title: [Restoration of elbow joint flexion using pectoral muscle transfer in patients with arthrogryposis multiplex congenita. Part I: surgical method, rehabilitation and clinical results].
abstract: OBJECTIVE
  In patients with type I arthrogryposis multiplex congenita, elbows are fixed in extension. The m. biceps brachii and m. brachialis are usually atrophic. The main objective of arm treatment is to restore flexion in the elbow that would enable the patient to reach the mouth with the hand as well as maintain active extension of the arm for hygienic purposes. This can be achieved by several techniques of muscle transfer. Of these, we selected and modified the method of Clark based on transfer of distal parts of the greater pectoral muscle. The aim of this study was to develop the surgical procedure in detail, to design the course of rehabilitation and to evaluate the outcomes of treatment.
  
  
  METHODS
  The procedure for optimal transfer of three fifths of the m. pectoralis major was based on an anatomical study. In addition, a unified course of rehabilitation was developed. Between 1996 and 1999, this approach was applied to nine upper limbs in five patients (age range, 4.3 to 9 years). All the patients were evaluated in terms of their clinical state according to selected subjective and objective criteria.
  
  
  RESULTS
  The outcomes of transfer of the m. pectoralis major were evaluated as very good and good in six cases. Active movement of the elbow was in the range of 15 degrees to 95 degrees; useful movement ranged from 40 degrees to 70 degrees. The strength of elbow flexion rated 4 or 4+. In three cases, although muscle transfer restricted active elbow extension it did not prevent the upper limb from being used for hygienic purposes. In the remaining three cases, the method failed to restore the patient's ability of reaching the mouth. The analysis of unsuccessful results showed that these were always related to a very limited pre-operative passive flexion of the elbow, restricted movement of the shoulder joint and a failure in distal fixation of the muscle transposed.
  
  
  CONCLUSIONS
  Our results show that transfer of the distal three fifths of the m. pectoralis major, performed by a modified method of Clark, was an effective approach because the working capacity of this muscle was comparable with those of the m. biceps brachii and m. brachialis. Bilateral transfer enabled the patients to reach the mouth with both hands and to use the remaining elbow extension for hygienic purposes. The best function was achieved when active movement of the shoulder had permitted raising the arm above the horizontal and passive elbow flexion had been 90 degrees. Our results are comparable with those reported in the literature. The critical phase of this transfer involved fixation of the m. pectoralis major to the forearm.
  
  
  CONCLUSIONS
  The surgical procedure for transfer of the m. pectoralis major and subsequent rehabilitation in patients with type I arthrogryposis are described in detail. Good results are achieved in patients who, pre-operatively, had passive movement of the elbow joint and active movement of the shoulder joint. The method is not suitable for patients with a markedly limited pre-operative movement of both the elbow and the shoulder in whom an alternative surgical treatment should be used.
authors.affiliation: Ortopedická klinika IPVZ a 1. LF UK, Na Bulovce, Praha.
authors.forename: J
authors.initials: J
authors.lastname: Chomiak
authors.forename: P
authors.initials: P
authors.lastname: Dungl
mesh_terms: D001176:Arthrogryposis / Q000503:physiopathology / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D003286:Contracture / Q000601:surgery; D004551:Elbow Joint / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D010369:Pectoralis Muscles / Q000637:transplantation*; D026741:Physical Therapy Modalities; D011182:Postoperative Care; D016059:Range of Motion, Articular