Pre-centralization soft tissue distraction for Bayne type IV congenital radial deficiency in children

Histopathological, Ultrastructural, and Immunohistochemical Findings in Radial Longitudinal Deficiency: A Prospective, Observational Study

PURPOSE

To report the histopathological, electron microscopic, and immunohistochemical findings of tissue samples obtained from patients with radial longitudinal deficiency (RLD) and investigate the contribution of abnormality in soft tissues as a secondary driver of deformity in RLD.

METHODS

Specimens from radial-sided muscles and tendons were obtained at the time of surgery (either radialization or centralization) from 14 patients with 16 limbs affected with Bayne type 3 and type 4 RLD. The specimens were evaluated using light microscopy, electron microscopy, and immunohistochemical examination.

RESULTS

Among the 16 frozen muscle specimens, 6 (37%) showed normal muscle, while 10 (63%) showed the presence of atrophic fibers. The 6 cases with normal muscle showed no abnormality in fiber type distribution. Six patients showed predominance of type 1 muscle fibers. None of the specimens had myofibroblasts; 4 of 16 specimens had mast cells, and 9 of 16 specimens showed the presence of platelet derived growth factor-positive cells. Features of myofibroblasts (the presence of basal lamina, intercellular junctions, or pinocytic vesicles) were not identified in any specimen on electron microscopy.

CONCLUSIONS

The histopathological, electron microscopic, and immunohistochemical findings, in particular the absence of myofibroblasts, in tissue samples obtained from patients with RLD, do not support the assumption of abnormality in soft tissues as a secondary driver of deformity in RLD.

CLINICAL RELEVANCE

This study provides a preliminary insight into a possible role of soft tissues in the development of the deformity in RLD.

Radial club hand treated with soft-tissue distraction and subsequent pin stabilization: mid- to long-term results

Radial club hand deformities are commonly treated with arthrolysis to allow centralization of the ulna. In this retrospective cohort study of 31 hands in 28 patients, we aimed to assess the outcomes of correction using progressive distraction and subsequent percutaneous pinning of the wrist with a corrective ulnar osteotomy. Mean follow-up time was 7 years (range 2 to 20). The angulation of the hand-forearm complex was decreased after each step of the procedure. Mean correction of the angulation was 64°, and the residual total forearm-hand angulation was 12° after completion of the surgery. At the time of bony maturity (four patients), all wrists had fused. Fifty-eight reoperations were required in 31 wrists because of pin migration or breakage, and in addition 18 secondary osteotomies of the ulna were performed. From this study we conclude that distraction and pinning provide satisfactory and stable realignment of the wrist to correct the deformity, but this treatment has drawbacks regarding the high number of reoperations and the loss of wrist mobility.Level of evidence: IV.

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.

Reconstruction of limb deformities in patients with thrombocytopenia-absent radius syndrome

OBJECTIVE

Developmental abnormalities of the appendicular skeleton are among the most common and easily identified birth defects. The aim of this report was to describe the phenotypic characterization of several patients with thrombocytopenia-absent radius (TAR) syndrome and the orthopaedic interventions performed on them. TAR syndrome is inherited in an autosomal recessive manner and results from compound heterozygosity of RBM8A mutations.

METHODS

Reconstructions were designed and performed in five patients with TAR syndrome, mainly comprising orthopaedic interventions to correct their upper limb defects. Additional lower limb deformities (severe internal rotation of the tibiae) was been encountered in one patient.

RESULTS

The affected patients' wrists were re-aligned and stabilized and the musculotendinous forces around the wrist rebalanced to reverse the ulnar forearm bow.

CONCLUSION

Patients with TAR syndrome who receive optimal treatment can expect to return to most activities of daily living with some limitation of wrist extension and ulnar deviation and, of course, with a reduced total active range of digital motion.

The effect of soft tissue distraction on deformity recurrence after centralization for radial longitudinal deficiency

PURPOSE

To assess recurrence and complications in children with radial longitudinal deficiency treated with or without external fixator soft tissue distraction prior to centralization.

METHODS

Thirteen upper extremities treated with centralization alone were compared with 13 treated with ring fixator distraction followed by centralization. Resting wrist position between the 2 groups was compared before surgery, approximately 2 years after surgery (midterm), and at final follow-up, which was at a mean of 10 years for the centralization-alone group and 6 years for the distraction group. Radiographs were reviewed for hand-forearm angle, hand-forearm position, volar carpal subluxation, ulnar length, and physeal integrity.

RESULTS

The clinical resting wrist position was improved significantly after surgery and at final follow-up in both groups, but recurrence was worse at final follow-up in the distraction group patients. Radiographically, in the centralization alone group, the hand-forearm angle improved from 53° before surgery to 13° at midterm but worsened to 27° at final follow-up. In the distraction group, the hand-forearm angle improved from 53° before surgery to 21° at midterm but worsened to 36° at final follow-up. The hand-forearm position improved between preoperative and final assessment in both groups, but at final follow-up, the centralization-alone group had a significantly better position. Volar subluxation was 4 mm improved in the centralization alone group and 2 mm worse in the distraction group at final follow-up.

CONCLUSIONS

Centralization, with or without distraction with an external fixator, resulted in improved alignment of the wrist. Distraction facilitated centralization, but it did not prevent deformity recurrence and was associated with a worse final radial deviation and volar subluxation position compared with wrists treated with centralization alone.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Embryology, diagnosis, and evaluation of congenital hand anomalies

Although congenital hand anomalies are rare, musculoskeletal clinicians should have a basic understanding of their clinical manifestations and the possibility of concurrent anomalies and syndromes. In this review, we provide a brief overview of the embryology of limb development and the molecular pathways involved. We also summarize the clinical manifestations, diagnostic evaluation, and principles of surgical treatment for radial longitudinal deficiency, thumb hypoplasia, ulnar longitudinal deficiency, central deficiency, syndactyly, polydactyly, and amniotic constriction band. Although one of the main goals of treatment is to provide a functional upper extremity, musculoskeletal clinicians should be aware of the clinical findings that should trigger referral to evaluate for life-threatening syndromes.

Recurrence of radial bowing after soft tissue distraction and subsequent radialization for radial longitudinal deficiency

PURPOSE

Centralization and radialization are the most widely reported surgical treatments for Bayne and Klug Type III and IV radial longitudinal deficiency. Prior soft tissue distraction has been introduced to improve reducibility of the deformity without skeletal resection. Satisfying long-term effects have been reported with centralization but are still unclear with radialization.

METHODS

This is a retrospective study of 8 consecutive children with Bayne and Klug Type III or IV radial longitudinal deficiency treated with preliminary soft tissue distraction followed by radialization between 2003 and 2008. All children underwent the same surgical protocol. End points of the study were clinical appearance, the hand-forearm angle, and mean angular correction at last follow-up.

RESULTS

The mean preoperative hand-forearm angle was 61° (26°-91°). The average duration of distraction was 1.9 month (1-3 mo). The initial postoperative angle averaged 12° (-14°-40°). There were 3 postoperative complications: 2 cases of pin loosening and 1 case of fracture of the base of the small finger metacarpal. Mean follow-up duration was 2.6 years (1-4 y). At last follow-up, 7 of the 8 patients had visible recurrence of the deformity, the hand-forearm angle had deteriorated to 44° (20°-69°), and the mean angular correction was 18° (-43°-59°).

CONCLUSIONS

Preoperative distraction allows a gradual realignment of the hand on the forearm without skeletal resection, but the recurrence rate after radialization is high. Tendon transfers and soft tissue tensioning were unable to maintain hand-forearm alignment following soft tissue distraction.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

CONGENITAL DEFORMITIES OF THE UPPER LIMBS.: PART I: FAILURE OF FORMATION

This article, divided into three parts, had the aims of reviewing the most common upper-limb malformations and describing their treatments. In this first part, failure of formation is discussed. The bibliography follows after the first part.

Changing paradigms in the treatment of radial club hand: microvascular joint transfer for correction of radial deviation and preservation of long-term growth

Radial longitudinal deficiency, also known as radial club hand, is a congenital deformity of the upper extremity which can present with a spectrum of upper limb deficiencies. The typical hand and forearm deformity in such cases consists of significant forearm shortening, radial deviation of the wrist and hypoplasia or absence of a thumb. Treatment goals focus on the creation of stable centralized and functionally hand, maintenance of a mobile and stable wrist and preservation of longitudinal forearm growth. Historically centralization procedures have been the most common treatment method for this condition; unfortunately centralization procedures are associated with a high recurrence rate and have the potential for injury to the distal ulnar physis resulting in a further decrease in forearm growth. Here we advocate for the use of a vascularized second metatarsophalangeal joint transfer for stabilization of the carpus and prevention of recurrent radial deformity and subluxation of the wrist. This technique was originally described by the senior author in 1992 and he has subsequently been performed in 24 cases with an average of 11-year follow-up. In this paper we present an overview of the technique and review the expected outcomes for this method of treatment of radial longitudinal deficiency.

Monoaxial distraction of ulna to second metacarpal followed by single bone forearm in massive post infective radial bone loss

INTRODUCTION

Radial bone loss associated with gross manus valgus deformity can be managed by open reduction internal fixation using intervening strut bone graft, callus distraction using ring or monoaxial fixator, and achieving union by distraction histogenesis. These methods are particularly suitable when bone loss is small. Single or staged procedure is described for congenital as well as in acquired extensive bone loss of radius. Distraction through radial proximal to distal segments, to achieve reduction of distal radio-ulnar joint (DRUJ), is also described in acquired cases. In the present series, functional results of distraction through ulna to 2(nd) metacarpal is studied alongwith, functional status of hand, stability of wrist, level of patient's satisfaction are also studied.

MATERIALS AND METHODS

7 unilateral cases of radial loss (M = 5, F = 2) affecting 4 right hands of mean age 17 years (range 9 to 24 years) were included in this study. They were treated by distracting through ulna to 2(nd) metacarpal to achieve DRUJ alignment in first stage. Subsequently ulna was osteotomised and translated to distal stump of radius. It was then fixed to the distal radial remnant in 30° pronation in dominant and 30° supination non dominant hands.

RESULTS

Union was achieved in all cases associated with beneficial cross union of distal ulna. Hand functions improved near to normal, with fully corrected stable wrist joint, hypertrophied ulna and without recurrence. All of them had practically complete loss of forearm rotations, however patients were fully satisfied.

CONCLUSION

This method is particularly suitable when associated with 6 cm or more radial bone loss. But when loss is small, sacrifice of one bone may not be justifiable.

Ulnocarpal epiphyseal arthrodesis for recurrent deformity after centralization for radial longitudinal deficiency

PURPOSE

To report our results for ulnocarpal epiphyseal arthrodesis for recurrent or late-presenting wrist deformity in patients with radial longitudinal deficiency, using both objective data and long-term subjective follow-up evaluation.

METHODS

A retrospective review of our surgical logs between 1970 and 2007 identified 12 postcentralization patients treated with ulnocarpal epiphyseal arthrodesis, and 1 patient (who had reached skeletal maturity) treated with traditional ulnocarpal arthrodesis. Indications for the arthrodesis included postcentralization recurrence of radial angulation to greater than 45°, an inability to actively extend the wrist to within 25° of neutral (ie, 25° of flexion), or both. We collected objective and radiographic data on all 12 patients by chart review at a mean of 89 months (range, 2-472 mo) after arthrodesis. We collected subjective data from 9 patients at a mean of 160 months (range, 14-602 mo) after arthrodesis.

RESULTS

Ulnocarpal union was obtained in 11 wrists at an average of 4 months (range, 2-6 mo); the 1 case of nonunion was treated successfully with revision arthrodesis. The mean radial angulation position was 20° after arthrodesis (range, 0° to 35°), an average improvement of 42°. The mean position of wrist fusion was 11° of flexion (range, 0° to 35° of flexion), an average improvement of 7°. The mean postoperative Disabilities of the Arm, Shoulder, and Hand score was 24.5 (SD, 12.3; range, 6.8-36.4). Final postoperative Visual Analog Score rating for function averaged 8 (range, 4-10); for appearance, it averaged 7 (range, 5-10), and for pain, it averaged 1 (range, 0-5).

CONCLUSIONS

Ulnocarpal and epiphyseal arthrodesis are appropriate surgical procedures to stabilize the carpus in postcentralization patients with recurrent or late-presenting wrist deformity.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Staged lengthening arthroplasty for pediatric osteosarcoma around the knee

BACKGROUND

Orthopaedic oncologists often must address leg-length discrepancy after resection of tumors in growing patients with osteosarcoma. There are various alternatives to address this problem. We describe a three-stage procedure: (1) temporary arthrodesis, (2) lengthening by Ilizarov apparatus, and (3) tumor prosthesis.

QUESTIONS/PURPOSES

We asked (1) to what extent are affected limbs actually lengthened; (2) how many of the patients who undergo a lengthening procedure eventually achieve joint arthroplasty; and (3) can the three-stage procedure give patients a functioning joint with equalization of limb length?

PATIENTS AND METHODS

We reviewed 56 patients (younger than 14 years) with osteosarcoma who had staged lengthening arthroplasty between 1991 and 2004.

RESULTS

Thirty-five of the 56 patients (63%) underwent soft tissue lengthening, and of these 35, 28 (50% of the original group of 56) had implantation of a mobile joint. Three of the 28 prostheses were later removed owing to infection after arthroplasty. The overall average length gained was 7.8 cm (range, 4-14 cm), and 25 (71%) of the 35 patients had a mobile joint at final followup. The average Musculoskeletal Tumor Society functional score was 23.2 (range, 15-28) and limb-length discrepancy at final followup was 2.6 cm (range, 0-6.5 cm). Although most mobile joints had an acceptable ROM (average, 74.2 degrees ; range, 35 degrees -110 degrees ), extension lag was frequent.

CONCLUSIONS

Our approach is one option for skeletally immature patients, especially in situations where an expandable prosthesis is not available. However, this technique requires multiple stages and would be inappropriate for patients who cannot accept prolonged functional deficit owing to a limited lifespan or other reasons.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

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.

Ilizarov distraction before revision hip arthroplasty after resection arthroplasty with profound limb shortening

We report the results of Ilizarov gradual distraction to regain 6.7 cm of leg length in a severely contracted hip 11 months after a resection arthroplasty. Restoration of leg length allowed revision hip arthroplasty. At 24 months after the revision arthroplasty, the patient is ambulating independently and pain free. The use of Ilizarov gradual distraction restored leg length and facilitated postoperative function.

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.

Preliminary soft tissue distraction using external fixator in radial club hand

Preliminary soft tissue distraction using an external fixator before centralisation and tendon transfer of the flexor and extensor carpi ulnaris to the little finger metacarpal was used to treat Bayne's type III and IV deformities in 18 hands of 14 patients with radial club hands. Treatment with external fixator was started at a mean age of 8 (range 3-30) months. In 16 of 18 hands, the surgical treatment was completed before 10 months of age. Adequate soft tissue stretching was achieved before centralisation using fractional distraction with the external fixator in the majority of hands. After an average follow-up period of 31 months, there were seven good, eight satisfactory and one unsatisfactory result.

Vascularized metatarsophalangeal joint transfer for radial hypoplasia

The relatively new concept and technique of microvascular joint transplantation for the correction of the congenitally deformed wrist is presented with a series of 24 operated radial club hands. The results from the 19 upper extremities with a mean follow-up of 11 years show that the new technique will not diminish the longitudinal growth of the ulna. The ulna length in the series is now 15.4 cm in mean and will develop further and presumably better than that reported in the previous long-term studies after centralization. The superiority in wrist active mobility compared with those of some previous long-term studies is reported with total active motion of 83 degrees in mean. The radial deviation deformity has become increased by 12 degrees in mean in the long-term follow-up compared with the results reported previously by the same author in the series of the first nine patients in 1998. The balance in the growth between the supporting metatarsal joint and the distal ulna has remained satisfactory, and the resting radial deviation angle is 28 degrees in mean (range, 0 to 45 degrees) in the cases with successful joint transfer. A subluxation tendency in six of the transplanted joints is a new finding, and its prevention needs careful attention during the reconstruction. With respect to timing, the joint alignment and transplantation procedure is best performed between the ages of 2.5 and 4 years according to the current experience of the author. A pollicization is usually added after the wrist alignment procedure. This technique will give the child a period of ~10 years without any new need for surgical treatment, and usually no splinting is needed during that period. However, an additional corrective osteotomy may be needed at early puberty depending on the growth properties of the joint graft and original ulna and because of ulnar bowing. The reported technique with preoperative and postoperative measures takes a period of about one-half year, and the whole procedure is considered quite demanding as far as an adequate preoperative soft tissue distraction and the microvascular joint transplantation are concerned. It is recommended that the treatment be performed in dedicated microsurgical centers with adequate pediatric tissue transfer experience.

Preoperative Soft-Tissue Distraction for Radial Longitudinal Deficiency: An Analysis of Indications and Outcomes

BACKGROUND

Preoperative soft-tissue distraction for congenital radial deficiency is well described, but indications are unclear and long-term outcomes are lacking.

METHODS

This study evaluated one surgeon's 16-year experience with preoperative soft-tissue distraction using uniplanar devices. Eight extremities in seven consecutive patients (average age, 2.5 years) with type 4 radial deficiency and severe wrist deformity were distracted before centralization (seven extremities) or radialization (one extremity).

RESULTS

In the short term, average hand-forearm angle improved by 89 degrees and average hand-forearm position improved by 31 mm. In the long-term, wrist deformity recurred commensurate with the degree of initial deformity. Fortuitously, one infant experienced unintended epiphyseal distraction that lengthened the ulna by 15 mm before radialization. One patient required recentralization; two developed minor pin-track infections. Multiple distractor readjustments were necessary early in the series.

CONCLUSIONS

Preoperative soft-tissue distraction for radial deficiency is indicated in late-presenting or neglected patients or cases with severe, irreducible wrist angulation and displacement. Dramatic correction is possible using uniplanar distractors. Although minor complications are common, they diminish with experience. Using this technique, the surgeon avoids skeletal shortening and undue strain on the nerves and vessels at the time of centralization or radialization.

Ulnocarpal arthrodesis and limb lengthening for the management of radial agenesis in a dog

Radial agenesis was diagnosed in a nine-week-old boxer. An ulnocarpal arthrodesis was performed when six months of age to improve limb alignment and enable weight bearing. When the dog was 10 months old, a hinged circular fixator was applied to the limb to gradually lengthen the ulna and correct angular and rotational deformity. The fixator was removed at 16 months of age. At this time, there was 1.7 cm (6 per cent) shortening of the affected antebrachium-metacarpus and 2.6 cm (15 per cent) compensatory overgrowth of the humerus compared with the contralateral limb. Inability to extend the digits was a complication that improved with physiotherapy. Follow-up at 23 months of age showed good limb use when walking and running. Radiographs of the elbow showed periarticular osteophytes and subcoronoid sclerosis of the ulna.

Soft-tissue distraction with a ring external fixator before centralization for radial longitudinal deficiency

PURPOSE

To review the techniques and evaluate the use of soft-tissue distraction with a ringed fixator for radial longitudinal deficiency (RLD) before centralization.

METHODS

Eight extremities in 6 patients with severe RLD were treated with ring fixator distraction followed by centralization. A clinical examination was performed and radiographic data were obtained prospectively and at an average follow-up period of 17 months. The techniques and the early objective (range of motion, position) and radiographic outcome were evaluated.

RESULTS

The preoperative ring fixator accomplished an average of 16 mm of distraction and allowed the centralization procedure to be performed effectively and without tension. Clinical alignment was improved markedly. The hand-forearm angle improved from 72 degrees radial to 8 degrees ulnar after surgery. The volar carpal subluxation improved by an average of 6 mm.

CONCLUSIONS

Precentralization ring fixator distraction allows the performance of a tensionless centralization procedure with good early radiographic and clinical outcome in patients severely affected with RLD.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic, Level IV.