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Advances in Motion

Shoulder Arthrodesis, Upper Trapezius Transfer Comparable for Secondary Reconstruction After Traumatic Brachial Plexus Injury

Journal

Originally published on Advances in Orthopedics

Key findings

  • This systematic review and meta-analysis synthesized 17 observational studies (378 patients) to compare outcomes of shoulder arthrodesis and upper trapezius transfer after adult traumatic brachial plexus injury
  • Weighted rates of complications and reoperations were higher after shoulder arthrodesis than after upper trapezius transfer, but the difference was not statistically significant
  • Complications after shoulder arthrodesis tended to be more severe and more frequently required reoperation than those following upper trapezius transfer; notably, the rate of nonunion of shoulder arthrodesis was 9% and all nonunions required reoperation
  • No conclusions could be drawn about differences between the procedures with respect to range of motion and functional outcome scores

Secondary shoulder reconstruction is commonly required in the treatment of adult traumatic brachial plexus injury (BPI). The two surgical options for secondary shoulder reconstruction are shoulder arthrodesis and upper trapezius transfer. Most patients are candidates for both, and no comparative evidence is available to guide the choice between the procedures.

Dafang Zhang, MD, orthopedic surgeon at Brigham and Women's Hospital, Rohit Garg, MD, MBBS, hand and upper extremity orthopedic surgeon in the Department of Orthopaedic Surgery at Massachusetts General Hospital, George S.M. Dyer, MD, director of the Harvard Combined Orthopaedic Residency Program, and colleagues performed a systematic review and meta-analysis of available literature on the two procedures in this setting.

Their report in Advances in Orthopedics describes different complication and reoperation profiles for the procedures, but no significant differences between them in complication or reoperation rates.

Methods

The team searched MEDLINE, EMBASE, CENTRAL and ClinicalTrials.gov from inception to September 20, 2020. Only observational studies (level IV evidence) were identified: 11 of shoulder arthrodesis and six of upper trapezius transfer.

Description of the Cohorts

  • Shoulder arthrodesis (SA)—232 patients, 94% male, mean age 28. The mean time from injury to shoulder arthrodesis was 37 months, and the mean postoperative follow-up was 48 months
  • Upper trapezius transfer (UTT)—142 patients, 88% male, mean age 29 years. The mean duration of time from injury to upper trapezius transfer was 54 months, and the mean postoperative follow-up was 22 months

Postoperative Complications

  • Weighted complication rates—29% with SA and 10% with UTT (not a significant difference)
  • Complications following SA—nonunion (n=22), humerus fracture (n=15), symptomatic hardware (n=11), deep infection (n=5), pin tract infection (n=5), skin breakdown (n=2), and one each of fixation failure, hardware loosening, hematoma, intraarticular screw-in acromioclavicular joint, malunion, scapular neck fracture and superficial infection
  • Complications following UTT—hardware loosening (n=7), deep infection (n=4), humerus fracture (n=2), persistent glenohumeral joint instability (n=2), skin breakdown (n=2), transient musculocutaneous nerve palsy (n=2), and one each of contralateral ulnar neuropathy, silk suture extrusion and superficial infection

Reoperations

  • Weighted reoperation rates—15% with SA and 5% with UTT (not a significant difference)
  • Reoperations following SA—revision arthrodesis ± bone grafting for nonunion (n=23), humeral shaft open reduction internal fixation (n=7), irrigation, debridement and hardware removal (n=3), irrigation and debridement (n=2), hematoma evacuation (n=1) and symptomatic hardware removal (n=1)
  • Reoperations following UTT—irrigation, debridement, and hardware removal (n=4), shoulder arthrodesis (n=2), and symptomatic hardware removal (n=2)

Other Primary Endpoints

No conclusions could be made about differences between SA and UTT in range of motion and functional outcome scores because of the limited sample size, variations in reporting and study heterogeneity.

Patient Counseling

Surgeons should make patients aware of the complication and reoperation profiles of SA and UTT, particularly the risk of nonunion (9%) and humerus fracture (6%) with SA. All cases of nonunion of SA required reoperation.

29%
complication rate with shoulder arthrodesis after adult traumatic brachial plexus injury

10%
complication rate with upper trapezius transfer after adult traumatic brachial plexus injury

15%
reoperation rate with shoulder arthrodesis after adult traumatic brachial plexus injury

5%
reoperation rate with upper trapezius transfer after adult traumatic brachial plexus injury

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