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Functional transposition of the latissimus dorsi muscle for biceps reconstruction after upper arm replantation
Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 755e759
Functional transposition of the latissimus dorsi muscle for biceps reconstruction after upper arm replantation Thomas Schoeller a, Gottfried Wechselberger a, Heribert Hussl a, Georg M. Huemer b,c,* a
Clinical Department of Plastic and Reconstructive Surgery, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria b Department of Plastic Surgery, Sisters of Mercy Hospital, Seilerstaette 4, 4010 Linz, Austria c maz e Mikrochirurgisches Ausbildungs- und Forschungszentrum, Garnisonstrasse 21, 4020 Linz, Austria Received 17 September 2006; accepted 12 November 2006
KEYWORDS Replantation; Upper arm; Latissimus dorsi muscle; Functional reconstruction; Elbow flexion
Summary Major upper arm amputations are often accompanied by different levels of softtissue divisions involving crushing, traction, and avulsion injuries to various structures. In these cases the goal is not only the re-establishment of circulation, but also functional outcome. Some patients require further reconstruction for functional restoration of elbow flexion and additional soft tissue coverage. Five patients underwent functional latissimus dorsi transfer for restoration of elbow flexion after successful upper arm replantation at our institution. The transfer was unipolar in four patients and bipolar in one. The patients’ ages ranged from seven to 55 years. The time period between replantation and transfer ranged from two weeks to 12 months. All flaps healed well with minimal donor site morbidity. At mean 43-month follow-up (range: 22e65 months), functional results were good with M4 in three patients and M3 in two patients for elbow flexion. The pedicled latissimus dorsi muscle flap is a valuable tool to restore elbow flexion and provide coverage of soft tissue defects after major upper arm replantations. ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Address: Department of Plastic Surgery, Sisters of Mercy Hospital, Seilerstaette 4, 4010 Linz, Austria. Tel.: þ4369910878705. E-mail address: [email protected] (G.M. Huemer).
Amputation of the upper arm is a life threatening injury. Even if feasible, replantation of the amputated part is not always indicated.1 It very much depends on the patient’s condition, the condition of the amputated limb and the stump, the expected outcome, the infrastructure of the hospital, the surgical experience of the replanting team
1748-6815/$ - see front matter ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2006.11.032
756 and the time elapsed since the amputation.2e8 Thus, careful selection for the right indication is necessary. If the replantation has been performed successfully, several functional deficits have to be expected. Beside the anticipated slow nerve regeneration,9,10 direct trauma to the biceps and triceps muscle at the amputation site is an obvious problem resulting not only in poor muscle function but also wound healing problems.11 Functional transfer of the latissimus dorsi muscle as a pedicled flap is suggested if missing biceps function has to be reconstructed,12e14 but additionally when well vascularised tissue is required to promote wound healing on the upper arm. However, the combination of upper arm macroreplantation and the functional transposition of the latissimus dorsi muscle has rarely been described in the literature.15,16 We report our experience of upper arm replantation with early latissimus dorsi muscle transposition in a consecutive series of five patients.
Patients and methods From August 1997 to May 2002 we treated six patients for upper arm amputation (Fig. 1) and replanted the arm. The patients’ ages ranged from seven to 55 years (mean: 35.5 years). In one case acute re-amputation had to be performed within 24 h despite unimpaired perfusion due to a septic shock syndrome. The remaining five patients underwent replantation successfully. In all cases the radial and median nerve were coapted directly whereas the ulnar nerve showed an avulsion at the level of the cubital tunnel and had to be bridged with sural nerve grafts. In one case the brachial artery had to be bridged by a saphenous vein graft due to a second level injury. In one case a microsurgical revision was necessary on the first postoperative day due to a venous thrombosis. In that case a saphenous vein graft was employed successfully. Bone fixation was achieved with an AO-plate in all cases. In three cases when the elapsed time came critically towards the six hours, we temporarily bridged the arterial inflow with a catheter to establish circulation for ten minutes. Thus, the reperfusion injury was reduced and the critical time interval until definite
Figure 1 Complete amputation of the left upper arm in a twenty-year old patient with extensive local crushing of both amputation stumps.
T. Schoeller et al.
Figure 2 After successful replantation, wounds could not be closed primarily and instead artificial skin substitute (Epigard; Biovision GmbH, Ilmenau, Germany) was used.
perfusion could be extended. In all five patients we encountered delayed wound healing with partial necrosis of soft tissue at the amputation site (Fig. 2). This was mainly due to a necrosis of the distal part of the repaired biceps muscle. To overcome these two problems we transposed a functional pedicled myocutaneous latissimus dorsi muscle to restore biceps muscle function and to provide soft tissue coverage. All five patients underwent functional latissimus dorsi transfer for restoration of elbow flexion after successful upper arm replantation (Figs. 3 and 4). Latissimus dorsi transfer was unipolar in four patients and bipolar in one. The time period between replantation and latissimus dorsi transfer ranged from two weeks to 12 months.
Results All flaps healed well, and donor site morbidity was minimal. At mean 43-month follow-up (range: 22e65 months),
Figure 3 Three months later a monopolar pedicled myocutaneous latissimus dorsi was utilised for secondary wound coverage and restoration of elbow flexion in the same patient. One portion of the muscle was woven into the extensors of the forearm.
Functional transposition of the latissimus dorsi muscle
757
Figure 4 Immediate postoperative result after partial splitthickness skin grafting of the remaining muscle.
functional results were good (Muscle manual test of the limb indicated M4 in three patients for the elbow flexion and M3 in two patients). Successful restoration with an adequate range of motion in the elbow joint was obtained. The patients were capable of carrying out normal daily errands and all were satisfied with their outcome (Figs. 5 and 6).
Discussion We present our concept of early transposition of functioning pedicled myocutaneous latissimus dorsi muscle after upper arm replantation to restore elbow flexion and provide well-vascularised tissue to support soft-tissue healing in a series of five patients. The outcomes of upper limb replantation vary according to the level of injury. Distal amputations tolerate longer ischemia times and are less dependent on motor and sensory reinnervation to achieve optimal function. Thus, the indication for replantation after upper arm amputation is controversial. A special subtype of these amputations is the so-called traction avulsion amputation, as proposed by Chuang et al.17 Traction avulsion amputation of the major upper extremity is distinguished both clinically and prognosticatively from the guillotine, or circular, amputation, in which all tissues are sharply divided with only local crushing.18,19 The replanting surgeon faces several problems with this type of injury that have to be considered preoperatively such as: (1) Should replantation be attempted at all? (2) Can a reasonable functional result be achieved after replantation? (3) How much debridement of soft tissue has to be undertaken? (4) What type of secondary procedures, immediate or delayed, will aid in healing and functional recovery? Replantation of an avulsed upper arm should be technically feasible in hospitals with microsurgical expertise. However, in replantation and limb salvage surgery, the success of the procedure depends not only on the viability of the replantation, but also on the functional outcome. The decision to attempt replantation rests on the prediction that the patient may attain better functionality with such surgery than with prosthesis. In severe injuries of the lower
Figure 5 a,b. Three-year postoperative result with excellent range of motion in the elbow joint and good strength of flexion (M4).
extremities, there are many benefits to immediate amputation,20,21 such as better patient acceptance, cost saving, and early mobilisation and return to work. However, this does not apply to the upper extremity. A sensate, prehensile upper limb will always be superior to a prosthesis, even if multiple procedures may be required to achieve a satisfactory result. One point to consider is that proximal tissue replantations are far more complex than distal amputations and can be associated with systemic complications following restoration of blood flow. Due to the large amount of muscle present only a short ischemic period is tolerable in upper arm replantation. Although initial replantation was successful, we had to perform re-amputation of the upper arm in one patient due to systemic shock.22 To avoid such complications, adequate debridement and excision of severely damaged muscle are crucial. This creates two problems for the replanting surgeon. In most cases there will be a large wound area in the anterior aspect of the upper arm that cannot be closed primarily. Even if extensive debridement of the biceps and brachialis muscle is undertaken, a large cutaneous defect has to be covered. Additionally, inevitably delicate structures such as vessels, nerves and sometimes bone are exposed. Wound coverage is a poor indication for shortening of the bone. Moreover, good bony union requires good soft tissue coverage, and flap coverage is mandatory to
758
T. Schoeller et al.
Figure 6 a,b. Postoperative result at 24-month follow-up in another patient after right-sided upper arm replantation and functional latissimus dorsi transposition. Again, range of motion and strength (M4) was very satisfactory in the affected elbow joint.
provide optimal environment for healing. Skin grafts would make later reconstruction difficult and hazardous. The pedicled latissimus dorsi flap can provide ample healthy soft tissue, but alternatively the rectus abdominis, rectus femoris or anterolateral thigh cutaneous flaps may be used for immediate wound coverage. The pedicled myocutaneous latissimus dorsi flap has the advantage of avoidance of microsurgery, which may create additional problems during primary reconstruction. If free flaps are used, muscle flaps with skin grafts are not recommended because of the difficulty in handling wound incision and closure in secondary surgical procedures. The second crucial point in treating these types of injuries is functional reconstruction. The primary goal for functional reconstruction of the replanted upper arm is achieving active flexion in the elbow joint after major loss of flexors (biceps and brachialis muscle). Since nerve regeneration progresses at about 1 mm/day under ideal circumstances, distally located muscles stand a much lower chance of regaining function at all, especially intrinsic muscles of the hand. The denervated muscles will have undergone irreversible degeneration and atrophy by the time the new axons have reached them.23 Thus, a secondary aim is to restore extension of the wrist. These reconstructive goals may be compared by functional reconstruction after traumatic brachial plexus injury.24 Strong active flexion and extension of the elbow joint can only be obtained with amputations through the distal third of the humerus, leaving the vascularisation and innervation of the upper
arm muscles intact. For restoration of elbow flexion after traumatic upper arm amputation above the distal third, the latissimus dorsi muscle is ideal for the following reasons: (1) it is a strong muscle, (2) the anatomy is well known with straight forward dissection and acceptable donor site morbidity, (3) when used monopolar the muscle remains tightly attached to the affected limb, (4) a stable shoulder is not a prerequisite for transfer of the muscle, as opposed to transfer of the pectoralis major muscle and (5) one portion of the origin of the muscle may be woven into the wrist extensor or even into the extensor of the thumb. Thus even the secondary goal of reconstruction, i.e. extension of the wrist, may be achieved. Alternatively, free muscle transfer, such as the gracilis or rectus femoris muscle, can achieve reconstruction of flexor or extensor function. However, this type of reconstruction is dependent on further microsurgical expertise and optimal nerve regeneration. In the management of avulsion-type amputations of the upper arm, the pedicled latissimus dorsi myocutaneous flap is a valuable tool to restore elbow flexion and to cover soft tissue defects. It further expands the versatility of this valuable donor site.
References 1. Kleinert JM, Graham B. Macroreplantation: an overview. Microsurgery 1990;11:229e33. 2. Wood MB, Cooney 3rd WP. Above elbow limb replantation: functional results. J Hand Surg [Am] 1986;11:682e7.
Functional transposition of the latissimus dorsi muscle 3. D’Addato M, Pedrini L, Bertoni M, et al. Traumatic amputation of the upper limb: replantation of the arm. J Trauma 1989;29: 876e9. 4. Daigle JP, Kleinert JM. Major limb replantation in children. Microsurgery 1991;12:221e31. 5. Romero-Zarate JL, Pastrana-Figueroa JM, Granados-Martinez R. Upper extremity replantation: three-year experience. Microsurgery 2000;20:202e6. 6. Chew WY, Tsai TM. Major upper limb replantation. Hand Clin 2001;17:395e410. 7. Papanastasiou S. Rehabilitation of the replanted upper extremity. Plast Reconstr Surg 2002;109:978e81. 8. Lloyd MS, Teo TC, Pickford MA, et al. Preoperative management of the amputated limb. Emerg Med J 2005;22:478e80. 9. Krarup C, Upton J, Creager MA. Nerve regeneration and reinnervation after limb amputation and replantation: clinical and physiological findings. Muscle Nerve 1990;13:291e304. 10. Renner A, Cserkuti F, Hankiss J. Late results after nerve transplantation on the upper extremities. Handchir Mikrochir Plast Chir 2004;36:13e8. 11. Meuli-Simmen C, Canova M, Bollinger A, et al. Long-term follow-up after finger and upper-limb replantation: clinical, angiologic, and lymphographic studies. J Reconstr Microsurg 1998;14:131e6. 12. Hochberg J, Fortes da Silva FB. Latissimus dorsi myocutaneous flap to restore elbow flexion and axillary burn contracture: a report on two pediatric patients. J Pediatr Orthop 1982;2:565e8. 13. Chen WS. Restoration of elbow flexion by latissimus dorsi myocutaneous or muscle flap. Arch Orthop Trauma Surg 1990;109: 117e20. 14. Mordick 2nd TG, Britton EN, Brantigan C. Pedicled latissimus dorsi transfer for immediate soft-tissue coverage and elbow flexion. Plast Reconstr Surg 1997;99:1742e4.
759 15. Parmaksizoglu F, Beyzadeoglu T. Functional latissimus dorsi island pedicle musculocutaneous flap to restore elbow flexion in replantation or revascularisation of above-elbow amputations. Handchir Mikrochir Plast Chir 2003;35:51e6. 16. Haas F, Hubmer M, Koch H, et al. Immediate functional transfer of the latissimus dorsi myocutaneous island flap for reestablishment of elbow flexion in upper arm replantation: two clinical cases. J Trauma 2004;57:1347e50. 17. Chuang DCC, Lai JB, Cheng SL, et al. Traction avulsion amputation of the major upper limb: a proposed new classification, guidelines for acute management, and strategies for secondary reconstruction. Plast Reconstr Surg 2001;108:1624e38. 18. Chen ZW, Meyer VE, Kleinert HE, et al. Present indications and contraindications for replantation as reflected by long-term functional results. Orthop Clin North Am 1981;12:849e70. 19. Buncke HJ, Rose EH. Traction avulsion amputation of the upper extremity replanted by microvascular anastomosis. In: Strickland JW, Steichen JB, editors. Difficult Problems in Hand Surgery. St. Louis: Mosby; 1982. p. 264. 20. Lange RH. Limb reconstruction versus amputation: Decision making in massive lower extremity trauma. Clin Orthop 1989; 243:92e9. 21. Russell WL, Sailors WM, Whittle WB, et al. Limb salvage versus traumatic amputation: A decision based on seven-part predictive index. Ann Surg 1991;213:473e80. 22. McCutcheon C, Hennessy B. Systemic reperfusion injury during arm replantation requiring Intraoperative amputation. Anaesth Intensive Care 2002;30:71e3. 23. Chuang DC, Mardini S. Extended phrenic nerve transfer. Plast Reconstr Surg 2003;112:354e6. 24. Gutowski KA, Orenstein HH. Restoration of elbow flexion after brachial plexus injury: the role of nerve and muscle transfers. Plast Reconstr Surg 2000;106:1348e57.
Functional transposition of the latissimus dorsi muscle for biceps reconstruction after upper arm replantation Thomas Schoeller a, Gottfried Wechselberger a, Heribert Hussl a, Georg M. Huemer b,c,* a
Clinical Department of Plastic and Reconstructive Surgery, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria b Department of Plastic Surgery, Sisters of Mercy Hospital, Seilerstaette 4, 4010 Linz, Austria c maz e Mikrochirurgisches Ausbildungs- und Forschungszentrum, Garnisonstrasse 21, 4020 Linz, Austria Received 17 September 2006; accepted 12 November 2006
KEYWORDS Replantation; Upper arm; Latissimus dorsi muscle; Functional reconstruction; Elbow flexion
Summary Major upper arm amputations are often accompanied by different levels of softtissue divisions involving crushing, traction, and avulsion injuries to various structures. In these cases the goal is not only the re-establishment of circulation, but also functional outcome. Some patients require further reconstruction for functional restoration of elbow flexion and additional soft tissue coverage. Five patients underwent functional latissimus dorsi transfer for restoration of elbow flexion after successful upper arm replantation at our institution. The transfer was unipolar in four patients and bipolar in one. The patients’ ages ranged from seven to 55 years. The time period between replantation and transfer ranged from two weeks to 12 months. All flaps healed well with minimal donor site morbidity. At mean 43-month follow-up (range: 22e65 months), functional results were good with M4 in three patients and M3 in two patients for elbow flexion. The pedicled latissimus dorsi muscle flap is a valuable tool to restore elbow flexion and provide coverage of soft tissue defects after major upper arm replantations. ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Address: Department of Plastic Surgery, Sisters of Mercy Hospital, Seilerstaette 4, 4010 Linz, Austria. Tel.: þ4369910878705. E-mail address: [email protected] (G.M. Huemer).
Amputation of the upper arm is a life threatening injury. Even if feasible, replantation of the amputated part is not always indicated.1 It very much depends on the patient’s condition, the condition of the amputated limb and the stump, the expected outcome, the infrastructure of the hospital, the surgical experience of the replanting team
1748-6815/$ - see front matter ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2006.11.032
756 and the time elapsed since the amputation.2e8 Thus, careful selection for the right indication is necessary. If the replantation has been performed successfully, several functional deficits have to be expected. Beside the anticipated slow nerve regeneration,9,10 direct trauma to the biceps and triceps muscle at the amputation site is an obvious problem resulting not only in poor muscle function but also wound healing problems.11 Functional transfer of the latissimus dorsi muscle as a pedicled flap is suggested if missing biceps function has to be reconstructed,12e14 but additionally when well vascularised tissue is required to promote wound healing on the upper arm. However, the combination of upper arm macroreplantation and the functional transposition of the latissimus dorsi muscle has rarely been described in the literature.15,16 We report our experience of upper arm replantation with early latissimus dorsi muscle transposition in a consecutive series of five patients.
Patients and methods From August 1997 to May 2002 we treated six patients for upper arm amputation (Fig. 1) and replanted the arm. The patients’ ages ranged from seven to 55 years (mean: 35.5 years). In one case acute re-amputation had to be performed within 24 h despite unimpaired perfusion due to a septic shock syndrome. The remaining five patients underwent replantation successfully. In all cases the radial and median nerve were coapted directly whereas the ulnar nerve showed an avulsion at the level of the cubital tunnel and had to be bridged with sural nerve grafts. In one case the brachial artery had to be bridged by a saphenous vein graft due to a second level injury. In one case a microsurgical revision was necessary on the first postoperative day due to a venous thrombosis. In that case a saphenous vein graft was employed successfully. Bone fixation was achieved with an AO-plate in all cases. In three cases when the elapsed time came critically towards the six hours, we temporarily bridged the arterial inflow with a catheter to establish circulation for ten minutes. Thus, the reperfusion injury was reduced and the critical time interval until definite
Figure 1 Complete amputation of the left upper arm in a twenty-year old patient with extensive local crushing of both amputation stumps.
T. Schoeller et al.
Figure 2 After successful replantation, wounds could not be closed primarily and instead artificial skin substitute (Epigard; Biovision GmbH, Ilmenau, Germany) was used.
perfusion could be extended. In all five patients we encountered delayed wound healing with partial necrosis of soft tissue at the amputation site (Fig. 2). This was mainly due to a necrosis of the distal part of the repaired biceps muscle. To overcome these two problems we transposed a functional pedicled myocutaneous latissimus dorsi muscle to restore biceps muscle function and to provide soft tissue coverage. All five patients underwent functional latissimus dorsi transfer for restoration of elbow flexion after successful upper arm replantation (Figs. 3 and 4). Latissimus dorsi transfer was unipolar in four patients and bipolar in one. The time period between replantation and latissimus dorsi transfer ranged from two weeks to 12 months.
Results All flaps healed well, and donor site morbidity was minimal. At mean 43-month follow-up (range: 22e65 months),
Figure 3 Three months later a monopolar pedicled myocutaneous latissimus dorsi was utilised for secondary wound coverage and restoration of elbow flexion in the same patient. One portion of the muscle was woven into the extensors of the forearm.
Functional transposition of the latissimus dorsi muscle
757
Figure 4 Immediate postoperative result after partial splitthickness skin grafting of the remaining muscle.
functional results were good (Muscle manual test of the limb indicated M4 in three patients for the elbow flexion and M3 in two patients). Successful restoration with an adequate range of motion in the elbow joint was obtained. The patients were capable of carrying out normal daily errands and all were satisfied with their outcome (Figs. 5 and 6).
Discussion We present our concept of early transposition of functioning pedicled myocutaneous latissimus dorsi muscle after upper arm replantation to restore elbow flexion and provide well-vascularised tissue to support soft-tissue healing in a series of five patients. The outcomes of upper limb replantation vary according to the level of injury. Distal amputations tolerate longer ischemia times and are less dependent on motor and sensory reinnervation to achieve optimal function. Thus, the indication for replantation after upper arm amputation is controversial. A special subtype of these amputations is the so-called traction avulsion amputation, as proposed by Chuang et al.17 Traction avulsion amputation of the major upper extremity is distinguished both clinically and prognosticatively from the guillotine, or circular, amputation, in which all tissues are sharply divided with only local crushing.18,19 The replanting surgeon faces several problems with this type of injury that have to be considered preoperatively such as: (1) Should replantation be attempted at all? (2) Can a reasonable functional result be achieved after replantation? (3) How much debridement of soft tissue has to be undertaken? (4) What type of secondary procedures, immediate or delayed, will aid in healing and functional recovery? Replantation of an avulsed upper arm should be technically feasible in hospitals with microsurgical expertise. However, in replantation and limb salvage surgery, the success of the procedure depends not only on the viability of the replantation, but also on the functional outcome. The decision to attempt replantation rests on the prediction that the patient may attain better functionality with such surgery than with prosthesis. In severe injuries of the lower
Figure 5 a,b. Three-year postoperative result with excellent range of motion in the elbow joint and good strength of flexion (M4).
extremities, there are many benefits to immediate amputation,20,21 such as better patient acceptance, cost saving, and early mobilisation and return to work. However, this does not apply to the upper extremity. A sensate, prehensile upper limb will always be superior to a prosthesis, even if multiple procedures may be required to achieve a satisfactory result. One point to consider is that proximal tissue replantations are far more complex than distal amputations and can be associated with systemic complications following restoration of blood flow. Due to the large amount of muscle present only a short ischemic period is tolerable in upper arm replantation. Although initial replantation was successful, we had to perform re-amputation of the upper arm in one patient due to systemic shock.22 To avoid such complications, adequate debridement and excision of severely damaged muscle are crucial. This creates two problems for the replanting surgeon. In most cases there will be a large wound area in the anterior aspect of the upper arm that cannot be closed primarily. Even if extensive debridement of the biceps and brachialis muscle is undertaken, a large cutaneous defect has to be covered. Additionally, inevitably delicate structures such as vessels, nerves and sometimes bone are exposed. Wound coverage is a poor indication for shortening of the bone. Moreover, good bony union requires good soft tissue coverage, and flap coverage is mandatory to
758
T. Schoeller et al.
Figure 6 a,b. Postoperative result at 24-month follow-up in another patient after right-sided upper arm replantation and functional latissimus dorsi transposition. Again, range of motion and strength (M4) was very satisfactory in the affected elbow joint.
provide optimal environment for healing. Skin grafts would make later reconstruction difficult and hazardous. The pedicled latissimus dorsi flap can provide ample healthy soft tissue, but alternatively the rectus abdominis, rectus femoris or anterolateral thigh cutaneous flaps may be used for immediate wound coverage. The pedicled myocutaneous latissimus dorsi flap has the advantage of avoidance of microsurgery, which may create additional problems during primary reconstruction. If free flaps are used, muscle flaps with skin grafts are not recommended because of the difficulty in handling wound incision and closure in secondary surgical procedures. The second crucial point in treating these types of injuries is functional reconstruction. The primary goal for functional reconstruction of the replanted upper arm is achieving active flexion in the elbow joint after major loss of flexors (biceps and brachialis muscle). Since nerve regeneration progresses at about 1 mm/day under ideal circumstances, distally located muscles stand a much lower chance of regaining function at all, especially intrinsic muscles of the hand. The denervated muscles will have undergone irreversible degeneration and atrophy by the time the new axons have reached them.23 Thus, a secondary aim is to restore extension of the wrist. These reconstructive goals may be compared by functional reconstruction after traumatic brachial plexus injury.24 Strong active flexion and extension of the elbow joint can only be obtained with amputations through the distal third of the humerus, leaving the vascularisation and innervation of the upper
arm muscles intact. For restoration of elbow flexion after traumatic upper arm amputation above the distal third, the latissimus dorsi muscle is ideal for the following reasons: (1) it is a strong muscle, (2) the anatomy is well known with straight forward dissection and acceptable donor site morbidity, (3) when used monopolar the muscle remains tightly attached to the affected limb, (4) a stable shoulder is not a prerequisite for transfer of the muscle, as opposed to transfer of the pectoralis major muscle and (5) one portion of the origin of the muscle may be woven into the wrist extensor or even into the extensor of the thumb. Thus even the secondary goal of reconstruction, i.e. extension of the wrist, may be achieved. Alternatively, free muscle transfer, such as the gracilis or rectus femoris muscle, can achieve reconstruction of flexor or extensor function. However, this type of reconstruction is dependent on further microsurgical expertise and optimal nerve regeneration. In the management of avulsion-type amputations of the upper arm, the pedicled latissimus dorsi myocutaneous flap is a valuable tool to restore elbow flexion and to cover soft tissue defects. It further expands the versatility of this valuable donor site.
References 1. Kleinert JM, Graham B. Macroreplantation: an overview. Microsurgery 1990;11:229e33. 2. Wood MB, Cooney 3rd WP. Above elbow limb replantation: functional results. J Hand Surg [Am] 1986;11:682e7.
Functional transposition of the latissimus dorsi muscle 3. D’Addato M, Pedrini L, Bertoni M, et al. Traumatic amputation of the upper limb: replantation of the arm. J Trauma 1989;29: 876e9. 4. Daigle JP, Kleinert JM. Major limb replantation in children. Microsurgery 1991;12:221e31. 5. Romero-Zarate JL, Pastrana-Figueroa JM, Granados-Martinez R. Upper extremity replantation: three-year experience. Microsurgery 2000;20:202e6. 6. Chew WY, Tsai TM. Major upper limb replantation. Hand Clin 2001;17:395e410. 7. Papanastasiou S. Rehabilitation of the replanted upper extremity. Plast Reconstr Surg 2002;109:978e81. 8. Lloyd MS, Teo TC, Pickford MA, et al. Preoperative management of the amputated limb. Emerg Med J 2005;22:478e80. 9. Krarup C, Upton J, Creager MA. Nerve regeneration and reinnervation after limb amputation and replantation: clinical and physiological findings. Muscle Nerve 1990;13:291e304. 10. Renner A, Cserkuti F, Hankiss J. Late results after nerve transplantation on the upper extremities. Handchir Mikrochir Plast Chir 2004;36:13e8. 11. Meuli-Simmen C, Canova M, Bollinger A, et al. Long-term follow-up after finger and upper-limb replantation: clinical, angiologic, and lymphographic studies. J Reconstr Microsurg 1998;14:131e6. 12. Hochberg J, Fortes da Silva FB. Latissimus dorsi myocutaneous flap to restore elbow flexion and axillary burn contracture: a report on two pediatric patients. J Pediatr Orthop 1982;2:565e8. 13. Chen WS. Restoration of elbow flexion by latissimus dorsi myocutaneous or muscle flap. Arch Orthop Trauma Surg 1990;109: 117e20. 14. Mordick 2nd TG, Britton EN, Brantigan C. Pedicled latissimus dorsi transfer for immediate soft-tissue coverage and elbow flexion. Plast Reconstr Surg 1997;99:1742e4.
759 15. Parmaksizoglu F, Beyzadeoglu T. Functional latissimus dorsi island pedicle musculocutaneous flap to restore elbow flexion in replantation or revascularisation of above-elbow amputations. Handchir Mikrochir Plast Chir 2003;35:51e6. 16. Haas F, Hubmer M, Koch H, et al. Immediate functional transfer of the latissimus dorsi myocutaneous island flap for reestablishment of elbow flexion in upper arm replantation: two clinical cases. J Trauma 2004;57:1347e50. 17. Chuang DCC, Lai JB, Cheng SL, et al. Traction avulsion amputation of the major upper limb: a proposed new classification, guidelines for acute management, and strategies for secondary reconstruction. Plast Reconstr Surg 2001;108:1624e38. 18. Chen ZW, Meyer VE, Kleinert HE, et al. Present indications and contraindications for replantation as reflected by long-term functional results. Orthop Clin North Am 1981;12:849e70. 19. Buncke HJ, Rose EH. Traction avulsion amputation of the upper extremity replanted by microvascular anastomosis. In: Strickland JW, Steichen JB, editors. Difficult Problems in Hand Surgery. St. Louis: Mosby; 1982. p. 264. 20. Lange RH. Limb reconstruction versus amputation: Decision making in massive lower extremity trauma. Clin Orthop 1989; 243:92e9. 21. Russell WL, Sailors WM, Whittle WB, et al. Limb salvage versus traumatic amputation: A decision based on seven-part predictive index. Ann Surg 1991;213:473e80. 22. McCutcheon C, Hennessy B. Systemic reperfusion injury during arm replantation requiring Intraoperative amputation. Anaesth Intensive Care 2002;30:71e3. 23. Chuang DC, Mardini S. Extended phrenic nerve transfer. Plast Reconstr Surg 2003;112:354e6. 24. Gutowski KA, Orenstein HH. Restoration of elbow flexion after brachial plexus injury: the role of nerve and muscle transfers. Plast Reconstr Surg 2000;106:1348e57.