Supraspinatus Slide and Puttiectomy to Manage Shoulder Abduction Contracture Due to Brachial Plexus Birth Injury

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Background: Shoulder abduction contracture is present in a high proportion of children with brachial plexus birth injury (BPBI). An esthetic concern that at least some patients with this condition express is prominence of the superomedial scapular angle (Putti sign). Surgical reduction of the glenohumeral joint to improve internal rotation contracture may worsen abduction contracture. The aims of this study were to document that worsening and to test whether supraspinatus slide can decrease abduction contracture without unacceptably weakening shoulder abduction. Methods: This study was a retrospective review of BPBI patients with Waters grade III to V glenohumeral dysplasia who underwent supraspinatus slide with or without resection of the prominent superomedial angle of the scapula (“Puttiectomy”) as adjuncts of combined subscapularis slide, open glenohumeral reduction, glenoid anteversion osteotomy, and tendon transfers. Abduction contracture was defined as the brachiothoracic angle with the shoulder in maximal passive adduction measured using a goniometer. Measurements were taken preoperatively, after glenohumeral reduction and after supraspinatus slide. One-way repeated measures analysis of variance (ANOVA) was used to determine mean differences at preoperative, postreduction, and postsupraspinatus slide periods. Results: Twenty-seven patients were included in the study. The average age at surgery was 9.0 years (SE = 0.8 y) and the preoperative distribution of Waters classification was the following: Type III in 5 patients (19%), Type IV in 6 (22%), and Type V in 16 (59%). Intraoperative reduction of the glenohumeral joint immediately worsened abduction contracture from a preoperative mean of 27° (SE = 17) to 51° (SE = 20, p < 0.0001). Supraspinatus slide improved the abduction contracture to 20° (SE = 14, p < 0.001). In 22 patients (82%), a subjective decision to improve cosmesis by Puttiectomy was made despite the contracture improvement. Active abduction remained stable before (161° ±30°) and after (160° ±29°, p = 0.9) surgery. Conclusions: Abduction contracture associated with glenohumeral dysplasia worsens with joint reduction. Supraspinatus slide can mitigate worsening of abduction contracture to near-baseline severity without diminishing shoulder abduction power. Level of Evidence: Level IV . See Instructions for Authors for a complete description of levels of evidence.

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