Download Pectoralis major inverse plasty for functional reconstruction in

yes no Was this document useful for you?
   Thank you for your participation!

* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project

Document related concepts

Scapula wikipedia , lookup

Muscle wikipedia , lookup

Smooth muscle tissue wikipedia , lookup

Myocyte wikipedia , lookup

Anatomical terminology wikipedia , lookup

Skeletal muscle wikipedia , lookup

Pectoralis major inverse plasty for functional
reconstruction in patients with anterolateral
deltoid deficiency
H. Resch,
P. Povacz,
H. Maurer,
H. Koller,
M. Tauber
From University
Hospital of Salzburg,
Salzburg, Austria
„ H. Resch, MD, Trauma
Surgeon, Professor, Head of
„ P. Povacz, MD, Trauma
„ H. Koller, MD, Trauma
„M. Tauber, MD, Trauma
Department of Traumatology
and Sports Injuries
University Hospital of Salzburg,
Muellner Hauptstrasse 48, 5020
Salzburg, Austria.
„ H. Maurer, MD, Anatomist,
Associate Professor
Institute of Anatomy,
University Hospital of
Innsbruck, Muellerstrasse 59,
6020 Innsbruck, Austria.
Correspondence should be sent
to Dr. M. Tauber;
e-mail: [email protected]
©2008 British Editorial Society
of Bone and Joint Surgery
19804 $2.00
J Bone Joint Surg [Br]
Received 8 June 2007;
Accepted after revision 25
January 2008
VOL. 90-B, No. 6, JUNE 2008
After establishing anatomical feasibility, functional reconstruction to replace the
anterolateral part of the deltoid was performed in 20 consecutive patients with irreversible
deltoid paralysis using the sternoclavicular portion of the pectoralis major muscle. The
indication for reconstruction was deltoid deficiency combined with massive rotator cuff tear
in 11 patients, brachial plexus palsy in seven, and an isolated axillary nerve lesion in two. All
patients were followed clinically and radiologically for a mean of 70 months (24 to 125). The
mean gender-adjusted Constant score increased from 28% (15% to 54%) to 51% (19% to
83%). Forward elevation improved by a mean of 37º, abduction by 30º and external rotation
by 9º.
The pectoralis inverse plasty may be used as a salvage procedure in irreversible deltoid
deficiency, providing subjectively satisfying results. Active forward elevation and abduction
can be significantly improved.
In a normal shoulder the deltoid represents the
muscle of power, not movement,1,2 and provides 50% of the power for elevation of the
arm in the scapular plane.3,4 Whereas patients
with massive rotator cuff tears can exhibit full
overhead elevation of the glenohumeral joint,
especially after a rehabilitation programme,
injury to the deltoid is poorly tolerated. Dysfunction of the anterior portion alone may preclude any overhead activity. In patients with
both deltoid paralysis and rotator cuff deficiency, shoulder function is very poor, requiring reconstructive surgery. The main causes of
deltoid paralysis are traumatic or idiopathic
lesions of the brachial plexus, isolated paralysis of the axillary nerve caused by anterior
shoulder dislocation, iatrogenic damage to the
deltoid muscle or its associated nerve, sustained during surgery to the shoulder,5 and the
now rare poliomyelitis. Options for treatment
depend on the underlying pathology and
include arthrodesis of the shoulder,6-11 muscle
transfer procedures and neural microsurgical
techniques.12-14 Because of the high associated
complication rate,8,11 loss of movement, irreversibility, and the fact that outcome is often
poor,9 arthrodesis should be the last choice.
Microsurgical techniques are indicated in cases
of brachial plexus or axillary nerve lesions.
The outcome, however, is unpredictable and
may not be determined for several years. For
functional reconstruction of the deltoid, sev-
eral muscle transfer techniques have been
described including the use of the trapezius
muscle,15-19 the long head of triceps,20 the long
head of the triceps combined with the short
head of the biceps,21 latissimus dorsi,22-24 pectoralis major,25 the intact posterior portion of
the deltoid muscle as replacement for the deficient anterior part,21,26 and a combined transfer of muscles such as pectoralis major,
trapezius and teres major27,28 or teres major,
levator scapulae and latissimus dorsi.29
The muscle mostly used for functional
reconstruction is trapezius. The typical indication for this procedure is a flail shoulder. Restoration of glenohumeral stability with
reduction of the inferior subluxation, and
moderate improvement of shoulder function
have been reported.15,17,30,31 However, the
function of trapezius might be poor, particularly where there is associated rotator cuff deficiency. Phylogenetically, pectoralis major is the
most suitable muscle for replacement of the
deltoid, particularly its anterior portion,
because of its similar direction, origin and
insertion. Thus, it may be used in anterior and
lateral deltoid deficiency. The main reason why
this muscle has been rarely used for this purpose previously is because of its vulnerable
neurovascular supply, which enters close to the
insertion of the clavicular portion, is quite
short, and makes direct transposition of the
muscle impossible. In rotating the muscle
Table I. Aetiological factors leading to deltoid deficiency
Deltoid paralysis + MRCT* (group 1) Skiing
Rotator cuff repair
Refixation of greater tuberosity 1
Brachial plexus palsy (group 2)
Birth trauma
Cervical spine fusion
Isolated axillary nerve (group 3)
Mountain biking
* MRCT, massive rotator cuff tear
around its root in such a way that the undersurface
becomes the surface, this anatomical problem can be
avoided. Before introducing this procedure, an anatomical
study on the pectoralis major muscle and its applicability to
deltoid reconstruction was performed.
The purpose of this anatomical and prospective, controlled clinical study was to evaluate the surgical feasibility and
clinical outcome after functional reconstruction using
pectoralis inverse plasty in patients with deltoid deficiency.
The surgical technique and anatomical characteristics are
Patients and Methods
An anatomical study was initially carried out to investigate
the feasibility of using pectoralis major as an active transplant to replace the deltoid, focusing on the vascularisation,
innervation and insertion of the muscle. In a total of 40
formalin-fixed shoulders (20 cadavers) pectoralis major
was examined, in particular the topography of the nerve
and blood supply and the proportions of the muscle. The
sizes of the three divisions of the muscle were measured to
establish which parts could be used to replace the anterior
and lateral aspects of the deltoid muscle.
Patient data. Between January 1996 and December 2004,
20 patients (13 men, seven women) underwent reconstruction of the deltoid using the sternoclavicular part of pectoralis major. All were included in this prospectivelycontrolled study after the anatomical feasibility of this technique had been proved. Criteria for inclusion were: failed
neurosurgical treatment, which included neurolysis of the
axillary nerve or brachial plexus, and neural anastomosis
or interposition; failure of intensive conservative treatment;
clinical and neurological evidence of deltoid paralysis without electromyographic signs of reinnervation; and an
intact, strong pectoralis major. The procedure was not
undertaken in patients with brachial plexus lesions where
involvement of the clavicular fibres of pectoralis major
caused atrophy. Any clinical or electromyographic evidence
of denervation of the clavicular fibres was an absolute
contraindication. Thus, it was not feasible in patients with
a complete brachial plexus palsy involving C5, C6 and C7.
Minimal remaining innervation of the clavicular fibres is a
prerequisite for a successful outcome.
The mean follow-up time was 70 months (24 to 125). The
mean age of the patients at the time of the procedure was 52
years (22 to 76). In 14 patients the right shoulder was
involved, and in six the left. The dominant side was affected
in 14 cases. The mean time between the onset of symptoms
of deltoid deficiency and the operation was 47 months (8
months to 24 years). An electromyographic examination of
pectoralis major was performed in all cases pre-operatively
and at follow-up. Normal electromyographic activity was a
basic requirement for reconstructive surgery.
The underlying disability requiring reconstruction was
irreversible loss of deltoid function, of either the whole
muscle or just the anterior or anterolateral portion. A total
of 11 patients (55%) had an associated massive rotator cuff
tear (group 1), seven (35%) had a brachial plexus lesion
(group 2), and two (10%) had an isolated axillary nerve
lesion (group 3). Thus, in 18 patients (90%) neither the deltoid muscle nor the rotator cuff was functioning. The aetiology of the deltoid deficiency was traumatic in 11 cases
(55%), iatrogenic in eight (40%) and idiopathic in one
(5%). Table I shows the aetiological factors. Of the 11
patients with a massive rotator cuff tear, five had primary
closed reduction of a glenohumeral dislocation without a
subsequent attempted repair of the rotator cuff, whereas
five had undergone repair of the rotator cuff at least once
previously. In one patient with an irreparable rotator cuff,
there was marked atrophy of the deltoid reconstruction.
Two patients (10%) with brachial plexus palsy had undergone previous attempted reconstruction using the trapezius
muscle, which had failed. Two patients (10%) had undergone hemiarthroplasty.
Surgical technique. A long deltopectoral incision is used,
starting approximately 3 cm above the middle of the clavicle and passing towards the insertion of the deltoid muscle.
Subcutaneously, the anterior part of the deltoid and the
Fig. 1
Fig. 2
The clavicular portion and the upper third of the sternocostal portion of pectoralis major are used. The broken line marks the inferior border of the muscle flap, whereas the black point indicates
the pivot point of the neurovascular bundle.
After detachment of the clavicular and the upper 5 cm of the sternocostal origin of pectoralis major and identification of the neurovascular bundle, the clavicular portion is further prepared from medial to
lateral. The muscle flap is turned laterally, covering the acromion and
the anterolateral aspects of the deltoid. The branches of the lateral
pectoral nerve are now visible on the under-surface of the muscle
flap, which is turned through 180°. Holes in the lateral clavicle and
distal to the humeral insertion are drilled for later transosseous fixation of the flap.
clavicular and superior parts of the sternal portion of the
pectoralis major are exposed, the latter to its insertion into
the sternum. As much of the origin of the muscle as is
required for the reconstruction is exposed. This includes the
whole of the clavicular portion and approximately 5 cm of
the superior part of the sternal portion (Fig. 1). The incision
is extended distally by approximately 5 cm in the midline in
order to detach the sternal portion of the muscle from the
sternoclavicular joint. In the first cases the muscle was
detached subperiosteally; we now include chips of bone
from the sternum, so that stable bony attachment to the
acromion may be achieved.
The muscle is carefully detached from the capsule of the
sternoclavicular joint without opening it. Detachment of
the muscle is started medially at the sternum and sternoclavicular joint and then proceeds to the clavicle. From
medial to lateral, the undersurface of the muscle is exposed
more and more until finally the thoracoacromial artery and
lateral pectoral nerve are encountered near the lateral edge
of the muscle. The flap is then rotated 180° around the
neurovascular pedicle so that the under-surface of the muscle is facing upwards, with the branches of the nerve and
the vessels (Fig. 2). The clavicular part of the flap is now
reattached to the lateral aspect of the clavicle, where, after
abrasion of the anterosuperior surface, several transosseous
holes are drilled. The atrophied deltoid muscle is left and is
not detached. With the arm in slight flexion at approximately 30°, the pectoralis major muscle is re-attached to the
clavicle using a number of strong non-absorbable transVOL. 90-B, No. 6, JUNE 2008
osseous sutures. On the lateral side, the former sternal part
is attached to the acromioclavicular joint, the scapular
spine, and the acromion, depending on the tension of the
muscle. Sometimes, an additional skin incision is required
for better exposure of this area.
Finally, the whole insertion of pectoralis major is detached
from the humeral shaft together with bony chips, with the
arm in slight flexion of 30°, and is re-attached approximately
2 cm to 3 cm distally in order to give the transposed muscle
more tension (Fig. 3). In patients suffering from brachial
plexus palsy the tendon is re-attached not only more distally,
but also more medially to avoid uncontrolled internal rotation. Post-operatively the arm is immobilised in a sling for
four weeks, during which time only passive exercises for
abduction, flexion and internal rotation are allowed in order
to avoid shoulder stiffness. Additionally, electrical stimulation therapy is applied directly over the transposed muscle.
The sling is then removed and increasing active assisted
range of movement exercises in all planes are begun. Full
loading of the shoulder is permitted after 12 weeks.
Evaluation. No patient was lost to follow-up. The Constant
score32 with gender adjustment was used for clinical assessment. Active abduction, flexion and external rotation were
measured in degrees. Internal rotation was graded according to the posterior spinal level the thumb was able to
reach. Pre- and post-operative subjective assessment of the
(0.8 to 2.25) below the clavicle and 9.1 cm (6 to 10.5)
medial to the acromioclavicular joint (Fig. 5). It then
divides immediately into several branches, which run
together with the branches of the artery on the undersurface of the muscle and enter the undersurface of the
muscle supplying the clavicular portion and the superior
half of the sternal portion segmentally. The medial pectoral
nerve (C8-Th1) is responsible for innervation of pectoralis
minor and the inferior part of the sternal portion and the
abdominal portion of pectoralis major.
Size of the various portions. The origin of the clavicular
portion was a mean of 9 cm (6.5 to 13) long, the origin of
the sternal portion 12 cm (10 to 15) long, and the origin of
the abdominal portion 13 cm (10 to 15) long. The craniocaudal extension of the insertion into the humerus was a
mean of 6 cm (5 to 6.5) long.
Ability to transfer parts of the muscle for replacement of the
deltoid muscle. The distance between the site of perforation
Fig. 3
Overview of the completed muscle transposition. The muscle belly is
fixed to the lateral clavicle, acromion and scapular spine by transosseous
sutures. The proximal two-thirds of the tendinous humeral insertion are
also detached with a smooth bone chip and refixed 2 cm to 3 cm distally
by transosseous sutures.
shoulder compared with the unaffected side was graded as
a percentage. The final outcome was graded by the patient
on a visual analogue scale (0 points for not satisfied, 5
points for an excellent result). On the radiographs, inferior
glenohumeral subluxation was evaluated.
Statistical methods. Statistical analysis was undertaken to
assess the outcome. A non-parametric distribution was
assumed and the paired Wilcoxon signed ranks test was
used to evaluate the difference between the pre- and postoperative values. The level of significance was set at
p ≤ 0.05.
Anatomical study
Blood supply. The thoracoacromial artery arises from the
axillary artery and runs beneath and almost exactly in the
middle of the clavicle, from posterior to anterior. It
perforates the clavipectoral fascia at a mean of 1.25 cm (1
to 2) below the clavicle and a mean of 9.5 cm (6 to 11)
medial to the acromioclavicular joint. It then divides into
four branches, the pectoral, acromial, clavicular and deltoid. The pectoral branch divides into between one and
three branches, which again divide into several branches to
supply the muscle segmentally.
Nerve supply. Pectoralis major is innervated by the medial
and lateral pectoral nerves, which arise from the brachial
plexus (Fig. 4). Most of the muscle is supplied by the lateral
pectoral nerve (C5-7), which perforates the clavipectoral
fascia with the thoracoacromial artery at a mean of 1.25 cm
of the thoracoacromial artery and the lateral pectoral nerve
through the clavipectoral fascia and the acromioclavicular
joint was a mean of 9.5 cm (6 to 11); it was a mean of 9 cm
(8 to 12.5) from the sternoclavicular joint. The mean length
of the origin of the clavicular portion was also 9 cm (6.5 to
13), which means that the site of perforation of the neurovascular pedicle was located almost at the lateral edge of
the muscle. This also means that the length of the origin of
the clavicular portion located medial to the neurovascular
pedicle was the same as the length of the clavicular portion
of the deltoid muscle. By turning the clavicular flap of pectoralis major around the neurovascular pedicle laterally, the
entire clavicular portion of deltoid was easily covered.
Owing to the nerve and blood supply being segmental from
proximal to distal, not only could the clavicular portion be
transposed, but also the most superior part of the sternal
portion. Thus, it was possible to cover the clavicular portion of the deltoid muscle as well as some of the anterolateral and lateral portions.
Clinical evaluation. The mean gender-adjusted Constant
score improved from 28% (15% to 54%) pre-operatively to
51% (19% to 83%) post-operatively. This was statistically
significant (p < 0.01). The mean score for the unaffected
shoulder at final follow-up was 100% (85% to 120%). A
total of 17 patients (85%) had improved, but three (15%)
remained unchanged. The mean active forward elevation
increased from 40° (0° to 120°) to 77° (20° to 180°); the mean
active abduction improved from 37° (0° to 90°) to 67° (20° to
180°), and the mean active external rotation improved from
18° (-20° to 60°) to 27° (0° to 70°). The mean active internal
rotation remained unchanged on the sacral level (thigh to XII
thoracic spine level). All improvements in the range of movement were statistically significant (p < 0.01).
The mean visual analogue scale score for satisfaction at
final follow-up was 4 points (1 to 5). The mean selfassessed function of the shoulder compared with the unaffected side increased from 22% (5% to 50%) to 52% (10%
to 90%) at final follow-up.
Fig. 4
The nerve supply of pectoralis major is shown. The lateral pectoral nerve
derives from the lateral cord (C5-7) of the brachial plexus and crosses in
front of the medial pectoral nerve (C8-Th1), which derives from the
medial cord, medially to innervate the largest part of the muscle.
The measurements of the pivot point of the neurovascular pedicle at its
perforation through the clavipectoral fascia are shown (AS, distance
between the acromioclavicular joint and the sternoclavicular joint; PV,
pivot point; AS/PV, intersection AS to the PV; PVC, distance between the
PV and the clavicle).
Table II. Results of the various aetiological subgroups of deltoid paralysis; mean (range)
37 (10 to 60)
71 (30 to 120)
25 (0 to 70)
57 (20 to 90)
105 (90 to 120)
175 (170 to 180)
40 (0 to 120)
77 (20 to 180)
Abduction (°)
40 (30 to 70)
63 (30 to 90)
20 (0 to 50)
42 (20 to 90)
85 (80 to 90)
15 (70 to 180)
37 (0 to 90)
67 (20 to 180)
External rotation (°)
26 (-10 to 50)
31 (10 to 60)
-1 (-20 to 30)
12 (0 to 40)
50 (40 to 60)
63 (55 to 70)
18 (-20 to 60)
27 (0 to 70)
29 (21 to 54)
53 (27 to 82)
103 (97 to 120)
22 (15 to 30)
28 (19 to 58)
98 (85 to 105)
43 (40 to 46)
82 (80 to 83)
98 (95 to 102)
28 (15 to 54)
51 (19 to 83)
100 (85 to 120)
27 (5 to 60)
3.7 (1 to 5)
43 (40 to 45)
5 (5 to 5)
30 (5 to 40)
4 (1 to 5)
Forward elevation (°)
Gender-related Constant score (%)
Unaffected side
Functional improvement (%)
Visual analogue scale (at follow-up)
29 (10 to 50)
4 (1 to 5)
* group 1, deltoid paralysis and massive rotator cuff tear; group 2, brachial plexus palsy; group 3, isolated axillary
The results varied in the different subgroups. In group 1
the mean active forward elevation increased from 37° (10°
to 60°) to 71° (30° to 120°). The mean active abduction
improved from 40° (30° to 70°) to 63° (30° to 90°),
whereas the mean active external rotation increased from
26° (-10° to 50°) to 31° (10° to 60°). In group 2, the mean
active forward elevation improved from 25° (0° to 70°) to
57° (20° to 90°), the mean active abduction from 20° (0° to
50°) to 42° (20° to 90°), and the mean active external rotation from -1° (-20° to 30°) to 12° (0° to 40°). The most
VOL. 90-B, No. 6, JUNE 2008
improvement was seen in group 3. Here, the mean active
forward elevation increased from 105° (90° to 120°) to
175° (170° to 180°), the mean active abduction from 85°
(80° to 90°) to 175° (70° to 180°), and the mean active
external rotation from 50° (40° to 60°) to 63° (55° to 70°).
Table II shows the results of the various aetiological subgroups of deltoid deficiency.
The electromyographic evaluation at follow-up showed
no pathological muscle activity with active contraction of
the transposed muscle in all cases.
Radiological evaluation. There was inferior subluxation of
the humeral head pre-operatively in three cases (15%). All
were in group 2, and two had persistent subluxation postoperatively. In all these cases the Constant score had not
Complications. In one patient, revision surgery was necessary six months after transposition, as no inferior pretensioning on the humeral shaft had been performed. Forward elevation had not improved, and at revision the
humeral insertion was moved distally by approximately
3 cm. At follow-up 38 months later, active forward elevation had increased by 35°, with an adjusted Constant score
of 64%.
In one case the procedure failed and arthrodesis of the
shoulder was undertaken eight months later. The final outcome was deemed moderate with no gain in the adjusted
Constant score of 27%.
In no case was there rupture or avulsion at the distalised
humeral insertion of the pectoralis major.
Irreversible loss of anterolateral deltoid function represents
a severe disability, particularly if combined with a massive
tear of the rotator cuff. In this study there were 11 patients
with this combination. In this context a muscle transfer
procedure aimed at restoring some shoulder function represents a salvage procedure involving replacement of the
anterolateral portion of the deltoid muscle, primarily
improving active forward elevation of the arm. Most
descriptions are of muscle transfer procedures for the treatment of brachial plexus lesions,15,23,26,29,31,33 whereas only
seven of our patients (35%) had this pathology.
Use of the pectoralis major muscle for reconstruction in
deltoid dysfunction was first described by Hildebrandt25 in
1905, in a patient with acute poliomyelitis. He prepared the
sternoclavicular portion of the muscle, rotated it through
90° laterally over the paralysed deltoid muscle, and fixed it
to the acromion and the lateral third of the clavicle. He
reported a successful outcome, with abduction of 90° being
obtained six weeks post-operatively.
Hou and Tai27 described a similar technique to that used
in our patients, undertaken in seven patients with deltoid
dysfunction. The author pointed out the following advantages: first, the transposed muscle improved both abduction and flexion; second, muscular power is in direct
proportion to the muscle mass, so that pectoralis major
with its broad origin can exert a strong force on the narrow
insertion on the humerus; and third, the force of abduction
is enhanced by the increased lever arm. In three of his
patients a combined trapezius and pectoralis major transfer
was undertaken. In addition to transfer of pectoralis major
we distalised the whole pectoral insertion on to the
humerus by approximately 2 cm to 3 cm. Hou and Tai27
described post-operative mobilisation for their patients in
90° of abduction with a frame, whereas we treated our
patients in a normal sling with the arm at the side.
In patients suffering from circumflex nerve palsy,
hypertrophy of pectoralis major may contribute somewhat to the power of forward flexion but the resulting
functional improvement is minimal. Also, in shoulders
with this nerve palsy, pectoralis major acts more as an
adductor and internal rotator than as a flexor of the
shoulder. During contracture of pectoralis major, the arm
moves along the chest wall. Performing the inverse plasty
with lateralisation of the muscle origin changes the direction of contraction, resulting in flexion forces at the glenohumeral joint with only slight internal rotation,
depending on the site of insertion of the transferred
muscle. Thus, there is no risk for loss of function. In contrast, flexion is increased significantly.
In our series, functional improvement was closely related
to the underlying cause of the deltoid deficiency. In a series
of 38 patients with complete brachial plexus palsy the socalled flail shoulder, Rühmann et al31 described improved
mean active abduction of 32° and of active forward elevation by 24° after transposition of the trapezius muscle. In
patients with this pathology (group 2) we achieved more
gain in forward elevation (on average 32°) but less in active
abduction (on average 22°). Kotwal et al30 reported a mean
gain of 60° in active abduction using trapezius. This is
explained by the different biomechanics of the two techniques. In performing the trapezius transfer, its insertion is
moved laterally over the humeral head. The resulting force
leads to abduction of the shoulder mainly in the scapular
plane. However, the main force in the pectoralis inverse
plasty is in a sagittal plane, improving primarily forward
elevation due to an increased lever arm caused by distalisation of the humeral insertion of the sternoclavicular portion
of pectoralis major.
Additionally, in fixing the humeral insertion more medially or laterally, the gain in external or internal rotation can
be controlled. In our series, the gain of active abduction and
flexion in the patients with brachial plexus palsy (group 2)
was similar to that with axillary nerve lesions combined
with rotator cuff deficiency (group 1). This is easy to
explain, as rotator cuff deficiency and brachial plexus palsy
result in the same functional deficiencies of the shoulder.
Aziz et al15 described trapezius transfer for patients with a
flail shoulder after brachial plexus injury, considering it to
be a simple procedure that provided functional improvement and usually eliminated pain. However, in contrast to
arthrodesis of the shoulder, muscle transfer procedures do
not reduce passive movement and keep open the possibility
of further surgical procedures. They are compatible with
the later return of some function to other shoulder girdle
muscles, whereas arthrodesis is an irreversible procedure
allowing no functional benefit if there is any subsequent
return of brachial plexus function.
In the two patients with an isolated axillary nerve lesion
and an intact rotator cuff, almost complete shoulder function could be restored following pectoralis major transfer.
Thus, the functional integrity of the rotator cuff very signifTHE JOURNAL OF BONE AND JOINT SURGERY
icantly influences outcome after reconstruction for anterolateral deltoid deficiency. This was also confirmed by Itoh
et al,24 who used the latissimus dorsi muscle to replace the
paralysed anterior deltoid muscle. In cases where the rotator cuff and biceps were completely paralysed, forward elevation of the shoulder was only to 90° or less, whereas in
patients with some power preserved in the rotator cuff and/
or the long head of the biceps, 110° or more of forward elevation was obtained.
When performing pectoralis inverse plasty, it is essential
to preserve the neurovascular bundle during preparation of
the sternoclavicular portion. The short length of the pedicle
(4 cm to 5 cm) allows for only a limited transposition.
Transferring the muscle laterally, as well as kinking or
twisting the neurovascular pedicle, must be avoided.
Owing to the symmetrical distances of the medial and
lateral aspect of the clavicle to the pedicle, which represents
the rotation centre as well, not much tension is loaded on
the neurovascular pedicle when transposing the muscle.
Stable fixation and adequate tension of the transferred
sternoclavicular portion of the muscle are key biomechanical factors for the restoration of active movement. Ideally
this involves bone-to-bone healing, therefore the origin of
the sternal portion and the humeral insertion are harvested
with smooth bone chips and fixed with transosseous
Patients with poor shoulder function due to irreversible
nerve damage can achieve moderate to good results following this pectoralis major inverse plasty.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
1. Bonnard C, Anastakis DJ, van Melle G, Narakas AO. Isolated and combined
lesions of the axillary nerve: a review of 146 cases. J Bone Joint Surg [Br] 1999;81B:212-17.
2. Narakas AO. Paralytic disorders of the shoulder girdle. Hand Clin 1988;4:619-32.
3. Brems JJ, Wilde AM. Shoulder arthroplasty: principles. In: Watson MS, ed. Surgical disorders of the shoulder. London: Churchill Livingstone 1991:459-71.
4. Howell SM, Imobersteg AM, Seger DH, Marone PJ. Clarification of the role of
the supraspinatus muscle in shoulder function. J Bone Joint Surg [Am] 1986;68A:398-404.
5. Groh GI, Simoni M, Rolla P, Rockwood CA. Loss of the deltoid after shoulder
operations: an operative disaster. J Shoulder Elbow Surg 1994;3:243-53.
6. Charnley J, Houston JK. Compression arthrodesis of the shoulder. J Bone Joint
Surg [Br] 1964;46-B:614-20.
VOL. 90-B, No. 6, JUNE 2008
7. Chuinard RG, Kinnard WH. Shoulder fusion in treatment of C5/6 brachial plexus
palsy: case report. Orthopedics 1980;3:901-3.
8. Cofield RH, Briggs BT. Glenohumeral arthrodesis: operative and long-term functional results. J Bone Joint Surg [Am] 1979;61-A:668-77.
9. Richards RR, Waddell JP. Hudson AR. Shoulder arthrodesis for the treatment of
brachial plexus palsy. Clin Orthop 1985;198:250-8.
10. Richards RR, Sherman RM, Hudson AR, Waddell JP. Shoulder arthrodesis using
a pelvic-reconstruction plate: a report of eleven cases. J Bone Joint Surg [Am]
11. Vastamäki M. Shoulder arthrodesis for paralysis and arthrodesis. Acta Orthop Scand
12. Kline DG, Judice DJ. Operative management of selected brachial plexus lesions. J
Neurosurg 1983;58:631-49.
13. Millesi H. Brachial plexus injuries: management and results. Clin Plast Surg
14. Takahashi M. Studies on conversion of motor function in intercostal nerves crossing
for complete brachial plexus injuries of root avulsion type. Nippon Seikeigeka Gakkai
Zasshi 1983;57:1799-807.
15. Aziz W, Singer RM, Wolff TW. Transfer of the trapezius for flail shoulder after brachial plexus injury. J Bone Joint Surg [Br] 1990;72-B:701-4.
16. Bateman JE. The shoulder and environs. St. Louis: CV Mosby, 1955.
17. Karev A. Trapezius transfer for paralysis of the deltoid. J Hand Surg [Br] 1986;11:813.
18. Mayer L. Transplantation of the trapezius for paralysis of the abductors of the arm. J
Bone Joint Surg 1927;9:412-20.
19. Saha AK. Surgery of the paralysed and flail shoulder. Acta Orthop Scand 1967;Suppl
97: 5-90.
20. Slomann HC. Ueber die Behandlung der Deltoideuslahmheit. Z Orthop Chir 1915;28.
21. Ober FR. An operation to relieve paralysis of deltoid muscle. JAMA 1932;99:2182.
22. Berger A, Schaller E, Mailänder P. Brachial plexus injuries: an integrated treatment concept. Ann Plast Surg 1991;26:70-6.
23. Chuang DC. Functioning free muscle transplantation for brachial plexus injury. Clin
Orthop 1995;314:104-11.
24. Itoh Y, Sasaki T, Ishiguro T, et al. Transfer of latissimus dorsi to replace a paralysed
anterior deltoid: a new technique using an inverted pedicled graft. J Bone Joint Surg
[Br] 1987;69-B:647-51.
25. Hildebrandt A. Muskeltransplantation. Dtsch Med Wochenschr 1905;39:1578.
26. Harmon PH. Surgical reconstruction of the paralytic shoulder by multiple muscle
transplantations. J Bone Joint Surg [Am] 1950;32-A:583-95.
27. Hou CL, Tai YH. Transfer of upper pectoralis major flap for functional reconstruction
of deltoid muscle. Chin Med J (Engl) 1991;104:753-7.
28. Riedel G. Zur Frage der Muskeltransplantation bei Deltoideuslähmung. Ergebn Chir
Orthop 1928;21:489-542.
29. Narakas AO. Muscle transpositions in the shoulder and upper arm for sequelae of
brachial plexus palsy. Clin Neurol Neurosurg 1993;95(Suppl):89-91.
30. Kotwal PP, Mittal R, Malhotra R. Trapezius transfer for deltoid paralysis. J Bone
Joint Surg [Br] 1998;80-B:114-16.
31. Rühmann O, Wirth CJ, Gossé F, Schmolke S. Trapezius transfer after brachial
plexus palsy: indications, difficulties and complications. J Bone Joint Surg [Br]
32. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop 1987;214:160-4.
33. Goldner JL. Strengthening of the partially paralyzed shoulder girdle by multiple muscle-tendon transfers. Hand Clin 1988;4:323-36.