Restoration Of Shoulder External Rotation Research Articles

Lower trapezius transfer to infraspinatus in cases of sequelae of obstetric brachial plexus injury

BackgroundDeficient shoulder function is a common and exhausting issue in children with obstetric brachial plexus injuries. Even with functioning elbow, wrist, and fingers, upper limb function is markedly disabled by limited shoulder abduction external rotation. Lower trapezius transfer carries many advantages; simple and safe technique, same line of pull as donor; reliable nerve supply (extraplexal from spinal accessory nerve), and not acting on rotation of the shoulder, mostly it will not adversely affect internal rotation range after the transfer. This study aims to evaluate the role of isolated lower trapezius transfer in reconstructing shoulder external rotation.Materials and methodsThis prospective case series study included 20 patients with sequelae of obstetric brachial plexus injury lacking shoulder external rotation who underwent lower trapezius transfer to infraspinatus. In all cases, the lower trapezius muscle was the donor, and the recipient tendon was the Infraspinatus muscle. Shoulder range of motion, Modified Gilbert grading, and Mallet Classification were used to evaluate results.ResultsThe mean age at the time of surgery was 4.5 years. The average increase in shoulder external rotation and abduction was 40⁰ and 42.5⁰ respectively, the modified Gilbert grading improved from a mean of 3.85 to 4.85 postoperative. Mallet classification improved from a mean of 3.5 preoperative to 4.8 postoperative. Improvement (Mallet classification of ≥ 4) was obtained in 18 cases (90%).ConclusionIsolated lower trapezius transfer is considered an effective option with promising results in cases of sequelae of obstetric brachial plexus injury for restoration of shoulder external rotation as well as abduction.

Change in shoulder external rotation strength and motion after lower trapezius transfer to the infraspinatus in children with obstetric brachial plexus palsy.

Quantifying changes in shoulder external rotation range of motion and strength after lower trapezius transfer in children with obstetric brachial plexus palsy (OBPP). This prospective study included five children with sequelae of OBPP, with a mean age of 6.4 years (range: 4-12 years) who underwent lower trapezius tendon transfer to restore active external rotation (ER) of the shoulder. Pre-operatively and at a 12-month follow-up assessment, we analyzed the passive and active shoulder ER, the modified Mallet score, and the shoulder rotator muscles strength using an isokinetic device. Clinical parameters improved significantly after trapezius transfer pre-operative passive ER from -8° (range: -20-0°) to 37° (range: 15-50°) (p = 0.035), the modified Mallet score from 13 (range: 10-15) to 18 (range: 17-19) (p = 0.035). Strength testing revealed improved ER muscle strength in all five cases; the mean Peak Torque increased from 1.95 to 4.46 N·m, albeit non-significantly (p = 0.062). Two patients exhibited a winged scapula post-operatively. Lower trapezius transfer seems encouraging to restore shoulder external rotation in OBPP children but with non-significant strength improvement. 18/07/31/5783, December 22, 2018.

Surgical procedure to restore shoulder external rotation in post-traumatic brachial plexus lesions in adults

The lack of active external rotation following a brachial plexus injury in adults is very disabling and very challenging to solve. If direct nerve surgery or nerve transfer fails or if the patient is seen too late, palliative surgery is the last resort. Shoulder fusion can stabilize the joint to increase strength at the elbow, but the patient loses all external rotation. A metaphyseal humeral osteotomy shifts the sector of mobility to push out the arm from the chest but does not restore any active external rotation. Latissimus dorsi and teres major transfers are not indicated in traumatic brachial plexus injuries. Lower trapezius (inferior fibers of the trapezius) transfer detached from the medial angle of the scapula and fixed to the infraspinatus tendon is the main option in paralyzed shoulders. It can restore 90° external rotation on average. This tendon transfer is an agonist, with the same direction but with less excursion and strength. If this muscle is paralyzed (nerve lesion), one can harvest and transfer the contralateral lower trapezius instead. The goals of this paper are to describe the surgical technique for these two tendons transfer, their indications and results.

Transfer of the rhomboid nerve for restoration of shoulder external rotation in partial brachial plexus palsy

Restoration of shoulder external rotation in partial brachial plexus palsies is a real challenge. The transfer of the spinal accessory nerve to the suprascapular nerve remains the gold standard. This transfer, however, cannot be always performed. Therefore, in these cases, we previously proposed the transfer of the rhomboid nerve to the suprascapular nerve through a posterior approach. The goal of the present study is to assess this technique through a short series.Eight male patients had a partial plexus palsy. Five patients had C5, C6 root injuries, two patients had C5, C6, C7 root injuries, and one patient had C5 to C8 root injuries. No patients had C5 or C6 root avulsions. In one patient, the spinal accessory nerve was injured and in seven patients, the proximal suprascapular nerve was not available. All patients underwent a transfer from the rhomboid nerve to the suprascapular nerve. Concerning shoulder elevation, transfers from the branch of the long head of the triceps or ulnar nerve fascicle were transferred to the axillary nerve. For elbow flexion, fascicles from the ulnar nerve, median nerve, or both were used. For elbow extension, three intercostal nerves in one patient and one fascicle from the ulnar nerve in two patients were transferred to the branch of the long head of the triceps. For wrist and finger extension, palliative surgery was proposed.All patients recovered external shoulder rotation (from 70–110º) and shoulder elevation (range, 80–140º). Active elbow flexion was coded M4 in seven patients and M3 in one patient. All patients recovered active elbow extension.The transfer of the rhomboid nerve to the suprascapular nerve is an efficient procedure for shoulder external rotation in partial brachial plexus palsies without C5 root avulsion. The results in terms of range-of-motion are, however, poorer than with the spinal accessory nerve. Therefore, this technique is appropriate if the spinal accessory nerve is injured or if the suprascapular nerve is not available in the cervical area. This technique must be associated with another transfer to the axillary nerve for shoulder elevation. The study of more patients will be necessary to confirm these results.

Kinematic profiles during activities of daily living in adults with traumatic brachial plexus injuries

BackgroundInjuries to the brachial plexus leave individuals with lasting effects in upper extremity motor function, even with successful surgical restoration of elbow flexion. Quantitatively describing independent patient function during activities of daily living utilizing motion analysis could aid in prioritization of secondary surgical targets, as well as serve as an outcome measure. This study explored the upper extremity kinematic profiles during activities of daily living in adults with brachial plexus injury. MethodsEight adult participants (4 subjects with brachial plexus injury, 4 healthy controls) completed activities of daily living during one motion capture setting. Trunk, shoulder, and elbow joint minima, maxima, and range of motion were calculated and compared between groups. Kinematic profiles over a motion cycle were compared between groups using statistical parametric mapping. FindingsSubjects with brachial plexus injuries had significantly greater trunk range of motion during feeding and dressing tasks compared to control subjects. This compensatory trunk motion was accompanied by limited shoulder external rotation demonstrated using conventional descriptors and statistical parametric mapping. InterpretationSignificant compensatory trunk motion is required to complete select activities of daily living in subjects with brachial plexus injury. Additionally, restoration of shoulder external rotation would be a beneficial secondary target of surgical restoration of motor function. These aspects should be considered in treatment planning, as they could impact patient outcomes. Combining conventional descriptors of patient motion (e.g. joint minima, maxima, and range of motion) with statistical parametric mapping can provide a rich description of patient compensations and limitations.

Restoration of shoulder external rotation by means of the infraspinatus muscle reinnervation with a radial nerve branch transfer

Background: Although reinnervation of the suprascapular nerve is frequently obtained through brachial plexus surgery, reestablishment of infraspinatus muscle function is rarely achieved.Methods: The viability of transfer of the radial nerve to the nerve branch to the infraspinatus muscle was determined anatomically, including histomorphometrical analysis on 30 adult cadavers. Eleven adult patients were then treated using the proposed nerve transfer.Results: The branch to the medial head was more suitable for the nerve transfer. In one cadaver, nerve transfer was impossible because there was no donor of sufficient length. According to axon counts, the branches to the lateral and medial heads had sufficient numbers of axons (means = 994.2 ± 447.6 and 1030.8 ± 258.5, respectively) for reinnervation of the branch to the infraspinatus (means = 830.2 ± 241.2 axons). In the surgical series, one patient was lost in the follow-up and only two patients achieved a good result from the transfer. Recovery of external shoulder rotation started 14 months after surgery in one patient and 8 months in the other. The first patient reached 90° of external rotation 6 months later and the second, achieved 120°of shoulder external rotation 6 months after surgery . Four other patients recovered small amounts of movement: 20, 35, 40 and 45°.Conclusions: Although anatomically feasible, the proposed nerve transfer resulted in a small number of good clinical outcomes.

Long-term results of latissimus dorsi transfer for internal rotation contracture of the shoulder in patients with obstetric brachial plexus injury

BackgroundThis study evaluated the long-term outcome of patients with obstetric brachial plexus injury who underwent transfer of the latissimus/teres major tendon to restore shoulder external rotation and determined whether loss of internal rotation would affect their quality of life.MethodsAll patients with a history of obstetric brachial plexus injury who underwent latissimus dorsi transfer for internal rotation contracture were included. Results from 3 clinic visits (preoperative, and short-term and long-term postoperatively) were recorded. Quality of life was evaluated with a questionnaire. Internal rotation impairment was evaluated using the Activities of Daily Living which require active Internal Rotation scoring system.ResultsThe study included 45 patients. At a mean 5 months postoperatively, shoulder motion was significantly improved in abduction and external rotation. This was associated with a significant loss of active internal rotation. These results deteriorated over time (at a mean 7.64 years postoperatively), especially in internal rotation (from being able to reach the sacrum to only being able to reach the trochanter) and in external rotation with the arm abducted. This decrease in function led 10 patients (22%) to undergo revision surgery. The mean score on the activities of daily living which require active internal rotation (ADLIR) at the last follow-up was 53.ConclusionAlthough the short-tem results of latissimus dorsi transfer and subscapularis release are encouraging, these gains deteriorated over a longitudinal follow-up period. Abduction is maintained over the long-term, but external rotation deteriorates. Internal rotation deteriorated over a long-term longitudinal follow-up, leading to functional impairment.

Traumatic Suprascapular Nerve Injury at the Notch-A Reason for the Posterior Approach in Brachial Plexus Reconstruction.

Background Optimal dynamic reconstruction of shoulder function requires a functional suprascapular nerve (SSN). Nerve transfer of the distal spinal accessory nerve (dSAN) to the SSN will in many cases restore very good supraspinatus and infraspinatus function. One potential cause of failure of this nerve transfer is an unrecognized more distal injury of the SSN. An anterior approach to this transfer does not allow for visualization of the nerve at the scapular notch which is a disadvantage when compared with a posterior approach to the SSN. Methods All patients of the senior author (S.F.) with traumatic brachial plexus injuries undergoing spinal accessory nerve to SSN transfer via the posterior approach were analyzed. Results Of the 58 patients, 11 (19.0%) demonstrated abnormal findings at the notch. In two of these 11 patients (18.2%), reconstruction was abandoned due to severe injury of the nerve. There was a higher rate of clavicular fractures in patients with SSN injuries at the notch, compared with no SSN injury at the notch (63.6 vs. 12.8%). Conclusion The dSAN to SSN transfer is a reliable reconstruction for restoration of shoulder external rotation and abduction. There is a high proportion of injuries to the nerve at the notch, which can be best appreciated from a posterior approach. The authors, therefore, advocate a posterior approach for this nerve transfer.

Contralateral Trapezius Transfer to Restore Shoulder External Rotation Following Adult Brachial Plexus Injury

To evaluate the outcome of contralateral lower trapezius origin transfer (CLTOT) to restore shoulder external rotation in patients with shoulder paralysis after brachial plexus injury (BPI). We evaluated 12 patients with a history of BPI with persistent shoulder paralysis. All patients had compromised ipsilateral lower trapezius muscle function. All patients underwent CLTOT prolonged with lumbar fascia to the affected infraspinatus tendon either isolated (7patients) or as part of multiple tendon transfer (5 patients). Standardized patient outcomes measures were obtained. At 23 months' follow-up, 10 patients had improved shoulder external rotation from no motion preoperatively to an average external rotation 110° from the abdomen. Five patients had marked improvement of pain, including 2 with isolated CLTOT and 3 with additional tendon transfers. Two patients experienced no change in pain. There were noted improvements in the Constant shoulder scores, simple shoulder value, and Disabilities of the Arm, Shoulder, and Hand scores. One patient sustained a fall resulting in stretch injury to the transfer, underwent successful revision surgery, and regained 100° active shoulder external rotation away from the abdomen more than a year after revision surgery. Another patient's transfer failed during rehabilitation but the patient elected not to pursue treatment. No patients had changes in contralateral shoulder motion or strength or any pain from the contralateral shoulder. This study demonstrated that CLTOT to the infraspinatus tendon was effective in improving shoulder external rotation in patients with BPI. Therapeutic IV.

External Rotation Osteotomy of the Humerus to Salvage the Failed Latissimus Dorsi Transfer in Children With Erb Birth Palsy and Supple Congruent Shoulders.

Management of the failed latissimus dorsi muscle transfer to restore shoulder external rotation has received little attention in the literature. We report on 6 children with Erb birth palsy and supple congruent shoulders and who underwent external rotation osteotomy to salvage a failed latissimus dorsi transfer. It is standard of care to do humerus osteotomies only to children with significant deformities of the glenohumeral joint. In the current article, the osteotomy was performed despite the presence of supple congruent shoulders because the osteotomy seemed the best and simplest option available. The functional outcome was satisfactory; with all patients reaching the occiput easily. Furthermore, there were improvement of the standing posture and improvement of the elbow flexion contracture. We conclude that the osteotomy procedure is a simple and effective option of management after a failed latissimus dorsi transfer.

Contralateral lower trapezius transfer for restoration of shoulder external rotation in traumatic brachial plexus palsy: a preliminary report and literature review

The importance of external rotation of the shoulder is well accepted. Patients with inadequate recovery of shoulder function after nerve transfers for a brachial plexus injury have difficulty in using their reconstructed limb. The options for secondary procedures to improve shoulder function are often limited, especially if the spinal accessory nerve has been used earlier for nerve transfer or as a donor nerve for a free functioning muscle transfer. We have used the contralateral lower trapezius transfer to the infraspinatus in three cases, to restore shoulder external rotation. All patients had significant improvement in shoulder external rotation (mean 97°; range 80°-110°) and improved disability of the arm, shoulder and hand scores. The rotation occurred mainly at the glenohumeral joint, and was independent of the donor side. All patients were greatly satisfied with the outcome. Contralateral lower trapezius transfer appears to help in overall improvement of shoulder function by stabilizing the scapula. The results have remained stable after mean follow-up of 58 months (range 12-86). No donor site deficit was seen in any patient.

Isolated latissimus dorsi transfer to restore shoulder external rotation in adults with brachial plexus injury

In adults with brachial plexus injuries, lack of active external rotation at the shoulder is one of the most common residual deficits, significantly compromising upper limb function. There is a paucity of evidence to address this complex issue. We present our experience of isolated latissimus dorsi (LD) muscle transfer to achieve active external rotation. This is a retrospective review of 24 adult post-traumatic plexopathy patients who underwent isolated latissimus dorsi muscle transfer to restore external rotation of the shoulder between 1997 and 2010. All patients were male with a mean age of 34 years (21 to 57). All the patients underwent isolated LD muscle transfer using a standard technique to correct external rotational deficit. Outcome was assessed for improvement in active external rotation, arc of movement, muscle strength and return to work. The mean improvement in active external rotation from neutral was 24° (10° to 50°). The mean increase in arc of rotation was 52° (38° to 55°). Mean power of the external rotators was 3.5 Medical Research Council (MRC) grades (2 to 5). A total of 21 patients (88%) were back in work by the time of last follow up. Of these, 13 had returned to their pre-injury occupation. Isolated latissimus dorsi muscle transfer provides a simple and reliable method of restoring useful active external rotation in adults with brachial plexus injuries with internal rotational deformity.

The Importance of Shoulder External Rotation in Activities of Daily Living: Improving Outcomes in Traumatic Brachial Plexus Palsy

To define the importance of shoulder external rotation in activities of daily living in normal individuals to better understand how restoration of shoulder external rotation in traumatic brachial plexus palsy could improve patient function. Thirty-one normal individuals performed 12 common activities of daily living (ADLs) wearing a custom shoulder orthosis designed to selectively limit shoulder external rotation to 3 different settings, ranging from 0° (most restrictive) to 90° (least restrictive) of external rotation. Outcomes were measured with a visual analog scale of perceived difficulty in accomplishing the ADLs with each orthosis setting and the Disabilities of the Arm, Shoulder, and Hand questionnaire administered after each set of 12 ADLs was completed. Subjects perceived increasing difficulty during all ADLs tested and registered higher disability scores with increasing restriction of shoulder external rotation. The ADLs requiring motions predominantly above the waist exhibited more marked and earlier changes in visual analog scale scores with increasing shoulder external rotation restriction. Traditionally, surgeons have pursued restoration of shoulder abduction and forward elevation in secondary reconstruction of traumatic brachial plexus injuries. Recently, the concept of preferentially restoring shoulder external rotation has been proposed, without clear evidence in the literature of the role of shoulder external rotation in ADLs. Our results support the notion that restoring shoulder external rotation in the treatment of traumatic brachial plexus palsy patients might improve outcomes by decreasing patient disability and increasing the ability to perform ADLs.

Biomechanical effectiveness of different types of tendon transfers to the shoulder for external rotation

Our purpose was to determine and compare the external rotation moment arm (ERMA) of the latissimus dorsi (LD), teres major (TM), and lower trapezius (LT) when transferred to selected locations on the proximal humerus. We hypothesize that the LT transfer has a higher ERMA compared with LD or TM. Six fresh frozen cadaveric hemithoraces were used in a novel experimental design. The tendon and joint displacement method was used to calculate ERMA for 6 transfer pairs: LD to superolateral humeral head (SHH), LD to proximal-lateral humeral diaphysis (LHD), TM to SHH, TM to LHD, LT to infraspinatus insertion (ISI), and LT to teres minor insertion (TMI). Tendon transfer pair had a significant effect on ERMA (P<.001), with a significant interaction effect between tendon transfer and position of the humerus (P<.0001). With the humerus at 0° abduction, the ERMAs of the LT-ISI (28.1 mm) or LT-TMI (22.3 mm) transfers were significantly higher than the ERMAs of LD-SHH (10.6 mm; P=.0001, P=.04) or LD-LHD (6.5 mm; P<.0001, P<.001). Also, ERMAs of LT-ISI and LT-TMI transfers were significantly higher than ERMA of TM-LHD (10.4 mm; P=.0001, P=.03). Shoulder external rotation tendon transfers differ in effectiveness and may be affected by arm position. LT potentially results in superior restoration of shoulder external rotation with the arm at the side compared with LD and should be considered as a potential tendon transfer to restore external rotation in selected patients.

Feasibility of contralateral trapezius transfer to restore shoulder external rotation: part I

We evaluated the feasibility of contralateral trapezius transfer to restore shoulder external rotation. The length of the lower trapezius and distance necessary for contralateral trapezius transfer were measured in 20 volunteers and directly in 12 cadavers. The average distances between the medial spine of the scapula and T12 (length of lower trapezius) and the spine to the greater tuberosity (distance for transfer) were measured with the scapula neutral, maximally protracted, and maximally retracted. In cadavers, the origin of the lower trapezius was detached, transferred to the contralateral greater tuberosity, and retracted to determine its effectiveness in external rotation and tension on the vascular pedicle. In volunteers, the average difference between the length of the lower trapezius and the transfer distance was 19 mm in neutral. When the scapula was protracted and retracted, the difference was 79 and -49 mm. In the cadavers, the average transfer distance (in mm) was 290 ± 12, 365 ± 15, and 209± 25 in the neutral, protracted, and retracted positions, respectively. The average length of the lower trapezius (in mm) was 270 ± 10, 285 ± 12, and 258 ± 10 in the neutral, protracted, and retracted positions. The transfer was universally feasible when the scapula was partially retracted. Prolongation of the lower trapezius with lumbar fascia made the transfer possible in all scapular positions. Pulling on the transferred muscle resulted in contralateral shoulder external rotation without tension or impingement on the neurovascular pedicle. Contralateral trapezius transfer to the infraspinatus insertion appears feasible and potentially effective in restoration of shoulder external rotation.

Our Experience with Secondary Reconstruction of External Rotation in Obstetrical Brachial Plexus Palsy

Restoration of shoulder external rotation is very important for upper extremity function. The purpose of this study was to present the authors' experience with secondary restoration of external rotation in patients with obstetrical brachial plexus palsy. From 1978 to 2002, 46 children underwent secondary surgery for restoration of external rotation. Outcomes were analyzed in relation to various factors, including the type of procedure, muscle transfer only versus nerve reconstruction and muscle transfer, denervation time, type of injury (Erb versus global palsy), and severity score. In addition, the effect of restoration of external rotation on the final outcome of shoulder abduction was assessed. There was significant improvement in every case (p < 0.01) between preoperatively and postoperatively. The overall mean postoperative Mallet score for the group undergoing muscle transfer only was 3.95, whereas in the nerve reconstruction and muscle transfer group, the score was 3.88 (p >0.05). The resulting gain in external rotation was 99 degrees versus 93.8 degrees. In both populations, a very significant improvement (p <0.0001) was identified in the final outcome of shoulder abduction (109 degrees after muscle transfer versus 48.3 degrees before muscle transfer, and 112 degrees postoperatively after neurotization and muscle transfer versus 43.8 degrees before any surgery). Patients with Erb palsy had a better but not significant result (p >0.05; p = 0.94), compared with those with global palsy in both Mallet score (3.77 versus 3.76) and final active external rotation (81.7 degrees versus 77.6 degrees). Secondary surgery for the restoration of external rotation is a rewarding procedure, which also significantly improves the final outcome of shoulder abduction.

54: PSEF 2006 Scientific Essay Contest Senior Award ??? Clinical Research, Integra Foundation: Restoration of Shoulder External Rotation in OBPP by Rerouting of Latissimus Dorsi and Teres Major

54: PSEF 2006 Scientific Essay Contest Senior Award ??? Clinical Research, Integra Foundation: Restoration of Shoulder External Rotation in OBPP by Rerouting of Latissimus Dorsi and Teres Major