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The reconstructive strategy for improving elbow function in late obstetric brachial plexus palsy
David Chwei-Chin Chuang1, Yasunori Hattori, Hae-Shya Ma And
1Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan. deardavid@pchome.com.tw
Insights
Surgical reconstruction can improve elbow function in children with obstetric brachial plexus palsy. Procedures like muscle transfers address aberrant reinnervation or muscle weakness, offering better outcomes for affected children.
Area of Science:
- Pediatric Orthopedics
- Neuromuscular Surgery
- Reconstructive Surgery
Background:
- Obstetric brachial plexus palsy (OBPP) often leads to abnormal elbow function due to aberrant reinnervation or muscle paresis/paralysis.
- Abnormal elbow function in OBPP can significantly impact a child's quality of life and functional independence.
Purpose of the Study:
- To evaluate various palliative reconstructive surgical methods for improving elbow function in children with OBPP.
- To assess the efficacy of different surgical interventions for aberrant reinnervation and muscle weakness affecting elbow function.
Main Methods:
- A 9-year study (1988-1997) involving 62 children with OBPP and elbow deformities.
- Surgical interventions included muscle transfers (e.g., triceps-to-biceps, biceps-to-triceps) for aberrant reinnervation, and free muscle transplantation or Steindler's flexorplasty for paresis/paralysis.
- Procedures were individualized based on aberrant reinnervation patterns; anterior deltoid-to-biceps transfer was used for specific shoulder and elbow involvement.
Main Results:
- Surgical reconstruction aimed to restore both elbow flexion and extension, with a general recommendation to address extension first.
- Specific muscle transfers, like biceps-to-triceps or brachialis-to-triceps, allowed approximately 50% of patients to achieve acceptable elbow flexion and extension in a single stage.
- The study assessed outcomes with a minimum 2-year follow-up, providing data for a recommended reconstructive algorithm.
Conclusions:
- Surgical reconstruction offers a viable solution for improving elbow function in children with OBPP-related deformities.
- Individualized surgical approaches, including muscle transfers and tendon/muscle grafts, can effectively address the complex challenges of aberrant reinnervation and muscle deficits.
- The findings support a structured approach to reconstruction, prioritizing elbow extension before flexion, to optimize functional recovery in affected children.
Abstract:
Children with previously untreated obstetric brachial plexus palsy frequently have abnormal elbow function because of motor recovery with aberrant reinnervation, or because of paresis or paralysis. From 1988 to 1997 (9-year period), 62 children with obstetric brachial plexus palsy with resulting elbow deformity underwent various methods of palliative reconstruction to improve elbow function. For motor recovery with aberrant reinnervation, release of aberrantly reinnervated antagonistic muscles and augmentation of paretic muscles form the basis of surgical intervention. The surgical procedures included triceps-to-biceps transfer, biceps-to-triceps transfer, brachialis-to-triceps transfer, or combined biceps- and brachialis-to-triceps transfer. Choice of procedures was individualized and randomly determined on the basis of the degree and pattern of aberrant reinnervation between elbow flexors and extensors. In patients' motor recovery with paresis or paralysis, persistently weak elbow flexion was salvaged with a functioning free muscle transplantation or Steindler's flexorplasty, or regional shoulder muscle transfer. In addition, patients with aberrant reinnervation between shoulder abductors and elbow flexors underwent anterior deltoid-to-biceps transfer with a fascia lata graft. All patients had a minimum follow-up of 2 years. Results are assessed and discussed and a reconstructive algorithm is recommended. In general, reconstruction of elbow extension should precede that of elbow flexion. Biceps-to-triceps transfer with preservation of an intact brachialis muscle, or brachialis-to-triceps transfer with preservation of an intact biceps, allows 50 percent of these patients to achieve acceptable elbow flexion and extension in a single-stage procedure.