title: A comprehensive analysis of pectoralis major transfer for long thoracic nerve palsy.
abstract: BACKGROUND
  In the treatment of long thoracic nerve palsy with pectoralis major transfer, it remains unknown whether direct transfer of the pectoralis to the scapula or indirect transfer with an interpositional graft provides superior outcomes.
  
  
  METHODS
  A 3-tiered study was performed to gain a comprehensive understanding. (1) A survey of the membership of the American Shoulder and Elbow Surgeons (ASES) was conducted to reach a Level V consensus. (2) A systematic review was conducted to identify all series evaluating direct and indirect transfer of the pectoralis major tendon to create a Level IV consensus. (3) A retrospective review was performed to provide Level III evidence.
  
  
  RESULTS
  (1) Surgeons were evenly split between whole and split tendon transfers, direct and indirect transfers, and graft types. More experienced surgeons were more likely to prefer an indirect transfer. (2) Analysis of 10 Level IV studies (131 shoulders) revealed that patients who underwent indirect transfer were significantly more likely to develop recurrent winging (P = .009) and had lower active forward elevation (P < .001) and ASES scores (P = .0016). (3) Twenty-four patients were included in our retrospective review with a mean follow-up of 4.3 years (77% follow-up), of whom 14 underwent indirect transfer and 10 underwent direct transfer. There were no significant differences in recurrence of winging, range of motion, or ASES scores.
  
  
  CONCLUSIONS
  Level V and III evidence suggests that there is no functional difference between direct and indirect transfer. Level IV evidence must be interpreted with caution.
authors: Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA. Electronic address: p.n.chalmers@gmail.com.
authors: Peter N
authors: PN
authors: Chalmers
authors: Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
authors: Bryan M
authors: BM
authors: Saltzman
authors: Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
authors: Terrence F
authors: TF
authors: Feldheim
authors: Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
authors: Randy
authors: R
authors: Mascarenhas
authors: Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
authors: Chris
authors: C
authors: Mellano
authors: Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
authors: Brian J
authors: BJ
authors: Cole
authors: Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
authors: Anthony A
authors: AA
authors: Romeo
authors: Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
authors: Gregory P
authors: GP
authors: Nicholson
mesh_terms: D000328:Adult; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D020422:Mononeuropathies / Q000601:surgery*; D010243:Paralysis / Q000601:surgery*; D010369:Pectoralis Muscles / Q000294:innervation / Q000601:surgery*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D013709:Tendon Transfer / Q000379:methods*; D013900:Thoracic Nerves / Q000293:injuries* / Q000601:surgery
keywords: Long thoracic nerve palsy; allograft; levels of evidence; meta-analysis; pectoralis major transfer; serratus anterior palsy