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Akgün D, Gebauer H, Paksoy A, Schafer F, Herbst E, Karczewski D, Pastor MF, Moroder P. Differences in Osseous Shoulder Morphology, Scapulothoracic Orientation, and Muscle Volume in Patients With Constitutional Static Posterior Shoulder Instability (Type C1) Compared With Healthy Controls. Am J Sports Med 2024; 52:1299-1307. [PMID: 38488401 PMCID: PMC10986147 DOI: 10.1177/03635465241233706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND Constitutional static posterior humeral decentering (type C1 according to ABC Classification) has been recognized as a pre-osteoarthritic deformity that may lead to early-onset posterior decentering osteoarthritis at a young age. Therefore, it is important to identify possible associations of this pathologic shoulder condition to find more effective treatment options. PURPOSE To perform a comprehensive analysis of all parameters reported to be associated with a C1 shoulder-including the osseous shoulder morphology, scapulothoracic orientation, and the muscle volume of the shoulder girdle in a single patient cohort. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS A retrospective, comparative study was conducted analyzing 17 C1 shoulders in 10 patients who underwent magnetic resonance imaging (MRI) with the complete depiction of the trunk from the base of the skull to the iliac crest, including both humeri. The mean age of the patients was 33.5 years, and all patients were men. To measure and compare the osseous shoulder morphology (glenoid version, glenoid offset, humeral torsion, anterior acromial coverage, posterior acromial coverage, posterior acromial height, and posterior acromial tilt) and scapulothoracic orientation (scapular protraction, scapular internal rotation, scapular upward rotation, scapular translation, scapular tilt, and thoracic kyphosis), these patients were matched 1 to 4 according their age, sex, and affected side with shoulder-healthy patients who had received positron emission tomography (PET)-computed tomography. To measure and compare the muscle volume of the shoulder girdle (subscapularis, infraspinatus/teres minor, supraspinatus, trapezius, deltoid, latissimus dorsi/teres major, pectoralis major, and pectoralis minor), patients were matched 1 to 2 with patients who had received PET-MRI. Patients with visible pathologies of the upper extremities were excluded. RESULTS The C1 group had a significantly higher glenoid retroversion, increased anterior glenoid offset, reduced humeral retrotorsion, increased anterior acromial coverage, reduced posterior acromial coverage, increased posterior acromial height, and increased posterior acromial tilt compared with controls (P < .05). Decreased humeral retrotorsion showed significant correlation with higher glenoid retroversion (r = -0.742; P < .001) and higher anterior glenoid offset (r = -0.757; P < .001). Significant differences were found regarding less scapular upward rotation, less scapular tilt, and less thoracic kyphosis in the C1 group (P < .05). The muscle volume of the trapezius and deltoid was significantly higher in the C1 group (P < .05). CONCLUSION Patients with C1 shoulders differ from healthy controls regarding osseous scapular and humeral morphology, scapulothoracic orientation, and shoulder girdle muscle distribution. These differences may be crucial in understanding the delicate balance of glenohumeral centering.
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Affiliation(s)
- Doruk Akgün
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Henry Gebauer
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Alp Paksoy
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Frederik Schafer
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Daniel Karczewski
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Mattar LT, Mahboobin AB, Popchak AJ, Anderst WJ, Musahl V, Irrgang JJ, Debski RE. Individuals with rotator cuff tears unsuccessfully treated with exercise therapy have less inferiorly oriented net muscle forces during scapular plane abduction. J Biomech 2024; 162:111859. [PMID: 37989027 PMCID: PMC10843663 DOI: 10.1016/j.jbiomech.2023.111859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/29/2023] [Accepted: 11/03/2023] [Indexed: 11/23/2023]
Abstract
Exercise therapy for individuals with rotator cuff tears fails in approximately 25.0 % of cases. One reason for failure of exercise therapy may be the inability to strengthen and balance the muscle forces crossing the glenohumeral joint that act to center the humeral head on the glenoid. The objective of the current study was to compare the magnitude and orientation of the net muscle force pre- and post-exercise therapy between subjects successfully and unsuccessfully (e.g. eventually underwent surgery) treated with a 12-week individualized exercise therapy program. Twelve computational musculoskeletal models (n = 6 successful, n = 6 unsuccessful) were developed in OpenSim (v4.0) that incorporated subject specific tear characteristics, muscle peak isometric force, in-vivo kinematics and bony morphology. The models were driven with experimental kinematics and the magnitude and orientation of the net muscle force was determined during scapular plane abduction at pre- and post-exercise therapy timepoints. Subjects unsuccessfully treated had less inferiorly oriented net muscle forces pre- and post-exercise therapy compared to subjects successfully treated (p = 0.039 & 0.045, respectively). No differences were observed in the magnitude of the net muscle force (p > 0.05). The current study developed novel computational musculoskeletal models with subject specific inputs capable of distinguishing between subjects successfully and unsuccessfully treated with exercise therapy. A less inferiorly oriented net muscle force in subjects unsuccessfully treated may increase the risk of superior migration leading to impingement. Adjustments to exercise therapy programs may be warranted to avoid surgery in subjects at risk of unsuccessful treatment.
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Affiliation(s)
- Luke T Mattar
- Orthopaedic Robotics Laboratory, University of Pittsburgh, United States; UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, United States
| | - Arash B Mahboobin
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, United States
| | - Adam J Popchak
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, United States
| | - William J Anderst
- Biodynamics Laboratory, University of Pittsburgh, United States; UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, United States
| | - Volker Musahl
- Orthopaedic Robotics Laboratory, University of Pittsburgh, United States; Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, United States; UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, United States
| | - James J Irrgang
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, United States; Department of Physical Therapy, University of Pittsburgh, Pittsburgh, United States
| | - Richard E Debski
- Orthopaedic Robotics Laboratory, University of Pittsburgh, United States; Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, United States; UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, United States.
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Doshi RM, Reid MY, Dixit NN, Fawcett EB, Cole JH, Saul KR. Location of brachial plexus birth injury affects functional outcomes in a rat model. J Orthop Res 2022; 40:1281-1292. [PMID: 34432311 PMCID: PMC8873217 DOI: 10.1002/jor.25173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/08/2021] [Accepted: 08/16/2021] [Indexed: 02/04/2023]
Abstract
Brachial plexus birth injury (BPBI) results in shoulder and elbow paralysis with shoulder internal rotation and elbow flexion contracture as frequent sequelae. The purpose of this study was to develop a technique for measuring functional movement and examine the effect of brachial plexus injury location (preganglionic and postganglionic) on functional movement outcomes in a rat model of BPBI, which we achieved through integration of gait analysis with musculoskeletal modeling and simulation. Eight weeks following unilateral brachial plexus injury, sagittal plane shoulder and elbow angles were extracted from gait recordings of young rats (n = 18), after which rats were sacrificed for bilateral muscle architecture measurements. Musculoskeletal models reflecting animal-specific muscle architecture parameters were used to simulate gait and extract muscle fiber lengths. The preganglionic neurectomy group spent significantly less (p = 0.00116) time in stance and walked with significantly less (p < 0.05) elbow flexion and shoulder protraction in the affected limb than postganglionic neurectomy or control groups. Linear regression revealed no significant linear relationship between passive shoulder external rotation and functional shoulder protraction range of motion. Despite significant restriction in longitudinal muscle growth, normalized functional fiber excursions did not differ significantly between groups. In fact, when superimposed on a normalized force-length curve, neurectomy-impaired muscle fibers (except subscapularis) accessed regions of the curve that overlapped with the control group. Our results suggest the presence of compensatory motor control strategies during locomotion following BPBI. The clinical implications of our findings support emphasis on functional movement analysis in treatment of BPBI, as functional and passive outcomes may differ substantially.
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Affiliation(s)
- Raveena M. Doshi
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC
| | - Monique Y. Reid
- Joint Department of Biomedical Engineering, University of North Carolina, Chapel Hill, NC and North Carolina State University, Raleigh, NC
| | - Nikhil N. Dixit
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC
| | - Emily B. Fawcett
- Joint Department of Biomedical Engineering, University of North Carolina, Chapel Hill, NC and North Carolina State University, Raleigh, NC
| | - Jacqueline H. Cole
- Joint Department of Biomedical Engineering, University of North Carolina, Chapel Hill, NC and North Carolina State University, Raleigh, NC
| | - Katherine R. Saul
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC
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Surgical Soft Tissue Management for Glenohumeral Deformity and Contractures in Brachial Plexus Birth Injury : A Systematic Review and Meta-analysis. Curr Rev Musculoskelet Med 2022; 15:107-120. [PMID: 35156170 DOI: 10.1007/s12178-022-09747-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE OF THE REVIEW Consensus on the effects of soft tissue surgical intervention in the management of brachial plexus birth injury (BPBI) sequalae is lacking. The purpose of this review is to examine the available literature on the functional and structural outcomes following soft tissue surgical management of BPBI sequalae. RECENT FINDINGS EMBASE, PubMed, and MEDLINE were searched for related literature from the point of database inception until April 2021. Relevant papers were screened by two reviewers independently and in duplicate. A meta-analysis was performed using a random effects model. A total of 25 studies (852 patients) were included in the review, with the number included in each meta-analysis varying based on outcome of interest. There were significant improvements from pre- to post-operative time points for the following measures: Mallet aggregate scores (5.0 points, p<0.0001), active external rotation in adduction (48.9°, p=0.003), passive external rotation in adduction (64.6°, p< 0.00001), active abduction (46.2°, p<0.00001), glenoid version (14.4°, p< 0.00001), and percentage of the humeral head anterior to the scapular line (17.53°, p< 0.00001). Furthermore, data revealed an overall complication rate of 9.3% (79/852 patients) and a major complication rate of 0.47% (4/852 patients). Patients with BPBI sequela experience statistically significant improvements in functional, structural, and range of motion outcomes of the GH joint following soft tissue surgical management. Understanding the ideal indications for each procedure and age of surgical management with future prospective studies will help to optimize surgical management of these patients.
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Dixit NN, McCormick CM, Cole JH, Saul KR. Influence of Brachial Plexus Birth Injury Location on Glenohumeral Joint Morphology. J Hand Surg Am 2021; 46:512.e1-512.e9. [PMID: 33358583 PMCID: PMC8180483 DOI: 10.1016/j.jhsa.2020.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/12/2020] [Accepted: 10/20/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Patient presentation after brachial plexus birth injury (BPBI) is influenced by nerve injury location; more contracture and bone deformity occur at the shoulder in postganglionic injuries. Although bone deformity after postganglionic injury is well-characterized, the extent of glenohumeral deformity after preganglionic BPBI is unclear. METHODS Twenty Sprague-Dawley rat pups received preganglionic or postganglionic neurectomy on a single forelimb at postnatal days 3 to 4. Glenohumeral joints on affected and unaffected sides were analyzed using micro-computed tomography scans after death at 8 weeks after birth. Glenoid version, glenoid inclination, glenoid and humeral head radius of curvature, and humeral head thickness and width were measured bilaterally. RESULTS The glenoid was significantly more declined in affected compared with unaffected shoulders after postganglionic (-17.7° ± 16.9°) but not preganglionic injury. Compared with the preganglionic group, the affected shoulder in the postganglionic group exhibited significantly greater declination and increased glenoid radius of curvature. In contrast, the humeral head was only affected after preganglionic but not postganglionic injury, with a significantly smaller humeral head radius of curvature (-0.2 ± 0.2 mm), thickness (-0.2 ± 0.3 mm), and width (-0.3 ± 0.4 mm) on the affected side compared with the unaffected side; changes in these metrics were significantly associated with each other. CONCLUSIONS These findings suggest that glenoid deformities occur after postganglionic BPBI but not after preganglionic BPBI, whereas the humeral head is smaller after preganglionic injury, possibly suggesting an overall decreased biological growth rate in this group. CLINICAL RELEVANCE This study expands understanding of the altered glenoid and humeral head morphologies after preganglionic BPBI and its comparisons with morphologies after postganglionic BPBI.
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Affiliation(s)
| | - Carolyn M. McCormick
- North Carolina State University, Raleigh, NC,University of North Carolina, Chapel Hill, NC
| | - Jacqueline H. Cole
- North Carolina State University, Raleigh, NC,University of North Carolina, Chapel Hill, NC
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Akgün D, Siegert P, Danzinger V, Plachel F, Minkus M, Thiele K, Moroder P. Glenoid vault and humeral head alignment in relation to the scapular blade axis in young patients with pre-osteoarthritic static posterior subluxation of the humeral head. J Shoulder Elbow Surg 2021; 30:756-762. [PMID: 32853792 DOI: 10.1016/j.jse.2020.08.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/27/2020] [Accepted: 08/02/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Static posterior subluxation of the humeral head is a pre-osteoarthritic deformity preceding posterior erosion in young patients. Its etiology remains unknown. The aim of this study was to analyze the differences in scapular morphology between young patients with pre-osteoarthritic static posterior subluxation of the humeral head and healthy controls with a centered humeral head. METHODS We performed a retrospective analysis of all patients with pre-osteoarthritic static posterior subluxation of the humeral head who were treated in our institution between January 2018 and November 2019. Fourteen shoulders in 12 patients were included in this study and then matched according their age, sex, and affected side with controls. Computed tomography images of both groups were compared in the standardized axial imaging plane for differences in scapular morphology. The following parameters were measured: glenoid version relative to the Friedman line and scapular blade axis, scapulohumeral and glenohumeral subluxation index, and neck angle, as well as glenoid and humeral offset. RESULTS The patients in the subluxation group showed significantly higher scapulohumeral and glenohumeral subluxation indexes than controls (0.76 vs. 0.55 [P < .0001] and 0.58 vs. 0.51 [P = .016], respectively). The mean measurements of glenoid version according to the Friedman line and relative to the scapular blade axis were significantly higher in the subluxation group than in controls (19° vs. 4° [P < .0001]and 14° vs. 2° [P = .0002], respectively). The glenoid vault was significantly more anteriorly positioned with respect to the scapular blade axis in the subluxation group than in controls (neck angle, 166° vs. 173° [P = .0003]; glenoid offset, 9.2 mm vs. 4.6 mm [P = .0005]). The midpoint of the humeral head showed a posterior offset with respect to the scapular blade axis in the subluxation group, whereas controls had an anteriorly placed midpoint of the humeral head (-2 mm vs. 3.1 mm, P = .01). A higher scapulohumeral subluxation index showed significant correlations with an increased anterior offset of the glenoid vault (increased glenoid offset: r = 0.493, P = .008 and decreased neck angle: r = -0.554, P = .002), a posterior humeral offset (r = -0.775, P < .0001), and excessive glenoid retroversion measured by both methods (Friedman line: r = 0.852, P < .0001; scapular blade axis: r = 0.803, P < .0001). A higher glenohumeral subluxation index also correlated significantly with an increased anterior offset of the glenoid vault (increased glenoid offset: r = 0.403, P = .034; decreased neck angle: r = -0.406, P = .032) and posterior humeral offset (r = -0.502, P = .006). CONCLUSION Young patients with pre-osteoarthritic static posterior subluxation of the humeral head have significant constitutional differences in scapular morphology in terms of an increased anterior glenoid offset, excessive glenoid retroversion, and increased posterior humeral offset in relation to the scapular blade compared with healthy matched controls.
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Affiliation(s)
- Doruk Akgün
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany.
| | - Paul Siegert
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Victor Danzinger
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Fabian Plachel
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Marvin Minkus
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Kathi Thiele
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Philipp Moroder
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
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Dixit NN, McCormick CM, Warren E, Cole JH, Saul KR. Preganglionic and Postganglionic Brachial Plexus Birth Injury Effects on Shoulder Muscle Growth. J Hand Surg Am 2021; 46:146.e1-146.e9. [PMID: 32919794 PMCID: PMC7864858 DOI: 10.1016/j.jhsa.2020.07.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 05/22/2020] [Accepted: 07/20/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE Brachial plexus birth injury can differ in presentation, depending on whether the nerve ruptures distal to, or avulses proximal to, the dorsal root ganglion. More substantial contracture and bone deformity at the shoulder is typical in postganglionic injuries. However, changes to the underlying muscle structure that drive these differences in presentation are unclear. METHODS Seventeen Sprague-Dawley rats received preganglionic or postganglionic neurectomy on a single limb on postnatal days 3 and 4. Muscles crossing the shoulder were retrieved once the rats were sacrificed at 8 weeks after birth. External rotation range of motion, muscle mass, muscle length, muscle sarcomere length, and calculated optimal muscle length were measured bilaterally. RESULTS Average shoulder range of motion in the postganglionic group was 61.8% and 56.2% more restricted at 4 and 8 weeks, respectively, compared with that in the preganglionic group, but affected muscles after preganglionic injury were altered more severely (compared with the unaffected limb) than after postganglionic injury. Optimal muscle length in preganglionic injury was shorter in the affected limb (compared with the unaffected limb: -18.2% ± 9.2%) and to a greater extent than in postganglionic injury (-5.1% ± 6.2%). Muscle mass in preganglionic injury was lower in the affected limb (relative to the unaffected limb: -57.2% ± 24.1%) and to a greater extent than in postganglionic injury (-28.1% ± 17.7%). CONCLUSIONS The findings suggest that the presence of contracture does not derive from restricted longitudinal muscle growth alone, but also depends on the extent of muscle mass loss occurring simultaneously after the injury. CLINICAL RELEVANCE This study expands our understanding of differences in muscle architecture and the role of muscle structure in contracture formation for preganglionic and postganglionic brachial plexus birth injury.
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Affiliation(s)
- Nikhil N. Dixit
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh
| | - Carolyn M. McCormick
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh;,the Joint Department of Biomedical Engineering, University of North Carolina Chapel Hill and North Carolina State University, Chapel Hill and Raleigh, NC
| | - Eric Warren
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh
| | - Jacqueline H. Cole
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh;,the Joint Department of Biomedical Engineering, University of North Carolina Chapel Hill and North Carolina State University, Chapel Hill and Raleigh, NC
| | - Katherine R. Saul
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh
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Dixit NN, McFarland DC, Fisher MB, Cole JH, Saul KR. Integrated iterative musculoskeletal modeling predicts bone morphology following brachial plexus birth injury (BPBI). J Biomech 2020; 103:109658. [PMID: 32089271 PMCID: PMC7141945 DOI: 10.1016/j.jbiomech.2020.109658] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 01/20/2020] [Accepted: 01/21/2020] [Indexed: 01/05/2023]
Abstract
Brachial plexus birth injury (BPBI) is the most common nerve injury among children. The glenohumeral joint of affected children can undergo severe osseous deformation and altered muscle properties, depending on location of the injury relative to the dorsal root ganglion (preganglionic or postganglionic). Preganglionic injury results in lower muscle mass and shorter optimal muscle length compared to postganglionic injury. We investigated whether these changes to muscle properties over time following BPBI provide a mechanically-driven explanation for observed differences in bone deformity between preganglionic and postganglionic BPBI. We developed a computational framework integrating musculoskeletal modeling to represent muscle changes over time and finite element modeling to simulate bone growth in response to mechanical and biological stimuli. The simulations predicted that the net glenohumeral joint loads in the postganglionic injury case were nearly 10.5% greater than in preganglionic. Predicted bone deformations were more severe in the postganglionic case, with the glenoid more declined (pre: -43.8°, post: -51.0°), flatter with higher radius of curvature (pre: 3.0 mm, post: 3.7 mm), and anteverted (pre: 2.53°, post: 4.93°) than in the preganglionic case. These simulated glenoid deformations were consistent with previous experimental studies. Thus, we concluded that the differences in muscle mass and length between the preganglionic and postganglionic injuries are critical mechanical drivers of the altered glenohumeral joint shape.
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Affiliation(s)
- Nikhil N Dixit
- North Carolina State University, Raleigh, NC, United States
| | | | - Matthew B Fisher
- North Carolina State University, Raleigh, NC, United States; University of North Carolina, Chapel Hill, NC, United States
| | - Jacqueline H Cole
- North Carolina State University, Raleigh, NC, United States; University of North Carolina, Chapel Hill, NC, United States
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Nikolaou S, Cramer AA, Hu L, Goh Q, Millay DP, Cornwall R. Proteasome inhibition preserves longitudinal growth of denervated muscle and prevents neonatal neuromuscular contractures. JCI Insight 2019; 4:128454. [PMID: 31661460 DOI: 10.1172/jci.insight.128454] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 10/16/2019] [Indexed: 12/14/2022] Open
Abstract
Muscle contractures are a prominent and disabling feature of many neuromuscular disorders, including the 2 most common forms of childhood neurologic dysfunction: neonatal brachial plexus injury (NBPI) and cerebral palsy. There are currently no treatment strategies to directly alter the contracture pathology, as the pathogenesis of these contractures is unknown. We previously showed in a mouse model of NBPI that contractures result from impaired longitudinal muscle growth. Current presumed explanations for growth impairment in contractures focus on the dysregulation of muscle stem cells, which differentiate and fuse to existing myofibers during growth, as this process has classically been thought to control muscle growth during the neonatal period. Here, we demonstrate in a mouse model of NBPI that denervation does not prevent myonuclear accretion and that reduction in myonuclear number has no effect on functional muscle length or contracture development, providing definitive evidence that altered myonuclear accretion is not a driver of neuromuscular contractures. In contrast, we observed elevated levels of protein degradation in NBPI muscle, and we demonstrate that contractures can be pharmacologically prevented with the proteasome inhibitor bortezomib. These studies provide what we believe is the first strategy to prevent neuromuscular contractures by correcting the underlying deficit in longitudinal muscle growth.
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Affiliation(s)
| | - Alyssa Aw Cramer
- Division of Molecular Cardiovascular Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | | | - Douglas P Millay
- Division of Molecular Cardiovascular Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Roger Cornwall
- Division of Orthopaedic Surgery, and.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Developmental Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Pons C, Eddi D, Le Gal G, Garetier M, Ben Salem D, Houx L, Fitoussi F, Quintero N, Brochard S. Effectiveness and safety of early intramuscular botulinum toxin injections to prevent shoulder deformity in babies with brachial plexus birth injury (POPB-TOX), a randomised controlled trial: study protocol. BMJ Open 2019; 9:e032901. [PMID: 31575585 PMCID: PMC6773354 DOI: 10.1136/bmjopen-2019-032901] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION In children with brachial plexus birth injury (BPBI), denervation of the shoulder muscles leads to bony deformity in the first months of life, reducing active and passive range of motion (ROM) and causing activity limitation. The aim of this multicentre randomised controlled trial is to evaluate the effectiveness of botulinum toxin injections (BTI) in the shoulder internal rotator muscles of 12-month-old babies in limiting the progression of posterior subluxation of the glenohumeral joint, compared with a sham procedure mimicking BTI. The secondary aims are to evaluate the effectiveness of BTI in (1) limiting the progression of glenoid retroversion and three-dimensional (3D) deformity and (2) improving shoulder ROM and upper limb function, as well as to confirm the tolerance of BTI. METHODS AND ANALYSIS Sixty-two babies with unilateral BPBI and a risk of posterior humeral head subluxation will be included. Only those with at least 7% posterior subluxation of the humeral head compared with the contralateral shoulder on the MRI will be randomised to one of two groups: 'BTI' and 'Sham'. The BTI group will receive BOTOX injections at the age of 12 months in the internal shoulder rotator muscles (8 UI/kg). The sham group will undergo a sham BTI procedure. Both groups will undergo repeated shoulder MRI at 18 months of age to quantify changes in the percentage of posterior migration of the humeral head (primary outcome), glenoid version and 3D bone deformity. Clinical evaluations (passive shoulder ROM, active movement scale) will be carried out at baseline and 15 and 18 months of age. The mini-assisting hand assessment will be rated between 10 and 11 months and at 18 months of age. Adverse events will be recorded at least monthly for each child. ETHICS AND DISSEMINATION Full ethical approval for this study has been obtained. The findings will be disseminated in peer-reviewed publications. TRIAL REGISTRATION NUMBER EudraCT: 2015-001402-34 in European Clinical Trial database; NCT03198702 in Clinical Trial database; Pre-results.
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Affiliation(s)
- Christelle Pons
- Pediatric rehabilitation department, Fondation ILDYS, Brest, France
- Laboratory of Medical Information Processing (LaTIM), INSERM UMR 1101, Brest, France
- Physical Medicine and Rehabilitation department, Brest CHRU, Brest, France
| | | | - Gregoire Le Gal
- Centre for Clinical Investigation INSERM CIC 1412, Brest CHRU, Brest, France
| | - Marc Garetier
- Laboratory of Medical Information Processing (LaTIM), INSERM UMR 1101, Brest, France
- Radiology department, Hopital d'Instruction des Armees Clermont-Tonnerre, Brest, France
| | - Douraied Ben Salem
- Laboratory of Medical Information Processing (LaTIM), INSERM UMR 1101, Brest, France
- Radiology department, Brest CHRU, Brest, France
- Medical School, Université de Bretagne Occidentale, Brest, France
| | - Laetitia Houx
- Pediatric rehabilitation department, Fondation ILDYS, Brest, France
- Laboratory of Medical Information Processing (LaTIM), INSERM UMR 1101, Brest, France
- Physical Medicine and Rehabilitation department, Brest CHRU, Brest, France
| | - Franck Fitoussi
- CHU Paris Est - Hôpital d'Enfants Armand-Trousseau, Paris, France
| | - Nathaly Quintero
- Physical Medicine and Rehabilitation department, Hopitaux de Saint-Maurice, Saint Maurice, France
| | - Sylvain Brochard
- Pediatric rehabilitation department, Fondation ILDYS, Brest, France
- Laboratory of Medical Information Processing (LaTIM), INSERM UMR 1101, Brest, France
- Physical Medicine and Rehabilitation department, Brest CHRU, Brest, France
- Medical School, Université de Bretagne Occidentale, Brest, France
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11
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Olofsson PN, Chu A, McGrath AM. The Pathogenesis of Glenohumeral Deformity and Contracture Formation in Obstetric Brachial Plexus Palsy-A Review. J Brachial Plex Peripher Nerve Inj 2019; 14:e24-e34. [PMID: 31308856 PMCID: PMC6625958 DOI: 10.1055/s-0039-1692420] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 11/05/2018] [Indexed: 01/25/2023] Open
Abstract
Contractures of the shoulder joint and glenohumeral joint dysplasia are well known complications to obstetrical brachial plexus palsy. Despite extensive description of these sequelae, the exact pathogenesis remains unknown. The prevailing theory to explain the contractures and glenohumeral joint dysplasia states that upper trunk injury leads to nonuniform muscle recovery and thus imbalance between internal and external rotators of the shoulder. More recently, another explanation has been proposed, hypothesizing that denervation leads to reduced growth of developing muscles and that reinnervation might suppress contracture formation. An understanding of the pathogenesis is desirable for development of effective prophylactic treatment. This article aims to describe the current state of knowledge regarding these important complications.
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Affiliation(s)
- Pontus N Olofsson
- Department of Hand and Plastic Surgery, Norrland's University Hospital, Umeå, Sweden.,Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Alice Chu
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York, United States
| | - Aleksandra M McGrath
- Department of Hand and Plastic Surgery, Norrland's University Hospital, Umeå, Sweden.,Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden.,Department of Clinical Science, Umeå University, Umeå, Sweden
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12
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Dixit NN, McFarland DC, Saul KR. Computational analysis of glenohumeral joint growth and morphology following a brachial plexus birth injury. J Biomech 2019; 86:48-54. [PMID: 30797561 DOI: 10.1016/j.jbiomech.2019.01.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 11/29/2018] [Accepted: 01/21/2019] [Indexed: 02/02/2023]
Abstract
Children affected with brachial plexus birth injury (BPBI) undergo muscle paralysis. About 33% of affected children experience permanent osseous deformities of the glenohumeral joint. Recent evidence suggests that some cases experience restricted muscle longitudinal growth in addition to paralysis and reduced range of motion at the shoulder and elbow. It is unknown whether altered loading due to paralysis, muscle growth restriction and contracture, or static loading due to disuse is the primary driver of joint deformity after BPBI. This study uses a computational framework integrating finite element analysis and musculoskeletal modeling to examine the mechanical factors contributing to changes in bone growth and morphometry following BPBI. Simulations of 8 weeks of glenohumeral growth in a rat model of BPBI predicted that static loading of the joint is primarily responsible for joint deformation consistent with experimental measures of bone morphology, whereas dynamic loads resulted in normal bone growth. Under dynamic loading, glenoid version angle (GVA), glenoid inclination angle (GIA), and glenoid radius of curvature (GRC) (-1.3°, 38.2°, 2.5 mm respectively) were similar to the baseline values (-1.8°, -38°, 2.1 mm respectively). In the static case with unrestricted muscle growth, these measures increased in magnitude (5.2°, -48°, 3.5 mm respectively). More severe joint deformations were observed in GIA and GRC when muscle growth was restricted (GVA: 3.6°, GIA: -55°, GRC: 4.0 mm). Predicted morphology was consistent with literature reports of in vivo glenoid morphology following postganglionic BPBI. This growth model provides a framework for understanding the most influential mechanical factors driving glenohumeral deformity following BPBI.
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Affiliation(s)
- Nikhil N Dixit
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC, United States
| | - Daniel C McFarland
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC, United States
| | - Katherine R Saul
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC, United States.
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13
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Stein J, Laor T, Carr P, Zbojniewicz A, Cornwall R. The Effect of Scapular Position on Magnetic Resonance Imaging Measurements of Glenohumeral Dysplasia Caused by Neonatal Brachial Plexus Palsy. J Hand Surg Am 2017; 42:1030.e1-1030.e11. [PMID: 28823534 DOI: 10.1016/j.jhsa.2017.07.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 06/27/2017] [Accepted: 07/03/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE Neonatal brachial plexus palsy (NBPP) frequently causes glenohumeral dysplasia. Quantification of this dysplasia on magnetic resonance imaging can determine the need for and the success of nonsurgical or surgical intervention. However, we hypothesize that the variable position of the scapula on the thorax between affected and unaffected shoulders affects dysplasia measurements. METHODS Magnetic resonance imaging studies were analyzed from 19 NBPP patients (ages 0.8-18 years; median, 2.4 years) without prior shoulder surgery. Three reviewers measured the glenoid version angle (GVA) and percentage of humeral head anterior to the midscapular line (PHHA) on standard axial images ("thoracic axial") and on reformatted axial images aligned perpendicular to the scapular plane ("scapular axial"), which corrects for scapulothoracic position. Scapular tilt and protraction were measured to assess their impact on the difference between thoracic and scapular GVA and PHHA measurements. Intra- and interrater reliability were calculated for GVA and PHHA on both views. RESULTS The GVA of the affected shoulder was significantly greater on thoracic than on scapular images, by an average of 5° and as much as 34°. The PHHA was significantly less in the affected shoulders on thoracic than on scapular images, by an average of 5% and as much as 33% of humeral head width. The difference in GVA, but not PHHA, between thoracic and scapular axial images in the affected shoulder correlated with scapular tilt. Unaffected shoulders showed no significant difference in GVA or PHHA between thoracic and scapular axial images. Interrater reliability ranged from fair to substantial and did not differ between thoracic and scapular images. CONCLUSIONS Thoracic axial images overestimate the severity of glenohumeral dysplasia in NBPP, owing at least in part to the variable position of the scapula on the thorax. This confounding effect must be considered in interpretation of axial quantitative measures of glenohumeral dysplasia in NBPP. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic III.
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Affiliation(s)
- Jill Stein
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Tal Laor
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Preston Carr
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Andrew Zbojniewicz
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Roger Cornwall
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
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14
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Metsaars WP, Biegstraaten M, Nelissen RGHH. Biceps Rerouting after Forearm Osteotomy: An Effective Treatment Strategy for Severe Supination Deformity in Obstetric Plexus Palsy. J Hand Microsurg 2017; 9:1-5. [PMID: 28442854 DOI: 10.1055/s-0037-1598088] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 12/20/2016] [Indexed: 10/20/2022] Open
Abstract
Study Design Retrospective cohort study. Objective Supination deformity in obstetric brachial plexus injury can have debilitating consequences for the functionality of the hand. Surgical treatment by a forearm osteotomy has a recurrence rate of 20 to 42%. As a complement to forearm osteotomy, a biceps rerouting may improve outcome. Methods Children with residual brachial plexus injury, who had a forearm osteotomy for a supination contracture and had a postoperative decrease of pronation to 50 degrees or less, were indicated for a biceps rerouting. Shoulder, elbow and hand function, biceps strength, Mallet score, and Raimondi score were assessed with a minimum follow-up of 2 years. Results Five patients (median age: 8 years; range: 4-10) underwent biceps rerouting between 2008 and 2012. Median follow-up time was 6.8 years (range: 3.2-7.0 years). Passive pronation increased in all cases (median 0 degree at baseline to 80 degrees at final follow-up). Active pronation also increased. Active median wrist extension was -30 degrees at baseline and 45 degrees at follow-up. Biceps strength and grip strength improved in two cases. No recurrences were present. Conclusion The sequentially planned surgical treatment of forearm osteotomy and biceps rerouting should be considered in the treatment of severe supination deformity, as it is effective in improving pronation of the forearm and hand function, without recurrence at follow-up. Level of Evidence/Type of Study Level III, case series, therapeutic study.
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Affiliation(s)
- W P Metsaars
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - M Biegstraaten
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - R G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
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15
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Abstract
Brachial plexus birth palsy (BPBP) is an upper extremity paralysis that occurs due to traction injury of the brachial plexus during childbirth. Approximately 20 % of children with brachial plexus birth palsy will have residual neurologic deficits. These permanent and significant impacts on upper limb function continue to spur interest in optimizing the management of a problem with a highly variable natural history. BPBP is generally diagnosed on clinical examination and does not typically require cross-sectional imaging. Physical examination is also the best modality to determine candidates for microsurgical reconstruction of the brachial plexus. The key finding on physical examination that determines need for microsurgery is recovery of antigravity elbow flexion by 3-6 months of age. When indicated, both microsurgery and secondary shoulder and elbow procedures are effective and can substantially improve functional outcomes. These procedures include nerve transfers and nerve grafting in infants and secondary procedures in children, such as botulinum toxin injection, shoulder tendon transfers, and humeral derotational osteotomy.
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Affiliation(s)
- Kristin L Buterbaugh
- Division of Orthopaedic Surgery, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Wood Building Room 2307, Philadelphia, PA, 19104-4318, USA
| | - Apurva S Shah
- Division of Orthopaedic Surgery, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Wood Building Room 2307, Philadelphia, PA, 19104-4318, USA.
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16
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Chagas-Neto FA, Dalto VF, Crema MD, Waters PM, Gregio-Junior E, Mazzer N, Nogueira-Barbosa MH. Imaging assessment of glenohumeral dysplasia secondary to brachial plexus birth palsy. Radiol Bras 2016; 49:144-9. [PMID: 27403013 PMCID: PMC4938443 DOI: 10.1590/0100-3984.2015.0039] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Objective To assess imaging parameters related to the morphology of the glenohumeral
joint in children with unilateral brachial plexus birth palsy (BPBP), in
comparison with those obtained for healthy shoulders. Materials and Methods We conducted a retrospective search for cases of unilateral BPBP diagnosed at
our facility. Only patients with a clinical diagnosis of unilateral BPBP
were included, and the final study sample consisted of 10 consecutive
patients who were assessed with cross-sectional imaging. The glenoid
version, the translation of the humeral head, and the degrees of
glenohumeral dysplasia were assessed. Results The mean diameter of the affected humeral heads was 1.93 cm, compared with
2.33 cm for those of the normal limbs. In two cases, there was no
significant posterior displacement of the humeral head, five cases showed
posterior subluxation of the humeral head, and the remaining three cases
showed total luxation of the humeral head. The mean glenoid version angle of
the affected limbs (90-α) was -9.6º, versus +1.6º for the normal,
contralateral limbs. Conclusion The main deformities found in this study were BPBP-associated retroversion of
the glenoid cavity, developmental delay of the humeral head, and posterior
translation of the humeral head.
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Affiliation(s)
- Francisco Abaete Chagas-Neto
- Radiology Professor, Division of Radiology, Universidade de Fortaleza (Unifor) and Centro Universitário Christus, Fortaleza, CE, Brazil
| | - Vitor Faeda Dalto
- PhD Student, Division of Radiology, Internal Medicine Department, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Michel Daoud Crema
- MD, Radiologist, Radiology Department, Hôpital Saint-Antoine, Université Paris VI, Paris, France; Department of Radiology, Quantitative Imaging Center, Boston University School of Medicine, Boston, MA, USA; Department of Radiology and Tele-Imaging, Hospital do Coração (HCor), São Paulo, SP, Brazil
| | - Peter M Waters
- Orthopedic Surgeon-in-Chief, Brachial Plexus Program Director, Orthopedic Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Nilton Mazzer
- Full Professor of Orthopedics, Department of Biomechanics, Medicine, and Rehabilitation of the Locomotor Apparatus, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Marcello Henrique Nogueira-Barbosa
- Associate Professor of Radiology, Division of Radiology, Internal Medicine Department, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
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17
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Crouch DL, Hutchinson ID, Plate JF, Antoniono J, Gong H, Cao G, Li Z, Saul KR. Biomechanical Basis of Shoulder Osseous Deformity and Contracture in a Rat Model of Brachial Plexus Birth Palsy. J Bone Joint Surg Am 2015; 97:1264-71. [PMID: 26246261 DOI: 10.2106/jbjs.n.01247] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to investigate the relative contributions of two proposed mechanisms, strength imbalance and impaired longitudinal muscle growth, to osseous and postural deformity in a rat model of brachial plexus birth palsy (BPBP). METHODS Thirty-two Sprague-Dawley rat pups were divided into four groups on the basis of surgical interventions to induce a strength imbalance, impaired growth, both a strength imbalance and impaired growth (a combined mechanism), and a sham condition in the left forelimb. Maximum passive external shoulder rotation angle (ERmax) was measured bilaterally at four and eight weeks postoperatively. After the rats were killed at eight weeks, the glenohumeral geometry (on microcomputed tomography) and shoulder muscle architecture properties were measured bilaterally. RESULTS Bilateral muscle mass and optimal length differences were greatest in the impaired growth and combined mechanism groups, which also exhibited >15° lower ERmax (p < 0.05; four weeks postoperatively), 14° to 18° more glenoid declination (p < 0.10), and 0.76 to 0.94 mm more inferior humeral head translation (p < 0.10) on the affected side. Across all four groups, optimal muscle length was significantly correlated with at least one osseous deformity measure for six of fourteen muscle compartments crossing the shoulder on the affected side (p < 0.05). In the strength imbalance group, the glenoid was 5° more inclined and the humeral head was translated 7.5% more posteriorly on the affected side (p < 0.05). CONCLUSIONS Impaired longitudinal muscle growth and shoulder deformity were most pronounced in the impaired growth and combined mechanism groups, which underwent neurectomy. Strength imbalance was associated with osseous deformity to a lesser extent. CLINICAL RELEVANCE Treatments to alleviate shoulder deformity should address mechanical effects of both strength imbalance and impaired longitudinal muscle growth, with an emphasis on developing new treatments to promote growth in muscles affected by BPBP.
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Affiliation(s)
- Dustin L Crouch
- UNC-NCSU Joint Department of Biomedical Engineering, North Carolina State University, 911 Oval Drive, Engineering Building 3, Campus Box 7115, Raleigh, NC 27695. E-mail address:
| | - Ian D Hutchinson
- Department of Orthopaedic Surgery and Rehabilitation, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27103. E-mail address for I.D. Hutchinson: . E-mail address for J.F. Plate: . E-mail address for Z. Li:
| | - Johannes F Plate
- Department of Orthopaedic Surgery and Rehabilitation, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27103. E-mail address for I.D. Hutchinson: . E-mail address for J.F. Plate: . E-mail address for Z. Li:
| | - Jennifer Antoniono
- Department of Mechanical and Aerospace Engineering, North Carolina State University, 911 Oval Drive, Engineering Building 3, Campus Box 7910, Raleigh, NC 27695. E-mail address for J. Antoniono: . E-mail address for K.R. Saul:
| | - Hao Gong
- Virginia Tech-Wake Forest School of Biomedical Engineering and Sciences, Virginia Polytechnic Institute and State University, Kelly Hall, 325 Stanger Street, MC 0298, Blacksburg, VA 24061. E-mail address for H. Gong: . E-mail address for G. Cao:
| | - Guohua Cao
- Virginia Tech-Wake Forest School of Biomedical Engineering and Sciences, Virginia Polytechnic Institute and State University, Kelly Hall, 325 Stanger Street, MC 0298, Blacksburg, VA 24061. E-mail address for H. Gong: . E-mail address for G. Cao:
| | - Zhongyu Li
- Department of Orthopaedic Surgery and Rehabilitation, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27103. E-mail address for I.D. Hutchinson: . E-mail address for J.F. Plate: . E-mail address for Z. Li:
| | - Katherine R Saul
- Department of Mechanical and Aerospace Engineering, North Carolina State University, 911 Oval Drive, Engineering Building 3, Campus Box 7910, Raleigh, NC 27695. E-mail address for J. Antoniono: . E-mail address for K.R. Saul:
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18
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Cheng W, Cornwall R, Crouch DL, Li Z, Saul KR. Contributions of muscle imbalance and impaired growth to postural and osseous shoulder deformity following brachial plexus birth palsy: a computational simulation analysis. J Hand Surg Am 2015; 40:1170-6. [PMID: 25847723 DOI: 10.1016/j.jhsa.2015.02.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 02/05/2015] [Accepted: 02/05/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE Two potential mechanisms leading to postural and osseous shoulder deformity after brachial plexus birth palsy are muscle imbalance between functioning internal rotators and paralyzed external rotators and impaired longitudinal growth of paralyzed muscles. Our goal was to evaluate the combined and isolated effects of these 2 mechanisms on transverse plane shoulder forces using a computational model of C5-6 brachial plexus injury. METHODS We modeled a C5-6 injury using a computational musculoskeletal upper limb model. Muscles expected to be denervated by C5-6 injury were classified as affected, with the remaining shoulder muscles classified as unaffected. To model muscle imbalance, affected muscles were given no resting tone whereas unaffected muscles were given resting tone at 30% of maximal activation. To model impaired growth, affected muscles were reduced in length by 30% compared with normal whereas unaffected muscles remained normal in length. Four scenarios were simulated: normal, muscle imbalance only, impaired growth only, and both muscle imbalance and impaired growth. Passive shoulder rotation range of motion and glenohumeral joint reaction forces were evaluated to assess postural and osseous deformity. RESULTS All impaired scenarios exhibited restricted range of motion and increased and posteriorly directed compressive glenohumeral joint forces. Individually, impaired muscle growth caused worse restriction in range of motion and higher and more posteriorly directed glenohumeral forces than did muscle imbalance. Combined muscle imbalance and impaired growth caused the most restricted joint range of motion and the highest joint reaction force of all scenarios. CONCLUSIONS Both muscle imbalance and impaired longitudinal growth contributed to range of motion and force changes consistent with clinically observed deformity, although the most substantial effects resulted from impaired muscle growth. CLINICAL RELEVANCE Simulations suggest that treatment strategies emphasizing treatment of impaired longitudinal growth are warranted for reducing deformity after brachial plexus birth palsy.
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Affiliation(s)
- Wei Cheng
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC
| | - Roger Cornwall
- Division of Orthopedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Dustin L Crouch
- Department of Biomedical Engineering, North Carolina State University, Raleigh, NC
| | - Zhongyu Li
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Katherine R Saul
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC.
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19
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Eismann EA, Little KJ, Laor T, Cornwall R. Glenohumeral abduction contracture in children with unresolved neonatal brachial plexus palsy. J Bone Joint Surg Am 2015; 97:112-8. [PMID: 25609437 DOI: 10.2106/jbjs.n.00203] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Following neonatal brachial plexus palsy, the Putti sign-obligatory tilt of the scapula with brachiothoracic adduction-suggests the presence of glenohumeral abduction contracture. In the present study, we utilized magnetic resonance imaging (MRI) to quantify this glenohumeral abduction contracture and evaluate its relationship to shoulder joint deformity, muscle atrophy, and function. METHODS We retrospectively reviewed MRIs of the thorax and shoulders obtained before and after shoulder rebalancing surgery (internal rotation contracture release and external rotation tendon transfer) for twenty-eight children with unresolved neonatal brachial plexus palsy. Two raters measured the coronal positions of the scapula, thoracic spine, and humeral shaft bilaterally on coronal images, correcting trigonometrically for scapular protraction on axial images. Supraspinatus, deltoid, and latissimus dorsi muscle atrophy was assessed, blinded to other measures. Correlations between glenohumeral abduction contracture and glenoid version, humeral head subluxation, passive external rotation, and Mallet shoulder function before and after surgery were performed. RESULTS MRI measurements were highly reliable between raters. Glenohumeral abduction contractures were present in twenty-five of twenty-eight patients, averaging 33° (range, 10° to 65°). Among those patients, abductor atrophy was present in twenty-three of twenty-five, with adductor atrophy in twelve of twenty-five. Preoperatively, greater abduction contracture severity correlated with greater Mallet global abduction and hand-to-neck function. Abduction contracture severity did not correlate preoperatively with axial measurements of glenohumeral dysplasia, but greater glenoid retroversion was associated with worse abduction contractures postoperatively. Surgery improved passive external rotation, active abduction, and hand-to-neck function, but did not change the abduction contracture. CONCLUSIONS A majority of patients with persistent shoulder weakness following neonatal brachial plexus palsy have glenohumeral abduction deformities, with contractures as severe as 65°. The abduction contracture occurs with abductor atrophy, with or without associated adductor atrophy. This contracture may improve global shoulder abduction by positioning the glenohumeral joint in abduction. Glenohumeral and scapulothoracic kinematics and muscle pathology must be further elucidated to advance an understanding of the etiology and the prevention and treatment of the complex shoulder deformity following neonatal brachial plexus palsy. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Emily A Eismann
- Division of Orthopaedic Surgery (E.A.E., K.J.L., and R.C.), and Department of Radiology (T.L.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229. E-mail address for R. Cornwall:
| | - Kevin J Little
- Division of Orthopaedic Surgery (E.A.E., K.J.L., and R.C.), and Department of Radiology (T.L.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229. E-mail address for R. Cornwall:
| | - Tal Laor
- Division of Orthopaedic Surgery (E.A.E., K.J.L., and R.C.), and Department of Radiology (T.L.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229. E-mail address for R. Cornwall:
| | - Roger Cornwall
- Division of Orthopaedic Surgery (E.A.E., K.J.L., and R.C.), and Department of Radiology (T.L.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229. E-mail address for R. Cornwall:
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