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Hardie CM, Bourke G, Salt E, Fort-Schaale A, Clark S, Wiberg M, Bains R. Demographics and deprivation in obstetric brachial plexus palsy: a retrospective cohort study. J Hand Surg Eur Vol 2024; 49:570-575. [PMID: 37694876 DOI: 10.1177/17531934231196421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
The present study analyses the relationships between deprivation and obstetric brachial plexus palsy (OBPP). A retrospective observational study was conducted of infants with OBPP seen between 2008 and 2020 (n = 321). The index of multiple deprivation (IMD) was used to assign an IMD rank to patients based on birth postcode and the relationship with OBPP was analysed, including deprivation, gestational diabetes, age at referral and at first assessment. Quintile-based analysis demonstrated over-representation of patients from more deprived neighbourhoods (n = 109, 39%) living in the top 20% most deprived neighbourhoods. A total of 48 (15%) mothers had diabetes and 98 (31%) infants underwent surgical brachial plexus exploration (a marker of disease severity). Neither diabetes, age at referral nor age at first assessment were associated with IMD score. This suggests that neighbourhood deprivation is associated with OBPP, though the mechanisms are unclear. Further studies in this area may enable targeted health intervention for more deprived maternal and infant groups.Level of evidence: III.
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Affiliation(s)
- Claire Madeline Hardie
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Grainne Bourke
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK
- Department of Integrative Medical Biology, Umeå University, Sweden
- Department of Surgical and Perioperative Science, Umeå University, Sweden
| | - Emily Salt
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Alice Fort-Schaale
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Stephen Clark
- Consumer Data Research Centre and School of Geography, University of Leeds, Leeds, UK
| | - Mikael Wiberg
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK
- Department of Integrative Medical Biology, Umeå University, Sweden
- Department of Surgical and Perioperative Science, Umeå University, Sweden
| | - Robert Bains
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK
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2
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Thatte MR, Nayak NS. Prospective study comparing outcomes of primary intraplexal repair versus distal nerve transfers in Narakas grade I birth brachial plexus palsy. J Hand Surg Eur Vol 2024; 49:591-595. [PMID: 37747709 DOI: 10.1177/17531934231201955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
To compare the results of intraplexal repair and distal nerve transfer in babies with birth brachial plexus palsy (BBPP), children with Narakas group I obstetric palsy were assigned to two groups of 16 each. Children in group A were treated with classical intraplexal repair and those in group B were treated by distal nerve transfers. At 6 months, all the children in group B had achieved Modified Medical Research Council (MMRC) grade 3 elbow flexion along with 8 of the 16 children in group A, which was a statistically significant difference. At 6 months, all the children in group B achieved MMRC grade 3 or higher shoulder abduction and 8 of the 16 children in group A had done so, which was also statistically significant. At the final follow-up, the distal transfer surgical treatment group had a significantly higher Mallet score. Distal nerve transfers have a significant advantage in early recovery in elbow flexion and shoulder abduction, but the outcomes became similar after 9 months.Level of evidence: III.
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Affiliation(s)
- Mukund R Thatte
- Department of Plastic and Reconstructive Surgery, Bombay Hospital & Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Nayana S Nayak
- Department of Plastic and Reconstructive Surgery, Bombay Hospital & Institute of Medical Sciences, Mumbai, Maharashtra, India
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3
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Zlotolow DA. Brachial plexus birth injuries: a multi-speciality approach. Commentary and opinions. J Hand Surg Eur Vol 2024; 49:645-648. [PMID: 38488628 DOI: 10.1177/17531934241237630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
The management of brachial plexus birth injuries (BPBI) remains controversial and ever evolving. In this article, studies are examined to provide further insight into the ongoing controversies and debates surrounding BPBI. The articles are diverse and examine the topics of aetiology, demographics, reliability versus accuracy of measurements and surgical management. The management of BPBI may differ depending on resources. Outcome measures may also vary depending on geography. Future research should focus on developing consensus-validated measures and reproducible surgical techniques. These can then guide further population-based research and provide guidelines to minimize the incidence of BPBI.
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Affiliation(s)
- Dan A Zlotolow
- The Sidney Kimmel Medical College, Philadelphia, PA, USA
- Shriners Children's Philadelphia, PA, USA
- The Hospital for Special Surgery, New York, NY, USA
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Siqueira MG, Heise CO, Martins RS, Zaccariotto M, Pessa M, Sterman-Neto H. Hand function outcomes following surgical treatment of complete neonatal brachial plexus palsy. Childs Nerv Syst 2024; 40:1455-1459. [PMID: 38183435 DOI: 10.1007/s00381-023-06269-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 12/22/2023] [Indexed: 01/08/2024]
Abstract
PURPOSE Although re-innervation of the hand is considered a priority in the treatment of infants with complete brachial plexus injury, there is currently a paucity of publications investigating hand function outcomes following primary nerve reconstruction in infants with neonatal brachial plexus palsy (NBPP). This study therefore aimed to evaluate hand function outcomes in a series of patients with complete NBPP. METHODS This retrospective case series included all patients who underwent primary nerve surgery for complete neonatal brachial plexus palsy over an 8-year period. Outcomes were assessed using the Raimond Hand Scale. Classification of grade 3 or higher indicates a functional hand (assistance in bimanual activity). RESULTS Nineteen patients with a complete NBPP underwent primary nerve reconstruction at a mean age of 3.7 months. Periodic clinical evaluations were performed until at least 4 years of age. According to the Raimondi hand scale, one patient did not recover (grade 0), three patients attained grade 1, four grade 2, ten grade 3, and in one grade 4. Overall hand functional recovery was achieved in 57.8% (11/19) of patients. CONCLUSION Sufficient recovery of hand function to perform bimanual activity tasks in patients with complete NBPP lesions is possible and should be a priority in the surgical treatment of these infants.
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Affiliation(s)
- Mario Gilberto Siqueira
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar 255, 05403-000, São Paulo, SP, Brazil.
| | - Carlos Otto Heise
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar 255, 05403-000, São Paulo, SP, Brazil
- Clinical Neurophysiology, Department of Neurology, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Roberto Sergio Martins
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar 255, 05403-000, São Paulo, SP, Brazil
| | - Monise Zaccariotto
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar 255, 05403-000, São Paulo, SP, Brazil
| | - Mariana Pessa
- Occupational Therapy, Department of Orthopedic Surgery, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Hugo Sterman-Neto
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar 255, 05403-000, São Paulo, SP, Brazil
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5
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Mendiratta D, Levidy MF, Chu A, McGrath A. Rehabilitation protocols in neonates undergoing primary nerve surgery for upper brachial plexus palsy: A scoping review. Microsurgery 2024; 44:e31154. [PMID: 38376241 DOI: 10.1002/micr.31154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/24/2023] [Accepted: 02/01/2024] [Indexed: 02/21/2024]
Abstract
INTRODUCTION Surgical management is recommended in patients with severe neonatal brachial plexus palsy (NBPP) within the first 6 months of age to regain best possible function. Rehabilitation post-surgery remains relatively unexplored. This is a scoping review that explores, which rehabilitation modalities exist and how they vary for different microsurgical approaches in NBPP. MATERIALS AND METHODS A systematic search was conducted to include articles about upper trunk obstetric brachial plexus nerve microsurgery in pediatric patients that made mention of rehabilitation protocols. The aims of rehabilitation modalities varied and were grouped: "passive" movement to prevent joint contracture or stiffness, "active" or task-oriented movement to improve motor function, or "providing initial motor recovery". Surgical approach was described as either exploration of the brachial plexus (EBP) or nerve transfer without root exploration (NTwoRE). Technique was categorized into transfers and non-transfers. RESULTS Thirty-six full-text articles were included. Initiation of rehabilitation was 22.26 days post-surgery. Twenty-eight studies were EBP, and six were NTwoRE. Of studies classifiable by aims, nine were "passive", nine were "active", and five were "providing initial motor recovery". Only 27.7% of EBP studies mentioned active therapy, while 75.0% of NTwoRE studies mentioned active therapy. The average age of patients in the EBP procedure category was 7.70 months, and NTwoRE was 17.76 months. Within transfers, the spinal accessory to suprascapular group was more likely to describe an active shoulder exercise therapy, whereas contralateral C7 group was more likely to describe "initial motor recovery", especially through the use of electrostimulation. All articles on electrostimulation recommended 15-20-minute daily treatment. CONCLUSION Information on rehabilitation is limited post-nerve surgery in NBPP. However, when mentioned, the aims of these therapies vary with respect to surgical approach and technique. The type of therapy to employ may be a multifaceted decision, involving factors such as patient age, initial deformity, and goals of the care team.
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Affiliation(s)
- Dhruv Mendiratta
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Michael F Levidy
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Alice Chu
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Aleksandra McGrath
- Department of Clinical Sciences, Umeå University, Umeå, Sweden
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
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6
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Socolovsky M, di Masi G, Bonilla G, Lovaglio A, Battaglia D, Rosler R, Malessy M. Brain plasticity in neonatal brachial plexus palsies: quantification and comparison with adults' brachial plexus injuries. Childs Nerv Syst 2024; 40:479-486. [PMID: 37436472 DOI: 10.1007/s00381-023-06072-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 07/05/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE To compare two populations of brachial plexus palsies, one neonatal (NBPP) and the other traumatic (NNBPP) who underwent different nerve transfers, using the plasticity grading scale (PGS) for detecting differences in brain plasticity between both groups. METHODS To be included, all patients had to have undergone a nerve transfer as the unique procedure to recover one lost function. The primary outcome was the PGS score. We also assessed patient compliance to rehabilitation using the rehabilitation quality scale (RQS). Statistical analysis of all variables was performed. A p ≤ 0.050 set as criterion for statistical significance. RESULTS A total of 153 NNBPP patients and 35 NBPP babies (with 38 nerve transfers) met the inclusion criteria. The mean age at surgery of the NBPP group was 9 months (SD 5.42, range 4 to 23 months). The mean age of NNBPP patients was 22 years (SD 12 years, range 3 to 69). They were operated around sixth months after the trauma. All transfers performed in NBPP patients had a maximum PGS score of 4. This was not the case for the NNBPP population that reached a PGS score of 4 in approximately 20% of the cases. This difference was statistically significant (p < 0.001). The RQS was not significantly different between groups. CONCLUSION We found that babies with NBPP have a significantly greater capacity for plastic rewiring than adults with NNBPP. The brain in the very young patient can process the changes induced by the peripheral nerve transfer better than in adults.
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Affiliation(s)
- Mariano Socolovsky
- Peripheral Nerve & Brachial Plexus Surgery Program, Department of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, La Pampa 1175 Torre 2 5A, 1428, Buenos Aires, Argentina.
- Peripheral Nerve & Brachial Plexus Surgery Unit, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Torre 2 5A, Buenos Aires, Argentina.
| | - Gilda di Masi
- Peripheral Nerve & Brachial Plexus Surgery Program, Department of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, La Pampa 1175 Torre 2 5A, 1428, Buenos Aires, Argentina
- Peripheral Nerve & Brachial Plexus Surgery Unit, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Torre 2 5A, Buenos Aires, Argentina
| | - Gonzalo Bonilla
- Peripheral Nerve & Brachial Plexus Surgery Program, Department of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, La Pampa 1175 Torre 2 5A, 1428, Buenos Aires, Argentina
- Peripheral Nerve & Brachial Plexus Surgery Unit, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Torre 2 5A, Buenos Aires, Argentina
| | - Ana Lovaglio
- Peripheral Nerve & Brachial Plexus Surgery Program, Department of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, La Pampa 1175 Torre 2 5A, 1428, Buenos Aires, Argentina
- Peripheral Nerve & Brachial Plexus Surgery Unit, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Torre 2 5A, Buenos Aires, Argentina
| | - Danilo Battaglia
- Peripheral Nerve & Brachial Plexus Surgery Program, Department of Physiotherapy and Rehabilitation, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Roberto Rosler
- Department of Neurology, Universidad Abierta Interamericana, Buenos Aires, Argentina
| | - Martijn Malessy
- Department of Neurosurgery, University of Leiden School of Medicine, Leiden, Holland
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Muhlestein WE, Chang KWC, Justice D, Nelson VS, Brown SH, Saadeh YS, Smith BW. Recovery of Shoulder, Elbow, and Forearm Movement After Nerve Reconstruction for Neonatal Brachial Plexus Palsy. Neurosurgery 2024; 94:193-201. [PMID: 37850933 DOI: 10.1227/neu.0000000000002726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/27/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES There is a relative dearth of published data with respect to recovery of upper extremity movement after nerve reconstruction for neonatal brachial plexus palsy (NBPP). This study aimed to demonstrate long-term recovery of active range of motion (AROM) at the shoulder, elbow, and forearm after nerve reconstruction for NBPP and to compare that with patients managed nonoperatively. METHODS We interrogated a prospectively collected database of all patients evaluated for NBPP at a single institution from 2005 to 2020. AROM measurements for shoulder, elbow, and forearm movements were collected at every visit up to 5 years of follow-up and normalized between 0 and 1. We used generalized estimated equations to predict AROM for each movement within local age windows over 5 years and compared the operative and nonoperative cohorts at each age interval. RESULTS In total, >13 000 collected datapoints representing 425 conservatively and 99 operatively managed children were included for analysis. At 5 years, absolute recovery of AROM after nerve reconstruction was ∼50% for shoulder abduction and forward flexion, ∼65% for shoulder external rotation, and ∼75% for elbow flexion and forearm supination, with ∼20% loss of elbow extension AROM. Despite more limited AROM on presentation for the operative cohort, at 5 years, there was no significant difference between the groups in AROM for shoulder external rotation, elbow extension, or forearm supination, and, in Narakas grade 1-2 injury, shoulder abduction and forward flexion. CONCLUSION We demonstrate recovery of upper extremity AROM after nerve surgery for NBPP. Despite more severe presenting injury, operative patients had similar recovery of AROM when compared with nonoperative patients for shoulder external rotation, elbow extension, forearm supination, and, for Narakas grade 1-2 injury, shoulder abduction and forward flexion.
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Affiliation(s)
| | - Kate W-C Chang
- Department of Neurosurgery, University of Michigan, Ann Arbor , Michigan , USA
| | - Denise Justice
- Department of Neurosurgery, University of Michigan, Ann Arbor , Michigan , USA
| | - Virginia S Nelson
- Department of Physical Medicine & Rehabilitation, University of Michigan, Ann Arbor , Michigan , USA
| | - Susan H Brown
- Department of Movement Science, School of Kinesiology, University of Michigan, Ann Arbor , Michigan , USA
| | - Yamaan S Saadeh
- Department of Neurosurgery, University of Michigan, Ann Arbor , Michigan , USA
| | - Brandon W Smith
- Department of Neurologic Surgery, Duke University, Durham , North Carolina , USA
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8
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Socolovsky M, Lovaglio A, Bonilla G, Masi GD, Barillaro K, Malessy M. Brain plasticity and age after restoring elbow flexion with distal nerve transfers in neonatal brachial plexus palsy and nonneonatal traumatic brachial plexus injury using the plasticity grading scale. J Neurosurg 2023; 139:1568-1575. [PMID: 37410633 DOI: 10.3171/2023.5.jns23673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 05/04/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE Ulnar and/or median nerve fascicle to musculocutaneous nerve (MCN) transfers are used to restore elbow flexion following severe neonatal and nonneonatal brachial plexus injuries (BPIs). Restoring volitional control requires plastic changes in the brain. To date, whether the potential for plasticity is influenced by a patient's age remains unknown. METHODS Patients who had presented with a traumatic upper (C5-6 or C5-7) BPI were divided into two groups: neonatal brachial plexus palsies (NBPPs) and nonneonatal traumatic BPIs (NNBPIs). Both groups underwent ulnar or median nerve transfers to the MCN for elbow flexion restoration between January 2002 and July 2020. Only those who attained a British Medical Research Council strength rating of 4 were reviewed. The primary comparison between the two groups was the plasticity grading scale (PGS) score to determine the level of independence of elbow flexion (target) from forearm motor muscle movement (donors). The authors also assessed patient compliance with rehabilitation using a 4-point Rehabilitation Quality Scale. Bivariable and multivariable analyses were used to identify intergroup differences. RESULTS In total, 66 patients were analyzed: 22 with NBPP (mean age at surgery 10 months) and 44 with NNBPI (age range at surgery 3-67 years, mean 30.2 years; mean time to surgery 7 months, p < 0.001). All NBPP patients obtained a PGS grade of 4 at the final follow-up versus just 47.7% of NNBPI patients (mean 3.27, p < 0.001). On ordinal regression analysis, after nature of the injury was excluded because of excessive collinearity with age, age was the only significant predictor of plasticity (β = -0.063, p = 0.003). Median rehabilitation compliance scores were not statistically different between the two groups. CONCLUSIONS The extent of plastic changes that occur for patients to regain volitional control over elbow flexion after upper arm distal nerve transfers following BPI is influenced by patient age, with complete plastic rewiring more likely in younger patients and virtually ubiquitous in infants. Older patients should be informed that elbow flexion after an ulnar or median nerve fascicle transfer to the MCN might require simultaneous wrist flexion.
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Affiliation(s)
- Mariano Socolovsky
- 1Department of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina; and
| | - Ana Lovaglio
- 1Department of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina; and
| | - Gonzalo Bonilla
- 1Department of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina; and
| | - Gilda Di Masi
- 1Department of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina; and
| | - Karina Barillaro
- 1Department of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina; and
| | - Martijn Malessy
- 2Department of Neurosurgery, University of Leiden School of Medicine, Leiden, Holland
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9
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Morscher MA, Thomas MD, Sahgal S, Adamczyk MJ. Onabotulinum toxin type A injection into the triceps unmasks elbow flexion in infant brachial plexus birth palsy: A retrospective observational cohort study. Medicine (Baltimore) 2020; 99:e21830. [PMID: 32846828 PMCID: PMC7447388 DOI: 10.1097/md.0000000000021830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Brachial plexus birth palsy (BPBP) is a neurologic injury that can result in mild to full paralysis of the affected upper extremity. In severe cases, nerve surgery is often performed before age 1 year. Several studies report gains in elbow flexion with onabotulinum toxin type A (OBTT-A) injections to the triceps; however, its use in infants is not widely reported. The purpose of this study is to present our experience using these injections before 6 months of age to therapeutically unmask elbow flexion and diagnostically guide surgical decision making.This is a retrospective observational cohort study. The cohort included infants with BPBP who received OBTT-A injection to the triceps before age 6 months. Indications for the injections include trace elbow flexion and palpable co-contraction of the biceps and triceps. Elbow flexion was evaluated using the Toronto Test score. Therapeutic success was defined as an increase in post-injection scores. These scores were then used diagnostically as an indication for surgery if the infant did not achieve full elbow flexion by 8 months. A treatment algorithm for OBTT-A triceps injection was developed based on all treatment options offered to infants with elbow flexion deficits seen in the clinic.Of the 12 infants that received OBTT-A triceps injections, 10 (83%) had improved Toronto test elbow flexion scores post-injection. Gains in elbow flexion once attained were maintained. Of the 9 OBTT-A infants with at least 2 years follow-up, 4 achieved full elbow flexion without surgery; the remainder after surgery. No complications with OBTT-A injections were noted and patients were followed on average 6 years. The average age at time of injection was 4 months (range: 2-5 months). Compared to other treatments given, OBTT-A infants tended to present with more elbow flexion than the 4 infants requiring immediate surgical intervention and less elbow flexion than the 16 infants treated conservatively.OBTT-A injection to the triceps in infants with BPBP before 6 months of age therapeutically improved elbow flexion and diagnostically guided surgical decisions when full elbow flexion was not achieved by 8 months of age with no known complications.
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Affiliation(s)
| | | | - Suneet Sahgal
- Rehabilitation Services, The Children's Center Rehabilitation Hospital, Bethany, OK
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10
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Adidharma W, Lewis SP, Liu Y, Osorio MB, Steinman SE, Tse RW. Shoulder Release and Tendon Transfer following Neonatal Brachial Plexus Palsy: Gains, Losses, and Midline Function. Plast Reconstr Surg 2020; 146:321-331. [PMID: 32740582 DOI: 10.1097/prs.0000000000007037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Shoulder release and tendon transfer is frequently performed to address persistent weakness from neonatal brachial plexus palsy. Although postoperative improvements in motion are well described, associated deficits are poorly documented, and functional assessments are lacking. Loss of ability to reach midline can occur with surgery and may result in impairment. The purpose of this study was to comprehensively assess the gains, losses, functional changes, and patient-reported outcome associated with the authors' surgical approach. METHODS Consecutive patients undergoing surgery with 2-year follow-up were included (n = 30). Prospectively recorded assessments by therapists were reviewed. Changes were assessed by t test and Wilcoxon rank sum (p < 0.05). RESULTS Active external rotation and abduction improved and internal rotation diminished. Aggregate modified Mallet score increased with improvements in all subscales, except that hand to spine was unchanged and hand to belly decreased. Functional assessment using the Brachial Plexus Outcome Measure revealed an increase of aggregate score, with no decline in any subscales. Improvements were in hand to back of head, forward overhead reach, holds plate with palm up, opening large container, and strings bead. Aggregate patient self-report of appearance and function increased (from 18 to 23). Loss of ability to reach midline occurred in three patients (10 percent) who had extended Erb or total palsy and preoperative limitations of internal rotation. CONCLUSIONS Secondary reconstruction rebalances shoulder motion by increasing external rotation and abduction and reducing internal rotation. In this study, a conservative surgical approach results in overall improvement in task-based abilities and self-reported outcomes and preservation of internal rotation within a functional range. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Widya Adidharma
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
| | - Sarah P Lewis
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
| | - Yusha Liu
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
| | - Marisa B Osorio
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
| | - Suzanne E Steinman
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
| | - Raymond W Tse
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
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11
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Burnier M, Le Hanneur M, Cambon-Binder A, Belkheyar Z. Isolated open anterior shoulder release in brachial plexus birth palsy. J Shoulder Elbow Surg 2019; 28:1347-1355. [PMID: 30981548 DOI: 10.1016/j.jse.2018.12.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 12/18/2018] [Accepted: 12/20/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND In children with brachial plexus birth palsy (BPBP), a shoulder joint internal contracture is commonly observed, which may result in glenohumeral osseous deformities and posterior joint subluxation. The purpose of this retrospective study was to evaluate the impact of an isolated anterior shoulder release on osteoarticular disorders and assess the subsequent clinical improvements. METHODS Forty consecutive BPBP patients with glenohumeral dysplasia underwent an open anterior shoulder release. Shoulder scans (ie, magnetic resonance imaging preoperatively and computed tomography postoperatively) were conducted to assess glenoid version and the percentage of the humeral head anterior to the middle of the glenoid fossa. Clinical data including analytical shoulder range of motion and modified Mallet scores were collected. RESULTS After a mean follow-up period of 23 months, glenoid version and the percentage of the humeral head anterior to the middle of the glenoid fossa significantly improved from -32° and 18%, respectively, to mean postoperative values of -12° (P < .001) and 45% (P < .001), respectively. Passive and active external rotation increased from -2° and -43°, respectively, to 76° (P < .001) and 54° (P < .001), respectively. The mean modified Mallet score significantly improved from 14.2 to 21.4 points (P < .001). In 8 children with satisfactory passive motion, a latissimus dorsi transfer was performed secondarily to obtain satisfactory active motion. CONCLUSION In BPBP patients with glenohumeral deformities, isolated open anterior release of the shoulder induces significant remodeling of the joint, reducing posterior joint subluxation and improving both passive and active shoulder ranges of motion. Additional latissimus transfer remains mandatory in selected cases to achieve satisfactory function.
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Affiliation(s)
- Marion Burnier
- Department of Hand and Upper Limb Surgery, Hôpital Edouard Herriot, Lyon, France; Department of Orthopedics, Service of Hand Surgery, Clinique du Mont Louis, Paris, France.
| | - Malo Le Hanneur
- Department of Orthopedics and Traumatology, Service of Hand, Upper Limb and Peripheral Nerve Surgery, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Adeline Cambon-Binder
- Department of Orthopedics and Traumatology, Service of Hand Surgery, Saint Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Zoubir Belkheyar
- Department of Orthopedics, Service of Hand Surgery, Clinique du Mont Louis, Paris, France
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Tora MS, Hardcastle N, Texakalidis P, Wetzel J, Chern JJ. Elbow flexion in neonatal brachial plexus palsy: a meta-analysis of graft versus transfer. Childs Nerv Syst 2019; 35:929-935. [PMID: 30923897 DOI: 10.1007/s00381-019-04133-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 03/20/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Functional elbow flexion recovery is one of the main goals of neonatal brachial plexus palsy (NBPP) reconstruction. The current neurosurgical treatment options include nerve grafting and nerve transfer. OBJECTIVE The present study sought to examine the literature for comparison of functional elbow flexion recovery in NBPP following nerve grafting or nerve transfer. We conducted a systematic literature review and meta-analysis according to PRISMA guidelines. A search was conducted on Pubmed/Medline and Cochrane for eligible studies published until November of 2018. Odd ratios (OR) and 95% confidence intervals (CI) were calculated to compare functional elbow flexion outcomes between nerve graft and nerve transfer. A random effects model meta-analysis was conducted. A Medical Research Council (MRC) score ≥ 3 or Active Movement Scale (AMS) ≥ 5 was considered a functional recovery of elbow flexion. RESULTS The present study included 194 patients from 1990 to 2015 across five observational trials. Only pediatric patients with obstetric brachial plexus injury were included. The mean patient age at surgery varied between studies from 5.7 months to 11.9 months and mean follow-up from 12 to 70 months. No complications or cases of donor site morbidity were reported. From the included studies, 118 patients were reported with MRC or AMS scoring usable for odd ratio comparison. Functional recovery occurred with nerve transfer in 95.2% of patients (n = 59/62) and with nerve grafting in 96.4% of patients (n = 54/56). Overall, the outcomes for elbow flexion between the groups appeared similar (OR 1.15, 95% CI 0.19-7.08, I2 2.9%). CONCLUSION Comparing nerve grafting and nerve transfer for NBPP, there is no statistically significant difference in functional elbow flexion recovery.
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Affiliation(s)
- Muhibullah S Tora
- Department of Neurosurgery, School of Medicine, Emory University Hospital, 101 Woodruff Circle, Suite 6204, Atlanta, GA, 30322, USA.
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA.
| | - Nathan Hardcastle
- Department of Neurosurgery, School of Medicine, Emory University Hospital, 101 Woodruff Circle, Suite 6204, Atlanta, GA, 30322, USA
| | - Pavlos Texakalidis
- Department of Neurosurgery, School of Medicine, Emory University Hospital, 101 Woodruff Circle, Suite 6204, Atlanta, GA, 30322, USA
| | - Jeremy Wetzel
- Department of Neurosurgery, School of Medicine, Emory University Hospital, 101 Woodruff Circle, Suite 6204, Atlanta, GA, 30322, USA
| | - Joshua J Chern
- Department of Neurosurgery, School of Medicine, Emory University Hospital, 101 Woodruff Circle, Suite 6204, Atlanta, GA, 30322, USA
- Children's Healthcare of Atlanta, Department of Neurosurgery, Egleston Hospital, Atlanta, GA, USA
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13
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Pehlivanoglu T, Erşen A, Bayram S, Atalar AC, Demirhan M. Arthroscopic versus open release of internal rotation contracture in the obstetrical brachial plexus paralysis (OBPP) sequela. J Shoulder Elbow Surg 2019; 28:28-35. [PMID: 30195621 DOI: 10.1016/j.jse.2018.06.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 06/01/2018] [Accepted: 06/13/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Latissimus dorsi (LD) and teres major (TM) tendon transfers are effective surgical procedures to improve shoulder abduction and external rotation for children with obstetrical brachial plexus palsy (OBPP). Open pectoralis major (PM) tendon Z-plasty and arthroscopic subscapularis (SS) release are 2 options for the release of internal rotation contractures to enhance muscle transfers. This study compared the functional results of LD and TM tendon transfers with open PM tendon Z-plasty or arthroscopic SS release. METHODS The study included 24 patients who underwent LD and TM tendon transfers for OBPP (9 arthroscopic SS release, 15 open PM tendon Z-plasty) with a mean follow-up of 41.33 months (range, 36-60 months) and 47.2 months (range, 36-60 months), respectively. Functional evaluation was made according to range of motion and Mallet scoring system. RESULTS Shoulder abduction-external rotation degrees and scores in all sections of the Mallet scoring system significantly increased in both groups (P < .001). Postoperatively, the arthroscopic SS release group had significantly better abduction degrees (P = .003), total Mallet scores (P < .001), and superior abduction (P = .043), active external rotation (P = .043), hand-to-head (P = .043), and hand-to-mouth (P < .001) scores for the Mallet scoring system. DISCUSSION Transfer of LD together with TM tendons combined with one of the internal rotation contracture release procedures yielded good clinical and functional results in patients younger than age 7, regardless of the type of release method. However, arthroscopic SS release, although requiring an experienced surgeon, revealed better clinical and functional outcomes and is considered to be a less invasive and superior method.
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Affiliation(s)
- Tuna Pehlivanoglu
- Department of Orthopaedic Surgery and Traumatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ali Erşen
- Department of Orthopaedic Surgery and Traumatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Serkan Bayram
- Department of Orthopaedic Surgery and Traumatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ata Can Atalar
- Department of Orthopaedic Surgery and Traumatology, Faculty of Medicine, Acıbadem University, Istanbul, Turkey.
| | - Mehmet Demirhan
- Department of Orthopaedic Surgery and Traumatology, School of Medicine, Koç University, Istanbul, Turkey
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Shah AS, Kalish LA, Bae DS, Peljovich AE, Cornwall R, Bauer AS, Waters PM. Early Predictors of Microsurgical Reconstruction in Brachial Plexus Birth Palsy. Iowa Orthop J 2019; 39:37-43. [PMID: 31413672 PMCID: PMC6604547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Microsurgical reconstruction is indicated for infants with brachial plexus birth palsy (BPBP) that demonstrate limited spontaneous neurological recovery. This investigation defines the demographic, perinatal, and physical examination characteristics leading to microsurgical reconstruction. METHODS Infants enrolled in a prospective multicenter investigation of BPBP were evaluated. Microsurgery was performed at the discretion of the treating provider/center. Inclusion required enrollment prior to six months of age and follow-up evaluation beyond twelve months of age. Demographic, perinatal, and examination characteristics were investigated as possible predictors of microsurgical reconstruction. Toronto Test scores and Hospital for Sick Children Active Movement Scale (AMS) scores were used if obtained prior to three months of age. Univariate and multivariate logistic regression analyses were performed. RESULTS 365 patients from six regional medical centers met the inclusion criteria. 127 of 365 (35%) underwent microsurgery at a median age of 5.4 months, with microsurgery rates and timing varying significantly by site. Univariate analysis demonstrated that several factors were associated with microsurgery including race, gestational diabetes, neonatal asphyxia, neonatal intensive care unit admission, Horner's syndrome, Toronto Test score, and AMS scores for finger/thumb/wrist flexion, finger/thumb extension, wrist extension, elbow flexion, and elbow extension. In multivariate analysis, four factors independently predicted microsurgical intervention including Horner's syndrome, mean AMS score for finger/thumb/ wrist flexion <4.5, AMS score for wrist extension <4.5, and AMS score for elbow flexion <4.5. In this cohort, microsurgical rates increased as the number of these four factors present increased from zero to four: 0/4 factors = 0%, 1/4 factors = 22%, 2/4 factors = 43%, 3/4 factors = 76%, and 4/4 factors = 93%. CONCLUSIONS In patients with BPBP, early physical examination findings independently predict microsurgical intervention. These factors can be used to provide counseling in early infancy for families regarding injury severity and plan for potential microsurgical intervention.Level of Evidence: Prognostic Level I.
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Affiliation(s)
- Apurva S. Shah
- The Children’s Hospital of Philadelphia, Division of Orthopaedics, Philadelphia, PA
| | - Leslie A. Kalish
- Boston Children’s Hospital, Department of Orthopaedic Surgery, Boston, MA
| | - Donald S. Bae
- Boston Children’s Hospital, Department of Orthopaedic Surgery, Boston, MA
| | | | - Roger Cornwall
- Cincinnati Children’s Hospital, Division of Orthopaedics, Cincinnati, OH
| | - Andrea S. Bauer
- Boston Children’s Hospital, Department of Orthopaedic Surgery, Boston, MA
| | - Peter M. Waters
- Boston Children’s Hospital, Department of Orthopaedic Surgery, Boston, MA
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