Treatment of supination deformity for obstetric brachial plexus injury: a systematic review and meta-analysis

Long-Term Outcomes of Biceps Rerouting for Flexible Supination Contractures in Children With Brachial Plexus Birth Injuries

PURPOSE

Forearm supination contractures occur in 7% of children with brachial plexus birth injuries (BPBI). Biceps rerouting is proposed when pronation has deteriorated but is passively correctable to at least 0° (neutral). The purpose of this investigation was to evaluate long-term outcomes of biceps rerouting for this indication, including magnitude and maintenance of correction, complications, and subsequent osteotomy.

METHODS

We conducted a retrospective review of all children with BPBI and forearm supination contractures treated with biceps rerouting alone, for the above indications, from 1993 to 2017 with at least 2 years follow-up. Demographic information, BPBI characteristics, surgical details, and ranges of motion were obtained from medical records. Pre- and postoperative active pronation (AP) and supination (AS), elbow flexion contracture, and arc of forearm rotation (Arc) were analyzed using linear mixed-effect models.

RESULTS

Twenty-five children (13 females; 13 left forearms; 15 global BPBI) underwent biceps rerouting at age 7 ± 3 years and were followed for 6 ± 3 years. Before surgery, the mean AP and AS were 6° ± 29° and 62° ± 27°, respectively. At the final follow-up, the mean AP, AS, and Arc were 39° ± 36°, 18° ± 34°, and 57° ± 42°, respectively. AP was significantly improved and AS was significantly decreased by 2 years after surgery and at the final follow-up. Neither Arc nor elbow flexion contracture changed significantly. Two of 25 (8%) children underwent subsequent forearm osteotomy.

CONCLUSIONS

Biceps rerouting in children with BPBI improves the forearm position when pronation is deteriorating by shifting the arc from supination to pronation without decreasing the arc of motion or worsening elbow flexion contractures. There is a low risk of complications and a limited need for subsequent forearm osteotomy. These results are maintained over time. When performed before passive pronation is reduced beyond neutral, this procedure may prevent severe supination contractures and reduce the need for forearm osteotomy.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

'Switch' technique to restore pronation and radial deviation in 17 patients with brachial plexus birth palsy

We report outcomes of 17 children with brachial plexus birth palsy that underwent extensor carpi ulnaris to brachioradialis and brachioradialis to abductor pollicis longus transfers to correct supination and ulnar deviation deformity. Mean age at the time of surgery was 8.7 years and mean follow-up time was 21 months (8-44). These patients had marked increases in active forearm rotation and Canadian Occupational Performance Measure scores. Activity performance score on the measure increased from 1.1 to 6.7 and satisfaction score increased from 0.8 to 8.7 at final follow-up. We conclude from our patient series that these tendon transfers are effective in correction of the supination and ulnar deviation deformities in brachial plexus birth palsy. Level of evidence: IV.

Surgical Management of Spasticity of the Forearm and Wrist

Upper extremity spasticity may result from a variety of types of brain injury, including cerebral palsy, stroke, or traumatic brain injury. These conditions lead to a predictable pattern of forearm and wrist deformities caused by opposing spasticity and flaccid paralysis. Upper extremity spasticity affects all ages and sociodemographics and is a complex clinical problem with a variety of treatment options depending on the patient, the underlying disease process, and postoperative expectations. This article discusses the cause, diagnosis, operative planning, operative techniques, postoperative outcomes, and rehabilitation protocols for the spastic wrist and forearm.

Supination Contractures in Brachial Plexus Birth Palsy: Long-Term Upper Limb Function and Recurrence After Forearm Osteotomy or Nonsurgical Treatment

PURPOSE

Forearm osteotomy for supination deformity in brachial plexus birth palsy (BPBP) may lead to improved function of the upper limb. However, recurrence rates are high and limit satisfactory results.

METHODS

We reviewed the long-term outcome of the entire upper limb of 22 BPBP patients with a supination contracture who were treated by forearm osteotomy and compared them with an age-matched group that was treated nonsurgically (n = 28). Recurrence was defined as a passive pronation below 30°.

RESULTS

The median follow-up was 5.0 years (range, 1.5-14 years). The mean passive pronation after forearm osteotomy, including patients with recurrence at follow-up, improved from -1° (SD, 9°) to 33° (SD, 48°) at final follow-up, mean active wrist extension improved from 23° (SD, 40°) to 41° (SD, 38°). An overall improvement of wrist and hand strength was present. In patients without recurrence, pronation improved to a mean of 66° (SD, 23°) at final follow-up. Recurrence of the supination contracture was present in 9 cases (41%) and was only present in patients with a single bone osteotomy. Recurrence was associated with lower age at surgery (recurrence mean, 4 [SD, 1.2] and no recurrence 8 [SD 4.5]), lower shoulder external rotation (recurrence mean, 28 [SD, 17] and no recurrence 49 [SD, 23]), and overall lower hand function at baseline.

CONCLUSIONS

Forearm osteotomy improves forearm pronation and hand function. Recurrence should be considered as a potential complication after forearm osteotomy and is associated with young age and lower function of shoulder and hand. Single-bone osteotomy might also be a risk factor for recurrence.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Forearm Pronation Osteotomy for Supination Contracture Secondary to Obstetrical Brachial Plexus Palsy: A Retrospective Cohort Study

BACKGROUND

Obstetrical brachial plexus palsy can lead to fixed forearm supination contracture. Fixed supination may lead to functional deficits as the affected hand cannot be positioned optimally for activities on a desk such as writing and typing, or for using tools including utensils, which require a neutral or pronated forearm. Forearm pronation osteotomy has been used to address this problem, although the functional benefit over nonoperative management has not been clearly defined. Potentially deleterious consequences on hand function that requires supination or fine motor skills are also uncertain.

METHODS

Patients with fixed forearm supination contracture were selected from our institutional brachial plexus database. Those who underwent both bone forearm rotational osteotomy were analyzed for age at time of surgery, preoperative forearm resting position, active and passive supination and pronation, and preoperative function assessed by the brachial plexus outcome measure (BPOM) and active movement scale (AMS). Preoperative results were compared with values obtained at follow-up at least 12 months postoperatively. A matched cohort of children with fixed forearm supination contracture that were treated nonoperatively and followed for at least 12 months, was also selected. For this group, forearm resting position, movement, AMS, and BPOM scores were analyzed at a baseline clinic visit and the most recent follow-up. Changes in forearm resting position, AMS, and BPOM activity scale scores were then compared between groups.

RESULTS

Records were obtained for 14 cases and 10 controls. Study groups were similar with respect to resting forearm position, hand function, and time from initial to final evaluation. Groups differed with respect to age and active supination. We observed a statistically significant change in resting position among operative patients compared with their preoperative status and compared with controls. Hand-specific AMS score did not change significantly in the operative group as compared with controls. The BPOM score for drums, reflective of function in neutral rotation to mild pronation, improved in the operated patients as compared with controls. There was no loss of plate holding ability (reflective of supination function, putty (grasp), or bead placement (fine motor) among the operated patients as compared with controls.

CONCLUSIONS

By pronating resting forearm position by about 90 degrees to near neutral, osteotomy resulted in improved neutral to mild pronation-dependent function without loss of supination-dependent function or hand motor skills.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Biceps Rerouting after Forearm Osteotomy: An Effective Treatment Strategy for Severe Supination Deformity in Obstetric Plexus Palsy

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.

Conversion from knee arthrodesis to arthroplasty: systematic review

PURPOSE

Arthrodesis (AD) of the knee reduces pain and provides stability, but has severe functional and social limitations. There has been ample discussion on the value of a conversion of an AD to a total knee arthroplasty (TKA). The aim of this study was to perform a review and meta-analysis of the current literature on conversion of an AD to TKA and assess clinical outcome, complication rate, surgical technique and overall patient-related outcome measures.

METHODS

PubMed, Embase, Web of Science, Cochrane, CENTRAL, CINAHL, Academic Search Premier, ScienceDirect and searching by hand for papers on conversion of AD of the knee to TKA. Two reviewers independently reviewed all titles and abstracts, and extracted the available data. Study eligibility criteria were: conversion of knee AD to TKA, five cases or more and non-oncology patients. Data consisted of study characteristics, patient demographics, clinical outcome and complications. Additionally, details on surgical technique were reviewed.

RESULTS

Of the 866 unique references identified, six papers were included for further analyses, comprising a total of 123 knees with conversion of AD of the knee to TKA. Mean gain of knee flexion was 80 degrees and the mean HSS score improved with 20 points. A complicated postoperative course was found in 65 % of all cases. The most frequent complication was skin necrosis (25 %), followed by arthrofibrosis (13 %), infection (11 %) and revision (11 %). Major complications such as refusion, amputation and death occurred in less than 5 % of all cases.

DISCUSSION

The majority of the papers consisted of small case series of moderate methodological quality, resulting in 123 included knees. Further series are necessary to draw definitive conclusions.

CONCLUSIONS

This is the first systematic review and meta-analysis on conversion of a knee arthrodesis to TKA. Good clinical results can be expected after conversion, albeit at a high risk of postoperative complications.

Spastic Paralysis of the Elbow and Forearm

As the physiologic recovery period concludes, the patient is evaluated for surgical procedures that may rebalance muscle function and correct deformity. Upper extremity function is the product of complex and highly sophisticated mechanisms working in unison, and a careful, systematic preoperative evaluation is critical. A good function of the hand cannot be achieved without adequate position of the shoulder, elbow, forearm, and wrist. The goals of surgery must be practical and clearly understood by the patient and the family.