Advancing glenohumeral dysplasia treatment in brachial plexus birth injury: the end-to-side spinal accessory to suprascapular nerve transfer technique.

PURPOSE: Brachial plexus birth injury (BPBI) is a common injury with the spectrum of disease prognosis ranging from spontaneous recovery to lifelong debilitating disability. A common sequela of BPBI is glenohumeral dysplasia (GHD) which, if not addressed early on, can lead to shoulder dysfunction as the child matures. However, there are no clear criteria for when to employ various surgical procedures for the correction of GHD. METHODS: We describe our approach to correcting GDH in infants with BPBIs using a reverse end-to-side (ETS) transfer from the spinal accessory to the suprascapular nerve. This technique is employed in infants that present with GHD with poor external rotation (ER) function who would not necessitate a complete end-to-end transfer and are still too young for a tendon transfer. In this study, we present our outcomes in seven patients. RESULTS: At presentation, all patients had persistent weakness of the upper trunk and functional limitations of the shoulder. Point-of-care ultrasounds confirmed GHD in each case. Five patients were male, and two patients were female, with a mean age of 3.3 months age (4 days-7 months) at presentation. Surgery was performed on average at 5.8 months of age (3-8.6 months). All seven patients treated with a reverse ETS approach had full recovery of ER according to active movement scores at the latest follow-up. Additionally, ultrasounds at the latest follow-up showed a complete resolution of GHD. CONCLUSION: In infants with BPBI and evidence of GHD with poor ER, end-to-end nerve transfers, which initially downgrade function, or tendon transfers, that are not age-appropriate for the patient, are not recommended. Instead, we report seven successful cases of infants who underwent ETS spinal accessory to suprascapular nerve transfer for the treatment of GHD following BPBI.

Technique of Adolescent Shoulder Reanimation in Brachial Plexus Birth Injury.

BACKGROUND: Brachial plexus birth injury (BPBI) is common and while most recover, 8-36% of patients experience permanent impairment. Typically, adolescents with untreated BPBI lack active and passive external shoulder rotation (ER) and overhead shoulder function. Limited shoulder function is due to 1) nonoperative BPBI 2) untreated BPBI or 3) unrecognized glenohumeral joint dysplasia. We describe a technique for achieving reanimation in adolescents who did not receive timely/effective BPBI care, a postoperative rehabilitation protocol, and results from a series of eight patients who underwent shoulder reanimation. METHODS: A comprehensive shoulder reanimation approach is performed. Anteriorly, the pectoralis minor, major, and anterior capsule necessitate release. In severe dysplasia, a coracoidectomy, posterior glenoid osteotomy, and/or subscapularis slide may be necessary. Acromial dysplasia is also common, frequently necessitating osteoplasty. The deltoid is usually nonfunctional, and we use a bipolar latissimus muscle transfer for reanimating abduction and forward flexion. To assist with ease of rehabilitation we will often transfer the tendon of the teres major. Levator scapulae transfer to the supraspinatus is often performed to assist with the initiation of abduction. For external rotation, the ipsilateral lower trapezius is used. Finally, ipsilateral rhomboid advancement and contralateral lower trapezius muscle transfer is performed for dynamic scapular stabilization. After surgery, all patients participated in our rigorous postoperative rehabilitation protocol. RESULTS: Eight patients (13.8±5.6 years, 35±24 weeks follow-up) were included. All patients participated in our rehabilitation protocol. Preoperatively, patients generally achieved 0° ER from neutral and in maximum abduction. Postoperatively, patients achieved an average of 71° (30-90°) ER from neutral and an average of 82° (65-90°) ER in maximum abduction. Preoperatively, patients generally had 0-20° of abduction, which they achieved through scapulothoracic motion. Postoperatively, patients could achieve an average of 115° (90-180°) of abduction. Preoperatively, patients had 0-20° of FF that was mediated through scapulothoracic motion. Postoperatively, patients' FF increased to an average of 91° (20-170°). CONCLUSION: This technique is intended to restore a congruent glenohumeral joint and reanimate structures allowing for abduction, FF, and ER. While we advocate for early treatment of BPBI, applying this technique to undertreated/untreated adolescent patients paired with our rehabilitation protocol results in significant functional improvement, allowing for an improved quality of life.

STRYDE versus PRECICE magnetic internal lengthening nail for femur lengthening.

INTRODUCTION: Magnetic internal lengthening nails (MILNs) have been used for femoral lengthening to avoid complications associated with external fixation. The titanium version of the MILN (PRECICE®) has been in use since 2011 but had limitations (50-75 lb) in post-operative weight bearing. A new stainless-steel version of the MILN (STRYDE®) allows 150-250 lb of post-operative weight bearing. The aim is to compare the outcomes of using these two different MILNs for both unilateral and bilateral femoral lengthening. METHODS: A single-center, retrospective cohort study was conducted in which patients' records were reviewed from the period from January 2017 to March 2020. A total of 66 femoral lengthening procedures were included in the study and were divided into two groups: STRYDE® group (30 femora) and PRECICE® group (36 femora). Outcomes assessed were the 6-months post-operative Limb Deformity-Scoliosis Research Society (LD-SRS) Score, adjacent joint range of motion (ROM), average distraction rate, bone healing index (BHI), and complications. RESULTS: No statistically significant difference was found between the two groups in regard to the (LD-SRS) score, hip ROM, or knee ROM. Statistically significant differences were found between the two groups in regard to BHI (average of 0.84 months/cm and 0.67 months/cm for STRYDE® and PRECICE®, respectively) and distraction rate (average of 0.6 mm/day and 0.9 mm/day for STRYDE® and PRECICE®, respectively). No mechanical nail complications were reported in the STRYDE® group compared to three events of nail failure in the PRECICE® group. One femur in the PRECICE® group needed BMAC injection for delayed healing compared to four femurs in the STRYDE® group. CONCLUSION: The STRYDE® MILN yields comparable functional results to those of PRECICE® MILN and shows fewer mechanical nail complications. However, STRYDE® MILN requires a slower distraction rate and yields slower healing (larger BHI). LEVEL OF EVIDENCE: Level III, Therapeutic study.

Clinical Assessment and Treatment Options for Posterior Hip Pain.

BACKGROUND: Diagnosis and treatment of posterior hip pain has increased due to advancements in clinical, anatomical, biomechanical, and related pathological understandings of the hip. Due to its complexity and close anatomical relationship with many osseous, neurovascular, and musculotendinous structures, posterior hip pain must be appropriately categorized based on its origin. Therefore, it is crucial that clinicians are able to determine whether patient complaints are of extra-articular or intra-articular nature so that they can implement the optimal treatment plan. In the current review article, we discussed posterior hip pain with an emphasis on the main differential diagnoses of deep gluteal syndrome, ischiofemoral impingement, and hamstring tear/hamstring syndrome. For the appropriate diagnosis and etiology of posterior hip pain, a thorough and conclusive clinical history is imperative. Physicians should rule out the possibility of spinal involvement by physical examination and if necessary, by magnetic resonance imaging (MRI). Furthermore, because of the vicinity to other, non-orthopedic structures, an obstetric and gynecologic history, general surgery history, and urologic history should be obtained. Following the collection of patient history clinicians should adhere to an established and efficient order of evaluation starting with standing then to seated, supine, lateral, and prone testing. Imaging assessment of posterior hip pain begins with a standard anterior-posterior pelvic radiograph, in addition to frog-leg lateral. MRI is pivotal for assessing soft tissue-related extra-articular causes of hip in patients with posterior hip pain. Non-surgical treatment is preferred in most cases of deep gluteal syndrome, ischiofemoral impingement, pudendal nerve entrapment, and proximal hamstring pathologies. Surgical treatment is saved as a last resort option in cases of failed non-surgical treatment.

Appendiceal actinomycosis mimicking malignant tumor: a rare case report.

Introduction: Actinomycosis is an uncommon bacterial infection caused by Actinomyces bacteria that typically progresses slowly and leads to the formation of masses. Although it commonly affects the cervicofacial area, about 20% of cases occur in the abdominopelvic region. Because the disease can be mistaken for a tumour due to its infiltrative mass-like nature on imaging, over 90% of cases are only diagnosed following surgery and histological confirmation. This report describes a case of an appendicular mass, initially suspected to be a malignant tumour, but eventually diagnosed as appendiceal actinomycosis. Presentation of case: Upon initial presentation, a 53-year-old woman with type II diabetes mellitus and no prior surgical history, displayed abnormal appendiceal uptake during a PET-computed tomography (CT) scan conducted for a suspected spinal tumour. Colonoscopy did not indicate any notable observations, and the patient chose to defer immediate action. Several months later, a CT scan revealed an increased mass-like appearance of the appendix compared to the previous PET-CT scan. After multidisciplinary discussions, a right laparoscopic hemicolectomy was recommended due to suspected malignancy. However, histological staining on microscopy confirmed actinomycosis originating from the appendix. Discussion: Chronic appendicitis with radiologic features similar to appendiceal carcinoma, or abdominal masses located in the ileocecal area, in patients with or without a previous surgical history should raise suspicion of actinomycosis. Conclusion: Appendiceal actinomycosis should be considered in the differential diagnosis in the aetiology of chronic appendicitis mimicking appendiceal carcinoma. Awareness and accurate diagnosis of appendiceal actinomycosis can prevent unnecessary extended surgery as was performed in this case.

Mapping the Landscape of Brachial Plexus Birth Injury Research: A Comprehensive Bibliometric Study.

Brachial plexus birth injury (BPBI) is a relatively common condition that poses a significant challenge to children who endure functional impairments later on. This comprehensive bibliometric analysis sought to quantitatively evaluate the existing literature on BPBI, shedding light on authorship, collaboration, publication trends, and keyword analysis to both inform the medical community and foster future research growth. A thorough search of the Web of Science database yielded 712 relevant documents published between 1986 and 2022. The analysis utilized Biblioshiny (K-Synth Srl, Naples, Italy) for bibliometric data, alongside VOSviewer (Centre for Science and Technology Studies, Leiden University, The Netherlands) and TextRazor (TextRazor Ltd., London, UK) for keyword categorization. The literature had an average annual growth rate of 7.94%, with an average document age of 12 years. Collaborative efforts demonstrated 9.6% international co-authorship, with the United States prominently leading global collaborations. Top producing authors included Yang, Kozin, and Clarke, while the most cited authors were Clarke, Waters, and Curtis. Journals such as the Journal of Pediatric Orthopedics and Plastic and Reconstructive Surgery emerged as key contributors to the literature. Keyword analysis illuminated prevalent categories like "society" and "health," underscoring the multifaceted nature of BPBI research. The findings from this bibliometric analysis highlight the dynamic and collaborative landscape of BPBI research, emphasizing the pressing need for continued contributions to address existing gaps in knowledge, enhance global collaboration, and advance the understanding and treatment of this complex condition. Beyond quantitative metrics, this study holds particular significance in its role as a compass for researchers, practitioners, and policymakers invested in BPBI. By offering insights into influential authors, institutions, and emerging trends, this analysis serves as a valuable resource, guiding future research endeavors, fostering interdisciplinary collaboration, and ultimately contributing to improved outcomes for individuals affected by BPBI. The importance of this study lies not only in its informative content but also in its potential to catalyze a collective effort toward refining treatment modalities, promoting preventative measures, and enhancing the overall quality of care for those navigating the challenges of BPBI.

Current Concepts in Brachial Plexus Birth Injuries: A Comprehensive Narrative Review.

Background: Brachial plexus birth injury (BPBI) encompasses a spectrum of upper extremity paralysis cases following childbirth. The etiology of BPBI is multifactorial, involving maternal, obstetric, and neonatal associative factors. Despite opportunities for spontaneous recovery, recent literature demonstrates that a significant proportion of infants experience residual deficits and functional limitations as they age. Understanding the complex anatomy of the brachial plexus, clinical presentations of the pathology, diagnostic workup, current treatment options, and common secondary sequelae is instrumental for appropriate management of BPBI. Methods: Following a comprehensive search strategy used by the authors to identify relevant literature relating to the progression, patho-anatomy, clinical presentation, management, and treatment of BPBI, this comprehensive narrative review outlines current approaches to assess, manage, and advance BPBI care. Results: We advocate for prompt referral to specialized multicenter brachial plexus clinics for accurate diagnosis, timely intervention, and individualized patient-centered assessment. Further research is needed to elucidate mechanisms of injury, refine diagnostic protocols, and optimize long-term outcomes. Conclusions: Collaboration between healthcare providers and families is paramount in providing comprehensive care for infants with BPBI. This review offers insights into the current understanding and management of BPBI, highlighting the importance of tailored approaches and intraoperative decision-making algorithms to optimize functional outcomes.

Contemporary Management of the Upper Limb in Apert Syndrome: A Review.

Background: Apert syndrome is a relatively rare genetic disorder with a constellation of distinct craniofacial deformities and bilateral syndactyly of the hands and feet. Although the literature contains ample evidence for the need to treat cranial, midfacial, and hand abnormalities, there are severe shortcomings in the literature when attempting to describe the pathology and management of the entire upper limb in patients with Apert syndrome. Methods: A thorough literature search was performed using PubMed, Scopus, Web of Science, and Google Scholar, on the management of the upper extremity in Apert syndrome, including the shoulder, elbow, and hand. Results: Our findings of the literature discuss the clinical presentation and management trends of the upper extremity in patients with Apert syndrome. Through multicenter collaboration, discussion among experts in the field, and evidence gathered from the literature, we propose treatment algorithms to treat deformities of the hand, shoulder, and elbow in patients with Apert syndrome. Conclusions: This review identifies that even if hand pathologies have been correctly treated, shoulder and elbow abnormalities in patients with Apert syndrome are largely ignored. To optimize outcomes, added cognizance of additional upper limb congenital differences and their management should be highly advocated in this patient population.

Outcomes of glenohumeral dysplasia after brachial plexus birth injury using the Sup-ER orthosis.

We investigated the efficacy of the supination-external rotation ('Sup-ER') orthosis, designed as a non-operative treatment to maintain normal anatomical growth of the shoulder, on the progression of glenohumeral dysplasia in patients with brachial plexus birth injuries. The Sup-ER orthosis was fabricated for 20 infants diagnosed with glenohumeral dysplasia after brachial plexus birth injuries and its success in correcting glenohumeral dysplasia was confirmed by objective calculations of the alpha angle on serial ultrasound findings and improvement in Active Movement Scale scores. Of the 20 patients, 14 had successful resolution of glenohumeral dysplasia, confirmed by shoulder abduction, shoulder flexion, external rotation and supination, Active Movement Scale scores and improving alpha angle measurements. Failure to rectify glenohumeral dysplasia, evidenced by worsening ultrasound findings and Active Movement Scale scores, necessitated a change to operative management in six patients.Level of evidence: IV.

Glenohumeral Dysplasia Following Brachial Plexus Birth Injuries: A Review.

BACKGROUND AND OBJECTIVES: Despite the high morbidity associated with glenohumeral dysplasia (GHD) in children with brachial plexus birth injuries, the progression of this condition often remains unnoticed, even after correcting for the underlying brachial plexus birth injuries. GHD, driven by a multifactorial process involving disruptions in both direct and indirect neural regulation of bony and muscular structures, can lead to intermittent or permanent shoulder mobility imbalances, significantly impacting the quality of life of those affected. Recent research efforts are increasingly directed toward identifying the root causes, managing the deformity, and determining effective treatment options for correcting GHD. METHODS: A comprehensive search strategy was used by the authors to identify relevant literature relating to the progression, pathoanatomy, clinical presentation, and management of GHD following brachial plexus birth injuries across various search engines, such as PubMed, Scopus, and Embase. Considering the topic's interdisciplinary nature, articles were retrieved from both neurosurgical and orthopaedic journals to enrich the review. RESULTS: Given the challenges in managing patients with brachial plexus birth injuries, a multidisciplinary care team consisting of certified occupational hand therapists, neurosurgeons, plastic surgeons, and orthopedic surgeons, specializing in brachial plexus injuries should be advocated for. The aim of this collaborative effort is to correct brachial plexus birth injuries and prevent the persistence of GHD. CONCLUSION: As research continues to focus on understanding the complexities of this condition, the aim of this review article is to summarize the current literature on the course of brachial plexus birth injury and the development of GHD. By doing so, we hope to provide neurosurgeons with the necessary knowledge and essential tools needed to identify and effectively treat GHD during management of brachial plexus birth injuries.

Current Concepts in the Management of Neurogenic Thoracic Outlet Syndrome: A Review.

Thoracic outlet syndrome is a constellation of signs and symptoms due to compression of the neurovascular bundle of the upper limb. In particular, neurogenic thoracic outlet syndrome can present with a wide constellation of clinical manifestations ranging from pain to paresthesia of the upper extremity, resulting in a challenge to correctly diagnose this syndrome. Treatment options range from nonoperative treatment, such as rehabilitation and physical therapy, to surgical correction, such as decompression of the neurovascular bundle. Methods: Following a systematic review of the literature, we describe the need for a thorough patient history, physical examination, and radiologic images which have been reported to correctly diagnose neurogenic thoracic outlet syndrome. Additionally, we review the various surgical techniques recommended to treat this syndrome. Results: Postoperative functional outcomes have been shown to be more favorable in arterial and venous thoracic outlet syndrome (TOS) patients when compared with neurogenic TOS patients, likely due to the ability to completely remove the site of compression in cases of vascular TOS as compared with incomplete decompression in neurogenic TOS. Conclusions: In this review article, we provide an overview of the anatomy, etiology, diagnostic modalities, and current treatment options of correcting neurogenic TOS. Additionally, we offer a detailed step-by-step technique of the supraclavicular approach to the brachial plexus, a preferred approach for decompressing neurogenic TOS.

Radial Polydactyly.

¼ Radial polydactyly is one of the most common congenital anomalies of the hand, with an incidence of 0.08 to 1.40 per 1,000 live births; it requires surgical treatment early in life.¼ Polydactyly occurs during weeks 5, 6, 7, and 8 of embryogenesis, principally due to misregulation of the sonic hedgehog protein within the developing limb bud.¼ The Flatt classification system of preaxial polydactyly (types I to VII), as published by Wassel, categorizes preaxial polydactyly based on osseous abnormalities, but it has substantial limitations.¼ For improved function and appearance, preaxial polydactyly ideally requires surgical intervention at an early age (between 1 and 2 years of age) before the development of fine motor skills.

Wrist arthroscopy for diagnosis and treatment of acute and chronic conditions.

Wrist arthroscopy is a constantly evolving procedure. Allowing direct visualization and dynamic testing of intra-articular structures led to a novel approach toward traumatic and degenerative lesions based on most of the classifications routinely used in wrist surgery. The development of specific instrumentation, combined with a novel understanding of the local anatomy, progressively allowed wrist surgeons to describe more ambitious and complex surgeries. Wrist arthroscopy has become an increasingly useful tool in hand and wrist surgeons' panoply and seems promised to have further development in the future. This paper discusses the surgical technique and the various pathologies that can be treated by arthroscopy of the wrist.

Humerus Lengthening: A Comparison of the Internal Lengthening Nail to External Fixation.

Introduction: Magnetic internal lengthening nails (MILNs) have been used for humeral lengthening to avoid complications associated with external fixation. Purpose/Questions: We compared the 1-year Disabilities of the Arm, Shoulder and Hand (DASH) score, adjacent joint range of motion (ROM), bone healing index (BHI), length achieved, distraction rate, and complications when lengthening the humerus using MILN vs using external fixation. Methods: We conducted a retrospective cohort study of 18 patients (22 humeri) from January 2001 to March 2020 divided into 2 groups, the MILN group (7 patients, 7 humeri) and the mono-lateral fixator group (11 patients, 15 humeri). Results: The MILN group showed larger improvement of DASH scores (average 26.8 and 8 for MILN and fixator groups, respectively), less loss of elbow ROM (average 5° and 7° for MILN and fixator groups, respectively), and shorter time to full recovery of elbow ROM (average 39 days and 122 days for MILN and fixator groups, respectively). In the MILN group, there was slower distraction rate (average 0.66 mm/day and 0.86 mm/day for MILN and fixator groups, respectively), less lengthening achieved (average 5.2 cm and 7 cm for MILN and fixator group, respectively), and a lower lengthening percentage (average 19% and 41% for MILN and fixator group, respectively). Bone healing index (BHI) of 0.94 and 0.99 months/cm for the MILN and the fixator groups were similar. Conclusion: Humeral lengthening using the MILN allowed for early full recovery of joint ROM with comparable functional and radiographic outcomes compared with using external fixators.

Early Experience with Femoral and Tibial Bone-Anchored Osseointegration Prostheses.

BACKGROUND: The use of bone-anchored osseointegration implants for amputation reconstruction continues to expand throughout the world. Benefits are thought to include the elimination of socket-related problems and improved control and proprioception of the prosthetic limb. Reported outcomes have been positive, but skepticism remains with regard to the risk of infection and implant failure. Further results from early adopters are therefore needed prior to widespread acceptance and regulatory approval. METHODS: A retrospective review of the first 31 consecutive patients who underwent implantation of a press-fit osseointegration implant of the femur or tibia with follow-up of at least 6 months was performed. The primary outcome was the patient-reported Questionnaire for persons with a Transfemoral Amputation (Q-TFA) measured preoperatively and 6 to 12 months postoperatively. Patient-Reported Outcomes Measurement Information System (PROMIS) and Limb Deformity-Scoliosis Research Society (LD-SRS) scores, 2-minute and 6-minute walk tests, and complications were also recorded. RESULTS: In this study, 18 femoral reconstructions and 13 tibial reconstructions were performed, with a mean follow-up (and standard deviation) of 21.1 ± 9.2 months. Twenty-eight reconstructions were single-stage implantations. All Q-TFA domains improved significantly (p < 0.001) from preoperatively to postoperatively, including the global score (25.0 ± 17.4 to 81.2 ± 17.6 points), prosthetic use (50.2 ± 39.9 to 91.2 ± 18.7 points), prosthetic mobility (49.7 ± 26.9 to 81.4 ± 21.5 points), and prosthetic problems (46.4 ± 17.5 to 9.1 ± 6.6 points). The overall and functional outcome domains of the PROMIS and LD-SRS and the 2-minute walk test (243 ± 107 to 369 ± 151 ft [74 ± 33 to 112 ± 46 m]; p = 0.022) and 6-minute walk test (609 ± 323 to 1,054 ± 555 ft [186 ± 98 to 321 ± 169 m]; p = 0.016) also improved significantly. Serious adverse events included 2 periprosthetic hip fractures, 1 explantation for septic loosening, and 1 explantation for aseptic loosening, with an overall implant retention of 93%. The most common complication was low-grade, soft-tissue infection requiring oral antibiotics. CONCLUSIONS: Similar to the early experience of other international centers, osseointegration implants improved the overall and functional experience of patients compared with socket prosthetics. Complications were present but manageable and were not a deterrent to ongoing support of the technology. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.