Latissimus dorsi tendon transfer (LDTT) is technically challenging. In order to clarify the local structural anatomy, we undertook a morphometric study using six complete cadavers (12 shoulders). Measurements were made from the tendon to the nearby neurovascular structures with the arm in two positions: flexed and internally rotated, and adducted in neutral rotation. The tendon was then transferred and measurements were taken from the edge of the tendon to a reference point on the humeral head in order to assess the effect of a novel two-stage release on the excursion of the tendon. With the shoulder flexed and internally rotated, the mean distances between the superior tendon edge and the radial nerve, brachial artery, axillary nerve and posterior circumflex artery were 30 mm (26 to 34), 28 mm (17 to 39), 21 mm (12 to 28) and 15 mm (10 to 21), respectively. The mean distance between the inferior tendon edge and the radial nerve, brachial artery and profunda brachii artery was 18 mm (8 to 27), 22 mm (15 to 32) and 14 mm (7 to 21), respectively. Moving the arm to a neutral position reduced these distances. A mean of 15 mm (8 to 21) was gained from a standard soft-tissue release, and 32 mm (20 to 45) from an extensile release. These figures help to define further the structural anatomy of this region and the potential for transfer of the latissimus dorsi tendon. Cite this article: Bone Joint J 2013;95-B:517–22

The aim of this study is to assess the clinical outcome following latissiumus dorsi transfer for massive irreparable tears of the rotator cuff. Between 1996 and 2002 seven patients with massive irreparable rotator cuff tears were treated by transfer of the latissimus dorsi by a single surgeon. Their mean age at time of surgery was 65 years. Five patients were female, five were primary procedures and two were revisions. Patients were assessed with MRI pre-operatively; the decision to plan a transfer was made clinically. At time of operation all were found to massive irreparable tears of the cuff including Supraspinatus and Infraspinatus, Subscapularis was intact in all cases. Five of the transfers were implanted to a bone trough, one was sutured to a tendon stump, and one was augmented with a Teflon patch. Mean time to follow up was 21 months. All patients were assessed by the lead author or by his Specialist Registrar. Six patients had a good result, one had a poor result this was a revision procedure resulting in deltoid origin detachment. Functional outcome significantly improved post-transfer. Constant score 62.1% vs 36.1% (p< 0.0005, Paired t-test), Pain was also significantly reduced post-transfer, both when active 7.1 vs. 2.2 p (< 0.005) and when at rest 3.7 vs. 1.2 (p< 0.005). Conclusion: These results are compatible with those published for Latissimus Dorsi Transfer. Latissimus Dorsi Transfer can be effective in restoring shoulder function and reducing pain following massive irreparable tears of the rotator cuff

Purpose of the study: Latissimus dorsi transfer is proposed for irreparable superior and posterior rotator cuff tears, particularly in the effect of deficient active external rotation. The purpose of this study was to analyzed outcome at minimum two years follow-up. Material and methods: Between 2001 and 2002, eleven patients underwent latissimus dorsi transfer for an irreparable tear of the supraspinatus and infraspinatus. Surgery was proposed because of the patient’s young age and occupational activity level, or because of a disabling deficit of active external rotation. There were six men and five women, mean age 52.5 years (range 36–66 years). There were seven right shoulders and nine dominant shoulders. Symptom onset was progressive in seven with a mean duration of 33 months (range 2–144 months). Active external rotation was measured at −14° to 29° in five patients with a positive dropping test. Three patients presented pseudoparalysis. The preoperative Constant score was 52±12 points. Preoperative the subacromial space measured less than 6 mm in all patients. Muscle degeneration of the infraspinatus was noted grade 2 or greater (Goutallier). Results: Mean follow-up was 26 months (range 24–36). Subjective outcome was very satisfactory for eight patients, satisfactory for one and disappointing for two. Seven of nine patients resumed their occupational activity. The postoperative Constant score was 73±10 points. None of the patients presented pseudoparalysis at review. Pain was improved in all. Active external rotation was significantly improved in six. Postoperative, the dropping test persisted in two patients. The subacromial space was still 6 mm. Better results were obtained when active deficit was predominant than when anterior elevation (pseudoparalytic shoulder) or external rotation (positive dropping test) were predominant. Discussion and conclusion: Latissimus dorsi transfer provides a solution for irreparable superior and posterior rotator cuff tears. The pain relief is significant. Active external rotation is improved. This is an interesting alternative in young patients or when the motor deficit is a severe handicap

Introduction. Latissimus dorsi transfer is a procedure used in massive irreparable posterosuperior rotator cuff tears, in young patient with severe pain and significant functional impairment. The purpose of this retrospective study was to evaluate its clinical, radiological and electromyographic results. Methods. Forteen massive irreparable posterosuperior rotator cuff tears were performed with latissimus dorsi transfer between 2000 and 2008, and were reviewed at an average follow-up of 56 months and minimum of 19 months. Five transfers were primary reconstructions, and nine were revision surgeries. Patients’ mean age was 52.7 years. Clinical outcomes were measured by the Constant score, pain level, active range of motion, and strength. Osteoarthritis and acromiohumeral distance were measured on standardized radiographs. Ultrasound examination evaluate the integrity of the tendon. Axial images in CT-scan looked for muscle atrophy of latissimus dorsi in comparison with the controlateral. Electromyographic activity was measured during active flexion, abduction, adduction and rotations. Results. Twelve patients were satisfied. At the last follow-up, the average pain level according to a 100 mm visual analog scale was 31. The mean age and gender-matched Constant and Murley score improved from 34 to 60 % (p=0.003), forward elevation from 89° to 132° (p=0.006), abduction from 92° to 104°, external rotation from 12° to 24° (p=0.015). Mean abduction and external rotation strength were measured at 2.5 kg. Osteoarthritis progressed, and mean acromio-humeral distance has a significant decrease from 7.5 mm to 4.4 mm (p=0.003). Ultrasound examination showed twelve transferred tendons healed to the greater tuberosity. CT-scan showed a small atrophy of the transferred muscle, with a measurement of the cross-sectional area of the muscle belly at the inferior angle of the scapula at 1405 mm2, versus 1644 mm2 for the controlateral (p=0.06). Electromyographic analysis demonstrated a significant higher electric activity on the operative side during abduction and external rotation, and significant lower activity during adduction and internal rotation in comparison with the nonoperative side. Conclusions. Latissimus dorsi transfer allows for significant pain relief and function improvement in irreparable posterosuperior rotator cuff tears at young patients. Its electric activity increase in abduction and external rotation shows that the transferred muscle can integrate a new function and act like an active muscle transfer, in addition to an interposition or tenodesis effect. However we didn't find any depression of the humeral head or strength improvement

Reverse total shoulder arthroplasty (RTSA) was designed to treat the cuff-deficient shoulder with arthritis and irreparable rotator cuff tears of the supraspinatus and infraspinatus tendons. The results of RTSA in this patient population have been very good and reliable in the majority of cases. However, it has also been reported that patients whose rotator cuff tear involves the supraspinatus, infraspinatus and teres minor and who demonstrate a ‘horn-blower's sign’ do very poorly if a muscle transfer is not performed to improve external rotation in these shoulders in abduction. The loss of the teres minor in these patients results in grave difficulty for the patient attempting to perform their activities of daily living even if they can obtain reasonable good forward flexion. The muscle transfer that is most commonly used for these select patients is a latissmus dorsi tendon transfer in conjunction with RTSA. The purpose of this talk is to review the pathology of this problem and review the technique for its surgical treatment.

We treated 12 shoulders in ten patients with irreparable rotator-cuff tears by transfer of the latissimus dorsi. There were nine men and one woman. Their average age was 64.0 years and the average follow-up was 35.6 months (26 to 42).

The results were excellent in four shoulders, good in four, fair in one, and poor in three. Active forward flexion improved from a preoperative average of 99° to a postoperative average of 135°. Osteoarthritic changes appeared in five shoulders and proximal migration of the humeral head progressed in six. EMG revealed that nine of the 12 transferred muscles showed activity which was synergistic with the supraspinatus on external rotation with abduction.

We conclude that latissimus dorsi transfer can be effective in restoring shoulder function after massive irreparable tears of the rotator cuff.

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.

Massive, irreparable rotator cuff tears occur in about 15% of patients with ruptures of the rotator cuff tendons. There is no consistently agreed management for irreparable rotator cuff tears, however, latissimus dorsi tendon transfer is a recognised technique. We aimed to review the functional outcome of patients undergoing this operation at a single tertiary referral centre.

Fourteen latissimus dorsi transfer procedures in thirteen patients from May 2007 to May 2008 were retrospectively reviewed. The mean age of patients undergoing the procedure was fifty nine years. All patients were confirmed to have massive, irreparable (>5cm) rotator cuff tears as determined by MRI or ultrasound. Modified Constant scores (assessing shoulder pain, functional activity and movement) determined pre-operatively and post latissmus dorsi transfer were compared. The mean duration of follow up was 12 months.

The mean Modified Constant Score (maximum = 75) improved from 23 points pre-operaively to 52 points post latissimus dorsi transfer (p < 0.05). All patients had improvement in shoulder pain following the operation. There was a trend for younger patients to have greater improvement in functional activity and shoulder movement.

From our series, latissimus dorsi transfer is effective at improving functional outcomes in patients with massive, irreparable rotator cuff tears, especially in younger age groups.

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.

INTRODUCTION: In irreparable rotator cuff tear associated with pseudoparalysis, inverse prostheses have shown to be able to restore overhead elevation and strength. If the rotator cuff disease involves the teres minor muscle, pseudoparalysis in external rotation can adversely affect function and functional outcome of inverse arthroplasty. The goal of our study was to evaluate the outcome of inverse total shoulder arthroplasty combined with latissimus dorsi transfer for combined pseudoparalysis in elevation and external rotation.

MATERIAL AND METHODS: From 1998 till 2005, we retrospectively analyzed 11 shoulders in 10 patients with at a mean follow up of 20 months. All 11 shoulders had a massive rotator cuff tear with fatty degeneration of the posterosuperior cuff including teres minor exceeding stage 2 according to Goutallier and an average osteoarthritis grade 2 according to Samilson and Prieto Data assessment included pre- and postoperative clinical examination and Constant Score as well as standard radiographs.

RESULTS At follow up, subjective shoulder value increased from 27% to 68%, Constant Score improved significantly from 48% to 94%, flexion from 106° to 141°, abduction from 95° to 150° and strength from 0.2 to 4.9 (p< 0.05). Although no gain was seen in active external rotation in adduction, a significant loss of external lag was noted from 47° to 9° (p< 0.05). All patients were able to perform overhead activities with increase in functional use of the arm (p< 0.05). Complication requiring revision included postoperative infection in one and hematoma in another case.

CONCLUSION: Irreparable rupture of the posterosuperior rotator cuff involving with pseudoparalysis of elevation and external rotation,, the implantation of an inverse prosthesis combined with latissimus dorsi transfer can increase active range of motion and substantially improve functional external rotation, as opposed to the published results of the inverse prosthesis alone, which do not improve active external rotation.

Purpose of the study: This retrospective analysis was conducted to study the gain provided by a latissimus dorsi flap used as first-intention treatment (group 1) or secondary treatment after prior failure (group 2) for irreparable rotator cuff tears.

Material and methods: This series included ten women and nine men, mean age 58 years (range 42-64). The initial tear was a massive (> 5 cm) posterosuperior tear in 16 patients and extended to the upper third of the infra-scapularis in three. Surgery was undertaken because of persistent pain and limited joint motion despite rehabilitation. A subacromial impingement was noted in 15/20 shoulders on the arthroscan and fatty degeneration was noted as grade 3.31 on average for the supraspinatus and 3.1 for the infraspinatus (Goutallier and Bernageau classification). The latissimus dorsi flap was harvested via the superolateral approach and fixed with anchors in the superior border of the infrascapularis and on the trochiter after avivement. Tendon stumps were sutured to the medial part of the aproneurotic sheath of the latissimus dorsi.

Results: Overall outcome and outcome in group 1 patients (14 shoulders) and group 2 patients (five shoulders) were noted. Mean follow-up was 19.72 months (range 12–48). The overall Constant score progressed from 33.10 to 54.9 with a mean gain of 53° for elevation (98–151°) and 11° for external rotation (21.5–32.1°). For group 1, the Constant score progressed from 31 (15/51) to 58 (40/75) with a mean gain of 37° elevation (121–155°) and 13° external rotation (22.8–35°). For group 2, the Constant score progressed from 33 to 52 (40/75) with a mean gain of 32° elevation (88–120°) and 6° external rotation (18–24°). Pain improved from 6.3 to 11.8 on the Constant score.

Discussion and conclusion: Used as a first intention treatment for massive irreparable cuff tears with fatty degeneration scored greater than grade 3, the latissimus dorsi flap provides better results than when it is used after failure of a prior procedure. Results are good for pain relief and active elevation (45°) but modest for external rotation (6–13°) and zero for force. The two failures and the two cases of only fair subjective outcome were in group 2. We reserve the procedure for painful pseudo-paralytic shoulders in subjects aimed less than 60 years who do not respond to prolonged rehabilitation.

The goal of this retrospective study was to evaluate the result of this technique proposed as initial treatment (group 1: 17 cases) or after a failure of repairing cuff (group 2: 7 cases).

Materials and Methods: Eleven females and thirteen males with an average age of fifty six years were available for this study. Initial rupture was always massive (2 tendons, retracted to the glenoid level), superior and posterior(20 cases) with superior lesion of the subscapularis in 4 cases. An ascension of the humeral head was found in 18 cases. Degree of fatty degeneration evaluated with CT arthrogram was 3.45 for the supra spinatus and 3.25 for the infra spinatus. The latissimus dorsi was harvested with axillary approach and released from the angle of the scapula to be able to cover the humeral head. Coraco acromial arch was preserved. Abduction splint was maintained 6 weeks.

Results: The average follow up was 21 months(12/48). For the 24 patients Constant score was improved from 34,6 to 55,6(+21): a significant improvement of forward active elevation from 98° to 153 (+55°) but a little improvement of external rotation from 23 to 33 (+10°). The best results were obtained in group 1: constant score progressed from 34 to 58 (+24) with an increasing of 66° (98 to 164°) of forward active elevation and 13°(22 to 35°) of external rotation. Results of group 2 are less: Constant score progressed from 36 to 51(+15), forward elvevation 33°(96 to 129°) and 3° (27 to 30°) of active external rotation. 2 failures caused by a rupture of the transfer. Painrelief was obtained in 90% but any improvement of strength.

Discussion and Conclusion: Ours results indicate that latissimus dorsi transfer improves range of motion, pain, function and patient satisfaction with irreparable rotator cuff tear. We recommend to use it for pseudoparalytic and painfull shoulder, with a persistent acriomo humeral space, after failure of rehabilatation, for young patient. A stable humeral head with a good subscapularis without previous operation are good pronostic factors.

Purpose of the study: The appropriate treatment for massive irreparable rotator cuff tears is a subject of debate. The purpose of this work was to analyze at mean five years follow-up a series of 16 shoulders treated with a latissimus dorsi flap.

Material and methods: These 16 patients (seven women) were aged 56 years on average. The procedure was a revision for four shoulders. The tears were all posterosuperior tears and caused invalidating pain in all patients. Mean anterior elevation was 93°. External rotation was 12°. The Constant score, assessed in eleven patients, was 27 points on average. The subacromial space measured 8 mm on average. Supraspinatus fatty degeneration was grade 2 in 45% and grade 3 in 55%. Infraspinatus degeneration was grade 3 in 80% and grade 4 in 20%. The latissimus dorsi flap was associated with a teres major flap in four shoulders and with a deltoid flap in seven. The semi-sitting position was used for 15 of the 16 patients.

Discussion: Treatment of massive irreparable rotator cuff tears is a controversial issue. When the subacromial space is preserved, the presence of muscle atrophy and tendon retraction despite forced mobilization it is logical to use several muscle transfers. This small series demonstrated that a significant improvement can be obtained. Nevertheless the postoperative period is long and indications must remain limited. We discuss our results in comparison with other reported series.

Although reverse total shoulder arthroplasty (TSA) may restore shoulder abduction and forward flexion in the setting of a massive rotator cuff tear, the ability to use the extremity for ADL’s is often limited by external rotation weakness. Even though the reverse TSA restores abduction, the patient may be unable to bring the hand to his or her mouth because with the elbow flexed the weight of the hand causes the shoulder to fall into internal rotation. Concomitant transfer of latissimus dorsi (LDT) to the posterior greater tuberosity is a solution advocated by some surgeons. It is hypothesized that this inferiorly-directed force partially counteracts the superiorly-directed force of the deltoid, resulting in decreased shear forces on the glenoid baseplate-bone interface.

Three cadaver shoulder specimens were dissected and implanted with the reverse TSA. The rotator cuff was completely released to simulate a massive rotator cuff tear. Each shoulder was mounted in a shoulder controller that simulates neuromuscular control and replicates in vivo glenohumeral kinematics. The controller utilizes an optical, three dimensional tracking system. The humerus was weighted to simulate the full mass of the upper extremity and stepper motors were connected to the insertion points of the anterior, middle and posterior divisions of the deltoid by Spectra^® cord. Simulated active abduction in the scapular plane was performed using position closed-loop feedback control. The joint reaction force at the glenosphere was measured at 5° intervals from 30°–70°. A fourth stepper motor was then connected to the greater tuberosity with 2.73kg applied to simulate a LDT and the test was repeated. Five trials were performed under each condition. Four-factor ANOVA statistical analysis with Bonferroni correction and α = 0.05 was performed.

After simulated LDT the JRF demonstrated an increase in magnitude at abduction angles between 30° and 65° inclusive (p=0.033). The superiorly-directed shear force was significantly decreased as a result of the LDT between 45° and 70° (p< 0.0001). The compressive component of the JRF was increased for all abduction angles (p=0.025). The force required to achieve abduction increased for the middle deltoid (p=0.035) and anterior deltoid (p=0.036) for the simulated LDT condition at all abduction angles. The posterior deltoid force required for abduction decreased at all abduction angles (p=0.031).

In this model of reverse total shoulder arthroplasty concomitant transfer of latissimus dorsi decreased the superiorly-directed shear force. In addition to providing improved external rotation strength, these lower shear forces may have a protective effect on baseplate fixation by reducing the risk of failure in shear. This may provide additional justification for the transfer. Although superior shear was decreased, total JRF was increased as a result of an increase in the compressive component. Further investigation is needed to determine the potential gain in joint stability and whether the glenoid bone can support such elevated compressive forces. Additionally, the force required in the anterior and middle deltoid was increased after the LDT. This indicates the need for sufficient deltoid strength and rehabilitation.

Purpose: Crush injury of the upper limb often causes bone and soft tissue damage leading to a paralytic hand. We report our experience with reactivating wrist and finger flexion using a neurotised latissimus dorsi transfer in patients with volkmann syndromes of the forearm.

Material and methods: Mean patient age was 25 years and mean follow-up was three years. The surgical procedure consisted in a free latissimus dorsi flap with arterial suture onto the ulnar artery and neurotisation using the largest median nerve branch innervating the finger flexors. The muscle was fixed proximally on the medial epicondyle; the distal fibrous lamina was divided for suture to the deep flexor tendons. Mobilisation started 21 days after surgery.

Results: The four-month electromyogram demonstrated reinnervation of the latissimus dorsi. The patient recovered thumb-index opposition with flexion of the long fingers enabling daily life activities. All patients required occupational reclassification but stated they were satisfied with the operation. Flexion of the fingers and wrist was active and was not obtained by tenodesis.

Discussion and conclusion: Volkmann syndrome leaves serious sequelae after crush injury to the forearm. The usual surgical techniques enable reduction of claw fingers by distention but do not, due to muscle necrosis, enable proper function. The free latissimus dorsi transfer method improves trophicity of the forearm and, by neurotisation, enables active hand flexion. Because the nervous pedicle of the flap is short, recovery is rapid, avoiding degeneration of the transferred muscle.

Purpose: This study was to assess shoulder function after breast reconstruction surgery using latissimus dorsi flap.

Materials and Method: Sixty-eight patients (72 breasts) had this operation between September 1999 and June 2002. fifty-four patients (58 breasts) were assessed. The average age was 50 year (range 30 – 66 year). Average follow up was 38 month (range 24 – 54 month). DASH and Constant-Murley were used for clinical assessment.

Results: Twenty-nine (50%) shoulders found to have a normal function; whereas, 11 (19%) shoulders had mild disability, 10 (17%) shoulders had moderate disability and 8 (14%) shoulders had severe disability. Only 6 (10%) patients reported being unsatisfied with their outcome; these were, from a shoulder function point view, 4 patients with sever disability, 1 patient with moderate disability and 1 patient with normal shoulder function. However, all these 6 patients were not satisfied with their breast reconstruction outcome.

Conclusion: This study confirms that following breast reconstruction surgery using latissimus dorsi flap, there is a considerable deterioration of shoulder function of varying degrees. Nevertheless, shoulder function is not the main concern of this group of patients.

Purpose of the study: The latissimus dorsi free flap is widely used for reconstruction of large tissue defects. It is always difficult however to explain the procedure to the patient, particularly the potential sequelae. The purpose of this work was to assess sequelae affecting shoulder function and the esthetic aspect of the harvesting site.

Material and methods: We reviewed 16 patients (17 harvestings) aged 37.8 years on average (range 22–62 years), twelve men and four women, at mean follow-up of 4.5 years. All flaps had been harvested to reconstruct tissue defects of the lower limb. Eleven were semi-emergency procedures, four for chronic defects or reconstruction after tumor resection. We assessed the esthetic aspect of the harvesting zone and shoulder function suing Cybex 6000 (comparative isokinetic tests of the two shoulders). The Dash score was noted.

Results: Functional impairment was minimum in all patients. The Dash score was 17.5%. (compared with the opposite side was: 27% abduction, 22% extension and 10% rotation. Adduction, flexion and external rotation were preserved. The esthetic aspect was acceptable but not negligible. Obesity appeared to accentuate disgraceful scars.

Discussion and conclusion: The latissimus dorsi free flap is often indicated for reconstruction of significant tissue defect. Shoulder function is largely preserved. Patients should be informed about the major scar. The side to be harvested should be discussed with the patient, even in the emergency situation.

The purpose of this study was to assess shoulder function after breast reconstruction surgery using latissimus dorsi flap.

Sixty-eight patients (72 breasts) had this operation. Average follow up was 38 months (range 24 to 54 months). DASH and Constant-Murley were used for clinical assessment. Twenty-nine shoulders found to have a normal function; whereas, 11 shoulders had mild disability, 10 shoulders had moderate disability and 8 shoulders had severe disability. However, only 6 patients reported being unsatisfied with their outcome. Furthermore, all these 6 patients were not satisfied with their breast reconstruction outcome.

This study confirms that following breast reconstruction surgery using latissimus dorsi flap, there is a considerable deterioration of shoulder function of varying degrees. Nevertheless, shoulder function is not the main concern of this group of patients.

Background:

The purpose of this study was to compare the biomechanical effects of the trapezius transfer and the latissimus dorsi transfer in a cadaveric model of a massive posterosuperior rotator cuff tear.

In late cases of brachial plexus palsy or when nerve reconstruction was not that beneficial, pedicled or free neurotized muscles i.e. latissimus dorsi are used to restore or enhance important functions i.e. elbow flexion or extention.

During the last three years, 43 patients with brachial plexus injuries were operated in our Clinic to reconstract the paralysed extremity. In nine of them, the ipsilateral latissimus dorsi was transferred as pedicled neurotized muscle to restore elbow flexion (seven patients) and elbow extension (two patients). Two patients had free latissimus dorsi transfer, which was neurotized directly via three intercostals. The neurovascular pedicle was dissected proximally up to the subclavian vessels and posterior cord, and the muscle was raised from its origin to its insertion and tailored to simulate the shape of biceps or triceps. Then it was passed via a subcutaneous tunnel on the anterior or posterior arm. The reattachment was done with Mitek anchors on the clavicle and the radial tuberosity (elbow flexion) or on the posterior edge of the acromion and the olecranon (elbow extension). The arm was immobilized in a prefabricated splint, which was removed after six to eight weeks.

After the first three months all patients had a powerful elbow flexion or extension. One of the free muscle transfers started to have elbow flexion after eight months and he is still progressing. In one patient skin necrosis and infection occurred near the elbow. The patient after IV antibiotics needed another operation to restore the distal insertion, using fascia lata.

Ipsilateral latissimus dorsi, if strong enough (at least M4), is an excellent transfer for elbow flexion or extension restoration or enhancement, in late cases of brachial plexus paralysis. Contralateral latissimus is an option when the ipsilateral is weak but it takes more time to function since there is a waiting period for reinnervation.