Humeral internal rotation osteotomy for the treatment of Erb-Duchenne-type obstetric palsy: clinical and radiographic results

OBJECTIVE: To evaluate the functional and radiographic results in patients undergoing shoulder anterior soft tissue stretching in association with open reduction and internal rotation osteotomy to centralize the humeral head as a treatment for Erb-Duchenne obstetric palsy sequelae. METHOD: A total of 35 patients underwent this surgical treatment, and the mean follow-up was 4.6 years. The Mallet scale was applied before and after the surgical procedure. A total of 20 patients underwent computed tomography to assess the glenoid version and humeral head subluxation. RESULTS: Functional improvement was achieved, as evidenced by an increase in the Mallet scale score from 12.14 to 16.46 (p<0.001). The correction of retroversion was achieved once the glenoid version ranged from -21.4 to -12 degrees (p<0.001). The humeral head subluxation improved from 6.5 to 35.2% (p<0.001). Patients older than 6 years of age did not achieve glenohumeral joint improvement with respect to dysplastic abnormalities. CONCLUSION: Internal rotation osteotomy in association with the stretching of anterior soft tissues of the shoulder in patients under the age of 7 years provided improvements in the function, retroversion, and subluxation of the glenohumeral joint. .

Avaliação da função do membro superior nos pacientes com paralisia obstétrica após cirurgia de Sever-L'Episcopo modificada / Evaluation of upper-limb function in patients with obstetric palsy after modified Sever-L'Episcopo procedure

OBJETIVO: Avaliar a função do membro superior acometido, por meio do escore de Mallet, nos pacientes com contratura em rotação medial do ombro submetidos à cirurgia de Sever-L'Episcopo modificada, e correlacionar a evolução com a idade e com o tempo de seguimento pós-operatório. MÉTODOS: Dezesseis pacientes foram avaliados, sendo comparadas as medidas pré e pós-operatórias do escore de Mallet, e correlacionada a diferença entre esses valores com a idade no momento da cirurgia e tempo de seguimento. RESULTADO: Observou-se melhora do escore de Mallet pós-operatório estatisticamente significante, enquanto a correlação da diferença dos valores do escore com a idade e o tempo de seguimento não foram estatisticamente significantes. CONCLUSÃO: A cirurgia de Sever-L'Episcopo modificada proporcionou melhora da função do membro superior, de acordo com o escore de Mallet. Não houve relação entre a idade e o tempo de seguimento com a função do membro.

OBJECTIVE: To evaluate upper-limb function by means of the Mallet score, in patients with medial rotation contracture of the shoulder who underwent the modified Sever-L'Episcopo procedure, and to correlate evolution with age and length of postoperative follow-up. METHODS: Sixteen patients were assessed by comparing the pre and postoperative Mallet scores and correlating the differences between these scores with age at the time of surgery and length of follow-up. RESULTS: A statistically significant improvement in the postoperative Mallet score was observed. The correlations of the differences in scores with age and length of follow-up were not statistically significant. CONCLUSION: The modified Sever-L'Episcopo procedure led to improved upper-limb function according to the Mallet score. Limb function did not present correlations with age or length of follow-up.

Latissimus dorsi transposition for sequelae of obstetric palsy / Transferencia del músculo dorsal ancho en secuelas obstétricas del plexo braquial

Background: In obstetric palsy, limitation in the external abduction and rotation of the shoulder is the most frequent sequelae. Glenohumeral deformity is the result of muscular imbalance between the external and internal rotators. Releasing the contracted muscles and transferring the latissimus dorsi are the most common surgeries in this case. Patients and methods: We operated on 24 children between 4 and 8 years of age with obstetric palsy sequelae to elevate the subscapularis muscle off the anterior surface of the scapula posteriorly and transfer the latissimus dorsi. The patients received a minimum of 2 years of follow up. They were evaluated based on Mallet’s and Gilbert’s classifications. Results: All of the patients recovered within the above mentioned classifications. Out of 22 children evaluated via Mallet’s classification, all improved from 3 to 4 on that scale. With respect to Gilbert’s classification, 16 children improved one degree and 8 improved 2 degrees. All of the patients’ parents were satisfied with the results. Discussion: The benefit from releasing contracted muscles and muscle transfer to improve shoulder abduction in the sequelae of obstetric palsy has been amply reported in the literature. The results we had from elevating the subscapularis muscle off the anterior surface of the scapula and transferring the latissimus dorsi were good. Children who were difficult to classify based on the described scale were taken note of and some sub-classifications for Gilbert’s descriptions were proposed. Patients must be selected carefully. To transfer the latissimus dorsi, it is necessary to have good passive mobility in abduction, a minimum of 20º of external rotation and no joint deformities. When negative external rotation is found, the subscapularis muscle should be released. When there is glenohumeral joint deformity in older children, other methods are recommended, such as rotational humeral osteotomy.

Introducción: Las limitaciones en la abducción y la rotación externa del hombro son las secuelas más frecuentes en la parálisis obstétrica. Se encuentra deformidad de la articulación glenohumeral como resultado del desequilibrio que existe entre los músculos rotadores externos e internos. Dentro de las cirugías más usadas para corregir las deformidades del hombro están las liberaciones musculares y la transposición del músculo dorsal ancho. Materiales y métodos: El autor operó 24 niños entre los 4 y 8 años de edad, con secuelas de parálisis braquial obstétrica, a quienes se les practicó liberación del subescapular por vía posterior y transferencia del músculo dorsal ancho. Se evaluaron según la escala de Mallet y la de Gilbert, con un seguimiento mínimo de dos años. Resultados: Todos los niños se recuperaron según las escalas mencionadas. En 22 evaluados según Mallet, todos mejoraron del nivel 3 al 4. Según la clasificación de Gilbert, 16 niños mejoraron un grado y 8 niños mejoraron dos grados. Todos los padres estuvieron satisfechos con los resultados. Discusión: Existen muchos informes en la literatura médica sobre los beneficios de liberar los músculos contracturados y de las transferencias musculares en el hombro en las secuelas de parálisis braquial obstétrica. Se obtuvieron buenos resultados en todos los niños. Algunos casos fueron difíciles de clasificar en las escalas usadas, para lo cual se propone una sub-clasificación. Se requiere tener una buena movilidad pasiva, que no haya deformidad articular en el hombro y mínimo 20º de rotación externa, para realizar la transferencia muscular del dorsal ancho. Cuando no se encuentra la rotación externa, se debe hacer la liberación del subescapular. Si hay deformidad de la articulación glenohumeral, no se recomiendan las transferencias musculares y entonces se recurre a osteotomías.