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1 MINERVA ORTOP TRAUMATOL 2014;65: Outcomes of transfer of latissimus dorsi and teres major on the rotator cuff with or without anterior release in children with obstetric paralysis: a retrospective study Aim. Latissimus dorsi and teres major (LD- TM) tendon transfer is frequently performed in patients with obstetrical brachial plexus palsy (OBPP). Adding an anterior release to a LD-TM transfer might help decrease residual internal rotation contractures. The aim of this study was to evaluate the results of LD- TM transfer with or without anterior release and to evaluate the influence of additional anterior release on shoulder motion in patients with OBPP. Methods. Twenty-two patients with a mean age of 8.1±4.7 years, who underwent LD-TM tendon transfers, were included in the study. In nine patients LD-TM transfer with an additional anterior release procedure (pectoralis major ± subscapularis release) was performed, whereas in 13 patients only LD-TM tendon transfer was performed. Shoulder abduction and external rotation were assessed according to Gilbert s classification system and also by using goniometric method, and internal rotation according to the Mallet scoring system. Results. The mean follow-up period was 51±37.3 months. Range of motion in both abduction and external rotation increased significantly in all patients. Gilbert score also increased significantly in all patients (P=0.000). When the two groups were compared, there were no significant differences besides age. The patients with anterior release were significantly older than the patients without anterior release (P=0.014). Conclusion. LD-TM transfer is an effective Corresponding author: G. Meric, Balikesir University Medical Faculty, Department of Orthopedics and Traumatology, Balikesir University Medical Faculty, Balikesir, Turkey. drgokhanmeric@gmail.com C. ¹, G. MERIC ², S. GULBAHAR ¹, O. EL ¹, A. K. BACAKOGLU ³ 1Dokuz Eylul University Medical Faculty Department of Physical Medicine and Rehabilitation, Izmir, Turkey ²Balikesir University Medical Faculty Department of Orthopedics and Traumatology Balikesir, Turkey ³Dokuz Eylul University Medical Faculty Department of Orthopedics and Traumatology Izmir, Turkey tecnique and can improve shoulder motions in patients with OBPP. LD-TM tendon transfers at an early age seem to prevent internal rotation contracture of the shoulder with a decrease in need for anterior release. Key words: Braxial plexus neuropathies - Shoulder - Tendons. Obstetrical brachial plexus palsy (OBPP) results from a stretch injury to the brachial plexus during labor and affects 0.1% to 0.4% of births. 1 Although the overall outcome is considered quite good, with spontaneous recovery in over 90% of infants, more recent literature have indicated that 20-30% patients have resiual deficits. 2, 3 In OBPP patients with C5-C6 nerve injury, there is a weakening of the shoulder abductor and external rotator muscles while adductor and internal rotators maintain their strength. Due to this muscle imbalance, internal rotation and adduction contractures and glenohumeral deformities can develop. 4-6 Vol No. 5 MINERVA ORTOPEDICA E TRAUMATOLOGICA 345

2 The aim of treatment in OBPP patients was to increase functionality of the upper extremity. There are many procedures to increase shoulder abduction and external rotation. Treatment options differ according to age. In the early periods of infants, nerve exploration, neurolysis and nerve reconstruction can be used. 5 Most authors perform these procedures, when infants between three and nine months of age. 7, 8 Muscle contractures and hence muscle imbalance may cause glenohumeral joint imbalance in untreated patients. 9, 10 These glenohumeral deformities can be reversible with soft tissue-relocation procedures. 5 Muscle releases and tendon transfers have been used to rebalance musculer dysfunction and improve shoulder motion. Latissimus dorsi and teres major (LD-TM) transfer is an accepted method to increase shoulder abduction and external rotation in OBPP sequela. 9, Adding an anterior release to a LD-TM transfer might help decrease residual internal rotation contractures. Most often the entire origin of subscapularis muscle is released from the anterior aspect of the scapula. 8 Strengthening of the external Table I. Clinical details and preoperative and postoperative findings of patients. Patient N. Sex Age Side Follow-up (month) Preop Abd rotators leads to changes in the muscle balance leading to further weakening of the internal rotators, and postoperative limitation of internal rotation. 7 The aim of this study was to evaluate the results of LD-TM transfer with or without anterior release in patients with OBPP. Materials and methods This is a retrospective comparative study which includes 22 patients (10 male, 12 female) with OBPP who have undergone LD-TM tendon transfer between the years 1998 and 2011 by the same surgeon. Our study was made retrospectively therefore we could not ask our patients parents to give their consent. Six patients had C5-C6 injury, 6 patients had C5-C6-C7 injury, and 10 had total brachial plexus injury. The right shoulder was affected in 12 cases and left in ten. To predict glenohumeral joint deformity and posterior dislocation; anteroposterior, oblique and axillary radiographies, of shoulder were assessed. None of the patients had marked glenohumeral deformity Postop Abd Preop External rotation Postop External rotation Anterior release Level of injury 1 F 5 R Total 2 F 2 L C5-C6-C7 3 F 3 L C5-C6-C7 4 F 2 L C5-C6-C7 5 M 11 L C5-C6 6 M 11 R Total 7 M 15 R C5-C6 8 M 11 R Total 9 M 15 L C5-C6-C7 10 M 16 R C5-C6-C7 11 F 11 R Total 12 F 4 L C5-C6 13 F 6 R Total 14 F 13 L C M 6 R C5-C6 16 M 11 L Total 17 F 2 L Total 18 M 4 R Total 19 F 9 R Total 20 M 3 R C5-C6-C7 21 F 5 R Total 22 F 12 L C5-C6 346 MINERVA ORTOPEDICA E TRAUMATOLOGICA October 2014

3 Table II. Gilbert s classification. Stage 0 Complete shoulder flail Stage I Abduction 45 antepulsion; no active ext. rotation Stage II Abduction <90 ; no ext. rotation Stage III Abduction = 90 ; weak ext. rotation Stage IV Abduction <120 ; incomplete ext. rotation Stage V Abduction >120 ; active ext. rotation on shoulder radiographies. LD-TM tendons were transferred to the rotator cuff (onto the infraspinatus and supraspinatus) by using Hoffer s LD-TM tendon transfer method. 9 In addition to the LD-TM tendon transfer, nine patients had an additional anterior release procedure (pectoralis major ± subscapularis release). Thirteen patiens had LD-TM tendon transfer without anterior release. The mean age of the patients at the time of operation was 8.1 years (range from 2 to 16 years). Demographic data and preoperative functional findings of patients are given in Table I. Shoulder abduction and external rotation were assessed according to Gilbert s classification system 10 (Table II). Goniometric measurements of active shoulder abduction and external rotation were also recorded. External rotation was measured with the shoulder at 90 of abduction whereas internal rotation was measured using the Mallet scoring system 14 (Table III). Surgical technique The child was placed in lateral decubitus position. Prior to surgery, passive range of motion of the shoulder was tested under general anesthesia. If the patient achieved 90 of abduction and 90 external rotation on passive examination without scapular rotation, anterior release was not performed. Otherwise, anterior release was performed via mini deltopectoral incision. Humerus insertion of the pectoralis major was released via Z-plasty. External rotation and abduction of the shoulder were retested. A gradual release of the subscapularis tendon was made if the shoulder anterior tension was present on passive external rotation. Muscle repair was done to the two muscles with the shoulder in 90 of abduction and 90 of Table III. Evaluation of internal rotation according to Mallet scoring system. 1 No movement 2 Imposible 3 S1 vertebra 4 T12 vertebra 5 Normal external rotation. A 7 cm incision was made towards the axilla and the shoulder was entered posteriorly. LD-TM tendons were released at the humeral insertion. Both tendons were suspended by non-absorbable sutures and were advanced towards the humeral head by going under the posterior portion of the deltoid. Both tendons were reinserted on the posterior footprint. After closing surgical incisions, the arm was placed in an airplane orthosis which was prepared before the surgery (Figure 1). Passive range of motion exercises for the shoulder, elbow and hand joints in the supine position were initiated at the third week as a home exercise program. At 6 weeks, airplane orthosis was completely Figure 1. Postoperative immobilization in airplane orthosis. Vol No. 5 MINERVA ORTOPEDICA E TRAUMATOLOGICA 347

4 discontinued, and active shoulder flexion and abduction were added to the exercise program. At the end of the second month, the patient was encouraged to use the extremity in daily activities, and strengthening exercises were gradually introduced. Statistical analysis All statistical analyses were performed by statistical software (SPSS 15.0 for windows; SPSS, Chicago, IL, USA). Continuous variables were expressed as mean ± standard deviation. Wilcoxon test was used to compare within group differences (preoperative vs. postoperative), and Mann-Whitney U test was used to compare the two groups. A P value <0.05 was considered as statistically significant. Figure 2. Mean shoulder abduction and external rotation values in all patients. Table IV. Preoperative and postoperative assessment results in all patients (mean±sd). Preoperative Postoperative P value Abduction 80.9± ± External rotation 29.8± ± Gilbert score 2.4± ± Mallet IR score 2.6± ± Table V. Comparison of patients with anterior release and without anterior release. ER: external rotation; IR: ınternal rotation. Preoperative Postoperative with release without release P value with release without release P value Abduction 69.4± ± ± ± ER 24.4± ± ± ± Gilbert score 2.3± ± ± ± Mallet IR score 2.9± ± ± ± Results The mean duration of follow up after operation was 51±37.3 months. Comparison of preoperative and postoperative assessment results is given in Table IV. In all patients with LD-TM transfer with and without anterior release, abduction and external rotation increased significantly (Figures 2-4; Table V). The Gilbert score in patients who underwent anterior release and did not undergo anterior release increased significantly (Figure 3). The Mallet internal rotation score decreased from 2.6±0.7 to 2.5±0.7 postoperatively. These differences were not statistically significant (P>0.05). On nonparametric comparison of the two groups with Mann-Whitney U test, there were no significant differences besides age. Figure 3. Gilbert and Mallet internal rotation scores of all patients. 348 MINERVA ORTOPEDICA E TRAUMATOLOGICA October 2014

5 A B C The mean age of the patients with anterior release (11.1 years, range 4-16 years) were significantly higher than that of the patients without anterior release (5.9 years, range 2-13 years) (P=0.014). Postperative functional findings of patients are given in Table I. Discussion In patients with OBPP, adduction-internal rotation contractures lead to glenohumeral joint dysfunction and subluxation of the humeral head posteriorly. 5, 15, 16 To prevent these contractures, anterior release and LD- TM tendon transfer combination may be performed. In our study, all patients had a significant increase in shoulder abduction and external rotation. There was a significant increase in the Gilbert score for shoulder function whereas there was no significant increase in internal rotation. When the anterior relase patiens and without anterior relase patients were compared, there were no significant differences else than ages. The patients with anterior release were significantly older than the patients without anterior release (P=0.014). The long-term results of LD-TM tendon transfer reminds that it is an effective method for regaining motions in OBPP patients. Figure 4. A) A 5-year-old patient with right sided brachial plexus injury; B, C) shoulder abduction and external rotation 47 months after surgery. In OBPP patients tendon transfers are one of the mainstays of the treatment. In superior brachial lesions an LD-TM tendon transfer is one of the most common procedures. Hoffer et al. used this procedure to attach LD-TM tendons to rotator cuff tendons. Tendon transfers are usually performed between the ages of 2 and 5 years. 8, 9 The timing of tendon transfer is an uncertain issue. Covey et al. believed the best age to increase shoulder function is between 3 to 4 years of age. 17 Terzis et al. suggested tendon transfers between 18 months and 4 years. 18 Bennet et al. showed bony involvement in those above 5 years of age with glenohumeral incongruity. 16 Vander Sluijs et al. reported that shoulder deformity developed in the first 14 months. 19 Waters et al. reported that early tendon transfer before shoulder deformity developed (2-5 years) led to the best results. 6, 20 There has also been studies which show that tendon transfer can take place at the ages of 9-10 if the glenohumeral joint is stable. 7 LD-TM transfer at an early age reduces the need for anterior release procedures. Some authors claimed that, tendon transfer operations can be applied till 9-10 years of age if glenohumeral joint is in balance. 7, 21 Ozben et al. treated 26 patients with transfer of LD-TM to rotator cuff muscles and pectoralis major tendon Z-plasty without release Vol No. 5 MINERVA ORTOPEDICA E TRAUMATOLOGICA 349

6 of subscapularis muscle. They observed significant improvement in shoulder function. Improvement in shoulder abduction and external rotation was higher in patients who were operated on before the age of 7. They concluded that subscapularis release is not always necessary. 21 Muscle imbalance between strong internal rotators and weak external rotators leads to an internal rotation contracture in patients with OBPP. Subscapularis release was not advised even in cases of glenohumeral dislocations. 9, 22 Bennet et al. suggested that releases should be performed between 12 and 24 months, but if the glenohumeral joint is congruent, the procedure may be useful in older children. 8 Newman et al. performed release of the subscapularis muscle in 13 patients. Postoperatively, patients presented significant gains in active external rotation (49 ) and active abduction (30 ); however, there was a loss of 12 degrees of active internal rotation at 90 of abduction. 23 Gilbert et al. recommended that anterior release should be performed in patients who had a suitable shoulder joint. 24 Pearl et al. performed arthroscopic contracture release for young children (less than three years old) and combined arthroscopic release with latissimus dorsi transfer for older children. They observed an average loss of 42 of internal rotation at 90 of abduction after latissimus dorsi transfer combined with a release, and a loss of 37 after an isolated release. 7 Terzis et al. found that in 53 patients who underwent LD-TM transfers with additional release procedure, internal rotation (to reach up the back) was impossible in 28% of the patients and was restricted but within a functional range in the remaining patients (72%). 18 We observed increase in shoulder abduction, external rotation, Gilbert s score for all patients who were treated with LD- TM tendon transfer. Although Mallet internal rotation score decreased slightly in all patients, these differences were not significant, probably because of the small sample size, which was a limitation of our study. Another limitation of our study was the usage of Mallet scoring system to measure the internal rotation of the shoulder. A more effective measurement method would be preferrable. Prospective studies with larger sample size comparing different treatment modalities might provide better results. Conclusions LD-TM tendon transfer is an effective technique to improve shoulder motions in patients with OBPP. Early LD-TM tendon transfer with anterior release can prevent secondary shoulder deformities and also increase shoulder abduction and external rotation. References 1. Waters PM. Obstetric brachial plexus injuries: evaluation and management. J Am Acad Orthop Surg 1997;5: Greenwald AG, Schute PC, Shiveley JL. Brachial plexus birth palsy: a 10-year report on the incidence and prognosis. J Pediatr Orthop 1984;4: Pondaag W, Malessy MJ, van Dijk JG, Thomeer RT. Natural history of obstetric brachial plexus palsy: a systematic review. Dev Med Child Neurol 2004;46: Javid M, Shahcheraghi GH. Shoulder reconstruction in obstetric brachial plexus palsy in older children via a one-stage release and tendon transfers. J Shoulder Elbow Surg 2009;18: Waters PM, Smith GR, Jaramillo D. Glenohumeral deformity secondary to brachial plexus birth palsy. J Bone Joint Surg Am 1998;80: Waters PM, Peljovich AE. Shoulder reconstruction in patients with chronic brachial plexus birth palsy: A case control study. Clin Orthop Relat Res 1999;364: Pearl ML, Edgerton BW, Kazimiroff, PA, Burchette RJ, Wong K. Arthroscopic release and latissimus dorsi transfer for shoulder internal rotation contractures and glenohumeral deformity secondary to brachial plexus birth palsy. J Bone Joint Surg Am 2006;88: Bennett JB, Allan CH. Tendon transfers about the shoulder and elbow in obstetrical brachial plexus palsy. J Bone Joint Surgery Am 1999;81: Hoffer MM, Wickenden R, Roper B. Brachial plexus birth palsies. Results of tendon transfers to the rotator cuff. J Bone Joint Surg Am 1978;60: Haerle M, Gilbert A. Management of complete obstetric brachial plexus lesions. J Pediatr Orthop 2004;24: Fairbank HAT. Birth palsy: subluxation of the shoulder joint in infants and young children. Lancet 1913;1: Sever JW. The results of a new operation for obstetrical paralysis. Am J Orthop Surg 1918;16: L Episcopo JB. Tendon transplantation in obstetrical paralysis. Am J Surg 1934;25: MINERVA ORTOPEDICA E TRAUMATOLOGICA October 2014

7 14. Mallet J. Paralysie obstetricale du plexus brachial. II. Therapeutique. Traitement des sequelles. Primaute du traitement de l epaule. Methode d expression des resultats. Rev Chir Orthop Reparatrice Appar Mot 1972;58(Suppl 1): Moukoko D, Ezaki M, Wilkes D, Carter P. Posterior shoulder dislocation in infants with neonatal brachial plexus palsy. J Bone Joint Surg Am 2004;86: Kambhampati SB, Birch R, Cobiella C, Chen L. Posterior subluxation and dislocation of the shoulder in obstetric brachial plexus palsy. J Bone Joint Surg Br 2006;88: Covey DC, Riordan DC, Milstead ME, Albright JA. Modification of the L Episcopo procedure for brachial plexus birth palsies. J Bone Joint Surg Br 1992;74: Terzis JK, Kokkalis ZT. Outcomes of secondary shoulder reconstruction in obstetrical brachial plexus palsy. Plast Reconstr Surg 2008;122: Van der Sluijs JA, van Ouwerkerk WJ, Manoliu RA, Wuisman PI. Secondary deformities of the shoulder in infants with an obstetrical brachial plexus lesions considered for neurosurgical treatment. Neurosurg Focus 2004;16: E Waters PM, Bae DS. Effect of tendon transfers and extra-articular soft-tissue balancing on glenohumeral development in brachial plexus birth palsy. J Bone Joint Surg Am 2005;87: Ozben H, Atalar AC, Bilsel K, Demirhan M. Transfer of latissmus dorsi and teres major tendons without subscapularis release for the treatment of obstetrical brachial plexus palsy sequela. J Shoulder Elbow Surg 2011;20: El-Gammal TA, Saleh WR, El-Sayed A, Kotb MM, Imam HM, Fathi NA. Tendon transfer around the shoulder in obstetric brachial plexus paralysis: Clinical and computed tomographic study. J Pediatr Orthop 2006;26: Newman CJ, Morrison L, Lynch B, Hynes D. Outcome of subscapularis muscle release for shoulder contracture secondary to brachial plexus palsy at birth. J Pediatr Orthop 2006;26: Gilbert A. Obstetrical brachial plexus palsy. In: Tubiana R, editor. The hand. Philadelphia, PA: WB Saunders; p Conflicts of interest. The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript. Received on June 27, Accepted for publication on April 11, Vol No. 5 MINERVA ORTOPEDICA E TRAUMATOLOGICA 351