The Early Effects of Tendon Transfers and Open Capsulorrhaphy on Glenohumeral Deformity in Brachial Plexus Birth Palsy Surgical Technique
ABSTRACT Persistent muscle imbalance and soft-tissue contractures can lead to progressive glenohumeral joint dysplasia in patients with brachial plexus birth palsy. The objective of the present investigation was to determine the effects of tendon transfers and open glenohumeral reduction on shoulder function and dysplasia in patients with preexisting joint deformity secondary to brachial plexus birth palsy.
Twenty-three patients with preexisting glenohumeral deformity underwent latissimus dorsi and teres major tendon transfers to the rotator cuff with concomitant musculotendinous lengthening of the pectoralis major and/or subscapularis and open glenohumeral joint reduction for the treatment of internal rotation contracture and external rotation weakness. Shoulder function was assessed with use of the modified Mallet classification system and the Active Movement Scale. Glenoid version and humeral head subluxation were quantified radiographically, and glenohumeral deformity was appropriately graded. The mean duration of clinical and radiographic follow-up was thirty-one and twenty-five months, respectively.
Clinically, all patients demonstrated improved global shoulder function, with the mean aggregate Mallet score improving from 10 points preoperatively to 18 points postoperatively (p < 0.01). The mean modified Mallet score for external rotation improved from 2 to 4 (p < 0.01). Similarly, the mean Active Movement Scale score for external rotation improved from 3 to 6 (p < 0.01). The mean Mallet hand-to-spine score improved from 1 to 2 (p < 0.01). The mean Active Movement Scale score for internal rotation remained constant at 6. Radiographically, the mean glenoid version improved from -39 degrees preoperatively to -18 degrees postoperatively (p < 0.01). The mean percentage of the humeral head anterior to the middle of the glenoid similarly improved from 13% to 38% (p < 0.01). The mean glenohumeral deformity score improved from 3 to 2 (p < 0.01). Nineteen (83%) of the twenty-three patients demonstrated glenohumeral remodeling; one patient had progressive worsening of glenohumeral deformity.
Tendon transfers to the rotator cuff, combined with musculotendinous lengthenings and open reduction of the glenohumeral joint, improve global shoulder function and lead to glenohumeral joint remodeling in the majority of selected patients with mild-to-moderate preexisting glenohumeral dysplasia secondary to brachial plexus birth palsy. Future study of the long-term outcomes of these procedures will help to clarify the ultimate effect on glenohumeral joint function.
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ABSTRACT: The incidence of obstetric brachial palsy is high and their sequelaes are frequent. Physiotherapy, microsurgical nerve reconstruction and secondary corrections are used together to improve the shoulder function. The most common posture is shoulder in internal rotation and adduction, because of the antagonist weakness. The muscle forces imbalance over the osteoarticular system, will result in a progressive glenohumeral joint deformity which can be recognized with a magnetic resonance image. Tendon transfers of the internal rotators towards the external abductor/rotator muscles, has good results, but has to be combined with antero-inferior soft-tissue releases, if passive range of motion is limited.Archivos argentinos de pediatría 10/2011; 109(5):429-36. DOI:10.1590/S0325-00752011000500010 · 0.29 Impact Factor
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ABSTRACT: The indication for hip arthrotomy accompanied by intraarticular work during periacetabular osteotomy (PAO) has not been precisely defined. To validate a role for routine hip arthrotomy accompanied by intraarticular work, frequent intraarticular pathology must exist, and the adjunct procedures must not be associated with inferior relief of pain, reduced function, radiographic osteoarthritis progression, or conversion to THA. (1) What is the prevalence of intraarticular pathology at the time of PAO? (2) Does concomitant hip arthrotomy with associated intraarticular work negatively affect PAO as reflected by differences in Harris hip scores (HHS), Tonnis grade, and failure rates? We retrospectively reviewed the intraarticular findings in all 151 patients who underwent PAO accompanied by routine hip arthrotomy and intraarticular work from 2002 to 2009. Using multivariate regression models, we compared the HHS and Tonnis grades of patients receiving arthrotomy with a cohort of 39 patients who received PAO alone. The overall prevalence of intraarticular pathology identified during PAO was 89%. Eight (5.3%) failures were identified within the arthrotomy cohort with mean postoperative HHS, postoperative Tonnis grade, postoperative change in HHS, and postoperative change in Tonnis grade of 87.5, 0.7, 29.8, and 0.3, respectively. By contrast, seven (17.9%) failures were identified in the nonarthrotomy cohort. The mean postoperative HHS, postoperative Tonnis grade, postoperative change in HHS, and postoperative change in Tonnis grade for the nonarthrotomy cohort were 83.1, 1.3, 19.0, and 0.3, respectively. We believe the high prevalence of intraarticular pathology is sufficient to warrant routine joint inspection at the time of PAO. Hip arthrotomy accompanied by intraarticular work at the time of PAO is safe and does not impose additional patient morbidity. Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.Clinical Orthopaedics and Related Research 10/2012; 471(2). DOI:10.1007/s11999-012-2602-2 · 2.88 Impact Factor
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ABSTRACT: Brachial plexus birth palsy occurs in 0.4 to 4.6 of every 1000 live births, with residual shoulder dysfunction in approximately one third of cases. Clinical measures, such as the Mallet classification, provide no insight into the scapulothoracic and glenohumeral contributions to tested global shoulder movements. This study describes the scapulothoracic and glenohumeral components of shoulder motion during the modified Mallet test. Twelve children with Erb's palsy (C5-6) and 8 children with extended Erb's palsy (C5-7) were recruited. The unaffected limbs of 6 subjects were also tested. Locations of markers placed on the thorax, humerus, and scapula were recorded in a neutral position and each of the modified Mallet positions. Scapulothoracic, glenohumeral, and humerothoracic helical displacements and acromion process linear displacements were compared between groups. The brachial plexus birth palsy groups exhibited significantly smaller glenohumeral displacements in all modified Mallet positions and significantly larger scapulothoracic displacements in the global external rotation and hand to mouth positions. Discriminant function analysis using only humerothoracic variables correctly classified 76.9% of subjects. Discriminant function analysis incorporating scapulothoracic, glenohumeral, and acromion process displacement variables produced accuracy of 92.6%. Children with brachial plexus birth palsy demonstrated decreased glenohumeral contributions to achieve every modified Mallet position and increased scapulothoracic contribution in two positions compared with the unaffected group. Different scapulothoracic and glenohumeral strategies were identified between groups. Finally, scapulothoracic and glenohumeral components of shoulder motion are more specific than humerothoracic measures to diagnostic classification.Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 09/2013; 23(3). DOI:10.1016/j.jse.2013.06.023 · 2.37 Impact Factor