Long Term Results of Tendon Transfers to Restore Shoulder Function in Obstetrical Brachial Plexus Injuries
Genevieve Dostaler, MD, MHA; Matthew WT Curran, MD, MSc; Kathleen O'Grady, BSc; Michael J Morhart, MD, M.Sc; Jaret Olson, MD
University of Alberta, Edmonton, AB, Canada
Purpose: Patients with obstetrical brachial plexus injuries (OBPI) can develop an adduction and internal rotation contracture with resultant poor external rotation and abduction. For patients that fail to reinnervate after nerve reconstruction or present after 18 months, tendon transfers offer a surgical option to restore function. Surgical options to restore shoulder abduction and/or external rotation include the Hoffer and the L'Episcopo procedure. Previous studies have shown that these procedures can significantly improve ROM scores in OBPI. The aim of this study was to determine the long-term results of tendon transfers to restore shoulder function.
Methods: A retrospective review of all patients with OBPI that underwent tendon transfer to improve shoulder abduction and external rotation was completed. All patients underwent either the Hoffer or L'Episcopo tendon transfer with myostatic pectoralis major release. Demographic data including age, gender, injury pattern and follow-up were collected. Range of motion and Mallet scores were collected pre-operatively and over the course of follow-up. Demographics and outcomes were analyzed using t-test and ANOVA.
Results: Twenty-six patients underwent tendon transfers to improve shoulder abduction and external rotation. Patients underwent the procedure at an age of 5.76 +/- 2.73 years (mean +/- SD), were more commonly male (n=18;69%) and had upper trunk injuries (n=18; 69%). Patients were followed for 5.2 +/- 2.1 years. Twenty-three patients underwent the Hoffer procedure and 3 had the L'Epsicopo transfer. Patients demonstrated significantly improved active ROM for shoulder abduction 79 +/-37 degrees to 96 +/- 36 degrees (p<0.05) and external rotation 17 +/- 11 degrees to 29 +/- 20 degrees (p<0.01). Mallet scores similarly improved over the follow-up period. However, when individual data was analyzed we found that 42% (n=11) patients had regression of their shoulder abduction and 50 % (n=13) of patients regressed their external rotation to pre-operative values or less. There was no difference in age at surgery or length of follow between patients that demonstrated regression and those that did not.
Conclusions: Tendon transfers improve shoulder abduction and external rotation in patients with OBPI. However, a subset of patients will experience a regression in ROM over time. Age, gender, and time after transfer do not appear to impact the regression of ROM.
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