Brachial Plexus Shoulder: Joint Reduction, Tendon Transfers, Humeral and Glenoid Osteotomies



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



Examination Under Anesthesia



  • Before positioning in lateral decubitus, check passive range of motion


  • Adduction (ADD), external rotation (ER)



    • Usually <0° (normal >60°)













  • 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


Surgical Approach (surgical approach ( video) Video)


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

Jun 9, 2022 | Posted by in Reconstructive surgery | Comments Off on Brachial Plexus Shoulder: Joint Reduction, Tendon Transfers, Humeral and Glenoid Osteotomies
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