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 Tao Department of Hand Surgery The First Hospital of Ji Lin University Chang Chun, Ji Lin Province

obstetric brachial plexus palsy Incidence ： %  Incidence ： %  Incomplete Recovery ： 49%-66%  Indication of Microsurgical Neural Reconstruction ： dysfunction of elbow flexion at the age of 3 month dysfunction of elbow flexion at the age of 3 month

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

Pathomechanics Internal Rotator 4 Pectoralis Major Subscapularis Teres Major Latissimus Dorsi External Rotator 2 Infraspinatus Teres Minor Fibrosis, Contracture Loss of Passive ER Palsy Inability of active ER 40% Walch G, et al. The ‘dropping’ and ‘hornblower’s’ signs in evaluation of rotator-cuff tears. JBJS-Br.1998

Shoulder Reconstruction L’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) Diagnosis: C5+C6 (n=5) C5+C6+C7 (n=1) 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

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 55±35.6° 130±24.5° 75°

48.3±22.73° 48° Results

Results

Preoperative: Abduction 70°, ER 0°( Mallet Score 3) Postoperative: Abduction 130°, ER 45°( Mallet Score 4) 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 AbductionER Pre-300 Post-15020

AbductionER Pre-00 Post-9045

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.

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