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Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Tendon Transfers About the Shoulder and Elbow in Obstetrical Brachial Plexus Palsy*

JAMES B. BENNETT, M.D., HOUSTON, TEXAS and CHRISTOPHER H. ALLAN, M.D., SEATTLE, WASHINGTON

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

	Introduction

Top Introduction Biomechanics of Shoulder... Muscle Contracture Tendon Transfers About the... Arthrodesis Tendon Transfers About the... Deformity of the Elbow Overview References

 
Obstetrical or birth palsy of the brachial plexus occurs in as many as one in 250 births^30,32. Predisposing factors include high birth weight, prolonged labor, breech presentation, and shoulder dystocia. The actual lesion is produced by traction on the neural elements—for example, stretching of the brachial plexus with forced lateral flexion of the head and neck. Most of these injuries resolve without operative intervention. For patients who are more severely affected, however, a variety of procedures are available (Table I). The treatment algorithm to maximize each child's long-term functional recovery is continuously evolving (Table II).

Patients with incomplete recovery who are seen more than six months after birth frequently have muscle contractures due to unopposed muscle forces and are no longer candidates for direct repair of the plexus. These children can often benefit from releases of the contractures to maintain a congruent joint and to maximize the range of motion. Releases are usually performed between the ages of twelve and twenty-four months, but they may be useful in older patients if the glenohumeral joint is congruent.

Waters et al. made the point that glenohumeral deformity occurs along a spectrum of severity, with less severe changes being potentially reversible with soft-tissue joint-relocation procedures, a situation that is analogous to the joint-remodeling seen in children managed for congenital dysplasia of the hip³³. The decision as to whether to perform tendon transfers or osseous procedures is therefore difficult when the deformity is not clearly at one end of the spectrum or the other, and it is based on assessment of the congruence of the glenohumeral joint. Plain radiographs may be inadequate for the evaluation of joint congruence in order to select treatment, since the glenoid is incompletely ossified at the age when these decisions must be made. Pearl and Edgerton recently reported their experience with the intraoperative use of axillary glenohumeral arthrography to assist with selection of the appropriate operative procedure²⁵. Waters et al. described the preoperative use of computed tomography or magnetic resonance imaging to better depict the glenohumeral deformity³³.

Tendon transfers are generally performed between the ages of two and five years, although some authorities advocate attempts at soft-tissue joint realignment in children as old as nine or ten years if the glenohumeral joint is congruent²⁵. Waters and Peljovich recently compared the results of tendon transfers with those of humeral derotation osteotomies; the patients who were managed with soft-tissue procedures had an average age of 4.9 ± 2.5 years at the time of the operation, whereas those managed with osteotomies had an average age of 8.4 ± 3.7 years³⁴.

In addition to an assessment of joint congruence, muscle-grading is necessary before tendon transfer, to ensure that the transferred muscle will provide adequate power. Adequate power requires a grade of at least 4 of 5, which corresponds to active movement against gravity and some resistance but not normal power. Accurate muscle-grading is not possible until optimum strength has been achieved, usually with the assistance of therapy, and the child is old enough to comply with testing.

Osseous procedures are usually performed in patients who are first seen when they are older than five years of age since, as we noted, joint incongruity tends to increase with the patient's age. Appropriate procedures for severely incongruent joints include humeral rotational osteotomy for persistent internal rotation contracture and glenohumeral arthrodesis in the setting of severe pain, instability, or arthritic changes. When posterior dislocation of the humeral head has occurred, posterior capsular plication may be necessary to prevent recurrent posterior instability³¹.

While each of these components of operative treatment has its role, the present discussion will be limited to release of contractures and tendon transfers and will specifically consider procedures that aim to restore function of the shoulder and elbow.

	Biomechanics of Shoulder Stability

Top Introduction Biomechanics of Shoulder... Muscle Contracture Tendon Transfers About the... Arthrodesis Tendon Transfers About the... Deformity of the Elbow Overview References

 
The longitudinal, proximal pull of the deltoid muscle (as well as the long head of the triceps, the pectoralis minor, and the coracobrachialis muscles) on the humerus is counteracted by the depressor force of the rotator cuff muscles. The line of action of this force is medial and slightly downward. The rotator cuff plays its greatest role as a stabilizer between 30 and 75 degrees of humeral elevation, with its role diminishing thereafter until, at 120 degrees of elevation, it no longer contributes to stability of the glenohumeral joint. In the absence of an intact rotator cuff, the inferior portion of the pectoralis major muscle, along with the latissimus dorsi muscle, may resist superior translation of the humeral head in the glenoid fossa.

The subscapularis muscle also functions to resist anterior glenohumeral instability. The long head of the biceps muscle assists in this. The subscapularis muscle may also prevent posterior translation through its anterior pull. Posterior stability is also provided by the infraspinatus muscle and the posterior aspect of the capsule of the glenohumeral joint.

Inferior stability is provided by the posterior part of the deltoid muscle, the supraspinatus muscle, and the superior portion of the glenohumeral joint capsule. The pull of the serratus anterior muscle on the scapula tilts the glenoid from a more vertical to a more horizontal position with humeral elevation; this provides an osseous shelf resisting inferior translation as well⁹.

	Muscle Contracture

Top Introduction Biomechanics of Shoulder... Muscle Contracture Tendon Transfers About the... Arthrodesis Tendon Transfers About the... Deformity of the Elbow Overview References

 
The most commonly encountered birth palsy involves the fifth and sixth cervical nerve roots (713 [48 percent] of 1486 patients in Gilbert's series had such involvement¹³) or the fifth, sixth, and seventh roots (431 [29 percent] of 1486 patients in Gilbert's series), with diminished or absent abduction and external rotation leading to an adduction and internal rotation contracture. The chief difference between these two patterns of involvement is the complete elbow extension due to intact triceps function in the first pattern. Other patterns involve more caudad nerve roots (the eighth cervical and first thoracic nerve roots) or whole-plexus injury. The more caudad nerve-root injuries tend to affect function of the hand and wrist and are not discussed here.

Release of the Subscapularis Muscle²
Release or recession of the subscapularis muscle, probably first described by Sever in 1918²⁸, has withstood the test of time and is still performed in various modified forms in patients who have an internal rotation contracture of the shoulder (Fig. 1). The pectoralis major muscle does not usually result in contracture and therefore does not require release.

View larger version (119K): [in this window] [in a new window]   Figs. 1 through 4: Release of the subscapularis muscle as described by Carlioz and Brahimi2. Fig. 1: Photograph demonstrating a preoperative adduction contracture of the left shoulder with an internal rotation contracture of approximately 20 degrees.

Technique: The patient is placed in lateral decubitus with use of a beanbag or another type of support. The affected shoulder and torso are prepared to the midline anteriorly and posteriorly. A longitudinal incision is made along the lateral border of the scapula, and dissection is carried out down to the latissimus dorsi muscle, the fibers of which cover the lateral aspect of the scapula. This muscle is retracted inferiorly, and the inferior angle of the scapula is identified and stabilized with towel clips. The subscapularis muscle is readily identified and is elevated in its entirety from the anterior surface of the scapula with use of electrocautery or a periosteal elevator (Fig. 2). Dissection is performed in a subperiosteal fashion, progressing from the inferior angle upward. The scapula is manipulated as needed with use of the towel clips. An external rotatory force on the humerus is applied gently throughout the release to confirm adequate release of the muscle and elimination of the contracture (Fig. 3). Care must be taken to avoid injury of the subscapular artery and nerve running anteromedial to the glenoid neck and anterior to the subscapularis muscle as well as injury of the suprascapular artery and nerve running from anterior to posterior over the scapular notch. After complete release of the subscapularis muscle, the wound is closed over a suction drain. A splint, made preoperatively, is applied to maintain the arm in abduction and external rotation (Fig. 4). The patient wears the splint full-time for three months, removing it only to bathe and for gentle range-of-motion exercises, which are begun at six weeks. The patient then wears the splint only at night for an additional three months. At six months postoperatively, treatment with the splint is discontinued.

View larger version (68K): [in this window] [in a new window]   Fig. 2 Drawings illustrating the release of the subscapularis muscle described by Carlioz and Brahimi2. The drawing on the left shows the approach to the left subscapularis muscle. The fibers of the latissimus dorsi muscle are split and retracted to the upper left and the lower right by two separate retractors. The upper-right retractor stabilizes the lateral border of the scapula. Below the upper-left retractor is a periosteal elevator elevating the subscapularis muscle off the anterior surface of the scapula. The drawing on the right shows the right subscapularis muscle being elevated off the anterior surface of the scapula by an osteotome.

View larger version (125K): [in this window] [in a new window]   Fig. 3 Intraoperative photograph showing recession of the subscapularis (held in the towel clip) off of the anterior surface of the scapula.

View larger version (117K): [in this window] [in a new window]   Fig. 4 Postoperative photograph made after release of the subscapularis muscle, demonstrating external rotation of approximately 45 degrees. (This is the same patient as is shown in Fig. 1.)

Transfer of the Infraspinatus Tendon to the Teres Minor Tendon
In the less common situation involving a combined external rotation and abduction contracture, it may be necessary to release the supraspinatus and infraspinatus tendons, as described by Zancolli and Zancolli³⁵. Release of the insertion of the deltoid muscle on the humerus may also be necessary. An anterior dislocation of the humeral head is often associated with this contracture. The glenohumeral joint is reduced after division of the tendons of the external rotators, step-cut lengthening of the infraspinatus tendon, and transfer of that tendon to the teres minor tendon. Anterior capsular plication may be necessary to tighten the lax anterior glenohumeral ligaments. It should be noted that some authors³⁵ think that this lesion occurs only as a complication of excessive splinting in the so-called Statue of Liberty position (marked abduction and external rotation), first described by Fairbank¹², rather than secondary to birth injury.

Technique: A posterior approach to the shoulder is used, with a longitudinal skin incision made from superior to inferior overlying the glenohumeral joint. The posterior part of the deltoid muscle is identified and elevated, revealing the underlying contracted infraspinatus and teres minor muscles. The tendon of the infraspinatus is divided several centimeters medial to its insertion on the greater tuberosity of the humeral head. The tendon of the teres minor is divided at its insertion and then sutured to the infraspinatus tendon attachment, thereby lengthening the course of the teres minor by several centimeters. The infraspinatus muscle is now closed to the reattached teres minor. The combined effect is to lengthen the external rotator complex. The arm is splinted in adduction and internal rotation; the patient wears the splint full-time for three months and only at night for an additional three months. Physical therapy for active and passive motion is performed with the splint off beginning at six weeks. As an alternative to the procedure just described, some authors have advocated recession or muscle slide of the supraspinatus, infraspinatus, and teres minor muscles, as described by Debeyre et al.¹¹.

	Tendon Transfers About the Shoulder

Top Introduction Biomechanics of Shoulder... Muscle Contracture Tendon Transfers About the... Arthrodesis Tendon Transfers About the... Deformity of the Elbow Overview References

 

Principles
The principles of tendon transfer are similar regardless of location.

The involved joint must have a functional range of motion. Achievement of such motion most often requires the involvement of therapists working with the child's parents to maintain a supple joint before the operation. The program can include dynamic splinting and stretching to improve passive motion. In addition, as we already discussed, joint contractures must be released and the joint must be congruent and reduced. Skin must be supple without constricting scars.

In an already injured extremity, the surgeon must ensure that the choice of the donor muscle-tendon unit or units will not interfere with existing function.

Adequate strength (a grade of at least 4 of 5) of the donor muscle must be confirmed. Preoperative and postoperative strengthening programs are routinely employed. Most transfers result in the loss of approximately one muscle grade, and this must be planned for. It is best to avoid transferring a tendon when the muscle of that tendon was previously paralyzed and has now recovered.

The excursion of the donor muscle-tendon unit must be adequate. In some patients, amplitude can be increased by the addition of a segment of fascia lata or by regional fascial extension. For example, intercostal fascia can be used to lengthen a latissimus dorsi muscle transfer, or rectus sheath can be used with a pectoralis major muscle transfer.

Each tendon should perform only one function. The transfer should employ a straight line of pull.

When possible, synergism should be employed such that the simultaneous contractions of different muscles combine to achieve a desired function. To this end, manual or electrodiagnostic testing to check for in-phase firing of planned donors with nearby, uninvolved motors should be performed preoperatively, to ensure that transferred motors and intact motors do not act as antagonists and prevent active motion. Reinnervation patterns of the brachial plexus may also result in co-contraction of antagonistic muscle groups.

Biomechanics
Shoulder elevation is most efficiently performed in the plane of the scapula. The glenohumeral joint has its greatest stability and mobility (150 degrees) in this position. Tendon transfers to restore shoulder elevation should therefore be done in the plane of the scapula when possible. Shoulder elevation involves both the supraspinatus and the deltoid muscle. Both muscles are active throughout the full range of elevation, although the supraspinatus muscle is most efficient in the first 45 degrees of this motion. The results of studies of the deltoid muscle are divided as to whether its efficiency is maximum at 90 degrees of elevation or at full elevation⁹.

The deltoid muscle behaves as if it were several smaller muscles pulling in slightly different directions and contracting separately in a sequential fashion. The middle part of the deltoid contracts first and, as it is most nearly in line with the plane of the scapula, has the greatest effect on elevation. The anterior fibers cause more flexion and the posterior fibers cause more extension than the middle portion. Some authors have concluded that transfer of the anterior or posterior portion of the deltoid muscle to a more lateral position is therefore justified in order to increase elevation⁹.

The most important scapular motor is the inferior portion of the serratus anterior muscle. This muscle positions the glenoid slightly beneath the humeral head during elevation through its pull laterally and inferiorly on the scapula and thereby stabilizes the glenohumeral joint. This function must be present if transfers are to be performed to restore elevation.

Because the humeral head has a greater diameter, tendons transferred to the humeral head (or to the rotator cuff) in order to bring about rotation are more efficient (have a greater lever arm) than transfers to the shaft of the humerus⁹.

Tendon transfers about the shoulder are most commonly performed for lesions of the fifth and sixth cervical nerve roots involving the suprascapular and axillary nerves and for deficits of the nerve to the subscapularis secondary to shoulder instability. Involved muscles include the supraspinatus and infraspinatus, all or part of the deltoid, and the subscapularis.

Suprascapular Nerve and Supraspinatus and Infraspinatus Muscles (Fifth and Sixth Cervical Nerve Roots)
Weak or absent function of the supraspinatus and infraspinatus muscles leads to decreased external rotation of the humerus and the characteristic internal rotation contracture of obstetric brachial plexus palsy (Fig. 5). This problem is commonly addressed either with transfer of the latissimus dorsi tendon to the posterior aspect of the rotator cuff or the greater tuberosity, as described by Hoffer et al.¹⁶ (Fig. 6), or with a shift of its insertion from anterior to posterior, converting it to an external rotator, as described originally by L'Episcopo²¹ and as modified by Covey et al.¹⁰.

View larger version (79K): [in this window] [in a new window]   Figs. 5, 6, and 7: Transfer of the latissimus dorsi tendon to the posterior aspect of the rotator cuff. Fig. 5: Preoperative photograph showing loss of external rotation and abduction of the shoulder.

View larger version (130K): [in this window] [in a new window]   Fig. 6 Drawing illustrating the modification, described by Hoffer et al.16, of the transfer of the latissimus dorsi tendon to the greater tuberosity or the rotator cuff. A retractor elevates the deltoid muscle. The shaded muscles are the transposed latissimus dorsi (below) and the teres major (above). These muscles are taken from their previous position (dotted lines) to a new site of attachment into the rotator cuff over the greater tuberosity, so that the muscles are converted from internal to external rotators and provide abduction.

The procedure described by Hoffer et al.¹⁶ has the advantage of increasing glenohumeral abduction as well as external rotation if function of the deltoid muscle is present. The transfer increases the stabilizing function of the rotator cuff, providing a secure glenohumeral fulcrum around which the deltoid can direct its pull on the lateral aspect of the humerus. Triceps function must be present to allow extension of the elbow when the shoulder is abducted and externally rotated.

Technique: The patient is placed in lateral decubitus, and the affected extremity is prepared and draped free. An anterior axillary incision is made, and the pectoralis major tendon insertion is identified and, if necessary, released. If the pectoralis major muscle is not contracted (and the senior one of us [J. B. B.] believes that it rarely is), then a single posterior incision is used. The subscapularis muscle may be released, as described earlier, if indicated. The tendons of the latissimus dorsi and teres major are identified through a separate, posterior incision. These tendons are released as well, with protection of the radial nerve and the contents of the quadrilateral space throughout. The interval between the posteroinferior margin of the deltoid muscle and the rotator cuff is then developed, and the arm is maximally abducted and externally rotated. The released tendons of the latissimus dorsi and the teres major are next transferred posterior to the long head of the triceps muscle and sutured as superiorly as possible to the rotator cuff. Two longitudinal incisions are made in the cuff, and the tendons are pulled through these incisions and sutured to themselves, thereby converting the latissimus dorsi and teres major muscles into external rotators of the shoulder. Postoperatively, a shoulder spica splint is applied with the shoulder in 60 to 90 degrees of abduction and external rotation. This splint is worn full time for three months and only at night for an additional three months (Fig. 7).

View larger version (71K): [in this window] [in a new window]   Fig. 7 Postoperative photograph showing external rotation and abduction of the shoulder with weak function of the triceps muscle.

With the modification¹⁰ of the L'Episcopo procedure²¹, the latissimus dorsi is transected at its musculotendinous junction and sutured to the teres major tendon, which has been taken directly off bone. The remaining latissimus tendon, still attached to the humeral shaft, is rerouted posterolaterally, while the combined latissimus muscle and teres major tendon are taken posteromedially. These are sutured together posterolateral to the shaft of the humerus, converting both muscles into external rotators.

Technique: The patient is placed in lateral decubitus. The arm is draped free, and an axillary incision five to six centimeters in length is made transversely from the anterior to the posterior axillary fold. The latissimus dorsi and teres major tendons are identified. The latissimus dorsi is dissected free from the teres major and transected at its musculotendinous junction, and its tendon, still attached to bone, is tagged. A three-centimeter lateral incision is made over the proximal part of the lateral aspect of the deltoid muscle. The latissimus muscle belly is sutured to the teres major muscle, which is then released from its humeral insertion. With use of tag sutures, the combined latissimus and teres major muscle group is tunneled posterior to the humerus. The tagged latissimus tendon is taken anterior to the humerus and out through the lateral deltoid incision. The tagged latissimus and teres major muscles are tied to the tagged latissimus tendon, and its course anterior to the humerus and then posterolateral converts the muscles to external rotators. Care is taken throughout to avoid the axillary nerve, particularly in patients who have intact deltoid function. A spica splint is applied with the shoulder in 30 to 45 degrees of abduction and external rotation and is used for three months, after which time gentle range-of-motion and strengthening exercises are begun. The patient wears the splint only at night for another three months.

Axillary Nerve and Deltoid Muscle (Fifth and Sixth Cervical Nerve Roots)
There are several procedures that can be used to replace some portion of the function of the deltoid muscle.

Anterior Transfer of the Posterior Third of the Deltoid

In patients in whom the anterior and middle thirds of the deltoid are nonfunctional but the posterior third is intact, an anterior transfer of the posterior third can be performed. As first described by Harmon¹⁴ for the treatment of deficits secondary to poliomyelitis, the posterior third of the deltoid muscle is freed from its scapular origin and sutured anteriorly along the lateral aspect of the clavicle, in the region of the nonfunctional anterior and middle deltoid muscle fibers.

Technique: A superoposterior incision is made, beginning at the middle third of the clavicle and extending posteriorly to the middle of the scapular spine. Full-thickness flaps are raised superiorly and inferiorly, revealing the posterior third of the deltoid muscle. The muscle is detached subperiosteally from its origin and freed for about half its length from underlying tissue. Care must be exercised to protect underlying branches of the axillary nerve. The outer third of the clavicle is exposed subperiosteally as well, and the free former origin of the posterior third of the deltoid muscle is sutured to this new location. Wounds are closed, and the arm is splinted in 60 to 90 degrees of abduction and forward elevation. The splint is worn full-time for three months, after which time gentle active and passive range-of-motion exercises are begun and the splint is worn for another three months at night only.

Transfer of the Trapezius Muscle to the Lateral Aspect of the Humeral Shaft

Alternatively, a modification of Mayer's²² transfer of the trapezius muscle can be performed (Fig. 8). Mayer's original procedure involved dissection of the trapezius muscle free of its insertion along the acromion, scapular spine, and lateral aspect of the clavicle; attachment of a segment of fascia lata rolled into a tube; and suture into a bone tunnel in the region of the deltoid tuberosity on the lateral aspect of the humerus. A modification in which a portion of the acromion is removed to allow for a more straight-line pull is now more commonly used. The lateral aspect of the acromion and its attached trapezius is removed, and its undersurface is roughened with a rasp. Fixation with a screw and washer secures the acromion and trapezius transfer to the proximal part of the humeral shaft (Fig. 9).

View larger version (63K): [in this window] [in a new window]   Figs. 8 and 9: Modification of Mayer's22 transfer of the trapezius muscle attached to an acromial bone block. Fig. 8: Drawings illustrating the procedure. The upper drawing shows a lateral view of the right shoulder, with the acromial bone block and attached trapezius muscle elevated. The lower drawing shows the acromial bone block with attached trapezius muscle secured with screw fixation to the roughened lateral aspect of the proximal part of the humerus distal to the greater tuberosity.

View larger version (77K): [in this window] [in a new window]   Fig. 9 Radiograph made after performance of the transfer to restore shoulder abduction.

Bipolar Transfer of the Latissimus Dorsi Muscle for Dysfunction of the Deltoid

Finally, bipolar transfer of the latissimus dorsi muscle (both ends of the muscle are rotated) on its neurovascular pedicle, as described by Itoh et al.¹⁸, can be used to treat dysfunction of the deltoid. The procedure involves transection of both the origin and the insertion of the latissimus dorsi muscle. The flat tendon that was originally the humeral insertion is sutured to the insertion of the deltoid muscle, and the broad muscular end is sutured to the periosteum of the acromion and the distal part of the clavicle or to the insertion of the trapezius muscle, thereby substituting for the nonfunctional deltoid muscle.

Technique: The patient is placed in lateral decubitus, with the involved side up, and three incisions are made. First, a longitudinal axillary incision is made over the lateral border of the latissimus dorsi muscle, extending up to the distal half of the deltopectoral groove; second, an anterolateral incision is made over the insertion of the deltoid muscle on the humerus; and, third, a curvilinear incision is made along the lateral third of the clavicle and the anterior and lateral aspects of the acromion. The anterior border of the latissimus dorsi muscle is bluntly elevated from the chest wall, with care taken to identify and protect the neurovascular bundle. This is followed proximally, with ligation of communicating branches. Subcutaneous tissue is cleared from the latissimus dorsi muscle for approximately twenty centimeters distal from its humeral insertion. Marking sutures are placed ten centimeters apart in the body of the muscle as a guide to its resting tension. The muscle is then taken off the inferior angle of the scapula and separated from the teres major muscle. Care must be taken to preserve the thoracodorsal vascular pedicle beneath these muscles. The humeral insertion is divided. The lumbodorsal fascia is then cut near the origin of the latissimus dorsi muscle and at least twenty centimeters from its humeral insertion. The entire latissimus dorsi muscle can then be raised, with its neurovascular bundle still attached, and rotated so that the undersurface with its attached neurovascular bundle is superficial. A superficial tunnel connecting the incision over the deltoid muscle insertion with that over the anterolateral aspect of the acromion and clavicle is then created. The latissimus dorsi muscle is again rotated in order to allow the flat tendon of insertion to be passed distally down the subcutaneous tunnel in the arm and sutured to the deltoid muscle insertion. The broad muscle end taken from the lumbodorsal fascia is rotated up to the acromioclavicular incision. The arm is flexed to 70 to 80 degrees and abducted to 60 degrees, and the proximal end of the transferred latissimus dorsi muscle is sutured to the periosteum of the anterolateral aspect of the acromion and clavicle or to the trapezius muscle insertion. The position of the neurovascular bundle must be checked frequently to be sure that no excessive torsion or traction is applied; at the completion of the transfer, the bundle should rest anterolaterally on the proximal border of the pectoralis major muscle. Again, a splint is worn for three months with the arm abducted to 60 to 90 degrees, after which the splint is worn only at night and range-of-motion exercises are begun. The splint is worn at night for three months.

Subscapularis Nerve and Muscle (Fifth and Sixth Cervical Nerve Roots)
The subscapularis nerve and muscle are usually functioning in brachial plexus palsy affecting the fifth and sixth cervical nerve roots, but occasionally the muscle's function is decreased, resulting in anterior glenohumeral instability. The subscapularis muscle's function as an internal rotator can be replaced by transfer either of the pectoralis major tendon or of the serratus anterior tendon to the lesser tuberosity of the humerus. It should be noted that the transferred pectoralis major tendon must be passed posterior to the conjoined tendon to duplicate the function of the subscapularis muscle; otherwise, anterior instability may result.

Transfer of the Serratus Anterior Tendon to the Lesser Tuberosity

Technique: The patient is placed in lateral decubitus with the involved side up. Through a saber-cut incision over the shoulder, the trapezius muscle is reflected up and back, exposing the superomedial angle of the scapula. The levator scapulae muscle is taken off its insertion here, and the underlying serratus anterior muscle is identified. The insertion of the proximal two digitations of the serratus anterior muscle merges with the medial limit of the subscapularis muscle on the anterior aspect of the scapula. These are separated with sharp dissection. The two muscular slips are now rolled into a tube and held with suture; the tube is left long for rerouting. The arm is then elevated to 60 to 90 degrees, and an incision is made along the posterior wall of the axilla. The neurovascular bundle is retracted upward and laterally, and blunt dissection is used to open a path proximal to the superior border of the serratus anterior muscle to the first rib. The tube consisting of the proximal two digitations is passed anteriorly with use of the attached suture and is sewn into the tendinous tissue over the lesser tuberosity of the humerus²⁶. The arm is splinted with the shoulder maintained in an internally rotated position and the forearm against the trunk, and the splint is worn full-time for three months. It is then worn only at night for another three months, and range-of-motion exercises are begun during this period.

Multiple Nerve Deficits
Occasionally, multiple transfers are required for multiple nerve deficits. These procedures most commonly involve some combination of the biceps-triceps-latissimus dorsi tendon transfers described by Harmon¹⁵ (first used in the treatment of functional losses secondary to poliomyelitis) and based on Ober's earlier work²³. Transfers performed in combination include transfer of the posterior third of the deltoid muscle to the lateral aspect of the clavicle, as described, together with transfer of the tendinous origins of the long head of the triceps muscle and the short head of the biceps muscle to the lateral aspect of the acromion, to aid in abduction, and transfer of the latissimus dorsi and teres major tendons or of the tendinous insertion of the clavicular head of the pectoralis major muscle posteriorly, to provide external rotation of the humerus. Multiple options are available, and one common combination will be described.

Multiple Transfers of the Biceps, Triceps, and Latissimus Dorsi Tendons

Technique: Through a saber-cut incision, the posterior third of the deltoid muscle is taken off the scapular spine. The tendon of the long head of the triceps muscle is released from the scapula, and the latissimus dorsi tendon is taken off its insertion on the humerus. The tendon of the short head of the biceps muscle is removed from the coracoid process. The arm is held in 90 degrees of abduction and 30 degrees of external rotation. The tendon of the short head of the biceps muscle is passed through the anterior third of the deltoid muscle and sutured to the anterior aspect of the acromion with the elbow flexed to 90 degrees. The tendon of the long head of the triceps muscle is then sutured to the posterolateral aspect of the acromion with the elbow flexed to 30 degrees. The released tendon of the latissimus dorsi muscle is sutured under tension to the insertion of the infraspinatus muscle. The released posterior third of the deltoid muscle is then sutured over these structures to the anterolateral aspect of the acromion and the lateral aspect of the clavicle. The arm is splinted in 60 to 90 degrees of abduction, 30 degrees of external rotation, and 90 degrees of elbow flexion.

	Arthrodesis

Top Introduction Biomechanics of Shoulder... Muscle Contracture Tendon Transfers About the... Arthrodesis Tendon Transfers About the... Deformity of the Elbow Overview References

 
When a patient has severe combined lesions and the surgeon cannot reasonably expect to achieve glenohumeral stability with any of the described soft-tissue procedures, it may be necessary to perform a glenohumeral arthrodesis to treat pain, instability, or arthritis (Fig. 10). Arthrodesis of the shoulder requires scapular stability and functional scapular muscles. Instability or incongruity of the shoulder should not be addressed if the arm or hand is nonfunctional. However, shoulder arthrodesis can enhance the power of weak elbow flexion or extension transfers by isolating the forces of the transfer to the elbow.

View larger version (98K): [in this window] [in a new window]   Fig. 10 Radiograph made after a shoulder arthrodesis performed with a 4.5-millimeter AO dynamic compression plate.

	Tendon Transfers About the Elbow

Top Introduction Biomechanics of Shoulder... Muscle Contracture Tendon Transfers About the... Arthrodesis Tendon Transfers About the... Deformity of the Elbow Overview References

 
Elbow flexion is frequently absent or diminished in obstetrical brachial plexus palsy involving the musculocutaneous nerve (the fifth and sixth cervical nerve roots) and therefore impairing the function of the biceps and brachialis muscles. Numerous procedures to restore this function have been described, with one of the earliest being the proximal reattachment of the origin of the flexor-pronator muscle group as outlined by Steindler²⁹. Despite later modifications to reduce some of the unwanted sequelae (for example, pronation deformity) of this transfer, other transfers are now often preferred to the Steindler flexorplasty, although it has the benefit of being simple to perform. Another procedure that was used more widely in the past is anterior transfer of the triceps tendon insertion, which provides better strength of elbow flexion than the Steindler transfer does but leaves the patient unable to actively extend the elbow on the side of the operation in order to use crutches or to assist in transfer from bed to chair. An early but cosmetically unacceptable procedure was transfer of the sternocleidomastoid muscle (Figs. 11 and 12), which involves detaching this muscle from its insertion and linking it to the insertion of the biceps muscle by means of a long strip of fascia lata. This transfer is now generally avoided.

View larger version (114K): [in this window] [in a new window]   Fig. 11 Photographs showing extension (Fig. 11) and flexion (Fig. 12) after transfer of the sternocleidomastoid muscle to the biceps tendon lengthened with a fascia lata graft.

View larger version (114K): [in this window] [in a new window]   Fig. 12 Photographs showing extension (Fig. 11) and flexion (Fig. 12) after transfer of the sternocleidomastoid muscle to the biceps tendon lengthened with a fascia lata graft.

Proximal Transfer of the Origin of the Flexor-Pronator Muscle Group
Technique: A curvilinear incision is made at the posteromedial aspect of the elbow, passing behind the medial epicondyle and angling laterally (radially) both proximal and distal to this level. The medial antebrachial cutaneous nerve is identified and protected. The ulnar nerve is transposed anteriorly. The median nerve is identified between the two heads of the pronator teres muscle and mobilized from surrounding tissue, with protection of the branches to the pronator teres muscle. An osteotome is used to remove a piece of the medial epicondyle that is less than one centimeter in thickness with its attached origin of the flexor-pronator muscle group. This mass is reflected distally, and the muscles are mobilized from inferior attachments, with their innervation protected as the dissection progresses. The elbow is then flexed to 130 degrees, and the flexor mass and the epicondyle are pulled proximally and radially several centimeters to the anterior humeral cortex. The site is chosen such that the elbow can be flexed to 60 degrees with the wrist and fingers fully flexed. An attachment site then is prepared, with a roughened spot made on the humerus. The epicondylar segment is placed in this spot, and the transfer is secured with a screw inserted over a washer. The epicondyle can be predrilled for ease of fixation. The anterolateral fixation prevents the pronation deformity that was seen after early versions of the transfer, which involved a more medial attachment. The arm is then splinted with the elbow flexed to 90 degrees and the forearm in full supination, and this position is maintained for four to six weeks. Gentle range-of-motion exercises are then begun to regain all but the terminal 30 degrees of elbow extension for eight weeks; then, full extension is slowly regained with continued therapy.

Anterior Transfer of the Triceps Tendon
As described by Carroll and Hill^3,4, this procedure was designed for patients in whom paralysis or injury had left the flexor-pronator mass unusable for transfer.

Technique: The patient is placed in lateral decubitus with the arm draped free. A posterior incision is made, curving slightly around the tip of the olecranon. The ulnar nerve is identified medially. The lateral intermuscular septum is exposed. The triceps tendon insertion is taken off the ulna with a longitudinal extension of periosteum. The muscle is carefully elevated off the posterior part of the humerus for ten to fifteen centimeters, with protection of both the radial nerve as it courses anteriorly through the lateral intermuscular septum and the previously identified ulnar nerve medially. The triceps insertion with attached periosteum is then rolled into a tube. Next, an anterior incision is made to identify the biceps tendon insertion. The interval between the brachioradialis and pronator teres muscles is developed, with protection of the anterior neurovascular bundle, and the bicipital tuberosity is identified. A tunnel lateral to the radius is created from back to front, and the tube consisting of the triceps and attached periosteum is pulled anteriorly, superficial to the radial nerve. The elbow is flexed to 90 degrees, and the forearm is supinated fully. The triceps is pulled to maximum tension, and the tube of tendon and attached periosteum is sutured to the biceps tendon near its insertion. The arm is splinted in this position for four to six weeks, after which time active range-of-motion exercises are begun.

Bipolar Transposition of the Pectoralis Major Muscle
Clark⁷, in 1946, described a transfer of the inferior aspect of the sternal origin of the pectoralis major muscle to the biceps tendon with good restoration of elbow flexion in one patient. Schottstaedt et al.²⁷ modified this procedure, releasing both the origin and the insertion of the inferior two-thirds of the muscle. The senior one of us prefers this complete transposition. The procedure requires a grade of at least 4 of 5 for the strength of the sternal head of the pectoralis major muscle.

Technique: The patient is placed supine, and the affected extremity and ipsilateral side of the chest are prepared and draped. An oblique incision is made from the axilla downward and medially, and the chondrosternal two-thirds of the pectoralis major muscle is identified and elevated from the ribs and sternum. Care is taken, as the dissection progresses cephalad, to identify and preserve the neurovascular bundle entering the underside of the muscle from beneath the clavicle. Electrocautery facilitates elevation of the muscle from the underlying ribs and intercostal muscles. As dissection of the pectoralis major muscle progresses, the intercostal perforating arteries are encountered near the sternum. These must be cauterized or ligated; otherwise, they may retract and cause bleeding within the thoracic cavity. The humeral insertion of the chondrosternal portion of the muscle is released through the same incision. The insertion of the superior one-third of the pectoralis major muscle (originating from the clavicle) is left intact. A second incision is made over the biceps tendon insertion in the volar aspect of the proximal part of the forearm, and a subcutaneous tunnel is bluntly created, joining the two incisions along the anterolateral aspect of the arm. The origin of the pectoralis major muscle released from the ribs and sternum is rolled into a tube and passed down this tunnel into the second incision. With the elbow flexed to 90 degrees, the tube consisting of the muscle origin is secured to the distal part of the biceps tendon or the bicipital tuberosity on the radius. One method is to use nonabsorbable suture passed in a crisscross weave through the muscle-end tube, pulled through drill-holes in the radial neck with use of straight free needles, and tied through a small dorsal incision. The free humeral insertion of the pectoralis major muscle is drawn upward and sutured to the conjoined tendon at the coracoid process (Fig. 13). The neurovascular bundle must be kept free from any torsion or traction. Postoperatively, the arm is splinted with the elbow flexed to 90 degrees; the splint is worn full-time for three months and then only at night for another three months. A program of active flexion is begun at six weeks.

View larger version (73K): [in this window] [in a new window]   Fig. 13 Drawings illustrating the bipolar pectoralis major flexorplasty as described by Schottstaedt et al.27. The drawing on the left shows the sternal and clavicular origins of the pectoralis major muscle. The drawing on the right illustrates how only the sternal origin is taken down, rolled into a tube, and tunneled under the skin to be attached to the insertion of the biceps tendon. The insertion of the pectoralis major muscle is taken off the humerus and is either attached to the coracoid process (sutured to the conjoined tendon) or, for greater shoulder stability, sutured through drill-holes in the anterior aspect of the acromion.

Bipolar Transfer of the Latissimus Dorsi Muscle
A second option is to transfer the latissimus dorsi muscle, as described by Hovnanian¹⁷. This procedure also requires a grade of 4 of 5 for the strength of the donor muscle. Like the transfer of the bipolar pectoralis major muscle, the procedure is technically demanding but results in moderate elbow flexion superior to that seen with other techniques.

Technique: The patient is placed in lateral decubitus, and the affected arm and hemithorax are prepared and draped. A long incision is made beginning over the origin of the latissimus dorsi muscle, following its anterolateral margin, and crossing the axillary fold to proceed down the medial border of the arm to the antecubital fossa. The origin of the latissimus dorsi muscle with its fascial investment is released. The proximal margin is cut across its muscle fibers posteriorly. The neurovascular bundle enters in the proximal third and is carefully preserved. Gradual dissection with electrocautery frees the muscle from surrounding tissue, with communicating vessels cauterized or ligated as required. The thoracodorsal nerve is readily identified entering the undersurface of the muscle and coursing from the apex of the axilla. Once the entire muscle has been freed, the only remaining attachments are its humeral insertion and the neurovascular bundle. The muscle origin is taken to the distal aspect of the arm and sutured to the biceps tendon and the radial tuberosity. The insertion is released and sutured to the conjoined tendon origin on the coracoid process or the anterior aspect of the acromion (Fig. 14). The wounds are closed, and the arm is splinted with the elbow flexed to 90 degrees. The splint is worn full-time for the first three months, except when range-of-motion exercises are performed, and it is worn only at night for another three months. Active flexion and extension are begun at six weeks (Figs. 15 and 16), but passive extension is avoided for three months.

View larger version (69K): [in this window] [in a new window]   Figs. 14, 15, and 16: Bipolar latissimus dorsi flexorplasty as described by Hovnanian17. Fig. 14: Drawing illustrating how the spinous origin of the latissimus dorsi muscle is rolled into a tube and tunneled subcutaneously to the biceps tendon insertion. The humeral insertion of the latissimus dorsi tendon is taken down and reattached, as is done with a transfer of the pectoralis major muscle, either to the conjoined tendon origin on the coracoid process or to the anterior aspect of the acromion.

View larger version (102K): [in this window] [in a new window]   Fig. 15 Photographs showing elbow flexion (Fig. 15) and extension (Fig. 16) after bipolar latissimus dorsi flexorplasty.

View larger version (89K): [in this window] [in a new window]   Fig. 16 Photographs showing elbow flexion (Fig. 15) and extension (Fig. 16) after bipolar latissimus dorsi flexorplasty.

Free Microneurovascular Transfer of the Gracilis Muscle¹⁹
A free microneurovascular muscle transfer may be performed^5,6 in a limited number of patients. The most commonly selected donor muscle is the gracilis. This procedure is indicated when no functional muscles are available for transfer in a child who has a good passive range of elbow motion and no or very weak active elbow flexion.

Technique: A medial thigh incision is made, extending longitudinally from a point two centimeters distal to the pubic tubercle to a point ten centimeters proximal to the adductor tubercle of the femur. Dissection is carried down to the longitudinal fibers of the gracilis muscle. Several vascular pedicles enter the muscle, but the dominant pedicle, comprising branches from the medial femoral circumflex artery and vein, along with the motor branch to the gracilis from the anterior division of the obturator nerve, can be found on the undersurface of the muscle, approximately one-quarter of the distance from the pubis to the adductor tubercle. The tendon of insertion is sectioned from the femur. Lesser vascular pedicles are ligated as the muscle is elevated from distal to proximal. The dominant neurovascular pedicle is then ligated and transected as close to the exit of the nerve and vessels from their main trunks as can be safely performed. The proximal part of the tendon is divided, and the muscle is taken from the donor site to the affected arm. An anterior axillary incision is made, and dissection is carried out to the level of the insertion of the pectoralis major tendon on the humerus. The tendon of origin of the free gracilis muscle is passed deep to the pectoralis major tendon and fixed to the coracoid process with interosseous wiring or is attached to the conjoined tendon with nonabsorbable suture. Additional attachments to surrounding fascia, the clavicle, or the second rib are performed as necessary with suture fixation. A second incision is made over the anterior aspect of the proximal part of the forearm, and the biceps tendon insertion is identified. The distal end of the free gracilis muscle transfer is tunneled subcutaneously down the anterior aspect of the arm and woven into the biceps tendon insertion with the elbow flexed to 110 degrees. An anterior incision is next made on the chest in line with the fourth rib, and the intercostal nerves beneath the third, fourth, and fifth ribs are identified. The nerves are sectioned anteriorly and taken posterior to the midaxial line, where the intercostal nerves of the fourth and fifth thoracic nerve roots are sutured into the motor nerve to the gracilis, and the intercostal nerve of the third thoracic nerve root is implanted directly into the muscle in neurotization fashion. Arterial anastomosis is made with use of the lateral thoracic, thoracodorsal, or thoracoacromial artery. Venous outflow is through the thoracoacromial or cephalic vein. Postoperative vascular assessment is critical to the successful application of this transfer as ischemia or decreased outflow may require re-exploration of the microvascular anastomoses. Postoperative rehabilitation requires a reinnervation time of six months to one year for maximum functional return.

Bipolar Latissimus Dorsi Tricepsplasty
Function of the triceps muscle may be restored in selected patients with transfer of the latissimus dorsi muscle (Fig. 17) as described by Hovnanian¹⁷ and previously in this paper. Gravity provides adequate extension for patients who have unilateral brachial plexus palsy. Involvement of the lower extremity or bilateral involvement of the upper extremity may require forceful extension for walking with crutches or for weight transfer.

View larger version (110K): [in this window] [in a new window]   Fig. 17 Drawing illustrating bipolar latissimus dorsi tricepsplasty as described by Hovnanian17. The spinous origin of the muscle is tunneled subcutaneously down the posterior aspect of the arm and reattached into either the triceps tendon or the olecranon. The tendinous insertion is taken off the humerus and reattached to the posterior aspect of the acromion.

	Deformity of the Elbow

Top Introduction Biomechanics of Shoulder... Muscle Contracture Tendon Transfers About the... Arthrodesis Tendon Transfers About the... Deformity of the Elbow Overview References

 
As first summarized by Aitken¹, a series of changes in the proximal parts of the radius and ulna is frequently seen in patients who have obstetrical brachial plexus palsy. These changes tend to occur in patients who have some, although incomplete, recovery. The commonly observed sequence begins with increased curvature of the ulna and slight backward displacement of the proximal part of the radius. The radial epiphysis becomes obliquely oriented with respect to the shaft. Left untreated, complete posterior dislocation of the radius occurs, a conical deformity of the radial head develops, and the head articulates with an abnormally flattened capitellum. Aitken suggested that the changes in the ulna are due to the uneven pull of the triceps muscle against the nonfunctional biceps and brachialis muscles, complicated by splinting of the elbow in flexion for too long a period of time. The radial dislocation may be related to splinting in supination against the pull of the pronator teres and a contracted interosseous membrane. In his series, Aitken reduced elbow flexion to 45 degrees at the first sign of such changes, and he weaned patients from splinting if and when biceps and brachialis function returned.

Other authors^20,30 have described the common occurrence of flexion contractures at the elbow in brachial plexus palsy. This can occur with overactivity of the biceps and brachialis. Medial and lateral instability can occur as well, necessitating augmentation or reefing of soft tissues. Incompetence of the annular ligament may necessitate reconstruction with a triceps tendon slip or fascia lata graft²⁴.

	Overview

Top Introduction Biomechanics of Shoulder... Muscle Contracture Tendon Transfers About the... Arthrodesis Tendon Transfers About the... Deformity of the Elbow Overview References

 
Obstetrical brachial plexus palsy remains a challenging clinical problem, with few data regarding the outcomes of the wide variety of operative procedures that have been described. Until recently, there have been no controlled clinical studies (of which we are aware) comparing different techniques, and surgeons have had to rely on reports summarizing results of individual procedures as compared with the natural history of the deformity. Rigorous and reproducible standardized outcomes measures are lacking, in part because of the wide variability in the severity of involvement of affected individuals, and this lack has made comparison difficult as well. The recent heightened interest in outcomes assessment appears to be leading to more work in this area, which will be crucial to the optimization of the care of patients who have this complicated disorder.

	Footnotes

 
*Printed with permission of the American Academy of Orthopaedic Surgeons. This article will appear in Instructional Course Lectures, Volume 49, American Academy of Orthopaedic Surgeons, Rosemont, Illinois, March 2000.

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

Texas Orthopaedic Hospital, 7401 South Main Street, Houston, Texas 77030. E-mail address for Dr. Bennett: bennett@fondren.com.

Department of Orthopaedics, University of Washington School of Medicine, Seattle, Washington 98195.

	References

Top Introduction Biomechanics of Shoulder... Muscle Contracture Tendon Transfers About the... Arthrodesis Tendon Transfers About the... Deformity of the Elbow Overview References

 

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