How to follow up patients with brachial plexus birth palsy in the long term: a survey of expert opinion.

There is no generally accepted diagnostic, treatment and follow-up algorithm for brachial plexus birth palsy in the current literature. This study evaluates the opinion of experts in the field of brachial plexus birth palsy surgery, to provide a follow-up guideline. A total of 35 experts attending an international meeting with a mean of 21.5 years (SD 10.1) of experience in the field filled out a questionnaire to evaluate the following: (1) the surgeons' background; (2) clinical follow-up; (3) radiological follow-up; and (4) International Classification of Functioning, Disability and Health (ICF) domains. A mean of 40 new brachial plexus birth palsy patients were seen per year by each expert, of which 36% needed surgery. In total, 27 experts scheduled a regular follow-up every year and the majority (83%) believed that standardized long-term clinical follow-up is necessary. However, standardized radiological follow-up is not necessary. Only 13 of 34 participants used patient-reported outcome measures to investigate ICF domains.Level of evidence: V.

[Rupture of the flexor carpi radialis tendon after corticosteroid injection of a ganglion cyst]. / Peesruptuur na injectie van corticosteroïden in ganglioncyste.

BACKGROUND: Although corticosteroid injections are frequently used in practice to treat tendinopathies, there are many adverse effects. CASE DESCRIPTION: A 62-year-old woman received an aspiration and corticosteroid injection of a ganglion on the volar side of the left wrist. A few weeks later, she presented with severe pain and loss of function of the left wrist. On physical examination, here was a notable swelling with hematoma formation, along the course of the flexor carpi radialis. An MRI confirmed complete rupture of the flexor carpi radialis (FCR) tendon. She was treated non operatively with analgesics and a protective brace. During final check-up minimal loss of function was seen. CONCLUSION: Cautiousness and judicious restraint are imperative when considering corticosteroid infiltrations targeting a volar ganglion at the level of the FCR. Aspiration combined with corticosteroid infiltration is not recommended for patients exhibiting (subclinical) STT-/CMC-1 osteoarthritis, as it may cause FCR tendon ruptures.

Biodegradable vs nonbiodegradable suture anchors for rotator cuff repair: a systematic review and meta-analysis.

Purpose: The use of non-biodegradable suture anchors (NBSA) in arthroscopic rotator cuff repair (RCR) has increased significantly. However, several complications such as migration, chondral damage, revision, and imaging difficulties have been reported. Meanwhile, the effectiveness of biodegradable suture anchors (BSA) in overcoming such complications and achieving functional outcomes requires further study. Thus, we aim to compare the clinical outcomes and complications of RCR using BSA and NBSA using direct comparison studies. Methods: Two independent reviewers conducted systematic searches in PubMed, Embase, Cochrane Library, and Web of Science from conception to September 2022. Using the RoB 2 and ROBINS-I tools, we assessed the included studies for bias. We applied GRADE to appraise our evidence. Our PROSPERO registration number is CRD42022354347. Results: Six studies (two randomized controlled trials, one retrospective cohort, and three case-control studies) involving 423 patients were included (211 patients received BSA and 212 patients received NBSA). BSA was comparable to NBSA in forward flexion, abduction, external rotation, Constant-Murley score, and perianchor cyst formation (P = 0.97, 0.81, 0.56, 0.29, and 0.56, respectively). Retear rates were slightly higher while tendon healing was reduced in BSA compared to NBSA, but the differences were not significant (P = 0.35 and 0.35, respectively). Conclusion: BSA and NBSA appear to yield similar shoulder functions and complications in rotator cuff repairs.

Time to surgery and myo-d expression in biceps muscle of adult brachial plexus injury: a preliminary study.

BACKGROUND: Brachial Plexus Injury (BPI) is one of the peripheral nerve injuries which causes severe functional impairment and disability. Without prompt treatment, prolonged denervation will cause severe muscle atrophy. MyoD, which is expressed by satellite cells, is one of the parameters that relate to the regeneration process in post-injury muscle and it is presumed to determine the clinical outcome following neurotization procedure. This study aims to understand the correlation between time to surgery (TTS) and MyoD expression in satellite cells in the biceps muscle of adult brachial plexus injury patients. METHODS: Analytic observational study with a cross-sectional design was conducted at Dr. Soetomo General Hospital. All patients with BPI who underwent surgery between May 2013 and December 2015 were included. Muscle biopsy was taken and stained using immunohistochemistry for MyoD expression. Pearson correlation test was used to assess the correlation between MyoD expression with TTS and with age. RESULTS: Twenty-two biceps muscle samples were examined. Most patients are males (81.8%) with an average age of 25.5 years. MyoD expression was found to be highest at TTS of 4 months and then dropped significantly (and plateau) from 9 to 36 months. MyoD expression is significantly correlated with TTS (r=-0.895; p = 0.00) but not with age (r=-0.294; p = 0.184). CONCLUSION: Our study found, from the cellular point of view, that treatment of BPI needs to be done as early as possible before the regenerative potential - as indicated by MyoD expression - declined.

Long-term functional outcome of secondary shoulder surgery in brachial plexus birth palsy patients.

Multiple secondary surgical procedures of the shoulder, such as soft-tissue releases, tendon transfers, and osteotomies, are described in brachial plexus birth palsy (BPBP) patients. The long-term functional outcomes of these procedures described in the literature are inconclusive. We aimed to analyze the literature looking for a consensus on treatment options. A systematic literature search in healthcare databases (PubMed, Embase, the Cochrane library, CINAHL, and Web of Science) was performed from January 2000 to July 2020, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The quality of the included studies was assessed with the Cochrane ROBINS-I risk of bias tool. Relevant trials studying BPBP with at least five years of follow-up and describing functional outcome were included. Of 5,941 studies, 19 were included after full-text screening. A total of 15 surgical techniques were described. All studies described an improvement in active external rotation (range 12° to 128°). A decrease in range of motion and Mallet score after long-term (five to 30 years) follow-up compared to short-term follow-up was seen in most studies. The literature reveals that functional outcome increases after different secondary procedures, even in the long term. Due to the poor methodological quality of the included studies and the variations in indication for surgery and surgical techniques described, a consensus on the long-term functional outcome after secondary surgical procedures in BPBP patients cannot be made.

Transhumeral amputation in brachial plexus lesion patients: A multicenter case series.

BACKGROUND: A flail limb can be the result of a traumatic complete brachial plexus lesion. Some patients prefer retaining the flail limb, however some patients feel that a flail limb negatively affects daily life. In these circumstances an elective amputation is sometimes elected, however long-term follow-up, with respect to satisfaction and function is unknown. The aim of this study is to evaluate the long-term outcome of this rare and life changing operation. MATERIALS AND METHODS: 8 patients with a transhumeral amputation performed in 2 specialized medical centers were included. Postoperatively, the functional- and psychological outcome and the quality of life were evaluated with standardized patient reported outcome measures (PROMs; DASH, SIP-68, EQ-5D-5L and HADS). RESULTS: After a median of 9.4 (range 7.5 - 12.8) years follow-up, 7 patients (88%) stated that they would undergo the operation again and were satisfied with the results. At latest follow-up the median DASH score was 37.3 (range 8.3-61.7), the median SIP-68 score was 6.5 (range 0-43) and the median HADS score was 3.0 (range 0-14) for anxiety and 3.0 (range 1-19) for depression. In the EQ-5D-5L patients had most difficulties in self-care, usual activities and pain/discomfort. The median overall health status was 69 (range 20-95). DISCUSSION: With the right indication a transhumeral amputation is a reasonable option for traumatic complete brachial plexus lesion with satisfying long-term results. LEVEL OF EVIDENCE: IV, multicenter case series.

Morphology of Humeral Head and Glenoid in Normal Shoulder of Indonesian Population.

Purpose: Shoulder prostheses designed and used around the world may not fit an Asian shoulder. Normal shoulder morphology in Asian population had been reported, ie, Chinese, Indian, Japanese, and Thai populations, but no data from the Indonesian population. The aim of this study was to evaluate the three-dimensional (3D) morphology of the glenohumeral joint in the normal Indonesian population, identify its normal values, and compare them with those of other populations in the literature. Patients and Methods: Images for analysis were computed tomography (CT) scans of 85 normal shoulders from 71 patients who had CT scans for another diagnosis. Morphometry of the humeral head and glenoid were measured using 3D reconstruction. Gender differences and correlations between age, height, and glenohumeral morphometry were evaluated. Indonesians' glenohumeral morphometry was compared with those of other populations in the literature. Results: In the normal Indonesian population, the mean of humeral head inclination (HHI), height (HHH), diameter in sagittal plane (DS), diameter in frontal plane (DF), radius of curvature in sagittal plane (RS), and radius of curvature in frontal plane (RF) were 134.1°, 15.6mm, 39.3mm, 41.3mm, 20.4mm, and 21.4mm, respectively. The glenoid height (GH), upper width (GUW), lower width (GLW), inclination (GI), and version (GV) mean values were 34.2mm, 18.4mm, 24.5mm, 74.0mm, and 12.3mm, respectively. There was a significant difference in HHH, DS, DF, RS, RF, GH, GUW, GLW between males and females. Except for HHI and GI, glenohumeral morphometry was correlated with patient height. Age was not correlated with any glenohumeral morphometry. Conclusion: In the Indonesian population, males had a larger humeral head and glenoid than females, and the size of the humeral head and glenoid was correlated to body height. Indonesians' humeral head and glenoid sizes were smaller than those of Western populations, but close to those of other Asian populations.

The Relationship Between Patient Factors and Clinical Outcomes of Free Functional Muscle Transfer in Patients with Complete Traumatic Brachial Plexus Injury.

Purpose: Traumatic brachial plexus injury (TBPI) causes severe disabilities to the patients, affecting not only upper limb function but also the psychosocial and economic aspects. Free functional muscle transfer (FFMT) is one of the reconstruction modalities for the management of TBPI. The aim of this study is to evaluate the functional outcomes and their correlation to patient factors. Patients and Methods: This is a retrospective study of 131 patients who suffered from complete TBPI (C5-T1) and were treated with the FFMT procedure to restore elbow flexion and wrist extension from 2010 to 2018 in our institution. We evaluated the active range of motion (AROM), muscle power with MRC (Medical Research Council) scale, DASH score, and complications, with a minimum of 12-month follow-up. Results: Following FFMT surgery, elbow flexion was significantly and successfully restored (MRC ≥ 3) in 75.5% of patients with an average AROM of 88.17 ± 41.29°. The wrist extension was restored in 42% of the patients with an average AROM of 20.69 ± 18.72°. There was no correlation between age, side of injury, and time to surgery with the functional outcomes. There was a weak correlation between education level, rehabilitation compliance, and elbow functional outcomes. Conclusion: FFMT is a reliable surgical option to restore elbow flexion in TBPI with a high satisfactory result. Our findings suggested that the FFMT indication is potentially expanded regardless of the patient factors.

Clavicle lengthening, a novel operation technique to reduce pain in brachial plexus birth injury patients.

BACKGROUND: Brachial plexus birth injury (BPBI) can lead to an imbalance of shoulder musculature that can lead to glenohumeral contractures, and joint and osseous deformities. Glenoid hypoplasia, lengthening of coracoid and acromion, protraction, lateral rotation and elevation of the scapula, and shortening of the clavicle can be observed. As a consequence, the trapezius, levator scapulae, rhomboid, and supraspinatus muscles are overloaded in daily activities causing pain, which can be difficult to treat conservatively. It is hypothesized that operative lengthening of the clavicle may lead to a more anatomic position of the scapula and periscapular muscles, which, as a consequence, may lead to less overloading pain. This study presents the results of this new technique in patients with BPBI. MATERIALS AND METHODS: Seven patients (median age 20 years) were included and underwent a lengthening osteotomy of the clavicle at the affective side. Preoperatively, the osseous deformities were confirmed with a computed tomography scan. Patient-reported outcome measures, Disabilities of Arm, Shoulder and Hand score, and Mallet score were evaluated pre- and postoperatively. RESULTS: After a median of 42 (interquartile range [IQR]: 8.0) months' follow-up, all patients were satisfied with the result. The median numeric rating scale for satisfaction was 8.0 (IQR: 2). Pain decreased from a median numeric rating scale of 7.0 (IQR: 2) preoperatively to 2.0 (IQR: 3) at the final follow-up. The median Mallet score was 14.5 (IQR: 1) preoperatively and 14 (IQR: 0) at the final follow-up. The median Disabilities of Arm, Shoulder and Hand score was 36.7 (IQR: 24.1) at the final follow-up. All patients returned to their normal work without changes in working conditions. CONCLUSION: Short-term follow-up shows that in patients with BPBI with a short clavicle at the affected side and malposition of the scapula, a lengthening osteotomy of the clavicle is a safe and promising technique to reduce pain based on overloading, without deterioration of shoulder function.

The humeral suspension technique: a novel operation for deltoid paralysis.

Isolated deltoid paralysis is a rare pathology that can occur after axillary nerve injury due to shoulder trauma or infection. This condition leads to loss of deltoid function that can cause glenohumeral instability and inferior subluxation, resulting in rotator cuff muscle fatigue and pain. To establish dynamic glenohumeral stability, a novel technique was invented. Humeral suspension is achieved using a double button implant with non-resorbable high strength cords between the acromion and humeral head. This novel technique was used in two patients with isolated deltoid paralysis due to axillary nerve injury. The results indicate that the humeral suspension technique is a method that supports centralizing the humeral head and simultaneously dynamically stabilizes the glenohumeral joint. This approach yielded high patient satisfaction and reduced pain. Glenohumeral alignment was improved and remained intact 5 years postoperative. The humeral suspension technique is a promising surgical method for subluxated glenohumeral joint instability due to isolated deltoid paralysis.

Early and late apoptosis protein expression (Bcl-2, BAX and p53) in traumatic brachial plexus injury.

OBJECTIVES: This research aims to analyze the expression of pro-apoptotic proteins (Bax, p53) and anti-apoptotic protein (Bcl-2) in the nerve roots of the brachial plexus following traumatic brachial plexus injury (TBPI) in the early and late stage. METHODS: A total of 30 biopsy samples were taken from the proximal stump of the postganglionic nerve roots of the TBPI patients' brachial plexus from January 2018 until September 2019. The samples were taken from patients within six months of trauma (early stage, group A) and more than six months following trauma (late stage, group B). Bcl-2, Bax, and p53 expressions in each group were measured and compared. RESULTS: We found significant differences in the Bcl-2 (p=0.04), Bax (p<0.0001), p53 (p<0.0001) expressions between group A and B. The Bcl-2/Bax expression ratio in group A and B was 2.26 and 0.22, respectively. Meanwhile, the Bcl-2/p53 expression ratio in group A and B was 1.64 and 0.23, respectively. CONCLUSION: Apoptosis is inhibited by Bcl-2 activities in the early stage following trauma. In the late stage, a significant decrease of Bcl-2 coupled with a substantial increase of Bax and p53 indicates a continuation of the apoptotic process.

Reverse total shoulder arthroplasty (RTSA) versus open reduction and internal fixation (ORIF) for displaced three-part or four-part proximal humeral fractures: a systematic review and meta-analysis.

Despite rapid medical technology development, various challenges exist in three- and four-part proximal humeral fracture (PHF) management. This condition has led to a notably increased use of the reverse total shoulder arthroplasty (RTSA); however, open reduction and internal fixation (ORIF) is still the most widely performed procedure. Thus, these two modalities are crucial and require further discussion. We aim to compare the outcomes of three- or four-part PHF surgeries using ORIF and RTSA based on direct/head-to-head comparative studies.We conducted a systematic review and meta-analysis based on the Cochrane handbook and PRISMA guidelines. We searched MEDLINE (PubMed), Embase (Ovid), and CENTRAL (Cochrane Library) from inception to October 2020. Our protocol was registered at PROSPERO (registration number CRD42020214681). We assessed the individual study risk of bias using ROB 2 and ROBINS-I tools, then appraised our evidence using the GRADE approach.Six head-to-head comparative studies were included, comprising one RCT and five retrospective case-control studies. We found that RTSA significantly improved forward flexion but was comparable to ORIF in abduction (p = 0.03 and p = 0.47, respectively) and more inferior in external rotation (p < 0.0001). Moreover, RTSA improved the overall Constant-Murley score, but the difference was not significant (p = 0.22). Interestingly, RTSA increased complications (by 42%) but reduced the revision surgery rates (by 63%) compared to ORIF (p = 0.04 and p = 0.02, respectively).RTSA is recommended to treat patients aged 65 years or older with a three- or four-part PHF. Compared to ORIF, RTSA resulted in better forward flexion and Constant-Murley score, equal abduction, less external rotation, increased complications but fewer revision surgeries. Cite this article: EFORT Open Rev 2021;6:941-955. DOI: 10.1302/2058-5241.6.210049.

Improved long-term functional outcome after a latissimus dorsi transfer with or without subscapularis muscle lengthening or release.

A brachial plexus birth injury (BPBI) can lead to a limited shoulder function, especially abduction and external rotation. One of the treatment options to restore those shoulder functions is a latissimus dorsi transfer (LDT). The aim of this study is to analyze long-term functional outcome after a single LDT and compare these results with LDT combined with subscapularis muscle lengthening (SSL) or subscapularis muscle release (SSR). This cohort study included 39 patients (≤12 years old) with one-sided BPBI. All patients had an inter- nal rotation- and adduction contracture without glenohumeral joint deformity. A LDT was performed with or without SSL or SSR, resulting in 3 patient study groups. Demographic data and pre- and post- operative Mallet scores were collected and analysed for each group. The median age was 4.0 years (IQR 3.1) and there were no differences in patient demographics. In all patients surgery improved external rotation and overall shoulder function, at 9.8 years follow-up. Also, the total Mallet score increased significantly with 1.7 (p=0.001) in our (entire) study cohort. A LDT, with a SSL or SSR in case of an intra-operative internal contracture, improves shoulder function and preserves external rotation in patients (≤12 years old) with BPBI, at a follow up of 9.8 years.

Medium term outcomes of the Universal 2 total wrist arthroplasty in patients with degenerative or posttraumatic osteoarthritis of the wrist.

This retrospective study reports medium term outcomes of 14 total wrist arthroplasties in patients with especially, non-rheumatoid, degenerative osteo- arthritis and post-traumatic osteoarthritis with a mean follow up of 5 to 10 years. Information of fourteen patients, 6 men and 8 women with a mean age of 61 years, was collected before and after total wrist arthroplasty (Universal 2 prosthesis, Integra) carried out by a single surgeon. Pre-operative mobility was determined by range of motion and compared to post- operative range of motion. Post-operative function was determined using the DASH (The disabilities of the arm, shoulder and hand) score and the PRWE (patient-rated wrist evaluation and grip strength) score. Grip force between the operated and non- operated hand were compared postoperatively. Three patients experienced complications. Range of motion improved post-operatively, although not significantly, due to an increase in palmar flexion. The mean DASH score was 20% and the mean total PRWE was 54%. This study shows that total wrist arthroplasty, using the Universal 2 wrist prosthesis, gives reasonable results (survival rate 84%) by decreasing pain while preserving range of motion in patients with degenerative osteoarthritis of the wrist after 5 years. However the 10-year survival rate decreases steeply to an unsatisfying 35%.

[Suspected traumatic posterior shoulder luxation]. / Een vermeende traumatische posterieure schouderluxatie.

BACKGROUND An obstetric brachial plexus lesion arises during childbirth as a consequence of excessive lateral traction of the neonate's head during shoulder dystocia. A small number of patients do not experience spontaneous recovery and secondary glenohumeral deformities can arise due to rotator cuff imbalance. CASE DESCRIPTION A 34-year-old man of Syrian descent with a history of a conservatively treated right-sided obstetric brachial plexus lesion went to the accident and emergency department (A and E) with acute pain in the right shoulder. Additional X-ray diagnostics suggested a posterior shoulder luxation, but attempts to relocate the glenohumeral joint in A and E failed. An additional CT scan of the shoulders revealed a severe right-sided dysplasia of the glenohumeral joint, with severe retroversion and posterior luxation of a rotated humeral head. After 3 weeks of relative rest through use of a sling and pain relief with an NSAID the pain had diminished and the patient had resumed his daily activities. CONCLUSION Posterior shoulder luxation can occur as a complication of obstetric brachial plexus lesion. Closed reduction is not of any use in these cases. The expertise of a specialized multidisciplinary team is indispensable for providing a patient with obstetric brachial plexus lesion with the best advice on treatment.

Souter-Strathclyde total elbow arthroplasty: medium-term results.

The Souter-Strathclyde unconstrained elbow prosthesis was prospectively studied in 36 patients (45 prostheses) with rheumatoid arthritis (Larsen grade 4 and grade 5). The mean age of the patients at the time of operation was 63 years (range: 39 to 75 years). Eight patients (9 prostheses) died within five years of implantation, from causes unrelated to the elbow arthroplasty. One patient was lost to follow-up, leaving 27 patients (35 prostheses) for review. The mean length of follow-up was 98 months (range: 60 to 174 months). At 8.2 years follow-up, the prosthesis showed a probability of survival of 76% (SD 9%) with revision of the humeral component as an end point; the percentage dropped to 67% (SD 9%) when radiographic loosening was taken as an end-point. Survival of the ulnar component was 98%. Loosening of the humeral component seems to be related to both the short humeral stem and a persistent extension deficit.