Isolated latissimus dorsi transfer to restore shoulder external rotation in adults with brachial plexus injury

Latissimus dorsi tendon transfer to restore shoulder abduction in patients with deltoid paralysis: A novel technique

Background

Shoulder abduction is an essential movement for placement of the hand in space and thus for upper limb function. The objective of this study was to introduce and test the effectiveness of a new technique of latissimus dorsi tendon transfer to deltoid insertion to restore shoulder abduction.

Methods

We prospectively included 10 male patients with a lost deltoid function. Their mean age was 34.6 years (range, 25-46). We describe a new technique to compensate for the loss of the deltoid function using a latissimus dorsi tendon transfer augmented with a semitendinosus tendon graft. The tendon graft is passed over the acromion and attached to the anatomical deltoid insertion. Postoperatively, a shoulder spica in 90° abduction was used for six weeks followed by physiotherapy.

Results

Patients were followed up for a mean of 25.4 months (range, 12-48). The mean range of active shoulder abduction rose to 110° (range, 90-140°) with a mean gain of 83° of abduction.

Conclusions

This procedure can be a useful technique for restoration of a significant range and strength of active shoulder abduction.

Prevention and Treatment of Nerve Injuries in Shoulder Arthroplasty

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Nerve injuries during shoulder arthroplasty have traditionally been considered rare events, but recent electrodiagnostic studies have shown that intraoperative nerve trauma is relatively common.

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The brachial plexus and axillary and suprascapular nerves are the most commonly injured neurologic structures, with the radial and musculocutaneous nerves being less common sites of injury.

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Specific measures taken during the surgical approach, component implantation, and revision surgery may help to prevent direct nerve injury. Intraoperative positioning maneuvers and arm lengthening warrant consideration to minimize indirect injuries.

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Suspected nerve injuries should be investigated with electromyography preferably at 6 weeks and no later than 3 months postoperatively, allowing for primary reconstruction within 3 to 6 months of injury when indicated. Primary reconstructive options include neurolysis, direct nerve repair, nerve grafting, and nerve transfers.

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Secondary reconstruction is preferred for injuries presenting >12 months after surgery. Secondary reconstructive options with favorable outcomes include tendon transfers and free functioning muscle transfers.

Indirect Cost of Traumatic Brachial Plexus Injuries in the United States

BACKGROUND

Traumatic brachial plexus injuries (BPIs) disproportionately affect young, able-bodied individuals. Beyond direct costs associated with medical treatment, there are far-reaching indirect costs related to disability and lost productivity. Our objective was to estimate per-patient indirect cost associated with BPI.

METHODS

We estimated indirect costs as the sum of (1) short-term wage loss, (2) long-term wage loss, and (3) disability payments. Short-term (6-month) wage loss was the product of missed work days and the average earnings per day. The probability of return to work was derived from a systematic review of the literature, and long-term wage loss and disability payments were estimated. Monte Carlo simulation was used to perform a sensitivity analysis of long-term wage loss by varying age, sex, and return to work simultaneously. Disability benefits were estimated from U.S. Social Security Administration data. All cost estimates are in 2018 U.S. dollars.

RESULTS

A systematic review of the literature demonstrated that the patients with BPI had a mean age of 26.4 years, 90.5% were male, and manual labor was the most represented occupation. On the basis on these demographics, our base case was a 26-year-old American man working as a manual laborer prior to BPI, with an annual wage of $36,590. Monte Carlo simulation estimated a short-term wage loss of $22,740, a long-term wage loss of $737,551, and disability benefits of $353,671. The mean total indirect cost of traumatic BPI in the Monte Carlo simulations was $1,113,962 per patient over the post-injury lifetime (median: $801,723, interquartile range: $22,740 to $2,350,979). If the probability of the patient returning to work at a different, lower-paying job was doubled, the per-patient total indirect cost was $867,987.

CONCLUSIONS

BPI can have a far-reaching economic impact on both individuals and society. If surgical reconstruction enables patients with a BPI to return to work, the indirect cost of this injury decreases.

LEVEL OF EVIDENCE

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Response to: Ghosh S, Singh VK, Jeyaseelan L,Sinisi M, Fox M. Isolated latissimus dorsi transfer to restore shoulder external rotation in adults with brachial plexus injury. Bone Joint J 2013;95-B:660–663

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