Orthopaedics & Traumatology: Surgery & Research (2012) 98, 199—205
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ORIGINAL ARTICLE
Centering osteotomy for treatment of posteriorshoulder dislocation in obstetrical palsy
P.R. Vilaca Jra,∗,b, M.K. Uezumib, A. Zoppi Filhob,c
a Shoulder and Elbow Group, Associacão Beneficente Nossa Senhora do Pari, Hospital do Pari, Rua Hannemann, 234 São Paulo, SP,Brazilb Brazilian Orthopaedics and Traumatology Society (SBOT), Associacão Beneficente Nossa Senhora do Pari/Hospital do Pari, RuaHannemann, 234 São Paulo, SP, Brazilc Shoulder and Elbow Group, University of Campinas Medical School, Associacão Beneficente Nossa Senhora do Pari/Hospital doPari, Rua Hannemann, 234 São Paulo, SP, Brazil
SummaryBackground: The main objective of this study is to describe a new surgical technique that,through a gleno-humeral approach, reduces the incongruent joint while a humeral head cen-tering osteotomy achieves shoulder stabilization. A humeral medial derotational osteotomy isperformed associated with the articular reduction.Patients and methods: Fourteen patients with obstetrical palsy presenting a posterior humeralhead dislocation were submitted to a centering osteotomy procedure. Our study includedpatients with: (1) more than 1.5 years postoperative follow-up, (2) presence of humeral headposterior dislocation. The exclusion criteria were the following: (1) patients with total flaccidparalysis, (2) low paralysis and (3) any kind of active infection at the time of the procedure.Results: Before treatment, in all patients, the shoulder joint was posteriorly dislocated and ininternal rotation. All patients went on to have successful healing at the osteotomy site. In allcases, an improvement in the functional Mallet scale was observed. In all patients, except one,the posterior dislocation was corrected. In two cases, a second surgery (external derotationosteotomy) was performed to improve the upper extremity’s position.
he shoulder deformities that occur after obstetric palsy
re a consequence of brachial plexus injuries that some-imes can be associated with proximal humeral epiphysisractures. After a few months, a muscle imbalance occurss there is a loss of the external rotators force and a
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redominance of the internal rotators and adductor mus-les. This muscle imbalance forces the humeral head into
posterior position causing an initial subluxation that canvolve to a complete posterior dislocation. This posteriorislocation occurs in 8% of the patients that have proximalumeral deformities and muscle contractures [1].
To this date, there is no consensus as to the best surgicalreatment for these patients. Nonetheless, many proceduresre performed to prevent or to treat these deformities:epair of the brachial plexus, tendon transfers and humeruserotation osteotomy [1—7]. All these procedures have theotential of improving function but none of them act at thehoulder joint that remains incongruent.
Soft tissue procedures are the first option for adduc-ion and medial rotation contractures that do not evolveell with the use of either orthoses or stretching exercises.ubscapularis release provides objective functional benefit,ven if this degrades over time. It is recommended in casef negative external rotation amplitude.
The main objective of this study is to describe a surgi-al technique that, through a gleno-humeral approach, thencongruent joint is reduced and a humeral head center-ng osteotomy achieves shoulder stabilization [8]. A medialerotational humeral osteotomy is performed associatedith the articular reduction.
atients and methods
n the period from February 2001 to November 2009, 14atients with obstetric palsy with posterior humeral headislocation had a centering osteotomy procedure.
Joint incongruence was diagnosed by clinical exam inhich the humeral head was palpated at the posteriorspect of the shoulder, limited external rotation and by theresence of the Putti sign. The Putti sign is present whenhere is an elevation of the upper corner of the scapula whenhe shoulder is passively adducted and externally rotated
ith the elbow in 90◦ of flexion.
In addition to the clinical exam, imaging tests (X-ray andTs or MRI) were also performed (Fig. 1).
igure 1 MRI scan showing a posterior humeral head disloca-ion.
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The modified Mallet’s classification was used to comparere- and postop data. This system is based on five criteria:he ability to actively abduct the arm, the ability to exter-ally rotate the arm, the ability to place the hand behindhe neck as well as behind the back, and the ability to placehe hand over the mouth. Grade I indicates a stiff shoulderr a flail arm. Grade II indicates active abduction of 30◦ oress, no active external rotation, and the inability to placehe hand behind the neck and the mid-portion of the back.he hand is brought to the mouth with the arm in abductionthe trumpeter sign). Grade III indicates active abductionf 30 to 90◦, active external rotation of 20 degrees or less,nd difficulty placing the hand behind the neck and cepha-ad to the sacrum. The hand can be brought to the mouthith slight abduction of the arm (the trumpeter sign). Grade
V indicates active abduction of at least 90◦, active exter-al rotation of more than 20◦, and the ability to place theand behind the neck and over the thoracolumbar regionf the back without difficulty. The hand can be broughto the mouth without abduction of the arm. Grade V indi-ates a clinically normal shoulder. If a patient does not meetll five criteria for a grade, he or she is assigned a lowerrade.
The postop follow-up was 5.8 years (range 1.5—9 years)Table 1).
atients
he patients’ age at the time of surgery was, on average 3.6ears (range: 1.8 to 9-years-old). Nine were male and fiveere female. Six were left shoulders while eight were right
houlders.All patients underwent conservative treatment with
hysiotherapy to gain external rotation and strength beforeurgery.
We included patients with:
more than 1.5 years postoperative follow-up;
Centering osteotomy for treatment of posterior shoulder dislocation in obstetrical palsy 201
• presence of humeral head posterior dislocation associatedwith shoulder internal rotation—adduction contracture.
The exclusion criteria:
• patients with total flaccid paralysis;• low paralysis in which usually there are no shoulder defor-
mities;• any kind of active infection at the time of the procedure.
All patients had joint contracture in adduction and inter-nal rotation produced by the obstetric lesion of the upperpart of the brachial plexus (C5—C6) and simultaneous obstet-ric trauma of the scapulohumeral joint.
Figure 2 Delto-pectoral approach with the upper extremity ininternal rotation and posterior dislocation of the humeral head.
Figure 3 External rotation of the upper extremity and jointr
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urgical technique
he patient is placed in a supine position and a delto-ectoral approach is used. The subscapularis tendon isdentified and its tenotomy with the anterior capsule is per-ormed at the level of the lesser tuberosity so that the jointan be reached (Fig. 2).
The reduction of the humeral head is obtained by exter-al rotation (Fig. 3).
Partial pectoralis major tenotomy can be made ifhere is difficulty for obtaining sufficient external rota-ion. Any tendon transfer is performed associated with thisrocedure.
The humeral head is fixed and centered with a trans-rticular Kirschner wire (Fig. 4). A transverse osteotomy ofhe humerus (Fig. 5) between the insertions of the del-oid and the pectoralis major muscles is performed. Theumerus is internally rotated until the patient’s hand is posi-
ioned over his abdomen and then the osteotomy is fixedith a 1/3 plate and 3.5 screws (Fig. 6). The Kirschnerire is then removed and the reduction is tested in all the
202 P.R. Vilaca Jr et al.
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Figure 5 Humeral transverse osteotomy and complete rota-tion of the upper limb until the abdomen. The joint remains inp
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igure 4 Joint reduction achieved with external rotation andxed temporarily with a Kirchner wire.
houlder’s range of motion, with internal rotations to thebdomen.
The subscapularis tendon is sutured to the humerus lesseruberosity with the arm in 30◦ of external rotation. Afterlosure, the upper limb is immobilized in a thoracobrachialast in 30◦ of external rotation for 4 to 6 weeks, so that theubscapularis tendon is elongated and so that the osteotomyeals (Fig. 7). The thoracobrachial immobilization was madeefore the surgery, in the outpatient clinic, and fitted on theatient in the operating room (OR).
After the immobilization is removed, the patient willtart physical therapy to gain range of motion, strength androprioception.
esults
ll patients went on to have successful healing at thesteotomy site.
In all cases, an improvement in the Mallet scale wasound. The global mallet scale for pre-op measures was 12.3
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range 10 to 16) and for postop measure was 18.3 (range 13o 20) (Table 2).
In all patients, except one, the posterior dislocation wasorrected (Fig. 8). In case 9 in which it was not corrected,
second centering osteotomy surgery was performed alsoith no success. Despite of it, the global Mallet score
mproved from 10 to 14.In two cases, a second surgery (external derotation
steotomy) was performed to improve the upper extremity’sosition. The aggregate Mallet classification score improvedfter the centering osteotomy from 10 to 11 in case 2 androm 11 to 13 in case 10. After the external derotationsteotomy, the same score went from 11 to 13 in case 2nd from 13 to 16 in case 10.
All elements of the modified Mallet classificationemonstrated improvements. External rotation improvedreoperatively from 2 (range 2 to 3 points) to 4 pointsrange, 2 to 4 points) postoperatively. Hand-to-mouth move-ent improved from 2 points (range, 2 to 4 points)
reoperatively to 4 points (range, 2 to 4 points) postopera-ively.
Centering osteotomy for treatment of posterior shoulder dislocation in obstetrical palsy 203
Figure 6 The osteotomy is fixed with a plate and screws. The
Figure 7 The upper limb is immobilized in a thoracobrachialpe
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otbiiEracdren from 10 to 14 years of age as a salvage procedure.Shoulder arthrodesis is indicated after bone maturity in
temporary fixation with K-wire is removed and the subscapularismuscle is re-attached. The joint remains congruent.
Two patients (cases 6, 7) had 9 years of age and, in spiteof this, a good joint reduction and functional improvementwas obtained. The global Mallet score went from 15 to 16 incase 6 and from 10 to 15 in case 7. Although the joint wascongruent after the surgery and there is still some capacityfor bone remodeling, humeral head and glenoid deformitiesstill existed.
The glenoid cavity developed well in all patients exceptin cases 6 and 7 (Fig. 8).
Discussion
A shoulder internal rotation contracture is the most commondeformity found as an obstetric palsy sequelae [2,9]. The
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osition in external rotation so that the subscapularis tendon islongated and so that the osteotomy reaches consolidation.
ubscapularis muscle is the main site of this contracture [10]nd, if this remains throughout the child’s growth, it willause joint deformities [11].
Treatments vary according to the phase of the disease:rthoses and rehabilitation are recommended during ini-ial phases, brachial plexus exploration if there are noiceps muscle recovery after 6 months. Tendon lengthen-ng associated or not with muscle transfers when theres shoulder adduction and internal rotation contracture.xternal derotation osteotomy is used whenever shouldereduction is not possible due to stabilized deformities. Itims to increase upper limb function with no attempt toorrect shoulder dislocation. It is recommended in chil-
igure 8 (Left) pre-op transverse CT scan. Humeral head pos-erior dislocation with dysplastic glenoid. (Right) one year afterurgery, the joint is congruent and the glenoid is more devel-ped.
204 P.R. Vilaca Jr et al.
Table 2 Patients’ status according to Mallet’s classification.
Case Surgical status Abduction External rotation Hand to neck Hand on spine Hand to mouth Global score
1 Pre II II II II II 10Post III III IV III IV 17
2 Pre II II II II II 10Post II II II II III 11Post2 II III II II IV 13
3 Pre III II III II III 13Post II IV IV III IV 17
4 Pre II III II II III 12Post IV IV IV III IV 19
5 Pre IV III III III III 16Post IV IV IV IV IV 20
6 Pre IV II III III IV 16Post IV III III III IV 17
7 Pre II II II II II 10Post III III III III III 15
8 Pre II II II II II 10Post III III IV III IV 16
9 Pre II II II II II 10Post III II II III II 12Post 2 IV III II III II 14
10 Pre III II II II II 11Post III II III II III 13Post 2 IV III III III III 16
11 Pre II II II II II 10Post III IV III III IV 17
12 Pre III II II II II 11Post IV IV IV III IV 19
13 Pre II II II II II 10Post IV IV IV IV IV 20
14 Pre III III II III II 13Post IV IV IV IV IV 20
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atients with painful shoulders caused by joint incongruity8].
Usually, tendon transfers and external derotationsteotomy are recommended for the treatment of theosterior humeral head incongruity that is a consequencef the brachial plexus injury [12—14]. Although theserocedures improve the extremity’s function, they are notble to correct the articular deformities [15].
Soft tissue procedures are the first option for adductionnd medial rotation contractures that do not evolve wellith the use of either orthoses or stretching exercises.
Subscapularis release provides objective functional ben-fit, even if this degrades over time. It is recommendedn case of negative external rotation amplitude. Associated
uscle transfer appears to be recommended [16].Cohen et al. released the subscapularis tendon of 32
atients with obstetric palsy. Twenty of them had poste-ior shoulder dislocation. Residual humeral head posterior
nihI
ubluxation was present in five patients after the procedure16].
The humeral head centering osteotomy achieves shouldertabilization and improves the anterior contractures by theubscapularis tenotomy. As it improves humeral positioning,he improved articular congruency can also improve rangef motion.
Its main objective, as in the newborn hip dysplasia, is toeep the joint centered and reduced so that its developmentccurs as normal as possible.
A medial derotational humeral osteotomy is performedssociated with the articular reduction. There is no fixedalue for the angular derotational osteotomy. The ideal ishat, after reducing the shoulder articulation with the exter-
al rotation maneuver, the humerus is osteotomyzed andnternally rotated until the patient’s hand is positioned overis abdomen. This procedure changes the humeral version.t increases the antetorsion.
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Centering osteotomy for treatment of posterior shoulder dis
Future studies will analyze specifically the humeral andglenoid changes after this procedure.
In addition to the humeral head centering osteotomyother procedures, like tendon transfers and tenotomies canbe performed, once the joint is reduced.
The specific indications for the procedure were: (1) pres-ence of humeral head posterior incongruence dislocation,(2) children with an articular remodeling potential (age lessthan 9 years in our series).
In one case (case 9), the posterior dislocation remainedin spite of two humeral head centering osteotomy surgeries.We believe this was caused by the absence of sufficientactive elbow flexion. Because of this, internal rotation couldnot be blocked by the abdomen and thus exceeded the nor-mal internal rotation range causing a posterior dislocation.Therefore, the absence of active elbow flexion, for exam-ple in a total brachial plexus lesion or an elbow deformityin extension may be a contraindication to a humeral headcentering osteotomy.
The contraindications were:
• any kind of active infection at the time of the procedure;• the absence of active elbow flexion or an elbow deformity
in extension;• total brachial plexus lesion;• destruction of the articular surface (by previous trauma
or infection);• age more than 9 years because the small potential for
articular remodeling.
All patients underwent conservative treatment withphysiotherapy to gain external rotation and strength beforesurgery but there were no articular surface changes withconservative treatment.
The humeral head centering osteotomy is recommendedas soon as articular incongruence is diagnosed. The youngerthe patient, the longer time there will be for the bone toremodel and avoid the articular deformities that occur bythe age of two.
Conclusion
Articular congruency, after posterior dislocations of thehumeral head, is achieved by a humeral head centeringosteotomy in patients with obstetric palsy sequelae and alsoimproves function.
Disclosure of interest
The authors declare that they have no conflicts of interestconcerning this article.
[
tion in obstetrical palsy 205
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