Surgical correction of the medial rotation contracture in obstetric brachial plexus palsy

A severe case of bilateral humerus varus deformity from the Middle Bronze age necropolis of Olmo di Nogara, Northeast Italy. The contribution of biomechanical analysis to paleopathological study

OBJECTIVE

To gain insights on possible impairment of a Middle Bronze Age individual with bilateral humerus varus buried with a sword in Northeastern Italy.

MATERIALS

A skeleton of a 40-50-year-old male from Olmo di Nogara (Italy) compared to other males from the same necropolis and to Neolithic and Iron Age samples from Italy.

METHODS

Macroscopic/X-rays analysis for pathological diagnosis and cross-sectional geometric analysis.

RESULTS

Both humeri of the individual appear short with destruction of the humeral heads, showing severe osteoarthrosis and flattening of the scapular glenoid cavities. The individual showed appreciable humeral bilateral asymmetry; there is no evidence for sustained immobilization.

CONCLUSIONS

The pathological modifications suggest a diagnosis of bilateral humeral varism probably following an injury at birth. The individual's life was likely not significantly affected, as evidence suggests that he remained active and possibly used weapons.

SIGNIFICANCE

Biomechanical analyses provided a useful tool to reconstruct the life of the subject within the community, showing that this individual's apparent upper limb abnormalities did not exempt him from a role as a warrior and highlighting the importance of the warrior identity in this Bronze Age society.

LIMITATIONS

The complex interaction between epiphyseal damage and shortening of the humerus makes it difficult to assess activity patterns. Only severe impairment leading to long-term immobilization can be excluded for this individual.

SUGGESTIONS FOR FURTHER RESEARCH

Cross-sectional geometry may be used in other cases of humerus varus or bone dysplasia to investigate functional impairment.

Three-Dimensional Upper Limb Movement Analysis in Children and Adolescents With Brachial Plexus Birth Injury: A Systematic Review

BACKGROUND

To synthesize the current evidence on clinical use of three-dimensional upper limb movement analysis (3D-ULMA) in children and adolescents with brachial plexus birth injury (BPBI).

METHODS

MEDLINE, Embase, and Web of Science were searched for relevant studies up to April 2022. An automatic e-mail alert was installed to ensure no eligible article was missed. Articles evaluating 3D-ULMA in children and adolescents with BPBI were included. Covidence web-based platform was used for blind screening of eligible articles. Twenty-one observational studies with a final sample size of 609, encompassing 493 BPBI cases, met the inclusion criteria. Data were extracted using a custom form to support standardized extraction conforming to the Cochrane Checklist of items. Risk of bias was assessed using the Newcastle-Ottawa Scale, the Strengthening the Reporting of Observational Studies in Epidemiology checklist, and a specifically established quality assessment form for kinematic analysis studies.

RESULTS

Study setups differed, including six different types of kinematic devices. Twelve studies used the (modified) Mallet positions for their 3D-ULMA. Throughout the studies, 3D-ULMA was used for various purposes. The Newcastle-Ottawa Scale scored 16 articles with five stars or more, indicating fair to moderate quality.

CONCLUSIONS

This systematic review summarizes the different 3D-ULMA kinematic devices, test protocols, and their clinical use for BPBI. The use of 3D-ULMA provides valuable, objective, and quantified data to clinicians with regard to movement strategies; it complements existing clinical scales and can be implemented to evaluate effectiveness of therapy interventions. Implications for future research and clinical practice are discussed.

Brachial Plexus Birth Injuries

Brachial plexus birth injuries (BPBIs) are typically traction type injuries to the newborn that occur during the delivery process. Although the incidence of these injuries has overall decreased from 1.5 to around 0.9 per 1000 live births in the United States over the past 2 decades, these injuries remain common, with incidence holding fairly steady from 2008 to 2014. Shoulder dystocia is the strongest identified risk factor, imparting a 100-fold greater risk. The newborn's shoulder is caught behind the mother's pubic bone, and traction performed on the child during delivery results in injury to the brachial plexus. Other risk factors associated with BPBI include macrosomia (birthweight > 4.5 kg), heavy for gestational age infants, birth hypoxia, gestational diabetes, and forceps or vacuum-assisted delivery. Breech presentation has also been described as a risk factor in the past, but there have been more recent data that challenge this association.

Comparing the Results of External Rotational Humeral Osteotomy in Older Children to the Mod Quad and Triangle Tilt Procedures in Adults with Obstetric Brachial Plexus Injury

BACKGROUND

External Rotational Humeral osteotomy is used to address the external rotation deficit in older children with obstetric brachial plexus Injury (OBPI). Although this procedure improves the cosmetic effect of shoulder subluxation, it has no effect on the underlying structural (glenohumeral deformity and scapular elevation and rotation) and functional problems. In this study, improvements in glenohumeral joint alignment; scapular hypoplasia, elevation, and rotation (SHEAR) deformity; and upper extremity functional movements were demonstrated in adult patients with OBPI 1 year after the mod Quad and/or triangle tilt surgeries.

METHODS AND PATIENTS

The outcome of humeral rotational osteotomy reported in the literature was compared with the results from 43 adult patients with OBPI (21 men and 22 women; 23 right and 20 left sides) with a mean age of 21.3 years (range, 17 to 38 years) who underwent mod Quad and/or triangle tilt surgeries and had over 12 months of postoperative follow-up (mean 22.9 months; range, 12 to 50 months).

RESULTS

The preoperative average modified total Mallet score, including supination, was 14.6 ± 3.5 (P < 0.0001) in the 43 adult patients with OBPI in this report. This total Mallet score was significantly improved to 22 ± 3.9 (P < 0.0001) over 12 months after mod Quad and/or triangle tilt surgeries. Thirty-two (75%) of the patients showed great improvement in all upper extremity functions: shoulder abduction, external rotation, hand-to-mouth, hand-to-neck, hand-to-spine, and supination. The improvement after humeral osteotomy reported in the literature was a cosmetic effect that did not address the underlying structural and functional problems and was found to decrease the improved shoulder abduction in long-term follow-up.

CONCLUSIONS

Thirty-two (75%) of 43 adult patients with OBPI showed great improvement in all upper extremity functions 1 year after mod Quad and/or triangle tilt surgeries. The other 11 patients (25%) showed improvement in hand-to-mouth movement and/or supination. In contrast, humeral osteotomy, as reported in the literature, improved the cosmetic effect of shoulder subluxation but had no effect on the underlying structural and functional problems.

10-year Follow-up of Mod Quad and Triangle Tilt Surgeries in Obstetric Brachial Plexus Injury

Aim:

To evaluate whether obstetric brachial plexus injury (OBPI) children who had mod Quad and triangle tilt surgeries maintained their recovered upper extremity functional movements over 10 years.

Background:

The short-term outcomes of surgery in OBPI patients are well documented. However, only a few publications with results over 10-year postoperative follow-up exist. We have previously reported the outcomes of these 2 surgeries in OBPI after 1, 2, and 5 years. Here, we report the successful outcomes in 17 of these patients over 10 years.

Methods:

Seventeen OBPI patients, who had mod Quad, a modified muscle release operation and triangle tilt, a bony surgical procedure with us between 2005 and 2008, had postoperative follow-up of 10 years and met the inclusion criteria. Patients who had multiple surgeries and did not have 10-year follow-up are excluded in this study.

Results:

Fifteen of 17 children maintain their recovered upper extremity functions for extended long period (mean, 10 years; range, 9–13 years). There was statistically significant improvement in total functional Mallet score after 3 years (mean, 18.8 ± 2.1; P ≤ 0.01) from the preoperative mean total Mallet score of 14.5 ± 1.2. This improvement was not only maintained for extended period but also improved (mean total Mallet score, 20.35 ± 2.3; P ≤ 0.01) in some patients.

Conclusions:

Overall, all upper extremity functions improved greatly after mod Quad and triangle tilt surgeries in OBPI children, and they were able to maintain their recovered functional movements over extended period of 10 years.

Kinematic differences between children with obstetric brachial plexus palsy and healthy controls while performing activities of daily living

BACKGROUND

Residual shoulder dysfunction and deformity impacts on functional performance in children with obstetric brachial plexus palsy. Clinical understanding of upper limb dynamic movement patterns is difficult with observation alone. This case-control study describes the significant kinematic differences between children with obstetric brachial plexus palsy compared to typically developing children while performing tasks of the modified Mallet Scale.

METHODS

Eleven children with obstetric brachial plexus palsy (mean 10 years, range 7-15 years, Narakas group I-III) and 10 typically developing children (mean 9 years 9 months, range 6-15 years) completed three-dimensional upper limb motion analysis using the acromion method to track dynamic scapular movement. Kinematic data were captured by a 4-CODA cx1 optoelectronic tracking system. Participants performed three trials of the modified Mallet scale tasks. Local coordinate systems, segment and joint rotations were defined as recommended by the International Society of Biomechanics.

FINDINGS

Joint rotation angles against time of the glenohumeral, thoracohumeral and scapulohumeral joints were calculated. Kinematic findings demonstrated increased internal rotation in all postures, reduced glenohumeral excursion, habitual "trumpet" posture of glenohumeral abduction/elevation and variability in movement strategies. Scapulohumeral rhythm during abduction task was 1.88:1 in typically developing children and 1.04:1 in children with obstetric brachial plexus palsy.

INTERPRETATION

Children with obstetric brachial plexus palsy demonstrate deficient external rotation in all tasks. Despite increased postural internal rotation, ability to move through internal rotation range is compromised. The glenohumeral joint showed the greatest range deficit, contributing to abnormal scapulohumeral rhythm. Future sub-group analysis of Narakas Classification is recommended.

Satisfied patients after shoulder arthrodesis for brachial plexus lesions even after 20 years of follow-up

Purpose

Patients with an upper brachial plexus lesion can suffer from dysfunction, joint deformities and instability of the shoulder. The goal of this study was to determine pain, shoulder function, patient satisfaction and muscle strength in shoulder arthrodesis in patients with an upper brachial plexus lesion more than 15 years after surgery.

Methods

We retrospectively studied 12 patients with a brachial plexus lesion of mean age 46 years (27–61). At a mean of 19.8 years (15.4–30.3) after shoulder arthrodesis, patient-reported outcome measures (PROMs), range of motion (e.g., active and passive), patient satisfaction, strength of the affected and non-affected side (e.g., maximum isometric strength in Newton in forward and retroflexion, ab- and adduction, internal and external rotation) and position of fusion were obtained. PROMS consisted of the Visual Analogue Scale (VAS; 0–100, 0 being painless) for pain and the Disabilities of the Arm, Shoulder and Hand Score (DASH; 0–100, 0 being the best score) for function.

Results

At latest follow-up, the median VAS pain score was 49 (0–96) and 0 for, respectively, the affected and unaffected side. The DASH was 15 (8–46), meaning a reasonable to good function of the upper extremity. Active and passive retroflexion was significantly different (p = 0.028). All subjects stated that in the same situation they would undergo a shoulder arthrodesis again. The unaffected side was significantly stronger in every direction. Arthrodesis showed position of fusion of 31° (12–70) abduction, 20° (10–50) forward flexion and 22° (− 14 to 58) internal rotation. The unaffected side was significantly (p ≤ 0.05) stronger in every movement direction.

Conclusion

At a mean of 20 years after shoulder arthrodesis, patients with an upper brachial plexus lesion are still satisfied with a good to moderate functional improvement.

Level of evidence III

A retrospective cohort study.

Reliability of 3D upper limb motion analysis in children with obstetric brachial plexus palsy

Kinematics, measured by 3D upper limb motion analysis (3D-ULMA), can potentially increase understanding of movement patterns by quantifying individual joint contributions. Reliability in children with obstetric brachial plexus palsy (OBPP) has not been established.

OBJECTIVE

This study aimed to determine between session reliability and measurement errors of 3D-ULMA using the acromion method (AM) in children with OBPP.

APPROACH

Ten participants (mean 10 years, range 7-15 years, Narakas classification I-III) completed 3D-ULMA on two occasions, mean interval of 8.6 d (±2.8 d). Kinematic data were captured by a 4-CODA cx1 optoelectronic tracking system. Participants performed three trials of the modified Mallet scale tasks. Local coordinate systems, segment and joint rotations were defined as recommended by the International Society of Biomechanics. The intraclass correlation coefficient (ICC 2,K) and standard error of measurement (SEM) were calculated for task duration, range and joint angle at point of task achievement (PTA).

MAIN RESULTS

Results indicated poor reliability for spatiotemporal parameters and range. Moderate to excellent reliability at PTA was observed in 19/60 variables (ICC: 0.77-0.98; SEM: 3.5°-10.4°). The Abduction Task had the highest (ICC: 0.79-0.98; SEM: 3.5°-10.3°) with External Rotation the lowest reliability. Glenohumeral and thoracohumeral elevation had the most consistent reliability. Scapular protraction/retraction had consistently poor reliability (ICC: 0-0.72; SEM: 3.5°-10.2°) with axial rotation also poor (ICC: 0.00-0.91; SEM: 6.3°-32.8°). This study determined inconsistent test-retest reliability of 3D-ULMA, using AM, to track dynamic performance of functional tasks in children with OBPP. It is the first study to outline measurement error in this population. This information permits more reliable interpretation of future studies of kinematic patterns in children with OBPP.

Improvements after mod Quad and triangle tilt revision surgical procedures in obstetric brachial plexus palsy

AIM

To compare outcomes of our revision surgical operations in obstetric brachial plexus palsy (OBPP) patients to results of conventional operative procedures at other institutions.

METHODS

We analyzed our OBPP data and identified 10 female and 10 male children aged 2.0 to 11.8 years (average age 6.5 years), who had prior conventional surgical therapies at other clinics. Of the 20 patients, 18 undergone triangle tilt, 2 had only mod Quad. Among 18 patients, 8 had only triangle tilt and 10 had also mod Quad as revision surgeries with us. We analyzed the anatomical improvements and functional modified Mallet statistically before and after a year post-revision operations.

RESULTS

Pre-revision surgery average modified Mallet score was 12.0 ± 1.5. This functional score was greatly improved to 18 ± 2.3 (P < 0.0001) at least one-year after revision surgical procedures. Radiological scores (PHHA and glenoid version) were also improved significantly to 31.9 ± 13.6 (P < 0.001), -16.3 ± 11 (P < 0.0002), at least one-year after triangle tilt procedure. Their mean pre-triangle tilt (yet after other surgeon’s surgeries) PHHA, glenoid version and SHEAR were 14.6 ± 21.7, -31.6 ± 19.3 and 16.1 ± 14.7 respectively.

CONCLUSION

We demonstrate here, mod Quad and triangle tilt as successful revision surgical procedures in 20 OBPP patients, who had other surgical treatments at other clinics before presenting to us for further treatment.

Triangle tilt and humeral surgery: Meta-analysis of efficacy and functional outcome

AIM: To systematically review and analyze the overall impact and effectiveness of bony surgical procedures, the triangle tilt and humeral surgery in a comparative manner in permanent obstetric brachial plexus injury (OBPI) patients.

METHODS: We conducted a literature search and identified original full research articles of OBPI patients treated with a secondary bony surgery, particularly addressing the limitation of shoulder abduction and functions. Further, we analyzed and compared the efficacy and the surgical outcomes of 9 humeral surgery papers with 179 patients, and 4 of our secondary bony procedure, the triangle tilt surgical papers with 86 patients.

RESULTS: Seven hundred and thirty-one articles were identified, using the search term “brachial plexus” and obstetric or pediatric (246 articles) or neonatal (219 articles) or congenital (188 articles) or “birth palsy” (121 articles). Further, only a few articles were identified using the bony surgery search, osteotomy “brachial plexus” obstetric (35), “humeral osteotomy” and “brachial plexus” (17), and triangle tilt “brachial plexus” (14). Of all, 12 studies reporting pre- and post- operative or improvement in total Mallet functional score were included in this study. Among these, 9 studies reported the humeral surgery and 4 were triangle tilt surgery. We used modified total Mallet functional score in this analysis. Various studies with humeral surgery showed improvement of 1.4, 2.3, 5.0 and 5.6 total Mallet score, whereas the triangle tilt surgery showed improvement of 5.0, 5.5, 6.0 and 6.2.

CONCLUSION: The triangle tilt surgery improves on what was achieved by humeral osteotomy in the management of shoulder function in OBPI patients.

Successful outcome of triangle tilt as revision surgery in a pediatric obstetric brachial plexus patient with multiple previous operations

Introduction. Obstetric brachial plexus injury (OBPI) occurs during the process of labor and childbirth. OBPI has been reported to be associated with shoulder dystocia, macrosomia, and breech delivery. Its occurrence in uncomplicated delivery is possible as well. Case Presentation. The patient in the present report is a 6.5-year-old girl, who suffered a severe brachial plexus injury at birth and had many reconstructive surgical procedures at an outside brachial plexus center before presenting to us. Discussion. The traditional surgical treatments by other surgical groups were unsuccessful and therefore the patient came to our clinic for further treatment. She had triangle tilt surgery with us, as a salvage procedure. Conclusion. The OBPI patient in this study clearly showed noticeable clinical and functional improvements after triangle tilt surgical management. The posture of the arm at rest was greatly improved to a more normal position, and hand to mouth movement was improved as well. Triangle tilt surgery should be conducted as a first choice treatment for medial rotation contracture of the shoulder in OBPI patients.

Management of Shoulder Problems Following Obstetric Brachial Plexus Injury

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.

Extended long-term (5 years) outcomes of triangle tilt surgery in obstetric brachial plexus injury

Objective:

We evaluated the "extended" long-term (5 years) functional outcomes in obstetric brachial plexus injury (OBPI) patients, who underwent triangle tilt surgery between February 2005 and January 2008.

Methods:

Twenty two children (9 girls and 13 boys, mean age at surgery was 5.8 years; ranging 2.1-11.8 years old), who initially presented with medial rotation contracture and scapula deformity secondary to obstetric brachial plexus injury were included in this study. Functional movements were evaluated pre-operatively, and 5 years following triangle tilt surgery by modified Mallet scale.

Results:

Here, we report long-term (5 years) follow-up of triangle tilt surgery for 22 OBPI patients. Upper extremity functional movements such as, external rotation (2.5±0.6 to 4.1±0.8, p<0.0001), hand-to-spine (2.6±0.6 to 3.4±1.1, p<0.005), hand-to-neck (2.7±0.7 to 4.3±0.7, p<0.0001), hand-to-mouth (2.3±0.9 (92º±33) to 4.2±0.5 (21º±16), p<0.0001), and supination (2.6±1.1 (-8.2º ±51) to 4.1±0.7 (61±32)) were significantly improved (p<0.0001), and maintained over the extended long-term (5 years). Total modified Mallet functional score was also shown to improve from 14.1±2.7 to 20.3±2.5.

Conclusions:

The triangle tilt surgery improved all shoulder functions significantly, and maintained over the extended long-term (5 years) in these patients.

Assessment of triangle tilt surgery in children with obstetric brachial plexus injury using the pediatric outcomes data collection instrument

Background:

The benefits of triangle tilt surgery in children with OBPI have been previously validated through measurements of statistical improvements in Mallet scores and in glenohumeral congruity. The purpose of the current study was to evaluate the effectiveness of triangle tilt surgery through the application of the Pediatric Outcomes Data Collection Instrument, a well validated questionnaire designed to evaluate function and comfort in children with musculoskeletal disorders.

Methods:

OBPI patients between 2 and 10 years of age who came to our institute for routine office visits between May 2009 and October 2009 were considered to participate in the study. Among the patient group, the first 130 completed surveys who met the study criteria were included in the study. The Pediatric Outcomes Data Collection Instrument was completed by the parents of patients who have undergone triangle tilt surgery (Group 1: N=63) or those who were considered candidates for this procedure (Group 2: N=67). The results were compared between the two patient groups and analyzed using the unpaired student’s t-test. Later, 23 patients from the group 2, underwent triangle tilt surgery (Group 3). We collected post-op data, compared and analyzed the outcome of the surgery in these patients to their own pre-op PODCI scores, using the paired student’s t test.

Results:

In patients who have undergone triangle tilt surgery, significantly higher PODCI scores were observed in the parameters of upper extremity function (p<0.05), sports/physical function (p<0.05), basic mobility (p<0.0001) and global functioning (p<0.05), when compared to patients who have not undergone triangle tilt surgery. Further, PODCI scores in group 3 patients were significantly higher after surgery in the parameters of upper extremity function (p <0.03), Pain/Comfort (p <0.05), basic mobility (p<0.0002) and global functioning (p<0.03), when compared to before triangle tilt surgery.

Conclusion:

The results of the Pediatric Outcomes Data Collection Instrument demonstrate the functional benefits of triangle tilt surgery in patients with obstetric brachial plexus injury.

Clinical outcome of shoulder muscle transfer for shoulder deformities in obstetric brachial plexus palsy: A study of 150 cases

Background:

Residual muscle weakness, cross-innervation (caused by misdirected regenerating axons), and muscular imbalance are the main causes of internal rotation contractures leading to limitation of shoulder joint movement, glenoid dysplasia, and deformity in obstetric brachial plexus palsy. Muscle transfers and release of antagonistic muscles improve range of motion as well as halt or reverse the deterioration in the bony architecture of the shoulder joint. The aim of our study was to evaluate the clinical outcome of shoulder muscle transfer for shoulder abnormalities in obstetric brachial plexus palsy.

Materials and Methods:

One hundred and fifty patients of obstetric brachial plexus palsy with shoulder deformity underwent shoulder muscle transfer along with anterior shoulder release at our institutions from 1999 to 2007. Shoulder function was assessed both preoperatively and postoperatively using aggregate modified Mallet score and active and passive range of motion. The mean duration of follow-up was 4 years (2.5–8 years).

Results:

The mean preoperative abduction was 45° ± 7.12, mean passive external rotation was 10° ± 6.79, the mean active external rotation was 0°, and the mean aggregate modified Mallet score was 11.2 ± 1.41. At a mean follow-up of 4 years (2.5–8 years), the mean active abduction was 120° ± 18.01, the mean passive external rotation was 80° ± 10.26, while the mean active external rotation was 45° ± 3.84. The mean aggregate modified Mallet score was 19.2 ± 1.66.

Conclusions:

This procedure can thus be seen as a very effective tool to treat internal rotation and adduction contractures, achieve functional active abduction and external rotation, as well as possibly prevent glenohumeral dysplasia, though the long-term effects of this procedure may still have to be studied in detail clinico-radiologically to confirm this hypothesis.

Level of evidence:

Therapeutic level IV

Triangle tilt and steel osteotomy: similar approaches to common problems

BACKGROUND

Each year, thousands of children worldwide suffer obstetric brachial plexus nerve injuries resulting not only in primary nerve injury, but also in development of secondary muscle and bone deformities of the shoulder. The triangle tilt surgery has been developed and shown to effectively address these deformities. The triangle tilt procedure was initially designed by the lead author (RKN) to follow the concepts of joint normalization featured in the Steel pelvic osteotomy used to correct developmental dysplasia of the hip joint, and indeed ultimately bears a striking resemblance to the Steel osteotomy. Prior to performing these bony surgical procedures, soft tissue procedures are performed to release the muscle contractures of the shoulder and hip. The purpose of this article is to compare and analyze the similarities between the indications, surgical techniques, involved anatomy, and outcomes of these operative procedures.

METHODS

A literature review was conducted using PubMed to identify articles pertaining to triangle tilt surgery and the Steel pelvic osteotomy. Functional parameters and surgical strategies were compared. Pre- and post-operative CTs were analyzed to compare anatomical results of the procedures.

RESULTS

Similarities were found between both procedures in terms of indications, involved anatomy, surgical techniques, and outcomes. The triangle tilt surgery is indicated to correct the developmental dysplasia of the glenohumeral joint in obstetric brachial plexus injury patients. Steel pelvic osteotomy is performed to correct the subluxation and dislocation of the hip innominate bone in patients with congenital dysplasia, cerebral palsy myelodysplasia, and poliomyelitis. The involved anatomy of both procedures is similar in that both involve limb girdles and ball-and-socket joints, namely the shoulder and hip. Both procedures are also triple osteotomies, the triangle tilt involving the acromion, clavicle and scapula while the Steel osteotomy involves the iliac spine, ischial and pubic ramus of the innominate bone. Surgical techniques also bear likenesses in that both can theoretically be done percutaneously. Post-operative CT outcomes of both surgeries showed improved anatomical positioning of the ball-and-socket joint congruency, and therefore better functional outcomes.

DISCUSSION

The similarities between the triangle tilt surgery and Steel pelvic osteotomy could potentially be useful as a model system in developing other procedures that involve the shoulder and hip. Future clinical applications include the development and implementation of new surgical procedures based on comparisons and adaptations from the hip to the shoulder and vice versa.

Comparing functional outcome of triangle tilt surgery performed before versus after two years of age

Background:

Many patients each year who are born with obstetric brachial plexus injuries eventually do not achieve complete recovery. As a result of the primary nerve injuries, these patients will often develop bony deformities involving the shoulder joint as a secondary consequence. The triangle tilt surgery has been shown to be an effective procedure to correct these deformities and has been performed on patients ranging in age from less than a year old to adolescence. The purpose of this retrospective study is to compare outcomes of triangle tilt surgery performed on patients before the age of 2 years versus after 2 years of age to determine an optimal age to operate on these children.

Methods:

36 patients with deformities developed secondarily from the initial obstetric brachial plexus injury in this study were divided into 2 groups. Group 1, those who had undergone triangle tilt surgery at < 2 yrs of age (16 patients). Group 2, those who were operated at > 2 yrs of age (20 patients). Group 1 age range: 9 months to 23 months, average: 18 months. Group 2 age range: 26 months to 9 years, average: 6 years.

Results:

Significant differences were found between the 2 groups (0-2 yrs vs > 2yrs) in regards to overall changes (pre- to post-op) in Mallet score, external rotation score, hand-to-mouth score, and supination angle.

Discussion:

This study demonstrates that triangle tilt surgery had better outcomes on clinical functioning if performed before the age of 2 years, however, improvement in clinical functioning can still be achieved if the triangle tilt surgery is performed after the age of 2 years as well. A possible mechanism to explain this phenomenon is the increased potential for anatomical remodeling if the triangle tilt surgery is performed at a younger age, thereby leading to significant functional improvement.

Range of motion and strength after surgery for brachial plexus birth palsy

BACKGROUND

There is little information about the range of motion (ROM) and strength of the affected upper limbs of patients with permanent brachial plexus birth palsy.

PATIENTS AND METHODS

107 patients who had brachial plexus surgery in Finland between 1971 and 1998 were investigated in this population-based, cross-sectional, 12-year follow-up study. During the follow-up, 59 patients underwent secondary procedures. ROM and isometric strength of the shoulders, elbows, wrists, and thumbs were measured. Ratios for ROM and strength between the affected and unaffected sides were calculated.

RESULTS

61 patients (57%) had no active shoulder external rotation (median 0° (-75-90)). Median active abduction was 90° (1-170). Shoulder external rotation strength of the affected side was diminished (median ratio 28% (0-83)). Active elbow extension deficiency was recorded in 82 patients (median 25° (5-80)). Elbow flexion strength of the affected side was uniformly impaired (median ratio 43% (0-79)). Median active extension of the wrist was 55° (-70-90). The median ratio of grip strength for the affected side vs. the unaffected side was 68% (0-121). Patients with total injury had poorer ROM and strength than those with C5-6 injury. Incongruity of the radiohumeral joint and avulsion were associated with poor strength values.

INTERPRETATION

ROM and strength of affected upper limbs of patients with surgically treated brachial plexus birth palsy were reduced. Patients with avulsion injuries and/or consequent joint deformities fared worst.

Surgical normalization of the shoulder joint in obstetric brachial plexus injury

Obstetric brachial plexus injuries (OBPI) result in bony derangements that include posterior humeral head subluxation, glenoid retroversion, and joint incongruity. Often these deformities are accompanied by scapular hypoplasia, elevation, and rotation, which further exacerbate shoulder dysfunction. The purpose of the current study was to investigate the effects of triangle tilt surgery on glenohumeral joint anatomy in 100 OBPI patients. The triangle tilt surgery restores the distal acromioclavicular triangle from an abnormal superiorly angled position to a neutral position, thereby restoring normal glenohumeral anatomic relationships.Axial computed tomography and magnetic resonance images taken before and 12- to 38-months after surgery showed significant improvements in both posterior subluxation and glenoid version. Patients with complete posterior glenohumeral dislocation improved from 19% preoperatively, to 11% postoperatively. Glenoid shape was also improved, with 81% of patients classified as concave or flat after surgery compared with 53% before surgery.Triangle tilt surgery allows for both repositioning and remodeling of the glenohumeral joint. These anatomic improvements after triangle tilt surgery hold promise for improving shoulder function and quality of life for OBPI patients.

Coracoid abnormalities and their relationship with glenohumeral deformities in children with obstetric brachial plexus injury

BACKGROUND

Patients with incomplete recovery from obstetric brachial plexus injury (OBPI) usually develop secondary muscle imbalances and bone deformities at the shoulder joint. Considerable efforts have been made to characterize and correct the glenohumeral deformities, and relatively less emphasis has been placed on the more subtle ones, such as those of the coracoid process. The purpose of this retrospective study is to determine the relationship between coracoid abnormalities and glenohumeral deformities in OBPI patients. We hypothesize that coracoscapular angles and distances, as well as coracohumeral distances, diminish with increasing glenohumeral deformity, whereas coracoid overlap will increase.

METHODS

39 patients (age range: 2-13 years, average: 4.7 years), with deformities secondary to OBPI were included in this study. Parameters for quantifying coracoid abnormalities (coracoscapular angle, coracoid overlap, coracohumeral distance, and coracoscapular distance) and shoulder deformities (posterior subluxation and glenoid retroversion) were measured on CT images from these patients before any surgical intervention. Paired Student t-tests and Pearson correlations were used to analyze different parameters.

RESULTS

Significant differences between affected and contralateral shoulders were found for all coracoid and shoulder deformity parameters. Percent of humeral head anterior to scapular line (PHHA), glenoid version, coracoscapular angles, and coracoscapular and coracohumeral distances were significantly lower for affected shoulders compared to contralateral ones. Coracoid overlap was significantly higher for affected sides compared to contralateral sides. Significant and positive correlations were found between coracoscapular distances and glenohumeral parameters (PHHA and version), as well as between coracoscapular angles and glenohumeral parameters, for affected shoulders. Moderate and positive correlations existed between coracoid overlap and glenohumeral parameters for affected shoulders. On the contrary, all correlations between the coracoid and glenohumeral parameters for contralateral shoulders were only moderate or relatively low.

CONCLUSIONS

These results indicate that the spatial orientation of the coracoid process differs significantly between affected and contralateral shoulders, and it is highly correlated with the glenohumeral deformity. With the progression of glenohumeral deformity, the coracoid process protrudes more caudally and follows the subluxation of the humeral head which may interfere with the success of repositioning the posteriorly subluxed humeral head anteriorly to articulate with the glenoid properly.

Our experience with secondary reconstruction of external rotation in obstetrical brachial plexus palsy

BACKGROUND

Restoration of shoulder external rotation is very important for upper extremity function. The purpose of this study was to present the authors' experience with secondary restoration of external rotation in patients with obstetrical brachial plexus palsy.

METHODS

From 1978 to 2002, 46 children underwent secondary surgery for restoration of external rotation. Outcomes were analyzed in relation to various factors, including the type of procedure, muscle transfer only versus nerve reconstruction and muscle transfer, denervation time, type of injury (Erb versus global palsy), and severity score. In addition, the effect of restoration of external rotation on the final outcome of shoulder abduction was assessed.

RESULTS

There was significant improvement in every case (p < 0.01) between preoperatively and postoperatively. The overall mean postoperative Mallet score for the group undergoing muscle transfer only was 3.95, whereas in the nerve reconstruction and muscle transfer group, the score was 3.88 (p >0.05). The resulting gain in external rotation was 99 degrees versus 93.8 degrees. In both populations, a very significant improvement (p <0.0001) was identified in the final outcome of shoulder abduction (109 degrees after muscle transfer versus 48.3 degrees before muscle transfer, and 112 degrees postoperatively after neurotization and muscle transfer versus 43.8 degrees before any surgery). Patients with Erb palsy had a better but not significant result (p >0.05; p = 0.94), compared with those with global palsy in both Mallet score (3.77 versus 3.76) and final active external rotation (81.7 degrees versus 77.6 degrees).

CONCLUSION

Secondary surgery for the restoration of external rotation is a rewarding procedure, which also significantly improves the final outcome of shoulder abduction.

Triangle tilt surgery as salvage procedure for failed shoulder surgery in obstetric brachial plexus injury

PURPOSE

The study was conducted to review the effects of triangle tilt surgery in children with OBPI (obstetric brachial plexus injury) who had previously undergone several operative procedures at other hospitals before presenting at our institute.

METHODS

The study included a group of 48 OBPI patients who had undergone previous operative procedures at outside hospitals by other surgeons. Patients were assessed for shoulder function using their radiological reports and the modified Mallet functional scale. The same patients underwent the triangle tilt procedure at our institution and were re-evaluated for shoulder function.

RESULTS

The results of the study showed an increase in Mallet scores from 11.88 points to 15.17 points (p < 0.01), improvement in PHHA (percentage of humeral head anterior to the glenoid) from 14% to 25% (p < 0.05), enhancement in glenoid version from -32 degrees to -25 degrees (p < 0.01), and a decrease in the SHEAR (scapular hypoplasia, elevation, and rotation) deformity after surgery.

CONCLUSION

The data obtained demonstrated that the triangle tilt procedure significantly enhanced shoulder function and glenohumeral congruity in these patients as evidenced by the improvements in Mallet scores, PHHA, glenoid version, and SHEAR deformity.

Long-term outcomes of triangle tilt surgery for obstetric brachial plexus injury

AIM

The purpose of this study was to evaluate long-term shoulder functional outcomes from a triangle tilt procedure on obstetric patients, who initially presented with medial rotation contracture and scapular deformity secondary to obstetric brachial plexus injury.

METHODS

We retrospectively studied long-term outcomes both functionally and anatomically in 61 patients (age ranging from 2 to 12 years). Functional movements were evaluated and scored using a modified Mallet scale at different time intervals: preoperatively, 1 year and 2 year following triangle tilt surgery. Shoulder anatomy was examined on radiologic images to evaluate the severity of shoulder deformities preoperatively and anatomical improvement after the surgery.

RESULTS

All shoulder functional movements were significantly improved at 1 and 2 year follow-ups. Functional improvements were maintained in shoulder abduction, external rotation and hand-to-mouth movements beyond the first year, and continued in hand-to-neck and hand-to-spine movements past 2 years. Remarkable glenohumeral remodeling or reservation of glenoid congruence was observed in all patients over a mean time of 27 months postoperatively.

CONCLUSION

The triangle tilt procedure, which addresses scapular and glenohumeral joint abnormalities characteristic of Erb's palsy, improves shoulder functional movements and anatomical structure in patients over the long-term.

Shoulder function and anatomy in complete obstetric brachial plexus palsy: long-term improvement after triangle tilt surgery

PURPOSE

Untreated complete obstetric brachial plexus injury (COBPI) usually results in limited spontaneous recovery of shoulder function. Older methods used to treat COBPI have had questionable success, with very few studies being published. The purpose of the current study was to examine the results of triangle tilt surgery on shoulder function and development in COBPI individuals.

METHODS

This study was conducted as a retrospective chart review. Inclusion criteria were COBPI patients that had undergone the triangle tilt procedure from 2005 to 2009 and were between the ages of 9 months and 12 years. COBPI was defined as permanent injury to all five nerve roots (C5-T1), with significant degradation in development and function of the hand. Twenty-five patients with a mean age of 5 (0.75-12) years were followed up clinically for more than 2 years.

RESULTS

The triangle tilt procedure resulted in demonstrable clinical enhancements with appreciable improvements in shoulder function, glenoid version, and humeral head congruity. There was a significant increase in the overall Mallet score (2.4 points, p < 0.0001) following surgical correction in patients that were followed up for more than 2 years.

CONCLUSIONS

The results of this study demonstrate that COBPI patients who develop SHEAR and medial rotation contracture deformities can benefit from the triangle tilt surgery, which improves shoulder function and anatomy across a range of pediatric ages. Despite these patients presenting late for surgery in general (5 years), significant improvements were observed in their glenohumeral (GH) dysplasia and their ability to perform shoulder and arm movements following surgery.

Lengthening of subscapularis and transfer of the lower trapezius in the correction of recurrent internal rotation contracture following obstetric brachial plexus palsy

An internal rotation contracture is a common complication of obstetric brachial plexus palsy. We describe the operative treatment of seven children with a recurrent internal rotation contracture of the shoulder following earlier corrective surgery which included subscapularis slide and latissimus dorsi transfer. We performed z-lengthening of the tendon of the subscapularis muscle and transferred the lower trapezius muscle to the infraspinatus tendon. Two years postoperatively the mean gain in active external rotation was 47.1 degrees, which increased to 54.3 degrees at four years. Lengthening of the tendon of subcapularis and lower trapezius transfer to infraspinatus improved the range of active external rotation in patients who had previously had surgery for an internal rotation contracture.

Nerve reconstruction in patients with obstetric brachial plexus injury results in worsening of glenohumeral deformity: a case-control study of 75 patients

Whereas a general trend in the management of obstetric brachial plexus injuries has been nerve reconstruction in patients without spontaneous recovery of biceps function by three to six months of age, many recent studies suggest this may be unnecessary. In this study, the severity of glenohumeral dysplasia and shoulder function and strength in two groups of matched patients with a C5-6 lesion at a mean age of seven years (2.7 to 13.3) were investigated. One group (23 patients) underwent nerve reconstruction and secondary operations, and the other (52 patients) underwent only secondary operations for similar initial clinical presentations. In the patients with nerve reconstruction shoulder function did not improve and they developed more severe shoulder deformities (posterior subluxation, glenoid version and scapular elevation) and required a mean of 2.4 times as many operations as patients without nerve reconstruction. This study suggests that less invasive management, addressing the muscle and bone complications, is a more effective approach. Nerve reconstruction should be reserved for those less common cases where the C5 and C6 nerve roots will not recover.

Arm rotated medially with supination - the ARMS variant: description of its surgical correction

BACKGROUND

Patients who have suffered obstetric brachial plexus injury (OBPI) have a high incidence of musculoskeletal complications stemming from the initial nerve injury. The presence of muscle imbalances and contractures leads to typical bony changes affecting the shoulder, including the SHEAR (Scapular Hypoplasia, Elevation and Rotation) deformity. The SHEAR deformity commonly occurs in conjunction with Medial Rotation Contracture (MRC) of the arm. OBPI also causes muscle imbalances at the level of the forearm, that lead to a fixed supination deformity (SD) in a small number of patients. Both MRC and SD will cause severe functional limitations without surgical intervention.

METHODS

Fourteen OBPI patients were diagnosed with MRC of the shoulder and SD of the forearm along with SHEAR deformity during a 16 month study period, with eight patients available to long-term follow-up (age range 2.2 - 18 years). Surgical correction of the MRC was performed as a triangle tilt or humeral osteotomy depending on the age of the child, after which, the patients were treated with a radial osteotomy to correct the fixed supination deformity. Function was assessed using the modified Mallet scale, examination of apparent supination and appearance of the extremity at rest.

RESULTS

Significant functional improvements were observed in patients with surgical reconstruction. Mallet score increased by an average of 5.2 (p < 0.05). Overall forearm position was not significantly changed from an average of 5 degrees to an average of 34 degrees maximum apparent supination after both shoulder rotation and forearm rotation corrective surgeries.

CONCLUSION

The simultaneous presence of two opposing deformities in the same limb will visually offset each other at the level of the wrist and hand, giving the false impression of neutral positioning of the limb. In reality, the neutral-appearing position of the hand indicates a fixed supination posture of the forearm in the face of a medial rotation contracture of the shoulder. Both of these deformities require surgical attention, and the presence of concurrent MRC and SD should be monitored for in OBPI patients.

Recording scapular motion using an acromion marker cluster

Disorders of the shoulder complex can be accompanied by changes in the movement pattern of the scapula. However, scapular motion is difficult to measure. A possible non-invasive method for dynamic three-dimensional kinematic measurement of the human scapula is the use of a marker cluster placed on the flat part of the acromion. A small light-weight acromion marker cluster (AMC) is presented in this study. In order to assess validity, kinematics obtained with the AMC were compared to simultaneous scapula locator (SL) recordings in a series of postures. The test/retest variability of replacement of the AMC, was also assessed. Measurement errors appeared to be sensitive for the plane of movement, the degree of humerus elevation, and replacement of the AMC. The AMC generally under-estimated scapula motion, compared to the SL. Some significant differences were found between the two methods, although the absolute differences were small (maximum mean difference 8.4 degrees in extreme position). In humerus forward flexion and abduction the maximum mean differences were 6 degrees or lower. In conclusion, the AMC is a valid method of measuring scapular movement during arm elevation that could be used in shoulder pathologies. Placement and planes of movement should be carefully considered and elevation of the humerus should not exceed 100 degrees.

Computed tomography of the shoulders in patients with obstetric brachial plexus injuries: a retrospective study

Background

Scapular hypoplasia, elevation, and rotation (SHEAR) deformity and posterior subluxation of the humeral head are common tertiary sequelae of obstetric brachial plexus injuries (OBPI). Interpretations of images from bilateral computed tomography (CT) scans of the upper extremities are critical to the diagnosis and treatment plan for patients with these bony deformities resulting from OBPI.

Methods

We conducted a retrospective study to investigate the accuracy of radiologic reports in the diagnosis of SHEAR or posterior subluxation of the humeral head in OBPI patients. CT studies from 43 consecutive patients over a 33-month period were used in the study. For each patient, we compared the results from the radiologic report to those from a clinical examination given by the attending surgeon and to measurements taken from the CT studies by biomedical researchers.

Results

A comparison of SHEAR measured from the 3-D CT images to the diagnoses from the radiologists, revealed that only 40% of the radiological reports were accurate. However, there was a direct correlation between the use of the 3-D CT images and an accurate SHEAR diagnosis by the radiologists (p < 0.0001). When posterior subluxation was measured in the affected and contralateral shoulders, 93% of the patients that had greater than a 10% difference between the two shoulders did not have their deformity diagnosed. The radiological reports diagnosed 17% of these patients with a 'normal' shoulder. Only 5% of the reports were complete, accurately diagnosing SHEAR in addition to posterior subluxation.

Conclusion

Due to the low incidence rate of OBPI, many radiologists may be unfamiliar with the sequelae of these injuries. It is therefore critical that radiologists are made aware of the importance of an accurate measurement and diagnosis of the SHEAR deformity. Due to their lack of completeness, the radiological reports in this study did not significantly contribute to the clinical care of the patients. In order for OBPI patients to receive the highest standard of care, the final diagnosis from their radiological imaging should be deferred to a brachial plexus specialist who is experienced with these types of injuries.

The function of the hand after operations for obstetric injuries to the brachial plexus

Hand function was evaluated in 105 patients who had been operated on in early infancy for brachial plexus birth palsy. The mean follow-up after surgery was for 13.4 years (5.0 to 31.5). Fine sensation, stereognosis, grip and pinch strength and the Raimondi scale were recorded.

Fine sensation was normal in 34 of 49 patients (69%) with C5–6 injury, 15 of 31 (48%) with C5–7 and in 8 of 25 (32%) with total injury. Loss of protective sensation or absent sensation was noted in some palmar areas of the hand in 12 of 105 patients (11%). Normal stereognosis was recorded in 88 of the 105 patients (84%), whereas only 9 of the 105 (9%) had normal grip strength. The mean Raimondi scale scores were 4.57 (3 to 5) (C5–6), 4.26 (1 to 5) (C5–7) and 2.16 (0 to 5) in patients with total injury.

The location of impaired sensation was related to the distribution of the root injury. Avulsion type of injury correlated with poor recovery of hand function.