Restoration of prehensile function for motor paralysis in Hopkins syndrome: case report.

Hopkins syndrome is a rare cause of poliomyelitis-like paralysis affecting 1 or more extremities after an acute attack of asthma. The exact etiology of Hopkins syndrome is not known. A 4-year-old girl developed acute asthma followed by complete flaccid paralysis of the left upper extremity. She underwent staged reconstruction using the double free muscle transfer technique. Rigorous postoperative physiotherapy was carried out to achieve a good functional outcome. At recent follow-up, 27 months after the first procedure, the patient was able to effectively use the reconstructed hand for most daily activities. She had good control and could perform 2-handed activities. The selection of a suitable operative treatment and suitable donor nerves is critical, and there are no clear guidelines in the literature. The double free muscle transfer can be effectively employed in similar cases to restore grasping function.

Microsurgery in the urgent and emergent management of the hand.

Appropriate use of microsurgical techniques in the emergency management of injured hands increases the salvage rate of complex upper limb injuries. Over time, the indications for replantation, both major and minor, have expanded and techniques refined to get better functional outcomes. The wide choice of free flaps available has made primary reconstruction possible to obtain a good functional and aesthetic outcome. The benefits microsurgery offers in the emergent management of the injured hand are now firmly established. The challenge is to create and maintain centers which can provide around-the-clock, high quality microsurgery services. The issues of adequate training opportunities, obtaining adequate work load to maintain high skill levels, attracting talent into the field are the challenges faced in maintaining high levels of service. In the developing countries, in addition to these issues, increasing the awareness of the potential of microsurgical services among the medical personal and the public has to be addressed.

Current Procedure of Double Free Muscle Transfer for Traumatic Total Brachial Plexus Palsy.

INTRODUCTION: We describe the current procedure of not only double free muscle transfer but also supplemental techniques including nerve transfer for shoulder and elbow reconstruction and secondary surgery for the wrist and fingers to improve prehensile function following traumatic total brachial plexus palsy1-4. STEP 1 PREOPERATIVE PLANNING: Coronal and transverse MRIs and intraoperative electrical stimulation are useful for nerve-root evaluation. STEP 2 RECONSTRUCTION OF SHOULDER FUNCTION STAGE I: If the nerve gap is <10 cm, use the sural nerve as an interpositional graft; if the nerve gap is >15 cm, use a vascularized ulnar or radial nerve graft from the ipsilateral forearm; if the ipsilateral nerve roots are not available, explore the contralateral plexus. STEP 3 FIRST FREE INNERVATED MUSCLE TRANSFER FOR ELBOW FLEXION AND FINGER EXTENSION STAGE II: Prepare the recipient site, harvest the gracilis muscle, and transfer the muscle graft. STEPS 4 AND 5 STAGE III NERVE TRANSFER FOR ELBOW EXTENSION AND SENSORY RESTORATION STEP 4 AND SECOND FREE INNERVATED MUSCLE TRANSFER FOR ELBOW FLEXION AND FINGER FLEXION STEP 5: Repair the long-head branches of the triceps brachii muscle of the radial nerve by using the third and fourth intercostal nerves, and the median nerve by using the sensory branch of the the second and third intercostal nerves; then transfer the second free muscle. STEP 6 POSTOPERATIVE MANAGEMENT: Immobilize the upper limb for eight weeks, and start early passive mobilization at one week. STEP 7 SECONDARY PROCEDURES STAGE IV: Secondary procedures include wrist fusion, correction of intrinsic minus deformity, etc. RESULTS: From 2002 to 2008, thirty-six patients underwent reconstruction with the double free muscle technique to treat a total brachial plexus palsy5. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

Complete avulsion of brachial plexus with associated vascular trauma: feasibility of reconstruction using the double free muscle technique.

BACKGROUND: Vascular trauma associated with brachial plexus injury affects the selection of reconstructive procedures. Often, there is a paucity of appropriate recipient vessels with adequate blood flow for functioning free muscle transfer. The presence of associated vascular injuries of the subclavian or axillary artery is considered a contraindication to the double free muscle technique. The authors hypothesized that vascular repair of subclavian or axillary artery trauma might not be necessary for successful reconstruction using the double free muscle technique, provided that the recipient arteries for functioning free muscle transfer (e.g., thoracoacromial and thoracodorsal arteries) are found to be patent on preoperative angiography. METHODS: The authors investigated the pathway of collateral circulation and potential recipient vessels for functioning free muscle transfer reconstruction in 20 brachial plexus injury patients associated with subclavian or axillary artery trauma using multidetector-row computed tomographic angiography. Based on these findings, the authors restored upper extremity function using the double free muscle technique without surgical repair of the injury to the major vessel in three patients. RESULTS: The suprascapular artery was the major stem artery for collateral circulation, and the circumflex scapular and subscapular arteries were major reentry arteries. The authors successfully used the thoracoacromial and thoracodorsal arteries as the recipient vessels for functioning free muscle transfers in the double free muscle technique. The preliminary functional outcomes of all three cases were satisfactory. CONCLUSION: This study demonstrates the feasibility of double free muscle technique reconstruction in brachial plexus injury patients, without actual vascular repair for the associated subclavian or axillary artery trauma. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.