A comprehensive analysis of pectoralis major transfer for long thoracic nerve palsy

In the treatment of long thoracic nerve palsy with pectoralis major transfer, it remains unknown whether direct transfer of the pectoralis to the scapula or indirect transfer with an interpositional graft provides superior outcomes.

A 3-tiered study was performed to gain a comprehensive understanding. (1) A survey of the membership of the American Shoulder and Elbow Surgeons (ASES) was conducted to reach a Level V consensus. (2) A systematic review was conducted to identify all series evaluating direct and indirect transfer of the pectoralis major tendon to create a Level IV consensus. (3) A retrospective review was performed to provide Level III evidence.

(1) Surgeons were evenly split between whole and split tendon transfers, direct and indirect transfers, and graft types. More experienced surgeons were more likely to prefer an indirect transfer. (2) Analysis of 10 Level IV studies (131 shoulders) revealed that patients who underwent indirect transfer were significantly more likely to develop recurrent winging (P = .009) and had lower active forward elevation (P < .001) and ASES scores (P = .0016). (3) Twenty-four patients were included in our retrospective review with a mean follow-up of 4.3 years (77% follow-up), of whom 14 underwent indirect transfer and 10 underwent direct transfer. There were no significant differences in recurrence of winging, range of motion, or ASES scores.

Level V and III evidence suggests that there is no functional difference between direct and indirect transfer. Level IV evidence must be interpreted with caution.