United Brachial Plexus Network, Inc.

Does the humeral osteotomy give any external rotation?

Has anyone had their child have the osteotomy after the triangle tilt?

Hi,

My son is 3 and he had this surgery, which was his first one, August was one year ago. He was internally rotated quite a bit and had no external rotation. He now has excellent external rotation. We are very pleased with the surgery and are glad we decided to do it. If you have any more questions feel free to ask.

Ashley, mom to Brayden 3 GA

Ashley, who did your son't osteotomy? I live in Alabama, about 1 hour 1/2 west of Atlanta.

Marnie, I learned today that a humeral osteotomy will not help a subluxed shoulder, will not help a biceps tendon contracture.

Maia has a grade level 1 (-1-2-3-4 4=normal) on the mallet scale for everything except reaching to midline which is a 4. So if she has a humeral osteotomy it will give her only one grade level higher and reduce her midline one grade level. And her ability to play her instruments may be at risk although the ranges necessary for the instruments will be measured in advance but it still is at risk.

I don't know if raising up one grade level is worth another surgery that contains risk of losing what she has now. And I wonder what will happen to the internal rotation forces. Will we have to redo this if those forces are still so strong ?

Each child is different, and Maia did not have the triangle tilt. So I hope that this information will just give you the basis for additional questions to ask for Peyton. I also hope that people share any information that they may have about osteotomies as well.

My husband thinks that we should wait until Maia stops growing before she has an osteotomy. I need more data about that - I don't know what to think about that. Part of me wants to make sure that she doesn't grow up with a backwards arm. But the other part of me knows that having so much surgery takes a huge toll on a child.

I'm torn. I'm open to all input available.

Francine:
Osteotomies were always considered the "last resort" because they were done on children whose shoulders did not respond to mq in terms of shoulder subluxation and/or glenoid formation.

I know a number of families whose children were indicated for this surgery, did it, and are supremely happy with the results.

You say that Maia is a 1 for all areas except crossing midline, where she is 4. What is it, exactly, that you are looking for? What is it you want to improve? If you want the shoulder in place, then you need to look to an ACR type surgery....the osteotomy cut is in the humerus above the growth plate-not in the shoulder at all. The kids that I know who had the osteotomy were tremendously internally rotated. The osteotomy put their arm in a more neutral position and allowed them greater use of their arm's function.

Is she functional? Is she happy with her functionality? We know that all the kids express frustration with their limitations, but beyond that...

I would rush to nothing. The changes in bpi surgery really are happening quickly. Just look at all of the things that have changed since Maia had primary, and that was only 8 years ago...pretty amazing.

good luck,
claudia


Message was edited by: claudia

It's too late for Maia to have an ACR. She's 8 1/2 and they stop doing them between 4 & 6. I'm thinking that the age range has something to do with the size of the arm or heaviness of the arm but that's just a guess.

Maia's shoulder is subluxed, she lost a great portion of her humeral head, it dissipated after it cracked from her fall 2 1/2 years ago. Her arm is internally rotated, elbow cocked up and she's lost even the passive range we could get before for supination to neutral. I feel like something should be done before her arm is completely backwards. It emotionally hurts to see her arm in such a bad way. She can't even clap in her compensatory way anymore. We haven't done a surgery in 3 1/2 years so we're not rushing into anything.

I was told today by a local specialist that Maia would only gain 1 grade (mallet). So although you may know a lot of kids who have done really well this was the evaluation as it pertains to Maia.

Maia's not happy to have her arm up in the air all the time. She's not happy that she can't clap. She's not happy that she's lost overhead. But she doesn't want surgery either and if she lost her ability to play her instruments, she would be devastated.

The decisions we have to make ARE tremendously hard. I don't wish this on anyone.

and I don't know about waiting.... can someone tell me that waiting is OK or waiting is NOT OK? does anyone really know what the consequences of waiting are at the specific point we are in?

Francine,

I'm so sorry for what you are going through. I wish that there were more options available for Maia

I think the main thing with the ACR is that you don't want to completely change the forces in the shoulder joint if there isn't enough growth left in the humerus and glenoid for them to remodel back to accomodate the new forces. You could do more harm than good in that case; the joint is now in "equilibrium" - the glenoid and humerus have changed shape to match the unbalanced forces on the joint - so even though the muscles are imbalanced, the joint has compensated so everything "fits" together. Changing that balance (like with the ACR) might actually cause damaging wear because of unbalanced forces on the joint itself.

The osteotomy increases function (to varying degrees), because the humerus is cut between the rotator cuff and the deltoid insertions. The rotator cuff/glenohumeral joint are left alone because they are now in harmony as a unit. The upper arm below the glenohumeral joint but above the deltoid insertion is rotated, which does two things. First, it puts the arm more neutral. Second, it changes the angles of the deltoids over the acromio-clavicular joint, putting them in a more effective position. So it is not *just* about "shifting the range" by derotating the arm, the deltoids also work more effectively after osteotomy.

I truly wish I could be more help in this terribly difficult decision you are facing. We are praying for your family.

Kate

Kate,

First of all, after all the "moments" that you and I have been through since you joined here, I sincerely appreciate how you've helped me out this week and now on here. It's nice to know that it's possible to mend bridges and join together as sisters in this bpi world. Thank you for your kindnesses and keeping this conversation going. It's been very helpful.

I have spoken to a number of parents about the results of their children's osteotomies and the range of results is incredible. I've gotten from "great" to "I didn't notice any change at all" to "we got great results at first and then it went away". Do you know if there is anything in the literature about what causes failures of osteotomies or are there any long term statistics on the results? I know that the humeral osteotomy is probably the longest running bpi surgery ever done but each child's arm/shoulder/muscles/situation is so different. How am I ever going to know if this is the right thing to do and when the right time is (if at all)? My husband is convinced that we shouldn't do anything else until all of her bones have stopped growing. I also understand that you have to have interventions sometimes in order for the bones to grow correctly.

I read what you said about the connection between subluxation and biceps tendon contracture - so now Maia has both. But if we there's nothing we can do to help the shoulder anymore then how will we ever attend to her biceps contracture? She already had the biceps tendon lengthening but she's contracted again. And if we serial cast, will it just come back because she's subluxated? So many questions...

When Maia broke her arm 2 1/2 years ago and lost it all, It was majorly devastating and traumatizing. Even though she's really tough and into so many activities - she has been shaken to the core and is left with extreme anxiety attacks and tremendous fear. I can't step into any kind of intervention for her easily. Every aspect has to be weighed. And she won't allow me to even touch her arm without saying "ouch". I think it's just protection and fear. We are going to have to work through this somehow.

Thanks again for all of your help.
-francine

One more thing -

I wonder if anyone has compiled any information on how each of the specialists does the osteotomy. I already know that some leave the plates/screws in and some don't. But are there other differences that I should be aware of?