United Brachial Plexus Network, Inc.

"The transition between the triangle tilt and the acromioplasty has always been quite confusing to me. Do you know *when* Dr. Nath stopped doing acromioplasty and started doing triangle tilt?"

Don't know exactly when.
In my opinion, the TT better addresses the winging as well as the dislocation.
And from what I understand, Nath would still do the acromio or caps, even the ACR, if needed. He may prefer TT because he feels the results will be better. I could be wrong in saying that, so don't take it as gospel. Dr. Nath would be the guy to ask.

Didn't you e-mail him about the TT and ACR awhile back?

"The thing is, Dr. Nath recently recommended for the triangle tilt, but I truly question this. All the reasons for having the acromioplasty are the same as why she should have the triangle tilt?!? I thought the acromio was supposed to have fixed these problems. Can't someone please explain why we are having a different surgery suggested for the same set of symptoms? Sorry to sound paranoid... but it is just not making sense to me. "

From what I understand, the TT does a better job at addressing the same issues the acromio did.

The first time Dr. Nath mentioned the TT to us, before he saw the 3D scan, I was skeptical myself. That is not a bad thing - it just means you are looking out for your child and are going to ask the right questions.

Interestingly, Dr. Nath's response to the ACR question on his weblog was to post a "report on one of the first Triangle Tilts I performed, one year after surgery". But the CT scan was taken 5/4/2004, thus Dr. Nath is claiming this first "triangle tilt" was performed in 2003. Why would he put a 1-year post-op of an ACROMIOPLASTY on his weblog as proof for the superiority of the triangle tilt if he wasn't even peforming the "triangle tilt" then?

The triangle tilt has less than a two-year history. Dr. Nath did not start performing these until after he left TCH and began his private practice. As you recall, in the spring of 2004 a bunch of acromioplasties at TCH were cancelled by TCH pending further review. Dr. Nath started doing them again only *after* he left TCH (and it could no longer restrict him from doing them) so that means August of 2004. Sometime after that he renamed the surgery ACPL (acromioclavicular plane leveling) which became "scapular derotation" and eventually "Triangle Tilt". The indications for the acromioplasty, and the explanations for why it worked were compelling but dramatically different than the explanations for how the triangle tilt is supposed to work.

I find myself wondering whether it was the original "overgrowth of the acromion/clavicle" explanation that was perhaps flawed or the "elevated scapula" explanation that is flawed, or both. Either way, the fact that I as a parent can find any particular argument convincing doesn't reassure me at all. I need to see other doctors, with vastly more experience and knowledge, convinced of the physiological basis and results for a surgery before I would choose it for my child. I might be willing to take a "leap of faith" with my own body, since I would be living with the consequences, but for my son... no way!

What disturbs me most is that, even in Dr. Nath's "white paper" on the triangle tilt, he acknowledges that all the patients in the original series had "glenoid hypoplasia" with retroverted and posteriorly displaced glenoids. Yet he has never claimed nor proven that the triangle tilt addresses these underlying malformations of the glenoid in any way. There is growing consensus among BPI specialists that glenohumeral malformation is THE primary cause of subluxation and later loss of function. Yet the triangle tilt doesn't address the glenohumeral joint at all, except to "tighten" the posterior capsule via the capsulodesis. The capsulodesis for dislocation repair has been performed in various permutations for nearly 8 years now. It has demonstrated a very high failure rate over its history (75% according to Dr. Nath), and has never been demonstrated to induce remodelling and normalization of the glenoid, which appears to be critical for maintaining long-term results.

Further, when the acromioplasty first came out, splinting was very short. This was, according to Dr. Nath's webpage on acromioplasty (which is no longer there but I archived it for reference) "Because the bony restriction has been removed, 4-6 weeks is sufficient for healing of the caps. The previous prolonged immobilization was to overcome the restriction from the acromion and clavicle." It sounded like acromioplasty surgery addressed the fundamental cause of dislocation and everything would be just fine after that underlying cause (bony overgrowth) was removed. But apparently that was *not* the case, as we have been seeing increasing splint times again with the caps/triangle tilt (and now a year wearing the splint at night) so it seems that there is *still* something else going on that requires "prolonged immobilization". I am waiting to see what that "something else" is.

I would love it if the triangle tilt solved all the problems that it claims and those improvements were permanent. Given the history of capsulodesis and the evolution of the triangle tilt, however, I think it is reasonable to be skeptical about the longevity of the results and this latest version's ability to fix the underlying problems.

Kate

If the shoulder is in more of a natural position from the triangle tilt or other surgeries, wouldn't that allow for the joint to reform in more of a normal way? Couldn't that be the way that the surgery addresses that problem. I do not know and that is why I am asking. It is interesting to me to get these different perspectives on this because we are deciding on if my child should have this or not.

This may sound stupid but is there anything that the triangle tilt could hurt? It is established that the caps surgery perhaps wasn't the greatest, but did it really hurt anything? I don't want to put my child through anymore surgeries than she needs, but if there is a chance that it would be a good thing for her and we will be out of the appropriate time frame that it should be done in soon, what does it exactly hurt? Why are some people so against it? That is the part I don't understand. Nobody has ever really said why it isn't a good thing. I have heard that other doctors don't do it yet, and this reason and that reason, but no concrete answer. For the people that think this surgery is so bad and are so passionate about proving that, could you pleeeezeee tell me why? I am not arguing, I don't know enough about the surgery yet to argue, I really want to know the information to make a good choice.

According to my pediatrician, who admitedly isn't a specialist in the matter, all of these surgeries are so new that long term results are hard to know. He gave me his opinion as a medical prof. but more importantly as a parent. He said he wouldn't consider surgery for his own child (if they had this injury) unless they had nothing to lose. In other words-if the injury was so severe that the surgery couldn't hurt-even if it didn't help much. I trust my pediatrician completely. He's probably the ONLY dr I trust completely! He's been nothing but 100% honest with us since my son's birth-even when the truth was hard to hear or say for him I'm sure. The thing about him is that he knows he doesn't know everything. That's what's scary about drs. The ones with the egos are the ones you have watch for.

i have another question.....WHY is bpi surgery still in its infancy stage????? this injury has been around for EVER! one would think by year 2006 we would have the results to make an informed decision. i just cannot believe that the doctors are just now getting results. it seems that people are just unaware of bpi & it seems that there should be more for us to go by than simply the ubpn/ do not get me wrong i come HERE for my education! but, PLEASE, i am SHOCKED and frustrated b/c it seems every month or may i say every week we are debating these docs & surgeries. i really wish we could have a bigger voice & MORE data before our children inter the doctors chart books!

There was a recent paper that discussed the results from surgeries from 3o years ago. It actually was not a very uplifting article, because many of the adults that had the muscle transfer surgeries were experiencing many issues around pain and loss of function. I discussed the papers results with our specialist and he said it would be very difficult to read into those results, because the number of patients is very small in this paper and the surgical technique they describe differs from what most that is performed at centers these days.

http://www.findarticles.com/p/articles/ ... 2#continue

This is the paper from Feb. 2005 in the Journal of Bone and Joint Surgery.

Richinma

To the the guest that asked what is so wrong about the surgeries...I am not necessarily against surgery...but I've had major surgery on my knee that was followed by intense physical therepy and I can tell IT'S NO FUN! I wouldn't want to put my child through that unless I was sure it would help him. That's just my opinion. But I think this decision is compeletely individual. Every BPI injury is different in severity as well as what kind of problems the child has, so I wouldn't say that anyone was wrong in their decision for their kid. Again...since their aren't a lot of hard and fast data from these surgeries to go by...we do have to use our "GUT" or just make a decision without enough info. Yes, it's very unfair and so was what happened to our children. But as we all know Life isn't fair. We just have to play the best hand with the cards we got dealt.

Jake's mom, you state your point well. I am not speaking about surgery in general. I am asking about a specific surgery, the triangle tilt, and why some people are so against it, but cannot supply a reason as to WHY.