From the Department of Orthopaedic Surgery, Emory University.
Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and Chang-Gung University.
Plast Reconstr Surg. 2023 Sep 1;152(3):472e-475e. doi: 10.1097/PRS.0000000000010397. Epub 2023 Mar 14.
Obstetric brachial plexus palsy can cause deformities of the upper extremity in up to 92% of patients. Elbow reconstruction is difficult because co-contraction of the elbow flexor (EF) and elbow extensor (EE) muscles makes the traditional treatment strategy ineffective. The authors propose a novel strategy to minimize the effect of co-contraction, comprising transfer of an EF to the triceps and a staged gracilis muscle transplantation [functioning free muscle transplantation (FFMT)] to augment EF. The authors hypothesize this will lead to improved elbow flexion and extension, as well as decreased elbow flexion contracture.
A single-center retrospective review of patients who received a gracilis FFMT for EF after EF-to-EE transfer was performed. EF/EE strength and range of motion data were collected from the last clinical visit. Patients were excluded if they had fewer than 1.5 years of follow-up. A control group with sequelae of obstetric brachial plexus palsy and nonsurgical treatment was used for comparison.
Twenty-one patients were included. Average age at muscle transfer was 7.6 ± 5.5 years (range, 3 to 22 years) and at gracilis FFMT was 10.4 ± 6.0 years (range, 5 to 26 years). Average follow-up was 7.3 ± 6.5 years (range, 1.5 to 14.8 years). After EF-to-EE transfer, EE strength increased significantly from Medical Research Council grade 2.2 ± 0.4 to 3.4 ± 0.5 ( P < 0.0001) and EF decreased from 3.2 ± 1.1 to 1.1 ± 1.1 ( P < 0.0001) and recovered to grade 3.3 ± 0.7 after gracilis FFMT. EF contracture was significantly lower compared with that in the nonsurgical cohort ( P = 0.029).
Patients who undergo EF-to-EE transfer followed by gracilis FFMT have equivalent EF strength with significantly improved EE and improved elbow flexion contracture.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
产科臂丛神经麻痹可导致高达 92%的患者上肢出现畸形。由于肘部屈肌（EF）和伸肌（EE）肌肉的共同收缩，肘部重建较为困难，这使得传统的治疗策略无效。作者提出了一种新的策略，通过将 EF 转移到三头肌并分期进行 gracilis 肌肉移植[功能性游离肌肉移植（FFMT）]来增强 EF，以最大限度地减少共同收缩的影响。作者假设这将导致肘部屈伸的改善，并减少肘部屈曲挛缩。
对接受 EF 至 EE 转移后 gracilis FFMT 的患者进行了一项单中心回顾性研究。从最后一次临床就诊中收集 EF/EE 力量和运动范围数据。如果患者的随访时间少于 1.5 年，则将其排除在外。使用患有产瘫后遗症和非手术治疗的对照组进行比较。
共纳入 21 例患者。肌肉转移的平均年龄为 7.6 ± 5.5 岁（范围，3 至 22 岁）， gracilis FFMT 的平均年龄为 10.4 ± 6.0 岁（范围，5 至 26 岁）。平均随访时间为 7.3 ± 6.5 年（范围，1.5 至 14.8 年）。EF 至 EE 转移后，EE 力量从医学研究委员会（MRC）分级 2.2 ± 0.4 显著增加至 3.4 ± 0.5（ P < 0.0001），EF 从 3.2 ± 1.1 减少至 1.1 ± 1.1（ P < 0.0001），并在 gracilis FFMT 后恢复至 3.3 ± 0.7 级。EF 挛缩明显低于非手术组（ P = 0.029）。
接受 EF 至 EE 转移后 gracilis FFMT 的患者 EF 力量相等，EE 显著改善，肘部屈曲挛缩改善。
临床问题/证据水平：治疗性，IV。
