For improvement of shoulder function and stability in paralysis of the deltoid and supraspinatus muscles, shoulder arthrodesis is recommended, as well as diverse muscle transpositions, in particular, the trapezius transfer procedure.

Paralysis of the infraspinatus muscle with loss of external rotation can be partially compensated by the transplantation of the teres major muscle alone or in combination with the latissimus dorsi muscle, also with external rotation osteotomy of the humerus.

For reconstruction of the elbow flexion, transposition of the forearm flexors and extensors of the triceps muscle, the pectoralis muscle, the latissimus dorsi muscle, and free muscles was performed.

Loss of dorsal extension in the wrist can be reconstructed by means of a transposition of the flexor carpi ulnaris to the tendons of extensor digitorum. Improvement of abduction function of the thumb can be achieved by transposition of the palmaris longus to extensor pollicis longus. Additionally, arthrodesis of the wrist can also be performed.

A decisive factor to be taken into account for the choice of secondary operation is the specific neurological-muscular defect, the passive joint function and bony deformities.

Our integrated therapy concept for brachial plexus lesions is presented here with 144 operations performed according to the individual forms of paralysis.

Patients and Methods

Between 04/1994 and 05/2001, we examined and advised a total of 521 patients who presented with brachial plexus lesion at an interdisciplinary neurosurgical-orthopaedic plexus consultation. Between 04/1994 and 12/2000, 109 of these patients underwent 144 reconstructive operations according to our differential therapy concept. 17 female and 92 male patients, all with plexus lesion were treated; 94 of these patients were involved in a traffic accident, 6 underwent trauma at birth, 5 from iatrogenic influence and 4 due to other causes. The mean age at the time of accident was 26 (0-60), at the time of operation 32 (15-59) years, with an interval between accident and secondary operation of, on average, 81 (1-450) months. 76 patients had already undergone neurosurgical procedures (17 neurolysis, 59 reconstructive surgery). In order to improve shoulder function and stability, 23 shoulder arthrodeses, 74 trapezius transfers and 9 rotation osteotomies of the humerus were performed. Reconstruction of elbow flexion was carried out by transposition of the triceps muscle (9), forearm flexors, respectively, extensors (8), latissimus dorsi muscle (7) as well as pectoralis major muscle (1), and, teres major muscle (1). To improve dorsal extension in the wrist, 10 patients underwent transposition of flexor carpi ulnaris to the tendons of extensor digitorum. Additionally, 3 patients underwent transposition of palmaris longus to extensor pollicis longus and 2 patients a wrist arthrodesis. Reconstructive surgery on one joint only was carried out in 82 patients, on two joints in 23 patients and finally, in 4 patients for shoulder, elbow and hand.

The aim of our concept was to initially improve the condition of the shoulder region to allow the patient control of the arm and, with further treatment, resulting finally in improved function of elbow and hand . Reconstructive surgery to the elbow and hand is only carried out after any necessary secondary operations to the shoulder.

Since secondary operations can only be indicated in connection with the bony condition and the individual neurological-muscular defect, the grade of muscle power of all muscles of the affected extremity was elvaluated in all patients prospectively and an appropriate therapy concept drawn up.

Follow-up period for all 144 operations performed was, on average, 22 (6-74) months, for the individual procedures, on average, between 15 and 32 months.

Results

Muscle status of shoulder
In over 80% of cases, the deltoid muscle, supraspinatus muscle, infraspinatus muscle and teres minor muscle showed evidence of insufficient grade of muscle power of 0-2 in the region of the shoulder. This resulted in reduced stability of shoulder with humeral head subluxation together with loss or limitation of abduction, forward flexion and external rotation, thus requiring shoulder arthrodesis, trapezius transfer and/or rotation osteotomy of the humerus. The necessary muscles required for trapezius transfer (trapezius muscle) and for shoulder arthrodesis (trapezius, levator scapulae, serratus anterior, rhomboids) indicated sufficient grade of muscle power of 4-5 in over 90% of cases.

Shoulder arthrodesis
As a result of shoulder arthrodesis, the active abduction increased, on average, from 10° to 57° (30°-80°) and forward flexion from 12° to 58° (20°-105°). 21 (92%) patients were content with the result of their operation. In particular, most important for the patients was the achieved stability in the shoulder joint together with a return of control over the arm and improved active function.

Trapezius transfer
The trapezius transfer resulted in an increase of active abduction, on average, from 7° to 36° (5°-90°) and of forward flexion from 12° to 31° (5°-90°). 69 patients (93%) with previous multidirectional shoulder instability reported a more stable condition of shoulder following surgery. Passive mobility in the glenohumeral joint showed no significant decrease following operation. 70 (94%) patients reported to be subjectively satisfied with the increase of shoulder stability and function.

External rotation osteotomy of humerus
The average preoperative existing external rotation deficit of 37° (10° deficit to 40° deficit) could be improved by rotation osteotomy of the humerus by 42° to 6° external rotation (10° deficit to 40° external rotation). Preoperatively, all patients were hindered by striking of the forearm against the thorax on flexion of the elbow. This condition was eliminated by the operation so that all patients were satisfied with the newly acquired function of the arm.

Muscle status of elbow
In more than 60% of cases, the elbow flexors showed insufficient grade of muscle power of 0-2 on flexion. The following muscles with a grade of muscle power of 4-5 are considered suitable for a transfer operation: triceps muscle – 35%, pectoralis major muscle – 35%, latissimus dorsi muscle – 34%. On transposition of the medial epicondyle, a total of 5 muscles are transferred. These muscles showed a necessary grade of power of 4-5 as follows: pronator teres muscle – 44%, flexor carpi radialis muscle – 50%, palmaris longus muscle – 55%, flexor digitorum superficialis muscle – 54%, flexor carpi ulnaris muscle – 50%. The muscles necessary for the proximalization of the lateral epicondyle do not often possess the required grade of muscle power: extensor carpi radialis muscle – 27%, extensor digitorum muscle – 29%, extensor carpi ulnaris muscle – 26%.

Transposition of medial or lateral epicondyle (Steindler flexorplasty)
Transposition of the medial, respectively, lateral epicondyle to the distal humerus (Steindler procedure) resulted in an active elbow flexion of, on average, 91° (70°-110°) with a muscle power of 3-4 in all patients. The outcome was an average extension deficit of 10° (0°-30°). 5 patients reported a good result and 3 satisfactory.

Triceps-biceps transfer
Triceps to biceps transposition resulted in an active elbow flexion of 113° (85°-140°) with a remaining 4° extension deficit. 4 patients underwent transposition due to previous co-contraction of both muscles. Postoperative grade of muscle power for flexion was 3-5. 2 patients were very content with the outcome, 6 pronounced the result as good and 1 as satisfactory.

Latissumus dorsi/pectoralis major/teres major transfer
4 of the 7 patients contracted an infection following latissimus dorsi transfer which led to explantation of the transferred muscle. This resulted in a corresponding negative outcome on transplantation of a non-local muscles. The postoperative elbow flexion achieved was, on average, only 46° (0°-90°). Following one transfer involving the teres major muscle and one with the pectoral major muscle, plus a latissimus transfer in 2 cases with no infection, each achieved a flexion of 90°. Subjectively, 4 patients were happy with the result and 5 were not.

Muscle status of hand
The hand and finger extensors showed a grade of muscle power of 0-2 in over 65%, demonstrating insufficient function; the flexors were less often affected with 42%-49%. The abductor pollicis longus muscle showed insufficient grade of muscle power in 47%. The flexor carpi ulnaris muscle used by us for reconstruction of the hand and finger extension showed in 50% of cases sufficient grade of muscle power, the palmaris longus muscle (transfer to extensor pollicis longus) in 55% of cases.

Transposition operations to hand
By transposition of flexor carpi ulnaris to the tendons of extensor digitorum, the preoperative marked wrist drop was eliminated in all cases with an average dorsal extension of wrist (finger extended) of 31° (0°-70°) and a muscle power of 3-4 (Fig. 9). The patients concluded the outcome as mostly positive; 1 as excellent, 7 good, 1 satisfactory and another poor. Transposition of palmaris longus muscle to extensor pollicis longus muscle led to improvement of thumb abduction of 10°, 60° and 20°. All patients were content with the results.

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