Free functional muscle belgrade VMA 2011


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Free functional muscle belgrade VMA 2011

  1. 1. Functional Free Muscle Transfer for UpperExtremity Reconstruction When and How Milan Stevanovic, MD Professor of Orthopaedic Surgery USC Keck School of Medicine
  2. 2. Introduction• Loss of upper extremity function secondary to brachial plexus injuries or severe trauma is a challenging problem
  3. 3. Introduction• Advances of microsurgery offered a new approach in the management of these injuries
  4. 4. •Tamai et al.Free muscle transplants indogs, with microsurgicalneurovascular anastomosesPlast Reconstr Surg. 1970
  5. 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. 6. •Stevanovic, Seaber, UrbaniakCanine experimental freemuscle transplantation.Microsurgery. 1986
  7. 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. 8. Functional Free Muscle Special Indications• Facial reanimation Ralph Manktelow and Ron Zucker
  9. 9. •Manktelow, Zuker, McKeeFunctioning freemuscle transplantation.J Hand Surg [Am]. 1984
  10. 10. Functional Free Muscle Indications• Functional reconstruction after: –Trauma –BPBP –Volkmann’s –Tumor –Congenital deficiencies
  11. 11. Functional Free MuscleUpper Extremity Indications• Deltoid• Biceps• Triceps• Finger Flexors• Finger Extensors• Thenar
  12. 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. 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. 14. Donor Muscle Options• Gracilis• Latissimus• Rectus femoris• Pectoralis Major• Medial gastrocnemius• Tensor fascia lata• Serratus Anterior
  15. 15. Free gracilis Indications• Deltoid reconstruction• Elbow flexion• Elbow extension• Finger flexion• Finger extension Gracilis Transfer with Skin
  16. 16. Pedicle LatissimusAnterior Deltoid
  17. 17. Free gracilisFinger extension Finger flexion
  18. 18. Surgical Technique: Key Points Achieve optimal muscle resting length
  19. 19. Surgical Technique: Key Points• Establish strong & appropriately located origin and insertion
  20. 20. Illustrative case: Free gracilis for finger extension
  21. 21. Flexor Origin Slide
  22. 22. Nerve Graft
  23. 23. Vascular Anastamosis and neurorraphy
  24. 24. Cable grafting of severelycompromised median nerve
  25. 25. Skin paddle post Debridement of partial necrosis Healthy and viable Underlying musclepedicle
  26. 26. tenolysisopponensplasty
  27. 27. Functional results at one year
  28. 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. 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. 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. 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. 32. Donor Muscle Considerations• Muscle Type –pennate (stronger) – Rectus femoris –strap (better excursion) – Gracilis, Latissimus dorsi,
  33. 33. Donor Muscle Considerations• Muscle Excursion –Ideally 6-7 cm of muscle excursion to produce functional range of flexion of fingers and elbow
  34. 34. Surgical TechniqueFree muscle transfer• technically demanding• microvascular anastomoses
  35. 35. Illustrative case: Free gracilis transfer to reconstruct finger flexion after rhabdomyosarcoma resection
  36. 36. Free gracilis for finger flexion tumor
  37. 37. Free gracilis for finger flexion
  38. 38. Free gracilis for finger flexion
  39. 39. Free gracilis for finger flexion
  40. 40. Free gracilis for finger flexion
  41. 41. Illustrative case: Free serratus anterior to reconstruct opposition3 yrs after crush left hand and thenar muscle debridement
  42. 42. Imaging
  43. 43. Operative
  44. 44. Operative
  45. 45. Operative
  46. 46. Operative
  47. 47. OperativeSerratus anterior
  48. 48. Operative
  49. 49. Operative
  50. 50. Operative
  51. 51. Operative
  52. 52. Functional Free Latissimus Courtesy MB Wood
  53. 53. Surgical Technique: Key Points• Minimize Ischemia Time –Irreversible muscle loss increases with time –Non-linear relationship
  54. 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. 55. Illustrative case Reconstruction of elbow flexion 4 years after brachial plexus injury
  56. 56. Functional Free MusclePost-Operative Management• Immobilization –Elbow • 8 weeks –Finger • Flexors - 4 weeks – start PROM • Extensors – 6 weeks start PROM
  57. 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. 58. Complications
  59. 59. Conclusions Functional Free Muscle Transfer• Demanding procedure• Meticulous technique• Experience in microsurgery
  60. 60. Immediate Reconstruction of finger flexion after severe Compartment Syndrome with liquifactive muscle necrosis
  61. 61. Immediate Functional Reconstruction Flexor TendonsMedian Nerve
  62. 62. Principles of Free Functional Muscle Transfers
  63. 63. 140
  64. 64. FIN
  65. 65. Thank you
  66. 66. Thank you