United Brachial Plexus Network, Inc.

http://www.genengnews.com/news/bnitem.a ... NEWSML.xml

http://www.ejbjs.org/cgi/content/abstract/88/3/564

I am curious. Does anyone know if it makes a difference if it is done in an open surgery vs. arthroscopic?

It makes a great deal of difference whether the surgery is open or arthroscopic. In order to access the capsule in an open procedure, frequently many other muscles and tissues have to be released in order to visualize the joint capsule. This can result in excessive loss of internal rotation. From the paper Rich cited:

"The arthroscopic method and surgical protocol that we
described here differ from previously described open techniques in several ways. As stated previously, early open techniques often required releasing essentially all structures anterior to the glenohumeral joint, beginning with the skin and multiple surrounding muscles, in order to gain exposure and achieve a release. The arthroscopic procedure releases only the capsule and subscapularis tendon, leaving the muscular portion of the subscapularis intact. Additionally, we transferred only the latissimus dorsi tendon, in contrast to techniques in which both the latissimus dorsi and the teres major are transferred together (with sacrifice of part or all of the pectoralis major). Transferring two powerful internal rotators to a position where they function as external rotators and sacrificing as many or more internal rotators, as part of a surgical procedure that also releases the internal rotation contracture, may excessively tip the balance between external rotation and internal rotation power."

Basically, doing the capsule release arthroscopically allows the surgeon to "do the minimum necessary" to releave the internal rotation contracture. An open procedure would require the release of many structures before the capsule itself could even be addressed, and risks excessive loss of internal rotation.

Internal rotation is nearly always lost when the internal rotation contracture and subluxation is resolved in ACR. This is partly because once the subluxation is resolved, the child is still usually left with a glenoid which is retroverted - the socket is basically facing backwards - so the ball is then sitting normally within a misdirected socket. Internal rotation power of the subscapularis is also reduced by it's release. I know that Dr. Kozin now only partially releases the subscapularis whereas in the beginning more of the tendon was released.

Many kids have gradually improving internal rotation as the joint itself normalizes. The simple presence of an internal rotation posture or contracture doesn't necessarily imply that the internal rotation muscles are full strength, just that there is muscle imbalance. The subluxed position "artificially" puts the arm into internal rotation but does not necessarily imply strong internal rotator muscles. Excessive internal rotation losses can result if too many internal rotators are released and the remainder are not strong enough to do the job.

Our son had the ACR with the subscapularis only minimally released, and *still* struggled with internal rotation after the surgery. 1 year later he is doing better... but still does not have full active internal rotation. I shudder to think what his internal rotation would be if we had also released the pec major, latissimus dorsi AND teres major before even getting to the capsule. I'd be willing to be he would have no internal rotation left at all.

Kate

I don't understand what would be loss if no internal rotation left? Is it very serious problem?

Guest:
my daughter has no internal rotation due to a FULL CUT modquad done five years ago. Tons of therapy have not improved this situation. She cannot come to midline, touch her body from chin to mid thigh, put hand on hip, and struggles to get food to her mouth with the affected hand (it requires moving her head to the food). We are now looking at ways to fix this problem but it is a major issue.

We need internal rotation as well as external rotation.

For those kids who have come after Juliana and have the ACR available, I am happy for you.. It sounds like an excellent way to deal wit this problem.

claudia

Anyone know what procedure would be done on a child older than 3 years old or can't this surgery be done after a certain age. I read about the results being for children under 3 years old. If a child is more than 3 would the open procedure be better.

Correction!!

I should have said "SOME internal rotation is nearly always lost" in my above post. Certainly not all!

Kate

Just saw this (thanks Erbs Coolist!):

http://www.genengnews.com/news/bnitem.aspx?name=64713

Kate

Dear Kate - How old was your son when he had the surgery. My son is four and I'm trying to decide some very good but slightly different options.

Dr. Pearl - the pioneer or arthroscopic capsule release - would release the lattisimus dors by an open incision, and release the shoulder capsule arthroscopically and also completely free the subscapularis. And then cast at waist level.

Children's Hospital LA would release the lats and teres major, and partially release the pectoralis and subscapularis through open incision.
They would release the shoulder capsule only arthroscopically. And then cast at shoulder level.

How can you possibly decide which is best? Who did your surgery. Do you know what Dr. Kozin does?

Any thoughts.

Helen

Helen:
email Dr. Kozin. He is very email (as well as personally) friendly. A big decision like this needs to be made after an exam, but perhaps he could just shed some light on things. Or, perhaps you would want to visit him in Philly (I know its a long trip--I did it the other way and saw Pearl; I'm from NY).

Personally, I'd go with the LEAST done. You can always do more. But if you do a lot at the outset, you can't reverse course.

I know how difficult this decision is, we are grappling with a surgery decision for our daughter.

good luck,
claudia