© 1992 British Editorial Society of Bone and Joint Surgery 0301 -620X/92/6444 $2.00 J Bone Joint Surg [Br] 1992; 74-B :897-90l. VOL. 74-B, No. 6. NOVEMBER 1992 897 MODIFICATION OF THE L’EPISCOPO PROCEDURE FOR BRACHIAL PLEXUS BIRTH PALSIES DANA C. COVEY, DANIEL C. RIORDAN, MARION E. MILSTEAD, JAMES A. ALBRIGHT From the Shriners Hospitalfor Crippled Children and Louisiana State University, Shreveport We reviewed 19 children who had undergone a new modification of the L’Episcopo procedure for obstetric brachial plexus palsy. Through an axillary approach the latissimus dorsi tendon was re-routed anteriorly to the humerus and then anastomosed to the teres major tendon routed posteriorly. At an average follow-up of four years two months, the mean increase in shoulder abduction was 26 and the mean increase in external rotation was 29#{176}. No neurovascular injury or postoperative infection occurred. Two patients had complications, and five did not gain from the procedure. The modified operation was relatively easier to perform and provided excellent cosmesis. Smellie (1 764) first described birth injuries ofthe brachia! plexus and numerous reports have discussed the patho- logical anatomy and management of these lesions (Erb 1874; Duchenne 1883; Klumpke 1885; Wickstrom, Haslam and Hutchinson 1955; Wickstrom 1962; Hoffer, Wickenden and Roper 1978 ; Meyer 1986). Although the severity as well as the incidence of birth-related brachial plexus injuries has decreased with refinements in obstetric care (Specht 1 975 ; Hardy 1 98 1 ; Zancolli 198 1 ), restora- tion of good function to the severely affected upper arm still poses problems. The main aim of surgery is to increase shoulder motion to allow the hand to reach the head (Zancolli 1981). Most procedures seek to increase abduction and external rotation ofthe shoulder (Riordan and Bayne 1986). The operations devised by Sever (1918) and L’Epis- copo (1934) have been used for more than 50 years. Sever recommended cutting the subscapularis and pectoralis major muscles to release the adduction contracture. The L’Episcopo technique involves detaching the latissimus dorsi and teres major muscles from their insertions and transferring them posteriorly and laterally so that they D. C. Covey, MD, MS. Lt-Cdr, MC, US Naval Reserve Department of Orthopaedic Surgery, Naval Hospital, Boone Road, Bremerton, Washington 98312, USA. D. C. Riordan, MD 1 5834 Hillside Falls Trail, Houston, Texas 77062, USA. M. E. Milstead, MD, Consultant and Clinical Instructor J. A. Albright, MD, Professor and Chairman Department ofOrthopaedic Surgery, Louisiana State University School ofMedicine, P0 Box 33932, Shreveport, Louisiana 71130, USA. Correspondence should be sent to Professor J. A. Albright. become external rotators. The original procedure utilised anterior and posterior incisions and the tendons were sutured in their new position under an osteoperiostea! flap. The disadvantages are the need for the two incisions with the risk of hypertrophic scarring of the anterior incision, and the difficulty of attaching the transferred tendon directly to bone. A modification of the procedure was developed by one of us (DCR) to simplify it and to improve the strength of the muscle transfer. We report the results in 19 patients. PATIENTS AND METHODS During the period 1977 to 1987, 21 children underwent the modified L’Episcopo procedure at the Shriners Hospital for Crippled Children, Shreveport; 19 were available for follow-up (12 girls and seven boys). Their mean age at first evaluation was four years four months (three months to nine years three months). The mean age at operation was five years 1 1 months (two years to ten years five months). Eighteen patients had Erb’s palsy (involvement of C5 and C6 nerve roots), and one (case 19) had whole plexus palsy (involvement of CS through to Tl nerve roots). Those patients who were first seen in infancy or early childhood were treated by passive and active range- of-motion exercises to prevent contracture and maintain muscle function. Serial muscle examinations showed that many developed improved muscle function with increas- ing age. When the improvement in function ceased, and ifthere was good sensory and motor function in the hand, they were considered for reconstructive surgery. Four patients (cases 4, 1 3, 1 5 and 1 7) initially presented at eight years of age or later and another (case 1 1), who was