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Brachial plexus birth palsy shoulder deformity treatment using subscapularis release combined to tendons transfer
G Cohen1, V Rampal, F Aubart-Cohen
1Orthopedic Surgery Department, Cochin-Saint-Vincent-de-Paul Hospital, Paris Hospitals Group, University of Paris Descartes, Paris, France. gilles_fcohen@hotmail.com
Insights
This study shows that surgery for obstetric brachial plexus palsy (OP) improves shoulder external rotation (ER) and corrects posterior humeral head subluxation. However, functional gains diminish over time, highlighting the importance of muscle transfers alongside surgical release.
Area of Science:
- Orthopedic surgery
- Pediatric orthopedics
- Brachial plexus injury management
Background:
- Obstetric brachial plexus palsy (OP) can lead to impaired shoulder external rotation (ER), causing functional deficits and posterior humeral head subluxation/dislocation.
- Surgical intervention aims to address these issues by releasing the subscapularis muscle and potentially transferring the latissimus dorsi and teres major muscles.
Purpose of the Study:
- To evaluate the medium-term clinical and radiological outcomes of subscapularis release combined with latissimus dorsi and teres major muscle transfer in patients with OP.
- To assess the impact of this surgical approach on shoulder function, glenoid retroversion, and humeral head subluxation.
Main Methods:
- A retrospective study of 32 OP patients (mean age 2.5 years) who underwent subscapularis release, with 24 also receiving muscle transfer.
- Shoulder function was evaluated using passive ER measurements and the modified Mallet classification at 1, 5, and 10 years post-surgery.
- Radiological assessment included CT scans to measure glenoid retroversion and humeral head subluxation before and 5 years after surgery.
Main Results:
- Significant improvement in passive ER (from -10° to 52°) and modified Mallet score at 1 year post-surgery.
- Progressive decline in ER (to 13°) and Mallet score (to 15.8) by 10 years, though glenoid retroversion and humeral head subluxation showed correction at 5 years.
- Patients without initial muscle transfer had higher rates of reoperation or ER insufficiency compared to those who received it.
Conclusions:
- Surgical treatment, including subscapularis release and muscle transfer, offers objective functional improvement and corrects posterior shoulder subluxation in OP patients.
- The benefits, particularly functional gains, may diminish over time, suggesting the importance of combining release with muscle transfer.
- Surgery is indicated for negative passive ER amplitude, and associating muscle transfer appears advisable.
Introduction:
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.
Patients And Methods:
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.
Results:
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.
Discussion And Conclusion:
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 Of Evidence:
Level IV Retrospective study.
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