Metacarpal and phalangeal lengthening by callus distraction

Distraction Lengthening of the Apert Thumb

BACKGROUND

The thumbs of patients with Apert syndrome are characteristically short and radially deviated, contributing to functional hand impairment. The authors report a two-staged technique for distraction lengthening of the Apert thumb using a robust cohort of pediatric patients.

METHODS

The authors retrospectively reviewed medical records of pediatric patients with Apert syndrome who underwent thumb distraction lengthening between 1999 and 2019. The technique was two-staged: (1) application of uniplanar distractor and phalangeal osteotomy, followed by (2) distractor removal, bone grafting, and fixation. Clinical records, preoperative and postoperative radiographs, and photographs were reviewed.

RESULTS

Twenty-two patients (41 thumbs) with Apert syndrome were identified and treated (mean age at initial distraction, 11.5 years). A mean distraction gap of 31.3 mm was achieved over a median time of 40.0 days. The mean healing index was 26.3 days per centimeter. The thumbnail complex was lengthened a median length of 3.0 mm. The median follow-up time was 5.0 years, with complications occurring in 36.4 percent (eight out of 22) of patients. A delayed bone union occurred in one patient, and rotational malunion occurred in one patient.

CONCLUSION

Although long-term outcomes data are needed, thumb distraction lengthening following syndactyly release in patients with Apert syndrome is safe and should be considered to augment the overall appearance and functionality of the hand.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

The effectiveness of distraction lengthening in traumatic hand amputation with Ilizarov mini fixator

BACKGROUND

Bone distraction lengthening has been used for hand reconstruction. The healing process involved in this technique is affected by many factors. Here, the effectiveness and rates of healing of the phalanges and the metacarpals were evaluated in cases of traumatic finger amputation treated using an Ilizarov mini-fixator.

METHODS

Fourteen phalanges and twelve metacarpals in 15 patients (13 males and 2 females) were treated with distraction lengthening using an Ilizarov mini-fixator between 2014 and 2017. All the digits had been subjected to traumatic amputation, and shortening of the remaining digit had occurred despite successful replantation in some cases. The healing indices of phalanges and metacarpals were analyzed.

RESULTS

The mean patient age was 42.8 years. The mean lengthening of the phalanges was 13.3 mm, while that of the metacarpals was 26.5 mm. The mean consolidation times were 144.4 days for the phalanges and 154.1 days for the metacarpals. The mean healing indices of the phalanges and metacarpals were 114 days/cm and 60 days/cm, respectively. No bone grafts were needed in any of the patients.

CONCLUSIONS

Distraction lengthening of the digits after traumatic amputation is an effective procedure for hand reconstructive surgery for either the phalanges or the metacarpals and is less invasive than other techniques. The rate of healing of the metacarpals is two times faster than that of the phalanges.

Distraction Lengthening of First Metacarpal in Traumatic Thumb Amputations

Introduction  Based on the level of the thumb loss, phalangization, toe-to-thumb transfer, pollicization, and distraction callotasis of the first metacarpal are the various options available for reconstruction. The aims of the study were to observe the length gained in the distraction process, duration of treatment required, functional recovery in the form of pinch strength, sensations, and patient satisfaction.

Patients and Methods  It was a prospective study of 10 patients of thumb amputation, conducted from January 2014 to July 2015. The patients’ age, mode of injury, level of amputation, and advantages and disadvantages of distraction callotasis were evaluated.

Results  The most common etiology of thumb loss was domestic accidents while working with a chaff cutter. The total duration of treatment was 124 (93–165) days and the mean gain in length was 25 (20–28) mm. The pinch strength increased from a mean of 0.91 to 2.06 kg, i.e., a 44.17% improvement from preoperative pinch strength. All of our patients retained their sensations of the reconstructed thumb post distraction.

Conclusions  Among many options for thumb reconstruction, distraction callotasis is a simple and safer option in the selective group of patients who are not keen on toe-to-thumb transfer which provide a significant improvement. The longer duration of treatment is the disadvantage associated with the need for proper counselling beforehand.

Metacarpal lengthening in children: comparison of three different techniques in 15 consecutive cases

Metacarpal lengthening is a useful procedure to address hand deficiencies in children. In this study, we aimed to compare the results of three different techniques from one consecutive clinical series of hand deficiencies. A total of 15 metacarpal lengthenings have been performed in 12 children aged from 9 to 14 years. The callotasis technique was used in seven cases, the two-stage distraction-graft technique in four cases and the single-stage lengthening in four cases. All the metacarpals healed with bone. The lengthening obtained was a mean of 13 mm (range 8-21 mm), a mean of 22 mm (range 13-32 mm) and a mean of 12 mm (range 9-15 mm), respectively, in the three different techniques. The healing index was longer for callotasis (81 days/cm) compared with the other techniques (41 days/cm and 46 days/cm, respectively). We observed one case of fracture after callotasis and one after distraction-graft. One patient underwent tenolysis of the extensor mechanism after single-stage lengthening. In conclusion, distraction graft and single-stage lengthening may be valuable alternatives to callotasis.

LEVEL OF EVIDENCE

IV; therapeutic study; multi-case series.

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.

Digital ray reconstruction through distraction osteogenesis: a retrospective study of 82 rays with long-term follow-up

PURPOSE

The aim of the present study was to present the long-term radiographic results with distraction osteogenesis in traumatic or congenital length discrepancies of long bones of the hand.

METHODS

The medical records and radiographs of 65 consecutive patients (27 metacarpals and 55 phalanges) with either traumatic or congenital digital length discrepancies were retrospectively reviewed. The mean follow-up was 8.2 years. The mean distraction period was 21 days with a distraction rate of 4×0.25mm/day. Callus consolidation was obtained in all patients.

RESULTS

The bones were lengthened by a mean amount of 17.5mm, with a mean increase in bone length of 68±17.3%. The mean healing index was 28.57 days/cm. Ray reconstruction with callus distraction can be applied effectively in skeletally immature or mature patients with congenital differences of the hand or amputated fingers.

CONCLUSION

A distraction rate of 1mm/day proved to be a safe rate of lengthening in both metacarpals and phalanges.

[Regenerative therapy approaches in plastic surgery]

BACKGROUND

The regeneration of tissue lost due to trauma or disease is considered as being ideal for reconstruction with respect to repair in which a donor defect arises in a different part of the body. Through a better understanding of the cellular and molecular mechanisms of healing, possibilities for regenerative therapies have been developed in recent years.

OBJECTIVES

To give an exemplary representation of current regenerative therapy approaches and their effect and clinical application.

MATERIAL AND METHODS

The PubMed database was searched for different regenerative approaches in plastic surgery and various methods are presented in this article.

RESULTS

Cell-based approaches, in which autologous mesenchymal stem cells from adipose tissue are preferably used, led to excellent healing results with minimal donor site morbidity. Likewise, growth factor-based approaches or the use of platelet-rich plasma achieve very good results in the field of wound and bone healing.

DISCUSSION

By using different cells or molecules and thus taking advantage of biological mechanisms, the regenerative capabilities of adult organisms could be improved. Many methods have already been implemented in clinical practice, not only in reconstructive but also in aesthetic surgery. However, the success should not conceal the potential risk that is inherent in both cell and growth factor-based approaches. Until long-term experiences of such therapies have been acquired, they should be used cautiously.

Is progressive lengthening of the distal phalanx of a child's index finger possible and safe?

Progressive lengthening using an external fixator has only recently been applied to the phalanges of the hand. A number of technical challenges exist, especially in pediatric cases, such as the size of the bone involved, the existence of the physis, and the risk of infection and neurovascular compromise. Here, we report a case of lengthening of a short distal phalanx following osteomyelitis in a 7-year-old child with a uniplanar mini-external fixator. Elongation of 63% was obtained, reaching 80% of the contralateral phalanx, with complete resolution of the preoperative functional impairment, and an acceptable cosmetic result for the patient. A mild limitation of the distal interphalangeal joint flexion as well as mild effort-related discomfort was still present at the last follow-up. No complications were recorded. Gradual lengthening of the phalanges using uniplanar minifixators can be performed safely in children with good results as long as appropriate indications and technical limitations are respected.

Distraction osteogenesis and free nail graft after distal phalanx amputation

PURPOSE

To describe the results in patients treated with distraction osteogenesis combined with free nail graft after distal phalanx amputation.

METHODS

We analyzed 14 patients with distal phalanx amputation (13 women). Mean age was 35 years. There were 9 amputations of the index finger, 3 of the middle finger, and 1 each of the thumb and ring finger. We started bone distraction 7 days after surgery, with 1 mm distraction every 3 days. After bone elongation, we inserted a free composite nail graft at the dorsal tip of the distracted finger. We evaluated distraction length, consolidation time, aesthetic result (using the Foucher and Leclère score), and complications.

RESULTS

The mean bone elongation was 17 mm and mean consolidation time was 149 days. Nail cosmetic results were satisfactory; the mean total Foucher score was 14 out of 20. Mean individual scores were patient's opinion (7.8 out of 10), adequate length (1.2 out of 2.5), adequate alignment (1 out of 1), adequate width (1.8 out of 4), and dorsal scar quality (2.2 out of 2.5). The mean total Leclère score was 14 out of 20. All patients retained sensibility in the grafted area and none had healing abnormalities. The mean opinion about the donor site was 7.5 out of 8. Nail growth less than 50% occurred in 2 patients. Mean follow-up was 62 months.

CONCLUSIONS

Distraction osteogenesis combined with free nail graft is a therapeutic option when replantation is not an option or when it fails. However, treatment takes time and requires the involvement of the patient, family, and medical team.

A simple and light weight external fixator for distraction advancement manoplasty

BACKGROUND

With the growing interest in long bone distraction several types of distractors have been introduced; all have the same principle of an outer structure which acts like a scaffold and the distracting mechanism is a separate device which is mounted on this outer structure.

OBJECTIVES

We have used a simple and very light weight external fixator we designed and discuss the results of distraction and advantages of this device .

MATERIALS AND METHODS

We applied our distractor to treat 14 men and four women, with a mean age of 39 years. There were three thumbs and 23 fingers; 26 digits (18 patients) lengthened by distraction callotasis and second stage bone grafting evaluated accordingly.

RESULTS

All patients but one were satisfied with the results and a stable pinch and grip was obtained. After lengthening, all patients maintained sensation of the finger pulp, as assessed by the Semes - Weinstein test.

CONCLUSIONS

The superiority of this device for manoplasty lies in its simplicity of construction in addition to being, lightweight and also eases of application.

Percutaneous distraction lengthening in brachymetacarpia

Brachymetacarpia is a condition manifesting a shortened metacarpal that is caused by early closure of the epiphyseal plate and believed to arise idiopathically. The correction for brachymetacarpia is usually for cosmetic reasons as brachymetacarpia does not impair function. The literature indicates several different approaches to lengthening digits, including single-stage lengthening and rapid distraction lengthening with a bone graft. However, gradual distraction is the preferred method due to excellent cosmetic outcomes and few postoperative complications. This article reports a case of brachymetacarpia treated with distraction lengthening using a minimally invasive, percutaneous approach. A 16-year-old girl presented with a shortened left ring finger and underwent surgery to correct the deformity. The left ring finger measured 12 mm shorter than her right ring finger; however, there was normal mobility at the joints. In the operating room, an external fixator was attached using 4 self-drilling, self-tapping pins through several 3-mm skin incisions. The total fixation time was 14 weeks; however, the achieved length of 12 mm was achieved 6 weeks postoperatively. The healing index of the fixation period was 81 days/cm. The postoperative course and fixation period were uneventful, with no complications except for 2 pin infections that were treated with oral antibiotics. The method of gradual distraction lengthening in this case successfully achieved the desired length and yielded an excellent cosmetic result.

Complications of distraction lengthening in the hand

This study examined the features of 16 complications from 51 distraction lengthenings in the hands of 43 patients. From 1996 to 2006, 24 metacarpals and 27 phalanges were lengthened at a rate of 0.5 and 0.25 mm/day, respectively, using a callus distraction technique. The indications were congenital (33 cases in 27 patients) and traumatic (18 cases in 16 patients) deformities. The average percentage lengthening in the phalanges and metacarpals was 62% (16 mm) and 63% (34 mm), respectively. The distraction rates in the phalanges and metacarpals were 69 and 52 days/cm, respectively. The overall complication rate was 31%. Major complications requiring secondary procedures were non-union (one case), fracture (one case), premature union (one case), angulations (two cases) and dislodgment of pins (two cases). The minor complications encountered were delayed callus formation (four cases), joint stiffness (four cases) and soft tissue thinning (one case). Traumatic deformities had more complications than the congenital ones (nine of 18 cases and seven of 33 cases, respectively). The phalanges had a higher rate of complication than the metacarpals (11 of 27 cases and four of 24 cases, respectively). Most patients with complications except for two children with dislodgment were as satisfied with the final results as those without complications. Although callus distraction in the hand requires a long treatment period and has a relatively high rate of complication, it appears to be effective in achieving adequate bone length. A high level of patient compliance and prompt management of complications by an experienced surgeon are essential for achieving good results.

La distraction osseuse progressive au niveau métacarpien ou phalangien chez l'enfant

We report the results of bone lengthening using progressive distraction performed for congenital hand deformities in 12 children between 1998 and 2004. The series is retrospective. Patients were aged between 2 and 11 years. The distraction site was metacarpal in 9 cases and phalangeal in 3 cases. The Mondéal micro distraction device was used. The lengthening procedure was a callotasis with a 0.25 to 0.5 mm/day distraction pace in all cases. The final mean lengthening was 16 mm, and the mean treatment duration was 107 days. The complication rate was 33%. The distraction procedure is described in detail. It is feasible in very young patients as a micro distraction device is used. Family education may prevent complications. This therapeutic procedure gave functional improvement without impairment of distal sensitivity.

Factors that affect the healing index of metacarpal lengthening: a retrospective study

PURPOSE

To determine factors that affect healing index and consolidation time following lengthening of congenitally short metacarpals (brachymetacarpia).

METHODS

18 metacarpals of 8 young women (mean age, 18.6 years) were lengthened using the callus distraction technique. The results, including healing index and consolidation time, were analysed and compared with those in the literature.

RESULTS

The mean length increase was 16.5 mm (55% of the original length of 30 mm). Age was positively correlated with healing index and consolidation time: younger patients healed faster than older patients. Healing index differed significantly between patients aged 0 to 18 years and those aged 19 to 30 years (p=0.002). Comparison of our results with 9 previous studies confirmed that increased age was associated with a greater healing index and consolidation time. Conversely, the faster the distraction rate, the less the healing index and consolidation time.

CONCLUSION

Age has the most effect on healing index and consolidation time. Metacarpal lengthening using callus distraction is recommended. Adolescence is the most appropriate time to perform distraction lengthening of a congenitally short metacarpal. This will avoid additional lengthening of normal metacarpals prior to epiphyseal closure.

First metacarpal lengthening following traumatic amputation of the thumb: long-term follow-up

Thumb amputation is a relatively frequent injury in industrial accidents, producing a significant effect on hand function. The long-term results of 18 first metacarpal elongations in patients who had had a non-replantable thumb amputation at the metacarpophalangeal level are reported. Lengthening was performed using a unilateral external fixator. After a learning curve with a high complication rate and prolonged treatment, good functional results were obtained after some technical modifications, with eight patients returning to their previous occupation, and the rest requiring a change in their job.