Advertisement

Options of bipolar muscle transfers to restore deltoid function: an anatomical study

  • Malo Le Hanneur
  • Julia Lee
  • Eric R. Wagner
  • Bassem T. Elhassan
Original Article
  • 14 Downloads

Abstract

Purpose

To outline the technical details and determine the ranges of two pedicled functioning flaps that are the upper pectoralis major (UPM) and latissimus dorsi (LD) to elucidate their respective indications with regards to deltoid impairment.

Methods

The UPM and LD bipolar transfers were performed in 14 paired cadaveric shoulders, one on each side. The UPM was flipped 180° laterally over its pedicle to be placed onto the anterior deltoid. The LD flap was elevated on its pedicle to be rotated and positioned onto the deltoid mid-axis. Their respective spans were defined according to the deltoid muscle origin and insertion.

Results

The UPM outreached the lateral edge of the anterior deltoid origin with a mean distance of 7.3 cm (range 4–9.1 cm) off the lateral edge of the clavicle. Distally, the flap consistently overcame the proximal end of the deltoid tuberosity for a mean distance of 2.1 cm (range 0.9–3.2 cm). The LD flap mdi-axis could be consistently placed onto the deltoid mid-axis; spans of the anterior and posterior borders of the LD flap averaged 1 cm (range − 1 to 2.3 cm) and 0.2 cm (range −1.8 to 1.9 cm), respectively.

Conclusions

The UPM flap optimal indications would be cases with deltoid defects limited to its anterior portion, whereas the LD bipolar transfer could be used in more extensive lesions. Additionally, the distal span of both transfers appears to allow their use in the setting of a reverse shoulder arthroplasty with subsequent humeral lengthening.

Level of evidence

Non-applicable—basic science study, cadaver dissection.

Keywords

Latissimus dorsi Pectoralis major Pedicled flap Bipolar transfer Deltoid palsy 

Notes

Acknowledgements

The authors would like to thank the staff of the Anatomy laboratory of the Mayo Clinic for ensuring the availability of the specimens for this study.

Author contributions

MLH: protocol development; data collection; data analysis; manuscript writing. JL: protocol development; data collection; data analysis; manuscript editing. ERW: data analysis; manuscript editing. BTE: protocol development; data analysis; manuscript editing.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interests. None of them has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. They have not received or will receive any financial aid, in any form, for this study, from any of the following organizations: National Institutes of Health (NIH); Wellcome Trust; Howard Hughes Medical Institute (HHMI); or other(s).

References

  1. 1.
    Ackland DC, Pak P, Richardson M, Pandy MG (2008) Moment arms of the muscles crossing the anatomical shoulder. J Anat 213:383–390CrossRefGoogle Scholar
  2. 2.
    Aszmann OC, Rab M, Kamolz L, Frey M (2000) The anatomy of the pectoral nerves and their significance in brachial plexus reconstruction. J Hand Surg Am 25:942–947CrossRefGoogle Scholar
  3. 3.
    Atlan F, Durand S, Fox M, Levy P, Belkheyar Z, Oberlin C (2012) Functional outcome of glenohumeral fusion in brachial plexus palsy: a report of 54 cases. J Hand Surg Am 37:683–688CrossRefGoogle Scholar
  4. 4.
    Brand PW (1988) Biomechanics of tendon transfers. Hand Clin 4:137–154PubMedGoogle Scholar
  5. 5.
    De Smet L (2009) Bipolar latissimus dorsi flap transfer for reconstruction of the deltoid. Acta Orthop Belg 75:32–36PubMedGoogle Scholar
  6. 6.
    Elhassan BT, Christensen TJ, Wagner ER (2014) Feasibility of latissimus and teres major transfer to reconstruct irreparable subscapularis tendon tear: an anatomic study. J Shoulder Elb Surg 23:492–499CrossRefGoogle Scholar
  7. 7.
    Elhassan BT, Wagner ER, Werthel JD, Le Hanneur M, Lee J (2018) Outcome of reverse shoulder arthroplasty with pedicled pectoralis transfer in patients with deltoid paralysis. J Shoulder Elb Surg 27:96–103CrossRefGoogle Scholar
  8. 8.
    Ferrante MA, Wilbourn AJ (2017) Lesion distribution among 281 patients with sporadic neuralgic amyotrophy. Muscle Nerve 55:858–861CrossRefGoogle Scholar
  9. 9.
    Gerber C, Vinh TS, Hertel R, Hess CW (1988) Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff. A preliminary report. Clin Orthop Relat Res 232:51–61Google Scholar
  10. 10.
    Goel DP, Ross DC, Drosdowech DS (2012) Rotator cuff tear arthropathy and deltoid avulsion treated with reverse total shoulder arthroplasty and latissimus dorsi transfer: case report and review of the literature. J Shoulder Elb Surg 21:e1–e7CrossRefGoogle Scholar
  11. 11.
    Harmon PH (1950) Surgical reconstruction of the paralytic shoulder by multiple muscle transplantations. J Bone Jt Surg Am 32-A:583–595CrossRefGoogle Scholar
  12. 12.
    Herzberg G, Urien JP, Dimnet J (1999) Potential excursion and relative tension of muscles in the shoulder girdle: relevance to tendon transfers. J Shoulder Elbow Surg 8(5):430–437CrossRefGoogle Scholar
  13. 13.
    Hou CL, Tai YH (1991) Transfer of upper pectoralis major flap for functional reconstruction of deltoid muscle. Chin Med J (Engl) 104:753–757Google Scholar
  14. 14.
    Holzbaur KR, Murray WM, Gold GE, Delp SL (2007) Upper limb muscle volumes in adult subjects. J Biomech 40:742–749CrossRefGoogle Scholar
  15. 15.
    Itoh Y, Sasaki T, Ishiguro T, Uchinishi K, Yabe Y, Fukuda H (1987) Transfer of latissimus dorsi to replace a paralysed anterior deltoid. A new technique using an inverted pedicled graft. J Bone Jt Surg Br 69:647–651CrossRefGoogle Scholar
  16. 16.
    Kermarrec G, Werthel JD, Canales P, Valenti P (2018) Review and clinical presentation in reverse shoulder arthroplasty in deltoid palsy. Eur J Orthop Surg Traumatol 28:747–751CrossRefGoogle Scholar
  17. 17.
    Kline DG, Kim DH (2003) Axillary nerve repair in 99 patients with 101 stretch injuries. J Neurosurg 99:630–636CrossRefGoogle Scholar
  18. 18.
    Kuechle DK, Newman SR, Itoi E, Niebur GL, Morrey BF, An KN (2000) The relevance of the moment arm of shoulder muscles with respect to axial rotation of the glenohumeral joint in four positions. Clin Biomech (Bristol Avon) 15:322–329CrossRefGoogle Scholar
  19. 19.
    Lädermann A, Walch G, Denard PJ, Collin P, Sirveaux F, Favard L, Edwards TB, Kherad O, Boileau P (2013) Reverse shoulder arthroplasty in patients with pre-operative impairment of the deltoid muscle. Bone Jt J 95-B:1106–1113CrossRefGoogle Scholar
  20. 20.
    Lädermann A, Walch G, Lubbeke A, Drake GN, Melis B, Bacle G, Collin P, Edwards TB, Sirveaux F (2012) Influence of arm lengthening in reverse shoulder arthroplasty. J Shoulder Elb Surg 21:336–341CrossRefGoogle Scholar
  21. 21.
    Leechavengvongs S, Malungpaishorpe K, Uerpairojkit C, Ng CY, Witoonchart K (2016) Nerve transfers to restore shoulder function. Hand Clin 32:153–164CrossRefGoogle Scholar
  22. 22.
    Lin H, Hou C, Xu Z (2009) Transfer of the superior portion of the pectoralis major flap for restoration of shoulder abduction. J Reconstr Microsurg 25:255–260CrossRefGoogle Scholar
  23. 23.
    Morelli M, Nagamori J, Gilbart M, Miniaci A (2008) Latissimus dorsi tendon transfer for massive irreparable cuff tears: an anatomic study. J Shoulder Elb Surg 17:139–143CrossRefGoogle Scholar
  24. 24.
    Neyton L, Erickson J, Ascione F, Bugelli G, Lunini E, Walch G (2018) Scapular fractures in reverse shoulder arthroplasty (Grammont style): prevalence, functional, and radiographic results with minimum 5-year follow-up. J Shoulder Elbow Surg.  https://doi.org/10.1016/j.jse.2018.07.004 CrossRefPubMedGoogle Scholar
  25. 25.
    Rowsell AR, Davies DM, Eisenberg N, Taylor GI (1984) The anatomy of the subscapular-thoracodorsal arterial system: study of 100 cadaver dissections. Br J Plast Surg 37:574–576CrossRefGoogle Scholar
  26. 26.
    Rühmann O, Schmolke S, Bohnsack M, Flamme C, Wirth CJ (2005) Shoulder arthrodesis: indications, technique, results, and complications. J Shoulder Elb Surg 14:38–50CrossRefGoogle Scholar
  27. 27.
    Saha AK (1967) Surgery of the paralysed and flail shoulder. Acta Orthop Scand 97:5–90Google Scholar
  28. 28.
    Shah AA, Butler RB, Romanowski J, Goel D, Karadagli D, Warner JJ (2012) Short-term complications of the Latarjet procedure. J Bone Jt Surg Am 94:495–501CrossRefGoogle Scholar
  29. 29.
    Tobin GR (1985) Pectoralis major segmental anatomy and segmentally split pectoralis major flaps. Plast Reconstr Surg 75:814–824CrossRefGoogle Scholar
  30. 30.
    Tubbs RS, Loukas M, Shahid K, Judge T, Pinyard J, Shoia MM, Slappey MM, McEvoy WC, Oakes WJ (2007) Anatomy and quantitation of the subscapular nerves. Clin Anat 20:656–659CrossRefGoogle Scholar
  31. 31.
    Tung TH, Mackinnon SE (2010) Nerve transfers: indications, techniques, and outcomes. J Hand Surg Am 35:332–341CrossRefGoogle Scholar
  32. 32.
    Werthel JD, Bertelli J, Elhassan BT (2017) Shoulder function in patients with deltoid paralysis and intact rotator cuff. Orthop Traumatol Surg Res 103:869–873CrossRefGoogle Scholar

Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of OrthopedicsMayo ClinicRochesterUSA
  2. 2.Department of Orthopedics and Traumatology-Service of Hand, Upper Limb and Peripheral Nerve SurgeryGeorges-Pompidou European Hospital (HEGP)-Assistance Publique-Hôpitaux de Paris (APHP)ParisFrance
  3. 3.Sierra Pacific OrthopedicsFresnoUSA
  4. 4.Department of Orthopedic SurgeryEmory UniversityAtlantaUSA

Personalised recommendations