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Children's Orthopaedics: R. K. Nath, A. B. Lyons, S. E. Melcher, and M. Paizi Surgical correction of the medial rotation contracture in obstetric brachial plexus palsy J Bone Joint Surg Br 2007; 89-B: 1638-1644 [Abstract] [Full text] [PDF]

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Triangle tilt surgery

Abdelouahed AMRANI   (20 May 2009)

Authors' reply:

Rahul K Nath, Andrew B. Lyons, Sonya E. Melcher, and Melia Paizi   (20 April 2009)

Limitations of triangular tilt procedure

Tim EJ Hems, David Sherlock   (20 February 2009)

Triangle tilt surgery 20 May 2009
Abdelouahed AMRANI, Paediatric Orthopaedic Surgeon Children's Hospital - Rabat - Morocco Send letter to journal: Re: Triangle tilt surgery amraniabdel{at}menara.ma Abdelouahed AMRANI	Sir, I read this paper with great interest. I am a paediatric orthopaedic surgeon in Morocco and I have been trained in traditional techniques (nerve grafting, muscle transfer, humeral osteotomy, etc) at a well-known centre in Europe. Recently I have trained in the techniques of triangle tilt and I have had excellent results which are superior to those I achieved previously. I disagree with Hems who suggests that the triangle tilt procedure may offer some improvement for neglected cases of severe posterior subluxation or dislocation of the shoulder, and that more effective management is by reduction of the joint and balancing of muscles around the shoulder as soon as the deformity is recognised. I have experience with cases of humeral head subluxation or dislocation treated only with soft-tissue release and muscle transfer without good results, and since I have started to use triangle tilt surgery I and my patients are very satisfied. In my experience the triangle tilt procedure described by Nath routinely results in improvement of external rotation of the shoulder as well as glenohumeral remodelling at all ages and varying severity of shoulder deformity. There is no other technique I have used that allows this degree of glenohumeral remodelling. A. Amrani, Paediatric Orthopaedic Surgeon, Children's Hospital, Rabat, Morocco.
Authors' reply: 20 April 2009
Rahul K Nath, Surgeon, Director Texas Nerve & Paralysis Institute, Houston, USA, Andrew B. Lyons, Sonya E. Melcher, and Melia Paizi Send letter to journal: Re: Authors' reply: nath{at}drnathmedical.com Rahul K Nath, et al.	Sir, We thank Hems and Sherlock for their interest in our paper and are happy to respond. There are a few points that we would like to emphasise regarding our results and experiences with the triangle tilt surgical approach. Our experiences are based on a patient population of several thousand obstetric brachial plexus patients in the past 12 years. The triangle tilt surgery was developed in response to our finding that scapular deformity is a major component of the glenohumeral deformity seen in the subset of the obstetric brachial plexus population where medial rotation contracture of the shoulder is present.1 Additionally, humeral osteotomy does not address the glenohumeral deformities which according to Birch are the most significant long-term cause of morbidity in these children.2 Professor Birch’s experience has been ours also. Therefore, the triangle tilt surgery was developed to address an unmet need and has been successful in doing so. In our experience, it is effective in improving function and anatomy of the shoulder joint in ways that are not possible with a humeral osteotomy or soft tissue correction alone. Since the publication of the current JBJS [Br] paper, we have further improved the technique. We do have specific responses. In response to the belief that our patients are suffering from untreated posterior dislocation: None of the 40 patients in this study for whom CT or MRI images were available was suffering from dislocation, and the triangle tilt procedure has provided them with functional and anatomical benefits. The patients we treat regularly are, however, suffering from the entire range of shoulder deformity from subluxation through pseudoglenoid formation and frank dislocation. We find that triangle tilt surgery routinely resolves dislocation as well, although there were no patients with dislocation in this reported set of 40. Therefore, our experience has been that triangle tilt surgery is useful throughout the wide range of shoulder deformities seen in the obstetric brachial plexus population and this is confirmed with clinical and statistical measurements of data extracted from large patient populations. In response to the claim that soft tissue procedures are superior: In our experience, the L’Episcopo and Hoffer-type soft tissue procedures do sometimes relieve minor subluxation of the glenohumeral joint, but function is impaired and the end result is routinely unsatisfactory. Our overall experience with these procedures has been poor, especially in regard to the loss of abduction and excessive external rotation that is consistently seen with these operations. In our experience, the modified quad surgery in conjunction with the triangle tilt operation achieves consistent improvements in functional and anatomical status in the patient. We have also used these procedures to reverse inadequate outcomes of the L’Episcopo and Hoffer-type transfers. In response to concerns regarding the age at which this surgery is appropriate: We have seen improved function and glenoid alignment in patients with a range of ages. The study includes children from 2.2 to 10.3 years old, and no statistical difference was seen in the functional improvements experienced by each age group. We agree that significant posterior subluxation can occur by age three months and when present, such deformity should be corrected as early as possible. We routinely achieve functional and anatomical improvements from age six months and even earlier. The youngest patients who have benefited from the triangle tilt surgery were seven months old at the time of surgery. In our study of reversal of failed humeral osteotomy by using triangle tilt surgery, we saw functional gains for patients aged between 7.9 and 11.9 years.3 We agree that the triangle tilt surgery should be considered for more patients whose prior treatment has failed or been neglected. Since humeral osteotomy does not address the glenohumeral deformity that is the greatest cause of morbidity in this patient population,2 it should not be considered as primary treatment for the medial rotation contracture if normalising glenohumeral anatomy is a goal of surgery. We do believe that improving the anatomy of the shoulder is a major goal of surgical treatment. We believe that the triangle tilt operation is an effective primary treatment for bony deformities that coincide with medial rotation even at very early ages. A pre-publication review of recent data for our youngest patients (under four years of age) shows functional and anatomical improvements which appear better than those in older children, presumably because of inherently better osseous plasticity. In response to the critique of the statistical methods used: Although we used a simple t-test, we acknowledge that a non-parametric test may also be used. We revisited our data employing a non-parametric test, and this also shows a statistically significant improvement in function (p<0.0001 for pre- versus post- operative total Mallet score, and a pre- versus post- operative test of all five individual Mallet movement scores, except for abduction with p=0.01). Abduction would not have been improved since this parameter had previously been optimised using the modified quad operation. Our results are therefore the same using both statistical methods. We continue to see in new patients that the hand to mouth movement is the most improved by the triangle tilt surgical approach, and since hand to mouth vectors are completely dependent on glenohumeral congruity, we are gratified to find this to be a consistent outcome after the triangle tilt operation. The improvement in supination is entirely due to improved shoulder position, and this is stated in the paper. We have recently published further on this subject.4 Analysis of this movement is one that we commonly use in younger children who are unable to perform the external rotation movement correctly. Comparison of the movements before and after surgery gives a picture of the change in external rotation. Our assumption is that there is no change in forearm rotation and that all change is due to improvements made at the shoulder level. In the current paper we show before-and-after photographic images of selected patients, and this is one of the few before-and-after photographic demonstrations of results in the obstetric brachial plexus literature. It seems self-evident that photographic evidence is critical in evaluating the results of intervention for movement disorders including the secondary deformities of obstetric brachial plexus injury. The lack of before-and-after visual evidence in the published literature is a significant limitation that should be addressed more widely. Perhaps the results of other operations are not sufficiently compelling. We have made an effort to publish before-and-after photographic data in all of our recent publications and we note that reviewers of such papers state that evaluation of surgical outcomes is objectively more feasible with the use of relevant photographs. Statements by Hems and Sherlock such as “more effective management is by reduction of the joint and balancing of the muscles around the shoulder” are impossible to support when not accompanied by data, statistics or photographs of the results using their techniques. We strongly encourage them to publish their data, including photographs, so that we may see the outcomes of their “more effective management” and compare them with our own results. We therefore currently feel that our results support the use of triangle tilt surgery for the treatment of glenohumeral deformity in the obstetric brachial plexus population. R.K. Nath, MD, A.B. Lyons, BS, S.E. Melcher, MLS, M. Paizi, DSc, Texas Nerve & Paralysis Institute, Houston, Texas, USA 1. Nath RK, Paizi M. Scapular deformity in obstetric brachial plexus palsy: a new finding. Surg Radiol Anat 2007;29:133-40. 2. Birch R. Medial rotation contracture and posterior dislocation of the shoulder. In: Gilbert A, ed. Brachial Plexus Injuries. First ed. London: Martin Dunitz Ltd., 2001:249-9. 3. Nath RK, Melcher SE, Paizi M. Surgical correction of unsuccessful derotational humeral osteotomy in obstetric brachial plexus palsy: evidence of the significance of scapular deformity in the pathophysiology of the medial rotation contracture. J Brachial Plex Peripher Nerve Inj 2006;1:9. 4. Nath RK, Somasundaram C, Melcher SE, Bala M, Wentz MJ. Arm rotated medially with supination - the ARMS variant: description of its surgical correction. BMC Musculoskelet Disord 2009;10:32.
Limitations of triangular tilt procedure 20 February 2009
Tim EJ Hems, Hand and Orthopaedic Surgeon The Victoria Infirmary and the Royal Hospital for Sick Children, Glasgow, David Sherlock Send letter to journal: Re: Limitations of triangular tilt procedure t.e.j.hems{at}doctors.org.uk Tim EJ Hems, et al.	Sir, We read the paper on surgical correction of the medial rotation contracture in obstetric brachial plexus palsy by Nath et al with interest.1 It describes deformity at the shoulder using CT and MRI including a complex deformity of the scapula and clavicle, the SHEAR deformity. The authors propose that, “secondary effects are medial rotation and posterior and inferior subluxation of the humerus in the glenoid fossa”. In addition they state that, “external rotation of the arm and shoulder is limited because of impingement of the distal acromio-clavicular triangle against the humeral head”. There is no evidence presented to support these statements. They report that soft-tissue releases do not correct the medial rotation contracture. The triangular tilt operation is proposed to correct some elements of the deformity of the clavicle and scapula and the medial rotation contracture. It is our impression that the deformities described by Nath et al are those seen in cases of untreated posterior dislocation or severe subluxation of the shoulder and are secondary rather than primary. We would define posterior dislocation of the shoulder as a situation where the humeral head is displaced completely from the true glenoid and lies in a separate 'false' glenoid. In subluxation the glenoid is flattened and retroverted but there are not two distinct facets. Dislocation is usually evident on clinical examination before the age of one year. Subluxation tends to be a more progressive process. Medial rotation contracture can be successfully corrected by contracture releases and tendon transfers providing the shoulder joint is adequately addressed.2 In cases of dislocation the humeral head must be reduced into the true glenoid and, as in the case of developmental dysplasia of the hip, the earlier the reduction is performed the more likely it is that the shoulder joint will develop satisfactorily. The triangular tilt procedure appears to have been carried out at too late an age to be able to alter established deformity and fails to correct the retroversion deformities of the glenoid and humeral neck. While the post-operative CT scans suggest some improvement in posterior subluxation of the humeral head, the case illustrated does not show reduction within the true glenoid. The mean Mallet score improved by 4.9 points. Statistical comparison was carried out using the t-test. A non-parametric test should have been used as the Mallet score is not a continuous variable. Much of the improvement is a result of the improvement in hand to mouth position, which is confirmed by the photographs. This is an interesting finding which deserves further investigation. The photographs suggest a rather limited improvement in external rotation and indeed in the posture of the limb. The improvement in supination is almost certainly secondary to shoulder position and represents a failure to isolate forearm rotation measurements from shoulder position. We would suggest that the triangular tilt procedure may offer some improvement for neglected cases of severe posterior subluxation or dislocation of the shoulder, but more effective management is by reduction of the joint and balancing of muscles around the shoulder as soon as the deformity is recognised. T.E.J. Hems, FRCSEd(Orth), D. Sherlock, DPhil, FRCS, Scottish National Childrens’ Brachial Plexus Injury Service, The Royal Hospital for Sick Children, Yorkhill, Glasgow, UK. 1. Nath RK, Lyons AB, Melcher SE, Paizi M. Surgical correction of the medial rotation contracture in obstetric brachial plexus palsy. J Bone Joint Surg [Br] 2007;89-B:1638–44. 2. Kambhampati SB, Birch R, Cobiella C, Chen L. Posterior subluxation and dislocation of the shoulder in obstetric brachial plexus palsy. J Bone Joint Surg [Br] 2006;88-B:213–9.