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Complete deltoid resection in early childhood without muscle transfer results in normal shoulder function at long-term follow-up: a case report
© The Author(s). 2016
Received: 17 March 2016
Accepted: 3 November 2016
Published: 14 January 2017
Musculoskeletal tumors involving the deltoid muscle and necessitating its complete resection are rare. The function after complete deltoid resection is reported to be limited, and several authors consider muscle transfer to improve shoulder motion. However, it still remains unclear whether such transfer adds function. To the best of our knowledge, all reports on complete deltoid resection refer to adult patients, and it is unknown what function results after deltoid resection in childhood. The remaining muscles may have the potential to compensate for the loss of deltoid function.
Here we report the case of a 5-year-old white boy with complete (isolated) deltoid muscle resection in infancy for a large aggressive soft tissue tumor. No reconstructive procedure or muscle transfer was performed at the time of index surgery. Pathology revealed an angiomatoid fibrous histiocytoma. His postoperative course was uneventful. At 11 years of follow-up, he remained disease-free and had excellent shoulder function, including normal range of motion.
This report implies that major muscles such as the deltoid can be resected in a child without compromising long-term function. Therefore, a muscle transfer at index surgery is probably not necessary.
Most of the knowledge related to deltoid dysfunction stems from patients with non-neoplastic pathologies such as brachial plexus injuries, axillary nerve palsy secondary to shoulder luxation, iatrogenic nerve or muscle lesions, or after poliomyelitis [1, 2]. Loss of anterior deltoid function had been historically associated with impairment of glenohumeral function and chronic pain [1–5]. When associated with a rotator cuff tear, impairment is higher, nerve reconstruction or muscle transfer success is lower [1, 3, 4, 6].
Muscle or nerve transfer or graft for deltoid insufficiencies of any cause is associated [1, 3–6] with variable success rates. Only a few authors reported a complete range of motion with complete deltoid palsy without any reconstructive procedure ; they suggested that sufficient function could be obtained to allow full duty work.
Complete resection of the deltoid muscle for musculoskeletal tumors is rarely performed [7, 8]. In the tumor literature, where the loss of the deltoid muscle can be regarded as an isolated lesion with a normal rotator cuff, it is thought that partial resection of the deltoid muscle may result in normal shoulder function [8, 9], whereas complete resection compromises its function. Because of the purported limited function, consideration is often given to the addition of a latissimus dorsi, a trapezius, or a pectoralis major transfer to potentially improve the functional outcome [10, 11].
Therefore, there is continuing debate on whether a muscle transfer may improve shoulder function after complete deltoid resection. Some authors recommend muscle transfer to improve shoulder motion or strength, whereas others recommend muscle transfer solely for tissue coverage because they believe it adds little to the improvement of shoulder function. Of interest, all this literature reports on adult patients and it is unclear whether this also applies to children, who may have a greater adaptability and potential compensation for their shoulder muscle function.
We can only speculate about the reasons why there is normal shoulder function despite the complete removal of the deltoid muscle. In the normal shoulder, a combination of muscles generates a complex movement: anterior deltoid, supraspinatus, coracobrachialis, long head of biceps brachii, and clavicular portion of pectoralis major act together to provide power and movement in forward flexion. Abduction in the scapular plane is generated by the middle portion of the deltoid, supraspinatus, and a coupled force between subscapularis and infraspinatus [12, 13]. A selective bloc of the suprascapular or axillary nerve showed that the deltoid muscle provides 50% of the power for forward elevation and abduction in the plane of the scapula. Supraspinatus and infraspinatus generate almost 50% of the torque; infraspinatus acts mostly above 90 degrees of abduction. Electromyographic studies  showed a silent signal before 90 degrees of abduction. In the absence of deltoid and rotator cuff muscles, other muscles cannot generate enough torque to overcome gravity but act as a movement generator [12, 13]. Of interest, our patient showed excellent strength in abduction in the plane of the scapula without deltoid muscle. In addition, an MRI of his shoulder at 11-years follow-up showed normal shoulder muscles, without intraarticular degenerative changes. Although up to 20% of the patients with a complete deltoid dysfunction may achieve full (passive) range of shoulder motion [6, 15], our patient also had very good strength. Altogether, this implies that the other shoulder muscles can compensate for the loss of deltoid function after its complete removal in early childhood. Isolated deltoid resection is a rare procedure, even more in the pediatric population, and consequently it is difficult to make recommendations regarding the need for reconstruction or not based on this specific case. On the other hand, the excellent long-term follow-up of this patient with an annual physical examination and medical photography have showed that excellent function and strength remain over years without reconstruction.
To the best of our knowledge, this is the first report of complete deltoid resection without muscle transfer in a child, resulting in a full range of motion, excellent strength, and excellent function of the shoulder at long-term follow-up. The remaining shoulder muscles have the potential to compensate for the loss of deltoid function in very young children thereby avoiding the need for complex procedures like pedicled latissimus muscle flap or trapezius transfer unless needed for soft tissue coverage.
The authors (AA, BF, FS) declare that they have not received an external source of funding for the present study.
Availability of data and materials
The data presented in this case report are the original patient’s data. Therefore, the authors will not share it in an additional file.
The tests used in this case report, namely Constant Shoulder Score and MSTS, are internationally approved, reliable, and validated. The tests are freely available and accessible for any scientist interested.
AA examined the patient, analyzed and interpreted the patient’s data, and wrote the first draft of the manuscript. FS acquired the patient data and was involved in drafting the manuscript. BF provided the concept and study design, analyzed and interpreted the data, and rewrote the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Ethics approval and consent to participate
The case was reviewed and waived by the leader of orthopedic research at Balgrist University Hospital, Zurich. Approval from the cantonal ethics committee of Zurich was not required and therefore not obtained.
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