Boyes thumb adduction reconstruction

Boyes thumb retraction function reconstruction for advanced upper limb function reconstruction of childbirth brachial plexus injury. Late upper limb functional reconstruction surgery for childbirth brachial plexus injury involves functional reconstruction of the shoulder, elbow, and wrist joints. Compared with adult brachial plexus avulsion injury, brachial plexus injury is relatively light, mostly partial injury, nerve continuity is maintained at the wound, nerve regeneration ability is strong, and most functions recover well. Because the degree of damage of the brachial plexus is different, although the nerve regeneration is better, but it is not synchronized, resulting in imbalance of shoulder muscle strength recovery, shoulder joint dysfunction, mostly manifested as internal rotation contracture deformity and abduction of the shoulder joint, Limited external rotation function; loss of elbow flexion function and wrist function. Surgical methods: 1 to 2 years old choose contracture muscle release, 2 to 5 years old choose tendon transfer surgery, especially over 5 years old with shoulder bone changes, choose bone surgery. Osteotomy or arthrodesis should be performed for patients with dislocated joints, pain, and instability. Proper surgical design, postoperative management, and rehabilitation are important factors in ensuring surgical outcomes. Power muscle cutting: Traditional muscle transplantation is to cut muscles under direct vision. The scar in the donor area is long and unacceptable from a cosmetic point of view, and the patient's satisfaction with the clinical effect is reduced. In order to solve this problem, in recent years, the application of endoscopic extraction of the donor muscle has been gradually developed, and good results have been achieved. Doi et al reported successful use of endoscopic scapular muscle reconstruction to reconstruct limb function. The advantage is that the surgical scar is small, especially suitable for children and women, but it takes a long time to cut muscles intuitively than conventional surgery. Lin used endoscopy to cut 22 cases of latissimus dorsi and 16 cases of gracilis. Twenty-six cases of latissimus dorsi and 22 cases of gracilis were cut by traditional methods. The incidence of intraoperative hemorrhage and postoperative hematoma were compared between the two groups. There was no statistically significant rate of wound infection in the area. The minimally invasive technique of endoscopy can cut the gracilis muscle within 40 minutes. It is a safe and relatively simple technique, which reduces the pain of the patient and improves the satisfaction of the early active limbs. Selectable use of dynamic muscle: With the development of microsurgical techniques and deeper understanding of muscle vascular and neuroanatomy, more and more motility muscles can be selected, including latissimus dorsi, gracilis, pectoralis major , ulnar wrist flexor, rectus femoris, finger flexor muscle and sternocleidomastoid muscle. Comparison of transplanted (position) muscles: Different muscles in the transplant (bit) can produce different effects. Therefore, it is necessary to grasp the characteristics and application range of each muscle before surgery to achieve good functional recovery. Berger believes that latissimus dorsiflexion provides the strongest force in flexion elbow function, followed by triceps shift. Egger also supports this view. Strafan found that the displacement of the latissimus dorsi can completely restore the elbow flexion function, and the triceps shift effect is also better. Factors affecting functional recovery: 1 The influence of innervation: The primary condition for restoring muscle function in transplants is to restore the innervation of muscles. Therefore, the selection of appropriate innervation (g) muscles is essential for the recovery of forearm function. Chuang chose musculocutaneous nerve, intercostal nerve, and accessory nerve to reconstruct the free muscle of flexion elbow function. According to the evaluation system of the Medical Research Committee, the muscle strength level 4 was successful, and the result was best with the musculocutaneous innervation group, followed by In the intercostal nerve innervation group, the paragangular innervation group was the worst. In addition, it is also related to the technique of anastomosis and the type of nerve in the area. The simple motor nerve is better than the mixed nerve. 2 The effect of muscle dynamics on functional recovery: The contractile force of the transplanted muscle can be maximized only under the appropriate tension. From the physiological point of view, the physiological resting length of the muscle is the optimal length capable of generating the maximum contractile force, so it is necessary to estimate the physiological resting length of the donor muscle and the required length of the receiving area. Chuang believes that when reconstructing the elbow flexion function, the proximal end of the transplanted (position) muscle is fixed in the condyle, and the postoperative function is satisfactory; if the proximal end of the transplanted muscle is fixed in the clavicle, the effect is not good. In addition, functional recovery is also related to whether muscle strength and exercise amplitude can meet the needs of the district. Muscle strength is determined by the cross-sectional area of the muscle fibers, the magnitude of the motion, the length of the muscle fibers or muscle bundles. The muscle fibers of the gracilis muscle are very long, have a medium cross-sectional area, and have a large contraction amplitude, but the muscle strength is limited. Therefore, according to the needs of the recipient and the dynamic characteristics of the transplanted muscle, the appropriate muscle graft is not selected, which is very important for functional recovery. 3 The influence of the coordinated activities of the upper limb joints on the function of the upper limbs: in the overall function of the upper limbs, the shoulders, elbows, forearms, wrists and hands are unified. When the shoulder joint is unstable and cannot be abducted, the function of the elbow joint cannot be fully exerted, and the elbow can be flexed, but the forearm cannot be rotated. When the fixed pronation position is in place, the functions of the wrist and the hand cannot be fully exerted. Therefore, in order to maximize the recovery of the reconstructed upper limb function, it is necessary to comprehensively consider the functional reconstruction of the shoulder, elbow, and forearm. In short, restoring the transplanted (position) muscle blood supply is the basis of functional recovery, while the principle of innervation and tension balance is the key to functional recovery. To obtain satisfactory function, the three are indispensable. Treatment of diseases: neonatal brachial plexus, paralysis, brachial plexus injury Indication The Boyes thumb retraction function reconstruction is based on the diaphragmatic muscle, and the free extension of the palmar tendon is used to reconstruct the thumb adduction function. For the thumb to the palm and abduction function, and the thumb adductor muscle completely paralyzed, this surgery should be done to further improve the function of the hand. Preoperative preparation Brachial plexus block anesthesia. In the supine position, the upper extremity is abducted on the surgical table next to the operating bed, and a balloon tourniquet is used. Surgical procedure 1. The first incision starts from the styloid process of the humerus and extends 7 to 10 cm in the proximal longitudinal direction. Cut the skin and subcutaneous tissue, free the flaps to both sides, and find the stop point of the tendon tendon at the styloid process of the humerus and cut off. In addition, the traction line is sutured at the end of the diaphragmatic tendon, and the tendon and the muscle abdomen are released from the distal end to the proximal end until nerves and blood vessels enter the muscle. 2. Make a transverse arc-shaped incision in the first and second metacarpal spaces on the dorsal side of the hand, about 2.5 cm long. In addition, the skin was cut 3 cm longitudinally in the third and fourth metacarpal spaces, and the third incision was made. 3. Cut the skin and subcutaneous tissue along the incision line of the first metacarpal space to reveal the adductor nodules and adductor tendon of the ulnar side of the proximal phalanx of the thumb. In the forearm or calf, the palmar tendon or tendon tendon is cut according to the routine as a material for free tendon transplantation. First suture one end of the palmar tendon to the adductor muscle nodules and the adductor tendon, and then use the tendon guide to transfer the other end of the palmar tendon to the palmar of the adductor's adductor, and send it to the back of the hand. 4 in the incision of the metacarpal space. 4. From the third incision (3rd, 4th metacarpal incision) to the inferior arm lateral incision, in the deep side of the extension of the total tendon, make a sneak tunnel, the proximal end of the palmar tendon into the forearm temporal incision, and Stitching with the distal end of the diaphragm. Before suturing, the wrist should be extended 45° and the thumb should be adducted to maintain the proper tension of the tendon after suturing. 5. Relax the tourniquet, completely stop bleeding and suture each skin incision layer by layer.

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