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CONDYLAR ADVANCEMENT OSTEOTOMY FOR CORRECTING CONDYLAR MALUNION OF THE FINGER
CONDYLAR ADVANCEMENT OSTEOTOMY FOR CORRECTING CONDYLAR MALUNION OF THE FINGER L. C. TEOH, F. C. YONG and K. C. CHONG From Department of Hand Surgery, Singapore General Hospital, Singapore
Unicondylar fractures of proximal and middle phalanges of the finger can unite with intra-articular malunion, which may result in joint pain, stiffness and deformity. There is currently no satisfactory technique of corrective osteotomy for these fractures. Extra-articular osteotomies often do not give good results and existing techniques of intra-articular osteotomy through the healed fracture site are technically difficult due to the small bone fragment, difficulty achieving stable fixation and the risk of avascular necrosis. We propose a different method of intra-articular correction with a longitudinal osteotomy and advancement of the malunited condyle. The ‘‘condylar advancement osteotomy’’ can overcome problems encountered with the other techniques. Excellent results were obtained in six patients. Journal of Hand Surgery (British and European Volume, 2002) 27B: 1: 31–35 non-operative management. Malunited fractures may cause pain, stiffness and finger deformity, and result in late-onset post-traumatic osteoarthritis. To our knowledge, there is currently no satisfactory method of corrective osteotomy for malunited unicondylar fractures. Extra-articular osteotomy can correct finger angular and rotational deformity, but does not address the incongruent articular surface which may cause persistent pain and limited joint motion (Gollamudi and
INTRODUCTION London (1971), Schenck (1994) and Weiss and Hastings (1993) have described classifications of condylar fractures of the phalanges of the fingers and recommended treatment options. Unicondylar fractures of the proximal and middle phalanges form a subset of these injuries and sometimes heal with malunion, either due to neglect by the patient, missed diagnosis or failure of
Fig 1 (a) Malunited condyle of the proximal phalanx. Shaded areas represent fracture callus. (b) A longitudinal osteotomy is made down the shaft and excess bone is removed with a burr. (c) The bone fragment is advanced, restoring joint congruity and correcting angular deformity. (d) Stable fixation is achieved with screws. 31
32
Jones, 2000). Intra-articular osteotomy restores articular congruity and in our experience gives better results with alleviation of pain, correction of deformity and improvement in range of motion. However, the techniques currently described involve an osteotomy through the healed fracture site (Light, 1987; Duncan and Jupiter,
THE JOURNAL OF HAND SURGERY VOL. 27B No. 1 FEBRUARY 2002
1989), which produces a small bone fragment which is difficult to handle and stabilize. In addition, the small fragment may undergo avascular necrosis. We describe our experience with a different technique of intra-articular osteotomy for malunited unicondylar fractures of phalanges of the finger. The ‘‘condylar
Fig 2 (a) A 16-year-old man present 3 months after injury to the left middle finger with pain, stiffness and angular deformity. (b) X-ray showed a malunited ulnar condyle of the proximal phalanx. (c) The condylar advancement osteotomy is performed with restoration of the joint congruity. (d) Stable fixation is achieved with 1.5 mm screws and the proximal osteotomy bone gap is bone grafted.
CONDYLAR ADVANCEMENT OSTEOTOMY
advancement osteotomy’’ overcomes most of the problems encountered with previous techniques.
PATIENTS AND MATERIALS Six patients with unicondylar malunions of phalanges of a finger presented with pain, stiffness and deformity (Table 1). There was one woman and five men with a mean age of 21 (range, 13–33) years. Four patients had malunion of a proximal phalanx condyle and two had malunion of a middle phalanx condyle. All patients underwent a corrective osteotomy at a mean of 10 (range, 3–30) months after injury. Pre-operatively, the patients were assessed for joint pain, angular deformity and loss of motion. The ranges of active motion for the proximal and distal interphalangeal joints were recorded individually, but were then combined to provide a total range of interphalangeal
33
joint motion (TAIM) as utilized by Strickland (1985) for assessing the outcome of flexor tendon surgery. The motion ranges of the metacarpophalangeal joints were all normal and were thus excluded. The post-operative outcome was similarly assessed and compared.
Surgical technique (Figs 1 and 2) The malunion site is approached through a dorsal midline incision and the condyles are exposed by longitudinal splitting of the extensor tendon and flexion of the joint. A longitudinal osteotomy is made with a micro-oscillating saw. This extends from the intercondylar articular surface for approximately 1.0 to 1.5 cm proximally along the mid-shaft of the phalanx. An additional transverse osteotomy proximally detaches the bone fragment, including the malunited condyle, from the shaft. If necessary, excess bone is then removed from
Fig 2 (e,f ) Results 2 years after surgery. (g) X-ray showed union of the osteotomy without avascular necrosis.
175
160
155
110
165
0–100 10–75 10–100 0–75 20–80 0–50 0–100 10–65 0–100 0–60 0–100 0–75 0
135
175
0
0 60
90
120
0
0
PIPJ DIPJ PIPJ DIPJ PIPJ DIPJ PIPJ DIPJ PIPJ DIPJ PIPJ DIPJ 0
PIPJ-Proximal interphalangeal joint. DIPJ–Distal interphalangeal joint. TAIM-Total active interphalangeal joint motion (PIPJ+DIPJ).
20 13 30 13/ Woman 6
Middle
20 35 11 20/ Man 5
Middle
15 24 3 23/ Man 4
Proximal
30 33 3 33/ Man 3
Proximal
20 65 3 16/ Man 2
Proximal
20/ Man 1
Proximal
10
25
20
PIPJ DIPJ PIPJ DIPJ PIPJ DIPJ PIPJ DIPJ PIPJ DIPJ PIPJ DIPJ
0–55 0–35 45–90 0–75 30–70 0–50 0–30 0–30 0–100 10–45 0–100 0–75
90
TAIM (degrees) Range of motion (degrees) Angular deformity (degrees) Duration of follow-up (months) Time from injury (months) Phalanx involved Age/Sex
Results of condylar advancement osteotomy
An intra-articular osteotomy is most appropriate for correction of malunion of unicondylar fractures. It corrects the articular ‘‘step-off ’’ and restores the congruity of the joint, thus alleviating pain, correcting angular deformity, improving finger motion and possibly preventing degenerative changes in the joint. The condylar advancement osteotomy is intended to achieve all these aims, whilst avoiding the problems encountered with an osteotomy through the healed fracture site. The dorsal, extensor tendon splitting, approach gives good visualisation of the malunion site and the bone fragment
Table 1
DISCUSSION
Pre-operative assessment
RESULTS At pre-operative assessment, all cases had joint pain and lateral angulation of the injured finger. The average joint angulation was 218 (range, 158–308) and all but one patient had a decreased TAIM. The average TAIM was 1128 (range, 608 to 1758). Two patients had extension lags of 308 and 458 in the proximal interphalangeal joint, and one had extension lag of 108 in the distal interphalangeal joint. At a mean follow-up period of 33 (range, 13–65) months, the overall results were excellent (Table 1). All six osteotomies united with no evidence of bone necrosis. Lateral deviation deformities were fully corrected and all patients regained normal pain-free use of the finger and hand. The postoperative range of motion of the joints was improved in five patients. The average TAIM was 1558 (range, 1108–1758). An extension lag of 108 persisted in the distal interphalangeal joints of two patients, and two patients had residual extension lags of the proximal interphalangeal joint of 108 and 208 respectively. There were no cases of osteoarthritis.
Range of motion (degrees) Angular deformity (degrees)
Post-operative assessment
TAIM (degrees)
the fragment with a burr in order to correct any rotational deformity. The bone fragment, with the malunited condyle, is then advanced distally so that the congruity of the articular surface of the joint is improved. Stable fixation is achieved with 1.5 mm inter-fragmentary screws and Kirschner wires. The joint is checked for malalignment, rotation deformity and passive range of motion. An additional soft tissue release may be necessary to improve the range of motion and intra-operative radiographs are taken to confirm the adequacy of the correction and internal fixation. Supervised free mobilization of the joint is started on the second day after surgery. The joints are splinted in extension between exercise sessions. The patient’s progress is closely followed with radiographs and clinical assessments, with particular attention to joint pain, deformity and range of motion. The patients were given the option of implant removal 6 months after union.
165
THE JOURNAL OF HAND SURGERY VOL. 27B No. 1 FEBRUARY 2002
Case
34
CONDYLAR ADVANCEMENT OSTEOTOMY
is larger, and has more soft tissue attachment. However, to prevent avascular necrosis of the condyle, care must be taken to prevent excessive soft tissue stripping during the dissection. The malunited fracture may not be exactly in the sagittal plane, and is often in a slightly oblique plane and has a rotational element. In such cases excess bone on either the palmar or dorsal cortex has to be removed to correct the rotational deformity. In our initial cases the proximal bone gap from the osteotomy was filled with bone graft, but this was later found to be unnecessary. As the osteotomy is firmly stabilized, finger mobilization can be started soon after surgery, so as to prevent the formation of intra-articular adhesions and extra-articular contractures (Kearney and Brown, 1994). As well as a trained therapist, an understanding and motivated patient contributes to the success of the procedure. The condylar advancement osteotomy should only be performed after the displaced fracture has healed, and we believe that the minimum interval between injury and the surgery is 3 months. However, the condylar advancement osteotomy should be done before osteoarthritic changes develop.
35
References Duncan KH, Jupiter JB (1989). Intraarticular osteotomy for malunion of metacarpal head fractures. Journal of Hand Surgery, 14A: 888–893. Gollamudi S, Jones WA (2000). Corrective osteotomy of malunited fractures of phalanges and metacarpals. Journal of Hand Surgery, 25B: 439–441. Kearney LM, Brown KK (1994). The therapist’s management of intra-articular fractures. Hand Clinics, 10: 199–209. Light TR (1987). Salvage of intraarticular malunions of the hand and wrist: the role of realignment osteotomy. Clinical Orthopaedics and Related Research, 214: 130–135. London PS (1971). Sprains and fractures involving the interphalangeal joints. The Hand, 3: 155–158. Schenck RR (1994). Classification of fractures and dislocations of the proximal interphalangeal joint. Hand Clinics, 10: 179–185. Strickland JW (1985). Results of flexor tendon surgery in zone II. Hand Clinics, 1: 167–179. Weiss APC, Hastings H (1993). Distal unicondylar fractures of the proximal phalanx. Journal of Hand Surgery, 18A: 594–599.
Received: 23 April 2001 Accepted after revision: 13 August 2001 Dr Lam-Chuan Teoh, Chief & Senior Consultant Hand Surgeon, Dept of Hand Surgery, Singapore General Hospital, Outram Road, Singapore 169608. E-mail: [email protected] # 2002 The British Society for Surgery of the Hand doi: 10.1054/jhsb.2001.0694, available online at http://www.idealibrary.com on
Unicondylar fractures of proximal and middle phalanges of the finger can unite with intra-articular malunion, which may result in joint pain, stiffness and deformity. There is currently no satisfactory technique of corrective osteotomy for these fractures. Extra-articular osteotomies often do not give good results and existing techniques of intra-articular osteotomy through the healed fracture site are technically difficult due to the small bone fragment, difficulty achieving stable fixation and the risk of avascular necrosis. We propose a different method of intra-articular correction with a longitudinal osteotomy and advancement of the malunited condyle. The ‘‘condylar advancement osteotomy’’ can overcome problems encountered with the other techniques. Excellent results were obtained in six patients. Journal of Hand Surgery (British and European Volume, 2002) 27B: 1: 31–35 non-operative management. Malunited fractures may cause pain, stiffness and finger deformity, and result in late-onset post-traumatic osteoarthritis. To our knowledge, there is currently no satisfactory method of corrective osteotomy for malunited unicondylar fractures. Extra-articular osteotomy can correct finger angular and rotational deformity, but does not address the incongruent articular surface which may cause persistent pain and limited joint motion (Gollamudi and
INTRODUCTION London (1971), Schenck (1994) and Weiss and Hastings (1993) have described classifications of condylar fractures of the phalanges of the fingers and recommended treatment options. Unicondylar fractures of the proximal and middle phalanges form a subset of these injuries and sometimes heal with malunion, either due to neglect by the patient, missed diagnosis or failure of
Fig 1 (a) Malunited condyle of the proximal phalanx. Shaded areas represent fracture callus. (b) A longitudinal osteotomy is made down the shaft and excess bone is removed with a burr. (c) The bone fragment is advanced, restoring joint congruity and correcting angular deformity. (d) Stable fixation is achieved with screws. 31
32
Jones, 2000). Intra-articular osteotomy restores articular congruity and in our experience gives better results with alleviation of pain, correction of deformity and improvement in range of motion. However, the techniques currently described involve an osteotomy through the healed fracture site (Light, 1987; Duncan and Jupiter,
THE JOURNAL OF HAND SURGERY VOL. 27B No. 1 FEBRUARY 2002
1989), which produces a small bone fragment which is difficult to handle and stabilize. In addition, the small fragment may undergo avascular necrosis. We describe our experience with a different technique of intra-articular osteotomy for malunited unicondylar fractures of phalanges of the finger. The ‘‘condylar
Fig 2 (a) A 16-year-old man present 3 months after injury to the left middle finger with pain, stiffness and angular deformity. (b) X-ray showed a malunited ulnar condyle of the proximal phalanx. (c) The condylar advancement osteotomy is performed with restoration of the joint congruity. (d) Stable fixation is achieved with 1.5 mm screws and the proximal osteotomy bone gap is bone grafted.
CONDYLAR ADVANCEMENT OSTEOTOMY
advancement osteotomy’’ overcomes most of the problems encountered with previous techniques.
PATIENTS AND MATERIALS Six patients with unicondylar malunions of phalanges of a finger presented with pain, stiffness and deformity (Table 1). There was one woman and five men with a mean age of 21 (range, 13–33) years. Four patients had malunion of a proximal phalanx condyle and two had malunion of a middle phalanx condyle. All patients underwent a corrective osteotomy at a mean of 10 (range, 3–30) months after injury. Pre-operatively, the patients were assessed for joint pain, angular deformity and loss of motion. The ranges of active motion for the proximal and distal interphalangeal joints were recorded individually, but were then combined to provide a total range of interphalangeal
33
joint motion (TAIM) as utilized by Strickland (1985) for assessing the outcome of flexor tendon surgery. The motion ranges of the metacarpophalangeal joints were all normal and were thus excluded. The post-operative outcome was similarly assessed and compared.
Surgical technique (Figs 1 and 2) The malunion site is approached through a dorsal midline incision and the condyles are exposed by longitudinal splitting of the extensor tendon and flexion of the joint. A longitudinal osteotomy is made with a micro-oscillating saw. This extends from the intercondylar articular surface for approximately 1.0 to 1.5 cm proximally along the mid-shaft of the phalanx. An additional transverse osteotomy proximally detaches the bone fragment, including the malunited condyle, from the shaft. If necessary, excess bone is then removed from
Fig 2 (e,f ) Results 2 years after surgery. (g) X-ray showed union of the osteotomy without avascular necrosis.
175
160
155
110
165
0–100 10–75 10–100 0–75 20–80 0–50 0–100 10–65 0–100 0–60 0–100 0–75 0
135
175
0
0 60
90
120
0
0
PIPJ DIPJ PIPJ DIPJ PIPJ DIPJ PIPJ DIPJ PIPJ DIPJ PIPJ DIPJ 0
PIPJ-Proximal interphalangeal joint. DIPJ–Distal interphalangeal joint. TAIM-Total active interphalangeal joint motion (PIPJ+DIPJ).
20 13 30 13/ Woman 6
Middle
20 35 11 20/ Man 5
Middle
15 24 3 23/ Man 4
Proximal
30 33 3 33/ Man 3
Proximal
20 65 3 16/ Man 2
Proximal
20/ Man 1
Proximal
10
25
20
PIPJ DIPJ PIPJ DIPJ PIPJ DIPJ PIPJ DIPJ PIPJ DIPJ PIPJ DIPJ
0–55 0–35 45–90 0–75 30–70 0–50 0–30 0–30 0–100 10–45 0–100 0–75
90
TAIM (degrees) Range of motion (degrees) Angular deformity (degrees) Duration of follow-up (months) Time from injury (months) Phalanx involved Age/Sex
Results of condylar advancement osteotomy
An intra-articular osteotomy is most appropriate for correction of malunion of unicondylar fractures. It corrects the articular ‘‘step-off ’’ and restores the congruity of the joint, thus alleviating pain, correcting angular deformity, improving finger motion and possibly preventing degenerative changes in the joint. The condylar advancement osteotomy is intended to achieve all these aims, whilst avoiding the problems encountered with an osteotomy through the healed fracture site. The dorsal, extensor tendon splitting, approach gives good visualisation of the malunion site and the bone fragment
Table 1
DISCUSSION
Pre-operative assessment
RESULTS At pre-operative assessment, all cases had joint pain and lateral angulation of the injured finger. The average joint angulation was 218 (range, 158–308) and all but one patient had a decreased TAIM. The average TAIM was 1128 (range, 608 to 1758). Two patients had extension lags of 308 and 458 in the proximal interphalangeal joint, and one had extension lag of 108 in the distal interphalangeal joint. At a mean follow-up period of 33 (range, 13–65) months, the overall results were excellent (Table 1). All six osteotomies united with no evidence of bone necrosis. Lateral deviation deformities were fully corrected and all patients regained normal pain-free use of the finger and hand. The postoperative range of motion of the joints was improved in five patients. The average TAIM was 1558 (range, 1108–1758). An extension lag of 108 persisted in the distal interphalangeal joints of two patients, and two patients had residual extension lags of the proximal interphalangeal joint of 108 and 208 respectively. There were no cases of osteoarthritis.
Range of motion (degrees) Angular deformity (degrees)
Post-operative assessment
TAIM (degrees)
the fragment with a burr in order to correct any rotational deformity. The bone fragment, with the malunited condyle, is then advanced distally so that the congruity of the articular surface of the joint is improved. Stable fixation is achieved with 1.5 mm inter-fragmentary screws and Kirschner wires. The joint is checked for malalignment, rotation deformity and passive range of motion. An additional soft tissue release may be necessary to improve the range of motion and intra-operative radiographs are taken to confirm the adequacy of the correction and internal fixation. Supervised free mobilization of the joint is started on the second day after surgery. The joints are splinted in extension between exercise sessions. The patient’s progress is closely followed with radiographs and clinical assessments, with particular attention to joint pain, deformity and range of motion. The patients were given the option of implant removal 6 months after union.
165
THE JOURNAL OF HAND SURGERY VOL. 27B No. 1 FEBRUARY 2002
Case
34
CONDYLAR ADVANCEMENT OSTEOTOMY
is larger, and has more soft tissue attachment. However, to prevent avascular necrosis of the condyle, care must be taken to prevent excessive soft tissue stripping during the dissection. The malunited fracture may not be exactly in the sagittal plane, and is often in a slightly oblique plane and has a rotational element. In such cases excess bone on either the palmar or dorsal cortex has to be removed to correct the rotational deformity. In our initial cases the proximal bone gap from the osteotomy was filled with bone graft, but this was later found to be unnecessary. As the osteotomy is firmly stabilized, finger mobilization can be started soon after surgery, so as to prevent the formation of intra-articular adhesions and extra-articular contractures (Kearney and Brown, 1994). As well as a trained therapist, an understanding and motivated patient contributes to the success of the procedure. The condylar advancement osteotomy should only be performed after the displaced fracture has healed, and we believe that the minimum interval between injury and the surgery is 3 months. However, the condylar advancement osteotomy should be done before osteoarthritic changes develop.
35
References Duncan KH, Jupiter JB (1989). Intraarticular osteotomy for malunion of metacarpal head fractures. Journal of Hand Surgery, 14A: 888–893. Gollamudi S, Jones WA (2000). Corrective osteotomy of malunited fractures of phalanges and metacarpals. Journal of Hand Surgery, 25B: 439–441. Kearney LM, Brown KK (1994). The therapist’s management of intra-articular fractures. Hand Clinics, 10: 199–209. Light TR (1987). Salvage of intraarticular malunions of the hand and wrist: the role of realignment osteotomy. Clinical Orthopaedics and Related Research, 214: 130–135. London PS (1971). Sprains and fractures involving the interphalangeal joints. The Hand, 3: 155–158. Schenck RR (1994). Classification of fractures and dislocations of the proximal interphalangeal joint. Hand Clinics, 10: 179–185. Strickland JW (1985). Results of flexor tendon surgery in zone II. Hand Clinics, 1: 167–179. Weiss APC, Hastings H (1993). Distal unicondylar fractures of the proximal phalanx. Journal of Hand Surgery, 18A: 594–599.
Received: 23 April 2001 Accepted after revision: 13 August 2001 Dr Lam-Chuan Teoh, Chief & Senior Consultant Hand Surgeon, Dept of Hand Surgery, Singapore General Hospital, Outram Road, Singapore 169608. E-mail: [email protected] # 2002 The British Society for Surgery of the Hand doi: 10.1054/jhsb.2001.0694, available online at http://www.idealibrary.com on