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Hyttinen M, Rönkkö H, Paavilainen P, Helminen M, Jokihaara J. Results of spinal accessory nerve to suprascapular nerve transfers in children with brachial plexus birth injury. J Hand Surg Eur Vol 2024:17531934241276372. [PMID: 39276380 DOI: 10.1177/17531934241276372] [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] [Indexed: 09/17/2024]
Abstract
Shoulder external rotation after brachial plexus birth injury can be restored by transfer of the spinal accessory nerve to the suprascapular nerve, or more distally to its infraspinatus branch. We studied the outcome of these nerve transfers in 52 patients with a minimum postoperative follow-up of 12 months (mean 7.3 years). The median postoperative improvement in shoulder external rotation was 120° (interquartile range [IQR] 45-135) after anterior and 110° (IQR 83-120) after dorsal spinal accessory nerve transfer to the suprascapular nerve main trunk, and 110° (IQR 80-125) after transfer to the infraspinatus branch. Patients operated after 20 months obtained external rotation ≥90° less frequently. The results of this study suggest that a decision about distal nerve transfer for shoulder external rotation is recommended at 1.5 years of age.Level of evidence: III.
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Affiliation(s)
- Maria Hyttinen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Henrikki Rönkkö
- Division of Musculoskeletal Diseases, Tampere University Hospital, Tampere, Finland
| | | | - Mika Helminen
- Tays Research Services, Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland and Faculty of Social Sciences, Health Sciences, Tampere University, Tampere, Finland
| | - Jarkko Jokihaara
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Division of Musculoskeletal Diseases, Tampere University Hospital, Tampere, Finland
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Burns HR, Moreno TA, McLennan AL, Xue EY, Nguyen JL, Moore BK. Surgical Technique: Spinal Accessory to Infraspinatus Nerve Transfer in Brachial Plexus Birth Injury. Tech Hand Up Extrem Surg 2024:00130911-990000000-00110. [PMID: 39267453 DOI: 10.1097/bth.0000000000000493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2024]
Abstract
Nerve transfers, nerve grafts, and tendon transfers have been used to restore shoulder active external rotation in patients with brachial plexus birth injuries. Traditionally used nerve surgery techniques are nerve transfer from the spinal accessory nerve to a suprascapular nerve (SSN) or nerve grafting from C5 to the SSN. However, results are often suboptimal. A more distal and more targeted transfer from the spinal accessory nerve directly to the infraspinatus branch of the SSN has previously been described and mid-term outcomes are encouraging. Herein, we describe a modification of this technique with accompanying step-by-step intraoperative photographs.
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Affiliation(s)
- Heather R Burns
- Michael E. DeBakey Division of Plastic Surgery, Department of Surgery, Baylor College of Medicine
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Tanir A Moreno
- Michael E. DeBakey Division of Plastic Surgery, Department of Surgery, Baylor College of Medicine
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Alexandra L McLennan
- Michael E. DeBakey Division of Plastic Surgery, Department of Surgery, Baylor College of Medicine
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Erica Y Xue
- Michael E. DeBakey Division of Plastic Surgery, Department of Surgery, Baylor College of Medicine
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Jenny Lee Nguyen
- Michael E. DeBakey Division of Plastic Surgery, Department of Surgery, Baylor College of Medicine
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Brinkley K Moore
- Michael E. DeBakey Division of Plastic Surgery, Department of Surgery, Baylor College of Medicine
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
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Grahn P, Pöyhiä T, Nietosvaara Y. Permanent Brachial Plexus Birth Injury: Helsinki Shoulder Protocol. Semin Plast Surg 2023; 37:108-116. [PMID: 37503533 PMCID: PMC10371410 DOI: 10.1055/s-0043-1768940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Passive shoulder exercises from birth and ultrasound screening from 3 to 12 months. Botox is given to shoulder internal rotators and a bracing commenced, if alpha-angle exceeds 30°, or passive shoulder external rotation is below 70 degrees. Plexus reconstruction is recommended to children with root avulsion(s) on magnetic resonance imaging or 3-month Toronto Test Score < 3.5. Specific neurotization is recommended to children without avulsions, but lack of progress in healing. Shoulder dysplasia was diagnosed in 49% of 270 patients with permanent brachial plexus birth injury in our catchment area from 1995 to 2021. The age at detection of shoulder dysplasia dropped from mean 5.4 years in children born before 2000 to mean 3.9 months in children born after 2009. Botox was given to 57% of the patients born after 2009. Rate of shoulder relocation decreased from 28 to 7% while mean active shoulder external rotation in adduction increased from 2 to 46°.
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Affiliation(s)
- Petra Grahn
- Department of Pediatric Orthopedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tiina Pöyhiä
- Department of Radiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Yrjänä Nietosvaara
- Department of Pediatric Orthopedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Pediatric Surgery, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
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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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Grahn P, Sommarhem A, Nietosvaara Y. A protocol-based treatment plan to improve shoulder function in children with brachial plexus birth injury: a comparative study. J Hand Surg Eur Vol 2022; 47:248-256. [PMID: 34763554 DOI: 10.1177/17531934211056998] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Children with permanent brachial plexus birth injury have a high risk of developing posterior shoulder subluxation. In 2010, we implemented a protocol to reduce the incidence of this deformity, including early passive exercises, ultrasound screening, botulinum toxin-A injections, shoulder splinting and targeted surgeries. Two-hundred and thirty-seven consecutive children treated at our institution, with a mean follow-up of 11 years (range 1 to 17) were compared in three groups: children born from 1995 to 1999 (n = 53), 2000-2009 (n = 109) and 2010-2019 (n = 75). Posterior shoulder subluxation developed in 48% of all patients but the mean age at detection of shoulder subluxation decreased from 5 years to 4.9 months. Need for shoulder relocation surgery also decreased from 28% to 7%. Mean active shoulder external rotation in adduction improved from 2° to 46°. In conclusion, our established protocol has the potential to reduce the incidence of posterior shoulder subluxation in children with brachial plexus birth injury.Level of evidence: II.
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Affiliation(s)
- Petra Grahn
- Department of Pediatric Orthopedics and Traumatology, HUS Helsinki University Hospital, Helsinki, Finland
| | - Antti Sommarhem
- Department of Surgery, South Karelia Central Hospital, Lappeenranta, Finland
| | - Yrjänä Nietosvaara
- Department of Pediatric Orthopedics and Traumatology, HUS Helsinki University Hospital, Helsinki, Finland.,Department of Pediatric Surgery, Kuopio University Hospital, Kuopio, Finland
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Mid-Term Outcome after Selective Neurotization of the Infraspinatus Muscle in Patients with Brachial Plexus Birth Injury. Plast Reconstr Surg Glob Open 2020; 8:e2814. [PMID: 32440459 PMCID: PMC7209859 DOI: 10.1097/gox.0000000000002814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 03/25/2020] [Indexed: 11/13/2022]
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