Double Versus Single Tendon Transfers to Improve Shoulder Function in Brachial Plexus Birth Palsy.

BACKGROUND: In children with brachial plexus birth palsy (BPBP) undergoing tendon transfers to augment shoulder external rotation, it is unclear whether transfer of the latissimus dorsi with its combined latissimus dorsi and teres major (cLT) versus isolated teres major (iTM) tendon transfer yield different outcomes. METHODS: Records of patients with BPBP who underwent shoulder tendon transfers to augment external rotation were retrospectively reviewed. Transfer type (cLT or iTM) was considered indiscriminate by virtue of surgeon preference. Modified Mallet Scale (mMS) and Active Movement Scale scores were recorded. Patients with <12 months' follow-up, C7 or lower palsy, humeral osteotomy, shoulder procedure(s) within 8 months, microsurgery within 1 year, or recurrent glenohumeral subluxation confirmed by postoperative imaging were excluded. Matched cohorts were identified within each tendon transfer group to yield similar preoperative shoulder function and glenohumeral alignment status. Outcomes for all tendon transfers as well as differences between cLT and iTM cohorts were analyzed. RESULTS: Among 121 cLT and 34 iTM transfers, 49 cLT and 14 iTM met the inclusion criteria. Subsequent matching of cohorts yielded 28 patients (14 cLT and 14 iTM). Average age at time of transfer was 3.0±1.4 years. Follow-up averaged 4.1±3.1 years. There were no statistically significant preoperative differences between cohorts, thus matching criteria were validated. Regardless of tendon(s) transferred, mMS external rotation improved (2.2 to 3.5, P<0.001), whereas mMS internal rotation decreased (3.8 to 3.2, P<0.001). When comparing matched cohorts, cLT transfer produced a greater mMS external rotation improvement than iTM (2.1 vs. 1.5, respectively; P=0.025). Loss of midline function (defined as mMS external rotation <3) occurred in 5 (35.7%) cLT and 2 (14.3%) iTM patients. CONCLUSIONS: Both cLT or iTM transfer are effective at augmenting shoulder external rotation in children with C5-C6 BPBP. Furthermore, cLT transfers may yield a larger improvement in external rotation in certain patients. However, both techniques slightly decrease shoulder internal rotation. Given that more total cLT patients lost midline function among matched cohorts, iTM transfer may still be considered when limited midline function is a concern. LEVEL OF EVIDENCE: Level III.

Does weight-bearing assignment after intramedullary nail placement alter healing of tibial shaft fractures?

INTRODUCTION: There is no consensus regarding postoperative weight-bearing (WB) assignment after treatment of tibial shaft fractures with an intramedullary nail. This study aims to determine if the postoperative WB assignment after tibia intramedullary nail placement alters healing. METHODS: Closed AO type 42A fractures treated with a reamed statically-locked intramedullary nail over a 10-year period were retrospectively reviewed from injury at 2, 3, 6, 9 and 12 month intervals until union or revision. Patients were categorized according to postoperative weight-bearing assignment: weight-bearing-as-tolerated (WBAT) or non-weight-bearing (NWB). Patients with additional diagnoses that confound routine fracture healing were excluded. Postoperative radiographic union scores for tibial fractures (RUST), coronal/sagittal angulations, and length were compared between different weight-bearing groups. Union was defined as a RUST≥10 at a painless fracture site. RESULTS: A total of 83 patients achieved union (32 WBAT, 51 NWB). Both WB groups had similar preoperative demographics. Average age was 37±13 years and follow-up averaged 1.3±0.2 years. There were no significant differences in average time to radiographic union between NWB versus WBAT groups (5.5 vs. 6.1 months, respectively; P=0.208) nor radiographic healing at 2, 3, and 6-month intervals (P=0.631). There were two nonunions and one fracture shortened in the NWB group. There were no reoperations for symptomatic or broken hardware in either cohort. CONCLUSION: Immediate WBAT after statically-locked intramedullary nail placement in simple tibial shaft fractures does not alter the time until or course of radiographic union. LEVEL OF EVIDENCE: IV.