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Management of Total Paralysis of the Brachial Plexus by the Double Free-muscle Transfer TechniqueFrom the Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi City, Japan Correspondence: Kazuteru Doi, MD, PhD, Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Shimoga 862-3, Ogori, Yamaguchi City, Yamaguchi-ken 754-0002, Japan. Tel.: +81 83 972 0333; fax: +81 83 973 8610. E-mail: doimicro{at}saikyo.or.jp.
The double free-muscle transfer technique achieved a dramatic revolution in the treatment of total paralysis of the brachial plexus by providing universal prehensile function, although several requirements such as successful free-muscle transfers, stability of the proximal joints and prolonged postoperative rehabilitation are necessary for the success of this procedure. To obtain the best outcome of double free-muscle transfer, it is imperative to understand the key factors, viz. selection of the donor muscle, meticulous microsurgical technique, importance of proximal joint stability, selection of the kind of grip and postoperative rehabilitation. Double free-muscle transfer is not a simple microsurgical muscle transfer for finger movement, but a universal reconstructive procedure for total paralysis of the upper limb.
Key Words: brachial plexus • free-muscle transfer • prehension • nerve transfer • shoulder function For the totally avulsed brachial plexus, several surgical approaches have been developed to restore prehension (Carlstedt, 2007; Chuang et al., 2002; Liang et al., 2007; Songcharoen et al., 2001). Most of these procedures, other than the double free-muscle transfer (DFMT) technique (Doi et al., 1995, 2000, 2003; Hentz and Doi, 2005), have not provided functional improvements for the patients in their daily activities and some authorities are still continuing to carry out meaningless procedures that have shown only academic advancements for traditional surgeons and not functional improvement for their patients. Most patients with brachial plexus injury have a normal contralateral upper limb and can perform most of the activities of daily living. This is very different from patients with spinal cord injuries, in whom both hands are paralysed and in whom key pinch is the most usable hand function. However, because of the greater difficulty pinching with the reconstructed hand, in comparison with the contralateral normal hand, patients with brachial plexus injuries rarely pinch with the injured hand, even if the active range of motion is satisfactory. Patients with complete brachial plexus palsy need to undergo reconstructive surgery to allow a few important two-handed activities, such as lifting a heavy box with both hands or holding a bottle while opening its cap (Doi et al., 2000; Hentz and Doi, 2005). They need both a powerful palmar grip in the affected limb, independent of the contralateral limb, and the ability to use both hands. Direct activation of finger flexion and extension is imperative for a powerful grip. Stability of the proximal joints is a primary requisite for hand function. Stability of shoulder and elbow joints is necessary for proper transmission of the power of the transferred muscle to achieve effective hand function in DFMT. We do not recommend scapulo-humeral arthrodesis as it limits the arc of the reconstructed hand and the patient’s subsequent motor activities. Hence, we attempt to restore shoulder function by nerve transfer (Doi et al., 2003). Not only movement of the elbow, but also its stability, is extremely important for optimal use of the hand (Doi et al., 1997). Many authors dismiss the significance of elbow stabilisation because of the technical difficulty in obtaining this and reconstruct finger flexion, or extension, without providing some form of elbow stabilisation. In addition to finger extension, or finger flexion, all of the transferred muscles in the DFMT technique simultaneously cause elbow flexion, similar to that achieved by brachioradialis muscle transfer in cases of spinal cord injury. In this situation, with lack of elbow extensor function, the patient must stabilise the unstable elbow with the contralateral hand, a useless manoeuvre in daily activities. To cater to the several requirements for reconstruction of universal prehensile function following total avulsion of the brachial plexus, we introduced the DFMT technique and, then, performed several modifications in response to patients’ requests (Takka et al., 2005). We have already reported the initial series of this technique (Doi et al., 1995, 2000), which provided satisfactory prehensile function, provided the indications for, and execution of, this procedure, i.e. selection of the donor muscle (the gracilis muscle only), are adhered to strictly. Most readers misunderstand that DFMT is a transfer intended only for reconstruction of finger flexion and extension. However, this treatment consists of several procedures, as detailed below. The other requirement for achieving good results is postoperative rehabilitation, the detailed techniques of which will be introduced below. In this article, I present our up-to-date indications, pre-operative evaluation, operative techniques, postoperative management, outcomes and intended future developments in the treatment of complete brachial plexus palsy.
Indications Not all patients with a total paralysis of the brachial plexus are candidates for DFMT. Suitable patients should be younger than 40 years-old and have sustained the injury within the preceding 6 months. They should have no adjacent major vessel injury (e.g. of the subclavian or axillary artery), have no injury or history of surgery, involving the donor motor nerve (e.g. the spinal accessory or the intercostal nerves). They should be motivated and have financial and emotional support to participate in a prolonged postoperative rehabilitation programme (Doi et al., 2000). Although all of our patients older than 40 years-old showed normal reinnervation of the transferred muscles, the ultimate power of the muscles that was achieved in these older patients was too weak to perform prehensile function, despite satisfactory elbow flexion. In DFMT, supplemental procedures, such as cross-nerve transfer for shoulder function and elbow extension, are indispensable to achieving useful prehension (Doi et al., 1997, 2003). These procedures should be conducted within 6 months of the injury, before atrophy of the denervated muscles becomes irreversible. Patients who sustained brachial plexus injury more than 6 months previously can be assessed as possible candidates for surgery, according to their shoulder and elbow function following spontaneous recovery of the upper C5 or C6 root, or after preceding surgical procedures. Patients who have sustained major vessel injury of the subclavian or axillary arteries, which have been repaired with artificial or autogenous vein graft, may possibly be candidates for DFMT provided the donor vessels are proven to be patent by pre-operative angiogram. However, they are not good candidates because of a risk of vascular compromise of the DFMT anastomoses. The recovered spinal accessory nerve should be avoided for use as the donor motor nerve. Displaced rib fractures are usually accompanied by intercostal nerve injury and these patients should not be enroled as candidates for DFMT. Causalgia is not a contra-indication for DFMT and severe pain always subsides after the procedure. Patients tolerate pain without medication during the periods of reconstructive surgery and postoperative rehabilitation.
Pre-operative evaluation We have tried to assess the possibility of requiring nerve root repair of the C5 nerve root using pre-operative clinical evaluation without using these two techniques. We found that Tinel’s sign, sensation in the C5 area and EMG study of the infraspinatus muscle are not useful in assessing the possible need for nerve root repair of the C5 nerve root. On the other hand, we found a highly significant correlation between the summary of the radiological findings, macro- and microscopic examination of the nerve root by surgical exploration and direct electric stimulation with the possibility of requiring nerve root repair of the C5 nerve root. Among the radiological parameters, a coronal view of a CT myelogram is the most simple and reliable indicator (Fig 1) (Yamazaki et al., 2007).
Operative technique The double free gracilis muscle transfer technique consists of five established, but modified, reconstructive procedures:
In addition, a sixth set of secondary reconstructive procedures such as arthrodesis of the wrist joint to increase stability and Zancolli’s metacarpophalangeal joint capsulodesis or transient immobilisation of the interphalangeal joints to control claw–finger deformity may be required. Tenolysis of the transferred muscles and tendons may also be necessary later. Timing of the various reconstructive procedures is important and is guided by several criteria. Procedures 1 and 2 were performed at a single first operation but, recently, we have carried out these procedures in two stages because of the prolonged duration of the combined surgery. Procedures 3 to 5 are performed at a third stage, usually 2 or 3 months after the first free-muscle transfer. Sometimes, the order of procedures 2 and 3 to 5 is reversed, when more than 6 months has elapsed, because the former consists of only a free-muscle transfer and the latter includes motor nerve repair. If the motor nerve of the triceps muscle was repaired in procedure 1, then the motor branch of the biceps muscle is repaired in procedure 4 to strengthen elbow flexion, or for use as a supplementary donor muscle for secondary reconstruction of failed, or weak, finger flexion or elbow extension. Any sixth procedure is done approximately 1.5 years after the first stage of the operation, depending on the degree of recovery.
Procedure 1
Procedures 2 to 5 For details of procedures 2 to 5, the reader should refer to "Doi’s procedure" (Figs 4, 5 and 6) (Addosooki et al., 2006; Doi et al., 1995, 2000, 2003; Hattori et al., 2001; Hentz and Doi, 2005; Wahegaonkar et al., 2007 ).
Postoperative management After each muscle transfer, the upper limb is immobilised with the shoulder in 30° of abduction and flexion and 60° of internal rotation, the elbow in 100° of flexion, the wrist in the neutral position and the fingers in forced flexion or extension, depending on the type of reconstruction. The limb is supported by an arm brace and cast for 8 weeks and, subsequently, by a sling to prevent subluxation of the glenohumeral joint until recovery of the shoulder girdle muscles.
Rehabilitation Before 1999, our routine postoperative protocol did not provide any passive mobilisation during the first 6 postoperative weeks. At this time, gentle passive exercises of the shoulder, elbow and all finger joints, but not the wrist joint, were, then, started. Following electromyographic documentation of re-innervation of the transferred muscle, usually performed between 3 and 8 months postoperatively, electromyographic feedback techniques using small portable myotrainers with surface electrodes, MYO ANALYZER, MA-230 (MINATO, Osaka, Japan), are started to train the transferred muscles to move the elbow and fingers (Fig 7), as the patients usually have difficulty contracting each muscle effectively. Surface electrodes are placed on the monitoring skin flap of each muscle transplant. The myotrainer, or myomonitor, allows the patient, or therapist, to see what the muscle is doing and, thereby, learn better control. Initially, the first free muscle for elbow flexion and finger extension, reinnervated from the terminal branch of the spinal accessory nerve, was activated by adduction of the scapula. The second free muscle for finger flexion, reinnervated from the fifth and sixth intercostal nerves, was activated by maximal expiration or inspiration. Electromyographic feedback has been very helpful in the early stages by allowing the patient to visualise and hear the activity. After gaining more appropriate feedback, patients can work on strengthening their own muscles without effort. They can then achieve contraction of the transferred gracilis muscle without having to simulate the original muscle action, such as adducting the scapula or respiration.
After recovery of active elbow and finger movements, electromyographic feedback to train for independent finger flexion and extension is commenced and simultaneous flexion of the elbow should be negated by the antagonist action of the triceps brachii, which depends on reinnervation from the third and fourth intercostal nerves. The patients are taught a home programme to activate the individual transferred gracilis and triceps muscles.
Usually, the patients stay for 2 months after the second free-muscle transfer and then attend a nearby rehabilitation centre two or three times a week and visit our clinic every 1 to 3 months for another Finally, most patients with satisfactory recovery of active finger motion develop an intrinsic-minus finger deformity but can use their hand for hook grip. In order to increase the strength of the hook grip and arm–trunk prehension, progressive resistance exercises, consisting of strengthening finger flexion, elbow flexion and shoulder adduction with pulleys and weights are recommended. The patients were then started on skilled activities, such as lifting, holding, carrying and pinching.
Early mobilisation technique The tendon compression technique is performed by compressing the tendinous portion of the transferred gracilis muscles at the elbow to move the fingers into extension, or flexion, depending on the reconstruction, while the therapist holds the patient’s wrist in the neutral position and the fingers in flexion, or extension, to resist the therapist’s compression, with the elbow in the extended position to make the gracilis tendon taut (Fig 8).
The tenodesis technique is also performed to move the finger joints while the patient’s wrist is forced passively into flexion and extension by the therapist. Intraoperative examination showed that tendon compression at the elbow moves the gracilis tendon by 5 mm and the tenodesis technique by another 10 mm at the wrist. However, by adding assisted movement of the metacarpophalangeal joints and the wrist, the sliding distance of the gracilis tendon using the compression technique is increased to 25 mm. This combined manoeuvre is included in the postoperative programme following double free gracilis muscle transfer and is continued until active movement of the fingers occurs. After successful reinnervation of the muscle, subsequent management is the same as after the conventional technique.
Secondary reconstructions
Wrist fusion
Control of claw-finger deformity Claw–finger deformity frequently develops after satisfactory recovery of finger flexion and extension and should be prevented by a plastic static volar splint, but most patients need secondary procedures, including wrist fusion with Zancolli’s MCP joint capsulodesis or transient interphalangeal joints fixation with K-wires, depending on the patient’s selection under a pre-operative trial with a simulation splint (Takka et al., 2005).
Over a period of 14 years, between March 1992 and September 2005, 67 patients have undergone the DFMT procedure for prehensile reconstruction following complete paralysis of the brachial plexus. Sixteen patients with a free-muscle transfer of the latissimus dorsi or the rectus femoris muscle and two patients in whom the spinal accessory nerve, which had been paralysed and partially recovered, was used as the donor nerve in the first series of double free gracilis muscle transfer techniques were excluded. Of the remaining 49 patients with double gracilis transfers, three patients did not come back for rehabilitation after surgery and one patient has had less than 24 months postoperative follow-up. One patient had a postoperative vascular compromise, which was revised successfully, but she developed a partial ischaemic necrosis of the muscle. The remaining 44 patients were analysed to assess the long-term results. The follow-up period was a mean of 40 (range 24–164) months after the second free-muscle transfer. Mean active shoulder abduction and flexion was 26° (range 0–70) and the mean arc of shoulder rotation was 57° (range 0–150). Mean active elbow flexion was 114° (range 70–145). The mean total active range of motion (TAM) of the fingers was 45° (range 0–110). Except for four patients, all of the patients (91%) obtained more than 20° of TAM (Fig 10).
Power of lifting with hook grip was examined using a specially designed machine (Digital Hanging Scale; Kansai Scale Co., Osaka, Japan) in 25 patients. Mean power of hook grip lifting was 4.1 kg (range 0–14) (Fig 11). There was no statistical correlation between finger TAM and power of hook grip lifting.
Sensory recovery was also satisfactory, with most patients obtaining protective sensation in the hand (Ihara et al., 1996). Half of the patients complained of causalgia pre-operatively, and, although we never treat their pain problems, other than by administration of conventional analgesics, they did not complain of too much pain during follow-up.
Similar DFMT techniques are reported in the literature (Bishop, 2005; Gu, 2005; Shin et al., 2005) although the authors of these studies did not adhere strictly to our procedure. Some still used the Latissimus Dorsi muscle as the donor muscle, although this muscle does not provide satisfactory finger function because of adhesion of the muscle to the pulley system or poor muscle excursion. The Gracilis muscle is the donor muscle of choice. Dynamic stability of shoulder and elbow joints is imperative to achieving satisfactory prehensile function (Doi et al., 2002). In other words, reconstruction of basic function of the proximal joints takes priority over restoration of finger function. The DFMT technique is not a simple free-muscle transfer. It is a complete functional reconstruction of the totally paralysed limb, which needs understanding of the basic science of biomechanics. There is significant correlation between the stability and function of elbow and shoulder joints and the total active range of finger motion.
The other essential requirement is postoperative rehabilitation. Most patients continue their postoperative rehabilitation for a mean period of The present target of grip function is palmar grip, especially digitopalmar prehension, which is commonly used to hold and lift larger objects. The patients usually use this to lift up bags while the contralateral hand is occupied doing something such as carrying a bag, or opening an umbrella. In the near future, when additional procedures such as the intelligent prosthesis can provide more functional muscles, we may aim for a more precise level of pinch. However, I am not sure that this will be accepted by the patients, because they can do all but a few things with the contralateral (normal) hand.
Manuscript received September 28, 2007. Accepted for publication December 20, 2007.
Addosooki AI, Doi K, Hattori Y (2006). Technique of harvesting the gracilis for free functioning muscle transplantation. Techniques of Hand and Upper Extremity Surgery, 10: 245–251.[CrossRef]Addosooki A, Doi K, Hattori Y, Wahegaonkar A (2007). Wrist arthrodesis after double free-muscle transfer in traumatic total brachial plexus palsy. Techniques of Hand and Upper Extremity Surgery, 11: 29–36.[CrossRef]Bishop AT (2005). Functioning free-muscle transfer for brachial plexus injury. Hand Clinic, 21: 91–102.[CrossRef]Carlstedt T. Central nerve plexus injury, London, Imperial College Press, 2007: 139–166.Chuang DCC, Ma HS, Borud LJ, Chen HC (2002). Surgical strategy for improving forearm and hand function in late obstetric brachial plexus palsy. Plastic and Reconstructive Surgery, 109: 1934–1946.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]Doi K, Hattori Y, Ikeda K, Dhawan V (2003). Significance of shoulder function in the reconstruction of prehension with double free-muscle transfer after complete paralysis of the brachial plexus. Plastic and Reconstructive Surgery, 112: 1596–1603.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]Doi K, Hattori Y, Tan SH, Dhawan V (2002). Basic science behind functioning free muscle transplantation. Clinics of Plastic Surgery, 29: 483–495.[CrossRef]Doi K, Muramatsu K, Hattori Y, Otsuka K, Tan SH, Nanda V, Watanabe M (2000). Restoration of prehension with the double free muscle technique following complete avulsion of the brachial plexus. Indications and long-term results. Journal of Bone and Joint Surgery A, 82: 652–666.[CrossRef]Doi K, Sakai K, Kuwata N, Ihara K, Kawai S (1995). Double free-muscle transfer to restore prehension following complete brachial plexus avulsion. Journal of Hand Surgery A, 20: 408–414.Doi K, Shigetomi M, Kaneko K, Soo-Heong T, Hiura Y, Hattori Y, Kawakami F (1997). Significance of elbow extension in reconstruction of prehension with reinnervated free-muscle transfer following complete brachial plexus avulsion. Plastic and Reconstructive Surgery, 100: 364–372 (Discussion 373–374).[CrossRef][Web of Science][Medline] [Order article via Infotrieve]Gu LQ (2005). Current advances in treatment of brachial plexus injury in China. Journal of Japanese Society for Reconstructive Microsurgery, 18: 87–90.Hattori Y, Doi K (2006). Vascularized ulnar nerve graft. Techniques of Hand and Upper Extremity Surgery, 10: 103–106.[CrossRef]Hattori Y, Doi K, Dhawan V, Ikeda K, Kaneko K, Ohi R (2004). Choline acetyltransferase activity and evoked spinal cord potentials for diagnosis of brachial plexus injury. Journal of Bone and Joint Surgery B, 86: 70–73.Hattori Y, Doi K, Toh S, Baliarsing AS (2001). Surgical approach to the spinal accessory nerve for brachial plexus reconstruction. Journal of Hand Surgery A, 26: 1073–1076.Hentz VR, Doi K. Traumatic brachial plexus injury. In: Green DP, Hotchikiss RN, Pederson WC, Wolfe SW (Eds). Green’s operative hand surgery. 5, Pennsylvania, Elsevier, 2005, vol. 2: 1351–1356.Ihara K, Doi K, Sakai K, Kuwata N, Kawai S (1996). Restoration of sensibility in the hand after complete brachial plexus injury. Journal of Hand Surgery A, 21: 381–386.[CrossRef][Medline] [Order article via Infotrieve]Chen Liang, Gu Yu-Dong, Hu Shao-Nan, Xu Jian-Guang, Xu Lei, Fu Yang (2007). Contralateral C7 transfer for the treatment of brachial plexus root avulsions in children – a report of 12 cases. Journal of Hand Surgery A, 32: 96–103.Shin AY, Spinner RJ, Steinmann SP, Bishop AT (2005). Adult traumatic brachial plexus injuries. Journal of American Academic Orthopedic Surgery, 13: 382–396.Songcharoen P, Wongtrakul S, Mahaisavariya B, Spinner RJ (2001). Hemi-contralateral C7 transfer to median nerve in the treatment of root avulsion brachial plexus injury. Journal of Hand Surgery A, 26: 1058–1064.Takka S, Doi K, Hattori Y, Kitajima I, Ikeda K, Guafen C (2005). Selection of grip function in double free gracilis transfer procedures after complete paralysis of the brachial plexus. Annals of Plastic Surgery, 54: 610–614.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]Wahegaonkar AL, Doi K, Hattori Y, Addosooki AI (2007). Technique of intercostal nerve harvest and transfer for various neurotization procedures in brachial plexus injuries. Techniques of Hand and Upper Extremity Surgery, 11: 184–194.[CrossRef]Yamazaki H, Doi K, Hattori Y, Sakamoto S (2007). Computerized tomography myelography with coronal and oblique coronal view for diagnosis of nerve root avulsion in brachial plexus injury. Journal of Brachial Plexus and Peripheral Nerve Injury, 2: 16.[CrossRef]
Journal of Hand Surgery (European Volume), Vol. 33, No. 3,
240-251 (2008)
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Abstract
PATIENTS AND METHODS
to 2 years. 
years after the second muscle transfer. However, not all of our patients attended our hospital for the whole of this period. They comprehended the detailed mechanism of the operative procedures and were educated on how to move the reinnervated muscles during their stay in hospital, and, then, they maintained the training themselves. The most important point of the rehabilitation is not to stop the power strength exercises and the patients should be encouraged to use the reconstructed hand, even if it is inconvenient and useless. Patients who have been persuaded to use the reconstructed hand for work have shown unbelievable functional recovery.