June 25, 2013
9:38:25am
WSPC/135-HS
FA1
1372019
Hand Surgery, Vol. 18, No. 2 (2013) 273275 © World Scientific Publishing Company DOI: 10.1142/S0218810413720192
ON-TOP PLASTY USING A FREE METACARPAL HEAD GRAFT FOR LENGTHENING OF PROXIMAL PHALANX IN SYMBRACHYDACTYLY — A CASE REPORT
Hand Surg. 2013.18:273-275. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/17/15. For personal use only.
Kousuke Iba, Takuro Wada and Toshihiko Yamashita Department of Orthopaedic Surgery Sapporo Medical University School of Medicine Sapporo 060-8543, Japan Received 29 September 2012; Revised 28 November 2012; Accepted 28 November 2012 ABSTRACT A three-year old patient with symbrachydactyly (didactyly type) presented with a little finger that was too short to allow pinching and consisting of a floppy soft-tissue envelope with hypoplastic phalanges, although the thumb was functional. As the proximal phalanx was too small to permit distraction lengthening or conventional bone grafting, on-top plasty using a 4th metacarpal graft with a cartilage head was undertaken for lengthening the proximal phalanx of the little finger for pinch reconstruction. At ten weeks after surgery, the patient achieved satisfactory pinch function due to the lengthened and bone-stabilised postoperative digit and reconstruction of functional proximal interphalangeal joint. In addition, the grafted metacarpal demonstrated satisfactory bone growth throughout the six-year follow-up period. Keywords: Bone Lengthening; Metacarpal Graft; On-Top Plasty; Symbrachydactyly; Bone Growth; PIP Joint.
INTRODUCTION
images before enrollment in this study and the study was approved by the institutional review board.
Various lengthening procedures for the shortened digits in congenital hand anomalies have been reported including distraction lengthening, bone grafting, free toe transfer, and nonvascularised free toe phalanx transplantation.14 Distraction lengthening or conventional bone grafting is not available for use in cases in which the host bone is too small to permit such surgical procedures. In this report, we presented a case that underwent on-top plasty using a free metacarpal head graft for lengthening of a small proximal phalanx in symbrachydactyly. Informed consent was obtained from the patient and parents for publication of this case report and any accompanying
CASE REPORT A three-year old child presented with symbrachydactyly (didactyly type) of the left hand. The little finger was too short to allow pinching with the thumb and revealed bony instability due to hypoplastic phalanges (Fig. 1). Under preservation of the extensor tendon- and the collateral ligament-like tissue, a joint space between the distal and proximal phalanges was opened. After resection of fibrous
Correspondence to: Dr. Kousuke Iba, Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo 060-8543, Japan. Tel: (þ81) 11-611-2111. Fax: (þ81) 11-641-6026. E-mail: [email protected] All authors declare that they have no conflicting interests and no author has anything to disclose. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. 273
June 25, 2013
9:38:26am
Hand Surg. 2013.18:273-275. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/17/15. For personal use only.
274
WSPC/135-HS
1372019
FA1
K. Iba, T. Wada & T. Yamashita
Fig. 1 Preoperative findings. The central three fingers were absent although there were nubbins. The thumb was normal in appearance and function, whereas its size was smaller than that on the right hand. Radiographic findings showed that all phalanges in the three central finger rays and the middle phalanx in the little finger were absent, and the 3rd metacarpal, distal and proximal phalanges in a little finger were very hypoplastic. The little finger was too short to allow pinching (black arrow) and revealed bony instability due to hypoplastic phalanges that a size of the proximal phalanx was only 2 mm along both the longitudinal and transverse axes (white arrow).
Fig. 2 The distal part of the 4th metacarpal (arrows) with a cartilage head (dot line), of which a bony component was 3 mm and cartilaginous component of 4 mm in length, was grafted on a top of the proximal phalanx (arrow head) in the little finger.
tissue, the distal cartilaginous component of proximal phalanx in the little finger was excised until the cancellous bone component was exposed. Based on the size of the space formed after the excision procedure, the 4th metacarpal with a bony and cartilaginous component was grafted onto the top of the proximal phalanx in the little finger, and fixed with a Kirschner wire (Fig. 2). At ten weeks after surgery, the patient achieved satisfactory pinch function based on the lengthened and bone-stabilised postoperative little finger and the reconstructed functional proximal interphalangeal (PIP) joint, of which degree of extension was 10 and flexion 40 (Fig. 3). Based on the good growth of the grafted 4th metacarpal and reconstruction of PIP joint, the clinical outcome as evaluated by pinch function has been good, and the patient and the parents are very satisfied with the hand function (Fig. 4).
Fig. 3 At ten weeks after surgery, complete union between the grafted metacarpal (arrow) and host bone (arrow head) was revealed. The grafted metacarpal bone has been survived (arrow).
June 25, 2013
9:38:27am
WSPC/135-HS
FA1
1372019
Hand Surg. 2013.18:273-275. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/17/15. For personal use only.
On-Top Plasty Using a Free Metacarpal Head Graft for Lengthening of Proximal Phalanx in Symbrachydactyly
275
Fig. 4 The relative size of the little finger to the thumb in comparison with hand growth (7 mm of bony growth over six years) was maintained for six years after surgery (black arrow) and the clinical outcome, as evaluated by pinch function, was regarded as good on the basis of good bone growth of the grafted 4th metacarpal (white arrow head). A small epiphyseal center was identified at distal part of the grafted 4th metacarpal (white arrow).
DISCUSSION We think that the distal part of a 4th metacarpal graft with a cartilage head has several advantages for the treatment of our case. First, significant bone growth after grafting can be expected because a growth plate exists in the distal part of the metacarpal. Second, it is possible to reconstruct a PIP joint using the cartilage head of the metacarpal. Third, there are no functional or aesthetic problems associated with the resection of the distal part of the 4th metacarpal. Fourth, the surgical procedure, in which the 4th metacarpal was grafted on top of the proximal phalanx, afforded a relatively simple and safe method of lengthening the little finger. A previous study showed that non-vascularised free toe phalanx transplantation was a useful method for the treatment of congenital hand anomalies with hypoplastic digits consisting of a floppy soft-tissue envelope with only a slight remnant of the proximal phalanx,4 similar to our case. Gohla4 showed that the growth capacity of the transplanted phalanx above the age of 18 months was markedly impaired compared with that before 18 months at their follow-up examination after surgery. In addition, a significant shortening of the remaining digit at the donor site invariably arose even after the placement of a spacer or bone graft in that site, although previous reports indicated that only a few patients revealed complication at the donor
site.4,5 With regard to aesthetic complications, shortening of the toe appears to be a problem for many Japanese patients as they customarily spend much time barefoot. In summary, we believe that transferring the distal part of a metacarpal graft with a cartilage head onto the top of a proximal phalanx is a useful method for finger lengthening and reconstruction of a PIP joint, even when the host bone is too small to undergo callotasis lengthening or conventional bone graft.
References 1. Ogino T, Saitou Y, Congenital constriction band syndrome and transverse deficiencies, J Hand Surg Br 12:342348, 1987. 2. Miyawaki T, Masuzawa G, Hirakawa M, Kurihara K, Bone-lengthening for symbrachydactyly of the hand with the technique of callus distraction, J Bone Joint Surg Am 84:986991, 2002. 3. Matsuno T, Ishida O, Sunagawa T, Ichikawa M, Ikuta Y, Ochi M, Bone lengthening for congenital differences of the hands and digits in children, J Hand Surg Am 29:712719, 2004. 4. Gohla T, Metz CH, Lanz U, Non-vascularized free toe phalanx transplantation in the treatment of symbrachydactyly and constriction ring syndrome, J Hand Surg Br 30:446451, 2005. 5. Cavallo AV, Smith PJ, Morley S, Morsi AW, Non-vascularized free toe phalanx transfers in congenital hand deformities — the Great Ormond street experience, J Hand Surg Br 28:520527, 2003.
9:38:25am
WSPC/135-HS
FA1
1372019
Hand Surgery, Vol. 18, No. 2 (2013) 273275 © World Scientific Publishing Company DOI: 10.1142/S0218810413720192
ON-TOP PLASTY USING A FREE METACARPAL HEAD GRAFT FOR LENGTHENING OF PROXIMAL PHALANX IN SYMBRACHYDACTYLY — A CASE REPORT
Hand Surg. 2013.18:273-275. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/17/15. For personal use only.
Kousuke Iba, Takuro Wada and Toshihiko Yamashita Department of Orthopaedic Surgery Sapporo Medical University School of Medicine Sapporo 060-8543, Japan Received 29 September 2012; Revised 28 November 2012; Accepted 28 November 2012 ABSTRACT A three-year old patient with symbrachydactyly (didactyly type) presented with a little finger that was too short to allow pinching and consisting of a floppy soft-tissue envelope with hypoplastic phalanges, although the thumb was functional. As the proximal phalanx was too small to permit distraction lengthening or conventional bone grafting, on-top plasty using a 4th metacarpal graft with a cartilage head was undertaken for lengthening the proximal phalanx of the little finger for pinch reconstruction. At ten weeks after surgery, the patient achieved satisfactory pinch function due to the lengthened and bone-stabilised postoperative digit and reconstruction of functional proximal interphalangeal joint. In addition, the grafted metacarpal demonstrated satisfactory bone growth throughout the six-year follow-up period. Keywords: Bone Lengthening; Metacarpal Graft; On-Top Plasty; Symbrachydactyly; Bone Growth; PIP Joint.
INTRODUCTION
images before enrollment in this study and the study was approved by the institutional review board.
Various lengthening procedures for the shortened digits in congenital hand anomalies have been reported including distraction lengthening, bone grafting, free toe transfer, and nonvascularised free toe phalanx transplantation.14 Distraction lengthening or conventional bone grafting is not available for use in cases in which the host bone is too small to permit such surgical procedures. In this report, we presented a case that underwent on-top plasty using a free metacarpal head graft for lengthening of a small proximal phalanx in symbrachydactyly. Informed consent was obtained from the patient and parents for publication of this case report and any accompanying
CASE REPORT A three-year old child presented with symbrachydactyly (didactyly type) of the left hand. The little finger was too short to allow pinching with the thumb and revealed bony instability due to hypoplastic phalanges (Fig. 1). Under preservation of the extensor tendon- and the collateral ligament-like tissue, a joint space between the distal and proximal phalanges was opened. After resection of fibrous
Correspondence to: Dr. Kousuke Iba, Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo 060-8543, Japan. Tel: (þ81) 11-611-2111. Fax: (þ81) 11-641-6026. E-mail: [email protected] All authors declare that they have no conflicting interests and no author has anything to disclose. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. 273
June 25, 2013
9:38:26am
Hand Surg. 2013.18:273-275. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/17/15. For personal use only.
274
WSPC/135-HS
1372019
FA1
K. Iba, T. Wada & T. Yamashita
Fig. 1 Preoperative findings. The central three fingers were absent although there were nubbins. The thumb was normal in appearance and function, whereas its size was smaller than that on the right hand. Radiographic findings showed that all phalanges in the three central finger rays and the middle phalanx in the little finger were absent, and the 3rd metacarpal, distal and proximal phalanges in a little finger were very hypoplastic. The little finger was too short to allow pinching (black arrow) and revealed bony instability due to hypoplastic phalanges that a size of the proximal phalanx was only 2 mm along both the longitudinal and transverse axes (white arrow).
Fig. 2 The distal part of the 4th metacarpal (arrows) with a cartilage head (dot line), of which a bony component was 3 mm and cartilaginous component of 4 mm in length, was grafted on a top of the proximal phalanx (arrow head) in the little finger.
tissue, the distal cartilaginous component of proximal phalanx in the little finger was excised until the cancellous bone component was exposed. Based on the size of the space formed after the excision procedure, the 4th metacarpal with a bony and cartilaginous component was grafted onto the top of the proximal phalanx in the little finger, and fixed with a Kirschner wire (Fig. 2). At ten weeks after surgery, the patient achieved satisfactory pinch function based on the lengthened and bone-stabilised postoperative little finger and the reconstructed functional proximal interphalangeal (PIP) joint, of which degree of extension was 10 and flexion 40 (Fig. 3). Based on the good growth of the grafted 4th metacarpal and reconstruction of PIP joint, the clinical outcome as evaluated by pinch function has been good, and the patient and the parents are very satisfied with the hand function (Fig. 4).
Fig. 3 At ten weeks after surgery, complete union between the grafted metacarpal (arrow) and host bone (arrow head) was revealed. The grafted metacarpal bone has been survived (arrow).
June 25, 2013
9:38:27am
WSPC/135-HS
FA1
1372019
Hand Surg. 2013.18:273-275. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/17/15. For personal use only.
On-Top Plasty Using a Free Metacarpal Head Graft for Lengthening of Proximal Phalanx in Symbrachydactyly
275
Fig. 4 The relative size of the little finger to the thumb in comparison with hand growth (7 mm of bony growth over six years) was maintained for six years after surgery (black arrow) and the clinical outcome, as evaluated by pinch function, was regarded as good on the basis of good bone growth of the grafted 4th metacarpal (white arrow head). A small epiphyseal center was identified at distal part of the grafted 4th metacarpal (white arrow).
DISCUSSION We think that the distal part of a 4th metacarpal graft with a cartilage head has several advantages for the treatment of our case. First, significant bone growth after grafting can be expected because a growth plate exists in the distal part of the metacarpal. Second, it is possible to reconstruct a PIP joint using the cartilage head of the metacarpal. Third, there are no functional or aesthetic problems associated with the resection of the distal part of the 4th metacarpal. Fourth, the surgical procedure, in which the 4th metacarpal was grafted on top of the proximal phalanx, afforded a relatively simple and safe method of lengthening the little finger. A previous study showed that non-vascularised free toe phalanx transplantation was a useful method for the treatment of congenital hand anomalies with hypoplastic digits consisting of a floppy soft-tissue envelope with only a slight remnant of the proximal phalanx,4 similar to our case. Gohla4 showed that the growth capacity of the transplanted phalanx above the age of 18 months was markedly impaired compared with that before 18 months at their follow-up examination after surgery. In addition, a significant shortening of the remaining digit at the donor site invariably arose even after the placement of a spacer or bone graft in that site, although previous reports indicated that only a few patients revealed complication at the donor
site.4,5 With regard to aesthetic complications, shortening of the toe appears to be a problem for many Japanese patients as they customarily spend much time barefoot. In summary, we believe that transferring the distal part of a metacarpal graft with a cartilage head onto the top of a proximal phalanx is a useful method for finger lengthening and reconstruction of a PIP joint, even when the host bone is too small to undergo callotasis lengthening or conventional bone graft.
References 1. Ogino T, Saitou Y, Congenital constriction band syndrome and transverse deficiencies, J Hand Surg Br 12:342348, 1987. 2. Miyawaki T, Masuzawa G, Hirakawa M, Kurihara K, Bone-lengthening for symbrachydactyly of the hand with the technique of callus distraction, J Bone Joint Surg Am 84:986991, 2002. 3. Matsuno T, Ishida O, Sunagawa T, Ichikawa M, Ikuta Y, Ochi M, Bone lengthening for congenital differences of the hands and digits in children, J Hand Surg Am 29:712719, 2004. 4. Gohla T, Metz CH, Lanz U, Non-vascularized free toe phalanx transplantation in the treatment of symbrachydactyly and constriction ring syndrome, J Hand Surg Br 30:446451, 2005. 5. Cavallo AV, Smith PJ, Morley S, Morsi AW, Non-vascularized free toe phalanx transfers in congenital hand deformities — the Great Ormond street experience, J Hand Surg Br 28:520527, 2003.
