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John A. I. Grossman - One of the best experts on this subject based on the ideXlab platform.

  • result of modified outerbridge kashiwagi procedure for elbow flexion contractures in brachial plexus Birth Injury
    Journal of Hand Surgery (European Volume), 2019
    Co-Authors: Herbert Valencia, Andrew E. Price, John A. I. Grossman, Harvey Chim
    Abstract:

    We report the results of ten consecutive patients who had correction of an elbow flexion contracture of greater than 30° in brachial plexus Birth Injury using a modified Outerbridge-Kashiwagi procedure. All patients had minimum 23-month follow-up. Pre- and post-operative elbow range of motion and DASH scores were recorded in all patients. The operative technique for the procedure and post-operative course is discussed. Surgery was supplemented by botulinum toxin injection into the biceps brachii muscle in most cases. The average age at surgery was 14 years 10 months. The initial plexus lesion was global in eight patients and upper in two. Pre-operative flexion contractures averaged 51° (range 35 to 60) and post-operative averaged 21° (range 15 to 30). Of these patients, one had no change in active flexion, four had loss of active flexion, and five had gain of active flexion. All ten patients were satisfied with their results and stated that they would recommend the procedure to other patients. Level of evidence: IV.

  • Subscapularis Slide Correction of the Shoulder Internal Rotation Contracture After Brachial Plexus Birth Injury: Technique and Outcomes
    2016
    Co-Authors: Igor Immerman, Herbert Valencia, Patricia W Ditaranto, Edward M. Delsole, Sergio Glait, Andrew E. Price, John A. I. Grossman
    Abstract:

    Abstract: Internal rotation contracture is the most common shoulder deformity in patients with brachial plexus Birth Injury. The purpose of this investigation is to describe the indications, technique, and results of the subscapularis slide procedure. The technique involves the release of the subscapularis muscle origin off the scapula, with pres-ervation of anterior shoulder structures. A standard postoperative protocol is used in all patients and includes a modified shoulder spica with the shoulder held in 60 degrees of external rotation and 30 degrees of abduction, aggressive occupational and physical therapy, and sub-sequent shoulder manipulation under anesthesia with botulinum toxin injections as needed. Seventy-one patients at 2 institutions treated with subscapularis slide between 1997 and 2010, with minimum follow-up of 39.2 months, were identified. Patients were divided into 5 groups based on the index procedure performed: subscapularis slide alone (group 1); subscapularis slide with a simultaneous microsurgical reconstruction (group 2); primary microsurgical brachial plexus reconstruction followed later by a subscapularis slide (group 3); pri-mary microsurgical brachial plexus reconstruction followed later by a subscapularis slide combined with tendon transfers for shoulder external rotation (group 4); and subscapularis slide with simultaneous tendon transfers, with no prior brachial plexus surgery (group 5). Full passive external rotation equivalent to the contralateral side was ach-ieved in the operating room in all cases. No cases resulted in anterior instability or internal rotation deficit. Internal rotation contracture of the shoulder after brachial plexus Birth Injury can be effectively managed with the technique of subscapularis slide. Key Words: brachial plexus, shoulder contracture, subscapularis slid

  • hand function in children with an upper brachial plexus Birth Injury results of the nine hole peg test
    Developmental Medicine & Child Neurology, 2012
    Co-Authors: Igor Immerman, Patricia W Ditaranto, John A. I. Grossman, Daniel T Alfonso, Lorna E Ramos, Leslie Grossman, Israel Alfonso
    Abstract:

    Aim  The aim of this study was to evaluate hand function in children with Erb upper brachial plexus palsy. Method  Hand function was evaluated in 25 children (eight males; 17 females) with a diagnosed upper (C5/C6) brachial plexus Birth Injury. Of these children, 22 had undergone primary nerve reconstruction and 13 of the 25 had undergone simultaneous and/or secondary shoulder procedures. Hand function was evaluated using the nine-hole peg test at a mean age of 9 years (SD 2y 2mo), and compared with the contralateral, uninvolved hand. Results were compared with age- and sex-matched population norms, and correlated with shoulder outcomes using the Gilbert and Miami scores. Results  Although shoulder function was graded as good or excellent in 24 of 25 children, hand function as measured by the nine-hole peg test was significantly altered in the involved hand in 80% (p=0.008). On average the participants took 18.8% longer to complete the task with the involved hand; this was significantly different from the expected difference of 7.2% (p=0.008). Interpretation  Hand function is impaired in individuals with upper brachial plexus Birth Injury. These results suggest that from the initiation of treatment in this population, attention should be paid to recognizing and focusing therapy on subtle limitations of hand function.

  • sensory restoration by lateral antebrachial cutaneous to ulnar nerve transfer in children with global brachial plexus injuries
    Hand, 2010
    Co-Authors: David E Ruchelsman, Herbert Valencia, Andrew E. Price, John A. I. Grossman, Lorna E Ramos
    Abstract:

    Selective peripheral nerve transfers represent an emerging reconstructive strategy in the management of both pediatric and adult brachial plexus and peripheral nerve injuries. Transfer of the lateral antebrachial cutaneous nerve of the forearm into the distal ulnar nerve is a useful means to restore sensibility to the ulnar side of the hand when indicated. This technique is particularly valuable in the management of global brachial plexus Birth injuries in children for which its application has not been previously reported. Four children ages 4 to 9 years who sustained brachial plexus Birth Injury with persistent absent sensibility on the unlar aspect of the hand underwent transfer of the lateral antebrachial cutaneous nerve to the distal ulnar nerve. In three patients, a direct transfer with a distal end-to-side repair through a deep longitudinal neurotomy was performed. In a single patient, an interposition nerve graft was required. Restoration of sensibility was evaluated by the “wrinkle test.”

  • diagnostic performance of mri and mr myelography in infants with a brachial plexus Birth Injury
    Pediatric Radiology, 2006
    Co-Authors: Santiago L Medina, John A. I. Grossman, Ilker Yaylali, David Zurakowski, Jennifer Ruiz, Nolan Altman
    Abstract:

    Detailed evaluation of a brachial plexus Birth Injury is important for treatment planning. To determine the diagnostic performance of MRI and MR myelography in infants with a brachial plexus Birth Injury. Included in the study were 31 children with perinatal brachial plexus Injury who underwent surgical intervention. All patients had cervical and brachial plexus MRI. The standard of reference was the combination of intraoperative (1) surgical evaluation and (2) electrophysiological studies (motor evoked potentials, MEP, and somatosensory evoked potentials, SSEP), and (3) the evaluation of histopathological neuronal loss. MRI findings of cord lesion, pseudomeningocele, and post-traumatic neuroma were correlated with the standard of reference. Diagnostic performance characteristics including sensitivity and specificity were determined. From June 2001 to March 2004, 31 children (mean age 7.3 months, standard deviation 1.6 months, range 4.8–12.1 months; 19 male, 12 female) with a brachial plexus Birth Injury who underwent surgical intervention were enrolled. Sensitivity and specificity of an MRI finding of post-traumatic neuroma were 97% (30/31) and 100% (31/31), respectively, using the contralateral normal brachial plexus as the control. However, MRI could not determine the exact anatomic area (i.e. trunk or division) of the post-traumatic brachial plexus neuroma Injury. Sensitivity and specificity for an MRI finding of pseudomeningocele in determining exiting nerve Injury were 50% and 100%, respectively, using MEP, and 44% and 80%, respectively, using SSEP as the standard of reference. MRI in infants could not image well the exiting nerve roots to determine consistently the presence or absence of definite avulsion. In children younger than 18 months with brachial plexus Injury, the MRI finding of pseudomeningocele has a low sensitivity and a high specificity for nerve root avulsion. MRI and MR myelography cannot image well the exiting nerve roots to determine consistently the presence or absence of avulsion of nerve roots. The MRI finding of post-traumatic neuroma has a high sensitivity and specificity in determining the side of the brachial plexus Injury but cannot reveal the exact anatomic area (i.e. trunk or division) involved. The information obtained is, however, useful to the surgeon during intraoperative evaluation of spinal nerve integrity for reconstruction.

Howard M. Clarke - One of the best experts on this subject based on the ideXlab platform.

  • long term hand function outcomes of the surgical management of complete brachial plexus Birth Injury
    Journal of Hand Surgery (European Volume), 2021
    Co-Authors: Brad T Morrow, Isaac Harvey, Howard M. Clarke
    Abstract:

    Purpose Hand function outcomes of primary nerve reconstruction for total brachial plexus Birth Injury (BPBI) are confounded by nerve roots left in continuity, inclusion of secondary procedures, and no assessment of the ability to perform activities of daily living. The purpose of this study was to evaluate the long-term hand function outcomes in a cohort of patients with a complete BPBI who had no nerve root in continuity prior to primary nerve reconstruction targeting the lower trunk. Methods This single-center retrospective case series of complete BPBI included patients who underwent primary nerve reconstruction. The outcomes were assessed using the active movement scale (AMS) and brachial plexus outcome measure preoperatively and at the age of 4 and 8 years. Results Fifty patients with a complete BPBI, of whom 82% (41/50) had an avulsion of C8-T1, underwent primary nerve reconstruction at a mean age of 4.1 months. Compared with the preoperative AMS scores, a statistically significant increase of AMS scores was observed at 4 and 8 years of age for all movements except forearm pronation. Between 4 and 8 years of age, there was a statistically significant improvement of external rotation of the shoulder and elbow flexion as well as diminution of thumb flexion. In the brachial plexus outcome measure assessment, there were 83% (24/29) at 4 years and 81% (21/26) at 8 years who had sufficient functional movement to perform wrist, finger, and thumb activities. Conclusions Functional hand outcome was restored to sufficiently perform bimanual activity tasks in 81% (21/26) of patients with a complete BPBI at 8 years of age. This affirmed that primary nerve reconstruction reinnervating the lower trunk can result in a functional extremity. Type of study/level of evidence Therapeutic IV.

  • sensory outcome in children following microsurgery for brachial plexus Birth Injury
    Journal of Hand Surgery (European Volume), 2019
    Co-Authors: Kristen M. Davidge, Christine G Curtis, Howard M. Clarke
    Abstract:

    Purpose Studies are limited on sensory outcome in children with brachial plexus Birth Injury (BPBI). The purpose of this research was to evaluate the sensory function of the hand in children with BPBI who had microsurgical reconstruction of the brachial plexus. Methods The sensory thresholds of children with upper and total plexus Injury were evaluated with the Weinstein Enhanced Sensory Test and a test of stereognosis. Results A total of 63 children participated (aged 10.92 ± 3.29 years), 24 (38%) of whom had abnormal sensory thresholds in the affected hand. Only 4 children had loss of protective sensation or higher thresholds. These 4 measurements were all identified in the territory of the superficial branch of the radial nerve. Twelve children with upper plexus (43%) and 12 (34%) with total plexus Injury had sensory impairment in the affected hand. These proportions were not statistically different. Of all children evaluated, 18 (29%) had a lower stereognosis score in the affected hand compared with the unaffected hand. The proportions of children with impairment in stereognosis in the upper plexus group (n = 5; 18%) versus the total plexus group (n = 13; 37%) were not statistically different. Age at the time of assessment, sex, upper versus total plexus Injury, number of root avulsions, subjective report of altered sensation, and Faces Pain Scale–Revised score were not related to sensory impairment in the affected hand. Conclusions Sensory recovery in BPBI after microsurgical reconstruction in children with total plexus Injury who had reconstruction of the lower trunk had the potential to achieve sensory recovery similar to their upper plexus counterparts. A large proportion of children achieve normal sensory outcome, and those who had deficits had mild impairments. Type of study/level of evidence Prognostic IV.

  • prevalence and etiology of elbow flexion contractures in brachial plexus Birth Injury a scoping review
    Journal of pediatric rehabilitation medicine, 2019
    Co-Authors: Dorothy Kim, Sevan Hopyan, Karen Klar, Kristen M. Davidge, Howard M. Clarke, Alison Anthony, Gregory H Borschel, Virginia F Wright
    Abstract:

    PURPOSE To synthesize the evidence on the prevalence and etiology of elbow flexion contractures secondary to brachial plexus Birth Injury (BPBI). METHODS Using Arksey and O'Malley's scoping review framework, MEDLINE, EMBASE, PsycINFO, and CINAHL databases were searched, followed by a comprehensive grey literature search. Articles and abstracts of studies of all level of evidence on the prevalence, natural history, clinical presentation, etiology, and treatment of elbow flexion contractures in BPBI were included. RESULTS Of the 884 records found, 130 full text articles were reviewed, and 57 records were included. The median prevalence of elbow flexion contracture in BPBI was 48%. The magnitude of the contractures was between 5 and 90 degrees. Contractures > 30 degrees were found in 21% to 36% of children. With recent clinical and lab studies, there is stronger evidence that the contractures are largely due to the effects of denervation causing failure in the growth of the affected flexor muscles, while muscle imbalance, splint positioning, and postural preferences play a smaller role. CONCLUSION The etiology of elbow flexion contractures is multifaceted. The contribution of growth impairment in the affected muscles offers greater understanding as to why maintaining passive range of motion in these contractures can be difficult.

  • effectiveness of non surgical and surgical interventions for elbow flexion contractures in brachial plexus Birth Injury a systematic review
    Journal of pediatric rehabilitation medicine, 2019
    Co-Authors: Jennifer Zuccaro, Sevan Hopyan, Karen Klar, Kristen M. Davidge, Howard M. Clarke, Alison Anthony, Gregory H Borschel, Virginia F Wright
    Abstract:

    PURPOSE To conduct a systematic review of studies on non-surgical and surgical interventions for elbow flexion contractures secondary to brachial plexus Birth Injury (BPBI). METHODS MEDLINE, EMBASE, PsycINFO, and CINAHL databases were searched for randomized controlled trials, observational studies, and case series studies on treatment of elbow flexion contractures secondary to BPBI. Study quality was evaluated using the Effective Public Health Practice Project tool. RESULTS Of the 950 records found, 132 full text articles were reviewed, and 3 cohort studies and 8 case series were included. The overall methodological quality of included studies was weak. The weak quality evidence demonstrated that significant gains in elbow extension passive range of motion (ROM) can be achieved with serial casting (range: 15 to 34.5 degrees) or elbow release surgery (range: 28.4 to 30.0 degrees). At best, a reduction to an elbow contracture between -15.0 and -18.8 degrees (casting) and -8.0 and -43.6 (elbow release surgery) can be achieved. Insufficient outcomes on elbow flexion ROM and strength were found in both non-surgical and surgical studies. CONCLUSION The quality of evidence on the effectiveness of interventions for an elbow flexion contracture secondary to BPBI is weak. In the context of insufficient evidence on the risks of pursuing such interventions, it is prudent to attempt non-surgical interventions prior to surgery. LEVEL OF EVIDENCE III - systematic review of level IV studies.

  • Elbow flexion contractures in brachial plexus Birth Injury: function and appearance related factors.
    Disability and rehabilitation, 2018
    Co-Authors: Karen Klar, Sevan Hopyan, Erin Klar, Kristen M. Davidge, Howard M. Clarke
    Abstract:

    Purpose: The purpose of this study was to identify the functional and aesthetic factors associated with an elbow flexion contracture in children with a brachial plexus Birth Injury who identified their elbow flexion contracture as a problem. Materials and methods: A retrospective cross-sectional study of children with brachial plexus Birth Injury between 7 and 18 years was conducted to compare the characteristics of children who had treatment for an elbow flexion contracture with those who did not. Results: Fifty of the 200 children included in the study had treatment (one surgical release, 49 serial casting/splinting) for the elbow flexion contracture. Children who had treatment were an average 12.4 years of age, which was significantly older than those who did not have treatment. Elbow extension passive range of motion was an average -40.6° prior to treatment. Stepwise logistical regression model indicated that children who had treatment had greater severity in elbow contracture, higher Brachial Plexus Outcome Measure Activity scores, and lower Brachial Plexus Outcome Measure Self-Evaluation Appearance scores. Conclusions: In addition to severity of contracture and function, perceived appearance of the limb is important factor to evaluate in the management of elbow flexion contractures. Implications for rehabilitation Priority is often given to evaluate the functional implications of elbow flexion contractures in brachial plexus Birth Injury to determine recommendations for rehabilitation interventions such as serial casting and splinting. Findings in this study indicate that severity of contracture, upper extremity activity function, and perceived upper extremity appearance are important factors in the management of elbow contractures. In addition to upper extremity function, routine evaluation of perceived upper extremity appearance in children and adolescents is important in the management of elbow flexion contractures.

Yrjänä Nietosvaara - One of the best experts on this subject based on the ideXlab platform.

  • Clinical significance of cervical MRI in brachial plexus Birth Injury
    Taylor & Francis Group, 2019
    Co-Authors: Petra Grahn, Tiina Poyhia, Antti Sommarhem, Yrjänä Nietosvaara
    Abstract:

    Background and purpose — Patient selection for nerve surgery in brachial plexus Birth Injury (BPBI) is difficult. Decision to operate is mostly based on clinical findings. We assessed whether MRI improves patient selection. Patients and methods — 157 BPBI patients were enrolled for a prospective study during 2007–2015. BPBI was classified at Birth as global plexus Injury (GP) or upper plexus Injury (UP). The global plexus Injury was subdivided into flail upper extremity (FUE) and complete plexus involvement (CP). Patients were seen at set intervals. MRI was scheduled for patients that had either GP at 1 month of age or UP with no antigravity biceps function by 3 months of age. Type (total or partial avulsion, thinned root), number and location of root injuries and pseudomeningoceles (PMC) were registered. Position of humeral head (normal, subluxated, dislocated) and glenoid shape (normal, posteriorly rounded, pseudoglenoid) were recorded. Outcome was assessed at median 4.5 years (1.6–8.6) of age. Results — Cervical MRI was performed on 34/157 patients at median 3.9 months (0.3–14). Total root avulsions (n = 1–3) were detected on MRI in 12 patients (8 FUE, 4 CP). Reconstructive surgery was performed on 10/12 with total avulsions on MRI, and on all 10 with FUE at Birth. Sensitivity and specificity of MRI in detecting total root avulsions was 0.88 and 1 respectively. Posterior shoulder subluxation/dislocation was seen in 15/34 patients (3.2–7.7 months of age). Interpretation — Root avulsion(s) on MRI and flail upper extremity at Birth are both good indicators for nerve surgery in brachial plexus Birth Injury. Shoulder pathology develops very early in permanent BPBI

  • selective neurotization of the infraspinatus muscle in brachial plexus Birth Injury patients using the accessory nerve
    Plastic and Reconstructive Surgery, 2015
    Co-Authors: Antti Sommarhem, Petra M Grahn, Yrjänä Nietosvaara
    Abstract:

    : The authors present a new technique to improve active shoulder external rotation in patients with brachial plexus Birth Injury. Eight brachial plexus Birth Injury patients (aged 1.5 to 4.7 years) lacking active external rotation in adduction ( 45 degrees) underwent neurotization of the infraspinatus branch of the suprascapular nerve with the spinal accessory nerve. Active and passive range of shoulder motion was measured postoperatively (3, 6, and 12 months). Parents' satisfaction was assessed. At 1-year follow-up, mean improvement for active external rotation was 47 degrees (range, 20 to 85 degrees) in adduction and 49 degrees (range, 5 to 85 degrees) in abduction. All but one patient's parents were satisfied. Functionally significant active external rotation can be restored in brachial plexus Birth Injury by direct neurotization of the infraspinatus muscle.

  • brachial plexus Birth Injury us screening for glenohumeral joint instability
    Radiology, 2010
    Co-Authors: Tiina Poyhia, Patrick Willamo, Mikko O Kirjavainen, Jari Peltonen, Antti Lamminen, Yrjänä Nietosvaara
    Abstract:

    We recommend routine US of the glenohumeral joint at the ages of 3 and 6 months in infants with brachial plexus Birth Injury if symptoms persist.

  • muscle changes in brachial plexus Birth Injury with elbow flexion contracture an mri study
    Pediatric Radiology, 2007
    Co-Authors: Tiina Poyhia, Mikko O Kirjavainen, Jari Peltonen, Antti Lamminen, Mika P Koivikko, Yrjänä Nietosvaara
    Abstract:

    Background Muscle pathology of the arm and forearm in brachial plexus Birth Injury (BPBI) with elbow flexion contracture has not been evaluated with MRI.

  • muscle changes in brachial plexus Birth Injury with elbow flexion contracture an mri study
    Pediatric Radiology, 2007
    Co-Authors: Tiina Poyhia, Mikko O Kirjavainen, Jari Peltonen, Antti Lamminen, Mika P Koivikko, Yrjänä Nietosvaara
    Abstract:

    Muscle pathology of the arm and forearm in brachial plexus Birth Injury (BPBI) with elbow flexion contracture has not been evaluated with MRI. To determine whether limited range of motion of the elbow in BPBI is correlated with specific patterns of muscular pathology. For 15 BPBI patients, total active motion (TAM) of the elbow (extension–flexion) and the forearm (pronation–supination) were measured. MRI of the elbow joints and musculature allowed assessment of elbow congruency. Fatty infiltration and size reduction of the muscles were graded semiquantitatively. Mean TAM of the elbow was 113° (50°–140°) and that of the forearm 91° (10°–165°). The greater the size reduction of the brachioradialis muscle, the more diminished was elbow TAM. The more extensive the BPBI and muscle pathology of the pronator teres muscle, the more limited was the TAM of the forearm. Pathology of the supinator and brachialis muscles was evident in every patient. Extensive BPBI may result in marked limitation of TAM. Elbow flexion contracture seems to be caused mainly by brachialis muscle pathology. Prosupination of the forearm is better preserved when the pronator teres is not severely affected. MRI can reliably show the extent of muscle pathology in BPBI.

Katherine R Saul - One of the best experts on this subject based on the ideXlab platform.

  • location of brachial plexus Birth Injury affects functional outcomes in a rat model
    Journal of Orthopaedic Research, 2021
    Co-Authors: Raveena M Doshi, Nikhil N Dixit, Jacqueline H Cole, Emily B Fawcett, Monique Y Reid, Katherine R Saul
    Abstract:

    Brachial plexus Birth Injury (BPBI) results in shoulder and elbow paralysis with shoulder internal rotation and elbow flexion contracture as frequent sequelae. The purpose of this study was to develop a technique for measuring functional movement and examine the effect of brachial plexus Injury location (preganglionic, postganglionic) on functional movement outcomes in a rat model of BPBI, which we achieved through integration of gait analysis with musculoskeletal modeling and simulation. Eight weeks following unilateral brachial plexus Injury, sagittal plane shoulder and elbow angles were extracted from gait recordings of young rats (n=18), after which rats were sacrificed for bilateral muscle architecture measurements. Musculoskeletal models reflecting animal-specific muscle architecture parameters were used to simulate gait and extract muscle fiber lengths. The preganglionic neurectomy group spent significantly less (p=0.00116) time in stance and walked with significantly less (p<0.05) elbow flexion and shoulder protraction in the affected limb than postganglionic neurectomy or control groups. Linear regression revealed no significant linear relationship between passive shoulder external rotation and functional shoulder protraction range of motion. Despite significant restriction in longitudinal muscle growth, normalized functional fiber excursions did not differ significantly between groups. In fact, when superimposed on a normalized force-length curve, neurectomy-impaired muscle fibers (except subscapularis) accessed regions of the curve that overlapped with the control group. Our results suggest the presence of compensatory motor control strategies during locomotion following BPBI. The clinical implications of our findings support emphasis on functional movement analysis in treatment of BPBI, as functional and passive outcomes may differ substantially. This article is protected by copyright. All rights reserved.

  • influence of brachial plexus Birth Injury location on glenohumeral joint morphology
    Journal of Hand Surgery (European Volume), 2021
    Co-Authors: Nikhil N Dixit, Jacqueline H Cole, Carolyn M Mccormick, Katherine R Saul
    Abstract:

    Purpose Patient presentation after brachial plexus Birth Injury (BPBI) is influenced by nerve Injury location; more contracture and bone deformity occur at the shoulder in postganglionic injuries. Although bone deformity after postganglionic Injury is well-characterized, the extent of glenohumeral deformity after preganglionic BPBI is unclear. Methods Twenty Sprague-Dawley rat pups received preganglionic or postganglionic neurectomy on a single forelimb at postnatal days 3 to 4. Glenohumeral joints on affected and unaffected sides were analyzed using micro–computed tomography scans after death at 8 weeks after Birth. Glenoid version, glenoid inclination, glenoid and humeral head radius of curvature, and humeral head thickness and width were measured bilaterally. Results The glenoid was significantly more declined in affected compared with unaffected shoulders after postganglionic (–17.7° ± 16.9°) but not preganglionic Injury. Compared with the preganglionic group, the affected shoulder in the postganglionic group exhibited significantly greater declination and increased glenoid radius of curvature. In contrast, the humeral head was only affected after preganglionic but not postganglionic Injury, with a significantly smaller humeral head radius of curvature (–0.2 ± 0.2 mm), thickness (–0.2 ± 0.3 mm), and width (–0.3 ± 0.4 mm) on the affected side compared with the unaffected side; changes in these metrics were significantly associated with each other. Conclusions These findings suggest that glenoid deformities occur after postganglionic BPBI but not after preganglionic BPBI, whereas the humeral head is smaller after preganglionic Injury, possibly suggesting an overall decreased biological growth rate in this group. Clinical relevance This study expands understanding of the altered glenoid and humeral head morphologies after preganglionic BPBI and its comparisons with morphologies after postganglionic BPBI.

  • preganglionic and postganglionic brachial plexus Birth Injury effects on shoulder muscle growth
    Journal of Hand Surgery (European Volume), 2021
    Co-Authors: Nikhil N Dixit, Jacqueline H Cole, Carolyn M Mccormick, Eric S Warren, Katherine R Saul
    Abstract:

    Purpose Brachial plexus Birth Injury can differ in presentation, depending on whether the nerve ruptures distal to, or avulses proximal to, the dorsal root ganglion. More substantial contracture and bone deformity at the shoulder is typical in postganglionic injuries. However, changes to the underlying muscle structure that drive these differences in presentation are unclear. Methods Seventeen Sprague-Dawley rats received preganglionic or postganglionic neurectomy on a single limb on postnatal days 3 and 4. Muscles crossing the shoulder were retrieved once the rats were sacrificed at 8 weeks after Birth. External rotation range of motion, muscle mass, muscle length, muscle sarcomere length, and calculated optimal muscle length were measured bilaterally. Results Average shoulder range of motion in the postganglionic group was 61.8% and 56.2% more restricted at 4 and 8 weeks, respectively, compared with that in the preganglionic group, but affected muscles after preganglionic Injury were altered more severely (compared with the unaffected limb) than after postganglionic Injury. Optimal muscle length in preganglionic Injury was shorter in the affected limb (compared with the unaffected limb: –18.2% ± 9.2%) and to a greater extent than in postganglionic Injury (–5.1% ± 6.2%). Muscle mass in preganglionic Injury was lower in the affected limb (relative to the unaffected limb: –57.2% ± 24.1%) and to a greater extent than in postganglionic Injury (–28.1% ± 17.7%). Conclusions The findings suggest that the presence of contracture does not derive from restricted longitudinal muscle growth alone, but also depends on the extent of muscle mass loss occurring simultaneously after the Injury. Clinical relevance This study expands our understanding of differences in muscle architecture and the role of muscle structure in contracture formation for preganglionic and postganglionic brachial plexus Birth Injury.

  • integrated iterative musculoskeletal modeling predicts bone morphology following brachial plexus Birth Injury bpbi
    Journal of Biomechanics, 2020
    Co-Authors: Nikhil N Dixit, Daniel C Mcfarland, Matthew B Fisher, Jacqueline H Cole, Katherine R Saul
    Abstract:

    Abstract Brachial plexus Birth Injury (BPBI) is the most common nerve Injury among children. The glenohumeral joint of affected children can undergo severe osseous deformation and altered muscle properties, depending on location of the Injury relative to the dorsal root ganglion (preganglionic or postganglionic). Preganglionic Injury results in lower muscle mass and shorter optimal muscle length compared to postganglionic Injury. We investigated whether these changes to muscle properties over time following BPBI provide a mechanically-driven explanation for observed differences in bone deformity between preganglionic and postganglionic BPBI. We developed a computational framework integrating musculoskeletal modeling to represent muscle changes over time and finite element modeling to simulate bone growth in response to mechanical and biological stimuli. The simulations predicted that the net glenohumeral joint loads in the postganglionic Injury case were nearly 10.5% greater than in preganglionic. Predicted bone deformations were more severe in the postganglionic case, with the glenoid more declined (pre: −43.8°, post: −51.0°), flatter with higher radius of curvature (pre: 3.0 mm, post: 3.7 mm), and anteverted (pre: 2.53°, post: 4.93°) than in the preganglionic case. These simulated glenoid deformations were consistent with previous experimental studies. Thus, we concluded that the differences in muscle mass and length between the preganglionic and postganglionic injuries are critical mechanical drivers of the altered glenohumeral joint shape.

  • characterizing trabecular bone properties near the glenohumeral joint following brachial plexus Birth Injury
    bioRxiv, 2020
    Co-Authors: Emily B Fawcett, Katherine R Saul, Carolyn M Mccormick, Anna Murray, Dustin L Crouch, Jacqueline H Cole
    Abstract:

    Brachial plexus Birth Injury (BPBI) causes functional arm impairment in 30-40% of those affected due to altered loading on the glenohumeral joint. While gross morphological osseous deformities have been seen in the humerus and scapula, alterations in the underlying trabecular bone microstructure and mineralization are not clear. Using a murine model of BPBI, trabecular bone alterations were explored in the proximal humerus and distal scapula, which surround the articulating surface of the joint. Samples were scanned using micro-CT, reoriented, and analyzed for standard trabecular metrics. The regions of interest closest to the articulating surface showed the greatest detriments. In the scapula, the scapular neck region showed less robust trabecular bone in the neurectomy group with decreased BV/TV (p=0.001), BMD (p=0.001), Conn.D (p=0.006), Tb.N (p<0.0001), and DA (p=0.033), and increased Tb.Sp (p<0.0001) compared to sham. In the humerus, the epiphysis showed less robust trabecular bone in neurectomy group, but to a much lesser extent than the scapular neck. The neurectomy group showed reduced BMD (p=0.007) and Tb.N (p=0.029) compared to sham. Data suggest deformities are worse near the articulating surface, likely due to the greater amount of mechanical loading. The reduction in trabecular microstructure and mineralization may compromise bone strength of the affected limb following BPBI. Further investigation of the underlying trabecular bone deformities following Injury are necessary to eventually inform better treatments to limit the development of deformities.

Andrea S Bauer - One of the best experts on this subject based on the ideXlab platform.

  • follow up study on the effects of tendon transfers and open reduction on moderate glenohumeral joint deformity in brachial plexus Birth Injury
    Journal of Bone and Joint Surgery American Volume, 2020
    Co-Authors: Carley Vuillermin, Andrea S Bauer, Leslie A Kalish, Donald S Bae, Eliza B Lewine, Peter M Waters
    Abstract:

    Background Soft-tissue contractures about the shoulder in patients with brachial plexus Birth Injury are common and can lead to progressive shoulder displacement and glenohumeral dysplasia. Open or arthroscopic reduction with musculotendinous lengthening and tendon transfers have become the standard of care. The clinical function and radiographic joint remodeling beyond the first 2 years after surgery are not well understood. Methods We performed a follow-up study of 20 patients with preexisting mild to moderate glenohumeral joint deformity who had undergone open glenohumeral joint reduction with latissimus dorsi and teres major tendon transfers and concomitant musculotendinous lengthening of the pectoralis major and/or subscapularis. Prospective collection of Modified Mallet and Active Movement Scale (AMS) scores and radiographic analysis of cross-sectional imaging for glenoid version, humeral head subluxation, and glenohumeral joint deformity classification were analyzed for changes over time. Results The average duration of radiographic follow-up was 4.2 years (range, 2 to 6 years). The mean glenoid version improved from -31.8° to -15.4° (p Conclusions All parameters showed the greatest magnitude of improvement between preoperative measurements and 1 year of follow-up. There were no significant changes beyond the 1-year time point in the Mallet scores, AMS scores, or radiographic outcome measures, possibly because of insufficient power, although trends of improvement were noted for some outcomes. No decline in outcome measures was found during the study period. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

  • reconstruction of the suprascapular nerve in brachial plexus Birth Injury a comparison of nerve grafting and nerve transfers
    Journal of Bone and Joint Surgery American Volume, 2020
    Co-Authors: Claire M Manske, Leslie A Kalish, Roger Cornwall, Allan E Peljovich, Andrea S Bauer
    Abstract:

    BACKGROUND Shoulder external rotation recovery in brachial plexus Birth Injury is often limited. Nerve grafting to the suprascapular nerve and transfer of the spinal accessory nerve to the suprascapular nerve are commonly performed to restore shoulder external rotation, but the optimal surgical technique has not been clearly demonstrated. We investigated whether there was a difference between nerve grafting and nerve transfer in terms of shoulder external rotation recovery or secondary shoulder procedures. METHODS This is a multicenter, retrospective cohort study of 145 infants with brachial plexus Birth Injury who underwent reconstruction with nerve grafting to the suprascapular nerve (n = 59) or spinal accessory nerve to suprascapular nerve transfer (n = 86) with a minimum follow-up of 18 months (median, 25.7 months [interquartile range, 22.0, 31.2 months]). The primary outcome was the Active Movement Scale (AMS) score for shoulder external rotation at 18 to 36 months. The secondary outcome was secondary shoulder surgery. Two-sample Wilcoxon and t tests were used to analyze continuous variables, and the Fisher exact test was used to analyze categorical variables. The Kaplan-Meier method was used to estimate the cumulative risk of subsequent shoulder procedures, and the proportional hazards model was used to estimate hazard ratios (HRs). RESULTS The grafting and transfer groups were similar in Narakas type, preoperative AMS scores, and shoulder subluxation. The mean postoperative shoulder external rotation AMS scores were 2.70 in the grafting group and 3.21 in the transfer group, with no difference in shoulder external rotation recovery between the groups (difference, 0.51 [95% confidence interval (CI), -0.31 to 1.33]). A greater proportion of the transfer group (24%) achieved an AMS score of >5 for shoulder external rotation compared with the grafting group (5%) (odds ratio, 5.9 [95% CI, 1.3 to 27.4]). Forty percent of the transfer group underwent a secondary shoulder surgical procedure compared with 53% of the grafting group; this was a significantly lower subsequent surgery rate (HR, 0.58 [95% CI, 0.35 to 0.95]). CONCLUSIONS Shoulder external rotation recovery in brachial plexus Birth Injury remains disappointing regardless of surgical technique, with a mean postoperative AMS score of 3, 17% of infants achieving an AMS score of >5, and a high frequency of secondary shoulder procedures in this study. Spinal accessory nerve to suprascapular nerve transfers were associated with a higher proportion of infants achieving functional shoulder external rotation (AMS score of >5) and fewer secondary shoulder procedures. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

  • outcomes of late microsurgical nerve reconstruction for brachial plexus Birth Injury
    Journal of Hand Surgery (European Volume), 2020
    Co-Authors: Michael C Daly, Andrea S Bauer, Hayley M Lynch, Donald S Bae, Peter M Waters
    Abstract:

    Purpose Microsurgical nerve reconstruction has been advocated between 3 and 9 months of life in select patients with brachial plexus Birth Injury (BPBI), yet some patients undergo indicated surgery after this time frame. Outcomes in these older patients remain poorly characterized. We analyzed outcomes of nerve reconstruction performed after 9 months of age and hypothesized that (1) Active Movement Scale (AMS) scores improve after surgery, and (2) there are no differences in AMS scores between patients undergoing nerve transfers versus those undergoing nerve grafting. Methods From 2000 to 2014, 750 patients at 6 U.S. centers were prospectively enrolled in a multicenter database. We included patients treated with nerve reconstruction after 9 months of age with minimum 12 months’ follow-up. Patients were evaluated using AMS scores. To focus on the results of microsurgery, only outcomes prior to secondary surgery were analyzed. We analyzed baseline variables using bivariate statistics and change in AMS scores over time and across treatment groups using linear mixed models. Results We identified 32 patients (63% female) with median follow-up of 29.8 months. Median age at microsurgery was 11.2 months. Twenty-five (78%) had an upper trunk Injury. Compared with before surgery, total AMS scores improved modestly at 1 year and 2 or more years follow-up. At 1 year follow-up, AMS scores improved for shoulder function (abduction, external rotation) and elbow flexion. Between-group comparisons found no differences in total AMS scores or AMS subscales between graft and transfer groups at 1 year or 2 or more years after surgery, so we cannot recommend one strategy over the other based on our findings. Conclusions Overall, nerve reconstruction in patients with BPBI after 9 months of age resulted in improved function over time. There was no difference in outcomes between nerve transfer and nerve graft groups and 1 or 2 or more years follow-up. Type of study/level of evidence Therapeutic IV.

  • long term outcomes of brachial plexus reconstruction with sural nerve autograft for brachial plexus Birth Injury
    Plastic and Reconstructive Surgery, 2019
    Co-Authors: Claire M Manske, Andrea S Bauer, Vincent R Hentz, Michelle A James
    Abstract:

    Background Infants with brachial plexus Birth Injury who do not recover motor function spontaneously in a timely manner are candidates for brachial plexus reconstruction with nerve autograft. Outcomes of this intervention are incompletely understood. The authors present the long-term outcomes of brachial plexus reconstruction with sural nerve autograft in infants with brachial plexus Birth Injury. Methods The authors retrospectively reviewed all infants with brachial plexus Birth Injury who underwent brachial plexus reconstruction with sural nerve autograft between 1992 and 2014 with a minimum 2-year follow-up. The authors used Active Movement Scale scores to determine the presence and timing of shoulder, elbow, and wrist recovery. They assessed recovery of hand function in infants with global brachial plexus Birth Injury with the Raimondi scale. The number and type of secondary reconstructive procedures were identified. Results Forty-three infants who underwent brachial plexus reconstruction at age 7 ± 2 months old were followed for 7 ± 5 years. Most infants recovered antigravity elbow flexion (91 percent) and shoulder abduction (67 percent), but fewer recovered antigravity shoulder external rotation (19 percent) and wrist extension (37 percent). Mean postoperative times until observed antigravity motor strength (Active Movement Scale score >5) at the shoulder, elbow, and wrist were all greater than 12 months; evidence of initial motor recovery (Active Movement Scale score >2) was observed earlier. The mean Raimondi score in infants with global brachial plexus Birth Injury was 2.2 (range, 0 to 5) at final follow-up. Thirty-three children underwent 2 ± 1.2 secondary reconstructive procedures. Conclusions Brachial plexus reconstruction with sural nerve autograft reliably results in recovery of shoulder abduction and elbow flexion, but recovery of shoulder external rotation and wrist extension is less predictable, and recovery often takes more than 1 year. Secondary procedures are often performed to optimize function. Clinical question/level of evidence Therapeutic, IV.