caps surgery description-I know I seen it here somewhere
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Alice--Josh'smom
- Posts: 16
- Joined: Sat Nov 30, 2002 5:53 pm
caps surgery description-I know I seen it here somewhere
Hey all. I know I read it here somewhere the description of what exactly is done in the caps surgery. I thought it was written by Dr. Nath, maybe not. I looked back a few pages but couldnt find it. Anyone remember it, please let me know. Thanks. (still trying to decide if we are going to do it or wait).
Re: caps surgery description-I know I seen it here somewhere
The capsulodesis surgery is relatively new to TCH because of the evolution of
our understanding of this complex injury. Basically, what we believe now is
that the shoulder joint is a very common site of deformity following brachial
plexus injury in developing children. This is probably due to 2 causes: the
muscle imbalances that exist as a result of C5 and C6 nerve injury (the most
common parts of the plexus involved). The muscle imbalances exist because the
deltoid muscle (abductor of the shoulder) and supraspinatus and infraspinatus
muscles (external rotators of the shoulder) are weakened as a result of the C5
injury; this allows the opposing muscles, the latissimus dorsi, the teres
major, the subscapularis, the pectoralis major and minor muscles (adductors
and internal rotators of the shoulder) to become short, tight and scarred
(contractures).
Because the predominant forces are now internal rotation and adduction, the
classic "waiter's tip" posture is seen at birth in many cases. This is the
earliest abnormal posture creating forces that prevent proper formation of the
shoulder joint. In addition, the nerve injury itself causes changes in the
development of bone so that development of the joint may be affected by this
factor as well.
The quad surgery was developed to address the contracture component of this
deformity, and has been very effective in improving abduction as well as
external rotation. However, it is possible that if an advanced degree of
shoulder joint deformity exists at the time of the quad surgery, it will not
reverse the internal rotation deformity completely. This is because the arm
bone (the humerus) is too far out of the area of the joint socket to return
easily even once the contracture is surgically released. Usually, the arm
moves backward (posteriorly) out of the region of the socket (actually, the
socket has not developed, so it cannot really be considered a true socket, but
is just a flattened area where the socket should be). This is known at
"posterior glenohumeral dislocation or instability".
So, even if the contracture component is treated with the quad surgery, we
sometimes need to assist the humerus back into the socket area with a surgery
that pushes the humerus forward and holds it there with a series of stitches
(the capsulodesis surgery). The hope is that this will allow formation at
least of a partial socket because movement directions will be more normal.
As an aside it is often noted that coexistent with the shoulder problem is a
contracture of the biceps tendon. This gives a bent elbow posture that is
surgically repaired if splinting over several months does not help. The biceps
tendon is split lengthwise then allowed to lengthen; it is then sewn together
in its longer position, thus allowing straightening of the elbow.
It is not true that the quad surgery causes the shoulder dislocation. The quad
surgery may unmask an existing shoulder deformity because suddenly there is a
dramatically greater range of motion. Magnification of internal rotation
movements that now noticeable whereas previously this was not the case,
because range of motion was severely restricted due to contractures discussed
above.
In our practice we have seen all possible combinations of shoulder anatomy
from normal position in severe BPI's to complete dislocation without
contractures or the need for any other surgery, including primary. Therefore,
it must be a combination of factors that combine to produce the shoulder
deformity.
If the capsulodesis does not work, or fails after some time, than humeral
osteotomy (cutting the bone and rotating it) will get the arm into the
position we want. However, this does require the use of plates and screws as
well as a significantly visible incision on the arm, so that it is not usually
the preferred first choice for shoulder joint management. We find that the
earlier the quad surgery is done, the less the need for capsulodesis (probably
the contractures are released before permanent changes can occur in the
shoulder joint). And, the earlier the capsulodesis is done, the less the
requirement for osteotomy.
The end goal is the same: to normalize the posture and anatomy of the shoulder
joint components so that shoulder, arm and hand function can be more natural.
The shoulder joint is a complex structure that requires normal nerve supply to
it and to its muscles in order to develop normally. We do not see the shoulder
deformities of children in adults with severe traumatic brachial plexus
injuries, who routinely have the same contracture patterns.
This is a complicated area and I will be happy to provide ongoing explanations
including diagrams as we get them made. If anyone wishes to contact me
directly I am always happy to do so by phone (832) 824-3193 or by email at
rnath@bcm.tmc.edu
our understanding of this complex injury. Basically, what we believe now is
that the shoulder joint is a very common site of deformity following brachial
plexus injury in developing children. This is probably due to 2 causes: the
muscle imbalances that exist as a result of C5 and C6 nerve injury (the most
common parts of the plexus involved). The muscle imbalances exist because the
deltoid muscle (abductor of the shoulder) and supraspinatus and infraspinatus
muscles (external rotators of the shoulder) are weakened as a result of the C5
injury; this allows the opposing muscles, the latissimus dorsi, the teres
major, the subscapularis, the pectoralis major and minor muscles (adductors
and internal rotators of the shoulder) to become short, tight and scarred
(contractures).
Because the predominant forces are now internal rotation and adduction, the
classic "waiter's tip" posture is seen at birth in many cases. This is the
earliest abnormal posture creating forces that prevent proper formation of the
shoulder joint. In addition, the nerve injury itself causes changes in the
development of bone so that development of the joint may be affected by this
factor as well.
The quad surgery was developed to address the contracture component of this
deformity, and has been very effective in improving abduction as well as
external rotation. However, it is possible that if an advanced degree of
shoulder joint deformity exists at the time of the quad surgery, it will not
reverse the internal rotation deformity completely. This is because the arm
bone (the humerus) is too far out of the area of the joint socket to return
easily even once the contracture is surgically released. Usually, the arm
moves backward (posteriorly) out of the region of the socket (actually, the
socket has not developed, so it cannot really be considered a true socket, but
is just a flattened area where the socket should be). This is known at
"posterior glenohumeral dislocation or instability".
So, even if the contracture component is treated with the quad surgery, we
sometimes need to assist the humerus back into the socket area with a surgery
that pushes the humerus forward and holds it there with a series of stitches
(the capsulodesis surgery). The hope is that this will allow formation at
least of a partial socket because movement directions will be more normal.
As an aside it is often noted that coexistent with the shoulder problem is a
contracture of the biceps tendon. This gives a bent elbow posture that is
surgically repaired if splinting over several months does not help. The biceps
tendon is split lengthwise then allowed to lengthen; it is then sewn together
in its longer position, thus allowing straightening of the elbow.
It is not true that the quad surgery causes the shoulder dislocation. The quad
surgery may unmask an existing shoulder deformity because suddenly there is a
dramatically greater range of motion. Magnification of internal rotation
movements that now noticeable whereas previously this was not the case,
because range of motion was severely restricted due to contractures discussed
above.
In our practice we have seen all possible combinations of shoulder anatomy
from normal position in severe BPI's to complete dislocation without
contractures or the need for any other surgery, including primary. Therefore,
it must be a combination of factors that combine to produce the shoulder
deformity.
If the capsulodesis does not work, or fails after some time, than humeral
osteotomy (cutting the bone and rotating it) will get the arm into the
position we want. However, this does require the use of plates and screws as
well as a significantly visible incision on the arm, so that it is not usually
the preferred first choice for shoulder joint management. We find that the
earlier the quad surgery is done, the less the need for capsulodesis (probably
the contractures are released before permanent changes can occur in the
shoulder joint). And, the earlier the capsulodesis is done, the less the
requirement for osteotomy.
The end goal is the same: to normalize the posture and anatomy of the shoulder
joint components so that shoulder, arm and hand function can be more natural.
The shoulder joint is a complex structure that requires normal nerve supply to
it and to its muscles in order to develop normally. We do not see the shoulder
deformities of children in adults with severe traumatic brachial plexus
injuries, who routinely have the same contracture patterns.
This is a complicated area and I will be happy to provide ongoing explanations
including diagrams as we get them made. If anyone wishes to contact me
directly I am always happy to do so by phone (832) 824-3193 or by email at
rnath@bcm.tmc.edu
-
Alice--Josh'smom
- Posts: 16
- Joined: Sat Nov 30, 2002 5:53 pm
Re: caps surgery description-I know I seen it here somewhere
I knew you would have it francine. Thanks a bunch. I'm printing it as I write.
Re: caps surgery description-I know I seen it here somewhere
I have a SAVE THIS folder.... wouldn't lose track of this one!
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admin
- Site Admin
- Posts: 19873
- Joined: Mon Nov 16, 2009 9:59 pm
Re: caps surgery description-I know I seen it here somewhere
How long have TCH been doing the caps surgery? From what I've read about this surgery when used in other settings, there is a very high rate of long term failure, which is apparently why it isn't often done now. I couldn't find that it had been used before in bpi, so maybe it's different. Have TCH found the results are still good long term, or have they not yet been doing it long enough to know for sure whether it works long term? I searched for articles about their results but haven't been able to find any. If anyone knows please post here.
Re: caps surgery description-I know I seen it here somewhere
When I researched this for Maia I found that the capsulodesis procedure has been performed on adults who have *multiple* anterior dislocations. (Because 90% of all humeral dislocations are anterior.) So any long term studies(/high failure rate) on capsulodesis procedure must point to this population (and also because they haven't been doing it too long on kids with bpi)
The majority of our kids have posterior dislocations (on this message board I have only heard of one anterior dislocation and one inferior dislocation), have deformed glenoids, and are having it done right at the age before the tendons get too tough. So this is a totally different set of circumstances.
We were told right up front that it may have to be repeated one more time within two years because of the glenoid/tendon issues. I wouldn't consider that a failure though... it's part of the plan.
I don't know if this helped any...
-francine
The majority of our kids have posterior dislocations (on this message board I have only heard of one anterior dislocation and one inferior dislocation), have deformed glenoids, and are having it done right at the age before the tendons get too tough. So this is a totally different set of circumstances.
We were told right up front that it may have to be repeated one more time within two years because of the glenoid/tendon issues. I wouldn't consider that a failure though... it's part of the plan.
I don't know if this helped any...
-francine