Brachial Plexus Birth Palsy: A Comparison of Surgical Outcomes
Jersey Burns, BA; Linda Chao, MD; Zhongyu Li, MD, PhD; L. Andrew Koman, MD
Wake Forest School of Medicine, Winston-Salem, NC
Introduction: Brachial plexus birth palsy (BPBP) is a condition caused by mechanical stretch injuries during the birthing process. Shoulder joint deformity and/or contracture are common even after full neurological recovery. Rerouting the latissimus dorsi tendon to the greater tuberosity (Sever-L'Episcopo procedure) or directly to the rotator cuff (Hoffer procedure) has been widely used for shoulder reconstruction in BPBP patients. The objective of this study was to compare the clinical outcomes of BPBP patients who had undergone either the modified Hoffer or Sever-L'Episcopo tendon transfer procedures to test the hypothesis that both procedures are effective in improving shoulder function.
Materials & Methods: This is a retrospective study of a total of 42 pediatric patients diagnosed with brachial plexus birth palsy who underwent either the modified Hoffer or modified Sever-L'Episcopo tendon transfer surgery. Information was collected on their birth history, surgical history, and preoperative and postoperative range of motion and functional status. Mallet scores were used when available. Information on functional status was obtained using office visit summaries and physical therapy session reports.
Results: The average age at the time of surgery was 4.2 years and average time of follow up after surgery was 1.3 years for the Hoffer surgery and 3.3 years for the Sever-L'Episcopo surgery. Of the 19 patients who underwent the Hoffer procedure, the average improvements in active shoulder range of motion were 31.1±6.8° in external rotation, 43.6±9.3° in forward flexion, and 40±10.6° in abduction. Of the 23 patients who underwent the Sever-L'Episcopo procedure, the average improvements were 29.2±5.2° in external rotation, 29.7±10.4° in forward flexion, and 23.8±9.9° in abduction. Two patients who initially had Sever-L'Episcopo procedures underwent a revision Hoffer procedure for increased shoulder adduction contracture with pain at a later age.
Conclusions: Both the modified Hoffer and Sever-L'Episcopo surgeries are effective in improving shoulder range of motion in children with brachial plexus birth palsy. Children appear to gain more shoulder range motion after the Hoffer procedure than after the Sever-L'Episcopo procedure. However, the difference was not statistically significant. Both surgeries resulted in improved shoulder function and increased arm use for daily activities such as eating and dressing.
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