Meta-analysis of function after secondary shoulder surgery in neonatal brachial plexus palsy

Surgical Treatment of Obstetric Plexus Lesions by Direct Coaptation Compared to Sural Nerve Graft Interposition

Background  To date, there are no uniform guidelines for the treatment of obstetric plexus lesions in German-speaking countries. An end-to-end direct suture after resection of trunk neuroma is recommended for surgical treatment if tension-free coaptation is possible, whereas the use of autologous nerve grafts bridging the gap between the adaptation margins is advised by consensus if tension-free coaptation is impossible. Objective  The aim of the study was to investigate which reconstruction strategy may provide a better recovery of motor function for patients after obstetric brachial plexus lesion. Methods  This study compared postoperative functional outcome after obstetric brachial plexus palsy from a patient collective including a total of 43 children. The surgical techniques of plexus reconstruction by end-to-end coaptation versus the use of sural nerve interposition graft have been analyzed. Therefore, the degrees of active motion of abduction and external rotation in the shoulder joint, and flexion in the elbow joint were assessed using the neutral zero method. Results  For abduction in the shoulder joint, significantly better motor function was found in the group with direct sutures ( p  = 0.033). For external rotation in the shoulder joint and flexion in the elbow joint, there was no statistically significant difference between the groups ( p  = 0.284 and p  = 0.270, respectively). Conclusions  This study could not demonstrate absolute superiority of either reconstruction method. Slight evidence was found for a better functional outcome for plexus reconstruction by direct coaptation. Further arguments support a better suitability of plexus reconstruction by direct suture if its use is justifiable.

The use of accelerometers to assess upper limb function in patients with obstetric brachial plexus palsy

For half a century, the Mallet Scale (MS) has been utilized to assess upper limb function in patients with obstetric brachial plexus palsy (OBPP). However, the correct use of the MS requires trained personnel and the MS does not measure compensatory movements. For this reason, new methods are needed to compensate for these weaknesses. This study introduces an innovative method for objective functional motion analysis using accelerometers to measure upper limb movements in thirty patients with obstetric brachial plexus lesions. Five triaxial accelerometers were positioned on the chest and each upper limb. They recorded acceleration signals during repetitive everyday tasks: hand-to-mouth (HM), hand-to-neck (HN), and hand-to-spine (HS). From these signals, 54 features were extracted and subjected to linear correlation tests to identify 5 suitable features. An algorithm was then developed to categorize patients into five groups and compute an individual movement performance score (iMPScore) assessing the patient's upper extremity function. By using the iMPScore more than 75% of all participants have been classified correctly with respect to their MS category. Identification of MS I category patients in general and assessing upper extremity function of MS I to III in HS tasks were most challenging. We conclude that the introduced approach is a valuable tool for gauging movement limitation of upper limbs in patients with obstetric brachial plexus palsy. Compared to other clinically established methods, it becomes possible to record and even quantify the extent of compensatory movements. In this way, an objective, user- and patient-friendly method is offered, which supports significantly physicians and therapists in their evaluation of OBPP.

Surgical treatment of a nonunion following clavicle osteotomy in a child with a history of Erb's palsy: A case report

INTRODUCTION AND IMPORTANCE

Erb's palsy defined as muscle weakness and loss of motion caused by a nerve condition in the shoulder and arm. Children with Erb's palsy might underwent clavicle osteotomy as an appropriate surgical treatment method. However, few number of these patients who underwent clavicle osteotomy experienced nonunion and complained of shoulder deformity and pain. The aim of the present case report was to present new surgical treatment of a nonunion following clavicle osteotomy in a child affected by Erb's palsy.

CASE PRESENTATION

A six years old boy with a history of Erb's palsy who underwent clavicle osteotomy at age of 6 months was referred to hospital. There was a nonunion following clavicle osteotomy. The patient had right shoulder deformity and complained of its-related pain. To correct a nonunion following clavicle osteotomy in this case, middle third fibula auto grafting and fixing it to the cite of clavicle nonunion by pins was used. After five months of follow-up, a clavicle nonunion and shoulder deformity was thoroughly corrected.

CLINICAL DISCUSSION

As clavicle osteotomy, the most commonly surgical method for Erb's palsy, has been demonstrated to not work effectively and cause nonunion in some cases, a new surgical method for correcting clavicle nonunion other than repeated clavicle osteotomy is needed. In the present case report, fibula auto grafting and fixing it to the cite of clavicle nonunion by pins was applied and demonstrated remarkable improvement.

CONCLUSION

Totally, use of fibula auto grafting and fixing it to the cite of clavicle nonunion by pins might be an effective surgical treatment for such cases.

Pediatric Shoulder Arthroscopy is Effective and Most Commonly Indicated for Instability, Obstetric Brachial Plexus Palsy, and Partial Rotator Cuff Tears

Purpose

The purpose of this review was to systematically evaluate the literature on pediatric shoulder arthroscopy and outline its indications, outcomes, and complications.

Methods

This systematic review was carried out in accordance with PRISMA guidelines. PubMed, Cochrane Library, ScienceDirect, and OVID Medline were searched for studies reporting the indications, outcomes, or complications in patients undergoing shoulder arthroscopy under the age of 18 years. Reviews, case reports, and letters to the editor were excluded. Data extracted included surgical techniques, indications, preoperative and postoperative functional and radiographic outcomes, and complications. The methodological quality of included studies was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) tool.

Results

Eighteen studies, with a mean MINORS score of 11.4/16, were identified, including a total of 761 shoulders (754 patients). Weighted average age was 13.6 years (range, 0.83-18.8 years) with a mean follow-up time of 34.6 months (range, 6-115). As part of their inclusion criteria, 6 studies (230 patients) recruited patients with anterior shoulder instability and 3 studies recruited patients with posterior shoulder instability (80 patients). Other indications for shoulder arthroscopy included obstetric brachial plexus palsy (157 patients) and rotator cuff tears (30 patients). Studies reported a significant improvement in functional outcomes for arthroscopy indicated for shoulder instability and obstetric brachial plexus palsy. A significant improvement was also noted in radiographic outcomes and range of motion for obstetric brachial plexus palsy patients. The overall rate of complication ranged from 0% to 25%, with 2 studies reporting no complications. The most common complication was recurrent instability (38 patients of 228 [16.7%]). Fourteen of the 38 patients (36.8%) underwent reoperation.

Conclusion

Among pediatric patients, shoulder arthroscopy was indicated most commonly for instability, followed by brachial plexus birth palsy, and partial rotator cuff tears. Its use resulted in good clinical and radiographic outcomes with limited complications.

Level of Evidence

Systematic review of Level II to IV studies.

Requirements for tele-health in children with obstetric brachial plexus palsy during Covid-19-like situations

The purpose of the study was to investigate families’ concerns and service requirements during the Covid-19 lockdown. In case of tele-consultation, we also aimed to assess the effects of this service on coping and the family’s worries. At end of lockdown, we contacted the parents of 67 obstetric brachial plexus palsy patients (0–10 years age) by e-mail. During lockdown, 42 of the families had had a tele-consultation with our team, while 25 reported that not receiving any service. A questionnaire consisting of 6 questions was sent to the families, and data were analyzed according to 4 age-groups. Parents' concerns varied according to the children’s age group (p = 0.001). All families replied that their children should receive remote services during Covid-19-like situations (p = 0.173). Parents of the 42 children who had tele-consultations reported that this had alleviated their worries, independently of age-group (p = 0.160). The usefulness of tele-consultation to manage the lockdown situation differed according to age-group (p = 0.002). The parents of under-3-year-olds experienced more worry during lockdown, but all respondents reported needing remote services. Although the tele-consultation alleviated the worries of almost all families, it was most useful in managing lockdown in families with under-3-year-olds.

Effect of arthroscopic shoulder release on shoulder mobility and bone deformity following brachial plexus birth injury: a systematic review and meta-analysis

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.

The outcome of soft-tissue release and tendon transfer in shoulders with brachial plexus birth palsy

Background

Shoulder involvement in brachial plexus birth palsy is common, and the adduction, internal rotation contracture deformity often requires some form of surgical treatment. There are very few long-term reports on release of contracted muscles and tendon transfers, especially in older children. We are reporting the single-center results of such a surgery with detailed outcome analysis.

Methods

The prospectively collected data from brachial plexus birth palsy cases who had undergone contracture release and tendon transfer were retrospectively studied and examined. The new Mallet and functional scores were compared with the original data forms and then analyzed. The radiographic evidence of glenoid dysplasia and its correlation with age and functional outcome was assessed.

Results

A total of 82 cases with surgery at mean age of 9.5 ± 5.09 years and a follow-up of 8 ± 3.8 (3-20) years entered the study. Of these, 56% of cases had 7 to 20 years of age at surgery. Fifty-four (66%) patients had only shoulder surgery, and 28 (34%) required additional reconstructive surgeries for hand and wrist. Moderate to severe glenohumeral dysplasia was present in 38%. The preoperative Mallet score of 10.6 ± 2.97 improved to 19.3 ± 3.39 (P < .001). Eighty-one percent of patients showed improvement in “reaching face” functions, 71% in “above head” functions, and 74% in “midline functions.” The cases with lack of improvement in midline function mostly belonged to pan-plexus injuries. Noticeable subjective and objective improvement was also observed in cases with glenohumeral dysplasia in their Mallet and functional scores (P < .001). The improvement in function and subjective satisfaction of 92% was observed irrespective of age at surgery.

Conclusion

Soft-tissue release and tendon transfer for brachial plexus birth palsy shoulder can improve function and limb appearance even in older children and young adults and even in the presence of glenohumeral dysplasia.

Health-care use and information needs of children with neonatal brachial plexus palsy: A cross-sectional survey among 465 Dutch patients

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.

Surgical Technique and Anatomical Considerations for the Modified L'Episcopo Tendon Transfer

BACKGROUND

Birth brachial plexus injury usually affects the upper trunks of the brachial plexus and can cause substantial loss of active shoulder external rotation and abduction. Due to the unbalanced rotational forces acting at the glenohumeral joint, the natural history of the condition involves progressive glenohumeral joint dysplasia with associated upper limb dysfunction. Surgical reconstruction methods have been described previously by Sever and L'Episcopo, and modified by Hoffer and Roper to release the adduction contracture and to restore external rotation and shoulder abduction.

METHODS

The authors describe their preferred technique for contracture release and tendon transfer to improve external rotation and shoulder abduction. Pertinent anatomy and highlights of surgical exposure are reviewed.

RESULTS

The senior author has utilized this technique with consistent clinical outcomes to improve shoulder function for patients with persisting nerve palsy associated with birth brachial plexus injury. A review of the literature supports utilization of this technique.

CONCLUSIONS

Transfer of the latissimus dorsi and teres major to the posterior rotator cuff for reanimation of shoulder abduction and external rotation deficits associated with birth brachial plexus injury is a safe and reliable technique. Careful patient selection and attention to surgical detail are critical for optimal outcomes.

Arthroscopic isolated capsular release for shoulder contracture after brachial plexus birth palsy: clinical outcomes in a prospective cohort of 28 children with 2 years' follow-up

BACKGROUND

The primary objective of this study was to evaluate improvements in external rotation after isolated arthroscopic capsular release in children with shoulder contracture due to brachial plexus birth palsy.

MATERIALS AND METHODS

This study included all children older than 2 years with a range of active external rotation limited to 30° or less and/or active anterior elevation (AE) limited to 90° or less secondary to brachial plexus palsy treated between 2011 and 2015. Passive glenohumeral motion, passive global (glenohumeral plus scapulothoracic) motion, active global motion for external rotation with the elbow at the side (ER1), AE, and internal rotation with the elbow at the side were recorded before and 2 years after surgery. Improvement was evaluated by comparing the preoperative and follow-up values. The operation performed was subscapularis-sparing arthroscopic capsular release.

RESULTS

Thirty-five patients were included, and 28 completed 2 years of follow-up. The average changes in active global ER1, passive glenohumeral ER1, and passive global ER1 were +35° (range, -20° to +100°; P <.0001), +35° (range, +0° to +75°; P <.0001), and +26° (range, -15° to +60°; P <.0001), respectively. There were no significant changes in internal rotation with the elbow at the side or AE. The mean improvement in the aggregate Mallet score was 3.9 points (range, -3 to +9 points; P <.0001).

CONCLUSIONS

For children with shoulder contracture secondary to brachial plexus palsy, subscapularis-sparing isolated capsular release improves external rotation and functional scores and avoids any loss of active internal rotation but does not improve AE.

The natural history and management of brachial plexus birth palsy

Brachial plexus birth palsy (BPBP) is an upper extremity paralysis that occurs due to traction injury of the brachial plexus during childbirth. Approximately 20 % of children with brachial plexus birth palsy will have residual neurologic deficits. These permanent and significant impacts on upper limb function continue to spur interest in optimizing the management of a problem with a highly variable natural history. BPBP is generally diagnosed on clinical examination and does not typically require cross-sectional imaging. Physical examination is also the best modality to determine candidates for microsurgical reconstruction of the brachial plexus. The key finding on physical examination that determines need for microsurgery is recovery of antigravity elbow flexion by 3-6 months of age. When indicated, both microsurgery and secondary shoulder and elbow procedures are effective and can substantially improve functional outcomes. These procedures include nerve transfers and nerve grafting in infants and secondary procedures in children, such as botulinum toxin injection, shoulder tendon transfers, and humeral derotational osteotomy.

Subscapularis Z-lengthening in children with brachial plexus birth palsy loses efficiency at mid-term follow-up: a retrospective cohort study

PURPOSE

The aim of this study was to evaluate early and mid-term clinical outcomes after isolated subscapularis Z-lengthening in children with shoulder internal rotation contractures resulting from brachial plexus birth palsy.

METHODS

Children with brachial plexus birth palsy treated with subscapularis tendon Z-lengthening from 2001 to 2011 were retrospectively reviewed. Over this period, 31 patients were identified. Primary outcome was improvement in Mallet score after surgery, and secondary outcome measures were active range of motion and Mallet sub-scores. Clinical outcomes were collected at three time intervals: pre-operatively, one-year post-operative and at latest follow-up.

RESULTS

After exclusion, 21 patients remained for further analysis. Mean age at surgery was 3.7 years (range, 1.2-8.7), and mean follow-up length was 6.5 years (2.9-9.7). Moderate improvements were found for mean Mallet score, active external rotation, active abduction and hand-to-mouth movement at one year and latest follow-up. However, improvements in active external rotation and Mallet score were not fully maintained at final follow up.

CONCLUSION

Isolated subscapularis Z-lengthening is effective at early follow-up, but results are not maintained at mid-term follow-up.