Outcome analysis of modified teres major and latissimus dorsi transfer in the treatment of

obstetric brachial plexus palsy shoulder sequelae

Gong Xu, Lu Lai Jin, Cui Jian Li, Sun Ru TaoDepartment of Hand Surgery

The First Hospital of Ji Lin UniversityChang Chun, Ji Lin Province

130021

obstetric brachial plexus palsy

Incidence ： 0.1-0.4%

Incomplete Recovery ： 49%-66%

Indication of Microsurgical Neural Reconstruction ： dysfunction of elbow flexion at the age of 3 month

Sequelae of shoulder

C5 ， C6 injuries （ Erb’s palsy ） C5 ， C6 ， +C7 injuries （ Erb’s palsy+C7 ）

loss of active ER

loss of shoulder elevation

Loss of active shoulder elevation and ER can lead to simple tasks, such as shaking hand, combing, brushing teeth, becoming impossible due to the inability of controlling the spatial positioning of the arm .

Sequelae of shoulder

PathomechanicsInternal Rotator 4 Pectoralis Major

Subscapularis

Teres Major

Latissimus Dorsi

External Rotator 2 Infraspinatus

Teres Minor

Fibrosis , Contracture

Loss of Passive ER

PalsyInability of active ER

40%

Walch G, et al. The ‘dropping’ and ‘hornblower’s’ signs in evaluation of rotator-cuff tears. JBJS-Br .1998

Shoulder ReconstructionL’Episcopo Transfer ( 1934)

Anterior Approach ： Releasing Pectoralis Major and Subscapularis Muscles

Posterior Approach ： Transfer Teres Major & Latissimus Dorsi muscles

Reinserting conjoint tendon on humeral shaft

Nath (2007)

Axillary Approach

Releasing Pectoralis Major and Subscapularis Muscles

Conjoint tendon suturing to Teres Minor

Shoulder Reconstruction

Background

We modified Teres Major & Latissimus Dorsi transfer, from original L’Episcopo’s and

Nath’s procedures, to reconstruct shoulder function.

The deltopectoral approach to release contracted subscapularis, pectoralis major and

conjoint tendon of the teres major and latissimus dorsi

The posterior approach to reinsert the conjoint tendon to the belly of the teres minor

Background

To retrospectively analyze the outcomes and related factors of modified teres major and

latissimus dorsi transfer in the treatment of obstetric brachial plexus palsy (OBPP)

shoulder sequelae.

Materials and Methods

General Conditions

From 2008 to 2011

six patients with OBPPs, aged from 16 months of age to 16 years of age.

2 males and 4 females

Left: 3, Right: 3

No primary microsurgical reconstruction

Diagnosis: C5+C6 (n=5)

C5+C6+C7 (n=1)

Materials and Methods

The pre- and postoperative active shoulder abduction and ER were recorded and

evaluated according to Mallet’s classification.

Comparison between the pre- and postoperative was performed by t-test.

Operative methods

Operative methods

Operative methods

Operative methods

The upper extremities were immobilized for 6-8 weeks in the position of

abduction 90 degrees and ER 45 degrees except for two patients in the

position of adduction and internal rotation.

All patients were followed for 3 to 22 months.

Postoperative Management

Results

Pre- Post-

Shoulder Ab-duction

55±35.6°

130±24.5°

75°

Pre- Post-

External Rotation

48.3±22.73°

48°

Results

Pre- Post-

Mallet Score (ER)

2.5

4.3

Results

Preoperative: Abduction 70°, ER 0°( Mallet Score 3)

Postoperative: Abduction 130°, ER 45°( Mallet Score 4)

Typical Cases

Typical Cases

Preoperative: Abduction 90°, ER 0°( Mallet Score 3)

Postoperative: Abduction 160°, ER 90°( Mallet Score 5)

Typical Cases

Preoperative: Abduction 50°, ER 0°( Mallet Score 3)

Postoperative: Abduction 130°, ER 45°( Mallet Score 5)

The position of postoperative Immobilization can influence outcomes of ER

2 patients were immobilized in shoulder adduction and internal rotation

Abduction ER

Pre- 30 0

Post- 150 20

Abduction ER

Pre- 0 0

Post- 90 45

Conclusion

Modified teres major & latissimus dorsi transfer can improve shoulder

abduction and ER by increasing stability of the glenohumeral joint.

The postoperative immobilization position can influence the improvement

of shoulder ER.

谢 谢