Disclosure Long-term Outcomes of External Rotation The authors have - - PowerPoint PPT Presentation

5/8/2014 1

Long-term Outcomes of External Rotation Tendon Transfers in Children with Brachial Plexus Birth Palsy

Lindsey C. Sheffler, MD, MAS Frederick Molitor, PhD Michelle A. James, MD

Disclosure

The authors have no disclosures to report

Brachial plexus birth palsy (BPBP)

• The incidence of brachial plexus birth palsy is 0.4-4.6 per 1000

live births

• Complete recovery in 60%
• Long-term sequelae
• Elbow flexion contracture
• Weakness of wrist extension
• Impaired hand function
• Internal rotation contracture of

the shoulder

External Rotation Tendon Transfer (ERTT)

• Sever, L’Episcopo, Hoffer
• Latissimus dorsi and teres major cut from their insertion on

anteromedial humerus and transferred to the rotator cuff

• Small case series with short

term follow-up demonstrate favorable results

• Long-term outcomes have

yet to be established

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Specific Aims

1) To determine if ERTT improves ER and abduction initially (within the first post-operative year) 2) To determine if gains in ER and/or abduction are maintained over time 3) To evaluate predictive factors of outcomes (age at the time of surgery, gender, subscapularis and/or pectoralis release)

Study Design

• Prospective, longitudinal case series
• 139 children undergoing ERTT (one surgeon) at Shriners Hospital

between 1994 and 2007

• 116 included in analysis (>2 yr f/u)
• Shoulder ER and abduction were measured pre-op, post-op and

yearly Statistical Analysis (SPSS)

• Paired t-test
• Linear mixed modeling
• Significance criterion p<0.05

Study Design

Table 1: Demographic Characteristics Variable N (%) Total 116 Median age at surgery (yr) 5.3 (2-13) Median follow-up (yr) 7 (2-13) Gender Male 49 (42) Female 67 (58) Narakas Classification I (C5-6) 63 (54) II (C5-7) 33 (28) III (global palsy) 21 (18) Pectoralis release 84 (72) Subscapularis release 17 (15)

Results

(Specific Aim #1 –Initial gains)

• Initial post-operative

abduction improved by 28 degrees (p<0.001)

• Initial post-operative ER

improved by 41 degrees (p<0.001)

• Improvements were

statistically significant whether or not the pectoralis and/or the subscapularis were released

Pre-op ROM (deg) Post-op ROM (deg) P-value

Abduction

All subjects 97.1 125.3 <0.001 Pectoralis release 99.2 126.8 <0.001 Subscapularis release 96.3 127.5 <0.001 Both released 95.6 120.9 <0.01 No releases 95 122 <0.001

ER

All subjects 13.6 54.8 <0.001 Pectoralis release 8.0 49.9 <0.001 Subscapularis release 13.8 56.3 <0.001 Both released 13.5 54.3 <0.001 No releases 30.2 67.1 <0.001

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Results

(Specific Aim #2 –Gains over time)

• Gains in ROM declined over time but was statistically

significant (p<0.05) through 8 years of follow-up

• 10

10 20 30 40 50

Change in ROM (degrees)

Time (years)

ER Abduction

95 116 103 62 55 56 48 43 30 27 17 12 9

Results

(Specific Aim #3 –predictive factors)

• There were no statistically significant difference in
• utcomes for patients who underwent pectoralis and/or

subscapularis releases

• Increased age at the time of surgery was predictive of

decreased gains in abduction and ER (correlation coefficient -0.22)

• Gender and Narakas classification were not predictive of
• utcome

Conclusions

• Largest case series to date to evaluate long-term outcomes of ERTT
• Aim #1: ERTT improves both abduction and ER in the initial post-
• perative period
• Aim #2: Gains in abduction and ER decrease over time but remain

statistically significant through 8 years of follow-up

• Aim #3: Additional releases are not predictive of outcomes.

Increased age at the time of surgery is predictive of decreased gains in ER and abduction

• New surgical techniques may improve initial and long-term
• utcomes of children with BPBP and an internal rotation shoulder

contracture

Acknowledgements

• Shriners Hospital for Children, Northern California
• Michelle A. James, MD
• Frederick Molitor, PhD
• Anita Bagley, PhD
• Medical Records Department
• Occupational Therapy Department
• The patients and their families