title: Triangle tilt and humeral surgery: Meta-analysis of efficacy and functional outcome.
abstract: OBJECTIVE
  To systematically review and analyze the overall impact and effectiveness of bony surgical procedures, the triangle tilt and humeral surgery in a comparative manner in permanent obstetric brachial plexus injury (OBPI) patients.
  
  
  METHODS
  We conducted a literature search and identified original full research articles of OBPI patients treated with a secondary bony surgery, particularly addressing the limitation of shoulder abduction and functions. Further, we analyzed and compared the efficacy and the surgical outcomes of 9 humeral surgery papers with 179 patients, and 4 of our secondary bony procedure, the triangle tilt surgical papers with 86 patients.
  
  
  RESULTS
  Seven hundred and thirty-one articles were identified, using the search term "brachial plexus" and obstetric or pediatric (246 articles) or neonatal (219 articles) or congenital (188 articles) or "birth palsy" (121 articles). Further, only a few articles were identified using the bony surgery search, osteotomy "brachial plexus" obstetric (35), "humeral osteotomy" and "brachial plexus" (17), and triangle tilt "brachial plexus" (14). Of all, 12 studies reporting pre- and post- operative or improvement in total Mallet functional score were included in this study. Among these, 9 studies reported the humeral surgery and 4 were triangle tilt surgery. We used modified total Mallet functional score in this analysis. Various studies with humeral surgery showed improvement of 1.4, 2.3, 5.0 and 5.6 total Mallet score, whereas the triangle tilt surgery showed improvement of 5.0, 5.5, 6.0 and 6.2.
  
  
  CONCLUSIONS
  The triangle tilt surgery improves on what was achieved by humeral osteotomy in the management of shoulder function in OBPI patients.
authors.affiliation: Rahul K Nath, Chandra Somasundaram, Texas Nerve and Paralysis Institute, Houston, TX 77030, United States.
authors.forename: Rahul K
authors.initials: RK
authors.lastname: Nath
authors.affiliation: Rahul K Nath, Chandra Somasundaram, Texas Nerve and Paralysis Institute, Houston, TX 77030, United States.
authors.forename: Chandra
authors.initials: C
authors.lastname: Somasundaram
keywords: Birth palsy; Humeral osteotomy; Mallet score; Meta-Analysis; Obstetric brachial plexus injury; SHEAR deformity; Shoulder function; Triangle tilt surgery