Monday, December 29, 2008

Shoulder Morbidity following Latissimus Dorsi Breast Reconstruction – an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

Not only can the shoulder function be impacted from the axillary dissection when treating breast cancer, it can also be impacted by the reconstruction of the breast.  This is of concern when using the latissimus dorsi muscle in breast reconstruction.  The action of the latissimus dorsi muscle is adduction, extension, and internal rotation of the humerus and plays a crucial role in the stability of the glenohumeral joint.
The authors of this article (see full reference below) wanted to look at this issue from a prospective view as current literature has only looked at it from a retrospective view. 
The literature already supports the absence of long-term effects from this procedure. However, all studies and subsequent reviews are based on retrospective studies, thus making it impossible to assess recovery time scales compared with preoperative values. In this prospective study, the authors set out to define the impact on shoulder function and, importantly, to assess recovery time scales compared with preoperative values.
Their methods included measuring shoulder range of motion, strength, function, and pain.  These assessments were done  preoperatively and then at 6 weeks, 6 months, and 1 year postoperatively.  The biggest weakness of the study (as they themselves point out) is the small number of subjects.  There were only 22 subjects in the study.  The ages ranged from 37 to 69 yrs with an average of 50 yr.
Of these 22 subjects, 17 underwent delayed reconstruction and five underwent immediate reconstruction, with five subjects requiring axillary node sampling. Fourteen subjects required a latissimus dorsi flap with implant breast reconstruction and eight required an extended latissimus dorsi flap breast reconstruction.
Their conclusions (remember too small a group to do statistical analysis).
Range of Motion
A loss of shoulder joint range of motion could be anticipated in the early period after surgery. However, the eventual increase in motion at 1 year after surgery was unexpected. When examining this increase in motion, it was noted that for each plane of movement the increase was less than 10 degrees. This minimal change could be attributed to measurement error, and it is also questionable whether such a small change would be clinically significant to the subject's function. ……. A number of subjects who previously underwent mastectomy reported a feeling of loosening of the shoulder joint following their breast reconstruction. This could have been attributable to release of residual scar tissue during the reconstructive surgery. Further investigation, with larger numbers of subjects, into morbidity following immediate and delayed reconstruction may establish whether this is a factor.
Although there was a slight decrease in shoulder strength at 1 year compared with preoperative values, this was minimal (<1 kg) and could therefore be attributed to measurement error. This loss of strength would also be unlikely to be clinically significant to the subject's function. The lack of significant deterioration in shoulder strength following removal of the latissimus dorsi muscle may be attributable to the synergistic action of the teres major, as has been suggested in other studies.  However, of the loss of power seen, it remained in the first 6 months, returning to or near preoperative values in the second 6-month period after surgery.
Absence of any significant alteration in upper limb function when compared with preoperative values supports the theory that the minimal increase in motion and decrease in strength have no impact on the subject's activities of daily living. However, this study would suggest that it takes a full 12 months for preoperative values to be achieved. This would fit with the period of significant scar maturation. However, when comparing the extended and traditional reconstruction groups, it is noted that the extended latissimus dorsi group reported a 7 percent higher disability. Further research with greater numbers of subjects would be necessary to explore this finding. This is particularly of note, as the extended latissimus dorsi flap is becoming even more popular. It is not surprising that those subjects whose breast reconstruction was on the same side as their dominant hand took longer to recover their activities of daily living.
The initial increase in pain following surgery was anticipated. However, the majority of subjects reported a decrease in pain at 1 year compared with preoperative measurements. Further examination would be necessary to establish the cause of the reported preoperative pain. The presence of adhesions following previous mastectomy could account for the pre-reconstruction pain.

Overall, a nice start.  It would be nice to see the study extended to include a statistically significant number of participants.  Until then, the take home message is that it takes a year to get the function and strength back in the shoulder.

A Prospective Assessment of Shoulder Morbidity and Recovery Time Scales following Latissimus Dorsi Breast Reconstruction; Plastic and Reconstructive Surgery:Volume 122(5)November 2008pp 1334-1340; Glassey, Nicole M.Sc., Grad.Dip.Phys.; Perks, Graeme B. F.R.C.S., F.R.C.S.(Plast.); McCulley, Stephen J. F.C.S.(S.A.)Plast., F.R.C.S.(Plast.)

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