Options of bipolar muscle transfers to restore deltoid function: an anatomical study

Free functional gracilis transfer for reconstruction of isolated anterior deltoid atrophy following surgical proximal humerus fixation

BACKGROUND

Palsy of the clavicular head of the deltoid is a complication after surgical fixation of proximal humerus fractures. Flexion of the shoulder joint may be impaired as a result. Additionally, patients may complain of joint instability, visible atrophy, and pain. Where nerve reconstruction is not possible, muscle transfers remain as secondary reconstructive procedures.

METHODS

Three patients with anterior deltoid palsy after proximal humerus fixation received a free functional gracilis transfer to the shoulder. Postoperatively, patients underwent biofeedback-based rehabilitation. Before and after the intervention, subjective complaints, pain level, and active range of motion (ROM) were recorded. At the final follow-up, patients completed a Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

RESULTS

The surgery was successful in all patients, with first muscle signals registered through surface electromyography approximately four months postoperatively. At the last follow-up (>3 years), the patients showed improved shoulder stability and pain scores. In two patients with preoperative restrictions, active ROM improved. The DASH score showed minimal to no disability in two patients and moderate disability in the third. Two patients voiced satisfaction with the restoration of the ventral bulk of the shoulder.

CONCLUSIONS

Free functional gracilis muscle transfer is a novel approach for secondary reconstruction in patients with anterior deltoid atrophy who do not qualify for nerve intervention. It addresses shoulder instability and pain and may improve active ROM. The addition of fresh muscle tissue to the ventral shoulder can improve its natural contour and prevent protrusion of the humeral head.

Tendon transfers in the setting of shoulder arthroplasty

Background

Tendon transfers in conjunction with reverse total shoulder arthroplasty can significantly improve functional outcomes in patients with glenohumeral arthritis and irreparable rotator cuff deficiency. There have been multiple promising new techniques described within the last 20 years that shoulder surgeons should become familiar with.

Methods

The authors reviewed the literature on tendon transfers in the setting of reverse total shoulder arthroplasty. Procedures to restore various shoulder functions were described including surgical anatomy, techniques, pearls and pitfalls, and photos.

Results

Subscapularis insufficiency can be reconstructed with a pectoralis major transfer or latissimus dorsi transfer, with the latter having better clinical outcomes and a more anatomic line of pull. Posterosuperior rotator cuff deficiency can be reconstructed with a latissimus transfer (L'Episcopo transfer) or lower trapezius transfer, with the latter proving superior in biomechanical and short-term studies. Deltoid deficiency can be reconstructed with a pedicled upper pectoralis major transfer. Massive proximal humerus bone loss can be reconstructed with an allograft-prosthetic composite, and any of the aforementioned transfers can be utilized in this setting as well.

Conclusion

Tendon transfers in conjunction with reverse shoulder arthroplasty can significantly improve functional outcomes in patients with glenohumeral arthritis and irreparable rotator cuff deficiency. There have been multiple promising new techniques described within the last 20 years that shoulder surgeons should become familiar with.

Revision Reverse Total Shoulder Arthroplasty With Pectoralis Major Transfer for Anterior Deltoid Deficiency: A Case Report

CASE

A 70-year-old male patient presented with anterior deltoid weakness from Parsonage-Turner neuropathy status post failed nerve transfer and a failed total shoulder arthroplasty with pseudoparalysis. The patient underwent revision to a reverse total shoulder arthroplasty with concomitant pectoralis major transfer to substitute for the anterior deltoid. An excellent functional result was attained as early as 6 weeks after surgery.

CONCLUSION

Pectoralis major transfer can be an effective treatment option for isolated anterior deltoid insufficiency, even in the setting of a reverse total shoulder arthroplasty.

Composite-Free Vascularized Fibular Epiphyseal Flap and Proximal Humeral Allograft for Proximal Humerus Reconstruction in a Pediatric Patient

Tumors involving the epiphysis in children present a reconstructive challenge. A free vascularized fibula epiphyseal transfer offers a means for biological reconstruction and longitudinal growth; however, it is often complicated by graft fracture and limited shoulder motion. Here, we present a case of a composite structural allograft with free vascularized fibula epiphyseal transfer for proximal humeral reconstruction. At 27-month follow-up, there was longitudinal growth, hypertrophy of the epiphysis, shoulder function which allowed activities of daily living, and no graft fracture.

Coverage losses of substance in the shoulder

Losses of substance of the shoulder are less common than elsewhere in the upper limb. They arise essentially from tumors (sarcomas), infectious diseases (hidradenitis) or traumatic events, (burns). The objectives of reconstruction depend on whether the losses of substance are located on the curve of the shoulder or in the axillary area. There exist numerous regional solutions, including perforator, propeller, pedicled and free flaps. The donor region may be the thorax (latissimus dorsi, serratus anterior), the back (trapezium, scapular or subscapular flaps, occipito-cervico-thoracic flap), the anterior surface of the thorax (pectoralis major or minor, supraclavicular, perforators of the acromiothoracic artery, delto-pectoral flap) or arm (brachial lateral or medial). Multitissular reconstructions are also possible in regional and pedicled form, as well as microanastomosed flaps in exceptional conditions.