R' Hierner

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Free functional muscle transfer in posttraumatic
brachial Plexus lesions is it worthwhile ?

• R. Hierner, A. Berger
• Plastic, Reconstructive, Aesthetic and Hand
  Surgery,
• Center for nterdisciplinary Reconstructive
  Surgery, Microsurgery, Burns
• University Hospital Essen
• University of Duisburg-Essen/Germany
• Plastic, Hand- and Reconstructive Surgery,
  University Hospital Hannover, Hannover Medical
  University/Germany
• Email robert.hierner_at_uk-essen.de

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Free Functionel Muscle Transplantation
multidisciplinary Therapy-Team
Profund Basis knowledge
standardized Patient Selection
Standardized operative technique and
postoperative care
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1) Profund Basis Knowledge
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2) Multidisciplinary Therapy Team
Surgeon (Orthopedic/Plastic/Neuro-/Vascular,
.....)
Radiology
Anesthesiology/ Pain clinic
Neurology
Nursing
Physiotherapy
Social Service
Insurance companies
Patient groups
Administration
Public relations
Facultative Members..
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3) Standardized Patient Selection
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4) Standardized Operative technique and
postoperative care
Mantkelow 1993
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Operative technique and postoperative care (6)-
Postoperative care and rehanbilitation

• d0 intermediate Care/ICU
• d1 return to ward
• d3 start passiv mobilisation
• d10 removal of skin sutures
• d14 (dynamic) splinting (if intact antagonistic
  muscles)
• 3w start standardized scar treatment
• Compression garment
• Silicon sheet
• 6w Physiotherapy without any restrictions
• 3-6m first muscle contractures expeted
  (evtl. EMG)
• 24m functional pleateau expected, expertise

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Patients and Method (n 28)
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Elbow Flexion (n 8)
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Elbow Flexion (n 8)
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Elbow/Wrist/Finger- Flexion (n 4)
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Elbow/Wrist/Finger- Flexion (n 4)
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Wrist/Finger- Flexion (n 16)
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Wrist/Finger- Flexion (n 16)
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Discussion (1)-Indications and Contraindications

• no sufficient muscle function
• no adequate possibility for muscle/tendon
  transfers
• Augmentation (M1 M3)
• direct muscle trauma
• reinnervated muscle
• Reconstruction (M0)
• direct muscle trauma
• Muscle denervation gt 12 m
• Missing requirement for muscle/tendon transfer
• no adequate possibility of neuro-vascular
  microanastomoses

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Discussion (1)- Function
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Discussion (3)- influencing factors

• passive ROM
• Age (children vs adult)
• Degree of remaining muscle power
• (augmentation vs. reconstruction)
• Choice of axon donor (contralat. C7 vs. ½ N. XI
  vs. 3 ICN vs. Phrenic nerve)
• Length of cold muscle ischemia time (lt 3 h)

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Conclusions

• Reliable technique for elbow flexion restoration
• Poor results in wrist/finger restoration
• More powerful axon donors (C7 ?)
• Additional use of myo-electric orthesis