Two-stage double-level rotational osteotomy in the treatment of congenital radioulnar synostosis

Congenital proximal radioulnar synostosis is a rare congenital anomaly that can be extremely disabling, especially when it occurs bilaterally or if there is severe hyperpronation. Currently, osteotomy to achieve a neutral or slightly pronated position is widely accepted for the management of patients who have severe pronation. The present study evaluates the result of two-stage double-level rotational osteotomy of both the radius and ulna in the treatment of severe congenital radioulnar synostosis. Nine children with severe congenital radioulnar synostosis underwent two-stage double-level rotational osteotomy of both the radius and ulna at Mansoura University Hospital. There were seven boys and two girls with a mean age of 5.6 years who were followed up for a mean of 26 months. The position of the forearm was improved from a mean pronation deformity of 76 degrees (60 degrees to 85 degrees) to 30 degrees of pronation in the affected dominant extremities and 20 degrees of supination in non-dominant extremities in all cases. Bony union was achieved by 5.9 weeks with no loss of correction. The advantages of this technique are that it is easy, safe, with absence of severe postoperative complications and requires a small surgical scar. A drawback of the technique is that the rotation correction depends only on a cast, so that a correction loss might occur if the plaster cast loosens.     

Treatment of Congenital Radioulnar Synostosis Using a Free Vascularized Fascia Lata Graft

ObjectiveTo describe the modified mobilization surgery technique that uses a free vascularized fascia lata graft as the interposition graft, and to evaluate the outcome of this procedure in treating congenital radioulnar synostosis (CRUS).MethodsEleven patients (eight boys and three girls with an average age of 6.0 years) were treated using this procedure between 2012 and 2017 in our institution. Five bilateral cases (four left forearms and one right forearm were treated), and six unilateral cases (three left forearms and three right forearms) were included. All 11 cases were treated with mobilization procedure with free vascularized fascia lata as the interposition graft, and were followed‐up for an average of 2.2 years (range, 2–4 years). The parental satisfaction, postoperative ankylosis at proximal radioulnar joint, and active range of forearm rotation motion (measured by physical examination) were evaluated at the last follow‐up.ResultsThe average preoperative fixed pronation angle was 67.3° (range, 20°–90°). Ipsilateral thumb hypoplasia was noted in one case, and cleft palate and bilateral thumb hypoplasia were noted in one case; none of the patients had a family history of congenital radioulnar synostosis. Pronation and supination splints were used 3 days after the operation and were worn every night for 4–6 months postoperatively. Active and passive rehabilitation for elbow flexion and forearm rotation was initiated 4 weeks postoperatively. All patients were followed up for at least 2 years (average, 26 months; range, 24–48 months). The average forearm pronation range was 39° (range, 20°–60°), and the average forearm supination range was 33.2° (range, 10°–60°) at the latest follow‐up. Re‐ankylosis occurred in one case. An osseous bridge developed between the radius and ulna at the osteotomy site in one case. Radial nerve paralysis developed in two cases and spontaneously resolved 2 months later. Plate breakage was noted in one case 9 weeks postoperatively; however, union was achieved 7 months later.ConclusionMobilization of proximal radioulnar synostosis using a free vascularized fascia lata graft as the interposition graft may prevent re‐ankylosis and restore the forearm rotation function, making it a good option for the surgical treatment of CRUS.     

Rotational osteotomies for congenital radioulnar synostosis

In five children, six forearms with a fixed pronation deformity secondary to congenital radioulnar synostosis were treated by a derotation osteotomy of the distal radius and the midshaft of the ulna.There were three boys and two girls with a mean age of 4.9 years (3.5 to 8.25) who were followed up for a mean of 29 months (18 to 43). The position of the forearm was improved from a mean pronation deformity of 68 degrees (40 degrees to 80 degrees ) to a pre-planned position of 10 degrees of supination in all cases. Bony union was achieved by 6.3 weeks with no loss of correction. There was one major complication involving a distal radial osteotomy which required exploration for a possible compartment syndrome.     

Derotational osteotomy at the shafts of the radius and ulna for congenital radioulnar synostosis

PURPOSE: The purpose of this study was to describe the results of a newly developed method of correction osteotomy for congenital radioulnar synostosis. With this method the osteotomy is performed at the distal one third of the radius and proximal one third of the ulna. After K-wires are inserted intramedullarly into both bones the forearm is derotated manually to the position planned before surgery followed by cast immobilization. METHODS: Four patients with an average age of 3.9 years underwent surgery with this method and were followed-up for 45.8 months. All of their forearms were fixed before surgery at over 70 degrees of pronation. RESULTS: The average correction after surgery was 65 degrees and bone union occurred at 8 weeks after surgery without any complications. The patients' ability to perform daily activities showed a marked improvement after surgery, but there was a 20 degrees loss of correction during cast immobilization in one case. CONCLUSION: This method is a simple and safe technique to derotate the forearms of the patients with congenital radioulnar synostosis that are fixed in pronation.     

Derotational osteotomy of the proximal radius and the distal ulna for congenital radioulnar synostosis

Objective  To evaluate the clinical and functional results of a technical procedure in the surgical treatment of congenital radioulnar synostosis in children. Materials and methods  A prospective study had been undertaken from January 1992 to December 2004. Thirty-four patients with congenital radioulnar synostosis that are fixed in pronation were recruited. Congenital radioulnar synostosis was classified for two types according to Tachdjian’s criteria. All patients were treated by resection of the proximal radius and the distal ulna to remove a segmental bone of both parts of the forearm. After K-wires are inserted intramedullarly into both bones, the forearm is derotated manually, followed by cast immobilization. Results  There were 34 patients (52 forearms) with congenital radioulnar synostosis, whom the average age at surgery was 6 years and 3 months. There were two types of congenital radioulnar synostosis: Type 1 in six forearms (11.6%) and Type 2 in 46 forearms (88.4%). The preoperative forearm rotation ranged from 65° to 85° pronation. The postoperative forearm rotation angle was corrected from 0° to 30°; the best end position appears to be 70–100% of pronation. Of the patients, 78.8% had good or excellent results. All patients were operated on without complications; five patients had loss of correction during cast immobilization. Overall, the patient’s ability to perform daily activities showed a marked improvement after surgery. Conclusion  This method is a simple and safe technique to derotate the forearms of patients with congenital radioulnar synostosis that are fixed in pronation.     

Double dome osteotomy for the treatment of cubitus varus in children

Purpose

The purpose of this study was to report double dome osteotomy used to correct paediatric cubitus varus and to avoid lateral prominence after correction.

Methods

Eighteen children with cubitus varus underwent double dome osteotomy. Preoperative templating created from radiographs was used to determine the bone cuts. Double dome osteotomy created a proximal and distal cut, then varus deformity and sagittal alignment were corrected. The osteotomies were fixed with K-wires and immobilised in a long-arm cast. Radiographics and clinical histories were evaluated. Ulno-humeral angle pre and postoperative, range of motion and lateral prominent index were evaluated.

Results

The osteotomy was performed in 18 patients, with an average age of 7.5 years. All patients ended up with flexion of 130° or greater with full and symmetrical pronation and supination. The average ulno-humeral angle difference compared to the uninjured side was 3.27°. The mean of the lateral prominent index was −0.91. The mean follow up was 50.3 months (30–115 months). All of the patients had excellent clinical and radiographic alignment. No revisions were made in this series. One transient radial nerve palsy and one superficial infection occurred.

Conclusion

This series demonstrates that double dome osteotomy can provide reliable correction of varus deformity and prevent lateral prominence with a minimal complication rate.     

Retrograde dynamic locked nailing for valgus knee correction: a revised technique

Purpose

Traditionally, valgus knee deformity is predominately corrected by stabilisation with a plate inserted via the medial approach to the supracondylar region of the femur. However, this technique is unfavourable from both a biomechanical and a biological point of view. A revised retrograde dynamic locked nailing was developed to improve correction of this defect.

Method

Forty-one knees with valgus deformity (average tibiofemoral angle, 22°; range, 16–29°) in 25 adult patients were treated by oblique femoral supracondylar varus osteotomy and stabilised with retrograde dynamic locked nails. Postoperatively, early ambulation with protected weight bearing and range of motion knee exercises were encouraged.

Result

Thirty-five knees of 21 patients were followed-up for an average of 2.6 years (range, 1.1–4.5 years). All osteotomy sites healed with an average union period of 3.4 months (range, 2.5–5.0 months). There were no significant complications. At the latest follow-up, the average tibiofemoral angle was 7.1° valgus (range, 4–10° valgus). For all of the knees, the outcomes were satisfactory (p < 0.001).

Conclusion

The technique described here may be a feasible alternative for correction of valgus knee deformity. The advantages of this technique include the use of a biomechanically more appropriate method, a minimal complication rate and a high rate of satisfactory outcomes.     

Both-bone forearm osteotomy for supination contracture: a cadaver model

PURPOSE: To quantify the magnitude of rotational correction possible when comparing a single forearm bone osteotomy and fixation with stepwise osteotomy and fixation of both bones in a cadaver model and to determine if the order in which the stepwise osteotomies are performed influences the amount of correction. METHODS: Ten fresh-frozen cadaveric forearms were fixed to a frame positioned in the field of view of a motion-capture system. An experimental supination contracture was induced in full supination. Cadaver forearms were assigned randomly to group I (ulna osteotomy, rotation, plating) or group II (radius osteotomy, rotation, plating). Cadavers in group I were used later in group III (ulna + radius) by completing a radial osteotomy, rotation, and fixation in the forearms with the plated ulna. Similarly the specimens assigned to group II were used later in group IV (radius + ulna) by completing an ulna osteotomy, rotation, and fixation in the forearms with the plated radiuses. Measurements of forearm pronation were made after single-bone (groups I, II) and stepwise both-bone (groups III, IV) rotational osteotomies. RESULTS: Stepwise rotational osteotomy and fixation of the ulna followed by the radius produced significantly more corrective pronation (101 degrees) than rotating the radius followed by the ulna (65 degrees). Rotating the radius gave only moderate correction (58 degrees) and minimal correction was produced by ulna osteotomy alone (15 degrees). CONCLUSIONS: Rotational osteotomy of both forearm bones can create approximately 100 degrees of correction when performed at the proximal ulna followed by the distal radius. If less rotation is needed then the distal radius osteotomy alone can provide approximately 60 degrees of correction.     

Post-traumatic radioulnar synostosis

There is a paucity of data about post-traumatic radioulnar synostosis, an unusual but serious complication of forearm fractures. Treatment methods have included excision of the synostosis with interposition of soft tissue or synthetic material, excision of the proximal radius, insertion of a screw to distract the radius from the ulna, and a rotational osteotomy of the radius to improve function. In the case of a 28-year-old woman, the treatment was excision of the synostosis, obliteration of the dead space with muscle, prevention of hematoma formation, and early mobilization. The result was an active range of motion of 80 degrees pronation and 60 degrees supination.     

Anatomic reconstruction of the radioulnar ligament

Introduction

Twenty-five patients (19 males and six females) were included in the study based on: chronic symptoms of distal radioulnar joint instability, demonstrable instability on examination, MRI evidence of radioulnar ligament deficiency, and arthroscopic findings of foveal disruption of the radioulnar ligament.

Materials and Methods

Exclusion criteria were: distal radius malunion, congenital malformation of the sigmoid notch, DRUJ arthritis, and less than 24 months minimum follow-up. Mean age was 35 years old with a mean interval from injury to surgery of 5 months. Surgery began with arthroscopic confirmation of the chronic foveal detachment followed by open reconstruction of the radioulnar ligament using the palmaris longus tendon. The specific method employed three drill tunnels corresponding to the true anatomic points of attachment of the radioulnar ligament. Patients were examined post-operatively at 2 weeks, 4 weeks, 6 weeks, 12 weeks, and 6 months.

Results and Discussion

Final evaluation averaged 51 (±14) months following surgery. Measures obtained before and after treatment included: wrist range of motion, forearm range of motion, grip strength, examination findings of distal radioulnar joint instability, and Disabilities of Arm, Shoulder, and Hand (DASH) scores. Pre-operative and post-operative measures were compared using the paired Student’s t test, accepting a p value of 0.05 as statistically significant. All patients healed the reconstruction without major complications and demonstrated distal radioulnar joint stability at the 6-week examination. Mean ranges of motion, in degrees, pre-/post-operative were: wrist flexion 53 (±13)/61 (±10), wrist extension 53 (±13)/62 (±15), supination 65 (±12)/74 (±7), and pronation 66 (±11)/71 (±8). Grip strengths expressed as % contralateral pre-/post-operative were: 57 (±23)/79 (±25). The differences in these measures were not found to be statistically significant. The mean pre-/post-operative DASH scores were: 62 (±16)/7 (±3). This difference was found to be statistically significant.

Conclusion

Reconstruction of the RUL with a free palmaris longus tendon graft using the truly anatomic points of original RUL attachment at both the ulna and radius restored DRUJ stability and improved DASH scores without limiting forearm or wrist motion.     

Corrective osteotomies of the radius and ulna for supination contracture of the pediatric and adolescent forearm secondary to neurologic injury

PURPOSE: To present the authors' experience with internal fixation of the radius and ulna as a surgical option for correction of supination contracture of the forearm. METHODS: Twelve patients (13 limbs) had an osteotomy of the radius and ulna for a supination deformity secondary to a residual brachial plexus or spinal cord injury. Surgery consisted of proximal ulna and distal radius osteotomies combined with plate fixation. RESULTS: The average age of the patients at the time of surgery was 11 years. Five limbs had fixed supination deformities and 8 limbs lacked pronation beyond neutral. The average preoperative supination deformity (either fixed or measured at midarc) was 76 degrees. The average intraoperative correction was 86 degrees. The average follow-up period was 16 months. The average midrange resting position maintained at final follow-up evaluation was 2 degrees of pronation. All limbs ultimately obtained radiographic and clinical union of the osteotomy sites. Complications included 6 plate fractures; however, only 1 patient required revision internal fixation. CONCLUSIONS: The combination of a proximal ulna and distal radius osteotomy with internal fixation can provide excellent correction, but the implant must be strong enough to hold the osteotomies rigidly in the corrected position during the time needed for union. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Ulnar nonunion after osteoclasis for rotational deformities of the forearm

PURPOSE: Osteoclasis, a minimally invasive technique to rotate the radius and ulna, is used commonly to correct forearm rotational deformities in children. The purpose of this investigation was to evaluate objectively osteotomy healing in patients treated with osteoclasis, with specific attention given to the risk for nonunion. METHODS: We identified 69 extremities in 65 children treated with osteoclasis and performed retrospective chart and radiographic reviews to evaluate the time to union of the radius and ulna and factors influencing healing. RESULTS: The average rotational correction was 90 degrees. Twenty-one ulnas had either delayed union or nonunion. Forty-eight of the forearms healed in less than 3 months. Factors correlated with a significantly decreased union rate included increased patient age, percutaneous technique, osteoclasis site in the proximal ulna, and primary diagnoses other than congenital radioulnar synostosis. Preoperative forearm position, magnitude of position correction, and treatment of the periosteum were not associated with changes in union rates. CONCLUSIONS: Forearm osteoclasis has a delayed union rate of 16%. Timely union of the ulna appears to be influenced by both patient-centered factors and surgical technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Ankle Deformity Secondary to Acquired Fibular Segmental Defect in Children

Background

The authors report the long-term effect of acquired pseudoarthrosis of the fibula on ankle development in children during skeletal growth, and the results of a long-term follow-up of Langenskiold''s supramalleolar synostosis to correct an ankle deformity induced by an acquired fibular segmental defect in children.

Methods

Since 1980, 19 children with acquired pseudoarthrosis of the fibula were treated and followed up for an average of 11 years. Pseudoarthrosis was the result of a fibulectomy for tumor surgery, osteomyelitis of the fibula and traumatic segmental loss of the fibula in 10, 6, and 3 cases, respectively. Initially, a Langenskiold''s operation (in 4 cases) and fusion of the lateral malleolus to the distal tibial epiphysis (in 1 case) were performed, whereas only skeletal growth was monitored in the other 14 cases. After a mean follow-up of 11 years, the valgus deformity and external tibial torsion of the ankle joint associated with proximal migration of the lateral malleolus needed to be treated with a supramallolar osteotomy in 12 cases (63%). These ankle deformities were evaluated using the serial radiographs and limb length scintigraphs.

Results

In all cases, early closure of the lateral part of the distal tibial physis, upward migration of the lateral malleolus, unstable valgus deformity and external tibial torsion of the ankle joint developed during a mean follow-up of 11 years (range, 5 to 21 years). The mean valgus deformity and external tibial torsion of the ankle at the final follow-up were 15.2° (range, 5° to 35°) and 10° (range, 5° to 12°), respectively. In 12 cases (12/19, 63%), a supramalleolar corrective osteotomy was performed but three children had a recurrence requiring an additional supramalleolar corrective osteotomy 2-4 times.

Conclusions

A valgus deformity and external tibial torsion are inevitable after acquired pseudoarthrosis of the fibula in children. Both Langenskiöld supramalleolar synostosis to prevent these ankle deformities and supramalleolar corrective osteotomy to correct them in children are effective initially. However, both procedures cannot maintain the permanent ankle stability during skeletal maturity. Therefore any type of prophylactic surgery should be carried out before epiphyseal closure of the distal tibia occurs, but the possibility of a recurrence of the ankle deformities and the need for final corrective surgery after skeletal maturity should be considered.     

Clinical Efficacy of Vertical or Parallel Technique of a Micro‐Locking Plate for Treatment of Dubberley B‐Type Capitellar Fractures

ObjectiveTo evaluate the clinical efficacy of micro‐locking plate through vertical or parallel technique for treatment of Dubberley B‐type capitellar fractures.MethodsA retrospective analysis was performed in 24 patients (17 males and seven females, with an average age of 44.9 years, range from 19 to 75 years) with capitellar fractures that were treated with micro‐locking plate using vertical or parallel technique between January 2016 to January 2019. The inclusion criteria include closed capitellar fracture, normal anterior elbow joint movement before injury, and recent capitellar fracture with injury within past 3 weeks. Fractures classified according to Dubberley included four cases of type IB, eight cases of type IIB, and 12 cases of type IIIB. Radiographic evaluation was performed. Surgery time, blood loss, range of motion of the elbow, forearm rotation, and complications were recorded. Elbow joint function was evaluated by Mayo Elbow Performance Score (MEPS).ResultsThe mean follow‐up period was 19.6 months (range, 12–36 months). The average clinical healing time for fractures was 11.2 ± 3.2 weeks (range, 8–20 weeks). Fracture united in all patients. Two patients showed slight delayed union, but union was achieved eventually. The mean time from injury to surgery was 6.3 ± 3.1 days (range, 2–15 days). The average surgical time was 68.1 ± 11.5 min (range, 50–90 min), and the mean blood loss was 75.2 ± 26.5 mL (range, 40–120 mL). The mean range of flexion was 122.5° ± 10.5°(range, 95°–140°). The mean range of extension was 8.5° ± 5.8°(range, 0°–20°). The mean range of pronation was 79.7° ± 8.0°(range, 65°–90°). The mean range of supination was 80.5° ± 7.1°(range, 60°–90°). The mean MEPS at final follow‐up was 89.8 ± 9.0 (range, 60–100). Based on the MEPS, 18 (75%) patients had excellent, five (20.8%) patients had good, and one (4.2%) patient had fair. None of the 24 patients suffered vascular or nerve injury. One patient showed superficial infection, which was treated with surgical dressing.ConclusionsThe vertical or parallel technique of the micro‐locking plate is an excellent method for treating Dubberley B‐type capitellar fractures.     

Combined Proximal Tibial Osteotomy for Adult Kashin–Beck Disease with Severe Varus Knee Osteoarthritis: Case Report and Literature Review

BackgroundKashin–Beck disease (KBD) is an endemic, chronic osteoarthropathy that seriously affects joint function and can lead to severe knee deformity. Osteotomy is considered to be one of the effective methods for the treatment of this disease. Therefore, we designed a novel type of osteotomy named combined proximal tibial osteotomy (CPTO), which combines the characteristics of opening‐wedge high tibial osteotomy and tibial condylar valgus osteotomy.Case presentationWe report the case of a 48‐year‐old male with knee pain and varus deformity who was diagnosed with KBD and varus knee osteoarthritis (Kellgren–Lawrence stage IV). Considering the patient''s relatively young age, a varus deformity of the right knee of 16.79°, and an intra‐articular instability, we performed a CPTO treatment. In this procedure, we performed an L‐shaped osteotomy from the medial edge of the proximal tibia to the intercondylar eminence and an osteotomy from the medial side of the proximal tibia to the lateral side through the same incision, to adjust the leg alignment and the congruity of the joint by valgus correction. At 29 months follow‐up, this patient achieved satisfactory results, with a varus right knee of 2.87°. There was significant improvement in his right knee function, pain, and joint stability.ConclusionsCPTO may be an acceptable treatment for KBD patients with severe knee varus deformity and intra‐articular instability. It can be considered as an alternative treatment, especially for patients with advanced osteoarthritis needing knee preservation.     

Preventing recurrence of radioulnar synostosis with pedicled adipofascial flaps

The surgical treatment of post-traumatic radioulnar synostosis is difficult. Recurrence after resection alone is a concern with poor long-term maintenance of forearm rotation. We report on the use of pedicled adipofascial flaps to prevent recurrence and facilitate maintenance of movement in six adult patients with radioulnar synostosis. Five involved the proximal radioulnar joint and one the distal radioulnar joint. In four the flap was based on the radial artery and in two on the posterior interosseous artery. Mean intraoperative supination was 78° and pronation was 76°. Mean follow up was 32 months. At follow-up, mean supination was 71° and pronation was 70°. No patient had radiological recurrence of synostosis. The only complication was a transient posterior interosseous nerve palsy. Pedicled adipofascial flaps are a safe addition to resection alone which may prevent recurrence and maintain the range of forearm rotation achieved at operation.     

Ostéotomie en roseau du radius chez l’enfant dans la paralysie de la pronation du plexus brachial obstétrical

We report our experience and results in the use of reed pronating osteotomy in supination deformities secondary to obstetrical brachial plexus injury. This retrospective study involved 11 patients with paralytic supination of the forearm due to a brachial plexus injury. Other causes of paralytic supination were excluded. The surgical technique consisted of a proximal osteotomy of the ulna fixed by an intramedullary nail and a stable elastic reed osteotomy of the radius. The minimum postoperative follow-up was 2 years. Four boys and seven girls mean aged 8 years (5–12) were operated on between 2000 and 2010. The mean preoperative supination was measured at 63°. The final position average pronation was 37°. Loss of pronation was measured at 15°. No complication was observed. With a mean follow-up of 4 years (2–12), the reed osteotomy of radius associated with a proximal transverse osteotomy of ulna has proven itself effective for correction of paralytic supination of the forearm without complication or reoperation.