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Free functional muscle belgrade VMA 2011
 

Free functional muscle belgrade VMA 2011

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    Free functional muscle belgrade VMA 2011 Free functional muscle belgrade VMA 2011 Presentation Transcript

    • Functional Free Muscle Transfer for UpperExtremity Reconstruction When and How Milan Stevanovic, MD Professor of Orthopaedic Surgery USC Keck School of Medicine
    • Introduction• Loss of upper extremity function secondary to brachial plexus injuries or severe trauma is a challenging problem
    • Introduction• Advances of microsurgery offered a new approach in the management of these injuries
    • •Tamai et al.Free muscle transplants indogs, with microsurgicalneurovascular anastomosesPlast Reconstr Surg. 1970
    • 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
    • •Stevanovic, Seaber, UrbaniakCanine experimental freemuscle transplantation.Microsurgery. 1986
    • 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
    • Functional Free Muscle Special Indications• Facial reanimation Ralph Manktelow and Ron Zucker
    • •Manktelow, Zuker, McKeeFunctioning freemuscle transplantation.J Hand Surg [Am]. 1984
    • Functional Free Muscle Indications• Functional reconstruction after: –Trauma –BPBP –Volkmann’s –Tumor –Congenital deficiencies
    • Functional Free MuscleUpper Extremity Indications• Deltoid• Biceps• Triceps• Finger Flexors• Finger Extensors• Thenar
    • Functional Free Muscle Goals (Manktelow)• Supply a useful range of motion• Provide adequate strength for functional activities• FMT must be under volitional control
    • 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
    • Donor Muscle Options• Gracilis• Latissimus• Rectus femoris• Pectoralis Major• Medial gastrocnemius• Tensor fascia lata• Serratus Anterior
    • Free gracilis Indications• Deltoid reconstruction• Elbow flexion• Elbow extension• Finger flexion• Finger extension Gracilis Transfer with Skin
    • Pedicle LatissimusAnterior Deltoid
    • Free gracilisFinger extension Finger flexion
    • Surgical Technique: Key Points Achieve optimal muscle resting length
    • Surgical Technique: Key Points• Establish strong & appropriately located origin and insertion
    • Illustrative case: Free gracilis for finger extension
    • Flexor Origin Slide
    • Nerve Graft
    • Vascular Anastamosis and neurorraphy
    • Cable grafting of severelycompromised median nerve
    • Skin paddle post Debridement of partial necrosis Healthy and viable Underlying musclepedicle
    • tenolysisopponensplasty
    • Functional results at one year
    • 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
    • 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
    • Free muscle transfer• Type of blood supply• I. Rectus femoris,Tensor fascia• lata• II. Gracilis,Biceps femoris,Soleus• V. Latissimus dorsi,Pectoralis• major
    • 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
    • Donor Muscle Considerations• Muscle Type –pennate (stronger) – Rectus femoris –strap (better excursion) – Gracilis, Latissimus dorsi,
    • Donor Muscle Considerations• Muscle Excursion –Ideally 6-7 cm of muscle excursion to produce functional range of flexion of fingers and elbow
    • Surgical TechniqueFree muscle transfer• technically demanding• microvascular anastomoses
    • Illustrative case: Free gracilis transfer to reconstruct finger flexion after rhabdomyosarcoma resection
    • Free gracilis for finger flexion tumor
    • Free gracilis for finger flexion
    • Free gracilis for finger flexion
    • Free gracilis for finger flexion
    • Free gracilis for finger flexion
    • Illustrative case: Free serratus anterior to reconstruct opposition3 yrs after crush left hand and thenar muscle debridement
    • Imaging
    • Operative
    • Operative
    • Operative
    • Operative
    • OperativeSerratus anterior
    • Operative
    • Operative
    • Operative
    • Operative
    • Functional Free Latissimus Courtesy MB Wood
    • Surgical Technique: Key Points• Minimize Ischemia Time –Irreversible muscle loss increases with time –Non-linear relationship
    • Surgical Technique: Key Points• Nerve Considerations –Recipient site nerve should be motor fibers –Neurorraphy should be done as close as possible to transplanted muscle
    • Illustrative case Reconstruction of elbow flexion 4 years after brachial plexus injury
    • Functional Free MusclePost-Operative Management• Immobilization –Elbow • 8 weeks –Finger • Flexors - 4 weeks – start PROM • Extensors – 6 weeks start PROM
    • 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
    • Complications
    • Conclusions Functional Free Muscle Transfer• Demanding procedure• Meticulous technique• Experience in microsurgery
    • Immediate Reconstruction of finger flexion after severe Compartment Syndrome with liquifactive muscle necrosis
    • Immediate Functional Reconstruction Flexor TendonsMedian Nerve
    • Principles of Free Functional Muscle Transfers
    • 140
    • FIN
    • Thank you
    • Thank you