Pectoralis minor transfer for elbow flexion restoration in late obstetric brachial plexus palsy.

PURPOSE: Obstetric brachial plexus palsy (OBPP) may result in a severe impairment of upper limb function, especially when major motor functions do not recover with or without early microsurgical reconstruction. Various methods to restore elbow flexion have been described. The aim of this study was to report the results after pectoralis minor transfer for elbow flexion restoration in late OBPP. METHODS: Nineteen patients were included. Mean age at surgery was six years (range, 2.3-12.8). The mean follow-up period was four years (range, 1-15). Shoulder function was evaluated by the Mallet classification and hand function by the Raimondi scale. We used the "active movement scale" (AMS) to evaluate elbow flexion function. RESULTS: Eighteen of the 19 patients had improvement in their elbow active flexion. There was significant improvement in biceps muscle power according to the BMRC grading system, from an average grading of 1.7 (range, 1-3) pre-operatively to 3 (range, 1-4) post-operatively (P < 0.05). The average active elbow flexion was significantly improved from a mean of 81° (range, 0-120; SD = 44) pre-operatively, most of them gravity eliminated, to a mean of 111° (range, 0-140; SD = 33) post-operatively (P < 0.05). According to the AMS, 12 patients (63%) had a good result, 4 (21%) a fair result and 5 (26%) a poor result. Poor results were significantly correlated with a low pre-operative AMS score (P < 0.05). CONCLUSIONS: The pectoral minor transfer can be a reliable technique for elbow flexion improvement in late OBPP by strengthening an already existing but inadequate active flexion. LEVEL OF EVIDENCE: IV.

Balloon treatment of posterior shoulder dislocation with reverse Hill-Sachs injury: description of a new technique.

PURPOSE: Posterior shoulder dislocations are rare, and are usually the result of seizures. Anterior defects of the humeral head known as "reverse Hill-Sachs lesions" may increase the risk of recurrent dislocation and are difficult to treat. We developed a percutaneous technique for reduction of the dislocation or reduction of the anterior impaction fracture, using percutaneous balloon dilatation and cement fixation. METHODS: From 2009 to 2012, three patients aged 33, 72 and 75 years were admitted to our institution with a posterior shoulder dislocation showing an anterior "reverse Hill-Sachs" impaction fracture. One case was bilateral (four fractures). Patients were operated upon in the sitting position; the humeral head was stabilised by external fixator pins during balloon inflation. Reduction or filling of the defect was obtained in all cases. All patients were followed up and two patients (three fractures) were examined after one year by an independent observer. The clinical results were assessed using the Constant score and the RAND-36 physical components score. A computed tomography (CT) scan was obtained in all patients before and after the operation and at the latest follow-up. RESULTS: At three months postoperatively, all patients had resumed work or daily life activities with no limitation. The mean Constant score was 71 and RAND-36 score was 85.5. After one year, the mean Constant score was 73 and the RAND-36 score was 86.4 for the two patients who had sufficient follow-up. On the postoperative radiograph and CT scan, sphericity of the humeral head was restored, and the reverse Hill-Sachs impaction was filled or reduced in all cases. There was no recurrent dislocation. CONCLUSION: Based on this small series, we believe that this technique should be added to our current armamentarium for posterior shoulder dislocations showing a deep impaction fracture of the humeral head that are at risk for recurrent dislocation.

Arthroscopic Reduction and Fixation With a Knotless Double-Row Construct Provides Good Results for Displaced Greater Tuberosity Fractures.

PURPOSE: The purpose of the study is to describe the functional and structural outcomes of the arthroscopic 4-strand, knotless, double-row construct with suture tapes for the surgical treatment of displaced and/or comminuted greater tuberosity fractures of the humerus. METHODS: Patients were enrolled between December 2012 and January 2018. The main inclusion criteria were a comminuted and/or displaced tuberosity fracture with a displacement of at least 5 mm in any plane fixed under arthroscopy using a 4-strand, knotless, double-row construct. The technique involves reducing the displaced fragment with 2 medially placed, transtendinous anchors and compressing the greater tuberosity using the tapes from these medial anchors in 2 laterally placed anchors. The exclusion criteria were a fracture that was more than 10 days old at the time of surgery or a history of shoulder surgery and 3- or 4-part fractures. The postoperative rehabilitation protocol was similar for all patients. Constant scores, Quick Dash, return to work and sport, and complications were reported after a minimum follow-up period of 24 months. Bone healing was systematically evaluated on standardized radiographs, including lateral scapula view and anteroposterior views. RESULTS: Twenty-one patients were enrolled in this study. One patient did not complete the follow-up examination period and thus was excluded, leaving 20 patients in this study. At a median (SD) follow-up of 32 (9) months, the median (SD) Constant score was 94.7 (7.3) points, the median (SD) Quick Dash was 1.7 (4) points, and median (SD) visual analog scale score was 0.5 (1.4). All patients returned to previous work and sport level. No malunions or nonunions were seen. One conversion to open surgery was required for failure of the lateral row during surgery in a 62-year-old woman with osteopenic bone. Two patients experienced complex regional pain syndrome in the postoperative period that resolved after nonoperative treatment. CONCLUSIONS: In this series, the use of arthroscopy combined with the biomechanical properties of knotless double-row constructs contributed to postoperative satisfactory functional results and healing of greater tuberosity fracture. In addition, range of motion was early, and no hardware removal was required. However, care should be taken with osteopenic bone where anchorage can fail. LEVEL OF EVIDENCE: Level IV, case series.