The Surgical Strategy to Correct the Rotational Imbalance of the Glenohumeral Joint after Brachial Plexus Birth Injury

Scapulothoracic and Glenohumeral Contributions to Humerothoracic Kinematics in Single Versus Double Tendon Transfers in Patients With Brachial Plexus Birth Injury

PURPOSE

Evidence suggests that patients with brachial plexus birth injury are more likely to retain midline function following a teres major tendon transfer without a concomitant latissimus dorsi transfer. Both procedures increase shoulder external rotation and abduction, but whether increased loss of midline frequency following double transfer is due to glenohumeral (GH) joint motion or scapulothoracic (ST) compensation is unknown. We hypothesized that double tendon transfers would exhibit greater GH external rotation than single tendon transfers, thus requiring greater ST rotation to internally rotate the shoulder, while GH and ST contributions to elevation remained equivalent between both groups.

METHODS

Twenty-six postsurgical children with C5/C6 brachial plexus birth injuries participated in this study. Thirteen patients with single tendon transfers were matched with 13 with double tendon transfer. Coordinate systems of the thorax, scapula, and humerus were measured utilizing motion capture in 6 arm positions. Joint angles were calculated by the helical (ST) and modified globe method (GH and humerothoracic [HT]). Differences between groups were compared with repeated measures of multivariate analyses of variance for each position. Pending significant multivariate analyses of variance, univariate analyses of variance determined joint differences between transfer groups.

RESULTS

Joint rotations from neutral were similar between groups in 5 of 6 tested positions, with double tendon transfers consistently demonstrating 15°-20˚ more internal rotation at the GH and HT joints. Still, only the internal rotation position showed statistically significant differences in GH and HT joint angles. The ST joint angles were similar in this position (45.2˚ and 48.5˚).

CONCLUSIONS

The arc of motion for patients with double tendon transfer was more internally rotated than in patients with single tendon transfer at the GH and HT joints for all positions. However, both groups demonstrated little active rotation from neutral. Based on this data, teres major-only tendon transfers may not reduce the risk of loss of midline function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Assessment of the relationship between Brachial Plexus Profile activity short form scores and modified Mallet scores

INTRODUCTION

This study aims to assess the relationship between the modified Mallet classification and the Brachial Plexus Profile activity short form (BP-PRO activity SF). The therapist or surgeon classifies upper extremity movement for the modified Mallet classification, while the BP-PRO assesses parents' perceptions of difficulty performing activities.

PURPOSE

To provide a deeper understanding of the relationship of functional and perceived outcome measurements.

STUDY DESIGN

Prospective, correlational design.

METHODS

Eighty children with brachial plexus birth injuries were evaluated using the modified Mallet classification, while parents simultaneously answered the BP-PRO activity SF questions. All patients had undergone one of three surgical interventions to improve shoulder function. The relationship between the two measures, patient injury levels, and surgical histories were assessed.

RESULTS

The average modified Mallet scores and BP-PRO activity SF scores weakly correlated (r = 0.312, P = .005) and both measures differentiated between C5-6 and C5-7 injury levels (P = .03 and P = .02, respectively). Conversely, the modified Mallet scores could differentiate between the three surgical groups (F = 8.2, P < .001), while the BP-PRO activity SF could not (P = .54).

CONCLUSION

The results suggest that these tools measure different aspects of patient outcomes. The Mallet classification may be more focused on shoulder motion than the BP-PRO activity SF. Additional questions that specifically require shoulder function could be incorporated into the BP-PRO activity SF to improve understanding of patient/parent perceptions of shoulder function for children with brachial plexus injuries. Clinicians should be aware of the strengths, weaknesses, and limitations of each outcome assessment tool for appropriate use and interpretation of results.

Improved long-term functional outcome after a latissimus dorsi transfer with or without subscapularis muscle lengthening or release

A brachial plexus birth injury (BPBI) can lead to a limited shoulder function, especially abduction and external rotation. One of the treatment options to restore those shoulder functions is a latissimus dorsi transfer (LDT). The aim of this study is to analyze long-term functional outcome after a single LDT and compare these results with LDT combined with subscapularis muscle lengthening (SSL) or subscapularis muscle release (SSR). This cohort study included 39 patients (≤12 years old) with one-sided BPBI. All patients had an inter- nal rotation- and adduction contracture without glenohumeral joint deformity. A LDT was performed with or without SSL or SSR, resulting in 3 patient study groups. Demographic data and pre- and post- operative Mallet scores were collected and analysed for each group. The median age was 4.0 years (IQR 3.1) and there were no differences in patient demographics. In all patients surgery improved external rotation and overall shoulder function, at 9.8 years follow-up. Also, the total Mallet score increased significantly with 1.7 (p=0.001) in our (entire) study cohort. A LDT, with a SSL or SSR in case of an intra-operative internal contracture, improves shoulder function and preserves external rotation in patients (≤12 years old) with BPBI, at a follow up of 9.8 years.

The Effect of Distal Transfer of the Spinal Accessory Nerve to the Suprascapular Nerve on the Shoulder Reanimation in Spontaneously Partially Recovered Obstetric Brachial Plexus Lesion

BACKGROUND

Spontaneous recovery of elbow flexion in obstetric brachial plexus palsy at 4 to 6 months of age is sufficient to exclude the child from the early microsurgical intervention. However, lack of complete active external rotation of shoulder is a common finding in such cases despite ongoing other arm and shoulder functions. Nerve transfer is proposed to manage such cases before the age of 18 months.

AIM

The aim of this study was to study the distal transfer of the spinal accessory nerve to the suprascapular nerve through posterior approach and its effect on the shoulder reanimation in patients with obstetric brachial plexus lesion who had spontaneously recovered biceps function but not shoulder function before the age of 18 months.

PATIENTS AND METHODS

This prospective study included 20 patients admitted to Elhadra University Hospital with obstetric brachial plexus lesion aged between 10 and 18 months with spontaneous recovery of biceps function, weak active shoulder abduction grade 4 or grade 5 and deficient active shoulder external rotation. All patients were assessed preoperative and postoperative by Active Movement Scale.

RESULTS

Active shoulder external rotation improved in all patients at the end of follow-up period, whereas the shoulder abduction improved in 80%. Early surgery in patient younger than 16 months shows better results.

CONCLUSIONS

The distal transfer of spinal accessory nerve to suprascapular nerve is an effective method for active shoulder abduction and external rotation recovery in spontaneously recovered elbow flexion in obstetric brachial plexus lesions. Better results are obtained in patients younger than 16 months old. Early transfer balances the forces around the shoulder joint, preventing shoulder internal rotation contracture.

The Pathogenesis of Glenohumeral Deformity and Contracture Formation in Obstetric Brachial Plexus Palsy-A Review

Contractures of the shoulder joint and glenohumeral joint dysplasia are well known complications to obstetrical brachial plexus palsy. Despite extensive description of these sequelae, the exact pathogenesis remains unknown. The prevailing theory to explain the contractures and glenohumeral joint dysplasia states that upper trunk injury leads to nonuniform muscle recovery and thus imbalance between internal and external rotators of the shoulder. More recently, another explanation has been proposed, hypothesizing that denervation leads to reduced growth of developing muscles and that reinnervation might suppress contracture formation. An understanding of the pathogenesis is desirable for development of effective prophylactic treatment. This article aims to describe the current state of knowledge regarding these important complications.

Oberlin transfer compared with nerve grafting for improving early supination in neonatal brachial plexus palsy

OBJECTIVE The use of nerve transfers versus nerve grafting for neonatal brachial plexus palsy (NBPP) remains controversial. In adult brachial plexus injury, transfer of an ulnar fascicle to the biceps branch of the musculocutaneous nerve (Oberlin transfer) is reportedly superior to nerve grafting for restoration of elbow flexion. In pediatric patients with NBPP, recovery of elbow flexion and forearm supination is an indicator of resolved NBPP. Currently, limited evidence exists of outcomes for flexion and supination when comparing nerve transfer and nerve grafting for NBPP. Therefore, the authors compared 1-year postoperative outcomes for infants with NBPP who underwent Oberlin transfer versus nerve grafting. METHODS This retrospective cohort study reviewed patients with NBPP who underwent Oberlin transfer (n = 19) and nerve grafting (n = 31) at a single institution between 2005 and 2015. A single surgeon conducted intraoperative exploration of the brachial plexus and determined the surgical nerve reconstruction strategy undertaken. Active range of motion was evaluated preoperatively and postoperatively at 1 year. RESULTS No significant difference between treatment groups was observed with respect to the mean change (pre- to postoperatively) in elbow flexion in adduction and abduction and biceps strength. The Oberlin transfer group gained significantly more supination (100° vs 19°; p < 0.0001). Forearm pronation was maintained at 90° in the Oberlin transfer group whereas it was slightly improved in the grafting group (0° vs 32°; p = 0.02). Shoulder, wrist, and hand functions were comparable between treatment groups. CONCLUSIONS The preliminary data from this study demonstrate that the Oberlin transfer confers an advantageous early recovery of forearm supination over grafting, with equivalent elbow flexion recovery. Further studies that monitor real-world arm usage will provide more insight into the most appropriate surgical strategy for NBPP.