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

Abstract

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.

The natural history and management of brachial plexus birth palsy

“…In particular, it has been used following closed reduction and casting of the shoulder to facilitate external rotation and prevent glenohumeral dysplasia and need for reconstructive shoulder surgery [7576•]. Additionally, botulinum toxin has been used to prevent post-operative contractures [77]. The efficacy of botulinum toxin remains unclear.…”

Current Concepts in the Management of Brachial Plexus Birth Palsy

“…It has been used to prevent contractures in the immediate postoperative period after microsurgery. 29,71,72 It has been used with serial casting as an adjunct to physical therapy. 73,74 The effect of the toxin is to reduce muscle tone and force to restore passive range of motion and joint alignment.…”

External Rotation Predicts Outcomes After Closed Glenohumeral Joint Reduction With Botulinum Toxin Type A in Brachial Plexus Birth Palsy

“…33,34 This may explain why some series demonstrate functional improvements beyond the established 3 to 4 months of therapeutic efficacy of BTX-A. 7 Ezaki et al 4 endorsed the use of BTX-A as an adjunct to closed reduction of subluxed glenohumeral joints in children with BPBP. In a series of 35 patients followed for a minimum of 1 year, 69% maintained reduction after receiving BTX-A to the shoulder internal rotators during closed reduction and casting.…”

“…Patients with incomplete medical records or <1-year follow-up were excluded. [5][6][7] Patients with concomitant or prior shoulder surgery, or microsurgery within 8 months, 5 were excluded. Two patients underwent repeat closed reductions and only their initial attempts were included.…”