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A technique of distraction osteosynthesis in the hand
The Journal of HAND SURGERY
Patel and Zinberg
9.
10.
II.
12.
synovitis of the wrist and penetration into bone. J Bone Joint Surg [Br] 50:312-7, 1968 Jones FE, Soule EH, Conventry MD: Fibrous xanthoma of synovium. A study of 118 cases. J Bone Joint Surg [Am] 51:76-86, 1969 Decker JP, Owen BJ: An invasive giant cell tumor of tendon sheath in the foot. Bull Ayer Clin Lab 4:43-53, 1954 Terisu T, Iwabuchi R, Kamo Y: Pigmented villonodular synovitis of elbow with bony invasion. Clin Orthop 94:275-80, 1973 Scott PM: Bone lesions in pigmented villonodular synovitis. J Bone Joint Surg [Br] 50:306-11, 1968
13. Breimer CW, Freilberger RH: Bone lesions associated with pigmented villonodular synovitis. Am J Roentgenol Rad Ther Nucl Med 79:618-29, 1958 14. Smith JH, Pugh DO: Roentgenographic aspects of articular pigmented villonodular synovitis. Am J Roentgenol Rad Ther Nucl Med 87:1146-56,1962 15. Nilsonne U, Moberger G: Pigmented villonodular synovitis of joints. Acta Orthop Scand 40:448, 1969 16. Kobak MW, Perlow S: Xanthomatous giant cell tumors arising in soft tissue. Report of an instance of malignant growth. Arch Surg 59:909-16, 1949
A technique of distraction osteosynthesis in the hand Moderate digital lengthening may be accomplished with a step osteotomy that preserves attached sleeves of periosteum. A new external fixation apparatus, the Mini-H-Fixator, allows gradual distraction and solid bone fixation after surgery and facilitates this operation. The advantage of this procedure is that it results in rapid bone formation in the osteotomy gaps, obviating the need for bone grafting. (J HAND SURG 9A:858-62, 1984.)
R. T. Manktelow, M.D., F.R.C.S.(C), and D. J. Wainwright, M.D., Toronto, Ontario, Canada
T
he distraction method of lengthening a shortened digit was first introduced by Matev l in 1967. He refined the technique with particular application to lengthening the thumb metacarpal after amputation. While periosteal new bone formation is adequate in children, his technique requires a bone graft in adults. This report presents a technique of bone lengthening that does not require bone grafting and describes the use of a new external fixation device that makes this technique feasible.
Distraction apparatus An external fixation device for the distraction of the bones of the hand must fulfill certain criteria. The apparatus must provide solid purchase and rigid immobiliFrom the Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada. Received for publication Jan. 14, 1983; accepted in revised form March 15, 1984. Reprint requests: Dr. R. T. Manktelow, M.D., EN 10-236 Toronto General Hospital, 101 College St., Toronto, Ontario, Canada.
858
THE JOURNAL OF HAND SURGERY
Fig. 1. The Mini-H-Fixator: A, connecting bar; B, sliding swivel clamp; C, simple swivel clamp; D, transfixing pins; E, half pins; and F, offset pin holder.
Vol. 9A , No . 6 November 1984
Dis/rac/ion os/eosylllhesis i/1 hand
859
A
Fig. 2. A, View during surgery with osteotomy designed on dorsum of phalanx . Extensor tendon is retracted proximally and transfixing pins are in place . B, Initial distraction is completed, with Mini-H-Fixator assembled .
Fig. 4. A, Appearance of patient's hand before surgery shows multiple levels of amputation and significantly shortened index and long fingers . B, Attempt at pinch. Note that pinch surfaces of thumb and index finger are not in ideal position for apposition .
Fig. 3. Schematic diagram of step osteotomy. Note periosteal sleeves (dotted area) are based at the level of the osteotomy cut and cover interosseous gap formed after distraction .
zation without damaging the bone . The design should be small enough to allow mobilization of the remainder of the hand yet be robust enough for adequate fixation. It should be adaptable for use on the phalanges and metacarpals of all digits and there must be minimal problems at the pin-skin interface. The surgeon must be able to make small accurate increments of distraction . We found the Mini-H-Fixator (Jaquet Freres, Geneva, Switzerland; Fig . 1) to satisfy these criteria. This system is designed specifically for small bones and modeled on the larger Hoffmann apparatus available for large bone external fixation. The system includes
Fig. 5. Early appearance after surgery with apparatus in place. The position of the fixator does not impede mobilization of adjacent joints .
interosseous 2 and 3 mm half pins and 1.5 mm transfixing pins . Offset pin holders allow easier access to the osteotomy site after pin insertion . The sliding swivel clamp provides a simple means of accurate graded distraction or compression.
860
Manktelow and Wainwright
The Journal of HAND SURGERY
Fig. 6. Patient's hand after both lengthening procedures . A, Index and long fingers are noticeably longer. B, Pinch . Significantly better opposition is seen with lengthened index phalanx.
Fig. 7B. View early after surgery illustrates distraction of fragments, with maintenance of bone-on-bone contact centrally.
Fig. 7 A. Radiograph before surgery.
Surgical technique The procedure incorporates a sliding step osteotomy and periosteal sleeves. Radiologic measurements are made before surgery to plan pin sites and length and location of the osteotomy. Through a dorsal incision, the extensor tendon of the shortened metacarpal or phalange is retracted and the
periosteum is exposed. The osteotomy and pin sites are marked before opening the periosteum. The selfthreading pins are inserted first through the skin and then placed in predrilled holes at either end of the bone (Fig. 2). It is necessary for the pin entrance sites in the skin to be further apart than in the bone to allow initial bone distraction without undue skin tension. The periosteal flaps are developed next. The longitudinal periosteal incision corresponds to the underlying osteotomy, while transverse incisions are made on the side opposite the osteotomy cut. In this way, periosteal sleeves are formed in the area where new bone formation is required (Fig. 3). Once the osteotomies are
Vol. 9A, No.6 November 1984
Fig. 7C. Three months after surgery. Note small amounts of callus at site of bone contact and early development of cortex beneath periosteal flaps.
completed and the remainder of the apparatus is assembled, distraction is performed under direct vision to ensure good bony contact. During the first week after surgery, further distraction is begun at a rate of 1 mm a day. Periodic radiologic assessment is necessary to ensure that lengthening is adequate and that bone contact is still maintained. Once adequate length is obtained, a protective splint is applied until bony union is complete. This is removed daily for joint mobilization. Soft tissue considerations include the management of skin, tendons, and neurovascular bundles. The skin incision should be curved and as far removed from the pin sites as possible. Adjacent scarring or adherent tendons may require release. If distraction is slow enough, neurovascular bundles and muscle-tendon units will accommodate lengthening .
Case report A 44-year-old right-handed male machinist injured his dominant hand in a grinding machine. He sustained an oblique amputation of all four fingers (Fig . 4, A). The digits were not suitable for replantation and the amputation stumps were closed in a conventional manner. After returning to work, he noted severe difficulty with fine pinch activities. As a machinist, his work required that he manipulate small measuring instruments with some dexterity . He complained that the stumps of his index and long fingers were too short to
Distraction osteosynthesis in hand
861
Fig. 7D. Radiographic appearance of hand after osteotomy to index phalanx.
Fig. 7E. Final radiographic appearance of hand shows lengthening of both stumps. Both osteotomies are solidly fused, and step gap sites are filled with bone. adequately oppose to his normal thumb and that his injured ring and small fingers were not suitable . The index finger amputation was just distal to the midshaft portion of the proximal phalanx and the long finger stump was 3 mm longer (Fig. 4. B). We suggested that he return to work in order to take more time to adjust his patterns of hand function to his shortened fingers. After I year, he came back with very specific and precise requests. After considerable on-the-job thought. he had decided that his requirements for precise manual capabilities would be satisfied if he had an additional 15 mm of length on both stumps, most particularly on the index phalanx.
862
The Journal of HAND SURGERY
Mankteluw and Wainwright
On April 3, 1981, an 18 mm step osteotomy with distraction by the Mini-H-Fixator was done on the index proximal phalanx. Distraction was completed in 8 days, with a total length of gain of 14 mm (Fig. 5). Union was complete at eight weeks (as assessed radiologically and clinically). After he had returned to work, he found his dexterity so improved that he requested lengthening of the now shorter third digit to improve three-point pinch function. On February 13, 1982, a 20 mm step osteotomy was done and 15 mm of distraction was attained over a lO-day period. As bony union was not solid at 8 weeks, the fixator was left for an additional 4 weeks until evidence of union was present. A single episode of cellulitis was controlled by oral cloxacillin. He returned to work 14 weeks after surgery. He had obtained length sufficient to improve functional capability (Fig. 6).
Discussion
A ray lengthening procedure should (1) provide adequate functional lengthening, (2) obtain good bony union, (3) not compromise soft tissue structures, (4) maintain stump sensibility, and (5) produce minimal donor defect. The most common means of lengthening a short digit, particularly an amputated thumb, is by the addition of tissue to the end of the stump. This addition can be accomplished with the skin flap-bone graft technique, pollicization, or toe-to-hand transfer. An alternate concept is to advance the end of the amputated stump by lengthening the center of the ray. This is useful when small increments of lengthening are required. Distraction osteosynthesis was first utilized in the early 1900s for femoral lengthening by Codivilla2 and Putti. 3 The concept was first applied in reconstructive hand surgery by Matev .1,4 His technique, as commonly applied to the first metacarpal after traumatic thumb amputation, involves a transverse subperiosteal osteotomy with gradual distraction of the segments. He emphasizes this subperiosteal approach to preserve the periosteum during distraction. 5 Although the distraction technique has had considerable success in children, the period of bone formation and union is frequently prolonged in adults since it depends on intramembranous ossification of the connective tissue traversing the osteotomy gap.6 This has prompted a more widespread use of interpositional bone grafting once distraction is
accomplished, as reported by Kessler et al. 7 and Paneva-Holewich and Yankov. 8 The technique of step osteotomy does not require a bone graft. Bone healing is both by conventional fracture healing at the site of bone-on-bone contact and by new bone formation from the periosteal flaps. With the availability of a reliable distraction apparatus and the assurance of good bone union, this approach to the short digit should have wider application. When a length of 2 to 3 cm of augmentation is required, Matev's technique with a bone graft in adults and spontaneous osteosynthesis in children is most suitable. For less lengthening, a step osteotomy should be considered in view of its improved potential for rapid osteosynthesis. The amount of lengthening that can be obtained by this method will depend on the length of bone stock that is available. Pin fixation should be in cortical bone and step osteotomy should not be distracted beyond the length of the step as illustrated in Fig. 7, B. REFERENCES 1. Matev I: Gradual elongation of the first metacarpal as a method of thumb reconstruction. In Proceedings of The Second Hand Club. 1975, British Society for Surgery of the Hand, p 431 2. Codivilla A: On the means of lengthening in the lower limbs the muscles and tissues which are shortened through deformity. Am J Orthop Surg 2:353-69, 1905 3. Putti V: The operative lengthening of the femur. JAM A 77:934-5, 1921 4. Matev I: Thumb reconstruction after amputation at the metacarpophalangeal joint by bony lengthening. J Bone Joint Surg [Am] 52:957-65, 1970 5. Matev I: New thoughts on hand surgery. Mod Trends Orthop 6:95-101, 1972 6. I1izarov BA, Shtin VP, Ledyaev VI: The course of reparative regeneration of cortical bone in distraction osteosynthesis under various conditions of fragment fixation. Sksp Khir Anest 14:3-12, 1969 7. Kessler I, Baruch A, Hecht 0: Experience with the distraction lengthening of digital rays in congenital anomalies. J HAND SURG 2:394-401, 1977 8. Paneva-Holevich E, Yankov E: A distraction method for lengthening of the finger metacarpals: A preliminary report. J HAND SURG 5:160-7,1980
Patel and Zinberg
9.
10.
II.
12.
synovitis of the wrist and penetration into bone. J Bone Joint Surg [Br] 50:312-7, 1968 Jones FE, Soule EH, Conventry MD: Fibrous xanthoma of synovium. A study of 118 cases. J Bone Joint Surg [Am] 51:76-86, 1969 Decker JP, Owen BJ: An invasive giant cell tumor of tendon sheath in the foot. Bull Ayer Clin Lab 4:43-53, 1954 Terisu T, Iwabuchi R, Kamo Y: Pigmented villonodular synovitis of elbow with bony invasion. Clin Orthop 94:275-80, 1973 Scott PM: Bone lesions in pigmented villonodular synovitis. J Bone Joint Surg [Br] 50:306-11, 1968
13. Breimer CW, Freilberger RH: Bone lesions associated with pigmented villonodular synovitis. Am J Roentgenol Rad Ther Nucl Med 79:618-29, 1958 14. Smith JH, Pugh DO: Roentgenographic aspects of articular pigmented villonodular synovitis. Am J Roentgenol Rad Ther Nucl Med 87:1146-56,1962 15. Nilsonne U, Moberger G: Pigmented villonodular synovitis of joints. Acta Orthop Scand 40:448, 1969 16. Kobak MW, Perlow S: Xanthomatous giant cell tumors arising in soft tissue. Report of an instance of malignant growth. Arch Surg 59:909-16, 1949
A technique of distraction osteosynthesis in the hand Moderate digital lengthening may be accomplished with a step osteotomy that preserves attached sleeves of periosteum. A new external fixation apparatus, the Mini-H-Fixator, allows gradual distraction and solid bone fixation after surgery and facilitates this operation. The advantage of this procedure is that it results in rapid bone formation in the osteotomy gaps, obviating the need for bone grafting. (J HAND SURG 9A:858-62, 1984.)
R. T. Manktelow, M.D., F.R.C.S.(C), and D. J. Wainwright, M.D., Toronto, Ontario, Canada
T
he distraction method of lengthening a shortened digit was first introduced by Matev l in 1967. He refined the technique with particular application to lengthening the thumb metacarpal after amputation. While periosteal new bone formation is adequate in children, his technique requires a bone graft in adults. This report presents a technique of bone lengthening that does not require bone grafting and describes the use of a new external fixation device that makes this technique feasible.
Distraction apparatus An external fixation device for the distraction of the bones of the hand must fulfill certain criteria. The apparatus must provide solid purchase and rigid immobiliFrom the Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada. Received for publication Jan. 14, 1983; accepted in revised form March 15, 1984. Reprint requests: Dr. R. T. Manktelow, M.D., EN 10-236 Toronto General Hospital, 101 College St., Toronto, Ontario, Canada.
858
THE JOURNAL OF HAND SURGERY
Fig. 1. The Mini-H-Fixator: A, connecting bar; B, sliding swivel clamp; C, simple swivel clamp; D, transfixing pins; E, half pins; and F, offset pin holder.
Vol. 9A , No . 6 November 1984
Dis/rac/ion os/eosylllhesis i/1 hand
859
A
Fig. 2. A, View during surgery with osteotomy designed on dorsum of phalanx . Extensor tendon is retracted proximally and transfixing pins are in place . B, Initial distraction is completed, with Mini-H-Fixator assembled .
Fig. 4. A, Appearance of patient's hand before surgery shows multiple levels of amputation and significantly shortened index and long fingers . B, Attempt at pinch. Note that pinch surfaces of thumb and index finger are not in ideal position for apposition .
Fig. 3. Schematic diagram of step osteotomy. Note periosteal sleeves (dotted area) are based at the level of the osteotomy cut and cover interosseous gap formed after distraction .
zation without damaging the bone . The design should be small enough to allow mobilization of the remainder of the hand yet be robust enough for adequate fixation. It should be adaptable for use on the phalanges and metacarpals of all digits and there must be minimal problems at the pin-skin interface. The surgeon must be able to make small accurate increments of distraction . We found the Mini-H-Fixator (Jaquet Freres, Geneva, Switzerland; Fig . 1) to satisfy these criteria. This system is designed specifically for small bones and modeled on the larger Hoffmann apparatus available for large bone external fixation. The system includes
Fig. 5. Early appearance after surgery with apparatus in place. The position of the fixator does not impede mobilization of adjacent joints .
interosseous 2 and 3 mm half pins and 1.5 mm transfixing pins . Offset pin holders allow easier access to the osteotomy site after pin insertion . The sliding swivel clamp provides a simple means of accurate graded distraction or compression.
860
Manktelow and Wainwright
The Journal of HAND SURGERY
Fig. 6. Patient's hand after both lengthening procedures . A, Index and long fingers are noticeably longer. B, Pinch . Significantly better opposition is seen with lengthened index phalanx.
Fig. 7B. View early after surgery illustrates distraction of fragments, with maintenance of bone-on-bone contact centrally.
Fig. 7 A. Radiograph before surgery.
Surgical technique The procedure incorporates a sliding step osteotomy and periosteal sleeves. Radiologic measurements are made before surgery to plan pin sites and length and location of the osteotomy. Through a dorsal incision, the extensor tendon of the shortened metacarpal or phalange is retracted and the
periosteum is exposed. The osteotomy and pin sites are marked before opening the periosteum. The selfthreading pins are inserted first through the skin and then placed in predrilled holes at either end of the bone (Fig. 2). It is necessary for the pin entrance sites in the skin to be further apart than in the bone to allow initial bone distraction without undue skin tension. The periosteal flaps are developed next. The longitudinal periosteal incision corresponds to the underlying osteotomy, while transverse incisions are made on the side opposite the osteotomy cut. In this way, periosteal sleeves are formed in the area where new bone formation is required (Fig. 3). Once the osteotomies are
Vol. 9A, No.6 November 1984
Fig. 7C. Three months after surgery. Note small amounts of callus at site of bone contact and early development of cortex beneath periosteal flaps.
completed and the remainder of the apparatus is assembled, distraction is performed under direct vision to ensure good bony contact. During the first week after surgery, further distraction is begun at a rate of 1 mm a day. Periodic radiologic assessment is necessary to ensure that lengthening is adequate and that bone contact is still maintained. Once adequate length is obtained, a protective splint is applied until bony union is complete. This is removed daily for joint mobilization. Soft tissue considerations include the management of skin, tendons, and neurovascular bundles. The skin incision should be curved and as far removed from the pin sites as possible. Adjacent scarring or adherent tendons may require release. If distraction is slow enough, neurovascular bundles and muscle-tendon units will accommodate lengthening .
Case report A 44-year-old right-handed male machinist injured his dominant hand in a grinding machine. He sustained an oblique amputation of all four fingers (Fig . 4, A). The digits were not suitable for replantation and the amputation stumps were closed in a conventional manner. After returning to work, he noted severe difficulty with fine pinch activities. As a machinist, his work required that he manipulate small measuring instruments with some dexterity . He complained that the stumps of his index and long fingers were too short to
Distraction osteosynthesis in hand
861
Fig. 7D. Radiographic appearance of hand after osteotomy to index phalanx.
Fig. 7E. Final radiographic appearance of hand shows lengthening of both stumps. Both osteotomies are solidly fused, and step gap sites are filled with bone. adequately oppose to his normal thumb and that his injured ring and small fingers were not suitable . The index finger amputation was just distal to the midshaft portion of the proximal phalanx and the long finger stump was 3 mm longer (Fig. 4. B). We suggested that he return to work in order to take more time to adjust his patterns of hand function to his shortened fingers. After I year, he came back with very specific and precise requests. After considerable on-the-job thought. he had decided that his requirements for precise manual capabilities would be satisfied if he had an additional 15 mm of length on both stumps, most particularly on the index phalanx.
862
The Journal of HAND SURGERY
Mankteluw and Wainwright
On April 3, 1981, an 18 mm step osteotomy with distraction by the Mini-H-Fixator was done on the index proximal phalanx. Distraction was completed in 8 days, with a total length of gain of 14 mm (Fig. 5). Union was complete at eight weeks (as assessed radiologically and clinically). After he had returned to work, he found his dexterity so improved that he requested lengthening of the now shorter third digit to improve three-point pinch function. On February 13, 1982, a 20 mm step osteotomy was done and 15 mm of distraction was attained over a lO-day period. As bony union was not solid at 8 weeks, the fixator was left for an additional 4 weeks until evidence of union was present. A single episode of cellulitis was controlled by oral cloxacillin. He returned to work 14 weeks after surgery. He had obtained length sufficient to improve functional capability (Fig. 6).
Discussion
A ray lengthening procedure should (1) provide adequate functional lengthening, (2) obtain good bony union, (3) not compromise soft tissue structures, (4) maintain stump sensibility, and (5) produce minimal donor defect. The most common means of lengthening a short digit, particularly an amputated thumb, is by the addition of tissue to the end of the stump. This addition can be accomplished with the skin flap-bone graft technique, pollicization, or toe-to-hand transfer. An alternate concept is to advance the end of the amputated stump by lengthening the center of the ray. This is useful when small increments of lengthening are required. Distraction osteosynthesis was first utilized in the early 1900s for femoral lengthening by Codivilla2 and Putti. 3 The concept was first applied in reconstructive hand surgery by Matev .1,4 His technique, as commonly applied to the first metacarpal after traumatic thumb amputation, involves a transverse subperiosteal osteotomy with gradual distraction of the segments. He emphasizes this subperiosteal approach to preserve the periosteum during distraction. 5 Although the distraction technique has had considerable success in children, the period of bone formation and union is frequently prolonged in adults since it depends on intramembranous ossification of the connective tissue traversing the osteotomy gap.6 This has prompted a more widespread use of interpositional bone grafting once distraction is
accomplished, as reported by Kessler et al. 7 and Paneva-Holewich and Yankov. 8 The technique of step osteotomy does not require a bone graft. Bone healing is both by conventional fracture healing at the site of bone-on-bone contact and by new bone formation from the periosteal flaps. With the availability of a reliable distraction apparatus and the assurance of good bone union, this approach to the short digit should have wider application. When a length of 2 to 3 cm of augmentation is required, Matev's technique with a bone graft in adults and spontaneous osteosynthesis in children is most suitable. For less lengthening, a step osteotomy should be considered in view of its improved potential for rapid osteosynthesis. The amount of lengthening that can be obtained by this method will depend on the length of bone stock that is available. Pin fixation should be in cortical bone and step osteotomy should not be distracted beyond the length of the step as illustrated in Fig. 7, B. REFERENCES 1. Matev I: Gradual elongation of the first metacarpal as a method of thumb reconstruction. In Proceedings of The Second Hand Club. 1975, British Society for Surgery of the Hand, p 431 2. Codivilla A: On the means of lengthening in the lower limbs the muscles and tissues which are shortened through deformity. Am J Orthop Surg 2:353-69, 1905 3. Putti V: The operative lengthening of the femur. JAM A 77:934-5, 1921 4. Matev I: Thumb reconstruction after amputation at the metacarpophalangeal joint by bony lengthening. J Bone Joint Surg [Am] 52:957-65, 1970 5. Matev I: New thoughts on hand surgery. Mod Trends Orthop 6:95-101, 1972 6. I1izarov BA, Shtin VP, Ledyaev VI: The course of reparative regeneration of cortical bone in distraction osteosynthesis under various conditions of fragment fixation. Sksp Khir Anest 14:3-12, 1969 7. Kessler I, Baruch A, Hecht 0: Experience with the distraction lengthening of digital rays in congenital anomalies. J HAND SURG 2:394-401, 1977 8. Paneva-Holevich E, Yankov E: A distraction method for lengthening of the finger metacarpals: A preliminary report. J HAND SURG 5:160-7,1980