SECONDARY SURGERY FOLLOWING BRACHIAL-PLEXUS INJURIES

The favourable treatment of post-traumatic brachial plexus lesions based on our experience of 362 cases over a 12 year period is reported. Twenty-five percent of the patients needed secondary operations. The spectrum of the latter consisted of arthrodesis, tenodesis, and musculotendinous transfer, including free neurovascular tissue transfer partially innervated by nerve transposition. Functionally, secondary tendon transfer can help to improve the effect of nerve repair techniques. To restore shoulder function the trapezius transfer (n = 22) has been used mainly; elbow flexion has been regained by pedicled latissimus dorsi translocation (n = 22), triceps-to-biceps transfer (n = 18), bipolar latissimus muscle transfer, and free neurovascular tissue transfer (n = 8). The Steindler flexorplasty was performed in four plexopathies, and finally a pedicled serratus muscle transfer was used. A unipolar latissimus dorsi transfer results in an ability to lift 10-15 kg, whilst the bipolar latissimus transfer and the triceps-to-biceps transfer produced a maximal strength of 5-8 kg. Epitrochlear flexor-pronator mass transfer produced a strength of 2-5 kg, whereas free neurovascular latissimus dorsi transfer developed a maximal muscular strength of 2-4 kg in the unipolar variation and 1-2 kg for the bipolar LD. In 97 secondary procedures to the lower arm and hand the following secondary operations were indicated: in 29 cases of radial nerve palsy transfers according to Merle d'Aubigne, a further 21 wrist tenodeses and 8 wrist arthrodeses were performed. To restore median nerve function, coupling tendon transfer (n = 4) and free neurovascular gracilis transfer (n = 3) were selected. Ulnar nerve palsy was corrected by seven Zancolli procedures. To improve rotation, two pronation plasties were applied. For dynamic opponensplasty the superficial flexor of the ring finger was the primary choice (n = 8). Static fusions between the first and second metacarpal bones served as a static opponensplasty of the thumb ray. Motor-driven orthoses should be reserved for boosting any voluntary muscle contraction or for frustrating cases in which restoration of useful pinch with the previously described surgical procedures is impossible. Improving the function of the formerly paralysed upper extremity in patients with a brachial plexus injury results in a greater independence in everyday activities and a superior psychological status. (C) 1995 Wiley-Liss, Inc.