SURGICAL TECHNIQUES

Elbow extension

Deltoid - to - triceps transfer

Marc Revol, MD, Jean-Marie Servant, MD

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

 

>>> Slideshow <<<
     
     
     
  Drawings of incisions. Main incision is S-shaped, continuous from the anterior border of deltoid muscle to the tip of olecranon.
     
  After preparing and draping the arm and the shoulder, nthere is no tourniquet nor Esmarch bandage.
     
  Skin incision.
     
  Skin margins are elevated along with the underlying deep fascia. The triceps tendon is exposed.
     
  The entire area of deltoid muscle is exposed, from its anterior border to its posterior border.This posterior border must be entirely freed from its surrounding connections. A great vascular pedicle originating from the circumflex artery and going to the skin is always encountered and must be ligated.
     
  The place of muscle division is located with ink, along muscular fibers, somewhere between the anterior half or 2/3, and the posterior half or 1/3.
     
  It is of paramount importance to expose the deltoid insertion onto the humerus. Proximal insertions of the Brachialis muscle must be stripped away from the deltoid. The posterior part of the tendon of deltoid muscle is first incised, then carefully separated from the bone.
     
  After elevation of the tendon, the muscle is divided between its fibers, according to the drawing.
     
  Dissection is made with a blunt instrument such as Obwegeser elevator or dissecting scissors.
     
  Dissection is carried up to the neurovascular bundle : circumflex artery and veins, and axiillary nerve. It must be protected, and great care is specially taken to protect the veins.
     
  Dissection is continued until excursion of the posterior deltoid can reach approximately 3 cm.
     
  A device is necessary in order to bridge the gap between the deltoid tendon and the triceps tendon. Some authors use tibialis anterior tendon. Others use synthetic devices. Our device is a simple Dacron ligament.
     
  The middle part of the ligament is interwoven in the deep part of the posterior deltoid tendon according to the following pictures.
     
   
     
   
     
   
     
  The Dacron ligament is interwoven at least 3 times in the deltoid tendon. It is sometimes difficult when the tendon is very short, but it is of paramount importance that this proximal fixation be very strong.
     
   
     
  The distal ends of the Dacron ligament are interwoven in a similar way into the triceps tendon. Tension must be set with complete extension of the elbow, and abduction of the shouder. In this position, tension must be set to a maximum.
     
   
     
   
     
  When distal fixation is completed, tension is checked by attempting to flex the elbow. A correct tension does not allow more than 45 elbow flexion when shoulder is abducted, and no more than 30 when shoulder is adducted.
     
  The muscular fibers of paralysed triceps are sutured to the others upon the synthetic device.
     
   
     
  The entire Dacron is covered by the triceps sutured to itself.
     
  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, but antepulsion and adduction of the shoulder are prohibited during 4 weeks.
  POSTOPERATIVE MANAGEMENT
  • Immobilization is 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 deltoid to extend the elbow.
     
     
     
     
     
     
   

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