Reliability of three classification systems measuring active motion in brachial plexus birth palsy

Brachial plexus birth injuries: a multi-speciality approach. Commentary and opinions

The management of brachial plexus birth injuries (BPBI) remains controversial and ever evolving. In this article, studies are examined to provide further insight into the ongoing controversies and debates surrounding BPBI. The articles are diverse and examine the topics of aetiology, demographics, reliability versus accuracy of measurements and surgical management. The management of BPBI may differ depending on resources. Outcome measures may also vary depending on geography. Future research should focus on developing consensus-validated measures and reproducible surgical techniques. These can then guide further population-based research and provide guidelines to minimize the incidence of BPBI.

Interrater reliability of face-to-face, tele- and video-based assessments with the modified Mallet classification in brachial plexus birth injuries

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.

Advancing glenohumeral dysplasia treatment in brachial plexus birth injury: the end-to-side spinal accessory to suprascapular nerve transfer technique

PURPOSE

Brachial plexus birth injury (BPBI) is a common injury with the spectrum of disease prognosis ranging from spontaneous recovery to lifelong debilitating disability. A common sequela of BPBI is glenohumeral dysplasia (GHD) which, if not addressed early on, can lead to shoulder dysfunction as the child matures. However, there are no clear criteria for when to employ various surgical procedures for the correction of GHD.

METHODS

We describe our approach to correcting GDH in infants with BPBIs using a reverse end-to-side (ETS) transfer from the spinal accessory to the suprascapular nerve. This technique is employed in infants that present with GHD with poor external rotation (ER) function who would not necessitate a complete end-to-end transfer and are still too young for a tendon transfer. In this study, we present our outcomes in seven patients.

RESULTS

At presentation, all patients had persistent weakness of the upper trunk and functional limitations of the shoulder. Point-of-care ultrasounds confirmed GHD in each case. Five patients were male, and two patients were female, with a mean age of 3.3 months age (4 days-7 months) at presentation. Surgery was performed on average at 5.8 months of age (3-8.6 months). All seven patients treated with a reverse ETS approach had full recovery of ER according to active movement scores at the latest follow-up. Additionally, ultrasounds at the latest follow-up showed a complete resolution of GHD.

CONCLUSION

In infants with BPBI and evidence of GHD with poor ER, end-to-end nerve transfers, which initially downgrade function, or tendon transfers, that are not age-appropriate for the patient, are not recommended. Instead, we report seven successful cases of infants who underwent ETS spinal accessory to suprascapular nerve transfer for the treatment of GHD following BPBI.

Three-Dimensional Upper Limb Movement Analysis in Children and Adolescents With Brachial Plexus Birth Injury: A Systematic Review

BACKGROUND

To synthesize the current evidence on clinical use of three-dimensional upper limb movement analysis (3D-ULMA) in children and adolescents with brachial plexus birth injury (BPBI).

METHODS

MEDLINE, Embase, and Web of Science were searched for relevant studies up to April 2022. An automatic e-mail alert was installed to ensure no eligible article was missed. Articles evaluating 3D-ULMA in children and adolescents with BPBI were included. Covidence web-based platform was used for blind screening of eligible articles. Twenty-one observational studies with a final sample size of 609, encompassing 493 BPBI cases, met the inclusion criteria. Data were extracted using a custom form to support standardized extraction conforming to the Cochrane Checklist of items. Risk of bias was assessed using the Newcastle-Ottawa Scale, the Strengthening the Reporting of Observational Studies in Epidemiology checklist, and a specifically established quality assessment form for kinematic analysis studies.

RESULTS

Study setups differed, including six different types of kinematic devices. Twelve studies used the (modified) Mallet positions for their 3D-ULMA. Throughout the studies, 3D-ULMA was used for various purposes. The Newcastle-Ottawa Scale scored 16 articles with five stars or more, indicating fair to moderate quality.

CONCLUSIONS

This systematic review summarizes the different 3D-ULMA kinematic devices, test protocols, and their clinical use for BPBI. The use of 3D-ULMA provides valuable, objective, and quantified data to clinicians with regard to movement strategies; it complements existing clinical scales and can be implemented to evaluate effectiveness of therapy interventions. Implications for future research and clinical practice are discussed.

Outcomes of glenohumeral dysplasia after brachial plexus birth injury using the Sup-ER orthosis

We investigated the efficacy of the supination-external rotation ('Sup-ER') orthosis, designed as a non-operative treatment to maintain normal anatomical growth of the shoulder, on the progression of glenohumeral dysplasia in patients with brachial plexus birth injuries. The Sup-ER orthosis was fabricated for 20 infants diagnosed with glenohumeral dysplasia after brachial plexus birth injuries and its success in correcting glenohumeral dysplasia was confirmed by objective calculations of the alpha angle on serial ultrasound findings and improvement in Active Movement Scale scores. Of the 20 patients, 14 had successful resolution of glenohumeral dysplasia, confirmed by shoulder abduction, shoulder flexion, external rotation and supination, Active Movement Scale scores and improving alpha angle measurements. Failure to rectify glenohumeral dysplasia, evidenced by worsening ultrasound findings and Active Movement Scale scores, necessitated a change to operative management in six patients.Level of evidence: IV.

Early Elbow Flexion Contracture Predicts Shoulder Contracture in Infants with Brachial Plexus Birth Injury

OBJECTIVE

To determine if children who present with an elbow flexion contracture (EFC) from brachial plexus birth injury (BPBI) are more likely to develop shoulder contracture and undergo surgical treatment.

STUDY DESIGN

Retrospective review of children <2 years of age with BPBI who presented to a single children's hospital from 1993 to 2020. Age, elbow and shoulder range of motion (ROM), imaging measurements, and surgical treatment and outcome were analyzed. Patients with an EFC of ≥10° were included in the study sample. Data from 2445 clinical evaluations (1190 patients) were assessed. The final study cohort included 72 EFC cases matched with 230 non-EFC controls. Three patients lacked sufficient follow-up data.

RESULTS

There were 299 included patients who showed no differences between study and control groups with respect to age, sex, race, ethnicity, or functional score. Patients with EFC had 12° less shoulder range of motion (95% CI, 5°-20°; P < .001) and had 2.5 times the odds of shoulder contracture (OR, 2.5; 95% CI, 1.3-4.7; P = .006). For each additional 5° of EFC, the odds of shoulder contracture increased by 50% (OR, 1.5; 95% CI, 1.2-1.8; P < .001) and odds of shoulder procedure increased by 62% (OR, 1.62; 95% CI, 1.04-2.53; P = .03). Sensitivity of EFC for predicting shoulder contracture was 49% and specificity was 82%.

CONCLUSIONS

In patients with BPBI <2 years of age, presence of EFC can be used as a screening tool in identifying shoulder contractures that may otherwise be difficult to assess. Prompt referral should be arranged for evaluation at a BPBI specialty clinic, because delayed presentation risks worsening shoulder contracture and potentially more complicated surgery.

Diagnostic Accuracy of Manual Muscle Testing to Identify Nerve Transfer Candidates in Children with Acute Flaccid Myelitis

BACKGROUND

Manual muscle testing is a mainstay of strength assessment despite not having been compared with intraoperative electrical stimulation of peripheral nerves.

METHODS

Intraoperative electrical stimulation served as the reference standard in evaluating predictive accuracy of the Active Movement Scale (AMS) and the Medical Research Council (MRC) scale. Retrospective consecutive sampling of all patients with AFM who underwent exploration or nerve transfer at a pediatric multidisciplinary brachial plexus and peripheral nerve center from March of 2016 to July of 2020 were included. The nonparametric area under the curve (AUC) was calculated. Optimal cutoff score (Youden J ) and diagnostic accuracy values were reported. The AMS and MRC scale were directly compared for predictive superiority.

RESULTS

A total of 181 upper extremity nerves (73 donor nerve candidates and 108 recipient nerve candidates) were tested intraoperatively from 40 children (mean age ± SD, 7.9 ± 4.9 years). The scales performed similarly ( P = 0.953) in classifying suitable donor nerves with satisfactory accuracy (AUC AMS , 71.5%; AUC MRC , 70.7%; optimal cutoff, AMS >5 and MRC >2). The scales performed similarly ( P = 0.688) in classifying suitable recipient nerves with good accuracy (AUC AMS , 92.1%; AUC MRC :, 94.9%; optimal cutoff, AMS ≤3 and MRC ≤1).

CONCLUSIONS

Manual muscle testing is an accurate, noninvasive means of identifying donor and recipient nerves for transfer in children with acute flaccid myelitis. The utility of these results is in minimizing unexpected findings in the operating room and aiding in the development of contingency plans. Further research may extend these findings to test the validity of manual muscle testing as an outcome measure of the success of nerve transfer.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, I.

Finding Effective Adjustment Levels for Upper Limb Exergames: Focus Group Study With Children With Physical Disabilities

BACKGROUND

We developed the Blexer system consisting of a database and a web interface for therapists that can host different types of adaptive and personally configurable virtual reality exergames based on Kinect (Microsoft Corp) motion capture to provide entertaining exercises for children with motor disabilities. It allows for parameter adjustment and the monitoring of results remotely, thereby providing a useful tool to complement traditional physical therapy sessions with home exercises.

OBJECTIVE

The aim of this study was to observe the motor benefits achieved through the use of a video exergame and the importance and implications of correctly setting the game's difficulty parameters.

METHODS

This was an observational case study of 6 children with different physical disabilities receiving physical therapy at school combined with the use of a fully configurable exergame under research that forms a part of the Blexer environment. The game integrates 4 repeatedly appearing upper limb exercises with individually adjustable difficulties (intermittent arm rising, arm forward and backward movement, rising and holding of one arm, and trunk control in all directions). The outcomes were 3 assessments of 2 efficacy measures: Box and Block Test and Jebsen Taylor Hand Function Test.

RESULTS

A total of 5 children with cerebral palsy (mean 8.4, SD 2.7 years; Gross Motor Function Classification II-2/5, 40%; III-2/5, 40%; and IV-1/5, 20%) and 1 child with obstetric brachial plexus palsy (aged 8 years; Mallet Classification III) received between 8 and 11 sessions of training (10-20 minutes per session), depending on age, motivation, and fatigue. Significant associations were observed between game parameter settings and improvements in motor function, on the one hand, and between the type of improvement and disability severity, on the other: with adjusted game parameters goal and time in the range of 70% to 100%, only less affected children improved in the Box and Block Test (+11 blocks vs -1 block), and more affected children improved more in the Jebsen Taylor Hand Function Test (+90 seconds vs +27 seconds).

CONCLUSIONS

When defining the difficulty parameters for an exergame, we suggest a classification in levels ranging from very easy to very hard. For practical use, we suggest setting the difficulty for the player to an easy or medium level rather than high-commitment goals, as this leads to a longer playtime with more fun and, therefore, seems to improve the results of the game and, consequently, mobility.

Clavicle lengthening, a novel operation technique to reduce pain in brachial plexus birth injury patients

BACKGROUND

Brachial plexus birth injury (BPBI) can lead to an imbalance of shoulder musculature that can lead to glenohumeral contractures, and joint and osseous deformities. Glenoid hypoplasia, lengthening of coracoid and acromion, protraction, lateral rotation and elevation of the scapula, and shortening of the clavicle can be observed. As a consequence, the trapezius, levator scapulae, rhomboid, and supraspinatus muscles are overloaded in daily activities causing pain, which can be difficult to treat conservatively. It is hypothesized that operative lengthening of the clavicle may lead to a more anatomic position of the scapula and periscapular muscles, which, as a consequence, may lead to less overloading pain. This study presents the results of this new technique in patients with BPBI.

MATERIALS AND METHODS

Seven patients (median age 20 years) were included and underwent a lengthening osteotomy of the clavicle at the affective side. Preoperatively, the osseous deformities were confirmed with a computed tomography scan. Patient-reported outcome measures, Disabilities of Arm, Shoulder and Hand score, and Mallet score were evaluated pre- and postoperatively.

RESULTS

After a median of 42 (interquartile range [IQR]: 8.0) months' follow-up, all patients were satisfied with the result. The median numeric rating scale for satisfaction was 8.0 (IQR: 2). Pain decreased from a median numeric rating scale of 7.0 (IQR: 2) preoperatively to 2.0 (IQR: 3) at the final follow-up. The median Mallet score was 14.5 (IQR: 1) preoperatively and 14 (IQR: 0) at the final follow-up. The median Disabilities of Arm, Shoulder and Hand score was 36.7 (IQR: 24.1) at the final follow-up. All patients returned to their normal work without changes in working conditions.

CONCLUSION

Short-term follow-up shows that in patients with BPBI with a short clavicle at the affected side and malposition of the scapula, a lengthening osteotomy of the clavicle is a safe and promising technique to reduce pain based on overloading, without deterioration of shoulder function.

Comparison of Shoulder Motion Measurements by Visual Estimate, Goniometer and Motion Capture

BACKGROUND

Brachial plexus birth injuries (BPBI) can result in lasting impairments of external rotation and cross-body adduction (CBA) that disrupt functional activities such as dressing, grooming, or throwing a ball. The purpose of this study was to compare the quantification of shoulder humerothoracic (HT) external rotation (ER), and glenohumeral (GH) CBA by 3 methods - physician visual estimate, goniometer measurement by an occupational therapist, and motion capture.

METHODS

Twenty-six patients with BPBI (average age of 9.9±3.2 y) participated in this study. Mallet scores and visual estimates of passive HT ER and GH CBA were recorded by a physician. The passive measures were repeated by an occupational therapist using a goniometer while motion capture measures were simultaneously collected. Active HT ER was also measured by motion capture. The passive measures were compared with analyses of variance with repeated measures, intraclass correlations, and Bland-Altman plots. External rotation Mallet scores determined by motion capture and by the physician were compared.

RESULTS

The measures of GH CBA were not statistically different and demonstrated good agreement, but substantial variation. For HT ER, all measures were significantly different and demonstrated poor agreement and substantial variation. When the joint angles measured by motion capture were used to determine the Mallet score, 79% of external rotation Mallet scores assigned by the physician were incorrectly categorized, with the physician always scoring the participant higher than predicted motion capture Mallet score.

CONCLUSIONS

Both GH CBA and HT ER measures demonstrated substantial variability between measurement types, but only HT ER joint angles were significantly different. In addition, more than three-quarters of external rotation Mallet scores were misclassified by the physician. Motion capture measurements offer the benefit of less susceptibility to patients' compensatory and/or out-of-plane movements and should be considered for clinical assessment of shoulder range of motion in children with BPBI. If motion capture is unavailable, the use of a goniometer provides more accurate clinical measures of shoulder motion than visual estimates and care should be taken to minimize and account for compensatory movement strategies.

LEVEL OF EVIDENCE

Level IV Case series.

Rehabilitation of a Child with Neonatal Brachial Plexus Palsy: Case Report Described by Parents

This paper presents a case report of a child with Neonatal Brachial Plexus Palsy on the right arm, with C5, C6, and C7 nerve injuries. The symptoms presented at birth and at the time of diagnosis were absence of movement in the right arm but with mobility of the fingers; internal rotation of the injured limb with elbow extension; active flexion of the wrist and fingers; and ulnar deviation of the hand. The rehabilitation plan followed the conservative approach and included different intervention strategies (passive and active mobilisation, kinesio tape, use of splints, bimanual stimulation, etc.) carried out by the occupational therapist and the physical therapist. The rehabilitation allowed the child to have a functional limb for daily activities, with bimanual motor integration and coordination; passive and active range of motion in the different joints except for pronation, sensibility, and maintained strength. In conclusion, it can be said that this case report describes a set of rehabilitation strategies that were used in the conservative treatment of a child with NBPP and the functional gains they allowed. Early intervention, parental involvement in the rehabilitation process, and continuous follow-up of the child favoured the prognosis and allowed the prevention of functional sequelae of the limb.

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

INTRODUCTION

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

PURPOSE

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

STUDY DESIGN

Prospective, correlational design.

METHODS

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

RESULTS

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

CONCLUSION

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

Comparison of 2 Patient-Reported Outcome Measures in Brachial Plexus Birth Injury: A Systematic Validation Study

BACKGROUND

Patient-reported outcome (PRO) measures are integral to clinical practice. While new instruments bring updated methodology and delivery methods, they must be compared with existing measures to ensure that they are comparable with currently used instruments and allow ongoing comparison. In this study, we evaluated 2 PRO measures for patients with brachial plexus birth injury (BPBI): the legacy Pediatric Outcomes Data Collection Instrument (PODCI) and the newer Patient-Reported Outcomes Measurement Information System (PROMIS). We hypothesized that the PROMIS and PODCI would be correlated, with high convergent validity, and that PROMIS assessment would have higher discriminant validity and take less time to complete than the PODCI.

METHODS

A cross-sectional prospective study was undertaken at a tertiary referral center. Subjects (n = 50) completed the PODCI and PROMIS, both as short form (SF) and computer-adaptive testing (CAT) measures, in randomized order. Patient and parent questionnaires were completed according to subject age. Physicians completed upper-extremity (UE) physical function tests. Correlations between PODCI and PROMIS scores were analyzed to determine convergent validity, UE subscores were analyzed relative to physical function scores to assess discriminant validity, and completion times were calculated to determine survey time to completion.

RESULTS

High convergent validity was found between the parent-reported PODCI, PROMIS SF, and PROMIS CAT measures. A ceiling effect was found for the PODCI but not for the PROMIS. The PROMIS CAT had better discriminant validity than either the PROMIS SF or PODCI. Patient and parent outcome scores did not highly correlate. Survey time to completion varied by PRO measure and method of delivery.

CONCLUSIONS

There was high convergent validity between the UE domains of the PROMIS and PODCI, with a lower time to completion for the PROMIS SF. Although results show that the PROMIS CAT may take longer to complete, there are notable benefits to its adoption, including high convergent validity with the PODCI and better discriminant validity than the PODCI and PROMIS SF measures.

Brachial Plexus Birth Injuries

Brachial plexus birth injuries (BPBIs) are typically traction type injuries to the newborn that occur during the delivery process. Although the incidence of these injuries has overall decreased from 1.5 to around 0.9 per 1000 live births in the United States over the past 2 decades, these injuries remain common, with incidence holding fairly steady from 2008 to 2014. Shoulder dystocia is the strongest identified risk factor, imparting a 100-fold greater risk. The newborn's shoulder is caught behind the mother's pubic bone, and traction performed on the child during delivery results in injury to the brachial plexus. Other risk factors associated with BPBI include macrosomia (birthweight > 4.5 kg), heavy for gestational age infants, birth hypoxia, gestational diabetes, and forceps or vacuum-assisted delivery. Breech presentation has also been described as a risk factor in the past, but there have been more recent data that challenge this association.

Upper-limb function in Brachial Plexus birth palsy: Does the Pediatric Outcomes Data Collection Instrument correlate with the Brachial Plexus Outcome Measure?

Functional outcome assessment for children with brachial plexus birth palsy (BPBP) is essential. We aimed to investigate the association between the Brachial Plexus Outcome Measure (BPOM) and the Pediatric Outcomes Data Collection Instrument (PODCI) in children with BPBP and healthy matched controls, and to explore upper-limb function and the discriminative properties of the two tests. Thirty children, aged 6-14 years, diagnosed with BPBP and undergoing shoulder tendon transfer and 20 age-matched healthy controls were included. In both groups, the Turkish version of the PODCI, used to evaluate daily living activities, was implemented. The Turkish version of the BPOM, specifically developed for BPBP, was applied in children with BPBP. Test results, demographic and clinical characteristics were recorded. The mean age of children with BPBP was 8.53 ± 2.53 years and their BPOM Activity scale score was 42.93 ± 8.28. The PODCI Upper Extremity Function score (74.97 ± 23.49 vs. 100) and the PODCI Global Functioning score (89.20 ± 7.73 vs. 99.36 ± 7.73) were significantly lower in the BPBP group (p < 0.01). While there was a significant and very strong relationship between the BPOM Activity and PODCI Global Functioning scores (r = 0.845; p = 0.037), no correlation was found between the BPOM Self-Evaluation scale and PODCI Global Functioning score (r = 0.456; p = -0.141). The PODCI correlated with the BPOM Activity scale, providing an appropriate alternative measurement for upper-limb function in children with BPBP after shoulder tendon transfer.

Timing of Nerve Recovery After Nerve Grafting in Obstetrical Brachial Plexus Palsy Patients With Isolated Upper Trunk Neuromas

BACKGROUND

The timing of nerve recovery after nerve grafting in obstetrical brachial plexus palsy patients has not been well reported. One prior study reported a return to baseline function at 3 to 6 months postoperatively. However, there is a paucity of studies to corroborate this timing, and there have been no studies delineating the timeline to obtain clinically meaningful function.

METHODS

OBPP patients with upper trunk neuromas-in-continuity who were treated with resection and sural nerve grafting at a single institution were studied. Time to return to baseline function was assessed by Active Movement Scale (AMS) scores preoperatively and postoperatively. Time to clinically meaningful function, defined as an AMS score of ≥6, was also assessed.

RESULTS

Eleven patients with isolated upper trunk neuromas-in-continuity underwent excision and reversed sural nerve grafting. Three of 11 patients also underwent spinal accessory to suprascapular nerve transfers. Average age at surgery was 9.8 ± 1.9 months. One patient did not have follow-up data and was excluded. Average follow-up was 37.1 ± 16.8 months. Average return to baseline AMS score was approximately 4 to 8 months for shoulder abduction, shoulder flexion, shoulder external rotation, elbow flexion, and forearm supination. Clinically meaningful function was obtained in most patients between 9 and 15 months. The remaining patients who did not achieve clinically meaningful function had all obtained scores of 5, which reflects less than one half normal range of motion against gravity.

CONCLUSIONS

Nerve recovery after surgical intervention in OBPP patients who undergo resection of an upper trunk neuroma-in-continuity and nerve grafting is more rapid than in adults but longer than previously reported in OBPP literature. This study provides an important data point in delineating the timeline of nerve recovery.

Recommendations for management of neonatal brachial plexus palsy: Based on clinical review

STUDY DESIGN

Descriptive report.

INTRODUCTION

Neonatal brachial plexus palsy (NBPP) involves a partial or total injury of the nerves that originate from spinal roots C5-C8 and T1. The reported incidence of NBPP is between 0.38 and 5.1 in 1000 births.

PURPOSE OF THE STUDY

This study describes the management NBPP in the first 3 years of life and to develop an assessment framework for infants with NBPP and postoperative guidelines for those undergoing primary surgery.

METHODS

Retrospective medical record audit from 2012 to 2017.

RESULTS

Of 187 children referred to brachial plexus clinic (BPC), 138 were new referrals and included in the audit. The average number of new referrals per annum was 37; average age at referral was 6.61 week; average age at first appointment was 16.9 weeks. Of the 138 infants, 104 were initially assessed by a physiotherapist before attending BPC. The most common comorbidity was plagiocephaly.

DISCUSSION

From 2012 to 2017, birth location, birth facility, referral source, and time between referral and initial assessment have remained stable. The age at referral, age at which the child was first assessed, and the number of children who received services externally before attending the hospital all decreased. The number of children seen by a physiotherapist before attending BPC increased. An NBPP assessment framework, including critical time points for assessment, and postoperative guidelines for infants and children undergoing primary surgery were created.

CONCLUSIONS

Early referral is essential for effective management of NBPP and ideally infants should be assessed and management implemented before 3 months of age.

Long-Term Hand Function Outcomes of the Surgical Management of Complete Brachial Plexus Birth Injury

PURPOSE

Hand function outcomes of primary nerve reconstruction for total brachial plexus birth injury (BPBI) are confounded by nerve roots left in continuity, inclusion of secondary procedures, and no assessment of the ability to perform activities of daily living. The purpose of this study was to evaluate the long-term hand function outcomes in a cohort of patients with a complete BPBI who had no nerve root in continuity prior to primary nerve reconstruction targeting the lower trunk.

METHODS

This single-center retrospective case series of complete BPBI included patients who underwent primary nerve reconstruction. The outcomes were assessed using the active movement scale (AMS) and brachial plexus outcome measure preoperatively and at the age of 4 and 8 years.

RESULTS

Fifty patients with a complete BPBI, of whom 82% (41/50) had an avulsion of C8-T1, underwent primary nerve reconstruction at a mean age of 4.1 months. Compared with the preoperative AMS scores, a statistically significant increase of AMS scores was observed at 4 and 8 years of age for all movements except forearm pronation. Between 4 and 8 years of age, there was a statistically significant improvement of external rotation of the shoulder and elbow flexion as well as diminution of thumb flexion. In the brachial plexus outcome measure assessment, there were 83% (24/29) at 4 years and 81% (21/26) at 8 years who had sufficient functional movement to perform wrist, finger, and thumb activities.

CONCLUSIONS

Functional hand outcome was restored to sufficiently perform bimanual activity tasks in 81% (21/26) of patients with a complete BPBI at 8 years of age. This affirmed that primary nerve reconstruction reinnervating the lower trunk can result in a functional extremity.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The importance of inertial measurement unit placement in assessing upper limb motion

Motion analysis using inertial measurement units (IMU) has emerged as an alternative to optical motion capture. However, the validity and reliability of upper limb measurements varies significantly between studies. The objective of this study was to determine how sensor placement affects kinematic output in the assessment of motion of the arm, shoulder, and scapula. IMUs were placed proximally/distally on arms, and medially/laterally on the scapula, in a group of eleven healthy participants, while performing nine different motion tasks. Linear regressions and mixed models analysed how these different sensor placements affected the estimated joint motion by establishing the linear relationship between sensors placed on the same body segment. The placement of sensors affected the measured kinematic output considerably, most prominent affect was seen for sensor placement on scapula during flexion and abduction, and on forearm during pronation/supination. The slope of the linear regression lines was 2.5 during flexion, 2.7 during abduction, and 1.8 for forearm pronation/supination. The results of this study suggest that the forearm sensor should be placed on the dorsal side of the forearm, at the distal end; the upper arm sensor should be placed laterally, on the distal part of the arm; and the sensor on the scapula should be placed cranially, along the spine of scapula.

Brachial Plexus Birth Injuries: A Critical Analysis Review

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The incidence of brachial plexus birth injury (BPBI) in the United States is declining and now occurs in <1 per 1,000 births.

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The gold standard for predicting the need for early intervention remains serial examination.

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Early treatment of BPBI with reconstructive surgery requires the ability to perform both interposition nerve grafting and nerve transfers.

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Given the heterogeneity of lesions, the evidence is largely limited to retrospective comparative studies and case series.

Palliative shoulder and elbow surgery in obstetrical brachial plexus birth palsy

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.

Relative importance of factors affecting activity and upper extremity function in children with Narakas Group 2 brachial plexus birth palsy

The aim of the study was to determine the differences in upper limb function and activity/participation levels between preschool children with Narakas Groups 2a and 2b obstetric brachial plexus injury; and to determine the significance level of the factors affecting upper limb functions in these patients. Sixty-seven children, aged 3 to 7, who had not had surgical intervention, were evaluated in terms of joint movements, modified Mallet classification, Raimondi hand classification, brachial plexus outcome measure, paediatric outcome data collection instrument and stereognosis. There were significant functional differences between the groups, in favour of Group 2a. The movements affecting total function of the upper limb were: hand to spine (p < 0.001), global abduction (p < 0.001) and hand to mouth (p < 0.001), in descending order of significance. Passive internal rotation was the most important passive joint movement affecting shoulder function (p < 0.001). The results of this study suggest that more emphasis should be placed on the shoulder internal rotation in treatment strategies.Level of evidence: III.

Morbidity of Nerve Transfers for Brachial Plexus Birth Injury: A Systematic Review

BACKGROUND

The purpose of this article is to systematically review the peer-reviewed literature on the morbidity of nerve transfers performed in patients with brachial plexus birth injury (BPBI). Nerve transfers for restoration of function in patients with BPBI that fail nonoperative management are increasing in popularity. However, relatively little attention has been paid to the morbidity of these transfers in the growing patient. The authors systematically review the current literature regarding donor site morbidity following nerve transfer for BPBI.

METHODS

A systematic review of the Medline and EMBASE databases was conducted through February 2020. Primary research articles written in English and reporting donor site morbidity after nerve transfer for BPBI were included for review.

RESULTS

Thirty-six articles met inclusion criteria, all of which were retrospective reviews or case reports. There was great heterogeneity in outcomes assessed. With 5 year or less follow-up, all transfers were relatively well tolerated with the exception of the hypoglossal nerve transfer.

CONCLUSION

Nerve transfers are a well-recognized treatment strategy for patients with BPBI and have an acceptable risk profile in the short term. Full hypoglossal nerve transfers for BPBI are of historical interest. Donor site morbidity is grossly underreported. This review highlights the need for more objective and systematic reporting of donor site outcomes, and the need for longer term follow-up in these patients.

LEVEL OF EVIDENCE

Systematic review. Level III-therapeutic.

Follow-up Study on the Effects of Tendon Transfers and Open Reduction on Moderate Glenohumeral Joint Deformity in Brachial Plexus Birth Injury

BACKGROUND

Soft-tissue contractures about the shoulder in patients with brachial plexus birth injury are common and can lead to progressive shoulder displacement and glenohumeral dysplasia. Open or arthroscopic reduction with musculotendinous lengthening and tendon transfers have become the standard of care. The clinical function and radiographic joint remodeling beyond the first 2 years after surgery are not well understood.

METHODS

We performed a follow-up study of 20 patients with preexisting mild to moderate glenohumeral joint deformity who had undergone open glenohumeral joint reduction with latissimus dorsi and teres major tendon transfers and concomitant musculotendinous lengthening of the pectoralis major and/or subscapularis. Prospective collection of Modified Mallet and Active Movement Scale (AMS) scores and radiographic analysis of cross-sectional imaging for glenoid version, humeral head subluxation, and glenohumeral joint deformity classification were analyzed for changes over time.

RESULTS

The average duration of radiographic follow-up was 4.2 years (range, 2 to 6 years). The mean glenoid version improved from -31.8° to -15.4° (p < 0.0001). The mean percentage of the humeral head anterior to the middle of the glenoid (PHHA) improved from 9.6% to 30.4% (p < 0.0001). The mean glenohumeral joint deformity score improved from 3.7 to 2.1 (p < 0.0001).

CONCLUSIONS

All parameters showed the greatest magnitude of improvement between preoperative measurements and 1 year of follow-up. There were no significant changes beyond the 1-year time point in the Mallet scores, AMS scores, or radiographic outcome measures, possibly because of insufficient power, although trends of improvement were noted for some outcomes. No decline in outcome measures was found during the study period.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparison of autograft versus allograft in the surgical repair of pediatric obstetrical brachial plexus injuries

OBJECTIVE

The goal of this study was to determine the functional efficacy of acellular processed nerve allograft (ALG) as compared to sural nerve autograft (AUG) harvested at time of surgery for children with obstetrical brachial plexus injury (OBPI).

METHODS

A retrospective review of records was performed in patients who underwent surgical repair of OBPI between 2009 and 2015 at Phoenix Children's Hospital. Patients were grouped based on the type of nerve graft used (AUG using the patient's own sural nerve or decellularized processed cadaveric nerve ALG) and compared in terms of motor strength, British Medical Research Council score, functionality (Mallet scale score), surgical time, rate of complications, and need for further intervention.

RESULTS

A total of 52 records were identified meeting study criteria. Sural nerve AUG was used in 22 cases and ALG in 30 cases. Changes from pre- to postsurgical assessment of motor strength were significant for all muscle groups measured except for elbow extension for both groups. All Mallet scores increased significantly. No significant differences were observed in motor strength and functional components between groups. Interventions using ALG had shorter operative times than those performed using AUG. No significant difference was observed in terms of need for further intervention. Two patients (9%) in the AUG group developed stitch abscesses at the harvest site, whereas there were no infectious complications reported in the ALG group.

CONCLUSIONS

These findings suggest equivalence in terms of muscle strength and functional outcomes between the use of AUG and ALG for patients with OBPI. However, the less invasive character of ALG repair decreases surgical time and risk of complications.

QUALITY OF LIFE AND UPPER LIMB FUNCTION OF CHILDREN WITH NEONATAL BRACHIAL PLEXUS PALSY

OBJECTIVE

To compare the upper limb function and quality of life between children with neonatal brachial plexus palsy and controls with unaffected brachial plexus (typical children).

METHODS

Twenty-four children with neonatal brachial plexus palsy and 24 typical ones were evaluated, both groups with 10±3 years of age. The upper limb function was assessed by the Modified Mallet Scale and the Active Movement Scale, whereas quality of life was analyzed by the Pediatric Outcome Data Collection Instrument and the Child Health Questionnaire. Mann-Whitney U tests investigated the differences between groups in such scales.

RESULTS

Children with neonatal brachial plexus palsy presented lower limb function compared to typical children in both scales. These children also presented lower scores for most of the Pediatric Outcome Data Collection Instrument domains, except for comfort/pain. In addition, they had lower scores in the following domains of the Child Health Questionnaire: physical functioning, pain, behavior, mental health, overall health perception, emotional impact on parents, and psychosocial summarized score.

CONCLUSIONS

Neonatal brachial plexus palsy has a negative influence on upper limb function and quality of life, mainly considering overall health, basic mobility, physical and psychosocial functions, happiness, pain, behavior, mental health, upper limb function, and emotional impact on their parents.

Effect of augmented biofeedback for improvement of range of motion and upper extremity functionality in obstetric brachial plexus injury: a randomised control trial

Background/Aims

The loss of mobility and functional activities of the upper limb are the main longstanding complications of obstetric brachial plexus injury. The aim of this study was to investigate the effect of the augmented biofeedback system in conjunction with traditional physical therapy on the range of motion and functional activities in children with obstetric brachial plexus injury.

Methods

A total of 45 children aged from 6 to 10 years with obstetric brachial plexus injury were assigned into two groups. The control group received a traditional physical therapy programme, and the study group received the same programme with augmented biofeedback for 6 weeks. The main outcome parameters were the upper limb active range of motion, Mallet scale and Active Movement scale.

Results

The children in the study group showed greater significant improvement in all measured parameters compared with those in the control group.

Conclusions

Adding augmented biofeedback to the physical therapy programme provided greater improvement in upper limb mobility and functional activities for children with obstetric brachial plexus injury children.

Functional outcomes of tendon transfer for brachial plexus birth palsy using the Hoffer technique

Aims

To describe and analyze the mid-term functional outcomes of a large series of patients who underwent the Hoffer procedure for brachial plexus birth palsy (BPBP).

Methods

All patients who underwent the Hoffer procedure with minimum two-year follow-up were retrospectively reviewed. Active shoulder range of movement (ROM), aggregate modified Mallet classification scores, Hospital for Sick Children Active Movement Scale (AMS) scores, and/or Toronto Test Scores were used to assess functional outcomes. Subgroup analysis based on age and level of injury was performed. Risk factors for subsequent humeral derotational osteotomy and other complications were also assessed. A total of 107 patients, average age 3.9 years (1.6 to 13) and 59% female, were included in the study with mean 68 months (24 to 194) follow-up.

Results

All patients demonstrated statistically significant improvement in all functional outcomes and active shoulder abduction and external rotation ROM (p < 0.001). Patients < 2.5 years of age had higher postoperative AMS, abduction ROM and strength scores, and aggregate postoperative Toronto scores (p ≤ 0.035) compared to patients ≥ 2.5 years old. There were 17 patients (16%) who required a subsequent humeral derotational osteotomy; lower preoperative AMS external rotation scores and external rotation ROM were predictive risk factors (p ≤ 0.016).

Conclusion

Patients with BPBP who underwent the Hoffer procedure demonstrated significant improvement in postoperative ROM, strength, and functional outcome scores at mid-term follow-up. Patients younger than 2.5 years at the time of surgery generally had better functional outcomes. Limited preoperative external rotation strength and ROM were significantly associated with requirement for subsequent humeral derotational osteotomy. In our chort significant improvements in shoulder function were obtained after the Hoffer procedure for BPBP. Cite this article: Bone Joint J 2020;102-B(2):246–253.

Reliability and validity of the Brachial Plexus Outcome Measure in children with obstetric brachial plexus palsy

STUDY DESIGN

Clinical measurement and cross-sectional study.

INTRODUCTION

Numerous scales have been developed to examine activities of daily living and function in children with brachial plexus palsy. The Brachial Plexus Outcome Measure (BPOM) scale was developed in 2012 by Emily S. Ho and contains 14 items that measure activity and self-evaluation.

PURPOSE OF THE STUDY

The aim of the study was to cross-culturally translate the BPOM scale into Turkish and test its measurement properties in children with brachial plexus palsy.

METHODS

The scale was translated into Turkish using standard cross-cultural translation procedures. Forty-eight children with obstetric brachial plexus palsy (OBPP) were included in psychometric evaluations. Internal structure consistency and test-retest reliability were measured for reliability analyses. For each item on the scale, Cronbach alpha coefficient and item-total score correlations for all subscales were calculated. The scale was administered at baseline and 1 week later by 2 different physiotherapists to evaluate test-retest reliability. Concurrent construct validity was assessed using Pearson correlations between the OBPP and the Mallet classification system.

RESULTS

Eighteen (37.5%) girls and 30 (62%) boys, in total 48 children, whose mean age was 8.7 ± 2.4 (minimum-maximum = 5-14) years were included in the study; 9 (18.9%) have a history of both early microsurgery and tendon transfers and 39 (81.3%) have a history of only tendon transfer. Cronbach alpha ranged from 0.89 to 0.96, and for the whole scale, it was calculated as 0.938.

DISCUSSION

Test-retest reliability was high. Moderate correlations were observed between the measures.

CONCLUSION

The Turkish BPOM scale is a valid and reliable measurement for assessing function in children with OBPP in the Turkish population.

Brachial plexus birth injuries and the association between pre-procedure and post-procedure pediatric outcomes data collection instrument scores and narakas classification

BACKGROUND

The brachial plexus is a network of nerves exiting the spinal cord through the fifth, sixth, seventh, and eighth cervical nerves (C5-C8) as well as the first thoracic nerve (T1) to conduct signals for motion and sensation throughout the arm. Brachial plexus birth injuries (BPBI) occur in 1.5 per 1,000 live births. The purpose of this study was to determine the perceived change in musculoskeletal health-related quality of life of brachial plexus patients utilizing the Pediatric Outcomes Data Collection Instrument (PODCI). PODCI scores were examined along with the patient's procedure history (surgical or Botulinum Toxin), extent of involvement and demographics.

PATIENTS

A total of 81 patients from two to eighteen years of age from nine different states met the inclusion criteria of having a pre-procedure and post-procedure PODCI score along with a Narakas score from 2002-2017. These patients were seen at the Brachial Plexus Center, which is an interdisciplinary clinic at a large academic medical centerMETHODS: This retrospective study utilized PODCI data collected annually during their regular brachial plexus clinic visits. Upper extremity (UE) and global functioning (GFx) scores pre- and post-procedure were stratified by Narakas Classification. Data were analyzed using paired t-test and ANOVA testing.

RESULTS

Patients with a Brachial Plexus Birth Injury (BPBI) had lower PODCI scores for UE and GFx when compared with the pediatric normative scores for age-matched healthy children. Scores in both UE and GFx domains were higher after procedure in the groups of Narakas I and IV. There was significant correlation between UE and GFx scores and documented first PODCI score (2 years of age) and age at intervention (5 years of age).

CONCLUSION

Procedures increased the perceived quality of life for children with a BPBI and increased their overall PODCI scores for both UE and GFx.

Efficacy of 3 therapeutic taping configurations for children with brachial plexus birth palsy

STUDY DESIGN

Cross-sectional clinical measurement study.

INTRODUCTION

Scapular winging is a frequent complaint among children with brachial plexus birth palsy (BPBP). Therapeutic taping for scapular stabilization has been reported to decrease scapular winging.

PURPOSE OF THE STUDY

This study aimed to determine which therapeutic taping construct was most effective for children with BPBP.

METHODS

Twenty-eight children with BPBP participated in motion capture assessment with 4 taping conditions: (1) no tape, (2) facilitation of rhomboid major and rhomboid minor, (3) facilitation of middle and lower trapezius, and (4) facilitation of rhomboid major, rhomboid minor, and middle and lower trapezius (combination of both 2 and 3, referred to as combined taping). The participants held their arms in 4 positions: (1) neutral with arms by their sides, (2) hand to mouth, (3) hand to belly, and (4) maximum crossbody adduction (CBA). The scapulothoracic, glenohumeral and humerothoracic (HT) joint angles and joint angular displacements were compared using multivariate analyses of variance with Bonferroni corrections.

RESULTS

Scapular winging was significantly decreased in both the trapezius and combined taping conditions in all positions compared with no tape. Rhomboids taping had no effect. Combined taping reduced HT CBA in the CBA position.

CONCLUSIONS

Rhomboid taping cannot be recommended for treatment of children with BPBP. Both trapezius and combined taping approaches reduced scapular winging, but HT CBA was limited with combined taping. Therefore, therapeutic taping of middle and lower trapezius was the most effective configuration for scapular stabilization in children with BPBP. Resting posture improved, but performance of the positions was not significantly improved.

LEVEL OF EVIDENCE

Level II.

Capturing Upper Limb Gross Motor Categories Using the Kinect® Sensor

IMPORTANCE

Along with growth in telerehabilitation, a concurrent need has arisen for standardized methods of tele-evaluation.

OBJECTIVE

To examine the feasibility of using the Kinect sensor in an objective, computerized clinical assessment of upper limb motor categories.

DESIGN

We developed a computerized Mallet classification using the Kinect sensor. Accuracy of computer scoring was assessed on the basis of reference scores determined collaboratively by multiple evaluators from reviewing video recording of movements. In addition, using the reference score, we assessed the accuracy of the typical clinical procedure in which scores were determined immediately on the basis of visual observation. The accuracy of the computer scores was compared with that of the typical clinical procedure.

SETTING

Research laboratory.

PARTICIPANTS

Seven patients with stroke and 10 healthy adult participants. Healthy participants intentionally achieved predetermined scores.

OUTCOMES AND MEASURES

Accuracy of the computer scores in comparison with accuracy of the typical clinical procedure (immediate visual assessment).

RESULTS

The computerized assessment placed participants' upper limb movements in motor categories as accurately as did typical clinical procedures.

CONCLUSIONS AND RELEVANCE

Computerized clinical assessment using the Kinect sensor promises to facilitate tele-evaluation and complement telehealth applications.

WHAT THIS ARTICLE ADDS

Computerized clinical assessment can enable patients to conduct evaluations remotely in their homes without therapists present.

Isolated open anterior shoulder release in brachial plexus birth palsy

BACKGROUND

In children with brachial plexus birth palsy (BPBP), a shoulder joint internal contracture is commonly observed, which may result in glenohumeral osseous deformities and posterior joint subluxation. The purpose of this retrospective study was to evaluate the impact of an isolated anterior shoulder release on osteoarticular disorders and assess the subsequent clinical improvements.

METHODS

Forty consecutive BPBP patients with glenohumeral dysplasia underwent an open anterior shoulder release. Shoulder scans (ie, magnetic resonance imaging preoperatively and computed tomography postoperatively) were conducted to assess glenoid version and the percentage of the humeral head anterior to the middle of the glenoid fossa. Clinical data including analytical shoulder range of motion and modified Mallet scores were collected.

RESULTS

After a mean follow-up period of 23 months, glenoid version and the percentage of the humeral head anterior to the middle of the glenoid fossa significantly improved from -32° and 18%, respectively, to mean postoperative values of -12° (P < .001) and 45% (P < .001), respectively. Passive and active external rotation increased from -2° and -43°, respectively, to 76° (P < .001) and 54° (P < .001), respectively. The mean modified Mallet score significantly improved from 14.2 to 21.4 points (P < .001). In 8 children with satisfactory passive motion, a latissimus dorsi transfer was performed secondarily to obtain satisfactory active motion.

CONCLUSION

In BPBP patients with glenohumeral deformities, isolated open anterior release of the shoulder induces significant remodeling of the joint, reducing posterior joint subluxation and improving both passive and active shoulder ranges of motion. Additional latissimus transfer remains mandatory in selected cases to achieve satisfactory function.

Double Versus Single Tendon Transfers to Improve Shoulder Function in Brachial Plexus Birth Palsy

BACKGROUND

In children with brachial plexus birth palsy (BPBP) undergoing tendon transfers to augment shoulder external rotation, it is unclear whether transfer of the latissimus dorsi with its combined latissimus dorsi and teres major (cLT) versus isolated teres major (iTM) tendon transfer yield different outcomes.

METHODS

Records of patients with BPBP who underwent shoulder tendon transfers to augment external rotation were retrospectively reviewed. Transfer type (cLT or iTM) was considered indiscriminate by virtue of surgeon preference. Modified Mallet Scale (mMS) and Active Movement Scale scores were recorded. Patients with <12 months' follow-up, C7 or lower palsy, humeral osteotomy, shoulder procedure(s) within 8 months, microsurgery within 1 year, or recurrent glenohumeral subluxation confirmed by postoperative imaging were excluded. Matched cohorts were identified within each tendon transfer group to yield similar preoperative shoulder function and glenohumeral alignment status. Outcomes for all tendon transfers as well as differences between cLT and iTM cohorts were analyzed.

RESULTS

Among 121 cLT and 34 iTM transfers, 49 cLT and 14 iTM met the inclusion criteria. Subsequent matching of cohorts yielded 28 patients (14 cLT and 14 iTM). Average age at time of transfer was 3.0±1.4 years. Follow-up averaged 4.1±3.1 years. There were no statistically significant preoperative differences between cohorts, thus matching criteria were validated. Regardless of tendon(s) transferred, mMS external rotation improved (2.2 to 3.5, P<0.001), whereas mMS internal rotation decreased (3.8 to 3.2, P<0.001). When comparing matched cohorts, cLT transfer produced a greater mMS external rotation improvement than iTM (2.1 vs. 1.5, respectively; P=0.025). Loss of midline function (defined as mMS external rotation <3) occurred in 5 (35.7%) cLT and 2 (14.3%) iTM patients.

CONCLUSIONS

Both cLT or iTM transfer are effective at augmenting shoulder external rotation in children with C5-C6 BPBP. Furthermore, cLT transfers may yield a larger improvement in external rotation in certain patients. However, both techniques slightly decrease shoulder internal rotation. Given that more total cLT patients lost midline function among matched cohorts, iTM transfer may still be considered when limited midline function is a concern.

LEVEL OF EVIDENCE

Level III.

Outcomes of Spinal Accessory-to-Suprascapular Nerve Transfers for Brachial Plexus Birth Injury

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.

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.

Loss of Midline Function in Brachial Plexus Birth Palsy Patients

BACKGROUND

Loss of midline function impairs the child's ability to perform certain activities of daily living such as dressing, buttoning, and perineal care. The purpose of this study was to assess brachial plexus birth palsy (BPBP) patients with loss of midline function with respect to etiology and treatment.

METHODS

A retrospective review of all BPBP patients with loss of midline function was performed. The modified Mallet scale was used with internal rotation assessed via hand on spine and hand to belly. Demographics, extent of BPBP, prior surgical intervention, procedure(s) performed to correct the loss of midline function, complications, and outcomes were assessed.

RESULTS

In total, 20 patients were identified with loss of midline function as defined by the inability to reach midline and touch their umbilicus. Nineteen patients had previously undergone tendon transfers about the shoulder with or without arthroscopic capsular release to improve external rotation. After the initial surgery, modified Mallet scores improved 1 grade for abduction, hand to mouth, hand to neck, and external rotation without altering the hand to spine category. However, the internal rotation category (hand to umbilicus) decreased from an average 2.71 preoperatively to an average 2.15 postoperatively. Nine patients underwent a derotational humeral osteotomy to improve midline function. The average correction of internal rotation was 47.8 degrees (range, 20 to 85 degrees). After this surgery, modified Mallet scores remained unchanged for hand to spine; however, the scores improved back to 2.7 for the internal rotation category. Two complications were noted including 1 plate fracture and 1 fracture through a screw hole.

CONCLUSIONS

BPBP patients who undergo surgical procedures to improve shoulder external rotation and/or obtain joint reduction may inadvertently lose midline function. Derotational humeral osteotomy can effectively restore midline function, which is needed to perform activities of daily living. Surgical procedures to improve external rotation should be performed in a manner that minimizes limitation of midline functions.

LEVEL OF EVIDENCE

Level III-therapeutic.

Utilization of a Wide Array of Nonvalidated Outcome Scales in Pediatric Orthopaedic Publications: Can't We All Measure the Same Thing?

PURPOSE

Clinical changes are best evaluated with standardized, validated outcomes, including both patient-reported outcome measures and surgeon-reported outcome measures (PROMs and SROMs). The purpose of this study was to describe the spectrum of outcome measures used in pediatric orthopaedic publications over the past 10 years and to determine the proportion that are in fact age-appropriate, validated, and appropriately applied in terms of condition and population.

METHODS

The Journal of Bone and Joint Surgery, The Bone and Joint Journal, Journal of Pediatric Orthopaedics A and B, and Journal of Children's Orthopaedics were systematically searched for studies including children aged 18 and below, over a 10-year period from January 2005 to December 2014. Economic evaluations, letters, editorials, review articles, and clinical guidelines were excluded. SROMs and PROMs used were extracted, as were details on subject age and condition for which they were used. Each outcome scale was assessed for validity, and the proportion of scales used appropriately was calculated. Cochrane-Armitage test of trend was used to determine changes in PROM and SROM utilization over the study period.

RESULTS

A total of 4614 articles were identified, of which 2251 met inclusion and exclusion criteria. In total, 259 (11.5%) of studies used a PROM, whereas 326 (14.5%) used a SROM. A total of 230 different outcome scales were identified; 115 were patient reported and 115 were surgeon reported. However, only 18.7% of SROMs and 38.3% of PROMs were applied to an age and disease-appropriate demographic. Overall, there was a significant increase in the overall utilization of PROMs during the study period (P=0.004), but no corresponding increase in pediatric-validated PROMs (P=0.164). SROM utilization did not significantly change over the study period (P=0.337).

CONCLUSIONS

Within the field of pediatric orthopaedics, an expansive variety of outcome scales are used, many of which have not been validated in children. Improved uniformity in reporting of outcomes and use of disease and age-validated outcomes scales is essential to improve multicenter research collaboration and data quality to generate appropriate evidence-based conclusions and treatment strategies in pediatric orthopaedics.

LEVEL OF EVIDENCE

Level IV-systematic review.

Kinematic differences between children with obstetric brachial plexus palsy and healthy controls while performing activities of daily living

BACKGROUND

Residual shoulder dysfunction and deformity impacts on functional performance in children with obstetric brachial plexus palsy. Clinical understanding of upper limb dynamic movement patterns is difficult with observation alone. This case-control study describes the significant kinematic differences between children with obstetric brachial plexus palsy compared to typically developing children while performing tasks of the modified Mallet Scale.

METHODS

Eleven children with obstetric brachial plexus palsy (mean 10 years, range 7-15 years, Narakas group I-III) and 10 typically developing children (mean 9 years 9 months, range 6-15 years) completed three-dimensional upper limb motion analysis using the acromion method to track dynamic scapular movement. Kinematic data were captured by a 4-CODA cx1 optoelectronic tracking system. Participants performed three trials of the modified Mallet scale tasks. Local coordinate systems, segment and joint rotations were defined as recommended by the International Society of Biomechanics.

FINDINGS

Joint rotation angles against time of the glenohumeral, thoracohumeral and scapulohumeral joints were calculated. Kinematic findings demonstrated increased internal rotation in all postures, reduced glenohumeral excursion, habitual "trumpet" posture of glenohumeral abduction/elevation and variability in movement strategies. Scapulohumeral rhythm during abduction task was 1.88:1 in typically developing children and 1.04:1 in children with obstetric brachial plexus palsy.

INTERPRETATION

Children with obstetric brachial plexus palsy demonstrate deficient external rotation in all tasks. Despite increased postural internal rotation, ability to move through internal rotation range is compromised. The glenohumeral joint showed the greatest range deficit, contributing to abnormal scapulohumeral rhythm. Future sub-group analysis of Narakas Classification is recommended.

Outcome assessment for Brachial Plexus birth injury. Results from the iPluto world-wide consensus survey

There is no consensus regarding strategies to optimally treat children with a brachial plexus birth injury (BPBI). Comparison of outcome data presented by different centers is impossible due to the use of (1) many different outcome measures to evaluate results; (2) different follow-up periods after interventions; and (3) different patient ages at the time of assessment. The goal of iPluto (international PLexus oUtcome sTudy grOup) was to define a standardized dataset which should be minimally collected to evaluate upper limb function in children with BPBI. This dataset must enable comparison of the treatment results of different centers if prospectively used. Three rounds of internet surveys were used to reach consensus on the dataset. A Delphi-derived technique was applied using a nine point Likert scale. Consensus was defined as having attained a rating of 7/8/9 by > = 75% of the participants. A total of 59 participants from five continents participated in the Second and Third Rounds of the survey. Consensus was reached regarding four elements: (1) evaluation should take place at the age of 1/3/5/7 years; range of motion in degrees should be measured for (2) passive joint movement; (3) active range of motion; and (4) the Mallet score should be determined. Consensus on how to asses and report outcome for BPBI was only reached on motor items from the "Body Function and Structure" domain. Consensus regarding additional ICF domains to obtain a more elaborate set of outcome items, should be addressed in future research. © 2018 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of the Orthopaedic Research Society. J Orthop Res 36:2533-2541, 2018.

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.

Postoperative Loss of Midline Function in Brachial Plexus Birth Palsy

PURPOSE

To identify the rate of and predictive variables for functionally limited shoulder internal rotation in postoperative patients with brachial plexus birth palsy.

METHODS

Records of patients with brachial plexus birth palsy who had surgery on the affected upper extremity during a 10-year period were retrospectively reviewed. Patient demographics, physical examinations, and all upper extremity procedures were recorded. Loss of midline function (LOM) was defined as a Modified Mallet Scale or Active Movement Scale (AMS) internal rotation score <3. Exclusion criteria were <1-year follow-up after the most recent procedure, insufficient documentation, or preexisting LOM. Multivariable logistic regression was performed on 3 different scenarios of candidate variables to identify those associated with LOM. All scenarios included each procedure as a candidate variable. Scenario A additionally analyzed preprocedural AMS scores. Scenario B additionally analyzed preprocedural Modified Mallet Scale scores. Scenario C isolated the surgical pathway without preprocedural examination scores.

RESULTS

Among 172 included patients, 34 (19.8%) developed LOM. Predictive variables associated with LOM included severity of initial palsy (C5-7, odds ratio 3.6; C5-T1, odds ratio 4.9), poor recovery of upper trunk motor function before the patient's first surgery (specifically Modified Mallet Scale abduction < 4, AMS elbow flexion < 3, and AMS wrist extension < 3), and patients who ultimately required surgical glenohumeral reduction (odds ratio 3.6). Age, number of procedures, closed shoulder reduction with casting, shoulder tendon transfers, and external rotation humeral osteotomies were not predictive of LOM.

CONCLUSIONS

Approximately 1 in every 5 patients with brachial plexus birth palsy will develop LOM after entering a surgical algorithm designed to improve shoulder external rotation. Patients with a more severe initial palsy (C5-7 or global), poor spontaneous recovery of upper trunk motor function (elbow flexion or wrist extension) before their first procedure, and those who ultimately require surgical glenohumeral joint reduction should be counseled as having a higher odds of LOM development.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Prompt Referral in the Nonoperative Treatment of Obstetrical Brachial Plexus Injuries

Background

Prompt physical and occupational therapy is crucial in managing nonsurgical candidates with obstetrical brachial plexus injuries (OBPI). The objective of our study was to identify newborns suffering from nonoperative OBPI in need of a "fast-track" evaluation by a multidisciplinary team.

Methods

This is a retrospective review of patients with OBPI from June 1995 to June 2015. All nonsurgical candidates (Narakas class 1) were included in the study. The Gilbert score and the Medical Research Council grading system were used to measure shoulder and elbow function, respectively. The relationship between shoulder and elbow functional outcomes and time delay to consultation was studied using analysis of variance and Welch's tests. Various subgroups were studied based on OBPI risk factors: maternal diabetes, birth weight >4 kg, use of forceps, asphyxia, multiple comorbidities, and Apgar score at 1 and 5 minutes.

Results

A total of 168 patients were included in this study. Mean follow-up time was 313.8 weeks (minimum: 52; maximum: 1072; SD: 228.1). A total of 19 patients had an Apgar scores <7 at 5 minutes. Time delay between birth and the first consult to our clinic had an impact on shoulder outcome in the subgroup of newborns with Apgar scores <7 at 5 minutes.

Conclusions

The subgroup of newborns with an Apgar score <7 at 5 minutes shows improved long-term shoulder function when promptly examined by an OBPI clinic. We recommend a "fast-track" referral for this time-sensitive population.

Active Range of Motion Over Time in Patients With Obstetrical Brachial Plexus Palsy: A 10-Year Analysis

PURPOSE

In our experience, and from the personal report of others, children with obstetrical brachial plexus palsy appear to lose some of their initially recovered active range of motion over the time in both operated and nonsurgical patients. This study investigates whether such a diminution of active movement occurs over time.

METHODS

We performed a retrospective analysis of data from our obstetrical brachial plexus clinic. Between 1991 and 2000, 139 patients with a minimum follow-up of 10 years were included in the study. Patients were divided into a nonsurgical group (n = 42) and a group who underwent either primary or secondary brachial plexus reconstruction or both (n = 97). Fifteen joint movements were assessed at 2, 4 to 6, and 9 to 11 years of age and at later final follow-up using the Active Movement Scale. Repeated measures analysis using age at each visit as the repeated measures covariate was undertaken.

RESULTS

Active movement scores were not diminished when patients were evaluated at the 10-year follow-up visit.

CONCLUSIONS

The suggested loss of active range of motion over time is not demonstrated at 10-year follow-up.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.

External Rotation Predicts Outcomes After Closed Glenohumeral Joint Reduction With Botulinum Toxin Type A in Brachial Plexus Birth Palsy

BACKGROUND

Few studies have investigated outcomes after adjunct botulinum toxin type A (BTX-A) injections into the shoulder internal rotator muscles during shoulder closed reduction and spica cast immobilization in children with brachial plexus birth palsy. The purpose of this study was to report success rates after treatment and identify pretreatment predictors of success.

METHODS

Children with brachial plexus birth palsy who underwent closed glenohumeral joint reduction with BTX-A and casting were included. Minimum follow-up was 1 year. Included patients did not receive concomitant shoulder surgery nor undergo microsurgery within 8 months. Records were reviewed for severity of palsy, age, physical examination scores, passive external rotation (PER), and subsequent orthopaedic procedures (repeat injections, repeat reduction, shoulder tendon transfers, and humeral osteotomy). Treatment success was defined in 3 separate ways: no subsequent surgical reduction, no subsequent closed or surgical reduction, and no subsequent procedure plus adequate external rotation.

RESULTS

Forty-nine patients were included. Average age at time of treatment was 11.5 months. Average follow-up was 21.1 months (range, 1 to 9 y). Thirty-two patients (65%) required repeat reduction (closed or surgical). Only 16% of all patients obtained adequate active external rotation without any subsequent procedure. Increased PER (average 41±14 degrees, odds ratio=1.21, P=0.01) and Active Movement Scale external rotation (average 1.3, odds ratio=2.36, P=0.02) predicted optimal treatment success. Limited pretreatment PER (average -1±17 degrees) was associated with treatment failure. Using the optimal definition for success, all patients with pretreatment PER>30 degrees qualified as successes and all patients with PER<15 degrees were treatment failures.

CONCLUSIONS

Pretreatment PER>30 degrees can help identify which patients are most likely to experience successful outcomes after shoulder closed reduction with BTX-A and cast immobilization. However, a large proportion of these patients will still have mild shoulder subluxation or external rotation deficits warranting subsequent intervention.

LEVEL OF EVIDENCE

Level IV-therapeutic.

The Effect of Scapular Position on Magnetic Resonance Imaging Measurements of Glenohumeral Dysplasia Caused by Neonatal Brachial Plexus Palsy

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.

Relationships Between 3 Classification Systems in Brachial Plexus Birth Palsy

BACKGROUND

The Mallet scale, Active Movement Scale (AMS), and Toronto Test are validated for use in children with brachial plexus birth palsy (BPBP). However, the inability to compare these evaluation systems has led to difficulty gauging treatment efficacy and interpreting available literature in which multiple scoring systems are reported. Given the critical importance of physical examination, we compared 3 scoring systems to clarify statistical relationships between current validated evaluation methods.

METHODS

The medical records of children with BPBP treated at a single institution over a 14-year period were retrospectively reviewed. Modified Mallet, AMS, and Toronto scores were recorded throughout the entire period. Data were included if at least 2 complete scoring systems were documented during the same examination session. Spearman correlation coefficients were calculated for all composite and subscore combinations. A concordance table was constructed for select variables found to be highly correlated.

RESULTS

Total single-session score combinations were as follows: 157 Mallet and AMS, 325 AMS and Toronto, and 143 Mallet and Toronto. Composite AMS and Toronto scores were found to have a strong correlation (r=0.928, P<0.001). A concordance table comparing these variables revealed that a Toronto score of 3.5 is concordant to an AMS score of 45. Modified Mallet scores had only a moderate correlation with composite AMS (r=0.512, P<0.001) and Toronto (r=0.458, P<0.001) scores. Specifically regarding the modified Mallet score, maneuvers requiring external rotation had stronger correlations with the composite modified Mallet score than maneuvers highlighting internal rotation.

CONCLUSIONS

Modified Mallet scores do not correlate well with AMS or Toronto scores and should be utilized separately when managing children with BPBP. Similarly, AMS and Toronto scores are inadequate to guide clinical decisions for which the literature cites Mallet scores as outcome measures, and vice versa. Lastly, Mallet scores should incorporate an isolated internal rotation component to adequately assess midline function.

LEVEL OF EVIDENCE

Diagnostic level III.

Forearm Pronation Osteotomy for Supination Contracture Secondary to Obstetrical Brachial Plexus Palsy: A Retrospective Cohort Study

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.