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Azer A, Mendiratta D, Saad A, Duan Y, Cedarstrand M, Chinta S, Hanna A, Shihora D, McGrath A, Chu A. Outcomes of humeral osteotomies versus soft-tissue procedures in secondary surgical procedures for neonatal brachial plexus palsy: a meta-analysis. Front Surg 2023; 10:1267064. [PMID: 38033527 PMCID: PMC10685892 DOI: 10.3389/fsurg.2023.1267064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/23/2023] [Indexed: 12/02/2023] Open
Abstract
Secondary surgical procedures can be used in brachial plexus birth injury to correct shoulder movement imbalances. This study compares outcomes of the two secondary surgical procedure types: humeral osteotomies and soft tissue procedures. Outcome measures assessed included active and passive internal and external rotation, active and passive abduction and adduction, active and passive flexion and extension, percentage of the humeral head anterior to the middle glenoid fossa, glenoid version, and Mallet Score. Nineteen full-text articles were included in the analysis. Humeral osteotomies resulted in a loss of internal rotation postoperatively (-15.94°). Active internal rotation was not evaluated for soft tissue procedures. All other assessed outcomes were improved postoperatively for bony and soft tissue procedures. Bony procedures exhibited a greater degree of active external rotation postoperatively when compared to soft tissue procedures (+67° vs. +40°). Both bony and soft tissue procedures Improve shoulder function in children with neonatal brachial plexus palsy, however, soft tissue procedures showed greater consistency in outcomes. Level of Evidence: IV.
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Affiliation(s)
- Amanda Azer
- Rutgers New Jersey Medical School, Newark, NJ, United States
| | | | - Anthony Saad
- Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Yajie Duan
- Department of Statistics, Rutgers University, Newark, NJ, United States
| | - Matthew Cedarstrand
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Sree Chinta
- Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Aedan Hanna
- Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Dhvani Shihora
- Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Aleksandra McGrath
- Department of Clinical Sciences, Umeå- University, Umeå, Sweden
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Alice Chu
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, NJ, United States
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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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Thamer S, Kijak N, Toraih E, Thabet AM, Abdelgawad A. Tendon Transfers to Restore Shoulder Function for Obstetrical Brachial Plexus Palsy: A Systematic Review of the Literature. JBJS Rev 2023; 11:01874474-202301000-00005. [PMID: 36608169 DOI: 10.2106/jbjs.rvw.22.00165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Obstetrical brachial plexus palsy (OBPP) is a relatively common stretch injury of the brachial plexus sustained during delivery. Tendon transfers are commonly performed to improve shoulder function among patients with OBPP. Although several techniques for the surgical management of OBPP exist, it is unclear whether tendon transfers to the rotator cuff vs. posterior humerus yield different outcomes. METHODS A systematic search in PubMed, Web of Science, the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, and Google Scholar up to January 1, 2021, was performed. Relevant publications were classified by surgical technique of tendon transfers to the rotator cuff or posterior humerus. The standard mean difference (SMD) and 95% confidence intervals were calculated to compare preoperative and postoperative aggregate Mallet scores as well as abduction and external rotation scores using the Mallet scale. A p value of <0.01 was considered significant. RESULTS Data from 26 studies and 951 patients (46.2% male patients) with a mean age of 68.9 ± 29.3 months were included. Eight hundred three patients underwent tendon transfer to the rotator cuff and 148 to the posterior humerus. The average postoperative follow-up period was 45.2 ± 21.7 months. The pooled cohort had an overall improvement in postoperative aggregate Mallet scores (SMD = 5.53, p < 0.001), abduction scores (SMD = 1.79, p < 0.001), and external rotation scores (SMD = 1.99, p < 0.001). Tendon transfer to the rotator cuff had a greater postoperative improvement in abduction (SMD = 1.90, p < 0.001) than transfer to the posterior humerus (SMD = 1.32, p < 0.001) while both techniques yielded similar improvements in external rotation (rotator cuff SMD = 2.01, p < 0.001, posterior humerus SMD = 1.98, p < 0.001). CONCLUSION This is the first systematic review comparing outcomes for tendon transfers to the rotator cuff vs. the posterior humerus for improving shoulder function in patients with OBPP. Overall, tendon transfers are an effective treatment for improving shoulder function. Transfer of the latissimus dorsi and teres major to the rotator cuff compared with transfer to the posterior humerus results in greater improvement in abduction while both techniques have similar results in improving external rotation. LEVEL OF EVIDENCE Level I Systematic review of Level I and Level II studies.
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Affiliation(s)
- Semran Thamer
- Dartmouth College Geisel School of Medicine, Hanover, New Hampshire
| | - Nicoletta Kijak
- State University of New York Downstate Medical Center, Brooklyn, New York
| | - Eman Toraih
- Division of General Endocrine and Oncologic Surgery, Department of Surgery, School of Medicine, Tulane University, New Orleans, Louisiana.,Medical Genetics Unit, Department of Histology and Cell Biology, Suez Canal University, Ismailia, Egypt
| | - Ahmed M Thabet
- Texas Tech University Health Sciences Center, El Paso, Texas
| | - Amr Abdelgawad
- Maimonides Medical Center, Department of Orthopaedics, Brooklyn, New York
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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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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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Liu Y, Lewis SP, Adidharma W, Osorio MB, Steinman SE, Allen H, Hottovy J, Tse RW. Reply: Shoulder Release and Tendon Transfer following Neonatal Brachial Plexus Palsy: Gains, Losses, and Midline Function. Plast Reconstr Surg 2021; 148:314e-315e. [PMID: 34228008 DOI: 10.1097/prs.0000000000008132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Yusha Liu
- Division of Plastic Surgery, University of Washington, Seattle, Wash
| | - Sarah P Lewis
- Department of Rehabilitation Medicine, Seattle Children's Hospital, Seattle, Wash
| | - Widya Adidharma
- Division of Plastic Surgery, University of Michigan, Ann Arbor, Mich
| | - Marisa B Osorio
- Department of Rehabilitation Medicine, Seattle Children's Hospital, Department of Rehabilitation Medicine, University of Washington, Seattle, Wash
| | - Suzanne E Steinman
- Orthopedics and Sports Medicine, Seattle Children's Hospital, Seattle, Wash
| | - Heidi Allen
- Department of Rehabilitation Medicine, Seattle Children's Hospital, Seattle, Wash
| | - Janine Hottovy
- Department of Rehabilitation Medicine, Seattle Children's Hospital, Seattle, Wash
| | - Raymond W Tse
- Division of Plastic Surgery, University of Washington, Division of Plastic Surgery, Seattle Children's Hospital, Seattle, Wash
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Crook JL, Uygur S, Konofaos P. Shoulder Release and Tendon Transfer following Neonatal Brachial Plexus Palsy: Gains, Losses, and Midline Function. Plast Reconstr Surg 2021; 148:312e-313e. [PMID: 34228032 DOI: 10.1097/prs.0000000000008131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Jennifer L Crook
- University of Tennessee Health Science, Center College of Medicine
| | - Safak Uygur
- Department of Plastic Surgery, University of Tennessee Health Science Center, Memphis, Tenn
| | - Petros Konofaos
- Department of Plastic Surgery, University of Tennessee Health Science Center, Memphis, Tenn
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Kaiser R, Krajcová A, Makel M, Ullas G, Němcová V. Anatomical aspects of the selective infraspinatus muscle neurotization by spinal accessory nerve. J Plast Surg Hand Surg 2020; 55:220-225. [PMID: 33317372 DOI: 10.1080/2000656x.2020.1856680] [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: 10/22/2022]
Abstract
The suprascapular nerve (SSN) is commonly reconstructed by spinal accessory nerve (SAN) transfer. However, reinnervation of its branch to the infraspinatus muscle (IB-SSN) is poor. Reconstruction of the SSN in cases of scapular fractures is frequently neglected in clinical practice. The morphological study was performed on 25 adult human cadavers. The course and the length of SSN of minimal diameter of 2 mm within the trapezius muscle, the length of the distal stump of IB-SSN to its branching point and the length of the SSN available for reconstructive procedure were measured. The feasibility study of the SAN - IB-SSN neurotization performed by using a bony canal under the spine of scapula was performed. The mean distance of the SAN from the spine was 8.5 cm (±0.88) at the point where it perforates the trapezius muscle and 4.49 cm (±0.72) at the most distal part of the nerve. The mean length of the intramuscular portion of the nerve was 14.74 cm (±1.99). It ran under a mean latero-medial angle of 15.54° (±2.51). The mean distance between the medial end of the scapular spine and the SAN was 2.44 cm (± 0.64). The mean length of the IB-SSN was 3.6 cm (± 0.67). The mean length of the SAN stump which was mobilized from its original course and transferred to the infraspinous fossa to reach distal stump of the IB-SSN was 8.09 cm (±1.6). Direct SAN to IB-SSN transfer is anatomically feasible in the adult population.
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Affiliation(s)
- Radek Kaiser
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital Prague, Prague, Czech Republic
| | - Aneta Krajcová
- Department of Plastic Surgery, First Faculty of Medicine, Charles University and Hospital Na Bulovce, Prague, Czech Republic.,Department of Anatomy, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Michal Makel
- Department of Plastic Surgery, Third Faculty of Medicine, Charles University and University Hospital Královské Vinohrady, Prague, Czech Republic
| | - Gautham Ullas
- Department of ENT, James Cook University Hospital, Middlesbrough, UK
| | - Veronika Němcová
- Department of Anatomy, First Faculty of Medicine, Charles University, Prague, Czech Republic
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