Stephan Schmolke

Reconstructive operations for the paralyzed shoulder in brachial plexus palsy: concept of treatment.

Sixty-three patients with persistent brachial plexus palsy underwent a transfer of the trapezius muscle and 14 patients a shoulder arthrodesis. Thirteen female and 64 male patients were treated with a mean age of 31 yr (17-69 yr). The average follow-up period was 14 months (6-50 months). In all cases, the trapezius transfer resulted in increased abduction from 6.1 degrees to an average of 36.4 degrees (20-80 degrees) and forward flexion from 13.8 degrees to an average of 31.9 degrees (10-90 degrees). The multidirectional shoulder instability was improved in 60 patients. Strength and functional improvement was, on average, greater following shoulder arthrodesis (abduction from 9.6 to 59.3 degrees (40-90 degrees), forward flexion from 11.4 to 50.7 degrees (30-90 degrees)). In patients with brachial plexus palsy, trapezius transfer resulted in an improvement of shoulder function and stability as well as subjectively. The increase in function was, however, less pronounced in comparison with shoulder arthrodesis. The advantages of the transfer are the regaining of normal passive function and the shorter duration of surgery. Shoulder fusion is more suitable for those patients who require the best possible extent of function and strength in the shoulder.

Trapezius transfer in brachial plexus palsy. Correlation of the outcome with muscle power and operative technique.

Between March 1994 and June 2003, 80 patients with brachial plexus palsy underwent a trapezius transfer. There were 11 women and 69 men with a mean age of 31 years (18 to 69). Before operation a full evaluation of muscle function in the affected arm was carried out. A completely flail arm was found in 37 patients (46%). Some peripheral function in the elbow and hand was seen in 43 (54%). No patient had full active movement of the elbow in combination with adequate function of the hand. Patients were followed up for a mean of 2.4 years (0.8 to 8). We performed the operations according to Sahas technique, with a modification in the last 22 cases. We demonstrated a difference in the results according to the pre-operative status of the muscles and the operative technique. The transfer resulted in an increase of function in all patients and in 74 (95%) a decrease in multidirectional instability of the shoulder. The mean increase in active abduction was from 6 degrees (0 to 45) to 34 degrees (5 to 90) at the last review. The mean forward flexion increased from 12 degrees (0 to 85) to 30 degrees (5 to 90). Abduction (41 degrees) and especially forward flexion (43 degrees) were greater when some residual function of the pectoralis major remained (n = 32). The best results were achieved in those patients with most pre-operative power of the biceps, coracobrachialis and triceps muscles (n = 7), with a mean of 42 degrees of abduction and 56 degrees of forward flexion. Active abduction (28 degrees) and forward flexion (19 degrees) were much less in completely flail shoulders (n = 34). Comparison of the 19 patients with the Saha technique and the 15 with the modified procedure, all with complete paralysis, showed the latter operation to be superior in improving shoulder stability. In all cases a decrease in instability was achieved and inferior subluxation was abolished. The results after trapezius transfer depend on the pre-operative pattern of paralysis and the operative technique. Better results can be achieved in patients who have some function of the biceps, coracobrachialis, pectoralis major and triceps muscles compared with those who have a complete palsy. A simple modification of the operation ensures a decrease in joint instability and an increase in function.

Osteotomy of the Humerus to Improve External Rotation in Nine Patients with Brachial Plexus Palsy

Malfunction of the infraspinatus muscle and teres minor muscle illustrate the typical clinical picture in patients with brachial plexus palsy. The arm hangs down in an inwardly rotated position and elbow flexion is hindered by striking of the lower arm against the thorax. Between 1995 and 2000, we have done external rotational osteotomy of the humerus for nine patients with brachial plexus palsy. The mean age of the patients at the time of operation was 29 years (range 15 to 42). The mean follow-up time was 24 (6 to 69) months. Preoperatively, the patients all had appreciable deficits of external rotation (mean deficit 37°, range 10° to 70°). As a result of osteotomy, external rotation was improved in all patients, the mean increase being 42° (range 25° to 60°). All patients were subjectively content with the improved position of the arm and its function. They were able to move their hands to their faces without striking the lower arm against the chest on elbow flexion, or without compensatory evasive movement of the shoulder.

Trapezius transfer after brachial plexus palsy: INDICATIONS, DIFFICULTIES AND COMPLICATIONS

Most brachial plexus palsies are due to trauma, often resulting from motorcycle accidents. When nerve repair and physiotherapy are unsuccessful, muscle transfer may be considered. Paralysis of the deltoid and supraspinatus muscles can be addressed by transfer of the trapezius. Between March 1994 and June 1997 we treated 38 patients with brachial plexus palsy by trapezius transfer and reviewed 31 of these (7 women, 24 men) after a mean follow-up of 23.8 months (12 to 39), reporting the clinical and radiological results and subjective assessment. The mean age of the patients was 29 years (18 to 46). The operations had been performed according to the method of Saha described in 1967, involving transfer of the acromion with the insertion of the trapezius to the proximal humerus, and immobilisation in an abduction support for six weeks. Rehabilitation started on the first postoperative day with active exercises for the elbow, hand and fingers, and electrical stimulation of the transferred trapezius. All 31 patients had improved function with a decrease in multidirectional instability of the shoulder. The average increase in active abduction was from 7.3 degrees (0 to 45) to 39 degrees (25 to 80) at the latest review. The mean forward flexion increased from 20 degrees (0 to 85) to 44 degrees (20 to 90). Twenty-nine of the 31 were satisfied with the improvement in stability and function. Trapezius transfer for brachial plexus palsy involving the shoulder improves function and stability with clear subjective benefits.

Transposition of local muscles to restore elbow flexion in brachial plexus palsy

Between 1994 and 2001, triceps to biceps transfers were done in 10 men and a transfer of the forearm flexors and extensors (Steindler procedure) in nine. All had suffered from a post-traumatic lesion of their brachial plexus, resulting in loss of elbow flexion. Their mean age at the time of the original accident was 27 years (range 16-50 years) and at the time of muscle transfer 35 years (range 22-56 years), with a mean observation period of 20 months (range 6-51 months). In 16 patients, a neurosurgical procedure had been performed after the trauma, and in 22 patients other reconstructive operations had been done. Transfer of the forearm flexors and extensors resulted in active elbow flexion with a mean of 94 degrees (range 70-130 degrees ). After triceps to biceps transposition a mean of 109 degrees (range 70-140 degrees ) was reached. A mean deficit of passive extension of 12 degrees (range 0-30 degrees ) remained after the Steindler procedure, and of 5 degrees (range 0-10 degrees ) after triceps to biceps transposition. Two complications occurred with the Steindler procedure. The transfer of the triceps muscle to the tendon of the biceps and the transfer of the forearm flexors or extensors on loss of elbow flexion, therefore, resulted in adequate movement and strength. Both procedures involve operating close to the elbow joint and had minimal complications. The triceps to biceps transfer is particularly suitable for co-contraction of triceps and biceps.

Open versus arthroscopic shoulder stabilization. An analysis of the treatment costs

ZusammenfassungIn dieser Studie werden die stationären Behandlungskosten der offenen anterioren Schulterstabilisierung nach Bankart und die Kosten der arthroskopischen anterioren Schulterstabilisierung (ASK) analysiert und miteinander verglichen.Von insgesamt 147 Patienten die zwischen 1988 und 1998 in unserer Klinik eine operative Schulterstabilisierung erhalten haben wurden per Zufallsgenerator jeweils 30 Patienten (25 männlich/5 weiblich, Durchschnittsalter 29 Jahre) nach offenem und 30 Patienten (25 männlich/5 weiblich, Durchschnittsalter 26 Jahre) nach arthroskopischem Vorgehen ausgewählt und deren stationäre Behandlungskosten ermittelt.Die Gesamtkosten der offenen Schulterstabilisierung nach Bankart waren mit durchschnittlich 5639 € signifikant (p<0,05, Mann- Whitney-U-Test) höher als die Kosten der arthroskopischen Schulterstabilisierung mit 4601 €. Der Unterschied der Operations- (Bankart: 2741 €, ASK: 2315 €; p<0,05) und der postoperativen klinischen Kosten (Bankart: 2202 €, ASK: 1630 €; p<0,05) war signifikant, während der Unterschied der präoperativen klinischen Kosten (Bankart: 696 €, ASK: 657 €) nicht signifikant war. Den höchsten Anteil an den Gesamtkosten hatten die Personalkosten im Operationssaal [Bankart: 1800 € (32%), ASK: 1319 € (29%)] sowie die Personalkosten des Pflegedienstes auf der Normalstation [Bankart: 1271 € (23%), ASK: 997 € (22%)]. Die mittlere stationäre Verweildauer betrug 15,8 Tage bei der offenen- und 12,4 Tage bei der arthroskopischen Schulterstabilisierung.AbstractIn this study the total costs of clinical open and arthroscopic anterior shoulder stabilization were evaluated, analyzed and compared.From 1988 to 1998 147 patients underwent open (Bankart) or arthroscopic (ASK) anterior shoulder stabilization. We randomized two groups of 30 patients for each method (Bankart: 25 male, 5 female, 29 years of age; ASK: 25 male, 5 female, 26 years of age) and evaluated the costs of their clinical treatment.The total cost was significantly (p<0,05, Mann-Whitney U-Test) higher for the open (5639 €) than for the arthroscopic (4601 €) therapy. There was a significant difference between the groups for the average cost of surgery (Bankart: 2741 €; ASK: 2315 €, p<0,05) and the average postoperative treatment cost (Bankart: 2202 €; ASK: 1630 €, p<0,05) whereas the average preoperative treatment cost was not significantly different (Bankart: 669 €, ASK: 657 €). The staff costs for the surgical procedure (Bankart: 1800 € (32%), ASK: 1319 € (29%)) and the postoperative staff costs of the nurses (Bankart: 1271 € (23%), ASK: 997 € (22%)) represented the greatest parts of the total costs. The average duration of the clinical treatment was 15,8 days for the open- and 12,4 days for the arthroscopic group.

Verlagerung der Unterarmmuskulatur nach Steindler zur Wiederherstellung der Ellbogenbeugung bei Lähmungen

ZusammenfassungOperationsziel Wiederherstellung der aktiven Ellbogenbeugung durch Verlagerung der Ursprünge der intakten Unterarmmuskulatur (Epicondylus medialis und/oder lateralis humeri) zum distalen Humerus. Dadurch wird die Gebrauchsfähigkeit des von der Lähmung betroffenen Arms verbessert. Indikationen Ausfall oder unzureichende Funktion der Ellbogenbeuger beim Armplexusschäden.Ausfall der Ellbogenbeugung nach peripherer Nervenläsion oder Poliomyelitis. Kontraindikationen Mögliche Besserung der Lähmung durch Reinnervation, spontan oder nach neurochirurgischem Eingriff.Unzureichender Kraftgrad der Unterarmbeuger oder -strecker.Kontraktes Ellbogengelenk.Nach Trauma oder degenerativen Veränderungen (Arthrose). Operationstechnik Der mediale und/oder laterale Epikondylus wird mit anhängender Muskulatur abgetragen, zum distalen Humerus verlagert und dort in einem vorbereiteten Knochenbett mit Kleinfragmentschrauben befestigt. Weiterbehandlung Der operierte Arm wird in einem Gilchrist-Verband in 100° Flexionsstellung für sechs Wochen immobilisiert. Danach werden die passive Ellbogenstreckung und die aktive Ellbogenbeugung bis zum Erreichen des maximal möglichen Bewegungsausmaßes geübt. Ergebnisse Der Vergleich unserer Ergebnisse bei sechs operierten Patienten mit denen die Literatur zeigt, dass eine adäquate Ellbogenbeugung in Bezug auf Bewegungsausmaß (mindestens 90° Ellbogenbeugung) und Kraftleistung (mindestens Unterarmbeugung gegen Eigenschwere) zu erwarten ist und Komplikationen selten sind.SummaryObjectives Restoration of active elbow flexion through transfer of the origin of the intact forearm muscles (medial and/or lateral epicondyle) to the distal humerus. This procedure will improve the function of the paralyzed arm. Indications Absent or inadequate function of elbow flexors in instances of plexus damage.Absent elbow flexion after peripheral nerve lesions or poliomyelitis. Contraindications Possibility of improvement through reinnervation, either spontaneous or after neurosurgical procedures.Inadequate strength of forearm flexors or extensors.Ankylosed elbow joint secondary to trauma or degenerative changes (osteoarthritis). Surgical Technique The medial and/or lateral epicondyle is osteotomized with the attached muscles, transferred to the distal humerus and attached to freshened bone with mini cortex screws. Results Results of 6 patients operated by us were compared to those reported in the literature. They showed that an elbow flexion of at least 90° can be obtained and that the strength is sufficient to bend the elbow against gravity. Complications are rare.

Offene vs. arthroskopische anteriore Schulterstabilisierung

ZusammenfassungIn dieser Studie werden die stationären Behandlungskosten der offenen anterioren Schulterstabilisierung nach Bankart und die Kosten der arthroskopischen anterioren Schulterstabilisierung (ASK) analysiert und miteinander verglichen.Von insgesamt 147 Patienten die zwischen 1988 und 1998 in unserer Klinik eine operative Schulterstabilisierung erhalten haben wurden per Zufallsgenerator jeweils 30 Patienten (25 männlich/5 weiblich, Durchschnittsalter 29 Jahre) nach offenem und 30 Patienten (25 männlich/5 weiblich, Durchschnittsalter 26 Jahre) nach arthroskopischem Vorgehen ausgewählt und deren stationäre Behandlungskosten ermittelt.Die Gesamtkosten der offenen Schulterstabilisierung nach Bankart waren mit durchschnittlich 5639 € signifikant (p<0,05, Mann- Whitney-U-Test) höher als die Kosten der arthroskopischen Schulterstabilisierung mit 4601 €. Der Unterschied der Operations- (Bankart: 2741 €, ASK: 2315 €; p<0,05) und der postoperativen klinischen Kosten (Bankart: 2202 €, ASK: 1630 €; p<0,05) war signifikant, während der Unterschied der präoperativen klinischen Kosten (Bankart: 696 €, ASK: 657 €) nicht signifikant war. Den höchsten Anteil an den Gesamtkosten hatten die Personalkosten im Operationssaal [Bankart: 1800 € (32%), ASK: 1319 € (29%)] sowie die Personalkosten des Pflegedienstes auf der Normalstation [Bankart: 1271 € (23%), ASK: 997 € (22%)]. Die mittlere stationäre Verweildauer betrug 15,8 Tage bei der offenen- und 12,4 Tage bei der arthroskopischen Schulterstabilisierung.AbstractIn this study the total costs of clinical open and arthroscopic anterior shoulder stabilization were evaluated, analyzed and compared.From 1988 to 1998 147 patients underwent open (Bankart) or arthroscopic (ASK) anterior shoulder stabilization. We randomized two groups of 30 patients for each method (Bankart: 25 male, 5 female, 29 years of age; ASK: 25 male, 5 female, 26 years of age) and evaluated the costs of their clinical treatment.The total cost was significantly (p<0,05, Mann-Whitney U-Test) higher for the open (5639 €) than for the arthroscopic (4601 €) therapy. There was a significant difference between the groups for the average cost of surgery (Bankart: 2741 €; ASK: 2315 €, p<0,05) and the average postoperative treatment cost (Bankart: 2202 €; ASK: 1630 €, p<0,05) whereas the average preoperative treatment cost was not significantly different (Bankart: 669 €, ASK: 657 €). The staff costs for the surgical procedure (Bankart: 1800 € (32%), ASK: 1319 € (29%)) and the postoperative staff costs of the nurses (Bankart: 1271 € (23%), ASK: 997 € (22%)) represented the greatest parts of the total costs. The average duration of the clinical treatment was 15,8 days for the open- and 12,4 days for the arthroscopic group.