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Hutanu D, Corona PS, Rojas-Neira J, Nguyen TQ, Velasquez-Giron E, Soldado F. Shoulder external rotation contracture following neonatal brachial plexus injury. J Shoulder Elbow Surg 2024:S1058-2746(24)00382-3. [PMID: 38810914 DOI: 10.1016/j.jse.2024.03.065] [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: 10/19/2023] [Revised: 03/19/2024] [Accepted: 03/29/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Glenohumeral posterior external rotation contractures and scapular winging are frequently overlooked problems in residual neonatal brachial plexus injury (NBPI). Recent attention has emphasized their impact on vital functions such as feeding and hygiene. This study aims to present the epidemiology of posterior glenohumeral contractures in a significant pediatric NBPI population and explore contributing factors. METHODS We conducted a retrospective analysis of data collected from January 2019 to November 2022, involving a case series of 262 children with residual NBPI. The data included demographics, palsy level, prior surgical history, and the modified Mallet scale. Glenohumeral passive internal rotation in abduction and cross-body adduction angles were measured bilaterally. Subjects were categorized into "Belly-" (Mallet hand-to-belly <3) and "Belly+" (Mallet hand-to-belly ≥3) groups. RESULTS The median participant age was 7.9 years (range: 3.5-21 years). Extension injury patterns included Erb's palsy (56.5%), extended Erb's palsy (28.6%), and global palsy (14.9%). Contractures exceeding 10°, 20°, and 30° were prevalent in both internal rotation in abduction and cross-body adduction angles. The "Belly-" group (9.5%) demonstrated a significant reduction in both angles compared to the "Belly+" group. Weak correlations were found between internal rotation in abduction (r = 0.390, P < .0001) or cross-body adduction (r = 0.163, P = .0083) angles and Mallet hand-to-abdomen item. Glenohumeral reduction and Hoffer procedures led to a notable decrease in cross-body adduction angle, without affecting "Belly-" prevalence. Global injuries exhibited decreased angles compared to Erb's group. CONCLUSIONS External rotation glenohumeral contractures are prevalent in residual NBPI, impacting midline access. Surprisingly, the history of glenohumeral procedures or extensive injuries did not increase the likelihood of losing the ability to reach the belly. Receiver operating characteristic analysis suggests specific thresholds for maintaining this ability.
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Affiliation(s)
- Dragos Hutanu
- George Emil Palade University of Medicine, Pharmacy, Science and Technology, Targu Mures, Romania
| | - Pablo S Corona
- Orthopedic Surgery Department, Hospital Vall Hebron, Barcelona, Spain
| | - Juliana Rojas-Neira
- Hand Surgery and Microsurgery Department, Farallones Clinic, Christus Health, Cali, Colombia.
| | | | | | - Francisco Soldado
- Pediatric Hand Surgery and Microsurgery Unit, HM Nens "Instituto de Investigación Sanitaria HM Hospitales" Barcelona, Spain
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Jambrina-Abasolo U, Hutanu D, Gonzalez-Morgado D, Blasco-Casado F, Rojas-Neira J, Soldado F. Shoulder extension impairment with residual neonatal brachial plexus injury. J Shoulder Elbow Surg 2023; 32:2082-2088. [PMID: 37178959 DOI: 10.1016/j.jse.2023.03.036] [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] [Received: 12/03/2022] [Revised: 03/11/2023] [Accepted: 03/27/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Impairment of both shoulder extension and behind-the-back function are common in patients with residual neonatal brachial plexus injury (NBPI), but have scarcely been studied or reported in the literature. Behind-the-back function is classically evaluated using the hand-to-spine task used for the Mallet score. Angular measurements of shoulder extension with residual NBPI have generally been studied utilizing kinematic motion laboratories. To date, no validated clinical examination method for this has been described. METHODS Intraobserver and interobserver reliability analyses of 2 shoulder extension angles-passive glenohumeral extension (PGE) and active shoulder extension (ASE)-were performed. Afterwards, a retrospective clinical study was conducted on prospectively collected data on 245 children with residual BPI treated from January 2019 through August 2022. Demographic characteristics, level of palsy, previous surgical procedures, modified Mallet score, and bilateral PGE and ASE data were analyzed. RESULTS All inter- and intraobserver agreements were excellent, ranging from 0.82 to 0.86. The median patient age was 8.1 years (3.5-21). Among the 245 children, 57.6% had Erb's palsy, 28.6% extended Erb's palsy, and 13.9% global palsy. One hundred sixty-eight (66%) of the children could not touch their lumbar spine, among whom 26.2% (n = 44) had to swing the arm to reach it. Both the degrees of ASE and PGE achieved correlation significantly with the hand-to-spine score, the ASE strongly (r = 0.705) and the PGE weakly (r = 0.372) (both P < .0001). Significant correlations also were found between lesion level and the hand-to-spine Mallet score (r = -0.339; P < .0001) and ASE (r = -0.299; P < .0001), and between patient age and the PGE (P = .0416, r = -0.130). A statistically significant decrease in PGE and incapacity to reach the spine were found in patients who underwent glenohumeral reduction, shoulder tendon transfer, or humeral osteotomy, relative to those who had microsurgery or no surgery. Receiver operating curves showed that, for both PGE and ASE, the minimum extension angle required to successfully perform the hand-to-spine task was 10°, with sensitivity levels of 69.9 and 82.2, and specificity levels of 69.5 and 87.8 (both P < .0001), respectively. CONCLUSIONS Glenohumeral flexion contracture and lost ASE are extremely common in children with residual NBPI. Both the PGE and ASE angles can be measured reliably with a clinical exam, with at least 10° of PGE and ASE necessary to perform the hand-to-spine Mallet task.
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Affiliation(s)
| | - Dragos Hutanu
- "George Emil Palade" University of Medicine, Pharmacy, Science and Technology, Targu Mures, Romania
| | | | | | | | - Francisco Soldado
- Pediatric Hand Surgery and Microsurgery, Barcelona Children's Hospital, HM Nens, HM Hospitales, Barcelona, Spain.
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Zuo KJ, Ho ES, Hopyan S, Clarke HM, Davidge KM. Recent Advances in the Treatment of Brachial Plexus Birth Injury. Plast Reconstr Surg 2023; 151:857e-874e. [PMID: 37185378 DOI: 10.1097/prs.0000000000010047] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Describe methods of clinical evaluation for neurologic recovery in brachial plexus birth injury. 2. Understand the role of different diagnostic imaging modalities to evaluate the upper limb. 3. List nonsurgical strategies and surgical procedures to manage shoulder abnormality. 4. Explain the advantages and disadvantages of microsurgical nerve reconstruction and distal nerve transfers in brachial plexus birth injury. 5. Recognize the prevalence of pain in this population and the need for greater sensory outcomes evaluation. SUMMARY Brachial plexus birth injury (BPBI) results from closed traction injury to the brachial plexus in the neck during an infant's vertex passage through the birth canal. Although spontaneous upper limb recovery occurs in most instances of BPBI, some infants do not demonstrate adequate motor recovery within an acceptable timeline and require surgical intervention to restore upper limb function. This article reviews major advances in the management of BPBI in the past decade that include improved understanding of shoulder pathology and its impact on observed motor recovery, novel surgical techniques, new insights in sensory function and pain, and global efforts to develop standardized outcomes assessment scales.
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Affiliation(s)
- Kevin J Zuo
- From the Divisions of Plastic, Reconstructive, and Aesthetic Surgery
| | - Emily S Ho
- From the Divisions of Plastic, Reconstructive, and Aesthetic Surgery
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children
| | - Sevan Hopyan
- From the Divisions of Plastic, Reconstructive, and Aesthetic Surgery
- Orthopedic Surgery, Department of Surgery, University of Toronto
| | - Howard M Clarke
- From the Divisions of Plastic, Reconstructive, and Aesthetic Surgery
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children
| | - Kristen M Davidge
- From the Divisions of Plastic, Reconstructive, and Aesthetic Surgery
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children
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Topley MT, Russo SA, Chafetz RS, Zlotolow DA, Kozin SH, Richards JG. Scapulothoracic and Glenohumeral Contributions to Humerothoracic Kinematics in Single Versus Double Tendon Transfers in Patients With Brachial Plexus Birth Injury. J Hand Surg Am 2022; 47:897.e1-897.e9. [PMID: 34489135 DOI: 10.1016/j.jhsa.2021.06.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/02/2021] [Accepted: 06/18/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Evidence suggests that patients with brachial plexus birth injury are more likely to retain midline function following a teres major tendon transfer without a concomitant latissimus dorsi transfer. Both procedures increase shoulder external rotation and abduction, but whether increased loss of midline frequency following double transfer is due to glenohumeral (GH) joint motion or scapulothoracic (ST) compensation is unknown. We hypothesized that double tendon transfers would exhibit greater GH external rotation than single tendon transfers, thus requiring greater ST rotation to internally rotate the shoulder, while GH and ST contributions to elevation remained equivalent between both groups. METHODS Twenty-six postsurgical children with C5/C6 brachial plexus birth injuries participated in this study. Thirteen patients with single tendon transfers were matched with 13 with double tendon transfer. Coordinate systems of the thorax, scapula, and humerus were measured utilizing motion capture in 6 arm positions. Joint angles were calculated by the helical (ST) and modified globe method (GH and humerothoracic [HT]). Differences between groups were compared with repeated measures of multivariate analyses of variance for each position. Pending significant multivariate analyses of variance, univariate analyses of variance determined joint differences between transfer groups. RESULTS Joint rotations from neutral were similar between groups in 5 of 6 tested positions, with double tendon transfers consistently demonstrating 15°-20˚ more internal rotation at the GH and HT joints. Still, only the internal rotation position showed statistically significant differences in GH and HT joint angles. The ST joint angles were similar in this position (45.2˚ and 48.5˚). CONCLUSIONS The arc of motion for patients with double tendon transfer was more internally rotated than in patients with single tendon transfer at the GH and HT joints for all positions. However, both groups demonstrated little active rotation from neutral. Based on this data, teres major-only tendon transfers may not reduce the risk of loss of midline function. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.
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Affiliation(s)
- Matthew T Topley
- Department of Health and Rehabilitation Sciences, Temple University, Philadelphia, PA.
| | - Stephanie A Russo
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center-Hamot, Erie, PA; Department of Orthopaedic Surgery, Shriners Hospital for Children, Philadelphia, PA
| | - Ross S Chafetz
- Motion Analysis Laboratory, Shriners Hospital for Children, Philadelphia, PA
| | - Dan A Zlotolow
- Department of Orthopaedic Surgery, Shriners Hospital for Children, Philadelphia, PA; Department of Orthopaedic Surgery, Temple University, Philadelphia, PA
| | - Scott H Kozin
- Department of Orthopaedic Surgery, Shriners Hospital for Children, Philadelphia, PA; Department of Orthopaedic Surgery, Temple University, Philadelphia, PA
| | - James G Richards
- Department of Biomechanics and Movement Science, University of Delaware, Newark, DE
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Jönsson K, Roos F, Hultgren T. Structures contributing to the shoulder contracture in brachial plexus birth palsy. An intraoperative biomechanical study. J Hand Surg Eur Vol 2022; 47:237-242. [PMID: 34344211 DOI: 10.1177/17531934211034968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Internal rotation contracture of the shoulder is a common sequel of the brachial plexus birth palsy. The purpose of this study is to describe the surgical method used in our centre and to measure the effect of sequentially releasing several anatomical structures that have been ascribed as the cause of the contracture. Twenty-four consecutive patients were operated on with an open release. We documented the increase in passive external rotation after each surgical step. We found small gains in passive external rotation when performing coracoidectomy and division of the upper part of the subscapularis tendon; 4° (95% confidence interval [CI] 2°-6° p < 0.01) and 6° (95% CI 4°-8° p < 0.01), respectively. A substantial gain in external rotation occurred when dividing the entire subscapularis tendon, 43° (95% CI 38°-48°, p < 0.01). Our findings indicate that a clinically relevant surgical release of the contracture requires lengthening of the entire subscapularis musculo-tendinous unit.Level of evidence: IV.
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Affiliation(s)
- Krister Jönsson
- Department of Hand Surgery, Karolinska Institutet Department of Clinical Science and Education, Södersjukhuset, Sweden
| | - Fredrik Roos
- Department of Hand Surgery, Karolinska Institutet Department of Clinical Science and Education, Södersjukhuset, Sweden
| | - Tomas Hultgren
- Department of Hand Surgery, Karolinska Institutet Department of Clinical Science and Education, Södersjukhuset, Sweden
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Abzug JM, Miller E, Case AL, Hogarth DA, Zlotolow DA, Kozin SH. Single Versus Double Tendon Transfer to Improve Shoulder External Rotation During the Treatment of Brachial Plexus Birth Palsy. Hand (N Y) 2022; 17:55-59. [PMID: 32188298 PMCID: PMC8721786 DOI: 10.1177/1558944720911211] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: Tendon transfers are commonly performed in patients with brachial plexus birth palsy (BPBP) to improve function. Transferring 2 tendons in patients with C5-7 injury has the potential complication of loss of midline function. The purpose of this study was to investigate whether a single tendon transfer (1TT) as opposed to the traditional double tendon transfer (2TT) resulted in any differences in functional outcomes in patients with C5-7 BPBP. Methods: A retrospective review of all patients with C5-7 BPBP who underwent tendon transfers to improve shoulder external rotation over a 5-year period was performed at 2 institutions. Outcomes were assessed using the modified Mallet (MM) classification scores. Results: Twenty-two C5-7 patients had complete records of preoperative and postoperative MM scores, including 11 sex-matched patients in both the 1TT and 2TT groups. When comparing preoperative and postoperative MM categories, there were significant improvements in both the 1TT and 2TT groups for global abduction (P < .05 and P < .01, respectively) and external rotation (P < .00001 for both). Modified Mallet (MM) hand to neck scores were significantly improved in the 2TT group (P < .05) but not in the 1TT group (P = .053). Internal rotation scores significantly decreased in both groups (P < .001). Both groups demonstrated significant increases in total scores from the preoperative MM scores (P < .01). Conclusion: The 1TT and 2TT procedures result in substantial gains in upper extremity functions for patients with C5-7 BPBP as measured by the MM score, specifically within the global abduction and external rotation subcategories. However, a significant loss occurs in internal rotation for both groups.
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Affiliation(s)
- Joshua M. Abzug
- University of Maryland School of Medicine, Baltimore, USA,Joshua M. Abzug, Department of Orthopaedics, University of Maryland School of Medicine, One Texas Station Court, Suite 300, Timonium, Baltimore, MD 21093, USA.
| | - Elie Miller
- University of Maryland School of Medicine, Baltimore, USA
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Russo SA, Richardson RT, Richards JG, Rapp van Roden EA, Chafetz RS, Topley MT, Zlotolow DA, Kozin SH. Effect of Glenohumeral Reduction Type Combined With Tendon Transfer for Brachial Plexus Injury on Objective, Functional, and Patient-Reported Outcomes. J Hand Surg Am 2021; 46:624.e1-624.e11. [PMID: 33526294 DOI: 10.1016/j.jhsa.2020.11.021] [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: 11/24/2019] [Revised: 09/19/2020] [Accepted: 11/24/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Glenohumeral (GH) joint reductions are frequently performed during tendon transfer surgery for brachial plexus birth injuries (BPBI); however, the effect of reduction method (none required, closed, surgical) has not been assessed. This study compared objective, functional, and patient-reported outcomes between children who underwent a tendon transfer and (1) did not require GH reduction, (2) required concomitant closed GH reduction, or (3) required concomitant surgical GH reduction. METHODS Fifty-four children with BPBI who previously underwent teres major and/or latissimus dorsi transfer with or without concomitant GH reduction participated. Joint reduction method was classified as none required (n = 21), closed (n = 9), or surgical (n = 24). Motion capture was collected in a neutral position, abduction, external rotation, and internal rotation. Glenohumeral joint angles and displacements were calculated. Joint angular displacements represented the differences between the joint angles in each terminal position and the joint angles of the arm at rest in the neutral position. A hand surgeon determined modified Mallet scores. Participants' parents completed the Brachial Plexus Profile Activity Short Form (BP-PRO-SF) to assess physical activity performance. RESULTS The no-reduction group had significantly less GH elevation than the surgical-reduction group for all positions and significantly less GH elevation than the closed-reduction group for the neutral, external rotation, and internal rotation positions. There were no differences in GH rotation angles. Glenohumeral joint displacements from neutral and modified Mallet scores were similar. The no-reduction group demonstrated significantly greater BP-PRO-SF scores than the surgical-reduction group. CONCLUSIONS Patients who underwent a closed or surgical GH joint reduction consistently displayed more GH elevation. Clinically, this corresponds to an abduction contracture. Whereas increased abduction contracture provided a benefit of greater overhead motion, modified Mallet scores were similar between groups. The surgical-reduction group demonstrated lower BP-PRO-SF outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Stephanie A Russo
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center-Hamot, Erie.
| | - R Tyler Richardson
- Kinesiology Program, School of Behavioral Sciences and Education, Pennsylvania State University Harrisburg, Middletown
| | - James G Richards
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE
| | | | | | | | - Dan A Zlotolow
- Upper Extremity Center of Excellence, Shriners Hospital for Children; Department of Orthopaedic Surgery, Temple University, Philadelphia
| | - Scott H Kozin
- Upper Extremity Center of Excellence, Shriners Hospital for Children; Department of Orthopaedic Surgery, Temple University, Philadelphia
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Adidharma W, Lewis SP, Liu Y, Osorio MB, Steinman SE, Tse RW. Shoulder Release and Tendon Transfer following Neonatal Brachial Plexus Palsy: Gains, Losses, and Midline Function. Plast Reconstr Surg 2020; 146:321-331. [PMID: 32740582 DOI: 10.1097/prs.0000000000007037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Shoulder release and tendon transfer is frequently performed to address persistent weakness from neonatal brachial plexus palsy. Although postoperative improvements in motion are well described, associated deficits are poorly documented, and functional assessments are lacking. Loss of ability to reach midline can occur with surgery and may result in impairment. The purpose of this study was to comprehensively assess the gains, losses, functional changes, and patient-reported outcome associated with the authors' surgical approach. METHODS Consecutive patients undergoing surgery with 2-year follow-up were included (n = 30). Prospectively recorded assessments by therapists were reviewed. Changes were assessed by t test and Wilcoxon rank sum (p < 0.05). RESULTS Active external rotation and abduction improved and internal rotation diminished. Aggregate modified Mallet score increased with improvements in all subscales, except that hand to spine was unchanged and hand to belly decreased. Functional assessment using the Brachial Plexus Outcome Measure revealed an increase of aggregate score, with no decline in any subscales. Improvements were in hand to back of head, forward overhead reach, holds plate with palm up, opening large container, and strings bead. Aggregate patient self-report of appearance and function increased (from 18 to 23). Loss of ability to reach midline occurred in three patients (10 percent) who had extended Erb or total palsy and preoperative limitations of internal rotation. CONCLUSIONS Secondary reconstruction rebalances shoulder motion by increasing external rotation and abduction and reducing internal rotation. In this study, a conservative surgical approach results in overall improvement in task-based abilities and self-reported outcomes and preservation of internal rotation within a functional range. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Widya Adidharma
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
| | - Sarah P Lewis
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
| | - Yusha Liu
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
| | - Marisa B Osorio
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
| | - Suzanne E Steinman
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
| | - Raymond W Tse
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
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9
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Soldado F. Double nerve transfer for restoring external rotation of the glenohumeral joint after neonatal brachial plexus injury. Microsurgery 2020; 40:846-851. [DOI: 10.1002/micr.30616] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 03/20/2020] [Accepted: 05/15/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Francisco Soldado
- Pediatric Upper Extremity Surgery and Microsurgery Barcelona Children's Hospital HM Nens Barcelona Spain
- UCA Unit Vithas San Jose Vitoria Spain
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10
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Jönsson K, Werner M, Roos F, Hultgren T. Development of the glenohumeral joint after subscapular release and open relocation in children with brachial plexus birth palsy: long-term results in 61 patients. J Shoulder Elbow Surg 2019; 28:1983-1990. [PMID: 31085034 DOI: 10.1016/j.jse.2019.02.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 02/19/2019] [Accepted: 02/27/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND We present the long-term results of remodeling of the glenohumeral joint after open subscapularis elongation and relocation of the humeral head in patients with an internal rotation contracture and joint incongruity due to brachial plexus birth palsy. METHODS In this before-and-after study, 61 patients who underwent open subscapularis elongation and reduction of the glenohumeral joint were evaluated with respect to joint remodeling, with a mean follow-up period of 10.2 years (range, 7-16 years). The mean age at operation was 3.2 years (range, 8 months to 15 years). Measurements of the percentage of the humeral head anterior to the midscapular line (PHHA), glenoid version, and diameter of the humeral head were recorded using magnetic resonance imaging, comparing the affected joints preoperatively vs. postoperatively (n = 31) and comparing the operated vs. unaffected sides postoperatively (n = 61). RESULTS The mean increase in PHHA was 27.6 percentage points (95% confidence interval, 22.4-32.7 percentage points; P < .01), from 13.2% to 40.8%. The glenoid retroversion changed by 14.8° (95% confidence interval, 11.1°-18.4°; P < .01), from 25.4° to 10.6°, approaching a normal value. All patients, even those older than 5 years, showed a clear benefit from surgery. CONCLUSIONS Our study confirms that open subscapularis lengthening with joint repositioning, up to the age of 5 years, gives consistent remodeling of incongruent shoulders with surprisingly small differences between the operated and unaffected shoulders at long-term follow-up. The findings indicate that open reduction is useful also in adolescents and challenges the notion that older children should be treated with derotational humeral osteotomy.
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Affiliation(s)
- Krister Jönsson
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden; Department of Hand Surgery, Södersjukhuset, Stockholm, Sweden.
| | - Michael Werner
- Department of Radiology, Södersjukhuset, Stockholm, Sweden
| | - Fredrik Roos
- Department of Hand Surgery, Södersjukhuset, Stockholm, Sweden
| | - Tomas Hultgren
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden; Department of Hand Surgery, Södersjukhuset, Stockholm, Sweden
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11
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Hodgson F, Alabau-Rodriguez S, Barrera-Ochoa S, Gharbaoui I, Knörr J, Soldado F. Clinical measurements for inferior, posterior, and superior glenohumeral joint contracture evaluation in children with brachial plexus birth palsy: intraobserver and interobserver reliability. J Shoulder Elbow Surg 2018; 27:1779-1784. [PMID: 29859662 DOI: 10.1016/j.jse.2018.04.014] [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: 11/05/2017] [Revised: 04/16/2018] [Accepted: 04/18/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Glenohumeral (GH) contractures appear in most patients with incomplete motor recovery as a result of progressive development of periarticular muscle contractures. The objectives of this study were to describe a method to measure the passive range of motion of the glenohumeral joint (GHJ) in patients with brachial plexus birth palsy (BPBP) and to evaluate its intraobserver and interobserver reproducibility. METHODS Three orthopedic surgeons measured the passive GHJ mobility of 25 patients older than 4 years with unilateral BPBP. Measurements were performed twice on both shoulders. They comprised the spinohumeral abduction angle (SHABD), spinohumeral adduction angle (SHADD), GH cross-body adduction (CBADD), and GH internal rotation in abduction (IRABD). Anterior GH contracture was not evaluated. RESULTS Passive shoulder measurements obtained from the uninvolved and involved shoulders were as follows: SHABD, 42° and 18°, respectively; SHADD, 14° and -1°, respectively; CBADD, 71° and 41°, respectively; and IRABD, 54° and 37°, respectively. Contracture of the lower portion of the involved GHJ was observed in 18 of 25 patients (72%); the upper portion, in 16 of 25 (64%); and the posterior portion, in 22 of 25 (88%). Interobserver variation (intraclass correlation coefficient) was 0.91 (excellent) for SHABD, 0.63 (good) for SHADD, 0.86 (excellent) for CBADD, and 0.67 (good) for IRABD. Intraobserver variation (intraclass correlation coefficient) was 0.94 (excellent) for SHABD, 0.87 (excellent) for SHADD, 0.92 (excellent) for CBADD, and 0.89 (excellent) for IRABD. CONCLUSIONS Clinical measurements of passive GHJ range-of-motion analyzed in this study showed excellent or good intraobserver and interobserver variability. Our study showed that BPBP resulted in a multidirectional GH contracture in most patients. We have described a simple and reliable way to evaluate passive GH motion, providing reliable anatomic landmarks.
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Affiliation(s)
- Felipe Hodgson
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Sergi Alabau-Rodriguez
- Pediatric Orthopaedic Surgery, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Spain
| | - Sergi Barrera-Ochoa
- Pediatric Hand Surgery and Microsurgery, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Spain
| | - Idriss Gharbaoui
- Pediatric Orthopaedic Surgery, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Spain
| | - Jorge Knörr
- Pediatric Orthopaedic Surgery, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Spain
| | - Francisco Soldado
- Pediatric Hand Surgery and Microsurgery, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Spain
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