Tendon Transfer Options About the Shoulder in Patients with Brachial Plexus Injury

Background: The purpose of this study was to evaluate the early outcome of shoulder tendon transfer in patients with brachial plexus injury and to determine the factors associated with favorable outcomes. Methods: Fifty-two patients with traumatic brachial plexus injury and a paralytic shoulder were included in the study. All patients were evaluated at a mean of nineteen months (range, twelve to twenty-eight months) postoperatively. Twelve patients had a C5-6 injury, twenty-two had a C5-7 injury, five had a C5-8 injury, and thirteen had a C5-T1 injury. Transfer of the lower portion of the trapezius muscle was performed either in isolation or as part of multiple tendon transfers to improve shoulder function. Additional muscles transferred included the middle and upper portions of the trapezius, levator scapulae, upper portion of the serratus anterior, teres major, latissimus dorsi, and pectoralis major. Results: All patients had a stable shoulder postoperatively. Shoulder external rotation improved substantially in all patients from no external rotation (hand-on-belly position) to a mean of 20 degrees (p = 0.001). Patients who underwent additional transfers had marginal improvement of shoulder flexion, from a mean of 10 degrees preoperatively to 60 degrees postoperatively, and of shoulder abduction, from a mean of 10 degrees to 50 degrees (p = 0.01 for each). Mean pain on a visual analog scale improved from 6 points preoperatively to 2 points postoperatively. The mean Disabilities of the Arm, Shoulder and Hand (DASH) score improved from 59 to 47 points (p = 0.001). The mean Subjective Shoulder Value improved from 5% to 40% (p = 0.001). Greater age, higher body mass index, and more extensive nerve injury were associated with a poorer DASH score in a multivariate analysis (p = 0.003). Conclusions: Tendon transfers about the shoulder can improve shoulder function in patients with brachial plexus injury resulting in a paralytic shoulder. Significant improvement of shoulder external rotation but only marginal improvements of shoulder abduction and flexion can be achieved. The outcome can be expected to be better in patients with less severe nerve injury.