Ahmet BİCER, Atakan AYDIN, Türker ÖZKAN, Safiye ÖZKAN, Zeynep HOSBAY, Ömer BERKÖZ

DOĞUMSAL BRAKİYAL PLEKSUS PARALİZİSİ NEDENİYLE DİRSEK EKSTANSİYON KUSURU BULUNAN HASTALARDA BRAKİYALİS TRİSEPS TENDON TRANSFERİ UYGULANAN OLGULARIN DEĞERLENDİRİLMESİ

Amaç: Brakiyal pleksus yaralanmaları sonrası dirsek ekstansiyonu sorunları genellikle ön planda tutulmaz. Obstetrik paralizinin erken evrelerinde dirsek fleksiyon kusurları ön plandadır ve erken dönem sinir cerrahisi endikasyonu için klinik bir belirteç olarak kullanılır. Yıllar geçtikçe fleksiyon işlevinin geri kazanımıyla birlikte dirsekte ekstansiyon kayıpları ön plana çıkabilir. Tendon transferleri obstetrik paralizi sekellerinin geç dönem dinamik rekonstrüktif tedavi seçenekleri arasında yer almaktadır. Obstetrik paralizili hastalarda deltoid ve biseps gibi klasik donörlerin güçleri dirsek ekstansiyonunu sağlamaya yetmeyebilir. Brakiyalis kası, kolda derin yerleşimiyle gizli bir alternatif olabilir. Bu çalışmada dirsek ekstansiyon kusuru sekeli bulunan obstetrik paralizi hastalarında brakiyalis triseps tendon transferinin dirsek ekstansiyonu ve omuz ekstansiyonu üzerine etkileri incelenmiştir. Gereç ve Yöntem: Çalışmaya dirsek ve omuz eklemleri çevresinde sekelleri bulunan ve bu amaçla brakiyalis triseps tendon transferi uygulanmış yedi obstetrik paralizi hastası dâhil edilmiştir. Tüm hastalara daha öncesinde modifiye Hoffer prosedürü uygulanmıştı. Hastalarda omuz ve dirsek aktif ve pasif eklem hareket açıklıkları gonyometrik olarak analiz edildi. Brakiyalis transferi, minimum dirsek fleksiyon gücü M3+ olan hastalara uygulandı. Bulgular: Dirsek ekstansiyonu ameliyat öncesi ortanca -70° (interkuartil açıklık, IQR: 10º)’den ameliyat sonrası izlemde ortanca -10° (IQR: 35º)’ye çıkmıştır (p<0,05). Omuz abdüksiyonu ise ameliyat öncesi ortanca 140° (IQR: 5º)’den ameliyat sonrası izlemde ortanca 170° (IQR: 15º)’ye çıkmıştır (p<0,05). Dirsek fleksiyonu ise ameliyat öncesi ortanca M4 (IQR: M3+, M5)’den, ameliyat sonrası ortanca M3 (IQR: M3, M3+)’e gerilemiştir (p<0,05). Sonuç: Brakiyalis triseps transferi obstetrik paralizi sekeli bulunan olgularda dirsek ekstansiyonunu sağlamak için geçerli bir seçenek olarak ortaya konmuştur. Bununla birlikte dirsek fleksiyonunda istatistiki olarak anlamlı bir kayıp gözlenmektedir. Bu kayıp klinik olarak kabul edilebilir düzeylerdedir.

Anahtar Kelimeler:

Tendon transferi, obstetrik paralizi, dirsek eklemi, omuz eklemi

TRANSFER OF BRACHIALIS MUSCLE TO TRICEPS FOR RESTORATION OF ELBOW EXTENSION IN PATIENTS WITH OBSTETRIC PALSY SEQUELAE

Objective: Elbow extension deficit following brachial plexus injuries can sometimes be overlooked. Elbow flexion deficit is more prominent in the early stages of obstetric paralysis and is used as an indication for early nerve surgery. However, in the future extension deficits may become more numerous. Residual disabilities following obstetric paralyses can be dynamically addressed by tendon transfers. In patients with obstetric paralysis, canonical donor muscles such as the deltoid or biceps may be insufficient for restoration of elbow extension. The brachialis muscle, because of its deep and secluded position, may be considered as one of the more recent options for selection as a donor in these patient groups. In this study, the efficiency of brachialis to triceps transfer both in elbow extension and in shoulder abduction was assessed. Materials and Methods: Seven obstetrical palsy patients with varying degrees of sequelae around the shoulder and elbow underwent a brachialis to triceps transfer procedure. All patients had previously undergone a modified Hoffer procedure. Ranges of motion in shoulder and elbow joints were recorded before and after the transfer. A minimum of M3+ in elbow flexion was set as a prerequisite for the transfer. Results: The elbow extension was improved from a median of -70° (interquertile range, IQR: 20º) to a median of -10° (IQR: 35º) in the follow-up (p<0.05). Shoulder abduction was improved from a median of 140° (IQR: 5º) to a median of 170° (IQR: 15º) (p<0.05). Elbow flexion power was found to be diminished from median M4 (Q1: M3+, Q3: M5) to M3 (Q1: M3, Q3: M3+) (p<0.05). Conclusions: Brachialis to triceps transfer was found to be a suitable alternative in palliative surgery of obstetric palsy patients in terms of elbow extension. Loss of elbow flexion power was within acceptable range.

Keywords:

endon transfer, obstetric paralysis, elbow joint, shoulder joint,

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