Aims. The free latissimus dorsi muscle (LDM) flap represents a workhorse procedure in the field of trauma and plastic surgery. However, only a small number of studies have examined this large group of patients with regard to the morbidity of flap harvest. The aim of this prospective study was therefore to objectively investigate the morbidity of a free LDM flap. Methods. A control group (n = 100) without surgery was recruited to assess the differences in strength and range of motion (ROM) in the shoulder joint with regard to handedness of patients. Additionally, in 40 patients with free LDM flap surgery, these parameters were assessed in an identical manner. Results. We measured higher values for all parameters assessing force in the shoulder joint on the dominant side of patients in the control group. Moreover, LDM flap harvest caused a significant reduction in strength in the glenohumeral joint in all functions of the LDM that were assessed, ranging from 9.0% to 13.8%. Equally, we found a significantly reduced ROM in the shoulder at the side of the flap harvest. For both parameters, this effect was diminished, when the flap harvest took place on the dominant side of the patient. Conclusion. LDM flap surgery leads to a significant impairment of the strength and ROM in the shoulder joint. Moreover, the donor morbidity must be differentiated with regard to handedness: harvest on the non-dominant side potentiates the already existing difference in strength and ROM. Conversely, if the harvest takes place on the dominant side of the patient, this difference is diminished. Cite this article: Bone Jt Open 2024;5(12):1114–1119

Aims

Favourable short-term outcomes have been reported following latissimus dorsi tendon transfer for patients with an irreparable subscapularis (SSC) tendon tear. The aim of this study was to investigate the long-term outcomes of this transfer in these patients.

We retrospectively reviewed the outcomes of 33 consecutive patients who had undergone an extra-articular, total or partial scapulectomy for a malignant tumour of the shoulder girdle between 1 July 2001 and 30 September 2013. Of these, 26 had tumours which originated in the scapula or the adjacent soft tissue and underwent a classic Tikhoff–Linberg procedure, while seven with tumours arising from the proximal humerus were treated with a modified Tikhoff-Linberg operation. We used a Ligament Advanced Reinforcement System for soft-tissue reconstruction in nine patients, but not in the other 24.

The mean Musculoskeletal Tumor Society score (MSTS) was 17.6 (95% confidence interval (CI) 15.9 to 19.4); 17.6 (95% CI 15.5 to 19.6) after the classic Tikhoff–Linberg procedure and 18.1 (95% CI 13.8 to 22.3) after the modified Tikhoff–Linberg procedure. Patients who had undergone a LARS soft-tissue reconstruction had a mean score of 18.6 (95% (CI) 13.9 to 22.4) compared with 17.2 (95% CI 15.5 to 19.0) for those who did not.

The Tikhoff–Linberg procedure is a useful method for wide resection of a malignant tumour of the shoulder girdle which helps to preserve hand and elbow function. The method of soft-tissue reconstruction has no effect on functional outcome.

Cite this article: Bone Joint J 2014;96-B:684–90.

In adults with brachial plexus injuries, lack of active external rotation at the shoulder is one of the most common residual deficits, significantly compromising upper limb function. There is a paucity of evidence to address this complex issue. We present our experience of isolated latissimus dorsi (LD) muscle transfer to achieve active external rotation. This is a retrospective review of 24 adult post-traumatic plexopathy patients who underwent isolated latissimus dorsi muscle transfer to restore external rotation of the shoulder between 1997 and 2010. All patients were male with a mean age of 34 years (21 to 57). All the patients underwent isolated LD muscle transfer using a standard technique to correct external rotational deficit. Outcome was assessed for improvement in active external rotation, arc of movement, muscle strength and return to work. The mean improvement in active external rotation from neutral was 24° (10° to 50°). The mean increase in arc of rotation was 52° (38° to 55°). Mean power of the external rotators was 3.5 Medical Research Council (MRC) grades (2 to 5). A total of 21 patients (88%) were back in work by the time of last follow up. Of these, 13 had returned to their pre-injury occupation. Isolated latissimus dorsi muscle transfer provides a simple and reliable method of restoring useful active external rotation in adults with brachial plexus injuries with internal rotational deformity. Cite this article: Bone Joint J 2013;95-B:660–3

Congenital infantile fibrosarcomas (CIFS) is a rare tumor of childhood that can be diagnosed from birth to 15 years. It has a ratio of 3.74/100 000 children and is well defined nosological entity with a well-defined pathogenetic patterns: translocation (12, 15) (p13, q25) with fusion of the gene ETV6-NTRK3. The differential diagnosis of upper CIFS in infants must be made with lymphatic malformations, and when associated with the Kasabach-Merritt phenomenon’s (disseminated intravascular coagulopathy), haemangiomas, emangioendotelioma kaposiforme. In 26% of cases is congenital, while in 63% is diagnosed in the first 5 years. Unlike fibrosarcomas of the adult is characterized by a low rate of metastasis and a high survival rate (90% at 5 years). 74% of cases is observed in the limbs (upper> lower, distal> proximal). The treatment of choice should to be, where possible, limb salvage and the recurrences are variable between 17% and 43%. The purpose of this paper is to present a case of CIFS, the clinical features, the oncological treatment, the reconstructive solutions and functional results obtained after reconstruction. Case report. The child (Z.A. female), was diagnosed with a neoplasia of soft tissues of the right forearm before birth. At birth the child underwent a needle biopsy with a diagnosis of CIFS. The patient received four cycles of chemotherapy with reduction tumor mass of more than 50% of volume. At month four she underwent an exeresi with wide margings and sacrifice of the radial nerve. The reconstruction required a free flap of re-innervated latissimus dorsi muscle. After 30 months from the surgical procedure the child is disease free and has recovered extesion of the muscles of the hand and fingers

A child with traumatic laceration of the tendo Achillis developed secondary infection after primary repair. This resulted in the loss of 5 cm of the distal part of the tendon and overlying soft tissue. The patient was treated with a free skin flap to cover the wound and to control the infection leaving reconstruction for a second-stage procedure.

However, when he was assessed two years after the skin-flap, delayed reconstruction proved to be unnecessary since he had regained normal ankle function spontaneously and could demonstrate equal function in both tendons.

Introduction: Large chronic tears of the supra and infraspinatus tendons lead to pain and dysfunction of the shoulder. If conservative treatment fails and repair is impossible, transfer of the latissimus dorsi (LD) muscle can be attempted to substitute for lost of supero-posterior cuff function. Method: In 2003 nad 2004, twenty five patients with an average age of 54,8 years (range, 51 to 62 years) who had ongoing pain and impaired function underwent the LD transfer after ultrasonographic examination and diagnostic arthroscopy as a primary surgery. The patients were examined at an average of fourteen months (range, twelve to twenty six months) after the operation. The results were assessed with use of Constant-Murley score pre–and postoperatively. Results: The mean Constant-Murley score increased from 32,50 points preoperatively to 78,75 points postoperatively. The mean score for pain improved of 8,75 points (from 3,75 to 12,50), activities of daily living improved of 10,00 points (from 6,00 to 16,00), range of motion of 15,00 points (from 14,00 to 29,00) and strengh improved of 11,50 points (from 8,75 to 21,25). 20 patients (80%) were very satisfied and 5 patients (20%) were satisfied. The postoperative pain relief was left as the predominant improvement. No patient was disappointed. All patients stated that they would have the operative procedure again under similar circumstances. There was only one complication – subcutaneous haematoma treated with revision and drainage. Conclusions: Our results indicate that LD transfer is a reasonable approach for salvage of a massive tear of the supero-posterior rotator cuff. Despite the difficult operation technique and long rehabilitation phase, this procedure improves the subjective and objective findings

An internal rotation contracture is a common complication of obstetric brachial plexus palsy. We describe the operative treatment of seven children with a recurrent internal rotation contracture of the shoulder following earlier corrective surgery which included subscapularis slide and latissimus dorsi transfer. We performed z-lengthening of the tendon of the subscapularis muscle and transferred the lower trapezius muscle to the infraspinatus tendon. Two years postoperatively the mean gain in active external rotation was 47.1°, which increased to 54.3° at four years.

Lengthening of the tendon of subcapularis and lower trapezius transfer to infraspinatus improved the range of active external rotation in patients who had previously had surgery for an internal rotation contracture.

After establishing anatomical feasibility, functional reconstruction to replace the anterolateral part of the deltoid was performed in 20 consecutive patients with irreversible deltoid paralysis using the sternoclavicular portion of the pectoralis major muscle. The indication for reconstruction was deltoid deficiency combined with massive rotator cuff tear in 11 patients, brachial plexus palsy in seven, and an isolated axillary nerve lesion in two. All patients were followed clinically and radiologically for a mean of 70 months (24 to 125). The mean gender-adjusted Constant score increased from 28% (15% to 54%) to 51% (19% to 83%). Forward elevation improved by a mean of 37°, abduction by 30° and external rotation by 9°.

The pectoralis inverse plasty may be used as a salvage procedure in irreversible deltoid deficiency, providing subjectively satisfying results. Active forward elevation and abduction can be significantly improved.

We have undertaken an in vivo assessment of the tissue metabolism and cellular activity in torn tendons of the rotator cuff. Cellular oxygen consumption was measured in 13 patients undergoing mini-open repair of small, medium, large and massive full-thickness tears. Measurements were also taken from three control patients who were undergoing open stabilisation of the shoulder with grossly normal tendons. The level of oxygen and nitrous oxide was measured amperometrically using silver needle microelectrodes at the apex of the tear and 1.5 cm from its edge. With nitrous oxide indicating the degree of perfusion, oxygen consumption was calculated at each location to reflect cellular activity.

All of the torn tendons had lower levels of cellular activity than the control group. This activity was lower still in the tissue nearest to the edge of the tear with the larger tears showing the lowest activity. This indicated reduced levels of tissue metabolism and infers a reduction in tendon viability.

Our findings suggest that surgical repair of torn tendons of the rotator-cuff should include the more proximal, viable tissue, and may help to explain the high rate of re-rupture seen in larger tears.

Residual muscle weakness in obstetric brachial plexus palsy results in soft-tissue contractures which limit the functional range of movement and lead to progressive glenoid dysplasia and joint instability. We describe the results of surgical treatment in 98 patients (mean age 2.5 years, 0.5 to 9.0) for the correction of active abduction of the shoulder. The patients underwent transfer of the latissimus dorsi and teres major muscles, release of contractures of subscapularis pectoralis major and minor, and axillary nerve decompression and neurolysis (the modified Quad procedure). The transferred muscles were sutured to the teres minor muscle, not to a point of bony insertion. The mean pre-operative active abduction was 45° (20° to 90°). At a mean follow-up of 4.8 years (2.0 to 8.7), the mean active abduction was 162° (100° to 180°) while 77 (78.6%) of the patients had active abduction of 160° or more. No decline in abduction was noted among the 29 patients (29.6%) followed up for six years or more. This procedure involving release of the contracted internal rotators of the shoulder combined with decompression and neurolysis of the axillary nerve greatly improves active abduction in young patients with muscle imbalance secondary to obstetric brachial plexus palsy.

Although it is widely accepted that grade IIIB open tibial fractures require combined specialised orthopaedic and plastic surgery, the majority of patients in the UK initially present to local hospitals without access to specialised trauma facilities. The aim of this study was to compare the outcome of patients presenting directly to a specialist centre (primary group) with that of patients initially managed at local centres (tertiary group).

We reviewed 73 consecutive grade IIIB open tibial shaft fractures with a mean follow-up of 14 months (8 to 48). There were 26 fractures in the primary and 47 in the tertiary group. The initial skeletal fixation required revision in 22 (47%) of the tertiary patients. Although there was no statistically-significant relationship between flap timing and flap failure, all the failures (6 of 63; 9.5%) occurred in the tertiary group. The overall mean time to union of 28 weeks was not influenced by the type of skeletal fixation. Deep infection occurred in 8.5% of patients, but there were no persistently infected fractures. The infection rate was not increased in those patients debrided more than six hours after injury.

The limb salvage rate was 93%. The mean limb functional score was 74% of that of the normal limb. At review, 67% of patients had returned to employment, with a further 10% considering a return after rehabilitation. The times to union, infection rates and Enneking limb reconstruction scores were not statistically different between the primary and tertiary groups.

The increased complications and revision surgery encountered in the tertiary group suggest that severe open tibial fractures should be referred directly to specialist centres for simultaneous combined management by orthopaedic and plastic surgeons.

We describe 14 patients who underwent transfer of latissimus dorsi using a new technique through a single-incision. Their mean age was 61 years (47 to 76) and the mean follow-up was 32 months (19 to 42).

The mean Constant score improved from 46.5 to 74.6 points. The mean active flexion increased from 119° to 170°, mean abduction from 118° to 169° and mean external rotation from 19° to 33°. The Hornblower sign remained positive in three patients (23%) as did the external rotation lag sign also in three patients (23%). No patient had a positive drop-arm sign at follow-up. No significant difference was noted between the mean pre- and postoperative acromiohumeral distance as seen on radiographs. An increased grade of osteoarthritis was found in three patients (23%). Electromyographic analysis showed activity of the transferred muscle in all patients.

Aim: To study the contribution of humeral avulsion of the glenohumeral ligaments (HAGL) to shoulder instability. Methods: In fourteen fresh cadaver shoulders a selective cutting sequence was performed. After each section an abduction-external rotation manoeuvre with axial compression and translation was carried out to provoke dislocation. The resulting instability was graded on a scale of five, ranging from no translation to a locked dislocation. Results: Cutting of only the inferior glenohumeral ligament complex resulted at the most in increased translation, but not in subluxation. For subluxation to occur, at least the middle glenohumeral ligament needed to be cut. The entire humeral capsuloligamentous complex needed to be sectioned before subluxation or dislocation occurred. In half of the cases an additional lesion of the subscapularis or the latissimus dorsi is necessary to allow a locked antero-inferior dislocation. Conclusion: Extensive damage to the humeral side of the capsulo-ligamentous complex and, frequently, associated lesions of the subscapularis or latissimus dorsi muscles are necessary to allow dislocation. This might be the primary reason for the low incidence of HAGL observed in clinical series of shoulder instability

Aims: The most common contracture secondary to brachial plexus birth injury in the shoulder is the internal rotation-adduction one. The purpose of this study was to report the long-term results of the anterior shoulder release combined with transfer of the teres major and latissimus dorsi muscles posteriorly and laterally to allow them to act as external rotators. Methods: The described surgical procedure was performed in ten patients. Nine of them were male and one female, while eight patients had a lesion of the superior trunk and two had involvement of the entire brachial plexus. The patientsñ age ranged from 5 to 9 years old (av. age: 6 years) at the time of the operation, while the average follow-up time was 30 years (range, 25 to 42 years). Results: No improvement of the active abduction was noticed in any of the patients. The average increase of the active external rotation, which had postoperatively been achieved, was 35¡ and was maintained for an average time of 10 years, after which in eight of them gradually began to reduce. At the end of the second postoperative decade the active external rotation of the arm ranged from -10¡ to 5¡. Conclusions: The satisfactory early results of the described surgical procedure are not permanent. The þnal long-term result was the loss of the initial postoperative active external rotation possibly due to the gradually increasing degeneration of the transferred muscles

Aims: Acquired defects of the back primarily are the result of radiation injury, trauma, tumour ablation, or wound dehiscence and infection. The incidence of these defects is growing, since the demand of spinal operations for degenerative spinal diseases and tumour resections is increasing. The reconstructive techniques for posterior trunk defects have improved, because of the use of muscle ßaps. When there are extensive wounds, free ßap reconstruction may be the only option to assure durable coverage. We wanted to evaluate the outcome of these patients. Methods: We review our series of these reconstructions. Results: 16 patients with difþcult wounds of the posterior trunk were treated with various ßaps. The causes of posterior trunk defects were a post operative wound dehiscence or infection (13), tumour (2), meningomyelocele (1). Mean follow-up period was 63 months. The wound location was cervical area (4), upper and midthoracic area (3), lower thoracic and thoracolumbar area (5), lumbosacral area (2), and sacral area (2). The defects were closed by fasciocutaneous ßaps (3), musculocutaneous trapezius ßaps (4), trapezius muscle ßap (1), latissimus dorsi muscle ßap (1), paraspinous muscle ßaps (3), and gluteus muscle ßap (1). In addition, three patients underwent microvascular transfer of the latissimus dorsi muscle. The exposed orthopedic hardware could be left in place in þve out of seven cases. The muscle ßaps did not cause any major functional deþcit in the donor sites. Conclusions: A high rate of success is obtained in the management of posterior trunk defects with muscle ßaps. Adequate debridement of all devitalised tissues and coverage with well vascularized tissue to obliterate any residual dead space and to cover orthopedic hardware are mandatory and prerequisite

1 . A case is described in which complete transposition of the latissimus dorsi muscle with its neurovascular pedicle was performed to compensate for complete paralysis of the triceps and partial paralysis of the posterior part of the deltoid muscle. 2. Muscle necrosis did not occur to any significant degree. 3. Strong substitute triceps function was achieved