Berger Alfred, Hierner Robert
Klinik für Plastische, Hand- und Wiederherstellungschirurgie, Schwerverbranntenzentrum der Medizinischen Hochschule Hannover, Hannover, Germany.
Oper Orthop Traumatol. 2009 Jun;21(2):141-56. doi: 10.1007/s00064-009-1704-9.
Reconstruction of powerful active elbow flexion. Reconstruction of missing muscle unit by neurovascular pedicled functional muscle transplantation.
Treatment of last choice for --secondary reconstruction of active elbow flexion in case of complete lesion of the brachial plexus or musculocutaneous nerve (M0 muscle function = replacement indication), partial but incomplete lesion of the brachial plexus or musculocutaneous nerve (M1-(3) muscle function = augmentation indication); --replacement of the elbow flexor muscles in case of primary muscle loss (tumor, trauma).
Concomitant lesions of the axillary artery. No adequate donor nerve. Relative: no sensibility at all at the forearm and hand.
Free functional biarticular myocutaneous transplantation of gracilis muscle. A myocutaneous gracilis flap is raised at the thigh. At the upper arm the flap is fixed proximally to the coracoid process or the lateral clavicle. The distal insertion is sutured to the distal biceps tendon. Vascular anastomoses are carried out in end-to-side fashion with the brachial artery and vein. Nerval coaptation is done in end-to-end technique using the muculocutaneous nerve.
Complete immobilization for 6 weeks. Dorsal upper arm splint until sufficient muscle power (M(4)). Progressive increase of active range of motion for another 6 weeks. Continuation of physiotherapy for 12-18 months. Postoperative standardized compression therapy, combined with scar therapy (silicone sheet).
Functionally useful results can be expected in 60-75% of patients, especially if there is some residual function (M1 or M2) left ("augmentation indication"). Early free functional muscle transplantation shows best results in patients with direct muscle defect, because all vascular and neuronal structures are still available, and no secondary changes such as fibrosis or joint stiffness are present yet. There are inconsistent results for patients with neurologic insufficiency (i.e., total brachial plexus palsy) or mixed neuromuscular insufficiency, such as compartment syndrome. Especially in complete brachial plexus lesion, free functional muscle transfer is often the only treatment option. Provided there is a good patient selection, satisfactory results can be achieved for elbow flexion. Whether a higher number of axons, as provided by the contralateral C7 transfer, will lead to better results is the topic of an ongoing study.
重建强大的主动屈肘功能。通过带神经血管蒂的功能性肌肉移植重建缺失的肌肉单元。
作为最后选择的治疗方法——用于臂丛神经或肌皮神经完全损伤时主动屈肘的二期重建（M0肌肉功能 = 替代适应症），臂丛神经或肌皮神经部分但不完全损伤（M1-(3)肌肉功能 = 增强适应症）；——原发性肌肉缺失（肿瘤、创伤）时替代屈肘肌。
腋动脉合并损伤。无合适的供体神经。相对禁忌症：前臂和手部完全无感觉。
股薄肌游离功能性双关节肌皮移植。在大腿掀起股薄肌肌皮瓣。在上臂，将肌皮瓣近端固定于喙突或锁骨外侧。远端止点缝合至肱二头肌远端肌腱。血管吻合采用与肱动脉和静脉端侧吻合的方式。神经吻合采用端端技术，使用肌皮神经。
完全固定6周。使用上臂背侧夹板直至肌肉力量足够（M(4)）。再进行6周主动活动范围的逐渐增加。继续物理治疗12 - 18个月。术后进行标准化压迫治疗，联合瘢痕治疗（硅胶片）。
60 - 75%的患者可预期获得功能上有用的结果，尤其是如果仍有一些残余功能（M1或M2）（“增强适应症）。早期游离功能性肌肉移植在直接肌肉缺损的患者中显示出最佳结果，因为所有血管和神经结构仍然可用，且尚未出现如纤维化或关节僵硬等继发性改变。对于神经功能不全（即完全性臂丛神经麻痹）或混合性神经肌肉功能不全（如骨筋膜室综合征）的患者，结果不一致。特别是在完全性臂丛神经损伤中，游离功能性肌肉转移往往是唯一的治疗选择。如果患者选择得当，屈肘可取得满意结果。由对侧C7转移提供更多轴突是否会导致更好的结果是一项正在进行的研究课题。
