Tendon transfers , Muscle transfers , Palliative 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
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)