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Domeshek LF, Zuo KJ, Letourneau S, Klar K, Anthony A, Ho ES, Hopyan S, Clarke HM, Davidge KM. Surgery for internal rotation contracture in infancy may obviate the need for brachial plexus nerve reconstruction: early experience. J Shoulder Elbow Surg 2024; 33:291-299. [PMID: 37479177 DOI: 10.1016/j.jse.2023.06.016] [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: 03/01/2023] [Revised: 05/22/2023] [Accepted: 06/13/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND Shoulder internal rotation contracture and subluxation in the first year of life has long been recognized in some patients with brachial plexus birth injury (BPBI). Surgical management of shoulder pathology has traditionally been undertaken following nerve reconstruction as necessary. In some patients; however, shoulder pathology may impair or obscure functional neuromuscular recovery of the upper extremity. As a proof of concept, we report a highly selected subset of patients with BPBI in whom shoulder surgery undertaken before one year of age obviated the need for neuroma resection and nerve grafting. METHODS A retrospective review was performed of all patients with upper trunk BPBI who underwent shoulder surgery before one year of age from 2015 to 2018. Upper extremity motor function was evaluated with preoperative and postoperative Active Movement Scale scores, Cookie tests, and the requirement for subsequent neuroma resection and nerve grafting. RESULTS Fifteen patients with BPBI meeting the inclusion criteria underwent shoulder surgery (including a subscapularis slide and tendon transfers of the teres major and latissimus dorsi muscles) before 1 year of age. Preoperatively, no patients of the appropriate age passed the Cookie test for elbow flexion. Thirteen patients either passed the Cookie test or scored Active Movement Scale score 7 for elbow flexion at or before the last available follow-up undertaken at a median age of 3.4 [1.4, 5.2] years. One of those 13 patients underwent single fascicular distal nerve transfer to improve elbow flexion before subsequently passing the Cookie test. Two patients did not have sufficient follow-up to assess elbow flexion. CONCLUSION Although the exact role of shoulder surgery in infancy for BPBI remains to be defined, the findings from this study provide proof of concept that early, targeted surgical treatment of the shoulder may obviate the need for brachial plexus nerve reconstruction in a highly selected group of infants with BPBI.
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Affiliation(s)
- Leahthan F Domeshek
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children and the Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Kevin J Zuo
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children and the Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Sasha Letourneau
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children and the Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Karen Klar
- Department of Rehabilitation, The Hospital for Sick Children, Toronto, ON, Canada
| | - Alison Anthony
- Department of Rehabilitation, The Hospital for Sick Children, Toronto, ON, Canada
| | - Emily S Ho
- Department of Rehabilitation, The Hospital for Sick Children, Toronto, ON, Canada
| | - Sevan Hopyan
- Division of Orthopedic Surgery, The Hospital for Sick Children and the Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Howard M Clarke
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children and the Department of Surgery, University of Toronto, Toronto, ON, Canada.
| | - Kristen M Davidge
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children and the Department of Surgery, University of Toronto, Toronto, ON, Canada
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Jönsson K, Hultgren T, Risling M, Sköld MK. Nerve Tracing in Juvenile Rats: A Feasible Model for the Study of Brachial Plexus Birth Palsy and Cocontractions? J Brachial Plex Peripher Nerve Inj 2024; 19:e6-e12. [PMID: 38263956 PMCID: PMC10803141 DOI: 10.1055/s-0044-1778691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 12/12/2023] [Indexed: 01/25/2024] Open
Abstract
Brachial plexus birth injuries cause diminished motor function in the upper extremity. The most common sequel is internal rotation contracture. A number of these patients also suffer from cocontractions, preventing the use of an otherwise good passive range of motion in the shoulder. One theory behind the co-contracture problem is that injured nerve fibers grow into distal support tissue not corresponding to the proximal support tissue, resulting in reinnervation of the wrong muscle groups. To further elucidate this hypothesis, we used rat neonates to investigate a possible model for the study of cocontractions in brachial plexus birth injuries. Five-day-old rats were subjected to a crush injury to the C5-C6 roots. After a healing period of 4 weeks, the infraspinatus muscle was injected with Fluoro-Gold. A week later, the animals were perfused and spinal cords harvested and sectioned. Differences in the uptake of Fluoro-Gold and NeuN positive cells of between sides of the spinal cord were recorded. We found a larger amount of Fluoro-Gold positive cells on the uninjured side, while the injured side had positive cells dispersed over a longer area in the craniocaudal direction. Our findings indicate that the method can be used to trace Fluoro-Gold from muscle through a neuroma. Our results also indicate that a neuroma in continuity somewhat prevents the correct connection from being established between the motor neuron pool in the spinal cord and target muscle and that some neurons succumb to a crushing injury. We also present future research ideas.
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Affiliation(s)
- Krister Jönsson
- Department of Handsurgery Södersjukhuset, Karolinska Institutet Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden
| | - Tomas Hultgren
- Department of Handsurgery Södersjukhuset, Karolinska Institutet Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden
| | - Mårten Risling
- Department of Neuroscience Karolinska Institutet, Experimental Traumatology Unit, Sweden
| | - Mattias K. Sköld
- Department of Neuroscience Karolinska Institutet, Experimental Traumatology Unit, Sweden
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Sweden
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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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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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5
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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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Triplanar Humeral Osteotomy for Restoration of Midline Function in Patients With Brachial Plexus Birth Palsy. Tech Hand Up Extrem Surg 2017; 21:48-54. [PMID: 28394871 DOI: 10.1097/bth.0000000000000156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Brachial plexus birth palsy resolves spontaneously in a majority of patients, however, others may have serious permanent dysfunction. Although nerve transfers or grafts are early options for treatment, many children have residual deficits or present too late for such procedures. In these patients, rotational osteotomy of the humerus may restore improved function and motion. Unfortunately, traditional humeral osteotomies only provide correction in a single plane, therefore appropriate correction of the typical residual deformity is incomplete. Here, we describe a novel technique for obtaining a calculated correction in 3 planes using a single osteotomy of the humerus on the basis of a mathematical equation. Nine patients are described here with an average of 35.4 months follow-up. Corrections were obtained in adduction, extension, and either internal or external rotation depending on the initial deformity and Modified Mallet scores were collected for each patient. There was 1 case of transient radial nerve palsy with no long-term complications overall.
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Subscapularis Z-lengthening in children with brachial plexus birth palsy loses efficiency at mid-term follow-up: a retrospective cohort study. INTERNATIONAL ORTHOPAEDICS 2015; 40:783-90. [PMID: 26649864 DOI: 10.1007/s00264-015-3062-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 11/23/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE The aim of this study was to evaluate early and mid-term clinical outcomes after isolated subscapularis Z-lengthening in children with shoulder internal rotation contractures resulting from brachial plexus birth palsy. METHODS Children with brachial plexus birth palsy treated with subscapularis tendon Z-lengthening from 2001 to 2011 were retrospectively reviewed. Over this period, 31 patients were identified. Primary outcome was improvement in Mallet score after surgery, and secondary outcome measures were active range of motion and Mallet sub-scores. Clinical outcomes were collected at three time intervals: pre-operatively, one-year post-operative and at latest follow-up. RESULTS After exclusion, 21 patients remained for further analysis. Mean age at surgery was 3.7 years (range, 1.2-8.7), and mean follow-up length was 6.5 years (2.9-9.7). Moderate improvements were found for mean Mallet score, active external rotation, active abduction and hand-to-mouth movement at one year and latest follow-up. However, improvements in active external rotation and Mallet score were not fully maintained at final follow up. CONCLUSION Isolated subscapularis Z-lengthening is effective at early follow-up, but results are not maintained at mid-term follow-up.
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Hultgren T, Jönsson K, Roos F, Järnbert-Pettersson H, Hammarberg H. Surgical correction of shoulder rotation deformity in brachial plexus birth palsy. Bone Joint J 2014; 96-B:1411-8. [DOI: 10.1302/0301-620x.96b10.33813] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We present the long-term results of open surgery for internal shoulder rotational deformity in brachial plexus birth palsy (BPBP). From 1997 to 2005, 207 patients (107 females, 100 males, mean age 6.2 (0.6 to 34)) were operated on with subscapularis elongation and/or latissimus dorsi to infraspinatus transfer. Incongruent shoulder joints were relocated. The early results of these patients has been reported previously. We analysed 118 (64 females, 54 males, mean age 15.1 (7.6 to 34)) of the original patient cohort at a mean of 10.4 years (7.0 to 15.1) post-operatively. A third of patients with relocated joints had undergone secondary internal rotational osteotomy of the humerus. A mixed effects models approach was used to evaluate the effects of surgery on shoulder rotation, abduction, and the Mallet score. Independent factors were time (pre-and post-surgery), gender, age, joint category (congruent, relocated, relocated plus osteotomy) and whether or not a transfer had been performed. Data from a previously published short-term evaluation were reworked in order to obtain pre-operative values. The mean improvement in external rotation from pre-surgery to the long-term follow-up was 66.5° (95% confidence interval (CI) 61.5 to 71.6). The internal rotation had decreased by a mean of 22.6° (95% CI -18.7 to -26.5). The mean improvement in the three-grade aggregate Mallet score was 3.1 (95% CI 2.7 to 3.4), from 8.7 (95% CI 8.4 to 9.0) to 11.8 (11.5 to 12.1). Our results show that open subscapularis elongation achieves good long-term results for patients with BPBP and an internal rotation contracture, providing lasting joint congruency and resolution of the trumpet sign, but with a moderate mean loss of internal rotation. Cite this article: Bone Joint J 2014;96-B:1411–18
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Affiliation(s)
- T. Hultgren
- Karolinska Institute, Department
of Clinical Science and Education, Section
for Hand Surgery, Södersjukhuset S-118 83 Stockholm, Sweden
| | - K. Jönsson
- Karolinska Institute, Department
of Clinical Science and Education, Section
for Hand Surgery, Södersjukhuset S-118 83 Stockholm, Sweden
| | - F. Roos
- Karolinska Institute, Department
of Clinical Science and Education, Section
for Hand Surgery, Södersjukhuset S-118 83 Stockholm, Sweden
| | - H. Järnbert-Pettersson
- Karolinska Institute, Department
of Clinical Science and Education, Södersjukhuset
S-118 83 Stockholm, Sweden
| | - H. Hammarberg
- Karolinska Institute, Department
of Clinical Science and Education, Section
for Hand Surgery, Södersjukhuset S-118 83 Stockholm, Sweden
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Chauhan SP, Blackwell SB, Ananth CV. Neonatal brachial plexus palsy: incidence, prevalence, and temporal trends. Semin Perinatol 2014; 38:210-8. [PMID: 24863027 DOI: 10.1053/j.semperi.2014.04.007] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Epidemiological knowledge of the incidence, prevalence, and temporal changes of neonatal brachial plexuses palsy (NBPP) should assist the clinician, avert unnecessary interventions, and help formulate evidence-based health policies. A summary of 63 publications in the English language with over 17 million births and 24,000 NBPPs is notable for six things. First, the rate of NBPP in the US and other countries is comparable: 1.5 vs. 1.3 per 1000 total births, respectively. Second, the rate of NBPP may be decreasing: 0.9, 1.0 and 0.5 per 1,000 births for publications before 1990, 1990-2000, and after 2000, respectively. Third, the likelihood of not having concomitant shoulder dystocia with NBPP was 76% overall, though it varied by whether the publication was from the US (78%) vs. other countries (47%). Fourth, the likelihood of NBPP being permanent (lasting at least 12 months) was 10-18% in the US-based reports and 19-23% in other countries. Fifth, in studies from the US, the rate of permanent NBPP is 1.1-2.2 per 10,000 births and 2.9-3.7 per 10,000 births in other nations. Sixth, we estimate that approximately 5000 NBPPs occur every year in the US, of which over 580-1050 are permanent, and that since birth, 63,000 adults have been afflicted with persistent paresis of their brachial plexus. The exceedingly infrequent nature of permanent NBPP necessitates a multi-center study to improve our understanding of the antecedent factors and to abate the long-term sequela.
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Affiliation(s)
- Suneet P Chauhan
- Department of Obstetrics and Gynecology, University of Texas, Houston, TX.
| | - Sean B Blackwell
- Department of Obstetrics and Gynecology, University of Texas, Houston, TX
| | - Cande V Ananth
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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