Functional muscle transfer for restoration of elbow flexion: a review

Abstract

Elbow flexion is essential to help position the hand in space and for functional use of the upper extremity. Loss of elbow function can be secondary to many etiologies, including but not limited to brachial plexus injury, traumatic muscle loss, oncologic treatment, poliomyelitis or congenital absence of motor function. The end result is a significant functional limitation of the upper extremity. One method to address the loss of elbow flexion is the use of a functional muscle transfer. These transfers can be performed as pedicled rotational transfers or free functional muscle transfers. This article reviews functional muscle transfers for restoration of elbow flexion as a treatment option for patients with an otherwise unreconstructable extremity.

Keywords

Brachial plexus injury / elbow flexion / functional muscle transfer / pedicled latissimus dorsi transfer / free latissimus dorsi transfer / free gracilis transfer

References

[1] Loeffler BJ.Restoration of elbow flexion.Hand Clin2016;32:311-21.

[2] Toussaint CP.The double fascicular nerve transfer for restoration of elbow flexion.Neurosurgery2011;68:64-7

[3] Garcia RM.Free flap functional muscle transfers.Hand Clin2016;32:397-405

[4] Hovnanian AP.Latissimus dorsi transplantation for loss of flexion or extension at the elbow; a preliminary report on technic.Ann Surg1956;143:493-9

[5] Schottstaedt ER,Bost FC.Complete muscle transposition.J Bone Joint Surg Am37:897-918; discussion, 918

[6] Manktelow RT.Free muscle transplantation to provide active finger flexion.J Hand Surg Am1978;3:416-26

[7] Zuker RM,Manktelow RT,Candlish S.Volkmann's ischemic contracture in children: the results of free vascularized muscle transplantation.Microsurg1991;12:341-5

[8] Doi K,Muramatsu K,Kawai S.Double muscle transfer for upper extremity reconstruction following complete avulsion of the brachial plexus.Hand Clin1999;15:757-767.

[9] Stevanovic M.Functional free muscle transfer for upper extremity reconstruction.Plast Reconstr Surg2014;134:257e-74e

[10] Doi K,Hattori Y.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 Am2000;82:652-666

[11] Doi K,Kawakami F,Otsuka K.Limb-sparing surgery with reinnervated free-muscle transfer following radical excision of soft-tissue sarcoma in the extremity.Plast Reconstr Surg1999;104:1679-87

[12] Ihara K,Kawai S,Yamamoto M.Functioning muscle transplantation after wide excision of sarcomas in the extremity.Clin Orthop Relat Res1999;358:140-8.

[13] Stevanovic MV,Ghiassi A.Single-stage reconstruction of elbow flexion associated with massive soft-tissue defect using the latissimus dorsi muscle bipolar rotational transfer.Plast Reconstr Surg Glob Open2016;4:e1066. PMCID:PMC5055029

[14] Pierce TD.Use of the pedicled latissimus muscle flap for upper-extremity reconstruction.J Am Acad Orthop Surg2000;8:324-31

[15] Mahajan RK,Bhamre A,Kumar P.A retrospective analysis of latissimus dorsi-serratus anterior chimeric flap reconstruction in 47 patients with extensive lower extremity trauma.Indian J Plast Surg2018;51:24-32. PMCID:PMC5992936

[16] Chuang DC,Yeh MC.Functional restoration of elbow flexion in brachial plexus injuries: results in 167 patients (excluding obstetric brachial plexus injury).J Hand Surg Am1993;18:285-91

[17] Haas F,Koch H.Immediate functional transfer of the latissimus dorsi myocutaneous island flap for reestablishment of elbow flexion in upper arm replantation: two clinical cases.J Trauma2004;57:1347-50.

[18] Haninec P.Reconstruction of paralyzed biceps brachii muscle by transposition of pedicled latissimus dorsi muscle: report of two cases.Acta Chir Plast1998;40:41-4.

[19] Kawamura K,Tomita Y,Shigematsu K.Restoration of elbow function with pedicled latissimus dorsi myocutaneous flap transfer.J Shoulder Elb Surg2007;16:84-90

[20] Martin S,McGarry K,Lewis H.A review of functional latissimus dorsi transfers for absent elbow flexion and supination.Shoulder Elb2021;13:329-33 PMCID:PMC8513000

[21] Moneim MS.Latissimus dorsi muscle transfer for restoration of elbow flexion after brachial plexus disruption.J Hand Surg Am1986;11:135-9

[22] O'Ceallaigh S,O'Connor TP.Functional latissimus dorsi muscle transfer to restore elbow flexion in extensive electrical burns.Burns2005;31:113-5.

[23] Schoeller T,Hussl H.Functional transposition of the latissimus dorsi muscle for biceps reconstruction after upper arm replantation.J Plast Reconstr Aesthet Surg2007;60:755-9

[24] Vekris MD,Lykissas MG,Vekris AD.Restoration of elbow function in severe brachial plexus paralysis via muscle transfers.Injury2008;39 Suppl 3:S15-22

[25] Zancolli E.Latissimus dorsi transfer to restore elbow flexion. An appraisal of eight cases.J Bone Joint Surg Am1973;55:1265-1275

[26] Hirayama T,Atsuta Y.Restoration of elbow flexion by complete latissimus dorsi muscle transposition.J Hand Surg Am1987;12:194-8.

[27] Rogachefsky RA,Brearley W.Latissimus dorsi pedicled flap for upper extremity soft-tissue reconstruction.Orthopedics2002;25:403-8

[28] Eggers IM,Matime AM.Elbow flexorplasty: a comparison between latissimus dorsi transfer and Steindler flexorplasty.J Hand Surg Br1992;17:522-5

[29] Cambon-Binder A,Durand S,Oberlin C.Elbow flexion restoration using pedicled latissimus dorsi transfer in seven cases.Chir Main2012;31:324-30

[30] Takami H,Ando M.Latissimus dorsi transplantation to restore elbow flexion to the paralysed limb.J Hand Surg Br1984;9:61-3

[31] Hochberg J.Latissimus dorsi myocutaneous flap to restore elbow flexion and axillary burn contracture: a report on two pediatric patients.J Pediatr Orthop1982;2:565-8

[32] Germann G.Functional soft-tissue coverage in skeletonizing injuries of the upper extremity using the ipsilateral latissimus dorsi myocutaneous flap.Plast Reconstr Surg1995;96:1130-5

[33] Mordick TG,Brantigan C.Pedicled latissimus dorsi transfer for immediate soft-tissue coverage and elbow flexion.Plast Reconstr Surg1997;99:1742-4.

[34] de Moraes FB,da Silva RP,de Paiva Magalhães D.Evaluation of elbow flexion following free muscle transfer from the medial gastrocnemius or transfer from the latissimus dorsi, in cases of traumatic injury of the brachial plexus.Rev Bras Ortop2015;50:660-5 PMCID:PMC4867918

[35] Alshammari SM,Almarzouq SF.Successful elbow flexion reconstruction using latissimus dorsi muscle transfer following a road traffic accident and upper limb trauma.Am J Case Rep2021;22:e933374 PMCID:PMC8552418

[36] Lupon E,Lellouch AG,Meresse T.Elbow flexion reconstruction after arm-sparing excision for high-grade triton sarcoma: a case report.J Med Case Rep2020;14:103 PMCID:PMC7412844

[37] Kameda T,Yokota T.Restoration of elbow flexion with a pedicled latissimus dorsi myocutaneous flap to a brachial plexus injury at the terminal nerve level.Plast Reconstr Surg Glob Open2019;7:e2472 PMCID:PMC6846311

[38] Sood A,Russo G.Functional latissimus dorsi transfer for upper-extremity reconstruction: a case report and review of the literature.Eplasty2017;17:e5. PMCID:PMC5317028

[39] Ma CH,Wu CH,Yu SW.Reconstruction of upper extremity large soft-tissue defects using pedicled latissimus dorsi muscle flaps--technique illustration and clinical outcomes.Injury2008;39:67-74

[40] Minami A,Ohnishi N.The latissimus dorsi musculocutaneous flap for extremity reconstruction in orthopedic surgery.Clin Orthop Relat Res1990;260:201-6

[41] Bostwick J 3rd,Wallace JG.Sixty latissimus dorsi flaps.Plast Reconstr Surg1979;63:31-41

[42] Botte MJ.Flexorplasty of the elbow.Clin Orthop Relat Res1989;245:110-6.

[43] Stern PJ.The latissimus dorsi flap for reconstruction of the brachium and shoulder.J Bone Joint Surg Am1988;70:526-535

[44] Terzis JK.Free muscle transfer in posttraumatic plexopathies part II: the elbow.Hand2010;5:160-70 PMCID:PMC2880674

[45] Doi K,Kuwata N,Kawai S.Reconstruction of finger and elbow function after complete avulsion of the brachial plexus.J Hand Surg Am1991;16:796-803

[46] Doi K,Kuwata N,Kawai S.Double free-muscle transfer to restore prehension following complete brachial plexus avulsion.J Hand Surg Am1995;20:408-14

[47] Terzis JK,Soucacos PN.Outcomes of brachial plexus reconstruction in 204 patients with devastating paralysis.Plast Reconstr Surg1999;104:1221-40.

[48] Martins-Filho FVF,Silva GB.Do technical components of microanastomoses influence the functional outcome of free gracilis muscle transfer for elbow flexion in traumatic brachial plexus injury?.Orthop Traumatol Surg Res2021;107:102827

[49] Chung DC,Wei FC.Results of functioning free muscle transplantation for elbow flexion.J Hand Surg Am1996;21:1071-7

[50] Wade SM,Wind GG,Souza JM.The inverted free functioning gracilis muscle transfer for restoration of elbow flexion following delayed presentation or failed primary nerve reconstruction of upper trunk injuries.Tech Hand Up Extrem Surg2020;24:26-31

[51] Bertelli JA.Free reverse gracilis muscle combined with Steindler flexorplasty for elbow flexion reconstruction after failed primary repair of extended upper-type paralysis of the brachial plexus.J Hand Surg Am2019;44:112-20

[52] Maldonado AA,Kircher R N MF,Bishop AT.Free functioning gracilis muscle transfer for elbow flexion reconstruction after traumatic adult brachial pan-plexus injury: where is the optimal distal tendon attachment for elbow flexion?.Plast Reconstr Surg2017;139:128-36

[53] Silva GB,Cho AB,de Resende MR.Gracilis muscle transfer to elbow flexion in brachial plexus injuries.Acta Ortop Bras2020;28:165-7 PMCID:PMC7405841

[54] Ikuta Y,Tsuge K.Free muscle graft as applied to brachial plexus injury-case report and experimental study.Ann Acad Med Singap1979;8:454-8.

[55] Krakauer JD.Intercostal nerve transfer for brachial plexopathy.J Hand Surg Am1994;19:829-35

[56] Barrie KA,Shin AY,Bishop AT.Gracilis free muscle transfer for restoration of function after complete brachial plexus avulsion.Neurosurg Focus2004;16:E8

[57] Kay S,Wiper J,Jones F.Microvascular free functioning gracilis transfer with nerve transfer to establish elbow flexion.J Plast Reconstr Aesthet Surg2010;63:1142-9

[58] Sungpet A,Kawinwonggowit V.Transfer of one fascicle of ulnar nerve to functioning free gracilis muscle transplantation for elbow flexion.ANZ J Surg2003;73:133-5

[59] Armangil M,Yıldırım T.Outcome of free gracilis muscle transfer for the restoration of elbow flexion in traumatic brachial plexus palsy.Jt Dis Relat Surg2021;32:633-41 PMCID:PMC8650652

[60] Chen J,Wang H,Yang J.Functional outcome of contralateral C7 nerve transfer combined with free functional gracilis transplantation to repair total brachial plexus avulsion: a report of thirty-nine cases.Int Orthop2022;46:1053-62. PMCID:PMC9001549

[61] Dodakundi C,Hattori Y.Outcome of surgical reconstruction after traumatic total brachial plexus palsy.J Bone Joint Surg Am2013;95:1505-12.

[62] Doi K,Yamazaki H,Addosooki A.Importance of early passive mobilization following double free gracilis muscle transfer.Plast Reconstr Surg2008;121:2037-45

[63] Elzinga K,Olson JL,Babicki S.Double free gracilis muscle transfer after complete brachial plexus injury: First Canadian experience.Plast Surg22:26-9. PMCID:PMC4128430

[64] Hosseinian MA.Cross pectoral nerve transfer following free gracilis muscle transplantation for chronic brachial plexus palsy: a case series.Int J Surg2008;6:125-8

[65] Yang Y,Fu G.Functioning free gracilis transfer to reconstruct elbow flexion and quality of life in global brachial plexus injured patients.Sci Rep2016;6:22479 PMCID:PMC4776154

[66] Potter SM.Reliability of functioning free muscle transfer and vascularized ulnar nerve grafting for elbow flexion in complete brachial plexus palsy.J Hand Surg Eur Vol2017;42:693-9

[67] Nicoson MC,Tung TH.Donor nerve sources in free functional gracilis muscle transfer for elbow flexion in adult brachial plexus injury.Microsurg2017;37:377-82

[68] Estrella EP.Functioning free muscle transfer for the restoration of elbow flexion in brachial plexus injury patients.Injury2016;47:2525-33.

[69] El-Gammal TA,Kotb MM.Free functioning gracilis transplantation for reconstruction of elbow and hand functions in late obstetric brachial plexus palsy.Microsurg2015;35:350-5

[70] Chim H,Spinner RJ,Shin AY.Free functioning gracilis transfer for traumatic brachial plexus injuries in children.J Hand Surg Am2014;39:1959-66

[71] Coulet B,Boretto J,Chammas M.Free gracilis muscle transfer to restore elbow flexion in brachial plexus injuries.Orthop Traumatol Surg Res2011;97:785-92

[72] Sochol KM,Stevanovic M.Restoration of elbow flexion with a free functional gracilis muscle transfer in an arthrogrypotic patient using a motor nerve to pectoralis major.Hand2020;15:739-43 PMCID:PMC7543222

[73] Madura T,Hattori Y,Shimoe T.Free functioning gracilis transfer for reanimation of elbow and hand in total traumatic brachial plexopathy in children.J Hand Surg Eur Vol2018;43:596-608

[74] Cho AB,Pisani MJ.Comparison between donor nerves to motorize the free functional gracilis muscle transfer for elbow flexion: Retrospective study of 38 consecutive cases in traumatic adult brachial plexus injuries.Microsurg2019;39:400-4

[75] Nath RK,Somasundaram C.Restoration of elbow flexion in patients with complete traumatic and obstetric brachial plexus injury after functional free gracilis muscle transfer: our experience and management.Eplasty2017;17:e34. PMCID:PMC5700453

[76] Kimura LK,Capócio R.Microsurgical transfer of the gracilis muscle for elbow flexion in brachial plexus injury in adults: retrospective study of eight cases.Rev Bras Ortop2011;46:534-9 PMCID:PMC4799279

[77] Yavari M,Nadri S.Contralateral medial pectoral nerve transfer with free gracilis muscle transfer in old brachial plexus palsy.J Surg Res2018;231:94-8

[78] De Rezende MR,Paulos RG,Ribak S.Free gracilis muscle transfer with ulnar nerve neurotization for elbow flexion restoration.Int Orthop2021;45:689-96

[79] Wechselberger G,Strickner N,Schoeller T.Restoration of elbow flexion after brachial plexus injury by free functional rectus femoris muscle transfer.J Plast Reconstr Aesthet Surg2009;62:e1-5

[80] Akasaka Y,Takahashi M.Restoration of elbow flexion and wrist extension in brachial plexus paralyses by means of free muscle transplantation innervated by intercostal nerve.Ann Chir Main Memb Super1990;9:341-50

[81] Doi K,Ihara K,Kawai S.Reinnervated free muscle transplantation for extremity reconstruction.Plast Reconstr Surg1993;91:872-83

[82] Ahmadi I,Miller G,Leong J.End-to-end versus end-to-side microvascular anastomosis: a meta-analysis of free flap outcomes.J Reconstr Microsurg2017;33:402-11

[83] Mahmood B,Wolfe SW,Fufa DT.Cadaveric evaluation of myelinated nerve fiber count in the nerve to the gracilis muscle in relation to use as a free functional muscle transfer for elbow flexion.J Reconstr Microsurg2020;36:311-5.

[84] Oliver JD,Graham EM,Hu MS.Functioning free muscle transfer for brachial plexus injury: a systematic review and pooled analysis comparing functional outcomes of intercostal nerve and spinal accessory nerve grafts.J Reconstr Microsurg2020;36:567-71

[85] Kovachevich R,Wood CM,Bishop AT.Complications of intercostal nerve transfer for brachial plexus reconstruction.J Hand Surg Am2010;35:1995-2000

[86] Stranix JT,Lee ZH.Skin paddles improve muscle flap salvage rates after microvascular compromise in lower extremity reconstruction.Ann Plast Surg2018;81:68-70