Doi K, Kuwata N, Muramatsu K, Hottori Y, Kawai S
Department of Orthopaedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan.
Hand Clin. 1999 Nov;15(4):757-67.
Recent interest in reconstruction of the upper limb following brachial plexus injuries has focused on the restoration of prehension following complete avulsion of the brachial plexus. The authors use free muscle transfers for reconstruction of the upper limb to resolve the difficult problems in complete avulsion of the brachial plexus. This article describes the authors' updated technique--the double free muscle procedure. Reconstruction of prehension to achieve independent voluntary finger and elbow flexion and extension by the use of double free muscle and multiple nerve transfers following complete avulsion of the brachial plexus (nerve roots C5 to T1) is presented. The procedure involves transferring the first free muscle, neurotized by the spinal accessory nerve for elbow flexion and finger extension, a second free muscle transfer reinnervated by the fifth and sixth intercostal nerves for finger flexion, and neurotization of the triceps brachii via its motor nerve by the third and fourth intercostal motor nerves to extend and stabilize the elbow. Restoration of hand sensibility is obtained via the suturing of sensory rami from the intercostal nerves to the median nerve. Secondary reconstruction, including arthrodesis of the carpometacarpal joint of the thumb and glenohumeral joint, and tenolysis of the transferred muscle and distal tendons, improve the functional outcome. Based on the long-term result, selection of the patient, donor muscle, and donor motor nerve were indicated. Most patients were able to achieve prehensile functions such as holding a can and lifting a heavy box. This double free muscle transfer has provided prehension for patients with complete avulsion of the brachial plexus and has given them new hope to be able to use their otherwise useless limbs.
近期，臂丛神经损伤后上肢重建的研究重点在于臂丛神经完全撕脱后抓握功能的恢复。作者采用游离肌肉移植来重建上肢，以解决臂丛神经完全撕脱的难题。本文介绍了作者更新后的技术——双游离肌肉手术。阐述了通过双游离肌肉和多神经移植，在臂丛神经（C5至T1神经根）完全撕脱后重建抓握功能，实现手指和肘部独立自主屈伸的方法。该手术包括移植第一块由副神经神经化的游离肌肉用于肘部屈曲和手指伸展，第二块由第五和第六肋间神经再支配的游离肌肉移植用于手指屈曲，以及通过第三和第四肋间运动神经经肱三头肌运动神经对其进行神经化以伸展和稳定肘部。通过将肋间神经的感觉支与正中神经缝合来恢复手部感觉。二次重建，包括拇指腕掌关节和盂肱关节的关节固定术，以及移植肌肉和远端肌腱的松解术，可改善功能结果。基于长期结果，对患者、供体肌肉和供体运动神经的选择给出了建议。大多数患者能够实现抓握功能，如握住罐子和提起重物。这种双游离肌肉移植为臂丛神经完全撕脱的患者提供了抓握功能，给了他们使用原本无用肢体的新希望。
