Adolescent shoulder reconstruction techniques in brachial plexus birth injury

Brachial plexus birth injury (BPBI) is common and while most recover, 8%-36% of patients experience permanent impairment. Typically, adolescents with untreated BPBI lack active and passive external rotation (ER) and overhead shoulder function. Limited shoulder function is due to 1) nonoperative BPBI, 2) untreated BPBI, or 3) unrecognized glenohumeral joint dysplasia. We describe a technique for achieving reanimation in adolescents who did not receive timely/effective BPBI care, a postoperative rehabilitation protocol, and results from a series of 8 patients who underwent shoulder reanimation.

A comprehensive shoulder reanimation approach is performed. Anteriorly, the pectoralis minor, major, and anterior capsule necessitate release. In severe dysplasia, a coracoidectomy, posterior glenoid osteotomy, and/or subscapularis slide may be necessary. Acromial dysplasia is also common, frequently necessitating osteoplasty. The deltoid is usually nonfunctional, and we use a bipolar latissimus muscle transfer for reanimating abduction and forward flexion (FF). To assist with ease of rehabilitation we will often transfer the tendon of the teres major. Levator scapulae transfer to the supraspinatus is often performed to assist with the initiation of abduction. For ER, the ipsilateral lower trapezius is used. Finally, ipsilateral rhomboid advancement and contralateral lower trapezius muscle transfer is performed for dynamic scapular stabilization. After surgery, all patients participated in our rigorous postoperative rehabilitation protocol.

Eight patients (13.8 ± 5.6 years, 35 ± 24 weeks follow-up) were included. All patients participated in our rehabilitation protocol. Preoperatively, patients generally achieved 0° ER from neutral and in maximum abduction. Postoperatively, patients achieved an average of 71° (30°-90°) ER from neutral and an average of 82° (65°-90°) ER in maximum abduction. Preoperatively, patients generally had 0°-20° of abduction, which they achieved through scapulothoracic motion. Postoperatively, patients could achieve an average of 115° (90°-180°) of abduction. Preoperatively, patients had 0°-20° of FF that was mediated through scapulothoracic motion. Postoperatively, patients' FF increased to an average of 91° (20°-170°).

This technique is intended to restore a congruent glenohumeral joint and reanimate structures allowing for abduction, FF, and ER. While we advocate for early treatment of BPBI, applying this technique to undertreated/untreated adolescent patients paired with our rehabilitation protocol results in significant functional improvement, allowing for an improved quality of life.