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Secondary Surgery

Either the  brachial plexus lesions have been surgically repaired or a spontaneous recovery is expected,  the baby continues to be seen at the Center periodically to evaluate the correct development of recovery.

The time necessary for the recovery to develop depends on the type, the level, the extension of the lesions and from the type of surgical repair.

For example in a superior paralysis (the so-called Erb's palsy) where the function of shoulder and the flexion of the elbow are mainly affected, an average time of 2 years is necessary to assess a stable final result.

But in many instances, only a partial recovery may occur. Especially in spontaneous recovery, we can assist a muscular imbalance due to the predominant function of some muscular groups which are strong, being normal in relationship to the weak or absent paralysed groups.

Normally the internal rotators (that allows the hand to reach the back of the body) are not affected by the paralysis, therefore the child is able to internally rotate his arm but not the contrary.

1. Shoulder

The most typical partial recovery at the shoulder level is an abduction which does not reach the right angle (90°) with a partial or total lack of external rotation of the arm. The hand can reach the mouth and frequently to do this movement the child elevates the shoulder (which is called the "trumpet sign").  The child's hand can hardly reach his ear and very seldom he can reach the nape of the neck.

To avoid the direction in which the muscular unbalance could lead, with growth, to lasting bone and joint deformities, if the passive external rotation of the shoulder is less than 20° an operation is indicated at one year of age. The subscapular muscle is released in order to improve the passive external rotation. This operation can aid to strengthen the weak external rotators muscles.

SUBSCAPULAR RELEASE

The skin incision is along the lateral border of the scapula
	The latissimus dorsi muscle is retracted and the border of the scapula is exposed
The internal rotation is substained by the retracted subscapular muscle that must be detached by its scapular insertions
	The muscle is completely detached from the scapula
Now the arm can be externally rotated thanks to the complete detachement of the subscapular muscle
	The arm is imobilized with a cast for 3 weeks with the shoulder adducted and completely externally rotated

At the age of two the recovery of the shoulder function, either spontaneously or after primary surgery, is considered completed. At that age, if a deficit of abduction or external rotation does still exist, an indication for secondary surgery is given.  

The secondary surgery has the aim to improve function by means of transferring active muscles by changing their original bone insertion and turning them towards the paralysed or poorly functioning muscles.

In the shoulder area for instances the operation has the aim to reduce the power of internal rotation and to gain external rotation by means of changing the insertion of one or more muscles transforming them by internal into external rotators. 

In severe deficit of shoulder abduction, the trapezius muscle transfer, eventually associated with the levator scapulae muscle transfer can restore, even though partially, a useful function. 

LEVATOR SCAPULAE AND TRAPEZIUS TRANSFER

Severe deficit of shoulder with a complete lack of abduction and external rotation: a good indication for a double transfer, levator scapulae for external rotation and trapezius for abduction

The skin incision follows the medial bord of the scapula, the spine of the scapula and the posterior deltoid region
	The levator scapulae muscle is identified at its insertion to the scapula and harvested with a long strip of periosteum along the medial border of the scapula
The muscle is completely detached from the scapula with its prolongation
	The muscle with its new tendon is trasposed and fixed to the humerus to substitute the paralyzed supraspinatus muscle
The trapezius muscle (see arrow) is detached from its distal bone insertion
	The trapezius is trasposed and fixed to the humerus to substitute the paralyzed muscle
The limb is immobilyzed with a plaster cast with abduction of 120° and maximal external rotation for the duration of 5 weeks

Functional result after double transfer with an abduction of 90°

in the scapular plane which is the best result that

we can obtain in a severe paralyzed shoulder

LATISSIMUS DORSI TRANSFER

An 18-month-old child with a spontaneous recovery with 95° of shoulder abduction with no external rotation neither active nor passive. There is an indication for subscapular release and latissimus dorsi transfer for external rotation in the same time

The skin incision follows the lateral border of the scapula and the posterior margin of deltoid
	The latissimus dorsi muscle is isolated (see arrow). The aim of the operation is to transform the intrarotation function of the muscle into an extrarotation one
The latissimus dorsi insertion has been devided from the humerus in order to change its distal insertion
	The tendon is reinserted to the rotator cuff transforming in this way the action of the latissimus dorsi into an external rotation

The functional result two years after surgery

with good recovery af the active external rotation

and a significant improvement of shoulder abduction

2. Elbow

Less frequently a lack of active elbow flexion can happen. An important number of surgical operations have been described to improve secondarily the elbow flexion. The rationale of these operations is to utilize good functioning muscle, changing their original bony insertion and to direct them to substitute the biceps muscle. They can vary depending on availability of good motors: pectoralis major, latissimus dorsi, wrist flexors, triceps etc.

THE STEINDLER OPERATION

The functional result of a Steindler operation

with an active flexion of the elbow due to the

action of the transposed epitroclear muscle;

see the scar at the elbow origin

PECTORALIS MAJOR TRANSFER

The functional result of a pectoralis major

transfer to elbow flexor with a good strenght

against resistance

LATISSIMUS DORSI TRANSFER

3. Forearm

Another example of muscular unbalance that needs a surgical correction is the supinated forearm;  the hand shows the palm upward and is unable to rotate with the palm downward as it is normally necessary for everyday life movements. This useless and unaesthetic position of the hand can be solved by means of a palliative operation that through a rerouting of the tendon of the biceps muscle transforms it into a pronator of the forearm, therefore allowing the hand to turn the palm downward.

4. Hand

At the wrist level one of the more frequent deficits that needs to be restored is the wrist extension. The transfers can vary depending of the availability of functioning muscles but they are generally possible even in more extensive paralysis.  Restoration of wrist extension is of paramount importance for the hand function and must be a priority objective.

Functional result in a total paralysis after primary repair

and after secondary repair by means of a transfer for

wrist and finger extension

The palliative surgery at the hand level for lack of finger function is more difficult to carry out, not for technical problems but due to the frequent lack of available muscles to be transposed.   This happens in total paralysis where lower roots of the brachial plexus had been avulsed and no possibility of spontaneous recovery can happen.  Despite the early microsurgical repair of these roots, the functional results can be sometimes poor and for this reason transfer to recover finger flexion must be performed.

In severe total paralysis when no muscle are available for transfer

there is the possibility to performe a tenodesys: it consists of fixing

extensor and flexor tendons to the bone (radius) win such away that

during eztension of the wrist (red arrows) the flexor are tightened and

the extensor are relaxed producing in this way a flexion of the fingers.

On the right side we can see that the passive drop of the hand produces

a passive extension of the fingers with an opening of the hand

The ideal age to perform these operations is generally around 4 years, as the completion of functional recovery takes more time to occur than in the upper part of the arm.

In selected cases in which no function at all is recovered, especially for elbow flexion, there is still the possibility to transfer with microsurgical techniques a muscle from the thigh. This type of surgery can restore only a unique limited function. 

All these type of secondary surgeries (except the last one) take less time to perform as compared to primary microsurgical repair of brachial plexus; it is also necessary to immobilize the affected arm in a cast for a period of 4 to 5 weeks depending of the type of muscular transfer.