Filho, Arnaldo Amado Ferreira MD; Neto, Arnaldo Amado Ferreira MD; Benegas, Eduardo MD; Neto, Raul Bolliger MD; Malavolta, Eduardo Angeli MD; Prada, Flavia Santis MD; Gracitelli, Mauro Em`lio Conforto MDı; Assunção, Jorge Henrique MD
Obstetric palsy (OP) occurs by traction injury of the brachial plexus secondary to difficult labor (as in breech extraction using forceps) and shoulder dystocia, in above average weight infants.1 This condition has an incidence of 2.5/1000 live births.1
OP is classified in neurapraxia, axonotmesis, and neurotmesis, according to the type of nerve injury or according to the nerve roots involved, in high palsy (Erb-Duchenne palsy—fifth and sixth cervical roots), low palsy (Klumpke palsy—eighth cervical and first thoracic nerve roots), and total palsy (involvement of the entire brachial plexus).1–3
Although full motor recovery can occur in many patients, the persistence of the nerve injury causes deformities not only on the shoulder, but also on other segments of the upper limb (in Erb-Duchenne palsy there is also impairment of elbow flexion and forearm supination), as a result of secondary muscle imbalance. In children with Erb-Duchenne palsy one of the most common deformities is the internal rotation and adduction of the shoulder resulting from the predominance of the internal rotator and adductor muscles of the shoulder in relation to the external rotator and abductor muscles, which is mainly caused by suprascapular nerve injury.4,5 This imbalance leads to a poor positioning of the humeral head in relation to the glenoid, causing both humeral head retroversion and glenoid retroversion, and hypoplasia. Glenoid lesions are a consequence of the eccentric compression exerted on it by the internally rotated humeral head resting on its posterior third and posterior edge. The persistence of this abnormal position over a short period of time progresses to posterior glenohumeral subluxation or even dislocation.6
The treatment of humeral head and glenoid lesions in OP, especially posterior subluxation and dislocation, is still a challenge. Once irreversible nerve injury sequelae are diagnosed, an early surgical treatment is mandatory to prevent osteoarticular injuries or to minimize those already established.
The first step in treatment is the classical Sever procedure that is the correction of the deformity established. This is performed by tendon lengthening (subscapularis and pectoralis major) and anterior joint capsulotomy. The goal is to undo the chronic unreduced internal rotation and adduction of the humerus read (imbalance muscle action), thereby preventing the progression of osteoarticular changes. Another procedure used is the transfer of the tendon of the latissimus dorsi and teres major to replace the external rotators weakness. The goal of this treatment is to improve the function of the patient through balance between internal and external rotators avoiding the progression of osteoarticular changes. However, the uncorrected retroversion of the humeral head may persist even after correction of contracted soft tissues and tendon transfer. Therefore, for the humeral head to be centered in the glenoid, the arm must be kept in external rotation brace after the surgery. After removal of the immobilization, recurrence of dislocation or subluxation may occur because of humeral head and glenoid deformity. Waters and Bae.7 showed that glenoid changes show little improvement with muscle and tendon elongation, even when associated with muscle transfers.
The vast experience in the treatment of hip dysplasia has shown that the early presence of the femoral head reduced and centered in the acetabulum, either achieved by conservative techniques or by surgical procedures8–10 is a paramount factor for a normal joint modeling. It is important to note that an early treatment is of vital importance, considering the greater and faster modeling capability of the hip during the first 12 to 24 months of life.
The same concepts can be applied for the treatment of humeral head and glenoid deformities in OP, and several investigators observed a decrease in glenoid retroversion when the humeral head is reduced and centered.11
Treatment using the technique described above is novel because it proposes a humeral head centering osteotomy in neutral position (internal osteotomy of the humerus) to correct its retroversion. The humeral head well positioned in relation to the glenoid will provide the remodeling of the shoulder joint. After the remodeling process is achieved with a normal or nearly normal joint, other procedures can be performed, such as tendon transfer, with better expectation of shoulder function. This benefit has been well described in the treatment of dysplasia of the hip, and it is noteworthy that this procedure should be performed as early as possible, in children around 1 year old, whose osteoarticular remodeling process is potentially great.
Owing to the large number of older children who seek our service for a first consultation and already present a posterior subluxation and even dislocation of the humeral head, the indication for centering osteotomy is now extended to them, even though we are aware of their limited ability to remodeling.
To obtain and maintain joint congruity of the glenohumeral joint, we indicate humeral head centering osteotomy for childrem with Erb-Duchenne type of OP (adduction and internal rotation contractures, with posterior subluxation or dislocation of the shoulder), and with little changes in the glenoid, confirmed by computed tomographic scanning (glenoid retroversion without a false glenoid).
We indicate this procedure for children from 1 year of age on, and extend it to older children with the same deformties described above, but keeping in mind the greater potential for osteoarticular remodeling in younger children.
We do not indicate this procedure in children with marked humeral head and glenoid deformities (such as glenoid dysplasia and false glenoid).
The patient is placed in modified beach-chair position, under general anesthesia, and a deltopectoral approach is performed. The dissection is performed in planes, and an elongation of the pectoralis major with z-lengthening manner is done. The subscapularis tendon is separated from the joint capsule, and its tenotomy is performed. The joint capsule is opened transversely approximately 0.5 cm away from the lesser tuberosity. This flap of capsule will be necessary to suture and for the lengthening of the subscapularis tendon. The shoulder joint is inspected allowing direct visualization of the glenoid and the degree of posterior displacement of the humeral head. (Figs. 1A, B, 2)
The reduction of the humeral head is obtained by external rotation of the arm; the humeral head is centered and fixed to the glenoid with a fine Kirschner wire (Figs. 3, 4)
A transverse osteotomy of the humerus diaphisys, between the insertions of the deltoid and the pectoralis major muscles is performed. The distal part of the humerus is internally rotated, in relation to humeral head earlier centered and fixed in the glenoid, so as to leave it in a neutral position (Fig. 4).
The proximal and distal humerus is fixed with a plate and screws (minimum of 4 and maximum of 8 cortical screws) (Fig. 5).
The Kirschner wire that held the joint reduction is removed, and the joint stability is tested (Fig. 6).
The subscapularis tendon is sutured to the flap of capsule reaching the lengthening required for each case. The pectoralis major is sutured as well.
The upper limb is immobilized in a thoracobrachial plaster cast with 45 degrees abduction and neutral rotation of the arm.
The immobilization is maintained for 4 weeks and the radiographic control of consolidation is performed weekly. After radiographic consolidation, rehabilitation is initiated.
The rehabilitation protocol involves passive and active assisted exercises to gain range of motion, mainly of external rotation and elevation.
The incidence, severity, and extent of OP have been minimized by better obstetric care and prenatal care (early identification of fetuses of great weight, early induction of labor, in utero ultrasonographic detection of changes in fetal position, and the choice of cesarean section for high risk newborns.12
Indications for the treatment of OP vary according to the phase of the disease. The use of orthoses along with rehabilitation is indicated in the initial phase (newborns). Brachial plexus exploration is indicated when there is no recovery of biceps muscle function after up to 6 months. Tendon elongation (Sever procedure) and tendon transfers (L'Episcopo) may be the first option when there is adduction and internal rotation of the shoulder still with no bone deformities, in patients who do not respond well to conservative methods.
In our country, we have observed that the natural history of osteoarticular sequelae of OP has been influenced by 2 factors: the use of conservative treatment methods (physiotherapy, orthoses, etc.) for exceedingly long periods owing to a traditional belief in their efficacy and a delay in surgical indications, either because parents fear to have their children undergo surgery, or because the professionals who intend to treat them are inexperienced.
As a result, the best time to avoid or at least minimize the severe osteoarticular changes caused by muscle injuries, sequelae of the peripheral nerve injuries in OP, is lost. However, in recent years, we have sought to change this situation by performing the treatment described in this study.
The prolongation of the contracture causes a posterior dislocation of the humeral head. In the initial stages, there are early changes in the proximal humeral epiphysis that evolve quickly to osteoarticular deformities (retroversion of the humerus and glenoid retroversion), followed by posterior subluxation/dislocation and, over time, by a complete loss of the articular surface, with serious consequences to shoulder function.13
Tendon transfers and tendon elongation (Sever and L'Episcopo procedures) significantly improves the overall function of the shoulder, but have a modest influence on the retroversion of the glenoid cavity, on deformity and subluxation of the humeral head, and on the evolution of glenohumeral dimorphism.7 We also do Sever and L'Episcopo procedures (associated or not) in cases where there is an adduction and internal contraction of the shoulder, but without dislocation or subluxation of the humeral head.
There is a current trend for more aggressive treatment in the early stages, including arthroscopic procedures for subscapularis tendon release, as described by Pedowitz et al14 to improve the prognosis in relation to the formation of the glenoid cavity.
In some cases, the external derotation osteotomy aims at improving the positioning of the upper limb and is recommended as salvage surgery in older children (from 10 to 14 y of age) with major deformities in the glenoid and the humeral head.15 It significantly improves the positioning of the arm, however, it does not improve the shoulder mobility.3,13,16,17 Hoffer18 indicates external derotation osteotomy for children older than 7 years, because he consider the reduction of the humeral head to be impossible to be achieved.
Other salvage procedures are reported in the literature such as arthrodesis.19 These surgeries are indicated in later stages, without the purpose of joint reconstruction.
The humeral head centering osteotomy described in this study has the same concept to what is done in the treatment of hip dysplasia of the newborn, and aims at maintaining the humeral head in the glenoid cavity. Mutual stimulation of it can form a congruent and functionally efficient joint, mainly when it is indicated in young children, whose osteoarticular remodeling process is potentially great. Although it is often impossible to restore the articular morphology owing to the deformities present in older children better shoulder function can be achieved.
This procedure should be used in younger children (from 1 year old), with potential for bone growth, when there are still no marked bone deformities of the glenohumeral joint (humeral head retrovertion and moderates glenoid retrovertion). We believe, in these cases, the soft-tissue elongation surgeries (associated or not with tendons transfers—L'Episcopo procedure) are not sufficient to maintain the reduction and centering of the humeral head because of osteoarticular deformities.
We perform and consider the internal derotatory osteotomy to be sufficient without changing the humeral head inclination angle. Kirkos and Papadopoulos20 recommend the fixation in valgus of the external derotatory osteotomy of the humerus for better results in the abduction. In our series, some cases in which the plate was fixed with only 2 cortical screws in each fragment, we observed a varus deformity at the osteotomy site, which, however, was fully corrected by bone remodeling as the patient grew up. The aforementioned deformity was not repeated when the fixation was done with 4 screws.
In all patients, centering osteotomy was performed simultaneously with subscapularis and pectoralis major tendon elongation (Sever procedure). This correction of tendon contraction is necessary to allow the humeral head reduction and keeping it in neutral position after the internal osteotomy.3
Although the purpose of this study was only to justify and describe the technique of humeral head centering in the treatment of shoulder osteoarticular sequelae in OP, we anticipate that the final results of 40 operated cases will be presented in the near future.
Preliminarily, we have the final results of 10 patients with mean follow-up of 3 years with improvement of global shoulder function. Their Mallet score ranged from 12.4 preoperatively to 16.4 postoperatively. On computed tomographic scan examination, the mean glenoid retroversion improved from 20.2 degrees preoperatively to 12.5 degrees postoperatively, and the mean posterior head subluxation improved from 7% to 35.9% (Figs. 7, 8).
In conclusion, humeral head centering osteotomy in the treatment of glenohumeral joint osteoarticular sequelae in OP has pathophysiologic basis and should be performed early and simultaneously with the correction of soft tissue injuries that cause adduction and internal rotation deformities of the shoulder.
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