Distraction lengthening of the forearm for congenital and developmental problems

Outcome of Centralization and Ulnarization of the Carpus with Ulnar Shortening Osteotomy on Functioning in Children with Radial Club Hand

BACKGROUND

Radial club hand (RCH) is characterized by a wide array of hand and forearm anomalies. Various treatment approaches have been described depending upon the stages of RCH. The major drawback of these studies is that the effectiveness of these interventions was reported on clinical and radiological outcomes. With the increasing focus on patient-centered care nowadays, we wanted to identify the components associated with functioning and evaluate the effectiveness of two surgical procedures on functional outcomes using the International Classification of Functioning, Disability and Health (ICF)-based tools.

MATERIALS AND METHODS

We identified 14 children from our records (nine boys, five girls) with a mean age of 5.6 years, classified as Bayne types III-IV and classified them into two groups; those who were operated by centralization (group 1) and ulnarization of the carpus with ulnar shortening osteotomy procedure (group 2). The outcomes were evaluated by the brief ICF core set for the child and youth with cerebral palsy up to the age of 5 and the brief ICF core set for hand conditions for a period of 1 year after surgery.

RESULTS

The results showed that both the operative techniques showed improvement in the structure component (s730-structure of upper extremity). ICF categories of d445-hand and arm use, d530-toileting, and d880-engagement in play showed a change in frequencies of more than 40% after surgery and were maintained till follow-up. However, categories related to muscle power functions (b730), muscle tone (b735), fine hand use (d440), hand and arm use (d445) and engagement in play (d880) showed no significant improvement (p > 0.05). There were no differences between both the surgical procedures in improving the outcomes (p > 0.05).

CONCLUSION

We conclude that surgical techniques may be more appropriate to improve the cosmetic or structural appearance of the upper extremity than functioning.

Bone Lengthening in the Pediatric Upper Extremity

➤Bone lengthening has been used successfully for several congenital and acquired conditions in the pediatric clavicle, humerus, radius, ulna, and phalanges.➤Common indications for bone lengthening include achondroplasia, radial longitudinal deficiency, multiple hereditary exostosis, brachymetacarpia, symbrachydactyly, and posttraumatic and postinfectious growth arrest.➤Most authors prefer distraction rates of <1 mm/day for each bone in the upper extremity except the humerus, which can safely be lengthened by 1 mm/day.➤Most authors define success by the amount of radiographic bone lengthening, joint motion after lengthening, and subjective patient satisfaction rather than validated patient-related outcome measures.➤Bone lengthening of the upper extremity is associated with a high complication rate, with complications including pin-track infections, fixation device failure, nerve lesions, nonunion, fracture of regenerate bone, and joint dislocations.

Elastic intramedullary nailing as a complement to Ilizarov's method for forearm lengthening: a comparative pediatric prospective study

PURPOSE

Most of the techniques for forearm lengthening involve external fixation to achieve stability and provide progressive distraction. We introduce the use of elastic stable intramedullar nailing (ESIN) in combination with external circular assembly for the procedure. The purpose of this prospective study was to compare Ilizarov's classical technique with this combined technique.

METHODS

Fifty-seven patients, with forearm length discrepancies or deformities either congenital or acquired, were prospectively followed-up. Patients were divided in two groups: 35 had only external fixation, and 22 had external fixation-ESIN combined techniques. Patients were assessed for clinical and radiographic outcome with a mean follow-up of 21 months after external device removal.

RESULTS

Overall lengthening was 45.0mm. Healing index (HI) was 22.2d/cm with the combined technique, and 32.0 d/cm with external fixation. HI was 30% better when ESIN was used, for congenital and for overall cases. Combined technique has a lower complication rate.

CONCLUSION

Although forearm lengthening still remains a time-consuming procedure, ESIN can shorten external fixator wearing time. No additional complication occurred and bony complications seem to be limited by the nails. We recommend this technique, which we now use for most of our patients undergoing limb lengthening.

LEVEL OF EVIDENCE

Level IV.

External fixation and centralization versus external fixation and ulnar osteotomy: the treatment of radial dysplasia using the resolved total angle of deformity

BACKGROUND

The purpose of this study is to compare preliminary external fixation and centralization to ulnar osteotomy with external fixation for the treatment of radial dysplasia as measured by the resolved total angle (RTA) of deformity.

METHODS

This is a retrospective review of 11 patients (14 limbs) with radial dysplasia. The 3-dimensional deformity was measured by the RTA. Six patients (8 limbs, group 1) underwent correction of their angular deformity with preliminary external fixator distraction followed by centralization. Five patients (6 limbs, group 2) underwent ulnar osteotomy with external fixation. Mean age was 9 years, with a mean follow-up of 41 months.

RESULTS

Initial RTA was 112 degrees for group 1, which improved to 38 degrees postoperatively, but worsened to 71 degrees at follow-up. In group 2 the initial RTA was 88 degrees, which improved to 50 degrees, with a worsening to 95 degrees at follow-up. The RTA was found to have high interrater and intrarater reliability.

CONCLUSIONS

The RTA defines the maximum deformity in radial dysplasia and is a reliable measure. Using the RTA, we showed that preliminary external fixation and centralization are more effective than ulnar osteotomy with external fixation, but both have a high recurrence rate.

LEVEL OF EVIDENCE

III.

Multi-axial correction system in the treatment of radial club hand

BACKGROUND

Radial club hand is a well-recognized congenital malformation characterized by hypoplasia of bone and soft tissue on the radial aspect of the forearm and hand. The modalities of treatment have traditionally varied from stretching casts with soft-tissue procedures to the use of multiple corrective osteotomies. These osteotomies can be stabilized by a variety of methods, including external fixators that allow the possibility of gradual distraction with neohistiogenesis. This current study outlines the usage of one such device (multi-axial correction system [MAC]) in the management of deformity associated with severe radial club hand.

METHODS

Three consecutive cases of unilateral or bilateral severe (Bayne type IV) congenital radial club hand were corrected using MAC fixation in the last 5 years. This is a retrospective review of all three cases. Data parameters included: patient demographics, presentation findings, degree of deformity, amount of correction/lengthening, length of procedure, length of treatment, and associated complications. The surgical technique is described in detail for the benefit of the readership.

RESULTS

The three patients with severe congenital radial club hand had a total of four limb involvements that underwent correction using osteotomies and usage of the MAC device for external fixation. All three patients underwent successful correction of deformity with the restoration of alignment, lengthening of forearm for improvement of function, and stabilization of the wrist (mean duration, mean lengthening, mean time to consolidation). The MAC system was well tolerated in all patients and associated complications were limited.

CONCLUSION

The MAC fixator seems to be a good alternative modality of stabilization and correction for severe congenital radial club hand deformities. Its usage is fairly simple and it provides the ease of application of a mono-lateral fixator with far superior three-dimensional control, like the circular external fixator. We recommend that clinicians should add this modality to their armamentarium for the deformity correction of severe radial club hand and others in general.

Congenital hand surgery: what's new and what's coming

Congenital hand surgery has advanced during the last 10 years with surgical technique improvements, the incorporation of new technologies, and an enhanced understanding of the basic pathology of upper extremity anomalies. This article reviews the literature with a survey of 70 articles from seven leading journals published in the last 12 years. The author concludes that the next decade should be even more exciting with the incorporation of an improved understanding of tissue engineering and molecular genetics into classification and treatment algorithms. Understanding the genetic pathways of normal, and therefore abnormal, development should allow improved classification schemes and intervention to prevent, modify, or remedy these birth abnormalities.

Congenital failure of formation of the upper limb

This article provides an overview of the various classification systems for radial longitudinal, central longitudinal, and ulnar longitudinal deficiencies. It looks specifically at radius deficiency, hypoplastic thumb, index finger pollicization, narrowed thumb web, forearm-elbow deformities, and hand abnormalities. Various surgical approaches to these conditions and their results are explored. The authors conclude that longitudinal failure of formation deformities comprises a substantial portion of the anomalies of the upper limb. Although much of the past and current congenital hand literature has been devoted to these conditions, they continue to be a reconstructive challenge to hand surgeons involved in their care.

Outcome Assessment after Reconstruction of Complex Defects of the Forearm and Hand with Osteocutaneous Free Flaps

BACKGROUND

Complex defects of the forearm and hand often require microvascular reconstruction with osteocutaneous free flaps for limb salvage.

METHODS

Fifteen patients with osseous and soft-tissue defects of the forearm and hand were treated with osteocutaneous flaps (1992 to 2004) and evaluated for postoperative results. Assessment focused on range of motion, pain, grip strength, and Disabilities of Arm, Shoulder, and Hand questionnaire score. Donor- and recipient-site morbidity was documented.

RESULTS

The defects resulted from trauma, infection, or malignancy. Reconstruction was possible by microvascular osteoseptocutaneous fibula transplantation (n = 8), osteocutaneous scapular or parascapular flaps(n = 6), and osteocutaneous lateral arm flap (n = 1). The average patient age was 38 years. The median osseous defect was 11.7 cm, and all patients needed additional soft-tissue reconstruction. All defects could be reconstructed in a one-step procedure after serial débridement or oncologic resection. Patients' hand function was markedly reduced compared with the unaffected extremity, but functional results were still satisfactory, with a mean Disabilities of Arm, Shoulder, and Hand score of 25.3 reflecting a moderate disability in activities of daily living. Two patients developed pseudarthrosis, and one had to undergo an ablation procedure because of persistent infection. Two patients developed wound dehiscence at the donor site, and one patient required a fasciotomy due to an imminent compartment syndrome after fibula harvest. For all patients, the functional results were acceptable when the potential alternatives were taken into consideration. This was also reflected by a high individual satisfaction rate.

CONCLUSION

This analysis demonstrates that limb salvage with osteocutaneous free flaps is the treatment of choice for three-dimensional defects of the forearm and hand.

MR imaging findings in ulnar-sided wrist impaction syndromes

Ulnar-sided wrist impaction syndromes are a common source of ulnar pain and limitation of motion. These conditions refer to a group of pathologic entities that result from repetitive or acute forced impaction between the distal ulna and ulnar carpus or distal radius and surrounding soft tissues. MR imaging allows earlier detection of the bone and soft-tissue lesions that are present in the different ulnar-sided wrist impaction syndromes and is helpful in formulating the extensive differential diagnosis in patients with ulnar wrist pain and limitation of motion.

Histomorphometry of distraction osteogenesis during experimental tibial lengthening

OBJECTIVES

The aim of the current study was to analyze distraction osteogenesis histomorphometrically to investigate the amount of enchondral ossification adjacent to intramembranous ossification.

STUDY DESIGN

Species-specific, longitudinal time study. METHODS Lengthening of 25% of the right tibia was performed in 24 beagle dogs by callus distraction after osteotomy and application of a ring fixator. Distraction was started at the fifth postoperative day with a distraction rate of 0.5 mm twice a day. Twelve dogs were killed at the end of the distraction phase of 25 days (group A) and the remaining 12 dogs after an additional consolidation period of 25 days (group B). The tibia was removed from the distracted right leg and from the left control side of each animal, and longitudinal sections were cut and stained with Pentachrome. In all tibiae, an area of 0.5 x 2.4 cm within the endosteal bone was evaluated histomorphometrically with a Merz grid, and the results were compared between distraction and control side as well as between the dogs of group A and group B.

RESULTS

On the distraction side, the typical signs of an increased de novo bone formation with a significant increase of osteoblasts and osteoid in group A, as well as an additional significant increase of bone volume and trabecular thickness in group B, were found. In all distraction cases, islands of cartilage formation, which underwent enchondral ossification, were found, besides membranous ossification. The ratio between membranous and enchondral ossification was found to be five to one.

CONCLUSION

Bone formation during distraction osteogenesis results from both membranous and enchondral ossification.

Imaging findings in ulnar-sided wrist impaction syndromes

Impaction syndromes related to ulnar-sided pain include ulnar impaction syndrome, ulnar impingement syndrome, ulnocarpal impaction syndrome secondary to nonunion of the ulnar styloid process, ulnar styloid impaction syndrome, and hamatolunate impingement syndrome. The most common of these, ulnar impaction syndrome, is a degenerative condition of the ulnar side of the wrist related to excessive load bearing across the ulnar carpus, triangular fibrocartilage (TFC) complex, and ulnar head. In an adequate clinical setting, characteristic osseous findings at radiography include positive ulnar variance in ulnar impaction syndrome, a short ulna in ulnar impingement syndrome, nonunion of the ulnar styloid process in ulnar impaction syndrome secondary to ulnar styloid nonunion, an excessively long ulnar styloid process in ulnar styloid impaction syndrome, and type II lunate bone in hamatolunate impingement syndrome. Nevertheless, confirmation of clinical and conventional radiographic findings with magnetic resonance (MR) imaging is often necessary to exclude other entities with similar clinical manifestations. MR imaging allows earlier detection of an abnormality in the TFC complex, cartilage, or bone marrow of carpal bones and is helpful in formulating the extensive differential diagnosis in patients with ulnar wrist pain and limitation of motion.