Functional Free Muscle

Transfer for Upper

Extremity Reconstruction

Milan Stevanovic, MD Professor of Orthopaedic Surgery

USC Keck School of Medicine

When and How

Introduction

• Loss of upper extremity function

secondary to brachial plexus

injuries or severe trauma is a

challenging problem

Introduction

• Advances of microsurgery

offered a new approach in

the management of these

injuries

•Tamai et al.

Free muscle transplants in

dogs, with microsurgical

neurovascular anastomoses

Plast Reconstr Surg. 1970

Donor Muscle

Considerations • Muscle Power

–Terzis, J Hand Surg, 1978

• Suggested that muscle bulk decreases with muscle transplantation to 25-50%

–Doi , Clin Plast Surg, 2002

• Transplanted muscles regained full strength, sometimes stronger than pre-transplanted power

•Stevanovic, Seaber,

Urbaniak

Canine experimental free

muscle transplantation.

Microsurgery. 1986

Functional Free Muscle

Indications

• Deficiency of critical motor function with no suitable tendon transfer options

• No suitable rotational muscle transfer

• Soft tissue defect requiring coverage in combination with functional loss

Functional Free Muscle

Special Indications

• Facial reanimation

Ralph Manktelow and Ron Zucker

•Manktelow, Zuker,

McKee

Functioning free

muscle transplantation.

J Hand Surg [Am]. 1984

Functional Free Muscle

Indications

• Functional reconstruction after: –Trauma

–BPBP

–Volkmann’s

–Tumor

–Congenital deficiencies

Functional Free Muscle

Upper Extremity Indications

• Deltoid

• Biceps

• Triceps

• Finger Flexors

• Finger Extensors

• Thenar

Functional Free Muscle

Goals (Manktelow)

• Supply a useful range of motion

• Provide adequate strength for functional activities

• FMT must be under volitional control

Functional Free Muscle

Pre-requisites

• Motivated patient

• Supple passive range of motion

• Suitable recipient site motor nerve and vessels

• Good soft tissue coverage and underlying tissue bed for tendon gliding

Donor Muscle

Options

• Gracilis

• Latissimus

• Rectus femoris

• Pectoralis Major

• Medial gastrocnemius

• Tensor fascia lata

• Serratus Anterior

Indications

Free gracilis

Gracilis Transfer with Skin

• Deltoid reconstruction

• Elbow flexion

• Elbow extension

• Finger flexion

• Finger extension

Anterior Deltoid

Pedicle Latissimus

Free gracilis

Finger extension Finger flexion

Achieve optimal muscle

resting length

Surgical Technique: Key Points

Surgical Technique: Key Points

• Establish strong & appropriately located origin and insertion

Free gracilis for

finger extension

Illustrative case:

Flexor Origin Slide

Nerve Graft

Vascular Anastamosis

and neurorraphy

Cable grafting of severely

compromised median nerve

pedicle

Skin paddle post

Debridement of

partial necrosis

Healthy and viable

Underlying muscle

opponensplasty

tenolysis

Functional results at one year

Donor Muscle

General Considerations

• Expendible donor muscle –sacrificed with acceptable donor site

morbidity

• Adequate length and excursion for new function

• Sufficient force

• Vascular pedicle permits transfer

Free muscle transfer • Type of blood supply

• I. One vascular pedicle

• II. Dominant pedicles and

minor pedicles

• V. One dominant pedicle

and secondary segmental

pedicles

Free muscle transfer • Type of blood supply

• I. Rectus femoris,Tensor fascia

• lata

• II. Gracilis,Biceps femoris,Soleus

• V. Latissimus dorsi,Pectoralis

• major

Donor Muscle

Considerations

• Muscle Type –pennate (stronger)

–strap (better excursion)

• Cross sectional area –pennate - greater cross sectional

area results in greater strength

• Excursion –estimated as 40% of the msucle

resting length

Donor Muscle

Considerations

• Muscle Type

–pennate (stronger)

–Rectus femoris

–strap (better excursion)

–Gracilis, Latissimus dorsi,

Donor Muscle

Considerations

• Muscle Excursion

–Ideally 6-7 cm of muscle

excursion to produce

functional range of flexion

of fingers and elbow

Surgical Technique

Free muscle transfer

• technically

demanding

• microvascular

anastomoses

Free gracilis transfer

to reconstruct finger flexion

after rhabdomyosarcoma

resection

Illustrative case:

Free gracilis for finger flexion

tumor

Free gracilis for finger flexion

Free gracilis for finger flexion

Free gracilis for finger flexion

Free gracilis for finger flexion

Free serratus anterior

to reconstruct opposition

3 yrs after crush left hand and

thenar muscle debridement

Illustrative case:

Imaging

Operative

Operative

Operative

Operative

Serratus anterior

Operative

Operative

Operative

Operative

Operative

Functional Free Latissimus Courtesy MB Wood

Surgical Technique: Key Points

• Minimize Ischemia Time

–Irreversible muscle loss

increases with time

–Non-linear relationship

Surgical Technique: Key Points

• Nerve Considerations

–Recipient site nerve should be

motor fibers

–Neurorraphy should be done

as close as possible to

transplanted muscle

Reconstruction of

elbow flexion 4 years after

brachial plexus injury

Illustrative case

Functional Free Muscle

Post-Operative Management

• Immobilization

–Elbow

• 8 weeks

–Finger

• Flexors - 4 weeks – start PROM

• Extensors – 6 weeks start PROM

Functional Free Muscle

Post-Operative Management

• After EMG evidence of reinnervation: – Motor re-education with therapist

guidance

– Short sessions, ending when muscle fatigues

– Slow , gradual correction of contracture. Passive elongation of muscle can result in muscle fiber injury

Complications

Functional Free Muscle

Transfer • Demanding procedure

• Meticulous technique

• Experience in microsurgery

Conclusions

Immediate Reconstruction

of

finger flexion after severe

Compartment

Syndrome with

liquifactive muscle

necrosis

Immediate Functional Reconstruction

Flexor Tendons

Median Nerve

Principles of Free Functional Muscle

Transfers

140

FIN

Thank you

Thank you