Tendon Transfer for Brachial Palsy

8/9/2019 Tendon Transfer for Brachial Palsy

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Tendon Transfers About the Shoulder andElbow in Obstetrical B rachial Plexus Palsy*†

BY JAMES B . BE NNETT, M.D.‡, HOU STON, TEXAS, AND CHR ISTOPH ER H. ALLAN, M.D.§, SEATTLE, WASHINGTON

A n I nstructional C ourse L ecture, A merican A cademy of O rthopaedic Surgeons

Obstetrical or birth palsy of the brachial plexus oc-curs in as many as one in 250 births 30,32 . Predisposingfactors include high birth weight, prolonged labor,breech presentation, and shoulder dystocia. The actuallesion is produced by tra ction on the neura l elements —for example, stretching of the brachial plexus withforced lateral flexion of the head and neck. Most ofthese injuries resolve without operative intervention.For patients who a re more severely af fected, however, avariety of procedures are a vailab le (Tab le I). The trea t-ment a lgorithm to maximize each child’s long-term func-tiona l recovery is continuously evolving (Tab le II ).

In the earliest phase of treatment, exploration, neu-rolysis, and operative repair or reconstruction of theinjured brachial plexus may be undertaken. The deci-sion to intervene with an operation depends on thetime that has elapsed since the injury, the recovery offunction to that point, and the surgeon’s personal phi-losophy regarding the likelihood of additional gainswith nonoperative treatment. Most surgeons performsuch procedures, when appropriate, in infants betweenthree and nine months of age 8,35. Joint mobilization andrange-of-motion exercises performed by the parentsand guided by a physical or occupational t herapist canhelp to maintain a congruent glenohumeral joint andto minimize contractures.

Patients with incomplete recovery who are seenmore tha n six months after birt h freq uently have muscle

contra ctures due to unopposed muscle forces and are nolonger cand idat es for direct repa ir of the plexus. Thesechildren can often benefit from releases of the contrac-

tures to maintain a congruent joint and to maximize therange of motion. Releases are usually performed be-tween the ages of twelve and twenty-four months, butthey ma y be useful in older pat ients if the glenohumeraljoint is congruent.

Waters et al. made the point that glenohumeral de-formity occurs along a spectrum of severity, with lesssevere changes being potentially reversible with soft-tissue joint-relocation procedures, a situation that isana logous to t he joint-remodeling seen in children ma n-aged fo r congenital d ysplasia of the hip 33. The decisionas to whether to perform tendon transfers or osseousprocedures is therefore difficult when the deformity isnot clearly at one end of the spectrum or the other, andit is based on assessment of the congruence of the gle-nohumeral joint. Plain radiographs may be inadequatefor the evaluation of joint congruence in order to selecttreatment, since the glenoid is incompletely ossified atthe age when these decisions must be made. Pearl andEdgerton recently reported their experience with theintraoperative use of axillary glenohumeral arthrogra-phy to assist with selection of the appropriate operativeprocedure 25. Wat ers et a l. described t he preoperat ive useof computed tomography o r magnetic resonance imag-ing to better depict the glenohumeral deformity 33.

Tendon tra nsfers are generally performed betw eenthe ages of two and five years, although some authori-ties advoca te at tempts at soft -tissue joint rea lignment in

children as old as nine or ten years if the glenohumeraljoint is congruent 25. Wat ers and P eljovich recently com-pared the results of tendon transfers with those of hu-meral derotation osteotomies; the patients who weremana ged with soft-tissue procedures had a n avera ge ageof 4.9 ± 2.5 years at the time of the operation, whereasthose managed with osteotomies had an a verage age of8.4 ± 3.7 years34.

In addition to an assessment of joint congruence,muscle-grading is necessary before tendon transfer, toensure tha t the tra nsferred muscle will provide adeq uatepower. Adeq uate power requires a grade of a t least 4 of5, which corresponds to active movement a gainst gravity

*Printed with permission of the American Academy of Orthopae-dic Surgeons. This article will appear in I nstructional C our se L ectures,Volu me 49, A merican A cademy of O rthopaedic Surgeons, Rosemont,Illino is, March 2000.

†No benefits in any form ha ve been received or will be receivedfrom a commercial party related directly or indirectly to the subjectof this a rticle. No funds w ere received in support of this study.

‡Texas Ortho paedic H ospital, 7401 South Ma in Street, Ho uston,Texas 77030. E-mail add ress for D r. B ennett: bennett@fond ren.com.

§D epartment of Orthopaedics, U niversity of Washington Schoolof Med icine, Seatt le, Washingt on 98195.

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and some resistance but not normal power. Accuratemuscle-grading is not possible until optimum strengthhas been achieved, usually with the assistance of ther-apy, and t he child is old enough to comply w ith testing.

Osseous procedures are usually performed in pa-tients who are first seen when they are older than fiveyears of age since, as we noted, joint incongruity tendsto increase with the patient’s age. Appropriate proce-dures for severely incongruent joints include humeralrotational osteotomy for persistent internal rotationcontracture and glenohumeral arthrodesis in the settingof severe pain, instability, or arthritic changes. Whenposterior dislocation of the humeral head has occurred,posterior capsular plicat ion may be necessary to preventrecurrent posterior instability 31.

While each of these components of operative treat-ment ha s its role, the present discussion w ill be limitedto release of contractures and tendon transfers and

will specifically consider procedures that aim to restorefunction of the shoulder and elbow.

Biomechanics of Shoulder Stability

The longitudinal, proximal pull of the deltoid muscle(as well as the long head of the triceps, the pectoralisminor, and the coracobrachialis muscles) on the hu-merus is counteracted by the depressor force of therotator cuff muscles. The line of action of this force ismedial and slightly downward. The rotator cuff plays itsgreatest role as a stabilizer between 30 and 75 degreesof humeral elevation, with its role diminishing thereaf-ter until, at 120 degrees of elevation, it no longer con-

tributes to stability of the glenohumeral joint. In theabsence of an intact rota tor cuff, the inferior portion ofthe pectoralis major muscle, along with the latissimusdorsi muscle, may resist superior translation of the hu-meral head in the glenoid fossa.

The subscapularis muscle a lso functions to resist an-terior glenohumeral instability. The long head of thebiceps muscle assists in this. The subscapularis musclemay also prevent posterior translation through its ante-rior pull. Posterior stability is also provided by the in-fraspinatus muscle and the posterior aspect of thecapsule of the glenohumeral joint.

Inferior stability is provided by the posterior partof t he delto id muscle, the supraspinatus muscle, and thesuperior port ion of the glenohumera l joint capsule. Thepull of the serratus anterior muscle on the scapula tilts

TAB LE IO PTIONS FO R TENDON R ELEASE , TENDON OR MUSCLE TRANSFER , AND O SSEOUS PR O C E D U R E S B Y SITE

Lesion Procedure

Shoulder A dduction and internal rota tion contracture R elease or recession of subscapularis muscle Isolated abduction contracture R elease or recession of deltoid muscle

A bductio n a nd externa l ro ta tio n co ntracture Tra nsfer o f infra spina tus tendon to teres mino r tendon;release or recession of infraspinatus and supraspinatustendons with or w ithout release of deltoid muscle

D ysfunction of supraspinatus or infraspinatus muscle

Transfer of la tissimus dorsi tendo n to grea ter tubero sity

D ysfunction of anterior and middle parts of deltoid muscle (partial reinnervation of paralyzed deltoid muscle)

Anterior transfer of posterior part of deltoid muscle

D ysfunction of deltoid muscle Transfer of trapezius muscle with bone to la teral aspectof humerus; bipolar transfer of latissimus dorsi muscle

D ysfunction of subscapularis muscle Transfer of serra tus anterior muscle; transfer of pectoralismajor tendon

Combined deficits Variable (multiple tendon and muscle transfers asdescribed by O ber 23 and by Harmon 15; see text)

Internal or external rotation deformity with incongruent glenohumeral joint

Humeral derotation osteotomy

Severe d ysf unct io n o f sho ulder w ith pa in o r insta bility G l eno hum era l a rt hro desisElbow D ysfunction of biceps muscle U nipolar or bipolar transposition of pectoralis major

muscle; bipola r tra nsposition of la tissimus dorsi muscle;free microvascular transfer of gracilis rectus muscle;modified Steindler flexorplasty; anterior tra nsfer oftriceps tendon

D ysfunction of triceps muscle Transfer of latissimus dorsi muscle

TAB LE II

T IMING OF O PERATIVE PR O C E D U R E S IN PATIENTSWHO H AVE O BSTETRICA L BRACHIAL PLEXUS PALSY

Age Procedure(mos.)

3-9 E xploration and repairof bra chial plexus

12-24 R elease of contractures24-60* Tendon and muscle

transfers>60 (and

incongruent joint)Osseous procedures

*As long as the glenohumeral joint is congruent, tendon andmuscle transfers may be performed at a later date, but they shouldbe considered at these earlier times to maximize functional recovery.

T E N D O N T R A N S F E R S A B O U T T H E S H O U L D E R A N D E L B O W I N O B S T E T R I C A L B R A C H I A L P L E X U S PA L S Y 1613

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the glenoid from a more vertical to a more horizontalposition with humeral elevation; this provides an osse-ous shelf resisting inferior translation as well 9.

Muscle Contracture

The most commonly encountered birth palsy in-volves the fifth and sixth cervical nerve roots (713 [48percent] of 1486 patients in G ilbert’s series had suchinvolvement 13) or t he fifth, sixth, and seventh roots (431[29 percent] of 1486 pat ients in G ilbert ’s series), wit hdiminished or absent abduction and external rotationleading to an adduction and internal rotation contrac-ture. The chief difference betw een these tw o pa tterns ofinvolvement is the complete elbow extension due tointact t riceps function in the first pat tern. Other pa tterns

involve more caudad nerve roots (the eighth cervicaland first thoracic nerve roots) or whole-plexus injury.The more cauda d nerve-root injuries tend to a ffect func-tion of the hand and wrist and are not discussed here.

Release of the Subscapul ari s M uscle 2

Release or recession of the subscapularis muscle,probably first described by Sever in 1918 28, has with-stood the test of time and is still performed in variousmodified forms in patients who have an internal rota-tion contra cture of the shoulder (Fig. 1). The pectora lismajor muscle does not usually result in contra cture andtherefore does not require release.

Most often the entire origin of the subscapularismuscle is released from the anterior aspect of the scap-

Figs. 1 through 4: Release of the subscapularis muscle as described by C arlioz a nd B rahimi 2.Fig. 1: Photograph demonstrating a preoperative adduction contracture of the left shoulder with an internal rotation contracture of

approximately 20 degrees.

F IG . 1

D rawings illustrating the release of the subscapularis muscle described by C arlioz and B rahimi 2. The draw ing on the left shows the a pproachto t he left subscapularis muscle. The fibers of t he latissimus dorsi muscle are split and retracted t o the upper left and the low er right by twoseparate retra ctors. The upper-right retracto r stabilizes the lateral bor der of the scapula. Below the upper-left retractor is a periostea l elevatorelevating the subscapularis muscle off the anterior surface o f the scapula. The draw ing on the right shows the right subscapularis muscle beingelevated off the an terior surface of the scapula by an o steotome.

F IG . 2

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ula, as described by Ca rlioz and B rahimi2; this allow s thehumerus to be externally rotated and splinted in thisposition. An advantage to this method compared withearlier techniques that involved the release of the inser-tion of the subscapularis tendon is the avoidance ofant erior instability o f the shoulder. The deformity recursif the period of immobilization is inadequate. Our pro-tocol dictates that the splint be worn full-time for three

months and then at night for a n additional three months;the splint is applied with the humerus in external rota-tion and the shoulder in 30 to 45 degrees of abduction.The strength of the external rotator muscles may re-cover or transfers may be required to provide activeexternal rota tion.

Technique: The pat ient is placed in latera l decubituswith use of a beanbag or another type of support. Theaffected shoulder and torso are prepared to the mid-line anteriorly and posteriorly. A longitudina l incision ismade along the lateral border of the scapula, and dis-section is carried out down to the latissimus dorsi mus-cle, the fibers of which cover the lateral aspect of thescapula. This muscle is retracted inferiorly, and the infe-rior angle of the scapula is identified a nd stab ilized withtowel clips. The subscapularis muscle is readily identi-fied and is elevated in its entirety from the anteriorsurface of the scapula with use of electrocautery or aperiosteal elevat or (Fig. 2). D issection is performed in asubperiosteal fashion, progressing from the inferior an-gle upward. The scapula is manipulated as needed withuse of the towel clips. An external rotatory force on thehumerus is applied gently thro ughout the release to con-firm adeq uate release of the muscle and elimination ofthe contracture (Fig. 3). Care must be taken to avoidinjury of the subscapular artery and nerve running an-teromedial to t he glenoid neck and a nterior to the sub-scapularis muscle as well as injury of the suprascapularartery and nerve running from a nterior to posterior overthe scapular notch. After complete release of the sub-scapularis muscle, the wound is closed over a suctiondra in. A splint, made preopera tively, is applied to ma in-tain the arm in abduction and external rotation (Fig. 4).The pat ient w ears t he splint full-time fo r t hree months,removing it only to bathe and for gentle range-of-motion exercises, which are begun at six weeks. The

Intraoperative photograph showing recession of the subscapularis(held in the towel clip) off of the a nterior surface of the scapula.

Postoperative photograph made after release of the subscapularis muscle, demonstrating external rotation of approximately 45 degrees.(This is the same pa tient a s is show n in Fig. 1.)

F IG . 3

F IG . 4




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patient then wears the splint only at night for an addi-tional three months. At six months postoperatively,treatment with the splint is discontinued.

Tr ansfer of the Inf raspinatus Tendon to the Teres M ino r Tendon

In the less common situation involving a combinedexternal rotation and abduction contracture, it may benecessary t o release the supraspinat us and infra spinat ustendons, as described by Zancolli and Zancolli 35. Re-lease of the insertion of the deltoid muscle on the hu-merus may a lso be necessary. An a nterior dislocation o fthe humeral head is often a ssociated w ith this contrac-ture. The glenohumeral joint is reduced a fter division o fthe tendons of the external rotators, step-cut lengthen-ing of the infraspinatus tendon, and transfer of thattendon to the teres minor tendon. Anterior capsularplication may be necessary to tighten the lax anteriorglenohumeral ligaments. It should be noted that someauthors 35 think that this lesion occurs only as a compli-cation of excessive splinting in the so-called Statue ofLiberty position (marked abduction and external rota-tion), first described by Fairbank 12, rather than second-ary to birth injury.

Technique: A posterior approach to the shoulder isused, with a longitudinal skin incision ma de fro m supe-rior to inferior overlying the glenohumeral joint. Theposterior part of the deltoid muscle is identified andelevated, revealing the underlying contracted infraspi-natus and teres minor muscles. The tendon of the in-fraspinatus is divided several centimeters medial to itsinsertion on the greater tuberosity of the humeral head.The tendon of t he teres minor is divided at its insertionand then sutured to the infraspinatus tendon attach-ment, thereby lengthening the course of the teres minorby several centimeters. The infraspinatus muscle is now closed to the reattached teres minor. The combined ef-fect is to lengthen the externa l rota tor co mplex. The armis splinted in adduction and internal rotation; the pa-tient wears the splint full-time for three months andonly at night for an additional three months. Physicaltherapy for active and passive motion is performed withthe splint off beginning at six weeks. As an alternativeto the procedure just described, some authors have ad-

vocated recession or muscle slide of the supraspinatus,infraspinatus, and teres minor muscles, as described byD ebeyre et al. 11.

Tendon Transfers About the Shoulder

Principles

The principles of tendon t ransfer a re similar rega rd-less of location.

The involved joint must have a functional range ofmotion. Achievement of such motion most often re-quires the involvement of therapists working with thechild’s parents to maintain a supple joint before theoperation. The program can include dynamic splinting

and stretching to improve passive motion. In addition,as we already discussed, joint contractures must be re-leased and the joint must be congruent and reduced.Skin must be supple witho ut constricting scars.

In an already injured extremity, the surgeon mustensure 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 andpostoperat ive strengthening programs ar e routinely em-ployed. Most tra nsfers result in the loss of a pproximatelyone muscle grade, and this must be planned fo r. It is bestto a void transferring a tendon w hen the muscle of thattendon wa s previously para lyzed and ha s now recovered.

The excursion of the donor muscle-tendon unit mustbe adequate. In some patients, amplitude can be in-creased by the a ddition of a segment of fa scia lata or byregional fascial extension. For example, intercostal fas-cia can be used to lengthen a latissimus dorsi muscletransfer, or rectus sheath can be used with a pectoralismajor muscle transfer.

E ach tend on should perform only one function. Thetransfer should employ a straight line of pull.

When possible, synergism should be employed suchthat the simultaneous contractions of different mus-cles combine to a chieve a d esired function. To this end,manual or electrodiagnostic testing to check for in-phase firing of planned donors with nearby, uninvolvedmotors should be performed preoperatively, to ensurethat transferred motors and intact motors do not actas antagonists and prevent active motion. Reinnerva-tion patterns of the brachial plexus may also result inco-contraction of antagonistic muscle groups.

Biomechanics

Shoulder elevation is most efficiently performed inthe plane of the scapula. The glenohumeral joint hasits greatest stability and mobility (150 degrees) in thisposition. Tendon t ransfers to restore shoulder eleva tionshould therefore be done in the plane of the scapulawhen possible. Shoulder elevation involves both thesupraspinat us and the deltoid muscle. Bo th muscles areactive throughout the full range of elevation, althoughthe supraspinatus muscle is most efficient in t he first 45

degrees of this motion. The results of studies of thedeltoid muscle are divided as to whether its efficiency ismaximum at 90 degrees of elevation or a t full elevat ion 9.

The deltoid muscle behaves as if it were severalsmaller muscles pulling in slightly different directionsand contracting separately in a sequential fashion. Themiddle part of the deltoid contracts first and, as it ismost nearly in line with the plane of t he scapula, has thegreatest effect on elevation. The anterior fibers causemore flexion and the posterior fibers cause more exten-sion than the middle portion. Some authors have con-cluded tha t tra nsfer of the a nterior or posterior portionof the deltoid muscle to a more lateral position is there-




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fore justified in order to increase elevation 9.The most important scapular motor is the inferior

portion of the serratus anterior muscle. This muscle po-sitions the glenoid slightly beneath the humeral headduring elevation through its pull laterally and inferiorlyon the scapula and thereby stabilizes the glenohumeraljoint. This function must be present if t ransfers a re to beperformed to restore elevation.

Because the humeral head has a greater diameter,tendons transferred to the humeral head (or to the ro-tator cuff) in order to bring about rotation are moreefficient (have a great er lever arm) t han tra nsfers to theshaft of the humerus 9.

Tendon tra nsfers about t he shoulder a re most com-monly performed for lesions of the fift h and sixth cervi-cal nerve roots involving the suprascapular and axillarynerves and for deficits of the nerve to the subscapularissecondary to shoulder instability. Involved muscles in-clude the supraspinatus and infraspinatus, all or part ofthe deltoid, and the subscapularis.

Suprascapular N erv e and Supraspinatus and I nfr aspinatus M uscles (Fif th and Sixth Cervical N erv e Roo ts)

Weak or absent function of the supraspinatus andinfraspinatus muscles leads to decreased external rota-

tion of the humerus and the characteristic internal ro-tation contracture of obstetric brachial plexus palsy(Fig. 5). This problem is commonly addressed eitherwith transfer of the latissimus dorsi tendon to the pos-terior aspect of the rotator cuff or the greater tuber-osity, as described by Hoffer et al. 16 (Fig. 6), or with a

shift of its insertion from anterior to posterior, convert-ing it to an external rotator, as described originally byL’Episcopo 21 and as modified by Covey et al.10.

Transfer of the L atissim us D orsi Tendon to the Posteri or A spect of the Rotator Cuf f

The procedure described by Hoffer et al. 16 has theadvantage of increasing glenohumeral abduction as wellas external rotation if function of the deltoid muscle ispresent. The transfer increases the stabilizing functionof the rotator cuff, providing a secure glenohumeralfulcrum around which the deltoid can direct its pull onthe la teral a spect of the humerus. Triceps function mustbe present to allow extension of the elbow when theshoulder is abducted and externally rotat ed.

Technique: The pat ient is placed in lat eral d ecubitus,and t he affected extremity is prepared a nd draped free.An anterior axillary incision is made, and the pectoralismajor tendon insertion is identified and, if necessary,released. If the pectora lis major muscle is not contra cted(and the senior one of us [J. B. B.] believes tha t it ra relyis), then a single posterior incision is used. The sub-Figs. 5, 6, and 7: Tran sfer of the la tissimus dorsi ten don to t he pos-

terior aspect of the rotat or cuff.Fig. 5: Preoperative photograph showing loss of external rotation

and abduction of the shoulder.

D rawing illustrating the modificatio n, described by Ho ffer et al.16,of the tra nsfer of the latissimus dorsi tendon to the greater tuberosityor the rotator cuff. A retractor elevates the deltoid muscle. Theshaded muscles are the transposed latissimus dorsi (below) and theteres major (above). These muscles are taken from their previousposition (dotted lines) to a new site of attachment into the rotatorcuff over the greater tuberosity, so that the muscles are convertedfrom internal to external rotators and provide abduction.

F IG . 6

F IG . 5




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scapularis muscle may be released, as described ea rlier,if indicated. The tendons of the latissimus dorsi andteres major are identified through a separate, posteriorincision. These tendons are released as well, with pro-tection of the radial nerve and the contents of the qua d-rilateral space throughout. The interval between theposteroinferior margin of the deltoid muscle and therota tor cuff is then developed, and the arm is maximallyabducted and externally rotated. The released tendonsof the latissimus dorsi and the teres major are nexttransferred posterior to the long head of the tricepsmuscle and sutured as superiorly as possible to the ro-ta tor cuff. Two longitudinal incisions are mad e in thecuff, and the tendons are pulled through these incisions

and sutured to themselves, thereby converting the latis-simus dorsi and teres major muscles into external rota-tors of the shoulder. Postoperatively, a shoulder spicasplint is applied with the shoulder in 60 to 90 degrees ofabduction and external rotation. This splint is worn fulltime for three months and only a t night for an a dditionalthree months (Fig. 7).

Posterol ateral Transfer of the L atissim us D orsi and Teres M ajor Tendons to the H umeral Shaft

With the modification 10 of the L’Episcopo proce-dure 21, the latissimus dorsi is transected at its muscu-

lotendinous junction and sutured to the teres ma jor ten-don, which has been taken directly off bone. The re-maining latissimus tendon, still attached to the humeralshaft, is rerouted posterolaterally, while the combinedlatissimus muscle and t eres major tendon a re ta ken pos-teromedially. These are sutured together posterolateral

to the shaft of the humerus, converting both musclesinto external rota tors.

Technique: The pat ient is placed in lat eral d ecubitus.The arm is draped free, and an axillary incision five tosix centimeters in length is made transversely from theanterior to the posterior axillary fold. The latissimusdorsi and teres major tendons are identified. The latis-simus dorsi is dissected free from the teres major andtra nsected at its musculotendinous junction, and its ten-don, still at ta ched to bo ne, is tagged. A three-centimeterlateral incision is made over the proximal part of thelatera l a spect of the d eltoid muscle. The lat issimus mus-cle belly is sutured to the teres major muscle, which isthen released fro m its humeral insertion. With use of ta gsutures, the combined latissimus a nd t eres major musclegroup is tunneled posterior to the humerus. The taggedlatissimus tendon is taken anterior to the humerus andout through the lateral deltoid incision. The tagged la-tissimus and teres major muscles are tied to the taggedlatissimus tendon, and its course anterior to the humerusand then posterolatera l converts the muscles to externalrotat ors. Ca re is taken throughout to avoid the a xillarynerve, particularly in patients who have intact deltoidfunction. A spica splint is applied with the shoulder in30 to 45 degrees of abduction and external rotation andis used for three months, after which time gentle range-of-motion and strengthening exercises are begun. Thepatient wea rs the splint only a t night for a nother threemonths.

A xillary N erve and D eltoid M uscle (Fi fth and Sixth Cervi cal N erve Roots)

There are severa l procedures that ca n be used to re-place some portion of t he function of t he deltoid muscle.

A nteri or T ransfer of the Posteri or Third of the Deltoid

In pat ients in whom the anterior a nd middle thirds

of t he deltoid a re nonfunctional but the posterior thirdis intact, an anterior tra nsfer of the posterior third canbe performed. As first described by Harmon 14 for thetrea tment of deficits seconda ry to poliomyelitis, the pos-terior third of the deltoid muscle is freed from its scap-ular origin and sutured anteriorly along the lateralaspect of t he clavicle, in the region of t he nonfunctiona lanterior and middle deltoid muscle fibers.

Technique: A superoposterior incision is made, be-ginning at the middle third of t he clavicle and extendingposteriorly to the middle of the scapular spine. Full-thickness flaps are raised superiorly and inferiorly, re-vealing the posterior third of the deltoid muscle. The

Postoperative photograph showing external rotation and abduc-tion of th e shoulder with weak function o f the triceps muscle.

F IG . 7




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muscle is detached subperiosteally from its origin andfreed for about half its length from underlying tissue.Care must be exercised to protect underlying branchesof the axillary nerve. The outer third of the clavicle isexposed subperiosteally as well, and the free formerorigin of the posterior third of the deltoid muscle is

sutured to t his new locat ion. Wounds are closed, and t hearm is splinted in 60 to 90 degrees of abduction andforw ard elevation. The splint is worn full-time for t hreemonths, after which time gentle active and passiverange-of-motion exercises are begun and the splint isworn fo r a nother three months at night only.

Transfer of the Trapezius M uscle to the L ateral A spect of the Hu meral Shaft

Alternatively, a modification of Mayer’s22 tra nsfer ofthe t rapezius muscle can be performed (Fig. 8). Mayer’soriginal procedure involved dissection of the trapeziusmuscle free of its insertion a long the a cromion, scapular

spine, and lateral aspect of the clavicle; attachment of asegment of fa scia lat a rolled into a tube; and suture intoa bone tunnel in the region of the deltoid tuberosity onthe lateral aspect of the humerus. A modification inwhich a portion of the a cromion is removed to a llow fora more straight-line pull is now more commonly used.

The lateral a spect of the a cromion a nd its atta ched tra -pezius is removed, and its undersurface is roughenedwith a rasp. Fixation with a screw and washer securesthe acromion and trapezius transfer to t he proximal partof t he humeral sha ft (Fig. 9).

Technique: A saber-cut incision is made from theinferior border of the anterior axillary fold over theanterior aspect of the shoulder to a point a few centi-meters lateral to the medial border of the scapula andjust distal to the scapular spine. The trapezius muscle isexposed by ca reful flap dissection along its entire inser-tion — tha t is, ant erior, lat eral, and posterior. E xtensivemobilization of the proximal and middle parts of thetra pezius muscle provides an increase o f five or six cen-timeters in length 26. The fibrotic deltoid muscle is splitlongitudinally to allow proximal exposure of the hu-meral head a nd shaft . The latera l aspect of the trapeziusmuscle with its underlying acromion is separated fromsurrounding tissue. Osseous cuts are made through thelatera l aspect of the scapular spine posteriorly. B onewith its a tta ched tra pezius muscle is rasped on its under-surface and pulled distally to the lateral aspect of theabducted humerus. The selected site of insertion, dis-tal to the tuberosity, is also rasped, and the bone-and-muscle transfer is secured with a screw over a washer.The arm is then abducted to 60 to 90 degrees and

Figs. 8 and 9: Modification of Mayer’s22 transfer of the trapezius

muscle attached to an acromial bone block.Fig. 8: D rawings illustrating the procedure. The upper dra wingshows a lateral view of the right shoulder, with the acromial boneblock and attached trapezius muscle elevated. The lower drawingshows the acromial bone block with attached trapezius muscle se-cured with screw fixation to the roughened lateral aspect of theproximal part o f the humerus distal to t he greater tuberosity.

F IG . 8

Ra diograph made after performance of the transfer to restore shoul-der a bduction.

F IG . 9




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splinted. The splint is worn full-time for three months,until bone-healing occurs, and then only at night foranother three months, during which time physical ther-apy is given for improvement of the range of motion a ndfor strengthening.

Bi polar Tr ansfer of the L atissimus D orsi M uscle for D ysfunction of the Deltoid

Finally, bipolar t ransfer o f t he lat issimus dorsi mus-cle (both ends of the muscle are rotated) on its neuro-vascular pedicle, as described by I toh et al. 18, can be usedto treat dysfunction of the deltoid. The procedure in-volves transection of both the origin and the insertionof the latissimus dorsi muscle. The flat tendon that wasoriginally the humeral insertion is sutured to the inser-tion of the deltoid muscle, and the broad muscular endis sutured to the periosteum of the acromion and thedistal pa rt of the clavicle or to the insertion of the tra -pezius muscle, thereby substituting for the nonfunc-tional deltoid muscle.

Technique: The pat ient is placed in lat eral d ecubitus,with t he involved side up, and three incisions are ma de.First, a longitudinal axillary incision is made over thelateral border of the latissimus dorsi muscle, extend-ing up to the distal half of the deltopectoral groove;second, an a nterola tera l incision is made over t he inser-tion of the deltoid muscle on the humerus; and, third,a curvilinear incision is made along the lateral third ofthe clavicle and the anterior and lateral aspects of theacromion. The anterior border of the latissimus dorsimuscle is bluntly elevated from the chest w all, with caretaken t o identify a nd protect t he neurovascular bundle.This is followed proximally, with ligation of communi-cating branches. Subcutaneous tissue is cleared fromthe latissimus dorsi muscle for approximately twentycentimeters distal from its humeral insertion. Markingsutures are placed ten centimeters apart in the bodyof t he muscle as a guide to its resting tension. The mus-cle is then taken off the inferior angle of the scapulaand separated from the teres major muscle. Care mustbe taken to preserve the thoracodorsal vascular pedi-cle beneath these muscles. The humeral insertion is di-vided. The lumbodorsa l fascia is then cut nea r the originof the latissimus dorsi muscle and at least twenty centi-

meters fro m its humera l insertion. The entire latissimusdorsi muscle can then be raised, with its neurovascularbundle still attached, and rotated so that the under-surface with its attached neurovascular bundle is su-perficial. A superficial tunnel connecting the incisionover the deltoid muscle insertion with that over theanterolatera l aspect o f the a cromion a nd clavicle is thencreated. The latissimus dorsi muscle is again rotated inorder to a llow the flat tendon of insertion to be passeddistally down the subcutaneous tunnel in the arm andsutured to the d eltoid muscle insertion. The broa d mus-cle end taken from the lumbodorsal fascia is rotatedup to the acromioclavicular incision. The arm is flexed

to 70 to 80 degrees and ab ducted t o 60 degrees, and theproximal end of the transferred latissimus dorsi muscleis sutured to the periosteum of the anterolateral aspectof the acromion and clavicle or to the trapezius mus-cle insertion. The position o f t he neurova scular bundlemust be checked frequently t o be sure tha t no excessive

torsion or traction is applied; at the completion of thetransfer, the bundle should rest anterolaterally on theproximal border of the pectoralis major muscle. Again,a splint is worn for three months with the arm ab-ducted to 60 to 90 degrees, after which the splint isworn only at night and range-of-motion exercises arebegun. The splint is w orn a t night for t hree months.

Subscapulari s N erv e and M uscle (Fi fth and Sixth Cervi cal N erve Roots)

The subscapularis nerve and muscle are usuallyfunctioning in brachial plexus palsy affecting the fifthand sixth cervical nerve root s, but occasionally the mus-cle’s function is decreased, resulting in anterior gleno-humeral instability. The subscapularis muscle’s functionas an internal rota tor can be replaced by tra nsfer eitherof the pectoralis major tendon or of the serratus ante-rior tendon to the lesser tuberosity of the humerus. Itshould be noted that the transferred pectoralis majortendon must be passed posterior to the conjoined ten-don to duplicate the function of the subscapularis mus-cle; otherwise, anterior instability may result.

Transfer of the Serr atus A nteri or Tendon to t he L esser T ubero sity

Technique: The pat ient is placed in latera l decubituswith the involved side up. Through a saber-cut incisionover the shoulder, the trapezius muscle is reflected upand back, exposing the superomedial angle of the scap-ula. The levator scapulae muscle is taken off its inser-tion here, and the underlying serratus anterior muscleis identified. The insertion of the proximal two digita-tions of the serratus anterior muscle merges with themedial limit of the subscapularis muscle on the a nterioraspect of the scapula. These are separated with sharpdissection. The tw o muscular slips are now rolled into atube and held with suture; the tube is left long for re-routing. The arm is then elevated to 60 to 90 degrees,

and an incision is made along the posterior wall of theaxilla. The neurovascular bundle is retracted upwardand la tera lly, and blunt dissection is used to open a pathproximal to the superior border of the serratus anteriormuscle to the first rib. The tube consisting of the proxi-mal two digitations is passed anteriorly with use of theattached suture and is sewn into the tendinous tissueover the lesser tuberosity of the humerus 26. The arm issplinted with the shoulder maintained in an internallyrotat ed position and t he forearm aga inst the trunk, andthe splint is worn full-time for three months. It is thenworn only a t night for anot her three months, and range-of-motion exercises are begun during this period.




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M ultiple Nerve Deficits Occasionally, multiple transfers are required for

multiple nerve deficits. These procedures most com-monly involve some combination of the biceps-triceps-latissimus dorsi tendon transfers described by Harmon 15

(first used in the treatment of functional losses second-ary to poliomyelitis) and based on O ber’s earlier work 23.Transfers performed in combinat ion include tra nsfer ofthe posterior third of the deltoid muscle to the lateralaspect of the clavicle, as described, together with trans-fer of the tendinous origins of the long head of thetriceps muscle and the short head of the biceps muscle

to the lateral aspect of the acromion, to aid in abduc-tion, and t ransfer of t he latissimus dorsi and t eres majortendons or of the tendinous insertion of the clavicularhead of the pectoralis major muscle posteriorly, to pro-vide external rotation of the humerus. Multiple op-tions are available, and one common combination willbe described.

M ult ip le Transfers of t he B iceps, Tr iceps,and L atissim us D orsi Tendons

Technique: Through a saber-cut incision, the poste-rior third of the deltoid muscle is taken off the scapularspine. The tendo n of the long hea d of the tr iceps muscle

is released from the scapula, and the latissimus dorsitendon is taken off its insertion on the humerus. Thetendon of the short head of the biceps muscle is re-moved from the coracoid process. The arm is held in 90degrees of abduction and 30 degrees of external rota-tion. The tendo n of t he short hea d of the biceps muscleis passed through the anterior third of the deltoid mus-cle and sutured to the anterior aspect of the acromionwith the elbow flexed to 90 degrees. The tendon of thelong head of the triceps muscle is then sutured to theposterolateral aspect of the acromion with the elbow flexed to 30 degrees. The released tendon of the latissi-mus dorsi muscle is sutured under t ension to t he inser-

tion o f t he infra spinatus muscle. The released posteriorthird of the deltoid muscle is then sutured over thesestructures to the anterolateral aspect of the acromionand the la tera l aspect of the clavicle. The arm is splintedin 60 to 90 degrees of ab duction, 30 degrees of externa lrotation, and 90 degrees of elbow flexion.

Arthrodesis

When a pa tient ha s severe combined lesions and t hesurgeon cannot reasonably expect to achieve glenohu-meral stability with any of the described soft-tissue pro-cedures, it ma y be necessary to perform a glenohumeralart hrodesis to t reat pain, insta bility, or art hritis (Fig. 10).Arthrodesis of the shoulder requires scapular stabilityand functiona l scapular muscles. Instability o r incongru-ity of the shoulder should not be addressed if the armor hand is nonfunctional. H ow ever, shoulder arthro desiscan enhance the power of weak elbow flexion or exten-sion transfers by isolating the forces of the transfer tothe elbow.

Tendon Transfers About the Elbow

Elbow flexion is frequently absent or diminished inobstetrical brachial plexus palsy involving the muscu-locutaneous nerve (the fifth and sixth cervical nerveroots) and therefore impairing the function of the bi-ceps and brachialis muscles. Numerous procedures torestore this function have been described, with one ofthe earliest being the proximal reattachment of the ori-gin of the flexor-pronator muscle group as outlined bySteindler 29. D espite lat er modificat ions to reduce someof the unwanted sequelae (for example, pronation de-formity) of this transfer, other transfers are now oftenpreferred to the Steindler flexorplasty, although it hasthe benefit of being simple to perform. Another pro-cedure that was used more widely in the past is anteriortransfer of the triceps tendon insertion, which providesbetter strength of elbow flexion than t he Steindler tra ns-fer does but leaves the patient unable to actively ex-tend the elbow o n the side of the operation in order touse crutches or to assist in transfer from bed to chair.An early but cosmetically unacceptable procedure wastra nsfer of the sternocleidoma stoid muscle (Figs. 11 and12), which involves detaching this muscle from its inser-

tion and linking it to the insertion of the biceps muscleby means of a long strip of fascia lata. This transfer isnow generally avoided.

Proximal Tr ansfer of the O rigin of the Flexor-Pronator M uscle G roup

Technique: A curvilinear incision is made a t the pos-teromedial aspect of the elbow, passing behind the me-dial epicondyle and angling laterally (radially) bothproximal and distal to this level. The medial antebra-chial cutaneous nerve is identified and protected. Theulnar nerve is transposed anteriorly. The median nerveis identified between the tw o heads of t he pronator teres

Radiograph made after a shoulder arthrodesis performed with a4.5-millimeter AO dynam ic compression plate.

F IG . 10




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muscle and mobilized from surrounding tissue, with pro-tection of t he branches to the prona tor teres muscle. Anosteotome is used to remove a piece of the medial epi-condyle that is less than one centimeter in thicknesswith its attached origin of the flexor-pronator musclegroup. This mass is reflected d ista lly, and the muscles a remobilized from inferior att achments, with their innerva-tion prot ected as t he dissection progresses. The elbow isthen flexed to 130 degrees, and the flexor ma ss and theepicondyle are pulled proximally and radially severalcentimeters to the anterior humeral cortex. The site ischosen such that the elbow can be flexed to 60 degreeswith the wrist and fingers fully flexed. An attachmentsite then is prepared, with a roughened spot made onthe humerus. The epicondylar segment is placed in thisspot, and the transfer is secured with a screw insertedover a wa sher. The epicondyle can be predrilled for ea seof fixation. The anterolateral fixation prevents the pro-nation deformity that was seen after early versions of

the tra nsfer, which involved a more medial at tachment.The arm is then splinted with the elbow flexed to 90degrees and the forearm in full supination, and this po-sition is maint ained fo r four to six weeks. G entle range-of-motion exercises ar e then begun to rega in all but theterminal 30 degrees of elbow extension for eight weeks;then, full extension is slowly regained with continuedtherapy.

A nteri or Transfer of the Triceps Tendon

As described by Carroll and Hill 3,4, this procedurewas designed for patients in whom paralysis or injuryhad left the flexor-pronator mass unusable for transfer.

Techni que: The patient is placed in la tera l decubituswith the arm draped free. A posterior incision is made,curving slightly around the tip of the olecranon. Theulnar nerve is identified medially. The lateral inter-muscular septum is exposed. The triceps tendon inser-tion is taken off the ulna with a longitudinal extensionof periosteum. The muscle is carefully elevated off theposterior part of the humerus for ten to fifteen centi-meters, with protection of both the radial nerve as itcourses anteriorly through the lateral intermuscularseptum and the previously identified ulnar nerve medi-ally. The triceps insertion with attached periosteum isthen rolled into a tube. Next, an anterior incision ismade to identify the biceps tendon insertion. The in-terval between the brachioradialis and pronator teresmuscles is developed, with protection of the anteriorneurovascular bundle, and the bicipital tuberosity isidentified. A tunnel lateral to the radius is created fromback to front, and the tube consisting of the triceps and

attached periosteum is pulled anteriorly, superficial tothe radial nerve. The elbow is flexed to 90 degrees, andthe forearm is supinated fully. The triceps is pulled tomaximum tension, and the tube of tendon a nd at tachedperiosteum is sutured to the biceps tendon near its in-sertion. The arm is splinted in this position for four tosix weeks, aft er w hich time a ctive range-of-motion exer-cises are begun.

B ipol ar Transposition of the Pectoralis M ajor M uscle

Clark7, in 1946, described a transfer of the inferioraspect of the sternal origin of the pectoralis major mus-

Photographs showing extension (Fig. 11) and flexion (Fig. 12) after transfer of the sternocleidomastoid muscle to the biceps tendonlengthened with a fa scia lata graft.

F IG . 11 F IG . 12




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freed, the only remaining attachments are its humeralinsertion and the neuro vascular b undle. The muscle or-igin is taken to the distal aspect of the arm and su-tured to the biceps tendon a nd the ra dial tub erosity. Theinsertion is released and sutured to the conjoined ten-don origin on the coracoid process or the anterior as-pect of the acromion (Fig. 14). The wounds are closed,and the arm is splinted with the elbow flexed to 90degrees. The splint is worn full-time for the first threemonths, except w hen ra nge-of-motion exercises are per-

formed, and it is worn only at night for another threemonths. Active flexion and extension are begun at sixweeks (Figs. 15 and 16), but passive extension is avoidedfor three months.

Free M icro neurovascular Tr ansfer of the Gr acili s M uscle 19

A free microneurovascular muscle transfer may beperformed 5,6 in a limited number of patients. The mostcommonly selected donor muscle is the gracilis. This

Figs. 14, 15, and 16: B ipola r latissimus dorsi flexor plasty a s described by H ovna nian 17.Fig. 14: D rawing illustrating how the spinous origin of the la tissimus dorsi muscle is rolled into a tube and tunneled subcutaneously to the

biceps tendon insertion. The humeral insertion of the la tissimus dorsi tendon is taken down a nd reatt ached, as is done with a tra nsfer of thepectoralis major muscle, either to the conjoined tendo n origin on the cora coid process or to the anterior a spect of the a cromion.

F IG . 14

Photographs showing elbow flexion (Fig. 15) and extension (Fig. 16) after bipolar latissimus dorsi flexorplasty.F IG . 15 F IG . 16




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procedure is indicated when no functional muscles areava ilable for transfer in a child w ho has a good passiverange of elbow motion and no or very weak active el-bow flexion.

Technique: A medial t high incision is mad e, extend-ing longitudinally from a point two centimeters distal to

the pubic tubercle to a point ten centimeters proximalto the a dductor tub ercle of the femur. D issection is car-ried down to the longitudinal fibers of the gracilis mus-cle. Several vascular pedicles enter the muscle, but thedomina nt pedicle, comprising bra nches from the media lfemoral circumflex artery and vein, along with the mo-tor branch to the gracilis from the anterior division ofthe obturator nerve, can be found on the undersurfaceof the muscle, approximately one-quarter of the dis-tance from the pubis to the adductor tubercle. The ten-don of insertion is sectioned from the femur. Lesservascular pedicles are ligated as the muscle is elevatedfrom distal to proximal. The dominant neurovascularpedicle is then ligat ed a nd tra nsected as close to t he exitof the nerve and vessels from their main trunks as canbe saf ely performed. The proximal part of t he tendon isdivided, and the muscle is taken from the donor site tothe affected arm. An anterior axillary incision is made,and dissection is carr ied out to t he level of the insertionof the pectoralis major tendon on the humerus. Thetendon of origin of the free gracilis muscle is passeddeep to the pectoralis major tendon and fixed to thecoracoid process with interosseous wiring or is attachedto the conjoined tendon with nona bsorba ble suture. Ad -ditional attachments to surrounding fascia, the clavicle,

or the second rib are performed as necessary with su-ture fixation. A second incision is made over the ante-rior aspect of the proximal part of the forearm, andthe b iceps tendon insertion is identified. The dista l endof the free gracilis muscle transfer is tunneled subcuta-neously down t he anterior aspect of the arm a nd woven

into the biceps tendon insertion with the elbow flexedto 110 degrees. An a nterior incision is next ma de on t hechest in line with the fourth rib, and the intercostalnerves beneath the third, fourth, and fifth ribs are iden-tified. The nerves are sectioned anteriorly and takenposterior to the midaxial line, where the intercostalnerves of the fourth and fifth thoracic nerve roots aresutured into the motor nerve to the gracilis, and theintercostal nerve of the third thoracic nerve root is im-planted directly into the muscle in neurotization fash-ion. Arterial anastomosis is made with use of the lateralthoracic, thoracodorsal, or thoracoacromial artery. Ve-nous outflow is through the thoracoa cromial or cephalicvein. Posto perative va scular a ssessment is critical to t hesuccessful application o f this tra nsfer as ischemia or de-creased outflow may require re-exploration of the mi-crovascular anastomoses. Postoperative rehabilitationrequires a reinnervation time of six months to one yearfor maximum functional return.

B ipolar L atissim us Do rsi Tri cepsplasty

Function of the triceps muscle may be restored inselected patients with transfer of the latissimus dorsimuscle (Fig. 17) as described by Hovnanian 17 and pre-viously in this paper. G ravity pro vides ad equa te exten-

D rawing illustrating bipolar latissimus dorsi tricepsplasty as described by H ovnania n 17. The spinous origin of the muscle is tunneledsubcutaneously down the po sterior aspect of the arm a nd reatt ached into either the triceps tendon o r the olecranon. The tendinous insertionis taken off the humerus and reat tached to the posterior aspect of the acromio n.

F IG . 17




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sion for patients who have unilateral brachial plexuspalsy. Involvement of the lower extremity or bilateralinvolvement of the upper extremity may require force-ful extension for walking with crutches or for weighttransfer.

Deformity of the ElbowAs first summarized by Aitken 1, a series of changes

in the proximal parts of the radius and ulna is fre-quently seen in patients who have obstetrical brachialplexus palsy. These changes tend to occur in patientswho have some, although incomplete, recovery. Thecommonly observed sequence begins with increasedcurvature of t he ulna a nd slight ba ckward displacementof the proximal part of the radius. The radial epiphysisbecomes obliquely oriented with respect to the shaft.Left untreated, complete posterior dislocation of theradius occurs, a conical deformity of the radial headdevelops, and the head articulates with an abnormallyflattened capitellum. Aitken suggested that the changesin the ulna are due to the uneven pull of the tricepsmuscle against the nonfunctional biceps and brachi-alis muscles, complicated by splinting of the elbow inflexion for too long a period of time. The radial dislo-cation may be related to splinting in supination againstthe pull of the pronator teres and a contracted inter-osseous 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 whenbiceps and brachialis function returned.

Ot her authors 20,30 have described the common occur-rence of flexion contractures at the elbow in brachialplexus palsy. This can occur with overactivity of thebiceps and brachialis. Medial and lateral instability can

occur as well, necessitating augmentation or reefing ofsoft tissues. Incompetence of the annular ligament maynecessitate reconstruction with a triceps tendon slip orfascia lata graft24.

Overview

O bstetrical bra chial plexus palsy rema ins a cha lleng-ing clinical problem, with few data regarding the out-comes of the wide variety of operative procedures thathave been d escribed. U ntil recently, there have been nocontrolled clinical studies (of w hich we are aw are) com-paring different techniques, and surgeons have had torely on reports summarizing results of individual pro-cedures as compared with the natural history of thedeformity. Rigorous and reproducible standardized out-comes measures are lacking, in part beca use of the widevariability in the severity of involvement of affectedindividuals, and this lack has made comparison difficultas w ell. The recent heightened interest in outco mes as-sessment appears to be leading to more work in thisarea, which will be crucial to t he optimization of the careof patients who have this complicated disorder.

References 1. Aitken, J .: D eformity of the elbo w joint as a sequel to Erb ’s obstetrical paralysis. J. B one and Joint Sur g., 34-B(3): 352-365, 1952. 2. Carlioz, H., and Brahimi, L.: La place de la désinsertion interne du sous-scapulaire dans la traitement de la paralysie obstétricale du

membre supérieur chez l’enfant. A nn. chir. infantil e, 12: 159-167, 1971. 3. Carroll, R. E.: Restoration of flexor power to the flail elbow by transplantation of the triceps tendon. Surg., Gyn ec. and O bstet., 95:

685-688, 1952. 4. Carroll, R. E., and Hill, N. A.: Triceps transfer to restore elbo w flexion. A study of f ifteen patients with para lytic lesions and a rthro-

gryposis. J. B one and Joint Sur g., 52-A: 239-244, March 1970. 5. Chuang, D. C.; Epstein, M. D.; Yeh, M. C.; and Wei, F. C.: Functional restora tion o f elbow flexion in brachial plexus injuries: results in

167 patients (excluding obstetric brachial plexus injury). J. H and Surg., 18A: 285-291, 1993. 6. Chuang, D. C.-C.: Functioning free muscle transplantation. In Surgery of the Hand and U pper E xtremity, pp. 1901-1910. Edited by C. A.

Peimer. New York, McG raw -Hill, 1996. 7. Clark, J. M. P.: R econstruction of biceps brachii by pectoral muscle transplantation. Br itish J. Surg., 34: 180-181, 1946. 8. Clarke, H. M., and Curtis, C. G.: An approa ch to o bstetrical brachial plexus injuries. H and Clin., 11: 563-581, 1995. 9. Comtet, J. J.; Herzberg, G.; and Naasan, I. A.: B iomechanical ba sis of tra nsfers for shoulder paralysis. H and Clin. , 5: 1-14, 1989.10. Covey, D. C.; Riordan, D. C.; Milstead, M. E.; and Albright, J. A.: Modification of the L’Episcopo procedure for brachial plexus birth

palsies. J. B one and Joint Sur g., 74-B(6): 897-901, 1992.11. Debeyre, J.; Patte, D.; and Elmelik, E.: Repair of ruptures of the rotator cuff of the shoulder. With a note on advancement of the

supraspina tus muscle. J. B one and Join t Surg., 47-B( 1): 36-42, 1965.12. Fairbank, H. A. T.: B irth palsy: subluxation o f the shoulder-joint in infants a nd yo ung children. L ancet, 1: 1217-1223, 1913.13. Gilbert, A.: Lo ng-term evaluat ion of brachial plexus surgery in obstetrical palsy. H and Clin., 11: 583-595, 1995.14. Harmon, P.: Anterior transplantation of the posterior deltoid for shoulder palsy and dislocation in poliomyelitis. Surg., Gy nec. and

O bstet., 32: 117-120, 1947.15. Harmon, P. H.: Surgical reconstruction of the paralytic shoulder by multiple muscle transplantations. J. B one and Joint Sur g., 32-A:

583-595, July 1950.16. Hoffer, M. M.; Wickenden, R.; and Roper, B.: B rachial plexus birth palsies. Results of tendon tra nsfers to the rotat or cuff. J. B one and

Joint Surg., 60-A: 691-695, Ju ly 1978.17. Hovnanian, A.: Latissimus dorsi transplantation for loss of flexion or extension at the elbow. A preliminary report on technic. Ann.

Surg., 143: 493-499, 1956.18. Itoh, Y.; Sasaki, T.; Ishiguro, T.; Uchinishi, K.; Yabe, Y.; and Fukuda, H.: Transfer of latissimus dorsi to replace a paralysed a nterior

deltoid. A new technique using an inverted pedicled graft. J. B one and Joint Surg., 69-B(4): 647-651, 1987.19. Krakauer, J. D., and Wood, M.: Ad ult injuries and salvage. In Surgery of the Hand and U pper E xtremity, p. 1411-1442. Ed ited by C. A .

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20. Leffert, R. D.: Br achial P lexus I njur ies, pp. 189-235. New York, Churchill Livingstone, 1985.21. L’Episcopo, J. B.: Tendon transplanta tion in obstetrical par alysis. A m. J. Surg., 25: 122-125, 1934.22. Mayer, L.: Transplantatio n of th e trapezius for para lysis of the a bductors of the a rm. J. B one and Joint Sur g., 9: 412-420, Ju ly 1927.23. Ober, F. R.: An o peration to relieve paralysis of the delto id muscle. J. A m. M ed. A ssn., 99: 2182, 1932.24. Oner, F. C., and Diepstraten, A. F. M.: Treatment o f chronic post-trauma tic dislocation of t he radial hea d in children. J. B one and Joint

Surg., 75-B(4): 577-581, 1993.25. Pearl, M. L., and Edgerton, B. W.: G lenoid deformity secondar y to brachia l plexus birth palsy. J. B one and Joint Surg., 80-A: 659-667,

Ma y 1998; err at um, 80-A: 1555-1559, O ct. 1998.26. Saha, A. K.: Surgery of the para lysed and flail shoulder. A cta O rthop. Scandinavica, Supplementum 97, 1967.27. Schottstaedt, E. R.; Larsen, L. J.; and Bost, F. C.: C omplete muscle transposition. J. B one and Joint Sur g., 37-A: 897-919, Oct . 1955.28. Sever, J. W.: The results of a new operation for o bstetrical paralysis. A m. J. Or thop. Surg., 16: 248-257, 1918.29. Steindler, A.: Tendon transplantat ion in the upper extremity. A m. J. Surg., 44: 260-271, 1939.30. Tachdjian, M. O.: Pediatri c O rthop aedics. E d. 2, pp. 2009-2057. Phil ad elphi a, W. B. Sa und ers, 1990.31. Troum, S.; Floyd, W. E., III; and Waters, P. M.: Posterior dislocation of t he humeral head in infancy a ssociated w ith obstetrical paralysis.

A ca se report. J. B one and Joint Sur g., 75-A: 1370-1375, Sept . 1993.32. Waters, P. M.: Ob stetric brachial plexus injuries: evaluation and ma nagement. J. A m. A cad. O rthop. Surgeons, 5: 205-214, 1997.33. Waters, P. M.; Smith, G. R.; and Jaramillo, D.: G lenohumeral defo rmity secondary to b rachial plexus birth palsy. J. B one and Joint Sur g.,

80-A: 668-677, Ma y 1998.34. Waters, P. M., and Peljovich, A. E.: Shoulder reconstruction in patients with chronic brachial plexus birth palsy. A case control study.

Cli n. Or thop., 364: 144-152, 1999.35. Zancolli, E. A., and Zancolli, E. R., Jr.: P alliative surgical procedures in sequelae of obstetric palsy. H and Clin., 4: 643-669, 1988.



Tendon Transfer for Brachial Palsy

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