Biceps Rerouting after Forearm Osteotomy: An Effective Treatment Strategy for Severe Supination Deformity in Obstetric Plexus Palsy.

Study Design Retrospective cohort study. Objective Supination deformity in obstetric brachial plexus injury can have debilitating consequences for the functionality of the hand. Surgical treatment by a forearm osteotomy has a recurrence rate of 20 to 42%. As a complement to forearm osteotomy, a biceps rerouting may improve outcome. Methods Children with residual brachial plexus injury, who had a forearm osteotomy for a supination contracture and had a postoperative decrease of pronation to 50 degrees or less, were indicated for a biceps rerouting. Shoulder, elbow and hand function, biceps strength, Mallet score, and Raimondi score were assessed with a minimum follow-up of 2 years. Results Five patients (median age: 8 years; range: 4-10) underwent biceps rerouting between 2008 and 2012. Median follow-up time was 6.8 years (range: 3.2-7.0 years). Passive pronation increased in all cases (median 0 degree at baseline to 80 degrees at final follow-up). Active pronation also increased. Active median wrist extension was -30 degrees at baseline and 45 degrees at follow-up. Biceps strength and grip strength improved in two cases. No recurrences were present. Conclusion The sequentially planned surgical treatment of forearm osteotomy and biceps rerouting should be considered in the treatment of severe supination deformity, as it is effective in improving pronation of the forearm and hand function, without recurrence at follow-up. Level of Evidence/Type of Study Level III, case series, therapeutic study.

Treatment of supination deformity for obstetric brachial plexus injury: a systematic review and meta-analysis.

PURPOSE: To conduct a systematic review and meta-analysis of the literature evaluating treatment outcome for supination deformity in obstetric brachial plexus injury. METHODS: We included studies on brachial plexus and supination deformity with follow-up of at least one year and quantitative measurements of forearm mean passive pronation and position at rest. Meta-analysis was used to explore modifying factors. RESULTS: An elaborate search strategy resulted in 366 studies, of which 13 were included totaling 238 patients (157 osteotomies and 71 biceps rerouting). There was a 75° gain in position at rest and a 65° gain in passive pronation for the osteotomy group, compared to a 79° gain in position at rest for the biceps rerouting group. More severe deformities had greater gains. No influence of age was found. Important adverse effects were hardware failure and a biceps rupture. Recurrence in the osteotomy group was 20% to 40%, versus none in the soft-tissue group. CONCLUSIONS: This review showed an overall benefit for forearm osteotomies and for biceps rerouting for supination deformity with the gain proportionate to the severity of the deformity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

The relationship between Bunina bodies, skein-like inclusions and neuronal loss in amyotrophic lateral sclerosis.

Specific pathological hallmarks have been described in amyotrophic lateral sclerosis (ALS), which include motor neuronal loss, Bunina bodies (BBs) and skein like inclusions (SLIs). We investigated the relation between these three lesions in the cervical and lumbar anterior horns and the hypoglossal nuclei of 20 ALS patients and 9 controls using a quantitative light microscopy study. Immunohistochemistry with anti-cystatin C and anti-ubiquitin was used to detect the BBs and SLIs, respectively. A significant relation between the severity of neuronal loss and the proportion of SLI-containing neurons was found in the spinal cord, whereas no relation was found with BBs. We therefore propose that BBs and SLIs participate in two different steps of the cascade leading to neuronal loss.