Gong Xu , Lu Lai Jin, Cui Jian Li, Sun Ru Tao Department of Hand Surgery

1. Outcome analysis of modified teres major and latissimus dorsi transfer in the treatment of obstetric brachial plexus palsy shoulder sequelae Gong Xu, Lu Lai Jin, Cui Jian Li, Sun Ru Tao Department of Hand Surgery The First Hospital of Ji Lin University Chang Chun, Ji Lin Province 130021

2. obstetric brachial plexus palsy • Incidence：0.1-0.4% • Incomplete Recovery：49%-66% • Indication of Microsurgical Neural Reconstruction： • dysfunction of elbow flexion at the age of 3 month

3. Sequelae of shoulder • C5，C6 injuries（Erb’s palsy） • C5，C6，+C7 injuries（Erb’s palsy+C7） • loss of active ER • loss of shoulder elevation

4. Sequelae of shoulder Loss of active shoulder elevation and ER can lead to simple tasks, such as shaking hand, combing, brushing teeth, becoming impossible due to the inability of controlling the spatial positioning of the arm .

5. Pathomechanics • Internal Rotator • 4 • Pectoralis Major • Subscapularis • Teres Major • Latissimus Dorsi Fibrosis , Contracture Loss of Passive ER • External Rotator • 2 • Infraspinatus • Teres Minor Palsy Inability of active ER 40% Walch G, et al. The ‘dropping’ and ‘hornblower’s’ signs in evaluation of rotator-cuff tears. JBJS-Br .1998

6. Shoulder Reconstruction • L’Episcopo Transfer ( 1934) • Anterior Approach：Releasing Pectoralis Major and Subscapularis Muscles • Posterior Approach：Transfer Teres Major & Latissimus Dorsi muscles • Reinserting conjoint tendon on humeral shaft

7. Shoulder Reconstruction • Nath (2007) • Axillary Approach • Releasing Pectoralis Major and Subscapularis Muscles • Conjoint tendon suturing to Teres Minor

8. Background • We modified Teres Major & Latissimus Dorsi transfer, from original L’Episcopo’s and Nath’s procedures, to reconstruct shoulder function. • The deltopectoral approach to release contracted subscapularis, pectoralis major and conjoint tendon of the teres major and latissimus dorsi • The posterior approach to reinsert the conjoint tendon to the belly of the teres minor

9. Background To retrospectively analyze the outcomes and related factors of modified teres major and latissimus dorsi transfer in the treatment of obstetric brachial plexus palsy (OBPP) shoulder sequelae.

10. Materials and Methods • General Conditions • From 2008 to 2011 • six patients with OBPPs, aged from 16 months of age to 16 years of age. • 2 males and 4 females • Left: 3, Right: 3 • No primary microsurgical reconstruction • Diagnosis: C5+C6 (n=5) • C5+C6+C7 (n=1)

11. Materials and Methods • The pre- and postoperative active shoulder abduction and ER were recorded and evaluated according to Mallet’s classification. • Comparison between the pre- and postoperative was performed by t-test.

12. Operative methods

13. Operative methods

14. Operative methods

15. Operative methods

16. Postoperative Management • The upper extremities were immobilized for 6-8 weeks in the position of abduction 90 degrees and ER 45 degrees except for two patients in the position of adduction and internal rotation. • All patients were followed for 3 to 22 months.

17. Results 130±24.5° 55±35.6° 75°

18. Results 48.3±22.73° 48°

19. Results 4.3 2.5

20. Typical Cases • Preoperative: Abduction 70°, ER 0°( Mallet Score 3) • Postoperative: Abduction 130°, ER 45°( Mallet Score 4)

21. Typical Cases • Preoperative: Abduction 90°, ER 0°( Mallet Score 3) • Postoperative: Abduction 160°, ER 90°( Mallet Score 5)

22. Typical Cases • Preoperative: Abduction 50°, ER 0°( Mallet Score 3) • Postoperative: Abduction 130°, ER 45°( Mallet Score 5)

23. The position of postoperative Immobilization can influence outcomes of ER • 2 patients were immobilized in shoulder adduction and internal rotation

25. Conclusion • Modified teres major & latissimus dorsi transfer can improve shoulder abduction and ER by increasing stability of the glenohumeral joint. • The postoperative immobilization position can influence the improvement of shoulder ER.

26. 谢 谢