Emily Dodwell1, Sevan Hopyan2. 1. Department of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, NY 10021. E-mail address: dodwelle@hss.edu. 2. Division of Orthopaedic Surgery, Hospital for Sick Children, Room S107, 555 University Avenue, Toronto, ON M5G 1X8, Canada. E-mail address: sevan.hopyan@sickkids.ca.
Abstract
INTRODUCTION: Combined glenoid osteotomy with tendon transfers is a new alternative procedure for patients with severe glenohumeral dysplasia secondary to brachial plexus birth palsy. STEP 1 MRI OR CT FOR PREOPERATIVE PLANNING: Use axial plane MRI or CT for preoperative planning. STEP 2 SURGICAL APPROACH WITH DELTOID ELEVATION: Position the patient laterally, and undertake a posterior approach, including lateral elevation of the deltoid origin. STEP 3 SUBSCAPULARIS SLIDE: Elevate the subscapularis from the scapula, provisionally reduce the humeral head, and apply gentle external rotation. STEP 4 HARVEST OF THE TERES MAJOR AND LATISSIMUS DORSI TENDONS: Incise the insertions of the teres major and latissimus dorsi from the proximal part of the humerus and perform a tenolysis. STEP 5 POSTERIOR APPROACH TO THE GLENOHUMERAL JOINT: Open the posterior glenohumeral joint and assess overhead elevation. STEP 6 ASSESSMENT AND IMPROVEMENT OF ABDUCTION CONTRACTURE: Improve abduction contracture if it is marked. STEP 7 HARVEST OF BONE GRAFT: Harvest tricortical graft from the scapular spine or posterior aspect of the acromion. STEP 8 SCAPULAR NECK OSTEOTOMY: Undertake a posterior opening wedge osteotomy of the scapular neck. STEP 9 POSTERIOR OPENING WEDGE AT THE OSTEOTOMY SITE: Insert the bone graft into the osteotomy site. STEP 10 JOINT CLOSURE AND INFRASPINATUS REPAIR: Close the posterior aspect of the capsule and the infraspinatus. STEP 11 TRANSFER OF THE TERES MAJOR AND LATISSIMUS DORSI: Transfer the teres major and latissimus dorsi tendons into an osseous trough at the greater tuberosity. STEP 12 CLOSURE AND IMMOBILIZATION: Repair the deltoid, close the wound in layers, and apply a shoulder spica cast. STEP 13 POSTOPERATIVE PLAN: Maintain the spica cast for five to six weeks; then initiate physiotherapy. RESULTS: In our series of thirty-two patients with severe glenohumeral dysplasia who underwent combined glenoid osteotomy and tendon transfers, early results suggest that the outcomes of this procedure are similar to those of proximal humeral external rotation osteotomy1. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.
INTRODUCTION: Combined glenoid osteotomy with tendon transfers is a new alternative procedure for patients with severe glenohumeral dysplasia secondary to brachial plexus birth palsy. STEP 1 MRI OR CT FOR PREOPERATIVE PLANNING: Use axial plane MRI or CT for preoperative planning. STEP 2 SURGICAL APPROACH WITH DELTOID ELEVATION: Position the patient laterally, and undertake a posterior approach, including lateral elevation of the deltoid origin. STEP 3 SUBSCAPULARIS SLIDE: Elevate the subscapularis from the scapula, provisionally reduce the humeral head, and apply gentle external rotation. STEP 4 HARVEST OF THE TERES MAJOR AND LATISSIMUS DORSI TENDONS: Incise the insertions of the teres major and latissimus dorsi from the proximal part of the humerus and perform a tenolysis. STEP 5 POSTERIOR APPROACH TO THE GLENOHUMERAL JOINT: Open the posterior glenohumeral joint and assess overhead elevation. STEP 6 ASSESSMENT AND IMPROVEMENT OF ABDUCTION CONTRACTURE: Improve abduction contracture if it is marked. STEP 7 HARVEST OF BONE GRAFT: Harvest tricortical graft from the scapular spine or posterior aspect of the acromion. STEP 8 SCAPULAR NECK OSTEOTOMY: Undertake a posterior opening wedge osteotomy of the scapular neck. STEP 9 POSTERIOR OPENING WEDGE AT THE OSTEOTOMY SITE: Insert the bone graft into the osteotomy site. STEP 10 JOINT CLOSURE AND INFRASPINATUS REPAIR: Close the posterior aspect of the capsule and the infraspinatus. STEP 11 TRANSFER OF THE TERES MAJOR AND LATISSIMUS DORSI: Transfer the teres major and latissimus dorsi tendons into an osseous trough at the greater tuberosity. STEP 12 CLOSURE AND IMMOBILIZATION: Repair the deltoid, close the wound in layers, and apply a shoulder spica cast. STEP 13 POSTOPERATIVE PLAN: Maintain the spica cast for five to six weeks; then initiate physiotherapy. RESULTS: In our series of thirty-two patients with severe glenohumeral dysplasia who underwent combined glenoid osteotomy and tendon transfers, early results suggest that the outcomes of this procedure are similar to those of proximal humeral external rotation osteotomy1. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.