The Role of Early Latissimus Dorsi Tendon Transfers for Shoulder Movement and Stability in Neonatal Brachial Plexus Injury

Abstract

INTRODUCTION: Neonatal brachial plexus injury (BPI) is a rare but devastating complication of birth. An upper trunk BPI can result in the loss of shoulder external rotation and abduction and often leads to glenohumeral joint dysplasia (GJD). The latissimus dorsi/teres major tendon transfer (LTT) is a procedure used to restore external rotation and shoulder abduction and potentially reduce the incidence of GJD. Historically, this tendon transfer has been performed when the child is older and has demonstrated impaired shoulder function. In this study, we sought to assess feasibility and short-term outcomes of LTT combined with BPI reconstruction. METHODS: A retrospective review of patients was performed. Inclusion criteria were patients under 18 years of age at Riley Children’s Hospital with BPI who underwent LTT between 2021-2022. RESULTS: Eighteen patients underwent LTT between 2021-2022 at the mean age of 2.2 +/- 2.2 years. Five patients (27.8%) underwent the transfer concurrently with BPI nerve reconstruction, 8 (44.4%) underwent staged LTT, and 5 (27.8%) patients underwent LTT with no previous or concurrent BPI reconstruction. Of the 8 patients that underwent staged repair, 7/8 (88%) had MRI evidence of GJD prior to their tendon transfer. There were no major complications in any subgroup. Average follow-up was 7.54 months. The mean age at surgery for patients undergoing staged LTT was 2.1 years old compared to 6 months in the concurrent group. In the staged cohort, available post-operative mean AMS scores were 3.5 for shoulder abduction, 1.67 for shoulder external rotation. and 4.83 for shoulder forward flexion. In the concurrent cohort, mean AMS scores were 3.2 for shoulder abduction, 1.8 for external rotation, and 3.6 for shoulder forward flexion. CONCLUSIONS: In this study, we found that LTT can be safely and efficiently combined with BPI reconstruction. Patients in the concurrent surgery cohort achieved similar shoulder functional scores as those in the staged surgery cohort, but these scores were achieved at a younger age (i.e.1.5 years earlier) and without a second surgery. In addition, a simultaneous or early approach may provide the very young pediatric patient shoulder stability needed to prevent GJD while also avoiding the need for a second anesthetic exposure. Future studies will focus on comparative assessment of long-term shoulder functional outcomes.