Congenital muscular torticollis: long-term follow-up of thirty-eight partial resections of the sternocleidomastoid muscle

Sternocleidomastoid Muscle Flap in an Older Patient With Congenital Muscular Torticollis

Congenital muscular torticollis (CMT) is caused by muscle damage during childbirth, tumors, or masses within the muscles and generally resolves with physical therapy during infancy. In this study, we performed reconstruction after resection of a parotid gland tumor using a sternocleidomastoid muscle (SCMM) flap in an older patient with neglected CMT. The patient was a 64-year-old woman who had had a left-sided oblique neck since infancy but had never received any treatment, including physical therapy. She underwent parotid tumor resection and SCMM flap transfer. The SCMM flap can be safely elevated using indocyanine green fluorescence angiography, with the middle pedicle serving as the feeding vessel to fill the parotid defect. Three months after surgery, the torticollis had improved and the cheek depression was not noticeable, indicating the effectiveness of surgical treatment for CMT in older patients and the possibility of using SCMM as a muscle flap.

Clinical Results after Release of Sternocleidomastoid Muscle Surgery for Neglected Congenital Muscular Torticollis-Unipolar vs. Bipolar Release Surgery

BACKGROUND

Although the surgical release of the sternocleidomastoid muscle (SCM) is required for residual congenital muscular torticollis (CMT), the surgical outcomes between bipolar and unipolar SCM release remained unclear. The purpose of the present study was to assess surgical outcomes after bipolar and unipolar release of SCM in adolescent/adult patients with neglected CMT.

METHODS

Twenty-one consecutive adolescent/adult patients with neglected CMT who underwent surgical treatment were enrolled. Clinical and radiographic outcomes were evaluated at preoperative and final follow-up.

RESULTS

The bipolar release of SCM was performed in 3 patients (B group; males, n = 1, females, n = 2) and the unipolar release of SCM in 18 patients (U group; males, n = 6, females, n = 12). The mean age at surgery was 40.0 ± 17.0 years in Group B, and that was 32.3 ± 13.1 years in Group U (p = 0.47). The mean follow-up period was 16.0 ± 5.7 months in Group B and 10.4 ± 7.6 months in Group U (p = 0.22). Cervicomandibular angle correction rates were comparable at 75.4 ± 2.4% for the B group and 73.1 ± 11.7% for the U group (p = 0.62). There was no significant difference in clinical outcome according to the modified Cheng and Tang score between the two groups (p = 0.89). No major complications arose, although one patient exhibited a transient neurological deficit of the greater auricular nerve, and one patient developed a hematoma in the B group.

CONCLUSIONS

The unipolar SCM release appeared to be a non-inferiority and less invasive procedure, minimizing surgical scars and avoiding potential auricular nerve damage in adolescent/adult patients with neglected CMT.

Surgical Treatment of Congenital Muscular Torticollis: Significant Improvement in Health-related Quality of Life Among a 2-year Follow-up Cohort of Children, Adolescents, and Young Adults

OBJECTIVE

Surgical treatment of congenital muscular torticollis (CMT) has been proven clinically effective in cases that fail to normalize after conservative treatment, but reports on self-reported outcome and quality of life have been scarce. This study aimed to assess health-related quality of life (HRQoL) in children, adolescents, and young adults undergoing surgical treatment for CMT, comparing HRQoL with clinical outcomes.

METHODS

We conducted a level 2 prospective observational study on a surgically treated CMT cohort at a single tertiary center. The surgeries focused on releasing all tightness, and the medial head was routinely elongated to preserve cosmetic function. Patients underwent rigorous pre/postoperative assessments and follow-up. A strict postoperative protocol entailing stretching, physiotherapy, and positional exercises was adhered to for a minimum of 6 months. The Cheng and Tang torticollis scoring system and PedsQLTM 4.0 generic core scales were used to evaluate clinical outcome and HRQoL, respectively.

RESULTS

The study included 31 patients, averaging 11.4 years. Significant improvements in range of motion, deformities, and overall subjective satisfaction were observed 2 years postoperatively. The Cheng and Tang score improved overall significantly from fair (9.9 points) to excellent (17.9 points) after 2 years ( P <0.001). The oldest patients showed less improvement than the youngest ones, especially regarding craniofacial asymmetry ( P =0.004). Patient PedsQL scores significantly improved 2 years post-surgery ( P =0.040), with no discernable age differences.

CONCLUSION

Our findings demonstrated significant improvements in both HRQoL and clinical outcomes after surgical treatment of CMT. The PedsQL score seemed sensitive to the clinical changes.

Outcome of surgical treatment for neglected congenital muscular torticollis: A series of 28 adolescent patients

Background:

Congenital muscular torticollis (CMT) is a common musculoskeletal anomaly that can be excellently managed at birth with conservative physiotherapy; as a result, literature on neglected cases of CMT in older patients is sparse, and there is controversy regarding the ideal surgical approach. This report aims to provide the outcome of 28 adolescent patients with neglected CMT who underwent unipolar release at the distal sternocleidomastoid muscle (SCM).

Methods:

Twenty-eight adolescent patients with untreated CMT presented to our department between 2016 and 2019 and underwent unipolar release at the distal end of their SCM. All patients had no other anomaly based on clinical examination and radiological investigations. At the time of surgery, the mean age of patients was 15.8 years (range 13–18 years). There were 10 male and 18 female patients with the right side affected in 20 cases. All patients were followed up for 2 years. Patients were evaluated using an adapted version of the modified Lee’s scoring system to assess cosmesis and the cervical-mandibular angle (CMA) to assess radiological change.

Results:

The adapted modified Lee’s scoring system indicated 17 patients (60.7%) had an excellent outcome, 6 patients (21.4%) had a good outcome, and 5 patients (17.9%) had a fair outcome. In particular, scarring was fine in 23 patients (82.1%) and only slight in the remaining. Independent to the categorical outcome, all patients subjectively reported high satisfaction with their cosmesis. The preoperative mean CMA was 19.6° (range, 8.5–31.5°), which was reduced to a mean of CMA of 14.0° (range, 3–28°) after surgery (P < 0.05). No patient developed any permanent complication or required surgery for recurrence. No serious postoperative complications such as infection or hematoma were observed.

Conclusion:

In uncomplicated cases of neglected CMT in adolescent patients, unipolar tenotomy of the distal SCM is a safe and reliable technique with good clinical outcomes.

Endoscopic release of congenital muscular torticollis with radiofrequency in teenagers

Background

Congenital muscular torticollis (CMT) is due to contracture of the sternocleidomastoid muscle which may cause activity limitations of the neck, tilt of the head, craniofacial asymmetry, and deformity of the skull. The authors present their experience of arthroscopic tight fibrous band release with radiofrequency in teenagers under local anesthesia and evaluate the clinical results.

Methods

A total of 69 patients who underwent arthroscopic release of CMT with radiofrequency under local anesthesia by a single surgeon could participate in this study. Before operation, surface landmarks of sternocleidomastoid muscle, bone, and neurovascular structures were marked. Local infiltrating anesthesia of the surgical region was then performed. Through a working space created by blunt dissection, the arthroscopy and radiofrequency devices were introduced. Then, the clavicular and sternal heads of the sternocleidomastoid muscle were identified and gradually transected. The patients were followed up postoperatively with Cheng’s scoring system.

Results

There were 31 male patients and 38 female patients. The mean age of the patients was 16.1 years. The mean length of follow-up in this series was 36.7 months (range, 28 to 67 months). During the operation, 62 patients (89.9%) had no pain, 6 patients (8.7%) felt mild pain, and only 1 patient (1.4%) regarded the procedure as very painful. At all follow-up periods, there were no repeat arthroscopies for any of these patients. At the final follow-up, the average rotation deficit improved from 22.5° to 4.1° postoperatively, and the average lateral bending deficit improved from 14.6° to 3.3° (p < 0.05). Overall, the clinical result was good or excellent in 65 patients (94.2%), fair in 4 patients, and poor in 0 patients within the follow-up period according to Cheng’s scoring system. To date, no patients had any intraoperative or postoperative complications from this procedure.

Conclusion

The arthroscopic release with radiofrequency under local anesthesia provides surgeons with an alternative to traditional open techniques for the management of congenital muscular torticollis (CMT). Our date shows that this method is minimally invasive and provides good functional recovery with a lower risk of complications.

Effectiveness of Surgical Treatment for Neglected Congenital Muscular Torticollis: A Systematic Review and Meta-Analysis

BACKGROUND

Findings on the effectiveness of surgical release for neglected congenital muscular torticollis have been conflicting. This systematic review aims to examine the literature describing the effectiveness of surgery for neglected congenital muscular torticollis.

METHODS

The authors conducted a systematic review to examine the effectiveness of surgical treatment for neglected congenital muscular torticollis by means of meta-analysis. The authors searched MEDLINE, EMBASE, the Cochrane library, and KoreaMed for all articles published before May of 2014. Studies with quantitative data describing the effectiveness of surgery for congenital muscular torticollis were included. The primary outcomes after surgery were (1) clinical outcome measured by scoring systems; (2) change in range of motion of the neck; and (3) change in skeletal deformities, measured by Cobb angle and the cervicomandibular angle. Effect estimates were pooled using a random-effects meta-analysis.

RESULTS

Twelve studies were included in the review (published between 1976 and 2014), including a total of 220 patients with neglected congenital muscular torticollis. All studies used an interrupted time-series design. Surgical treatment was successful in 81 percent of cases, based on the scoring systems for surgical outcome. Outcomes of surgery performed in patients older than 15 years did not differ significantly from those of surgery performed in patients aged 15 years or younger. The range of motion of the neck and skeletal deformities showed significant improvement after surgery.

CONCLUSIONS

Surgical treatment for neglected congenital muscular torticollis produced satisfactorily successful results, with improvement in both the range of motion of the neck and secondary skeletal deformities.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Arthroscopic surgical treatment for neglected congenital muscular torticollis in adults

BACKGROUND

Congenital muscular torticollis (CMT) is the third most common congenital musculoskeletal anomaly. The efficacy of surgical treatment of neglected CMT after skeletal maturity in adults remains controversial. The aim of this retrospective study was to determine the efficacy of arthroscopic release of the sternocleidomastoid (SCM) muscle for the treatment of neglected CMT in adult cases.

METHODS

From April 2008 to July 2013, a total of 20 adult patients (9 men and 11 women) with a mean age of 23.0 years were surgically treated for neglected CMT with local anesthesia. The SCM muscle and clavicle were preoperatively marked. Through an artificial lacuna, an arthroscope and a radiofrequency probe were inserted. The sternal and clavicular attachments were dissected and divided via radiofrequency. Clinical evaluation was assessed using a modified Cheng and Tang score.

RESULTS

The operation was successfully completed in all the patients. Follow-up examinations from 12 to 40 months in the 20 patients showed complete muscular release and satisfactory cosmetic appearance with no recurrence. There was no evidence of serious complications. The neck scars were no longer visible after several weeks. According to the modified Cheng and Tang scale, 11 patients displayed an excellent result and 9 patients had a good result.

CONCLUSIONS

Arthroscopic release of the SCM muscle with local anesthesia is a simple and effective way to surgically manage neglected CMT without any risk for either damage to the neurovascular structures or leaving visible scars.

Application of cicatricial contracture release principles in muscular torticollis treatment

BACKGROUND

Numerous surgical approaches for muscular torticollis are not effective enough to completely release the contracture and prevent further development of craniofacial asymmetry. Cosmetically unacceptable scars on the neck and compulsory functional exercises after surgery were also common problems. We applied the therapeutic principle of scar contracture to the surgical treatment of muscular torticollis. Surgical incision determination and the postoperative protocol were considerably improved. Satisfactory results were obtained.

METHOD

According to the therapeutic principle of scar contracture, complete release of the contracted muscles and peripheral streak fascia and release or partial resection of peripheral normal tissues such as the scalenus anterior, anterior trapezius border, platysma, and partial carotid sheath are required to release all the affected contracted and tightened tissues. We chose to incise underneath the affected side of the clavicular border. We obtained a tension-free closure of the incision through an advanced skin flap of the inferior incision sutured on the clavicular fascia. Maximum head and neck stretch to the unaffected side of the shoulder when the patient lied down gave the affected side lateral decubitus position after surgery.

RESULTS

Satisfactory results were obtained and no complications were identified for all of the 104 patients. The development of craniofacial asymmetry and progressive deformities was prevented. The incision scar appeared linear in the pit above or below the clavicle border and was relatively inconspicuous.

CONCLUSION

The application of the therapeutic principle of scar contracture to the surgical treatment of muscular torticollis was successful.

Is it Time for Cementless Hip Resurfacing?

BACKGROUND

Metal-on-metal bearing with cemented femoral component and cementless acetabular fixation is the current standard in surface replacement arthroplasty (RSA) of the hip. Because of concerns about the long-term survivorship of cemented stems in conventional hip arthroplasty, it seems logical to achieve cementless fixation on the femoral side with RSA.

QUESTIONS/PURPOSES

The goals of this review were to evaluate clinical and radiological data reported from previously published cementless RSA series. In addition, we intend to review author's preliminary experience with Conserve Plus cementless devices specifically assessing the clinical outcomes, the complications rate, the survivorship, and the metallic ions levels measured in follow-up.

METHODS

A references search was done with PubMed using the key words "cementless hip resurfacing", "cementless hip resurfacing prosthesis", and "femoral cementless hip resurfacing". Additionally, the clinical outcomes, the complications rate, the survivorship, and the metallic ions levels were measured in 94 cementless Conserve Plus(©) devices in 90 patients (68 males and 22 females) with a mean age of 41.1 years (18-59). Mean follow-up was 13.1 months (8-16).

RESULTS

No revision was performed during the observed follow-up. Neither radiological signs of loosening nor neck narrowing >10% were evident. Chromium and cobalt levels in whole blood samples rose respectively from 0.53 μg/l (0.1-1.7) to 1.7 μg/l (0.6-2.9) and from 0.54 μg/l (0.1-1.4) to 1.98 μg/l (0.1-2.8).

CONCLUSIONS

Cementless "fit and fill" femoral-side fixation, which seems to be potentially evolved and design-related, should be considered for future hip-resurfacing device generations.

Use of a rugby helmet brace for postoperative treatment of muscular torticollis

Prior to 1992, our postoperative management for congenital muscular torticollis consisted of either plaster cast immobilization or no immobilization, depending on the patient's age and the degree of contracture. However, some patients required further surgery and developed complications. In 1992, we produced rugby helmet braces for postoperative management. The purpose of this study was to compare the clinical results of the previous postoperative management with the results achieved using rugby helmet braces. Twenty-five children aged younger than 6 years underwent caudal partial resection of the sternocleidomastoid muscle. Twelve children aged 6 years and older underwent cranial tenotomy. These 37 patients were divided into 2 groups: no immobilization or plaster immobilization (group A; n=19) and rugby helmet braces (group B; n=18). Canale's method was used for evaluation of clinical results. In group A, the results were good in 12 patients, fair in 4, and poor in 3, whereas all 18 patients in group B had good results. Two patients in group A required further surgery, and complications were observed in 5 patients. In group B, alopecia areata was observed in 1 patient.The rugby helmet brace is easy to put on and remove, providing good retention and allowing for physiotherapy. It provides a useful method of postoperative management for congenital muscular torticollis.

Clinical features and outcome of physiotherapy in early presenting congenital muscular torticollis with severe fibrosis on ultrasonography: a prospective study

BACKGROUND

It has been reported that ultrasonography (US) can detect the severity of congenital muscular torticollis (CMT), and severe fibrosis of the sternocleidomastoid (SCM) muscle noted on US is irreversible and likely to require surgery. Clinical outcome of CMT depends mainly on the patient's age, which is also associated with the severity of fibrosis as determined by US. However, there has been no well-designed study to elucidate the true relationship among these factors nor a definite consensus on treatment of young infants with severe fibrosis in the SCM compared with well-documented reports that late cases require surgery.

PURPOSE

The purpose of the current study was to investigate whether severity of SCM fibrosis on US is correlated with clinical severity and outcome of standardized physiotherapy in early presenting CMT.

METHODS

Fifty patients with a palpable neck mass, initial deficit of passive neck rotation (ΔROT) more than 10°, and age less than 3 months were classified into 4 US types according to the severity of fibrosis in the SCM and underwent standardized physiotherapy and regular assessment. Relationship between US types and 2 variables (ΔROT and treatment duration) and success rate of physiotherapy was assessed.

RESULTS

None of the cases was classified as type 4. Type 3 showed greatest ΔROT and longest mean treatment duration. Both variables showed a significant linear trend of association with US types by P for trend (P = .003, P < .001, respectively). Treatment was "successful" in 49 patients (98%).

CONCLUSION

In young infants with CMT, US can document severity; and an early and adequate physiotherapy is a good treatment option, particularly even in those with severe fibrosis.

Adult presentation of congenital muscular torticollis

Adult presentation of neglected congenital muscular torticollis is rare. We report 12 patients with this condition who underwent a modified Ferkel’s release comprising a bipolar release of sternocleidomastoid with Z-lengthening. They had a mean age of 24 years (17 to 31) and were followed up for a minimum of two years. Post-operatively a cervical collar was applied for three weeks with intermittent supervised active assisted exercises for six weeks. Outcome was assessed using a modified Lee score and a Cheng and Tang score. The mean pre-operative rotational deficit was 8.25° (0° to 15°) and mean lateral flexion deficit was 20.42° (15° to 30°), which improved after treatment to a mean of 1.67° (0° to 5°) and 7.0° (4° to 14°) after treatment, respectively. According to the modified Lee scoring system, six patients had excellent results, two had good results and four had fair results, and using the Cheng and Tang score, eight patients had excellent results and four had good results.

Surgical management of adult patients with neglected congenital muscular torticollis using a modified Ferkel’s bipolar release gives excellent results. The range of neck movement and head tilt improved in all 12 patients and cosmesis improved in 11, despite the long-standing nature of the deformity.

Diagnosis of fibromatosis colli by fine-needle aspiration

Fibromatosis colli is a benign disorder presenting as a neck mass in neonates and older children. The differential diagnosis includes malignancies such as rhabdomyosarcoma. Neck masses in ten infants, discovered between the second and sixth week of age, were evaluated by fine-needle aspiration (FNA). The male to female ratio was 7:3. In 8 patients there was good obstetrical history. Six of the 8 patients had a difficult delivery, as indicated by breech presentation or the need for forceps. Diagnostic aspirations were performed between the second to ninth week of age. The major cytologic finding was benign spindle fibroblasts, usually arrayed in clusters. The cells possessed plump, ovoid nuclei. There were also multinucleated cells consistent with degenerating skeletal muscle fibers. Only one case demonstrated significant inflammation. FNA can provide a rapid and reliable diagnosis in fibromatosis colli. There is support for the idea that in this setting, the disorder is related to perinatal muscular trauma.

New surgical technique for the correction of congenital muscular torticollis (wry neck)

Congenital muscular torticollis (wry neck) results from shortening of the sternocleidomastoid muscle and may lead to limitation of neck movement and craniofacial deformity. If conservative treatment is started early, with a regimen of passive stretching exercises and active strengthening of the contralateral muscle, about 95% of patients achieve an acceptable range of neck movement. The surgical management of patients who do not respond to physiotherapy remains controversial. Its aim is to provide a long-term, cosmetic restoration of neck mobility while minimizing the development of craniofacial deformity and upper cervical scoliosis; few previously advocated techniques achieve both these goals. We describe a technique that combines subperiosteal lengthening of the sternocleidomastoid muscle at its mastoid insertion, and division of lower fibrotic bands with minimal postoperative fibrosis. As the sternomastoid muscle is reattached lower down on the mastoid process, the lengthening of the muscle is stable, because the tendency to fibrosis and shortening is minimized. Comparison of the results with previous series shows that this technique provides immediate benefit and good long-term results.

Correlation of clinical and ultrasonographic features in congenital muscular torticollis

OBJECTIVE

To find the relationship between the ultrasonographic pictures and the clinical features of patients with congenital muscular torticollis (CMT).

DESIGN

Prospective survey of patients with clinically suspected CMT by high-resolution ultrasonography.

SETTING

Rehabilitation department of a tertiary care center.

PARTICIPANTS

Two hundred fifty-six CMT patients, from the ages of 9 days to 16yrs, with a mean follow-up period of 6.7 months.

MAIN OUTCOME MEASURES

Correlation of the ultrasound appearance of the involved sternocleidomastoid (SCM) muscles with clinical features. The pathologic findings in diseased muscles from patients who underwent surgical intervention were also evaluated.

RESULTS

Muscle abnormalities were identified ultrasonographically in 218 CMT patients (85%) and were classified into four types: a fibrotic mass in the involved muscle (type I, 15%); diffuse fibrosis mixing with normal muscle (type II, 77%) and without normal muscle in the involved muscle (type III, 5%); and a fibrotic cord in the involved muscle (type IV, 3%). Compared with type I patients, type IV patients were more likely to undergo surgical treatment (odds ratio = 31.54, p = .0196). Type III patients were more likely to undergo surgical treatment, although this tendency was not statistically significant.

CONCLUSION

Ultrasonography can precisely identify pathologic changes in the involved SCM muscle of CMT patients. Type III and IV patients are more likely to require surgical intervention.