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Conjoined Versus Isolated Shoulder Tendon Transfers in Brachial Plexus Birth Palsy
William Smith, MD1; Dustin Greenhill, MD1; Scott Kozin, MD2; Dan Zlotolow, MD2
1Temple University Hospital, Philadelphia, PA; 2Shriners Hospital for Children Philadelphia, Philadelphia, PA

Background: In children with brachial plexus birth palsy (BPBP) undergoing tendon transfers to augment shoulder external rotation, it is unclear whether transfer of the latissimus dorsi with its conjoined teres major tendon (cLT) versus isolated teres major tendon transfer (iTM) yield different outcomes.

Methods: Records of patients with BPBP who underwent shoulder tendon transfers to augment external rotation were retrospectively reviewed. Transfer type (cLT or iTM) was considered indiscriminate by virtue of surgeon preference. Modified Mallet Scale (mMS) and Active Movement Scale (AMS) scores were recorded. Patients with <12 months follow-up, C7 or lower palsy, humeral osteotomy, shoulder procedure(s) within 8 months, microsurgery within one year, or recurrent glenohumeral subluxation confirmed by postoperative imaging were excluded. Matched cohorts were identified within each tendon transfer group to yield similar preoperative shoulder function and glenohumeral alignment status. Outcomes for all tendon transfers as well as differences between cLT and iTM cohorts were analyzed.

Results: Among 121 cLT and 34 iTM transfers, matching cohorts yielded 28 patients (14 cLT and 14 iTM) for study inclusion. Average age at time of transfer was 2.21.0 years. Follow-up averaged 2.31.9 years. There were no statistically significant preoperative differences between cohorts, thus matching criteria were validated. Regardless of tendon(s) transferred, mMS external rotation improved (2.14 to 3.75, p<0.0001) while mMS internal rotation decreased (3.80 to 2.96, p=0.008). When comparing cohorts, cLT produced a greater improvement than iTM in mMS external rotation (2.0 versus 1.2, p=0.01). Loss of midline function (defined as mMS external rotation <3) occurred in five cLT and two iTM patients.

Conclusion: Both cLT or iTM transfer are effective at augmenting shoulder external rotation in children with C5-C6 BPBP. Furthermore, cLT transfers may be superior in most patients given a larger improvement in external rotation. However, both techniques slightly decrease shoulder internal rotation. Given that more total cLT patients lost midline function, iTM transfer can still be considered when limited midline function is a concern.

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