Mallet Score Research Articles

EVALUATION OF UPPER-LIMB FUNCTION IN PATIENTS WITH OBSTETRIC PALSY AFTER MODIFIED SEVER-L'EPISCOPO PROCEDURE

Objective: To evaluate upper-limb function by means of the Mallet score, in patients with medial rotation contracture of the shoulder who underwent the modified Sever-L'Episcopo procedure, and to correlate evolution with age and length of postoperative follow-up. Methods: Sixteen patients were assessed by comparing the pre and postoperative Mallet scores and correlating the differences between these scores with age at the time of surgery and length of follow-up. Results: A statistically significant improvement in the postoperative Mallet score was observed. The correlations of the differences in scores with age and length of follow-up were not statistically significant. Conclusion: The modified Sever-L'Episcopo procedure led to improved upper-limb function according to the Mallet score. Limb function did not present correlations with age or length of follow-up.

Surgical treatment of shoulder joint posterior dislocation secondary to internal rotation contractnre deformity in brachial plexus birth palsy

Objective To observe the functional recovery of shoulder joint and the reduction of posterior dislocated humeral head in children with shoulder joint internal rotation contracture and humeral head posterior dislocation secondary to brachial plexus birth palsy treated by a modified surgical procedure through the anterior combined posterior approach of the shoulder. Methods Ninteen patients,ranging in age from 2.5 to 8.5 years (average 5 years),suffered posterior dislocation of the shoulder joint secondary to internal rotation contracture in brachial plexus birth palsy. The gleno-humeral joint deformity was confirmed by X-ray and CT examination and classified as type Ⅳ in 15 eases and typeⅤin 4 cases according to the modified water's criteria.The surgical procedure was as follows:the contracture soft tissue around the anterior of shoulder joint was released firstly through the anterior approach, and the posterior-inferior capsule of the shoulder was exposed and separated with the pseudoglenoid through the posterior approach,the humeral head was reduced by external rotation the arm,then the posterior-inferior capsule was retighten.A plaster cast was used to fix the shoulder at the neutral position of 0° for 4 weeks. Results After 12 to 36 months follow up(average of 20 months), the Mallet score of the shoulder was from 11.4 ± 1.7 (range 7-16)preoperative to 15.5 ± 1.8(range 13-19) postoperative,the difference was significantly (P ＜ 0.05).The central relocation of humeral head was achieved in 16 patients, but the humeral head was still dislocated to posterior in 3 cases. Conclusions The posterior-inferior capsule was separated with the pseudo-glenoid and retighten through the posterior approach,and reduction of the humeral head by soft tissue releaseing through the anterior approach can recover the concentric relationship of gleno-humeral joint and improve the function of shoulder joint with posterior dislocation secondary to internal rotated contracture deformity in brachial plexus birth palsy. Key words: Brachial plexus birth palsy; Shoulder joint; Internal rotation contracture; Glenohumeral deformity

Management strategies for shoulder reconstruction in obstetric brachial plexus injury with special reference to loss of internal rotation after surgery

We assessed the outcomes in 24 of 25 children (mean age 3 years) who had soft-tissue shoulder reconstruction procedures for obstetric brachial plexus injuries. All had latissimus dorsi and teres major transfers to strengthen external rotation combined with subscapularis lengthening, reduction of posterior dislocation or subluxation, and humeral osteotomy, if necessary. At a mean follow-up of 3.8 years, the mean Mallet score improved from 12.3 preoperatively to 17.4 postoperatively, active external rotation improved from 21° to 32°, and passive external rotation improved from 26° to 67°. The shoulder remained in joint in all patients. Active internal rotation deteriorated in nine shoulders, two requiring secondary internal rotation osteotomy. Combined soft tissue rebalancing and bony procedures gives reliable shoulder function improvement. Care is required regarding the effect on internal rotation.

Avaliação da função do membro superior nos pacientes com paralisia obstétrica após cirurgia de Sever-L'Episcopo modificada

OBJETIVO: Avaliar a função do membro superior acometido, por meio do escore de Mallet, nos pacientes com contratura em rotação medial do ombro submetidos à cirurgia de Sever-L'Episcopo modificada, e correlacionar a evolução com a idade e com o tempo de seguimento pós-operatório. MÉTODOS: Dezesseis pacientes foram avaliados, sendo comparadas as medidas pré e pós-operatórias do escore de Mallet, e correlacionada a diferença entre esses valores com a idade no momento da cirurgia e tempo de seguimento. RESULTADO: Observou-se melhora do escore de Mallet pós-operatório estatisticamente significante, enquanto a correlação da diferença dos valores do escore com a idade e o tempo de seguimento não foram estatisticamente significantes. CONCLUSÃO: A cirurgia de Sever-L'Episcopo modificada proporcionou melhora da função do membro superior, de acordo com o escore de Mallet. Não houve relação entre a idade e o tempo de seguimento com a função do membro.

Assessment of Triangle Tilt Surgery in Children with Obstetric Brachial Plexus Injury Using the Pediatric Outcomes Data Collection Instrument

Background:The benefits of triangle tilt surgery in children with OBPI have been previously validated through measurements of statistical improvements in Mallet scores and in glenohumeral congruity. The purpose of the current study was to evaluate the effectiveness of triangle tilt surgery through the application of the Pediatric Outcomes Data Collection Instrument, a well validated questionnaire designed to evaluate function and comfort in children with musculoskeletal disorders.Methods:OBPI patients between 2 and 10 years of age who came to our institute for routine office visits between May 2009 and October 2009 were considered to participate in the study. Among the patient group, the first 130 completed surveys who met the study criteria were included in the study. The Pediatric Outcomes Data Collection Instrument was completed by the parents of patients who have undergone triangle tilt surgery (Group 1: N=63) or those who were considered candidates for this procedure (Group 2: N=67). The results were compared between the two patient groups and analyzed using the unpaired student’s t-test. Later, 23 patients from the group 2, underwent triangle tilt surgery (Group 3). We collected post-op data, compared and analyzed the outcome of the surgery in these patients to their own pre-op PODCI scores, using the paired student’s t test.Results:In patients who have undergone triangle tilt surgery, significantly higher PODCI scores were observed in the parameters of upper extremity function (p<0.05), sports/physical function (p<0.05), basic mobility (p<0.0001) and global functioning (p<0.05), when compared to patients who have not undergone triangle tilt surgery. Further, PODCI scores in group 3 patients were significantly higher after surgery in the parameters of upper extremity function (p <0.03), Pain/Comfort (p <0.05), basic mobility (p<0.0002) and global functioning (p<0.03), when compared to before triangle tilt surgery.Conclusion:The results of the Pediatric Outcomes Data Collection Instrument demonstrate the functional benefits of triangle tilt surgery in patients with obstetric brachial plexus injury.

Traitement conservateur des paralysies obstétricales hautes du plexus brachial. Résultats à long terme chez 22 enfants

Treatment of obstetrical brachial plexus palsy (OBPP) is always debated, especially for upper plexus palsy. Some authors perform early surgical treatment in case of absence of biceps contraction at the age of 3months. Others prefer to wait until the age of 6months before considering a surgical procedure when no suspicion of root avulsion is found. We think that a conservative approach with intensive rehabilitation program can obtain good functional outcome for patients who will recover biceps function spontaneously between 3and 6months, and that it is not necessary to perform surgery at 3months. To argue our choice, we have compared the long-term outcome of two groups of children with upper OBPP conservatively treated regarding the age of biceps recovery (before or after 3months). Twenty-two patients with non operated upper roots birth palsy, followed in Timone's Hospital of Marseille by a multidisciplinary team, have recovered a biceps contraction between 1and 8months and were retrospectively included in this study. All children underwent an intensive rehabilitation program since birth, performed by a specialized physiotherapist. Patients were reviewed, and their shoulder function was assessed using Mallet score. The score was analysed regarding the age of biceps recovery. The mean follow up was 8.2years. Nine children recovered a biceps contraction at 3months of age or before; the mean global Mallet score was 4.11. Thirteen children recovered a biceps contraction after 3months of age (between 3and 8months); the mean global Mallet score was 3.92. The difference was not statistically significant. This study shows that global shoulder function is comparable for two groups. The children who did not recover a biceps contraction at 3months of age had a global shoulder function as good as the one who recovered biceps function earlier. We think our intensive rehabilitation program allowed us to avoid a useless early surgery. Surgical plexus treatment was indicated for children who did not have biceps contraction after 6months of age.

Treatment of shoulder sequelae in brachial plexus birth injury

Background Many children with permanent brachial plexus birth injury (BPBI) develop shoulder problems, with subsequent joint deformity without treatment. We assessed the indications and outcome of shoulder operations for BPBI.Patients and methods 31 BPBI patients who had undergone a shoulder operation in our hospital between March 2002 and December 2005 were included in the study. Relocation of the humeral head had been performed in 13 patients, external rotation osteotomy of the humerus in 5 patients, subscapular tendon lengthening in 5 patients, and teres major transposition in 8 patients. Subjective results were registered. Shoulder range of motion was measured, and function assessed according to the Mallet scale. Magnetic resonance imaging (MRI) was performed pre- and postoperatively. Glenoscapular angle (GSA) and percentage of humeral head anterior to the middle of the glenoid fossa (PHHA) were measured. Congruency of the glenohumeral joint (GHJ) was estimated. The mean follow-up time was 3.8 (1.7–6.8) years.Results At follow-up, the subjective result was satisfactory in 30 of the 31 patients. There were 4 failures, which in retrospect were due to wrong choice of surgical method in 3 of these 4 patients. Mean increase in Mallet score was 5.5 after successful relocation, 1.4 after rotation osteotomy, 2.2 after subscapular tendon lengthening, and 3.1 after teres major transposition. Congruency of the shoulder joint improved in 10 of 13 patients who had undergone a relocation operation, with mean improvement in GSA of 33º and mean increase in PHHA of 25%. There were no substantial changes in congruency of the glenohumeral joint in patients treated with other operation types.Interpretation Restriction of the range of motion and malposition of the glenohumeral joint can be improved surgically in brachial plexus birth injury. Remodeling of the joint takes place after successful relocation of the humeral head in young patients.

Arthroscopically Assisted Sever-L'Episcopo Procedure Improves Clinical and Radiographic Outcomes in Neonatal Brachial Plexus Palsy Patients

Muscle pathology resulting in internal rotation contractures in children with neonatal brachial plexus palsy places abnormal stresses on the glenohumeral joint and limits global shoulder function. The objective of this study was to assess the clinical and radiographic outcomes in children treated with an arthroscopic release with or without tendon transfer, the so-called arthroscopically assisted Sever-L'Episcopo procedure. Fifty children with an average age of 5.1 years who underwent an arthroscopic release with or without tendon transfer were retrospectively reviewed. Clinical outcomes were assessed using Mallet classification scores, whereas glenoid retroversion and posterior humeral head subluxation were measured on magnetic resonance images to quantify radiographic outcomes. Mean clinical follow-up was 30 months (range: 24 to 65 mo) and mean radiographic follow-up was 24 months (range: 11 to 42 mo). Aggregate Mallet score improved significantly from 12.6 to 16.3 (P<0.0001), with shoulder abduction from 3.4 to 3.8 (P=0.0007), shoulder external rotation from 2.2 to 3.3 (P<0.0001), hand-to-neck from 2.3 to 3.2 (P<0.0001), and hand-to-mouth from 2.3 to 3.3 (P<0.0001). Hand-to-spine Mallet score did not significantly change from preoperative (2.4) to postoperative (2.6) (P=0.1348), although 4 patients experienced a loss in internal rotation function. Forty-eight percent of children improved by at least 4 points on the total Mallet score. Glenoid retroversion improved from 25 to 14.1 degrees (P<0.0001) and percent humeral head anterior to the central axis of the scapula increased from 30.5% to 38.8% (P=0.0001). Sixty-seven percent of patients demonstrated glenohumeral joint remodeling on magnetic resonance imaging. No child exhibited a worsening of glenohumeral anatomy. An arthroscopic release with or without tendon transfer is effective in reducing internal rotation contractures and increasing global shoulder function. Both clinical and radiographic outcomes were significantly improved at 2-year follow-up. Furthermore, in the majority of children, aggregate, abduction, and external rotation Mallet scores all increased without sacrificing internal rotation. Therapeutic Level IV.

Transfer of latissmus dorsi and teres major tendons without subscapularis release for the treatment of obstetrical brachial plexus palsy sequela

Patients with obstetrical brachial plexus palsy (OBPP) sequela exhibit adduction and internal rotation contractures. The muscular imbalance may result in secondary bony changes. Tendon transfers and muscular releases may improve shoulder function in these patients. The aim of this study is to evaluate the functional and radiological results of pectoralis major tendon Z-plasty with transfer of latissimus dorsi and teres major tendons to rotator cuff tendons without release of subscapularis muscle in patients with mild sequela of OBPP. Twenty-six consecutive patients, who were treated with tendon transfer and met the eligibility criteria, were included in the study. No additional humeral osteotomy or subscapularis tenotomy was performed. Functional evaluation is made according to range of motion and Mallet scoring system. Preoperative radiologic evaluation was made according to the grading system of Waters. A significant increase in shoulder function was found in all patients. Postoperative radiographs revealed glenohumeral congruity was maintained in all patients. Improvement in shoulder abduction and external rotation was higher in patients who were operated before the age of 7. Pectoralis major tendon lengthening with transfer of latissimus dorsi and teres major tendons to rotator cuff is an effective and reproducible technique and can improve shoulder functions in patients with OBPP. Subscapularis release is not always required to overcome internal rotation contracture. Secondary glenohumeral changes might also be prevented with this approach.

Comparing Functional Outcome of Triangle Tilt Surgery Performed Before Versus After Two Years of Age

Background:Many patients each year who are born with obstetric brachial plexus injuries eventually do not achieve complete recovery. As a result of the primary nerve injuries, these patients will often develop bony deformities involving the shoulder joint as a secondary consequence. The triangle tilt surgery has been shown to be an effective procedure to correct these deformities and has been performed on patients ranging in age from less than a year old to adolescence. The purpose of this retrospective study is to compare outcomes of triangle tilt surgery performed on patients before the age of 2 years versus after 2 years of age to determine an optimal age to operate on these children.Methods:36 patients with deformities developed secondarily from the initial obstetric brachial plexus injury in this study were divided into 2 groups. Group 1, those who had undergone triangle tilt surgery at < 2 yrs of age (16 patients). Group 2, those who were operated at > 2 yrs of age (20 patients). Group 1 age range: 9 months to 23 months, average: 18 months. Group 2 age range: 26 months to 9 years, average: 6 years.Results:Significant differences were found between the 2 groups (0-2 yrs vs > 2yrs) in regards to overall changes (pre- to post-op) in Mallet score, external rotation score, hand-to-mouth score, and supination angle.Discussion:This study demonstrates that triangle tilt surgery had better outcomes on clinical functioning if performed before the age of 2 years, however, improvement in clinical functioning can still be achieved if the triangle tilt surgery is performed after the age of 2 years as well. A possible mechanism to explain this phenomenon is the increased potential for anatomical remodeling if the triangle tilt surgery is performed at a younger age, thereby leading to significant functional improvement.

EMG and MRI are Independently Related toShoulderExternal Rotation Function inNeonatalBrachial Plexus Palsy

Few studies exist with regard to the ability of electromyography (EMG) and volumetric magnetic resonance imaging (MRI) of the infraspinatus muscle to complement the physical assessment of active global shoulder external rotation (GER) in the neonatal brachial plexus palsy (NBPP) population. Therefore, the purpose of this study was to evaluate the relationships of EMG and MRI with active GER based on analysis of the infraspinatus muscle. Seventy-four NBPP patients (mean age, 5 y 1 m; range, 1 y 1 m to 13 y 3 m) who had undergone physical examination of the shoulder, EMG evaluation of the infraspinatus muscle, and shoulder MRI were included in this study. The outcome variable active GER was dichotomized into <0 degree active GER (poor) and ≥0 degree active GER (good). The interference pattern on EMG of the infraspinatus muscle was graded on a 6-point scale and dichotomized into ≤4 and ≥5. On shoulder MRI, infraspinatus muscle volume was measured. The infraspinatus muscle interference pattern and volume were compared with active GER. Interference pattern on EMG of the infraspinatus muscle was significantly related to the Mallet Score (P=0.0022), with a poor interference pattern associated with an approximately 7 times higher likelihood [odds ratio=7.391; 95% confidence interval (2.054, 26.588)] of poor active GER. Infraspinatus muscle volume decrease on MRI was also significantly related to active GER (P=0.0413), with each percent volume decrease corresponding to an increase of 0.094 in the odds of having a poor Mallet Score for active GER [odds ratio=1.094; 95% confidence interval (1.004, 1.193)]. The interference pattern of the infraspinatus muscle on EMG and the infraspinatus muscle volume on MRI are strongly related to active GER as assessed by the Mallet Score. Integrating clinical assessment with electrophysiological and imaging findings may improve the accuracy in evaluating shoulder dysfunction in NBPP and provide improved guidance in selecting interventions specific to the patient's pattern of deficits. Diagnostic study, level II.

Clinical outcome of shoulder muscle transfer for shoulder deformities in obstetric brachial plexus palsy: A study of 150 cases

Background:Residual muscle weakness, cross-innervation (caused by misdirected regenerating axons), and muscular imbalance are the main causes of internal rotation contractures leading to limitation of shoulder joint movement, glenoid dysplasia, and deformity in obstetric brachial plexus palsy. Muscle transfers and release of antagonistic muscles improve range of motion as well as halt or reverse the deterioration in the bony architecture of the shoulder joint. The aim of our study was to evaluate the clinical outcome of shoulder muscle transfer for shoulder abnormalities in obstetric brachial plexus palsy.Materials and Methods:One hundred and fifty patients of obstetric brachial plexus palsy with shoulder deformity underwent shoulder muscle transfer along with anterior shoulder release at our institutions from 1999 to 2007. Shoulder function was assessed both preoperatively and postoperatively using aggregate modified Mallet score and active and passive range of motion. The mean duration of follow-up was 4 years (2.5–8 years).Results:The mean preoperative abduction was 45° ± 7.12, mean passive external rotation was 10° ± 6.79, the mean active external rotation was 0°, and the mean aggregate modified Mallet score was 11.2 ± 1.41. At a mean follow-up of 4 years (2.5–8 years), the mean active abduction was 120° ± 18.01, the mean passive external rotation was 80° ± 10.26, while the mean active external rotation was 45° ± 3.84. The mean aggregate modified Mallet score was 19.2 ± 1.66.Conclusions:This procedure can thus be seen as a very effective tool to treat internal rotation and adduction contractures, achieve functional active abduction and external rotation, as well as possibly prevent glenohumeral dysplasia, though the long-term effects of this procedure may still have to be studied in detail clinico-radiologically to confirm this hypothesis.Level of evidence:Therapeutic level IV

Glenoplasty for complex shoulder subluxation and dislocation in children with obstetric brachial plexus palsy

We describe the early results of glenoplasty as part of the technique of operative reduction of posterior dislocation of the shoulder in 29 children with obstetric brachial plexus palsy. The mean age at operation was five years (1 to 18) and they were followed up for a mean of 34 months (12 to 67). The mean Mallet score increased from 8 (5 to 13) to 12 (8 to 15) at final follow-up (p < 0.001). The mean passive forward flexion was increased by 18° (p = 0.017) and the mean passive abduction by 24° (p = 0.001). The mean passive lateral rotation also increased by 54° (p < 0.001), but passive medial rotation was reduced by a mean of only 7°. One patient required two further operations. Glenohumeral stability was achieved in all cases.

Our Experience with Secondary Reconstruction of External Rotation in Obstetrical Brachial Plexus Palsy

Restoration of shoulder external rotation is very important for upper extremity function. The purpose of this study was to present the authors' experience with secondary restoration of external rotation in patients with obstetrical brachial plexus palsy. From 1978 to 2002, 46 children underwent secondary surgery for restoration of external rotation. Outcomes were analyzed in relation to various factors, including the type of procedure, muscle transfer only versus nerve reconstruction and muscle transfer, denervation time, type of injury (Erb versus global palsy), and severity score. In addition, the effect of restoration of external rotation on the final outcome of shoulder abduction was assessed. There was significant improvement in every case (p < 0.01) between preoperatively and postoperatively. The overall mean postoperative Mallet score for the group undergoing muscle transfer only was 3.95, whereas in the nerve reconstruction and muscle transfer group, the score was 3.88 (p >0.05). The resulting gain in external rotation was 99 degrees versus 93.8 degrees. In both populations, a very significant improvement (p <0.0001) was identified in the final outcome of shoulder abduction (109 degrees after muscle transfer versus 48.3 degrees before muscle transfer, and 112 degrees postoperatively after neurotization and muscle transfer versus 43.8 degrees before any surgery). Patients with Erb palsy had a better but not significant result (p >0.05; p = 0.94), compared with those with global palsy in both Mallet score (3.77 versus 3.76) and final active external rotation (81.7 degrees versus 77.6 degrees). Secondary surgery for the restoration of external rotation is a rewarding procedure, which also significantly improves the final outcome of shoulder abduction.

Shoulder Function After Medial Approach and Derotational Humeral Osteotomy in Patients With Brachial Plexus Birth Palsy

The purpose of this study was to assess outcome after rotational humeral osteotomies, using a medial approach, in children with brachial plexus birth palsy. A retrospective review of children with brachial plexus birth palsy who underwent external rotational humeral osteotomies, using a medial approach, for the treatment of internal rotation contractures was performed. Presurgical and postsurgical range of motion, standard Mallet, and modified Mallet scores were recorded. The traditional Mallet score was modified to include a sixth subscale that further evaluated internal rotation. This was assessed by having the patients' attempts to place their palm flat on their naval. Twenty-three children underwent external rotational humeral osteotomies. The mean rotational correction achieved during the procedure was 43.2+/-11.6 degrees (range: 20-70 degrees). The mean preoperative standard aggregate Mallet score was 13.8+/-2.8 and the mean postoperative score was 16.1+/-2.5 (P=0.002). When the additional internal rotation scale was added into the score, the mean preoperative aggregate score was 18.0+/-2.1 and the mean postoperative score was 19.5+/-2.8 (P=0.032). Further analysis revealed a statistically significant improvement (P<0.05) in external rotation, hand to neck, and hand to mouth functions. Internal rotation was decreased as represented by statistically significant decreases in hand to spine and hand to belly (P<0.05). Rotational humeral osteotomies can be performed safely and effectively using a medial approach. These osteotomies significantly improve activities associated with external rotation. However, the degree of external rotation must be carefully balanced against the loss of internal rotation, which would impede midline function. The addition of a sixth subscale to the Mallet score that assesses hand to belly provides more clinically relevant information regarding midline function than hand to spine. This is a Level IV study.

Shoulder function and anatomy in complete obstetric brachial plexus palsy: long-term improvement after triangle tilt surgery

PurposeUntreated complete obstetric brachial plexus injury (COBPI) usually results in limited spontaneous recovery of shoulder function. Older methods used to treat COBPI have had questionable success, with very few studies being published. The purpose of the current study was to examine the results of triangle tilt surgery on shoulder function and development in COBPI individuals.MethodsThis study was conducted as a retrospective chart review. Inclusion criteria were COBPI patients that had undergone the triangle tilt procedure from 2005 to 2009 and were between the ages of 9 months and 12 years. COBPI was defined as permanent injury to all five nerve roots (C5–T1), with significant degradation in development and function of the hand. Twenty-five patients with a mean age of 5 (0.75–12) years were followed up clinically for more than 2 years.ResultsThe triangle tilt procedure resulted in demonstrable clinical enhancements with appreciable improvements in shoulder function, glenoid version, and humeral head congruity. There was a significant increase in the overall Mallet score (2.4 points, p < 0.0001) following surgical correction in patients that were followed up for more than 2 years.ConclusionsThe results of this study demonstrate that COBPI patients who develop SHEAR and medial rotation contracture deformities can benefit from the triangle tilt surgery, which improves shoulder function and anatomy across a range of pediatric ages. Despite these patients presenting late for surgery in general (5 years), significant improvements were observed in their glenohumeral (GH) dysplasia and their ability to perform shoulder and arm movements following surgery.

Brachial plexus birth palsy shoulder deformity treatment using subscapularis release combined to tendons transfer

One possible sequela of obstetric brachial plexus palsy (OP) is impaired external rotation (ER) of the shoulder which, in addition to its functional consequences, can generate a posterior humeral head subluxation or dislocation. The goal of the present study was to assess medium-term clinical and radiological results of release of the subscapularis muscle with transfer of the latissimus dorsi and teres major muscles. From 1985 to 1995, a continuous series of 32 OP patients underwent subscapularis muscle release, associated in 24 cases to muscle transfer. Mean age was 2.5 years (range, 1-9.2 years). Shoulder function was assessed by measurement of passive ER and graded according to the modified Mallet classification at 1, 5 and 10 years' follow-up or before revision. The evolution of the glenohumeral deformity was assessed on CT images of glenoid retroversion and the humeral head subluxation (% of humeral head covered), before and 5 years after surgery. Mean postoperative follow-up was 9.5+/-5.6 years. Treatment brought significant improvement in passive ER (mean preoperative and 1-year follow-up values: -10 degrees and 52 degrees, respectively). This explained the good modified Mallet score at 1 year: mean=18.4/25. Subsequent significant progressive degradation was noted: 10 years postoperatively, mean ER amplitude and modified Mallet score were respectively 13 degrees and 15.8. The CT study showed correction of the glenoid retroversion (mean preoperative and 5-year follow-up values: 29 degrees and 18 degrees, respectively), and of the humeral head subluxation (mean preoperative and 5-year follow-up values: 25 and 39%, respectively). Surgical revision was indicated six times (five patients): two latissimus dorsi and teres major transfers (not performed initially) and four derotational humeral osteotomies. Three-quarters of the patients who did not initially have muscle transfer had to be reoperated or else showed ER insufficiency at last follow-up. Surgical treatment produces objective functional gain, even if this diminishes over time. Moreover, it prevents or corrects posterior subluxation of the shoulder. It is indicated when passive ER amplitude is negative. It seems advisable to associate release to muscle transfer. Level IV Retrospective study.

Soft tissue rebalancing procedures with and without internal rotation osteotomy for shoulder deformity in children with persistent obstetric brachial plexus palsy

Children with obstetric brachial plexus palsy (OBPP) frequently have problems related to their shoulder. The aim of the investigation was to determine our results in treating shoulder deformity with tendon transfers and soft tissue releases with and without internal rotational osteotomy. We also evaluated the relationships between neurological status, age and selected clinical parameters. We reviewed data of 25 patients (12 girls) after latissimus dorsi and teres major tendon transfers to the rotator cuff. Internal rotation osteotomy was performed in ten children. The mean age of patients at the time of operation was 3.2 years (range from 10 months to 7.7 years). Patients were followed up for a mean of 3.8 years (minimum 2 years). Mallet score improved 4.7 points at last follow-up (p = 0.00002). No patient had shoulder function deterioration. Active and passive external rotation increased significantly after operation: p < 0.00001, p < 0.00001, respectively. Statistically significant reduction in active internal rotation was noted (p = 0.04). The other movements have not statistically changed after operation. Active internal rotation difference after internal rotation osteotomy was significantly better than without osteotomy (p = 0.03). Neurological involvement and age had neither positive nor negative influence on final range of motion and outcome. Soft tissue rebalancing procedures significantly improve shoulder function in children with persistent OBPP. Addition of internal rotational osteotomy to muscle transfers for severe cases allows maintaining of stabile joint, prevents loosening of internal rotation and does not influence other movements of the shoulder.

Reconstruction of shoulder abduction and external rotation with latissimus dorsi and teres major transfer in obstetric brachial plexus palsy

We evaluated the results of latissimus dorsi and teres major tendon transfer to the rotator cuff together with musculotendinous lengthening of the subscapularis and/or pectoralis major muscles in patients with internal rotation contracture and decreased external rotation and abduction secondary to obstetrical brachial plexus palsy. Thirty patients (18 boys, 12 girls; mean age 9 years; range 4 to 15 years) with internal rotation contracture and loss of external rotation and abduction of the shoulder secondary to obstetrical brachial plexus palsy underwent transfer of the latissimus dorsi/teres major tendons to the rotator cuff. In addition, musculotendinous lengthening of the subscapularis and pectoralis major (n=15), pectoralis major (n=9), and subscapularis (n=6) were performed. Nine patients had upper plexus involvement (C5-6), 14 had C5-7 involvement, and seven had complete plexus involvement (C5-T1). According to the Waters and Peljovich classification, all the patients had a congruent glenohumeral joint, which was classified as type 1 in one patient, type 2 in 15 patients, and type 3 in 14 patients. Pre- and postoperative range of motion values of the patients were measured and their motor functions were evaluated with the Mallet scoring system. The mean follow-up period was 47.8 months (range 9 to 84 months). Preoperatively, the mean active abduction was 75.8°, and the mean active external rotation was 25.2°. Postoperatively, the mean abduction and external rotation increased to 138.3° (by 62.5°, 82.5%) and 76.4 degrees (by 51.2°, 203.2%), respectively. Improvements in the degrees of abduction and external rotation were significant (p=0.000). According to the Mallet scoring system, the mean preoperative global abduction and global external rotation scores were 2.97 and 2.43, respectively; the mean Mallet scores for the ability to move the hand to the mouth, neck, and back were 2.50, 2.17, and 2.67, respectively. Postoperatively, the mean global abduction score increased to 3.97 (by 33.7%, p=0.000), and the mean global external rotation score increased to 3.77 (by 55.1%, p=0.000). The mean scores for the ability to move the hand to the mouth, neck, and back were 3.30 (increased by 32%, p=0.000), 3.73 (increased by 71.9%, p=0.000), and 2.30 (decreased by 13.9%, p=0.003), respectively. Postoperative changes in the Mallet scores were all significant. Improvements in abduction and external rotation were not significant between patients ≤ 9 years and > 9 years of age (p > 0.05). Transfer of the latissimus dorsi and teres major tendons to the rotator cuff combined with musculotendinous lengthening of the subscapularis and/or pectoralis major provides satisfactory increases in shoulder abduction and external rotation, regardless of the age, in patients with no or minimal glenohumeral joint incongruency.

A Study on the Risk Factors for Obstetrical Brachial Plexus Palsy

Objective Considerable medical and legal debates have surrounded the prognosis and outcome of obstetrical brachial plexus injuries and obstetricians are often considered responsible for the injury. In this study, we assessed the factors related to the outcome of brachial plexus palsy. Material & Methods During 24 months, 21 neonates with obstetrical brachial plexus injuries were enrolled. Electrophysiology studies were done at the age of three weeks. They received physiotherapy and occupational therapy. They were examined every 3 months for one year and limbs function was assessed according to Mallet scores; also, maternal and neonatal factors were collected by a questionnaire. Results There were 10 boys and 11 girls. Of all, 76.2% had Erb's palsy, 19% had total brachial palsy and 4.8% had klumpke paralysis. Risk factors including primiparity, high birth weight, shoulder dystocia, and prolonged second stage of labor were assessed. Electrophysiology studies showed neuropraxia in 52.4% and axonal injuries in 42.9% of the patients. At the end of the first year, 81% of the patients had functioned recovery around grade III or IV of Mallet scores. There were only significant relationships between functional improvement and neurophysiologic findings. Conclusion Outcome of obstetrical brachial injuries has a close relationship to neurophysiologic study results than other risk factors.