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

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.

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.

Lower trapezius transfer with Achilles tendon augmentation: indication and clinical results

Lower trapezius tendon transfer with Achilles tendon allograft augmentation may be used to treat patients with lack of active external rotation following shoulder paralysis or massive irreparable posterosuperior rotator cuff tears. In the setting of shoulder paralysis, the integrity of the ipsilateral lower trapezius may be compromised. In this instance, the contralateral lower trapezius may be used with reasonable results. In the setting of irreparable rotator cuff tears, the procedure may be performed through an open or arthroscopically assisted technique. The latter avoids the need for an acromial osteotomy and risk of nonunion associated with repair of the osteotomy. Both are effective in reversing pseudoparesis or pseudoparalysis. Advanced degenerative changes have an effect on outcomes, resulting in less pain improvement, decreased range of motion, and greater need for reoperation with conversion to reverse total shoulder arthroplasty. Nonetheless, the lower trapezius tendon transfer is an effective option for restoring active external rotation with relatively consistent results.

Nerve fascicle transfer using a part of the C-7 nerve for spinal accessory nerve injury

OBJECTIVE Spinal accessory nerve (SAN) injury results in a series of shoulder dysfunctions and continuous pain. However, current treatments are limited by the lack of donor nerves as well as by undesirable nerve regeneration. Here, the authors report a modified nerve transfer technique in which they employ a nerve fascicle from the posterior division (PD) of the ipsilateral C-7 nerve to repair SAN injury. The technique, first performed in cadavers, was then undertaken in 2 patients. METHODS Six fresh cadavers (12 sides of the SAN and ipsilateral C-7) were studied to observe the anatomical relationship between the SAN and C-7 nerve. The length from artificial bifurcation of the middle trunk to the point of the posterior cord formation in the PD (namely, donor nerve fascicle) and the linear distance from the cut end of the donor fascicle to both sites of the jugular foramen and medial border of the trapezius muscle (d-SCM and d-Traps, respectively) were measured. Meanwhile, an optimal route for nerve fascicle transfer (NFT) was designed. The authors then performed successful NFT operations in 2 patients, one with an injury at the proximal SAN and another with an injury at the distal SAN. RESULTS The mean lengths of the cadaver donor nerve fascicle, d-SCM, and d-Traps were 4.2, 5.2, and 2.5 cm, respectively. In one patient who underwent proximal SAN excision necessitated by a partial thyroidectomy, early signs of reinnervation were seen on electrophysiological testing at 6 months after surgery, and an impaired left trapezius muscle, which was completely atrophic preoperatively, had visible signs of improvement (from grade M0 to grade M3 strength). In the other patient in whom a distal SAN injury was the result of a neck cyst resection, reinnervation and complex repetitive discharges were seen 1 year after surgery. Additionally, the patient's denervated trapezius muscle was completely resolved (from grade M2 to grade M4 strength), and her shoulder pain had disappeared by the time of final assessment. CONCLUSIONS NFT using a partial C-7 nerve is a feasible and efficacious method to repair an injured SAN, which provides an alternative option for treatment of SAN injury.

Restoration of Shoulder Function

Restoration of shoulder function in patients with brachial plexus injury can be challenging. Initial reported efforts were focused on stabilizing the shoulder, improving inferior subluxation and restoring abduction and flexion of the joint. Recent advancements and improved understanding of coordinated shoulder motion and the biomechanical properties of the muscles around the shoulder applicable to tendon transfer have expanded available surgical options to improve shoulder function, specifically external rotation. Despite the advances in reconstructive options, brachial plexus injury remains a serious problem that requires complex surgical solutions, prolonged recovery, and acceptance of functional loss.

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

PURPOSE

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).

METHODS

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 (7 patients) or as part of multiple tendon transfer (5 patients). Standardized patient outcomes measures were obtained.

RESULTS

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.

CONCLUSIONS

This study demonstrated that CLTOT to the infraspinatus tendon was effective in improving shoulder external rotation in patients with BPI.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.