Vascularized Metatarsophalangeal Joint Transfer for Radial Hypoplasia

ABSTRACT

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.

KEYWORDS

Congenital hand deformity - radial aplasia - toe-to-hand transplantation - joint transplantation - microsurgery

REFERENCES

• 1 Buck-Gramcko D. Radialization as a new treatment for radial club hand.  J Hand Surg. 1985;  10A 964-968
• 2 Urban M A, Osterman A L. Management of radial dysplasia.  Hand Clin. 1990;  6 589-605
• 3 Sabharwal S, Finuoli A L, Ghobadi F. Pre-centralization soft tissue distraction for Bayne type IV congenital radial deficiency in children.  J Pediatr Orthop. 2005;  25 377-381
• 4 Goldfarb C A, Murtha Y M, Gordon J E, Manske P R. Soft-tissue distraction with a ring external fixator before centralization for radial longitudinal deficiency.  J Hand Surg. 2006;  31A 952-959
• 5 Vilkki S K. Advances in microsurgical reconstruction of the congenitally adactylous hand.  Clin Orthop Relat Res. 1995;  314 45-58
• 6 Vilkki S K. Distraction lengthening and microvascular bone transplantation in the treatment of radial club hand. In Canadell J, Ferial F, Lazo-Zbikowski J Proceedings of the 14th International Hoffman External Fixation Conference. EUROGRAF, Pampolona, Spain; 1992: pp. 249-251
• 7 Vilkki S K. Vascularized joint transfer for radial club hand techniques in hand and upper extremity surgery.  Tech Hand Up Extrem Surg. 1998;  2 126-137
• 8 Vilkki S K. Distraction and microvascular epiphysis transfer for radial club hand.  J Hand Surg. 1998;  23B 445-452
• 9 Kaariainen H, Ryoppy S, Norio R. RAPADILINO syndrome with radial and patellar aplasia/hypoplasia as main manifestations.  Am J Med Genet. 1989;  33 346-351
• 10 Bayne L G, Klug M S. Long-term review of the surgical treatment of radial deficiencies.  J Hand Surg. 1987;  12A 169-179
• 11 Albee F H. Formation of radius congenitally absent. Conditions seven years after implantation of bone graft.  Ann Surg. 1928;  87 105-110
• 12 Starr D E. Congenital absence of the radius. A method of surgical correction.  J Bone Joint Surg. 1945;  27A 572-577
• 13 Pho R WH, Patterson M H, Kumar V P. Free vascularized epiphyseal transplantation in upper extremity reconstruction.  J Hand Surg. 1988;  13B 440-447
• 14 Tsai T M, Ludvig L, Tonkin M. Vascularised fibular epiphyseal transfer. A clinical study.  Clin Orthop Relat Res. 1986;  210 228-234
• 15 Nettelblad H. Microvascular Growth Plate Transplantation [master's thesis]. Linköping Medical University Linköping, Sweden; 1984
• 16 Bowen C VA, Ethridge C P, O`Brien B M, Frykman G K, Gumley G J. Experimental microvascular free growth plate transfers. Parts I and II.  J Bone Joint Surg. 1988;  70B 305-314
• 17 Kawabata H, Shibata T, Masatomi T, Yasui N. Residual deformity in congenital radial club hands after previous centralisation of the wrist. Ulnar lengthening and correction by the Ilizarov method.  J Bone Joint Surg. 1998;  80B 762-765
• 18 Pickford M A, Scheker L R. Distraction lengthening of the ulna in radial club hand using the Ilizarov technique.  J Hand Surg. 1998;  23B 186-191
• 19 Damore E, Kozin S H, Thoder J J, Porter S. The recurrence of deformity after surgical centralization for radial club hand.  J Hand Surg. 2000;  25A 745-751
• 20 Catagni M A, Szabo R M, Cattaneo R. Preliminary experience with Ilizarov method in late reconstruction of radial hemimelia.  J Hand Surg. 1993;  18A 316-321
• 21 De Pablos J, Canadell J. Experimental physeal distraction in immature sheep.  Clin Orthop Relat Res. 1990;  250 73-80
• 22 Alberty A. The effects of physeal distraction and compression on the growth plate. An experimental study on rabbits [master's thesis]. Helsinki, Finland; University of Helsinki 1993
• 23 Vilkki S K. Radial club hand: distraction and joint transplantation. In: Duparc, Alnot, Soucacos P Surgical Techniques in Orthopaedics and Traumatology. Paris, Elsevier; 2001: Chapter: 55-370-C-10, 1-5
• 24 Vilkki Simo K. Radial club hand. Guidelines for wrist distraction technique before microvascular epiphyseal joint transfer. In: Wei FC, Chuang DCC, Chen H Reconstructive Microsurgery. Proceedings of the Inaugural Congress of the World Society for Reconstructive Microsurgery, Taipei, Taiwan. Bologna; Monduzzi Editore 2001: 199-200
• 25 Skerik S K, Flatt A E. The anatomy of congenital radial dysplasia.  Clin Orthop Relat Res. 1969;  66 125-143
• 26 Inberg P, Kassila M, Vilkki S, Neuvonen P. Anesthesia for microvascular surgery in children. A combination of general anesthesia and axillary plexus block.  Acta Anaesthesiol Scand. 1995;  39 518-522
• 27 Sestero A M, Van Heest A, Agel J. Ulnar growth patterns in radial longitudinal deficiency.  J Hand Surg. 2006;  31A 960-967
• 28 Heikel H VA. Aplasia and hypoplasia of the radius: studies on 64 cases and on epiphyseal transplantation in rabbits with the imitated defect.  Acta Orthop Scand. 1959;  Suppl 39 1-155
• 29 Vilkki Simo K. Aplasia radii and the material of Henrik Heikel: the results of the long-term follow-up after 35-years.  Finnish Journal of Orthopaedics and Traumatology. 1997;  20 205-208 , [in Finnish]
• 30 Lamb D W. Radial club hand.  J Bone Joint Surg. 1977;  59A 1-13
• 31 Bora Jr F W, Osterman A L, Kaneda R R, Esterhai J. Radial club hand deformity. Long term follow-up.  J Bone Joint Surg. 1981;  63A 741-745
• 32 Goldfarb C A, Klepps S J, Dailey L A, Manske P R. Functional outcome after centralization for radius dysplasia.  J Hand Surg. 2002;  27A 118-124
• 33 Innocenti M, Delcroix L, Romano G F, Capanna R. Vascularized epiphyseal transplant.  Orthop Clin North Am. 2007;  38 95-101
• 34 Innocenti M, Delcroix L, Manfrini M, Ceruso M, Capanna R. Vascularized proximal fibular epiphyseal transfer for distal radial reconstruction.  J Bone Joint Surg. 2004;  86A 1504-1511