United Brachial Plexus Network, Inc.

Kate,

I understand that.

I was making the point that TCH and Nath splinted the 2 surgeries differently, hence the 2 separate surgeries.

Kate, check your mail. I had a question for you.

Bernie, I was referring to this information on his website were he does the ACR with Mod Quad. An ACR procedure was not down when Matthew had Mod Quad at that time we were told the mod quad would correct his internal rotation, he wasn't dislocated at the time of mod quad, that happened later on. Like I said though Matthew had his Mod Quad when he was 18 months old and I was sure things changed. I was just agreeing with Krista's statement about the differences in the surgeries which I should have stated instead of just saying I agree like a blanket statement )

Just curious, how is the splinting when Nath's ACR is done with mod quad?


If yes, is it done alone or along with tendon transfers?
IT IS TYPICALLY DONE AT THE SAME TIME AS TENDON TRANSFERS, (Mod Quad surgery) . I KNOW THAT IN THE PAST, BEFORE I ARRIVED THERE, ACR AND SUBSCAPULARIS LENGTHENING WERE DONE BY THEMSELVES BUT THE RATE OF RE-OPERATION FOR RESIDUAL DEFICITS (THAT THE MOD QUAD ANSWERS) WAS TOO HIGH, SO ACR IS RARELY IF EVER DONE IN MY PRACTICE ON ITS OWN.

So, is the letter to Dr. Nath about the ACR from katep???? I thought your son already had the ACR procedure done, you imply that this procedure was suggested for your son.

I just wanted to chime in and say thank you to all who have participated in this post. I have learned so much and everyone has been respectful of differing views. This is the whole purpose of this site.
Mommy of 3yr LOBPI

If a shoulder joint hasn't formed properly, can the ACR address the shoulder problems? I guess what I am saying is, is there a certain point where it may be too late for the ACR? What issues exactly does the ACR address? My son had the triangle tilt July 2005 and the results were wonderful after surgery, however he has regressed. His arm almost looks and functions like it did prior to surgery. I am not posting this to start a "war" about the triangle tilt, I am just posting our experience and there may be many others who this surgery has worked for, but I am not too sure that it has worked fully for us. What are other options? Anyone doing theratogs with success for internal rotation and supination?

Marnie,

I know Dr. Kozin doesn't do the ACR *unless* the child's shoulder is subluxed and the glenoid is malformed. He does it specifically to address these issues. He may or may not do tendon transfers at the same time, but those are for function. The ACR is for shoulder malformation. If there is no malformation, he doesn't release the capsule. The ACR is, so far, the only surgery that has demonstrated the ability to cause the shoulder joint to form more correctly. Multiple teams are now showing the same kind of results, which is encouraging.

But you are right, there is a point at which it is too late for the ACR to work. There has to be enough growth left, because the shoulder joint has to "grow into" a better formation by converting cartilage to bone in the new position. The ACR puts the ball back in the socket at normalizes the stresses on the capsule so it stays there. With the ball in a better position and the forces balanced, the glenoid grows outward more aligned with the scapula and the humerus develops a more round shape. But if there isn't enough growth left, the joint can't normalize.

That limiting point might depend on how much malformation there is vs how much growth is left. Some recent studies have shown that the joint normalizes significantly over the first year and then gradually improves in subsequent years. If there is a lot of malformation, it will take longer to normalize or may never get there all the way.

Here are some of the latest papers on this subject:

Latest on ACR from Kozin/et al:

http://www.ncbi.nlm.nih.gov/entrez/quer ... med_docsum

Waters' article showing the malformation of the shoulder isn't improved with standard tendon transfers:

http://www.ncbi.nlm.nih.gov/entrez/quer ... s=15687154

Pearl/Edgerton's followup of their ACR results (since 1999):

http://www.ncbi.nlm.nih.gov/entrez/quer ... s=16510824

A paper from an Australian team that I believe perform open ACR but it isn't that clear from the paper. Their MRI/CT scan results look exactly like those I've seen of Kozin patients (including Joshua). Their patients showed significant improvement in glenoid malformation first year, with subsequent continued improvement yearly. Also discussed is the probable "upper age limit" for possible correction of the joint:

http://www.ncbi.nlm.nih.gov/entrez/quer ... med_docsum

A paper discussion the effects of excessive glenoid retroversion on posterior dislocation instability in non-BPI athletes, who have essentially the same problems as BPI kids do with excessive retroversion. Interestingly, they discuss a opening-wedge osteotomy of the scapula neck as a way to correct excessive retroversion. I don't know of any BPI docs who do that surgery, but it sounds like a good possible treatment for excessive glenoid retroversion if it is too late for the ACR:

http://www.ncbi.nlm.nih.gov/entrez/quer ... med_docsum


The arthroscopic ACR has only been around since 1999, so long-term followup is still not available. It remains to be seen how ACR kids respond to adolescence and whether or not results are maintained. But a lot of evidence suggests that shoulder joint malformation is the cause of long-term or late-developing instability of the shoulder. I'll admit, my husband and I are the ultimate in conservative when it comes to choosing surgery. But we knew that Joshua's shoulder was so deformed at only 10 months of age, he would never have a chance at a good recovery with his shoulder joint that bad. We still are not sure if Joshua would benefit from tendon transfers. But I think we have good reason to believe that he will at least keep the function he has now, since he won't be fighting against an unstable joint.

Good luck in your decision!! I hope you find a way to get your child's shoulder function back. Perhaps you might also try asking some BPI docs *and* regular shoulder surgeons if an osteotomy for the glenoid is a possibility, if it turns out your child is too old for the ACR?

Kate

Thanks Kate, this is alot to take in. It also very confusing and hard to understand. I will read the articles over and over though to try to understand. Ugh!

Hi,

We were just recommended that Alyssa have the ACR by Dr. Nath. This is after having the Triangle Tilt back in May 2005. Alyssa's TT only took partially and she too is regressing. I have some serious concerns about the Triangle Tilt surgery. I feel we may have jumped in too soon on Alyssa having it. I am hearing from alot of parent whose kids have regressed. Scares me honestly.

Jody - mom to Alyssa (9) LOBPI

Kate,

Thanks for posting the articles. I'm going through them as we speak.

Tanya in NY
Amber's Mom, ROBPI, 4 years old

Krista do you have a view on whether ACR plus tendon transfer increases abduction or leaves it the same?