (range: 0 to 50 degrees) was created. Fourteen patients (20%) had significant loss of supination, for 11 of whom flexor carpi ulnaris–to–extensor carpi radialis brevis tendon transfers were performed to regain supination. Using Mayer and Green’s scoring system,¹⁵⁸ results were excellent in 32%, good in 47%, fair in 13%, and poor in 8%. A clear improvement was seen over time; the results in operations performed between 1981 and 1987 were significantly better than those performed between 1970 and 1980 (57% versus 16% excellent results). This difference was attributed by the authors to the addition of shoulder arthrodesis as a stabilizing supplementary procedure in 45 cases, and the aforementioned tendon transfers in patients without active supination.

Andrisano⁹ reported on the long-term follow up (3-13 years, average 8.6 years) in 22 patients. These authors found good results in 50%, fair in 19% and poor results in 38%. These results were independent of the etiology of the elbow paralysis and the patient’s age, but were strongly dependent on surgical factors, such as the correct tension and placement of the epitrochlear mass.

Brunelli and coworkers³⁶ have modified the procedure such that during transfer of the flexor carpi ulnaris, flexor carpi radialis, and palmaris longus, they are carefully separated from the flexor digitorum superficialis, which is left in place. Together with placement of the transfer on the anterior aspect of the humerus, the so-called Steindler effect (pronation and simultaneous elbow and finger flexion) could be avoided in 28 of 32 cases.

Complications

The main complications of Steindler’s transfer are pronation and flexion contractures. Pronation contractures are related to (1) preoperative absence of active supination in most of these patients and (2) tightening of the pronator teres as a result of its proximal shift. Inserting the transfer more anteriorly and laterally on the humerus diminishes this tendency, but if no active supination is present, pronation deformity still may be a problem. Segal and associates²¹³ and Nyholm¹⁸³ did not notice any great change in passive supination after Steindler flexorplasty in their patients. Carroll and Gartland⁴² noted that approximately half of the 23 patients who were improved by the flexorplasty had pronation defects. Lindholm and Einola¹⁴⁵ encountered pronation contracture in 17 of 61 patients who had had a flexorplasty, but 14 of them had had no active supination preoperatively. Dutton and Dawson noted an average loss of supination of 39 degrees in the 25 patients on whom they reported.⁷⁶

The strength of the transferred muscles, the duration of immobilization, and the strength of the opposing triceps muscle affect the extent of the flexion contracture. A flexion contracture of the elbow does increase the mechanical advantage of the transferred muscle, and this is especially important in patients who have significant weakness of the transferred muscle group. The degree of fixed flexion contracture of the elbow that is considered acceptable varies a good deal among surgeons. Steindler believed that a 60-degree flexion contracture was acceptable,²²³ and Carroll and Gartland accepted 40 degrees.⁴² Kettlekamp and Larson¹²⁴ observed that, when strength rather than appearance was important (typically for men and patients with severe paralysis of the contralateral arm), flexorplasties are more satisfactory with a flexion contracture between 30 and 60 degrees. Mayer and Green¹⁵⁸ were not satisfied if the flexion contracture exceeded 15 degrees, and they used turnbuckle splints postoperatively to minimize the flexion deformity. Dutton and Dawson⁷⁶ preferred a flexion contracture of 15 to 30 degrees, which allows the arm to “hang at the side” more normally in patients concerned with appearance, and a 30- to 45-degree contracture in patients who were more concerned with function.

Dutton and Dawson⁷⁶ reported transient ulnar nerve paresthesias in two patients. Lindholm and Einola¹⁴⁵ reported on two patients with postoperative ulnar nerve paresthesias, one of whom was still having symptoms at follow-up. Description of the transferred muscle occasionally occurs with variable impact. Steindler reported an excellent result after reinsertion,²²³ whereas Kettelkamp and Larson recorded a poor result in a patient with an untreated description.¹²⁴

Inherent in the Steindler flexorplasty is the increased pronatory effect on the forearm and the associated risk of pronation deformity (Steindler effect). The incidence in the literature varies from 28% to 50%.^42,76,145 Theoretically, inserting the flexor mass more anteriorly and laterally on the humerus will decrease this effect.¹⁴⁶ The flexor carpi ulnaris can be transferred to the flexor carpi radialis⁴⁰ or extensor carpi radialis brevis¹⁴⁶ primarily or secondarily, or the flexor digitorum superficialis origin can be left in place.³⁶

History

Schottstaedt and colleagues²⁰⁷ were the first investigators to report successful restoration of elbow flexion by rotating the entire latissimus dorsi muscle on its neurovascular pedicle, reattaching its insertion to the coracoid and its origin to the distal biceps muscle and tendon. One patient could lift 4 pounds. They noted that the procedure was contraindicated when the latissimus dorsi was the only muscle capable of elevating the pelvis for a forward step. Zancolli and Mitre refined the technique described by Schottstaedt and associates and coined the term bipolar transfer.²⁵⁴ Brones and colleagues³³ reported that the bipolar myocutaneous latissimus dorsi flap restored contour and function in a post-traumatic condition.

Restoration of elbow flexion by transferring only the origin of the latissimus dorsi to the biceps insertion (unipolar transfer) was reported by Hovnanian in 1956.¹¹⁷ He noted that the cross-sectional area, fiber length, and excursion of the latissimus dorsi muscle compared favorably with those of the biceps and brachialis. Axer¹¹ and others modified the unipolar technique by using only the upper third of the latissimus dorsi, transferring its origin off several spinous processes to the biceps tendon. Excursion of 7 cm was obtained by stimulating this part of the muscle. According to these authors, transferring only a portion of the muscle avoids the sometimes bulky enlargement of the arm that results when the whole muscle is used. Preservation of some function in the undisturbed portion of the latissimus dorsi was noted in one of the patients. Botte and Wood²⁸ decided whether to do bipolar or unipolar transfer at the time of surgery. If the line of pull stabilized in the plane of elbow motion and there was no tension on its neurovascular pedicle, the transfer was completed as a unipolar transfer. If the line of pull deviated outside the plane of elbow flexion or there was tension on the neurovascular pedicle, the transfer was converted to a bipolar transfer.

The latissimus muscle flap is widely used as a pedicled muscle flap for restoration of elbow flexion.^{53,55,155,182}

Anatomy

The latissimus dorsi is a broad, thin muscle (Fig. 71-7) with a wide origin from the lower six thoracic vertebrae, from the spinous processes of the lumbar and sacral vertebrae by an aponeurosis from the iliac crest, and by muscle slips from the lower four ribs. It inserts into the medial wall and floor of the intertubercular groove of the humerus. The major vascular pedicle of the muscle is the thoracodorsal artery, a terminal branch of the subscapular artery. In 94% of the 114 specimens, a bifurcation of the common neurovascular trunk into lateral (parallel to the lateral border of the muscle) and medial (parallel to the upper border) branches has been documented.²³⁷ Bartlett and coworkers¹⁵ studied 50 latissimus dorsi muscles and noted the same bifurcation in 56% of the dissections. These studies provide the anatomic basis for the clinical findings noted by Axer and colleagues.¹¹ The thoracodorsal nerve (C6-8) is derived from the posterior cord, and enters the muscle with the artery and its vein on its deep surface about 10 cm from its insertion. There are one to three branches from the thoracodorsal artery to the serratus muscle that have to be ligated to allow complete mobilization of the latissimus during a bipolar transfer. In the study by Bartlett and coworkers,¹⁵ the vascular pedicle to the latissimus dorsi had an average length of 11 cm and the thoracodorsal nerve a mean length of 12.3 cm.

FIGURE 71-7 A and B, The anatomy of the latissimus dorsi. Shortly after entering the muscle, the single neurovascular pedicle (thoracodorsal nerve and artery) divides into lateral and medial branches.

Technique

The bipolar transplantation is preferable to the unipolar transfer for several reasons. The mechanical efficiency of the transplant is increased by the more anterior placement of the origin into the coracoid process, the proper length is easier to determine when the distal insertion is completed first, and there is less chance for kinking the neurovascular pedicle.

Results

Experience is with small patient samples.^11,27,117 Zancolli and Mitre²⁵⁴ observed eight patients who had had bipolar transplantation of the latissimus dorsi for more than 4 years. Active range of flexion was 105 to 140 degrees, and flexion strength varied from 0.7 to 5 kg. Flexion contractures of 10 degrees and 15 degrees occurred in two, and active supination of 20 to 50 degrees was achieved in six. Takami and others²³⁰ reported on two patients. One obtained elbow motion from 0 to 125 degrees and supination of 30 degrees and could lift 3 kg; the other had motion from 0 to 130 degrees with 60 degrees of supination and could lift 2 kg. Moneim and Omer¹⁷¹ achieved satisfactory flexion (100 degrees or more) in three of five patients. The two others achieved 65 to 70 degrees of flexion and initially had paralysis of the latissimus dorsi, so they were advised that the procedure should not be done unless the muscle was normal. Preoperative EMG evaluation of the muscle was recommended. Hirayama and associates¹¹¹ reported four excellent results, three good results, and one failure among eight patients who had transfers of the latissimus dorsi. Botte and Wood²⁸ noted satisfactory function in four of five patients treated with unipolar or bipolar latissimus dorsi transfer, and flexion that averaged 87 degrees (range 35 to 130). Chen⁴⁸ achieved satisfactory function with average motion from 32 degrees of extension to 126 degrees of flexion in six patients who had bipolar transfers of the latissimus dorsi. They could lift only 1.5 to 2.5 kg, which was sufficient for most activities of daily living but not for heavy manual work. Concurrent skin coverage with restoration of elbow flexion is accomplished nicely with a latissimus dorsi myocutaneous flap.^{33,112,199,225} Clinical evidence of a functional deficit after transfer or transplantation of the latissimus dorsi is unusual. Russell and coworkers²⁰³ did document some minimal changes in shoulder strength and range of motion after transfer or transplantation of the latissimus dorsi in 24 patients.

Patients are able to hold weights between 8 and 15 kg,¹⁸ and up to 115 degrees of elbow flexion can be achieved (Fig. 71-11).¹⁷¹ Haninec and Smrcka¹⁰² reported M3 flexion up to 120 degrees at 16 months, unchanged from 5 months, in two patients.

FIGURE 71-11 A and B, This 36-year-old man who had C5-C6 paralysis following a closed brachial plexus injury underwent a bipolar transfer of the latissimus dorsi 3 years after the injury. Good elbow flexion was restored (A), and nearly full extension of the elbow was maintained (B). Shoulder arthrodesis was also performed.

History

The first use of the pectoralis major muscle to restore elbow flexion was reported in the European literature in 1917 by Schulze-Berge,²⁰⁹ who transferred its tendon of insertion directly into the belly of the biceps. Subsequent modifications of the method of insertion of the pectoralis major included the use of fascia lata or strands of silk to form tendons of insertion, either into the biceps tendon or directly into the ulna.^{115,137,138,198} Clark⁵⁹ reported the first really successful physiologic transfer of the pectoralis major in 1946. In his procedure, the sternocostal origin of the muscle with its separate nerve (medial pectoral) and blood supply was mobilized, passed subcutaneously down the upper arm, and attached to the biceps tendon. Seddon modified Clark’s operation by elevating a segment of rectus abdominis sheath in continuity with the distal end of the transplant to act as a tendon.²¹⁰

Brooks and Seddon³⁴ described a unipolar transfer of the entire pectoralis major muscle, employing the devascularized long head of the biceps as its tendon of insertion. They recommended this operation instead of a Clark transfer when either the lower part of the pectoralis major was paralyzed but the clavicular head strong, or the whole muscle was weak.²¹³

In 1955, Schottstaedt and others first reported bipolar transplantation of the chondrosternal portion (lower two thirds) of the pectoralis major on its neurovascular pedicle to restore elbow flexion.²⁰⁷ The humeral insertion was detached and shifted to the coracoid process, and the origin was transplanted to the biceps tendon. Carroll and Kleinman⁴⁶ transplanted the entire pectoralis major muscle on both of its neurovascular pedicles. The muscle origin with its attached anterior rectus abdominis sheath was attached to the biceps tendon, and its tendon of insertion was secured to the anterior aspect of the acromion. With bipolar transplantation of the entire muscle, they noted increased shoulder stability, which obviated shoulder arthrodesis and improved mechanical efficiency for elbow flexion as compared with the unipolar transfer. Matory and coworkers¹⁵⁷ transferred the lower sternocostal portion of the muscle with a 4-cm portion of rectus sheath mobilized with the medial and lateral pectoral nerves and accompanying vessels. The muscle was “tubularized” and woven through the biceps tendon, and the transverse aponeurosis was repaired to restore a pulley. Separate midline and deltopectoral incisions were used to avoid the undesirable scar from the standard pectoralis transfer approach.

Tsai and associates²³⁹ added unipolar transfer of the pectoralis minor muscle to a bipolar pectoralis major transplant, noting excellent strength of elbow flexion without endangering the two muscles’ common neurovascular bundles. The lateral half of the clavicular origin of the pectoralis major was left intact to preserve shoulder adduction.

The first transfer of the pectoralis minor to the paralyzed biceps to restore elbow flexion was done in 1910 by Bradford.³⁰ Spira²¹⁹ reported on one patient who had complete paralysis of the pectoralis major secondary to poliomyelitis who enjoyed excellent function after the transfer of the origin of the pectoralis minor into the distal biceps. Alnot⁷ recommended transferring the pectoralis minor to the biceps at the time of plexus exploration and nerve repair.

Concerns such as diminished excursion, the obligatory supination of the forearm, and the oblique scar on the chest have been the focus of several modifications to the technique. Especially in women, there are cosmetic concerns because the procedure may create breast asymmetry.¹⁵⁵ Another concern has been that the pectoralis major muscle is not strong enough to substitute for the biceps in cases of complete absence of elbow flexion.²¹⁸

Anatomy

Phylogenetically, the pectoralis major muscle evolved from three separate ones, and today it has a segmental configuration with an independent neurovascular supply (Fig. 71-12). The pectoralis major muscle has two constant (clavicular and sternocostal) subunits, and in about half of humans, an abdominal subunit.²³⁶ The clavicular portion of the muscle originates from the medial third of the clavicle. The sternocostal portion arises from the anterior surface of the manubrium and the body of the sternum and cartilage of the first six ribs. The abdominal portion, when present, arises from the aponeurosis of the external oblique muscle and is found posterior to the axillary border of the sternocostal portion. The lateral pectoral nerve, derived from the lateral cord and containing fibers from nerve roots C5, C6, and C7, supplies the clavicular and upper portions of the sternocostal parts of the muscle. The medial pectoral nerve, derived from the medial cord and containing fibers from C8 and T1, innervates the lower sternocostal and abdominal parts of the pectoralis major after piercing the pectoralis minor or passing around its lateral edge as it also innervates this muscle. The clavicular and upper sternocostal portions of the pectoralis major are supplied by the pectoral branch of the thoracoacromial artery. The lower sternocostal portion and the abdominal portion, when present, receive their blood supply from the lateral thoracic artery.

FIGURE 71-12 Unipolar transfer of the pectoralis major for elbow flexion. A, The anatomy of the pectoralis major muscle. The lateral pectoral nerve and pectoral branch of the thoracoacromial artery supply the clavicular portion and the upper part of the sternocostal portion of the muscle. The medial pectoral nerve and branches from the lateral thoracic artery supply the lower part of the sternocostal portion and the abdominal portion (when present) of the pectoralis major. B, Incisions employed in performing a unipolar transfer of the lower sternocostal portion of the pectoralis major (Clark’s transfer). C, The lower third of the pectoralis major, detached with a 6-cm segment of anterior rectus abdominis sheath, is mobilized proximally on its neurovascular pedicle. D, The detached origin with the attached rectus abdominis sheath is passed through a subcutaneous tunnel and attached to the biceps tendon.

Technique

Prerequisites to this technique are that the sternocostal part of the pectoralis major muscle is of normal strength, and the elbow has full passive range of motion.²¹⁸

Results

The original description was of only one patient, who had flexion limited by only 15 degrees, extension limited by 5 degrees, and flexion power 40% of normal 16 weeks after a partial bipolar transfer of the pectoralis major.⁵⁹ Seddon noted excellent results (powerful flexion against gravity and resistance) in seven of 16 Clark’s transfer patients on whom he reported.²¹⁰ In the remainder, the elbow could be flexed against gravity and slight resistance. Seven patients regained supination against resistance (from 10 to 90 degrees). In four cases in which the pectoralis major power was subnormal, the pectoralis minor was used in addition. D’Aubigne reported excellent active flexion, independent of shoulder adduction, in two patients who had Clark’s transfer.⁶² Using the unipolar transfer of the pectoralis major into the devascularized long head of the biceps, Brooks and Seddon³⁴ achieved three excellent, three good, and two fair results (less active flexion than passive or flexion against gravity but not against resistance), and two complete failures. Two of the good results, however, required second operations (triceps to biceps) because of simultaneous action of the pectoralis major and the triceps, a phenomenon they ascribed to axonal confusion during regeneration after brachial plexus lesions. Holtmann and associates¹¹⁶ noted useful active elbow flexion through a mean range of 96 degrees, accompanied by supination of the forearm, in all seven of Clark’s transfers on which they reported. Four of the patients had arthrogryposis, and, in all cases, the transfer was extended with a 6-cm segment of anterior rectus sheath. Leffert and Pess¹⁴¹ reported the results of 15 pectoralis transfers: good result in eight, improvement in four, and no improvement in three cases. They recommended that shoulder fusion be carried out several months before the transfer in patients who have a paralyzed shoulder.

Botte and Wood²⁸ recorded satisfactory results in all five patients who had bipolar pectoralis major transfers but cautioned against using it in women because of the cosmetic disfigurement. Matory and associates¹⁵⁷ transferred the lower sternocostal segment of the pectoralis major in seven patients and achieved a functional range of elbow flexion (mean 98 degrees) in all. Extension loss was only 15 to 25 degrees, and sustained flexion strength averaged 8 pounds. Tsai and others used modified bipolar transplantation of the pectoralis major (leaving the lateral half of the clavicular origin intact), supplemented with a unipolar transfer of the pectoralis minor, in four patients.²³⁹ Three of the four achieved excellent results (full extension with at least 60 degrees of flexion), and the other patient required a secondary Steindler’s flexorplasty.

Spira achieved strong flexion through a range of 135 degrees with virtually full extension in a patient with total paralysis of the pectoralis major and elbow flexors secondary to poliomyelitis whose pectoralis minor origin he transferred to the biceps tendon.²¹⁹

Complications

Doyle and associates⁷⁴ reported on two patients who developed transient nerve palsy, one medial and one radial, after pectoralis major transfer. Both problems resolved completely after several weeks. Simultaneous contraction of the triceps when the elbow is flexed by the transfixed pectoralis major was noted in three cases by Segal and coworkers.²¹³ All three had brachial plexus injuries and initially had had paralysis of the triceps and elbow flexors. Axonal confusion after regeneration seems to be the likely explanation, but the complication cannot be predicted, because in six other cases in which the triceps initially was paralyzed and later recovered, no simultaneous flexor-extensor action developed.

History

Biesalski and Mayer²³ and later Vulpius and Stoffel²⁴⁶ were the first to describe the transfer of part of the triceps muscle to compensate for the loss of elbow flexion. Since that time, it has been used in the treatment of the flaccid elbow in brachial plexus palsy to a varying degree.^7,28,43 Use of the triceps muscle to restore elbow flexion was condemned by Steindler in 1939 because, he felt, “Loss of the normal function of the triceps is too great a sacrifice.”²²³ Bunnell, however, described a successful triceps transfer.³⁹ In his opinion, “It is more important to flex than to extend the elbow.”⁴⁰ Some modern authors have again abandoned this technique because the concurrent loss of elbow extension, critical for joint stabilization, is considered too disadvantageous.²³³ In 1955, Carroll described the technical details⁴³ and, in 1970, reported the results of triceps transfer in 15 patients.⁴⁵ They advised against performing triceps transfer bilaterally or in a patient who uses crutches. Botte and Wood²⁸ also advised against the procedure in patients who use a cane or a wheelchair and those who have to work with their hands overhead. Several authors have recommended triceps-to-biceps transfer with poorly functioning biceps when there is co-contraction of a reinnervated triceps.^7,28,202 This may yield a favorable result even when there is insufficient triceps strength. Otherwise this would be a contraindication. A clear disadvantage is the loss of active extension but when compared with transfers of the hand flexors and extensors, the power of elbow extension is greater, with fewer extension deficits.²⁰²

Anatomy

The triceps muscle arises from three heads—one from the scapula (long head) and two from the posterior humerus (lateral and medial heads). The medial head has an extensive origin from the posterior shaft of the humerus, extending from the insertion of the teres major to within 2.5 cm of the trochlea of the humerus. The muscle is supplied by the radial nerve (C7 and C8, with a smaller contribution from C6) through multiple branches that arise above the spiral groove. An exception is the posterior branch to the medial head, which leaves the radial nerve just as it enters the groove.³²

Technique

This description is based on that of Carroll (Fig. 71-14). The patient is placed in the distal decubitus position and the extremity is draped free. A posterior midline incision is made that extends over the distal two thirds of the arm and then curves laterally to the olecranon, extending distally over the subcutaneous border of the ulna for 5 cm. The skin flaps are widely undermined so that the ulnar nerve can be exposed medially and the lateral intermuscular septum laterally. A tail of periosteum as long as possible is raised from the ulna in continuity with the triceps insertion, and the medial head is mobilized from the distal third of the shaft of the humerus. The radial motor nerves enter the muscle in the interval between the lateral and medial heads as the radial nerve enters the spiral groove. The raw surface of the stripped medial head is then covered by suturing its two edges together into a tube.

FIGURE 71-14 Transfer of triceps insertion around the lateral side of the elbow to the biceps tendon.

The biceps tendon is exposed through a curvilinear incision in the antecubital fossa, and the tendon is dissected free to its insertion onto the radius. The biceps tendon is split longitudinally. The triceps tendon is passed through a laterally placed subcutaneous tunnel between the two incisions, superficial to the radial nerve. The triceps tendon is then passed through the split biceps tendon and sutured in place under maximum tension with the elbow at 90 degrees of flexion and the forearm in full supination. As an alternative, the triceps tendon can be attached to the radial tuberosity using a pull-out wire technique, as described by Bunnell.⁴⁰ The elbow is immobilized in a posterior splint at 90 degrees of flexion and full supination for 4 weeks, at which time active exercises are begun.

Results

Carroll and Hill recorded the results of 15 triceps transfers.⁴⁵ Five successes (flexion against gravity with ability to bring the hand to the mouth), one limited result, and one failure were noted in the seven trauma or paralysis patients. Among the eight patients with arthrogryposis, there were five successes, one limited result, and two failures. The average range of motion was 116 degrees and average flexion contracture 24 degrees in the first group, whereas in the arthrogrypotic group motion averaged only 43 degrees and the average fixed flexion deformity was 59 degrees (Fig. 71-15). Seven of the eight arthrogrypotic patients required adjunctive procedures such as excision of a dislocated radial head or modified elbow arthroplasty to achieve an acceptable passive range of motion before triceps transfer. Williams reported improvement measured by flexion against gravity in all 19 arthrogrypotic elbows submitted to triceps transfer, and he did not hesitate to perform the procedure bilaterally.²⁴⁸ However, extension was usually restricted to approximately a right angle because of the tenodesis effect of the triceps. Other authors have reported variable improvement, if any, after triceps transfer in arthrogrypotic patients.^74,96,169 Leffert and Pess¹⁴¹ recorded four good and three improved results in seven patients who underwent triceps-to-biceps transfers. Botte and Wood²⁸ reported mean flexion of 125 degrees in three patients who had triceps-to-biceps transfers. No effort was made to mobilize elbow extension past a 30-degree flexion contracture, because this was thought to be mechanically advantageous for elbow flexion. Alnot⁷ achieved 10 good and one acceptable result in 11 triceps-to-biceps transfers. Three were done after spontaneous triceps recovery, two in patients with co-contraction, and eight after nerve grafting. The investigators noted that 36% of their patients had a dominant triceps innervation from C8 and T1, making it available for transfer in C5, C6, and C7 lesions in these patients. Rühmann²⁰² reported on a series of three patients, resulting in active elbow function in all patients (mean flexion 113 degrees, range 90 to 30 degrees) with function against resistance (M4-5) and no passive stretching deficit. Loss of active elbow extension was not considered of great importance to these patients. Complications have not been reported for any of these series.

FIGURE 71-15 A, A 5-year-old boy with arthrogryposis multiplex congenita underwent triceps transfer on the right extremity. B, Six months after surgery, he was able to flex the elbow to 95 degrees and gravity extension was possible to 50 degrees. C, The opposite elbow was left in extension.

Sternocleidomastoid transfer

In 1951, Bunnell reported on a single patient with a paralyzed upper extremity secondary to poliomyelitis who gained elbow flexion from transfer of the insertion of the sternocleidomastoid muscle, extended with a strip of fascia lata, into the bicipital tuberosity.⁴⁴ Carroll reported 80% satisfactory results in 15 cases with this technique.⁴⁰ Kumar et al¹³⁰ described a modification to Bunnell’s⁴⁰ original technique, whereby the sternocleidomastoid muscle is sutured to a fascia lata tube under the clavicle to eliminate the bow-stringing and unsightly skin fold that would otherwise occur during flexion.

Flexor Carpi Ulnaris Transfer

In 1975, Ahmad published a single case report of a patient with a brachial plexus palsy who achieved 130 degrees of elbow flexion after the transfer of the insertion of the flexor carpi ulnaris, turned back on itself, into the distal humerus.¹ No subsequent reports of this transfer have appeared in the literature.

History

Free muscle transfer for elbow reanimation is indicated when there are no available local donor muscles,^59,155 due to trauma, tumor resection, or chronic denervation. Microneurovascular muscle transfer for recovery of motor function in cases of severely injured extremities has grown from successful experimental studies^{81,129,231,234} into a clinical reality^{119,120,152,184} and is now a useful reconstructive option in these difficult cases.^50,52,69 Despite requiring meticulous technique and microsurgical skills, overall survival and reinnervation of transplanted muscles are consistently successful in large series.^14,52,69 Although reconstruction of elbow function alone with a free-functioning muscle transfer in acute cases of brachial plexus palsy is inferior to direct neurotization of the musculocutaneous nerve when performed within 6 months of injury,^3,181 it is indicated to restore elbow flexion in chronic cases,⁶⁹ when there is irreparable injury to the biceps or distal portion of the musculocutaneous nerve, or when used for a dual purpose combining elbow flexion with animation of the wrist or hand.^{14,19,67,68,71} Important prerequisites for free muscle transfer include adequate skin cover; a normal or at least functional arc of passive elbow motion; a compliant, stable soft tissue bed permitting tendon gliding; and available motor nerves and blood vessels. The presence of vascular bypass grafts at the planned site of vessel repair, for example, is in general a contraindication to functioning free muscle transfer.

In cases of flaccid elbow paralysis resulting from a brachial plexus injury or lesion, innervation may be provided, even when the limb is flail and all nerve roots avulsed, by direct nerve transfer of two to four intercostal motor nerves or spinal accessory nerve, or following regeneration across a banked nerve graft from the contralateral C7 root.^{3,52,69,70,153,218} In more favorable circumstances, intraplexal nerve transfer using two to three fascicles of the ulnar nerve supplying flexor carpi ulnaris motor branches,¹⁸⁶ median nerve fascicles supplying flexor carpi radialis,^147,151,157 or direct repair/graft of the musculocutaneous nerve itself will provide superior results and minimal donor morbidity. In chronic cases requiring free functioning muscle transfer, neurotization of the motor nerve can also be performed using an ulnar nerve fascicle.^105,229 In any of the above-mentioned nerve procedures, efforts should be made to place the nerve transfer or repair in close proximity to the transferred muscle motor point, thus minimizing the reinnervation time. An accurate epineural repair using microsurgical methods is important. Intercostal nerve transfer is performed with the shoulder in maximal external rotation and 90 degrees of abduction, to allow postoperative shoulder motion up to this positioning limit.⁶⁶

At surgery, certain principles must be followed to optimize results. It is desirable to place the transferred muscle at its optimal resting tension, with a straight line of pull and anatomic insertion, avoiding crossing of a flail or unstable shoulder when possible, and no bow-stringing.⁶⁶ Best results are seen when antagonistic (triceps) function is either present or reconstructed through direct reinnervation, tendon transfer, tenodesis, or the addition of another free-functioning muscle transfer. Use of the muscle for a second purpose has been demonstrated to weaken elbow flexion.¹⁶

Preparation of the Recipient Site

Initial dissection is performed at the recipient site, before any dissection of the donor muscle is performed. A deltopectoral approach is used, with a supraclavicular transverse component needed to expose the lateral clavicle and acromion for proximal tendon fixation, as well as the thoracoacromial trunk. Initially, the cephalic vein is identified and protected. When performed within 6 months of a brachial plexus injury, a surgical exploration of the brachial plexus is performed and intraoperative electrophysiologic studies performed. This commonly includes SEPs and motor evoked potentials (MEPs) to evaluate nerve roots, and neuromuscular stimulation of ulnar and/or median nerves if intraplexal nerve transfers are considered.

If the surgical plan includes use of spinal accessory or intercostal nerve transfer, these nerves are next prepared. The spinal accessory nerve is identified through the same incision on the deep anterior surface of the trapezius muscle. A nerve stimulator demonstrates its motor function, and dissection is used to spare two branches, those to the sternocleidomastoid muscle and to the upper part of the trapezius. This preserves muscle function that provides scapulohumeral movement. This is especially important if the shoulder is to be arthrodesed.² In order to avoid needing a nerve graft, a dorsal approach can be used to dissect more distally, as described by Vathana.²⁴⁴ This provides nerve length reaching to the terminal branches of the brachial plexus and certainly to the motor nerve supplying the free functioning muscle. Another option is to harvest the obturator nerve from the level of the obturator foramen, permitting its length to reach 10 cm. The phrenic nerve remains an alternative choice when no plexal nerves are available, and staged reconstruction with contralateral C7 has also been described, although few results have been reported.⁵⁶ For hand reanimation, contralateral cross-chest C7 donors have been associated with inferior outcome in some hands,²³⁵ whereas others report more encouraging preliminary results.⁵⁰

Should intercostal nerves be required, the deltopectoral incision is extended across the anterior wall of the axilla, curving beneath the nipple to allow elevation of the pectoralis muscles caudally to expose the ribs. Generally, two intercostal nerves will be sufficient to satisfy the obturator branch fascicles. Usually the third and fourth intercostal nerves are used (T3 and T4), easily transferred to lie next to the thoracoacromial trunk. The periosteum is dissected free circumferentially from ribs from the costochondral junction anteriorly to the axilla. By incising the deep (osseous) surface of the reflected interior periosteum, the motor branch is identified at the nipple line and dissected to the costochondral junction. Meticulous dissection is needed to avoid injury to the pleura. Simultaneous biceps reinnervation with the T5 and T6 motor nerves may also be performed. For each transfer, the shoulder is positioned in 90 degrees of abduction and maximal external rotation to ensure adequate nerve length.

When the surgical plan is to use ulnar or median nerve fascicles, the muscle is positioned somewhat more distally, and the thoracodorsal vessels are used instead; these muscles are identified lying on the anterior surface of the latissimus dorsi.

Next, an antecubital incision exposes the biceps tendon, and subcutaneous tunneling connects the shoulder and elbow incisions. The thoracoacromial trunk is the most commonly used pedicle for arterial anastomosis. It is exposed most readily by caudal dissection of the clavicular head of the pectoralis major, and is facilitated with limited release of the more lateral clavicular origin of the muscle and release of the pectoralis minor from the coracoid process. The latter is tagged for later repair.

The muscle will be placed to overlie the distal clavicle and acromion, allowing adjustment of its position proximally or distally to center the vascular pedicle over the thoracoacromial trunk. Three or four suture anchors are placed for securing the muscle before its harvest.

Harvest of the Gracilis Muscle

The gracilis muscle is a superficial muscle of the medial aspect of the thigh. It is supplied by the obturator nerve, entering the muscle obliquely, cephalad to the main vascular pedicle, at 6 to 12 cm from its origin. The vascular supply is from a 4 to 6 cm long branch of the profunda femoris artery located 8 to 12 cm from the muscle origin and passing between the adductor longus anteriorly and the adductor magnus posteriorly. The gracilis may be harvested to include a paddle of skin serving as a buoy flap centered at this location (Fig. 71-16).¹⁵⁴ Three small incisions are sufficient, beginning with exposure of the distal tendon medial and proximal to the tibial tubercle, then a second posteromedially overlying the tendon in the distal thigh to visualize the distal musculotendinous junction. A more proximal incision is made including the skin paddle at the location of the proximal neuromuscular junction. The position of the skin, centered over the muscle, is facilitated by palpation with traction on the distal tendon previously exposed. The skin paddle base includes fascia overlying both the adductor longus anteriorly and the adductor magnus posteriorly. The dissection then converges on the intermuscular plane between the adductor muscles, at which time the neurovascular pedicle is easily identified. The motor nerve lies cephalad, aligned roughly 45 degrees to the muscle, whereas the vessels pass perpendicularly toward the gracilis muslce. Dissection of the vessels requires careful elevation of the adductor longus and ligation of multiple small muscular branches from the pedicle to it. The nerve is dissected as far cephalad as feasible, often aided with fiberoptic-illuminated retractors, and then divided. The muscle is next released from the pubic symphysis proximally and from the pes anserinus distally. Use of lighted retractors permits tunneling between the three incisions to harvest the muscle. One or more secondary pedicles distally require ligation. Only when the recipient site is fully prepared and the operating microscope positioned is the vascular pedicle divided and the muscle immediately transferred (Fig. 71-17).

FIGURE 71-16 Gracilis muscle during harvest. The monitor skin paddle is shown to the left; the vascular pedicle (not shown) is marked by vessel loops. Distally, the tendon is released from its insertion on the lateral aspect of the tibial tubercle.

(By permission of Mayo Foundation for Medical Education and Research. All rights reserved.)

FIGURE 71-17 Gracilis muscle after harvest.

(By permission of Mayo Foundation for Medical Education and Research. All rights reserved.)

Free Muscle Transfer

When all is ready, the gracilis muscle is brought to the arm, and the proximal tendon connections made and the distal tendon tunneled into the antecubital incision, but not yet fixed. The microarterial anastomosis is made next, most frequently performed end to end to an appropriately sized arterial branch of the thoracoacromial trunk or thoracodorsal artery. A single venous connection to the cephalic vein is made. The nerve transfer is next performed, followed by repair of the distal tendon to the biceps tendon (Fig. 71-18). Tension is adjusted to produce a 30-degree flexion contracture at the elbow. We have found this method to provide reliable postoperative arc of motion without use of marking sutures, as described by Manktelow and Zuker, which require more extensive incisions for muscle exposure in the thigh before harvest.¹⁵³ The distal end can also be sutured to more distal targets, if needed. In our brachial plexus practice, for example, a single gracilis muscle transfer is sometimes used to provide finger flexion in addition to elbow flexion (Fig. 71-19). The distal gracilis tendon is prolonged with a forearm tendon graft (usually the paralyzed flexor carpi radialis) to reach the flexor digitorum profundus and flexor pollicis longus tendons. To avoid bow-stringing, an antecubital pulley is used, which is either the intact lacertus fibrosis or a fabricated antecubital pulley using the flexor carpi ulnaris (Fig. 71-20). In such a procedure, we also reinnervate the biceps with two additional intercostal nerves to improve elbow flexion strength and reconstruct antagonist triceps function with nerve transfer or grafting.

FIGURE 71-18 Single-stage reconstruction of elbow flexion with a free-functioning gracilis myocutaneous flap neurotized with the spinal accessory nerve. The muscle is attached proximally to the lateral clavicle and acromion using suture anchors, and is woven into the biceps tendon distally.

(By permission of Mayo Foundation for Medical Education and Research. All rights reserved.)

FIGURE 71-19 Reconstruction of elbow and finger flexion with a single free gracilis muscle flap. The distal gracilis tendon is prolonged with a forearm tendon graft (usually the paralyzed flexor carpi radialis) to reach the flexor digitorum profundus and flexor pollicis longus tendons.

(By permission of Mayo Foundation for Medical Education and Research. All rights reserved.)

FIGURE 71-20 Occasionally, there is bow-stringing of the gracilis muscle when using it as an elbow flexor and finger flexor. In this case, a pulley can be created using the flexor carpi ulnaris (FCU). The FCU can be released from its distal insertion and looped under the forearm extensor origin to create a more effective pulley at the antecubital fossa.

(By permission of Mayo Foundation for Medical Education and Research. All rights reserved.)

Aftercare

Aftercare consists of close monitoring of the buoy flap by skin color, turgor and capillary refill, and Doppler examination of myocutaneous perforators for the first 48 hours postoperatively, preferably in an intensive care unit. Passive range of motion exercises in uninvolved joints and edema control are begun immediately, after which patients are progressively mobilized. The shoulder and joints in the operated arm are immobilized for up to 3 weeks, after which gentle passive range of motion exercises are begun. Early recovery is recognized by a “squeeze test” of the muscle, producing a painful sensation, electromyographic evidence of muscle activation using the original function of the transferred nerve (e.g., cough or Valsalva firing intercostal nerves), or visible muscle contraction. This generally occurs 4 to 6 months after surgery. Once reinnervation is documented, biofeedback and re-education techniques with gravity-eliminated motion are used until muscle power has reached antigravity stage. Maximum return of strength requires up to 2 years from the date of surgery.

Optimal results are obtained through active participation in rehabilitation programs. Noncompliance with these programs, possibly due to socioeconomic factors in some western countries, may affect the long-term outcomes when these are compared with Asian countries, for example.

Technique—Two-Stage Reconstruction

Doi et al^66,67,71 have described a method of double gracilis transfer combined with neurotization of the triceps and sensory neurotization of the hand to provide patients with four or five brachial plexus root avulsions with shoulder stability and function, as well as active elbow flexion and extension, protective hand sensibility, and rudimentary hand grasp and release. Simple nerve transfers, such as intercostal to musculocutaneous nerve to reconstruct elbow function alone, is not included in this procedure, even in acute cases. In the first stage, the gracilis muscle attached to the clavicle is neurotized with the spinal accessory nerve and an available C5 root, phrenic nerve, or contralateral hemi-C7 transfer is used for shoulder motor reconstruction. The gracilis tendon is sutured to the extensor digitorum communis tendon in the proximal forearm (Fig. 71-21). The applied tension is such that full finger flexion is permitted with the elbow flexed. Using wrist extensors as the distal insertion instead of the finger extensors may improve finger flexion through a tenodesis effect.²⁴ Originally, the brachioradialis muscle was used as a pulley to prevent bow-stringing of the gracilis muscle transfer at the elbow. However, bow-stringing would still sometimes occur, prompting the use of a distal portion of the flexor carpi ulnaris, which is detached and used to create a pulley at the level of the proximal forearm (see Fig. 71-20) (David Khoo, personal communication). Alternatively, the flexor carpi radialis has been used for the same purpose.²⁰

FIGURE 71-21 Doi stage I procedure.⁷¹ Free muscle transfer is used for restoration of elbow flexion and wrist extension. This procedure is usually combined with neurotization of shoulder girdle musculature (not shown).

(By permission of Mayo Foundation for Medical Education and Research. All rights reserved.)

The second-stage gracilis transfer, used for finger flexion, is neurotized by two or three intercostal nerves, and is attached to the second rib with multiple drill holes proximally (Fig. 71-22). Vascular connections are to the thoracodorsal vessels. Through a separate incision in the forearm, the flexor digitorum profundus and flexor pollicis longus tendons are sutured in such a way as to create a key pinch and grasp on traction. The gracilis tendon is tunneled under the pronator teres muscle, which serves as the pulley for this transfer, and is secured to the flexor digitorum profundus and flexor pollicis longus tendons using a Pulvertaft weave. Tension is set such that the fingers can extend with elbow flexion and such that the fingers and thumb can close with elbow extension. The second stage is completed by neurotization of the motor branch of the triceps brachii muscle with two intercostal motor nerves and the neurotization of the lateral portion of the median nerve with intercostal nerve sensory branches to restore protective hand sensibility (Figs. 71-23 and 71-24). The supraclavicular nerve sensory rami may also be used for this purpose.

FIGURE 71-22 Doi stage II procedure.⁷¹ A second free-functioning gracilis transfer for finger flexion is performed, neurotized with two intercostal motor nerves. Additional nerve transfers for protective hand sensibility and triceps motor function are also performed (see Fig. 71-23).

(By permission of Mayo Foundation for Medical Education and Research. All rights reserved.)

FIGURE 71-23 Neurotization of the triceps branch of the radial nerve with motor branches of the third and fourth intercostal nerves, and transfer of the fifth and sixth intercostal nerve motor branches to the free-functioning muscle motor nerve. The third to sixth intercostal sensory branches are transferred to the lateral cord of the median nerve to provide protective hand sensation.

(By permission of Mayo Foundation for Medical Education and Research. All rights reserved.)

FIGURE 71-24 Intercostal nerves can be divided into sensory and motor branches under the operating microscope.

Shoulder function and stability are important pre-requisites for prehension, and for this reason, Doi has augmented his double free-muscle transfer technique with neurotization of the suprascapular nerve with the C5 or C6 nerve root via a nerve graft. If these are not available, neurotization can be performed from a contralateral C7 nerve donor and a vascularized ulnar nerve graft.⁶⁵

Results

Early results of free-functioning muscle reconstruction for elbow flexion were variable. Gilbert reported an excellent result in a 5-year-old child treated with free transplantation of the gracilis, using the musculocutaneous nerve as the recipient nerve, after traumatic destruction of the biceps muscle.⁹¹ Five other patients (two with poliomyelitis and three with brachial plexus palsies), however, achieved no useful flexion after a gracilis transplantation that was innervated through a long nerve graft connected to the sternocleidomastoid nerve. O’Brien and colleagues also recorded a failure in one patient 8 years after a free gracilis transplant that was innervated by the second and third intercostal nerves.¹⁸⁴ Hirayama and others¹¹¹ used a free latissimus dorsi muscle flap innervated by the intercostal nerve in a 35-year-old man with a complete brachial plexus palsy and disuse atrophy of the biceps. Three years later, he had 90 degrees of flexion and a 30-degree flexion contracture. Botte and Wood²⁸ achieved no useful flexion in three patients who had free latissimus dorsi transfers (two had distant neurotization) and recommended against the procedure. Manktelow¹⁵² reported on one patient who had a free gracilis transfer that was innervated by the musculocutaneous nerve to replace crushed biceps and brachialis muscles. Eighteen months after surgery, the patient could flex to 120 degrees from the fully extended position with a 15-pound weight.

More recently, Chuang and associates⁵² reported on the results of 38 cases of brachial plexus injury treated with free-functioning gracilis muscle transfer for elbow flexion. Thirty-one muscle transfers were reinnervated by intercostal nerves; three cases with traumatic loss of the biceps treated at an interval of 6 to 12 months were reinnervated by the original musculocutaneous nerve; the remaining four cases were reinnervated by the spinal accessory nerve. All 38 patients were followed for at least 2 years. All three patients with traumatic biceps loss regained M4 flexion power within 1 year of rehabilitation. Where three intercostal nerves were used for reinnervation, 78% regained M4 strength. Failures (M3 or less) in the intercostal nerve neurotization group were attributed to the site of proximal muscle insertion, with 1 of 5 failures where attachment was to the coracoid process of the scapula (N = 20), and 4 of 5 failures where attachment was to the second rib or the clavicle (N = 11). Transfer for combined elbow flexion and finger flexion yielded only a limited range of motion (0 to 90 degrees) but M4 strength. Finger flexion was attributed to a tenodesis effect rather than to actual muscle excursion. Rehabilitation for patients reinnervated with two instead of three intercostal nerves was longer (more than 2 years) and yielded less power. After a shorter delay to treatment (6-12 months), reinnervation of a free-functioning muscle by two intercostal nerves supplemented by two intercostal nerve transfers to the musculocutaneous nerve yielded M4 power from both the free-functioning muscle and the brachialis muscles. Last, the group reinnervated by the spinal accessory nerve achieved only M2 to M3 elbow flexion strength even after 3 years’ rehabilitation.

Barrie et al¹⁴ reported our results at least 1 year after gracilis muscle transfer for elbow flexion and found ≥M4 strength in 79% of single-function transfers, and in 63% of muscles transferred for combined motion (P > 0.05). Comparing results between the two stages of the double gracilis transfer, 75% of stage I transfers (elbow flexion and wrist extension) achieved ≥M4 strength, whereas only one of seven procedures for finger flexion yielded ≥M4 strength. Protective sensation returned in two of seven patients who underwent a two-stage reconstruction.¹⁴

After double gracilis transfer, Doi et al⁶⁸ restored excellent to good elbow flexion in 96%, and 65% achieved more than 30 degrees of total active finger motion with the second stage. Other authors have not been able to consistently restore prehension, although in general, some active flexion is achieved.²⁴ Active motion may be improved by a tenolysis⁶⁸ or improving the gliding surface of the muscle transfer with silicone sheeting,²⁴ although some authors¹⁴⁴ believe that weak muscle excursion is usually due to a lack of muscle recovery as opposed to tendon or muscle adhesion. The number of patients achieving M4 strength is slightly diminished when a single free muscle transfer is used for two functions, and it seems the results are more predictable when a single muscle is used for a single function.²⁴ Shoulder stability and triceps recovery are important added functions that improve outcome after free muscle transfer.^65,72 Results in children seem to be superior to those in adults, presumably due to the increased potential for nerve recovery.^13,106

In a group of 58 single or double free muscle transfers, Doi et al⁶⁹ found significantly shorter times to reinnervation by the spinal accessory nerve (mean 3.3 months) as opposed to the intercostal nerves (mean 5.25 months) (P < 0.002), with no difference in motor nerve length. These authors found no difference in time to reinnervation between gracilis, latissimus dorsi, and rectus femoris muscles. The power of elbow flexion was equally excellent in these muscles, and no significant difference in the means was found. The rectus femoris muscle, however, had a significantly lower range of motion (mean 34 degrees) and a flexion contracture at the elbow, compared with the gracilis muscle (mean 74 degrees) and latissimus dorsi (mean 78 degrees). When reinnervated with the spinal accessory nerve, the latissimus dorsi transfer gave the most powerful contraction and the greatest range of joint motion. No statistical relationship could be found in brachial plexus patients younger than 50 years of age between patient age and functional recovery or time to reinnervation. Those patients treated after oncologic resection and requiring postoperative chemotherapy showed no significant difference in time to reinnervation. Patients whose shoulder function was augmented by ipsilateral suprascapular nerve neurotization demonstrated statistically better ranges of motion for shoulder flexion and abduction.⁶⁵

History

This technique is not mentioned in the literature of the past decade, and most authors now mention only the options of the biceps and deltoid transfers for elbow extension.

Several authors have proposed unipolar transfer of the latissimus dorsi insertion into the extensor mechanism to restore elbow extension.^103,115,137 Harmon¹⁰³ added the teres major to the latissimus dorsi transfer in one case report. Hovnanian¹¹⁸ devised a unipolar transfer of the latissimus dorsi in which its origin was transferred to the triceps tendon. Myocutaneous unipolar transfer of the latissimus dorsi was reported by Landra to provide skin coverage and elbow extension at the same time.¹³⁶ Tobin and associates performed a similar procedure but used only the lateral segment of the latissimus dorsi with an attached island of skin.²³⁷

Bipolar transplantation of the latissimus dorsi was first reported by Schottstaedt and coworkers in 1955.²⁰⁷ The origin was sutured to the triceps tendon, and the insertion was moved to the acromion. DuToit and Levy⁷⁵ emphasized the necessity for discarding the distal 3 inches of the latissimus dorsi to get the transplant tight enough.

Technique

Unipolar Transfer

This description is based on that of Hovnanian (Fig. 71-25). The patient is placed on the side, with the arm draped free. The technique of exposing, detaching, and mobilizing the latissimus dorsi on its neurovascular pedicle is the same as that described for flexor replacement. The incision on the arm, however, is carried over from the posterior axillary fold onto the posteromedial aspect without crossing the neurovascular bundle. Distally, the incision is carried over the medial epicondyle onto the posterior aspect of the proximal ulna. The aponeurotic fascia at the free end of the latissimus dorsi muscle is then sutured under tension to the triceps tendon, the periosteum over the olecranon, and the connective tissue and muscle septa on the extensor surface of the forearm, keeping the elbow in full extension. A considerable amount of muscle usually has to be excised to make the transfer as tight as possible.

FIGURE 71-25 Unipolar transfer of the latissimus dorsi for elbow extension. A, The incisions. The solid line indicates skin incisions, and the dotted line indicates the muscle incision. B, The insertion is undisturbed, and the muscle is rotated on its long neurovascular pedicle. Its origin (after appropriate shortening) is attached to the triceps tendon and olecranon periosteum under maximum tension with the elbow fully extended.

The elbow is immobilized in extension and bandaged to the side of the body. Passive and active elbow movements are begun after 3 to 4 weeks.

Results

Bipolar

Schottstaedt and associates²⁰⁷ achieved full extension of the elbow against gravity after bipolar transplantation of the latissimus dorsi in a 5-year-old child with poliomyelitis. DuToit and Levy⁷⁵ reported on a 44-year-old man who was able to do push-ups after bipolar transplantation of the latissimus dorsi. They noted that the distal 3 inches of muscle had to be discarded to secure the proper tension in the transplant, and they made the proximal acromial attachment before the distal attachment. No complications have been reported. An illustrative case is shown in Figure 71-27.

FIGURE 71-27 A, This 19-year-old airman sustained a severe posterior compartment soft tissue injury and an open comminuted fracture of the humerus in a half-track accident. There was complex loss of elbow extension. B, The humeral fracture united after two bone-grafting procedures, and passive extension of the elbow was obtained with a turnbuckle splint. C, Bipolar transplantation of the latissimus dorsi restored satisfactory elbow extension, and full flexion of the elbow was maintained (D).

History

In 1949, d’Aubigne⁶² mentioned the possibility of transferring the posterior part of the deltoid into the triceps as a method of restoring active extension of the elbow. The first procedure was carried out in a tetraplegic patient in 1975 by Moberg, who mobilized the separately innervated posterior part of the deltoid, extending it with multiple toe extensor tendon grafts inserted into the triceps aponeurosis.¹⁶⁶ Converting the transferred deltoid from a one-joint to a two-joint muscle achieved elbow extension without creating any detectable shoulder dysfunction. Since this communication, there have been several other reports of tetraplegic patients in whom posterior deltoid transfer has been used to achieve elbow extension.^37,107 Hentz and colleagues’ communication¹⁰⁸ indicates that the deltoid transfer is now being attached directly to the triceps aponeurosis without any intervening graft material. Castro-Sierra and Lopez-Pita⁴⁷ used two opposing periosteal flaps, one from the deltoid insertion and one turned backward from the triceps insertion into the olecranon, to join the deltoid and triceps. Freehafer and associates⁸² advised using the anterior tibial tendon as an interposition graft. If the patient can walk or might later be able to, they recommended using fascia lata to connect the deltoid to the triceps insertion.

The deltoid-to-triceps transfer is the most frequently used method to restore elbow extension¹⁷³ and has become the standard method of treatment over the past 10 years when the deltoid has a minimum of M4 strength.⁷⁸ The varying techniques differ in the type of material used to attach the deltoid to the triceps.⁸⁴ Most surgeons prefer lower extremity tendon graft or fascia lata, although a consensus has not been reached on the optimum interpositional graft.¹²⁷ A new technique described by Mennen and Boonzaier¹⁶² involves the use of the bony insertion of the deltoid, which is attached by steel wires to the bony insertion of the triceps into the olecranon reflected cranially with a 10-mm wide central section of the triceps tendon and aponeurosis. No subsequent use of this technique has been described in the literature. A number of investigators have found adequate strength and excursion for elbow extension from this transfer.^83,134,167 This procedure is indicated in tetraplegic patients with a good passive range of motion (to within 30 degrees of full extension) at the elbow and with sufficient strength in the posterior deltoid. Inadequate strength on manual muscle testing of the deltoid is an absolute contraindication, and fixed contracture greater than 30 to 45 degrees is a relative contraindication to this procedure.^78,110

Anatomy

The deltoid muscle is supplied by two terminal branches of the circumflex nerve, which divides about 6 cm below the level of the acromion. The posterior branch is short and runs almost horizontally to supply the portion of the deltoid arising from the spine of the scapula. The anterior branch is longer and runs horizontally to supply the acromial and clavicular portions of the deltoid.³²

The architectural properties of the posterior deltoid and triceps muscle were studied by Fridén et al⁸⁶ to determine whether triceps function is appropriately matched by that of the posterior deltoid. It was found that the cross-sectional area of the posterior deltoid was significantly less than that of the three heads of the triceps and that only 20% of the maximum isometric tension could be provided. Despite this factor, the posterior deltoid muscle fiber length was significantly greater, allowing its force to be generated over a much wider range of muscle length, which would explain the relative independence of perioperative posterior deltoid tension on the functional results after transfer.⁸⁶ The large fiber excursion approaches 25 mm and can potentially offset the potential tendon stretch.¹¹⁸

Technique

This procedure is based on that of Moberg (Fig. 71-28). Through a slightly curved incision along the posterior border of the deltoid, the posterior half of the muscle is exposed to its insertion. There is usually a natural cleavage between the two parts of the deltoid where the separation can be accomplished by blunt dissection. Because the deltoid muscle lacks a large tendon of insertion, the tendon of insertion and the surrounding periosteum and a rectangular strip of fascia from the adjacent brachialis muscle should remain attached to the deltoid muscle. The posterior deltoid is mobilized proximally, attaining 3 cm of amplitude, the amount necessary for elbow extension. Care is taken to avoid injury to the axillary nerve branches.

FIGURE 71-28 A, Transplantation of the posterior third of the deltoid, extended with toe extensor grafts, to the triceps tendon. This transfer is used to restore extension in a tetraplegic patient. B, Transplantation of the posterior third of the deltoid using fascia lata rather than tendon grafts.

(Courtesy of Elizabeth Roselius.), (Courtesy of Mikki Senkarik.)

The triceps aponeurosis is exposed through separate, slightly curved, longitudinal incisions proximal to the olecranon. The conjoined extensor tendons to the second, third, and fourth toes (nonfunctioning in tetraplegic patients) are removed with the aid of a Brand tendon stripper. The graft is attached to the deltoid muscle by at least twice looping the end of the graft through the deltoid tendon and adjacent fascia and periosteum and suturing the graft to the adjacent structures. The graft is then passed distally through a subcutaneous tunnel created between the two incisions. The tendon graft is looped twice through and sutured to the triceps aponeurosis, passed again subcutaneously in a proximal direction and again attached to the deltoid muscle. Suturing of the graft should be done with the elbow extended fully and the shoulder abducted 30 degrees. Fascia lata is an alternative of comparable effectiveness. This graft is applied and attached as shown in Figure 71-28B. The posterior deltoid muscle is infiltrated with 20 mL of 1% lidocaine with epinephrine 1:200,000 to prevent disruption of the anastomosis during recovery from anesthesia.

The central third portion of the triceps tendon is used as the interposition graft.¹⁷³ The procedure can be performed simultaneously with other tendon transfers for hand reanimation, such as a brachioradialis-to-flexor pollicis longus transfer for key pinch.¹⁹⁰ Also, the procedure is possible with the patient in supine position under axillary block and a block of the axillary nerve with or without local anesthesia.⁷⁸

Aftercare

A long-arm cast, applied from the upper humerus to just proximal to the wrist with the elbow in 10 degrees of flexion, is worn for 6 weeks. Then the patient begins active extension exercises. To prevent stretching of the newly transferred muscle-tendon unit, however, elbow flexion is increased only 10 degrees per week. A polycentric adjustable elbow splint that allows full extension but blocks flexion at whatever position is desired is useful.¹⁰⁷ During the rehabilitation period, elbow extension power must be closely monitored. If a temporary decrease in extension power is observed, reimmobilization in the extended position is carried out until active full extension is regained. Bryan postulated that late stretching originates in the central portion of the grafts secondary to revascularization and advised protecting the arm from flexion past 90 degrees for 3 months after surgery.³⁷

Some authors, after seeing unpredictable results and the considerable elongation that takes place in the two junctions with immediate wheelchair use, have altered their aftercare regimen to include an electric wheelchair and initial casting (4 weeks) and treatment with hinged splints permitting increasing levels of flexion (6 weeks).⁷⁸

Results

Only one failure is reported by Moberg’s experience with posterior deltoid transfers.¹⁶⁷ In general, elbow extension power was noted to be several times stronger with the extremity at the side in the position for lifting the body than with the limb extended over the head. Bryan³⁷ reported satisfactory results in 10 of 14 deltoid transfers performed in seven tetraplegic patients. In all but one, bilateral deltoid-to-triceps transfers were performed in single operations. De Bendetti⁶³ evaluated 13 tetraplegic patients with 14 deltoid-to-triceps transfers. He noted a mean function of 5, as compared with a preoperative mean of 0.5. Castro-Sierra and Lopez-Pita⁴⁷ noted 10 satisfactory results in 13 tetraplegic patients using Moberg’s technique but were able to shorten the postoperative immobilization period to 35 days. A proximally based flap of triceps tendon with an attached flap of olecranon periosteum is turned back on itself and sutured to the deltoid insertion with the attached periosteum. Lamb and Chan¹³⁴ reported satisfactory results after 16 Moberg transfers in 10 tetraplegic patients. Hentz and others used a tubed fascia lata strip inserted through drill holes in the olecranon and allowed up to 30 degrees of immediate flexion postoperatively,¹⁰⁷ but no follow-up results were given.^107,108 Significant preoperative flexion contracture was believed to compromise the result of deltoid-to-triceps transfer. Under these circumstances, they recommend biceps-to-triceps transfer.

Freehafer and others⁸² reported successful results in all 15 cases of triceps paralysis treated by deltoid-to-triceps transfer using the anterior tibial tendon as an interposition graft. All of the patients could reach above their heads and noted significant improvement in performing depressor push-ups and transfers from bed to chair. Lacey and associates¹³² performed a similar procedure in 16 elbows. At surgery, they documented excursion of the posterior deltoid of 7.31 cm. They believed that optimal tension was achieved by suturing the graft with the deltoid pulled to its original insertion length and with the elbow at 90 degrees of flexion. All but one transfer achieved muscle strength of 3 or better. Ejeskar⁷⁷ recorded the results of deltoid-to-triceps transfer in 40 elbows of 32 patients. Ten of the 30 procedures performed using Moberg’s technique and 1 of the 10 procedures using the method of Castro-Sierra and Lopez-Pita produced full extension of the elbow. Twenty elbows showed no extension beyond 60 degrees, but most had enough extension to maintain elbow control in daily activities. Most of the patients did not have significant use of the elbow extensor when moving between bed and chair, and stretching of some of the transfers was documented.¹⁵⁹ Vanden Berghe and colleagues²⁴² initially used the Moberg technique for deltoid-to-triceps transfer. After the first two cases, they changed to the Castro-Sierra and Lopez-Pita technique for the next six cases because of the shorter immobilization time. All eight elbows gained extensor power of 3 or better. One patient ruptured a transfer in a fall.

Twenty-four transfers were evaluated at an average follow-up of 37 months.¹⁷⁰ These authors report M4 strength in 42% and M3 in 29%. Even M2 strength provided some useful increase in hand function, allowing hand positioning at eye level or above. Lamb and Chan reported M5 power in 50% of their posterior deltoid-to-triceps transfers,¹³⁴ but the discrepancy may be explained by the difference in patient positioning during evaluation. When the patient is supine, the contribution from the pectoral girdle muscles is eliminated in raising the arm above the head, thereby giving true elbow extension strength evaluation.¹⁷⁰

The short-term versus long-term comparative results after 11 deltoid-to-triceps procedures in six patients were evaluated with a mean follow-up of 3 years and 24 years after surgery by Vastamäki.²⁴³ The study group originally consisted of 27 patients with tetraplegia, but many were lost due to death before they could be evaluated, but the functional results showed an average decrease in extension strength of approximately 1% per year, which may be due mostly to patient aging. This study showed the permanency of results obtained with this procedure. A study using motion analysis methods found increased speed and stability of elbow flexion and extension, and a parallel increase in the speed of shoulder flexion and extension.¹⁹⁵ Another biomechanically oriented study found that the posterior deltoid was predicted to operate exclusively on the ascending limb of the length-tension curve, that it generated only 65% of its predicted force, and that the elbow extension moment did not change significantly after rehabilitation.¹⁴³ Other biomechanical studies have shown that the strength of extension depends on the position of the upper arm relative to the shoulder.¹²⁵ When the shoulder is weak, as is often the case in C5 or C6 tetraplegia, the upper arm is elevated to shoulder level, which unfortunately corresponds to the position in which the posterior deltoid-to-triceps transfer is the weakest.

Complications

Stretching and disruption of the proximal or distal anastomosis may require reoperation. In these instances, Moberg has advanced the triceps tendon by osteotomizing the olecranon, advancing the bone, and reattaching the tendon distally with a screw.¹⁵⁹ Spasticity of the elbow flexors may compromise the result.

Complications adversely affecting results have included elongation of the tendon transfer caused by rapid and early mobilization and attenuation over time,¹⁷³ as well as graft failure, elbow flexion contractures,¹⁶⁸ biceps spacicity,⁸² and the difficulties associated with the tolerance of a long post-operative course of immobilization.^{109,168–170} There are multiple reasons why a tendon transfer can fail, including incorrect tension, scar formation, disruption or attenuation of the interposition graft or tendon weave, and progressive weakness of the donor muscle.^127,131,190

History

In 1954, Friedenberg reported a patient with poliomyelitis who had difficulty arising from a chair and walking with crutches because of bilateral absence of triceps function.⁸⁷ After lateral subcutaneous transfer of the biceps tendon into the triceps aponeurosis, the patient was able to support 7.5 pounds in extension on the right and 8.5 pounds on the left. He was able to transfer independently and to use crutches without difficulty. Friedenberg,⁸⁷ Hentz and associates,¹⁰⁷ and Lamb and Chan¹³⁴ recorded cases of tetraplegic patients for whom this procedure was unsuccessful.

Zancolli²⁵⁵ believes that elbow extension is the most important function one could add for tetraplegic patients. He uses Friedenberg’s method⁸⁷ after establishing that the supinator is functioning. If there is no supinator muscle function, he transfers the posterior deltoid. Zancolli noted only 24% reduction in elbow flexion power after biceps transfer. Falconer⁸⁰ has described Zancolli’s technique of biceps transfer. The biceps is exposed through a Z incision along its lateral border, placing the horizontal limb of the Z in the flexion crease. The incision extends 10 cm proximally to the flexion crease and 5 cm distally. The musculocutaneous nerve is identified and mobilized from the undersurface of the biceps muscle 5 cm proximally. The muscle is detached at the radial tubercle and mobilized 10 cm proximally to the elbow, care being taken to protect the radial nerve. A second incision is made over the olecranon, and a flap of triceps aponeurosis is developed. The biceps is passed subcutaneously into the posterior wound and sutured under tension to the aponeurosis flap. The elbow is immobilized in extension for 4 weeks. Ejeskar,⁷⁷ noting that biceps-to-triceps transfer was the procedure of choice for restoring elbow extension when there is a flexion contracture, reported his results in six cases. One patient died of other causes, two regained full extension, one lacked 80 degrees of extension, and two achieved no extension. One patient sustained a radial nerve palsy that was recovering at 5 months.

Some authors have recently reported better results with biceps-to-triceps than with posterior deltoid-to-triceps transfer.^16,173 Before transfer, an elbow contracture of more than 30 degrees is corrected by some authors, because this degree of biceps contracture would prevent the rerouted tendon from reaching the olecranon.¹⁶ However, this technique is better suited to alleviate a mild elbow flexion contracture than the posterior deltoid transfer,¹¹⁸ and as such, an elbow flexion contracture of 30 degrees or more is seen by some authors as an indication for biceps-to-triceps transfer over deltoid-to-triceps transfer.⁷⁸ Also, the need for tendon augmentation is obviated because a direct transfer is possible, and the operation generally takes less time. Active supinator and brachialis muscles must be present (on electromyography) to maintain forearm supination and elbow flexion. If there is doubt about this, the musculocutaneous nerve can be blocked to temporarily paralyze the biceps.¹¹⁰ Some authors^4,159,196 argue that paralysis of the pectoralis muscle is an indication for the biceps-to-triceps procedure to avoid the potential for further weakening of the shoulder, although others disagree that this should be taken into account.⁷⁸ The biceps tendon can be routed around the lateral or medial side of the humerus. Lateral routing techniques have been complicated by radial nerve injuries and consequent diminished function of the brachioradialis and extensor carpi radialis longus.^77,131,196 The medial approach, in contrast, has yielded excellent results.^{77,107,127,131,196} There remains the potential for ulnar nerve injury, but in tetraplegic patients with injury at level C6 or above, the ulnar nerve is nonfunctional. Also, the medial route is a more direct one, with less potential risk of adhesions.¹³¹ Even under maximal tension, no median nerve injuries or vascular compression have been observed.¹⁹⁷ This procedure is generally associated with a 40⁷⁸ to 47%¹⁹⁶ loss in elbow flexion force, but most authors report that their patients to not register any significant complaints related to this loss^110,196 even in contrast to the 24% reduction noted with the lateral route.^159,255

Technique

Preoperative clinical examination is essential to ensure the presence of an active supinator and brachialis muscle. Ulnar innervated muscles must be assessed to determine if there is any remaining function that could be reduced. This procedure can also be performed with the patient in supine position under axillary block.⁷⁹

The medial approach is clearly established.^131,196 This requires a longitudinal incision along the medial intermuscular septum, through which the ulnar nerve is identified. The biceps tendon is released from the radial tuberosity anteriorly through an incision in the antecubital fossa, passed over the ulnar nerve, and attached to the olecranon via a bony tunnel posteriorly with the elbow in full extension. Fixation is performed by drilling a unicortical hole from the tip of the olecranon to the posterior cortex with a small drill bit. This hole is enlarged sequentially by drilling until it can accommodate the biceps tendon. Two small drill holes are placed through the opposite posterior cortex through which nonabsorbable braided suture, also placed within the tendon, is passed. The sutures are used to pull the tendon into the unicortical hole, and then tied over the bone with the elbow in extension.

General protocols have been established for the postoperative care.^109,159,173 The arm is usually immobilized for 3 weeks, after which a brace is fitted with the elbow in extension. Active flexion and extension develops at 15 degrees per week, and movement is integrated into daily activities in a graded fashion. More rigorous precaution can be afforded through added protection as described by Fridén and Lieber⁸⁸ and Kuz et al.¹³¹

Results

Results of the medial approach have been encouraging, with consistent restoration of elbow extension. Kuz et al¹³¹ reported on the outcome in four transfers, and Revol et al¹⁹⁶ in 13 cases, with all patients achieving M4 elbow extension strength 18 months postoperatively. Loss of elbow flexion strength was significant (47% on average), but subclinical in all cases. The lateral routing technique has been associated with a 24% reduction in elbow flexion power.¹⁵⁹ Mulcahey et al,¹⁷³ in a prospective study comparing eight deltoid-to-triceps and eight biceps-to-triceps transfers, found M3 or better strength in 7 of 8 biceps transfers compared with 1 of 8 deltoid transfers. Impressive loss in elbow flexion torque was seen (52%), which persisted through the 24-month follow-up period despite some clinical improvement. Kozin and Schloth¹²⁷ reported a case in which bilateral biceps-to-triceps transfer was successfully used to salvage a failed bilateral deltoid-to-triceps transfer. Furthermore, the technique has been shown to increase the pinch strength from a previous brachioradialis transfer.³⁸ The learning time to activate the biceps as an elbow extensor takes from 3 to 6 months.¹⁹⁶

Brachioradialis Transfer

In 1938, Ober and Barr¹⁸⁵ described the posterior transfer of the freed anterior margin of the brachioradialis into the proximal ulna, olecranon, and triceps tendon to restore active elbow extension. The addition of the extensor carpi radialis to strengthen the brachioradialis was advised if its power was insufficient. Immobilization of the elbow in full extension and supination was advised, and exercises were started at 10 days. Extension of the elbow against gravity was possible in all six cases. No subsequent reports of the procedure have appeared in the literature.

The technique was modified in 2005 by Ozkan et al¹⁸⁹ to include a bipolar transfer of the brachioradialis muscle. The short-term results showed slight improvement postoperatively, depending on shoulder abduction. The relative weakness of the brachioradialis muscle was cited as a possible reason for this finding. It is a radial nerve innervated muscle but may be available for transfer due to possible mixed lesions or the higher likelihood of cross-innervation from multiple roots.

Teres Major-To-Triceps Transfer

A teres major to triceps transfer has been postulated to be strong enough to keep the forearm positioned on a table but not strong enough to lift the body from a chair in paraplegia.¹⁸² No cases have been reported in the literature to date.

Transfers for Restoration of Forearm Rotation

Children with posterior cord or mixed palsies that develop a supination contracture not permitting any active pronation past neutral in a patient with a functional hand are generally considered for operative management.¹¹³

History

Paralytic supination contracture of the forearm can occur as a result of brachial plexus palsy and poliomyelitis,^41,188,253 or in tetraplegia levels below C5.⁸⁹ Secondary partial or complete paralysis of the flexor-pronator muscles in the presence of unopposed biceps and supinator muscles is the underlying common denominator. The deformity not only is cosmetically displeasing but also seriously limits the function of the hand for grasping and two-handed activities. Patients with this deformity cannot perform tasks that require pronation, such as controlling a wheelchair joystick, as well as most personal hygiene functions. In children, this is especially cumbersome because it prevents the use of a computer keyboard.¹⁹²

Patients presenting with supination contracture concurrent with an anterior dislocation of the radial head can be treated by transfer of the biceps insertion to the ulna. Nondynamic correction of the supination deformity by closed osteoclasis^26,41 or open osteotomy of the forearm bones²⁵⁶ was advised by earlier authors. Schottstaedt and colleagues²⁰⁸ suggested changing the biceps from a supinator to a pronator by transferring its tendon to the side of the radial tuberosity opposite its normal insertion, but they did not report their results. Zancolli performed a long Z lengthening of the tendon, rerouting the distal strip of the tendon around the neck of the radius.²⁵³ All 14 of his patients also required release of the contracted soft tissues, particularly the interosseous membrane, to obtain passive correction of the supination deformity before the biceps rerouting. Manske and coworkers believed that soft tissue releases could be avoided by performing the biceps rerouting earlier; if correction was unsatisfactory, a secondary percutane-ous osteoclasis of the radius and ulna was recommended.¹⁵⁴

The goal for any surgery is active elbow flexion, with the forearm positioned in neutral rotation or slight pronation.^113,191 If the radial head is not dislocated, the forearm can be pronated passively, and there is active supination (on electromyography), then a Zancolli-type biceps rerouting can be carried out, with or without release of the contracture.²⁵³ Here the goal is to achieve active pronation, and this is the most frequently used corrective procedure. Finally, Hoyen and colleagues¹¹⁹ prefer to perform a radius pronation osteotomy, which allows full correction past that offered by biceps-pronator plasty and interosseous membrane and distal radioulnar joint release. The osteotomy is made just distal to the pronator insertion, and fixation is performed after the radius is rotated a desired amount to position the forearm more optimally. This allows more rapid rehabilitation, and offers reliable results.¹¹⁰ Although biceps rerouting has been found to give the best forearm motion, afterward it will not be available for tendon transfer, leaving elbow extension to be achieved by posterior deltoid-to-triceps transfer in most cases. Elbow extension strength may be improved in patients who undergo forearm osteotomy and a biceps-to-triceps transfer, but at this time, the choice of procedure seems to depend in some degree on surgeon preference.

Biceps Rerouting: Technique

This description is based on those of Zancolli²⁵³ and Manske and coworkers¹⁵⁴ (Fig. 71-29). A high tourniquet is employed, and the biceps tendon is exposed through an incision starting on the medial aspect of the distal arm and extending across the flexion crease of the elbow and distally on the lateral aspect of the forearm. The lacertus fibrosus is incised, and the median nerve and brachial artery are retracted medially. The biceps tendon is exposed to its insertion into the bicipital tuberosity, and the radial recurrent leash of vessels is divided. The tendon is divided by a long Z-plasty to its insertion, and the distal segment is passed posteriorly around the radial neck at the level of the tuberosity using a ligature carrier. The tendons are reattached by side-to-side suture, effectively lengthening the tendon by about 1.5 cm. A long-arm cast is applied with the forearm in the neutral position and the elbow at a right angle for 4 to 6 weeks. If the deformity is long standing and the patient is older, soft tissue releases often are required to obtain passive forearm rotation. The interosseous membrane and supinator muscle can be released through a long dorsal incision overlying the ulna. The extensor muscles are retracted toward the radius, and this protects the interosseous nerve. Owings and colleagues¹⁸⁸ suggested releasing the supinator from the volar lateral surfaces of the radius through the anterior incision.

FIGURE 71-29 Biceps tendon rerouting to restore pronation. A, The biceps tendon is divided by a long Z-plasty extended to its insertion. B and C, The distal end of the divided tendon is passed around the neck of the radius using a ligature passer. The two layers of the tendon are reattached side to side, effectively lengthening the tendon by about 1.5 cm.

(After Zancolli, E. A., and Mitre, H. Latissimus dorsi transfer to restore elbow flexion. J. Bone Joint Surg. 55A:1265, 1973.)

Results

Zancolli performed soft tissue releases and biceps tendon rerouting in 14 patients with paralytic supination contracture of the forearm (four had poliomyelitis, eight birth palsies, and two tetraplegia).²⁵³ Correction to the neutral position or some pronation was maintained in all patients, and eight had 10 to 60 degrees of active pronation. Owings and others reported nine good results, 11 satisfactory results, and two poor results in 26 patients who had biceps tendon rerouting using the Z-plasty technique.¹⁸⁸ The two poor results were related to problems with stability of the proximal radius. Manske and associates¹⁵⁴ reported the results of Zancolli’s biceps tendon rerouting in 11 patients with supination deformity secondary to obstetric paralysis. The neutral position was obtained in nine, and six had active supination-pronation movement averaging 42 degrees (range 15 to 65 degrees). Two patients, neither of whom had preoperative passive pronation to neutral, obtained satisfactory results after a secondary percutaneous osteoclasis of the radius and ulna. The authors recommended that surgical correction of paralytic supination deformity of the forearm be done between 3 and 6 years of age. Leffert and Pess¹⁴¹ reported four good and two improved results among six patients using Zancolli’s method of biceps rerouting.

More than 2 years’ follow-up was reported on five patients with C5, C6 obstetric brachial plexus palsy, and biceps-to-ulna transfers for correction of supination contractures concurrent with dislocation of the radial head.¹¹³ No pronation past neutral was possible preoperatively in each case. Postoperatively, there was full active flexion with no rotation and muscle grades from M3 to M5, with passive pro- and supination from 60 to 75 degrees, respectively. The transfer did not affect active rotation. These authors also reported on eight children with supination contracture and located the radial head where biceps rerouting was performed and evaluated after more than 2 years. In all cases, no passive pronation was possible. Postoperatively, more effective flexion was possible in neutral rotation, with active pronation against gravity possible in all, ranging from 30 to 90 degrees.¹¹³ Eleven of 14 flexion-supination contractures in Freehafer’s group were corrected by cast treatment alone, but five elbows in three patients went on to undergo biceps tendon tenotomy. There were no complications, one patient required six tenotomies due to bilateral recurrence, and all elbows achieved acceptable ADL function and regained M4 flexion and supination.⁸⁶ However, biceps tendon tenotomy in tetraplegia is not found in other current literature.

Complications

Zancolli²⁵³ reported on two patients who had overcorrection, presumably because the biceps tendon suture was under excessive tension. Owings and colleagues¹⁸⁸ reported on one patient who had persistent weakness of thumb extension, two who had proximal radial instability, and one who developed excessive pronation.

History

Because it is infrequently indicated, muscle transfer to regain supination in the paralyzed upper extremity has received scant attention in the literature. Steindler²²³ described transferring the flexor carpi ulnaris tendon into the dorsal aspect of the distal radius. Tubby²⁴⁰ described transferring the flexor carpi radialis and pronator teres through the interosseous space to the back of the radius to achieve supination in the spastic upper extremity. Schottstaedt and associates²⁰⁸ noted that providing active supination using the flexor carpi ulnaris or palmaris longus redirected dorsally into the radial shaft was often necessary after Steindler’s flexorplasty.

Technique—Flexor Carpi Ulnaris Transposition to the Radius

This technique is based on Steindler’s method (Fig. 71-30).²²³ The flexor carpi ulnaris tendon is detached, and its distal half is mobilized through a 12-cm incision along the volar-ulnar aspect of the forearm. The dorsolateral surface of the distal radius is exposed between the extensor pollicis brevis and the extensor carpi radialis longus tendons using a 5-cm longitudinal incision. A subcutaneous tunnel is created between this incision and the proximal end of the first incision, and the flexor carpi ulnaris tendon is pulled through. A hole is drilled through the distal radius, and the tendon is fed through the hole from the dorsal to the volar aspect. Its end is reflected back and sutured to itself under tension with the forearm supinated and the elbow flexed. A long-arm cast, with the wrist in slight dorsiflexion, the forearm in full supination, and the elbow at a right angle, is worn for 3 weeks. Part-time splinting is continued for 2 months.

FIGURE 71-30 Transfer of the flexor carpi ulnaris to restore supination. A, The flexor carpi ulnaris tendon is detached distally, mobilized proximally, and brought out through the proximal incision. B and C, The dorsoradial aspect of the distal radius is exposed. The flexor carpi ulnaris is redirected through a subcutaneous tunnel and attached to the radius through a drill hole.

(After Steindler, A.: Muscle and tendon transplantation at the elbow. In AAOS: Instructional Course Lectures on Reconstruction Surgery. Ann Arbor, JW Edwards, 1944, p. 276.)

Results

Steindler²²⁴ reported 11 good and 5 poor results from 16 flexor carpi ulnaris transfers to the radius. A good transfer functioned actively through a useful arc with at least 40 degrees of pronation-supination movement.