Download Trapezius transfer for deltoid paralysis

Trapezius transfer for deltoid paralysis
P. P. Kotwal, R. Mittal, R. Malhotra
From the All India Institute of Medical Sciences, New Delhi, India
e have reviewed 26 patients treated by trapezius
transfer for deltoid paralysis due to brachial
plexus injury or old poliomyelitis. We assessed the
power of shoulder abduction and the tendency for
subluxation. There were good results in 16 patients
(60%); five were fair and five poor.
Trapezius transfer appears to give reasonable
results in the salvage of abductor paralysis of the
shoulder.
W
J Bone Joint Surg [Br] 1998;80-B:114-6.
Received 2 August 1997; Accepted 15 September 1997
3
and short head of biceps to the acromion and the posterior
3,4
deltoid to the paralysed anterior part.
Transfer of the trapezius insertion was first described by
5
Mayer, who used a fascia lata graft to extend its attachment to the deltoid tuberosity. The results were poor
because the graft stretched and became adherent to sur6
rounding structures. Bateman modified the procedure by
advising resection of part of the spine of the scapula with
the trapezius, to allow screw fixation of the transfer to the
7
humerus. This procedure was further modified by Saha.
Patients and Methods
Abduction of the shoulder to 90° is provided by supraspinatus and deltoid. After 90° of abduction at the glenohumeral
joint, the main external rotators of the scapula for full
shoulder abduction are serratus anterior and trapezius,
while other muscles are involved in rotating and stabilising
the humeral head.
In the scapular plane, shoulder abduction is mainly by
the action of the anterior and middle thirds of the deltoid
with some involvement of the posterior third. In the coronal
plane and posterior to it, the contribution of the anterior
third decreases and that of the posterior third becomes
greater. Paralysis produces weakness in abduction and
some flexion and is most commonly due to old poliomyelitis or to injuries of the brachial plexus. Loss of abduction at
the shoulder is a severe disability in daily living and in
employment. A number of tendon transfers have been
1
described to replace the function of the deltoid. Haas
reports that Hildebrandt described the transfer of the origin
of pectoralis major to the clavicle and acromion in 1906.
Other tendon transfers which have been used are the long
2
head of triceps to the acromion, the long head of triceps
P. P. Kotwal, MS Orth, Additional Professor
R. Mittal, MS Orth, Senior Resident
R. Malhotra, MS Orth, Assistant Professor
Department of Orthopaedics, All India Institute of Medical Sciences,
Ansari Nagar, New Delhi 110029, India.
Correspondence should be sent to Dr R. Malhotra.
©1998 British Editorial Society of Bone and Joint Surgery
0301-620X/98/18251 $2.00
114
We treated 26 patients with deltoid paralysis by trapezius
transfer. Eighteen had residual paralysis due to old poliomyelitis and eight had injuries of the brachial plexus. The
latter were all young men aged between 15 and 25 years;
one had been stabbed in the neck and the others had had
closed injuries in road-traffic accidents. The patients with
poliomyelitis were mainly children aged from nine to 14
years with an equal gender distribution. All the patients had
good ipsilateral hand function, and six had had previous
Steindler’s flexor plasties on the same side to improve
elbow flexion.
Operative technique. Trapezius transfer to the proximal
humerus was accomplished by a modification of Bateman’s
6
7
technique, described by Saha. The patient is placed
supine with a sand-bag under the shoulder. A Y-shaped
incision is made over the lateral third of the clavicle and the
acromioclavicular joint and acromion, extending down the
arm. The origin of the deltoid is exposed and detached
subperiosteally. The clavicle is then divided lateral to the
conoid ligament and the spine of the scapula medial to the
acromion with posterior bevelling (Fig. 1). The central part
of the insertion of the trapezius is elevated with the cut end
of the clavicle, the acromioclavicular joint, and the scapular
fragment, freeing the remainder of the posterior insertion
from the scapular spine. The bone fragments of the clavicle
and acromion are then fractured in several places. The
proximal humerus is exposed by splitting the paralysed
deltoid and the bone is roughened with an osteotome.
Screws are then passed through the bone fragments in the
detached insertion and used to secure them just distal to the
head of the humerus, with the shoulder held in abduction
THE JOURNAL OF BONE AND JOINT SURGERY
TRAPEZIUS TRANSFER FOR DELTOID PARALYSIS
Fig. 1
115
Fig. 2
Fig. 3
Figure 1 – Division of the clavicle and the acromion to allow transfer of the insertion of the central part of the trapezius. Figure 2 – The transfer
unit is fixed to the humeral shaft with screws. Figure 3 – Radiograph after operation.
Fig. 4a
Fig. 4b
Active abduction before (a) and after (b) surgery.
(Figs 2 and 3). The wound is closed and a shoulder spica
applied with the shoulder in 45 to 60° of abduction. The
spica is removed at six weeks and carefully supervised
physiotherapy is started.
Results
Patients were reviewed at a mean of 12 months (10 to 25).
We assessed our results by recording the power of shoulder
abduction and any tendency for the joint to sublux (Table
I). There were 16 good results (Fig. 4), five fair and five
poor. In the eight patients with brachial plexus injuries
there were five good results, two fair and one poor (Table
I). The last was due to persistent paraesthesiae which made
the patient reluctant to move his shoulder. Of the postpoliomyelitis group, 11 had good results, three fair and four
poor. Two of the patients with poor results had associated
severe weakness of all rotator-cuff muscles, and the other
two had shown anterior subluxation of the shoulder before
operation, which did not improve after surgery (Fig. 5). No
patient became infected and there was no failure of fixation
or pain on movement. The average gain in active abduction
of the shoulder was 60° in the brachial plexus group and
45° in the poliomyelitis group.
VOL. 80-B, NO. 1, JANUARY 1998
Fig. 5
Failure due to persistent anterior subluxation after trapezius
transfer.
Discussion
In India, both poliomyelitis and injury to the brachial
plexus are relatively common causes of shoulder weakness.
The disability from this is considerable both for activities
of daily living and in earning a livelihood. Many patients
demand a reconstructive procedure.
7
Saha’s logical modification of the trapezius transfer
6
described by Bateman provides a more distal fixation of
the transfer after a more proximal release. This gives a
greater lever arm, and fracture of the bony insertion transferred from the acromion allows better fixation to the
narrow cylindrical shaft of the humerus. An important
modification was to consider transfer for paralysed muscles
of the rotator cuff, to improve control of the humeral head
and prevent subluxation. Saha recommends careful assessTable I.
Good
Fair
Poor
Total
Results of 26 patients at 12 months
Power
(MRC)
Subluxation Post-polio
Brachial plexus Total
4
2 to 3
0 to 1
No
No
Yes
5 (62.5%)
2 (25%)
1 (12.5%)
8
11 (61%)
3 (16%)
4 (22%)
18
16
5
5
116
P. P. KOTWAL,
R. MITTAL,
ment of all muscles about the joint. He considered the
deltoid and the clavicular head of the pectoralis major as
prime movers for abduction; they also lift the humeral shaft.
Subscapularis, supraspinatus and infraspinatus are a steering
group which stabilise the humeral head in the glenoid. The
sternal head of pectoralis major, latissimus dorsi, teres
major and teres minor form a depressor group which also
rotate the shaft and pull the humeral head downwards
during the last few degrees of abduction. Saha confirmed
that when any two of the steering group of muscles were
paralysed a single muscle transfer to replace the deltoid
would not provide abduction beyond 90°. He describes the
transfer of pectoralis minor, the upper two digitations of
serratus anterior, latissimus dorsi and teres major in various
combinations. He also discusses transfers of the levator
scapulae, sternocleidomastoid, scalenus anterior, scalenus
medius and scalenus capitis. He reported that these principles make it possible to restore reasonable function of the
7
shoulder with nearly normal control and no subluxation.
Trapezius transfer in poliomyelitis has also been dis8
cussed by Yadav, who used a modified Meyer’s technique
with two separate incisions and no slot in the acromion. He
believed that these modifications prevented the formation
of adhesions, but did not discuss the role of the rotator-cuff
muscles. He reported frequent subluxation of the humeral
head with satisfactory results only when there was good
residual power in the accessory muscles.
An alternative management is by arthrodesis of the
shoulder which is indicated especially in an associated
dislocation with good power in the trapezius and serratus
anterior. Saha argues against arthrodesis after poliomyelitis
and points out that the fulcrum is moved to the scapulothoracic joint. This gives a much longer lever arm for the
thoracic muscles, which may defeat the very purpose of
rehabilitation. He found that the use of spare thoracic
muscles for glenohumeral abduction provided a better
option and also emphasised that the principles of rehabilitation were as important as surgical technique.
R. MALHOTRA
9
Aziz, Singer and Wolff discuss trapezius transfer for
flail shoulder after injury to the brachial plexus, finding it a
simple procedure with minimal blood loss, which provided
functional improvement and usually eliminated pain.
Cofield and Briggs point out that the disadvantages of
arthrodesis include a high incidence of fracture, worsening
10
of pain and relative reduction of passive movements. Aziz
9
et al also argue that simple trapezius transfer is compatible
with the later return of some function to other shoulder
girdle muscles, while arthrodesis is irreversible and no
benefit can be derived from any late return of brachial
plexus function.
We consider that trapezius transfer can provide satisfactory functional improvement and is a better procedure
than arthrodesis for paralysis of shoulder abduction caused
by poliomyelitis or injury to the brachial plexus.
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.
References
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1935;104:99-103.
2. Slomann. Ueber die BehandLung der Deltoidenslahmheit, Z. Orthop
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of deltoid muscle. JAMA 1935;104:99-103.
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6. Bateman JE. The shoulder and environs. St Louis: CV Mosby,
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72-B:701-4.
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