functional transposition of the latissimus dorsi muscle for

FUNCTIONAL TRANSPOSITION OF THE LATISSIMUS DORSI MUSCLE FOR BICEPS RECONSTRUCTION

AFTER UPPER ARM REPLANTATION

Bagus Nur Graha Wahyu Aji

Pembimbing :Dr. Dewi Haryanti, SpBP-RE

Upper Arm Amputation Life threatening Indication replantation of the amputated part

Patient condition Amputated limb condition Stump condition Surgeon experience Time elapsed since amputation

Introduction

Burden after replantation poor muscle function

and wound healing problem Slow nerve regeneration Direct trauma at the amputation site

Functional transfer of LDM suggestion

reconstruction biceps function is needed, provide well vascularised tissue

Combination of upper arm macroreplantation and Functional transposition of LDM rarely described in literatur

August 1997 – May 2002 6 patient Aged Range 7-55 Y.O. ( mean : 35.4 Y.O.) 1 Patient re-amputation e.c. Septic shock

syndrome unimpaired perfusion

Patient and Methods

Radial and median nerve were coaptated directly

bridged with Sural Nerve grafts 1 case brachial Artery bridged with Saphenous

Vein 1 case Venous trombosis microsurgical revision

first day post operatif Bone fixation AO-Plate

Complete amputation with extensive local crushing of both amputation stump

3 Cases bridged the arterial inflow w/ catheter

reduced reperfusion injury and extend critical time interval

All patients delayed wound healing + partial soft tissue necrosis e.c. Necrosis of distal part of repaired biceps muscle (fig.2)

Solution ?

Using of artificial skin substitute after successful replantation

Transposed a functional pedicled myocutaneus

LDM : restore BcM function Provide soft tissue coverage

All 5 Patient Functional LDM transfer Elbow flexion restoration (fig 3,4)

3 months later, monopolar pedicled myocutaneus LDM used for secondary wound coverage and restoration elbow flexion

Immediate post operative result after partial split-thickness skin grafting of the remaining muscle

LDM transfer 4 pts unipolar, 1 pt bipolar Time period : 2 weeks to 12 months

All flaps healed well Donor site morbidity minimal 22-65 months follow up (mean : 43 month)

functional result good (3 Pts M4, 2 pts M3) (Fig)

Result

3 Years post-op Excellent ROM Good strength of flexion

24 months post operative result

Outcomes depend on level of injury Distal amputations tolerate longer ischemia

time and reinervation Indication is controversial Traction avulsion amputation special

subtype distinguished from guillotine/circular amputation

Discussion

Problem for surgeon :

Should replantation be attempted et all Reasonable functional result achieved Debridement of soft tissue Secondary procedure

Replantation of an avulsed upper arm

microsurgical expertise hospital ready Succes of the procedure viability and

functional outcome Decision of replantation based on prediction of

this procedure will be better than prosthesis.

Replantation of the upper extremity is more

important than lower extremity replantation. Even it requires multiple procedures.

Large amount of muscle Short ischemic procedure upper arm

Adequate debridement and excision are crucial to avoid systemic shock complication

Most cases there will be large wound area in

the anterior aspect od the upper arm, more over delicate structures and bone.

It has to be covered! Flap coverage is mandatory Skin graft later reconstruction will be difficult

and hazardous

Pedicled LD flap provide ample healthy soft

tissue Other choice wound coverage :

Rectus abdominis Rectus femoris Anterolateral thigh cutaneus flap

Muscle free flaps with skin graft is not

recomended Functional reconstruction

Important Major goal : achieving active flexion of elbow

after major loss of flexion Secondary aim : restore wrist extension

Distally located muscle has lower chance of

regaining funtional (intrinsic hand muscle) Strong active flexion and extension elbow

can be obtained w/ distal third amputation of humerus

Why LDM ideal for restoration of elbow flexion

after traumatic upper arm amputation Strong muscle Anatomy well known Acceptable donor site morbidity Muscle remain tightly attached with monopolar

pedicle Stable shoulder not prerequisite One portion of origin can be woven to wrist

extensor even thumb extensor

The pedicled LDM flap is a valuable tool to

restore elbow flexion and provide coverage of soft tissue defects after major upper arm replantation

Summary

Thank You