Outcomes of secondary shoulder reconstruction in obstetrical brachial plexus palsy.

Abstract

In this study, children with obstetrical brachial plexus palsy who underwent various secondary reconstructions for shoulder stability and function were studied. The outcomes were analyzed in relation to the type of injury, the timing of surgery, and the type of secondary reconstruction. Palliative surgery was performed in 67 patients (68 extremities) for improvement of shoulder function. These patients received a combination of soft-tissue releases and/or tendon transfers, pedicled and/or free muscle transfers, and humeral osteotomies. A total of 197 secondary procedures were performed with a mean follow-up of 7.5 years (range, 12 months to 22 years). The average shoulder abduction increased from 52 +/- 31 degrees preoperatively to 121 +/- 36 degrees postoperatively (average gain, 69 degrees) (p < 0.001). The average active external rotation with the arm at the side increased from -21 +/- 17 degrees preoperatively to 61 +/- 23 degrees postoperatively (average gain, 82 degrees) (p < 0.001). The mean aggregate modified Mallet score improved from 13.4 to 20.7 (p < 0.001). Transfers involving rerouting of latissimus dorsi and teres major tendons, combined with appropriate extraarticular musculotendinous lengthening, significantly improved global shoulder function. The results were better in children who had surgery between 18 months and 4 years of age. The concurrent transfer of the trapezius with other pedicle muscles, such as the latissimus dorsi or pectoralis major, has given significantly better results than the transfer of the trapezius alone and/or free muscle transfers for the treatment of paralytic shoulder sequelae.