Transfer of the Trapezius to the Deltoid for Treatment of Shoulder Instability after Lesions of the Brachial Plexus

doi:10.4236/ss.2013.410090

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Surgical Science, 2013, 4, 459-463

http://dx.doi.org/10.4236/ss.2013.410090 Published Online October 2013 (http://www.scirp.org/journal/ss)

Transfer of the Trapezius to the Deltoid for Treatment of

Shoulder Instability after Lesions of the Brachial Plexus*

Antônio L. Severo1#, Philipe E. C. Maia1, Marcelo B. Lemos1, Paulo C. F. Piluski1,

Osvandré L. C. Lech1, Walter Y. Fukushima2

1Department of Hand and Microsurgery, Institute of Orthopedics and Traumatology (IOT), Passo Fundo, Brazil

2Faculty of Medicine of ABC, Santo André, Brazil

Email: #[email protected]

Received May 20, 2013; revised June 18, 2013; accepted June 26, 2013

cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Objective: To clarify the indications and to describe the surgical technique and outcomes of surgery involving transfer

of the trapezius to the deltoid for the treatment of lesions of the brachial plexus in patients with multidirectional

instability in the sh oulder. Method: In 17 patients (mean age, 23 years) operated at São Vicente de Paulo Hospital and

the Institute of Orthopedics and Traumatology of Passo Fundo, Brazil from 1999 to 2009, we performed trapezius

transfer to the proximal humerus. In these patients, the mean interval between trauma and surgery was 8 months.

Results: Functional improvement and resolution of multidirection al instability of the shou lder were observed in all the

patients. No patient showed immediate postoperative complications. The mean active mobility was as follows: 95˚

flexion, 50˚ abduction, 45˚ external rotation, and internal rotation at the level of the first lumbar vertebra (L1). The

trapezius muscle strength was classified as grade III, and the UCLA functional outcome was 22 points. The

postoperative satisfaction was excellent, and occasional pain and weakness was reported by all the patients. Conclusions:

Transfer of the trapezius muscle to the proximal humerus provides better results in patients with a more than 6-month-

old lesion. This procedure also preserves passive mobility of the limb, confers shoulder stability, provides active

mobility, and prevents osteo arthrosis.

Keywords: Brachial Plexus Lesion; Shoulder Instability; Trapezius Transfer; Active Mobility; Shoulder Stability

1. Introduction

Thus far, no consensus has been reached regarding the

treatment of instability of the shoulder secondary to bra-

chial plexus lesion. There are, however, a few available

treatment options. Neurotization and nerve grafting are

the best treatment options for acute injury [1-5]. Since

the occurrence of the choice, if it is too late to undergo

nerve reconstruction surgery, muscle transfer and ar-

throdesis remain the only treatment options [6-8].

Muscle transfer was first performed in 1927 by Mayer

for the treatment of poliomyelitis sequels [9]. In 1967,

Saha [10], in his monograph, described in detail the

technique for trapezius transfer, using a modification of

the procedure originally described by Bateman [11].

Muscle transfer enhances the function and stability of the

shoulder in paralysis of the deltoid and supraspinatus

[12]. The other treatment option, arthrodesis, also re-

stores stability; howev er, its indication is limited and it is

less suitable as the first treatment option for treatment in

cases of paralysis of the deltoid [5,13].

The aim of this study was to clarify the indicatio ns and

to describe the surgical technique and outcomes of the

transfer of the trapezius to the deltoid after brachial

plexus lesion in patients with shoulder instability.

2. Subjects and Methods

Seventeen patients (14 men and 3 women) with a bra-

chial plexus lesion of traumatic origin underwent transfer

of the trapezius to the proximal humerus at São Vicente

de Paulo Hospital and the Institute of Orthopedics and

Traumatology of Passo Fundo, Brazil between 1999 to

2009 The average age of the patients was 23 years (age

*Study performed at the Institute of Orthopedics and Traumatology

(IOT) and the University Hospital São Vicente de Paulo, Passo Fundo/

RS, in association with the Faculty of Medicine of ABC, Santo André/

SP-Brazil.

#Corresponding author.

range, 17 - 37 years), and the median follow-up period was

12 months (range, 8 - 24 months). The average interval

A. L. SEVERO ET AL.

460

between trauma and surgery was 8 months (6 - 10

months).

Preoperative evaluation included a physical examina-

tion, radiography, and electroneuromyography (ENMG).

All patients presented with shoulder instability, normal

passive mobility, moderate pain, and degree zero strength

of the deltoid and supraspinatus muscles. Hand and el-

bow function was normal in all the patients, except in 1,

who showed complete plexus lesion, having previously

undergone nerve reconstruction surgery, only with return

of flexion of the forearm relative to the arm. The active

abduction angle measured between the trunk and arms

varied between 0˚ and 30˚ (average, 4˚). The active flex-

ion varied between 0˚ and 40˚ (average, 10˚). Radiologi-

cal examinations revealed that 1 patient had inferior

glenohumeral luxation and 6 presented with subluxation;

there were no signs of glenohumeral arthrosis in these

patients. In 6 patients, the ENMG showed neurotmesis

C5, C6, and in 1 patient, complete lesion of the brachial

plexus was observed.

Transfer of the trapezius to the deltoid muscle was in-

dicated in patients with shoulder instability secondary to

brachial plexus lesions, in whom nerve reconstruction

surgery was not successful or for whom more than 6

months had elapsed since the occurrence of the injury.

The following conditions were, however, required to be

fulfilled: complete paralysis of the deltoid and supraspi-

natus confirmed by a clinical ENMG examination,

strength level of V degrees of the trapezius muscle, pas-

sive abduction g reater than 80˚, and no signs of arthrosis

in the joints [9]. All patients were clinically assessed

postoperatively by functional criteria of the University of

California at Los Angeles (UCLA) [14].

2.1. Surgical Technique

The patient is placed in a supine position on a beach

chair, and his shoulder is approached by a Y incision,

extending across the tran sverse portion around the shou l-

der over the spine of the scapula and the acromion and

ending just above the coracoid process. The longitudinal

incision is extended distally along the lateral region of

the shoulder and upper arm by 6 cm (Figure 1(a)). The

atrophied deltoid muscle is mobilised and divided. The

soft parts of the underside of the acromion and spine of

the scapula are released.

Then, the spine of the scapula is osteotomised at its

base in an obliquely distal and lateral plane. Thus, a por-

tion of the trapezius distal is released, while it is still at-

tached to the spine and the acromion. Subsequently, 2 cm

of the lateral clavicle is drilled with care to avoid any

injury to the coracoclavicular ligament (Figure 1(b)).

The deep surfaces of the acromion and spine are sub-

jected to curettage, the arm is abducted at 90˚, to the ap-

propriate level in the lateral region of the humerus, the

corresponding area to the insertion of the acromion un-

dergoes curettage. Next, using firm traction, the portion

side of the trapezoid is moved to the humeral head, and

the acromion is fixed to the humerus as distally as possi-

ble, with two 4.5-mm screws (Figure 1(c)). Haemostasis

is carried out, and closure is performed in layers (Figure

1(d)).

2.2. Postoperative Treatment

The arm is immobilized using a brace with the shoulder

abducted at 90˚ (Figure 2). The brace is maintained for 8

- 12 weeks, varying according to the signs of bone heal-

ing. After 4 weeks, the abduction angle is decreased by

10˚ per week, until 30˚ is reached. Th e flexion-exten sion

of the elbow and wrist are stimulated early. After re-

moval of the brace, physical therapy is started to gain

range of motion and strengthen the muscles.

3. Results

In all the patients, a functional improvement and resolu-

tion of shoulder instability was observed. The average

time taken to perfo rm the surgery was 150 minutes, with

blood loss of approximately 200 ml. No patient had

(a) (b)

Figure 1. Illustration of the surgical technique.

Figure 2. Position of the brace at 90˚ of abduction in the

postoperative period.

A. L. SEVERO ET AL.

461

achieved in all cases. Functional improvement and satis-

faction with surgery was achieved in all the patients in

our study. Similar results were obtained in studies per-

formed by Aziz et al. [9], Ruhmann et al. [16,17], Mon-

real et al. [18], Singh et al. [19], and Elhassan et al. [20].

The only contraindication to this technique is severe

glenohumeral arthrosis , which was not encountered in

the current study.

immediate postoperative complications, but in 1 patient,

it was necessary to remove one of the screws within 12

weeks after the operation. The average active mobility

was as follows: flexion 77˚, active abduction 75.8˚, ex-

ternal rotation 57˚, and internal rotation at the first lum-

bar vertebra (L1) (Table 1). The average postoperative

University of California at Los Angeles (UCLA) [14]

functional outcome was 22 points. The functional out-

come according to Ellman’s [15] 4-level scale (excellent,

good, fair, poor) was fair. After surgery, there was a re-

duction in subluxation for all the patients, and the trape-

zius muscle strength was classified as grade III. All the

patients experienced occasional pain and weakness ac-

cording to the same UCLA criteria. The patients were

satisfied with the procedure, despite the “fair” functional

outcome (Figure 3).

Arthrodesis of the shoulder is usually considered in

patients with instability secondary to brachial plexus le-

sion; however, its complications limit its use. The surgi-

cal technique is difficult, surgical procedure is long, and

there is no consensus regarding the ideal position for

fixing the head of the humerus to the scapu la. In addition,

the rates of pseudoarthro sis, fracture, residual pain, repo-

sitioning of the limb, and irreversibility of the procedure

are factors that make it a second option. Cofield and

Briggs [21] reported a 24% incidence of fractures with

arthrodesis, and 15% of them were associated with in-

creasing pain. Richards et al. [6] performed arthrodesis

using an acetabular reconstruction plate with 30˚ abduc-

tion, flexion, and internal rotation. They encountered

very few complications and better results than expected;

however, muscle transfer was indicated in 5 of the 17

patients who underwent the procedure. According to

Goldner [22], muscle transfer should be considered the

first treatment option; therefore, it is indicated in cases of

severe arthrosis, inveterate luxatio n, intractable pain, and

failure of muscle transfers.

Descriptive statistical analysis was conducted using

SPSS 16.0 (2007). Sixteen patients exhibited similar be-

haviour in flexion, abduction, and external rotation, and

only 1 patient with total brachial plexus lesion showed a

comparatively low degree of movement amplitude. The

overall sample average and median were similar for

flexion and abduction (flexion

: 77.06 ± 17.59 and Md:

80.00; abduction

: 75.88 ± 14.60 and Md: 80.00). In

terms of external rotation, a high variation between sam-

ple average and median was observed (

: 57.06 ± 27 .50

and Md: 70.00) (Figure 4).

4. Discussion The development of microsurgery has contributed to

advances in surgery of the brachial plexus. Neurotization

and nerve grafting are proposed to restore the physiology

of the injured region, without causing any anatomical

changes. Recent studies have clarified their indications

and applications [1].

Transfer of the trapezius to the deltoid for the treatment

of deltoid paralysis has several advantages. It is a rela-

tively simple procedure with minimal postoperative

complications. The recovery of glenohumeral stability,

which is an important outcome of this operation, was

Figure 3. Active mobility results in the postope rative period. (A/B) Flexion; (C) Abduction; (D) External rotation; (E) Inter-

al rotation; (F) Cosmetic appearance. n

A. L. SEVERO ET AL.

462

Table 1. Post operatory evaluation of the patients.

Patient Flexion Abduction

External

Rotation Internal

Rotation UCLA

1 70˚ 90˚ 80˚ L1 22

2 80˚ 80˚ 40˚ L1 22

3 60˚ 80˚ 30˚ L3 22

4 90˚ 90˚ 30˚ L1 23

5 90˚ 80˚ 45˚ T10 23

6 60˚ 60˚ 20˚ L5 22

7* 30˚ 30˚ 0˚ 0º 20

8 90˚ 70˚ 80˚ L2 22

9 80˚ 70˚ 80˚ L1 22

10 70˚ 90˚ 80˚ L1 22

11 70˚ 90˚ 80˚ L1 21

12 80˚ 70˚ 70˚ L2 22

13 70˚ 80˚ 80˚ L3 22

14 90˚ 70˚ 70˚ L4 23

15 90˚ 80˚ 80˚ L1 23

16 80˚ 80˚ 80˚ L3 22

17 110˚ 80˚ 25˚ L1 24

Average 77˚ 75.8˚ 57˚ L1 22.17

*Patient with complete lesion of the brachial plexus with early neurotization.

Source: Medical records of the São Vicente de Paulo Hospital and the Insti-

tute of Orthopedics a nd Traumatology of Passo Fundo.

Figure 4. Mobility of the active shoulder in flexion, abduc-

tion, and external rotation in 17 patients undergoing sur-

gery for transfer of the trapezius to the deltoid.

Nagano et al. [1] performed neurotization of the in ter-

jury. According to these authors, surgery is indicated for

patients under 40 years of age and for lesions less than 6

months old, because, after this period, the positive out-

come rate drops to 29.4%. In patients over 50 years of

age and in those injured for more than 10 months, muscle

transfer is recommended.

According to Guyton [2

costal nerve in the case of a brachial plexus avulsio

3] when the muscle is dener-

here is no algorithm for the treatment of

ilar to arthrodesis, the brachial plexus microsur-

5. Conclusion

antages and disadvantages of the tech-

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