The timing of secondary reconstructions depends on determining that the neurologic recovery for a particular muscle, either the recovery has plateaued sub-optimally, or is unlikely or impossible. It is also based on direct knowledge of the status of nerves or generally a post injury time of more than 18 months without any evidences of recovery. Secondary reconstructions are carried out on the shoulder, elbow, wrist and hand.
The mobility of the shoulder should be preserved with any or all possibilities of providing muscular control by means of multiple muscle/tendon transfers. According to Haas, it was Hildebrandtin 1906, who laid the foundation for tendon and muscle transfers about the shoulder joint for paralysis of the Deltoid Muscle. He transferred the entire origin of the pectoralis major muscle to the Clavicle and Acromion Process. Slomann in 1916 reported transferring of the origin of the long head of Triceps Muscle to Acromion Process. Ober transferred the long head of Triceps muscle along with short head of Biceps muscle to the Acromion Process.
The Mayer’s Transfer of the insertion of the Trapezius Muscle has been described by Haas as the most satisfactory transfer for complete paralysis of the Deltoid Muscle. Bateman modified the Mayers Trapezius Muscle Transfer by osteotomizing the Acromion and transferring it laterally along with the Trapezius muscle and anchoring the Acromion directly to the Humerus. Saha also modified Mayer’s Trapezius Muscle Transfer, by completely mobilizing the superior and middle Trapezius muscle laterally from its origin. This makes the transfer two inches longer without endangering its nerve or blood supply and thus
the additional length provided, increases the leverage of transfer on the humerus.
Karev reported good results following Mayer’s Trapezius Muscle Transfer. Aziz reported successful treatment in 27 patients with Brachial Plexus Injury by transfer of Trapezius muscle to proximal humerus.
Itoh used latissimus dorsi muscle to replace paralyzed Anterior Deltoid Muscle and stated that in patients, who have suffered partial lesions, it may be possible to use multiple adjacent muscles to augment shoulder control.
Leffert states that for patients with total loss of? shoulder control and in whom transfers are not possible, Arthrodesis of the gleno-humeral joint is a potential salvage procedure. In order to have maximal control of the shoulder arm complex the patient must have at least functioning Serratus anterior and Trapezius muscles. Shoulder fusion should generally be done as the last of staged Reconstructive Procedures.
Although neural reconstruction can restore good elbow flexion, Leffert states that in patients, who have a partial lesion with maintained hand sensibility, tendon transfer may be preferable due to better predictability.
Stiendler in 1918 recommended use of the Flexor/Pronator Muscle group arising from the medial Epicondyle, to be used and their origin to be transposed proximally to humerus so that the Elbow Flexion increases with Acute Contraction of these muscles. Mayer and Green modified the original Flexoroplasty in 1954 by attaching the Medial Epicondyle to the bone (humerus) and more laterally to decrease the pronator effect. Though most patients can flex through a useful range against gravity, it is rare to be able to lift more than 5 pounds following such transfer.