Congenital pseudarthrosis of the ulna

Vascularized Growth Plate Transfer in Paediatric Ulna Non-Union: Operative Technique and Review of the Literature

Congenital pseudarthrosis of forearm fractures is rare and is strongly associated with neurofibromatosis type 1 (NF1). Our case report illustrates the progression of a non-union of the ulna after minor trauma in a twelve-year-old boy, newly diagnosed with NF1, and presents the technique of microsurgical bone reconstruction, including the growth plate. More than seven years after the first operation, follow-up presents a favorable outcome with a pain-free patient and unrestricted function of the forearm after a secondary correction of the remaining radial bowing. This treatment is discussed with a comprehensive review of the current literature on ulnar congenital pseudarthrosis in PubMed and Google Scholar and free fibular growth plate transfer in PubMed and Google Scholar. Nine publications reporting on 20 cases of congenital ulnar non-unions were identified. With this reconstructive option, favorable outcomes were achieved in all cases with the union after primary surgery and complications requiring further surgeries in nine cases. The benefit of vascularized growth plate bone transfer in congenital ulna non-union seems to be significant compared to other therapies such as open reduction internal fixation (ORIF), non-vascularized bone grafts, or one-bone-forearms and beneficial when growth reconstruction is needed. Other techniques might be necessary to improve insufficient long-term results.

Microsurgery in pediatric upper limb reconstructions: An overview

The use of microsurgery has spread during the last decades, making resolvable many complex defects considered hitherto inapproachable. Although the small vessel diameter in children was initially considered a technical limitation, the increase in microsurgical expertise over the past three decades allowed us to manage many pediatric conditions by means of free tissue transfers. Pediatric microsurgery has been shown to be feasible, gaining a prominent place in the treatment of children affected by limb malformations, tumors, nerve injuries, and post-traumatic defects. The aim of this current concepts review is to describe the more frequent pediatric upper limb conditions in which the use of microsurgical reconstructions should be considered in the range of treatment options.

Congenital pseudarthrosis of the forearm as a single manifestation of neurofibromatosis type 1 at birth: A case report

Congenital pseudoarthrosis of the forearm is an extremely rare condition. It is most commonly associated with neurofibromatosis type I (NF1). Patients with NF1-associated pseudoarthrosis have complex medical management and often require surgical intervention due to higher failure rates of union. In this case report, we present a unique case of a newborn baby with congenital pseudoarthrosis of both the radius and ulna that was manifested at birth and shortly thereafter, was diagnosed with NF type 1.

Congenital pseudarthrosis of the forearm treated with induced membrane technique: A case report

Congenital pseudarthrosis of the forearm (CPF) is an uncommon entity frequently described in association with neurofibromatosis type 1. Surgical treatment Is required. This is a challenging pathology in pediatric orthopedic surgery due to the difficulty of achieving a satisfying result in terms of bone defect healing. Many techniques are described such us free vascularized fibula, illizarov and induced membrane. We describe a first case of the forearm non union associated with neurofibromatosis type 1 successfully treated with 2 steps of induced membrane. Whatever the technique selected it's remain challenging problem in pediatric orthopaedic.

Congenital pseudoarthrosis of the radius in Neurofibromatosis Type 1: An entity not to be missed!

Congenital pseudoarthrosis of the radius is exceedingly rare. We report an isolated pseudoarthrosis of the radius in a five-year-old girl child with Neurofibromatosis type-I (NF-I). She underwent excision of the pseudoarthrosis tissue, ulna osteotomy, iliac crest cortico-cancellous bone grafting, and K wire fixation of both bones. A sound union of the radius and the ulna was achieved after 4 months. At two-year follow-up, mild shortening of the forearm persisted with maintenance of sound union of both bones. Accurate diagnosis of the condition is central in avoiding complications and the need for complex surgical procedures.

Congenital Forearm Pseudarthrosis, a Systematic Review for a Treatment Algorithm on a Rare Condition

BACKGROUND

A congenital forearm pseudarthrosis is a rare condition and is strongly associated with neurofibromatosis type 1. Several surgical techniques are described in the literature, but the most optimal treatment strategy remains unclear. This systematic review aims to develop a treatment algorithm that may aid in clinical decision making.

METHODS

The PROSPERO registration number for this study was CRD42018099602 and adheres to the PRISMA guidelines for systematic reviews. Embase, MEDLINE, Cochrane Central, Web of Science, and Google Scholar databases were searched for published studies reporting on congenital forearm pseudarthrosis not related to other underlying pathologies like bacterial infection or fibrous dysplasia. Results were not restricted by date or study type, only English literature was allowed. Studies were assessed for quality using the critical appraisal checklist for case reports from the Joanna Briggs Institute. Patient characteristics, underlying disease, type of surgery, union rate, and functional outcome were extracted from included studies.

RESULTS

Of 829 studies identified, 47 were included in this review (17 case series and 30 case reports, a total of 84 cases). A one-bone forearm procedure showed highest union rates (92%), however, it results in loss of forearm rotation. Free vascularized fibula grafting showed high union rates (87%) and was related to good functional outcome of elbow flexion and forearm rotations. Other procedures showed disappointing outcomes.

CONCLUSIONS

Congenital forearm pseudarthrosis is best treated with a free vascularized fibula grafting, a one-bone forearm procedure should be used as a salvage procedure. Evidence extracted from the case reports was sufficient to generate a treatment algorithm to be used in clinical pediatric practice.

LEVEL OF EVIDENCE

Level IV-therapeutic.

Congenital deficiency of distal ulna and dislocation of the radial head treated by single bone forearm procedure

Congenital deficiency of part of distal ulna affecting the distal radio-ulnar joint is a rare disorder. It is even rarer to find the association of proximal radio-ulnar joint dislocation along with distal ulnar deficiency. This type of congenital forearm anomaly is difficult to treat. Conversion to a single bone forearm in the expense of pronation-supination movement is a viable option. By doing so the elbow and wrist can be stabilized; however movement is possible in only one plane. We are describing here a girl of 8 years having proximal radio-ulnar joint dislocation along with deficiency of distal ulna treated by converting into a single bone forearm.

Free vascularized fibular transfer with langenskiöld procedure for the treatment of congenital pseudarthrosis of the forearm

Congenital pseudarthrosis of the radius or ulna is a rare entity. It is associated with neurofibromatosis, but occurs much less commonly than congenital pseudarthrosis of the tibia. Pseudarthrosis of the forearm can lead to pain, deformity, and limited forearm rotation. Nonsurgical management leads to poor results, as do surgical treatments such as open reduction internal fixation and conventional bone grafting. The transfer of a free vascularized fibula to the forearm pseudarthrosis has been more successful, and it is our preferred method of treatment for children with this condition. Because the transfer is often performed in young children, there is the potential for valgus deformity at the ankle after the fibula is removed. We describe here our technique for the transfer, including the technique for distal tibiofibular fusion (Langenskiöld procedure) after removal of the fibular graft. In addition, we present the results of 5 patients who have undergone this combination of procedures for pseudarthrosis of the forearm at our institution.

One-bone forearm procedure for acquired pseudoarthrosis of the ulna combined with radial head dislocation in a child: a case with 20 years follow-up

This report describes a 6 year-old boy who was treated with one-bone forearm procedure for acquired pseudoarthrosis of the ulna combined with radial head dislocation after radical ulna debridement for osteomyelitis. At more than 20 years of follow-up, the patient had a nearly full range of elbow movements with a few additional surgical procedures. Pronation and supination was restricted by 45°, but the patient had near-normal elbow and hand functions without the restriction of any daily living activity. This case shows that one-bone forearm formation is a reasonable option for forearm stability in longstanding pseudoarthrosis of the ulna with radial head dislocation in a child.

[Vascularized bone transfer of scapula apophysis]

The vascularized bone transfer of the scapular apophysis was described for the first time by Gilbert and Téot (1982) [1]. The growing pattern of this specific apophysis has large capacity and the plasticity during remodeling is unique. Primarily used for mandibular reconstruction, the scapular crest is also suitable for humeral or femoral reconstruction as well as for carpal stabilization in radial hand malformation, which is considered to be the main clinical indication. The radial hand malformation is characterized by an insufficient ulnar carpal stabilization which leads to luxation and radial deviation of the carpus. Using the vascularized scapular transfer in volar apposition to the ulnar, it enables enlarging the contact surface area with the carpus, thus stabilizing the wrist. Due to the preserved epiphyseal vascularization, good remodeling and integration of the scapular crest is achieved until consolidation takes place.

Congenital pseudarthrosis of the radius treated with gradual distraction and free vascularized fibular graft: case report

Only 18 cases of congenital radial pseudarthrosis have been reported in the English literature; of these, 4 have been treated with free vascularized fibular graft. We present a case of a 9-year-old female patient with neurofibromatosis type 1 who underwent gradual distraction through the pseudarthrosis site and subsequent vascularized fibular grafting for isolated congenital pseudarthrosis of her left radius and concomitant longitudinal and angular deformity of the wrist joint. At the last follow-up, 10 years postoperatively, the patient has maintained bony union, with full wrist flexion-extension and forearm pronation-supination.

Free vascularized fibular flap for congenital ulnar pseudarthrosis: a report of two cases and review of the literature

Congenital pseudarthrosis of the ulna (CPU) is an extremely rare disorder that has been treated with various traditional methods with poor results on long-term deformity correction and bony union. Free vascularized fibular grafting (FVFG) has been used to treat congenital pseudarthroses with improved success rates. We report herein 2 cases of CPU treated with FVFG in which bone union was obtained without major difficulty. The distal ulnar hypoplastic physis and epiphysis were spared during excision of the pseudarthrosis in both cases leading to continuous ulnar growth following bone healing. The main challenge concerned the stability of the radiocapitellar joint. There was no complication at the donor site. Free vascularized fibula is a safe and effective method for the treatment of congenital pseudarthrosis of the ulna.

Congenital bilateral pseudarthrosis of the index metacarpal bones

Congenital pseudarthrosis is very rare in upper extremity, and has only previously been reported in the forearm. A case of bilateral congenital pseudarthrosis of the index metacarpal bones is described.

Congenital pseudarthrosis of the ulna

We report a case of congenital pseudarthrosis of the ulna along with generalized neurofibromatosis (type I). The patient had a good clinical outcome after single-bone forearm reconstruction. In the setting of radial head dislocation following long-standing congenital pseudarthrosis of the ulna, single-bone forearm reconstruction is a viable option. It prevents the loss of hand function by the effective shortening of flexor tendons and spares movements of the humeroulnar and radiocarpal joints.

Use of free vascularized fibular graft for congenital ulnar pseudarthrosis: surgical decision making in the growing child

Congenital pseudarthrosis of the ulna may cause growth disturbance and progressive forearm deformity, leading to functional compromise of the upper extremity. Treatment is challenging, and surgical decision making must take into account three goals of treatment: bony healing, distal radioulnar joint (DRUJ) stability, and continued skeletal growth. Four cases of congenital ulnar pseudarthrosis treated with free vascularized fibular graft are presented here. In two cases, the vascularized fibular graft included the proximal fibular epiphysis to reconstruct the DRUJ and ulnocarpal joints. Average age of the four patients at time of vascularized fibular grafting was 10 years (range 3-16 years). Patients had undergone up to three previous failed operations. A step-cut osteotomy technique with rigid internal fixation was used in all patients. Donor-site distal tibiofibular arthrodesis was performed in skeletally immature patients when appropriate. At average follow-up of 60 months (range 33-83 months), all patients achieved bony union with full wrist range of motion compared with the contralateral extremity. The DRUJ was stable in all patients. Two skeletally immature patients with concomitant epiphyseal transfer showed continued skeletal growth. Two patients nearing skeletal maturity achieved revascularization of the distal ulna. Free vascularized fibular grafting is a successful option in the treatment of congenital ulnar pseudarthrosis. Reconstruction of the distal radioulnar and ulnocarpal joints using concomitant proximal fibular epiphyseal transfer should be considered in the skeletally immature patient with distal ulnar involvement.

Pseudarthrose congénitale de l’avant-bras associée à la neurofibromatose

We report a case of congenital pseudarthrosis of the forearm associated with neurofibromatosis type 1 which was treated by free vascularized periosteal flap transplant and repeated bone grafting. The young female patient recovered good hand and forearm function. A review of the literature revealed the rare occurrence of this disease (approximately 100 cases reported to date), which probably explains the wide variety of surgical proposals.

History of hand surgery in Hong Kong

The development of hand surgery in Hong Kong can be largely divided into three phases: the early years, the 1960s and 70s, and the present. In the immediate post-World War II years, incidence of infectious diseases was high; there were many patients with tuberculosis, poliomyelitis, leprosy and osteomyelitis. In the 1960s and 70s, the light industry revolution brought along many patients with serious hand injuries caused by machines. Dr Yen-Shui Tsao was the first local surgeon trained in hand surgery. Prof. SP Chow and Prof. PC Leung were the two pioneers who developed this subspecialty and microsurgery during that period.

At present, with the change in economic environment, the disease pattern has also changed. Despite our heavy clinical involvement, we have been very active in academic researches. The Hong Kong Society for Surgery of Hand was formed in 1986. For the past 15 years, the society organized Workshops and Annual Congresses attended by overseas speakers, including surgeons from China. It also provided scholarships for Fellows of the Asia-Pacific countries. In addition, the society provided the participants with the chance to exchange ideas and forge friendships. Hong Kong has thus been and will continue to be the meeting point of the East and the West.

Congenital pseudarthrosis of the ulna treated by free vascularized fibular graft--a case report

Congenital pseudarthrosis of the ulna is very rare. We have experienced a case of pseudarthrosis of ulna to be treated with the vascularized fibular graft in a seven-years-and-three-month-old boy.

Congenital pseudarthrosis of the forearm treated by free vascularized fibular graft: a report of three cases and a review of the literature

Congenital pseudarthrosis of the forearm is a rare condition; approximately 60 cases have been reported in the English literature. We report 3 patients treated by wide excision of the pseudarthrosis and free vascularized fibular grafting. The pseudarthrosis involved the radius in 1 patient and the ulna in 2. Neurofibromatosis was present in 2 patients. The technical problems encountered during the procedures included preservation of the distal epiphysis and attaining stable fixation of the fibular graft without damaging its vascular supply. A review of 15 previously reported patients treated by free vascularized fibular grafting showed that this procedure is excellent in the treatment of congenital pseudarthrosis of the forearm and that the result is consistently reproducible.

Lengthening of a one-bone forearm. A sequel of neonatal osteomyelitis

An 8-year-old girl presented with marked shortening of the right forearm due to destruction of both the radius and ulna secondary to neonatal osteomyelitis. A one-bone forearm operation was performed to achieve a stable forearm. Two years later, the one-bone forearm was lengthened for 6 months by callus distraction (callotasis) achieving 12 cm of extra length. The patient was last followed up at the age of 16. The appearance and functional outcome of the right upper limb had been improved and she was independent in all activities of daily living.

[Reconstruction of the loss of bone substance of the forearm by cubitalization of the radius (one bone forearm). Apropos of 6 cases]

Extensive forearm bone loss, whatever its etiology, presents a difficult reconstruction problem. This is mainly the case in the presence of lesions of the interosseous membrane associated with the radio-ulnar joint. When preservation of forearm rotation is not possible, cubitalization of the radius and reconstruction of the forearm by creation of a "one bone forearm" seems to be an excellent salvage technique both functionally and cosmetically. Our experience concerns six clinical cases; two of these cases are original and give the authors the opportunity to describe a new reconstructive technique of the distal humerus and elbow by vascularized transfer of the radius onto the radial artery (with a cutaneo-osseous transfer in one case). The etiology of the bone defect included severe trauma in three cases, and a Volkman's syndrome complicated by osteomyelitis in one case. Two cases represent an original technique of reconstruction of the distal humerus by a vascularised transfer of the radius onto the radial artery. Forearm reconstruction is performed by cubitalization of the radius. The etiology was traumatic in one case and neoplastic in another, and a cutaneo-osseous transfer was performed in the latter case. In this difficult problem of bone reconstruction, a favorable functional and cosmetic result was obtained in our series.

Familial congenital pseudarthrosis of the ulna

A mother and daughter, both presented with congenital pseudarthrosis of the ulna due to neurofibromatosis. The daughter is one of identical twins, the second twin not having a pseudarthrosis. The mother's uncle also had pseudarthrosis of the tibia. This suggests a complex variable genetic inheritance pattern for pseudarthrosis in neurofibromatosis. Despite having had no treatment, the mother had minimal symptoms, minimal deformity, and no radial head dislocation.