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Free functioning muscle transfer


Alain Gilbert and Vittore Costa

In cases of severe muscle paralysis or destruction there are often few surrounding
muscles left for tendon transfers. These are the most common indications for
microsurgical muscle transplantations. Muscle transfers have been used for a long time
for the coverage of large or infected defects. Although the addition of function in muscle
transfer seems logical, it is not easy as several factors complicate the procedure such as
the presence/absence of a good donor nerve and the tension of the muscle belly.
Tamai et al (1970) had experimentally proved in dogs that the muscle transplant could
remain vital and functioning. Following this, reports of clinical cases were published in
several parts of the world (Shanghai 1976, Ikuta et al 1976, Harii et al 1976, Manktelow
and McKee 1978, OBrien 1977, Gilbert, 1981).
However, even 25 years later, there are very few large series with long follow-up. This
may be due to few indications and a certain scepticism regarding this technique.

Muscles used for free functioning transfer

For transplantation of a muscle several conditions need to be fulfilled:


1. The defect created by removal should be easily filled.
2. It should be a rather long muscle with, if possible, a tendon on each extremity.
3. It should have only one neurovascular hilus or at least a major one.
4. The excursion of the muscle should be as long as possible, to obtain maximum
movement.
5. Its cross-section should be thick enough to produce sufficient force (the maximum
tension in mammals is 4 kg/cm2 of cross-sectional area; Carlson, 1974).
Several muscles have been used:

Gracilis
This muscle is most frequently used. It is long (3040 cm), with a strong terminal tendon.
It is not too bulky and can be fitted into a limb without additional skin cover. It has a
single proximal motor nerve, coming from the obturator nerve, that measures 68 cm.
The only drawback is its vascular supply: there is a dominant proximal pedicle but also a
secondary pedicle going to the middle part of the muscle and a small distal pedicle; since
this distal pedicle is never necessary, there may sometimes be problems when the middle
pedicle is
Severe traumatic defects of the upper limb 324

Figure 1
The gracilis muscle. The main proximal neurovascular
pedicle.

ligated. If, after this ligation, the distal part of the muscle becomes dark (congested), it
may be necessary to anastomose the vein from the middle pedicle. This was necessary in
two cases out of 20.

Pectoralis major
This is a large muscle with a single vascular pedicle, but it has several motor nerves, is
very bulky, and its removal creates a severe defect.

Pectoralis minor
This is small and weak and has been used only in facial reconstruction. It is difficult to
raise, as it is deep to pectoralis major but can be isolated on one or two pedicles.

Latissimus dorsi
This is a very well known muscle, long, strong, with a single vascular and motor pedicle.
Its removal does not create a severe defect. However, some techniques of lengthening the
latissimus dorsi with the gluteal aponeurosis allow its transplantation up to the fingers.
There are few indications for using a free latissimus dorsi muscle transfer in the upper
extremity.

Gastrocnemius
This is a very strong muscle (the strongest in the body), easy to raise, with a proximal
neurovascular pedicle. The sural nerve as a vascularized nerve graft (useful in
Volkmanns contracture) and/or the overlying skin can be raised at the same time. The
defect created is compensated by the soleus. Its main drawbacks are its bulk and very
short excursion.
Free functioning muscle transfer 325

Other muscles that have been used are rectus femoris (it has several vascular hila);
extensor carpi radialis brevis (too small); extensor digitorum brevis from the foot (whose
vascularization is very delicate and has been used mainly for the face).

Figure 2
In some cases, it is necessary to use the second pedicle.

Surgical technique

The surgical technique for gracilis transfer for elbow flexion is as follows. With the
patient lying supine, the thigh is prepared including the pubis area. The muscle can be
felt, at least in thin patients, by feeling its contraction during flexionextension of the
knee. This positioning is important if a combined muscle and skin flap is to be used: the
area covering the muscle is very narrow and if the skin incision is not precisely
positioned, the vitality of the skin flap may be impaired. Finding the muscle is not always
easy as all the adductor muscles have the same direction and size. However, among these
muscles, the gracilis is relatively thin and has a large proximal pedicle.
Once the muscle is found, dissection is easy. On the medial aspect, the three pedicles
can be found:
The distal pedicle is small and systematically sacrificed.
The middle pedicle is cut but with the vessels kept long, in order to be accessible if
needed.
The proximal major pedicle is dissected carefully. The vascular pedicle is followed
until the trunk of the perforator where the diameter of the artery is 1.5 mm. The nerve
has an upward direction towards the inguinal ligament. It originates from the obturator
nerve.
Severe traumatic defects of the upper limb 326

Figure 3
(a) A 6-year-old patient. The arm was previously
replanted. The biceps is destroyed. (b) The gracilis is
transplanted with neurovascular anastomoses. The nerve
from the biceps is used. (c,d) Active elbow flexion after 8
months.

This motor nerve gives one or two branches to the muscle before the main hilus. The
existence of these branches that provoke separate contraction of some groups of muscle
fibres has led some authors (Mankletow 1988) to suture them separately and expect an
individual contraction to reconstruct a different movement (thumb + fingers).
Free functioning muscle transfer 327

Figure 4
(a) Proximal long standing paralysis of the brachial plexus.
(b) Gracilis transplantation on the intercostal nerves. (c)
Strong elbow flexion, lifting 2 kg.

Once the pedicle is dissected (68 cm for vessels, 810 cm of nerve), the muscle can
be detached; before detaching it, it is important to mark the length with regular stitches,
in order to fix it with the exact tension. At this moment it is useful to inject the patient
with a muscle relaxant to avoid contraction, once it is be detached. The distal tendon is
cut and, protecting the pedicle, the proximal fibrous attachment to the pubis. It is then
possible to cut the pedicle and transfer the muscle to the upper extremity.
The muscle is placed in the arm which is widely exposed. It will be fixed proximally
to the coracoid process or to the pectoralis major aponeurosis. The nerve is sutured to the
donor nerve, usually the sural nerve placed 1 year before (taken from the pectoralis major
nerve on the contralateral side). The size matches well and there should be no tension.
The artery is sutured usually with a branch of the profundus humeral artery; the venous
suture connects the vein to a superficial vein. The revascularization of the muscle is
assessed, particularly the venous drainage of the distal third. If after 1015 minutes it is
dark and seems congested, the vein from the middle pedicle is sutured.
Then the distal tendon is fixed with the elbow in acute flexion, using the stitches
placed before to control the tension. It is usually fixed to the biceps tendon. After closure,
the elbow is immobilized in flexion for 6 weeks.
Severe traumatic defects of the upper limb 328

Surgical technique for transplantation in the forearm after Volkmanns


contracture
There are some differences in the forearm.
The gracilis is usually too long. It is possible to use another shorter muscle
(gastrocnemius, latissimus) or fix the gracilis higher in the arm.
The distal fixation is different. The tendon is sutured to the deep flexors and a special
technique allows simultaneous positioning of the thumb.
It is usually possible to use a local nerve. The anterior interosseus nerve is often
separated at its origin and can be used.

Figure 5
(a) Volkmanns contracture with destruction of the flexor
muscles in a 10-year-old child. (b) Transplantation of the
medial gastrocnemius with the sural nerve. (c,d) Limited
flexionextension.
Free functioning muscle transfer 329

A flap may be needed as the forearm is often scarred.

Personal series

Between 1977 and 2001, 39 free muscle transplantations were done in 38 patients, for
various aetiologies. Only 31 were done following traumatic destruction or paralysis of
muscles. One patient had a postoperative haematoma and necrosis of the muscle; he
subsequently had a second gracilis transfer to the arm.
Twenty-four cases were followed-up for a maximum of 12.4 years and a minimum of
11 months (average 4.7 years). The aetiologies of these were traumatic brachial plexus (n
= 15); obstetrical brachial plexus (n = 3); and Volkmanns contracture (n = 6).
Gracilis was used most often (20 times) but we used also gastrocnemius (three times)
and extensor carpi radialis brevis (once) in the forearm. There were 15 reconstructions of
elbow flexion, seven reconstructions of finger flexion and 2 extensor reconstructions. The
criteria used for assessment were: joint ROM and MMT, and the modified scale for end-
result evaluation (Dellon et al 1974, Mackinnon and Dellon 1988).
The results showed that 12 patients had muscle function >M3 and 12 <M3. The results
are easier to assess in the arm for an elbow reconstruction secondary to paralysis than in a
forearm after Volkmanns contracture. In the latter case, the associated nerve paralysis,
intrinsic wasting, and stiffness will have a deleterious

Figure 6
(a) Young paraplegic with complete brachial plexus. The
gracilis is transferred using cross-chest pectoralis major
nerve neurotization. (b) Elbow flexion after 1 year.
Severe traumatic defects of the upper limb 330

effect on the result, even with excellent muscle contraction.


For elbow flexion reconstruction, the donor nerve used was the upper pectoralis nerve
from the contralateral side (13 times) and twice the sternomastoid nerve from the same
side. Both of the latter had poor results with weak muscle contraction and no function.
The contralateral pectoralis nerve was used in two stages. In the first stage, the upper
nerve was isolated and sutured to the end of the sural nerve. The nerve was passed
subcutaneously, anterior to the chest to the upper arm. At this level, a small incision
allowed us to find the nerve end and mark it with a metal clip. After 3 weeks of
immobilization, the progression of nerve regeneration was followed with the Tinel sign.
When tapping the nerve over the chest the patient felt a slight tingling over the thorax on
the donor site. Usually, after 1 year, the regeneration was considered complete and the
second stage of muscle transplantation was possible.
For reconstruction of finger flexion or extension, the anterior interosseus nerve was
used seven times and twice a contralateral graft from the pectoralis nerve was used.

Discussion

Since the first reports on clinical muscle transplantation in 1976, few series have been
published.
In 1988, Manktelow, using mostly gracilis, reported the results of his first 12 transfers
for the forearm. Ten of these cases had good results. Akasaka et al in 1991 showed that in
17 cases of rectus femoris transplantation for elbow flexion, eight of the 11 cases
assessed had resulting function >M3. In wrist extension surgery, they had performed 29
transfers in conjunction with elbow flexion. They found that nine cases had regained M3
function after 1 year. Chuang et al (1993) stated that in a series of 17 patients, using
intercostal nerve transfers, seven had good results (>M3).
Groting et al (1990), used gracilis and tensor fascia lata in 12 patients with satisfactory
results (M4) in 11 cases. Berger and Brenner (1995) used a free latissimus dorsi (8 times)
for elbow reconstruction after brachial plexus paralysis. They found an average of 12 kg
of power against resistance.
Doi et al (1993) suggested using free muscle transfers for the combined reconstruction
of two functions, i.e. elbow flexion and fingers flexion or elbow flexion and wrist
extension. They operated 46 patients (58 muscles) of which 31 had had post-traumatic
loss. The donor nerves were the accessory nerve or intercostal nerves. They claimed that
with a double muscle transfer or a double function, single muscle transfer, the results are
good, allowing useful function in completely paralysed patients. Ercetin (1994) showed
that in transplanting gracilis muscle for Volkmanns contracture, he could obtain active
flexion of the fingers in 23 cases out of 28.
Although these series are few in number, they all demonstrate the feasibility of
vascularized muscle transfer. The results vary from 40% to 70%. Useful results were
acheived depending on various factors such as:
A good donor nerve is necessary. In cases of brachial plexus paralysis, authors have
used several extraplexal neurotizations (sternomastoid nerve, intercostal nerves,
contralateral C7 or pectoralis nerve). These nerves cannot bring axonal influx of the
same quality as an anterior interosseus nerve, or a musculocutaneous nerve.
Free functioning muscle transfer 331

Sensation in the hand is very important, not for recovery of the motor nerve but for its
use.
Associated nerve lesions can impair the result. In finger flexors reconstruction, the
addition of an ulnar nerve paralysis, with claw and lack of thumb adduction will not
allow good function.
Provided these problems can be avoided, the procedure is reliable and can give some very
good results.

References

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intercostals nerve crossing for reconstruction of elbow flexion and wrist extension in
brachial plexus injuries, Microsurgery 12:34651.
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proximal forearm associated with radial and/or median nerve palsy: nerve recovery
after coverage with a pedicle latissimus dorsi muscle flap, Ann Plast Surg 46:125.
Berger A, Brenner P (1995) Secondary surgery following brachial plexus injuries,
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injuries), J Hand Surg (Am) 18:285.
Chuang DC, Carver N, Wei FC (1996) Results of functioning free muscle transplantation
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Clark JM (1946) Reconstruction of biceps brachii by pectoral muscle transplantation, Br
J Surg 34:180.
Dellon AL, Curtis RM, Edgerton MT (1974) Reeducation of sensation in the hand after
nerve injury and repair, Plast Reconstr Surg 53:297305.
Doi K, Sakai K, Ihara K et al (1993) Reinnervated free muscle transplantation for
extremity reconstruction, Plast Reconstr Surg 91:872.
Doi K, Marumatsu K, Hattori Y et al (2000) Restoration of prehension with the double
free muscle technique following complete avulsion of the brachial plexus. Indications
and long-term results, J Bone Joint Surg (Am) 82:65266.
Ercetin O, Akinci M (1994) Free muscle transfer in Volkmanns ischaemic contracture,
Ann Chir Main 13: 512.

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