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Shoulder internal rotation contracture in brachial plexus birth injury: proximal or distal subscapularis release?
Romain Allard1, Franck Fitoussi1, Mohammad Reza Azarpira1
1Department of Pediatric Orthopedics, Armand Trousseau Hospital-Sorbonne University, Paris, France.
Insights
Proximal subscapularis release is effective for children with brachial plexus birth injury and internal rotation contractures, especially those under 4 years old. Distal releases offer benefits for older patients, though less pronounced.
Area of Science:
- Orthopedic Surgery
- Pediatric Orthopedics
- Brachial Plexus Injury Management
Background:
- Brachial plexus birth injury can cause shoulder internal rotation contractures.
- Subscapularis muscle release can be performed proximally or distally.
- Surgical approach is hypothesized to depend on patient age, bone remodeling potential, and soft-tissue contractures.
Purpose of the Study:
- To analyze the outcomes of a strategy differentiating subscapularis release based on patient characteristics.
- To evaluate the efficacy of proximal versus distal release in pediatric patients with internal rotation contractures.
Main Methods:
- Retrospective chart review of 28 children with brachial plexus birth injury and shoulder internal rotation contractures.
- Included patients underwent subscapularis release and infraspinatus reanimation (tendon transfer).
- Preoperative and postoperative data included range of motion, modified Mallet score, glenoid version, and humeral head centering.
Main Results:
- Proximal release (n=13) in younger patients (<4 years) showed significant improvements in active/passive external rotation, Mallet score, glenoid version, and humeral head centering (mean follow-up 4 years).
- Distal release (n=15) in older patients showed significant improvements in active/passive external rotation and Mallet score, but less pronounced changes in glenoid version and humeral head centering (mean follow-up 3 years).
- P-values indicate statistically significant improvements for most parameters in both groups, except for glenoid version and humeral head centering in the distal release group.
Conclusions:
- Proximal subscapularis release, combined with axial rebalancing, is sufficient for satisfactory outcomes in younger patients with good bone remodeling potential.
- Distal release in older patients yields significant but lower clinical improvements compared to proximal release in younger patients.
- The findings support an age-dependent surgical strategy for subscapularis release in brachial plexus birth injury.
Background:
In cases of brachial plexus birth injury with internal rotation contracture of the shoulder, the subscapularis muscle may be released proximally, from the subscapular fossa, or distally, along with periarticular soft tissues arthroscopic to the glenohumeral joint. We hypothesized that the indication for each procedure would rely primarily on patients' bone remodeling potential and periarticular soft-tissue contractures, performing proximal releases in patients aged < 4 years and periarticular distal releases in older patients. The purpose of this study was to analyze the outcomes such a strategy could provide.
Methods:
All patients presenting with brachial plexus birth injury-related shoulder internal rotation contractures who underwent a subscapularis release were included; in addition, to restore the joint axial balance, the infraspinatus was systematically reanimated with a tendon transfer (ie, latissimus dorsi or lower trapezius) during the same operating time. Chart review yielded preoperative and postoperative clinical and radiographic measurements, including active and passive range of motion of the shoulder in external rotation (ER) with the arm at the side of the body, the modified Mallet score, glenoid version, and the percentage of the humeral head arthroscopic to the middle of the glenoid process.
Results:
Between July 2012 and January 2018, 28 children were operated on at our institution. In patients who underwent proximal subscapularis release (n = 13), significant improvements were observed regarding active shoulder ER, passive shoulder ER, the modified Mallet score, glenoid version, and the percentage of the humeral head arthroscopic to the middle of the glenoid process, averaging 58° ± 32° (P < .0001), 56° ± 20° (P < .0001), 9.7 ± 3.1 points (P = .0006), 15° ± 10° (P = .0034), and 24% ± 20% (P = .0113), respectively, after a mean follow-up period of 4 years. Following distal release procedures (n = 15), these improvements averaged 26° ± 29° (P = .0024), 27° ± 28° (P = .0011), 3.3 ± 4.1 points (P = .0049), 2° ± 17° (P = .4086), and 4% ± 18% (P = .215), respectively, after a mean follow-up period of 3 years.
Conclusion:
When combined with axial rebalancing of the joint, the proximal release of the subscapularis muscle appears to be sufficient to provide satisfactory functional outcomes in patients with great bone remodeling potential and supple periarticular soft tissues. In older patients, a more comprehensive release of the glenohumeral joint's arthroscopic aspect seems to provide lower but still significant clinical improvements.
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