Surgical Science, 2013, 4, 459-463 Published Online October 2013 (
Transfer of the Trapezius to the Deltoid for Treatment of
Shoulder Instability after Lesions of the Brachial Plexus*
Antônio L. Severo1#, Philipe E. C. Maia1, Marcelo B. Lemos1, Paulo C. F. Piluski1,
Osvandré L. C. Lech1, Walter Y. Fukushima2
1Department of Hand and Microsurgery, Institute of Orthopedics and Traumatology (IOT), Passo Fundo, Brazil
2Faculty of Medicine of ABC, Santo André, Brazil
Received May 20, 2013; revised June 18, 2013; accepted June 26, 2013
Copyright © 2013 Antônio L. Severo et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objective: To clarify the indications and to describe the surgical technique and outcomes of surgery involving transfer
of the trapezius to the deltoid for the treatment of lesions of the brachial plexus in patients with multidirectional
instability in the sh oulder. Method: In 17 patients (mean age, 23 years) operated at São Vicente de Paulo Hospital and
the Institute of Orthopedics and Traumatology of Passo Fundo, Brazil from 1999 to 2009, we performed trapezius
transfer to the proximal humerus. In these patients, the mean interval between trauma and surgery was 8 months.
Results: Functional improvement and resolution of multidirection al instability of the shou lder were observed in all the
patients. No patient showed immediate postoperative complications. The mean active mobility was as follows: 95˚
flexion, 50˚ abduction, 45˚ external rotation, and internal rotation at the level of the first lumbar vertebra (L1). The
trapezius muscle strength was classified as grade III, and the UCLA functional outcome was 22 points. The
postoperative satisfaction was excellent, and occasional pain and weakness was reported by all the patients. Conclusions:
Transfer of the trapezius muscle to the proximal humerus provides better results in patients with a more than 6-month-
old lesion. This procedure also preserves passive mobility of the limb, confers shoulder stability, provides active
mobility, and prevents osteo arthrosis.
Keywords: Brachial Plexus Lesion; Shoulder Instability; Trapezius Transfer; Active Mobility; Shoulder Stability
1. Introduction
Thus far, no consensus has been reached regarding the
treatment of instability of the shoulder secondary to bra-
chial plexus lesion. There are, however, a few available
treatment options. Neurotization and nerve grafting are
the best treatment options for acute injury [1-5]. Since
the occurrence of the choice, if it is too late to undergo
nerve reconstruction surgery, muscle transfer and ar-
throdesis remain the only treatment options [6-8].
Muscle transfer was first performed in 1927 by Mayer
for the treatment of poliomyelitis sequels [9]. In 1967,
Saha [10], in his monograph, described in detail the
technique for trapezius transfer, using a modification of
the procedure originally described by Bateman [11].
Muscle transfer enhances the function and stability of the
shoulder in paralysis of the deltoid and supraspinatus
[12]. The other treatment option, arthrodesis, also re-
stores stability; howev er, its indication is limited and it is
less suitable as the first treatment option for treatment in
cases of paralysis of the deltoid [5,13].
The aim of this study was to clarify the indicatio ns and
to describe the surgical technique and outcomes of the
transfer of the trapezius to the deltoid after brachial
plexus lesion in patients with shoulder instability.
2. Subjects and Methods
Seventeen patients (14 men and 3 women) with a bra-
chial plexus lesion of traumatic origin underwent transfer
of the trapezius to the proximal humerus at São Vicente
de Paulo Hospital and the Institute of Orthopedics and
Traumatology of Passo Fundo, Brazil between 1999 to
2009 The average age of the patients was 23 years (age
*Study performed at the Institute of Orthopedics and Traumatology
(IOT) and the University Hospital São Vicente de Paulo, Passo Fundo/
RS, in association with the Faculty of Medicine of ABC, Santo André/
#Corresponding author.
range, 17 - 37 years), and the median follow-up period was
12 months (range, 8 - 24 months). The average interval
opyright © 2013 SciRes. SS
between trauma and surgery was 8 months (6 - 10
Preoperative evaluation included a physical examina-
tion, radiography, and electroneuromyography (ENMG).
All patients presented with shoulder instability, normal
passive mobility, moderate pain, and degree zero strength
of the deltoid and supraspinatus muscles. Hand and el-
bow function was normal in all the patients, except in 1,
who showed complete plexus lesion, having previously
undergone nerve reconstruction surgery, only with return
of flexion of the forearm relative to the arm. The active
abduction angle measured between the trunk and arms
varied between 0˚ and 30˚ (average, 4˚). The active flex-
ion varied between 0˚ and 40˚ (average, 10˚). Radiologi-
cal examinations revealed that 1 patient had inferior
glenohumeral luxation and 6 presented with subluxation;
there were no signs of glenohumeral arthrosis in these
patients. In 6 patients, the ENMG showed neurotmesis
C5, C6, and in 1 patient, complete lesion of the brachial
plexus was observed.
Transfer of the trapezius to the deltoid muscle was in-
dicated in patients with shoulder instability secondary to
brachial plexus lesions, in whom nerve reconstruction
surgery was not successful or for whom more than 6
months had elapsed since the occurrence of the injury.
The following conditions were, however, required to be
fulfilled: complete paralysis of the deltoid and supraspi-
natus confirmed by a clinical ENMG examination,
strength level of V degrees of the trapezius muscle, pas-
sive abduction g reater than 80˚, and no signs of arthrosis
in the joints [9]. All patients were clinically assessed
postoperatively by functional criteria of the University of
California at Los Angeles (UCLA) [14].
2.1. Surgical Technique
The patient is placed in a supine position on a beach
chair, and his shoulder is approached by a Y incision,
extending across the tran sverse portion around the shou l-
der over the spine of the scapula and the acromion and
ending just above the coracoid process. The longitudinal
incision is extended distally along the lateral region of
the shoulder and upper arm by 6 cm (Figure 1(a)). The
atrophied deltoid muscle is mobilised and divided. The
soft parts of the underside of the acromion and spine of
the scapula are released.
Then, the spine of the scapula is osteotomised at its
base in an obliquely distal and lateral plane. Thus, a por-
tion of the trapezius distal is released, while it is still at-
tached to the spine and the acromion. Subsequently, 2 cm
of the lateral clavicle is drilled with care to avoid any
injury to the coracoclavicular ligament (Figure 1(b)).
The deep surfaces of the acromion and spine are sub-
jected to curettage, the arm is abducted at 90˚, to the ap-
propriate level in the lateral region of the humerus, the
corresponding area to the insertion of the acromion un-
dergoes curettage. Next, using firm traction, the portion
side of the trapezoid is moved to the humeral head, and
the acromion is fixed to the humerus as distally as possi-
ble, with two 4.5-mm screws (Figure 1(c)). Haemostasis
is carried out, and closure is performed in layers (Figure
2.2. Postoperative Treatment
The arm is immobilized using a brace with the shoulder
abducted at 90˚ (Figure 2). The brace is maintained for 8
- 12 weeks, varying according to the signs of bone heal-
ing. After 4 weeks, the abduction angle is decreased by
10˚ per week, until 30˚ is reached. Th e flexion-exten sion
of the elbow and wrist are stimulated early. After re-
moval of the brace, physical therapy is started to gain
range of motion and strengthen the muscles.
3. Results
In all the patients, a functional improvement and resolu-
tion of shoulder instability was observed. The average
time taken to perfo rm the surgery was 150 minutes, with
blood loss of approximately 200 ml. No patient had
(a) (b)
(c) (d)
Figure 1. Illustration of the surgical technique.
Figure 2. Position of the brace at 90˚ of abduction in the
postoperative period.
Copyright © 2013 SciRes. SS
Copyright © 2013 SciRes. SS
achieved in all cases. Functional improvement and satis-
faction with surgery was achieved in all the patients in
our study. Similar results were obtained in studies per-
formed by Aziz et al. [9], Ruhmann et al. [16,17], Mon-
real et al. [18], Singh et al. [19], and Elhassan et al. [20].
The only contraindication to this technique is severe
glenohumeral arthrosis , which was not encountered in
the current study.
immediate postoperative complications, but in 1 patient,
it was necessary to remove one of the screws within 12
weeks after the operation. The average active mobility
was as follows: flexion 77˚, active abduction 75.8˚, ex-
ternal rotation 57˚, and internal rotation at the first lum-
bar vertebra (L1) (Table 1). The average postoperative
University of California at Los Angeles (UCLA) [14]
functional outcome was 22 points. The functional out-
come according to Ellman’s [15] 4-level scale (excellent,
good, fair, poor) was fair. After surgery, there was a re-
duction in subluxation for all the patients, and the trape-
zius muscle strength was classified as grade III. All the
patients experienced occasional pain and weakness ac-
cording to the same UCLA criteria. The patients were
satisfied with the procedure, despite the “fair” functional
outcome (Figure 3).
Arthrodesis of the shoulder is usually considered in
patients with instability secondary to brachial plexus le-
sion; however, its complications limit its use. The surgi-
cal technique is difficult, surgical procedure is long, and
there is no consensus regarding the ideal position for
fixing the head of the humerus to the scapu la. In addition,
the rates of pseudoarthro sis, fracture, residual pain, repo-
sitioning of the limb, and irreversibility of the procedure
are factors that make it a second option. Cofield and
Briggs [21] reported a 24% incidence of fractures with
arthrodesis, and 15% of them were associated with in-
creasing pain. Richards et al. [6] performed arthrodesis
using an acetabular reconstruction plate with 30˚ abduc-
tion, flexion, and internal rotation. They encountered
very few complications and better results than expected;
however, muscle transfer was indicated in 5 of the 17
patients who underwent the procedure. According to
Goldner [22], muscle transfer should be considered the
first treatment option; therefore, it is indicated in cases of
severe arthrosis, inveterate luxatio n, intractable pain, and
failure of muscle transfers.
Descriptive statistical analysis was conducted using
SPSS 16.0 (2007). Sixteen patients exhibited similar be-
haviour in flexion, abduction, and external rotation, and
only 1 patient with total brachial plexus lesion showed a
comparatively low degree of movement amplitude. The
overall sample average and median were similar for
flexion and abduction (flexion
: 77.06 ± 17.59 and Md:
80.00; abduction
: 75.88 ± 14.60 and Md: 80.00). In
terms of external rotation, a high variation between sam-
ple average and median was observed (
: 57.06 ± 27 .50
and Md: 70.00) (Figure 4).
4. Discussion The development of microsurgery has contributed to
advances in surgery of the brachial plexus. Neurotization
and nerve grafting are proposed to restore the physiology
of the injured region, without causing any anatomical
changes. Recent studies have clarified their indications
and applications [1].
Transfer of the trapezius to the deltoid for the treatment
of deltoid paralysis has several advantages. It is a rela-
tively simple procedure with minimal postoperative
complications. The recovery of glenohumeral stability,
which is an important outcome of this operation, was
Figure 3. Active mobility results in the postope rative period. (A/B) Flexion; (C) Abduction; (D) External rotation; (E) Inter-
al rotation; (F) Cosmetic appearance. n
Table 1. Post operatory evaluation of the patients.
Patient Flexion Abduction
Rotation Internal
Rotation UCLA
1 70˚ 90˚ 80˚ L1 22
2 80˚ 80˚ 40˚ L1 22
3 60˚ 80˚ 30˚ L3 22
4 90˚ 90˚ 30˚ L1 23
5 90˚ 80˚ 45˚ T10 23
6 60˚ 60˚ 20˚ L5 22
7* 30˚ 30˚ 0˚ 0º 20
8 90˚ 70˚ 80˚ L2 22
9 80˚ 70˚ 80˚ L1 22
10 70˚ 90˚ 80˚ L1 22
11 70˚ 90˚ 80˚ L1 21
12 80˚ 70˚ 70˚ L2 22
13 70˚ 80˚ 80˚ L3 22
14 90˚ 70˚ 70˚ L4 23
15 90˚ 80˚ 80˚ L1 23
16 80˚ 80˚ 80˚ L3 22
17 110˚ 80˚ 25˚ L1 24
Average 77˚ 75.8˚ 57˚ L1 22.17
*Patient with complete lesion of the brachial plexus with early neurotization.
Source: Medical records of the São Vicente de Paulo Hospital and the Insti-
tute of Orthopedics a nd Traumatology of Passo Fundo.
Figure 4. Mobility of the active shoulder in flexion, abduc-
tion, and external rotation in 17 patients undergoing sur-
gery for transfer of the trapezius to the deltoid.
Nagano et al. [1] performed neurotization of the in ter-
jury. According to these authors, surgery is indicated for
patients under 40 years of age and for lesions less than 6
months old, because, after this period, the positive out-
come rate drops to 29.4%. In patients over 50 years of
age and in those injured for more than 10 months, muscle
transfer is recommended.
According to Guyton [2
costal nerve in the case of a brachial plexus avulsio
3] when the muscle is dener-
here is no algorithm for the treatment of
ilar to arthrodesis, the brachial plexus microsur-
5. Conclusion
antages and disadvantages of the tech-
[1] A. Nagano, N.. Hara and M. Ta-
hiai, A. Nagano, H. Sugoka and T. Hara, “Nerve
n in- “Results of Nerve Grafting for Injuries of the Axillary
and Suprascapular Nerves,” Journal of Bone and Joint
ted, it immediately begins to atrophy and continues to
decrease in size for several years. If the muscle is grafted
with a new nerve during the first 3 or 4 months after in-
jury, its complete function often returns, but after 4
months of denervation, some muscle fibres degenerate.
Reinnervation after 2 years rarely results in the return of
any function.
Currently, t
praclavicular lesions, but it is well established that
avulsion injuries are best treated by neurotization. In
acute injuries or cross-sections, nerve suture is the best
option. Functional results of these techniques are satis-
factory, although many patients require the use of braces
to prevent subluxation, and some continue to experience
ry is difficult to implement and warrants a long learn-
ing curve for the surgeon and increased surgical time.
Moreover, the outcomes are not always positiv e. Instead,
muscle transfers have excellent and reproducible results
for several surgeons, when his nomination, surgical tech-
nique and observation of immobilisation and postopera-
tive rehabilitation are respected
In view of the adv
niques described, we conclude that surgical transfer of
the trapezius to the proximal humerus provides a better
outcome in patients in whom more than 6 months have
lapsed after injury. This surg ery preserves passive mobil-
ity of the limb, confers stability, and improves active
mobility. These improvements also correspond to good
patient satisfaction.
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