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Delioğlu K, Unes S, Tuncdemir M, Ozal C, Bıyık KS, Uzumcugil A. Interrater reliability of face-to-face, tele- and video-based assessments with the modified Mallet classification in brachial plexus birth injuries. J Hand Surg Eur Vol 2024; 49:576-582. [PMID: 37684022 DOI: 10.1177/17531934231196118] [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] [Indexed: 09/10/2023]
Abstract
The modified Mallet classification is widely used to measure motor function in brachial plexus birth injuries. The aim of the study was to investigate agreement and reliability of this classification under three different evaluation conditions: face-to-face; live tele-assessment; and delayed video-based assessment. A total of 100 children aged 4-15 years were included. Children were assessed by two raters except for live tele-assessment, which was performed by four raters. Agreement between the three different assessment conditions for the same rater were between strong and excellent for both raters 1 and 2. The interrater reliability for raters 1 and 2 under different assessment conditions was strong to excellent. Interrater reliability among the four raters was moderate to strong in tele-assessment. The modified Mallet classification may have appropriate reliability to be used in remote medical follow-up.Level of evidence: III.
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Affiliation(s)
- Kıvanç Delioğlu
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Sefa Unes
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Merve Tuncdemir
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Cemil Ozal
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Kubra Seyhan Bıyık
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Akin Uzumcugil
- Department of Orthopedics and Traumatology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Ogilvie KM, Mah AML, Klar K, Anthony A, Davidge KM, Clarke HM, Ho ES. Prevalence and predictors of elbow flexion contractures during early childhood following brachial plexus birth injury. J Hand Ther 2024:S0894-1130(23)00130-8. [PMID: 38342639 DOI: 10.1016/j.jht.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 08/10/2023] [Accepted: 09/16/2023] [Indexed: 02/13/2024]
Abstract
BACKGROUND Elbow flexion contracture development in school-age children with a brachial plexus birth injury (BPBI) is common. Reports indicate onset between 2 and 4 years; however, little is known about early childhood prevalence, development, and trajectory of these contractures. PURPOSE To determine the prevalence and predictors of BPBI elbow flexion contractures during early childhood. STUDY DESIGN A retrospective cross-sectional study. METHODS Demographic, diagnostic, treatment, and elbow contracture data were collected for children with a BPBI <4 years between 2015 and 2019 from a prospectively collected database. Spinal root motor contributions and injury were determined using Active Movement Scale (AMS) scores at 6 weeks of age and used to predict contracture development. RESULTS Of the 171 children that met inclusion criteria, 87% (n = 149) had upper plexus injuries. The mean age at the time of evaluation for an elbow contracture was 21.4 ± 12.7 months. The prevalence of elbow flexion contractures was 22% (n = 38), with mean onset at 13.4 ± 11.0 months. Mean contracture degree was -10.8 ± -6.9 degrees with 76% (n = 29) <-10 degrees. AMS shoulder abduction, flexion, and external rotation; elbow flexion; forearm supination; and wrist extension scores at a mean 2.3 ± 1.4 months were significantly lower in children who developed elbow flexion contractures (p < 0.001). Logistic regression found that low AMS elbow flexion with high elbow extension scores were a significant (p < 0.003) predictor of elbow contracture development. CONCLUSIONS The prevalence of elbow flexion contractures in early childhood is greater than previously understood. These findings indicate that C5-C6 injury affecting elbow flexion with relative preservation of elbow extension is a predictor of contracture development. Further research is needed to investigate the nature and sequelae of C5-C6 injury and its effects on elbow flexion contracture development.
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Affiliation(s)
- Karen M Ogilvie
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada; Alberta Health Services, Calgary, Canada
| | - Allison M L Mah
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Karen Klar
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Alison Anthony
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Kristen M Davidge
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Howard M Clarke
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Canada; Department of Surgery, University of Toronto, Toronto, Canada
| | - Emily S Ho
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada; Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Canada.
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Porcellini G, Montemagno M, Manzini C, Fiumana G, Giorgini A, Micheloni G, Tarallo L. Reverse shoulder arthroplasty in obstetric brachial plexus injury: our experience with shoulder motion analysis. J Orthop Traumatol 2023; 24:59. [PMID: 37947898 PMCID: PMC10638338 DOI: 10.1186/s10195-023-00736-0] [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: 04/11/2023] [Accepted: 10/18/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Obstetric brachial plexus injury (OBPI) is a weakening or paralysis of the upper arm caused by brachial plexus injury followed by a muscle paralysis with severe repercussions on the movement of the shoulder joint following a progressive glenohumeral joint deformity. This case series analyzes the clinical and radiological outcomes of reverse total shoulder arthroplasty (RSA) in OBPI patients with a follow-up of 2 years. MATERIALS AND METHODS OBPI patients with secondary end-stage glenohumeral arthritis were enrolled in the study and they were treated with RSA. Patient demographics and clinical outcomes [Range of Motion (ROM), Visual Analog Scale (VAS), Oxford Shoulder Score (OSS)] were evaluated. A novel Shoulder motion analysis was carried out to investigate specific movement patterns of scapulothoracic movements in these patients. This study is a prospective cohort study. RESULTS Four Patients (M: F = 1:3) were enrolled in the study, the mean age was 49.3 years (+ 2.75), the mean OSS (Oxford Shoulder Score) decreased from 48.8 (± 2.5) preoperatively to 18.30 (± 2.78), the mean VAS (Visual Analog Scale) decreased from 7.25 (± 0.5) to 1.7 (± 0.3) in the follow up (∆% relative pain reduction:- 76.5%), Shoulder ROM obtained an improvement (p < 0.05) except for abduction and external rotation. The average follow-up time was 26.3 months (+- 4.5). Shoulder motion analysis showed a complete loss of the scapular tilting above 90 degrees of flexion compared to the typical one of standard RSA with a pattern shifted towards scapular retraction (engaging trapezius and rhomboid muscles) to compensate the loss of the posterior tilting. CONCLUSIONS RSA in OBPI patients demonstrated a significant improvement of pain symptoms and a moderate improvement in daily activities, anyway with a more appreciable quality of life over time even if the marked hypotrophy especially of the posterior shoulder muscles showed some limits in maintaining suspension of the upper limb and a minor external rotation, with an internal rotation attitude during the movements. LEVEL OF EVIDENCE Level IV, Case series.
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Affiliation(s)
- Giuseppe Porcellini
- Orthopedic and Traumatology Department, University of Modena and Reggio Emilia, Modena, Italy.
| | - Marco Montemagno
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-San Marco, University of Catania, Catania, Italy
| | - Chiara Manzini
- Orthopedic and Traumatology Department, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Andrea Giorgini
- Orthopedic and Traumatology Department, University of Modena and Reggio Emilia, Modena, Italy
| | - Gianmario Micheloni
- Orthopedic and Traumatology Department, University of Modena and Reggio Emilia, Modena, Italy
| | - Luigi Tarallo
- Orthopedic and Traumatology Department, University of Modena and Reggio Emilia, Modena, Italy
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Delioğlu K, Uzumcugil A, Öztürk E, Bıyık KS, Ozal C, Gunel MK. Cut-off values of internal rotation in the glenohumeral joint for functional tasks in children with brachial plexus birth injury. J Hand Surg Eur Vol 2023; 48:738-746. [PMID: 36788751 DOI: 10.1177/17531934231154362] [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] [Indexed: 02/16/2023]
Abstract
The aim of this study was to determine the cut-off values of the range of internal rotation motion in the isolated glenohumeral joint that is required for functional tasks in children with an upper root injury of the brachial plexus. Internal rotation motion was measured using a universal goniometer in 97 participants. The Mallet Hand to Spine and Mallet Hand to Belly tasks were assessed as functional tasks that require internal rotation of the shoulder. For the Hand to Spine task, 41° passive and 30° active internal rotation were necessary to reach the S1 level. For the Hand to Belly task, 42° passive and 29° active internal rotation were required to place the palm on the belly without wrist flexion. Of our participants, 97% could touch the belly with or without wrist flexion, but 28% could not reach S1 in the Hand to Spine task. The results of this study show the necessary amount of internal rotation of the shoulder that should be considered in treatment strategies.Level of evidence: III.
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Affiliation(s)
- Kıvanç Delioğlu
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Akin Uzumcugil
- Faculty of Medicine, Department of Orthopedics and Traumatology, Hacettepe University, Ankara, Turkey
| | - Ebru Öztürk
- Faculty of Medicine, Department of Biostatistics, Hacettepe University, Ankara, Turkey
| | - Kubra Seyhan Bıyık
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Cemil Ozal
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Mintaze Kerem Gunel
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
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Wong VCY, Balumuka D, Tuen YJ, Bucevska M, Courtemanche R, Durlacher K, Bellows D, Hynes S, Verchere C. How Institution of the Sup-ER Protocol in a Clinic Changed Procedure Patterns in Upper Brachial Plexus (Erb's Type) Birth Injuries. Hand (N Y) 2023:15589447231184896. [PMID: 37452572 DOI: 10.1177/15589447231184896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND For children with upper brachial plexus birth injury (BPBI; C5, C6, ±C7 roots), most clinics first recommend nonsurgical treatment followed by primary and/or secondary surgical interventions in selected patients. Since 2008, we have used an infant shoulder repositioning protocol (supination-external rotation [Sup-ER]) designed to prevent shoulder internal rotation contracture and its potential effects on the shoulder joint. This study characterizes our clinic's current choice, number, and timing of primary and secondary procedural interventions (including Botox) and compares Sup-ER protocol patients with those of our historical controls. METHODS The records of all patients with upper BPBI who underwent procedures from 2001 to 2018 were retrospectively reviewed and grouped into a historical (2001-2007, n = 20) and recent (2008-2018, n = 23) cohort. Patient demographics, procedure types and timing, and functional outcomes were collected and analyzed. RESULTS Since the 2008 institution of the Sup-ER protocol, fewer brachial plexus exploration and grafting (BPEG) surgeries were performed and none in later infancy, where nerve transfers were preferred. There were more and earlier Botox injections. There were fewer tendon transfers, and the preoperative indications were from a higher level of function. CONCLUSIONS We now see fewer indications for BPEG surgeries overall. After the 3-month-age group, more direct nerve transfers are indicated instead of the BPEG surgery if nerve surgery is required at all. Shoulder tendon transfer rates have decreased. Humeral osteotomies are not seen in our recent group. Glenoid osteotomies within tendon transfers are rare in both groups.
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Affiliation(s)
| | | | | | | | | | - Kim Durlacher
- British Columbia Children's Hospital, Vancouver, Canada
| | - Doria Bellows
- British Columbia Children's Hospital, Vancouver, Canada
| | - Sally Hynes
- University of British Columbia, Vancouver, Canada
- British Columbia Children's Hospital, Vancouver, Canada
| | - Cynthia Verchere
- University of British Columbia, Vancouver, Canada
- British Columbia Children's Hospital, Vancouver, Canada
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Zargarbashi R, Rabie H, Panjavi B, Kamran H, Mosalamiaghili S, Erfani Z, Mirghaderi SP, Salimi M. Glenoid osteotomy with various tendon transfers for brachial plexus birth palsy: clinical outcomes. J Shoulder Elbow Surg 2023; 32:e60-e70. [PMID: 36115612 DOI: 10.1016/j.jse.2022.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 07/20/2022] [Accepted: 07/27/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Posterior shoulder dislocation is one of the disabling complications of brachial plexus birth injury (BPBI), and various treatment options including capsule and surrounding muscles release for open reduction, humeral derotational osteotomy, and tendon transfers have been recommended to manage it. In the present study, we aimed to determine the clinical outcome of open reduction with soft tissue release, tendon transfer, and glenoid osteotomy in patients with BPBI and posterior shoulder dislocation or subluxation. METHODS From 2018 to 2020, 33 patients who underwent open reduction, glenoid osteotomy, and tendon transfer were included. The glenohumeral deformity was classified according to the Waters radiographic classification. Functional assessment was performed using the Mallet grading system before and at least 2 years after the surgery. RESULTS The patients were monitored for 26.88 ± 5.47 months. Their average age was 27.5 ± 14 months. Significant improvement was seen in the overall Mallet score (from 13.5 to 18.91 points) and its segments including hand-to-mouth, hand-to-neck, global abduction, global external rotation, abduction range of motion (ROM), and external rotation ROM. Hand-to-back score and the presence of a Trumpet sign were significantly decreased in the postoperation phase (all P values < .001). The above-mentioned variables significantly changed for both infantile and noninfantile dislocations. CONCLUSION Our study demonstrated that open reduction along with glenoid osteotomy improves retroversion, and muscle strengthening with different muscle transfers is an effective technique for BPBI.
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Affiliation(s)
- Ramin Zargarbashi
- Pediatric Orthopaedic Surgery, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran
| | - Hamid Rabie
- Orthopaedic Surgery Department, Shariati Hospital and School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Behnam Panjavi
- Pediatric Orthopaedic Surgery, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran
| | - Hooman Kamran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Zohre Erfani
- Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Peyman Mirghaderi
- Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Salimi
- Bone and Joint Diseases Research Center, Department of Orthopedic Surgery, Shiraz University of Medical Sciences, Shiraz, Iran.
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Ulmann ETE, Malessy MJA, Nagels J, Pondaag W. Shoulder Internal Rotation Contracture Formation in Surgically Managed C5, C6 Brachial Plexus Birth Injuries: Neurotmetic Lesions Fare Worse Than Avulsions. J Bone Joint Surg Am 2022; 104:2008-2015. [PMID: 36083976 DOI: 10.2106/jbjs.22.00373] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND A typical feature in infants with severe C5-C6 brachial plexus birth injury (BPBI) requiring nerve repair is the formation of shoulder internal rotation contracture (IRC). The underlying pathophysiological mechanism is unknown, and the sequelae can be difficult to treat. The severity of the IRC differs among children. C5-C6 lesions are heterogeneous at the root level. Our null hypothesis was that the type of root-level lesion (axonotmesis or neurotmesis versus avulsion) was not associated with the extent of IRC formation over time in children with upper-trunk BPBI. METHODS We performed a retrospective analysis of all patients with upper-trunk BPBI who underwent primary surgery of the C5 and/or C6 spinal nerves between 1990 and 2020 and had follow-up of at least 2 years. The primary outcome was passive shoulder external rotation (ER) in adduction at 1, 3, 5, 7, and 15 years of age. The secondary outcome was whether additional shoulder surgery was performed. The relationship between the nature of the C5-C6 lesion and IRC formation was analyzed using linear mixed models. The Kaplan-Meier method was used to estimate the cumulative risk of secondary shoulder procedures. RESULTS In total, 322 patients were analyzed; mean follow-up was 7.2 ± 4.6 years. The C5-C6 root lesion type was significantly related to the passive range of ER (overall test in linear mixed model, p = 0.007). Children with avulsion of C5 and C6 (n = 21) had, on average, 18° (95% confidence interval [CI], 6.3° to 30°) less IRC formation than those with neurotmesis of C5 and C6 (n = 175) and 17° (2.9° to 31°) less than those with neurotmesis of C5 and avulsion of C6 (n = 34). IRC formation did not differ between the neurotmesis C5-C6 and neurotmesis C5-avulsion C6 groups. Secondary shoulder procedures were performed in 77 patients (10-year risk, 28% [95%CI, 23% to 34%]). CONCLUSIONS Shoulder IRC formation in infants with BPBI with surgically treated C5-C6 lesions occurs to a lesser degree if the C5 root is avulsed than when C5 is neurotmetic. This finding provides insight into the possible causative pathoanatomy and may ultimately lead to strategies to mitigate IRC. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Eva T E Ulmann
- Department of Neurosurgery, Leiden Nerve Center, Leiden University Medical Center, Leiden, the Netherlands
| | - Martijn J A Malessy
- Department of Neurosurgery, Leiden Nerve Center, Leiden University Medical Center, Leiden, the Netherlands
| | - Jochem Nagels
- Department of Orthopedic Surgery, Leiden Nerve Center, Leiden University Medical Center, Leiden, the Netherlands
| | - Willem Pondaag
- Department of Neurosurgery, Leiden Nerve Center, Leiden University Medical Center, Leiden, the Netherlands
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Forrester LA, Fang F, Jacobsen T, Hu Y, Kurtaliaj I, Roye BD, Guo XE, Chahine NO, Thomopoulos S. Transient neonatal shoulder paralysis causes early osteoarthritis in a mouse model. J Orthop Res 2022; 40:1981-1992. [PMID: 34812543 PMCID: PMC9124737 DOI: 10.1002/jor.25225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 11/08/2021] [Accepted: 11/20/2021] [Indexed: 02/04/2023]
Abstract
Neonatal brachial plexus palsy (NBPP) occurs in approximately 1.5 of every 1,000 live births. The majority of children with NBPP recover function of the shoulder. However, the long-term risk of osteoarthritis (OA) in this population is unknown. The purpose of this study was to investigate the development of OA in a mouse model of transient neonatal shoulder paralysis. Neonatal mice were injected twice per week for 4 weeks with saline in the right supraspinatus muscle (Saline, control) and botulinum toxin A (BtxA, transient paralysis) in the left supraspinatus muscle, and then allowed to recover for 20 or 36 weeks. Control mice received no injections, and all mice were sacrificed at 24 or 40 weeks. BtxA mice exhibited abnormalities in gait compared to controls through 10 weeks of age, but these differences did not persist into adulthood. BtxA shoulders had decreased bone volume (-9%) and abnormal trabecular microstructure compared to controls. Histomorphometry analysis demonstrated that BtxA shoulders had higher murine shoulder arthritis scale scores (+30%), and therefore more shoulder OA compared to controls. Articular cartilage of BtxA shoulders demonstrated stiffening of the tissue. Compared with controls, articular cartilage from BtxA shoulders had 2-fold and 10-fold decreases in Dkk1 and BMP2 expression, respectively, and 3-fold and 14-fold increases in Col10A1 and BGLAP expression, respectively, consistent with established models of OA. In summary, a brief period of paralysis of the neonatal mouse shoulder was sufficient to generate early signs of OA in adult cartilage and bone.
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Affiliation(s)
- Lynn Ann Forrester
- Department of Orthopedic Surgery, Columbia University, New York, New York, USA
| | - Fei Fang
- Department of Orthopedic Surgery, Columbia University, New York, New York, USA
| | - Timothy Jacobsen
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Yizhong Hu
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Iden Kurtaliaj
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Benjamin D. Roye
- Department of Orthopedic Surgery, Columbia University, New York, New York, USA
| | - X. Edward Guo
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Nadeen O. Chahine
- Department of Orthopedic Surgery, Columbia University, New York, New York, USA
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Stavros Thomopoulos
- Department of Orthopedic Surgery, Columbia University, New York, New York, USA
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
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Sarac C, Nelissen RGHH, van der Holst M, Malessy MJA, Pondaag W. Differences in the perspectives of functioning and health in the ICF model between patients with brachial plexus birth injury and their parents versus healthcare professionals. Disabil Rehabil 2022; 45:1805-1810. [PMID: 35611466 DOI: 10.1080/09638288.2022.2075475] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE To explore and compare the perspectives of patients and their parents (PPs) with a brachial plexus birth injury (BPBI) with those of health care professionals (HCPs). MATERIALS AND METHODS We conducted a study using a questionnaire among PPs and HCPs. Importance of different outcome categories was scored on a Likert scale. Items were linked to corresponding categories of the International Classification of Functioning, Disability and Health. Means were compared using analysis of variance (ANOVA). RESULTS Data were collected from 184 patients and 65 HCPs. We found a difference in 7/14 outcome categories between joint PP groups and HCPs. Parents scored outcome evaluation categories as more important than patients, categories filled out together by patient and parent scored in between (p < 0.05). The majority of PPs and HCPs rated outcome assessment as important in more domains than "Body functions" and "Body structures". The biggest difference was found in the importance of evaluation of pain. CONCLUSIONS Outcome assessment in the domains "Activities and participation" and "Environmental factors" was rated as important by both PPs and HCPs. Evaluation of pain was more often scored as important by PPs. Different domains seem to be underestimated by HCPs and need more attention during consultation. Implications for rehabilitationThe importance of outcome evaluation concerning "Pain", "Interaction with peers", and "Interaction with medical and paramedical specialists" should be taken into account in the rehabilitation for this specific group of patients and their parents (PPs).Comparison of perspectives on functioning between brachial plexus birth injury (BPBI) PPs and health care professionals.Outcome assessment in domains "Activities and participation" and "Environmental factors" is important.Health care professionals undervalue the importance of pain evaluation in BPBI as compared with PPs.
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Affiliation(s)
- Cigdem Sarac
- Department of Orthopaedics, Rehabilitation and Physical Therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - Rob G H H Nelissen
- Department of Orthopaedics, Rehabilitation and Physical Therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno van der Holst
- Department of Orthopaedics, Rehabilitation and Physical Therapy, Leiden University Medical Center, Leiden, The Netherlands.,Basalt Rehabilitation, Leiden, The Netherlands
| | - Martijn J A Malessy
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem Pondaag
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
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Delioğlu K, Uzumcugil A, Gunel M. Activity-based hand-function profile in preschool children with obstetric brachial plexus palsy. HAND SURGERY & REHABILITATION 2022; 41:487-493. [DOI: 10.1016/j.hansur.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 04/03/2022] [Accepted: 05/16/2022] [Indexed: 11/28/2022]
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Alabau-Rodriguez S, Romero-Larrauri P, Soldado F. Glenohumeral abduction contractures after residual neonatal brachial plexus injury. J Hand Surg Eur Vol 2022; 47:243-247. [PMID: 34521296 DOI: 10.1177/17531934211045509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Glenohumeral abduction contractures are common in patients with neonatal brachial plexus injury, but little has been previously published about them. We conducted a retrospective analysis of data prospectively collected from 205 consecutive children (108 female) of mean age 9.6 years with neonatal brachial plexus injury (C5-C6, 58%; C5-C7, 29%; C5-T1, 14%). Most children (69%) showed a glenohumeral abduction contracture, it being more common in those with upper neonatal brachial plexus injury.Level of evidence: III.
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Affiliation(s)
- Sergi Alabau-Rodriguez
- Hand, Elbow & Microsurgery Department, Hospital Universitari Quiron-Dexeus, Barcelona, Spain
| | | | - Francisco Soldado
- International Pediatric Hand Surgery and Microsurgery Institute, Barcelona University Childrens Hospital, Barcelona, Spain
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12
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McNeely MM, Chang KWC, Smith BW, Justice D, Daunter AK, Yang LJS, McGillicuddy JE. Knowledge of neonatal brachial plexus palsy among medical professionals in North America. Childs Nerv Syst 2021; 37:3797-3807. [PMID: 34406450 DOI: 10.1007/s00381-021-05310-9] [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: 07/19/2021] [Accepted: 07/24/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Early referral of neonatal brachial plexus palsy (NBPP) patients to multidisciplinary clinics is critical for timely diagnosis, treatment, and improved functional outcomes. In Saudi Arabia, inadequate knowledge regarding NBPP is a reason for delayed referral. We aimed to evaluate the knowledge of North American healthcare providers (HCPs) regarding the diagnosis, management, and prognosis of NBPP. METHODS A 12-question survey regarding NBPP was distributed via electronic and paper formats to North American providers from various referring and treating specialties. NBPP knowledge was compared between Saudi Arabian vs. North American providers, referring vs. treating specialties, academic vs. community hospitals, and providers with self-reported confidence vs. nonconfidence in NBPP knowledge. RESULTS Of the 273 surveys collected, 45% were from referring providers and 55% were from treating providers. Saudi Arabian and North American HCPs demonstrated similar NBPP knowledge except for potential etiologies for NBPP and surgery timing. In North America, referring and treating providers had similar overall knowledge of NBPP but lacked familiarity with its natural history. A knowledge gap existed between academic and community hospitals regarding timing of referral/initiation of physical/occupational therapy (PT/OT) and Horner's syndrome. Providers with self-reported confidence in treating NBPP had greater knowledge of types of NBPP and timing for PT/OT initiation. CONCLUSIONS Overall, North American providers demonstrated adequate knowledge of NBPP. However, both eastern and western physicians remain overly optimistic in believing that most infants recover spontaneously. This study revealed a unique and universal knowledge gap in NBPP diagnosis, referral, and management worldwide. Continuous efforts to increase NBPP knowledge are indicated.
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Affiliation(s)
- Molly M McNeely
- School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Brandon W Smith
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Denise Justice
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Alecia K Daunter
- Physical Medicine & Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Lynda J-S Yang
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
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13
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Massamba Vuvu T, Dorniol M, Le Nen D, Thépaut M, Brochard S, Pons C. Effect of arthroscopic shoulder release on shoulder mobility and bone deformity following brachial plexus birth injury: a systematic review and meta-analysis. J Shoulder Elbow Surg 2021; 30:2428-2437. [PMID: 33567353 DOI: 10.1016/j.jse.2020.12.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/20/2020] [Accepted: 12/27/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Specific information to guide clinical practice is lacking for the effects of arthroscopic release on bone and joint deformities, as well as the additional benefits of tendon transfer, in children with brachial plexus birth injury. The aims of this study were (1) to evaluate changes in shoulder mobility and bone and joint deformity, (2) to evaluate the effect of release with and without tendon transfer on the same outcomes, and (3) to evaluate the perioperative and long-term complications. METHODS We conducted a systematic review and meta-analysis. Four databases were searched using relevant inclusion and exclusion criteria from inception until May 2020. The quality of articles was evaluated using the Methodological Index for Non-randomized Studies (MINORS) scale. Data regarding patients, interventions, and clinical and radiologic outcomes were reported. RESULTS Thirteen articles were included: 6 of low quality and 7 of moderate quality separated into 17 studies (266 children). The mean follow-up duration was 32.4 months (standard deviation, 15.2 months). Arthroscopic release significantly improved the Mallet score (standardized mean difference [SMD], 3.1 [95% confidence interval (CI), 1.5-4.7]; P < .001) and passive external rotation (SMD, 3.6 [95% CI, 2.3-4.9]; P = .02). The percentage of humeral head anterior (SMD, 1.3 [95% CI, 0.7-1.9]; P = .003) and glenoid retroversion (SMD, 1.4 [95% CI, 0.9-2]; P = .01) also improved. Descriptive analysis of the data suggested that concomitant tendon transfer further improved mobility. Recurrence of internal-rotation contracture was reported in 8 of 157 children. DISCUSSION This systematic review showed that arthroscopic release effectively improves both shoulder mobility and bone deformity, with few complications in young children with brachial plexus birth injury. As such, it seems reasonable to propose a stepwise approach starting with a release without transfer.
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Affiliation(s)
- Tatiana Massamba Vuvu
- Hand Surgery Unit, Orthopaedic Surgery Department, Centre Hospitalier Régional Universitaire (CHRU) La Cavale Blanche, Brest, France; Paediatric Surgery Department, Centre Hospitalier Régional Universitaire (CHRU) Morvan, Brest, France; Université de Bretagne Occidentale, Brest, France.
| | - Morgane Dorniol
- Hand Surgery Unit, Orthopaedic Surgery Department, Centre Hospitalier Régional Universitaire (CHRU) La Cavale Blanche, Brest, France; Université de Bretagne Occidentale, Brest, France
| | - Dominique Le Nen
- Hand Surgery Unit, Orthopaedic Surgery Department, Centre Hospitalier Régional Universitaire (CHRU) La Cavale Blanche, Brest, France; Université de Bretagne Occidentale, Brest, France
| | - Matthias Thépaut
- Paediatric Surgery Department, Centre Hospitalier Régional Universitaire (CHRU) Morvan, Brest, France; Université de Bretagne Occidentale, Brest, France
| | - Sylvain Brochard
- Physical Medicine and Rehabilitation Department, Centre Hospitalier Régional Universitaire (CHRU) Brest, Brest, France; Laboratoire de Traitement de l'Information Médicale, Inserm U1101, Université de Bretagne Occidentale, Brest, France; Pediatric Rehabilitation Department, Fondation Ildys, Brest, France
| | - Christelle Pons
- Physical Medicine and Rehabilitation Department, Centre Hospitalier Régional Universitaire (CHRU) Brest, Brest, France; Laboratoire de Traitement de l'Information Médicale, Inserm U1101, Université de Bretagne Occidentale, Brest, France; Pediatric Rehabilitation Department, Fondation Ildys, Brest, France
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Kluemper C, Aversano M, Kozin S, Zlotolow DA. Long Thoracic Nerve Transfer for Children With Brachial Plexus Injuries. J Pediatr Orthop 2021; 41:374-378. [PMID: 34096554 DOI: 10.1097/bpo.0000000000001774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The transfer of intraplexal and extraplexal nerves for restoration of function in children with traumatic and birth brachial plexus palsies has become well accepted. Little has been written about using the long thoracic nerve (LTN) as a donor in reanimation of the upper extremity. The authors present a case series of nerve transfers using the LTN as a donor in brachial plexus injury. METHODS A retrospective chart review was performed over a 10-year period at a single institution. The primary outcome measure was the active movement scale. RESULTS Fourteen patients were included in the study: 10 birth injury patients and 4 blunt trauma patients. Average follow-up time was 21.3 and 10.75 months, respectively. The best outcomes were seen when the LTN was used for reinnervation of the obturator nerve in free functioning muscle transfers. The next most successful recipients were the musculocutaneous and axillary nerves. Outcomes were poor in transfers to the posterior interosseous fascicles of the radial nerve and the radial nerve branches to the triceps. DISCUSSION The LTN may be a potential nerve donor for musculocutaneous or axillary nerve reinnervation in patients with brachial plexus injuries when other donors are not available during a primary plexus reconstruction. However, the best use may be for delayed neurotization of a free functioning muscle transfer after the initial plexus reconstruction has failed and no other donors are available. LEVEL OF EVIDENCE Level IV-therapeutic study.
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Affiliation(s)
| | | | - Scott Kozin
- Shriners Hospital for Children, Philadelphia, PA
| | - Dan A Zlotolow
- Philadelphia Hand to Shoulder Center.,Shriners Hospital for Children, Philadelphia, PA
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De Joode S, Germawi L, Schotanus M, Van der Lingen J, Van Mulken T, Van Nie F, Samijo S. Improved long-term functional outcome after a latissimus dorsi transfer with or without subscapularis muscle lengthening or release. Acta Orthop Belg 2021. [DOI: 10.52628/87.1.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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Dixit NN, McCormick CM, Cole JH, Saul KR. Influence of Brachial Plexus Birth Injury Location on Glenohumeral Joint Morphology. J Hand Surg Am 2021; 46:512.e1-512.e9. [PMID: 33358583 PMCID: PMC8180483 DOI: 10.1016/j.jhsa.2020.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/12/2020] [Accepted: 10/20/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Patient presentation after brachial plexus birth injury (BPBI) is influenced by nerve injury location; more contracture and bone deformity occur at the shoulder in postganglionic injuries. Although bone deformity after postganglionic injury is well-characterized, the extent of glenohumeral deformity after preganglionic BPBI is unclear. METHODS Twenty Sprague-Dawley rat pups received preganglionic or postganglionic neurectomy on a single forelimb at postnatal days 3 to 4. Glenohumeral joints on affected and unaffected sides were analyzed using micro-computed tomography scans after death at 8 weeks after birth. Glenoid version, glenoid inclination, glenoid and humeral head radius of curvature, and humeral head thickness and width were measured bilaterally. RESULTS The glenoid was significantly more declined in affected compared with unaffected shoulders after postganglionic (-17.7° ± 16.9°) but not preganglionic injury. Compared with the preganglionic group, the affected shoulder in the postganglionic group exhibited significantly greater declination and increased glenoid radius of curvature. In contrast, the humeral head was only affected after preganglionic but not postganglionic injury, with a significantly smaller humeral head radius of curvature (-0.2 ± 0.2 mm), thickness (-0.2 ± 0.3 mm), and width (-0.3 ± 0.4 mm) on the affected side compared with the unaffected side; changes in these metrics were significantly associated with each other. CONCLUSIONS These findings suggest that glenoid deformities occur after postganglionic BPBI but not after preganglionic BPBI, whereas the humeral head is smaller after preganglionic injury, possibly suggesting an overall decreased biological growth rate in this group. CLINICAL RELEVANCE This study expands understanding of the altered glenoid and humeral head morphologies after preganglionic BPBI and its comparisons with morphologies after postganglionic BPBI.
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Affiliation(s)
| | - Carolyn M. McCormick
- North Carolina State University, Raleigh, NC,University of North Carolina, Chapel Hill, NC
| | - Jacqueline H. Cole
- North Carolina State University, Raleigh, NC,University of North Carolina, Chapel Hill, NC
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17
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Bachy M, Lallemant P, Grimberg J, Fitoussi F. Palliative shoulder and elbow surgery in obstetrical brachial plexus birth palsy. HAND SURGERY & REHABILITATION 2021; 41S:S63-S70. [PMID: 34058395 DOI: 10.1016/j.hansur.2020.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 08/29/2018] [Accepted: 05/08/2020] [Indexed: 11/26/2022]
Abstract
Palliative surgery in a child with incomplete recovery following obstetric brachial plexus birth palsy (BPBP) is common. Surgical management strategies for BPBP sequelae have the common objectives of decreasing the risk of functional limitations in the long term and improving function. There is no single treatment to deal with the sequelae of BPBP. While there is a myriad of possible clinical presentations, the ages for surgery extend from a 6- to 12-month-old infant to the mature adolescent. Numerous procedures have been described in the literature, ranging from simple soft tissue release to muscular transfers and osteotomies. The indications will depend on a combination of all these factors. In certain cases, an early intervention is recommended to prevent joint deformities, and to allow joint remodeling, often at the shoulder. In other cases, the indications are less clear, thus the expected benefit must be carefully considered. The indications for these operations must meet certain rules to be beneficial for the patient and should only be considered after a comprehensive clinical examination and a commitment from the child and the family to the therapeutic strategy.
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Affiliation(s)
- M Bachy
- Service de Chirurgie Orthopédique et Réparatrice de l'Enfant, Hôpital Armand Trousseau, APHP, 26, Avenue du Dr Arnold Netter, 75012 Paris, France.
| | - P Lallemant
- Service de Chirurgie Orthopédique et Réparatrice de l'Enfant, Hôpital Armand Trousseau, APHP, 26, Avenue du Dr Arnold Netter, 75012 Paris, France
| | - J Grimberg
- Service de Chirurgie Orthopédique et Réparatrice de l'Enfant, Hôpital Armand Trousseau, APHP, 26, Avenue du Dr Arnold Netter, 75012 Paris, France
| | - F Fitoussi
- Service de Chirurgie Orthopédique et Réparatrice de l'Enfant, Hôpital Armand Trousseau, APHP, 26, Avenue du Dr Arnold Netter, 75012 Paris, France
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18
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Alabau-Rodriguez S, Hodgson F, Soldado F. Glenohumeral adduction contractures with residual neonatal brachial plexus injury. J Hand Surg Eur Vol 2021; 46:432-434. [PMID: 33143536 DOI: 10.1177/1753193420968384] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Sergi Alabau-Rodriguez
- Hand, Elbow & Microsurgery Department - icatMA (ICATME) Hospital Universitari Quiron-Dexeus, Barcelona, Spain
| | - Felipe Hodgson
- Department of Orthopaedic Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Soldado
- International Pediatric Hand Surgery and Microsurgery Institute, Barcelona University Childrens Hospital HM Nens, Barcelona, Spain.,Unidad UCA Mikel Sanchez, Vitoria, Spain
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19
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Sénès FM, Nucci AM, Valore A, Catena N. Corrective Procedure for Flexion Contracture of the Elbow in Neonatal Palsy Sequelae: Long-term Follow-up. Indian J Orthop 2021; 55:452-459. [PMID: 34306560 PMCID: PMC8275703 DOI: 10.1007/s43465-020-00316-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 11/16/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Aim of this paper is to validate a procedure for correcting elbow flexion contracture in patients suffering from brachial plexus neonatal palsy sequelae during their teens. Elbow flexion contracture represents an unsolved problem in the natural history of obstetric brachial plexus palsy (OBPP) because of the consistent deformity recurrence. Following a previous paper, in which an original technique was proposed in a small sample of patients, the authors show the possible correction of the deformity in a larger group of patients. METHODS The procedure includes a combination of a posterior approach to the elbow with olecranon tip section and an anterior one with capsulotomy and soft tissue release to improve elbow range of motion. A series of 26 patients, who underwent the procedure, were checked out in medium and long term. Collected data were age, type of brachial plexus palsy, length of hospitalization, duration of surgery, preoperative and postoperative elbow range of motion, preoperative and postoperative DASH scores and satisfaction scores. Explaining further details about the procedure, the Authors report their results, including a statistical analysis. RESULTS At the final follow-up, the mean increase of elbow extension was about 22°. Functional outcomes were successful as well, with a mean increase of 10 points of DASH score. Over 75% of patients were fully satisfied with their outcome. CONCLUSIONS The outcome has confirmed the good efficacy of the procedure in increasing elbow extension but also in improving cosmetic appearance in adolescents suffering from flexed elbow in OBPP sequelae.
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Affiliation(s)
- Filippo Maria Sénès
- grid.419504.d0000 0004 1760 0109Hand Surgery and Reconstructive Microsurgery Unit, IRCSS Giannina Gaslini Institute, Via Gerolamo Gaslini 5, 16147 Genoa, Italy
| | - Anna Maria Nucci
- Traumatology and Orthopedics Unit, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Via Paradisa 2, 56125 Pisa, Italy
| | - Annalisa Valore
- grid.419504.d0000 0004 1760 0109Hand Surgery and Reconstructive Microsurgery Unit, IRCSS Giannina Gaslini Institute, Via Gerolamo Gaslini 5, 16147 Genoa, Italy
| | - Nunzio Catena
- Pediatric Orthopedic and Traumatology Unit, Children’s Hospital, AON SS Antonio E Biagio E Cesare Arrigo, Spalto Marengo 46, 15121 Alessandria, Italy
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20
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Dixit NN, McCormick CM, Warren E, Cole JH, Saul KR. Preganglionic and Postganglionic Brachial Plexus Birth Injury Effects on Shoulder Muscle Growth. J Hand Surg Am 2021; 46:146.e1-146.e9. [PMID: 32919794 PMCID: PMC7864858 DOI: 10.1016/j.jhsa.2020.07.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 05/22/2020] [Accepted: 07/20/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE Brachial plexus birth injury can differ in presentation, depending on whether the nerve ruptures distal to, or avulses proximal to, the dorsal root ganglion. More substantial contracture and bone deformity at the shoulder is typical in postganglionic injuries. However, changes to the underlying muscle structure that drive these differences in presentation are unclear. METHODS Seventeen Sprague-Dawley rats received preganglionic or postganglionic neurectomy on a single limb on postnatal days 3 and 4. Muscles crossing the shoulder were retrieved once the rats were sacrificed at 8 weeks after birth. External rotation range of motion, muscle mass, muscle length, muscle sarcomere length, and calculated optimal muscle length were measured bilaterally. RESULTS Average shoulder range of motion in the postganglionic group was 61.8% and 56.2% more restricted at 4 and 8 weeks, respectively, compared with that in the preganglionic group, but affected muscles after preganglionic injury were altered more severely (compared with the unaffected limb) than after postganglionic injury. Optimal muscle length in preganglionic injury was shorter in the affected limb (compared with the unaffected limb: -18.2% ± 9.2%) and to a greater extent than in postganglionic injury (-5.1% ± 6.2%). Muscle mass in preganglionic injury was lower in the affected limb (relative to the unaffected limb: -57.2% ± 24.1%) and to a greater extent than in postganglionic injury (-28.1% ± 17.7%). CONCLUSIONS The findings suggest that the presence of contracture does not derive from restricted longitudinal muscle growth alone, but also depends on the extent of muscle mass loss occurring simultaneously after the injury. CLINICAL RELEVANCE This study expands our understanding of differences in muscle architecture and the role of muscle structure in contracture formation for preganglionic and postganglionic brachial plexus birth injury.
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Affiliation(s)
- Nikhil N. Dixit
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh
| | - Carolyn M. McCormick
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh;,the Joint Department of Biomedical Engineering, University of North Carolina Chapel Hill and North Carolina State University, Chapel Hill and Raleigh, NC
| | - Eric Warren
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh
| | - Jacqueline H. Cole
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh;,the Joint Department of Biomedical Engineering, University of North Carolina Chapel Hill and North Carolina State University, Chapel Hill and Raleigh, NC
| | - Katherine R. Saul
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh
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21
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Gkiatas I, Kostas-Agnantis I, Batistatou A, Kosmas D, Korompilia M, Gelalis I, Pakos E, Vekris M, Korompilias A. Neonatal brachial plexus injuries and their impact on growing bone. An experimental study. Injury 2020; 51:2851-2854. [PMID: 32122625 DOI: 10.1016/j.injury.2020.02.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 02/17/2020] [Accepted: 02/21/2020] [Indexed: 02/02/2023]
Abstract
Neonatal brachial plexus palsy remains a problem, even in light of current advances in perinatal care. While many cases resolve spontaneously, the concern remains on the best means of surgical management for restoration of elbow flexion and shoulder reanimation. The present experimental study in an animal model examines the evidence that supports that neonatal brachial plexus injuries result in structural changes in the affected bone. The study suggests that if the microsurgical reinnervation takes place early enough, these changes may be diminished. On the other hand there is no way to identify at birth, which injuries will be permanent and will need surgical repair and which will spontaneously improve.
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Affiliation(s)
- Ioannis Gkiatas
- Department of Orthopaedic Surgery, University of Ioannina, School of Medicine, Ioannina, Greece.
| | - Ioannis Kostas-Agnantis
- Department of Orthopaedic Surgery, University of Ioannina, School of Medicine, Ioannina, Greece
| | - Anna Batistatou
- Department of Pathology, University of Ioannina, School of Medicine, Ioannina, Greece
| | - Dimitrios Kosmas
- Department of Orthopaedic Surgery, University of Ioannina, School of Medicine, Ioannina, Greece
| | - Maria Korompilia
- Department of Orthopaedic Surgery, University of Ioannina, School of Medicine, Ioannina, Greece
| | - Ioannis Gelalis
- Department of Orthopaedic Surgery, University of Ioannina, School of Medicine, Ioannina, Greece
| | - Emilios Pakos
- Department of Orthopaedic Surgery, University of Ioannina, School of Medicine, Ioannina, Greece
| | - Marios Vekris
- Department of Orthopaedic Surgery, University of Ioannina, School of Medicine, Ioannina, Greece
| | - Anastasios Korompilias
- Department of Orthopaedic Surgery, University of Ioannina, School of Medicine, Ioannina, Greece
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22
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Conjoint muscle transfer and subscapularis slide in brachial plexus birth palsy: Clinical outcomes in shoulder functions. Med J Armed Forces India 2020; 77:181-186. [PMID: 33867635 DOI: 10.1016/j.mjafi.2020.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 05/11/2020] [Indexed: 11/20/2022] Open
Abstract
Background Shoulder deformity and inadequate shoulder function in brachial plexus birth palsy (BPBP) occur due to imbalance between the shoulder abductors, external rotators, adductors and internal rotators. This is due to cross innervation of the regenerating axons and subsequent target muscle innervation. These lead to internal rotation deformity along with glenohumeral dysplasia. Conjoint muscle transfer in the form of latissimus dorsi and teres major muscle combined with release and slide of subscapularis muscle improves shoulder functions. This study aims to evaluate the outcomes of shoulder function after a simultaneous conjoint muscle transfer and subscapularis slide in the management of BPBP. Methods 18 children with BPBP, who presented with shoulder deformity and inadequate shoulder functions, underwent conjoint muscle transfer along with subscapularis muscle slide. At 18 months, shoulder functions were assessed preoperatively and postoperatively using Mallet score system and range of motions. Statistical analysis was performed to ascertain if the outcomes were statistically significant. Results Mean age was 4.64 years with a mean preoperative Mallet score of 10.89 ± 1.60 and mean postoperative Mallet score of 16.22 ± 1.86. At 18 months, mean gain in shoulder abduction at 18 months was 57.22 ± 16.11° with external rotation of 26.66 ± 7.67°. All children showed improvement in shoulder functions. There was no correlation between the clinical outcomes and age of the child. Conclusion This procedure was effective in improving shoulder functions in a cohort of patients. The long-term effect of this procedure, however, remains to be evaluated by further follow-up and with similar such studies.
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Mazal AT, Faramarzalian A, Samet JD, Gill K, Cheng J, Chhabra A. MR neurography of the brachial plexus in adult and pediatric age groups: evolution, recent advances, and future directions. Expert Rev Med Devices 2020; 17:111-122. [PMID: 31964194 DOI: 10.1080/17434440.2020.1719830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: MR neurography (MRN) of the brachial plexus has emerged in recent years as a safe and accurate modality for the identification of brachial plexopathies in pediatric and adult populations. While clinical differentiation of brachial plexopathy from cervical spine-related radiculopathy or nerve injury has long relied upon nonspecific physical exam and electrodiagnostic testing modalities, MRN now permits detailed interrogation of peripheral nerve anatomy and pathology, as well as assessment of surrounding soft tissues and musculature, thereby facilitating accurate diagnosis. The reader will learn about the current state of brachial plexus MRN, including recent advances and future directions, and gain knowledge about the adult and pediatric brachial plexopathies that can be characterized using these techniques.Areas Covered: The review details recent developments in brachial plexus MRN, including increasing availability of 3.0-T MR scanners at both private and academic diagnostic imaging centers, as well as the advent of multiple new vascular and fat signal suppression techniques. A literature search of PubMed and SCOPUS was used as the principal source of information gathered for this review.Expert Opinion: Refinement of fat-suppression, 3D techniques and diffusion MR imaging modalities has improved the accuracy of MRN, rendering it as a useful adjunct to clinical findings during the evaluation of suspected brachial plexus lesions.
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Affiliation(s)
- Alexander T Mazal
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ali Faramarzalian
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Jonathan D Samet
- Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kevin Gill
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Jonathan Cheng
- Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Avneesh Chhabra
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA.,Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
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Daly MC, Bauer AS, Lynch H, Bae DS, Waters PM. Outcomes of Late Microsurgical Nerve Reconstruction for Brachial Plexus Birth Injury. J Hand Surg Am 2020; 45:555.e1-555.e9. [PMID: 31928798 DOI: 10.1016/j.jhsa.2019.10.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 08/21/2019] [Accepted: 10/30/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE Microsurgical nerve reconstruction has been advocated between 3 and 9 months of life in select patients with brachial plexus birth injury (BPBI), yet some patients undergo indicated surgery after this time frame. Outcomes in these older patients remain poorly characterized. We analyzed outcomes of nerve reconstruction performed after 9 months of age and hypothesized that (1) Active Movement Scale (AMS) scores improve after surgery, and (2) there are no differences in AMS scores between patients undergoing nerve transfers versus those undergoing nerve grafting. METHODS From 2000 to 2014, 750 patients at 6 U.S. centers were prospectively enrolled in a multicenter database. We included patients treated with nerve reconstruction after 9 months of age with minimum 12 months' follow-up. Patients were evaluated using AMS scores. To focus on the results of microsurgery, only outcomes prior to secondary surgery were analyzed. We analyzed baseline variables using bivariate statistics and change in AMS scores over time and across treatment groups using linear mixed models. RESULTS We identified 32 patients (63% female) with median follow-up of 29.8 months. Median age at microsurgery was 11.2 months. Twenty-five (78%) had an upper trunk injury. Compared with before surgery, total AMS scores improved modestly at 1 year and 2 or more years follow-up. At 1 year follow-up, AMS scores improved for shoulder function (abduction, external rotation) and elbow flexion. Between-group comparisons found no differences in total AMS scores or AMS subscales between graft and transfer groups at 1 year or 2 or more years after surgery, so we cannot recommend one strategy over the other based on our findings. CONCLUSIONS Overall, nerve reconstruction in patients with BPBI after 9 months of age resulted in improved function over time. There was no difference in outcomes between nerve transfer and nerve graft groups and 1 or 2 or more years follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Michael C Daly
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA; Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA
| | - Andrea S Bauer
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA.
| | - Hayley Lynch
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA
| | - Donald S Bae
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA
| | - Peter M Waters
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA
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Dixit NN, McFarland DC, Fisher MB, Cole JH, Saul KR. Integrated iterative musculoskeletal modeling predicts bone morphology following brachial plexus birth injury (BPBI). J Biomech 2020; 103:109658. [PMID: 32089271 PMCID: PMC7141945 DOI: 10.1016/j.jbiomech.2020.109658] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 01/20/2020] [Accepted: 01/21/2020] [Indexed: 01/05/2023]
Abstract
Brachial plexus birth injury (BPBI) is the most common nerve injury among children. The glenohumeral joint of affected children can undergo severe osseous deformation and altered muscle properties, depending on location of the injury relative to the dorsal root ganglion (preganglionic or postganglionic). Preganglionic injury results in lower muscle mass and shorter optimal muscle length compared to postganglionic injury. We investigated whether these changes to muscle properties over time following BPBI provide a mechanically-driven explanation for observed differences in bone deformity between preganglionic and postganglionic BPBI. We developed a computational framework integrating musculoskeletal modeling to represent muscle changes over time and finite element modeling to simulate bone growth in response to mechanical and biological stimuli. The simulations predicted that the net glenohumeral joint loads in the postganglionic injury case were nearly 10.5% greater than in preganglionic. Predicted bone deformations were more severe in the postganglionic case, with the glenoid more declined (pre: -43.8°, post: -51.0°), flatter with higher radius of curvature (pre: 3.0 mm, post: 3.7 mm), and anteverted (pre: 2.53°, post: 4.93°) than in the preganglionic case. These simulated glenoid deformations were consistent with previous experimental studies. Thus, we concluded that the differences in muscle mass and length between the preganglionic and postganglionic injuries are critical mechanical drivers of the altered glenohumeral joint shape.
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Affiliation(s)
- Nikhil N Dixit
- North Carolina State University, Raleigh, NC, United States
| | | | - Matthew B Fisher
- North Carolina State University, Raleigh, NC, United States; University of North Carolina, Chapel Hill, NC, United States
| | - Jacqueline H Cole
- North Carolina State University, Raleigh, NC, United States; University of North Carolina, Chapel Hill, NC, United States
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26
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Elnaggar RK. Integrated Electromyography: Discriminant Analysis and Prediction of Recovery 3 to 6 Years After Brachial Plexus Birth Injury. Pediatr Phys Ther 2020; 32:120-128. [PMID: 32150027 DOI: 10.1097/pep.0000000000000684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To assess the recovery likelihood, 3 to 6 years after brachial plexus birth injury (BPBI), and predict the functional recovery from integrated electromyography (IEMG). METHODS Thirty children with BPBI limited to C5-C6 lesion participated. Maximal electromyography activity of deltoid and biceps brachii was measured at entry. Shoulder and elbow functions were assessed at the baseline and at 4 intervals across 2 years. RESULTS Shoulder and elbow function significantly changed across the follow-up period. Shoulder and elbow functions were significantly dependent on deltoid and biceps brachii muscles' IEMG level, respectively, with the groups showing higher IEMG achieving better recovery. The deltoid and biceps IEMG explained a portion of the improvement in shoulder and elbow function over 2 years. CONCLUSION Recovery of the shoulder and elbow function continues 3 to 6 years after BPBI. IEMG may partially explain variation in the prognosis for children with BPBI.
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Affiliation(s)
- Ragab K Elnaggar
- Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, Giza, Egypt
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27
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van der Holst M, Steenbeek D, Pondaag W, Nelissen RGHH, Vlieland TPMV. Health-care use and information needs of children with neonatal
brachial plexus palsy: A cross-sectional survey among 465 Dutch
patients. J Child Health Care 2020; 24:46-63. [PMID: 30590948 PMCID: PMC7323837 DOI: 10.1177/1367493518814916] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
To investigate health-care use (HCU) and information needs of children aged 0-18 years with neonatal brachial plexus palsy (NBPP), a cross-sectional study was performed. Patients and/or parents seen in our NBPP clinic were invited to complete a survey comprising questions on HCU due to NBPP and current information needs. Outcomes were described for three age-groups (0-1/2-9/10-18 years), based on follow-up status (early/late/no-discharge). Four hundred sixty-five parents/patients participated (59 in the 0-1, 226 in the 2-9, and 180 in the 10-18-year group). Two hundred ninety-three patients had C5-C6 lesions, 193 were discharged from follow-up, 83 of whom categorized as 'early discharged' (<1 year of age). Over the past year, 198 patients had contact with the expert team (49 in the 0-1, 81 in the 2-9, and 68 in the 10-18-year group) and 288 with at least one other health-care professional (53 in the 0-1, 133 in the 2-9, and 102 in the 10-18-year group). Of the 83 patients discharged early, 34 reported health-care use. Two hundred twenty-eight participants reported current information needs of whom 23 were discharged early. HCU and information needs of Dutch children with NBPP remains considerable even in children who were discharged. Stricter follow-up and information provision for these patients is needed.
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Affiliation(s)
- Menno van der Holst
- Department of Orthopaedics, Rehabilitation and Physical Therapy,
Leiden University Medical Center, Leiden, the Netherlands,Rijnlands Rehabilitation Center, Leiden, the Netherlands,Sophia Rehabilitation, The Hague, the Netherlands,Menno van der Holst, Department of
Orthopaedics, Rehabilitation and Physical Therapy, Leiden University Medical
Center, Postal Zone H0Q, RC Leiden, the Netherlands.
| | - Duco Steenbeek
- Department of Orthopaedics, Rehabilitation and Physical Therapy,
Leiden University Medical Center, Leiden, the Netherlands,Rijnlands Rehabilitation Center, Leiden, the Netherlands
| | - Willem Pondaag
- Department of Neurosurgery, Leiden University Medical Center,
Leiden, the Netherlands
| | - Rob GHH Nelissen
- Department of Orthopaedics, Rehabilitation and Physical Therapy,
Leiden University Medical Center, Leiden, the Netherlands
| | - Thea PM Vliet Vlieland
- Department of Orthopaedics, Rehabilitation and Physical Therapy,
Leiden University Medical Center, Leiden, the Netherlands,Rijnlands Rehabilitation Center, Leiden, the Netherlands,Sophia Rehabilitation, The Hague, the Netherlands
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28
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Mid-Term Outcome after Selective Neurotization of the Infraspinatus Muscle in Patients with Brachial Plexus Birth Injury. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2605. [PMID: 32095409 PMCID: PMC7015608 DOI: 10.1097/gox.0000000000002605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 11/04/2019] [Indexed: 01/25/2023]
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What Range of Motion is Achieved 5 Years After External Rotationplasty of the Shoulder in Infants with an Obstetric Brachial Plexus Injury? Clin Orthop Relat Res 2020; 478:114-123. [PMID: 31651590 PMCID: PMC7000049 DOI: 10.1097/corr.0000000000000996] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Obstetric brachial plexus injuries result from traction injuries during delivery, and 30% of these children have persisting functional limitations related to an external rotation deficit of the shoulder. Little is known about the long-term effect of soft-tissue procedures of the shoulder in patients with obstetric brachial plexus injuries. QUESTIONS/PURPOSES (1) After soft-tissue release for patients with passive external rotation less than 20° and age younger than 2 years and for patients older than 2 years with good external rotation strength, what are the improvements in passive external rotation and abduction arcs at 1 and 5 years? (2) For patients who underwent staged tendon transfer after soft-tissue release, what are the improvements in active external rotation and abduction arcs at 1 and 5 years? (3) For patients with passive external rotation less than 20° and no active external rotation, what are the improvements in active external rotation and abduction arcs at 1 and 5 years? METHODS This was a retrospective analysis of a longitudinally maintained institutional database. Between 1996 and 2009, 149 children underwent a soft-tissue procedure of the shoulder for an internal rotation contracture. The inclusion criteria were treatment with an internal contracture release and/or tendon transfer, a maximum age of 18 years at the time of surgery, and a minimum follow-up period of 2 years. Six patients were older than 18 years at the time of surgery and 31 children were seen at our clinic until 1 year postoperatively, but because they had good clinical results and lived far away from our center, these children were discharged to physical therapists in their hometown for annual follow-up. Thus, 112 children (59 boys) were available for analysis. Patients with passive external rotation less than 20° and age younger than 2 years and patients older than 2 years with good external rotation strength received soft-tissue release only (n = 37). Of these patients, 17 children did not have adequate active external rotation, and second-stage tendon transfer surgery was performed. For patients with passive external rotation less than 20° with no active external rotation, single-stage contracture release with tendon transfer was performed (n = 68). When no contracture was present (greater than 20° of external rotation) but the patient had an active deficit (n = 7), tendon transfer alone was performed; this group was not analyzed. A functional assessment of the shoulder was performed preoperatively and postoperatively at 6 weeks, 3 months, and annually thereafter and included abduction, external rotation in adduction and abduction, and the Mallet scale. RESULTS Internal contracture release resulted in an improvement in passive external rotation in adduction and abduction of 29° (95% confidence interval, 21 to 38; p < 0.001) and 17° (95% CI, 10 to 24; p < 0.001) at 1 year of follow-up and 25° (95% CI, 15-35; p < 0.001) and 15° (95% CI, 7 to 24; p = 0.001) at 5 years. Because of insufficient strength of the external rotators after release, 46% of the children (17 of 37) underwent an additional tendon transfer for active external rotation, resulting in an improvement in active external rotation in adduction and abduction at each successive follow-up visit. Patients with staged transfers had improved active function; improvements in active external rotation in adduction and abduction were 49° (95% CI, 28 to 69; p < 0.05) and 45° (95% CI, 11 to 79; p < 0.001) at 1 year of follow-up and 38° (95% CI, 19 to 58; p < 0.05) and 23° (95% CI, -8 to 55; p < 0.001) at 5 years. In patients starting with less than 20° of passive external rotation and no active external rotation, after single-stage contracture release and tendon transfer, active ROM was improved. Active external rotation in adduction and abduction were 75° (95% CI, 66 to 84; p < 0.001) and 50° (95% CI, 43 to 57; p < 0.001) at 1 year of follow-up and 65° (95% CI, 50 to 79; p < 0.001) and 40° (95% CI, 28 to 52; p < 0.001) at 5 years. CONCLUSION Young children with obstetric brachial plexus injuries who have internal rotation contractures may benefit from soft-tissue release. When active external rotation is lacking, soft-tissue release combined with tendon transfer improved active external rotation in this small series. Future studies on the degree of glenohumeral deformities and functional outcome might give more insight into the level of increase in external rotation. LEVEL OF EVIDENCE Level III, therapeutic study.
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30
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Graessle E. Infant crawling orthosis and home program to strengthen a neurologically impaired upper extremity. J Hand Ther 2019; 31:411-415. [PMID: 28673444 DOI: 10.1016/j.jht.2017.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 05/25/2017] [Indexed: 02/03/2023]
Affiliation(s)
- Eileen Graessle
- Department of Occupational Therapy, Rehabilitation Services, Shriners Hospitals for Children-St. Louis, St. Louis, MO, USA.
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31
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Pons C, Eddi D, Le Gal G, Garetier M, Ben Salem D, Houx L, Fitoussi F, Quintero N, Brochard S. Effectiveness and safety of early intramuscular botulinum toxin injections to prevent shoulder deformity in babies with brachial plexus birth injury (POPB-TOX), a randomised controlled trial: study protocol. BMJ Open 2019; 9:e032901. [PMID: 31575585 PMCID: PMC6773354 DOI: 10.1136/bmjopen-2019-032901] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION In children with brachial plexus birth injury (BPBI), denervation of the shoulder muscles leads to bony deformity in the first months of life, reducing active and passive range of motion (ROM) and causing activity limitation. The aim of this multicentre randomised controlled trial is to evaluate the effectiveness of botulinum toxin injections (BTI) in the shoulder internal rotator muscles of 12-month-old babies in limiting the progression of posterior subluxation of the glenohumeral joint, compared with a sham procedure mimicking BTI. The secondary aims are to evaluate the effectiveness of BTI in (1) limiting the progression of glenoid retroversion and three-dimensional (3D) deformity and (2) improving shoulder ROM and upper limb function, as well as to confirm the tolerance of BTI. METHODS AND ANALYSIS Sixty-two babies with unilateral BPBI and a risk of posterior humeral head subluxation will be included. Only those with at least 7% posterior subluxation of the humeral head compared with the contralateral shoulder on the MRI will be randomised to one of two groups: 'BTI' and 'Sham'. The BTI group will receive BOTOX injections at the age of 12 months in the internal shoulder rotator muscles (8 UI/kg). The sham group will undergo a sham BTI procedure. Both groups will undergo repeated shoulder MRI at 18 months of age to quantify changes in the percentage of posterior migration of the humeral head (primary outcome), glenoid version and 3D bone deformity. Clinical evaluations (passive shoulder ROM, active movement scale) will be carried out at baseline and 15 and 18 months of age. The mini-assisting hand assessment will be rated between 10 and 11 months and at 18 months of age. Adverse events will be recorded at least monthly for each child. ETHICS AND DISSEMINATION Full ethical approval for this study has been obtained. The findings will be disseminated in peer-reviewed publications. TRIAL REGISTRATION NUMBER EudraCT: 2015-001402-34 in European Clinical Trial database; NCT03198702 in Clinical Trial database; Pre-results.
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Affiliation(s)
- Christelle Pons
- Pediatric rehabilitation department, Fondation ILDYS, Brest, France
- Laboratory of Medical Information Processing (LaTIM), INSERM UMR 1101, Brest, France
- Physical Medicine and Rehabilitation department, Brest CHRU, Brest, France
| | | | - Gregoire Le Gal
- Centre for Clinical Investigation INSERM CIC 1412, Brest CHRU, Brest, France
| | - Marc Garetier
- Laboratory of Medical Information Processing (LaTIM), INSERM UMR 1101, Brest, France
- Radiology department, Hopital d'Instruction des Armees Clermont-Tonnerre, Brest, France
| | - Douraied Ben Salem
- Laboratory of Medical Information Processing (LaTIM), INSERM UMR 1101, Brest, France
- Radiology department, Brest CHRU, Brest, France
- Medical School, Université de Bretagne Occidentale, Brest, France
| | - Laetitia Houx
- Pediatric rehabilitation department, Fondation ILDYS, Brest, France
- Laboratory of Medical Information Processing (LaTIM), INSERM UMR 1101, Brest, France
- Physical Medicine and Rehabilitation department, Brest CHRU, Brest, France
| | - Franck Fitoussi
- CHU Paris Est - Hôpital d'Enfants Armand-Trousseau, Paris, France
| | - Nathaly Quintero
- Physical Medicine and Rehabilitation department, Hopitaux de Saint-Maurice, Saint Maurice, France
| | - Sylvain Brochard
- Pediatric rehabilitation department, Fondation ILDYS, Brest, France
- Laboratory of Medical Information Processing (LaTIM), INSERM UMR 1101, Brest, France
- Physical Medicine and Rehabilitation department, Brest CHRU, Brest, France
- Medical School, Université de Bretagne Occidentale, Brest, France
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32
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Sarac C, Hogendoorn S, Nelissen RGHH. A New Surgical Technique for Internal Shoulder Contractures Secondary to Obstetric Brachial Plexus Injury: An Anterior Coracohumeral Ligament Release. J Brachial Plex Peripher Nerve Inj 2019; 14:e35-e38. [PMID: 31413723 PMCID: PMC6692147 DOI: 10.1055/s-0039-1693746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 05/20/2019] [Indexed: 11/16/2022] Open
Abstract
Background
Obstetric brachial plexus injuries result from traction injury during delivery; 30% of these children sustain persisting functional limitations related to an external rotation deficit of the shoulder. The aim of this study was to compare the intraoperative gain in external rotation after a posterior subscapular release and an anterior coracohumeral ligament release.
Methods
This is a prospective study on 102 children with an internal rotation contracture of the shoulder who received either a posterior subscapular release (posterior skin incision along the medial border of the scapula of 3–5 cm) or an anterior (5-mm skin incision) coracohumeral ligament release between 1996 and 2010. After general anesthesia, internal and external rotations in both adduction and abduction were measured before and after the surgical release.
Results
After a posterior subscapular release, the intraoperative external rotation improved with a mean of 64 degrees (95% confidence interval [CI]: 54–74;
p
< 0.001) in adduction and with a mean of 41 degrees (95% CI: 32–49;
p
< 0.001) in abduction. After an anterior coracohumeral ligament release, external rotation increased with a mean of 61 degrees (95% CI: 56–66;
p
< 0.001) in adduction and a mean of 42 degrees in abduction (95%CI: 39–45,
p
< 0.001). Differences between these two groups were not statistically different.
Conclusion
The anterior release technique shows comparable results with the posterior subscapular release. And since it is performed through a smaller incision of 5 mm, this is our preferred method to increase passive external rotation.
Level of evidence
II.
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Affiliation(s)
- C Sarac
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - S Hogendoorn
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - R G H H Nelissen
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
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Sabapathy SR, Bhardwaj P, Venkatramani H. Value of Soft Tissue Release Procedure around the Shoulder to Improve Shoulder Abduction in Birth Brachial Plexus Palsy and Analysis of the Factors Affecting Outcome. J Hand Surg Asian Pac Vol 2019; 22:174-183. [PMID: 28506179 DOI: 10.1142/s0218810417500216] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND A lack of shoulder abduction in spontaneously recovered birth brachial plexus palsy (BBPP) is a common presentation. We have performed a soft tissue release operation in these patients to remove the tethering effect of the tight and cocontracting shoulder adductors. This study was undertaken in order to assess the outcome of this surgical procedure. METHODS We performed a retrospective analysis of 120 patients who displayed spontaneous recovery from BBPP and subsequently underwent soft tissue release procedure to improve shoulder abduction. The operation involved release of the pectoralis major, latissimus dorsi (LD) and teres major (TM) with axillary nerve neurolysis and transfer of LD and TM to teres minor at a lower position. Outcomes were assessed at a minimum follow up of two years. The primary outcome measures were range of shoulder abduction and Mallet score. Parents were interviewed and their satisfaction was graded on a Likert scale. We also explored prognostic factors responsible for better outcomes namely, age at operation, extent of involvement; preoperative shoulder abduction range, internal rotation deformity, triceps power and Mallet score. RESULTS The average patient age was 5.8 years(range 1-17). Follow up ranged from 2-6 years. Average preoperative shoulder abduction was 85° (range 30°-140°). Postoperatively the average shoulder abduction was 161° (range 80°-180°). The mean improvement in abduction was 76° (range 20°-110°) [p < 0.001]. Mallet score improved from 16.4 to 19.5 (p < 0.001). High parental satisfaction was recorded by Likert scale assessment. Regression analysis indicated a favourable outcome in patients who are younger, have a better preoperative abduction range and a preoperative triceps power > grade 3. CONCLUSIONS Soft tissue release procedure employed in this series is effective in improving shoulder abduction. Patients who are of younger age, have better preoperative abduction and triceps power of > grade 3 are expected to achieve the best outcome.
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Affiliation(s)
- S Raja Sabapathy
- 1 Department of Plastic, Hand and Reconstructive Microsurgery and Burns, Ganga Hospital, Tamil Nadu, India
| | - Praveen Bhardwaj
- 1 Department of Plastic, Hand and Reconstructive Microsurgery and Burns, Ganga Hospital, Tamil Nadu, India
| | - Hari Venkatramani
- 1 Department of Plastic, Hand and Reconstructive Microsurgery and Burns, Ganga Hospital, Tamil Nadu, India
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Segal D, Cornwall R, Little KJ. Outcomes of Spinal Accessory-to-Suprascapular Nerve Transfers for Brachial Plexus Birth Injury. J Hand Surg Am 2019; 44:578-587. [PMID: 30898464 DOI: 10.1016/j.jhsa.2019.02.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 12/29/2018] [Accepted: 02/06/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE The results of a spinal accessory nerve-to-suprascapular (SAN-SSN) nerve transfer for brachial plexus birth injuries (BPBIs) have thus far been presented only in limited case series. Our study evaluates the recovery of shoulder function of patients who underwent an SAN-SSN for BPBI as an isolated procedure or as part of a multinerve reconstruction (MNR) surgery. METHODS We retrospectively reviewed the medical records of patients at a single institution who underwent an SAN-SSN after BPBI. Inclusion criteria were patients with both preoperative and a minimum 12-months postoperative active movement scale (AMS) scores. Patients for whom the primary surgery involved tendon transfers were excluded. The primary outcome measures were AMS scores for shoulder abduction, forward flexion, and external rotation and secondary outcomes included the need for further shoulder surgery to improve function. RESULTS Seventy-three patients met the inclusion criteria. Forty-three patients (58.9%) obtained functional shoulder motion (AMS ≥ 6) of at least 1 of 3 planes (abduction/flexion/external rotation) following surgery, with 13 patients (17.8%) achieving full recovery of 1 of these shoulder motions against gravity (AMS = 7). Fifty-six patients (76.7%) did not undergo subsequent tendon transfers or corrective osteotomies to augment shoulder function. The MNR procedures were performed in 46 patients (63%), of whom 45.7% gained a functional recovery. In 27 patients for whom SAN-SSN nerve transfer was conducted in isolation, 81.5% gained functional shoulder motion. However, isolated SAN-SSNs were conducted at a later age than MNR procedures (13.2 vs 4.8 months) and had higher preoperative AMS scores. The anterior and posterior approaches for SAN-SSN were both found to be effective when used for SAN-SSN in BPBI. When the follow-up duration cutoff was set to 3 years, the outcomes were found to be superior. CONCLUSIONS In 76.7% of the patients, SAN-SSN was able to recover function that was sufficient to prevent tendon transfers and corrective osteotomies. A cutoff of 3 postoperative years should be used as a benchmark for analyzing the results of this procedure. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- David Segal
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, affiliated with Cincinnati University, Cincinnati, OH; Department of Orthopaedic Surgery, Meir Medical Center, Kfar Saba, affiliated with Tel Aviv University, Tel Aviv, Israel.
| | - Roger Cornwall
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, affiliated with Cincinnati University, Cincinnati, OH
| | - Kevin J Little
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, affiliated with Cincinnati University, Cincinnati, OH
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Larson EL, Santosa KB, Mackinnon SE, Snyder-Warwick AK. Median to radial nerve transfer after traumatic radial nerve avulsion in a pediatric patient. J Neurosurg Pediatr 2019; 24:209-214. [PMID: 31151095 PMCID: PMC7191611 DOI: 10.3171/2019.3.peds18550] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 03/26/2019] [Indexed: 11/06/2022]
Abstract
This case report describes an isolated radial nerve avulsion in a pediatric patient, treated by combination sensory and motor median to radial nerve transfers. After traumatic avulsion of the proximal radial nerve, a 12-year-old male patient underwent end-to-end transfer of median nerve branches to flexor carpi radialis and flexor digitorum superficialis to the posterior interosseous nerve and extensor carpi radialis nerve, respectively. He underwent end-to-side sensory transfer of the superficial radial sensory to the median sensory nerve. Pronator teres to extensor carpi radialis brevis tendon transfer was simultaneously performed to power short-term wrist extension. Within months after surgery, the patient had regained 9-10/10 sensation in the hand and forearm. In the following months and years, he regained dexterity, independent fine-finger and thumb motions, and 4-5/5 strength in all extensors except the abductor pollicis longus muscle. He grew 25 cm without extremity deformity or need for secondary orthopedic procedures. In appropriate adult and pediatric patients with proximal radial nerve injuries, nerve transfers have advantages over tendon transfers, including restored independent fine finger motions, regained sensation, and reinnervation of multiple muscle groups with minimal donor sacrifice.
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Affiliation(s)
- Ellen L. Larson
- Washington University School of Medicine, St. Louis, Missouri
| | - Katherine B. Santosa
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Susan E. Mackinnon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Alison K. Snyder-Warwick
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
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Price AE, Chim H, Valencia H, Grossman JAI. Result of modified Outerbridge-Kashiwagi procedure for elbow flexion contractures in brachial plexus birth injury. J Hand Surg Eur Vol 2019; 44:242-247. [PMID: 30200797 DOI: 10.1177/1753193418797924] [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] [Indexed: 02/03/2023]
Abstract
We report the results of ten consecutive patients who had correction of an elbow flexion contracture of greater than 30° in brachial plexus birth injury using a modified Outerbridge-Kashiwagi procedure. All patients had minimum 23-month follow-up. Pre- and post-operative elbow range of motion and DASH scores were recorded in all patients. The operative technique for the procedure and post-operative course is discussed. Surgery was supplemented by botulinum toxin injection into the biceps brachii muscle in most cases. The average age at surgery was 14 years 10 months. The initial plexus lesion was global in eight patients and upper in two. Pre-operative flexion contractures averaged 51° (range 35 to 60) and post-operative averaged 21° (range 15 to 30). Of these patients, one had no change in active flexion, four had loss of active flexion, and five had gain of active flexion. All ten patients were satisfied with their results and stated that they would recommend the procedure to other patients. Level of evidence: IV.
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Affiliation(s)
- Andrew E Price
- 1 Brachial Plexus Program, Nicklaus Children's Hospital, Miami, FL, USA.,2 Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, New York, NY, USA
| | - Harvey Chim
- 3 Division of Plastic and Reconstructive Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Herbert Valencia
- 1 Brachial Plexus Program, Nicklaus Children's Hospital, Miami, FL, USA
| | - John A I Grossman
- 1 Brachial Plexus Program, Nicklaus Children's Hospital, Miami, FL, USA.,2 Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, New York, NY, USA
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37
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Outcomes from primary surgical reconstruction of neonatal brachial plexus palsy in 104 children. Childs Nerv Syst 2019; 35:349-354. [PMID: 30610478 DOI: 10.1007/s00381-018-04036-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 12/17/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE The outcome from microsurgical reconstruction of neonatal brachial plexus palsy (NBPP) varies, and comparison between different series is difficult, given the differences in preoperative evaluation, surgical strategies, and outcome analysis. To evaluate our results, we reviewed a series of children who underwent surgical treatment in a period of 14 years. METHODS We made a retrospective review of 104 cases in which microsurgical repair of the brachial plexus was performed. Strength was graded using the Active Movement Scale. Whenever possible, upper palsies underwent surgery 4 to 6 months after birth and total lesions around 3 months. The lesions were repaired, according to the type of injury: neurolysis, nerve grafting, nerve transfer, or a combination of techniques. The children were followed for at least 24 months. RESULTS The majority of cases were complete lesions (56/53.8%). Erb's palsy was present in 10 cases (9.6%), and 39 infants (37.5%) presented an extended Erb's palsy. The surgical techniques applied were neurolysis (10.5%), nerve grafts (25.9%), nerve transfers (34.6%), and a combination of grafts and transfers (30.7%). The final outcome was considered poor in 41.3% of the cases, good in 34.3%, and excellent in 24%. A functional result (good plus excellent) was achieved in 58.3% of the cases. CONCLUSIONS There is no consensus regarding strategies for treatment of NBPP. Our surgical outcomes indicated a good general result comparing with the literature. However, our results were lower than the best results reported. Maybe the explanation is our much higher number of total palsy cases (53.8% vs. 25% in the literature).
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Secondary procedures for restoration of upper limb function in late cases of neonatal brachial plexus palsy. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 29:329-336. [DOI: 10.1007/s00590-019-02362-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 01/02/2019] [Indexed: 12/17/2022]
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Natural History of the Elbow Bony Architecture in Patients With Obstetric Brachial Plexus Injury and the Association With Flexion Contractures. J Am Acad Orthop Surg 2018; 26:e490-e495. [PMID: 30169445 DOI: 10.5435/jaaos-d-17-00110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
PURPOSE The purposes of this study were to evaluate the radiographic anatomy of the elbow and try to determine its possible relation to elbow flexion contracture in patients with obstetric brachial plexus injury (OBPI). METHODS All patients with a history of OBPI with elbow flexion contracture who were evaluated clinically and radiographically were included in the study. A review was performed to include serial elbow examinations and previous treatment. Radiographs of the elbow were examined for the presence of bony abnormalities as a potential cause of elbow flexion contracture or the presence of progressive arthritic changes over time. RESULTS Fifty-nine patients with a history of OBPI with elbow flexion contracture were included in the study. Of them, 53 had normal bony architecture, 2 had mild radial head subluxation, and 4 had chronic anterior radial head dislocations. At a mean age at final clinical follow-up of 21 years (range, 7 to 83 years), only 7% of patients had pain localized to their elbow. There were only three patients with elbow arthritis, including two of the four with radial head dislocations. CONCLUSIONS In the absence of a radial head dislocation, most elbow joints do not seem to undergo abnormal anatomic bony changes in patients with OBPI and flexion contractures. LEVEL OF EVIDENCE Level IV (retrospective case series).
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Chinchalkar SJ, Larocerie-Salgado J, Cepek J, Grenier ML. The Use of Dynamic Assist Orthosis for Muscle Reeducation following Brachial Plexus Injury and Reconstruction. J Hand Microsurg 2018; 10:172-177. [PMID: 30483028 DOI: 10.1055/s-0038-1642068] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 03/07/2018] [Indexed: 10/17/2022] Open
Abstract
Therapeutic management of brachial plexus injuries remains complex. The impact of brachial plexus injuries on everyday human functioning should not be underestimated. Early active-assisted range of motion following such injuries may prevent myostatic contractures, minimize muscle atrophy, facilitate muscle fiber recruitment, and enable a faster return to baseline strength levels. The dynamic assist elbow flexion orthosis proposed is designed to provide patients with a graded system for muscle reeducation and function. No clinical data are currently available on the use of this orthosis design; however, this article presents a treatment option based on sound clinical reasoning to facilitate rehabilitation following this devastating injury.
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Affiliation(s)
- Shrikant J Chinchalkar
- Roth-McFarlane Hand and Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada
| | | | - Jeremy Cepek
- Schullic School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
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Shoulder Arthroplasty for Sequelae of Obstetrical Brachial Plexus Injury. J Hand Surg Am 2018; 43:871.e1-871.e7. [PMID: 29605518 DOI: 10.1016/j.jhsa.2018.02.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 12/19/2017] [Accepted: 02/05/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE Shoulder arthroplasty following obstetrical brachial plexus injury (OBPI) is technically challenging because glenoid morphology, muscle balance, and humeral version are substantially altered compared with the neurologically intact shoulder. The purpose of this study is to report the outcome of shoulder arthroplasty in a group of patients with end-stage arthritis secondary to OBPI. MATERIALS AND METHODS Seven patients with OBPI and secondary glenohumeral arthritis were treated with shoulder arthroplasty between 1976 and 2014. Two underwent hemiarthroplasty (HA), 2 underwent total shoulder arthroplasty (TSA), and 3 underwent reverse shoulder arthroplasty (RSA). One HA was lost to follow-up and was excluded. The remaining 6 patients (mean age, 62.5 years old at the time of surgery) were followed for a minimum of 2 years (mean, 7.5 years; range, 2-13 years) Outcome measures included pain, range of motion, and postoperative modified Neer ratings. RESULTS Pain improved in all shoulders. Mean forward flexion was unchanged. No shoulders treated with HA/TSA regained forward elevation above 90°, compared with 1 out of the 3 RSAs. External rotation improved from a mean of -10° to 20°. Active internal rotation decreased from L1 to L5. Immediate postoperative radiographs showed either severe posterior or posterosuperior subluxation in all 3 patients treated with nonconstrained implants. CONCLUSIONS Shoulder arthroplasty is an acceptable option to relieve pain in patients with symptomatic shoulder arthritis as a sequel of OBPI. However, range of motion improvements are not expected. TYPE OF STUDY /LEVEL OF EVIDENCE Therapeutic V.
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Long-term results of latissimus dorsi transfer for internal rotation contracture of the shoulder in patients with obstetric brachial plexus injury. JSES OPEN ACCESS 2018; 2:159-164. [PMID: 30675588 PMCID: PMC6334879 DOI: 10.1016/j.jses.2018.05.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background This study evaluated the long-term outcome of patients with obstetric brachial plexus injury who underwent transfer of the latissimus/teres major tendon to restore shoulder external rotation and determined whether loss of internal rotation would affect their quality of life. Methods All patients with a history of obstetric brachial plexus injury who underwent latissimus dorsi transfer for internal rotation contracture were included. Results from 3 clinic visits (preoperative, and short-term and long-term postoperatively) were recorded. Quality of life was evaluated with a questionnaire. Internal rotation impairment was evaluated using the Activities of Daily Living which require active Internal Rotation scoring system. Results The study included 45 patients. At a mean 5 months postoperatively, shoulder motion was significantly improved in abduction and external rotation. This was associated with a significant loss of active internal rotation. These results deteriorated over time (at a mean 7.64 years postoperatively), especially in internal rotation (from being able to reach the sacrum to only being able to reach the trochanter) and in external rotation with the arm abducted. This decrease in function led 10 patients (22%) to undergo revision surgery. The mean score on the activities of daily living which require active internal rotation (ADLIR) at the last follow-up was 53. Conclusion Although the short-tem results of latissimus dorsi transfer and subscapularis release are encouraging, these gains deteriorated over a longitudinal follow-up period. Abduction is maintained over the long-term, but external rotation deteriorates. Internal rotation deteriorated over a long-term longitudinal follow-up, leading to functional impairment.
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Stein J, Laor T, Carr P, Zbojniewicz A, Cornwall R. The Effect of Scapular Position on Magnetic Resonance Imaging Measurements of Glenohumeral Dysplasia Caused by Neonatal Brachial Plexus Palsy. J Hand Surg Am 2017; 42:1030.e1-1030.e11. [PMID: 28823534 DOI: 10.1016/j.jhsa.2017.07.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 06/27/2017] [Accepted: 07/03/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE Neonatal brachial plexus palsy (NBPP) frequently causes glenohumeral dysplasia. Quantification of this dysplasia on magnetic resonance imaging can determine the need for and the success of nonsurgical or surgical intervention. However, we hypothesize that the variable position of the scapula on the thorax between affected and unaffected shoulders affects dysplasia measurements. METHODS Magnetic resonance imaging studies were analyzed from 19 NBPP patients (ages 0.8-18 years; median, 2.4 years) without prior shoulder surgery. Three reviewers measured the glenoid version angle (GVA) and percentage of humeral head anterior to the midscapular line (PHHA) on standard axial images ("thoracic axial") and on reformatted axial images aligned perpendicular to the scapular plane ("scapular axial"), which corrects for scapulothoracic position. Scapular tilt and protraction were measured to assess their impact on the difference between thoracic and scapular GVA and PHHA measurements. Intra- and interrater reliability were calculated for GVA and PHHA on both views. RESULTS The GVA of the affected shoulder was significantly greater on thoracic than on scapular images, by an average of 5° and as much as 34°. The PHHA was significantly less in the affected shoulders on thoracic than on scapular images, by an average of 5% and as much as 33% of humeral head width. The difference in GVA, but not PHHA, between thoracic and scapular axial images in the affected shoulder correlated with scapular tilt. Unaffected shoulders showed no significant difference in GVA or PHHA between thoracic and scapular axial images. Interrater reliability ranged from fair to substantial and did not differ between thoracic and scapular images. CONCLUSIONS Thoracic axial images overestimate the severity of glenohumeral dysplasia in NBPP, owing at least in part to the variable position of the scapula on the thorax. This confounding effect must be considered in interpretation of axial quantitative measures of glenohumeral dysplasia in NBPP. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic III.
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Affiliation(s)
- Jill Stein
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Tal Laor
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Preston Carr
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Andrew Zbojniewicz
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Roger Cornwall
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
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Transfer of Pectoralis Major to Subscapularis in the Management of Brachial Plexus Birth Palsy Sequels. J Pediatr Orthop 2017; 37:305-310. [PMID: 26368856 DOI: 10.1097/bpo.0000000000000648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Limitations in abduction and external rotation are the sequel of brachial palsy. The purpose of this study was to evaluate functional outcomes of modified L'Episcopo procedure in children with brachial palsy who do not have gross shoulder joint subluxation. METHODS From 2002 to 2012, a continuous series of 22 patients with brachial plexus birth palsy underwent a modified L'Episcopo procedure. Through an axillary approach, subscapularis release with latissimus dorsi rerouting and transfer of pectoralis major to subscapularis footprint was performed. RESULTS The mean age of patients at surgery was 49 months. The mean follow-up time was 51 months (range, 24 to 90 mo). Preoperatively, the mean active abduction and external rotation were 77.5 and 2.5 degrees, respectively. The mean active abduction and external rotation were 135.6 and 32 degrees, respectively, at the final follow-up (P<0.001). CONCLUSIONS This modified L'Episcopo technique is an effective and reproducible procedure that improves shoulder function significantly. LEVEL OF EVIDENCE Level III.
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van der Holst M, Groot J, Steenbeek D, Pondaag W, Nelissen RG, Vliet Vlieland TP. Participation restrictions among adolescents and adults with neonatal brachial plexus palsy: the patient perspective. Disabil Rehabil 2017; 40:3147-3155. [PMID: 28944700 DOI: 10.1080/09638288.2017.1380717] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To examine the impact of neonatal brachial plexus palsy (NBPP) on societal participation of adolescents and adults. METHODS This cross-sectional study was conducted among patients with NBPP, aged ≥16 years, who had visited our NBPP clinic. Patients completed questions on the influence of NBPP on their choices regarding education/work and their work-performance, the Impact on Participation/Autonomy questionnaire and the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P). In addition, health-related quality of life (HRQoL) was assessed. RESULTS Seventy-five patients participated (median age 20, inter quartile range 17-27). Twenty were full-time students, 28 students with a job, 21 employed, two unemployed, and four work-disabled. Sixty-six patients had had a job at some stage. Patients' overall HRQoL was comparable to the general population. 27/75 patients reported that NBPP had affected their choices regarding education and 26/75 those regarding work. 33/66 reported impact on their work performance. On the Impact on Participation/Autonomy questionnaire, 80% (49/61) reported restrictions in the work-and-education domain, 74% in social-relations and 67% in autonomy-outdoors. 37/61 reported participation restrictions on the USER-P. CONCLUSIONS Although their overall HRQoL was not impaired, a substantial proportion of adolescent/adult patients reported that NBPP had an impact on choices regarding education and profession, as well as on work-performance. Restrictions in participation, especially in work and education were also reported. Guiding patients in making choices on education and work at an early stage and providing tailored physical as well as psychosocial care may prevent or address restrictions, which may improve participation. Implications for Rehabilitation Adolescent and adult patients with neonatal brachial plexus palsy perceive restrictions in societal participation, especially regarding the work-and-education domain. All patients with neonatal brachial plexus palsy may perceive restrictions in societal participation regardless of lesion severity, treatment history and side of the lesion. Adolescents and adults with neonatal brachial plexus palsy report that their choices regarding education and work, as well as their work-performance are influenced by their neonatal brachial plexus palsy. Patients with neonatal brachial plexus palsy should be followed throughout their life in order to provide them with appropriate information and treatment when health- or participation-related issues arise. Rehabilitation treatment is the best option to address all of the aforementioned issues, as surgical options in adolescents and adults are limited.
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Affiliation(s)
- Menno van der Holst
- a Department of Orthopaedics, Rehabilitation and Physical Therapy , Leiden University Medical Center , Leiden , The Netherlands.,b Rijnlands Rehabilitation Center , Leiden , The Netherlands
| | - Jeroen Groot
- a Department of Orthopaedics, Rehabilitation and Physical Therapy , Leiden University Medical Center , Leiden , The Netherlands.,c Sophia Rehabilitation , The Hague , The Netherlands
| | - Duco Steenbeek
- a Department of Orthopaedics, Rehabilitation and Physical Therapy , Leiden University Medical Center , Leiden , The Netherlands.,b Rijnlands Rehabilitation Center , Leiden , The Netherlands
| | - Willem Pondaag
- d Department of Neurosurgery , Leiden University Medical Center , Leiden , The Netherlands
| | - Rob Ghh Nelissen
- a Department of Orthopaedics, Rehabilitation and Physical Therapy , Leiden University Medical Center , Leiden , The Netherlands
| | - Thea Pm Vliet Vlieland
- a Department of Orthopaedics, Rehabilitation and Physical Therapy , Leiden University Medical Center , Leiden , The Netherlands.,b Rijnlands Rehabilitation Center , Leiden , The Netherlands.,c Sophia Rehabilitation , The Hague , The Netherlands
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Forearm Pronation Osteotomy for Supination Contracture Secondary to Obstetrical Brachial Plexus Palsy: A Retrospective Cohort Study. J Pediatr Orthop 2017; 37:e357-e363. [PMID: 28719548 DOI: 10.1097/bpo.0000000000001053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Obstetrical brachial plexus palsy can lead to fixed forearm supination contracture. Fixed supination may lead to functional deficits as the affected hand cannot be positioned optimally for activities on a desk such as writing and typing, or for using tools including utensils, which require a neutral or pronated forearm. Forearm pronation osteotomy has been used to address this problem, although the functional benefit over nonoperative management has not been clearly defined. Potentially deleterious consequences on hand function that requires supination or fine motor skills are also uncertain. METHODS Patients with fixed forearm supination contracture were selected from our institutional brachial plexus database. Those who underwent both bone forearm rotational osteotomy were analyzed for age at time of surgery, preoperative forearm resting position, active and passive supination and pronation, and preoperative function assessed by the brachial plexus outcome measure (BPOM) and active movement scale (AMS). Preoperative results were compared with values obtained at follow-up at least 12 months postoperatively. A matched cohort of children with fixed forearm supination contracture that were treated nonoperatively and followed for at least 12 months, was also selected. For this group, forearm resting position, movement, AMS, and BPOM scores were analyzed at a baseline clinic visit and the most recent follow-up. Changes in forearm resting position, AMS, and BPOM activity scale scores were then compared between groups. RESULTS Records were obtained for 14 cases and 10 controls. Study groups were similar with respect to resting forearm position, hand function, and time from initial to final evaluation. Groups differed with respect to age and active supination. We observed a statistically significant change in resting position among operative patients compared with their preoperative status and compared with controls. Hand-specific AMS score did not change significantly in the operative group as compared with controls. The BPOM score for drums, reflective of function in neutral rotation to mild pronation, improved in the operated patients as compared with controls. There was no loss of plate holding ability (reflective of supination function, putty (grasp), or bead placement (fine motor) among the operated patients as compared with controls. CONCLUSIONS By pronating resting forearm position by about 90 degrees to near neutral, osteotomy resulted in improved neutral to mild pronation-dependent function without loss of supination-dependent function or hand motor skills. LEVEL OF EVIDENCE Level III-retrospective cohort study.
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Wilson TJ, Chang KWC, Yang LJS. Prediction Algorithm for Surgical Intervention in Neonatal Brachial Plexus Palsy. Neurosurgery 2017; 82:335-342. [DOI: 10.1093/neuros/nyx190] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 03/20/2017] [Indexed: 11/14/2022] Open
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Herisson O, Maurel N, Diop A, Le Chatelier M, Cambon-Binder A, Fitoussi F. Shoulder and elbow kinematics during the Mallet score in obstetrical brachial plexus palsy. Clin Biomech (Bristol, Avon) 2017; 43:1-7. [PMID: 28161491 DOI: 10.1016/j.clinbiomech.2017.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 01/09/2017] [Accepted: 01/10/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND The physical signs of obstetrical brachial plexus palsy range from temporary upper-limb dysfunction to a lifelong impairment and deformity in one arm. The aim of this study was to analyze the kinematics of the upper limb and to evaluate the contribution of glenohumeral and scapulothoracic joints of obstetrical brachial plexus palsy children. METHODS Six children participated in this study: 2 males and 4 females with a mean age of 11.7years. Three patients had a C5, C6 lesion and 3 had a C5, C6, C7 lesion. They were asked to perform five tasks based on the Mallet scale and the kinematic data were collected using the Fastrak electromagnetic tracking device. FINDINGS The scapulothoracic protraction and posterior tilt were significantly increased in the involved limb during the hand to mouth task (p=0.006 and p=0.015 respectively). The scapulothoracic Protraction/glenohumeral Elevation ratio was significantly increased in the involved limb during the hand to neck task (p=0.041) and the elevation task (p=0.015). The ratios of scapulothoracic Tilt on the three glenohumeral excursion angles were significantly increased during the hand to mouth task (p≤0.041). The scapulothoracic Mediolateral/glenohumeral Elevation ratio was significantly increased in the involved limb during the elevation task (p=0.038). The glenohumeral elevation excursion was significantly decreased in the involved limb during the hand to neck task (p<0.001) and the elevation task (p=0.0003). INTERPRETATION This study gives us information about the greater contribution of the scapulothoracic joint to shoulder motion for affected arm of obstetrical brachial plexus palsy patients compared to their unaffected arm. Kinematic analysis could be useful in shoulder motion evaluation during the Mallet score and to evaluate outcomes after surgery.
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Affiliation(s)
- Olivier Herisson
- Hôpital Trousseau, Service de chirurgie orthopédique pédiatrique, 26 Avenue du Dr Arnold Netter, 75012 Paris, France.
| | - Nathalie Maurel
- Ecole Nationale Supérieure d'Arts et Métiers - Equipe Biomécanique et Remodelage Osseux, 151 boulevard de l'Hôpital, 75013 Paris, France.
| | - Amadou Diop
- Ecole Nationale Supérieure d'Arts et Métiers - Equipe Biomécanique et Remodelage Osseux, 151 boulevard de l'Hôpital, 75013 Paris, France.
| | - Morgane Le Chatelier
- Hôpital Trousseau, Service de chirurgie orthopédique pédiatrique, 26 Avenue du Dr Arnold Netter, 75012 Paris, France.
| | | | - Franck Fitoussi
- Hôpital Trousseau, Service de chirurgie orthopédique pédiatrique, 26 Avenue du Dr Arnold Netter, 75012 Paris, France; Université Pierre et Marie Curie, 91 Boulevard de l'Hôpital, 75013 Paris, France.
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Coroneos CJ, Voineskos SH, Christakis MK, Thoma A, Bain JR, Brouwers MC. Obstetrical brachial plexus injury (OBPI): Canada's national clinical practice guideline. BMJ Open 2017; 7:e014141. [PMID: 28132014 PMCID: PMC5278272 DOI: 10.1136/bmjopen-2016-014141] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE The objective of this study was to establish an evidence-based clinical practice guideline for the primary management of obstetrical brachial plexus injury (OBPI). This clinical practice guideline addresses 4 existing gaps: (1) historic poor use of evidence, (2) timing of referral to multidisciplinary care, (3) Indications and timing of operative nerve repair and (4) distribution of expertise. SETTING The guideline is intended for all healthcare providers treating infants and children, and all specialists treating upper extremity injuries. PARTICIPANTS The evidence interpretation and recommendation consensus team (Canadian OBPI Working Group) was composed of clinicians representing each of Canada's 10 multidisciplinary centres. OUTCOME MEASURES An electronic modified Delphi approach was used for consensus, with agreement criteria defined a priori. Quality indicators for referral to a multidisciplinary centre were established by consensus. An original meta-analysis of primary nerve repair and review of Canadian epidemiology and burden were previously completed. RESULTS 7 recommendations address clinical gaps and guide identification, referral, treatment and outcome assessment: (1) physically examine for OBPI in newborns with arm asymmetry or risk factors; (2) refer newborns with OBPI to a multidisciplinary centre by 1 month; (3) provide pregnancy/birth history and physical examination findings at birth; (4) multidisciplinary centres should include a therapist and peripheral nerve surgeon experienced with OBPI; (5) physical therapy should be advised by a multidisciplinary team; (6) microsurgical nerve repair is indicated in root avulsion and other OBPI meeting centre operative criteria; (7) the common data set includes the Narakas classification, limb length, Active Movement Scale (AMS) and Brachial Plexus Outcome Measure (BPOM) 2 years after birth/surgery. CONCLUSIONS The process established a new network of opinion leaders and researchers for further guideline development and multicentre research. A structured referral form is available for primary care, including referral recommendations.
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Affiliation(s)
- Christopher J Coroneos
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Sophocles H Voineskos
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Marie K Christakis
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Achilleas Thoma
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - James R Bain
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Melissa C Brouwers
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
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Tang M, Gorbutt KA, Peethambaran A, Yang L, Nelson VS, Chang KWC. High prevalence of cranial asymmetry exists in infants with neonatal brachial plexus palsy. J Pediatr Rehabil Med 2016; 9:271-277. [PMID: 27935564 DOI: 10.3233/prm-160396] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE This study aimed to: 1) evaluate the prevalence of cranial asymmetry (positional plagiocephaly) in infants with neonatal brachial plexus palsy (NBPP); 2) examine the association of patient demographics, arm function, and NBPP-related factors to positional plagiocephaly; and 3) determine percentage of spontaneous recovery from positional plagiocephaly and its association with arm function. METHODS Infants < 1 year of age with NBPP and no previous exposure to plagiocephaly cranial remolding therapy or surgical intervention were recruited for this prospective cross-sectional study. Positional plagiocephaly (diagonal difference) measurements were captured using a fiberglass circumferential mold of the cranium. Included infants were divided into 2 groups: 1) those with positional plagiocephaly at most recent evaluation (plagio group), including infants with resolved positional plagiocephaly (plagio-resolved subgroup); and 2) those who never had positional plagiocephaly (non-plagio group). Standard statistics were applied. RESULTS Eighteen of 28 infants (64%) had positional plagiocephaly. Delivery type might be predictive for plagiocephaly. Infants in the non-plagio group exhibited more active range of motion than infants in the plagio group. All other factors had no significant correlations. CONCLUSIONS A high prevalence of positional plagiocephaly exists among the NBPP population examined. Parents and physicians should encourage infants to use their upper extremities to change position and reduce chance of cranial asymmetry.
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Affiliation(s)
- Megan Tang
- South Georgia Orthopedic Resources, Hiram, GA, USA
| | | | | | - Lynda Yang
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Virginia S Nelson
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
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