title: Arthroscopically assisted Sever-L'Episcopo procedure improves clinical and radiographic outcomes in neonatal brachial plexus palsy patients.
abstract: BACKGROUND
  Muscle pathology resulting in internal rotation contractures in children with neonatal brachial plexus palsy places abnormal stresses on the glenohumeral joint and limits global shoulder function. The objective of this study was to assess the clinical and radiographic outcomes in children treated with an arthroscopic release with or without tendon transfer, the so-called arthroscopically assisted Sever-L'Episcopo procedure.
  
  
  METHODS
  Fifty children with an average age of 5.1 years who underwent an arthroscopic release with or without tendon transfer were retrospectively reviewed. Clinical outcomes were assessed using Mallet classification scores, whereas glenoid retroversion and posterior humeral head subluxation were measured on magnetic resonance images to quantify radiographic outcomes. Mean clinical follow-up was 30 months (range: 24 to 65 mo) and mean radiographic follow-up was 24 months (range: 11 to 42 mo).
  
  
  RESULTS
  Aggregate Mallet score improved significantly from 12.6 to 16.3 (P<0.0001), with shoulder abduction from 3.4 to 3.8 (P=0.0007), shoulder external rotation from 2.2 to 3.3 (P<0.0001), hand-to-neck from 2.3 to 3.2 (P<0.0001), and hand-to-mouth from 2.3 to 3.3 (P<0.0001). Hand-to-spine Mallet score did not significantly change from preoperative (2.4) to postoperative (2.6) (P=0.1348), although 4 patients experienced a loss in internal rotation function. Forty-eight percent of children improved by at least 4 points on the total Mallet score. Glenoid retroversion improved from 25 to 14.1 degrees (P<0.0001) and percent humeral head anterior to the central axis of the scapula increased from 30.5% to 38.8% (P=0.0001). Sixty-seven percent of patients demonstrated glenohumeral joint remodeling on magnetic resonance imaging. No child exhibited a worsening of glenohumeral anatomy.
  
  
  CONCLUSIONS
  An arthroscopic release with or without tendon transfer is effective in reducing internal rotation contractures and increasing global shoulder function. Both clinical and radiographic outcomes were significantly improved at 2-year follow-up. Furthermore, in the majority of children, aggregate, abduction, and external rotation Mallet scores all increased without sacrificing internal rotation.
  
  
  METHODS
  Therapeutic Level IV.
authors.affiliation: Division of Pediatric Orthopaedic Surgery, Cincinnati Children's Brachial Plexus Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA. charles.mehlman@cchmc.org
authors.forename: Charles T
authors.initials: CT
authors.lastname: Mehlman
authors.forename: William B
authors.initials: WB
authors.lastname: DeVoe
authors.forename: William C
authors.initials: WC
authors.lastname: Lippert
authors.forename: Linda J
authors.initials: LJ
authors.lastname: Michaud
authors.forename: Allison J
authors.initials: AJ
authors.lastname: Allgier
authors.forename: Susan L
authors.initials: SL
authors.lastname: Foad
mesh_terms: D001182:Arthroscopy / Q000379:methods*; D020516:Brachial Plexus Neuropathies / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D003286:Contracture / Q000209:etiology / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D008279:Magnetic Resonance Imaging; D008297:Male; D019637:Orthopedic Procedures / Q000379:methods*; D011859:Radiography; D016059:Range of Motion, Articular; D020127:Recovery of Function; D012189:Retrospective Studies; D012785:Shoulder Joint / Q000503:physiopathology / Q000601:surgery; D013709:Tendon Transfer / Q000379:methods; D016896:Treatment Outcome