Original Article

ROLE OF SAHA'S PROCEDURE IN CHANGE OF MOVEMENT AT

SHOULDER JOINT IN TRAUMATIC BRACHIAL PLEXUS INJURIES
Shujaat Hussain,1 Aftab Hussain,1 Muhammad Javed,1 Tahseen Ahmed Cheema1

ABSTRACT
Background: Brachial plexus injuries are difficult to manage situation for surgeons. Objective: To assess the effects of saha's
procedure on improving the range of movement of shoulder joint with brachial plexus injury. Methodology: We conducted a
quasi-experimental study of twelve patients with absent or extremely weak shoulder abduction (motor grade 2 or less) due to
traumatic brachial plexus injuries (C5-C6-C7/C5-C6 deficit), who had undergone surgical reconstruction of the flail shoulder by
tendon transfer (Steindler elbow flexorplasty). The etiology of shoulder weakness in all patients was traumatic brachial plexus
palsy (C5-C6-C7/C5-C6 deficit) from 1st January 2011 to 31st December 2014. Shoulder abduction improved or not improved
measured in term of range of motion at shoulder joint. Age, gender, preoperative strength (rated on a 0 to 5 scale for the trapezius),
previous surgery, length of follow-up, other associated operative procedures, results and complications were recorded. Results:
We operated on twelve patients and average age at which patients presented was 22.83 in which only one was female. The
percentage years of C5-C6 and C5-C6-C7 were 86.66% and 13.33% respectively. Average time elapsed since injury was 23
months. We followed the patients on average of about 2 years. The Average increase (change) in the abduction range was 74.10
Conclusion: Saha's procedure is good and effective procedure in improving the range of motion (Change) at shoulder joint in
traumatic brachial plexus injuries (C5-C6-C7/C5-C6 deficit).
Key word: Saha's procedure, Shoulders, Abduction, Brachial plexus, Injury.

INTRODUCTION surgeries, are planned. A number of tendon transfers

Abduction is the most important functional have been described to replace the function of the
2,3,4,5
movement of the glenohumeral joint, and at the deltoid.
same time one of the most complex movements of Transfer of the trapezium insertion was first
5
the entire body.1 Traction injury of the brachial described by Mayer, who used a fascia lat graft to
plexus results in paralysis of the upper limb, which extend its attachment to the deltoid tuberosity.
6
may be partial or total. Hand function is affected Bateman modified the procedure by advising
if the hand cannot be maintained in a useful resection of part of the spine of the scapula with the
2
position. Upper trunk lesions of the brachial trapezium, to allow screw fixation of the transfer to
plexus (C5 and C6 or C5-6-7 injuries) generally the hummers. This procedure was further modified
7
occur due to high-energy mechanisms, mainly due by Saha. This study was planned to assess the
to motorbike accidents, falls from heights and outcome of Saha’s procedure on the improvement of
sports trauma), mainly affecting people in a young movement at shoulder joint, with brachial plexus
and productive age group. injuries.
One of the first goal in the management of the flail
arm is to restore arm function by primary direct METHODOLOGY
nerve surgery or nerve transfer or with secondary This quasi experimental study was conducted on 12
reconstructive surgery. Indications for trapezes patients. The patients selected had traumatic lesions
transfer are irreversible absence of active of the upper trunk of the brachial plexus (C5 and C6
abduction at shoulder, passive abduction of the with or without impairment of C7) who came
st st
shoulder greater than 90," with having a strong between 1 January 2011 to 31 December 2014. All
trapezium muscle, and absence of substantial the patients were operated at National Orthopedic
degenerative changes in the shoulder joint. Mostly Hospital, Bahawalpur. The functional evaluations
nerve reconstruction/transfer is done but in were carried out in the pre- and postoperative periods
absence of good results or when patients present after 90 days and in the six month after surgery up to 2
with lapse of golden period, then muscle transfer years. The functional evaluation (Clinical) was done

1. Department of Orthopaedics, QAMC/BVH, Bhawalpur, University of Health Sciences Lahore, Pakistan.

Correspondence: Dr. Muhammad Javed, Department of Orthopaedics, QAMC/BVH, Bhawalpur, Pakistan

Phone: +92-3009688616 Received: 22-08-2017 Accepted: 25-09-2017

JSZMC Vol.8 No.4 1277

 Original Article

with MRC grading of shoulder power M0 to M5 and brace preformed before operation at 90" during 6
shoulder abduction improvement measured in weeks. After this, progressive adduction of the
degrees with the help of goniometer. Study Design shoulder was allowed in the splint during 2-3 weeks
was quasi experimental study, with total duration and a rehabilitation program for 2 months was
of study was 3 years. started.
Goniometry was performed using a standardized
Table I : Case wise Description of patients goniometer. The active range of motion of the
Time
Case.
Age Gender since
Level of
Previous surgery shoulder was evaluated with measurements in
No injury
1 20 M
injury
2y C5-C6 NO
degrees mainly abduction.
2 19 M 12m C5-C6 NO
3 22 M 2y C5-C6 Exploration
The muscle test was carried out to scale the
4 42 M 13m C5-C6- Wrist arthrodesis evolution of shoulder abduction force. Muscle
C7
5 36 M 12m C5-C6 Median nerve strength was scaled as ; grade 5 : Normal, Grade 4:
parenthesis
6 33 M 18m C5-C6 NO
active movement against gravity with ruses Fannie,
7 19 M 4y C5-C6 NO Grade3 : active movement against gravity without
8 18 M 4y C5-C6 NO
9 19 M 3y C5-C6 NO resistance, Grade2 : active movement without
10 28 F 2y C5-C6 NO gravity without gravity Grade 1: Only flickev
11 22 M 12m C5-C6 Hip surgery
12 20 M 13m C5-C6- WRIST arthrodesis movement and Grade 0 no movement.
C7

Inclusion criteria: Traumatic closed upper trunk RESULTS

lesion of the brachial plexus (C5-C6, with or
without C7 lesion); with good hand function with We operated on twelve patients and average age at
reconstructed or recovered elbow patients with which patients presented was 22.83 24± 8 years in
one year or more of lesion; total passive ROM of which only one patient was female. The percentage
shoulder greater than 800. of C5-C6 and C5-C6-C7 were 86.66% and 13.33%
respectively. Average time elapsed since injury was
Exclusion criteria: Open or non-traumatic lesion 1.9± 1 years' months. We followed the patients on
of brachial plexus upper trunk; complete lesion of average of about 2 years. Our 75% patients (nine) got
the brachial plexus; patients with less than one M4 power and 25% got M3 power respectively. The
year of lesion; stiffness upon passive movement of Average increase (change) in the abduction range
the shoulder. was 74.10 (postoperative abduction and forward
Surgical technique: We used a technique flexion with some minor differences) from 4
0

described by Saha (1967), which was earlier Preoperatively .

reported by Mayer (1927) and Bateman (1955).
The patient in surgery was placed in the lateral
position. Y shaped (Cyber-cut) skin incision was Figure I: Patients pictures before and after
given, centered over the acromion. The insertion surgery
zone was identified for the trapezius at the
acromion and the distal aspect of the clavicle. An Case II
osteotomy with an oscillating saw was made at the
base of the acromion and through the clavicle. The
deltoid was longitudinally sectioned to expose the
proximal humerus.
The inferior part of the acromion and the lateral
part of the proximal humerus were buried. In 90"
of abduction and 20" external rotation, the
acromion was fixed to the proximal humerus with (Case 6)
two 4.5 mm malleolar screws but before deltoid
transfer. Two muscles from the steering group
were restored. The deltoid was sutured over the
transferred trapezius. Postoperatively, the
shoulder was immobilized with an abduction

JSZMC Vol.8 No.4 1278

 Original Article

(Case 10) Saha confirmed that when any two of the steering
group of muscles were paralysed a single muscle
transfer to replace the deltoid would not provide
abduction beyond 90°. Saha describes principles to
restore function of shoulder by the transfer of
pectoralis minor, the upper two digitations of serratus
anterior, latissimus dorsi and teres major in various
combinations, with levator scapulae,
sternocleidomastoid, scalenus anterior, scalenus
7
medius and scalenus capitis.
Some of the authors preferred shoulder arthrodesis
8,9,10
Table II: Case wise outcome of range of for palliation of the posttraumatic flail shoulder.
movements pre and postoperatively. There are some disadvantages with arthrodesis, as
Range of
well like limited range of abduction. Arthrodesis
CASE
No.
Trapeizus
/Deltoid
Length of
Associated
Power movement pre op makes the passive mobility of the joint difficult.8,12
follow up (MRC) and post op 14
T
power
D
(Years)
procedures
(Abduction & Narakas achieved abduction of 120° in few patients
forward flexion )
1 5 0 2 Steindler Flexoplasty 3 50 300 300 with combined transfers of teres major, levator
2 5 0 1.5 Wrist arthrodesis and
Steindler Flexoplasty
4 100 1100 1000 scapulae and latissimus dorsi. Chun-lin and Yong-
3 5 0 1.5 Steindler Flexoplasty 3 00 450 400 hua15reported seven cases of pectoralis major
4 5 0 1.5 Steindler Flexoplasty 4 50 900 900
5 5 0 2.5 Steindler Flexoplasty 4 70 1000 1000
transfers with additional trapezius transfer in three.
6 5 0 3 Steindler Flexoplasty 4 50 800 800
00 500 300
7
8
5
5
0
0
1.5
2.5
Steindler Flexoplasty
Wrist arthrodesis,
3
4 50 1000 1000
CONCLUSION
Steindler Flexoplasty This study showed that Saha'procedure is good and
9 5 0 2 Steindler Flexoplasty 3 50 300 300
10 5 0 2.5 Steindler Flexoplasty 3 00 450 450 effective procedure in improving the range of motion
11 5 0 1.5 Steindler Flexoplasty 4 100 110 0 110 0 at shoulder joint in traumatic brachial plexus injuries
12 5 0 3 Steindler Flexoplasty 3 50 1000 1000
(C5-C6-C7/C5-C6 deficit).

DISCUSSION REFERENCES
In brachial plexus palsy, sometime secondary 1. Doody SG, Freedman L, Waterland JC. Shoulder
surgery is needed to improve the stability and movements during abduction in the scapular plane. Arch
13
function of the shoulder. and tendon transfer are Phys Med Rehabil 1970 ; 51 : 595-604.
2. Slomann. Ueber die BehandLung der
needed depending upon lesion.13 Saha's7 logical Deltoidenslahmheit, Z. Orthop Chir, 35:1916 Cited by
modification of the trapezius transfer described by Haas SL. The treatment of permanent paralysis of deltoid
Bateman6 provides a more distal fixation of the muscle. JAMA 1935;104:99-103.
transfer after a more proximal release. This gives a 3. Ober FR. Operation to relieve paralysis of deltoid muscle.
greater lever arm, and fracture of the bony JAMA 1932;99:2182-85
4. Harmon PH. Surgical reconstruction of the paralytic
insertion transferred from the acromion allows shoulder by multiple muscle and tendon
better fixation to the narrow cylindrical shaft of transplantations. J Bone Joint Surg [Am] 1950;32-A:583-
the humerus. An important modification was to 95.
consider transfer for paralysed muscles of the 5. PP kotwal, R Mittal , R Mashotra. Trapezius transfer
rotator cuff, to improve control of the humeral for deltoid paralysis J Bone & Joint Surg: 1998 : 80 – B:
114-6
head and prevent subluxation. Careful assessment 6. Antonio LS, philipe EC, Marcelo BL, Paulo FP,
of muscles at shoulder joint is necessary deltoid Osvandre LL Walter y. Transfer of trapezius to deltoid
and clavicular head of pectoris's major are prime for treatment of shoulder instability. Surgical
movers subscapularis, supraspinatus and Science. 2013 : 4 : 459 -63
infraspinatus were considered as steering group 7. Saha AK. Surgery of the paralyzed and flail shoulder.
Acta Orthop Scand 1967: 38 Suppl 97 : Available at :
which stabilise the humeral head in the glenoid. http : lldx . doi . org / 10.3109 / ort. 1967.38. suppl -
Additionally, sternal head of pectoralis major, 97.01
latissimus dorsi, teres major and teres minor pull 8. Katia TB, Hugo JA. Rehabilitation after partial
the humeral head downwards during the last few brachial plexus palsy. Rev Bras Cir Plast. 2013: 28 (1):
degrees of abduction. 175 -9
9. Rowe C R. Re-evaluation of the position of the arm in

JSZMC Vol.8 No.4 1279

 Original Article

arthrodesis of the shoulder in the adult. J Bone Joint 15. Chun-lin H, Yong-hua T. Transfer of upper pectoralis
Surg (Am) 1974; 56: 913-22. major flap for functional reconstruction of deltoid
10. Beltran J E, Trilla J C, Barjau R. A simplified muscle. Chin Med J 1991;104: 753-7
compression arthrodesis of the shoulder. J Bone Joint
Surg (Am) 1975; 57: 538-41
11. Vastamiki M. Shoulder arthrodesis for paralysis and
arthrodesis. Acta Orthop Scand 1987; 58: 549-53.
12. Ducloyer P H, Nizard R, Sedel L. Arthrodke d'kpaule
dansles paralysies du plexus brachial. Rev Chir
Orthop 1991; 77: 396-405
13. Berger A, Brenner PD. Secondary surgery following
brachial plexus injuries. Microsurgery 1995;16:43-7.
14. Narakas AO. Muscle transpositions in the shoulder
and upper arm for sequelae of brachial plexus palsy.
Clin Neurol Neurosurg 1993;95: 89-91

Article Citation: Hussain S, Hussain A, Javed M, Cheema TA. Role of saha's procedure in change of movement at shoulder joint in
traumatic brachial plexus injuries. JSZMC 2017;8(4):1277-80

JSZMC Vol.8 No.4 1280