Surgical normalization of the shoulder joint in obstetric brachial plexus injury. Ann Plast Surg. 2010;65:411-417. [PMID: 20841993 DOI: 10.1097/sap.0b013e3181e1335b]

Comparing the Results of External Rotational Humeral Osteotomy in Older Children to the Mod Quad and Triangle Tilt Procedures in Adults with Obstetric Brachial Plexus Injury

BACKGROUND

External Rotational Humeral osteotomy is used to address the external rotation deficit in older children with obstetric brachial plexus Injury (OBPI). Although this procedure improves the cosmetic effect of shoulder subluxation, it has no effect on the underlying structural (glenohumeral deformity and scapular elevation and rotation) and functional problems. In this study, improvements in glenohumeral joint alignment; scapular hypoplasia, elevation, and rotation (SHEAR) deformity; and upper extremity functional movements were demonstrated in adult patients with OBPI 1 year after the mod Quad and/or triangle tilt surgeries.

METHODS AND PATIENTS

The outcome of humeral rotational osteotomy reported in the literature was compared with the results from 43 adult patients with OBPI (21 men and 22 women; 23 right and 20 left sides) with a mean age of 21.3 years (range, 17 to 38 years) who underwent mod Quad and/or triangle tilt surgeries and had over 12 months of postoperative follow-up (mean 22.9 months; range, 12 to 50 months).

RESULTS

The preoperative average modified total Mallet score, including supination, was 14.6 ± 3.5 (P < 0.0001) in the 43 adult patients with OBPI in this report. This total Mallet score was significantly improved to 22 ± 3.9 (P < 0.0001) over 12 months after mod Quad and/or triangle tilt surgeries. Thirty-two (75%) of the patients showed great improvement in all upper extremity functions: shoulder abduction, external rotation, hand-to-mouth, hand-to-neck, hand-to-spine, and supination. The improvement after humeral osteotomy reported in the literature was a cosmetic effect that did not address the underlying structural and functional problems and was found to decrease the improved shoulder abduction in long-term follow-up.

CONCLUSIONS

Thirty-two (75%) of 43 adult patients with OBPI showed great improvement in all upper extremity functions 1 year after mod Quad and/or triangle tilt surgeries. The other 11 patients (25%) showed improvement in hand-to-mouth movement and/or supination. In contrast, humeral osteotomy, as reported in the literature, improved the cosmetic effect of shoulder subluxation but had no effect on the underlying structural and functional problems.

10-year Follow-up of Mod Quad and Triangle Tilt Surgeries in Obstetric Brachial Plexus Injury

Aim:

To evaluate whether obstetric brachial plexus injury (OBPI) children who had mod Quad and triangle tilt surgeries maintained their recovered upper extremity functional movements over 10 years.

Background:

The short-term outcomes of surgery in OBPI patients are well documented. However, only a few publications with results over 10-year postoperative follow-up exist. We have previously reported the outcomes of these 2 surgeries in OBPI after 1, 2, and 5 years. Here, we report the successful outcomes in 17 of these patients over 10 years.

Methods:

Seventeen OBPI patients, who had mod Quad, a modified muscle release operation and triangle tilt, a bony surgical procedure with us between 2005 and 2008, had postoperative follow-up of 10 years and met the inclusion criteria. Patients who had multiple surgeries and did not have 10-year follow-up are excluded in this study.

Results:

Fifteen of 17 children maintain their recovered upper extremity functions for extended long period (mean, 10 years; range, 9–13 years). There was statistically significant improvement in total functional Mallet score after 3 years (mean, 18.8 ± 2.1; P ≤ 0.01) from the preoperative mean total Mallet score of 14.5 ± 1.2. This improvement was not only maintained for extended period but also improved (mean total Mallet score, 20.35 ± 2.3; P ≤ 0.01) in some patients.

Conclusions:

Overall, all upper extremity functions improved greatly after mod Quad and triangle tilt surgeries in OBPI children, and they were able to maintain their recovered functional movements over extended period of 10 years.

Improvements after mod Quad and triangle tilt revision surgical procedures in obstetric brachial plexus palsy

AIM

To compare outcomes of our revision surgical operations in obstetric brachial plexus palsy (OBPP) patients to results of conventional operative procedures at other institutions.

METHODS

We analyzed our OBPP data and identified 10 female and 10 male children aged 2.0 to 11.8 years (average age 6.5 years), who had prior conventional surgical therapies at other clinics. Of the 20 patients, 18 undergone triangle tilt, 2 had only mod Quad. Among 18 patients, 8 had only triangle tilt and 10 had also mod Quad as revision surgeries with us. We analyzed the anatomical improvements and functional modified Mallet statistically before and after a year post-revision operations.

RESULTS

Pre-revision surgery average modified Mallet score was 12.0 ± 1.5. This functional score was greatly improved to 18 ± 2.3 (P < 0.0001) at least one-year after revision surgical procedures. Radiological scores (PHHA and glenoid version) were also improved significantly to 31.9 ± 13.6 (P < 0.001), -16.3 ± 11 (P < 0.0002), at least one-year after triangle tilt procedure. Their mean pre-triangle tilt (yet after other surgeon’s surgeries) PHHA, glenoid version and SHEAR were 14.6 ± 21.7, -31.6 ± 19.3 and 16.1 ± 14.7 respectively.

CONCLUSION

We demonstrate here, mod Quad and triangle tilt as successful revision surgical procedures in 20 OBPP patients, who had other surgical treatments at other clinics before presenting to us for further treatment.

Successful outcome of triangle tilt as revision surgery in a pediatric obstetric brachial plexus patient with multiple previous operations

Introduction. Obstetric brachial plexus injury (OBPI) occurs during the process of labor and childbirth. OBPI has been reported to be associated with shoulder dystocia, macrosomia, and breech delivery. Its occurrence in uncomplicated delivery is possible as well. Case Presentation. The patient in the present report is a 6.5-year-old girl, who suffered a severe brachial plexus injury at birth and had many reconstructive surgical procedures at an outside brachial plexus center before presenting to us. Discussion. The traditional surgical treatments by other surgical groups were unsuccessful and therefore the patient came to our clinic for further treatment. She had triangle tilt surgery with us, as a salvage procedure. Conclusion. The OBPI patient in this study clearly showed noticeable clinical and functional improvements after triangle tilt surgical management. The posture of the arm at rest was greatly improved to a more normal position, and hand to mouth movement was improved as well. Triangle tilt surgery should be conducted as a first choice treatment for medial rotation contracture of the shoulder in OBPI patients.

An early shoulder repositioning program in birth-related brachial plexus injury: a pilot study of the Sup-ER protocol

BACKGROUND

Birth-related brachial plexus injury (BRBPI) occurs in 1.2/1,000 births in British Columbia. Even in children with "good" recovery, external rotation (ER) and supination (Sup) are often weaker, and permanent skeletal imbalance ensues. A preventive early infant shoulder passive repositioning program was created using primarily a novel custom splint holding the affected arm in full ER and Sup: the Sup-ER splint. The details of the splint and the shoulder repositioning program evolved with experience over several years. This study reviews the first 4 years.

METHODS

A retrospective review of BCCH patients managed with the Sup-ER protocol from 2008 to 2011 compared their recovery scores to matched historical controls selected from our database by two independent reviewers.

RESULTS

The protocol was initiated in 18 children during the study period. Six were excluded due to the following: insufficient data points, non-compliance, late splint initiation, and loss to follow-up. Of the 12 matches, the Sup-ER group final score at 2 years was better than controls by 1.18 active movement scale (AMS) points (p = 0.036) in Sup and 0.96 AMS points in ER (but not statistically significant (p = 0.13)). Unexpectedly, but importantly, during the study period, zero subjects were assessed to have the active functional criteria to indicate brachial plexus reconstruction, where previously we operated on 13 %.

CONCLUSIONS

Early application of passive shoulder repositioning into Sup and ER may improve outcomes in function of the arm in infants with BRBPI. A North American multi-site randomized control trial has been approved and has started recruitment.

Extended long-term (5 years) outcomes of triangle tilt surgery in obstetric brachial plexus injury

Objective:

We evaluated the "extended" long-term (5 years) functional outcomes in obstetric brachial plexus injury (OBPI) patients, who underwent triangle tilt surgery between February 2005 and January 2008.

Methods:

Twenty two children (9 girls and 13 boys, mean age at surgery was 5.8 years; ranging 2.1-11.8 years old), who initially presented with medial rotation contracture and scapula deformity secondary to obstetric brachial plexus injury were included in this study. Functional movements were evaluated pre-operatively, and 5 years following triangle tilt surgery by modified Mallet scale.

Results:

Here, we report long-term (5 years) follow-up of triangle tilt surgery for 22 OBPI patients. Upper extremity functional movements such as, external rotation (2.5±0.6 to 4.1±0.8, p<0.0001), hand-to-spine (2.6±0.6 to 3.4±1.1, p<0.005), hand-to-neck (2.7±0.7 to 4.3±0.7, p<0.0001), hand-to-mouth (2.3±0.9 (92º±33) to 4.2±0.5 (21º±16), p<0.0001), and supination (2.6±1.1 (-8.2º ±51) to 4.1±0.7 (61±32)) were significantly improved (p<0.0001), and maintained over the extended long-term (5 years). Total modified Mallet functional score was also shown to improve from 14.1±2.7 to 20.3±2.5.

Conclusions:

The triangle tilt surgery improved all shoulder functions significantly, and maintained over the extended long-term (5 years) in these patients.

Finger movement at birth in brachial plexus birth palsy

AIM: To investigate whether the finger movement at birth is a better predictor of the brachial plexus birth injury.

METHODS: We conducted a retrospective study reviewing pre-surgical records of 87 patients with residual obstetric brachial plexus palsy in study 1. Posterior subluxation of the humeral head (PHHA), and glenoid retroversion were measured from computed tomography or Magnetic resonance imaging, and correlated with the finger movement at birth. The study 2 consisted of 141 obstetric brachial plexus injury patients, who underwent primary surgeries and/or secondary surgery at the Texas Nerve and Paralysis Institute. Information regarding finger movement was obtained from the patient’s parent or guardian during the initial evaluation.

RESULTS: Among 87 patients, 9 (10.3%) patients who lacked finger movement at birth had a PHHA > 40%, and glenoid retroversion < -12°, whereas only 1 patient (1.1%) with finger movement had a PHHA > 40%, and retroversion < -8° in study 1. The improvement in glenohumeral deformity (PHHA, 31.8% ± 14.3%; and glenoid retroversion 22.0°± 15.0°) was significantly higher in patients, who have not had any primary surgeries and had finger movement at birth (group 1), when compared to those patients, who had primary surgeries (nerve and muscle surgeries), and lacked finger movement at birth (group 2), (PHHA 10.7% ± 15.8%; Version -8.0°± 8.4°, P = 0.005 and P = 0.030, respectively) in study 2. No finger movement at birth was observed in 55% of the patients in this study group.

CONCLUSION: Posterior subluxation and glenoid retroversion measurements indicated significantly severe shoulder deformities in children with finger movement at birth, in comparison with those lacked finger movement. However, the improvement after triangle tilt surgery was higher in patients who had finger movement at birth.

Triangle tilt and steel osteotomy: similar approaches to common problems

BACKGROUND

Each year, thousands of children worldwide suffer obstetric brachial plexus nerve injuries resulting not only in primary nerve injury, but also in development of secondary muscle and bone deformities of the shoulder. The triangle tilt surgery has been developed and shown to effectively address these deformities. The triangle tilt procedure was initially designed by the lead author (RKN) to follow the concepts of joint normalization featured in the Steel pelvic osteotomy used to correct developmental dysplasia of the hip joint, and indeed ultimately bears a striking resemblance to the Steel osteotomy. Prior to performing these bony surgical procedures, soft tissue procedures are performed to release the muscle contractures of the shoulder and hip. The purpose of this article is to compare and analyze the similarities between the indications, surgical techniques, involved anatomy, and outcomes of these operative procedures.

METHODS

A literature review was conducted using PubMed to identify articles pertaining to triangle tilt surgery and the Steel pelvic osteotomy. Functional parameters and surgical strategies were compared. Pre- and post-operative CTs were analyzed to compare anatomical results of the procedures.

RESULTS

Similarities were found between both procedures in terms of indications, involved anatomy, surgical techniques, and outcomes. The triangle tilt surgery is indicated to correct the developmental dysplasia of the glenohumeral joint in obstetric brachial plexus injury patients. Steel pelvic osteotomy is performed to correct the subluxation and dislocation of the hip innominate bone in patients with congenital dysplasia, cerebral palsy myelodysplasia, and poliomyelitis. The involved anatomy of both procedures is similar in that both involve limb girdles and ball-and-socket joints, namely the shoulder and hip. Both procedures are also triple osteotomies, the triangle tilt involving the acromion, clavicle and scapula while the Steel osteotomy involves the iliac spine, ischial and pubic ramus of the innominate bone. Surgical techniques also bear likenesses in that both can theoretically be done percutaneously. Post-operative CT outcomes of both surgeries showed improved anatomical positioning of the ball-and-socket joint congruency, and therefore better functional outcomes.

DISCUSSION

The similarities between the triangle tilt surgery and Steel pelvic osteotomy could potentially be useful as a model system in developing other procedures that involve the shoulder and hip. Future clinical applications include the development and implementation of new surgical procedures based on comparisons and adaptations from the hip to the shoulder and vice versa.

Comparing functional outcome of triangle tilt surgery performed before versus after two years of age

Background:

Many patients each year who are born with obstetric brachial plexus injuries eventually do not achieve complete recovery. As a result of the primary nerve injuries, these patients will often develop bony deformities involving the shoulder joint as a secondary consequence. The triangle tilt surgery has been shown to be an effective procedure to correct these deformities and has been performed on patients ranging in age from less than a year old to adolescence. The purpose of this retrospective study is to compare outcomes of triangle tilt surgery performed on patients before the age of 2 years versus after 2 years of age to determine an optimal age to operate on these children.

Methods:

36 patients with deformities developed secondarily from the initial obstetric brachial plexus injury in this study were divided into 2 groups. Group 1, those who had undergone triangle tilt surgery at < 2 yrs of age (16 patients). Group 2, those who were operated at > 2 yrs of age (20 patients). Group 1 age range: 9 months to 23 months, average: 18 months. Group 2 age range: 26 months to 9 years, average: 6 years.

Results:

Significant differences were found between the 2 groups (0-2 yrs vs > 2yrs) in regards to overall changes (pre- to post-op) in Mallet score, external rotation score, hand-to-mouth score, and supination angle.

Discussion:

This study demonstrates that triangle tilt surgery had better outcomes on clinical functioning if performed before the age of 2 years, however, improvement in clinical functioning can still be achieved if the triangle tilt surgery is performed after the age of 2 years as well. A possible mechanism to explain this phenomenon is the increased potential for anatomical remodeling if the triangle tilt surgery is performed at a younger age, thereby leading to significant functional improvement.