TRANSFER OF BRACHIALIS MUSCLE TO TRICEPS FOR RESTORATION OF ELBOW EXTENSION IN PATIENTS WITH OBSTETRIC PALSY SEQUELAE

Yıl 2022, Cilt: 85 Sayı: 2, 185 - 191, 24.03.2022

Ahmet Bicer , Atakan Aydın , Türker Özkan , Safiye Özkan Zeynep Hosbay , Ömer Berköz

https://doi.org/10.26650/IUITFD.1035427

Öz

Objective: Elbow extension deficit following brachial plexus injuries can sometimes be overlooked. Elbow flexion deficit is more prominent in the early stages of obstetric paralysis and is used as an indication for early nerve surgery. However, in the future extension deficits may become more numerous. Residual disabilities following obstetric paralyses can be dynamically addressed by tendon transfers. In patients with obstetric paralysis, canonical donor muscles such as the deltoid or biceps may be insufficient for restoration of elbow extension. The brachialis muscle, because of its deep and secluded position, may be considered as one of the more recent options for selection as a donor in these patient groups. In this study, the efficiency of brachialis to triceps transfer both in elbow extension and in shoulder abduction was assessed. Materials and Methods: Seven obstetrical palsy patients with varying degrees of sequelae around the shoulder and elbow underwent a brachialis to triceps transfer procedure. All patients had previously undergone a modified Hoffer procedure. Ranges of motion in shoulder and elbow joints were recorded before and after the transfer. A minimum of M3+ in elbow flexion was set as a prerequisite for the transfer. Results: The elbow extension was improved from a median of -70° (interquertile range, IQR: 20º) to a median of -10° (IQR: 35º) in the follow-up (p<0.05). Shoulder abduction was improved from a median of 140° (IQR: 5º) to a median of 170° (IQR: 15º) (p<0.05). Elbow flexion power was found to be diminished from median M4 (Q1: M3+, Q3: M5) to M3 (Q1: M3, Q3: M3+) (p<0.05). Conclusions: Brachialis to triceps transfer was found to be a suitable alternative in palliative surgery of obstetric palsy patients in terms of elbow extension. Loss of elbow flexion power was within acceptable range.

Anahtar Kelimeler

endon transfer, obstetric paralysis, elbow joint, shoulder joint

Destekleyen Kurum

Scientific Research Projects Coordination Unit of Istanbul University

Proje Numarası

37697

DOĞUMSAL BRAKİYAL PLEKSUS PARALİZİSİ NEDENİYLE DİRSEK EKSTANSİYON KUSURU BULUNAN HASTALARDA BRAKİYALİS TRİSEPS TENDON TRANSFERİ UYGULANAN OLGULARIN DEĞERLENDİRİLMESİ

Öz

Amaç: Brakiyal pleksus yaralanmaları sonrası dirsek ekstansiyonu sorunları genellikle ön planda tutulmaz. Obstetrik paralizinin erken evrelerinde dirsek fleksiyon kusurları ön plandadır ve erken dönem sinir cerrahisi endikasyonu için klinik bir belirteç olarak kullanılır. Yıllar geçtikçe fleksiyon işlevinin geri kazanımıyla birlikte dirsekte ekstansiyon kayıpları ön plana çıkabilir. Tendon transferleri obstetrik paralizi sekellerinin geç dönem dinamik rekonstrüktif tedavi seçenekleri arasında yer almaktadır. Obstetrik paralizili hastalarda deltoid ve biseps gibi klasik donörlerin güçleri dirsek ekstansiyonunu sağlamaya yetmeyebilir. Brakiyalis kası, kolda derin yerleşimiyle gizli bir alternatif olabilir. Bu çalışmada dirsek ekstansiyon kusuru sekeli bulunan obstetrik paralizi hastalarında brakiyalis triseps tendon transferinin dirsek ekstansiyonu ve omuz ekstansiyonu üzerine etkileri incelenmiştir. Gereç ve Yöntem: Çalışmaya dirsek ve omuz eklemleri çevresinde sekelleri bulunan ve bu amaçla brakiyalis triseps tendon transferi uygulanmış yedi obstetrik paralizi hastası dâhil edilmiştir. Tüm hastalara daha öncesinde modifiye Hoffer prosedürü uygulanmıştı. Hastalarda omuz ve dirsek aktif ve pasif eklem hareket açıklıkları gonyometrik olarak analiz edildi. Brakiyalis transferi, minimum dirsek fleksiyon gücü M3+ olan hastalara uygulandı. Bulgular: Dirsek ekstansiyonu ameliyat öncesi ortanca -70° (interkuartil açıklık, IQR: 10º)’den ameliyat sonrası izlemde ortanca -10° (IQR: 35º)’ye çıkmıştır (p<0,05). Omuz abdüksiyonu ise ameliyat öncesi ortanca 140° (IQR: 5º)’den ameliyat sonrası izlemde ortanca 170° (IQR: 15º)’ye çıkmıştır (p<0,05). Dirsek fleksiyonu ise ameliyat öncesi ortanca M4 (IQR: M3+, M5)’den, ameliyat sonrası ortanca M3 (IQR: M3, M3+)’e gerilemiştir (p<0,05). Sonuç: Brakiyalis triseps transferi obstetrik paralizi sekeli bulunan olgularda dirsek ekstansiyonunu sağlamak için geçerli bir seçenek olarak ortaya konmuştur. Bununla birlikte dirsek fleksiyonunda istatistiki olarak anlamlı bir kayıp gözlenmektedir. Bu kayıp klinik olarak kabul edilebilir düzeylerdedir.

Anahtar Kelimeler

Tendon transferi, obstetrik paralizi, dirsek eklemi, omuz eklemi

Proje Numarası

37697

Kaynakça

• 1. Bager B. Perinatally acquired brachial plexus palsy-a persisting challenge. Acta Paediatr 1997;86(11):1214-9. [CrossRef]
• 2. DiTaranto P, Campagna L, Price AE, Grossman JAI. Outcome Following Nonoperative Treatment of Brachial Plexus Birth Injuries. J Child Neurol 2004;19(2):87-90. [CrossRef]
• 3. Brown T, Cupido C, Scarfone H, Pape K, Galea V, McComas A. Developmental apraxia arising from neonatal brachial plexus palsy. Neurology 2000;55(1):24-30. [CrossRef]
• 4. Annika J, Paul U, Anna-Lena L. Obstetric brachial plexus palsy - A prospective, population-based study of incidence, recovery, and long-term residual impairment at 10 to 12 years of age. Eur J Paediatr Neurol 2019;23(1):87-93. [CrossRef]
• 5. Pondaag W, Malessy MJA. Evidence that nerve surgery improves functional outcome for obstetric brachial plexus injury. J Hand Surg Eur Vol 2021;46(3):229-36. [CrossRef]
• 6. Oberlin C. Rethinking surgical strategy in the management of obstetrical palsy. J Hand Surg Eur Vol 2021;46(7):705-7. [CrossRef]
• 7. Vekris MD, Beris AE, Lykissas MG, Korompilias AV, Vekris AD, Soucacos PN. Restoration of elbow function in severe brachial plexus paralysis via muscle transfers. Injury 2008;39(3):15-22. [CrossRef]
• 8. Coulet B, Chammas M. Palsy of elbow extension. Hand Surg Rehabil 2021;S2468-1229(21)00243-7.
• 9. Vekris MD, Papadopoulos DV, Gelalis ID, Kontogeorgakos V, Tsantes AG, Gkiatas I, et al. Secondary procedures for restoration of upper limb function in late cases of neonatal brachial plexus palsy. Eur J Orthop Surg Traumatol 2019;29(2):329-36. [CrossRef]
• 10. Ejeskär A. Elbow extension. Hand Clinics 2002;18(3):449-59. [CrossRef]
• 11. Friedenberg ZB. Transposition of the biceps brachii for triceps weakness. J Bone Joint Surg Am 1954;36-A(3):656-8. [CrossRef]
• 12. Moberg E. Surgical treatment for absent single-hand grip and elbow extension in quadriplegia. Principles and preliminary experience. J Bone Joint Surg Am 1975;57(2):196-206. [CrossRef]
• 13. Bertelli JA. Lower Trapezius Muscle Transfer for Reconstruction of Elbow Extension in Brachial Plexus Injuries. J Hand Surg Eur Vol 2009;34(4):459-64. [CrossRef]
• 14. Ozkan T, Okumus A, Aydin A, Ozkan S, Tuncer S. Brachioradialis Transposition for Elbow Extension in Obstetrical Brachial Plexus Palsy. Techniques in Hand and Upper Extremity Surgery 2005;9(1):60-5. [CrossRef]
• 15. Leonello DT, Galley IJ, Bain GI, Carter CD. Brachialis Muscle Anatomy. J Bone Joint Surg Am 2007;89(6):1293-7. [CrossRef]
• 16. Chuang DC, Hattori Y, Ma And HS, Chen HC. The Reconstructive Strategy for Improving Elbow Function in Late Obstetric Brachial Plexus Palsy. Plast Reconstr Surg 2002;109(1):116-26. [CrossRef]
• 17. Terzis JK, Vekris MD, Soucacos PN. Outcomes of Brachial Plexus Reconstruction in 204 Patients with Devastating Paralysis. Plast Reconstr Surg 1999;104(5):1221-40. [CrossRef]
• 18. Jones BN, Manske PR, Schoenecker PL, Dailey L. Latissimus Dorsi Transfer to Restore Elbow Extension in Obstetrical Palsy. J Pediatr Orthop 1985;5(3):287-9. [CrossRef]
• 19. Doi K, Sakai K, Fuchigami Y, Kawai S. Reconstruction of irreparable brachial plexus injuries with reinnervated freemuscle transfer. J Neurosurg 1996;85(1):174-7. [CrossRef]
• 20. Bertelli JA. Brachialis Muscle Transfer to the Forearm Muscles in Obstetric Brachial Plexus Palsy. J Hand Surg Br 2006;31(3):261-5. [CrossRef]
• 21. Murray WM, Buchanan TS, Delp SL. The isometric functional capacity of muscles that cross the elbow. J Biomech 2000;33(8):943-52. [CrossRef]
• 22. Ozkan T, Aydin A, Onel D, Ozkan S. [Reconstruction of shoulder abduction and external rotation in obstetric brachial plexus palsy]. Acta Orthop Traumatol Turc 2004;38(3):161-9.