United Brachial Plexus Network, Inc.

Hi Grandma,

This is my understanding of it all, standard disclaimers apply

The decision is usually made for one or the other based on the child's age and amount of glenoid deformity. If the child is young and the glenoid not hugely deformed, they will do the capsule release (and sometimes also tendon transfers) with the hope that the glenoid will gradually normalize with subsequent growth. The capsule release loosens the tight anterior capsule which these docs believe is primarily responsible for posterior dislocation and malformation of the joint. Usually release of the subscapularis or other internal rotators is also done.

The osteotomy is usually recommended in older children or where the shoulder joint is very malformed. The thought is that it is best to work with an established joint, rather than to fight it. The osteotomy can also increase function considerably because the humerus is cut above the insertion of the deltoid muscles. The lower part of the humerus is "derotated" to a more normal position, and the deltoid muscles themselves are also derotated, providing a better position for them to work.

That said, some doctors do not believe the capsule release is a good idea, and only recommend tendon transfers (relocation of lats and teres major for external rotation and abduction if the joint is well formed) or osteotomy if the joint is malformed. Only time will tell which approach is correct.

Our son had the capsule release only (are doing "wait and see" for tendon transfers) and we hope, of course, that our doctor made the right decision

Kate

Kate,

So let me reiterate to make sure that I understand. Capsule release can be done by itself...or...it can be done with release of subscap and internal rotators...or it can be done with all of the above and tendon transfers?

Joshua had capsule release without release of subscap and internal rotators and tendon transfers?

My local doc mentioned the possibility of doing a lat transfer in the future. She wants to wait and see though how Kanaan progress. He is only 8 mths. I asked her about the anterior capsule release. She said exactly what you are saying...that more than capsule release is done during these joint capsule procedures a lot of times and that she didn't agree necessarily. Without me knowing the details on what is done or why I wasn't able to get any further. I decided to wait until after we got more info and then to go from there...

Do you happen to know why some docs disagree w/capsule release? It seems to make sense to me so far...

Chrystal

Chrystal,

I think more or less of the subscap is usually released with the capsule release; I am not sure if it is *always* released, but I think so. It depends on what is contracted, and how much. Joshua had the capsule release with a moderate release of the subscap.

Some docs only do the capsule release with tendon transfers (lats and teres major) at the same time. Dr. Kozin does either way, depending on the child (younger child like Joshua will do only the capsule and part of subscap release, older child with more fully known recovery will do transfers at the same time or only transfers if the joint looks good). I liked the idea of doing as little as possible, and reserving transfers for the future.

I've heard a few different thoughts from docs on why they don't agree with the capsule release. A weakened anterior capsule is usually responsible for reoccurring shoulder dislocation in "normal" shoulders, and so some docs are understandably worried about intentionally weakening it in BPI kids. There isn't enough long-long term data to say if this is a real concern or not. Some just don't think it works, or don't think there is enough data to say. The surgery has only been around since 1999 on BPI kids, so long-term results are still a ways off.

Kate

Do you have to have a referral to see Dr. Kozin and about how long does it take to get an appointment?

Jana

Jana,

Your best bet is to email Dr. Kozin directly. His direct email and phone are in the UBPN medical directory:

http://ubpn.org/medicalresources/

If he thinks he can help, he'll get you an appointment.

Kate

We took our son Kanaan, 8mo ROPBI to visit Dr. Kozin yesterday. I have never been treated with such care and respect on this BPI journey. Dr. Kozin explained so much to us during our visit. My husband who is normally at every visit but thoroughly confused amongst my questions and conversations with docs (since I'm the one with most of the time to research) came away with a clear understanding of what this injury is and where we are in our journey.

Dr. Kozin confirmed what our local doc has been saying and also told us what our path will look like based on Kanaan's progress. It appears that he is very balanced in his approach - choosing to wait on surgery and look for progress in the child's development but able to help if there should be a need to intervene.

Dr. Kozin's staff was the same. They descended on the room and took turns holding Kanaan whilst introducing themselves to us. What was an examination really felt like a visit. Dr. Kozin reiterated his availability to us via email or phone. I know this is real b/c he willingly emailed me and even called me once BEFORE Kanaan was his patient.

Anyway, I hope our experience helps someone else who has been contemplating visiting him. He was well worth the trip.