Lower Trapezius Transfer for Patients With Brachial Plexus Injury

Arthroscopic Lower Trapezius Tendon Transfer for a Patient with Axillary Nerve Injury and Concomitant Rotator Cuff Tear: A Case Report and Technical Notes

Introduction: Concomitant nerve injuries with musculoskeletal injuries present a challenging problem. The goals of nerve reconstruction for the shoulder include shoulder abduction and external rotation. When patients fail to achieve acceptable shoulder external rotation and shoulder abduction, tendon transfers such as trapezius transfer offer a reliable option in the subsequent stage. Case Presentation: A 32-year-old male presented with weak external rotation in his left shoulder, after previous axillary nerve reconstruction. He received the ipsilateral lower trapezius transfer with the aim of improving the external rotation. Discussion: The lower trapezius restores a better joint reaction force in both the compressive-distractive and anterior-posterior balancing and provides a centering force through the restoration of the anterior-posterior force couple. Conclusion: We believe that the ipsilateral lower trapezius transfer to the infraspinatus is a good outcome and is effective in improving overall shoulder stability and the shoulder external rotation moment arm or at least maintaining in neutral position with the arm fully adducted in patients with post axillary nerve injuries post unsatisfactory nerve reconstruction to increase the quality of life and activities of daily living.

Shoulder Arthrodesis for Traumatic Brachial Plexus Injuries: Functional Outcomes and Complications

BACKGROUND

The external rotation and abduction of shoulder are considered one of the priorities of reconstruction in brachial plexus injury. The aim of this study was to evaluate the functional results and complications of shoulder arthrodesis in patients with brachial plexus injury to better comprehend the benefits of this procedure.

METHODS

Between 2015 and 2019, 15 shoulder arthrodesis were performed in patients with long-standing brachial plexus injury. The main indication for arthrodesis was absent or poor recovery of shoulder abduction and external rotation. Patients presented different levels of injury. Shoulder measurements of active abduction and external rotation were made based on image records of the patients. A long 4.5-mm reconstruction plate was fit along the scapular spine, acromion, and lateral proximal third of the humerus. Structured bone graft was fit into the subacromial space.

RESULTS

The mean preoperative abduction was 16°, and the mean postoperative abduction was 42°. The mean preoperative external rotation was -59°, and the mean postoperative external rotation was -13°. The mean increase in abduction and external rotation was 25° and 45°, respectively. Bone union was achieved in all cases at an average time of 5.23 months. We experienced humeral fractures in 26.66% of the cases, which were all successfully treated nonoperatively.

CONCLUSIONS

Shoulder arthrodesis is a rewarding procedure for patients with brachial plexus injuries. A marked improvement in the upper limb positioning was observed in all patients. It should be considered as the main therapeutic option in cases where nerve reconstruction is no longer possible.

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

PURPOSE

Quantifying changes in shoulder external rotation range of motion and strength after lower trapezius transfer in children with obstetric brachial plexus palsy (OBPP).

METHODS

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.

RESULTS

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.

CONCLUSION

Lower trapezius transfer seems encouraging to restore shoulder external rotation in OBPP children but with non-significant strength improvement.

TRIAL REGISTRATION

18/07/31/5783, December 22, 2018.

Prevention and Treatment of Nerve Injuries in Shoulder Arthroplasty

➤

Nerve injuries during shoulder arthroplasty have traditionally been considered rare events, but recent electrodiagnostic studies have shown that intraoperative nerve trauma is relatively common.

➤

The brachial plexus and axillary and suprascapular nerves are the most commonly injured neurologic structures, with the radial and musculocutaneous nerves being less common sites of injury.

➤

Specific measures taken during the surgical approach, component implantation, and revision surgery may help to prevent direct nerve injury. Intraoperative positioning maneuvers and arm lengthening warrant consideration to minimize indirect injuries.

➤

Suspected nerve injuries should be investigated with electromyography preferably at 6 weeks and no later than 3 months postoperatively, allowing for primary reconstruction within 3 to 6 months of injury when indicated. Primary reconstructive options include neurolysis, direct nerve repair, nerve grafting, and nerve transfers.

➤

Secondary reconstruction is preferred for injuries presenting >12 months after surgery. Secondary reconstructive options with favorable outcomes include tendon transfers and free functioning muscle transfers.

Surgical Technique: Lower Trapezius Transfer in Paediatric Paralytic Shoulder

The therapeutic management of the paralytic shoulder after an obstetric brachial plexus injury is complex. When nerve repair or neurotization fail, or if the biological times for nerve reconstruction is over, tendon transfer to restore active external rotation of the shoulder becomes the main surgical alternative. The purpose of this manuscript is to describe the surgical technique of the lower trapezius muscle transfer to the infraspinatus muscle, to restore active shoulder external rotation in the child with paralytic shoulder, step by step with details and pearls.

The lower trapezius transfer: a systematic review of biomechanical data, techniques, and clinical outcomes

BACKGROUND

Lower trapezius (LT) transfers were originally described to restore external rotation (ER) in the management of brachial plexus palsy; however, there is recent interest in the role of this transfer to restore shoulder function, specifically ER, in patients with a massive irreparable rotator cuff tear (RCT). The purpose of this systematic review is to summarize the current literature pertaining to LT transfers, including biomechanics, techniques, and clinical outcomes for patients with brachial plexus palsy and massive RCTs.

METHODS

MEDLINE, EMBASE, and PubMed were searched for biomechanical and clinical studies, as well as technique articles. Four biomechanical studies reported on moment arms, range of motion (ROM), and force vectors. Seven clinical studies reported postoperative ROM and functional outcomes, and weighted mean improvements in ROM were calculated.

RESULTS

Overall, 18 studies were included, and then subdivided into 3 themes: biomechanical, technique, and clinical. Biomechanical studies comparing LT and latissimus dorsi (LD) transfers observed an overall larger moment arm in abduction and ER in adduction for the LT transfer, with similar results in forward elevation. Clinical studies noted significant improvement in shoulder function following the LT transfer, including ROM and functional outcome scores. There were several described techniques for performing the LT transfer, including arthroscopically assisted and open approaches, and the use of both allograft and autograft augmentation.

CONCLUSION

This study suggests that the LT transfer is generally safe, and the clinical and biomechanical data to date support the use of the LT transfer for restoration of function in these challenging patient populations.