Botulinum toxin type A as an adjunct to the surgical treatment of the medial rotation deformity of the shoulder in birth injuries of the brachial plexus.

We retrospectively reviewed 26 patients who underwent reconstruction of the shoulder for a medial rotation contracture after birth injury of the brachial plexus. Of these, 13 patients with a mean age of 5.8 years (2.8 to 12.9) received an injection of botulinum toxin type A into the pectoralis major as a surgical adjunct. They were matched with 13 patients with a mean age of 4.0 years (1.9 to 7.2) who underwent an identical operation before the introduction of botulinum toxin therapy to our unit. Pre-operatively, there was no significant difference (p = 0.093) in the modified Gilbert shoulder scores for the two groups. Post-operatively, the patients who received the botulinum toxin had significantly better Gilbert shoulder scores (p = 0.012) at a mean follow-up of three years (1.5 to 9.8). It appears that botulinum toxin type A produces benefits which are sustained beyond the period for which the toxin is recognised to be active. We suggest that by temporarily weakening some of the power of medial rotation, afferent signals to the brain are reduced and cortical recruitment for the injured nerves is improved.

Outcome after later combined brachial plexus and shoulder surgery after birth trauma.

Of 22 infants aged between 11 and 29 months who underwent a combined reconstruction of the upper brachial plexus and shoulder for the sequelae of a birth injury, 19 were followed up for two or more years. The results were evaluated using a modified Gilbert scale. Three patients required a secondary procedure before follow-up. Three patients had a persistent minor internal rotation contracture. All improved by at least two grades on a modified Gilbert scale.

Perioperative complications associated with brachial plexus repair in infants.

This report details the complications experienced during 100 consecutive cases of brachial plexus surgery in infants. There were eight perioperative complications. There was no mortality or permanent sequelae from any complication.

Studies on the microheterogeneity and in vitro activity of glycosylated and nonglycosylated recombinant human prolactin separated using a novel purification process.

Recombinant human PRL was produced in a murine C127 cell expression system and purified to greater than 97% homogeneity using anion and cation exchange chromatography. This material was biologically equivalent to pituitary-derived PRL in both an enzyme-linked immunosorbent assay and the Nb2 lymphoma cell proliferation assay. The predominant PRL forms were identified by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and immunoblotting as being 23 and 25 kilodaltons (kDa). These mass values were confirmed by electrospray mass spectroscopy. Glycosidase digestions indicated that the 25-kDa PRL is N-glycosylated and sialylated, whereas 23-kDa PRL is nonglycosylated. Glycosylated and nonglycosylated forms of the hormone were individually purified to greater than 95% homogeneity using novel cation exchange chromatography. Isoelectric focusing demonstrated that both forms consist of multiple charge isomers, with the charge heterogeneity of the glycosylated form primarily due to differences in sialylation. Monosaccharide analysis of the glycosylated form suggested a minimal complex oligosaccharide chain that may be fucosylated and partially sialylated. Oligosaccharide mol wt were determined by electrospray ionization mass spectroscopy. Analysis of the oligosaccharides by fluorophore-assisted carbohydrate electrophoresis indicated that bi- and triantennary oligosaccharide forms are predominant and have multiple combinations of terminal sialylation. Both forms of PRL were active in the Nb2 lymphoma cell proliferation assay; however, the 23-kDa nonglycosylated form was 3-4 times more active in this assay than the 25-kDa glycosylated form.

A management approach for secondary shoulder and forearm deformities following obstetrical brachial plexus injury.

This article provides an overview of the historical perspectives of shoulder deformity. Biomechanical considerations are discussed, as well as the authors' personal approach to these types of injuries.

Computed tomographic analysis of pes cavus.

Patterns of muscle degeneration in patients with peripheral neuropathies exhibiting pes cavus deformity were studied by computed tomography (CT). Twenty-six patients attending the muscle disease clinic at Newington Children's Hospital with hereditary sensory motor neuropathies (HSMN) I, II, or III had clinical and radiographic assessment in addition to CT scans of the feet and legs at designated levels. The pattern of muscle degeneration was analyzed with other variables, including age, sex, tibial torsion, cavus, heel varus, and claw toes. Multiple regression/correlation analysis clearly demonstrated earlier and more severe involvement of the intrinsic muscles of the foot as compared with the extrinsic muscles. The most consistent early degeneration occurred in the pedal lumbricals and interossei, which have the most distal innervation. The order of muscle degeneration is a centripetal pattern, with two types of degeneration occurring in the leg muscles: type P patients had earlier degeneration of the leg muscles innervated by the peroneal nerve, and type T patients showed earlier degeneration of those extrinsics innervated by the posterior tibial nerve.

Tips of the trade #30. Constructing a bracket for fixation of supracondylar fractures in children.

Displaced supracondylar fractures in children are best treated with anatomic reduction and percutaneous fixation. Flynn et al first described the pediatric application of a simple holding bracket to facilitate reduction and percutaneous pinning of supracondylar fractures. A similar bracket can be easily constructed with connecting rods and clamps from a Hoffman or an AO external fixator tray.

Bilateral simultaneous achilles tendon ruptures. A case report and review of the literature.

Bilateral simultaneous Achilles tendon ruptures are rare, with only ten cases reported in the English literature. Our case is that of a 44-year-old woman, along with a review of the literature. Affected persons usually are on chronic steroid treatment and in the fifth to seventh decades of life. The patient may have concomitant systemic disease, and the injury occurs with relatively mild trauma. The goals of treatment are mainly preventative, i.e., cessation of steroids as soon as possible and protective bracing of the remaining intact Achilles tendon.