الفهرس 
ABSTRACT
Aim of the workOnly 14 pages are availabe for public view
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Abstract
Twenty six children are included in this study. All initially had postganglionic C5-6 or C5-7 (Narakas types I and II) OBPP which spontaneously recovered. Children included are those operated at an age older than 1.5 year, who had persistent external rotation weakness with or without internal rotation contracture, non-dysplastic glenohumeral joint and functioning teres major. All had anterior shoulder release and teres major to infraspinatus transfer to correct internal rotation deformity and/or increase active shoulder external rotation. Patients were 18 males and 8 females. The right upper limb was affected in 16 patients and the left in 10. Surgery was performed at an average age of 1.5 years (range one to 10 years). Follow up averaged 7.3 years (range 5 to 16 years). Age at final follow up averaged 8.9 years (range to 6 to 17.8 years). Active shoulder movement were classified with the modified Mallet system. In addition to ranges of shoulder abduction, internal and external rotation are measured with the arm adducted by side and with the arm abducted 90 degrees. Glenoid retroversion and humeral head subluxation were measured according to standardized techniques.
Most authors transferred the teres major and latissimus dorsi as one conjoined tendon to the posterior aspect of the greater tuberosity. The rational for using teres major alone in this series depends on the following; 1, relieving the deltoid (C5) and teres major (C6) co-contraction that occurs following recovery of C5-6 injury 2, preserving the internal rotation action of the latissimus especially when both the subscapularis and pectoralis major are released or lengthened.
The effect of age at surgery on the functional and radiological outcomes was not clear, since all but five cases were operated at an age < 4 years. Our results showed significant improvement of abduction and external rotation, and significant loss of internal rotation 67o (63%), 71.3o (412%), and –32o (-35%), respectively. There was no single recurrence of internal rotation deformity. Global Mallet score averaged 20+2.7. Global abduction and external rotation averaged 3.5+0.8 and 4+0.3, respectively. Majority of children were able to place hand to mouth with an average score of 3.2+1. Shoulder abduction range included an average of 45o glenohumeral (GH) and 65o scapulothoracic (ST) motion. Postoperative internal rotation in adduction was limited to 55.96o+25.65 and was significantly lower that the preoperative value. Only 7 children (26%) were able to reach first sacral spine. Nine children (35%) could touch their abdomen with the wrist in neutral position. The loss of internal rotation could be attributed to opening of the joint capsule while attempting joint relocation, and contracture of the transferred muscle because of the differential growth between the upper humerus and the muscle as it is crossing the upper humeral physis.
soft tissue rebalancing, combined with open reduction when required, prevent significant glenoid retroversion or glenohumeral subluxation as evidenced by absence of significant differences between the operated and normal sides. The alpha angle averaged -4o+8 on the operated side and -2o on the normal side. Posterior humeral head subluxation averaged 40%+15 on the operated side and 43.6%+9.3 on the normal side. None of the radiological measurements correlated with the age at surgery, length of follow up, shoulder range of motion or global Mallet score.
Conclusions
Although the current study includes only a subset of patients that were previously reported in 2006, the long term results demonstrated significant loss of internal rotation that could be attributed to contracture of the transferred muscle with continued growth of the upper humerus, periarticular adhesions, and progressive disuse. The difference in glenoid version and humeral head subluxation continued to be insignificant compared to the normal side.
Recommendations for the future
Recently, we have adopted some modifications of the technique to avoid internal rotation deficiency. The lower fibers of the subscapularis and the anterior capsule should be preserved if possible, the transferred muscle is sutured to the tendon of infraspinatus and not necessarily anchored into the greater tuberosity to avoid muscle overstretching, and the arm is immobilized in 60o instead of 90o to avoid adhesions around the coracoid. If internal rotation deficiency persists despite physiotherapy, internal rotation osteotomy of the humerus is performed to allow easy placement of the hand to the abdomen.
Limitations of the study
The limitations of this study include the unequal distribution of the age groups at which the patients were operated, which made determining the effect of age on the various postoperative parameters equivocal, and the absence of preoperative MRI documentation of secondary bone changes, which made us unable to conclude the remodeling ability of the glenoid after joint reduction and tendon transfer