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Modified Pedicled Latissimus Functional Muscle Transfer Using an Achilles Tendon Allograft
James Clune, MD; Antony Hazel, MD; Helen Vasey, NP; Neil F. Jones, MD; Ranjan Gupta, MD
University of California, Irvine, Irvine, CA

Hypothesis: Major trauma to the upper extremity including brachial plexus injuries are difficult to reconstruct and have limited treatment options. Elbow flexion must be restored to gain meaningful use of the limb. While a pedicled latissimus transfer to restore elbow flexion is a classic procedure, it often produces variable functional improvement. Here, we describe a novel technique for using this pedicled latissimus muscle transfer with Achilles tendon allograft to improve functional outcomes.
Methods: Four patients who had sustained major traumatic injuries to the upper extremity underwent this procedure with three patients sustaining traumatic brachial plexus injuries. After the latissimus muscle is mobilized from its origin and insertion, the muscle is tunneled through the axilla and the latissimus tendinous insertion is passed behind the insertion of the pectoralis major and anchored to the acromion and coracoid to serve as the origin of this rotated muscle as classically described. The Achilles allograft is secured to the radial tuberosity via a button and Fiberloop (Arthrex, Naples, FL). Once the distal portion of the allograft is secured to the radial tuberosity, the latissimus is tensioned as the Achilles allograft is sutured into place onto the anterior aspect of the latissimus dorsi with a modification of the Krackow stitch using Fibertape (Arthrex, Naples, FL). The patients were immobilized in a sling for six weeks with no passive or active extension. During the 6 12 week time period, patients were allowed to perform gentile active flexion with gravity eliminated. After 12 weeks, patient were allowed to start strengthening with therapy and against gravity.
Results: All patients had successful transfers of their latissimus to the anterior aspect of the humerus. Two of the patients had a concomitant shoulder arthrodesis. There were no postoperative re-explorations, muscle necrosis, or wound complications. There was no failure of the distal repair with the button. All patients were able to achieve at least 90 degrees of flexion. Three patients achieved M4 strength and one patient achieved M5 strength.
Summary: Our modified latissimus muscle transfer with an Achilles tendon allograft is a robust method of providing elbow flexion. The fixation at the radial tuberosity is similar to a distal biceps repair and allows for secure bone to tendon healing without loss of tension. Patients are able to achieve range of motion and strength that allows the limb to be functional for normal activities of daily living.


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