TO THE EDITOR:
I read with interest "Closed Reduction and Tendon Transfer for Treatment of Dislocation of the Glenohumeral Joint Secondary to Brachial Plexus Birth Palsy" (80-A: 997—1001, July 1998), by Hoffer and Phipps, but one point needs clarification.
During the operative procedure, the latissimus dorsi and the teres major were released and then were transferred to the rotator cuff. However, no information is given about the released pectoralis major. If this muscle is detached and left untransferred, as in the Sever procedure2,3, the transferred medial rotators might cause an imbalance of the muscles about the shoulder. This procedure also creates a large defect due to retraction of the muscle.
Tachdjian advocated elongation of the pectoralis major with z-lengthening, as described by Green, in order to increase the ranges of abduction and lateral rotation of the shoulder4. I wonder which procedure Dr. Hoffer and Dr. Phipps chose for the pectoralis major in their series, and I would like to know their opinion about this.
Emre Çullu, M.D.: Department of Orthopaedic Surgery, Adnan Menderes University Medical Faculty, 09100 Aydin, Turkey
Dr. Hoffer and Dr. Phipps reply:
We thank Dr. Çullu for his comments. We are aware that Tachdjian suggested z-lengthening4, as described by Green. However, we have been performing releases of the insertion of the pectoralis major since our original article was published in the 1970s1. We leave the subscapularis intact and do not release it as Sever and Green did2-4. Perhaps that is why we have observed no problem with residual weakness in medial rotation. In all of our patients, we have seen that the pectoralis major reattaches, albeit in an elongated fashion.
This does not suggest that casual treatment is appropriate for the rare case of a rupture of the pectoralis major in a normal athlete. However, in disabled children, we believe that the release of the pectoralis major with the subscapularis left intact works just like a lengthening.
M. Mark Hoffer, M.D.: Orthopaedic Hospital, 2300 South Flower Street, Suite 200, Los Angeles, California 90007
Gary J. Phipps, M.D.: Rancho Los Amigos Hospital, 7601 East Imperial Highway, Downey, California 90242