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latissimus dorsi muscle for reconstruction
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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
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