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Lower Trapezius Muscle Transfer for Elbow Extension Reconstruction After Failed Nerve Transfer for Tetraplegia
CASE REPOSITORY
Lower Trapezius Muscle Transfer for Elbow Extension Reconstruction After Failed Nerve Transfer for Tetraplegia Sushil Nehete, MD,* Jayme Augusto Bertelli, MD, PhD† Reconstruction of elbow extension is a first priority in the surgical management of patients with tetraplegia. Traditionally, posterior deltoid and biceps to triceps muscle transfers were used, but in recent years, nerve transfers have become the preferred choice of a few surgeons. However, nerve transfer reconstruction failures exist, often related to poor donor nerves, prolonged intervals between the injury and surgery, and advanced patient age. As a valid surgical alternative in such cases, we propose transferring the lower trapezius muscle to reconstruct elbow extension, because this procedure is already being performed successfully in patients with brachial plexus injury. We report 2 patients in whom a lower trapezius transfer was employed as a successful salvage procedure after failed nerve transfer surgery. (J Hand Surg Am. 2019;-(-):1.e1-e4. Copyright Ó 2019 by the American Society for Surgery of the Hand. All rights reserved.) Key words Brachial plexus, elbow extension, nerve transfer, tetraplegia, trapezio muscle.
I
goals of surgery are to reconstruct elbow extension, wrist extension if not preserved, and finger and thumb flexion/extension. Traditionally, elbow extension has been reconstructed by transferring the posterior deltoid1 or biceps muscle.2 Recently, transferring the posterior division of the axillary nerve (PDAN) to triceps branches has demonstrated consistent recovery of M4 elbow extension strength, thereby supplanting muscle transfers. 3 However, failed nerve transfer reconstructions N MIDCERVICAL TETRAPLEGIA, THE
From the *Wockhardt Hospital, The Umrao IMSR, Thane, Maharashtra, India; and the †Center of Biological and Health Sciences, Department of Neurosurgery, University of the South of Santa Catarina (Unisul), Tubarão, Santa Catarina, Brazil Received for publication November 20, 2018; accepted in revised form July 10, 2019. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Jayme Augusto Bertelli, MD, PhD, Hospital Celso Ramos, Rua Newton Ramos, 70, apto 901, Florianopolis, Santa Catarina 88015395, Brazil; e-mail: [email protected]. 0363-5023/19/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2019.07.016
exist, often related to poor donor nerves, a prolonged interval between the injury and surgery, and more advanced patient age. In this situation, salvage surgery is complicated. If the surgeons have used the PDAN as the donor, the posterior deltoid muscle is unavailable for transfer. The biceps muscle would still be available. However, concomitant to triceps reconstruction, thumb and finger extension is typically reconstructed by transferring the nerve to supinator to the posterior interosseous nerve.3 In the case of a biceps transfer, supination will be lost. A roughly 50% decrease in elbow flexion strength is routine after a biceps to triceps transfer, 4,5 which may make surgeons reluctant to propose this surgery in the first place. Bertelli6 and Alrabai et al7 successfully transferred the lower trapezius muscle to reconstruct elbow extension in patients with brachial plexus injuries. We hypothesized that this technique could also be useful to reconstruct elbow extension in tetraplegics in whom a nerve transfer has failed to achieve adequate results. In this paper, we present 2 patients
Ó 2019 ASSH
r
Published by Elsevier, Inc. All rights reserved.
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1.e1
1.e2
LOWER TRAPEZIUS MUSCLE TRANSFER
FIGURE 2: Case 2: intraoperative view of the dissected lower trapezius muscle and its transposition over the triceps. A segment of lumbar fascia was harvested to reinforce the lower trapezius muscle’s attachment to the triceps tendon. LT, lower trapezius sutured to the medial margin of the scapula; RB, rhomboid muscles.
FIGURE 1: Case 1: intraoperative view of the dissected lower trapezius muscle and its transposition over the triceps.
with tetraplegia who did not improve adequately after a nerve transfer procedure and subsequently underwent a lower trapezius transfer to reconstruct elbow extension.
to the nerve of the extensor carpi radialis longus. On the left side, we transferred the nerve to the brachioradialis to the anterior interosseous nerve and the nerve to supinator to the posterior interosseous nerve. At 24-month follow-up, full passive range of elbow motion and full active flexion were observed bilaterally. Elbow extension scored M4 on the right side, as rated using the British Medical Research Council scale grading muscle strength. However, left elbow extension strength only scored M2. Shoulder abduction improved from baseline 90 to 140 , bilaterally. At that time, we performed a lower trapezius transfer to the triceps to reconstruct left elbow extension. Sixteen months after this second surgery, full range of elbow flexion/extension was observed in the horizontal position. At 90 of elbow flexion, the patient was able to resist further flexion against a pressure applied to the distal forearm. The patient was able to fully extend his elbow with his shoulder at 100 of abduction, but not in full abduction. However, he was able to keep his elbow extended with his shoulder fully abducted, which had been impossible for him before the trapezius transfer. Thirty months after the trapezius transfer no further improvement was observed. Video 1 (available on the Journal’s Web site at www. jhandsurg.org) shows pre- and postoperative results for case 1.
CASE REPORTS In advance of any data collection, the protocol of the present study was approved by our local ethics committee. Each patient provided his or her verbal informed consent before participating, in accordance with the Declaration of Helsinki guiding biomedical research involving human subjects. Case 1 A 17-year-old boy presented with tetraplegia after an injury sustained by diving into shallow water. On examination, 9 months after the accident, he was found to be group 1 on the right and group 2 on the left, as per the International Classification for Surgery of the Hand in Tetraplegia. He had bilateral elbow flexion contractures of 90 . Under general anesthesia, both elbows were mobilized to gain extension. Elbow extension reconstruction was performed via the axillary access.5 Intraoperative electrical stimulation guided our choice of axillary nerve donor branches for transfer. On the right side, given that the PDAN was paralyzed, we transferred the branch to the middle deltoid to the long and upper medial heads of the triceps. On the left side, despite weak contraction obtained after electrical stimulation of the PDAN, we transferred it to triceps motor branches. In addition, on the right side, we transferred the nerve to brachialis to median nerve fascicles destined for finger flexion and the nerve to the brachioradialis J Hand Surg Am.
Case 2 A 21-year-old man was left tetraplegic after a road traffic accident. Ten months after the spinal cord r
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LOWER TRAPEZIUS MUSCLE TRANSFER
TABLE 1.
Results of Global Reconstruction of Upper Limb Function in 2 Tetraplegic Patients
Age/sex
Case 1
Case 2
17/M
21/M
9
10
INR (mo) Elbow ext surg; results R
NMD to triceps, M4
ADAN to triceps, M2
L
PDAN to triceps, M2
ADAN to triceps, M4
R
NBR to ECRL, M3
Not attempted
L
Preserved M4
Preserved M4
R
Not attempted. No donors available
Not attempted. No donors available
L
NS to PIN, M3
NS to PIN, M3
R
NB to median nerve finger flexion fascicles, M2
Not attempted
L
NBR to AIN, M3
Brachialis muscle extended with a tendon graft to FDP and FPL, M4
Wrist ext surg; results
Finger ext surg; results
Finger flex surg; results
Twenty-four months was the minimal follow-up for evaluation of the results. ADAN, anterior division of the axillary nerve; AIN, anterior interosseous nerve; ECRL, extensor carpi radialis longus; FDP, flexor digitorum profundus; FPL, flexor pollicis longus; INR, interval between accident and surgery; L, left; NB, nerve to brachialis; NBR, nerve to brachioradialis; NMD, nerve to middle deltoid; NS, nerve to supinator; PDAN, posterior division of the axillary nerve; PIN, posterior interosseous nerve; R, right.
to extend his elbow with his shoulder at 90 of abduction through the full range of motion. Video 2 (available on the Journal’s Web site at www. jhandsurg.org) documents the pre- and postoperative views after the lower trapezius transfer in case 2.
injury, he scored as International Classification group 2 for tetraplegia on the right and group 3 on the left. Wrist extension scored M2 and M4 on the right and left, respectively. Bilaterally, via an axillary access, we dissected and electrically stimulated axillary nerve branches. On both sides, the PDAN was paralyzed and we transferred the anterior division of the axillary nerve to the triceps medial and long head motor branches. On the left side, we transferred the nerve to supinator to the posterior interosseous nerve. Twenty-eight months after nerve surgery, we reoperated on the left upper limb to transfer the brachialis muscle extended by a tendon graft of the anterior tibialis muscle to the flexor digitorum profundus and flexor pollicis longus. We also fused the distal radioulnar joint. He exhibited no active elbow extension recovery on the right side even 36 months after the nerve transfer. By then, left triceps strength scored M4 with complete elbow range of motion. Shoulder abduction improved from baseline 90 to 110 , bilaterally. At this time, a trapezius to triceps transfer was performed to restore right elbow extension. Twentyfour months after this surgery, the patient was able J Hand Surg Am.
Surgical technique Under general anesthesia without relaxants, each patient was placed in a lateral decubitus position. An incision was made from the spine of the scapula to the T12 vertebra. The trapezius muscle was harvested from the T12 vertebra, in continuity with a 1- to 2-cm-wide and 6- to 8-cm-long strip of fascia over the spinous processes of T12 to L3. The trapezius was detached from the spine up to C7 to improve the rotation arc. Care was taken not to injure the rhomboid muscles (Fig. 1). The spinal accessory nerve was identified and protected. The medial side of the lower trapezius, which was inserted into the spine, was sutured to the medial border and spine of the scapula. A 10-cm-long incision was created over the posterior surface of the shoulder and upper arm, and a second incision, again 10 cm long, over the triceps tendon. These r
Vol. -, - 2019
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LOWER TRAPEZIUS MUSCLE TRANSFER
incisions were made to permit tunneling of the lower trapezius to the triceps tendon. With the arm adducted, shoulder extended, and elbow fully extended, the lower trapezius fascia was sutured side by side to the triceps tendon under maximal tension. In case 2, a portion of lumbar fascia of 8 cm was removed to reinforce the lower trapezius tendon (Fig. 2). After skin closure, the upper extremity was immobilized in a plaster cast, with the arm completely adducted and extended 30 , and the elbow flexed 20 . The shoulder was placed in 30 of extension to allow for some relaxation of the transplanted muscle. The cast was maintained for 4 weeks. Over this period, patients were asked to individualize their lower trapezius and contract it 10 times per cycle, 3 cycles per day. To instruct patients how to individualize lower trapezius muscle function, the surgeon gently squeezed the transferred muscle and asked the patient to contract where they felt pressure. After 4 weeks, we released the patients for all activities. In Table 1, we summarize the strategy and global results for upper limb reconstruction in case 1 and 2.
elbow extension was useful for improving arm positioning and, thereby, increasing its functional range. Removing the lower trapezius did not impair trunk control. It is possible that the contralateral trapezius compensated for any deficit. In fact, both patients reported better trunk control after surgery: while sitting, they now used their restored elbow extension to control their balance, using the armrest of the wheelchair as support. The lower trapezius muscle can be used not only as a fall-back option, as in our patients, but also in patients in whom the deltoid and biceps are unavailable for transfer or have been used unsuccessfully. Despite weak elbow extension recovery, we observed improved elbow and shoulder motion and trunk control. ACKNOWLEDGMENT S. Nehete received grants from the Bombay Hospital and Medical Research Centre, Mumbai, India. REFERENCES 1. Bryden A, Peljovich A, Hoyen H, Nemunaitis G, Kilgore K, Keith M. Surgical restoration of arm and hand function in people with tetraplegia. Top Spinal Cord Inj Rehabil. 2012;18(1):43e49. 2. Kuz JE, Van Heest AE, House JH. Biceps-to-triceps transfer in tetraplegic patients: report of the medial routing technique and follow-up of three cases. J Hand Surg Am. 1999;24(1): 161e172. 3. Bertelli JA, Ghizoni MF. Nerve transfers for elbow and finger extension reconstruction in midcervical spinal cord injuries. J Neurosurg. 2015;122(1):121e127. 4. Medina J, Marcos-García A, Jiménez I, Muratore G, MéndezSuárez JL. Biceps to triceps transfer in tetraplegic patients: our experience and review of the literature. Hand. 2017;12(1): 85e90. 5. Mulcahey MJ, Lutz C, Kozin SH, Betz RR. Prospective evaluation of biceps to triceps and deltoid to triceps for elbow extension in tetraplegia. J Hand Surg Am. 2003;13(2):94e97. 6. Bertelli JA. Lower trapezius muscle transfer for reconstruction of elbow extension in brachial plexus injuries. J Hand Surg Eur Vol. 2009;34E(4):45464. 7. Alrabai HM, Gesheff MG, Hammouda AI, Conway JD. Trapezius muscle transfer for restoration of elbow extension in a traumatic brachial plexus injury. J Hand Surg Am. 2018;43(9): 872.e1-e6.
DISCUSSION We believe that the poor quality of our donor nerve for elbow extension reconstruction to be the reason behind failure. In the first case, adding a branch from the anterior division of the axillary nerve would have possibly improved the results. In the second case, bilaterally, the PDAN was paralyzed and we harvested the anterior division of the axillary nerve. In both cases, there was no impact on shoulder abduction. The initial nerve harvesting for transfer did not influence the subsequent care because the posterior deltoid muscle was not adequate for transfer. We did not consider the biceps to triceps muscle transfer because that would have made the nerve to brachialis or its tendon unavailable for finger flexion reconstruction. Even though insufficiently strong to permit patients to raise their body up for transfer, the restoration of
J Hand Surg Am.
r
Vol. -, - 2019
Lower Trapezius Muscle Transfer for Elbow Extension Reconstruction After Failed Nerve Transfer for Tetraplegia Sushil Nehete, MD,* Jayme Augusto Bertelli, MD, PhD† Reconstruction of elbow extension is a first priority in the surgical management of patients with tetraplegia. Traditionally, posterior deltoid and biceps to triceps muscle transfers were used, but in recent years, nerve transfers have become the preferred choice of a few surgeons. However, nerve transfer reconstruction failures exist, often related to poor donor nerves, prolonged intervals between the injury and surgery, and advanced patient age. As a valid surgical alternative in such cases, we propose transferring the lower trapezius muscle to reconstruct elbow extension, because this procedure is already being performed successfully in patients with brachial plexus injury. We report 2 patients in whom a lower trapezius transfer was employed as a successful salvage procedure after failed nerve transfer surgery. (J Hand Surg Am. 2019;-(-):1.e1-e4. Copyright Ó 2019 by the American Society for Surgery of the Hand. All rights reserved.) Key words Brachial plexus, elbow extension, nerve transfer, tetraplegia, trapezio muscle.
I
goals of surgery are to reconstruct elbow extension, wrist extension if not preserved, and finger and thumb flexion/extension. Traditionally, elbow extension has been reconstructed by transferring the posterior deltoid1 or biceps muscle.2 Recently, transferring the posterior division of the axillary nerve (PDAN) to triceps branches has demonstrated consistent recovery of M4 elbow extension strength, thereby supplanting muscle transfers. 3 However, failed nerve transfer reconstructions N MIDCERVICAL TETRAPLEGIA, THE
From the *Wockhardt Hospital, The Umrao IMSR, Thane, Maharashtra, India; and the †Center of Biological and Health Sciences, Department of Neurosurgery, University of the South of Santa Catarina (Unisul), Tubarão, Santa Catarina, Brazil Received for publication November 20, 2018; accepted in revised form July 10, 2019. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Jayme Augusto Bertelli, MD, PhD, Hospital Celso Ramos, Rua Newton Ramos, 70, apto 901, Florianopolis, Santa Catarina 88015395, Brazil; e-mail: [email protected]. 0363-5023/19/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2019.07.016
exist, often related to poor donor nerves, a prolonged interval between the injury and surgery, and more advanced patient age. In this situation, salvage surgery is complicated. If the surgeons have used the PDAN as the donor, the posterior deltoid muscle is unavailable for transfer. The biceps muscle would still be available. However, concomitant to triceps reconstruction, thumb and finger extension is typically reconstructed by transferring the nerve to supinator to the posterior interosseous nerve.3 In the case of a biceps transfer, supination will be lost. A roughly 50% decrease in elbow flexion strength is routine after a biceps to triceps transfer, 4,5 which may make surgeons reluctant to propose this surgery in the first place. Bertelli6 and Alrabai et al7 successfully transferred the lower trapezius muscle to reconstruct elbow extension in patients with brachial plexus injuries. We hypothesized that this technique could also be useful to reconstruct elbow extension in tetraplegics in whom a nerve transfer has failed to achieve adequate results. In this paper, we present 2 patients
Ó 2019 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1.e1
1.e2
LOWER TRAPEZIUS MUSCLE TRANSFER
FIGURE 2: Case 2: intraoperative view of the dissected lower trapezius muscle and its transposition over the triceps. A segment of lumbar fascia was harvested to reinforce the lower trapezius muscle’s attachment to the triceps tendon. LT, lower trapezius sutured to the medial margin of the scapula; RB, rhomboid muscles.
FIGURE 1: Case 1: intraoperative view of the dissected lower trapezius muscle and its transposition over the triceps.
with tetraplegia who did not improve adequately after a nerve transfer procedure and subsequently underwent a lower trapezius transfer to reconstruct elbow extension.
to the nerve of the extensor carpi radialis longus. On the left side, we transferred the nerve to the brachioradialis to the anterior interosseous nerve and the nerve to supinator to the posterior interosseous nerve. At 24-month follow-up, full passive range of elbow motion and full active flexion were observed bilaterally. Elbow extension scored M4 on the right side, as rated using the British Medical Research Council scale grading muscle strength. However, left elbow extension strength only scored M2. Shoulder abduction improved from baseline 90 to 140 , bilaterally. At that time, we performed a lower trapezius transfer to the triceps to reconstruct left elbow extension. Sixteen months after this second surgery, full range of elbow flexion/extension was observed in the horizontal position. At 90 of elbow flexion, the patient was able to resist further flexion against a pressure applied to the distal forearm. The patient was able to fully extend his elbow with his shoulder at 100 of abduction, but not in full abduction. However, he was able to keep his elbow extended with his shoulder fully abducted, which had been impossible for him before the trapezius transfer. Thirty months after the trapezius transfer no further improvement was observed. Video 1 (available on the Journal’s Web site at www. jhandsurg.org) shows pre- and postoperative results for case 1.
CASE REPORTS In advance of any data collection, the protocol of the present study was approved by our local ethics committee. Each patient provided his or her verbal informed consent before participating, in accordance with the Declaration of Helsinki guiding biomedical research involving human subjects. Case 1 A 17-year-old boy presented with tetraplegia after an injury sustained by diving into shallow water. On examination, 9 months after the accident, he was found to be group 1 on the right and group 2 on the left, as per the International Classification for Surgery of the Hand in Tetraplegia. He had bilateral elbow flexion contractures of 90 . Under general anesthesia, both elbows were mobilized to gain extension. Elbow extension reconstruction was performed via the axillary access.5 Intraoperative electrical stimulation guided our choice of axillary nerve donor branches for transfer. On the right side, given that the PDAN was paralyzed, we transferred the branch to the middle deltoid to the long and upper medial heads of the triceps. On the left side, despite weak contraction obtained after electrical stimulation of the PDAN, we transferred it to triceps motor branches. In addition, on the right side, we transferred the nerve to brachialis to median nerve fascicles destined for finger flexion and the nerve to the brachioradialis J Hand Surg Am.
Case 2 A 21-year-old man was left tetraplegic after a road traffic accident. Ten months after the spinal cord r
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LOWER TRAPEZIUS MUSCLE TRANSFER
TABLE 1.
Results of Global Reconstruction of Upper Limb Function in 2 Tetraplegic Patients
Age/sex
Case 1
Case 2
17/M
21/M
9
10
INR (mo) Elbow ext surg; results R
NMD to triceps, M4
ADAN to triceps, M2
L
PDAN to triceps, M2
ADAN to triceps, M4
R
NBR to ECRL, M3
Not attempted
L
Preserved M4
Preserved M4
R
Not attempted. No donors available
Not attempted. No donors available
L
NS to PIN, M3
NS to PIN, M3
R
NB to median nerve finger flexion fascicles, M2
Not attempted
L
NBR to AIN, M3
Brachialis muscle extended with a tendon graft to FDP and FPL, M4
Wrist ext surg; results
Finger ext surg; results
Finger flex surg; results
Twenty-four months was the minimal follow-up for evaluation of the results. ADAN, anterior division of the axillary nerve; AIN, anterior interosseous nerve; ECRL, extensor carpi radialis longus; FDP, flexor digitorum profundus; FPL, flexor pollicis longus; INR, interval between accident and surgery; L, left; NB, nerve to brachialis; NBR, nerve to brachioradialis; NMD, nerve to middle deltoid; NS, nerve to supinator; PDAN, posterior division of the axillary nerve; PIN, posterior interosseous nerve; R, right.
to extend his elbow with his shoulder at 90 of abduction through the full range of motion. Video 2 (available on the Journal’s Web site at www. jhandsurg.org) documents the pre- and postoperative views after the lower trapezius transfer in case 2.
injury, he scored as International Classification group 2 for tetraplegia on the right and group 3 on the left. Wrist extension scored M2 and M4 on the right and left, respectively. Bilaterally, via an axillary access, we dissected and electrically stimulated axillary nerve branches. On both sides, the PDAN was paralyzed and we transferred the anterior division of the axillary nerve to the triceps medial and long head motor branches. On the left side, we transferred the nerve to supinator to the posterior interosseous nerve. Twenty-eight months after nerve surgery, we reoperated on the left upper limb to transfer the brachialis muscle extended by a tendon graft of the anterior tibialis muscle to the flexor digitorum profundus and flexor pollicis longus. We also fused the distal radioulnar joint. He exhibited no active elbow extension recovery on the right side even 36 months after the nerve transfer. By then, left triceps strength scored M4 with complete elbow range of motion. Shoulder abduction improved from baseline 90 to 110 , bilaterally. At this time, a trapezius to triceps transfer was performed to restore right elbow extension. Twentyfour months after this surgery, the patient was able J Hand Surg Am.
Surgical technique Under general anesthesia without relaxants, each patient was placed in a lateral decubitus position. An incision was made from the spine of the scapula to the T12 vertebra. The trapezius muscle was harvested from the T12 vertebra, in continuity with a 1- to 2-cm-wide and 6- to 8-cm-long strip of fascia over the spinous processes of T12 to L3. The trapezius was detached from the spine up to C7 to improve the rotation arc. Care was taken not to injure the rhomboid muscles (Fig. 1). The spinal accessory nerve was identified and protected. The medial side of the lower trapezius, which was inserted into the spine, was sutured to the medial border and spine of the scapula. A 10-cm-long incision was created over the posterior surface of the shoulder and upper arm, and a second incision, again 10 cm long, over the triceps tendon. These r
Vol. -, - 2019
1.e4
LOWER TRAPEZIUS MUSCLE TRANSFER
incisions were made to permit tunneling of the lower trapezius to the triceps tendon. With the arm adducted, shoulder extended, and elbow fully extended, the lower trapezius fascia was sutured side by side to the triceps tendon under maximal tension. In case 2, a portion of lumbar fascia of 8 cm was removed to reinforce the lower trapezius tendon (Fig. 2). After skin closure, the upper extremity was immobilized in a plaster cast, with the arm completely adducted and extended 30 , and the elbow flexed 20 . The shoulder was placed in 30 of extension to allow for some relaxation of the transplanted muscle. The cast was maintained for 4 weeks. Over this period, patients were asked to individualize their lower trapezius and contract it 10 times per cycle, 3 cycles per day. To instruct patients how to individualize lower trapezius muscle function, the surgeon gently squeezed the transferred muscle and asked the patient to contract where they felt pressure. After 4 weeks, we released the patients for all activities. In Table 1, we summarize the strategy and global results for upper limb reconstruction in case 1 and 2.
elbow extension was useful for improving arm positioning and, thereby, increasing its functional range. Removing the lower trapezius did not impair trunk control. It is possible that the contralateral trapezius compensated for any deficit. In fact, both patients reported better trunk control after surgery: while sitting, they now used their restored elbow extension to control their balance, using the armrest of the wheelchair as support. The lower trapezius muscle can be used not only as a fall-back option, as in our patients, but also in patients in whom the deltoid and biceps are unavailable for transfer or have been used unsuccessfully. Despite weak elbow extension recovery, we observed improved elbow and shoulder motion and trunk control. ACKNOWLEDGMENT S. Nehete received grants from the Bombay Hospital and Medical Research Centre, Mumbai, India. REFERENCES 1. Bryden A, Peljovich A, Hoyen H, Nemunaitis G, Kilgore K, Keith M. Surgical restoration of arm and hand function in people with tetraplegia. Top Spinal Cord Inj Rehabil. 2012;18(1):43e49. 2. Kuz JE, Van Heest AE, House JH. Biceps-to-triceps transfer in tetraplegic patients: report of the medial routing technique and follow-up of three cases. J Hand Surg Am. 1999;24(1): 161e172. 3. Bertelli JA, Ghizoni MF. Nerve transfers for elbow and finger extension reconstruction in midcervical spinal cord injuries. J Neurosurg. 2015;122(1):121e127. 4. Medina J, Marcos-García A, Jiménez I, Muratore G, MéndezSuárez JL. Biceps to triceps transfer in tetraplegic patients: our experience and review of the literature. Hand. 2017;12(1): 85e90. 5. Mulcahey MJ, Lutz C, Kozin SH, Betz RR. Prospective evaluation of biceps to triceps and deltoid to triceps for elbow extension in tetraplegia. J Hand Surg Am. 2003;13(2):94e97. 6. Bertelli JA. Lower trapezius muscle transfer for reconstruction of elbow extension in brachial plexus injuries. J Hand Surg Eur Vol. 2009;34E(4):45464. 7. Alrabai HM, Gesheff MG, Hammouda AI, Conway JD. Trapezius muscle transfer for restoration of elbow extension in a traumatic brachial plexus injury. J Hand Surg Am. 2018;43(9): 872.e1-e6.
DISCUSSION We believe that the poor quality of our donor nerve for elbow extension reconstruction to be the reason behind failure. In the first case, adding a branch from the anterior division of the axillary nerve would have possibly improved the results. In the second case, bilaterally, the PDAN was paralyzed and we harvested the anterior division of the axillary nerve. In both cases, there was no impact on shoulder abduction. The initial nerve harvesting for transfer did not influence the subsequent care because the posterior deltoid muscle was not adequate for transfer. We did not consider the biceps to triceps muscle transfer because that would have made the nerve to brachialis or its tendon unavailable for finger flexion reconstruction. Even though insufficiently strong to permit patients to raise their body up for transfer, the restoration of
J Hand Surg Am.
r
Vol. -, - 2019