Long-term results of callus distraction-lengthening in the hand and upper extremity for traumatic and congenital skeletal deficiencies

Novel Use of an Internal Distractor for Metacarpal Lengthening

BACKGROUND

In patients who have had proximal digit amputation, metacarpal distraction osteogenesis is an option to improve digital length and function. One drawback is that traditional external distraction devices are large and cumbersome; the option of a low-profile internal device is therefore appealing. Internal distractors are commonly used in craniofacial reconstruction, but use in the hand has not been reported. We describe a case series of the novel use of an internal distractor in metacarpal lengthening.

METHODS

In this single-center case series, patients who underwent metacarpal distraction by the senior author using a uniplanar internal distractor were reviewed, and indications, outcomes, and complications were analyzed.

RESULTS

There were 5 cases in 4 patients (age range: 7-33 years). Indications were traumatic amputation in 4 cases and congenital hypoplasia in 1. All were successfully distracted, with a mean final length gain of 1.3 cm (range: 1.0-1.7 mm). Mean time from device placement to consolidation was 3.5 months. Complications included activation arm site infection in 2 cases, both occurring after the distraction period, necessitating device removal before full consolidation. In these cases, the device was removed after the distraction period and replaced with a Kirschner wire for stabilization through the consolidation period.

CONCLUSIONS

Metacarpal distraction was successfully achieved with an internal distraction device. Although infection was common, it occurred after the distraction period and did not preclude length gain. We feel that this low-profile device offers advantages over cumbersome external devices typically used for metacarpal lengthening.

Surgical Technique and Outcomes of Reconstruction for Blauth Type III Thumb Hypoplasia

BACKGROUND

Historically, amputation and pollicization has been the recommended surgical treatment for Blauth type III hypoplastic thumbs. However, due to aesthetic objections or cultural preferences, some parents seek out alternative surgical options. The present study describes a nontraditional technique that preserves and augments the hypoplastic thumb.

METHODS

Patient charts were retrospectively reviewed to identify patients with Blauth type III hypoplastic thumbs who underwent thumb reconstruction at our institution from 2008 to 2018. The reconstruction procedure involved toe phalanx transfer, staged tendon transfers, and lengthening as needed. Motion was assessed categorically as ability to flex, extend, or oppose the thumb. Functionality was assessed as ability to pinch and grasp with the surgical hand. Patient- or parent-reported improvement in thumb function was also recorded.

RESULTS

Of the 13 patients, 100% could flex, extend, and oppose the thumb to some degree. Eleven patients (85%) had functional one-handed grasp, and 9 (69%) had a functional pinch. Eleven patients (85%) reported no functional limitations of the operative hand. Thirteen patients (100%) reported improvement in hand function after surgery as compared to pre-operatively. There were 2 minor complications (15%), both of which resolved after intervention. No patients experienced donor-site morbidity.

CONCLUSIONS

Reconstruction of Blauth III thumbs is a nontraditional technique that allows for digit retention by salvaging the hypoplastic thumb. In the present study, the majority of patients had functional thumbs and all reported postoperative improvement. Overall, our results suggest that reconstruction is a viable surgical option for Blauth III hypoplastic thumbs.

Age-related Outcomes and Complications of Osteodistraction in the Pediatric Upper Extremity: A Large Retrospective Single-center Study of 61 Cases

BACKGROUND

The study purpose was to assess: (1) the complication rate of osteodistraction in the pediatric upper extremity, its severity and relation to patient-specific and treatment-specific parameters, and (2) dedicated patient-reported outcome scores after these procedures.

METHODS

This retrospective study analyzed a chart of patients undergoing osteodistraction of the upper limb between 2003 and 2020. Demographics, distraction-specific parameters, healing index, and any complications graded according to the Sink grading scale (grades 1 to 5) were extracted. An additional phone interview was performed to assess patient satisfaction and functionality of the elongated limb using the Quick-DASH (Disabilities of Arm, Shoulder, and Hand) score.

RESULTS

This study included 61 cases from 48 individual patients. The mean age at the start of distraction was 11.5±3.6 years. The ulna was the most frequently lengthened bone, with 21 (34.4%) cases. Ninety-four complications were observed, with an average complication rate of 77.0%. Based on the Sink grading scale (1 to 5), grade 3 complications were most common (n=29; 47.5%) followed by grade 1 (n=14; 23.0%), 2 (n=14; 23.0%), and 4 (n=4; 6.6%). A significantly lower and thus better bone healing index was observed for the age category less than 10 years compared with the 14 to 18 years group (P=0.006). The average satisfaction was 4.2±1.0 points of 5. The mean Quick-DASH score was 14.1±12.5, indicating very good clinical outcomes.

CONCLUSIONS

Despite the occurrence of numerous complications, high patient satisfaction and good daily life functionality of the treated limb was observed. An age of more than 14 years at the beginning of therapy had a negative prognostic effect on bone healing during distraction. Thus, osteodistraction in the upper extremity may preferably be performed less than 10 years of age because of enhanced bone regeneration.

LEVEL OF EVIDENCE

Level IV-retrospective case series.

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.

Long-Term Donor-Site Morbidity After Free, Nonvascularized Toe Phalanx Transfer for Congenital Differences of the Hand

PURPOSE

Toe phalanx transplantation is a well-established technique for addressing bony deficiency in the reconstruction of hypoplastic digits in patients with congenital differences of the hand. Prior studies have commented on varying degrees of donor-site morbidity, although assessment of morbidity with validated outcome scores is lacking. This study seeks to evaluate donor-site morbidity after toe phalanx harvest using validated outcome measures.

METHODS

We identified all children who underwent free, nonvascularized toe phalanx transfer to the hand at our institution from 2001 to 2011. We administered the Oxford Ankle Foot Questionnaire for Children (OXAFQ-C) and the Foot and Ankle Ability Measure (FAAM) to all patients, scaling results according to published scoring instructions.

RESULTS

Thirty-six patients with 83 toe phalanx transfers were able to be contacted, with a mean follow-up of 5.3 years (range, 18 months-11.2 years). The results of the OXAFQ-C showed mean scores of 99.96% (Physical), 100% (School and Play), and 96.01% (Emotional). The FAAM mean scores were 99.08% (Sports) and 99.17% (Activities of Daily Living). There were no lower extremity complications during the study period.

CONCLUSIONS

In contrast to varying degrees of donor-site morbidity reported in the current literature, this study demonstrates that toe phalanx harvest causes almost no measurable lower extremity morbidity or dysfunction over the mid- to long-term.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.

Forearm lengthening and prosthetic management in children with transverse congenital forearm deficiency

In cases of transverse congenital forearm deficiency, achieving a good prosthesis fit during childhood remains a challenge. Ulnar lengthening is a treatment option for improving the prosthesis fit. The objective of this study was to evaluate surgical ulnar lengthening and the subsequent prosthesis fit. We reviewed four cases of ulnar lengthening in children with transverse congenital forearm deficiency. The procedure was evaluated in terms of the duration of lengthening, increase in ulnar length and healing index. The elbow range of motion, functional outcome (Prosthetic Upper Extremity Functional Index, PUFI) and time spent using the prosthesis per day were evaluated. The mean age at the time of the lengthening procedure was 3.5 years, the mean duration of lengthening was 58.3 days, the mean length gain was 21 mm, and the mean healing index was 70.1 days/cm. Elbow range of motion was restricted in one patient (100°-140°) and full in the other three patients. Based on the PUFI, 88.4% of activities were performed without the prosthesis. Children only used their prosthesis to perform specific tasks. Given the high complication rate and the lack of prosthesis use during daily activities, the main indication for forearm lengthening is a very short forearm that prevents prosthesis fitting. This procedure should be performed later in life - in adolescence.

Distraction Lengthening Following Vascularized Second Toe Transfer for Isolated Middle Finger Reconstruction

PURPOSE

We report the use of distraction lengthening of the middle phalanx after vascularized second toe transfer for middle finger reconstruction to lengthen the digit to match the index and ring fingers.

METHODS

We performed a retrospective review of 3 patients with a mean follow-up of 30 months.

RESULTS

A mean increase of 2.0 cm in the length in the digit was achieved. The range of motion at the proximal interphalangeal joint was preserved and bony union was seen at the distraction site in all 3 cases. All patients had an excellent functional and aesthetic outcome.

CONCLUSIONS

Distraction lengthening of vascularized toe transfers is a feasible undertaking.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Presentation and Treatment of Poland Anomaly

Background: Poland anomaly is a sporadic, phenotypically variable congenital condition usually characterized by unilateral pectoral muscle agenesis and ipsilateral hand deformity. Methods: A comprehensive review of the medical literature on Poland anomaly was performed using a Medline search. Results: Poland anomaly is a sporadic, phenotypically variable congenital condition usually characterized by unilateral, simple syndactyly with ipsilateral limb hypoplasia and pectoralis muscle agenesis. Operative management of syndactyly in Poland anomaly is determined by the severity of hand involvement and the resulting anatomical dysfunction. Syndactyly reconstruction is recommended in all but the mildest cases because most patients with Poland anomaly have notable brachydactyly, and digital separation can improve functional length. Conclusions: Improved understanding the etiology and presentation of Poland anomaly can improve clinician recognition and management of this rare congenital condition.

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.

Symbrachydactyly

Background: Symbrachydactyly is a unilateral congenital hand malformation characterized by failure of formation of fingers and the presence of rudimentary digit nubbins. The management is variable and are investigated in this review. Methods: A detailed review of the literature was compiled into succinct clinically relevant categories. Results: Etiology, classification, non-surgical management, surgical intervention, and patient oriented outcomes are discussed. Conclusions: All interventions should prioritize realistic, evidence-supported appearance and functional gains. Studies of the baseline function and quality of life of children with symbrachydactyly would allow surgeons to better understand functional changes associated with various interventions and would help surgeons and parents to make the best treatment decisions.

The Use of Composite Tissue Spare Parts to Restore Tripod Hand Function in Post-Traumatic and Congenital Hand Deficiency

The principle aim in complex defects in hand is to restore a functioning tripod pinch. Among the various options, the use of locally available spare parts offers to improve both functions and cosmetics. 10 patients underwent surgeries to restore tripod pinch using this concept of spare parts. Four of them were children with congenital differences and the rest were adults with post traumatic defects. Eight of them underwent on-top plasty out of which four underwent an island pedicled transfer of phalanges and the rest involved distraction lengthening and transfer of metacarpals. One patient underwent a vascularized tenocutaneous joint transfer and another, a non-vascularized metacarpal transfer. At last follow up, eight of them were using hand with tripod pinch and one, using a lateral pinch. A carefully planned use of local tissues as spare part results in satisfactory outcome without the need for additional graft material in hands with absent or poor function.

Metacarpal Lengthening Of The Thumb Via Distraction Osteogenesis: A Case Report

Amputation of the thumb invariably causes marked functional impairment of the hand especially, pinch and grasp functions. In rural areas where highly skilled microvascular surgeries are not available, distraction osteogenesis provides an easy and safe alternative of thumb reconstruction. We report a case of crush injury of the right hand in a 37 year old gentleman in which the right thumb was amputated at the level of the proximal phalanx. Metacarpal lengthening of the thumb was performed by using distraction osteogenesis.

Masquelet technique for treatment of segmental bone loss in the upper extremity

A relatively simple technique to address large segmental bone defects in the upper extremity is described, along with a case example.

Osteosarcoma of the distal radius treated with segmental forearm resection, hand replantation, and subsequent limb lengthening: case report

A 9-year-old girl with osteosarcoma of the radius was treated with segmental forearm resection and replantation followed by forearm lengthening of 11 cm. At 9-year follow-up, she had recovered sensory function, and her pinch and grasp were sufficient for performing daily activities. Functional outcomes evaluated by the Disabilities of the Arm, Shoulder, and Hand questionnaire and International Society of Limb Salvage functional score system were 4/100 and 23/30, respectively.

Endoscopic iliotibial band release in snapping hip

Several open surgical techniques have been used to treat recalcitrant cases of snapping iliotibial band with varying results. Recently, endoscopic techniques have become available. The purpose of this study was to investigate the results of a modified endoscopic iliotibial band release using a longitudinal retrospective case series.
 Fifteen patients (three men and 12 women) with symptomatic external snapping hip were treated with an endoscopic release of the iliotibial band. The average age was 25 years (range 16-37 years). The procedure was performed in the lateral decubitus position using two portals; the iliotibial band was transversally released using a radiofrequency hook probe. The mean follow-up period was 33.8 months (range 12-84 months).
 The snapping phenomenon was overcome in all the patients. The mean pre-op pain VAS score was 5.5 mm (range 5-7 mm) and the mean post-op pain VAS score was 0.53 mm (range 0-2 mm) with a statistically significant reduction with respect to the preoperative value (p<0.0001); sixty percent of the patients were pain-free. The mean postoperative Harris Hip Score was 97.5 (range 94-100). No revision procedures were indicated and all the patients returned to their previous level of activity. The mean patient satisfaction score was, on average, 9.3 mm (range 8-10 mm) on the VAS scale. No complications occurred.
 Endoscopic iliotibial band release is a safe and reproducible technique with excellent results in terms of snapping phenomenon resolution, patient satisfaction, and return to previous level of activity. After strenuous sporting activities 40% of patients complained of very slight pain.

The reconstruction of large bone defects in the upper limb

Large bone defects in the upper limb pose many challenges in reconstructive surgery. Conventional and innovative methods have been described, employing the use of microsurgical and non-microsurgical techniques to overcome both bony and soft tissue defects. This article reviews the success and pitfalls of different techniques of reconstruction of large bone defects in the upper limb, including microsurgical transfer of the free vascularised fibula graft as a diaphyseal bone replacement and as a hemivascularised joint transplant, and non-microsurgical options using conventional bone grafting, the induced membrane technique and the role of callotatic distraction-lengthening procedures.