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MISCELLANEOUS Table of Contents   
Year : 2005  |  Volume : 39  |  Issue : 1  |  Page : 45-46
Bipolar release for neglected and relapsed cases of congenital muscular torticollis


Department of Orthopaedics, PGIMER, Chandigarh, India

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   Abstract 

Background: Congenital muscular torticolis is a common congenital problem that on adequate treatment gives very gratifying results. Many treatment modalities can be taken to from non surgical physiotherapy only, surgical releases (unipolar, bipolar) and total excision of the muscle.
Method: Bipolar release of both the inferior and superior heads of sternomastoid muscle was performed in neglected or relapsed cases of torticolis.
Results: Nine cases good results. Only one case had residual head tilt. Four cases had residual facial asymmetry.
Conclusion: Bipolar release is a good method for correcting difficult cases of congenital muscular torticollis

Keywords: Torticollis, Bipolar release.

How to cite this article:
Gill S S, Nagi O N, Gakhar H. Bipolar release for neglected and relapsed cases of congenital muscular torticollis. Indian J Orthop 2005;39:45-6

How to cite this URL:
Gill S S, Nagi O N, Gakhar H. Bipolar release for neglected and relapsed cases of congenital muscular torticollis. Indian J Orthop [serial online] 2005 [cited 2014 Nov 28];39:45-6. Available from: http://www.ijoonline.com/text.asp?2005/39/1/45/36897

   Introduction Top


Congenital muscular torticollis secondary to contracture of sternocleidomastoid is common with an incidence of 0.4% of live births [1] . This demands effort towards management form outside. If that is delayed beyond a certain point in time it needs surgical efforts to correct the deformity [1],[2],[3],[4] . The sequelae are generally cosmetic such as facial asymmetry [1] , residual tight bands [5] , unsightly scars and loss of contour of neck [6] . We report results on 10 cases that were treated by a bipolar release of sternocleidomastoid.


   Method and Material Top


Over a period of 3 years, 10 cases were operated for neglected and post surgical relapsed congenital muscular torticollis. Inclusion criteria was age more than 5 years, neglected cases, persistent deformity after previous surgery and absence of any other congenital malformation

All cases were more than 5 years of age (avg . age 7.5 years). None of the cases had any other congenital deformity, or abnormal fixation of macular vision In all the case there was significant increase in lateral rotation as compared to that present before the surgery. There was reversal of abnormal facies in four cases where as in three cases the facies improved but not completely. There was no case in which there was recurrence of deformity.

In all cases bipolar release was performed i.e. the release of both the inferior (clavicular and sternal) heads and superior (mastoid) head using the Ferkels [7] modified technique. Two incisions were made, one 1 cm above the medial third of clavicle for cosmetic purposes and the other just below the tip of the mastoid process. Adequate release was done for all the contracted soft tissues (fasciae and muscles). Care was taken to protect the facial nerve in the upper incision and the jugular veins in the lower incision. The neck was put through a full range of motion before closure of the wound.

Postoperatively head halter traction was applied for 3 weeks. In between the patient was encouraged for active and active assisted exercises. After 3 weeks traction was applied during the night only. During day the patient was put on a cervical collar. Cases were called for follow up every 3 weeks for 3 months then 6 weekly for the remaining one year. At each follow up visit the patients were assessed for neck range of motion, recurrence of deformity, residual facial asymmetry and any developing visual errors


   Results Top


All the cases achieved significant improvement in lateral rotation than the preoperative phase. Residual head tilt was present in one case. All other cases had no residual deformity at the end of the follow up period. Facial asymmetry that was present before the surgery tended to resolve to a different extent in different cases. In four cases it reverted back to almost normal, whereas in other six cases some residual asymmetry persisted. Scar healing gave problem in only one case that it had a tendency to hypertrophic changes. Overall nine cases had good results and one case fair result.


   Discussion Top


Congential muscular torticollis is an entity on which there are not many published reports from the Indian subcontinent, however there are certain points over which some consensus has been developed over the years. Firstly that congenital muscular torticollis is a fibromatosis that affects the sternocleidomastoid muscle primarily and if left untreated leads to secondary shortening of other soft tissue structures in the neck. Secondly till the age of infancy conservative management in the form of passive stretching may help in the resolution of the deformity. But once there has occurred irreversible formation of contractures in the sternomastoid then only surgical treatment may benefit [4] . Thirdly there are no clear guide lines as to which surgery to do in one index case i.e. clavicular release, mastoid release bipolar release, total muscle excision etc [7] . Ling [5] regarded surgical treatment after 5 years as to be of uncertain value and liable to complications. We have in our small series tried to show in cases that are more that 5 years of age that have not received any treatment or have relapsed after a pervious attempt to corrective surgery, bipolar release is a very viable option and leads to both functional and cosmetic improvement. Surgery in patients more than 10 years was thought to be less rewarding [2],[8] . Our series had only one case more than 10 years that had fair results. She persisted with a residual head tilt and facial asymmetry that had obvious improvement over the preoperative phase.

It can be concluded is that surgical treatment can be safely offered to patients till the age of 12 years with at least less than normal functional and cosmetic improvement. One observation that we would like to highlight is that the perception of facial asymmetry decreased markedly in the immediate postoperative period indicating that whatever the bony changes that occur usually look compounded by the abnormal soft tissue structures.

Bipolar release is a very viable option for correction of neglected and relapsed congenital muscular torticollis. There is a very important role of postoperative head halter traction and long well planned physiotherapy schedule that needs to be closely observed for achieving results.

 
   References Top

1.Coventry MB, Harris LE. Congential muscular torticollis in infancy. Some observation regarding treatment. J Bone Joint Surg [Am] 1959; 41-A: 815-822.  Back to cited text no. 1    
2.Canale ST, Griffin DW, Hubbard CN. Congential muscular torticollis. J Bone Surg 1982; 64-A: 810-816.  Back to cited text no. 2    
3.Staheli LT. Muscular torticollis: late results of operative treatment. Surgery 1971; 9: 469-473.  Back to cited text no. 3    
4.Paul et al. Surgery for neglected congential torticollis. Acta Orthop Scand, 1987; 58: 270-272.  Back to cited text no. 4    
5.Ling CM. The influence of age on the results of open sternomastoid tenotomy in muscular torticollis. Clin Orthop, 1976; 116: 142-148.  Back to cited text no. 5    
6.Hough G den Jr. Congential torticollis. A review and result study. Surg Gynec Obstet. 1934; 58: 972-981.  Back to cited text no. 6    
7.Ferkel RD et al. Muscullar torticollis. A modified surgical approach. J Bone Joint Surg. 1983; 65-A: 894-900.  Back to cited text no. 7    
8.Ippolito E et al. Long term results of open sternomastoid tenotomy for idiopathic muscular torticollis. J Bone Joint Surg 1985; 67-A: 30-38.  Back to cited text no. 8    

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Correspondence Address:
S S Gill
House No 8h/2, sector 12, PGIMER, Chandigarh
India
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    Abstract
    Introduction
    Method and Material
    Results
    Discussion
    References
    Article Figures
 

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