Brachial Plexus Shoulder: Joint Reduction, Tendon Transfers, Humeral and Glenoid Osteotomies
Andrea S. Bauer
Tendon Transfer—Lengthening and Joint Reduction
Pectoralis major musculotendinous lengthening
Subscapularis partial lengthening or slide, open or arthroscopic
Latissimus dorsi (LD) and teres major (TM) tendon transfer
Open anterior-inferior capsulotomy and glenohumeral joint reduction
Posterior capsular reefing
Operative Indications
Internal rotation (IR) contracture unresponsive to aggressive therapy (Figure 10.1)
External rotation weakness despite sufficient neural recovery time
Subluxated or dislocated humeral with glenohumeral deformity on MRI scan (Figure 10.2)
Age range can be as young as 6 to 12 months when there is rare infantile dislocation
Operative age usually 18 months to 3 years in a dysplastic shoulder which is unresponsive to therapy
Surgery tailored to each patient in terms of releases, lengthenings, transfers, and joint reduction
Final Decision on Extent of Reconstruction Made During Operative Care
Equipment
Bean bag for lateral decubitus positioning
Gel pads, axillary rolls, pillows, and head support for safe positioning
Standard fine instrument dissecting kit
Nonabsorbable suture for transfer insertions
2.7 mm arthroscope and ipsilateral biter for arthroscopic subscapularis release
Examination Under Anesthesia
Before positioning in lateral decubitus, check passive range of motion
Adduction (ADD), external rotation (ER)
Usually <0° (normal >60°)
Figure 10-1 ▪ Child with an internal rotation contracture of the right shoulder. (Courtesy of Shriners Hospitals for Children, Northern California and Children’s Orthopaedic Surgery Foundation.)
Figure 10-2 ▪ Axial MRI image demonstrating a normal right glenohumeral joint and a dysplastic left glenohumeral joint. (Courtesy of Children’s Orthopaedic Surgery Foundation.)
Abduction (ABD), ER
Usually <90° (normal >120°)
Scapulohumeral angle
Usually <135° (normal >150°)
Check for glenohumeral joint dislocation, instability, or reducibility
These measurements will be repeated throughout stepwise surgery to determine extent of releases, lengthenings, and joint reduction and stability with each step
Positioning
Lateral decubitus position with the affected side up
Care taken to protect all bony prominences and neurovascular structures including:
Peroneal nerves (especially downside)
Unaffected downside brachial plexus
Cervical nerve roots with padded head position without tension
Entire affected arm, axillae, shoulder girdle including entire scapula prepped
Entire scapula must be visible in operative field to allow accurate assessment of scapulothoracic versus glenohumeral motion
Techniques in Steps
Axillary Exposure and Pectoralis Major Lengthening (Figure 10.3A and B)
Transaxillary from edge of anterior pectoralis major to posterior extent axillary crease
Incision carefully placed in axillary line for aesthetic result
Can be modified to 2 incisions: small anterior and larger posterior incisions if joint reduction not required
Elevate skin and subcutaneous flaps protecting intercostobrachial nerve branches in midline of incision
Identify pectoralis major anterior edge and dissect underneath tendon to insertion site
Separate pectoralis major from underlying coracobrachialis, pectoralis minor, and short head of biceps inserting into coracoid
Protect musculocutaneous nerve deep
Identify and palpate tight, thickened tendon
Release sharply with knife or cautery only the tight, thickened tendon near insertion
Preserve pectoralis major muscle
Visualize slide of musculotendinous junction
Reassess ABD-ER ROM, which improves beyond vertical as desired
ADD-ER may improve but usually not
Humeral head may now be reducible but usually not
Posterior Exposure and LD-TM Transfer
Dissect carefully in axillae to expose LD and TM muscle insertion
Protect brachial plexus anterior to latissimus tendon
Protect axillary nerve underneath tendons as it transverses quadrilateral space
D and TM tendons are more posterior than triceps tendon, but can be confused especially for the uninitiated surgeon not used to operative exposure of shoulder through axillae in sidelying position with arm elevated and abducted for exposure
Triceps tendon heads to infraglenoid tubercle
D and TM tendons head to humeral shaft and lie anterior to triceps
IR positioning of humerus aids in exposure
Release LD and TM tendons from humeral insertion periosteum
LD and TM often conjoint in young and often transferred together
Takedown of insertion needs to be very close to periosteum
Protects underlying axillary nerve and circumflex vessels
Maintains sufficient tendon length for secure transfer insertion
Fully mobilize LD and TM tendons and muscles back to NV pedicle
Carefully release adjacent fascia while protecting all vessels and nerves
Place inverted nonabsorbable horizontal mattress sutures in tendons
Maximize excursion of LD and TM for transfer including release of overlying skin and fascia
Retest passive range of motion (ROM) for ABD-ER and ADD-ER as well as joint stability
If ABD-ER >110° (20° beyond vertical) and ADD-ER >40° with light 2-finger testing; and glenohumeral joint reduced and stable
Extra-articular tendon transfer sufficient and proceed to tendon transfer beneath deltoid into greater tuberosity region
If ADD-ER <20° and joint is not reduced and stable
Proceed to joint capsulotomy, reduction, and subscapularis partial lengthening
Subscapularis Partial Lengthening and Joint Capsulotomy and Reduction
Very, very important NOT to overlengthen subscapularis or overrelease joint
This leads to external rotation posture and loss of IR power
This will become very problematic later if the child cannot reach midline with strength to do buttons, zippers, and other important self-care activities
Subscapularis Mobilization and Lengthening
After release and mobilization of LD and TM, carefully dissect down to subscapularis and glenohumeral joint while protecting brachial plexus
Subscapularis insertion into lesser tuberosity of humerus traversing across anterior and inferior glenohumeral joint can be carefully identified
Elevate subscapularis of glenohumeral joint capsule
This interval is hard to distinguish
Requires use of elevator into interval without entering capsule
Subscapularis mobilization including musculotendinous junction
This can improve ADD-ER > 40° with a reduced and stable joint and if so,
We can progress to LD-TM tendon transfer insertion
If subscapularis mobilization is not sufficient to improve passive ROM, proceed to partial subscapularis musculotendinous lengthening and capsulotomy to reduce humeral head centered on dysplastic glenoid
Again do not overrelease subscapularis
Anterior-Inferior Glenohumeral Joint Release and Reduction
If ADD-ER contracture persists with dislocated humeral head
Elevate subscapularis mobilization off capsule
Start sequential capsular release while testing reduction and motion
Be careful not to injure labrum or articular cartilage
Again be careful not to overrelease anterior-inferior capsule that results in ER posture and IR weakness
Once 2-finger testing of ADD-ER exceeds 60° and joint is reduced, progress to tendon transfer insertion
LD-TM Tendon Transfer Insertion
Dissect interval beneath deltoid to greater tuberosity
Be aware of and protect axillary nerve course and insertion into deltoid as you dissect to supraspinatus, infraspinatus tendon insertions into greater tuberosityStay updated, free articles. Join our Telegram channel
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