Free functional muscle belgrade VMA 2011

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  • 1. Functional Free Muscle Transfer for UpperExtremity Reconstruction When and How Milan Stevanovic, MD Professor of Orthopaedic Surgery USC Keck School of Medicine
  • 2. Introduction• Loss of upper extremity function secondary to brachial plexus injuries or severe trauma is a challenging problem
  • 3. Introduction• Advances of microsurgery offered a new approach in the management of these injuries
  • 4. •Tamai et al.Free muscle transplants indogs, with microsurgicalneurovascular anastomosesPlast Reconstr Surg. 1970
  • 5. Donor Muscle Considerations• Muscle Power –Terzis, J Hand Surg, 1978 • Suggested that muscle bulk decreases with muscle transplantation to 25-50% –Doi , Clin Plast Surg, 2002 • Transplanted muscles regained full strength, sometimes stronger than pre-transplanted power
  • 6. •Stevanovic, Seaber, UrbaniakCanine experimental freemuscle transplantation.Microsurgery. 1986
  • 7. Functional Free Muscle Indications• Deficiency of critical motor function with no suitable tendon transfer options• No suitable rotational muscle transfer• Soft tissue defect requiring coverage in combination with functional loss
  • 8. Functional Free Muscle Special Indications• Facial reanimation Ralph Manktelow and Ron Zucker
  • 9. •Manktelow, Zuker, McKeeFunctioning freemuscle transplantation.J Hand Surg [Am]. 1984
  • 10. Functional Free Muscle Indications• Functional reconstruction after: –Trauma –BPBP –Volkmann’s –Tumor –Congenital deficiencies
  • 11. Functional Free MuscleUpper Extremity Indications• Deltoid• Biceps• Triceps• Finger Flexors• Finger Extensors• Thenar
  • 12. Functional Free Muscle Goals (Manktelow)• Supply a useful range of motion• Provide adequate strength for functional activities• FMT must be under volitional control
  • 13. Functional Free Muscle Pre-requisites• Motivated patient• Supple passive range of motion• Suitable recipient site motor nerve and vessels• Good soft tissue coverage and underlying tissue bed for tendon gliding
  • 14. Donor Muscle Options• Gracilis• Latissimus• Rectus femoris• Pectoralis Major• Medial gastrocnemius• Tensor fascia lata• Serratus Anterior
  • 15. Free gracilis Indications• Deltoid reconstruction• Elbow flexion• Elbow extension• Finger flexion• Finger extension Gracilis Transfer with Skin
  • 16. Pedicle LatissimusAnterior Deltoid
  • 17. Free gracilisFinger extension Finger flexion
  • 18. Surgical Technique: Key Points Achieve optimal muscle resting length
  • 19. Surgical Technique: Key Points• Establish strong & appropriately located origin and insertion
  • 20. Illustrative case: Free gracilis for finger extension
  • 21. Flexor Origin Slide
  • 22. Nerve Graft
  • 23. Vascular Anastamosis and neurorraphy
  • 24. Cable grafting of severelycompromised median nerve
  • 25. Skin paddle post Debridement of partial necrosis Healthy and viable Underlying musclepedicle
  • 26. tenolysisopponensplasty
  • 27. Functional results at one year
  • 28. Donor Muscle General Considerations• Expendible donor muscle – sacrificed with acceptable donor site morbidity• Adequate length and excursion for new function• Sufficient force• Vascular pedicle permits transfer
  • 29. Free muscle transfer• Type of blood supply• I. One vascular pedicle• II. Dominant pedicles and minor pedicles• V. One dominant pedicle and secondary segmental pedicles
  • 30. Free muscle transfer• Type of blood supply• I. Rectus femoris,Tensor fascia• lata• II. Gracilis,Biceps femoris,Soleus• V. Latissimus dorsi,Pectoralis• major
  • 31. Donor Muscle Considerations• Muscle Type – pennate (stronger) – strap (better excursion)• Cross sectional area – pennate - greater cross sectional area results in greater strength• Excursion – estimated as 40% of the msucle resting length
  • 32. Donor Muscle Considerations• Muscle Type –pennate (stronger) – Rectus femoris –strap (better excursion) – Gracilis, Latissimus dorsi,
  • 33. Donor Muscle Considerations• Muscle Excursion –Ideally 6-7 cm of muscle excursion to produce functional range of flexion of fingers and elbow
  • 34. Surgical TechniqueFree muscle transfer• technically demanding• microvascular anastomoses
  • 35. Illustrative case: Free gracilis transfer to reconstruct finger flexion after rhabdomyosarcoma resection
  • 36. Free gracilis for finger flexion tumor
  • 37. Free gracilis for finger flexion
  • 38. Free gracilis for finger flexion
  • 39. Free gracilis for finger flexion
  • 40. Free gracilis for finger flexion
  • 41. Illustrative case: Free serratus anterior to reconstruct opposition3 yrs after crush left hand and thenar muscle debridement
  • 42. Imaging
  • 43. Operative
  • 44. Operative
  • 45. Operative
  • 46. Operative
  • 47. OperativeSerratus anterior
  • 48. Operative
  • 49. Operative
  • 50. Operative
  • 51. Operative
  • 52. Functional Free Latissimus Courtesy MB Wood
  • 53. Surgical Technique: Key Points• Minimize Ischemia Time –Irreversible muscle loss increases with time –Non-linear relationship
  • 54. Surgical Technique: Key Points• Nerve Considerations –Recipient site nerve should be motor fibers –Neurorraphy should be done as close as possible to transplanted muscle
  • 55. Illustrative case Reconstruction of elbow flexion 4 years after brachial plexus injury
  • 56. Functional Free MusclePost-Operative Management• Immobilization –Elbow • 8 weeks –Finger • Flexors - 4 weeks – start PROM • Extensors – 6 weeks start PROM
  • 57. Functional Free MusclePost-Operative Management• After EMG evidence of reinnervation: – Motor re-education with therapist guidance – Short sessions, ending when muscle fatigues – Slow , gradual correction of contracture. Passive elongation of muscle can result in muscle fiber injury
  • 58. Complications
  • 59. Conclusions Functional Free Muscle Transfer• Demanding procedure• Meticulous technique• Experience in microsurgery
  • 60. Immediate Reconstruction of finger flexion after severe Compartment Syndrome with liquifactive muscle necrosis
  • 61. Immediate Functional Reconstruction Flexor TendonsMedian Nerve
  • 62. Principles of Free Functional Muscle Transfers
  • 63. 140
  • 64. FIN
  • 65. Thank you
  • 66. Thank you