1
|
Azer A, Hanna A, Shihora D, Saad A, Duan Y, McGrath A, Chu A. Forearm and elbow secondary surgical procedures in neonatal brachial plexus palsy: a systematic scoping review. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:61-69. [PMID: 38323202 PMCID: PMC10840578 DOI: 10.1016/j.xrrt.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Background Neonatal Brachial plexus palsy is an injury during delivery that can lead to loss of motor function and limited range of motion in patients due to damage of nerves in the brachial plexus. This scoping review aims to explore types of procedures performed and assess outcomes of forearm and elbow secondary surgery in pediatric patients. Methods Searches of PubMed, Cochrane, Cumulative Index to Nursing and Allied Health Literature, Web of Sciences, and Scopus were completed to obtain studies describing surgical treatment of elbow and forearm in pediatric patients with neonatal Brachial plexus palsy. 865 abstracts and titles were screened by two independent reviewers resulting in 295 full text papers; after applying of inclusion and exclusion criteria 18 articles were included. The level of evidence of this study is level IV. Results Ten main procedures were performed to regain function of the forearm and elbow in neonatal brachial plexus birth palsy patients. Procedures had different aims, with supination contracture (6) and elbow flexion restoration (5) being the most prevalent. The variance between preoperative and postoperative soft tissue and bony procedures outcomes decreased and showed improvement with respect to the aim of each procedure category. For soft tissue procedures, a statistically significant increase was found between preoperative and postoperative values for active elbow flexion, passive supination, and active supination. For bony procedures, there was a statistically significant decrease between preoperative and postoperative values of passive and active supination. Conclusion Overall, all procedures completed in the assessed articles of this study were successful in their aim. Bony procedures, specifically osteotomies, were found to have a wider range of results, whereas soft tissue procedures were found to be more consistent and reproducible with respect to their outcomes. Bony and soft tissue procedures were found vary in their aims and outcomes. This study indicates the need for further research to augment knowledge about indications and long-term benefits to each procedure.
Collapse
Affiliation(s)
- Amanda Azer
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Aedan Hanna
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Dhvani Shihora
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Anthony Saad
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Yajie Duan
- Department of Statistics, Rutgers University, Newark, NJ, USA
| | - Aleksandra McGrath
- Department of Clinical Sciences, Umeå- University, Umeå, Sweden
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Alice Chu
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
- Department of Orthopedic Surgery, Rutgers University, Newark, NJ, USA
| |
Collapse
|
2
|
Abdelmalek G, Mina GE, Pant K, Zheng Z, Mahajan J, Srinivasan N, Gupta S, Shafei J, Levidy MF, McGrath A, Chu A. Intercostal Nerve Transfer for Biceps Reinnervation in Obstetrical Brachial Plexus Palsy: A Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Individual Patient Data Systematic Review using Individualized Fusion and Comparison to Supraclavicular Exploration and Nerve Grafting. J Child Orthop 2024; 18:54-63. [PMID: 38348437 PMCID: PMC10859120 DOI: 10.1177/18632521231211644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2024] Open
Abstract
Introduction The objective of this study was to search existing literature on nerve reconstruction surgery in patients with obstetric brachial plexus palsy to determine whether treatment with supraclavicular exploration and nerve grafting produced better elbow flexion outcomes compared to intercostal nerve transfer. Methods This study was a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Individual Patient Data guidelines. A systematic search was conducted using multiple databases. An ordinal regression model was used to analyze the effect of using supraclavicular exploration and nerve grafting or intercostal nerve on elbow flexion with the two scores measured: elbow flexion Medical Research Council scores and Toronto active movements scale scores for elbow flexion. Results A final patient database from 6 published articles consisted of 83 supraclavicular exploration and nerve grafting patients (73 patients with Medical Research Council and 10 patients with Toronto score) and 7 published articles which consisted of 131 intercostal nerve patients (84 patients with Medical Research Council and 47 patients with Toronto scores). Patients who underwent supraclavicular exploration and nerve grafting presented with an average Medical Research Council score of 3.9 ± 0.72 and an average Toronto score of 6.2 ± 2.2. Patients who underwent intercostal nerve transfer presented with an average Medical Research Council score of 3.9 ± 0.71 and an average Toronto score of 6.4 ± 1.2. There was no statistical difference between supraclavicular exploration and nerve grafting and intercostal nerve transfer when utilizing Medical Research Council elbow flexion scores (ordinal regression: 0.3821, standard error: 0.4590, p = 0.2551) or Toronto Active Movement Scale score for elbow flexion (ordinal regression: 0.7154, standard error: 0.8487, p = 0.2188). Conclusion Regardless of surgical intervention utilized (supraclavicular exploration and nerve grafting or intercostal nerve transfers), patients had excellent outcomes for elbow flexion following obstetric brachial plexus palsy when utilizing Medical Research Council or Toronto scores for elbow flexion. The difference between these scores was not statistically significant. Type of study/Level of evidence Therapeutic Study: Investigating the Result of Treatment/level III.
Collapse
Affiliation(s)
| | | | | | - Zheshi Zheng
- Department of Statistics, Rutgers University, Piscataway, NJ, USA
| | | | | | | | | | | | - Aleksandra McGrath
- Department of Hand Surgery, Norrland’s University Hospital, Umea, Sweden
- Department of Anatomy, Umea University, Umea, Sweden
| | - Alice Chu
- Division of Pediatric Orthopedics, Department of Orthopedic Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| |
Collapse
|
3
|
Zelenski NA, Lu JCY, Chang TNJ, Chuang DCC. Resolving Co-Contraction of the Elbow in Patient with Sequelae of Obstetric Brachial Plexus Palsy: A Cohort Study. Plast Reconstr Surg 2023; 152:472e-475e. [PMID: 36917744 DOI: 10.1097/prs.0000000000010397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Obstetric brachial plexus palsy can cause deformities of the upper extremity in up to 92% of patients. Elbow reconstruction is difficult because co-contraction of the elbow flexor (EF) and elbow extensor (EE) muscles makes the traditional treatment strategy ineffective. The authors propose a novel strategy to minimize the effect of co-contraction, comprising transfer of an EF to the triceps and a staged gracilis muscle transplantation [functioning free muscle transplantation (FFMT)] to augment EF. The authors hypothesize this will lead to improved elbow flexion and extension, as well as decreased elbow flexion contracture. METHODS A single-center retrospective review of patients who received a gracilis FFMT for EF after EF-to-EE transfer was performed. EF/EE strength and range of motion data were collected from the last clinical visit. Patients were excluded if they had fewer than 1.5 years of follow-up. A control group with sequelae of obstetric brachial plexus palsy and nonsurgical treatment was used for comparison. RESULTS Twenty-one patients were included. Average age at muscle transfer was 7.6 ± 5.5 years (range, 3 to 22 years) and at gracilis FFMT was 10.4 ± 6.0 years (range, 5 to 26 years). Average follow-up was 7.3 ± 6.5 years (range, 1.5 to 14.8 years). After EF-to-EE transfer, EE strength increased significantly from Medical Research Council grade 2.2 ± 0.4 to 3.4 ± 0.5 ( P < 0.0001) and EF decreased from 3.2 ± 1.1 to 1.1 ± 1.1 ( P < 0.0001) and recovered to grade 3.3 ± 0.7 after gracilis FFMT. EF contracture was significantly lower compared with that in the nonsurgical cohort ( P = 0.029). CONCLUSION Patients who undergo EF-to-EE transfer followed by gracilis FFMT have equivalent EF strength with significantly improved EE and improved elbow flexion contracture. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
Collapse
Affiliation(s)
- Nicole A Zelenski
- From the Department of Orthopaedic Surgery, Emory University
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and Chang-Gung University
| | - Johnny Chuieng-Yi Lu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and Chang-Gung University
| | - Tommy Nai-Jen Chang
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and Chang-Gung University
| | - David Chwei-Chin Chuang
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and Chang-Gung University
| |
Collapse
|
4
|
Zelenski NA, Karzon AL, Chang TNJ, Chuang DCC, Lu JCY. Outcomes of Functioning Free Gracilis Muscle Transplantation to Restore Elbow Flexion in Late Brachial Plexus Birth Injury. J Reconstr Microsurg 2022; 39:361-366. [PMID: 36261055 DOI: 10.1055/s-0042-1757750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Restoring elbow function is challenging after late presenting brachial plexus birth injury (BPBI). Free functioning muscle transplantation (FFMT) using the gracilis muscle is a reliable procedure to restore elbow flexion in patients with impaired function after spontaneous recovery or failed surgical reconstruction. METHODS A retrospective review was performed on BPBI patients more than 2 years of age who received a FFMT between January 1993 and January 2018, with the aim of improving elbow flexion as the primary or secondary functional goal. Patients with preoperative elbow flexion Medical Research Council (MRC) grades less than 3 with more than or equal to 18 months of follow-up duration were included in the analysis. Patient demographic information and pre/postoperative clinical parameters including elbow flexion MRC scale, passive elbow range of motion, and complications were recorded. Surgical data including donor nerve choice, site of the FFMT tendon attachment, and necessity of concomitant procedures or reoperation were also analyzed. RESULTS Fifty-six FFMTs were performed for the primary (29 patients) or secondary (26 patients) objective of restoring elbow flexion. The mean age at the time of the procedure was 9.6 years (standard deviation [SD] = 6.29, R = 3-35). Mean follow-up was 7.9 years (SD = 5.2). Elbow flexion improved from a median MRC grade 2 to 4 after a FFMT (p < 0.05). Patients who had a FFMT to restore two functions had 86% lower elbow flexion MRC grades than those who had a FFMT to restore flexion only (p < 0.05). Patients less than 12 years old at the time of surgery had more complications, reoperations, and rates of a flexion contracture more than or equal to 30 degrees than those aged more than 12 years (p < 0.05). CONCLUSION FFMT is a reliable option for upper extremity reanimation. Patients aged less than 12 years old at the time of FFMT had significantly more complications, reoperations, and rates of postoperative elbow flexion contracture more than or equal to 30 degrees, but equivalent elbow flexion MRC grades. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Nicole A Zelenski
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia.,Department of Plastic and Reconstructive Surgery, Division of Reconstructive Microsurgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Anthony L Karzon
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Tommy Nai-Jen Chang
- Department of Plastic and Reconstructive Surgery, Division of Reconstructive Microsurgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - David Chwei-Chin Chuang
- Department of Plastic and Reconstructive Surgery, Division of Reconstructive Microsurgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Johnny Chuieng-Yi Lu
- Department of Plastic and Reconstructive Surgery, Division of Reconstructive Microsurgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| |
Collapse
|
5
|
Outcomes of gracilis free-flap muscle transfers and non-free-flap procedures for restoration of elbow flexion: A systematic review. J Plast Reconstr Aesthet Surg 2022; 75:2625-2636. [PMID: 35644885 DOI: 10.1016/j.bjps.2022.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 08/14/2021] [Accepted: 04/12/2022] [Indexed: 11/22/2022]
Abstract
PURPOSE Elbow flexion is one of the most important functions to restore following brachial plexus damage. The authors sought to systematically review available evidence to summarize outcomes of free gracilis and non-free muscle transfers in restoring elbow flexion. METHODS MEDLINE, EMBASE, and Cochrane were searched to identify articles reporting on elbow flexion reanimation in terms of transfer failure rates, strengths, range of motion (ROM), and/or Disabilities of the Arm, Shoulder and Hand (DASH) scores. A systematic review was chosen to select studies and reported according to PRISMA guidelines. RESULTS Forty-six studies met the inclusion criteria for this study. A total of 432 cases were gracilis free-flap muscle transfers (FFMT), and 982 cases were non-free muscle transfers. FFMT were shown to have higher Medical Research Council (MRC) strength scores than non-free muscle transfer groups. However, 42 studies, totaling 1,266 cases, were useful in evaluating graft failure, showing failure (MRC<3) in 77/419 (∼18.4%) of gracilis free-flap transfers and 215/847 (∼25.4%) of non-free muscle transfers. Sixteen articles, 285 cases, were useful to evaluate ROMs (total range: 0-140°), and eight articles, 215 cases, provided DASH scores (total range: 8-90.8). CONCLUSIONS Of patients who underwent gracilis FFMT procedures, higher mean strength scores and lower failure rates were observed when compared with non-free muscle transfers. Articles reporting non-free muscle transfer procedures (pectoralis, pedicled, Steindler, vascularized ulnar nerve grafts, Oberlin, single/double nerve transfers) provided comprehensive insight into outcomes and indicated that they may result in pooerer poorer DASH scores and ROM.
Collapse
|
6
|
Reed AJ, Claireaux HA, Wormald JC, Thurley N, Shirley R, Chan JK. Free functional muscle transfer for upper limb paralysis - A systematic review. J Plast Reconstr Aesthet Surg 2021; 75:1001-1017. [PMID: 34986998 DOI: 10.1016/j.bjps.2021.09.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 03/28/2021] [Accepted: 09/19/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Functional restoration of upper limb paralysis represents a major reconstructive challenge. Free functional muscle transfer (FFMT) enables reanimation in patients with a lack of local donor tissues or delayed presentation. This systematic review summarises the evidence for FFMT in the reconstruction of upper limb paralysis. METHODS A comprehensive search of MEDLINE and EMBASE was performed with a systematic review using methodology adapted from the Cochrane Handbook and the PRISMA statement. Data from included studies were compiled and narratively synthesised. Studies were assessed for risk of bias. RESULTS A total of 1155 records were screened, with 39 observational studies of 904 patients included. The most common aetiology was brachial plexus injury (736, 81.4%). Mean time from injury to intervention was 26 months. Restoration of elbow flexion was the commonest reconstructive goal. The most common donor muscle was gracilis (91.5%). Reported outcomes were heterogeneous with patient-reported outcome measures (PROMs) available in only 7 of 39 studies. Nearly half of FFMTs had a post-operative MRC grade of <4 and 18.1% had an MRC <3. Mean flap failure rate was 3.6% (range 0-10.5%). All studies were at high risk of bias. CONCLUSIONS FFMT may be an effective surgical intervention for upper limb paralysis; however, the current evidence has significant shortcomings. There is no consensus regarding outcome measures nor is it possible to identify prognostic factors for its effectiveness. This review highlights a need for improved study design with pre-operative assessment, standardisation in outcome reporting, and the use of PROMs to determine the effectiveness of FFMT in upper limb paralysis.
Collapse
Affiliation(s)
- Alistair Jm Reed
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, UK.
| | - Henry A Claireaux
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, UK
| | - Justin Cr Wormald
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, UK; Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, UK
| | - Neal Thurley
- Bodleian Health Care Libraries, University of Oxford, UK
| | - Rebecca Shirley
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, UK
| | - James Kk Chan
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, UK; Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, UK
| |
Collapse
|
7
|
Bachy M, Lallemant P, Grimberg J, Fitoussi F. Palliative shoulder and elbow surgery in obstetrical brachial plexus birth palsy. HAND SURGERY & REHABILITATION 2021; 41S:S63-S70. [PMID: 34058395 DOI: 10.1016/j.hansur.2020.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 08/29/2018] [Accepted: 05/08/2020] [Indexed: 11/26/2022]
Abstract
Palliative surgery in a child with incomplete recovery following obstetric brachial plexus birth palsy (BPBP) is common. Surgical management strategies for BPBP sequelae have the common objectives of decreasing the risk of functional limitations in the long term and improving function. There is no single treatment to deal with the sequelae of BPBP. While there is a myriad of possible clinical presentations, the ages for surgery extend from a 6- to 12-month-old infant to the mature adolescent. Numerous procedures have been described in the literature, ranging from simple soft tissue release to muscular transfers and osteotomies. The indications will depend on a combination of all these factors. In certain cases, an early intervention is recommended to prevent joint deformities, and to allow joint remodeling, often at the shoulder. In other cases, the indications are less clear, thus the expected benefit must be carefully considered. The indications for these operations must meet certain rules to be beneficial for the patient and should only be considered after a comprehensive clinical examination and a commitment from the child and the family to the therapeutic strategy.
Collapse
Affiliation(s)
- M Bachy
- Service de Chirurgie Orthopédique et Réparatrice de l'Enfant, Hôpital Armand Trousseau, APHP, 26, Avenue du Dr Arnold Netter, 75012 Paris, France.
| | - P Lallemant
- Service de Chirurgie Orthopédique et Réparatrice de l'Enfant, Hôpital Armand Trousseau, APHP, 26, Avenue du Dr Arnold Netter, 75012 Paris, France
| | - J Grimberg
- Service de Chirurgie Orthopédique et Réparatrice de l'Enfant, Hôpital Armand Trousseau, APHP, 26, Avenue du Dr Arnold Netter, 75012 Paris, France
| | - F Fitoussi
- Service de Chirurgie Orthopédique et Réparatrice de l'Enfant, Hôpital Armand Trousseau, APHP, 26, Avenue du Dr Arnold Netter, 75012 Paris, France
| |
Collapse
|
8
|
Scollan JP, Newman JM, Shah NV, Kuehn E, Koehler SM. Free Gracilis Muscle Transfers Compared with Nonfree Muscle Flaps for Reanimation of Elbow Flexion: A Meta-Analysis. J Hand Microsurg 2019; 12:37-42. [PMID: 32280180 DOI: 10.1055/s-0039-1697064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 07/31/2019] [Indexed: 01/22/2023] Open
Abstract
Objectives Elbow flexion loss is a debilitating upper extremity injury. Surgical treatment options include nonfree muscle transfers (tendon transfers, nerve transfers, Steindler procedure, Oberlin transfers, and pedicled muscle transfers) or free muscle transfers. We sought to determine if free muscle transfers and nonfree muscle transfers have similar outcomes for elbow flexion reanimation. Materials and Methods A literature search for studies evaluating free and nonfree muscle transfers for elbow flexion reanimation was performed. Included studies reported on transfer failure (strength <M3, unable to flex arm against gravity), strength, range of motion (ROM), or Disabilities of the Arm, Shoulder, and Hand (DASH) score. Pooled odds ratios were used to calculate failure rate, and pooled mean differences were used to calculate differences in strength, ROM, and DASH scores. Results Six studies were included ( n = 331 patients). Free muscle patients experienced lower failure rates than nonfree muscle patients. There was no significant difference in ROM. A nonsignificant trend toward better mean strength and DASH scores among free muscle patients was observed. Conclusion Free muscle transfers may be superior to nonfree muscle transfers for elbow flexion reanimation, given their lower failure rates. Well-powered future studies may reveal differences in strength and DASH scores between free and nonfree muscle transfers.
Collapse
Affiliation(s)
- Joseph P Scollan
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York SUNY Downstate Medical Center, Brooklyn, New York, United States
| | - Jared M Newman
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York SUNY Downstate Medical Center, Brooklyn, New York, United States
| | - Neil V Shah
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York SUNY Downstate Medical Center, Brooklyn, New York, United States
| | - Erika Kuehn
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York SUNY Downstate Medical Center, Brooklyn, New York, United States.,Department of Orthopedics, University of Massachusetts, Worcester, Massachusetts, United States
| | - Steven M Koehler
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York SUNY Downstate Medical Center, Brooklyn, New York, United States
| |
Collapse
|
9
|
Affiliation(s)
- Neil V Shah
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York
| | - John J Kelly
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York.,School of Medicine, SUNY Upstate Medical University, Syracuse, New York
| | - Aakash M Patel
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York.,Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, Illinois
| | - Colin M White
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York
| | - Michael R Hausman
- Leni & Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven M Koehler
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York
| |
Collapse
|
10
|
Costil V, Romana C, Fitoussi F. Pectoralis minor transfer for elbow flexion restoration in late obstetric brachial plexus palsy. INTERNATIONAL ORTHOPAEDICS 2018; 42:1137-1141. [PMID: 29285664 DOI: 10.1007/s00264-017-3725-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 12/10/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE Obstetric brachial plexus palsy (OBPP) may result in a severe impairment of upper limb function, especially when major motor functions do not recover with or without early microsurgical reconstruction. Various methods to restore elbow flexion have been described. The aim of this study was to report the results after pectoralis minor transfer for elbow flexion restoration in late OBPP. METHODS Nineteen patients were included. Mean age at surgery was six years (range, 2.3-12.8). The mean follow-up period was four years (range, 1-15). Shoulder function was evaluated by the Mallet classification and hand function by the Raimondi scale. We used the "active movement scale" (AMS) to evaluate elbow flexion function. RESULTS Eighteen of the 19 patients had improvement in their elbow active flexion. There was significant improvement in biceps muscle power according to the BMRC grading system, from an average grading of 1.7 (range, 1-3) pre-operatively to 3 (range, 1-4) post-operatively (P < 0.05). The average active elbow flexion was significantly improved from a mean of 81° (range, 0-120; SD = 44) pre-operatively, most of them gravity eliminated, to a mean of 111° (range, 0-140; SD = 33) post-operatively (P < 0.05). According to the AMS, 12 patients (63%) had a good result, 4 (21%) a fair result and 5 (26%) a poor result. Poor results were significantly correlated with a low pre-operative AMS score (P < 0.05). CONCLUSIONS The pectoral minor transfer can be a reliable technique for elbow flexion improvement in late OBPP by strengthening an already existing but inadequate active flexion. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Vanessa Costil
- Department of Pediatric Orthopaedic and Reconstructive Surgery, Trousseau Hospital, Paris 6 University, Paris, France
| | - Claudia Romana
- Department of Pediatric Orthopaedic and Reconstructive Surgery, Trousseau Hospital, Paris 6 University, Paris, France
| | - Frank Fitoussi
- Department of Pediatric Orthopaedic and Reconstructive Surgery, Trousseau Hospital, Paris 6 University, Paris, France.
| |
Collapse
|
11
|
Bipolar Transfer of Latissimus Dorsi Myocutaneous Flap for Restoration of Elbow Flexion in Late Traumatic Brachial Plexus Injury: Evaluation of 13 Cases. Ann Plast Surg 2017; 78:198-201. [PMID: 27787271 DOI: 10.1097/sap.0000000000000907] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Restoration of elbow flexion following traumatic brachial plexus injury represents a great challenge to the reconstructive surgeons. Functional muscle transfers come next to the sophisticated types of nerve surgery in this area. Many transfers are well known for restoration of elbow flexion; bipolar or unipolar latissimus dorsi, triceps brachii, sternocleidomastoid, pectoralis major, and Steindler flexorplasty. OBJECTIVE Evaluation of the outcome of bipolar transfer of latissimus dorsi myocutaneous flap when used to restore elbow flexion in late traumatic brachial plexus injury. PATIENTS AND METHODS Thirteen patients were included in this case series with careful evaluation both preoperatively and postoperatively both clinically and using electromyography. RESULTS Almost 84.6% of patients (11 of 13) developed G3-4 on the Medical Research Council grading with relatively minimal both donor-site and recipient-site morbidity. CONCLUSIONS Bipolar transfer of latissimus dorsi myocutaneous flap is a reliable method for restoration of elbow flexion in patients suffering from late sequelae of traumatic brachial plexus injury.
Collapse
|
12
|
El-Gammal TA, El-Sayed A, Kotb MM, Saleh WR, Ragheb YF, Refai O, Morsy MM. Free functioning gracilis transplantation for reconstruction of elbow and hand functions in late obstetric brachial plexus palsy. Microsurgery 2015; 35:350-5. [PMID: 25643924 DOI: 10.1002/micr.22373] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Revised: 12/11/2014] [Accepted: 12/15/2014] [Indexed: 11/06/2022]
Abstract
BACKGROUND In late obstetric brachial plexus palsy (OBPP), restoration of elbow and hand functions is a difficult challenge. The use of free functioning muscle transplantation in late OBPP was very scarcely reported. In this study, we present our experience on the use of free functioning gracilis transfer for restoration of elbow and hand functions in late cases of OBPP. PATIENTS AND METHODS Eighteen patients with late OBPP underwent free gracilis transfer for reconstruction of elbow and/or hand functions. The procedure was indicated when there was no evidence of reinnervation on EMG and in the absence of local donors. Average age at surgery was 102.5 months. Patients were evaluated using the British Medical Research Council (MRC) grading system and the Toronto Active Movement Scale. Hand function was evaluated by the Raimondi scoring system. RESULTS The average follow-up was 65.8 ± 41.7 months. Contraction of the transferred gracilis started at an average of 4.5 ± 1.03 months. Average range of elbow flexion significantly improved from 30 ± 55.7 to 104 ± 31.6 degrees (P <0.001). Elbow flexion power significantly increased with an average of 3.8 grades (P = 0.000147). Passive elbow range of motion significantly decreased from an average of 147 to 117 degrees (P = 0.003). Active finger flexion significantly improved from 5 ± 8.3 to 63 ± 39.9 degrees (P < 0.001). Finger flexion power significantly increased with an average 2.7 grades (P < 0.001). Only 17% achieved useful hand (grade 3) on Raimondi hand score. Triceps reconstruction resulted in an average of M4 power and 45 degrees elbow extension. CONCLUSION Free gracilis transfer may be a useful option for reconstruction of elbow and/or hand functions in late OBPP.
Collapse
Affiliation(s)
- Tarek A El-Gammal
- Hand and Reconstructive Microsurgery Unit, Department of Orthopedics and Traumatology, Assiut University School of Medicine, Assiut, Egypt
| | - Amr El-Sayed
- Hand and Reconstructive Microsurgery Unit, Department of Orthopedics and Traumatology, Assiut University School of Medicine, Assiut, Egypt
| | - Mohamed M Kotb
- Hand and Reconstructive Microsurgery Unit, Department of Orthopedics and Traumatology, Assiut University School of Medicine, Assiut, Egypt
| | - Waleed Riad Saleh
- Hand and Reconstructive Microsurgery Unit, Department of Orthopedics and Traumatology, Assiut University School of Medicine, Assiut, Egypt
| | - Yasser Farouk Ragheb
- Hand and Reconstructive Microsurgery Unit, Department of Orthopedics and Traumatology, Assiut University School of Medicine, Assiut, Egypt
| | - Omar Refai
- Hand and Reconstructive Microsurgery Unit, Department of Orthopedics and Traumatology, Assiut University School of Medicine, Assiut, Egypt
| | - Mohamed Mohamed Morsy
- Hand and Reconstructive Microsurgery Unit, Department of Orthopedics and Traumatology, Assiut University School of Medicine, Assiut, Egypt
| |
Collapse
|
13
|
Abstract
BACKGROUND Elbow flexion is often lacking in patients with brachial plexus palsy or anterior arm trauma. Restoring elbow flexion helps position the functioning hand for activity and nonfunctioning hand for stabilization. Bipolar latissimus transfer is one method of improving elbow flexion. METHODS A clinical case of bipolar latissimus transfer is presented. Additionally, results of a literature search are incorporated. RESULTS Bipolar latissimus can effectively improve elbow function, however residual deficits are to be expected. Additional transfers include unipolar latissimus, triceps, sternocleidomastoid, and pectoralis. Other methods include primary nerve transfer, Steindler flexorplasty, free muscle transfer, and elbow fusion. CONCLUSION Elbow flexion can be improved through various techniques. Each individual's clinical picture should be examined by an experienced clinician when choosing which technique to apply.
Collapse
|