Internal Rotation Contracture Research Articles

Shoulder Function Reconstruction in Brachial Plexus Birth Injury: Anterior Shoulder Release and Spinal Accessory to Suprascapular Nerve Transfer.

This study evaluated the efficacy of the spinal accessory to suprascapular nerve transfer accompanied by anterior shoulder release in restoring shoulder external rotation and abduction in patients with brachial plexus birth injury. A cohort of 41 children with brachial plexus birth injury and shoulder internal rotation contractures underwent surgical intervention. The procedure involved an anterior shoulder release encompassing subscapularis tenotomy, capsulotomy and division of the coracohumeral ligament, and transfer of the spinal accessory nerve to the suprascapular nerve. At an average of 31 months after surgery, we conducted postoperative evaluations of shoulder abduction and external rotation range of motion and compared those with the preoperative status of the patients. From the initial cohort, 26 patients with sufficient follow-up were included in the analysis. The average age at surgery was 15 months. Before surgery, patients demonstrated an average active abduction of 36° and an internal rotation contracture of 64°, measured with the elbow flexed, the shoulder adducted, and using the thorax as the 0° reference point. After surgery, there were significant improvements, with average external rotation increasing to 116° and abduction to 94°. One patient failed to recover external rotation, but most patients showed improved function without the recurrence of internal rotation contractures. Spinal accessory to suprascapular nerve transfer before or after 6 months of age combined with subscapularis tenotomy significantly improves shoulder external rotation and abduction in children with brachial plexus birth injury and internal rotation contractures. Therapeutic IV.

Arthroscopic Capsular Release Versus Subscapularis Recession for Internal Shoulder Contracture in Obstetric Brachial Plexus Palsy: A Systematic Review and Meta-Analysis

Abstract Background Shoulder internal rotation contracture, active abduction and external rotation deficits are frequent secondary complications observed in children with obstetric brachial plexus palsy (OBPP). Soft tissue shoulder operations are often done for treatment as arthroscopic capsular release and open subscapularis recession. There is a lack of studies regarding the subscapularis recession and also regarding the comparison between the two techniques. Aim of the Work to review systematically and meta-analyze the currently available literature regarding arthroscopic capsular release (ACR) and open subscapularis recession (OSR) in internal shoulder contracture in OBPP regarding the clinical efficacy and complications. Methods A literature search pooled the studies pertaining to the children with OBPP in early age treated with ACR and OSR. A systematic review and meta-analysis was conducted to assess the success rates of the two techniques using the Mallet score. We excluded the studies or the patients with history of any concomitant surgical interventions eg: humeral osteotomy, tendon transfer. Results Data from eight studies (152 patients) were compiled for our meta-analysis. The mean follow-up duration was 23.87 months with average age 2.4 years. The standardized difference in means (SMD) for the active abduction (ABD. score was 0.59 for the ACR in comparison to the OSR (SMD= 0.427). The Std. diff. regarding the ACR was 1.22 in passive abduction, 1.68 in passive external rotation (ER) in ABD., 2.31 in passive ER in adduction, 2.38 in hand to mouth, 2.67 in hand to neck, -0.49 in hand to spine, 2.84 in total Mallet score, 3.18 in the active ER (in comparison to the OSR the SMD was 0.427) and -2.06 in active internal rotation (in comparison to the OSR the SMD was 0.128). Recurrence of internal shoulder contracture was documented in 8 of 93 children after ACR and regional pain syndrome with shoulder stiffness was reported in only on case out of 28 cases after ACR. Conclusion In this study, we found that the ACR is highly effective than the OSR technique regarding the functional outcome of the shoulder in all the Mallet score items except in hand to spine and internal rotation. The ACR shows more advantages than OSR intra-operatively regarding soft tissue identification and post-operatively regarding scarring and infection, but with higher risk of recurrence and axillary nerve injury.

Kinematic Effects of Derotational Osteotomy of the Humerus in Patients with Internal Shoulder Contracture Secondary to Erb's Palsy-A Retrospective Cohort Study.

Background: Internal rotation contractures of the shoulder are common sequelae of conservatively treated obstetric brachial plexus palsy (OBPP) with incomplete spontaneous neurological recovery. Humerus derotation osteotomy has been suggested as a possible treatment option to improve arm positioning. However, consensus as to whether humerus derotation osteotomy can successfully restore limb function is missing. Methods: In the present controlled cohort study, we aimed at analyzing global upper extremity kinematics with a 3D-video analysis system in children with shoulder internal rotation contractures secondary to OBPP before, and one year after, humerus derotation osteotomy. Patients under 18 years of age that presented to our center with conservatively treated internal rotation contractures of the shoulder and subsequently underwent humerus derotation osteotomy were included. The unimpaired arm served as a respective control. Results: Pre-operatively, all patients showed severe internal rotation contractures of the shoulder of almost 60° at rest. At the follow-up, the position of the shoulder at rest was greatly shifted to 9° of internal rotation. The patients showed statistically significant improvement in maximum external rotation and abduction of the shoulder, as well as in maximum flexion of the elbow, and the range of motion of pro/supination. The maximum internal rotation of the shoulder, however, was diminished after the osteotomy. Conclusions: Our data indicated that derotational osteotomy is a promising procedure which can be used to correct for internal rotation contractures secondary to OBPP. Moreover, 3D-video analysis proved to be a useful tool that supplies the surgeon with both precise information about the degree of distortion pre-operatively, thus helping to decide on the amount of correction, and secondly, a measurement of the post-operative gain in upper extremity function.

Nerve Tracing in Juvenile Rats: A Feasible Model for the Study of Brachial Plexus Birth Palsy and Cocontractions?

Brachial plexus birth injuries cause diminished motor function in the upper extremity. The most common sequel is internal rotation contracture. A number of these patients also suffer from cocontractions, preventing the use of an otherwise good passive range of motion in the shoulder. One theory behind the co-contracture problem is that injured nerve fibers grow into distal support tissue not corresponding to the proximal support tissue, resulting in reinnervation of the wrong muscle groups. To further elucidate this hypothesis, we used rat neonates to investigate a possible model for the study of cocontractions in brachial plexus birth injuries. Five-day-old rats were subjected to a crush injury to the C5-C6 roots. After a healing period of 4 weeks, the infraspinatus muscle was injected with Fluoro-Gold. A week later, the animals were perfused and spinal cords harvested and sectioned. Differences in the uptake of Fluoro-Gold and NeuN positive cells of between sides of the spinal cord were recorded. We found a larger amount of Fluoro-Gold positive cells on the uninjured side, while the injured side had positive cells dispersed over a longer area in the craniocaudal direction. Our findings indicate that the method can be used to trace Fluoro-Gold from muscle through a neuroma. Our results also indicate that a neuroma in continuity somewhat prevents the correct connection from being established between the motor neuron pool in the spinal cord and target muscle and that some neurons succumb to a crushing injury. We also present future research ideas.

Long-Term Results of Isolated Latissimus Dorsi to Rotator Cuff Transfer in Brachial Plexus Birth Injury.

Background Brachial plexus birth injury results in deficits in strength and motion, occasionally requiring surgery to restore power to the deficient external rotators of the shoulder in these patients. This is a retrospective analysis of the long-term results of an isolated latissimus dorsi transfer to the rotator cuff in patients with brachial plexus birth injury. Methods This is a retrospective review of prospectively collected data for patients undergoing isolated latissimus dorsi transfer into the infraspinatus in addition to release of the internal rotation contracture of the shoulder with greater than 5 years' follow-up. Preoperative and postoperative shoulder elevation and external rotation were documented. Failure of surgery was defined as a return of the internal rotation contracture and a clinically apparent clarion sign. Results A total of 22 patients satisfied the inclusion criteria: 9 global palsies and 13 upper trunk palsies. The average follow-up was 11 years, ranging from 7.5 to 15.9 years. There was a trend for improved external rotation in the global palsy cohort at final follow-up ( p = 0.084). All nine global palsies maintained adequate external rotation without a clarion sign. Five of the 13 upper trunk palsies failed the latissimus dorsi transfer and subsequently required either teres major transfer and/or rotational osteotomy. In these five failures, the period from initial transfer to failure averaged 6.6 years, ranging from 3.4 to 9.5 years. Conclusion The results of this study indicate that patients with global palsy have sustained long-term improved outcomes with isolated latissimus dorsi transfer while patients with upper trunk palsy have a high rate of failure. Based on these results, we recommend isolated latissimus dorsi transfer for global palsy patients who have isolated infraspinatus weakness. Level of Evidence: Case series - Level IV.

Long-Term Hand and Shoulder Function in Children following Early Surgical Intervention for a Birth-Related Upper Brachial Plexus Injury.

Purpose To better understand the long-term hand and shoulder outcomes of upper brachial plexus birth injuries. Methods We evaluated shoulder and hand function in 32 patients (13 males; 19 females) with a C5/C6 birth injury history). All patients had undergone primary nerve surgery as infants, and 12 underwent a simultaneous shoulder procedure as they presented with a fixed internal rotation contracture of the shoulder. On average, all patients were evaluated and examined 15 years postoperatively. The shoulder function was evaluated using the Miami Shoulder Scale. Hand function was measured by the 9-hole peg test (9-HPT) and statistical analysis included comparison of 9-HPT time against normative data using the Student's t -test. Results The cohort includes 22 right-hand-dominant and 10 left-hand-dominant patients. Mean age at surgery was 10 months; mean age at follow-up was 15 years ± 2 years 2 months. Cumulative shoulder function was "good" or "excellent" (Miami score) in 23 patients. For 9-HPT, 23 out of 32 patients seen had an involved hand with a significant alteration in function. Conclusion Early nerve surgery in cases of upper brachial plexus birth injuries result in the desired outcome. To ensure timely and targeted therapy for any residual deficits, it is imperative that limitations in hand function among children with an Erb's palsy.

Subscapularis Z-plasty With Coracoidectomy for Internal Rotation Contracture in Children With Brachial Plexus Birth Injury.

Brachial plexus birth injury (BPBI) is a rare dystocia complication. Although it has a good prognosis, a significant number retain functional impairment to varying degrees. The data concerning shoulder function improvement and complication rates are conflicting due to variations in outcome measures between the studies. Therefore, we report our experience with this approach. It was a retrospective study conducted at King Faisal Specialist Hospital and Research Center in Riyadh (FSH&RC), Saudi Arabia. Data such as patient demographics, Mallet scores, and passive external rotation (PER) in adduction and abduction were retrieved from the medical records. In active shoulder function, Mallet score significantly improved (P=0.00). The improvement was most remarkable in active external rotation movement (P=0.00) followed by hand to the neck. However, no significant gain was observed in active abduction and hand-to-back. At the final follow-up, with a mean of 2.9 years, the improvement in PER in adduction and abduction was maintained. Compared to six months postoperative, no significant difference was found in hand-to-neck, hand-to-back, and total Mallet score. Subscapularis z-lengthening with coracoidectomy was consistently effective in correcting internal rotation contraction in a patient with BPBI. Significant improvements were observed in the Mallet score and PER in adduction and abduction.

Surgery for internal rotation contracture in infancy may obviate the need for brachial plexus nerve reconstruction: early experience

Shoulder internal rotation contracture and subluxation in the first year of life has long been recognized in some patients with brachial plexus birth injury (BPBI). Surgical management of shoulder pathology has traditionally been undertaken following nerve reconstruction as necessary. In some patients, however, shoulder pathology may impair or obscure functional neuromuscular recovery of the upper extremity. As a proof of concept, we report a highly selected subset of patients with BPBI in whom shoulder surgery undertaken before one year of age obviated the need for neuroma resection and nerve grafting. A retrospective review was performed of all patients with upper trunk BPBI who underwent shoulder surgery before one year of age from 2015 to 2018. Upper extremity motor function was evaluated with preoperative and postoperative Active Movement Scale (AMS) scores, Cookie Tests, and the requirement for subsequent neuroma resection and nerve grafting. Fifteen patients with BPBI meeting the inclusion criteria underwent shoulder surgery (including a subscapularis slide and tendon transfers of the teres major and latissimus dorsi muscles) before 1 year of age. Preoperatively, no patients of the appropriate age passed the Cookie Test for elbow flexion. Thirteen patients either passed the Cookie Test or scored AMS 7 for elbow flexion at or before the last available follow-up undertaken at a median age of 3.4 [1.4, 5.2] years. One of those 13 patients underwent single fascicular distal nerve transfer to improve elbow flexion before subsequently passing the Cookie Test. Two patients did not have sufficient follow to assess elbow flexion. Although the exact role of shoulder surgery in infancy for BPBI remains to be defined, the findings from this study provide proof of concept that early, targeted surgical treatment of the shoulder may obviate the need for brachial plexus nerve reconstruction in a highly selected group of infants with BPBI.

How Institution of the Sup-ER Protocol in a Clinic Changed Procedure Patterns in Upper Brachial Plexus (Erb's Type) Birth Injuries.

For children with upper brachial plexus birth injury (BPBI; C5, C6, ±C7 roots), most clinics first recommend nonsurgical treatment followed by primary and/or secondary surgical interventions in selected patients. Since 2008, we have used an infant shoulder repositioning protocol (supination-external rotation [Sup-ER]) designed to prevent shoulder internal rotation contracture and its potential effects on the shoulder joint. This study characterizes our clinic's current choice, number, and timing of primary and secondary procedural interventions (including Botox) and compares Sup-ER protocol patients with those of our historical controls. The records of all patients with upper BPBI who underwent procedures from 2001 to 2018 were retrospectively reviewed and grouped into a historical (2001-2007, n = 20) and recent (2008-2018, n = 23) cohort. Patient demographics, procedure types and timing, and functional outcomes were collected and analyzed. Since the 2008 institution of the Sup-ER protocol, fewer brachial plexus exploration and grafting (BPEG) surgeries were performed and none in later infancy, where nerve transfers were preferred. There were more and earlier Botox injections. There were fewer tendon transfers, and the preoperative indications were from a higher level of function. We now see fewer indications for BPEG surgeries overall. After the 3-month-age group, more direct nerve transfers are indicated instead of the BPEG surgery if nerve surgery is required at all. Shoulder tendon transfer rates have decreased. Humeral osteotomies are not seen in our recent group. Glenoid osteotomies within tendon transfers are rare in both groups.

Pathologic external tibial torsion as one of the causes of knee joint dysfunction and formation of pronation deformity in children with cerebral palsy

Introduction. One of the complications of the clinical course of cerebral palsy in children is external torsion of the tibia. The issue of localization and the mechanism of its formation, as well as effective methods of its elimination, is debatable. Purpose - to study the mechanisms of the formation of pathological external torsion of the tibia in children with cerebral palsy, its effect on knee joint contracture and foot deformity, and effective methods of their correction. Materials and methods. The data obtained during the observation of 45 patients (90 cases) aged from 6 to 16 years with spastic diplegia, spastic tetraparesis and foot pronation were analyzed. To study the mechanisms of formation of external torsion of the lower leg and its correction, 2 groups of patients were selected. The Group I - 24 patients with internal rotation contractures of the hip joint (10 patients with internal rotation contractures of the hip joint; 10 patients - in combination with pathological antetorsion of the femoral neck; 4 patients - in combination with flexion contractures of the knee joints). The relationship between internal rotation contracture of the hip joint and external torsion of the tibia. The Group II consisted of 21 patients who were diagnosed with flexion contracture of the knee joints in combination with external torsion of the tibia. In order to study the effectiveness of operative treatment of knee flexion contracture and external torsion of the tibia in the Group II, 2 subgroups were distinguished: the subgroup IIA - 9 patients who underwent osteotomy of the tibial bone; the subgroup IIB - 12 patients who only underwent biceps femoris transposition. Results. Based on the study of clinical and radiological indicators, it was established that pathological torsion of the tibial bone is combined with flexion contracture of the knee joints. Proximal derotational osteotomy of the tibia has a positive effect on the results of correction of knee flexion contracture and foot position. Conclusions. The main reason for the formation of external torsion of the tibia is the imbalance of the flexor muscles of the knee joint and the supinator and pronator muscles of the foot. Proximal tibial derotation osteotomy eliminates not only pathological torsion, but also flexion contracture of the knee joints and excessive pronation of the foot. The study was conducted in accordance with the principles of the Declaration of Helsinki. The study protocol was approved by the local ethics committees of all institutions participating in the study. Informed consent of the patients was obtained for the research. No conflict of interests was declared by the authors.

The effect of botulinum toxin application on latissimus dorsi and teres major muscles in patients with brachial plexus birth palsy: An electron microscopic and clinical study.

In brachial plexus birth palsy (BPBP), botulinum toxin may be utilized to prevent glenohumeral dysplasia and to maintain the stable growth of the glenohumeral joint. Repeated injections may cause muscular atrophy and their functional effects are uncertain. The aim of this study was to compare the microstructure and the function of the muscles that received two injections before transfer with the muscles that were not injected. BPBP patients that were operated between January 2013 and December 2015 were included in the study. Latissimus dorsi and teres major muscles were transferred to humerus in standard fashion. Patients were divided in two groups according to bo-tulinum toxin status. Group 1 was toxin negative whereas Group 2 was toxin positive. For each patient, mean latissimus dorsi myocyte thickness (LDMT) was measured with electron microscopy and pre-operative and post-operative active shoulder abduction, flexion, external and internal rotation, and Mallet scores were evaluated with goniometry. Fourteen patients (seven patients per group) were evaluated. Five patients were female whereas nine were male. Mean LDMT was not affected significantly (p>0.05). The operation improved shoulder abduction, flexion, and external rotation significantly (p<0.05), independent of the toxin status. The internal rotation decreased significantly only in Group 2 (p<0.05). The Mallet score increased in both groups, but it was not significant (p>0.05), independent of the toxin status. Botulinum toxin that was applied twice prevented glenohumeral dysplasia and it did not cause permanent latissimus dorsi muscle atropy and function loss in late period. It augmented upper extremity functions by alleviating internal rotation contracture.

Clinical Diagnosis of the Infantile Shoulder Subluxation in Residual Brachial Plexus Birth Injury and Its Correlation With Ultrasound Diagnosis.

Timely detection of shoulder subluxation in infants with brachial plexus birth injury (BPBI) is essential to prevent the progression of glenohumeral deformity. Shoulder ultrasonography (USG) is routinely used to detect an infantile subluxation/dislocation, but its use is limited because of the paucity of expert radiologists in developing countries. The aim of this study was to determine the clinical examination predictors to determine shoulder subluxation in patients with BPBI correlating with ultrasound confirmation. We prospectively studied children who presented to our hospital between 2017 and 2021 diagnosed as brachial plexus birth injury. In patients developing internal rotation contracture of the shoulder, we looked for 3 standard clinical signs: reduced passive external rotation <60 degrees, deep anterior crease (DAC) and relatively short arm segment. Shoulder subluxation was defined as USG measurement of alpha angle>30 degrees and ossific nuclei of the humerus lying behind the dorsal scapular line. Sensitivity and specificity were used to assess their efficacy in clinical diagnosis of shoulder subluxation in different groups. The predicted probability of shoulder subluxation from each prediction rule was compared with actual distributions based on USG confirmation. Of the 58 BPBI infants who developed PER<60 degrees at the shoulder, 41 had USG confirmed shoulder subluxation. The 2 independent predictors of shoulder subluxation (PER<45 degrees and DAC) were identified in the current patient population based on data analysis. The presence of short arm segment is a very specific marker of shoulder subluxation but not sensitive. The predicted probability of shoulder subluxation from the prediction rule combining all the 3 markers were similar to the actual distributions in the current patient population. PER<45 degrees and presence of deep anterior crease are clinical markers indicating shoulder dislocation in patients with BPBI developing reduced external rotation at the shoulder. On the basis of the proposed clinical diagnosis algorithm, the above markers along with the selective use of USG can help in early detection and treatment of infantile shoulder dislocation.

Shoulder Internal Rotation Contracture Formation in Surgically Managed C5, C6 Brachial Plexus Birth Injuries: Neurotmetic Lesions Fare Worse Than Avulsions.

A typical feature in infants with severe C5-C6 brachial plexus birth injury (BPBI) requiring nerve repair is the formation of shoulder internal rotation contracture (IRC). The underlying pathophysiological mechanism is unknown, and the sequelae can be difficult to treat. The severity of the IRC differs among children. C5-C6 lesions are heterogeneous at the root level. Our null hypothesis was that the type of root-level lesion (axonotmesis or neurotmesis versus avulsion) was not associated with the extent of IRC formation over time in children with upper-trunk BPBI. We performed a retrospective analysis of all patients with upper-trunk BPBI who underwent primary surgery of the C5 and/or C6 spinal nerves between 1990 and 2020 and had follow-up of at least 2 years. The primary outcome was passive shoulder external rotation (ER) in adduction at 1, 3, 5, 7, and 15 years of age. The secondary outcome was whether additional shoulder surgery was performed. The relationship between the nature of the C5-C6 lesion and IRC formation was analyzed using linear mixed models. The Kaplan-Meier method was used to estimate the cumulative risk of secondary shoulder procedures. In total, 322 patients were analyzed; mean follow-up was 7.2 ± 4.6 years. The C5-C6 root lesion type was significantly related to the passive range of ER (overall test in linear mixed model, p = 0.007). Children with avulsion of C5 and C6 (n = 21) had, on average, 18° (95% confidence interval [CI], 6.3° to 30°) less IRC formation than those with neurotmesis of C5 and C6 (n = 175) and 17° (2.9° to 31°) less than those with neurotmesis of C5 and avulsion of C6 (n = 34). IRC formation did not differ between the neurotmesis C5-C6 and neurotmesis C5-avulsion C6 groups. Secondary shoulder procedures were performed in 77 patients (10-year risk, 28% [95%CI, 23% to 34%]). Shoulder IRC formation in infants with BPBI with surgically treated C5-C6 lesions occurs to a lesser degree if the C5 root is avulsed than when C5 is neurotmetic. This finding provides insight into the possible causative pathoanatomy and may ultimately lead to strategies to mitigate IRC. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

THE RESULTS OF ARTHROSCOPIC RELEASE WITH TENDON TRANSFERS IN CASES OF B.P.B.P WITH GLENOHUMERAL DYSPLASIA

Background: Internal rotation deformity due to brachial plexus birth palsy frequently lead to glenohumeral deformity . Our surgical approach to treat these contractures relies on arthroscopic release and tendon transfer of latissimus dorsi muscle for young children . We report the results for twenty children followed for a minimum of two years after such treatment Patients and methods: This study was done in the Orthopedic department, Sohag University Hospitals including all patients with brachial plexus birth palsy with internal rotation contracure of the shoulder. Twenty children with a mean age of 4 years (between 2 and 6 years old) underwent arthroscopic contracture release and tendon transfer of latissimus dorsi muscle as a primary procedure.Passive and active external rotation, internal rotation, and elevation were measured for all patients pre and postoperatively. Modified mallet score and active movement score was measured pre and postoperatively. Magnetic resonance imaging was performed preoperatively and postoperatively to evaluate glenoid version and head sublaxation. Results: At the time of follow-up, the mean passive external rotation was increased by 67° (p &lt; 0.005) in the children with a successful arthroscopic release and tendon transfer. The mean active elevation increased by 12°. Internal rotation was not measured consistently preoperatively, but when it had been it was found to have decreased substantially postoperatively. Mean glenoid version improved from -33° to -7° following soft-tissue releases and The percentage of the humeral head anterior to the middle of the glenoid improved from 8% to 43%. While the average duration of clinical and radiographic follow-up was twenty-four months, improvements in both shoulder motion and glenohumeral joint morphology were seen early and were maintained during the follow up period. Conclusion: In children with internal rotation contracture, arthroscopic release and tendon transfer effectively restores nearly normal passive external rotation and a centered glenohumeral joint at the time of surgery. In most of these children, external rotation strength is sufficient to maintain this range of motion and to improve glenoid development when preoperative deformity was present. Improvement in active elevation was minimal. All children have a loss of internal rotation, which is moderate in most of them.

Dislocation Arthropathy of the Shoulder.

Glenohumeral osteoarthrosis (OA) may develop after primary, recurrent shoulder dislocation or instability surgery. The incidence is reported from 12 to 62%, depending on different risk factors. The risk of severe OA of the shoulder following dislocation is 10 to 20 times greater than the average population. Risk factors include the patient’s age at the first episode of instability or instability surgery, bony lesions, and rotator cuff tears. For mild stages of OA, arthroscopic removal of intraarticular material, arthroscopic debridement, or arthroscopic arthrolysis of an internal rotation contracture might be sufficient. For severe stages, mobilization of the internal rotation contracture and arthroplasty is indicated. With an intact rotator cuff and without a bone graft, results for anatomical shoulder arthroplasty are comparable to those following primary OA. With a bone graft at the glenoidal side, the risk for implant loosening is ten times greater. For the functional outcome, the quality of the rotator cuff is more predictive than the type of the previous surgery or the preoperative external rotation contracture. Reverse shoulder arthroplasty could be justified due to the higher rate of complications and revisions of non-constrained anatomic shoulder arthroplasties reported. Satisfactory clinical and radiological results have been published with mid to long term data now available.

Comparison of latissimus dorsi tendon transfer with subscapularis release versus sliding of internal rotation contracture in obstetrical brachial plexus paralysis sequela

BackgroundThe purpose of this study was to compare the functional results of latissimus dorsi (LD) tendon transfer with those of subscapularis (SS) muscle release versus sliding.MethodsFifty-six patients with internal rotation contracture and external rotation (ER) weakness as sequelae of Erb’s palsy were included in the study. Of the patients, 24 were included in group 1 (11 boys and 13 girls), with a mean age of 2 years 8 months (range 1.5–5 years) and a follow-up period of 62 months (range 38–68 months). The patients in group 1 underwent LD tendon transfer, with internal rotation contracture and SS release procedures. Thirty-two patients were included in group 2 (18 boys and 14 girls), with a mean age of 2 years 6 months (range 1.5–4.8 years) and a follow-up period of 58 months (range 38–68 months). The patients in group 2 underwent LD tendon transfer with SS sliding.ResultsA significant improvement in preoperative passive ER from − 3.6° to 67.3° after operation was observed in group 1. In group 2, preoperative passive ER in adduction improved from 0° to 72.3°. We found no significant difference (P = 0.1) in postoperative improvement in active ER in both groups (group 1 vs. group 2: 75° vs. 77.3°). Similarly, no significant difference (P = 0.7) in postoperative improvement in passive ER was found between the groups (group 1 vs. group 2: 71° vs. 72.3°).ConclusionsLD tendon transfer with SS release or sliding is an effective procedure to improve shoulder ER in patients with OBPP, with no inferiority of SS muscle release or sliding for internal rotation contractures and increased passive range of shoulder motion.Level of evidenceLevel III; Retrospective Cohort Comparison; Treatment Study.

Structures contributing to the shoulder contracture in brachial plexus birth palsy. An intraoperative biomechanical study.

Internal rotation contracture of the shoulder is a common sequel of the brachial plexus birth palsy. The purpose of this study is to describe the surgical method used in our centre and to measure the effect of sequentially releasing several anatomical structures that have been ascribed as the cause of the contracture. Twenty-four consecutive patients were operated on with an open release. We documented the increase in passive external rotation after each surgical step. We found small gains in passive external rotation when performing coracoidectomy and division of the upper part of the subscapularis tendon; 4° (95% confidence interval [CI] 2°-6° p < 0.01) and 6° (95% CI 4°-8° p < 0.01), respectively. A substantial gain in external rotation occurred when dividing the entire subscapularis tendon, 43° (95% CI 38°-48°, p < 0.01). Our findings indicate that a clinically relevant surgical release of the contracture requires lengthening of the entire subscapularis musculo-tendinous unit.Level of evidence: IV.

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

BackgroundShoulder involvement in brachial plexus birth palsy is common, and the adduction, internal rotation contracture deformity often requires some form of surgical treatment. There are very few long-term reports on release of contracted muscles and tendon transfers, especially in older children. We are reporting the single-center results of such a surgery with detailed outcome analysis.MethodsThe prospectively collected data from brachial plexus birth palsy cases who had undergone contracture release and tendon transfer were retrospectively studied and examined. The new Mallet and functional scores were compared with the original data forms and then analyzed. The radiographic evidence of glenoid dysplasia and its correlation with age and functional outcome was assessed.ResultsA total of 82 cases with surgery at mean age of 9.5 ± 5.09 years and a follow-up of 8 ± 3.8 (3-20) years entered the study. Of these, 56% of cases had 7 to 20 years of age at surgery. Fifty-four (66%) patients had only shoulder surgery, and 28 (34%) required additional reconstructive surgeries for hand and wrist. Moderate to severe glenohumeral dysplasia was present in 38%. The preoperative Mallet score of 10.6 ± 2.97 improved to 19.3 ± 3.39 (P < .001). Eighty-one percent of patients showed improvement in “reaching face” functions, 71% in “above head” functions, and 74% in “midline functions.” The cases with lack of improvement in midline function mostly belonged to pan-plexus injuries. Noticeable subjective and objective improvement was also observed in cases with glenohumeral dysplasia in their Mallet and functional scores (P < .001). The improvement in function and subjective satisfaction of 92% was observed irrespective of age at surgery.ConclusionSoft-tissue release and tendon transfer for brachial plexus birth palsy shoulder can improve function and limb appearance even in older children and young adults and even in the presence of glenohumeral dysplasia.

Rate of Recurrence of Internal Rotation Contracture after Latissimus Dorsi Transfer and Subscapularis Sliding in Obstetric Brachial Plexus Palsy

Abstract Background: Internal rotation contracture is the most common complication of obstetric brachial plexus palsy, tendon transfer is used to treat limited shoulder abduction and external rotation. Aim of Study: In our study we observe the incidence of recurrency of internal rotation contracture after lattissmus dorsi transfer and Subscapularis sliding. Patients and Methods: We conducted a randomized trail study over 20 patients with internal rotation contracture due to obstetric brachial plexus palsy. From 2015 to 2017 in Abo El Resh Hospital. We done subscapularis sliding combined with latissimus dorsi transfer for. The mean age at the time of operation was 2 years. We used modified gilbert score to asset shoulder function pre and postoperative. Results: All patient after surgery shows marked improve-ment of shoulder abduction and external rotation. We had recurrence of internal rotation contracture in 4 patients. Conclusion: After subscapularis sliding with latissimus dorsi transfer it is preferable to keep in close follow-up of the patient and continuous physiotherapy to prevent recurrence of internal rotation contracture.

Improvement of Shoulder Function after Teres Major Transfer and Subscapularis Sliding in Obstetric Brachial Plexus Palsy

Abstract Background: Obstetrical brachial plexus injury occurs as a result of forceful traction of the upper extremity for a long period of time during delivery and/or compression injury. Which result in internal rotation contracture of the shoulder and loss of external rotation. which may benefit from release of the contracture, tendon transfers. Aim of Study: This study we do teres major transfer and subscapularis sliding and measure shoulder function improve-ment. Patients and Methods: We conducted a randomized trail study over 20 patients with internal rotation contracture due to obstetric brachial plexus palsy. From 2015 to 2017 in Abo El Resh Hospital. We done subscapularis sliding combined with Teres major transfer for. The mean age at the time of operation was 2 years. We used modified gilbert score to asset shoulder function pre and postoperative. Results: All patient after surgery show marked improve-ment of shoulder abduction and external rotation. Severe external rotation contracture occurred in 3 patients. Conclusion: After subscapularis sliding with teres major transfer have perfect result in improving of shoulder function with increase the risk of external rotation contracture after transfer.