Several authors emphasize the importance of preoperative evaluation of the latissimus dorsi muscle before using this as a transfer as the functional outcome is correlated to the preoperative strength of the latissimus.11,21,22 It is difficult to isolate the latissimus for strength testing, especially separating latissimus dorsi function from the teres major, which functions in concert with the latissimus dorsi to internally rotate and adduct the humerus. We describe several techniques to examine the latissimus dorsi. In the setting of acute trauma, many of these tests cannot be performed; however, the use of palpation for muscle bulk and contour and having the patient cough when the examiner palpates for muscle contraction are the most useful tools in this setting. The other techniques described provide a more detailed assessment of the muscle which can be conducted in the setting of late trauma, congenital anomalies, and brachial plexus injuries.
There are several points to the surgical technique that we have found important in improving functional outcomes. The inclusion of a skin paddle improves cosmesis, allows for monitoring of the flap, and improves muscle and tendon gliding of the transferred latissimus muscle. Next, the establishment of appropriately placed and secure fixation at the neo origin and neo insertion is important in the biomechanics of the transfer and reducing muscle stretching that may occur at the sites of attachment. Moving the latissimus insertion from the humerus to the coracoid improves the mechanical advantage of the muscle transfer and may also help stabilize the anterior shoulder when there is weakness about the shoulder girdle.21 The tensioning of any muscle transfer remains a surgical art rather than an exact science. Both overtensioning and undertensioning of a transferred muscle lead to disturbance of the length–tension curve for muscle force generation.30 Marking and restoring the muscle resting length helps maintain the appropriate actin–myosin overlap, so as to retain muscle strength in transfer. Slight overtightening of the transfer may help compensate for the anticipated stretching that may occur at the coaptation sites. To this end, the transferred muscle is expected to be able to maintain the elbow at a minimum of 90 degrees of flexion at the completion of the transfer. Finally, our postoperative protocol is slower than that described in other series. It is thought that this may contribute to the patients not requiring additional surgeries to tighten the muscle transfer. The muscular origin of the latissimus dorsi at the thoracodorsal fascia and the frequent need to trim the transferred muscle result in coaptation of latissimus to the stump of the biceps through muscle fibers that do not hold sutures well. For this reason, the repair site is protected for a longer period of time and the rehabilitation is progressed slowly.21,22,29
One of the patients developed an infected hematoma at the donor site. In the long term, no patients in this study reported complaints at the donor site. Any deficits in upper extremity function related to latissimus harvest were obscured by the traumatic injury. Early complications that can be seen at the latissimus dorsi harvest site include hematoma and seroma formation. We employ a quilting technique for donor site closure and maintain drains at the donor site until output is <5 mL over 24 hours.31,32 Shoulder girdle weakness has been measured after the harvest of the latissimus dorsi, particularly the loss of extension strength. Despite isolated weakness in muscle testing, global shoulder function scores remain high due to compensation for latissimus dorsi function by synergistic muscle groups (predominantly teres major, pectoralis major, and subscapularis).33–35
This study is limited by a small patient cohort and limited long-term follow-up. This is not uncommon for trauma patients, particularly those treated at an urban referral center.36 Nevertheless, final available data are comparable to previous reports in the literature. Although several options exist for reconstruction of elbow flexion, none except a functional free muscle transfer provides simultaneous reconstruction of a soft-tissue defect. This article adds to the available data on a procedure that is not commonly performed, and provides supplemental videos to help physicians refresh their technique and surgical pearls critical to achieving good functional outcomes.
Parents or guardians provided written consent for the use of the patient’s image.
1. Magermans DJ, Chadwick EK, Veeger HE, et al. Requirements for upper extremity motions during activities of daily living. Clin Biomech (Bristol, Avon). 2005;20:591599.
2. Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am. 1981;63:872877.
3. Bostwick J 3rd. Latissimus dorsi flap: current applications. Ann Plast Surg. 1982;9:377380.
4. Bostwick J 3rd, Nahai F, Wallace JG, et al. Sixty latissimus dorsi flaps. Plast Reconstr Surg. 1979;63:3141.
5. Jutte DL, Rees R, Nanney L, et al. Latissimus dorsi flap: a valuable resource in lower arm reconstruction. South Med J. 1987;80:3740.
6. Stevanovic M, Sharpe F, Itamura JM. Treatment of soft tissue problems about the elbow. Clin Orthop Relat Res. 2000;370:127137.
7. Stevanovic M, Sharpe F, Thommen VD, et al. Latissimus dorsi pedicle flap for coverage of soft tissue defects about the elbow. J Shoulder Elbow Surg. 1999;8:634643.
8. Schottstaedt ER, Larsen LJ, Bost FC. Complete muscle transposition. J Bone Joint Surg Am. 1955:37-A:897918; discussion, 918–919.
9. Chen WS. Restoration of elbow flexion by latissimus dorsi myocutaneous or muscle flap. Arch Orthop Trauma Surg. 1990;109:117120.
10. Chuang DC, Epstein MD, Yeh MC, et al. Functional restoration of elbow flexion in brachial plexus injuries: results in 167 patients (excluding obstetric brachial plexus injury). J Hand Surg Am. 1993;18:285291.
11. Moneim MS, Omer GE. Latissimus dorsi muscle transfer for restoration of elbow flexion after brachial plexus disruption. J Hand Surg Am. 1986;11:135139.
12. Mordick TG 2nd, Britton EN, Brantigan C. Pedicled latissimus dorsi transfer for immediate soft-tissue coverage and elbow flexion. Plast Reconstr Surg. 1997;99:17421744.
13. O’Ceallaigh S, Mehboob Ali KS, O’Connor TP. Functional latissimus dorsi muscle transfer to restore elbow flexion in extensive electrical burns. Burns 2005;31:113115.
14. Rivet D, Boileau R, Saiveau M, et al. Restoration of elbow flexion using the latissimus dorsi musculo-cutaneous flap. Ann Chir Main. 1989;8:110123.
15. Schoeller T, Wechselberger G, Hussl H, et al. Functional transposition of the latissimus dorsi muscle for biceps reconstruction after upper arm replantation. J Plast Reconstr Aesthet Surg. 2007;60:755759.
16. Takami H, Takahashi S, Ando M. Latissimus dorsi transplantation to restore elbow flexion to the paralysed limb. J Hand Surg Br. 1984;9:6163.
17. Vekris MD, Beris AE, Lykissas MG, et al. Restoration of elbow function in severe brachial plexus paralysis via muscle transfers. Injury 2008;39(Suppl 3):S15S22.
18. Wahegaonkar AL, Doi K, Hattori Y, et al. Surgical technique of pedicled bipolar pectoralis major transfer for reconstruction of elbow flexion in brachial plexus palsy. Tech Hand Up Extrem Surg. 2008;12:1219.
19. Werthel JD, Zargarbashi R, Valenti P. Radial clubhand with congenital absence of elbow flexors treated by pedicled latissimus dorsi bipolar transfer: report of one case. J Shoulder Elbow Surg. 2015;24:7.
20. Zancolli E, Mitre H. Latissimus dorsi transfer to restore elbow flexion. An appraisal of eight cases. J Bone Joint Surg Am. 1973;55:12651275.
21. Cambon-Binder A, Belkheyar Z, Durand S, et al. Elbow flexion restoration using pedicled latissimus dorsi transfer in seven cases. Chir Main. 2012;31:324330.
22. Kawamura K, Yajima H, Tomita Y, et al. Restoration of elbow function with pedicled latissimus dorsi myocutaneous flap transfer. J Shoulder Elbow Surg. 2007;16:8490.
23. Germann G, Steinau HU. Functional soft-tissue coverage in skeletonizing injuries of the upper extremity using the ipsilateral latissimus dorsi myocutaneous flap. Plast Reconstr Surg. 1995;96:11301135.
24. Hochberg J, Fortes da Silva FB. Latissimus dorsi myocutaneous flap to restore elbow flexion and axillary burn contracture: a report on two pediatric patients. J Pediatr Orthop. 1982;2:565568.
25. Stern PJ, Carey JP. The latissimus dorsi flap for reconstruction of the brachium and shoulder. J Bone Joint Surg Am. 1988;70:526535.
26. Stern PJ, Neale HW, Gregory RO, et al. Latissimus dorsi musculocutaneous flap for elbow flexion. J Hand Surg Am. 1982;7:2530.
27. Harmon PH. Muscle transplantation for triceps palsy; the technique of utilizing the latissimus dorsi. J Bone Joint Surg Am. 1949;31A:409412.
28. Hovnanian AP. Latissimus dorsi transplantation for loss of flexion or extension at the elbow; a preliminary report on technic. Ann Surg. 1956;143:493499.
29. Hirayama T, Takemitsu Y, Atsuta Y, et al. Restoration of elbow flexion by complete latissimus dorsi muscle transposition. J Hand Surg Br. 1987;12:194198.
30. Oatis CA. Kinesiology: The Mechanics and Pathomechanics of Human Movement. 2008:Philadelphia: Lippincott Williams &Wilkins; 4568.
31. Ali SN, Gill P, Oikonomou D, et al. The combination of fibrin glue and quilting reduces drainage in the extended latissimus dorsi flap donor site. Plast Reconstr Surg. 2010;125:16151619.
32. Gruber S, Whitworth AB, Kemmler G, et al. New risk factors for donor site seroma formation after latissimus dorsi flap breast reconstruction: 10-year period outcome analysis. J Plast Reconstr Aesthet Surg. 2011;64:6974.
33. Button J, Scott J, Taghizadeh R, et al. Shoulder function following autologous latissimus dorsi breast reconstruction. A prospective three year observational study comparing quilting and non-quilting donor site techniques. J Plast Reconstr Aesthet Surg. 2010;63:15051512.
34. Lee KT, Mun GH. A systematic review of functional donor-site morbidity after latissimus dorsi muscle transfer. Plast Reconstr Surg. 2014;134:303314.
35. Russell RC, Pribaz J, Zook EG, et al. Functional evaluation of latissimus dorsi donor site. Plast Reconstr Surg. 1986;78:336344.
36. Aaland MO, Marose K, Zhu TH. The lost to trauma patient follow-up: a system or patient problem. J Trauma Acute Care Surg. 2012;73:15071511.