Triangle tilt and humeral surgery: Meta-analysis of efficacy and functional outcome

Table 1 Bony surgical procedures and outcomes in obstetric brachial plexus injury patients

Name of thesurgery	Ref.	No. of patients (age at surgery)	Follow-up (yr)	Surgical outcomes
Internal/external rotational/derotational osteotomy of the humerus	Abzug et al[13]	23 patients Mean age 10.1	2.2	13.8 ± 2.8, 16.1 ± 2.5 (P = 0.002), Mallet increased about 2.3
	Al-Qattan[7]	15 patients mean age 6.5	3	Mallet increased about 4.0
	Al-Qattan et al[9]	13 patients mean age 6 (4.5-9)	2	Improved the cosmetic appearance
	Al-Qattan[8]	17 patients mean age 6 (range 8-14) Recalled back to the clinic at a mean of 10 yr (range 8-14) after surgery. Mean age of 16, (range 13-20)	10	Found surprisingly, a significant (P = 0.003) decrease in shoulder abduction on long-term follow-up (the mean shoulder abduction was 135º, 146º and 109º measured pre-, early post- and late postoperatively, respectively)
	Waters et al[1]	16 patients mean age 8.4	3	Mallet improved 9.5 to 15.1 (P < 0.001)
	Waters et al[12]	27 patients mean age 7.6 range 2. 3-17	3.7	Mallet improved13 to 18 (P = 0.01). External rotation achieved with osteotomy was 64° (range, 35° to 90°)
	Pöyhiä et al[15]	5 patients	3.8	Mallet increased about 1.4 (P = 0.1)
	Kirkoset al[14]	22 patients mean age 10.0 age range 5-12	Vary, no mean	Increase in active abduction of the arm was 27 º (range, 0 to 60), and the average increase in the arc of rotation was 25 º (range, 5 to 85)
	Al-Zahrani[6]	12 patients age range 0.5 to 6	3.5 (1-5)	Cosmetic and functional improvement. ER improved 32º (20-40), abduction improved about 61º (60-70).
Relocation of the humerus	Pöyhiä et al[15]	13 patients	3.8	Mallet increased about 5.5 (P = 0.003)
Triangle Tilt surgery	Nath et al[16]	4 patients, mean age 10.2 (range 7.9-11.9)	< 1.0	Mallet improved 12.8 to 18.3 (P < 0.05)
	Nath et al[17]	40 patients, mean age 6.5 (range 2.2-10.3)	1.3	Mallet improved 13.6 to 18.6 (P < 0.000)
	Nath et al[20]	20 patients, mean age 5.0 (range 1.3-13)	1.5	Mallet improved about 6.0 (P < 0.001)
	Nath et al[18]	22 patients, mean age 5.8 (range 2.1-11.8)	5	Mallet improved 14.1 to 20.3 extended long term follow-up (5 yr, P < 0.0001)

Table 2 Improvement in functional score of triangle tilt and humeral surgery

Surgery	Ref.	Total Mallet improved
Humeral osteotomy	Abzug et al[13]	2.3 (P < 0.002)
Humeral osteotomy	Waters et al[1]	5.6 (P < 0.001)
Humeral osteotomy	Waters et al[12]	5.0 (P = 0.01)
Humeral osteotomy	Pöyhiä et al[15]	1.4 (P = 0.1)
Relocation of the humerus	Pöyhiä et al[15]	5.5 (P = 0.003)
Triangle tilt	Nath et al[16]	5.5 (P < 0.05)
Triangle tilt	Nath et al[17]	5.0 (P < 0.000)
Triangle tilt	Nath et al[20]	6.0 (P < 0.001)
Triangle tilt	Nath et al[18]	6.2 (P < 0.0001)

Table 3 Research articles in English only included

Search term	Pubmed	Scopus
“Brachial plexus” obstetric	731	620
“Brachial plexus” pediatric	246	176
“Brachial plexus” neonatal	219	226
“Brachial plexus” congenital	188	259
“Brachial plexus”“birth palsy”	121	115
Bony Surgery search
Osteotomy “brachial plexus” obstetric	35	34
“Humeral osteotomy”“brachial plexus”	17	23
Osteotomy “brachial plexus”“birth palsy”	11	13
Osteotomy “brachial plexus” congenital	8	14
Osteotomy “brachial plexus” pediatric	10	8
Osteotomy “brachial plexus” neonatal	0	3
Triangle tilt “brachial plexus”	14	8

Table 4 Inclusion Criteria

Article parameters	Original full research paper with secondary bony surgical outcome of obstetric brachial plexus injury patients, English language publication, published till December 2013 in PubMed
Treatment options	Surgical-bony, humeral, triangle tilt
Patient age range	9 mo-18 yr old
Functional outcome	Improvement in total Mallet score