Free functional muscle belgrade VMA 2011
-
Upload
lksedukacija -
Category
Health & Medicine
-
view
479 -
download
3
Transcript of Free functional muscle belgrade VMA 2011
![Page 1: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/1.jpg)
Functional Free Muscle
Transfer for Upper
Extremity Reconstruction
Milan Stevanovic, MD Professor of Orthopaedic Surgery
USC Keck School of Medicine
When and How
![Page 2: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/2.jpg)
![Page 3: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/3.jpg)
![Page 4: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/4.jpg)
![Page 5: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/5.jpg)
![Page 6: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/6.jpg)
![Page 7: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/7.jpg)
![Page 8: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/8.jpg)
![Page 9: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/9.jpg)
![Page 10: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/10.jpg)
![Page 11: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/11.jpg)
![Page 12: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/12.jpg)
![Page 13: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/13.jpg)
![Page 14: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/14.jpg)
![Page 15: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/15.jpg)
![Page 16: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/16.jpg)
Introduction
• Loss of upper extremity function
secondary to brachial plexus
injuries or severe trauma is a
challenging problem
![Page 17: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/17.jpg)
Introduction
• Advances of microsurgery
offered a new approach in
the management of these
injuries
![Page 18: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/18.jpg)
•Tamai et al.
Free muscle transplants in
dogs, with microsurgical
neurovascular anastomoses
Plast Reconstr Surg. 1970
![Page 19: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/19.jpg)
Donor Muscle
Considerations • Muscle Power
–Terzis, J Hand Surg, 1978
• Suggested that muscle bulk decreases with muscle transplantation to 25-50%
–Doi , Clin Plast Surg, 2002
• Transplanted muscles regained full strength, sometimes stronger than pre-transplanted power
![Page 20: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/20.jpg)
•Stevanovic, Seaber,
Urbaniak
Canine experimental free
muscle transplantation.
Microsurgery. 1986
![Page 21: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/21.jpg)
Functional Free Muscle
Indications
• Deficiency of critical motor function with no suitable tendon transfer options
• No suitable rotational muscle transfer
• Soft tissue defect requiring coverage in combination with functional loss
![Page 22: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/22.jpg)
Functional Free Muscle
Special Indications
• Facial reanimation
Ralph Manktelow and Ron Zucker
![Page 23: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/23.jpg)
![Page 24: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/24.jpg)
•Manktelow, Zuker,
McKee
Functioning free
muscle transplantation.
J Hand Surg [Am]. 1984
![Page 25: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/25.jpg)
Functional Free Muscle
Indications
• Functional reconstruction after: –Trauma
–BPBP
–Volkmann’s
–Tumor
–Congenital deficiencies
![Page 26: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/26.jpg)
Functional Free Muscle
Upper Extremity Indications
• Deltoid
• Biceps
• Triceps
• Finger Flexors
• Finger Extensors
• Thenar
![Page 27: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/27.jpg)
Functional Free Muscle
Goals (Manktelow)
• Supply a useful range of motion
• Provide adequate strength for functional activities
• FMT must be under volitional control
![Page 28: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/28.jpg)
Functional Free Muscle
Pre-requisites
• Motivated patient
• Supple passive range of motion
• Suitable recipient site motor nerve and vessels
• Good soft tissue coverage and underlying tissue bed for tendon gliding
![Page 29: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/29.jpg)
Donor Muscle
Options
• Gracilis
• Latissimus
• Rectus femoris
• Pectoralis Major
• Medial gastrocnemius
• Tensor fascia lata
• Serratus Anterior
![Page 30: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/30.jpg)
Indications
Free gracilis
Gracilis Transfer with Skin
• Deltoid reconstruction
• Elbow flexion
• Elbow extension
• Finger flexion
• Finger extension
![Page 31: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/31.jpg)
![Page 32: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/32.jpg)
Anterior Deltoid
Pedicle Latissimus
![Page 33: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/33.jpg)
![Page 34: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/34.jpg)
![Page 35: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/35.jpg)
![Page 36: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/36.jpg)
![Page 37: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/37.jpg)
![Page 38: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/38.jpg)
![Page 39: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/39.jpg)
Free gracilis
Finger extension Finger flexion
![Page 40: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/40.jpg)
Achieve optimal muscle
resting length
Surgical Technique: Key Points
![Page 41: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/41.jpg)
Surgical Technique: Key Points
• Establish strong & appropriately located origin and insertion
![Page 42: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/42.jpg)
Free gracilis for
finger extension
Illustrative case:
![Page 43: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/43.jpg)
![Page 44: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/44.jpg)
![Page 45: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/45.jpg)
![Page 46: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/46.jpg)
![Page 47: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/47.jpg)
![Page 48: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/48.jpg)
![Page 49: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/49.jpg)
![Page 50: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/50.jpg)
Flexor Origin Slide
![Page 51: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/51.jpg)
![Page 52: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/52.jpg)
![Page 53: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/53.jpg)
Nerve Graft
![Page 54: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/54.jpg)
![Page 55: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/55.jpg)
![Page 56: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/56.jpg)
![Page 57: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/57.jpg)
![Page 58: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/58.jpg)
![Page 59: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/59.jpg)
![Page 60: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/60.jpg)
![Page 61: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/61.jpg)
Vascular Anastamosis
and neurorraphy
![Page 62: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/62.jpg)
![Page 63: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/63.jpg)
![Page 64: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/64.jpg)
Cable grafting of severely
compromised median nerve
![Page 65: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/65.jpg)
![Page 66: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/66.jpg)
pedicle
Skin paddle post
Debridement of
partial necrosis
Healthy and viable
Underlying muscle
![Page 67: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/67.jpg)
opponensplasty
tenolysis
![Page 68: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/68.jpg)
Functional results at one year
![Page 69: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/69.jpg)
![Page 70: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/70.jpg)
![Page 71: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/71.jpg)
Donor Muscle
General Considerations
• Expendible donor muscle –sacrificed with acceptable donor site
morbidity
• Adequate length and excursion for new function
• Sufficient force
• Vascular pedicle permits transfer
![Page 72: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/72.jpg)
Free muscle transfer • Type of blood supply
• I. One vascular pedicle
• II. Dominant pedicles and
minor pedicles
• V. One dominant pedicle
and secondary segmental
pedicles
![Page 73: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/73.jpg)
Free muscle transfer • Type of blood supply
• I. Rectus femoris,Tensor fascia
• lata
• II. Gracilis,Biceps femoris,Soleus
• V. Latissimus dorsi,Pectoralis
• major
![Page 74: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/74.jpg)
Donor Muscle
Considerations
• Muscle Type –pennate (stronger)
–strap (better excursion)
• Cross sectional area –pennate - greater cross sectional
area results in greater strength
• Excursion –estimated as 40% of the msucle
resting length
![Page 75: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/75.jpg)
Donor Muscle
Considerations
• Muscle Type
–pennate (stronger)
–Rectus femoris
–strap (better excursion)
–Gracilis, Latissimus dorsi,
![Page 76: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/76.jpg)
Donor Muscle
Considerations
• Muscle Excursion
–Ideally 6-7 cm of muscle
excursion to produce
functional range of flexion
of fingers and elbow
![Page 77: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/77.jpg)
Surgical Technique
Free muscle transfer
• technically
demanding
• microvascular
anastomoses
![Page 78: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/78.jpg)
Free gracilis transfer
to reconstruct finger flexion
after rhabdomyosarcoma
resection
Illustrative case:
![Page 79: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/79.jpg)
Free gracilis for finger flexion
tumor
![Page 80: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/80.jpg)
Free gracilis for finger flexion
![Page 81: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/81.jpg)
Free gracilis for finger flexion
![Page 82: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/82.jpg)
Free gracilis for finger flexion
![Page 83: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/83.jpg)
Free gracilis for finger flexion
![Page 84: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/84.jpg)
Free serratus anterior
to reconstruct opposition
3 yrs after crush left hand and
thenar muscle debridement
Illustrative case:
![Page 85: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/85.jpg)
![Page 86: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/86.jpg)
![Page 87: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/87.jpg)
Imaging
![Page 88: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/88.jpg)
Operative
![Page 89: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/89.jpg)
Operative
![Page 90: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/90.jpg)
Operative
![Page 91: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/91.jpg)
Operative
![Page 92: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/92.jpg)
Serratus anterior
Operative
![Page 93: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/93.jpg)
Operative
![Page 94: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/94.jpg)
Operative
![Page 95: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/95.jpg)
Operative
![Page 96: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/96.jpg)
Operative
![Page 97: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/97.jpg)
![Page 98: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/98.jpg)
![Page 99: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/99.jpg)
![Page 100: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/100.jpg)
![Page 101: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/101.jpg)
![Page 102: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/102.jpg)
![Page 103: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/103.jpg)
Functional Free Latissimus Courtesy MB Wood
![Page 104: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/104.jpg)
![Page 105: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/105.jpg)
![Page 106: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/106.jpg)
Surgical Technique: Key Points
• Minimize Ischemia Time
–Irreversible muscle loss
increases with time
–Non-linear relationship
![Page 107: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/107.jpg)
Surgical Technique: Key Points
• Nerve Considerations
–Recipient site nerve should be
motor fibers
–Neurorraphy should be done
as close as possible to
transplanted muscle
![Page 108: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/108.jpg)
Reconstruction of
elbow flexion 4 years after
brachial plexus injury
Illustrative case
![Page 109: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/109.jpg)
![Page 110: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/110.jpg)
![Page 111: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/111.jpg)
![Page 112: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/112.jpg)
![Page 113: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/113.jpg)
![Page 114: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/114.jpg)
![Page 115: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/115.jpg)
![Page 116: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/116.jpg)
![Page 117: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/117.jpg)
![Page 118: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/118.jpg)
![Page 119: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/119.jpg)
![Page 120: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/120.jpg)
![Page 121: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/121.jpg)
![Page 122: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/122.jpg)
![Page 123: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/123.jpg)
![Page 124: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/124.jpg)
![Page 125: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/125.jpg)
![Page 126: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/126.jpg)
Functional Free Muscle
Post-Operative Management
• Immobilization
–Elbow
• 8 weeks
–Finger
• Flexors - 4 weeks – start PROM
• Extensors – 6 weeks start PROM
![Page 127: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/127.jpg)
Functional Free Muscle
Post-Operative Management
• After EMG evidence of reinnervation: – Motor re-education with therapist
guidance
– Short sessions, ending when muscle fatigues
– Slow , gradual correction of contracture. Passive elongation of muscle can result in muscle fiber injury
![Page 128: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/128.jpg)
Complications
![Page 129: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/129.jpg)
![Page 130: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/130.jpg)
![Page 131: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/131.jpg)
![Page 132: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/132.jpg)
![Page 133: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/133.jpg)
Functional Free Muscle
Transfer • Demanding procedure
• Meticulous technique
• Experience in microsurgery
Conclusions
![Page 134: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/134.jpg)
Immediate Reconstruction
of
finger flexion after severe
Compartment
Syndrome with
liquifactive muscle
necrosis
![Page 135: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/135.jpg)
Immediate Functional Reconstruction
Flexor Tendons
Median Nerve
![Page 136: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/136.jpg)
![Page 137: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/137.jpg)
![Page 138: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/138.jpg)
![Page 139: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/139.jpg)
Principles of Free Functional Muscle
Transfers
![Page 140: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/140.jpg)
140
![Page 141: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/141.jpg)
FIN
![Page 142: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/142.jpg)
![Page 143: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/143.jpg)
Thank you
![Page 144: Free functional muscle belgrade VMA 2011](https://reader033.fdocuments.net/reader033/viewer/2022052619/556b9d2ed8b42ada358b5436/html5/thumbnails/144.jpg)
Thank you