Table 2.
Patient characteristics
| Authors (year) | % right shoulder affected | Type of brachial plexus injury | Prior surgical procedures | Indications for inclusion and surgical intervention |
|---|---|---|---|---|
| Abid et al. (2012) | 64.3% of original | 10 C5C6 root damage, 4 C5-C7 root damage | 1 case of nerve graft | Shoulder IR contracture secondary to BPBI. Surgical release was indicated when pER was ≤0. |
| Ahmed and Hashmi (2006) | 70% | Erb’s palsy | No prior procedures | Patients identified by medical records maintained by the Health Information Management System to have Erb’s palsy. |
| Andres-Cano et al. (2015) | 60% | C5C6 brachial plexus injury | 2 cases of neurotisation; 1 case of open reduction of GH joint. | BPBI surgically treated or spontaneously recovered with acceptable shoulder functionality and a marked limitation of ER and ABD. Mild-to-moderate GH dysplasia (Water’s grades I to IV) according to ultrasound and MRI. Adequate family support. |
| Breton et al. (2012) | 9 C5C6, 4 C5-C7 and 5 Complete brachial plexus injuries | pER with elbow at side of less than 10°, secondary to BPBI, all with bicep function that allowed for elbow flexion. Excluded patients with secondary osteotomy procedures. | ||
| Burnier et al. (2019) | 62.5% | 27 C5C6 and13 C5-C7 brachial plexus injuries | No prior shoulder surgeries. |
Inclusion criteria: ≥1 year and ER with arm at side <0° and palpable and irreducible posterior displacement of the humeral head or evidence of osseous deformities of GH joint as noted on imaging. Exclusion: Patients without imaging evidence of dysplasia of the glenoid process or GH incongruity and patients with prior procedures or treatment of their shoulder other than PT. |
| Cohen et al. (2010) | 46.875% | 26 C5C6, 2 C5-C7, 2 C5-C8 and 2 C5-C8D1 brach plexus injuries | Surgical indications: pER and aER deficits despite treatment with nocturnal bracing in ER and PT, all with regard to BPBI. | |
| El-Gammal et al. (2019) | 61.54% | C5C6 or C5-C7 (Narakas types I and II) |
Inclusion: Spontaneous recovered BPBI, with persistent ER weakness with or without IR contractures, a nondysplastic GH joint and functioning TM. All had shoulder Abd of ≥45° pre-operative. Exclusion: Patients with total palsy, brachial plexus exploration, and reconstruction. Patients with other tendon transferred or humeral osteotomy. Patients followed for <5 years were excluded. |
|
| Greenhill et al. (2019) | C5C6 brachial plexus injuries | 2 cases of nerve graft/transfer (1 per group) |
Inclusion: shoulder abduction of ~90°, limited shoulder ER and adequate midline function. Choice between tendon transfer was by virtue of the surgeon. Exclusion: no pre-op Mallet score ≤1 month of operation, <12 months FU, poor compliance with post-op protocols, persistent C7 or lower trunk dysfunction, pre-op humeral osteotomy, any shoulder or microsurgical procedure ≤8 months prior to tendon transfer, upper extremity surgery within specified FU period, recurrent post-op GH subluxation confirmed by US or MRI, or incomplete modified Mallet score suggesting noncompliance with PT at >12 months FU. |
|
| Hoffer and Phipps (1998) | 87.50% | 6 C5C6 and 2 C5-C7 brachial plexus injuries | Surgery performed on children with shoulder dislocation identified on radiograph, secondary to BPBI. | |
| Hui and Torode (2003) | 47.83% | 21 Upper BPBP and 2 whole brachial plexus injuries |
Surgical indication: Shoulder subluxation or dislocation that required open reduction and tendon lengthening. Inclusion in data: ≥22 months FU. |
|
| Jonsson et al. (2019) | 59 Erb-type Palsy and 2 C5-T1 brachial plexus injuries | 5 cases of nerve reconstruction |
Indications for surgery: (1) aER of ≤0 or (2) aER of <20° w/ positive trumpet sign and have an aIR >70°. Exact surgery type is based on meeting following criteria. Indications for isolated transfer: above conditions, plus age >2 years, pER≥50°. Indications for release and transfer: above conditions, age >2 years, pER ≤0° or ≤40° w/ trumpet sign, and weak aER. Indications for isolated release: above, plus age ≤2 years, and pER≤10° or palpable dorsal head displacement. Exclusion: Patient too young for MRI without sedation. |
|
| Kirkos et al. (2005) | 80% | 8 C5C6 and 2 C5-T1 brachial plexus injuries | 1 case of transfer of the flexor carpi ulnaris to the extensor tendons of the fingers and thumb | Criteria for surgery: Beyond the age at which any spontaneous recovery could be expected. Had radiological appearance of the GH joint showing only minor osseous changes with no flattening or deformity of the humeral head and no evidence of subluxation or dislocation. Power of the LT and TM must be 4+ or 5 on the Medical Research Council Scale. |
| Kozin et al. (2010) | 54.55% | 36 C5C6 and 8 C5-C7 brachial plexus injuries | 6 cases of nerve grafting/transfers |
Criteria for release: Dysplastic GH joint and impaired motion secondary to BPBI in children <3 years old. Criteria for release and tendon transfer: Dysplastic GH joint and impaired motion secondary to BPBI in child >3 years old or parents saw additional surgery as unacceptable or family had difficulty returning to hospital. Patients must have had pre-op and post-op imaging and clinical measurements. |
| Kozin et al. (2010) (2) | 45.83% | 19 C5C6 and 5 C5-C7 brachial plexus injuries | 3 cases of nerve grafts, 1 case of anterior capsule and pectoralis major release | Candidates for tendon transfer surgery were children who failed to attain adequate active Abd and aER. |
| Mehlman et al. (2011) | 54% | 38 C5-C7 (Narakas I (31) or II (7)) and 12 complete (Narakas III (9) or IV (3)) brachial plexus injuries | Surgical indications: ≥18 months of age with IR contracture of the shoulder (≤3 on ER Mallet score) and variable amounts of shoulder ABD deficit or select younger children who demonstrated radiographic evidence of significant GH dysplasia. The decision to pursue arthroscopic release alone versus arthroscopic release and open LT tendon transfer was made according to review of physical and EMG evidence. Favourable EMG characteristics of the muscles innervated by the suprascapular nerve underwent release alone. Unfavourable EMG findings underwent release and transfer. If ABD and ER deficits coexist, the LT tendon was transferred to the posterosuperior greater tuberosity. If deficit was more isolated to ER, the LT tendon was transferred to the posterolateral proximal humeral shaft. Every child had to have a minimum of 24 months of FU. | |
| Ozben et al. (2011) | 61.54% | 13 C5C6 and 13 C5-C7 brachial plexus injuries | Inclusion: Reasonable elbow and hand function, GH changes ≤III (Water’s scoring), ABD and ER could be maximized by passive motion, and deltoid function was ≥3 (British Medical Research Council Scale for muscle strength). Exclusion: humeral osteotomy, subscapularis release or capsular plication was necessary during surgery or if the patient was lost to FU or operated on ≤6 months before the onset of the study or pan-plexus injury or if the deltoid power ≤2. | |
| Ozturk et al. (2009) | 60% | 9 C5C6, 14 C5-C7 and 7 C5-T1 brachial plexus injuries | Prior procedures noted, but not specified. | Inclusion: unable to use the involved extremity in daily activities due to loss of ER and ABD with an IR deformity, all resultant of a BPBI. To be eligible for a tendon transfer, the patients had to have sufficient deltoid muscle strength (M3 or M4 according to the British Medical Research Council Grading System). |
| Pearl et al. (2006) | 26 C5C6 and 7 C5-C7 brachial plexus injuries | Inclusion for study: IR contracture secondary to BPBI treated with arthroscopic release. Surgical indications: Failure to respond to 2–3 months of supervised stretching exercises as well as ER <0° with the arm at the side or ER was sufficiently restricted as to impair the child’s ability to reach overhead, as indicated by a Burglar’s position. Further indication was palpable posterior displacement of the humeral head that did not reduce with attempted ER. Isolated contracture release was recommended for children who were <4 years old and additional LT tendon transfer was for older children. Tendon transfer was also indicated when families expressed desire to avoid a future operation in younger children. Minimum of 2 years FU. | ||
| Pedowitz et al. (2007) | 68.18% | Brachial plexus birth palsies | 5 cases of previous tendon transfer that failed to reduce the GH joint (all in isolated release group) | Inclusion: Children with GH subluxation as a result of BPBI. Selected for surgery when patients were found to have the presence of an IR contracture and MRI studies that should GH joint deformity. Additional LT and TM tendon transfers were performed on patients based on age, degree of deformity, capacity for continued nerve regeneration and family education. |
| Ruyer et al. (2018) | 60% | 9 C5C6, 22 C5-C7 and 3 C5-T1 brachial plexus injuries | 10 cases of primary nerve repair (7 C5-C7; 3 C5-T1) |
Inclusion: Children >2 years with limited ROM of the shoulder, secondary to BPBP. Patients had to have aER with the elbow at the side of ≤30° and/or their range of active anterior elevation had to be ≤90°. Exclusion: Secondary shoulder surgery before or during FU or parents and/or child refused surgery. |
| Sarac et al. (2020) | 58.9% | 67 C5-C6, 37 C5-C7, 4 C5-C8, and 4 C5-T1 brachial plexus injuries |
70 cases of nerve reconstruction 8 cases of neurolysis |
Inclusion to study: Obstetric brachial plexus injuries that underwent treatment with internal contracture release and/or tendon transfer, a maximum age of 18 years at the time of surgery, and a minimum follow-up period of 2 years. Selection criterion for surgical intervention, was based on pre-operative values of passive and active ER. Children with limited pER and good function of aER or those who had a chance of recovery, underwent only contracture release—if not recovered 4 weeks after the release, an additional Tendon transfer was performed. Children with no aER and pER in ADD of less than 20° received anterior release and tendon transfer. Patients with pER greater than 20° in ADD with no aER underwent a tendon transfer without soft-tissue release. |
| Shah et al. (2019) | 19 Narakas-1 and 1 Narakas-3 brachial plexus injuries |
Surgical indications: Passive IR of <30° and no aER. Study required a FU ≥2 years. Exclusion: non-congruous GH joints on axial MRI. |
||
| Thatte et al. (2011) | 52% | 80 C5C6, 34 C5-C7, 32 C5-T1 and 4 C5-T1+Horner’s sign, brachial plexus injuries | 62 cases of exploration, neurotisation and nerve grafting (18 C5C6, 15C5-C7, 25 C5-T1, 4 C5-T1 w/ Horner’s sign) | Indications: Children with BPBI with shoulder deformities and contractures. All patients had shoulder ABD and ER weakness with a concomitant IR contracture. |
| Van Heest et al. (2010) | 57.69% | Brachial plexus birth injuries |
Inclusion for study: documented shoulder IR contracture with loss of aER that lead to tendon transfer surgery. Required patients to have had pre-op and 1 year post-op 3D imaging of the shoulder. Exclusion: Diagnosis other than BPBP as cause of GH dysplasia, humeral osteotomies at time of surgery, or tendon transfers other than LT and TM. Surgical indications: absent aER with loss of pER. |
|
| Vuillermin et al. (2020) | N/A | Brachial plexus birth injuries |
Surgical indications: made on the basis of neurological status, muscle strength, soft-tissue contractures, and underlying GH joint deformity—all had an IR contracture and ER weakness. Those with mild-to-moderate GH joint deformity and a joint reducible with surgery were managed with the operation. Study inclusion required patients to have radiological FU ≥2 years. |
BPBI, brachial plexus birth injury; GH, glenohumeral; PT, physiotherapy; pER, passive external rotation; aER, active external rotation; IR, internal rotation; ER, external rotation; TM, teres major; ABD, abduction; ADD, adduction; cLT, conjoined tendon; iTM, isolated teres major; FU, follow-up; LT, latissimus dorsi; ROM, range-of-motion; US, ultrasound; MRI, magnetic resonance imaging; N/A, not available