Shoulder internal rotation contracture in brachial plexus birth injury: proximal or distal subscapularis release?

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.

Association of eNOS 27-bp VNTR, 894G>T and 786T>C polymorphisms with susceptibility to Legg-Calve-Perthes Disease in Iranian children.

BACKGROUND: The aim of this study was to analyze the association of eNOS polymorphisms with risk of Legg-Calve-Perthes Disease (LCPD). METHODS: The study comprised of 45 LCPD patients and 55 controls. The eNOS polymorphisms were genotyped with PCR and by PCR-RFLP. RESULTS: The eNOS 894G > T and -786T > C polymorphisms were significantly associated with an increased risk of LCPD. However, there was no significant association between eNOS 27-bp VNTR polymorphism and LCPD risk. CONCLUSION: Our results suggest that the eNOS 894G > T and -786T > C polymorphisms may be a risk factor for LCPD in Iranian children, but not 27-bp VNTR polymorphism.

Association of MTHFR and TNF-α genes polymorphisms with susceptibility to Legg-Calve-Perthes disease in Iranian children: A case-control study.

OBJECTIVE: The aim of this study was to assess the association of MTHFR and TNF-α genes polymorphisms with Legg-Calvé-Perthes' disease (LCPD) risk in the Iranian children. METHODS: A total of 45 children with LCPD and 55 healthy controls were recruited to the study. Genotyping was performed via the RFLP-PCR method and genetic risk was calculated by odds ratio (OR) with its corresponding 95% confidence interval (CI). RESULTS & CONCLUSION: Our case-control study failed to determine any association of MTHFR (677C > T and 1298A > C) and TNF-α (-308G > A and -238G > A) polymorphisms with LCPD risk. More studies with larger sample size are warranted to validate our findings.

Factors associated with recurrence of clubfoot treated by the Ponseti method.

AIM: To assess several associated factors on the recurrence of clubfoot after successful correction by the Ponseti method. METHODS: A total of 115 children with 196 clubfeet deformities, treated by the Ponseti method, were evaluated. Demographic data, family history of clubfoot in first-degree relatives, maternal educational level and brace compliance were enquired. Based on their medical files, the characteristics of the patients at the time of presentation such as age, possible associated neuromuscular disease or especial syndrome, severity of the deformity according to the Dimeglio grade and Pirani score, residual deformity after previous Ponseti method and number of casts needed for the correction were recorded. RESULTS: There were 83 boys (72.2%) and 32 girls (27.8%) with a male to female ratio of 2.6. The mean age at the initiation of treatment was 5.4 d (range: 1 to 60 d). The average number of casts applied to achieve complete correction of all clubfoot deformities was 4.2. Follow-up range was 11 to 60 mo. In total, 39 feet had recurrence with a minimum Dimeglio grade of 1 or Pirani score of 0.5 at the follow-up visit. More recurrence was observed in non-idiopathic clubfoot deformities (P = 0.001), non-compliance to wear braces (P < 0.001), low educational level of mother (P = 0.033), increased number of casts (P < 0.001), and more follow-up periods (P < 0.001). No increase in the possibility of recurrence was observed when the previous unsuccessful casting was further treated using the Ponseti method (P = 0.091). Also, no significant correlation was found for variables of age (P = 0.763), Dimeglio grade (P = 0.875), and Pirani score (P = 0.624) obtaining at the beginning of the serial casting. CONCLUSION: Using the Ponseti method, non-idiopathic clubfoot, non-compliance to wear braces, low educational level of mother, increased number of casts and more follow-up periods had more association to possible increase in recurrence rate after correction of clubfoot deformity.