Surgical Technique and Anatomical Considerations for the Modified L’Episcopo Tendon Transfer

Background: Birth brachial plexus injury usually affects the upper trunks of the brachial plexus and can cause substantial loss of active shoulder external rotation and abduction. Due to the unbalanced rotational forces acting at the glenohumeral joint, the natural history of the condition involves progressive glenohumeral joint dysplasia with associated upper limb dysfunction. Surgical reconstruction methods have been described previously by Sever and L’Episcopo, and modified by Hoffer and Roper to release the adduction contracture and to restore external rotation and shoulder abduction. Methods: The authors describe their preferred technique for contracture release and tendon transfer to improve external rotation and shoulder abduction. Pertinent anatomy and highlights of surgical exposure are reviewed. Results: The senior author has utilized this technique with consistent clinical outcomes to improve shoulder function for patients with persisting nerve palsy associated with birth brachial plexus injury. A review of the literature supports utilization of this technique. Conclusions: Transfer of the latissimus dorsi and teres major to the posterior rotator cuff for reanimation of shoulder abduction and external rotation deficits associated with birth brachial plexus injury is a safe and reliable technique. Careful patient selection and attention to surgical detail are critical for optimal outcomes.