JORR
Journal of Orthopedics Research and Rehabilitation

The Journal of Orthopedics Research and Rehabilitation welcomes scholarly papers in orthopaedic surgery, physical therapy and rehabilitation, physiotherapy, neurology and clinic anesthesiology and reanimation.

eISSN: 2980-0560
Creative Commons CC BY-NC-ND 4.0 International License.

Online Manuscript System

Index
Original Article
Age-dependent outcomes of secondary surgical and complementary rehabilitation interventions in children with brachial plexus birth injury: a one-year follow-up study
Abstract
Aims: To determine the one-year functional gain following secondary transfer surgery in children with BPBI and analyse the outcomes in relation to surgical timing and clinical changes over time after rehabilitation.
Methods: Forty-seven children, aged 3 to 18 years, who underwent transfer surgery and completed a 3-month rehabilitation program post-surgery, participated in this study. Active shoulder range of motion and Modified Mallet Scoring were assessed preoperatively and at 3, 6, and 12 months postoperatively. Children were grouped as having surgery younger and older than 7 years old and the results were compared. The repeated measures analysis was completed for comparison, along with post-hoc tests. Cohen’s d formula is used for effect size calculation.
Results: The increase in shoulder flexion, abduction and external rotation was significant for all groups. However, the children having surgery older than 7 years demonstrated greater effect sizes for all shoulder motion ranges except internal rotation at 3-month follow-up while the younger group had higher effect sizes for flexion and abduction at 6-month follow-up. In general, only abduction, internal rotation and hand-to-mouth parameters increase were significant at 12 months follow-up. Additionally, the increase in external rotation started to decrease after 6 months.
Conclusion: The Hoffer technique increased shoulder flexion, abduction, and external rotation regardless of the onset of the surgery. However, hand-to-head function did not increase after 3 months and external rotation started to decrease after 6 months in general. It is important to develop strategies to maintain the gain after surgeries, especially in rotation angles.

Keywords : Brachial plexus, rehabilitation, tendon transfer

Download Article


1. Yang LJ. Neonatal brachial plexus palsy-management and prognostic factors. Semin Perinatol. 2014;38(4):222-234. doi:10.1053/j.semperi.2014.04.009
2. Foad SL, Mehlman CT, Foad MB, Lippert WC. Prognosis following neonatal brachial plexus palsy: an evidence-based review. J Child Orthop. 2009;3(6):459-463. doi:10.1007/s11832-009-0208-3
3. Coroneos CJ, Voineskos SH, Christakis MK, et al. Obstetrical brachial plexus injury (OBPI): Canada’s national clinical practice guideline. BMJ Open. 2017;7(1):e014141. doi:10.1136/bmjopen-2016-014141
4. Daly MC, Bauer AS, Lynch H, Bae DS, Waters PM; Treatment and Outcomes of Brachial Plexus Birth Injury (TOBI) study group. Outcomes of late microsurgical nerve reconstruction for brachial plexus birth injury. J Hand Surg Am. 2020;45(6):555.e1-555.e9. doi:10.1016/j.jhsa.2019.10.036
5. Terzis JK, Kokkalis ZT. Primary and secondary shoulder reconstruction in obstetric brachial plexus palsy. Injury. 2008;39(3):S5-S14. doi:10.1016/j.injury.2008.06.001
6. Javid M, Shahcheraghi GH. Shoulder reconstruction in obstetric brachial plexus palsy in older children via a one-stage release and tendon transfers. J Shoulder Elbow Surg. 2009;18(1):107-113. doi:10.1016/ j.jse.2008.06.013
7. Hulleberg G, Elvrum AK, Brandal M, Vik T. Outcome in adolescence of brachial plexus birth palsy. 69 individuals re-examined after 10-20 years. Acta Orthop. 2014;85(6):633-640. doi:10.3109/17453674.2014.964614
8. Hoffer MM, Wickenden R, Roper B. Brachial plexus birth palsies. Results of tendon transfers to the rotator cuff. J Bone Joint Surg Am. 1978;60(5):691-695.
9. Hale HB, Bae DS, Waters PM. Current concepts in the management of brachial plexus birth palsy. J Hand Surg Am. 2010;35(2):322-331. doi:10. 1016/j.jhsa.2009.11.026
10. Brochard S, Alter K, Damiano D. Shoulder strength profiles in children with and without brachial PLEXUS PALSY. Muscle Nerve. 2014;50(1): 60-66. doi:10.1002/mus.24099
11. Safoury YA, Eldesoky MT, Abutaleb EE, Atteya MR, Gabr AM. Postoperative physical therapy program for latissimus dorsi and teres major tendons transfer to rotator cuff in children with obstetrical brachial plexus injury. Eur J Phys Rehabil Med. 2017;53(2):277-285. doi: 10.23736/S1973-9087.16.03910-1
12. Diop B, Daffe M, Dembele B, et al. Treatment of obstetrical brachial plexus palsy sequelae: preliminary results about 18 cases. Ann Med Surg (Lond). 2022;80:104339. doi:10.1016/j.amsu.2022.104339
13. Bellew M, Kay SP, Webb F, Ward A. Developmental and behavioural outcome in obstetric brachial plexus palsy. J Hand Surg Br. 2000;25(1): 49-51. doi:10.1054/jhsb.1999.0331
14. Bhardwaj P, Varadharajan V, Salyan S, Venkatramani H, Sabapathy SR. Forearm deformities in birth brachial plexus palsy - patient profile and management algorithm. J Hand Surg Asian Pac Vol. 2023;28(6):624-633. doi:10.1142/S2424835523300025
15. Bae DS, Waters PM, Zurakowski D. Reliability of three classification systems measuring active motion in brachial plexus birth palsy. J Bone Joint Surg Am. 2003;85(9):1733-1738. doi:10.2106/00004623-2003090 00-00012
16. Ozben H, Atalar AC, Bilsel K, Demirhan M. Transfer of latissmus dorsi and teres major tendons without subscapularis release for the treatment of obstetrical brachial plexus palsy sequela. J Shoulder Elbow Surg. 2011; 20(8):1265-1274. doi:10.1016/j.jse.2011.01.004
17. Alluri RK, Lightdale-Miric N, Meisel E, et al. Functional outcomes of tendon transfer for brachial plexus birth palsy using the Hoffer technique. Bone Joint J. 2020;102-B(2):246-253. doi:10.1302/0301-620X. 102B2.BJJ-2019-0999.R1
18. Aydin A, Ozkan T, Onel D. Does preoperative abduction value affect functional outcome of combined muscle transfer and release procedures in obstetrical palsy patients with shoulder involvement?. BMC Musculoskelet Disord. 2004;5:25. doi:10.1186/1471-2474-5-25
19. Covey DC, Riordan DC, Milstead ME, Albright JA. Modification of the L’Episcopo procedure for brachial plexus birth palsies. J Bone Joint Surg Br. 1992;74(6):897-901. doi:10.1302/0301-620X.74B6.1447254
20. Riquier-Le Chatelier M, Giai J, Lallement-Dudek P, Herisson O, Fitoussi F. Muscle elasticity in patients with neonatal brachial plexus palsy using shear-wave ultrasound elastography. Preliminary results. J Pediatr Orthop B. 2021;30(4):385-392. doi:10.1097/BPB.0000000000000781
21. Kodama Y, Masuda S, Ohmori T, et al. Response to mechanical properties and physiological challenges of fascia: diagnosis and rehabilitative therapeutic intervention for myofascial system disorders. Bioengineering (Basel). 2023;10(4):474. doi:10.3390/bioengineering10040474
22. Mulla DM, Keir PJ. Neuromuscular control: from a biomechanist’s perspective. Front Sports Act Living. 2023;5:1217009. doi:10.3389/fspor. 2023.1217009
23. Stanev D, Moustakas K. Stiffness modulation of redundant musculoskeletal systems. J Biomechanics. 2019;85:101-107. doi:10.1016/j.jbiomech.2019.01.017
24. Cohen G, Rampal V, Aubart-Cohen F, Seringe R, Wicart P. Brachial plexus birth palsy shoulder deformity treatment using subscapularis release combined to tendons transfer. Orthop Traumatol Surg Res. 2010; 96(4):334-339. doi:10.1016/j.otsr.2010.02.004
25. Werthel JD, Wagner ER, Elhassan BT. Long-term results of latissimus dorsi transfer for internal rotation contracture of the shoulder in patients with obstetric brachial plexus injury. JSES Open Access. 2018;2 (3):159-164. doi:10.1016/j.jses.2018.05.002
26. Soldado F, Fontecha CG, Marotta M, et al. The role of muscle imbalance in the pathogenesis of shoulder contracture after neonatal brachial plexus palsy: a study in a rat model. Journal of Shoulder and Elbow Surgery. 2014;23(7):1003-1009. doi:10.1016/j.jse.2013.09.031
27. Thamer S, Kijak N, Toraih E, Thabet AM, Abdelgawad A. Tendon transfers to restore shoulder function for obstetrical brachial plexus palsy: a systematic review of the literature. JBJS Rev. 2023;11(1):10.2106/JBJS.RVW.22.00165. doi:10.2106/JBJS.RVW.22.00165
28. Delioğlu K, Uzumcugil A, Öztürk E, Bıyık KS, Ozal C, Gunel MK. Cut-off values of internal rotation in the glenohumeral joint for functional tasks in children with brachial plexus birth injury. J Hand Surg Eur Vol. 2023;48(8):738-746. doi:10.1177/17531934231154362
29. Namdari S, Yagnik G, Ebaugh DD, et al. Defining functional shoulder range of motion for activities of daily living. J Shoulder Elbow Surg. 2012;21(9):1177-1183. doi:10.1016/j.jse.2011.07.032
30. Pagnotta A, Haerle M, Gilbert A. Long-term results on abduction and external rotation of the shoulder after latissimus dorsi transfer for sequelae of obstetric palsy. Clin Orthop Relat Res. 2004;(426):199-205. doi:10.1097/01.blo.0000138957.11939.70
31. Herisson O, Maurel N, Diop A, Le Chatelier M, Cambon-Binder A, Fitoussi F. Shoulder and elbow kinematics during the Mallet score in obstetrical brachial plexus palsy. Clinical Biomechanics. 2017;43:1-7. doi:10.1016/j.clinbiomech.2017.01.006
32. Russo SA, Kozin SH, Zlotolow DA, Nicholson KF, Richards JG. Motion necessary to achieve mallet internal rotation positions in children with brachial plexus birth palsy. J Pediatr Orthop. 2019;39(1):14-21. doi:10.1097/BPO.0000000000001010
Article available in :
Volume 4, Issue 1, 2026
Page : 1-7
https://doi.org/10.51271/JORR-0062
Article Information
Received : 22 Tem 2025
Accepted : 11 Eki 2025
Published : 31 Oca 2026
Corresponding Author :

Burcu Semin Akel: Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, İstanbul Kültür University, İstanbul, Turkiye

[email protected]
Citation : Özkan S, Evrendilek H, Berköz Ö, Akel BS. Age-dependent outcomes of secondary surgical and complementary rehabilitation interventions in children with brachial plexus birth injury: a one-year follow-up study. J Orthop Res Rehabil. 2026;4(1):1-7.

Read: 86
Download : 47
Cited: 0
_Footer