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Boubkraoui MEM, Rouaghi H, Cherqaoui Y, Bjitro C, Aboumaarouf M, Cherqaoui A. Open Anterior Subscapularis Release for Adduction and Medial Rotation Shoulder Contracture in Neonatal Brachial Plexus Palsy. Afr J Paediatr Surg 2024:01434821-990000000-00028. [PMID: 39316020 DOI: 10.4103/ajps.ajps_132_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 04/01/2024] [Indexed: 09/25/2024] Open
Abstract
INTRODUCTION Adduction and medial rotation shoulder contracture are prevalent in unresolved neonatal brachial plexus palsy (NBPP). Various surgical options exist, including open anterior subscapularis release, to address this condition. This study assessed the outcomes of this procedure. MATERIALS AND METHODS This cross-sectional, observational study focused on a cohort of children aged over 12 months who underwent open anterior subscapularis release to remedy residual shoulder contracture from upper or global NBPP over 11 years. The Mallet score was utilised to appraise deficits in shoulder function. RESULTS The study included 32 patients. The sex ratio was 0.78. The median age at surgery was 36 months (25; 56). The right side was affected in 75% of cases. The median improvement in the Mallet score after subscapularis release was 4 (2; 6). This enhancement was statistically significant (P < 0.001), with a median follow-up duration of 78 months (72; 82). There was a substantial increase in shoulder abduction (P < 0.001) and lateral rotation (P < 0.001). Hand-to-mouth (P < 0.001) and hand-to-head (P < 0.001) manoeuvres exhibited significant enhancement. The hand-to-spine manoeuvre did not show a substantial alteration. A significant correlation was found between the injury severity and the enhancement of the Mallet score post-surgery (P = 0.009). CONCLUSION Open anterior subscapularis release yielded significant mid-term functional enhancements in shoulder motion, with no modification in medial rotation. Improvements were observed even in children beyond 4 years of age, with those having more severe injuries showing greater functional recovery.
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Affiliation(s)
- Mohamed El Mahdi Boubkraoui
- Department of Paediatric Orthopaedics and Traumatology, Abderrahim Harouchi Mother and Child Hospital, Ibn Rochd University Hospital, Casablanca, Morocco
- Department of Child Diseases, Faculty of Medicine and Pharmacy of Casablanca, Hassan II University of Casablanca, Casablanca, Morocco
| | - Hajar Rouaghi
- Department of Paediatric Orthopaedics and Traumatology, Abderrahim Harouchi Mother and Child Hospital, Ibn Rochd University Hospital, Casablanca, Morocco
- Department of Child Diseases, Faculty of Medicine and Pharmacy of Casablanca, Hassan II University of Casablanca, Casablanca, Morocco
| | - Yassine Cherqaoui
- Department of Paediatric Orthopaedics and Traumatology, Abderrahim Harouchi Mother and Child Hospital, Ibn Rochd University Hospital, Casablanca, Morocco
- Department of Child Diseases, Faculty of Medicine and Pharmacy of Casablanca, Hassan II University of Casablanca, Casablanca, Morocco
| | - Chafik Bjitro
- Department of Paediatric Orthopaedics and Traumatology, Abderrahim Harouchi Mother and Child Hospital, Ibn Rochd University Hospital, Casablanca, Morocco
- Department of Child Diseases, Faculty of Medicine and Pharmacy of Casablanca, Hassan II University of Casablanca, Casablanca, Morocco
| | - Mustapha Aboumaarouf
- Department of Paediatric Orthopaedics and Traumatology, Abderrahim Harouchi Mother and Child Hospital, Ibn Rochd University Hospital, Casablanca, Morocco
- Department of Child Diseases, Faculty of Medicine and Pharmacy of Casablanca, Hassan II University of Casablanca, Casablanca, Morocco
| | - Abdelmounim Cherqaoui
- Department of Paediatric Orthopaedics and Traumatology, Abderrahim Harouchi Mother and Child Hospital, Ibn Rochd University Hospital, Casablanca, Morocco
- Department of Child Diseases, Faculty of Medicine and Pharmacy of Casablanca, Hassan II University of Casablanca, Casablanca, Morocco
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Balloufaud M, Hosni S, Bolivar J, Saguintaah M, Virassamy M, Laffont I, Coulet B, Lambert K, Delpont M. Subscapularis impairment on magnetic resonance imaging is correlated with functional limitations in neonatal brachial plexus palsy. INTERNATIONAL ORTHOPAEDICS 2024; 48:1635-1643. [PMID: 38167960 DOI: 10.1007/s00264-023-06081-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/23/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE The relationship between functional shoulder deficits in children with neonatal brachial plexus palsy (NBPP) and magnetic resonance imaging (MRI) shoulder abnormalities was evaluated. METHODS Shoulder function was assessed in 16 children (mean age: 5.8 years; range: 3-12 years) with NBPP based on shoulder rotator muscle strength, as measured using an isokinetic dynamometer and the modified Mallet score. The thickness and fatty infiltration of the subscapularis and infraspinatus muscles, and the morphology of the glenoid on MRI, were also determined. RESULTS The highest subscapularis fatty infiltration subgroup of NBPP patients promoted the highest alteration muscle thickness and modified Mallet score. CONCLUSIONS In NBPP children, subscapularis impairments play a major role in the functional limitations. This study of pediatric NBPP patients highlighted the value of adding an examination of the muscles to routine MRI assessment of bone parameters in the shoulders of NBPP children. TRIAL REGISTRATION NCT03440658.
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Affiliation(s)
- Maxime Balloufaud
- PhyMedExp, CNRS UMR 9214, INSERM U1046, University of Montpellier, Montpellier, France
| | - Sarah Hosni
- Orthopedic Pediatric Surgery Department, Lapeyronie Hospital, CHU Montpellier, University of Montpellier, 191 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France
| | - Julie Bolivar
- Pediatric Radiology, Arnaud De Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Magali Saguintaah
- Pediatric Radiology, Arnaud De Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Maxime Virassamy
- Orthopedic Pediatric Surgery Department, Lapeyronie Hospital, CHU Montpellier, University of Montpellier, 191 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France
| | - Isabelle Laffont
- Physical Medicine and Rehabilitation Department, CHU Montpellier, University of Montpellier, Montpellier, France
- Euromov, UFR STAPS, University of Montpellier, Montpellier, France
| | - Bertrand Coulet
- Euromov, UFR STAPS, University of Montpellier, Montpellier, France
- Orthopedic Surgery, Upper Extremity, Hand and Peripheral Nerve Surgery Department, Lapeyronie Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Karen Lambert
- PhyMedExp, CNRS UMR 9214, INSERM U1046, University of Montpellier, Montpellier, France
| | - Marion Delpont
- PhyMedExp, CNRS UMR 9214, INSERM U1046, University of Montpellier, Montpellier, France.
- Orthopedic Pediatric Surgery Department, Lapeyronie Hospital, CHU Montpellier, University of Montpellier, 191 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France.
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de Joode SGCJ, Meijer R, Samijo S, Heymans MJLF, Chen N, van Rhijn LW, Schotanus MGM. Long-term functional outcome of secondary shoulder surgery in brachial plexus birth palsy patients. Bone Joint J 2023; 105-B:455-464. [PMID: 36924164 DOI: 10.1302/0301-620x.105b4.bjj-2022-1069.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Multiple secondary surgical procedures of the shoulder, such as soft-tissue releases, tendon transfers, and osteotomies, are described in brachial plexus birth palsy (BPBP) patients. The long-term functional outcomes of these procedures described in the literature are inconclusive. We aimed to analyze the literature looking for a consensus on treatment options. A systematic literature search in healthcare databases (PubMed, Embase, the Cochrane library, CINAHL, and Web of Science) was performed from January 2000 to July 2020, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The quality of the included studies was assessed with the Cochrane ROBINS-I risk of bias tool. Relevant trials studying BPBP with at least five years of follow-up and describing functional outcome were included. Of 5,941 studies, 19 were included after full-text screening. A total of 15 surgical techniques were described. All studies described an improvement in active external rotation (range 12° to 128°). A decrease in range of motion and Mallet score after long-term (five to 30 years) follow-up compared to short-term follow-up was seen in most studies. The literature reveals that functional outcome increases after different secondary procedures, even in the long term. Due to the poor methodological quality of the included studies and the variations in indication for surgery and surgical techniques described, a consensus on the long-term functional outcome after secondary surgical procedures in BPBP patients cannot be made.
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Affiliation(s)
- Stijn G C J de Joode
- Department of Orthopedic Surgery and Traumatology, Zuyderland Medical Center, Heerlen, Netherlands
- Department of Orthopedic Surgery, Balgrist University Hospital, Zürich, Switzerland
- School of Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht, Netherlands
| | - Remco Meijer
- Department of Orthopedic Surgery and Traumatology, Zuyderland Medical Center, Heerlen, Netherlands
| | - Steven Samijo
- Department of Orthopedic Surgery and Traumatology, Zuyderland Medical Center, Heerlen, Netherlands
| | - Marion J L F Heymans
- Zuyderland Academy, Zuyderland Medical Center, Sittard-Geleen and Heerlen, Netherlands
| | - Neal Chen
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lodewijk W van Rhijn
- School of Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht, Netherlands
- Department of Orthopedic Surgery and Traumatology, Maastricht University Medical Center, Maastricht, Netherlands
- Department of Orthopedic Surgery, UMC Utrecht, Utrecht, Netherlands
| | - Martijn G M Schotanus
- Department of Orthopedic Surgery and Traumatology, Zuyderland Medical Center, Heerlen, Netherlands
- School of Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht, Netherlands
- Department of Orthopedic Surgery and Traumatology, Maastricht University Medical Center, Maastricht, Netherlands
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Ibrahim MR, Abdelmaksoud IM, Ahmad MH, Semaya AE. Comparing the Results of Latissimus Dorsi Versus Teres Major Transfer in Children With Obstetric Brachial Plexus Injury and Residual Shoulder Sequelae. Ann Plast Surg 2023; 90:144-150. [PMID: 36688857 DOI: 10.1097/sap.0000000000003434] [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: 01/24/2023]
Abstract
BACKGROUND Obstetric brachial plexus injury (OBPI) remains a fairly common problem in newborns despite the improved obstetric care. Children who do not show complete recovery often present with residual shoulder deformity of limited external rotation and abduction. Secondary interventions in the form of tendon transfer and soft tissue release are aimed at correcting the implicated muscular imbalance to restore shoulder function. AIM The aim of this work was to compare the results of latissimus dorsi versus teres major tendon transfer in patients with OBPI with limited shoulder external rotation. PATIENTS AND METHODS This study included 40 patients admitted to El Hadara University Hospital with OBPI and limited shoulder abduction and external rotation aged between 1.5 and 4 years. Half of the patients had a latissimus dorsi transfer, and the other half, a teres major one. Children with limited preoperative passive external rotation in both groups required a subscapularis slide. Patients were evaluated preoperatively, at 6 months, and 12 months postoperatively using the Gilbert scale. RESULTS Teres major tendon transfer showed better results in restoring limited shoulder abduction and external rotation than latissimus dorsi transfer. Limited shoulder internal rotation was the main complication occurring postoperatively. Loss of the last degree of internal rotation occurred in most patients who had subscapularis slide. Most patients regained functional midline abilities with physiotherapy and required no further interventions. CONCLUSIONS Isolated teres major transfer has shown better results in improving the range of external rotation and abduction compared with isolated latissimus dorsi tendon transfer. Age of the patients did not affect the overall final improvement in shoulder range of motion. Limited internal rotation is the main complication postoperatively, which was prevalent in patients who required a subscapularis slide but was not statistically significant.
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Affiliation(s)
- Marwa Raafat Ibrahim
- From the Department of Orthopedics Surgery and Traumatology, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
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Russo SA, Topley MT, Richardson RT, Richards JG, Chafetz RS, Rapp van Roden EA, Zlotolow DA, Mulcahey MJ, Kozin SH. Assessment of the relationship between Brachial Plexus Profile activity short form scores and modified Mallet scores. J Hand Ther 2022; 35:51-57. [PMID: 33308927 DOI: 10.1016/j.jht.2020.10.003] [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: 07/31/2019] [Revised: 09/19/2020] [Accepted: 10/09/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION This study aims to assess the relationship between the modified Mallet classification and the Brachial Plexus Profile activity short form (BP-PRO activity SF). The therapist or surgeon classifies upper extremity movement for the modified Mallet classification, while the BP-PRO assesses parents' perceptions of difficulty performing activities. PURPOSE To provide a deeper understanding of the relationship of functional and perceived outcome measurements. STUDY DESIGN Prospective, correlational design. METHODS Eighty children with brachial plexus birth injuries were evaluated using the modified Mallet classification, while parents simultaneously answered the BP-PRO activity SF questions. All patients had undergone one of three surgical interventions to improve shoulder function. The relationship between the two measures, patient injury levels, and surgical histories were assessed. RESULTS The average modified Mallet scores and BP-PRO activity SF scores weakly correlated (r = 0.312, P = .005) and both measures differentiated between C5-6 and C5-7 injury levels (P = .03 and P = .02, respectively). Conversely, the modified Mallet scores could differentiate between the three surgical groups (F = 8.2, P < .001), while the BP-PRO activity SF could not (P = .54). CONCLUSION The results suggest that these tools measure different aspects of patient outcomes. The Mallet classification may be more focused on shoulder motion than the BP-PRO activity SF. Additional questions that specifically require shoulder function could be incorporated into the BP-PRO activity SF to improve understanding of patient/parent perceptions of shoulder function for children with brachial plexus injuries. Clinicians should be aware of the strengths, weaknesses, and limitations of each outcome assessment tool for appropriate use and interpretation of results.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Scott H Kozin
- Shriners Hospital for Children, Philadelphia, PA, USA
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Abdelaziz AM, AbdAlfattah MA, El-Sherief FAH, Wahd YESH, Soliman HAG, El Behairy HF, Ismail MA. Comparison of latissimus dorsi tendon transfer with subscapularis release versus sliding of internal rotation contracture in obstetrical brachial plexus paralysis sequela. J Orthop Surg Res 2022; 17:163. [PMID: 35292063 PMCID: PMC8922728 DOI: 10.1186/s13018-022-03065-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study was to compare the functional results of latissimus dorsi (LD) tendon transfer with those of subscapularis (SS) muscle release versus sliding. METHODS Fifty-six patients with internal rotation contracture and external rotation (ER) weakness as sequelae of Erb's palsy were included in the study. Of the patients, 24 were included in group 1 (11 boys and 13 girls), with a mean age of 2 years 8 months (range 1.5-5 years) and a follow-up period of 62 months (range 38-68 months). The patients in group 1 underwent LD tendon transfer, with internal rotation contracture and SS release procedures. Thirty-two patients were included in group 2 (18 boys and 14 girls), with a mean age of 2 years 6 months (range 1.5-4.8 years) and a follow-up period of 58 months (range 38-68 months). The patients in group 2 underwent LD tendon transfer with SS sliding. RESULTS A significant improvement in preoperative passive ER from - 3.6° to 67.3° after operation was observed in group 1. In group 2, preoperative passive ER in adduction improved from 0° to 72.3°. We found no significant difference (P = 0.1) in postoperative improvement in active ER in both groups (group 1 vs. group 2: 75° vs. 77.3°). Similarly, no significant difference (P = 0.7) in postoperative improvement in passive ER was found between the groups (group 1 vs. group 2: 71° vs. 72.3°). CONCLUSIONS LD tendon transfer with SS release or sliding is an effective procedure to improve shoulder ER in patients with OBPP, with no inferiority of SS muscle release or sliding for internal rotation contractures and increased passive range of shoulder motion. LEVEL OF EVIDENCE Level III; Retrospective Cohort Comparison; Treatment Study.
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Affiliation(s)
- Ashraf M Abdelaziz
- Alzhraa University Hospital, Faculty of Medicine for Girls, Al-Azhar University, Cairo, 11517, Egypt.
| | - Mohammed A AbdAlfattah
- Alzhraa University Hospital, Faculty of Medicine for Girls, Al-Azhar University, Cairo, 11517, Egypt
| | | | | | - Hany Abdel Gawwad Soliman
- Alzhraa University Hospital, Faculty of Medicine for Girls, Al-Azhar University, Cairo, 11517, Egypt
| | - Hassan Fathy El Behairy
- Alzhraa University Hospital, Faculty of Medicine for Girls, Al-Azhar University, Cairo, 11517, Egypt
| | - Mahmoud Ali Ismail
- Alzhraa University Hospital, Faculty of Medicine for Girls, Al-Azhar University, Cairo, 11517, Egypt
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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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Conjoint muscle transfer and subscapularis slide in brachial plexus birth palsy: Clinical outcomes in shoulder functions. Med J Armed Forces India 2020; 77:181-186. [PMID: 33867635 DOI: 10.1016/j.mjafi.2020.05.008] [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: 01/02/2020] [Accepted: 05/11/2020] [Indexed: 11/20/2022] Open
Abstract
Background Shoulder deformity and inadequate shoulder function in brachial plexus birth palsy (BPBP) occur due to imbalance between the shoulder abductors, external rotators, adductors and internal rotators. This is due to cross innervation of the regenerating axons and subsequent target muscle innervation. These lead to internal rotation deformity along with glenohumeral dysplasia. Conjoint muscle transfer in the form of latissimus dorsi and teres major muscle combined with release and slide of subscapularis muscle improves shoulder functions. This study aims to evaluate the outcomes of shoulder function after a simultaneous conjoint muscle transfer and subscapularis slide in the management of BPBP. Methods 18 children with BPBP, who presented with shoulder deformity and inadequate shoulder functions, underwent conjoint muscle transfer along with subscapularis muscle slide. At 18 months, shoulder functions were assessed preoperatively and postoperatively using Mallet score system and range of motions. Statistical analysis was performed to ascertain if the outcomes were statistically significant. Results Mean age was 4.64 years with a mean preoperative Mallet score of 10.89 ± 1.60 and mean postoperative Mallet score of 16.22 ± 1.86. At 18 months, mean gain in shoulder abduction at 18 months was 57.22 ± 16.11° with external rotation of 26.66 ± 7.67°. All children showed improvement in shoulder functions. There was no correlation between the clinical outcomes and age of the child. Conclusion This procedure was effective in improving shoulder functions in a cohort of patients. The long-term effect of this procedure, however, remains to be evaluated by further follow-up and with similar such studies.
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Abdelaziz AM, Aldahshan W, Hashem Elsherief FA, Ismail MA, Fouaad AA, Mahmoud WS, Al Akeed T, Said MM. Teres major transfer to restore external rotation of shoulder in Erb palsy patients. J Shoulder Elbow Surg 2020; 29:941-945. [PMID: 31759877 DOI: 10.1016/j.jse.2019.09.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 08/26/2019] [Accepted: 09/12/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The lack of external rotation and shoulder abduction as sequelae of obstetric brachial plexus palsy requires a release of the subscapularis muscle associated with tendon transfer of the internal rotator of the shoulder. The aim of this study was to present the results of a teres major transfer to the infraspinatus tendon. METHODS This study included 20 patients (9 boys and 11 girls) with a mean age of 3 years 8 months (range, 1.5-14 years). The average follow-up time was 42 months (range, 12-48 months) to determine whether external rotation weakness and internal rotation contracture sequelae were managed by anterior release of the subscapularis and teres major tendon transfer to the infraspinatus tendon. RESULTS We found marked improvement in shoulder abduction from 67° before surgery to 158° after surgery. We also found marked improvements in active external rotation from 8° before surgery to 85° after surgery and in passive external rotation from 0° preoperatively to 72° postoperatively. Two cases showed a loss of the last degrees of internal rotation, but this improved after physiotherapy. CONCLUSIONS Anterior release of the subscapularis tendon with a teres major transfer to the infraspinatus tendon significantly improves shoulder function in Erb palsy patients with internal rotation contracture.
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Affiliation(s)
- Ashraf M Abdelaziz
- Alzhraa University Hospital, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt.
| | - Wael Aldahshan
- Alzhraa University Hospital, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
| | | | - Mahmoud Ali Ismail
- Alzhraa University Hospital, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
| | - Amro A Fouaad
- Alzhraa University Hospital, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
| | - Wael Sh Mahmoud
- Alzhraa University Hospital, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
| | - Tharwat Al Akeed
- Alzhraa University Hospital, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
| | - Mahmoud Mabrouk Said
- Alzhraa University Hospital, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
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Long-term Evaluation of Teres Major to Infraspinatus Transfer for Treatment of Shoulder Sequelae in Obstetrical Brachial Plexus Palsy. Ann Plast Surg 2020; 84:565-569. [DOI: 10.1097/sap.0000000000002288] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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CORR Insights®: What Range of Motion is Achieved Five Years After an External Rotationplasty of the Shoulder in Infants with Obstetric Brachial Plexus Injury? Clin Orthop Relat Res 2020; 478:124-126. [PMID: 31764318 PMCID: PMC7000053 DOI: 10.1097/corr.0000000000001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Sabapathy SR, Bhardwaj P, Venkatramani H. Value of Soft Tissue Release Procedure around the Shoulder to Improve Shoulder Abduction in Birth Brachial Plexus Palsy and Analysis of the Factors Affecting Outcome. J Hand Surg Asian Pac Vol 2019; 22:174-183. [PMID: 28506179 DOI: 10.1142/s0218810417500216] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND A lack of shoulder abduction in spontaneously recovered birth brachial plexus palsy (BBPP) is a common presentation. We have performed a soft tissue release operation in these patients to remove the tethering effect of the tight and cocontracting shoulder adductors. This study was undertaken in order to assess the outcome of this surgical procedure. METHODS We performed a retrospective analysis of 120 patients who displayed spontaneous recovery from BBPP and subsequently underwent soft tissue release procedure to improve shoulder abduction. The operation involved release of the pectoralis major, latissimus dorsi (LD) and teres major (TM) with axillary nerve neurolysis and transfer of LD and TM to teres minor at a lower position. Outcomes were assessed at a minimum follow up of two years. The primary outcome measures were range of shoulder abduction and Mallet score. Parents were interviewed and their satisfaction was graded on a Likert scale. We also explored prognostic factors responsible for better outcomes namely, age at operation, extent of involvement; preoperative shoulder abduction range, internal rotation deformity, triceps power and Mallet score. RESULTS The average patient age was 5.8 years(range 1-17). Follow up ranged from 2-6 years. Average preoperative shoulder abduction was 85° (range 30°-140°). Postoperatively the average shoulder abduction was 161° (range 80°-180°). The mean improvement in abduction was 76° (range 20°-110°) [p < 0.001]. Mallet score improved from 16.4 to 19.5 (p < 0.001). High parental satisfaction was recorded by Likert scale assessment. Regression analysis indicated a favourable outcome in patients who are younger, have a better preoperative abduction range and a preoperative triceps power > grade 3. CONCLUSIONS Soft tissue release procedure employed in this series is effective in improving shoulder abduction. Patients who are of younger age, have better preoperative abduction and triceps power of > grade 3 are expected to achieve the best outcome.
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Affiliation(s)
- S Raja Sabapathy
- 1 Department of Plastic, Hand and Reconstructive Microsurgery and Burns, Ganga Hospital, Tamil Nadu, India
| | - Praveen Bhardwaj
- 1 Department of Plastic, Hand and Reconstructive Microsurgery and Burns, Ganga Hospital, Tamil Nadu, India
| | - Hari Venkatramani
- 1 Department of Plastic, Hand and Reconstructive Microsurgery and Burns, Ganga Hospital, Tamil Nadu, India
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Crepaldi BE, Neto JQL, Rezende MR, Júnior RM, Scarcella DS. Lower Trapezius Transfer for Patients With Brachial Plexus Injury. Hand (N Y) 2019; 14:179-186. [PMID: 29103305 PMCID: PMC6436124 DOI: 10.1177/1558944717735944] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Brachial plexus injury is a complex entity that often results in partial recovery. Most studies to date have focused on improving shoulder abduction. However, a recent technique has been outlined-one that transfers the lower trapezius to improve the external rotation of the shoulder. The primary objective of this study was to evaluate the gains in external rotation of the shoulder in patients who have undergone transfer of the lower trapezius; secondarily, we assessed the range of motion in the elbow and shoulder joints, as well as the muscle strength and quality of life. METHODS This article presents a prospective cohort study of 10 patients who underwent transfer of the lower trapezius. During the preoperative period and at 6 months after the operation, both active and passive goniometric measurements were assessed, as were muscle strength, Mallet's classification, and patients' responses to the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. RESULTS External rotation exhibited an improvement of 17° in the active range of motion and 14° the passive range, which was not statistically significant. Flexion and active abduction of the shoulder, as well as the responses to the DASH, showed positive results. The Mallet's classification and muscle strength measurement results were not significant. CONCLUSIONS The procedure might be an alternative for restoration of shoulder function and glenohumeral stabilization and mainly to improve quality of life. However, additional studies are required to define and refine this surgical technique.
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Secondary procedures for restoration of upper limb function in late cases of neonatal brachial plexus palsy. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 29:329-336. [DOI: 10.1007/s00590-019-02362-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 01/02/2019] [Indexed: 12/17/2022]
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Pehlivanoglu T, Erşen A, Bayram S, Atalar AC, Demirhan M. Arthroscopic versus open release of internal rotation contracture in the obstetrical brachial plexus paralysis (OBPP) sequela. J Shoulder Elbow Surg 2019; 28:28-35. [PMID: 30195621 DOI: 10.1016/j.jse.2018.06.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 06/01/2018] [Accepted: 06/13/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Latissimus dorsi (LD) and teres major (TM) tendon transfers are effective surgical procedures to improve shoulder abduction and external rotation for children with obstetrical brachial plexus palsy (OBPP). Open pectoralis major (PM) tendon Z-plasty and arthroscopic subscapularis (SS) release are 2 options for the release of internal rotation contractures to enhance muscle transfers. This study compared the functional results of LD and TM tendon transfers with open PM tendon Z-plasty or arthroscopic SS release. METHODS The study included 24 patients who underwent LD and TM tendon transfers for OBPP (9 arthroscopic SS release, 15 open PM tendon Z-plasty) with a mean follow-up of 41.33 months (range, 36-60 months) and 47.2 months (range, 36-60 months), respectively. Functional evaluation was made according to range of motion and Mallet scoring system. RESULTS Shoulder abduction-external rotation degrees and scores in all sections of the Mallet scoring system significantly increased in both groups (P < .001). Postoperatively, the arthroscopic SS release group had significantly better abduction degrees (P = .003), total Mallet scores (P < .001), and superior abduction (P = .043), active external rotation (P = .043), hand-to-head (P = .043), and hand-to-mouth (P < .001) scores for the Mallet scoring system. DISCUSSION Transfer of LD together with TM tendons combined with one of the internal rotation contracture release procedures yielded good clinical and functional results in patients younger than age 7, regardless of the type of release method. However, arthroscopic SS release, although requiring an experienced surgeon, revealed better clinical and functional outcomes and is considered to be a less invasive and superior method.
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Affiliation(s)
- Tuna Pehlivanoglu
- Department of Orthopaedic Surgery and Traumatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ali Erşen
- Department of Orthopaedic Surgery and Traumatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Serkan Bayram
- Department of Orthopaedic Surgery and Traumatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ata Can Atalar
- Department of Orthopaedic Surgery and Traumatology, Faculty of Medicine, Acıbadem University, Istanbul, Turkey.
| | - Mehmet Demirhan
- Department of Orthopaedic Surgery and Traumatology, School of Medicine, Koç University, Istanbul, Turkey
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Rui L, Xu G, Lv X, Ma Z. A Comprehensive Protocol to Prevent Brachial Plexus Injury During Ankylosing Spondylitis Surgery. J Perianesth Nurs 2018; 33:908-914. [PMID: 30449439 DOI: 10.1016/j.jopan.2017.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 09/16/2017] [Accepted: 09/17/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE This article describes a comprehensive protocol to protect the brachial plexus when performing pedicle subtraction osteotomy for ankylosing spondylitis patients with thoracolumbar kyphosis. DESIGN A descriptive study was conducted. METHODS Records of 101 cases from October 2013 to December 2016 were retrospectively audited. The protocol included five items: (1) preoperative assessment of motion range and nerve function of limbs and trunks; (2) preoperative positioning according to the assessment results; (3) intra-operative somatosensory evoked potential and blood pressure monitoring; (4) intra-operative repositioning according to the monitoring alarm signals; and (5) postoperative neurological function check. FINDINGS Five patients showed impending brachial plexus injury indicators, including two who had a decrease in blood pressure and three who had a decrease in the amplitude of somatosensory evoked potential. After adjustment of position and soft pads, one patient had brachial plexus injury (0.99%) and the recovery time was 2 weeks. CONCLUSIONS With this comprehensive strategy, the brachial plexus could be effectively protected during the surgery.
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Ruyer J, Grosclaude S, Lacroix P, Jardel S, Gazarian A. Arthroscopic isolated capsular release for shoulder contracture after brachial plexus birth palsy: clinical outcomes in a prospective cohort of 28 children with 2 years' follow-up. J Shoulder Elbow Surg 2018; 27:e243-e251. [PMID: 29609998 DOI: 10.1016/j.jse.2018.01.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 01/14/2018] [Accepted: 01/22/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND The primary objective of this study was to evaluate improvements in external rotation after isolated arthroscopic capsular release in children with shoulder contracture due to brachial plexus birth palsy. MATERIALS AND METHODS This study included all children older than 2 years with a range of active external rotation limited to 30° or less and/or active anterior elevation (AE) limited to 90° or less secondary to brachial plexus palsy treated between 2011 and 2015. Passive glenohumeral motion, passive global (glenohumeral plus scapulothoracic) motion, active global motion for external rotation with the elbow at the side (ER1), AE, and internal rotation with the elbow at the side were recorded before and 2 years after surgery. Improvement was evaluated by comparing the preoperative and follow-up values. The operation performed was subscapularis-sparing arthroscopic capsular release. RESULTS Thirty-five patients were included, and 28 completed 2 years of follow-up. The average changes in active global ER1, passive glenohumeral ER1, and passive global ER1 were +35° (range, -20° to +100°; P <.0001), +35° (range, +0° to +75°; P <.0001), and +26° (range, -15° to +60°; P <.0001), respectively. There were no significant changes in internal rotation with the elbow at the side or AE. The mean improvement in the aggregate Mallet score was 3.9 points (range, -3 to +9 points; P <.0001). CONCLUSIONS For children with shoulder contracture secondary to brachial plexus palsy, subscapularis-sparing isolated capsular release improves external rotation and functional scores and avoids any loss of active internal rotation but does not improve AE.
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Affiliation(s)
- Justin Ruyer
- Université Claude Bernard Lyon 1, Villeurbanne, France; Chirurgie Orthopédique et Traumatologie, Clinique du Parc Lyon, Lyon, France
| | - Sophie Grosclaude
- Chirurgie Orthopédique et Traumatologie, Clinique du Parc Lyon, Lyon, France
| | - Philippe Lacroix
- Médecine et Traumatologie du Sport, Clinique du Parc Lyon, Lyon, France
| | - Sabine Jardel
- Service de Médecine Interne et Pathologies Vasculaires, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Aram Gazarian
- Chirurgie Orthopédique et Traumatologie, Clinique du Parc Lyon, Lyon, France; Orthopédie et Traumatologie Pédiatrique, Hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, Bron, France.
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Transfer of Pectoralis Major to Subscapularis in the Management of Brachial Plexus Birth Palsy Sequels. J Pediatr Orthop 2017; 37:305-310. [PMID: 26368856 DOI: 10.1097/bpo.0000000000000648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Limitations in abduction and external rotation are the sequel of brachial palsy. The purpose of this study was to evaluate functional outcomes of modified L'Episcopo procedure in children with brachial palsy who do not have gross shoulder joint subluxation. METHODS From 2002 to 2012, a continuous series of 22 patients with brachial plexus birth palsy underwent a modified L'Episcopo procedure. Through an axillary approach, subscapularis release with latissimus dorsi rerouting and transfer of pectoralis major to subscapularis footprint was performed. RESULTS The mean age of patients at surgery was 49 months. The mean follow-up time was 51 months (range, 24 to 90 mo). Preoperatively, the mean active abduction and external rotation were 77.5 and 2.5 degrees, respectively. The mean active abduction and external rotation were 135.6 and 32 degrees, respectively, at the final follow-up (P<0.001). CONCLUSIONS This modified L'Episcopo technique is an effective and reproducible procedure that improves shoulder function significantly. LEVEL OF EVIDENCE Level III.
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Bahm J. The Surgical Strategy to Correct the Rotational Imbalance of the Glenohumeral Joint after Brachial Plexus Birth Injury. J Brachial Plex Peripher Nerve Inj 2017; 11:e10-e17. [PMID: 28077955 DOI: 10.1055/s-0036-1579763] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 01/22/2016] [Indexed: 10/22/2022] Open
Abstract
In upper brachial plexus birth injury, rotational balance of the glenohumeral joint is frequently affected and contracture in medial rotation of the arm develops, due to a severe palsy or insufficient recovery of the lateral rotators. Some of these children present with a severe glenohumeral joint contracture in the first months, although regular physiotherapy has been provided, a condition associated with a posteriorly subdislocated or dislocated humeral head. These conditions should be screened early by a pediatrician or specialized physiotherapist. Both aspects of muscular weakness affecting the lateral rotators and the initial or progressive glenohumeral deformity and/or subdislocation must be identified and treated accordingly, focusing on the reestablishment of joint congruence and strengthening of the lateral rotators to improve rotational balance, thus working against joint dysplasia and loss of motor function of the shoulder in a growing child. Our treatment strategy adapted over the last 20 years to results from retrospective studies, including biomechanical aspects on muscular imbalance and tendon transfers. With this review, we confront our actual concept to recent literature.
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Affiliation(s)
- J Bahm
- Euregio Reconstructive Microsurgery Unit, Franziskushospital, Aachen (D), Germany
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Subscapularis Z-lengthening in children with brachial plexus birth palsy loses efficiency at mid-term follow-up: a retrospective cohort study. INTERNATIONAL ORTHOPAEDICS 2015; 40:783-90. [PMID: 26649864 DOI: 10.1007/s00264-015-3062-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 11/23/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE The aim of this study was to evaluate early and mid-term clinical outcomes after isolated subscapularis Z-lengthening in children with shoulder internal rotation contractures resulting from brachial plexus birth palsy. METHODS Children with brachial plexus birth palsy treated with subscapularis tendon Z-lengthening from 2001 to 2011 were retrospectively reviewed. Over this period, 31 patients were identified. Primary outcome was improvement in Mallet score after surgery, and secondary outcome measures were active range of motion and Mallet sub-scores. Clinical outcomes were collected at three time intervals: pre-operatively, one-year post-operative and at latest follow-up. RESULTS After exclusion, 21 patients remained for further analysis. Mean age at surgery was 3.7 years (range, 1.2-8.7), and mean follow-up length was 6.5 years (2.9-9.7). Moderate improvements were found for mean Mallet score, active external rotation, active abduction and hand-to-mouth movement at one year and latest follow-up. However, improvements in active external rotation and Mallet score were not fully maintained at final follow up. CONCLUSION Isolated subscapularis Z-lengthening is effective at early follow-up, but results are not maintained at mid-term follow-up.
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de Luna Cabrai JR, Crepaldi BE, de Sambuy MTC, da Costa AC, Abdouni YA, Chakkour I. EVALUATION OF UPPER-LIMB FUNCTION IN PATIENTS WITH OBSTETRIC PALSY AFTER MODIFIED SEVER-L'EPISCOPO PROCEDURE. Rev Bras Ortop 2015; 47:451-4. [PMID: 27047849 PMCID: PMC4799431 DOI: 10.1016/s2255-4971(15)30127-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Accepted: 10/04/2011] [Indexed: 11/08/2022] Open
Abstract
Objective: To evaluate upper-limb function by means of the Mallet score, in patients with medial rotation contracture of the shoulder who underwent the modified Sever-L'Episcopo procedure, and to correlate evolution with age and length of postoperative follow-up. Methods: Sixteen patients were assessed by comparing the pre and postoperative Mallet scores and correlating the differences between these scores with age at the time of surgery and length of follow-up. Results: A statistically significant improvement in the postoperative Mallet score was observed. The correlations of the differences in scores with age and length of follow-up were not statistically significant. Conclusion: The modified Sever-L'Episcopo procedure led to improved upper-limb function according to the Mallet score. Limb function did not present correlations with age or length of follow-up.
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Affiliation(s)
- José Roberval de Luna Cabrai
- Attending Physician in the Hand Surgery and Microsurgery Group, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Bruno Eiras Crepaldi
- Resident Physician in the Orthopedics and Traumatology Clinic, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Marina Tommasini Carrara de Sambuy
- Resident Physician in the Orthopedics and Traumatology Clinic, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Antonio Carlos da Costa
- PhD. Head of the Hand Surgery and Microsurgery Group, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Yussef Ali Abdouni
- Specialist Physician in Hand Surgery and Microsurgery and Volunteer in the Hand Surgery and Microsurgery Group, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Ivan Chakkour
- PhD. Senior Consultant in the Hand Surgery and Microsurgery Group, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
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Hultgren T, Jönsson K, Roos F, Järnbert-Pettersson H, Hammarberg H. Surgical correction of shoulder rotation deformity in brachial plexus birth palsy. Bone Joint J 2014; 96-B:1411-8. [DOI: 10.1302/0301-620x.96b10.33813] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We present the long-term results of open surgery for internal shoulder rotational deformity in brachial plexus birth palsy (BPBP). From 1997 to 2005, 207 patients (107 females, 100 males, mean age 6.2 (0.6 to 34)) were operated on with subscapularis elongation and/or latissimus dorsi to infraspinatus transfer. Incongruent shoulder joints were relocated. The early results of these patients has been reported previously. We analysed 118 (64 females, 54 males, mean age 15.1 (7.6 to 34)) of the original patient cohort at a mean of 10.4 years (7.0 to 15.1) post-operatively. A third of patients with relocated joints had undergone secondary internal rotational osteotomy of the humerus. A mixed effects models approach was used to evaluate the effects of surgery on shoulder rotation, abduction, and the Mallet score. Independent factors were time (pre-and post-surgery), gender, age, joint category (congruent, relocated, relocated plus osteotomy) and whether or not a transfer had been performed. Data from a previously published short-term evaluation were reworked in order to obtain pre-operative values. The mean improvement in external rotation from pre-surgery to the long-term follow-up was 66.5° (95% confidence interval (CI) 61.5 to 71.6). The internal rotation had decreased by a mean of 22.6° (95% CI -18.7 to -26.5). The mean improvement in the three-grade aggregate Mallet score was 3.1 (95% CI 2.7 to 3.4), from 8.7 (95% CI 8.4 to 9.0) to 11.8 (11.5 to 12.1). Our results show that open subscapularis elongation achieves good long-term results for patients with BPBP and an internal rotation contracture, providing lasting joint congruency and resolution of the trumpet sign, but with a moderate mean loss of internal rotation. Cite this article: Bone Joint J 2014;96-B:1411–18
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Affiliation(s)
- T. Hultgren
- Karolinska Institute, Department
of Clinical Science and Education, Section
for Hand Surgery, Södersjukhuset S-118 83 Stockholm, Sweden
| | - K. Jönsson
- Karolinska Institute, Department
of Clinical Science and Education, Section
for Hand Surgery, Södersjukhuset S-118 83 Stockholm, Sweden
| | - F. Roos
- Karolinska Institute, Department
of Clinical Science and Education, Section
for Hand Surgery, Södersjukhuset S-118 83 Stockholm, Sweden
| | - H. Järnbert-Pettersson
- Karolinska Institute, Department
of Clinical Science and Education, Södersjukhuset
S-118 83 Stockholm, Sweden
| | - H. Hammarberg
- Karolinska Institute, Department
of Clinical Science and Education, Section
for Hand Surgery, Södersjukhuset S-118 83 Stockholm, Sweden
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Nixon M, Trail I. Management of Shoulder Problems Following Obstetric Brachial Plexus Injury. Shoulder Elbow 2014; 6:12-7. [PMID: 27582903 PMCID: PMC4986645 DOI: 10.1111/sae.12003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 11/15/2012] [Indexed: 12/12/2022]
Abstract
Obstetric brachial plexus injuries are common, with an incidence of 0.42 per 1000 live births in the UK, and with 25% of patients being left with permanent disability without intervention. The shoulder is the most commonly affected joint and, as a result of the subsequent imbalance of musculature, the abnormal deforming forces cause dysplasia of the glenohumeral joint. In the growing child, this presents with changing pattern of pathology, which requires a multidisciplinary approach and a broad range of treatment modalities to optimize function.
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Affiliation(s)
- Matthew Nixon
- Department of Orthopaedic Surgery, Manchester Children's Hospital, Manchester, UK, Department of Orthopaedic Surgery, Countess of Chester Hospital, Chester, UK,
Correspondence: Matthew Nixon, Department of Orthopaedic Surgery, Countess of Chester Hospital – Orthopaedics, Chester, UK. Tel.: +44 (0)124 4366288. Fax: +44 (0)124 4366324. E-mail:
| | - Ian Trail
- Department of Orthopaedic Surgery, Manchester Children's Hospital, Manchester, UK, Department of Orthopaedic Surgery, Wrightington Hospital, Wigan, UK
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Abstract
BACKGROUND Shoulder internal rotation contracture, active abduction, and external rotation deficits are common secondary problems in neonatal brachial plexus palsy (NBPP). Soft tissue shoulder operations are often utilized for treatment. The objective was to conduct a meta-analysis and systematic review analyzing the clinical outcomes of NBPP treated with a secondary soft-tissue shoulder operation. METHODS A literature search identified studies of NBPP treated with a soft-tissue shoulder operation. A meta-analysis evaluated success rates for the aggregate Mallet score (≥ 4 point increase), global abduction score (≥ 1 point increase), and external rotation score (≥ 1 point increase) using the Mallet scale. Subgroup analysis was performed to assess these success rates when the author chose arthroscopic release technique versus open release technique with or without tendon transfer. RESULTS Data from 17 studies and 405 patients were pooled for meta-analysis. The success rate for the global abduction score was significantly higher for the open technique (67.4%) relative to the arthroscopic technique (27.7%, P<0.0001). The success rates for the global abduction score were significantly different among sexes (P=0.01). The success rate for external rotation was not significantly different between the open (71.4%) and arthroscopic techniques (74.1%, P=0.86). No other variable was found to have significant impact on the external rotation outcomes. The success rate for the aggregate Mallet score was 57.9% for the open technique, a nonsignificant increase relative to the arthroscopic technique (53.5%, P=0.63). Data suggest a correlation between increasing age at the time of surgery and a decreasing likelihood of success with regards to aggregate Mallet with an odds ratio of 0.98 (P=0.04). CONCLUSIONS Overall, the secondary soft-tissue shoulder operation is an effective treatment for improving shoulder function in NBPP in appropriately selected patients. The open technique had significantly higher success rates in improving global abduction. There were no significant differences in the success rates for improvement in the external rotation or aggregate Mallet score among these surgical techniques.
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Subscapularis slide correction of the shoulder internal rotation contracture after brachial plexus birth injury: technique and outcomes. Tech Hand Up Extrem Surg 2013; 17:52-6. [PMID: 23423238 DOI: 10.1097/bth.0b013e31827b4a23] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Internal rotation contracture is the most common shoulder deformity in patients with brachial plexus birth injury. The purpose of this investigation is to describe the indications, technique, and results of the subscapularis slide procedure. The technique involves the release of the subscapularis muscle origin off the scapula, with preservation of anterior shoulder structures. A standard postoperative protocol is used in all patients and includes a modified shoulder spica with the shoulder held in 60 degrees of external rotation and 30 degrees of abduction, aggressive occupational and physical therapy, and subsequent shoulder manipulation under anesthesia with botulinum toxin injections as needed. Seventy-one patients at 2 institutions treated with subscapularis slide between 1997 and 2010, with minimum follow-up of 39.2 months, were identified. Patients were divided into 5 groups based on the index procedure performed: subscapularis slide alone (group 1); subscapularis slide with a simultaneous microsurgical reconstruction (group 2); primary microsurgical brachial plexus reconstruction followed later by a subscapularis slide (group 3); primary microsurgical brachial plexus reconstruction followed later by a subscapularis slide combined with tendon transfers for shoulder external rotation (group 4); and subscapularis slide with simultaneous tendon transfers, with no prior brachial plexus surgery (group 5). Full passive external rotation equivalent to the contralateral side was achieved in the operating room in all cases. No cases resulted in anterior instability or internal rotation deficit. Internal rotation contracture of the shoulder after brachial plexus birth injury can be effectively managed with the technique of subscapularis slide.
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Arthroscopic release of shoulder contracture secondary to obstetric brachial plexus palsy: retrospective study of 18 children with an average follow-up of 4.5 years. Orthop Traumatol Surg Res 2012; 98:638-44. [PMID: 22981703 DOI: 10.1016/j.otsr.2012.06.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2011] [Revised: 05/21/2012] [Accepted: 06/11/2012] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Children affected by obstetric brachial plexus palsy have an internal rotation contracture of the shoulder and a deformed glenohumeral joint. In 2003, Pearl proposed doing an arthroscopic release of the shoulder to restore external rotation and allow the glenohumeral joint to remodel. The goal of the current study was to evaluate the active and passive shoulder external rotation range of motion and glenohumeral joint remodelling in children treated with arthroscopic-directed release. MATERIALS AND METHODS Between 2004 and 2010, 18 children with passive external rotation under 10° were treated with shoulder arthroscopy to release the anterior capsule and ligaments and perform a subscapularis tenotomy; no tendon transfer was performed. The average age was 4 years, 2 months. Nine children had an injury at C5C6, four had an injury at C5C6C7 and five had a complete injury. The average follow-up was 4.5 years. The clinical evaluation consisted of active and passive external rotation (ER) with elbow at the side, active internal rotation, and the modified Mallet score. One child who required an external rotation osteotomy of the proximal humerus was excluded from the clinical outcomes. An MRI was performed on both shoulders to assess glenoid retroversion, glenoid type, degree of posterior subluxation (measured by the percentage of humeral head anterior to the middle glenoid fossa) and humeral head hypoplasia. RESULTS At the latest follow-up, passive ER was 58° on average and active ER was 42°. Eleven children had regained more than 30° of active ER. The average internal rotation had decreased after the release. The MRI assessment showed that the glenohumeral joint had remodelled in 66% of cases; the glenoid type had improved, the glenoid retroversion had diminished and the humeral head was recentred. Humeral head hypoplasia was found in 28% of cases. DISCUSSION AND CONCLUSION Arthroscopic release of the shoulder results in more external rotation and allows for glenohumeral joint remodelling. Tendon transfer is not always necessary to restore active external rotation. LEVEL OF EVIDENCE Level IV - Retrospective study.
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Abid A, Accadbled F, Louis D, Kany J, Knörr J, Cahuzac JP, de Gauzy JS. Arthroscopic release for shoulder internal rotation contracture secondary to brachial plexus birth palsy: clinical and magnetic resonance imaging results on glenohumeral dysplasia. J Pediatr Orthop B 2012; 21:305-9. [PMID: 22525453 DOI: 10.1097/bpb.0b013e328353688e] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Internal rotation contracture of the shoulder in brachial plexus birth palsy frequently leads to shoulder dysplasia. Six children underwent anterior arthroscopic release sparing the subscapularis. Clinical examination and MRI were performed preoperatively and repeated at the 5-year follow-up. MRI was carried out for assessment of glenohumeral dysplasia. Passive external rotation was improved by 63.3° without any limitation of active internal rotation. Active antepulsion/abduction was improved by 90°. Remodeling of the glenoid and improved coverage of the humeral head were observed in all cases. Shoulder arthroscopic release sparing the subscapularis seems to be an efficient procedure to restore external rotation without affecting active internal rotation.
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Affiliation(s)
- Abdelaziz Abid
- Department of Paediatric Orthopaedic Surgery, Children's Hospital, CHU de Toulouse, Toulouse, France
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Vilaça PR, Uezumi MK, Zoppi Filho A. Centering osteotomy for treatment of posterior shoulder dislocation in obstetrical palsy. Orthop Traumatol Surg Res 2012; 98:199-205. [PMID: 22342551 DOI: 10.1016/j.otsr.2011.09.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Revised: 08/09/2011] [Accepted: 09/19/2011] [Indexed: 02/02/2023]
Abstract
BACKGROUND The main objective of this study is to describe a new surgical technique that, through a gleno-humeral approach, reduces the incongruent joint while a humeral head centering osteotomy achieves shoulder stabilization. A humeral medial derotational osteotomy is performed associated with the articular reduction. PATIENTS AND METHODS Fourteen patients with obstetrical palsy presenting a posterior humeral head dislocation were submitted to a centering osteotomy procedure. Our study included patients with: (1) more than 1.5 years postoperative follow-up, (2) presence of humeral head posterior dislocation. The exclusion criteria were the following: (1) patients with total flaccid paralysis, (2) low paralysis and (3) any kind of active infection at the time of the procedure. RESULTS Before treatment, in all patients, the shoulder joint was posteriorly dislocated and in internal rotation. All patients went on to have successful healing at the osteotomy site. In all cases, an improvement in the functional Mallet scale was observed. In all patients, except one, the posterior dislocation was corrected. In two cases, a second surgery (external derotation osteotomy) was performed to improve the upper extremity's position. CONCLUSIONS Articular congruency, after posterior dislocations of the humeral head, is achieved by humeral head centering osteotomy in patients with obstetrical palsy late deformities and also improves function. LEVEL OF EVIDENCE Level IV; case series.
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Affiliation(s)
- P R Vilaça
- Shoulder and Elbow Group, Associação Beneficente Nossa Senhora do Pari, Hospital do Pari, Rua Hannemann, 234 São Paulo, SP, Brazil.
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Ozben H, Atalar AC, Bilsel K, Demirhan M. Transfer of latissmus dorsi and teres major tendons without subscapularis release for the treatment of obstetrical brachial plexus palsy sequela. J Shoulder Elbow Surg 2011; 20:1265-74. [PMID: 21444219 DOI: 10.1016/j.jse.2011.01.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 12/23/2010] [Accepted: 01/01/2011] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients with obstetrical brachial plexus palsy (OBPP) sequela exhibit adduction and internal rotation contractures. The muscular imbalance may result in secondary bony changes. Tendon transfers and muscular releases may improve shoulder function in these patients. The aim of this study is to evaluate the functional and radiological results of pectoralis major tendon Z-plasty with transfer of latissimus dorsi and teres major tendons to rotator cuff tendons without release of subscapularis muscle in patients with mild sequela of OBPP. MATERIALS AND METHODS Twenty-six consecutive patients, who were treated with tendon transfer and met the eligibility criteria, were included in the study. No additional humeral osteotomy or subscapularis tenotomy was performed. Functional evaluation is made according to range of motion and Mallet scoring system. Preoperative radiologic evaluation was made according to the grading system of Waters. RESULTS A significant increase in shoulder function was found in all patients. Postoperative radiographs revealed glenohumeral congruity was maintained in all patients. Improvement in shoulder abduction and external rotation was higher in patients who were operated before the age of 7. DISCUSSION/CONCLUSION Pectoralis major tendon lengthening with transfer of latissimus dorsi and teres major tendons to rotator cuff is an effective and reproducible technique and can improve shoulder functions in patients with OBPP. Subscapularis release is not always required to overcome internal rotation contracture. Secondary glenohumeral changes might also be prevented with this approach.
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Affiliation(s)
- Hakan Ozben
- Department of Orthopaedics and Traumatology, Istanbul University, Istanbul Medical Faculty, Istanbul, Turkey
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