United Brachial Plexus Network, Inc.

Has anyone out there had a surgery, by Dr. Nath, to loosen the ligaments in the shoulder area? My daughter, who is 7, had the triangular tilt 7 months ago and although she is responding wonderfully her elbow is beginning to tighten and we don't know why. We saw Dr. Nath a couple of days ago and he mentioned possibly doing this procedure but only if necessary. So he told me he did this for someone and I was wondering if that person was somewhere out here and could give me some insight. Thank you.

I think that is his version of the acr. My son had the triangle tilt, has regressed and Dr. Nath is suggesting doing redoing the triangle tilt along with loosening ligaments at the front of the shoulder, which he said Peyton could lose some midline function along with this procedure which he would then correct with a rerotational osteotomy. Lots to think about. I had another doctor tell me he wouldn't do this with my child at his age (9yo) because of the loss of midline function. Ask lots of questions, ask if your child could lose function from this, what would your child gain from this. How will this procedure affect your child at the current age. How many times has he done this procedure, what are the results? Good luck, keep us posted on what you decide!

For those interested, here is a link of photos of Peyton pre triangle tilt, post triangle tilt, and then some recent photos of him, he had triangle tilt July 2005.
Notice the dates at the bottom of the pictures.

http://pg.photos.yahoo.com/ph/marniehar ... ?.dir=8828

Thank you so much. I so appreciate your reply. I will do everything you say and I will just pray that over the next few months my daughter will improve.

A lot of people choose Dr. Nath because his extensive experience with BPI. But in the area of ACRs, he is certainly not the most experienced surgeon out there. I would suggest getting a second opinion with a surgeon who has done many ACRs on many different kids and who is up to date on the experience of others with this surgery. You might find that someone more experienced with the ACR would not consider your child a good candidate (because of excessive glenoid deformity and age, for instance, which the surgery cannot overcome).

Dr. Nath is not the most experienced surgeon out there when it comes to performing anterior capsule releases. I have heard he now claims that the ACR has always been a part of Mod Quad for its whole history, but this has only recently been asserted. It is news to quite a number of parents whose kids had the Mod Quad at Texas. And the Mod Quad has NOT been shown to improve glenoid malformation, but only reduces or prevents continued malformation (just like other surgeons have found with tendon transfers). Thus, it does NOT sound like the same thing that Pearl/Edgerton/Kozin/Waters/etc do. These surgeons have shown, for instance, that the ACR significantly improves glenoid malformation, it doesn't just prevent it from getting worse.

I am truly glad to see Dr. Nath finally acknowledging that anterior capsule tightness is a major culprit in internal rotation contracture and shoulder joint malformation. But I would still strongly advise anyone considering this surgery with him to get a second opinion. It is not just the technical aspects of doing the surgery itself (along with whether open or closed is better which is a debate in and of itself) but also experience with many patients and solid communication with others who perform this surgery, all which help a surgeon determine which kids are good candidates. The ACR *does* carry risk of internal rotation loss, and only a knowledgeable and experienced surgeon can make a good educated guess on whether or not the risk vs potential gains is worth it for your child.

Kate

I just want to say thank you for taking the time to reply to my post. You have taken time to help me and I so appreciate that. I am lead by faith and motherly instincts and when he mentioned this surgery to me I felt extremely uneasy as I have before about another surgery that my daughter did not have and now never really needed. My daughter is 7 almost 8 months post TT and is doing amazing except for the tighting of the elbow. She is not at all internally rotated since surgery. We stay on top of her. I never for one second believed Dr. Nath when he said this may be her last surgery...he has told me that before. I did however know that this was something she needed and my goodness the results are amazing but we have so sit and watch and see if it stays. So far so good. For the very first time in her 8 years of life...she has visible muscle strength even without a flex. My family and I are hopeful but definately not anxious. You have given me so much information and have definately confirmed what my instinct were telling me...GET A SECOND OPINION. Thank you so much.

I also wanted to point out. Dr Nath ..he didn't seem anxious to do this surgery he wanted to wait to see what she does over the next couple of months. To me that made me feel better that he is not anxious.