Spring 2009

Restoring Form and Function to Upper Extremities

In the fall of 2007, AG, a 36-year-old East Bay musician, was driving home with his wife when they rolled their 10-year-old sedan. AG's left arm was extended through the driver's side window, and as the car rolled, his elbow slammed against the pavement and ripped open. The impact cracked off a large piece of his ulna, damaged his ulnar nerve and left a large, soft tissue defect.

After emergency room physicians at an East Bay hospital stabilized AG, they transferred him to UCSF Medical Center, where a team of surgeons — including orthopaedic surgeon Lisa Lattanza, M.D., chief of the Hand and Upper Extremity Service, and plastic surgeons David S. Chang, M.D., and David M. Young, M.D. — reconstructed AG's severely damaged elbow.

Lattanza began the process with an open reduction and internal fixation that required a large tricortical iliac crest graft. As she worked through that phase of the operation, other members of the team harvested a sural nerve from the leg and a free flap from the rectus abdominis. The team then performed the microvascular surgery required to complete a nerve graft and to connect the blood vessels from the free flap to those in the arm.

Today, AG is healing well and has begun playing music again. "It's been very rewarding to see him regain strength and range of motion," says Lattanza.

Addressing a Spectrum of Concerns

AG's case clearly illustrates the many factors necessary for successful reconstructive surgery of the upper extremities. One factor is having a full surgical team available with all of the necessary expertise. "Without a full team of surgeons who have complementary skill sets, the surgery would have taken much longer and involved more risk," says Lattanza.

For example, at UCSF Medical Center, Lattanza and her new colleague Mohana Amirtharajah, M.D., typically handle the large, bony defects, while plastic surgeon Scott Hansen, M.D., often works on the soft tissue portion of these cases. All three are trained to handle nerve injuries, although in complex cases they often call in neurosurgeon Nicholas Barbaro, M.D., who leads the UCSF Nerve Injury Clinic, where Lattanza consults as part of a multidisciplinary team.

The Hand and Upper Extremity Service team also includes hand surgeon Mathias Masem, M.D., and Bryan Werner, M.D., a physiatrist specializing in nonoperative treatment of upper extremity problems.

Experience also is essential for addressing the overlapping concerns that characterize complex reconstructions. "As one example, with a very large bone graft you need to have enough experience to correctly assess what needs to be restored, how to shape the bone to fit, and when there is extensive joint destruction, how to complete an interposition arthroplasty," says Lattanza.

In addition, in many cases, restoring motion can pose a difficult challenge, depending on the specific nerve and tissue damage. Lattanza describes the case of a man who suffered a work-related crush injury that left him with a soft tissue defect, a broken radius and nerve damage in his forearm.

After initial treatment at San Francisco General Hospital for the severe trauma, the patient came to Lattanza, hoping to regain motion that had been lost due to post-traumatic synostosis of the radius and ulna, as well as to severe muscle loss. Lattanza removed the extra bone growth from the synostosis and then reconstructed the biceps, which restored active elbow and forearm motion.

"Volume is the difference in these complex cases," says Hansen. He notes, for example, that outcomes for gracilis free muscle transfers that restore finger movement tend to be better when surgeons have extensive microsurgery experience. "In the last year, the division has done over 100 free tissue transfers, and my job is often to provide healthy, well-vascularized soft tissue coverage while minimizing donor site morbidity."

One newer technique that Hansen sometimes employs is perforator flap reconstruction. "We use magnification to dissect perforating vessels and preserve the muscle," says Hansen. "It can be a tedious and time-consuming procedure, but it's effective. We will even do very small free flaps — one millimeter and less."

Understanding the Range of Injury

Successful outcomes also can involve more than technique; they can require understanding the way upper extremity injuries play themselves out over the course of a lifetime.

For example, Lattanza's work with both children and adults helped her in the case of a patient who, as a young child, had suffered a traumatic radial head fracture and elbow dislocation. Unfortunately, the original procedure had failed to stabilize the elbow. When the young woman — a still active rugby player at age 25 — arrived in Lattanza's office, she presented with elbow pain and inability to rotate her forearm.

"The pain and lack of motion were limiting her daily activity and her ability to play her sport," says Lattanza. With a radial head implant, proper reconstruction of the elbow ligaments and a shortening of the ulna at the wrist, Lattanza was able to restore the normal relationships among the elbow, forearm and wrist.

Finally, a well-planned postsurgical rehabilitation is essential for optimal recovery. "Sometimes as early as post-op day one, we will use continuous passive motion machines to keep the elbow from stiffening," says Lattanza. "The motion is sometimes limited by the flap — and operative reconstruction needs to render the parts stable so motion can resume — but early movement helps control edema, restore function and prevent scar formation."

What are the most common indicators for considering complex reconstructive surgery?

  • Any injury of the hand and upper extremity that combines bone loss, soft tissue loss, nerve defect or a combination of these factors
  • Acute and chronic elbow instability
  • Post-traumatic contracted elbow
  • Nerve injuries of the upper extremity requiring repair, graft or tendon transfers
  • Complex congenital anomalies of the upper extremity
  • Arthritic conditions of the upper extremity requiring joint replacement or resurfacing
  • Tendon repair and reconstruction

Lisa Lattanza, M.D. can be contacted at (415) 353–7584.

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