American Society for Peripheral Nerve

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Release of the Internal Rotation Contracture of the Shoulder in Children with a Brachial Plexus Injury Using the Subscapularis Slide
Igor Immerman, MD; Sergio Glait, MD; Herbert Valencia, RN, CFA; Patricia DiTaranto, MD; Edward Delsole, BS; Andrew E. Price, MD; John A. Grossman, MD
New York University Hospital for Joint Diseases, New York, NY, USA

Introduction: Internal rotation (IR) contracture of the shoulder is the most common deformity in patients with brachial plexus birth injury. Many procedures exist to correct this problem but none have demonstrated superiority. A subscapularis slide (SS) can effectively manage an IR contracture in this patient population. The purpose of this investigation is to describe results of the SS on children with IR contracture from brachial plexus birth injury.

Materials and Methods: A total of 117 patients treated with SS between 1997 and 2010 were identified between two institutions. Only 70 patients had a minimum 2-year follow-up and were included in this study. All surgeries were performed by the one of the senior authors and included the SS with or without additional procedures to improve passive external rotation (ER) without violating the anterior capsule. Medical charts were retrospectively reviewed.

Patients were divided into five groups based on the index procedure performed: SS alone (group 1); SS with a simultaneous microsurgical reconstruction (group 2); primary microsurgical brachial plexus reconstruction followed by a later SS (group 3); primary microsurgical brachial plexus reconstruction followed by a later SS combined with tendon transfers for shoulder external rotation (group 4), and primary SS with simultaneous tendon transfers (group 5). Data was collected and statistically analyzed for each group.

Results: Average follow-up among the 70 patients (45 females and 25 males) was 59 months with a mean age at initial surgery of 42 months (range: 5 months – 13 years). Group 1 had 6 patients (9%), group 2 had 39 (56%), group 3 had 8 (11%), group 4 had 9 (13%), and group 5 had 8 (11%). All cases intra-operatively achieved full passive ER. Among all five groups the pre-surgical active ER was 9.8±7.4 degrees and at final follow-up it was 48.4±7.6 degrees (p<0.5). At final follow-up, 21 patients (30%) developed a recurrence of IR contracture requiring a redo operation, but only 1 of these patients was from group 4 and 5 combined. There were no post-operative complications and no cases of anterior instability.

Conclusions: Internal rotation contracture of the shoulder following brachial plexus birth injury is effectively managed with the SS technique achieving full passive ER intra-operatively while avoiding the complication of shoulder instability. Recurrence of contracture is less frequent when the index procedure includes a tendon transfer to restore muscle balance in the shoulder. A repeat SS is easily performed when indicated with no reported complications.


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