Abstract
Shoulder arthrodesis and upper trapezius transfer are two surgical options for secondary shoulder reconstruction for traumatic brachial plexus injury (BPI). There is a lack of comparative evidence to guide the choice for one procedure over the other. The objectives of this study were to compare (1) rates of complications and reoperation and (2) shoulder range of motion and functional outcome scores following shoulder arthrodesis versus upper trapezius transfer for traumatic BPI. A systematic review and meta-analysis were conducted by a search of four databases of studies assessing shoulder arthrodesis and/or upper trapezius transfer for shoulder reconstruction following adult traumatic BPI. A proportional meta-analysis was performed using a random effects model in anticipation of unobserved heterogeneity. The final meta-analysis included 374 patients from 17 studies, including 232 patients from 11 studies on shoulder arthrodesis and 142 patients from 6 studies on upper trapezius transfer. Shoulder arthrodesis had higher rates of complications and reoperations than upper trapezius transfer for traumatic BPI, but these differences did not reach a statistical significance. Due to the limited sample size, variations in reporting, and study heterogeneity in the published literature, we were not able to draw conclusions regarding shoulder range of motion and functional outcome scores between these two procedures. Shoulder arthrodesis and upper trapezius transfer are both viable options for secondary shoulder reconstruction for traumatic BPI, but with different complications and reoperation profiles. Patients should be counseled on the risk of nonunion and humerus fracture following shoulder arthrodesis.
Highlights
Adult traumatic brachial plexus injuries (BPI) are uncommon but devastating injuries to the upper extremity [1]. e primary reconstruction of traumatic BPI generally consists of nerve grafting, nerve transfer, or tendon transfer
Sixty-seven complications occurred in 232 shoulder arthrodesis procedures (29%), and 22 complications occurred in 142 upper trapezius transfer procedures (15%) (Table 3). e overall weighted prevalence of complication was 0.22. e weighted prevalence of complications in the shoulder arthrodesis group was 0.29. e weighted prevalence of complications in the upper trapezius transfer group was 0.10. e difference in the complication rate between the two procedures was not statistically significant (Figure 2)
Forty-five reoperations (12%) were performed in this meta-analysis. irty-seven reoperations were performed in the shoulder arthrodesis group (16%), and 8 reoperations were performed in the upper trapezius transfer group (6%) (Table 4). e overall weighted prevalence of reoperation was 0.11. e weighted prevalence of reoperations in the shoulder arthrodesis group was 0.15. e weighted prevalence of reoperations in the upper trapezius transfer group was 0.05. e difference in the complication rate between the two procedures was not statistically significant (Figure 3)
Summary
Adult traumatic brachial plexus injuries (BPI) are uncommon but devastating injuries to the upper extremity [1]. e primary reconstruction of traumatic BPI generally consists of nerve grafting, nerve transfer, or tendon transfer. Lack of shoulder function is a common problem after traumatic BPI due to paralysis of the deltoid, supraspinatus, and infraspinatus. Such a flail shoulder can arise due to the severity of the initial injury, failure of spontaneous recovery, paucity of viable donor nerves for primary nerve reconstruction, or failure of primary nerve reconstruction [2]. Secondary reconstruction options for the flail shoulder in the setting of traumatic BPI include shoulder arthrodesis [3] and upper trapezius transfer [2, 4]. E prerequisites for upper trapezius transfer include at least M4 strength in the trapezius muscle, passive glenohumeral joint motion to at least 80°, and no advanced degeneration of the glenohumeral joint [5,6,7,8] Intact motor function in the periscapular muscles, including the trapezius, levator scapulae, serratus anterior, and rhomboids, is preferred for an optimal functional result after shoulder arthrodesis, but not required [3]. e prerequisites for upper trapezius transfer include at least M4 strength in the trapezius muscle, passive glenohumeral joint motion to at least 80°, and no advanced degeneration of the glenohumeral joint [5,6,7,8]
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