Secondary Surgery

Tendon transfers , Muscle transfers , Palliative surgery

Secondary Surgery

When a sufficient period of time from nerve repair (or lack of repair) without a useful functional recovery has elapsed, a secondary surgery strategy can be advised. We can define as secondary surgery all these operations devoted to restore, even if partially, some fundamental functions not achieved by nerve repair or spontaneous recovery; this can be obtained by tendon or muscle transfers by means of changing their original insertion in order to obtain new movements by a different motors.
Secondary surgery, even called palliative surgery, must be considered as a forced limited solution for a deficit whose original cause can’t be restored. The ideal time to perform this surgery will depend from the functional territory of the arm whose function we intend to restore. For the shoulder, for instance, whose nerves need at least two years to lead to a functional recovery, we will indicate a secondary surgery not before 2 years. For more distal functions to be restored, for instance for wrist extension we will wait at least three to four years that is the time that a nerve regeneration will need to reach the distal target so far from the point of lesion/repair.

The reason why the results we can obtain by secondary surgery in plexus palsies are very frequently only partial, is that the motors which can be used to substitute the deficits are very limited and moreover quite always not sufficiently strong. In fact a prerequisite for this type of reconstructive surgery apart avoid to add functional impairment to the arm, is to use sufficiently strong muscles which is rarely the case in sequelae of plexus palsies.
Just to give some examples for abduction of the shoulder a trapezius muscle can be reinserted more distally from his original scapular insertion to reach the humerus, changing in this way his physiological lever arm in order to recover a certain degree of abduction. For elbow flexion, depending on the motors a our disposal, we can transpose the epitroclear muscles, latissimus dorsi or pectoralis major to substitute biceps function.

Latissimus dorsi, a strong adductor muscle, is transferred to substitute the biceps to achieve elbow flexion

To restore wrist extension, transfer of wrist flexors are usually used. In absence of any muscles to be transposed there is the possibility to completely transplant a muscles, usually the gracilis muscle harvested from the thigh, that will be revascularized and reinnervated by microsurgical techniques. We must underline that this sophisticated and complex surgery can partially restore only one single function and even If repeated will never succeed to obtain a useful result in terms of function of the hand.

After secondary surgery and a period of 6 to 7 weeks of immobilization of the arm necessary to favour the anatomical healing of the transfer, a long period of rehabilitation will be needed. Physiotherapy will have the aim to reinforce the muscles in their new anatomical site to recover a reasonable function and to allow the patient to learn the new cortical schema of recovering movement.

1) A schema of gracilis muscles harvested from the thigh with an island of skin and with his vascular and nerve pedicle.
2) The muscles transposed in the arm has been revascularized (artery and vein) and reinnervated (with two intercostals nerves) to achieve an active elbow flexion (against resistance)