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Arthroscopic Treatment of Internal Rotation Contracture and Glenohumeral Dysplasia in Brachial Plexus Birth Palsy
Scott Kozin, MD1; Joshua M. Abzug, MD2; Dan Zlotolow, MD1; Alexis Williams, BS1; Gerald Williams, MD3
1Shriners Hospital for Children Philadelphia, Philadelphia, PA; 2Department of Orthopaedic Surgery, University of Maryland, Baltimore, MD; 3Department of Orthopaedic Surgery, Thomas Jefferson University Hospital - Rothman Institute, Philadelphia, PA

Introduction: The purpose of this study was to report on the one and three year radiographic and clinical outcomes of children who underwent arthroscopic anterior release, with or without tendon transfer, to maintain shoulder joint alignment in children with brachial plexus birth palsy. 

Methods: Forty-four patients who underwent arthroscopic release, with or without tendon transfers, for glenohumeral dysplasia in children with brachial plexus birth palsies were prospectively followed for a minimum of three years.  Clinical data collected included active abduction, external rotation, and Mallet scores.  Magnetic resonance imaging (MRI) data collected included the amount of retroversion and the percentage of the humeral head anterior to the middle of the glenoid fossa (PHHA).  As per standard of care, patients were seen All data points were collected pre-operatively, and at one and three years post-operatively.  Tests of fixed effects were performed to assess statistical significance between data points at different times.

Results: Retroversion improved from -34° pre-operatively to -19° at one year and -14° at three years (p<0.001).  Similarly, PHHA improved from 19% pre-operatively to 33% at one year and was maintained at 36% at three years.   Passive external rotation improved from -26° preoperatively to 48°at one year, and was maintained at 49° at three years .Likewise active abduction improved from 112° preoperatively to 130° at one year and 132° at three years (p<0.01).  Individual Mallet components were significantly improved (p<0.001) for external rotation, hand to neck, and hand to mouth when comparing preoperative scores to those at one and three years.  No statistical improvement was noted in Mallet abduction or hand to spine (p>0.05).  All improvements were maintained between one and three years but no significant improvement was noted over this time.

Discussion and Conclusion: Arthroscopic anterior release, with or without tendon transfers, results in improved glenohumeral alignment and joint remodeling. The positive post-operative outcomes found at one year were successfully maintained at 3 year follow-up. We believe that prompt recognition, timely diagnosis, and early surgical intervention results in a better aligned joint and superior function.  Arthroscopic release is easier in the young child with less deformity compared to an older shoulder with severe joint subluxation and glenoid retroversion. In addition, less subscapularis release is required to obtain joint reduction, which preserves midline function.

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