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.