骨痂延长术治疗尺骨远端遗传性多发性骨软骨瘤致前臂畸形的疗效分析

[目的]探讨应用尺骨骨痂延长术治疗尺骨远端遗传性多发性骨软骨瘤致前臂畸形的临床疗效.[方法]回顾性研究尺骨远端遗传性多发性骨软骨瘤导致前臂畸形患者17例19臂,采用尺骨骨痂延长术治疗.对手术前后的X线评价和功能评价进行统计学分析比较.[结果]17例患者均获随访,平均随访时间36个月(25～52个月),尺骨短缩、桡骨弯曲、桡骨远端骨骺尺侧倾斜及腕骨尺侧移位等畸形得到明显纠正,且前臂旋前、旋后和腕关节桡偏功能优于术前,通过Krimmer腕关节功能评分分析得出术后腕关节总体功能较术前明显改善.[结论]应用尺骨骨痂延长术治疗尺骨远端遗传性多发性骨软骨瘤致前臂畸形可以有效纠正其诸多外观畸形并改善前臂功能,临床疗效满意.     

镶嵌式外固定支架治疗尺骨骨软骨瘤所致前臂畸形

目的探讨镶嵌式外固定支架治疗尺骨骨软骨瘤所致前臂畸形的效果。方法使用镶嵌式外固定支架进行尺骨延长,治疗7例尺骨骨软骨瘤引起的前臂畸形患者。结果7例尺骨分别延长1．5-5．3cm,脱位桡骨小头自行复位,手内翻和肘内翻畸形明显减轻,肘关节屈伸和前臂旋转功能亦有改善。结论使用镶嵌式外固定支架进行尺骨延长治疗尺骨骨软骨瘤所致前臂畸形是一种简单有效的方法。     

Ilizarov外固定技术治疗多发性骨软骨瘤致前臂畸形

[目的]介绍Ilizarov外固定治疗多发性骨软骨瘤致前臂畸形的手术技术。[方法] 2014年7月～2017年7月收治6例多发性骨软骨瘤前臂畸形患者,男2例,女4例,年龄6～20岁,平均(12.72±5.23)岁;应用Ilizarov外固定器行尺骨牵伸延长、桡骨截骨矫形等处理,1例患者同期行尺骨远端骨软骨瘤切除术,1例患者同期行桡骨近端骨软骨瘤切除术。[结果]患者前臂畸形矫正满意;尺骨近端延长25～35 mm,平均(30.00±5.00) mm,均达到骨性愈合,未见延迟愈合;桡骨截骨矫形良好、截骨端骨性愈合;腕关节尺偏畸形得到大部分纠正,下尺桡关节复位,前臂旋转功能明显恢复,腕关节及肘关节活动功能明显改善。术后1例患者出现轻度屈腕畸形,予以配置辅具与前臂外固定器相结合很快纠正并有效预防复发。[结论] Ilizarov外固定技术治疗多发性骨软骨瘤致前臂畸形的临床效果满意,具有创伤小、并发症少、操作简便灵活等优点。     

尺骨延长矫正前臂畸形

目的：探讨尺骨发育不良所至的前臂畸形的手术矫正方法及其疗效。方法：采用单臂肢体延长器对短缩的尺骨进行渐进性延长。共治疗5例患者，其中4例尺骨发育不良是由尺骨骨软骨瘤造成，1例由内生软骨瘤所致。结果：5例尺骨分别延长3．5－5．2cm，平均4.2cm。脱位的桡骨小头全部复位，肝内翻及腕关节内收畸形均获得不同程度矫正。结论：对尺骨发育不良造成的前臂畸形行尺骨渐进性延长是一个简便且疗效颇佳的治疗方法。     

儿童桡骨远段骨不连并重度腕部畸形的手术治疗

目的 探讨小儿桡骨远段骨不连并腕部畸形的治疗方法.方法 收治小儿桡骨远段骨不连并腕部畸形9例,其中开放性骨折合并感染7例,闭合性骨折2例.全部采用尺骨缩短、桡骨撑开植骨延长手术治疗.结果 术后随访6～30个月,平均22个月,骨不连全部愈合.8例取得良好外观和满意功能.术后感染1例,经治疗后愈合.腕部畸形复发1例,经再次行尺骨缩短联合远端骨骺阻滞术后改善.结论 治疗成功的关键是保证尺桡骨同步发育、促进骨折愈合和矫正畸形,尺骨缩短、桡骨撑开植骨延长是一种可行的方法.     

截骨延长髂骨植骨治疗桡骨远端陈旧性骨折并下尺桡关节脱位

目的探讨截骨延长、髂骨块植骨加锁定钢板治疗桡骨远端陈旧性骨折并下尺桡关节脱位的方法及疗效。方法对30例桡骨远端陈旧性骨折短缩畸形伴下尺桡关节脱位的患者行截骨延长加髂骨块植骨、桡骨远端锁定钢板内固定治疗。结果 30例均获得随访,时间12~15个月。患者腕关节前屈、后伸、尺偏、桡偏、旋前和旋后功能较术前均明显改善(P0.05),术后桡骨短缩、掌倾角及尺偏角与术前比较差异均有统计学意义(P0.05)。根据Garland-Werley功能评定:优21例,良5例,可2例,差2例,优良率86.7%。术后未出现桡骨高度丢失、内固定失败及骨不连等并发症。结论截骨延长、髂骨块植骨加锁定钢板治疗桡骨远端陈旧性骨折并下尺桡关节脱位有利于恢复腕关节的正常解剖结构,明显改善腕关节功能,减少创伤性关节炎的发生。     

尺骨干骺端续连症不同手术方法的疗效观察

目的:探讨尺骨骨软骨瘤切除、尺骨微创截骨、外固定尺骨延长术治疗尺骨干骺端续连症前臂畸形治疗效果和安全性。方法:自2005年8月至2013年12月,20例尺骨干骺端续连症患者,男15例,女5例;年龄7~13(10.00±2.34)岁;病程6~11(8.10±1.52)个月;临床表现为患侧前臂短缩并向尺侧弯曲畸形。采用尺骨骨软骨瘤切除、尺骨微创截骨、外固定尺骨延长术治疗,术后评估包括评估疼痛、日常生活活动、外观矫形效果及腕关节、肘关节和前臂的运动范围,放射学评估包括尺骨长度、桡骨关节面倾斜角和腕部骨骺生长情况。结果:所有患者术后伤口愈合,未出现感染,与并发症相关的惟一术式是尺骨延长,包括1例骨不连、2例尺骨延长骨痂骨折、1例暂时性的桡神经麻痹。所有患者获得随访4~7.5(6.03±1.33)年。所有病例腕关节桡偏尺偏活动度数、前臂旋前旋后度数变化差异有统计学意义(P0.05),放射学评估参数(尺骨方差,桡骨关节角,腕骨滑动)得到了改善且差异具有统计学意义(P0.05),末次随访时改良Green和O'Brien腕关节功能评分与术前比较差异有统计学意义(P0.05),腕关节的临床疗效与术前比较差异有统计学意义(P0.05),末次随访Mayo肘关节功能评分与术前比较差异有统计学意义(P0.05),肘关节的临床疗效与术前比较差异有统计学意义(P0.05)。结论:尺骨骨延长对阻止远期畸形的进展无益,单纯的尺骨远端骨软骨瘤切除术有利于阻止畸形的发展,腕关节和前臂旋转活动受限及对外观的改善有强烈的要求的患者可积极进行手术治疗。     

外固定架尺骨延长治疗遗传性多发性骨软骨瘤所致前臂畸形

目的探讨采用外固定架尺骨延长治疗遗传性多发性骨软骨瘤(HMO)所致前臂畸形的疗效。方法回顾分析2014年4月至2018年4月北京积水潭医院创伤骨科采用外固定架尺骨延长治疗HMO所致前臂畸形患者5例。其中男4例,女1例;平均年龄14.5岁(12~16岁);右侧2例,左侧3例;MasadaⅠ型2例,MasadaⅡB型3例。5例患者均接受尺骨延长手术治疗。对3例MasadaⅡB型患者采用环形外固定架,另2例采用单边外固定架。1例合并桡骨骨折患者同时行桡骨骨折切开复位内固定术。截骨术后8~10 d开始行尺骨牵开延长。结果5例患者均获得随访,平均随访时间16个月(12~30个月)。3例MasadaⅡB型患者桡骨头均自行复位。5例患者尺骨平均延长37.5 mm(30~45 mm),平均应用外固定架时间162 d(122~274 d),平均外固定架指数48.9 d/cm。术前和术后平均梅奥肘关节评分分别为36.4分和92.7分,平均肘关节屈曲活动范围分别为118.0°(110°~130°)和130.0°(120°~150°),平均伸肘活动范围分别为12.7°(10°~20°)和3.5°(0°~10°),平均前臂旋前活动范围分别为18.6°(5°~30°)和44.7°(30°~65°),平均前臂旋后活动范围分别为71.2°(50°~85°)和86.5°(75°~90°)。1例桡骨干骨折患者术后3个月骨折愈合。2例出现针道感染;1例尺骨过早愈合,行第2次截骨手术后延长顺利。未见神经血管并发症。5例患者对治疗结果均满意。结论采用外固定架逐渐延长尺骨治疗HMO患者尺骨短缩畸形和桡骨头脱位安全有效。     

桡骨远端骨折畸形愈合截骨矫形治疗的近期随访

[目的] 探讨桡骨远端骨折畸形愈合截骨矫形的临床疗效.[方法]背侧入路行桡骨远端截骨、自体髂骨植骨、“T”型解剖锁定接骨板固定手术治疗,有桡尺远端关节炎患者进行了尺侧腕伸肌移植Bowers关节成形手术治疗.[结果]随访16～36个月,平均20.6个月,X线复查示桡骨远端畸形矫形良好,根据改良的Mcbridge腕关节功能评分标准,术后10例病人患肢腕关节功能明显改善.[结论]应用截骨矫形治疗桡骨远端骨折畸形愈合手术效果良好,安全可靠.     

带骨间背侧动脉蒂的尺骨远端骨块移植治疗尺,桡骨骨不连接

在解剖研究基础上设计出带村问背侧动脉蒂的尺骨远端骨块移植治疗尺、桡骨骨不连接。通过对７０侧尸体上肢解剖观察，发现骨间背侧动脉在远侧段发出２～３个骨膜支营养尺骨远端。临床应用７例，术中紧贴尺侧腕伸肌桡侧．在其深面游离骨间背侧动脉连同周围１．０ｃｍ深筋膜，直至见到进入民骨的骨膜支，切取风骨远端，将此带血管蒂的尺骨块移植至近端尺、桡骨骨缺损处．随访６～１２个月，３．５个月时均达到骨性愈合。骨块切取后保留了尺骨的连续性和下尺桡关节的完整性，不影响前臂及腕关节的运动。我们为治疗尺、桡骨骨不连接提供了一种新的有效方法。     

Correction and lengthening for deformities of the forearm in multiple cartilaginous exostoses

Background Multiple cartilaginous exostoses cause various deformities of the epiphysis. In exostoses of the ulna, the ulna is shortened and the radius acquires varus deformity, which may lead to dislocation of the radial head. In this study, we present the results of exostoses resection, with correction and lengthening with external fixators for functional and cosmetic improvement, and prevention of radial head dislocation. Methods We retrospectively reviewed seven forearms of seven patients who had deformities of the forearm associated with multiple cartilaginous exostoses. One patient had dislocation of the radial head. Operative technique was excision of osteochondromas from the distal ulna, correction of the radius, and ulnar lengthening with external fixation up to 5 mm plus variance. We evaluated radiographs and the range of pronation and supination. Furthermore, we conducted a follow-up of ulnar length after the operation. Results Dislocation of the radial head of one patient was naturally reduced without any operative intervention. At the most recent follow-up, six of the seven patients showed full improvement in pronation–supination. Ulnar shortening recurred with skeletal growth of four skeletally immature patients; however, it did not recur in one skeletally mature patient. Overlength of 5 mm was negated by the recurrence of ulnar shortening about 1.5 years after the operation. Conclusions We treated seven forearms of seven patients by excision of osteochondromas, correction of radii, and gradual lengthening of ulnas with external fixators. The results of the procedure were satisfactory, especially for function of the elbow and wrist. However, we must consider the possible recurrence of ulnar shortening within about 1.5 years during skeletal growth periods in immature patients.     

Long-term results of surgery for forearm deformities in patients with multiple cartilaginous exostoses

BACKGROUND: Surgical treatment of forearm deformities in patients with multiple cartilaginous exostoses remains controversial. The purpose of the present study was to determine the reasonable indications for operative treatment and to evaluate long-term results of forearm surgery in these patients. METHODS: We retrospectively reviewed twenty-three patients (thirty-one forearms) after a mean duration of follow-up of nearly thirteen years. The mean age at the time of the initial procedure was eleven years. The patients underwent a variety of surgical procedures, including excision of exostoses; corrective procedures (lengthening of the radius or ulna and/or corrective osteotomy of the radius and/or ulna) and open reduction or excision of a dislocated radial head. Clinical evaluation involved the assessment of pain, activities of daily living, the cosmetic outcome, and the ranges of motion of the wrist, forearm, and elbow. The radiographic parameters that were assessed were ulnar variance, the radial articular angle, and carpal slip. RESULTS: Four patients had mild pain, and five patients had mild restriction of daily activities at the time of follow-up. Eight patients stated that the appearance of the forearm was unsatisfactory. Radiographic parameters (ulnar variance, radial articular angle, carpal slip) were initially improved; however, at the time of the final follow-up visit, the deformities had again progressed and showed no significant improvement. The only procedure that was associated with complications was ulnar lengthening. Complications included nonunion (three forearms), fracture of callus at the site of lengthening (two forearms), and temporary radial nerve paresis following an ulnar distraction osteotomy (one forearm). Excision of exostoses significantly improved the range of pronation (p = 0.036). CONCLUSIONS: In our patients with multiple cartilaginous exostoses, corrective osteotomy and/or lengthening of forearm bones was not beneficial. The most beneficial procedure was excision of exostoses. Reasonable indications for forearm surgery in these patients are (1) to improve forearm rotation and (2) to improve the appearance.     

Management of deformities of the forearm in multiple hereditary osteochondromas

A patient with multiple hereditary osteochondromas may have any of several severe deformities of the forearm, the most common of which are ulnar deviation of the wrist associated with relative shortening of the ulna, bowing of either or both of the bones of the forearm, shortening of the forearm, and late dislocation of the radial head. The natural history of these deformities is progression, with variable weakness, functional impairment, and cosmetic deformity of the extremity. We describe the results, after a follow-up of at least two years, in eighteen patients who underwent major surgical procedures: excision of the osteochondromas (ten patients), ulnar lengthening with excision of the osteochondromas (three patients), and ulnar lengthening with radial hemiepiphyseal stapling (seven forearms of five patients). Early excision of the osteochondromas alone did not slow the progression of the deformity. Ulnar lengthening did, on occasion, correct the ulnar drift at the wrist, but the relative shortening of the ulna recurred. Distal radial hemiepiphyseal stapling should accompany ulnar lengthening if radiocarpal angulation or subluxation of the lunate occurs with ulnar shortening. Deformities of the forearm should be treated early and aggressively to prevent disability.     

Use of free vascularized fibular graft for congenital ulnar pseudarthrosis: surgical decision making in the growing child

Congenital pseudarthrosis of the ulna may cause growth disturbance and progressive forearm deformity, leading to functional compromise of the upper extremity. Treatment is challenging, and surgical decision making must take into account three goals of treatment: bony healing, distal radioulnar joint (DRUJ) stability, and continued skeletal growth. Four cases of congenital ulnar pseudarthrosis treated with free vascularized fibular graft are presented here. In two cases, the vascularized fibular graft included the proximal fibular epiphysis to reconstruct the DRUJ and ulnocarpal joints. Average age of the four patients at time of vascularized fibular grafting was 10 years (range 3-16 years). Patients had undergone up to three previous failed operations. A step-cut osteotomy technique with rigid internal fixation was used in all patients. Donor-site distal tibiofibular arthrodesis was performed in skeletally immature patients when appropriate. At average follow-up of 60 months (range 33-83 months), all patients achieved bony union with full wrist range of motion compared with the contralateral extremity. The DRUJ was stable in all patients. Two skeletally immature patients with concomitant epiphyseal transfer showed continued skeletal growth. Two patients nearing skeletal maturity achieved revascularization of the distal ulna. Free vascularized fibular grafting is a successful option in the treatment of congenital ulnar pseudarthrosis. Reconstruction of the distal radioulnar and ulnocarpal joints using concomitant proximal fibular epiphyseal transfer should be considered in the skeletally immature patient with distal ulnar involvement.     

Treatment of multiple hereditary osteochondromas of the forearm in children: a study of surgical procedures

We have evaluated the clinical outcomes of simple excision, ulnar lengthening and the Sauvé-Kapandji procedure in the treatment of deformities of the forearm in patients with multiple hereditary osteochondromas. The medical records of 29 patients (33 forearms) were reviewed; 22 patients (22 forearms) underwent simple excision (four with ulnar lengthening) and seven the Sauvé-Kapandji procedure.Simple excision increased the mean supination of the forearm from 63.2 degrees to 75.0 degrees (p = 0.049). Ulnar lengthening did not significantly affect the clinical outcome. The Sauvé-Kapandji technique improved the mean pronation from 33.6 degrees to 55.0 degrees (p = 0.047) and supination from 70.0 degrees to 81.4 degrees (p = 0.045). Simple excision may improve the range of movement of the forearm but will not halt the progression of disease, particularly in younger patients. No discernable clinical or radiological improvement was noted with ulnar lengthening. The Sauvé-Kapandji procedure combined with simple excision of osteochondromas can improve stability of the wrist, movement of the forearm and the radiological appearance.     

Multiple hereditary osteochondromata

Multiple hereditary osteochondromata is a disorder consisting of multiple projections of bone (exostoses) capped by cartilage. The lesions are most numerous in the metaphyses of long bones but may appear on diaphyses of long bones and on flat bones and vertebrae. The transmission is autosomal dominant. Sarcomatous transformation is uncommon and probably occurs in fewer than 1% of patients. The more common indications for surgical excision of lesions are pain, growth disturbance, compromised joint motion, cosmesis, and secondary impingement of tendon, nerve, or vessel. Excision of the lesions is effective in relieving pain, improving cosmesis and joint motion, and removing secondary impingement of tendon, nerve, or vessel, and may retard or prevent progressive disturbance of osseous growth. Wrist and ankle deformities are often associated with relative shortening and bowing of the ulna and fibula, respectively; tilt and tapering of the distal radial and tibial epiphyses; and distal radioulnar and tibio-fibular diastasis. These deformities can be effectively treated by ulnar and fibular lengthening combined with hemiphyseal stapling of the distal radius and tibia. Progressive genu valgum is well corrected by placement of staples over the medial side of the physis of the distal femur or proximal tibia or both.     

Radius lengthening for the treatment of Bayne and Klug type II and type III radial longitudinal deficiency

PURPOSE: We performed radius lengthening to treat radial deviation of the wrist in patients with Bayne and Klug type II and type III radial longitudinal deficiencies. The purpose of this investigation was to review our results of radius lengthening for radial longitudinal deficiency. METHODS: Beginning in 1991 radius lengthening was performed to treat 4 patients with radial longitudinal deficiency whose mean age at the initial lengthening was 16 months. The corrections for radial deviation of the wrists were performed simultaneously by soft-tissue distraction of the wrist. According to Bayne and Klug's classification 2 patients had type II and 2 patients had type III deficiencies. All but 1 patient had lengthening several times to correct the recurring discrepancy between the radius and the ulna. RESULTS: The corrections were achieved just after the lengthening but deformities recurred because of growth discrepancies between the radius and the ulna as the children grew. The radius was lengthened by a mean of 28 mm, with a mean length gain of 79%. The mean period in the fixator was 136 days. Two patients had both functionally and cosmetically acceptable correction after several lengthening procedures. In the other patient we abandoned this treatment method because of severe bone absorption at the distal end of the lengthened radius. One patient died of cardiac disease after one lengthening. CONCLUSIONS: Radius lengthening for Bayne and Klug type II and type III deficiencies may be accomplished successfully with the primary benefit of maintaining wrist and forearm motion. It is likely that at least 3 lengthenings may be required and this may need to be accompanied by a soft-tissue distraction at the ulnar carpal joint as well. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Management of forearm deformities with ulnar shortening more than 15 mm caused by hereditary multiple osteochondromas

Background

Treatment for forearm deformities caused by hereditary multiple osteochondromas is still controversial. The purpose of the study was to describe the outcome of treatment with the combined use of ulnar lengthening and excision of osteochondromas.

Methods

Fourteen patients with hereditary multiple osteochondromas had forearm deformities which belongs to type I Masada deformity. The mean relative ulnar shortening was 19.9 mm (range, 16–23). All patients ranging from 4 to 15 years old had operative treatment. Clinical evaluation involving the assessment of pain, activities of daily living, and range of motion of the wrist and forearm was performed. The radiographic evaluation was relative ulnar shortening (RUS), radial articular angle (RAA), carpal slip (CS), and radial bowing. Besides, we also evaluated the amount of ulnar lengthening, external fixation time, and external fixation index.

Results

The mean EFT was 101 days (range, 84–133), and the mean external fixation index was 44.4 days/cm (range, 33.6–51.2). During the mean 43.1 months follow-up, four patients had mild pain and two patients had mild restriction of daily activities. The rotation of forearm and motion of wrist had increased except in Case 3. The RAA, CS, and radial bowing had been improved except in Case 6 and 7. In all patients, relative ulnar shortening had been corrected. According to the functional evaluation criteria recommended by Krimmer, there were ten excellent and four good.

Conclusions

The combined use of ulna lengthening and excision of osteochondromas is a proper and effective treatment method to the type I Masada deformity with the relative ulnar shortening more than 15 mm.