SURGICAL TECHNIQUES

Elbow extension

Biceps - to - triceps transfer

Marc Revol, MD, Jean-Marie Servant, MD

(Service de Chirurgie Plastique. Hopital Saint-Louis. 75475 Paris Cedex 10. France)

 

In spite of its bad reputation, the biceps-to-triceps transfer is a very good surgical procedure, simple and effective, provided that the postoperative period be managed by a specifically experienced rehabilitation team.

It is true that biceps to triceps transfer decreases by about 40% the elbow's flexion strength. Nevertheless, none of our patients complained about this loss of strength, which was not noticeable in daily life's activity. Moreover, most of our patients who underwent a biceps to triceps transfer asked for the same surgical procedure to be performed on their other arm. Today, the biceps-to-triceps transfer is our first choice for restoring active extension of the elbow, in systematic preference to the deltoid-to-triceps transfer.

The biceps to triceps transfer is possible either at the lateral or at the medial side of the arm. Because the lateral way has a documented danger of radial nerve compression, we advocate the medial route, at the medial aspect of the arm.

Although the medial route has a theoretical danger of median nerve, ulnar nerve, and brachial artery compression, we never observed any compression in our 57 cases experience.

>>> It is not necessary to insert the biceps tendon into olecranon. Direct suture into triceps  tendon according to modified Pulvertaft method is sufficient, simple and efficient.

 

Video of biceps_triceps technique can be downloaded at : https://public.me.com/mrevol
There are 2 files of the same video (18 minutes) : .mov (499 Mb), and .mp4 (49 Mb)

 

>>> Slideshow <<<
     
     
    After preparing and draping the arm and the shoulder, a sterile Esmarch bandage is applied to the arm as proximally as possible.
     
 

A bayonet-shaped incision is made vertically along the medial aspect of the arm (15-20 cm long), then horizontally at the anterior crease of the elbow (5-7 cm long), and vertically along the proximal forearm over the brachioradialis belly (0 - 5 cm long)
     
   
     
  Skin margins are elevated along with the underlying deep fascia, and close care is taken to preserve basilic and cephalic veins and the lateral cutaneous nerve of the forearm.
     
  The bicipital aponeurosis is divided, and the distal tendon of the biceps is dissected to its insertion into the radius, where it is transected as distally far as possible. At this point, great care is taken to avoid any damage to the recurrent radial vessels since they are the main blood supply of the brachioradialis and extensor carpi radialis muscles.
     
  The muscle belly of the biceps is then dissected proximally and raised up to its vascular pedicle, which always enter the deep aspect of the muscle at its proximal third.Some minor distal vessels are frequently encountered and ligated.
     
  A posterior separate curved incision is then made on the dorsal aspect of the distal third of the arm.
     
  The tendon of the triceps is exposed in its entire length, and a wide tunnel is made under the deep fascia of the medial aspect of the arm, leading from the posterior to the anterior wound.
     
   
     
   
     
  The proximal border of this tunnel is located near the distal end of the Esmarch bandage. Once the skin flap has been elevated, the deep fascia is entirely excised to prevent its adhesion to the transferred tendon.
     
  The Esmarch bandage is then removed, allowing the incision on the medial aspect of the arm to be lengthened proximally, in order to improve the dissection of the proximal part of the biceps.
     
   
     
  In most cases, the tendon of the biceps is lengthened proximally by up to 3 cm at its musculotendinous junction by carefully stripping away the insertions of the distal muscular fibers of the biceps from their tendon. This point is of paramount importance.
     
  The tendon of the biceps is then interwoven into the tendon of the triceps, and secured with multiple 2/0 non-absorbable sutures. The tension of the transfer is set to the maximum while the elbow is held in full extension, so that the elbow cannot  be flexed passively  beyond 30 when the arm is abducted about 30 or 40.
     
   
     
  Finally, haemostasis is secured, two succion drains are placed, and the skin is sutured. A well-padded long-arm fiberglass splint is applied to hold the elbow in full extension or 10 flexion, and the wrist in 30 extension. The shoulder is left free.
     
  POSTOPERATIVE MANAGEMENT
  • Immobilization is classically set for 4 weeks
  • An active exercise program is then started, in order to gain flexion of the elbow at a rate of 15 to 20 per week.
  • Intensive occupational therapy is used to train the biceps to extend the elbow.
  • In our experience, a short immobilisation protocol (7 to 10 days) is nowadays often possible.

 

     
     
   

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