Pectoral transplantation for paralysis of the flexors of the elbow; a new technique.

Restoration of elbow flexion in paralytic disorders has taxed the ingenuity of surgeons for half a century. Four types of operation have emerged : 1) proximal transplantation of the flexor or extensor origins of the forearm muscles, or both ; 2) transplantation of triceps to biceps; 3) transplantation of pectoralis major to biceps; and 4) transplantation of sternomastoid to biceps. This communication is concerned solely with pectoral transplantation. The first such operation was described in 1917 ; Schulze-Berge transplanted the tendon of insertion of pectoralis major direct into the belly of biceps. Various modifications of this technique were later employed by Hohmann (1918), Rivarola (1928), Fritz Lange (1930) and Max Lange ( 195 1). These authors were dissatisfied with the original method of insertion of pectoralis major into biceps and used fascia lata or strands of silk to form tendons of insertion either into the biceps tendon or into the ulna. It was not until after 1946 that the ingenious pectoral transplantation described by Clark came into general use. Clark’s operation differs fundamentally from those previously described. The lower fibres, comprising the sternal origin of the muscle, are detached from the chest wall and mobilised towards the axilla as far as the nerve and blood supply will allow. The muscle mass is then passed down the arm and attached to the biceps tendon. This operation is particularly useful for patients who have suffered a traction lesion of the upper trunk of the brachial plexus because the sternal head of pectoralis major is not paralysed. In 1952 one of us (D. M. B.) was confronted with an awkward problem. A girl of ten years was left with extensive paralysis of the upper limb after an attack of poliomyelitis. The distribution of the paralysis was such that neither Steindler’s operation nor a triceps transplantation was possible. The clavicular head of pectoralis major, however, contracted strongly and caused the head of the humerus to luxate anteriorly; the sternal head was completely paralysed. At first sight it appeared a good opportunity to carry out one of the earlier techniques of pectoral transplantation. Unfortunately, the fascia lata had been removed previously for a reconstructive procedure on the shoulder. To overcome this difficulty the long head of biceps was converted into a” tendon” by the technique to be described.