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Tendon transfer around the shoulder in obstetric brachial plexus paralysis: clinical and computed tomographic study
Tarek Abdalla El-Gammal1, Waleed Riad Saleh, Amr El-Sayed
1Department of Orthopaedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University School of Medicine, Assiut, Egypt. micro@acc.aun.edu.eg
Insights
This study shows that surgical correction for obstetric brachial plexus palsy is most effective before age 2, significantly improving shoulder abduction and external rotation while preventing bone deformities. Surgery after age 4 yields minimal gains.
Area of Science:
- Orthopedic Surgery
- Pediatric Orthopedics
- Reconstructive Surgery
Background:
- Obstetric brachial plexus palsy (OBPP) often results in shoulder dysfunction, including limited abduction and external rotation.
- Secondary bone deformities like glenoid retroversion and posterior subluxation can develop with delayed treatment.
Purpose of the Study:
- To evaluate the efficacy of subscapularis release and teres major transfer for OBPP.
- To determine the optimal age for surgical intervention to maximize functional outcomes and minimize secondary bone changes.
Main Methods:
- A cohort of 109 patients with OBPP underwent subscapularis release and teres major transfer, with some also receiving pectoralis major transfer.
- Surgical age, functional outcomes (abduction, external rotation), and radiographic changes (glenoid retroversion, posterior subluxation) were analyzed.
- Follow-up included clinical assessment and CT scans in 39 cases.
Main Results:
- Significant improvements in abduction (64 degrees) and external rotation (50 degrees) were observed.
- Outcomes were negatively correlated with age at surgery; younger patients (<4 years) showed superior motion gains.
- Glenoid retroversion positively correlated with age at surgery, being higher in those operated after 4 years.
Conclusions:
- Subscapularis release and teres major transfer is an effective surgical treatment for OBPP.
- Optimal results are achieved when surgery is performed before age 2, maximizing motion improvement and preventing bone deformities.
- Intervention between ages 2-4 improves motion and prevents glenoid retroversion, but not posterior subluxation; surgery after 4 yields limited benefits.
Abstract:
One hundred nine obstetrical palsy patients with defective shoulder abduction and external rotation had subscapularis release and transfer of teres major to infraspinatus with or without pedicle transfer of the clavicular head of pectoralis major to deltoid. The age at surgery averaged 67 months (11-192) and follow-up averaged 36 months (12-80). Thirty-nine cases had follow-up CT scan of both shoulders. Improvement of abduction averaged 64 degrees and that of external rotation 50 degrees, 100% and 290% gain, respectively. Both negatively correlated with the age at surgery (P < 0.001), and were significantly higher in patients operated younger than 4 years. On computed tomographic scans, the degree of glenoid retroversion positively correlated (P < 0.001) with the age at surgery, and was significantly higher in patients operated older than 4 years. The degree of posterior subluxation showed no significant difference between different ages. There was no significant difference between the operated and normal sides in patients operated younger than 4years with regard to glenoid retroversion and in those operated younger than 2 years with regard to posterior subluxation. The operation is useful for correction of defective shoulder abduction and external rotation in obstetric palsy. It is best performed before the age of 2 to get maximal improvement in motion and prevent secondary bone changes. Between the ages of 2 and 4, it also resulted in significant improvement in motion and prevented glenoid retroversion, but not posterior subluxation. After the age of 4, the improvement in motion was not significant and secondary bone changes were not prevented.
