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      Assessment of Triangle Tilt Surgery in Children with Obstetric Brachial Plexus Injury Using the Pediatric Outcomes Data Collection Instrument

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          Abstract

          Background:

          The benefits of triangle tilt surgery in children with OBPI have been previously validated through measurements of statistical improvements in Mallet scores and in glenohumeral congruity. The purpose of the current study was to evaluate the effectiveness of triangle tilt surgery through the application of the Pediatric Outcomes Data Collection Instrument, a well validated questionnaire designed to evaluate function and comfort in children with musculoskeletal disorders.

          Methods:

          OBPI patients between 2 and 10 years of age who came to our institute for routine office visits between May 2009 and October 2009 were considered to participate in the study. Among the patient group, the first 130 completed surveys who met the study criteria were included in the study. The Pediatric Outcomes Data Collection Instrument was completed by the parents of patients who have undergone triangle tilt surgery (Group 1: N=63) or those who were considered candidates for this procedure (Group 2: N=67). The results were compared between the two patient groups and analyzed using the unpaired student’s t-test. Later, 23 patients from the group 2, underwent triangle tilt surgery (Group 3). We collected post-op data, compared and analyzed the outcome of the surgery in these patients to their own pre-op PODCI scores, using the paired student’s t test.

          Results:

          In patients who have undergone triangle tilt surgery, significantly higher PODCI scores were observed in the parameters of upper extremity function (p<0.05), sports/physical function (p<0.05), basic mobility (p<0.0001) and global functioning (p<0.05), when compared to patients who have not undergone triangle tilt surgery. Further, PODCI scores in group 3 patients were significantly higher after surgery in the parameters of upper extremity function (p <0.03), Pain/Comfort (p <0.05), basic mobility (p<0.0002) and global functioning (p<0.03), when compared to before triangle tilt surgery.

          Conclusion:

          The results of the Pediatric Outcomes Data Collection Instrument demonstrate the functional benefits of triangle tilt surgery in patients with obstetric brachial plexus injury.

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          Most cited references23

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          Glenohumeral deformity secondary to brachial plexus birth palsy.

          Andrew P. Waters, Vinicio Jaramillo, J. G. Smith (1998)
          Ninety-four patients who had brachial plexus birth palsy were entered into a prospective study to evaluate the association between persistent palsy, age-related musculoskeletal deformity, and functional limitations. Of these patients, forty-two had either computerized tomography or magnetic resonance imaging to assess the presence and degree of incongruity of the glenohumeral joint, deformity of the humeral head, and hypoplasia of the glenoid as part of the preoperative planning for a reconstructive operation. Functional ability was rated with use of the classification of Mallet, on a scale of 1 to 5. The mean glenoscapular angle (the degree of retroversion of the glenoid) on the affected side was -25.7 degrees compared with -5.5 degrees on the unaffected side. Twenty-six (62 per cent) of the forty-two shoulders had evidence of posterior subluxation of the humeral head, with a mean of only 25 per cent (range, 0 to 50 per cent) of the head being intersected by the scapular line. Progressive deformity was found with increasing age (p < 0.001). The natural history of untreated brachial plexus birth palsy with residual weakness is progressive glenohumeral deformity due to persistent muscle imbalance. The status of the glenohumeral joint must be addressed when the choice between tendon transfer and humeral derotation osteotomy for reconstruction of the shoulder is considered for these patients.
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            The POSNA pediatric musculoskeletal functional health questionnaire: report on reliability, validity, and sensitivity to change. Pediatric Outcomes Instrument Development Group. Pediatric Orthopaedic Society of North America.

            L Daltroy, M Liang, A Fossel … (2015)
            The goal of orthopaedic interventions is to improve the functional health of patients, particularly physical function. The American Academy of Orthopaedic Surgeons and the Pediatric Orthopaedic Society of North America (POSNA) commissioned a work group to construct functional health outcomes scales for children and adolescents, focusing on musculoskeletal health. The work group developed scales assessing upper extremity function, transfers and mobility, physical function and sports, comfort (pain free), happiness and satisfaction, and expectations for treatment. Parent and adolescent self-report forms were developed and tested on 470 subjects aged 2-18 years. The POSNA scales demonstrated good reliability, construct validity, sensitivity to change over a 9-month period, and ability to outperform a standard instrument, the Child Health Questionnaire physical functioning scale. They were useful for a wide variety of ages and diagnoses. They appear to be ideally suited for orthopaedic surgeons to assess the functional health and efficacy of treatment of their patients at baseline and follow-up.
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              Effect of tendon transfers and extra-articular soft-tissue balancing on glenohumeral development in brachial plexus birth palsy.

              Peter M Waters, Donald S Bae (2005)
              Persistent muscle imbalance and soft-tissue contractures can lead to progressive glenohumeral joint deformity in patients with brachial plexus birth palsy. The objective of this investigation was to determine the effects of correction of external rotation weakness and internal rotation contractures with tendon transfers and extra-articular soft-tissue releases on glenohumeral development in patients with brachial plexus birth palsy. Twenty-five patients with brachial plexus birth palsy who underwent latissimus dorsi and teres major tendon transfers to the rotator cuff-with or without concomitant musculotendinous lengthenings-were evaluated clinically and radiographically before the operation and at a minimum of two years (average, forty-three months) postoperatively. Shoulder function was prospectively assessed with use of the modified Mallet classification system, in which aggregate shoulder function is assigned a score of 5 to 25 points. Glenoid version and humeral head subluxation were quantified with magnetic resonance imaging or computed tomography, and glenohumeral deformity was graded. Clinically, all patients demonstrated improved global shoulder function, with the mean aggregate Mallet score improving from 13 points preoperatively to 18 points postoperatively (p < 0.01). As seen radiographically, the mean glenoid retroversion improved from 22 degrees preoperatively to 16.5 degrees postoperatively (p = 0.012). The mean posterior humeral head subluxation improved from 30% to 37% (p = 0.03). No patient had progressive worsening of the glenohumeral deformity. Latissimus dorsi and teres major tendon transfers to the rotator cuff, combined with appropriate extraarticular musculotendinous lengthenings, significantly improved global shoulder function but led to only modest improvements in glenoid retroversion and humeral head subluxation. No profound glenohumeral remodeling occurs after these extra-articular rebalancing procedures, even when they are performed in patients of a young age. While the long-term clinical and radiographically apparent effects at skeletal maturity are uncertain, soft-tissue rebalancing procedures alone were found to have halted the progression of, but not to have markedly decreased, glenohumeral dysplasia at the time of a two to five-year follow-up.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Open Orthop J
                Journal ID (publisher-id): TOORTHJ
                Title: The Open Orthopaedics Journal
                Publisher: Bentham Open
                ISSN (Electronic): 1874-3250
                Publication date (Electronic): 14 December 2011
                Publication date Collection: 2011
                Volume: 5
                Pages: 385-388
                Affiliations
                Texas Nerve and Paralysis Institute, 6400 Fannin Street, Houston, Texas 77030, USA
                Author notes
                [* ]Address correspondence to this author at the Texas Nerve and Paralysis Institute, 6400 Fannin Street, Houston, Texas 77030, USA; Tel: (+1) 713.592.9900; Fax: (+1) 713.592.9921; E-mail: drnath@ 123456drnathmedical.com
                Article
                Publisher ID: TOORTHJ-5-385
                DOI: 10.2174/1874325001105010385
                PMC ID: 3249689
                PubMed ID: 22216072
                SO-VID: cc9ad5ef-ca95-4a1f-b6e2-0a5a8070ad86
                Copyright © © Nath et al.; Licensee Bentham Open.
                License:

                This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.

                History
                Date received : 20 September 2011
                Date revision received : 3 November 2011
                Date accepted : 3 November 2011
                Categories
                Subject: Article

                ScienceOpen disciplines: Orthopedics
                Keywords: triangle tilt surgery,obstetric brachial plexus injury,pediatric outcome data collection instrument.
                Data availability:
                ScienceOpen disciplines: Orthopedics
                Keywords: triangle tilt surgery, obstetric brachial plexus injury, pediatric outcome data collection instrument.

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