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• W3182789976 abstract "Sir: We read with great interest the article entitled “Shoulder Release and Tendon Transfer following Neonatal Brachial Plexus Palsy: Gains, Losses, and Midline Function,” by Adidharma et al. in Plastic and Reconstructive Surgery.1 The authors presented their experience with shoulder reconstruction for persistent deficits from neonatal brachial plexus palsy, in attempts to rebalance internal and external rotators. The authors elected to release the coracohumeral ligament, fractionally lengthen the pectoralis major, and transfer the latissimus dorsi and teres major into the rotator cuff. However, the mean follow-up was only 25 months, despite many authors’ having demonstrated that outcomes continue to change past this period.2–5 This study had a minimum 2-year follow-up period, but studies with similar criteria still had drastically higher mean follow-up periods of more than 5 years,2,3 and some even longer (8.2 years4 and 30 years5) (Table 1). Studies with stepwise evaluation of outcomes showed that range of motion continues to change over time.3–5 This change is most apparent in the graphical representation of temporal changes in range of motion across 5 years presented in the study by Sarac et al.3 The study cited with the longest follow-up period of 30 years went so far as to state that early benefits obtained from surgery dissipated almost entirely over time.5 Table 1. - Follow-Up Periods in Studies of Shoulder Reconstruction for Neonatal Brachial Plexus Palsy* Reference Sample Size (n) Mean Age at Time of Surgery Surgical Technique Follow-Up Period Adidharma et al., 20201 30 45 mo Coracohumeral ligament release and latissimus dorsi + teres major tendon transfer Minimum required 2 yr; mean duration: 2.1 yr (25 mo) Alluri et al., 20202 107 47 mo Latissimus dorsi + teres major tendon transfer Minimum required 2 yr; mean duration: 5.7 yr (68 mo) Sarac et al., 20203 105 48 mo (median) Internal contracture; release ± latissimus dorsi + teres major tendon transfer Minimum required 2 yr; mean duration: 5.3 yr (63.6 mo) El-Gammal et al., 20204 26 36 mo Subscapularis release and teres major tendon transfer Minimum required 5 yr; mean duration: 8.2 yr (98.4 mo) Kirkos et al., 20055 10 72 mo Subscapularis release and latissimus dorsi + teres major tendon transfer Minimum required unspecified; minimum observed: 25 yr (300 mo); mean duration: 30 yr (360 mo) *Adidharma et al.’s study had a minimum 2-year follow-up, but studies with similar criteria still had drastically higher mean follow-up periods. However, we do acknowledge the limited comparability of studies conducted across different institutions. Each institution’s technique and recovery protocol are slightly different. Despite this, there is ample evidence that, regardless of exact technique chosen, the benefits of surgery fade with time. Although we recognize the difficulties of collecting longitudinal uniform patient data, we believe that long-term standardized outcomes are crucial in evaluating the effectiveness and value of shoulder release and tendon transfer following neonatal brachial plexus palsy. To overcome this shortfall, we suggest longer follow-up periods in successive studies with stepwise evaluation of outcomes at set postoperative intervals to better evaluate the lasting effects of surgery. In addition, we ask the authors to comment on the results of Sarac et al.3 At the time of submission of our Letter, there were no published results on combined coracohumeral ligament release with tendon transfer, but Sarac et al.3 have now published their own results. Outcomes at 1 and 5 years postoperatively show that, after 5 years, there is no longer a statistically significant difference in passive external rotation range of motion with the arm in the abducted or adducted position. Do the authors predict the results would be similar in their own patient population if it was followed for a longer period of time? Lastly, we ask authors to further clarify patients’ preoperative status, including prior surgical procedures. What were the results of these patients’ prior surgical procedures and how do the authors account for varying degrees of primary lesion in comparing outcome measures, as well as different outcomes, after primary surgery? We are also unfamiliar with the nomenclature of extended Erb palsy that includes a C8 lesion and would like to hear the authors’ reasoning behind this classification and how they substantiate outcome differences in children with Erb palsy (C5 to C6) with those with total palsy (C5 to T1). DISCLOSURE The authors have no financial interests to disclose. No funding was received for this communication. Jennifer L. Crook, B.A., B.S.University of Tennessee Health ScienceCenter College of Medicine Safak Uygur, M.D.Petros Konofaos, M.D., Ph.D.Department of Plastic SurgeryUniversity of Tennessee Health Science CenterMemphis, Tenn." @default.
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• W3182789976 title "Shoulder Release and Tendon Transfer following Neonatal Brachial Plexus Palsy: Gains, Losses, and Midline Function" @default.
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• W3182789976 doi "https://doi.org/10.1097/prs.0000000000008131" @default.
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