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by Mayer who used a fascia lata graft, albeit with poor
[7]
results. Bateman’s procedure involved resection of part of
[4]
the spine of the scapula with the trapezius. This procedure
was further modified by Saha, who also mobilized the
[5]
upper and middle segments of the trapezius muscle.
The trapezius has three functional segments, consisting
of a descending segment which supports the weight of
the arm; a transverse segment which retracts the scapula; a b
and an ascending segment which medially rotates and
depresses the scapula. Along with the levator scapulae
and the serratus anterior, the middle and lower fibers of
the trapezius muscle provide shoulder stability for arm
movements and for that reason should be spared. The
descending fibers which attach to the posterior aspect of
the lateral third of the clavicle can be safely used. A more c d
anterolateral fixation on the humerus is expected to
abduct and forward flex the arm. Because the clavicle is a Figure 1: (a) Mobilisation of descending fibres of the trapezius muscle
and their insertion on the posterior border of lateral third of clavicle;
superficial bone, it is more amenable to dissection which (b) exposure of anterolateral surface of humerus by splitting the deltoid
obviates a more difficult dissection of the scapular spine. muscle; (c) fixation of clavicular segment to the anterolateral surface of
The current study was undertaken with the objective of the humerus by cancellous screws; (d) suturing of deltoid with trapezius
and bury the screws
using the descending fibers of the trapezius muscle to
evaluate their effect on shoulder movements.
to the acromion and spine of the scapula were left intact.
The proximal humerus was exposed by splitting the
METHODS
deltoid longitudinally [Figure 1b] and slightly chiseled
out to roughen the anterolateral surface of humerus. The
Patients with brachial plexus injuries who presented to rotator cuff was left untouched. With the humerus held
the outpatient clinic of the Plastic Surgery Department in 90°‑100° of abduction, the clavicular fragment with
were candidates for the study. A total of 41 patients its trapezius insertion was transferred and fixed to the
were evaluated between 2009 and 2014, and 32 patients humerus with two 4 mm cancellous screws [Figure 1c].
met inclusion criteria. All patients involved in this The deltoid was then sutured over the trapezius with
article agreed to have their facial pictures published a polypropylene 1‑0 suture to render strength to the
and signed the consent form. The average age of the trapezius and to bury the screws [Figure 1d]. The skin
patients was 23.5 years with a range from 17 years was closed over a suction drain. The arm was splinted
to 42 years. Inclusion criteria were a supple shoulder, in 90°‑100° arm abduction. The mean operative time
passive abduction more than 90°, good adductor muscles, was 112 min. Radiographs were taken on the 2nd
trapezius muscle power more than 4+ and an absence postoperative day to assess the position of the screws and
of locoregional injury. Exclusion criteria were dislocation the clavicular fragment, and at 3 and 6 weeks to monitor
or subluxation of the shoulder, a stiff shoulder, passive any signs of union. The arm was immobilized for 6 weeks,
abduction less than 90°, weak adductor muscles, a weak but assisted and active exercises of the elbow, hand and
trapezius muscle, the presence of a clavicular fracture and fingers were initiated on postoperative day one. At one
injury to the locoregional structures. Patients who had week, the splint was removed and a custom‑made airplane
failed previous nerve reconstruction or nerve transfer and splint was applied maintaining the position of abduction.
patients presenting 2 years or more following injury were Progressive passive adduction of the arm was started at
the primary candidates for trapezius muscle transfer.
that time, while active adduction and passive abduction
Operative technique in the supine position were initiated after 21 days. The
The patient was placed in the supine position with a same exercise was gradually done in the sitting position.
pillow under the scapula and the neck turned to the After 6 weeks, active abduction and forward flexion were
opposite side. An incision was made on the anterior encouraged with splinting between exercises. The patient
border of the trapezius muscle and extended down to the was evaluated monthly for 3 months and then every
upper 4th of the humerus. The attachments of the upper 3 months for one year.
descending fibers of the trapezius to the posterior border
of the lateral 3rd of the clavicle and the attachment of RESULTS
the deltoid muscle to the anterior border of the clavicle
were identified. The deltoid attachment was released and In all the 32 patients, the transfer improved both the
the attachment of the trapezius to the lateral clavicle was function and stability of the shoulder [Table 1]. The average
divided lateral to the coracoclavicular ligament [Figure 1a]. increase in active abduction was from 7.5° (range: 0°‑30°) to
The deep surface of the clavicle was abraded with a 85° (range: 45°‑140°) at a mean follow‑up of 8.25 months
bone rasp for bony union between the clavicle and the [Figures 2a and b, Figure 3a and b]. The range of improvement
abraded humerus. The remaining fibers of the trapezius was from 35° to 140°. Mean forward flexion improved from

Plast Aesthet Res || Vol 2 || Issue 6 || Nov 12, 2015 347