Comparing the Surgical Outcomes of Modified Quad and Triangle Tilt Surgeries to other Procedures Performed in Obstetric Brachial Plexus Injury

Abstract

<p> <b><span>Purpose:</span></b><span> To compare results from our<b> </b>surgical treatment experiences in children with obstetric brachial plexus injuries (OBPI), to those who have had other surgical treatments. <b>Methods: </b>We conducted a retrospective study in our medical records consisting of two groups of OBPI patients. <b>Group 1</b>: 26 OBPI children (16 girls and 10 boys), age range be</span><span>tween 2.0 and 12.0 (mean age 6.9), who have undergone surgical treatments at other institutions between 2005 and 2010. <b>Group 2</b>: 45 OBPI children (20 boys and 25 girls), age between 0.7 and 12.9 (mean age 3.7), who have had modified Quad and triangle tilt surgical treatment between 2005 and 2010 at our institution. In both groups Mean modi</span><span>fied Mallet scores and radiological scores were measured and compared. All measurements were made at least one year post surgery in both groups. <b>Results:</b> Post-operative mean modified Mallet score was 11.8 </span><span style="font-family:Symbol;">±</span><span> 2.4 in group 1 patients, whereas post-mean modified Mallet score was 20 </span><span style="font-family:Symbol;">±</span><span> 2.7</span><span> </span><span>(P <</span><span> </span><span>0.0001) following modified Quad and triangle tilt surgeries in group 2 patients. Further, their radiological scores such as posterior subluxation, and glenoid version were 13.4 </span><span style="font-family:Symbol;">±</span><span> 21.3 and <span style="white-space:nowrap;">﹣</span>30.2 </span><span style="font-family:Symbol;">±</span><span> 19.1 in group 1, whereas 32.1 </span><span style="font-family:Symbol;">±</span><span>13.5 (P</span><span> </span><span><</span><span> </span><span>0.0004), and <span style="white-space:nowrap;">﹣</span>16.3 </span><span style="font-family:Symbol;">±</span><span> 11.5 (P</span><span> </span><span><</span><span> </span><span>0.008) in group 2 patients, when compared to normal values of 50, and 0 respectively.</span><b><span style="font-size:12.0pt;"> </span><span>Conclusion:</span></b><span> Patients who have had mod Quad and triangle tilt for OBPI obtained significantly better functional outcomes in modified total Mallet score as well as in radiological scores, when compared to those OBPI children, who underwent other procedures such as posterior glenohumeral cap</span><span>sulorrhaphy, biceps tendon lengthening, humeral osteotomy, anterior capsule release, nerve transfer/graft, botox and muscle/tendon transfer and release.</span><span></span> </p

The triangle tilt procedure for treatment of secondary shoulder deformities in obstetric brachial plexus injury

“…However, our results also indicate that improvement in clinical functioning can still be achieved in older children. Other alternative traditional secondary procedures exist [12,18] . Open or arthroscopic anterior shoulder release may improve certain shoulder functions and/or glenoid remodeling [13,15,16,17] but results in significantly reduced internal rotation, a deformity equal to that being addressed [3,4,12] .…”

“…Other alternative traditional secondary procedures exist [12,18] . Open or arthroscopic anterior shoulder release may improve certain shoulder functions and/or glenoid remodeling [13,15,16,17] but results in significantly reduced internal rotation, a deformity equal to that being addressed [3,4,12] . Muscle/tendon transfer with or without open reduction works only on younger patients with a normal to mildly deformed GH-joint, while leaving patients with severe GH-deformity (including complete dislocation) untreatable [12,14,17] .…”

“…Other deformities include flattening of the glenoid fossa and hooking of the acromion process which impinges on the humeral head [2,5,[7][8][9][10] . Management of significant shoulder deformities in OBPI includes soft tissue procedures and/or bony procedures [7,11,12] . Soft tissue operations include anterior capsule release [open or arthroscopic], tendon transfers, nerve transfers, axillary nerve decompression, glenohumeral posterior capsulorrhaphy and biceps tendon lengthening [13][14][15][16][17] .…”

“…Soft tissue operations include anterior capsule release [open or arthroscopic], tendon transfers, nerve transfers, axillary nerve decompression, glenohumeral posterior capsulorrhaphy and biceps tendon lengthening [13][14][15][16][17] . These surgical procedures may lead to only marginal clinical improvement [with better shoulder abduction and flexion, and improved resting position of the arm], but, no improvement in deformity, because these procedures do not address or attempt to correct the SHEAR deformity [3,4,6,12,19,20] . Bony operations include the traditional external rotational humeral osteotomy and the more recent, triangle tilt procedure [11,12] .…”

“…These surgical procedures may lead to only marginal clinical improvement [with better shoulder abduction and flexion, and improved resting position of the arm], but, no improvement in deformity, because these procedures do not address or attempt to correct the SHEAR deformity [3,4,6,12,19,20] . Bony operations include the traditional external rotational humeral osteotomy and the more recent, triangle tilt procedure [11,12] . Derotational osteotomy of the humerus may improve the cosmesis of the resting position of the arm and shoulder external rotation to some degree [18,19], but it is associated with a common recurrence of MRC due to uncorrected scapular deformity.…”