United Brachial Plexus Network, Inc.

Thanks Claudia. I e-mailed Dr. Kozin and he was very helpful. What did you conclude from your consult with Dr. Pearl? What kind of surgery are you looking at? Would love to compare notes. It seems the whole field is progressing so rapidly that even the surgeons at the top of it all have slightly different approaches.

I'm stuck on the abduction issue. Dr. Pearl believes that tendon transfer plus ACR doesn't increase abduction, whereas Dr. Kozin believes it does.

Helen

Kate - do you have a view on whether abduction is increased by ACR/tendon transfer combination.
Some surgeons ( Pearl) believe that there is very little increase - just the appearance of an increase because of increased external rotation.

Others ( Kozin) beleive there is a real increase.

It's hard to know which way to turn.

Helen

Hi Helen,

Sorry to take so long to get to this. I think it depends on how you measure pre-operative abduction really. If you measure abduction as the angle the upper arm makes to the body, as Dr. Pearl does, then I tend to agree that it doesn't really change with surgery. For instance, Joshua had the ACR. He has had oustanding functional results in every way but abduction. His abduction still is limited to about 95 degrees. But if you look at how he postured to get his hand to his mouth pre-surgery, he was able to get his upper arm to about 95 degrees to his body. EXACTLY THE SAME. His deltoids only partly worked before... and they only partly work now.

Furthermore, I've seen so many kids who had really great results from Mod Quad/tendon transfers or ACR who had really dramatic trumpet signs (elbow up to the side posture) when trying to get hand to mouth. These same kids might show very little actual upper arm raising when trying to actually abduct their arm to the side (as in raise the hand up in the air). And guess what? Those kids who had horrific trumpet signs pre-surgery got great abduction FROM surgery!

So I think it really depends on how you measure pre-op abduction, whether or not you'll see much "improvement". I think that is where the disagreement arises. A child who is very internally rotated might "consequentially" get their elbow up very high in an attempt to touch their mouth, nose, or head, and yet barely be able to raise their arm at all if they are trying to reach out to the side for something. If you put pre-op abduction as the maximum angle that upper arm gets to the body, regardless of what it was the child was actually trying to do, then I don't think you are going to see a change post-ACR or tendon transfer. The child is just going to be able to translate that upper-arm-raising-ability to active abduction to the side and it will look different because of the new external rotation. But if you take as the pre-op measurement how high the child can actually reach up and to the side, I think that number WILL significantly improve after surgery. I think both doctors see similar post-operative results, they are just viewing the pre-operative picture differently.

As an aside, I'd love to see someone do a retrospective analysis and see if post-op abduction is correlated to pre-operative trumpet sign. I would be willing to bet that the worse the Mallet score for hand to mouth (ie, the higher that elbow goes up!) prior to surgery, the better the abduction result FROM surgery.

Kate