580066 research-article2015
JHS0010.1177/1753193415580066Journal of Hand Surgery (European Volume)Hwang et al.
JHS(E)
Full Length Article
One-stage rotational osteotomy for congenital radioulnar synostosis J. H. Hwang, H. W. Kim, D. H. Lee, J. H. Chung and H. Park
The Journal of Hand Surgery (European Volume) 2015, Vol. 40E(8) 855–861 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1753193415580066 jhs.sagepub.com
Abstract We report the results of a one-stage rotational osteotomy of the proximal third of the ulna and distal third of the radius with segmental bone resection for treating congenital radioulnar synostosis. We retrospectively reviewed 25 patients (28 forearms) treated by operation. Patients were divided into two groups according to the method of internal fixation at the osteotomy sites. In Group 1 the ulnar osteotomy was stabilized with an intramedullary pin and in Group 2 no fixation was used. The average forearm position improved from 47° pronation before surgery, to 27° supination after surgery. There were no statistically significant differences between the two groups in surgical outcomes. One-stage rotational osteotomy of the proximal third of the ulna and distal third of the radius with segmental bone resection is a simple and safe treatment for patients with congenital radioulnar synostosis. Internal fixation at the osteotomy site seems to be unnecessary. Level of Evidence: Level 4 Keywords Rotational osteotomy, derotational osteotomy, internal fixation, congenital radioulnar synostosis Date received: 10th December 2014; revised: 4th March 2015; accepted: 10th March 2015
Introduction The forearms of patients with congenital radioulnar synostosis are often fixed in positions that vary from neutral rotation to considerable pronation (Cleary and Omer, 1985; Murase et al., 2003). Many patients with this condition find it difficult to perform activities associated with daily living, such as face washing and eating with chopsticks, because movements of the shoulder and wrist are less able to compensate for a position of pronation than a position of supination (Cleary and Omer, 1985; Hansen and Andersen, 1970; Ogino and Hikino, 1987; Shingade et al., 2014; Simmons et al., 1983). Surgical intervention is recommended by most surgeons when the loss of forearm rotation causes the patient to complain of functional difficulties. To date, two types of surgical treatments have been described: mobilization of the synostosis (Funakoshi et al., 2004; Jones et al., 2004; Kanaya and Ibaraki, 1998; Kao et al., 2005; Sakamoto et al., 2014), which frequently results in recurrence of the ankylosis with unsatisfactory results (Kanaya and Ibaraki, 1998; Miura et al., 1984; Sachar et al., 1994); and rotational osteotomy, which provides functional improvement (El-Adl, 2007; Griffet et al., 1986; Horii et al., 2014; Hung, 2008; Lin et al., 1995; Ogino and Hikino, 1987; Ramachandran et al., 2005; Shingade et al., 2014; Simmons et al., 1983). Therefore, rotational
osteotomy is the accepted treatment for congenital radioulnar synostosis. Several complications have been reported with this technique, however, including loss of correction, nerve palsy and compartment syndrome (Green and Mital, 1979; Hankin et al., 1987; Miura et al., 1984; Ogino and Hikino, 1987; Simmons et al., 1983). To prevent these complications, various surgical interventions have been described with variable results; these include segmental bone resection (Ezaki and Oishi, 2012; Hung, 2008), osteotomy of the radius alone (Horii et al., 2014; Simmons et al., 1983), two-stage osteotomy (Dalton et al., 2006; El-Adl, 2007; Lin et al., 1995) and osteotomy at two sites on both bones (Murase et al., 2003; Ramachandran et al., 2005; Shingade et al., 2014). We have used a one-stage rotational osteotomy of the proximal third of the ulna and distal third of the
Department of Orthopaedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea Corresponding author: H. Park, Department of Orthopaedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 135-720, Korea. Email: [email protected]
Downloaded from jhs.sagepub.com at UNIV MASSACHUSETTS BOSTON on September 27, 2015
856
The Journal of Hand Surgery (Eur) 40(8)
radius with segmental bone resection, a previously reported technique that decreases excessive softtissue tightness (Ezaki and Oishi, 2012; Hung, 2008; Yammine et al., 1998). Our technique differs from previously described methods in that it uses different osteotomy sites and fixation methods. In this study we aimed to first determine the efficacy of one-stage rotational osteotomy of the proximal third of the ulna and distal third of the radius with segmental bone resection for treating congenital radioulnar synostosis, and then to compare the outcomes of rotational osteotomy in two groups, divided according to the method of fixation.
Methods This study was approved by our Institutional Review Board. Informed consent was obtained from parents. We identified 25 patients (28 forearms) who had been treated with rotational osteotomy between December 2005 and August 2012 for congenital radioulnar synostosis. Our surgical indication was determined by the subjective symptoms of the patient rather than the amount of pronation deformity. The patients included had difficulty using chopsticks, drinking from a glass, dressing, opening a door, performing personal hygiene and using the hand to carry an object. We prefer a final position of 30° supination to the neutral position because this is a useful functional position and slight supination can be compensated for by shoulder movements (Shingade et al., 2014). The mean age of patients at the time of surgery was 7 years (range 4–16). There were 18 male and seven female patients; three of these patients underwent bilateral operations. Of the 28 forearms studied, 25 were dominant and three were non-dominant. None of the children had ipsilateral congenital anomalies or previous surgical procedures on the involved extremities. Pre-operatively, fixed deformities were present in 24 forearms, and a little rotational motion was present in only four forearms. No abnormal patterns of motion in the ipsilateral shoulder or wrist joint were noted in any of the patients. Operations were carried out by two surgeons. Patients in this study were divided into two groups based on the method of fixation used by the two surgeons. Group 1 consisted of 15 patients (18 forearms) treated with internal fixation, by Surgeon 1, who used an intramedullary flexible nail in the ulna after reports of successful outcomes being obtained by fixing a single bone in paediatric forearm fractures (Myers et al., 2004). Group 2 consisted of ten patients (ten forearms) treated without fixation, by Surgeon 2, who preferred
Table 1. The Cleary and Omer (1985) classification of congenital radioulnar synostosis. Types
Radiographic patterns of radioulnar synostosis
I II
Clinical synostosis but normal radiograph Visible osseous synostosis is present but otherwise normal findings Osseous synostosis is present with a hypoplastic and posteriorly dislocated radial head Short osseous synostosis is present with an unusual mushroom-shaped anteriorly dislocated radial head
III IV
this technique to avoid having to later remove an implant used to stabilize the osteotomy site. The pre-operative and post-operative ranges of forearm pronation and supination were measured using a method described by Ogino and Hikino (1987). Pronation and supination motion must be measured with the patient’s elbow held fixed to the side of the chest, the forearm at 90° and a line between the radial and ulnar styloid processes used in conjunction with a goniometer. Pronation and supination ranges were measured by two independent orthopaedic residents who were blinded to the study. In four patients who had a little rotational motion, we measured the pre-operative rotation in the position of maximum supination. We classified patients according to the radiographic system reported by Cleary and Omer (1985) (Table 1). The Liverpool Elbow Score, which measures clinical improvement and the degree of functional recovery, was used pre- and post-operatively (Sathyamoorthy et al., 2004). The Liverpool Elbow Score consists of two main components: clinical assessment, which can be measured objectively to assess the condition of the elbow, and a patientanswered questionnaire, which assesses the functional ability to perform activities of daily living (Table 2). The final score can range from 0 (worst) to 53 (best). Improvement was rated as score. Satisfaction was rated as ‘yes’ or ‘no’. To ensure that the surveys were impartial, two independent orthopaedic residents who were blinded to the study carried out the clinical assessments.
Surgical technique With the patient supine under general anaesthesia and with tourniquet control, a direct approach was taken to the ulna, distal to the level of the synostosis and at the distal diaphyseal–metaphyseal junction for the radius. After exposing the periosteum longitudinally, osteotomy was carried out using an oscillating saw. A 1 cm bone segment was removed at
Downloaded from jhs.sagepub.com at UNIV MASSACHUSETTS BOSTON on September 27, 2015
857
Hwang et al. Table 2. The components of the Liverpool Elbow Score. Score 4
Score 3
Score 2
Score 1
Score 0
– – –
>135° None –
120–135° < 20° >50°
90−120° 20−30° 50−20°
30° 50°
50−20°
30° of forearm pronation, which is consistent with the opinion of Shingade et al. (2014). We believe that a supinated position of the forearm improves function for the activities that are required in East Asia. Only one study before ours has used a validated scoring system to assess outcomes (Shingade et al., 2014). We used the Liverpool Elbow Score for assessment of outcomes because it is a validated score consisting of both a clinical assessment measured by a surgeon and a functional assessment filled in by the patient (Sathyamoorthy et al., 2004). Although the Liverpool Elbow Score is validated only in adults, we think that this scoring system is more relevant to daily activities that require rotational function in the forearm, such as washing, feeding and combing, than other scoring systems. Although there was no change in the range of motion of the elbow, there were significant improvements in carrying out the activities of daily living. There were several limitations to our study. First, it was based on a retrospective review. The relatively small number of cases may have decreased the power for statistical analysis. Second, two surgeons were
involved and so the operative techniques and postoperative protocols could not be completely standardized. Third, although the Liverpool Elbow Score is a validated method, it has not been used previously for functional assessment in paediatric patients with congenital radioulnar synostosis. Unfortunately, we could not formally evaluate pre- and post-operative function in this study by objective measures, such as the Jebsen–Taylor hand-function test. One-stage rotational osteotomy of the proximal third of the ulna and distal third of the radius with segmental bone resection is a simple and safe treatment for patients with congenital radioulnar synostosis. Internal fixation at the osteotomy site does not seem to be necessary. Acknowledgements We thank Dr Jae Young Roh for the data collection of the patients.
Conflict of interests None declared.
Ethical approval Granted by the Severance Hospital Institutional Review Board (4-2013-0297). Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that the informed consent for participation in the study was obtained.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References Cleary JE, Omer GE. Congenital proximal radio-ulnar synostosis. Natural history and functional assessment. J Bone Joint Surg Am. 1985, 67: 539–45. Dalton JF, Manske PR, Walker JC, Goldfarb CA. Ulnar nonunion after osteoclasis for rotational deformities of the forearm. J Hand Surg Am. 2006, 31: 973–8. El-Adl W. Two-stage double-level rotational osteotomy in the treatment of congenital radioulnar synostosis. Acta Orthop Belg. 2007, 73: 704–9. Ezaki M, Oishi SN. Technique of forearm osteotomy for pediatric problems. J Hand Surg Am. 2012, 37: 2400–3. Funakoshi T, Kato H, Minami A, Suenaga N, Iwasaki N. The use of pedicled posterior interosseous fat graft for mobilization of congenital radioulnar synostosis: a case report. J Shoulder Elbow Surg. 2004, 13: 230–4. Green WT, Mital MA. Congenital radio-ulnar synostosis: surgical treatment. J Bone Joint Surg Am. 1979, 61: 738–43.
Downloaded from jhs.sagepub.com at UNIV MASSACHUSETTS BOSTON on September 27, 2015
861
Hwang et al. Griffet J, Berard J, Michel CR, Caton J. [Congenital superior radioulnar synostoses. A study of 43 cases]. Int Orthop. 1986, 10: 265–9. Hankin FM, Smith PA, Kling TF Jr, Louis DS. Ulnar nerve palsy following rotational osteotomy of congenital radioulnar synostosis. J Pediatr Orthop. 1987, 7: 103–6. Hansen OH, Andersen NO. Congenital radio-ulnar synostosis. Report of 37 cases. Acta Orthop Scand. 1970, 41: 225–30. Horii E, Koh S, Hattori T, Otsuka J. Single osteotomy at the radial diaphysis for congenital radioulnar synostosis. J Hand Surg Am. 2014, 39: 1553–7. Hung NN. Derotational osteotomy of the proximal radius and the distal ulna for congenital radioulnar synostosis. J Child Orthop. 2008, 2: 481–9. Jones NF, Esmail A, Shin EK. Treatment of radioulnar synostosis by radical excision and interposition of a radial forearm adipofascial flap. J Hand Surg Am. 2004, 29: 1143–7. Kanaya F, Ibaraki K. Mobilization of a congenital proximal radioulnar synostosis with use of a free vascularized fascio-fat graft. J Bone Joint Surg Am. 1998, 80: 1186–92. Kao HK, Chen HC, Chen HT. Congenital radioulnar synostosis treated using a microvascular free fasio-fat flap. Chang Gung Med J. 2005, 28: 117–22. Lin HH, Strecker WB, Manske PR, Schoenecker PL, Seyer DM. A surgical technique of radioulnar osteoclasis to correct severe forearm rotation deformities. J Pediatr Orthop. 1995, 15: 53–8. Miura T, Nakamura R, Suzuki M, Kanie J. Congenital radioulnar synostosis. J Hand Surg Br. 1984, 9: 153–5.
Murase T, Tada K, Yoshida T, Moritomo H. Derotational osteotomy at the shafts of the radius and ulna for congenital radioulnar synostosis. J Hand Surg Am. 2003, 28: 133–7. Myers GJ, Gibbons PJ, Glithero PR. Nancy nailing of diaphyseal forearm fractures. Single bone fixation for fractures of both bones. J Bone Joint Surg Br. 2004, 86: 581–4. Ogino T, Hikino K. Congenital radio-ulnar synostosis: compensatory rotation around the wrist and rotation osteotomy. J Hand Surg Br. 1987, 12: 173–8. Ramachandran M, Lau K, Jones DH. Rotational osteotomies for congenital radioulnar synostosis. J Bone Joint Surg Br. 2005, 87: 1406–10. Sachar K, Akelman E, Ehrlich MG. Radioulnar synostosis. Hand Clin. 1994, 10: 399–404. Sakamoto S, Doi K, Hattori Y, Dodakundi C, Montales T. Modified osteotomy (Kanaya’s procedure) for congenital proximal radioulnar synostosis with posterior dislocation of the radial head. J Hand Surg Eur. 2014, 39: 541–8. Sathyamoorthy P, Kemp GJ, Rawal A, Rayner V, Frostick SP. Development and validation of an elbow score. Rheumatology (Oxford). 2004, 43: 1434–40. Shingade VU, Shingade RV, Ughade SN. Results of singlestaged rotational osteotomy in a child with congenital proximal radioulnar synostosis: subjective and objective evaluation. J Pediatr Orthop. 2014, 34: 63–9. Simmons BP, Southmayd WW, Riseborough EJ. Congenital radioulnar synostosis. J Hand Surg Am. 1983, 8: 829–38. Yammine K, Salon A, Pouliquen JC. Congenital radioulnar synostosis. Study of a series of 37 children and adolescents. Chir Main. 1998, 17: 300–8.
Downloaded from jhs.sagepub.com at UNIV MASSACHUSETTS BOSTON on September 27, 2015
JHS0010.1177/1753193415580066Journal of Hand Surgery (European Volume)Hwang et al.
JHS(E)
Full Length Article
One-stage rotational osteotomy for congenital radioulnar synostosis J. H. Hwang, H. W. Kim, D. H. Lee, J. H. Chung and H. Park
The Journal of Hand Surgery (European Volume) 2015, Vol. 40E(8) 855–861 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1753193415580066 jhs.sagepub.com
Abstract We report the results of a one-stage rotational osteotomy of the proximal third of the ulna and distal third of the radius with segmental bone resection for treating congenital radioulnar synostosis. We retrospectively reviewed 25 patients (28 forearms) treated by operation. Patients were divided into two groups according to the method of internal fixation at the osteotomy sites. In Group 1 the ulnar osteotomy was stabilized with an intramedullary pin and in Group 2 no fixation was used. The average forearm position improved from 47° pronation before surgery, to 27° supination after surgery. There were no statistically significant differences between the two groups in surgical outcomes. One-stage rotational osteotomy of the proximal third of the ulna and distal third of the radius with segmental bone resection is a simple and safe treatment for patients with congenital radioulnar synostosis. Internal fixation at the osteotomy site seems to be unnecessary. Level of Evidence: Level 4 Keywords Rotational osteotomy, derotational osteotomy, internal fixation, congenital radioulnar synostosis Date received: 10th December 2014; revised: 4th March 2015; accepted: 10th March 2015
Introduction The forearms of patients with congenital radioulnar synostosis are often fixed in positions that vary from neutral rotation to considerable pronation (Cleary and Omer, 1985; Murase et al., 2003). Many patients with this condition find it difficult to perform activities associated with daily living, such as face washing and eating with chopsticks, because movements of the shoulder and wrist are less able to compensate for a position of pronation than a position of supination (Cleary and Omer, 1985; Hansen and Andersen, 1970; Ogino and Hikino, 1987; Shingade et al., 2014; Simmons et al., 1983). Surgical intervention is recommended by most surgeons when the loss of forearm rotation causes the patient to complain of functional difficulties. To date, two types of surgical treatments have been described: mobilization of the synostosis (Funakoshi et al., 2004; Jones et al., 2004; Kanaya and Ibaraki, 1998; Kao et al., 2005; Sakamoto et al., 2014), which frequently results in recurrence of the ankylosis with unsatisfactory results (Kanaya and Ibaraki, 1998; Miura et al., 1984; Sachar et al., 1994); and rotational osteotomy, which provides functional improvement (El-Adl, 2007; Griffet et al., 1986; Horii et al., 2014; Hung, 2008; Lin et al., 1995; Ogino and Hikino, 1987; Ramachandran et al., 2005; Shingade et al., 2014; Simmons et al., 1983). Therefore, rotational
osteotomy is the accepted treatment for congenital radioulnar synostosis. Several complications have been reported with this technique, however, including loss of correction, nerve palsy and compartment syndrome (Green and Mital, 1979; Hankin et al., 1987; Miura et al., 1984; Ogino and Hikino, 1987; Simmons et al., 1983). To prevent these complications, various surgical interventions have been described with variable results; these include segmental bone resection (Ezaki and Oishi, 2012; Hung, 2008), osteotomy of the radius alone (Horii et al., 2014; Simmons et al., 1983), two-stage osteotomy (Dalton et al., 2006; El-Adl, 2007; Lin et al., 1995) and osteotomy at two sites on both bones (Murase et al., 2003; Ramachandran et al., 2005; Shingade et al., 2014). We have used a one-stage rotational osteotomy of the proximal third of the ulna and distal third of the
Department of Orthopaedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea Corresponding author: H. Park, Department of Orthopaedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 135-720, Korea. Email: [email protected]
Downloaded from jhs.sagepub.com at UNIV MASSACHUSETTS BOSTON on September 27, 2015
856
The Journal of Hand Surgery (Eur) 40(8)
radius with segmental bone resection, a previously reported technique that decreases excessive softtissue tightness (Ezaki and Oishi, 2012; Hung, 2008; Yammine et al., 1998). Our technique differs from previously described methods in that it uses different osteotomy sites and fixation methods. In this study we aimed to first determine the efficacy of one-stage rotational osteotomy of the proximal third of the ulna and distal third of the radius with segmental bone resection for treating congenital radioulnar synostosis, and then to compare the outcomes of rotational osteotomy in two groups, divided according to the method of fixation.
Methods This study was approved by our Institutional Review Board. Informed consent was obtained from parents. We identified 25 patients (28 forearms) who had been treated with rotational osteotomy between December 2005 and August 2012 for congenital radioulnar synostosis. Our surgical indication was determined by the subjective symptoms of the patient rather than the amount of pronation deformity. The patients included had difficulty using chopsticks, drinking from a glass, dressing, opening a door, performing personal hygiene and using the hand to carry an object. We prefer a final position of 30° supination to the neutral position because this is a useful functional position and slight supination can be compensated for by shoulder movements (Shingade et al., 2014). The mean age of patients at the time of surgery was 7 years (range 4–16). There were 18 male and seven female patients; three of these patients underwent bilateral operations. Of the 28 forearms studied, 25 were dominant and three were non-dominant. None of the children had ipsilateral congenital anomalies or previous surgical procedures on the involved extremities. Pre-operatively, fixed deformities were present in 24 forearms, and a little rotational motion was present in only four forearms. No abnormal patterns of motion in the ipsilateral shoulder or wrist joint were noted in any of the patients. Operations were carried out by two surgeons. Patients in this study were divided into two groups based on the method of fixation used by the two surgeons. Group 1 consisted of 15 patients (18 forearms) treated with internal fixation, by Surgeon 1, who used an intramedullary flexible nail in the ulna after reports of successful outcomes being obtained by fixing a single bone in paediatric forearm fractures (Myers et al., 2004). Group 2 consisted of ten patients (ten forearms) treated without fixation, by Surgeon 2, who preferred
Table 1. The Cleary and Omer (1985) classification of congenital radioulnar synostosis. Types
Radiographic patterns of radioulnar synostosis
I II
Clinical synostosis but normal radiograph Visible osseous synostosis is present but otherwise normal findings Osseous synostosis is present with a hypoplastic and posteriorly dislocated radial head Short osseous synostosis is present with an unusual mushroom-shaped anteriorly dislocated radial head
III IV
this technique to avoid having to later remove an implant used to stabilize the osteotomy site. The pre-operative and post-operative ranges of forearm pronation and supination were measured using a method described by Ogino and Hikino (1987). Pronation and supination motion must be measured with the patient’s elbow held fixed to the side of the chest, the forearm at 90° and a line between the radial and ulnar styloid processes used in conjunction with a goniometer. Pronation and supination ranges were measured by two independent orthopaedic residents who were blinded to the study. In four patients who had a little rotational motion, we measured the pre-operative rotation in the position of maximum supination. We classified patients according to the radiographic system reported by Cleary and Omer (1985) (Table 1). The Liverpool Elbow Score, which measures clinical improvement and the degree of functional recovery, was used pre- and post-operatively (Sathyamoorthy et al., 2004). The Liverpool Elbow Score consists of two main components: clinical assessment, which can be measured objectively to assess the condition of the elbow, and a patientanswered questionnaire, which assesses the functional ability to perform activities of daily living (Table 2). The final score can range from 0 (worst) to 53 (best). Improvement was rated as score. Satisfaction was rated as ‘yes’ or ‘no’. To ensure that the surveys were impartial, two independent orthopaedic residents who were blinded to the study carried out the clinical assessments.
Surgical technique With the patient supine under general anaesthesia and with tourniquet control, a direct approach was taken to the ulna, distal to the level of the synostosis and at the distal diaphyseal–metaphyseal junction for the radius. After exposing the periosteum longitudinally, osteotomy was carried out using an oscillating saw. A 1 cm bone segment was removed at
Downloaded from jhs.sagepub.com at UNIV MASSACHUSETTS BOSTON on September 27, 2015
857
Hwang et al. Table 2. The components of the Liverpool Elbow Score. Score 4
Score 3
Score 2
Score 1
Score 0
– – –
>135° None –
120–135° < 20° >50°
90−120° 20−30° 50−20°
30° 50°
50−20°
30° of forearm pronation, which is consistent with the opinion of Shingade et al. (2014). We believe that a supinated position of the forearm improves function for the activities that are required in East Asia. Only one study before ours has used a validated scoring system to assess outcomes (Shingade et al., 2014). We used the Liverpool Elbow Score for assessment of outcomes because it is a validated score consisting of both a clinical assessment measured by a surgeon and a functional assessment filled in by the patient (Sathyamoorthy et al., 2004). Although the Liverpool Elbow Score is validated only in adults, we think that this scoring system is more relevant to daily activities that require rotational function in the forearm, such as washing, feeding and combing, than other scoring systems. Although there was no change in the range of motion of the elbow, there were significant improvements in carrying out the activities of daily living. There were several limitations to our study. First, it was based on a retrospective review. The relatively small number of cases may have decreased the power for statistical analysis. Second, two surgeons were
involved and so the operative techniques and postoperative protocols could not be completely standardized. Third, although the Liverpool Elbow Score is a validated method, it has not been used previously for functional assessment in paediatric patients with congenital radioulnar synostosis. Unfortunately, we could not formally evaluate pre- and post-operative function in this study by objective measures, such as the Jebsen–Taylor hand-function test. One-stage rotational osteotomy of the proximal third of the ulna and distal third of the radius with segmental bone resection is a simple and safe treatment for patients with congenital radioulnar synostosis. Internal fixation at the osteotomy site does not seem to be necessary. Acknowledgements We thank Dr Jae Young Roh for the data collection of the patients.
Conflict of interests None declared.
Ethical approval Granted by the Severance Hospital Institutional Review Board (4-2013-0297). Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that the informed consent for participation in the study was obtained.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References Cleary JE, Omer GE. Congenital proximal radio-ulnar synostosis. Natural history and functional assessment. J Bone Joint Surg Am. 1985, 67: 539–45. Dalton JF, Manske PR, Walker JC, Goldfarb CA. Ulnar nonunion after osteoclasis for rotational deformities of the forearm. J Hand Surg Am. 2006, 31: 973–8. El-Adl W. Two-stage double-level rotational osteotomy in the treatment of congenital radioulnar synostosis. Acta Orthop Belg. 2007, 73: 704–9. Ezaki M, Oishi SN. Technique of forearm osteotomy for pediatric problems. J Hand Surg Am. 2012, 37: 2400–3. Funakoshi T, Kato H, Minami A, Suenaga N, Iwasaki N. The use of pedicled posterior interosseous fat graft for mobilization of congenital radioulnar synostosis: a case report. J Shoulder Elbow Surg. 2004, 13: 230–4. Green WT, Mital MA. Congenital radio-ulnar synostosis: surgical treatment. J Bone Joint Surg Am. 1979, 61: 738–43.
Downloaded from jhs.sagepub.com at UNIV MASSACHUSETTS BOSTON on September 27, 2015
861
Hwang et al. Griffet J, Berard J, Michel CR, Caton J. [Congenital superior radioulnar synostoses. A study of 43 cases]. Int Orthop. 1986, 10: 265–9. Hankin FM, Smith PA, Kling TF Jr, Louis DS. Ulnar nerve palsy following rotational osteotomy of congenital radioulnar synostosis. J Pediatr Orthop. 1987, 7: 103–6. Hansen OH, Andersen NO. Congenital radio-ulnar synostosis. Report of 37 cases. Acta Orthop Scand. 1970, 41: 225–30. Horii E, Koh S, Hattori T, Otsuka J. Single osteotomy at the radial diaphysis for congenital radioulnar synostosis. J Hand Surg Am. 2014, 39: 1553–7. Hung NN. Derotational osteotomy of the proximal radius and the distal ulna for congenital radioulnar synostosis. J Child Orthop. 2008, 2: 481–9. Jones NF, Esmail A, Shin EK. Treatment of radioulnar synostosis by radical excision and interposition of a radial forearm adipofascial flap. J Hand Surg Am. 2004, 29: 1143–7. Kanaya F, Ibaraki K. Mobilization of a congenital proximal radioulnar synostosis with use of a free vascularized fascio-fat graft. J Bone Joint Surg Am. 1998, 80: 1186–92. Kao HK, Chen HC, Chen HT. Congenital radioulnar synostosis treated using a microvascular free fasio-fat flap. Chang Gung Med J. 2005, 28: 117–22. Lin HH, Strecker WB, Manske PR, Schoenecker PL, Seyer DM. A surgical technique of radioulnar osteoclasis to correct severe forearm rotation deformities. J Pediatr Orthop. 1995, 15: 53–8. Miura T, Nakamura R, Suzuki M, Kanie J. Congenital radioulnar synostosis. J Hand Surg Br. 1984, 9: 153–5.
Murase T, Tada K, Yoshida T, Moritomo H. Derotational osteotomy at the shafts of the radius and ulna for congenital radioulnar synostosis. J Hand Surg Am. 2003, 28: 133–7. Myers GJ, Gibbons PJ, Glithero PR. Nancy nailing of diaphyseal forearm fractures. Single bone fixation for fractures of both bones. J Bone Joint Surg Br. 2004, 86: 581–4. Ogino T, Hikino K. Congenital radio-ulnar synostosis: compensatory rotation around the wrist and rotation osteotomy. J Hand Surg Br. 1987, 12: 173–8. Ramachandran M, Lau K, Jones DH. Rotational osteotomies for congenital radioulnar synostosis. J Bone Joint Surg Br. 2005, 87: 1406–10. Sachar K, Akelman E, Ehrlich MG. Radioulnar synostosis. Hand Clin. 1994, 10: 399–404. Sakamoto S, Doi K, Hattori Y, Dodakundi C, Montales T. Modified osteotomy (Kanaya’s procedure) for congenital proximal radioulnar synostosis with posterior dislocation of the radial head. J Hand Surg Eur. 2014, 39: 541–8. Sathyamoorthy P, Kemp GJ, Rawal A, Rayner V, Frostick SP. Development and validation of an elbow score. Rheumatology (Oxford). 2004, 43: 1434–40. Shingade VU, Shingade RV, Ughade SN. Results of singlestaged rotational osteotomy in a child with congenital proximal radioulnar synostosis: subjective and objective evaluation. J Pediatr Orthop. 2014, 34: 63–9. Simmons BP, Southmayd WW, Riseborough EJ. Congenital radioulnar synostosis. J Hand Surg Am. 1983, 8: 829–38. Yammine K, Salon A, Pouliquen JC. Congenital radioulnar synostosis. Study of a series of 37 children and adolescents. Chir Main. 1998, 17: 300–8.
Downloaded from jhs.sagepub.com at UNIV MASSACHUSETTS BOSTON on September 27, 2015
