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Digital ray reconstruction through distraction osteogenesis: A retrospective study of 82 rays with long-term follow-up
Injury, Int. J. Care Injured 46 (2015) 1354–1358
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Digital ray reconstruction through distraction osteogenesis: A retrospective study of 82 rays with long-term follow-up Marios Vekris a, Marios Lykissas a,*, Emilios Pakos b, Ioannis Gelalis b, Anastasios Korompilias a, Panayotis Soucacos c, Alexandros Beris a a b c
University Hospital of Ioannina, Ioannina, Greece University of Ioannina, Ioannina, Greece University of Athens, Athens, Greece
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 24 January 2015
Purpose: The aim of the present study was to present the long-term radiographic results with distraction osteogenesis in traumatic or congenital length discrepancies of long bones of the hand. Methods: The medical records and radiographs of 65 consecutive patients (27 metacarpals and 55 phalanges) with either traumatic or congenital digital length discrepancies were retrospectively reviewed. The mean follow-up was 8.2 years. The mean distraction period was 21 days with a distraction rate of 4 0.25 mm/day. Callus consolidation was obtained in all patients. Results: The bones were lengthened by a mean amount of 17.5 mm, with a mean increase in bone length of 68 17.3%. The mean healing index was 28.57 days/cm. Ray reconstruction with callus distraction can be applied effectively in skeletally immature or mature patients with congenital differences of the hand or amputated fingers. Conclusion: A distraction rate of 1 mm/day proved to be a safe rate of lengthening in both metacarpals and phalanges. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Distraction osteogenesis Digital length discrepancy Phalangeal lengthening Metacarpal lengthening Healing index
Introduction After the Ilizarov era, limb-lengthening procedures for the reconstruction of congenital or posttraumatic length discrepancies were popularised. Several surgical techniques have been reported ‘up to date’ for the elongation of the long bones of the hand including single stage lengthening [1], distraction lengthening with bone graft and distraction osteogenesis [2]. The application of distraction osteogenesis in hand surgery was made possible due to the manufacture of sophisticated external fixators. The biomechanics of small external fixators are similar to large external fixators [3]. The indications of digital lengthening include traumatic or congenital digital length discrepancies with functional impairment. Matev in 1970 [4] and Kessler et al. in 1977 [5] first reported reconstruction of ray deficiencies with the use of bone graft. Digital lengthening through a distraction osteogenesis technique was applied later in the early 1980s (Matev [6]; Manktelow and
* Corresponding author. Tel.: +30 6944591915; fax: +30 2651034816. E-mail address: [email protected] (M. Lykissas). http://dx.doi.org/10.1016/j.injury.2015.01.036 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
Wainwright [7]). Since then, several authors have reported on the same technique [8–11]. The use of distraction lengthening has produced satisfactory results in the management of hand problems, such as congenital anomalies, traumatic amputations, burns and infection sequelae. The aim of the present study was to present the long-term radiographic results with distraction osteogenesis in traumatic or congenital length discrepancies of long bones of the hand. Methods Between January 1998 and December 2009, 65 consecutive patients (82 rays) with either traumatic or congenital digital length discrepancies underwent a lengthening procedure with the distraction osteogenesis method at our institution. The clinical records and radiographs were retrospectively reviewed after obtaining institutional review board approval and informed consent from each patient. The mean age of the patients was 20 years (range: 3–63 years). Of these patients, 46 were males and 19 females. The right hand was involved in 23 cases and the left hand in 42 cases. The reason for patients undergoing digital ray lengthening was traumatic
M. Vekris et al. / Injury, Int. J. Care Injured 46 (2015) 1354–1358
amputation in 47 cases (>25 years: 30 patients; <25 years: 17 patients) and congenital abnormalities in 18 cases (>25 years: five patients; <25 years: 13 patients). The congenital abnormalities included brachydactyly in nine cases, symbrachydactyly in four cases, longitudinal deficiency in two cases (hypoplastic thumb) and constriction band syndrome in three cases. In three cases, the patients exhibited bilateral involvement. Distraction osteogenesis was performed in 27 metacarpals and in 55 phalanges. In four patients, two phalanges were corrected simultaneously. Of the 27 metacarpals that underwent distraction osteogenesis, the first ray was involved in eight cases, the second in four, the third in three, the fourth in five and the fifth ray in seven cases. Of the 55 phalanges, the procedure was performed to the first ray in 14 cases, to the second in 12 cases, to the third in 13 cases, to the fourth in eight cases and to the fifth in ten cases. The proximal phalanx was lengthened in 35 cases, the middle in 15 and the distal in five cases. The physical therapy was not in the inclusion criteria of the present study. Surgical procedure The distraction osteogenesis was performed with a miniexternal fixator in all cases. This included either an Orthrofix Mini Rail System (Orthofix Srl, Verona, Italy) in 70 cases or a Hoffmann II Micro Lengthener (Stryker Trauma, Geneva, Switzerland) in 12 of our early cases. Under local or general anaesthesia and via a dorsal longitudinal approach, the extensor tendon was longitudinally dissected and retracted laterally in order to expose the bony segment to be distracted. The position of the bone osteotomy was performed in the proximal metaphysis or the junction of the proximal metaphysis with the diaphysis taking care to have enough bone proximally and distally in order to place two pairs of pins. This position was marked and two pairs of self-drilling, selftapping pins were inserted vertically to the dorsal aspect of the bone using the mini-lengthener as a guide. The size of the pins used ranged between 1.65 and 2.5 mm depending on the bone diameter and the age of the patient. The order of the pin placement was one pin on each side of the osteotomy site and close to it, while the second pin of each pair was placed further away from the osteotomy site. In children, the proximal pin was placed 3–4 mm away from the epiphyseal plate to avoid distraction damage to the growth plate. After the pin placement, the clamps of the device were firmly secured on the pins taking care to maintain a 3-mm gap between the two clumps at the site where the osteotomy is to be performed. The next step was a subperiosteal osteotomy performed with a mini-drill of 1.2 mm midway between the two clumps. The subperiosteal osteotomy was performed with a mini-drill of 1.2 mm midway between the two clumps. The periosteum and bone were pierced several times transversally at different angles, and the bone was fractured with a small chisel. The periosteum and bone were pierced several times transversally at different angles, and the bone was fractured with a small chisel. After the osteotomy, a slight compression was applied in order to bring the bony ends at the osteotomy site (Fig. 1). No additional bone graft was used and no protective splinting was applied. Patients were discharged from the hospital within the first 24 h after the operation. Following a latency period of 5 days, to allow the initiation of the healing process, distraction was applied at a rate of 0.25 mm every 6 h. The distraction rate was the same for all patients, regardless of the lengthening site (metacarpus or phalanx) and the patient’s age. Patients were assessed radiologically every week during the distraction period to evaluate the amount of distraction performed by the patient and the alignment of bone under distraction. The distraction process was terminated after achieving the desirable length in comparison to the
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Fig. 1. Intraoperative photograph demonstrating the osteotomy site in relation to the pins. Compression is initially applied at the osteotomy site for 5 days followed by distraction at a rate of 0.25 mm every 6 h.
contralateral normal ray. After this period, the device was locked and the patient was followed up every 3 weeks with new X-rays until callus formation and ossification were confirmed (Fig. 2). The distraction device was removed on an outpatient basis under local anaesthesia in the case of adult patients or under general anaesthesia in the case of young children once the bone formation in the distraction gap fulfilled the desired length and width of the metacarpal or phalangeal bone and there was adequate consolidation of at least three cortical surfaces as evaluated in anteroposterior and lateral radiographic views. Full use of the hand was allowed after complete mineralisation of the callus. Statistical analysis Statistical comparison of different groups was performed using the Mann–Whitney U test for non-parametric data. All tests were calculated with the use of SPSS, version 20.0 (SPSS Inc., Chicago, IL, USA) statistical package for personal computers. In all instances, p < 0.05 was regarded as statistically significant. Results The mean follow-up for all patients was 8.2 years (range: 2–11 years). Patients with follow-up <2 years were excluded from the study. For our children population, the mean follow-up was 7.3 years (range: 5–9 years). The mean distraction period was 21 days (range: 17–27 days). Callus consolidation was obtained in the majority of the patients. The median time of consolidation of the callus after the lengthening was finished was 5 2 weeks and the total days of treatment were 56 20 days. The bone formation was incomplete only in three patients. In these patients, the distraction was performed in the distal bony remnant of the finer stump and a second surgery was needed to stabilise the distal bone with internal fixation and to enhance bone healing with a bone graft. No statistically significant differences were noted between patients undergoing lengthening for traumatic amputation and for congenital abnormalities in terms of the consolidation period, healing index, metacarpal or phalangeal lengthening, increase in bone length, and time of gained millimetres of length (Table 1). At the last follow-up, no patient reported pain or functional impairment with restriction in the range of motion in the metacarpophalangeal (MCP) or interphalangeal (IP) joint, unless one of these joints was involved in the initial trauma. In these
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M. Vekris et al. / Injury, Int. J. Care Injured 46 (2015) 1354–1358
Fig. 2. (A) Lengthening of the first ray stump in a congenital transverse deficiency of the hand in a 14-month-old patient. Lengthening of the fifth ray stump after 6 months from the completion of the first ray lengthening. (B) Two years post distraction. Note the utilisation of the hand like a lobster hand.
patients (12), the joint restriction remained in the pre-distraction levels, and this improved after arthrodiatasis in six of them. No patient sustained bony prominence, subluxation of the MCP joint, skin necrosis or neurovascular impairment. In a young patient with symbrachydactyly after phalanx lengthening of 18 mm, an oblique fracture at the middle of the newly formed bone was present 1 month after the removal of the device. It was treated conservatively with finger immobilisation for 3 weeks. In three patients (5.45%), <58 of angulation of the new callus was observed that did not require any further treatment. In addition, pin-tract infection was diagnosed in two patients (3.64%). Both patients were managed conservatively with oral antibiotics and local wound care. Pin loosening was observed in five patients (three children) in whom stubby fingers were distracted at the fingertip. However, this pin loosening was not because of infection but it was mostly mechanical as the initial pin placement was in an area with minimal surrounding bone. Fortunately, the lengthening procedure did not terminate because the other pin of the pair was firmly inserted to the bone. Discussion The purpose of the present study was to present the authors’ experience concerning the method of distraction osteogenesis in traumatic or congenital digital length discrepancies as well as to report the long-term results of the method. In our series, the mean follow-up was 8.2 years and the total days of treatment were 56 20 days. There was no statistically significant difference between patients undergoing lengthening for traumatic amputation and congenital abnormalities. Miyawaki et al. [9] presented a series of
patients who were treated for symbrachydactyly with the distraction technique. Compared with our series, the mean lengthening of the digits as well as the mean duration of distraction was larger. Their length rate was 0.6 mm/day; the mean duration of distraction was 37.3 days, whereas the mean lengthening was 81.6% of the original length of the digit. In our series, the mean duration of distraction was 21 days, and the mean lengthening was 67% (66% in traumatic amputations and 68% in congenital abnormalities) of the original length. The total duration of the treatment was higher in the study by Ko¨mu¨rcu¨ et al. [11] (2.1 months compared to 56 days in our series); nevertheless, the lengthening percentage was smaller compared to our study (54%). Callus distraction without using an autologous bone graft was first reported by Manktelow and Wainwright in 1984 [7]. Although many minor complications may occur during the distraction course, this method appears to be more effective than bone grafting [8]. It is associated with an increased gain in length, intact sensory function, and absence of donor-site morbidity. The disadvantages include joint stiffness, pin-track infection, angular deformity that necessitates reoperation, premature consolidation of bone, inadequate or slow consolidation, fracture, and dislocation of the MCP joint [7,12–17]. In our series, we faced setbacks such as pin loosening and inadequate or slow consolidation. The authors believe that the reason underlying the pin loosening was mechanical and specifically due to inadequate bone stock surrounding the most distally placed pin in finger stumps. Pin loosening can be prevented by using at least two pins at each stump, which was not possible in children with ‘stubby fingers’ and which resulted in a high loosening rate. The slow or inadequate consolidation was noticed in posttraumatic cases where the distal part of the amputated finger was distracted or in children with congenital stubby fingers where the underlying bone remnant was
Table 1 Differences between patients undergoing lengthening for traumatic amputation and congenital abnormality.
Consolidation period (days) Healing index (days/cm) Metacarpal or phalangeal lengthening (mm) Increase in bone length (%) Time of gained mm of length (days) p 0.05 indicates statistical significance. All values are expressed as mean (minimum–maximum).
Traumatic amputation
Congenital abnormality
Difference p
50 (44–60) 28.3 (26.2–33.33) 18.6 (17–25) 66 (50–72) 4.4 (4–5)
48 (42–57) 27.24 (24–29) 17.1 (15–19) 68 (58–85) 4.1 (4–5)
0.34 0.28 0.09 0.32 0.68
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too thin. In both cases, the authors believe that the insufficient periosteum and vascularity were the main reasons for this complication. In general, comparing the complications of the specific method with the one-stage method, it can be concluded that by using autologous graft the reconstruction can be acute. On the other hand, the reconstruction through distraction osteogenesis is a method that requires more time in order to reach the final result. Despite the delay of the specific method, more lengthening can be achieved as described in the study by Ogino et al. [2] who treated congenital hand deformities with the one-stage method as well as with the distraction method. With the one-stage method, the lengthening was 2–10 mm, whereas with the distraction method the lengthening was 12–30 mm. Age should be taken into account when callus distraction is used for ray reconstruction. Universally accepted criteria on the age at which ray reconstruction should be performed, especially in cases of congenital hand anomalies, have not yet been developed [18]. According to Matev [6], in patients older than 20 years, ossification of the callus is insufficient. In addition, Moy et al. [19] supported the use of autologous corticocancellous grafts in patients older than 25 years with gaps larger than 3 cm due to inadequate callus ossification. Although patients over the age of 60 years are considered as a relative contraindication, recent evidence suggests that sufficient new bone formation can be achieved in patients older than 60 years of age [20]. In the present study, the distraction rate was the same, regardless of the patient’s age. We believe that the optimal age of distraction is after the age of 1 year and before the child starts school. In all cases, consolidation was achieved without any difference in ossification between patients older or younger than 25 years of age. In our series, we treated successfully a 63-year-old patient who underwent traumatic amputation at the level of the proximal phalanx of the thumb with distraction osteogenesis of the proximal phalanx. The proximal phalanx was lengthened by 19 mm, the consolidation period was 56 days and the increase in bone length was 55% compared to the initial length of the phalanx. The healing index was measured to be 29.47 days/cm. The authors consider the most important factor for bone healing at the distraction area to be the vascularity of the surrounding tissues and the distracted bone. In our series, the delayed bone formation was present in lengthening at the most distal bony remnant in amputated fingers. Distraction rate is another factor that should be considered during bone lengthening. The optimal distraction rate fluctuates between 0.3 and 1.5 mm/day [2,9,14,21–25]. An increased distraction rate seems to result in a longer consolidation period and an increased healing index. According to many authors, the healing index is reduced by applying a distraction rate of 0.5 mm/day (2 0.25 mm/day) [17,25]. However, recent data showed that, while age affects the healing index of the metacarpal lengthening, both healing index and consolidation period do not correlate with the distraction rate [26]. According to our series, a distraction rate of 1 mm/day can be performed effectively without a significant increase in the consolidation period, as reflected by the healing index, in both metacarpal and phalangeal bones. We believe that a major important factor for the consolidation and the healing index reduction is the quality of the distracted bone. To prevent delayed bone healing, the surgeon should always have in mind periosteum protection during osteotomy and coverage of the osteotomy site by suturing the periosteum afterwards. Avoidance of lengthening by >40% of the preoperative length has also been suggested by some authors [27]. In the present study, we measured a mean increase in bone length of 68%, which is higher than that proposed by the literature, without any major complications or increase in the consolidation period. Our study had specific limitations. First of all, it presents the results of the distraction method without comparing them with
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another method for lengthening (i.e., bone graft). Second, there were a number of patients from our series who did not appear for the programmed follow-up. The prerequisites for a good functional outcome after the first ray reconstruction include the following: (1) a bone stump >3 cm in length or at least two-thirds of the first metacarpal, (2) good motion of the trapezometacarpal joint and (3) adequate surrounding soft tissue in order to allow the reconstructed thumb to be covered by its own innervated skin [28–31]. The indications and lengthening procedure in children are the same as in adults. However, attention should be paid to the growing metacarpal bone by placing the proximal pins 3–4 mm away from the metacarpal epiphyseal plate [31]. Despite the good results of the distraction method, future research needs to be conducted comparing the specific method with the digit lengthening using bone grafts in order to compare not only the functional but also the cosmetic results. In summary, ray reconstruction with callus distraction is a valuable technique with satisfactory functional and aesthetic results. It can be applied effectively in skeletally immature or mature patients with congenital differences of the hand or amputated fingers, even in patients older than 60 years of age. A distraction rate of 1 mm/day can be performed without a significant increase in the consolidation period in both the metacarpals and phalanges. Although the treatment course may be prolonged, it is a worthy and safe procedure without any donorsite morbidity or major complications. Conflict of interest statement There is no conflict of interest for the specific study. References [1] Smith RJ, Gumley GJ. Metacarpal distraction lengthening. Hand Clin 1985;1:417–29. [2] Ogino T, Kato H, Ishii S, Usui M. Digital lengthening in congenital hand deformities. J Hand Surg Br 1994;19:120–9. [3] Stuchin SA, Kummer FJ. Stiffness of small-bone external fixation methods: an experimental study. J Hand Surg Am 1984;9:718–24. [4] Matev IB. Thumb reconstruction after amputation at the metacarpophalangeal joint by bone-lengthening. A preliminary report of three cases. J Bone Joint Surg Am 1970;52:957–65. [5] Kessler I, Baruch A, Hecht O. Experience with distraction lengthening of digital rays in congenital anomalies. J Hand Surg Am 1977;2:394–401. [6] Matev I. The distraction method in reconstructive surgery of the thumb and fingers. Handchirurgie 1979;11:153–6. [7] Manktelow RT, Wainwright DJ. A technique of distraction osteosynthesis in the hand. J Hand Surg Am 1984;9:858–62. [8] Houshian S, Ipsen T. Metacarpal and phalangeal lengthening by callus distraction. J Hand Surg Br 2001;26:13–6. [9] 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 2002;84:986–91. [10] 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 2004;29:712–9. [11] Ko¨mu¨rcu¨ M, Ku¨rklu¨ M, Demiralp B, Atesalp AS, Alsancak S, Basbozkurt M. First ray reconstruction with distraction osteogenesis. Prosthet Orthot Int 2008;32:50–6. [12] Seitz Jr WH, Dobyns JH. Digital lengthening. With emphasis on distraction osteogenesis in the upper limb. Hand Clin 1993;9:699–706. [13] Velazquez RJ, Bell DF, Armstrong PF, Babyn P, Tibshirani R. Complications of use of the Ilizarov technique in the correction of limb deformities in children. J Bone Joint Surg Am 1993;75:1148–56. [14] Seitz Jr WH, Froimson AL. Digital lengthening using the callotasis technique. Orthopedics 1995;18:129–38. [15] Masada K, Fujita S, Fuji T, Ohno H. Complications following metatarsal lengthening by callus distraction for brachymetatarsia. J Pediatr Orthop 1999;19:394–7. [16] Seitz Jr WH, Bley LA. Distraction lengthening in the hand using the principle of callotasis. Atlas Hand Clin 2000;5:31–9. [17] Song HR, Oh CW, Kyung HS, Kim SJ, Guille JT, Lee SM, et al. Fourth brachymetatarsia treated with distraction osteogenesis. Foot Ankle Int 2003;24: 706–711.
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[18] Aydinlioglu A, Akpinar F, Tosun N. Mathematical relations between the lengths of the metacarpal bones and phalanges: surgical significance. Tohoku J Exp Med 1998;185:209–16. [19] Moy OJ, Peimer CA, Sherwin FS. Reconstruction of traumatic or congenital amputation of the thumb by distraction lengthening. Hand Clin 1982;8:57–62. [20] Zimmermann R, Sailer R, Pechlaner S, Gabl M. Functional outcome with special attention to the DASH questionnaire following callus distraction and phalangization of the thumb after traumatic amputation in the middle onethird. Arch Orthop Trauma Surg 2003;123:521–6. [21] Matev IB. Thumb reconstruction through metacarpal bone lengthening. J Hand Surg Am 1980;5:482–7. [22] Finsen V, Russwurm H. Metacarpal lengthening after traumatic amputation of the thumb. J Bone Joint Surg Br 1996;78:133–6. [23] Toh S, Narita S, Arai K, Nakashima K, Tsubo K. Distraction lengthening by callotasis in the hand. J Bone Joint Surg Br 2002;84:205–10. [24] Sen C, Kocaoglu M, Eralp L, Cinar M. Bone lengthening of congenitally short metacarpus and metatarsus by the callus distraction technique. Acta Orthop Traumatol Turc 2003;37:154–61 [in Turkish].
[25] Kato H, Minami A, Suenaga N, Iwasaki M, Kimura T. Callotasis lengthening in patients with brachymetacarpia. J Pediatr Orthop 2005;22:497– 500. [26] Bozan ME, Altinel L, Kuru I, Maralcan G, Acar M, Durmaz H. Factors that affect the healing index of metacarpal lengthening: a retrospective study. J Orthop Surg 2006;14:167–71. [27] Erdem M, Sen C, Eralp L, Kocaoglu M, Ozden V. Lengthening of short bones by distraction osteogenesis – results and complications. Int Orthop 2009;33: 807–13. [28] Hette K, Lemke T, Knaepler H. Distraction of the first metacarpal bone for thumb reconstruction. Unfallchirurg 1992;95:294–7. [29] Joist A, Neuber M, Frebel T, Joosten U. Callus distraction of the first metacarpal bone for thumb reconstruction after traumatic amputation. Unfallchirurg 2000;103:1073–8. [30] Zimmermann R. Phalangization des daumens nach traumatischer amputation. Oper Orthop Traumatol 2002;4:280–9. [31] Matev I. Thumb metacarpal lengthening. Tech Hand Up Extrem Surg 2003;7:157–63.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Digital ray reconstruction through distraction osteogenesis: A retrospective study of 82 rays with long-term follow-up Marios Vekris a, Marios Lykissas a,*, Emilios Pakos b, Ioannis Gelalis b, Anastasios Korompilias a, Panayotis Soucacos c, Alexandros Beris a a b c
University Hospital of Ioannina, Ioannina, Greece University of Ioannina, Ioannina, Greece University of Athens, Athens, Greece
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 24 January 2015
Purpose: The aim of the present study was to present the long-term radiographic results with distraction osteogenesis in traumatic or congenital length discrepancies of long bones of the hand. Methods: The medical records and radiographs of 65 consecutive patients (27 metacarpals and 55 phalanges) with either traumatic or congenital digital length discrepancies were retrospectively reviewed. The mean follow-up was 8.2 years. The mean distraction period was 21 days with a distraction rate of 4 0.25 mm/day. Callus consolidation was obtained in all patients. Results: The bones were lengthened by a mean amount of 17.5 mm, with a mean increase in bone length of 68 17.3%. The mean healing index was 28.57 days/cm. Ray reconstruction with callus distraction can be applied effectively in skeletally immature or mature patients with congenital differences of the hand or amputated fingers. Conclusion: A distraction rate of 1 mm/day proved to be a safe rate of lengthening in both metacarpals and phalanges. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Distraction osteogenesis Digital length discrepancy Phalangeal lengthening Metacarpal lengthening Healing index
Introduction After the Ilizarov era, limb-lengthening procedures for the reconstruction of congenital or posttraumatic length discrepancies were popularised. Several surgical techniques have been reported ‘up to date’ for the elongation of the long bones of the hand including single stage lengthening [1], distraction lengthening with bone graft and distraction osteogenesis [2]. The application of distraction osteogenesis in hand surgery was made possible due to the manufacture of sophisticated external fixators. The biomechanics of small external fixators are similar to large external fixators [3]. The indications of digital lengthening include traumatic or congenital digital length discrepancies with functional impairment. Matev in 1970 [4] and Kessler et al. in 1977 [5] first reported reconstruction of ray deficiencies with the use of bone graft. Digital lengthening through a distraction osteogenesis technique was applied later in the early 1980s (Matev [6]; Manktelow and
* Corresponding author. Tel.: +30 6944591915; fax: +30 2651034816. E-mail address: [email protected] (M. Lykissas). http://dx.doi.org/10.1016/j.injury.2015.01.036 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
Wainwright [7]). Since then, several authors have reported on the same technique [8–11]. The use of distraction lengthening has produced satisfactory results in the management of hand problems, such as congenital anomalies, traumatic amputations, burns and infection sequelae. The aim of the present study was to present the long-term radiographic results with distraction osteogenesis in traumatic or congenital length discrepancies of long bones of the hand. Methods Between January 1998 and December 2009, 65 consecutive patients (82 rays) with either traumatic or congenital digital length discrepancies underwent a lengthening procedure with the distraction osteogenesis method at our institution. The clinical records and radiographs were retrospectively reviewed after obtaining institutional review board approval and informed consent from each patient. The mean age of the patients was 20 years (range: 3–63 years). Of these patients, 46 were males and 19 females. The right hand was involved in 23 cases and the left hand in 42 cases. The reason for patients undergoing digital ray lengthening was traumatic
M. Vekris et al. / Injury, Int. J. Care Injured 46 (2015) 1354–1358
amputation in 47 cases (>25 years: 30 patients; <25 years: 17 patients) and congenital abnormalities in 18 cases (>25 years: five patients; <25 years: 13 patients). The congenital abnormalities included brachydactyly in nine cases, symbrachydactyly in four cases, longitudinal deficiency in two cases (hypoplastic thumb) and constriction band syndrome in three cases. In three cases, the patients exhibited bilateral involvement. Distraction osteogenesis was performed in 27 metacarpals and in 55 phalanges. In four patients, two phalanges were corrected simultaneously. Of the 27 metacarpals that underwent distraction osteogenesis, the first ray was involved in eight cases, the second in four, the third in three, the fourth in five and the fifth ray in seven cases. Of the 55 phalanges, the procedure was performed to the first ray in 14 cases, to the second in 12 cases, to the third in 13 cases, to the fourth in eight cases and to the fifth in ten cases. The proximal phalanx was lengthened in 35 cases, the middle in 15 and the distal in five cases. The physical therapy was not in the inclusion criteria of the present study. Surgical procedure The distraction osteogenesis was performed with a miniexternal fixator in all cases. This included either an Orthrofix Mini Rail System (Orthofix Srl, Verona, Italy) in 70 cases or a Hoffmann II Micro Lengthener (Stryker Trauma, Geneva, Switzerland) in 12 of our early cases. Under local or general anaesthesia and via a dorsal longitudinal approach, the extensor tendon was longitudinally dissected and retracted laterally in order to expose the bony segment to be distracted. The position of the bone osteotomy was performed in the proximal metaphysis or the junction of the proximal metaphysis with the diaphysis taking care to have enough bone proximally and distally in order to place two pairs of pins. This position was marked and two pairs of self-drilling, selftapping pins were inserted vertically to the dorsal aspect of the bone using the mini-lengthener as a guide. The size of the pins used ranged between 1.65 and 2.5 mm depending on the bone diameter and the age of the patient. The order of the pin placement was one pin on each side of the osteotomy site and close to it, while the second pin of each pair was placed further away from the osteotomy site. In children, the proximal pin was placed 3–4 mm away from the epiphyseal plate to avoid distraction damage to the growth plate. After the pin placement, the clamps of the device were firmly secured on the pins taking care to maintain a 3-mm gap between the two clumps at the site where the osteotomy is to be performed. The next step was a subperiosteal osteotomy performed with a mini-drill of 1.2 mm midway between the two clumps. The subperiosteal osteotomy was performed with a mini-drill of 1.2 mm midway between the two clumps. The periosteum and bone were pierced several times transversally at different angles, and the bone was fractured with a small chisel. The periosteum and bone were pierced several times transversally at different angles, and the bone was fractured with a small chisel. After the osteotomy, a slight compression was applied in order to bring the bony ends at the osteotomy site (Fig. 1). No additional bone graft was used and no protective splinting was applied. Patients were discharged from the hospital within the first 24 h after the operation. Following a latency period of 5 days, to allow the initiation of the healing process, distraction was applied at a rate of 0.25 mm every 6 h. The distraction rate was the same for all patients, regardless of the lengthening site (metacarpus or phalanx) and the patient’s age. Patients were assessed radiologically every week during the distraction period to evaluate the amount of distraction performed by the patient and the alignment of bone under distraction. The distraction process was terminated after achieving the desirable length in comparison to the
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Fig. 1. Intraoperative photograph demonstrating the osteotomy site in relation to the pins. Compression is initially applied at the osteotomy site for 5 days followed by distraction at a rate of 0.25 mm every 6 h.
contralateral normal ray. After this period, the device was locked and the patient was followed up every 3 weeks with new X-rays until callus formation and ossification were confirmed (Fig. 2). The distraction device was removed on an outpatient basis under local anaesthesia in the case of adult patients or under general anaesthesia in the case of young children once the bone formation in the distraction gap fulfilled the desired length and width of the metacarpal or phalangeal bone and there was adequate consolidation of at least three cortical surfaces as evaluated in anteroposterior and lateral radiographic views. Full use of the hand was allowed after complete mineralisation of the callus. Statistical analysis Statistical comparison of different groups was performed using the Mann–Whitney U test for non-parametric data. All tests were calculated with the use of SPSS, version 20.0 (SPSS Inc., Chicago, IL, USA) statistical package for personal computers. In all instances, p < 0.05 was regarded as statistically significant. Results The mean follow-up for all patients was 8.2 years (range: 2–11 years). Patients with follow-up <2 years were excluded from the study. For our children population, the mean follow-up was 7.3 years (range: 5–9 years). The mean distraction period was 21 days (range: 17–27 days). Callus consolidation was obtained in the majority of the patients. The median time of consolidation of the callus after the lengthening was finished was 5 2 weeks and the total days of treatment were 56 20 days. The bone formation was incomplete only in three patients. In these patients, the distraction was performed in the distal bony remnant of the finer stump and a second surgery was needed to stabilise the distal bone with internal fixation and to enhance bone healing with a bone graft. No statistically significant differences were noted between patients undergoing lengthening for traumatic amputation and for congenital abnormalities in terms of the consolidation period, healing index, metacarpal or phalangeal lengthening, increase in bone length, and time of gained millimetres of length (Table 1). At the last follow-up, no patient reported pain or functional impairment with restriction in the range of motion in the metacarpophalangeal (MCP) or interphalangeal (IP) joint, unless one of these joints was involved in the initial trauma. In these
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Fig. 2. (A) Lengthening of the first ray stump in a congenital transverse deficiency of the hand in a 14-month-old patient. Lengthening of the fifth ray stump after 6 months from the completion of the first ray lengthening. (B) Two years post distraction. Note the utilisation of the hand like a lobster hand.
patients (12), the joint restriction remained in the pre-distraction levels, and this improved after arthrodiatasis in six of them. No patient sustained bony prominence, subluxation of the MCP joint, skin necrosis or neurovascular impairment. In a young patient with symbrachydactyly after phalanx lengthening of 18 mm, an oblique fracture at the middle of the newly formed bone was present 1 month after the removal of the device. It was treated conservatively with finger immobilisation for 3 weeks. In three patients (5.45%), <58 of angulation of the new callus was observed that did not require any further treatment. In addition, pin-tract infection was diagnosed in two patients (3.64%). Both patients were managed conservatively with oral antibiotics and local wound care. Pin loosening was observed in five patients (three children) in whom stubby fingers were distracted at the fingertip. However, this pin loosening was not because of infection but it was mostly mechanical as the initial pin placement was in an area with minimal surrounding bone. Fortunately, the lengthening procedure did not terminate because the other pin of the pair was firmly inserted to the bone. Discussion The purpose of the present study was to present the authors’ experience concerning the method of distraction osteogenesis in traumatic or congenital digital length discrepancies as well as to report the long-term results of the method. In our series, the mean follow-up was 8.2 years and the total days of treatment were 56 20 days. There was no statistically significant difference between patients undergoing lengthening for traumatic amputation and congenital abnormalities. Miyawaki et al. [9] presented a series of
patients who were treated for symbrachydactyly with the distraction technique. Compared with our series, the mean lengthening of the digits as well as the mean duration of distraction was larger. Their length rate was 0.6 mm/day; the mean duration of distraction was 37.3 days, whereas the mean lengthening was 81.6% of the original length of the digit. In our series, the mean duration of distraction was 21 days, and the mean lengthening was 67% (66% in traumatic amputations and 68% in congenital abnormalities) of the original length. The total duration of the treatment was higher in the study by Ko¨mu¨rcu¨ et al. [11] (2.1 months compared to 56 days in our series); nevertheless, the lengthening percentage was smaller compared to our study (54%). Callus distraction without using an autologous bone graft was first reported by Manktelow and Wainwright in 1984 [7]. Although many minor complications may occur during the distraction course, this method appears to be more effective than bone grafting [8]. It is associated with an increased gain in length, intact sensory function, and absence of donor-site morbidity. The disadvantages include joint stiffness, pin-track infection, angular deformity that necessitates reoperation, premature consolidation of bone, inadequate or slow consolidation, fracture, and dislocation of the MCP joint [7,12–17]. In our series, we faced setbacks such as pin loosening and inadequate or slow consolidation. The authors believe that the reason underlying the pin loosening was mechanical and specifically due to inadequate bone stock surrounding the most distally placed pin in finger stumps. Pin loosening can be prevented by using at least two pins at each stump, which was not possible in children with ‘stubby fingers’ and which resulted in a high loosening rate. The slow or inadequate consolidation was noticed in posttraumatic cases where the distal part of the amputated finger was distracted or in children with congenital stubby fingers where the underlying bone remnant was
Table 1 Differences between patients undergoing lengthening for traumatic amputation and congenital abnormality.
Consolidation period (days) Healing index (days/cm) Metacarpal or phalangeal lengthening (mm) Increase in bone length (%) Time of gained mm of length (days) p 0.05 indicates statistical significance. All values are expressed as mean (minimum–maximum).
Traumatic amputation
Congenital abnormality
Difference p
50 (44–60) 28.3 (26.2–33.33) 18.6 (17–25) 66 (50–72) 4.4 (4–5)
48 (42–57) 27.24 (24–29) 17.1 (15–19) 68 (58–85) 4.1 (4–5)
0.34 0.28 0.09 0.32 0.68
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too thin. In both cases, the authors believe that the insufficient periosteum and vascularity were the main reasons for this complication. In general, comparing the complications of the specific method with the one-stage method, it can be concluded that by using autologous graft the reconstruction can be acute. On the other hand, the reconstruction through distraction osteogenesis is a method that requires more time in order to reach the final result. Despite the delay of the specific method, more lengthening can be achieved as described in the study by Ogino et al. [2] who treated congenital hand deformities with the one-stage method as well as with the distraction method. With the one-stage method, the lengthening was 2–10 mm, whereas with the distraction method the lengthening was 12–30 mm. Age should be taken into account when callus distraction is used for ray reconstruction. Universally accepted criteria on the age at which ray reconstruction should be performed, especially in cases of congenital hand anomalies, have not yet been developed [18]. According to Matev [6], in patients older than 20 years, ossification of the callus is insufficient. In addition, Moy et al. [19] supported the use of autologous corticocancellous grafts in patients older than 25 years with gaps larger than 3 cm due to inadequate callus ossification. Although patients over the age of 60 years are considered as a relative contraindication, recent evidence suggests that sufficient new bone formation can be achieved in patients older than 60 years of age [20]. In the present study, the distraction rate was the same, regardless of the patient’s age. We believe that the optimal age of distraction is after the age of 1 year and before the child starts school. In all cases, consolidation was achieved without any difference in ossification between patients older or younger than 25 years of age. In our series, we treated successfully a 63-year-old patient who underwent traumatic amputation at the level of the proximal phalanx of the thumb with distraction osteogenesis of the proximal phalanx. The proximal phalanx was lengthened by 19 mm, the consolidation period was 56 days and the increase in bone length was 55% compared to the initial length of the phalanx. The healing index was measured to be 29.47 days/cm. The authors consider the most important factor for bone healing at the distraction area to be the vascularity of the surrounding tissues and the distracted bone. In our series, the delayed bone formation was present in lengthening at the most distal bony remnant in amputated fingers. Distraction rate is another factor that should be considered during bone lengthening. The optimal distraction rate fluctuates between 0.3 and 1.5 mm/day [2,9,14,21–25]. An increased distraction rate seems to result in a longer consolidation period and an increased healing index. According to many authors, the healing index is reduced by applying a distraction rate of 0.5 mm/day (2 0.25 mm/day) [17,25]. However, recent data showed that, while age affects the healing index of the metacarpal lengthening, both healing index and consolidation period do not correlate with the distraction rate [26]. According to our series, a distraction rate of 1 mm/day can be performed effectively without a significant increase in the consolidation period, as reflected by the healing index, in both metacarpal and phalangeal bones. We believe that a major important factor for the consolidation and the healing index reduction is the quality of the distracted bone. To prevent delayed bone healing, the surgeon should always have in mind periosteum protection during osteotomy and coverage of the osteotomy site by suturing the periosteum afterwards. Avoidance of lengthening by >40% of the preoperative length has also been suggested by some authors [27]. In the present study, we measured a mean increase in bone length of 68%, which is higher than that proposed by the literature, without any major complications or increase in the consolidation period. Our study had specific limitations. First of all, it presents the results of the distraction method without comparing them with
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another method for lengthening (i.e., bone graft). Second, there were a number of patients from our series who did not appear for the programmed follow-up. The prerequisites for a good functional outcome after the first ray reconstruction include the following: (1) a bone stump >3 cm in length or at least two-thirds of the first metacarpal, (2) good motion of the trapezometacarpal joint and (3) adequate surrounding soft tissue in order to allow the reconstructed thumb to be covered by its own innervated skin [28–31]. The indications and lengthening procedure in children are the same as in adults. However, attention should be paid to the growing metacarpal bone by placing the proximal pins 3–4 mm away from the metacarpal epiphyseal plate [31]. Despite the good results of the distraction method, future research needs to be conducted comparing the specific method with the digit lengthening using bone grafts in order to compare not only the functional but also the cosmetic results. In summary, ray reconstruction with callus distraction is a valuable technique with satisfactory functional and aesthetic results. It can be applied effectively in skeletally immature or mature patients with congenital differences of the hand or amputated fingers, even in patients older than 60 years of age. A distraction rate of 1 mm/day can be performed without a significant increase in the consolidation period in both the metacarpals and phalanges. Although the treatment course may be prolonged, it is a worthy and safe procedure without any donorsite morbidity or major complications. Conflict of interest statement There is no conflict of interest for the specific study. References [1] Smith RJ, Gumley GJ. Metacarpal distraction lengthening. Hand Clin 1985;1:417–29. [2] Ogino T, Kato H, Ishii S, Usui M. Digital lengthening in congenital hand deformities. J Hand Surg Br 1994;19:120–9. [3] Stuchin SA, Kummer FJ. Stiffness of small-bone external fixation methods: an experimental study. J Hand Surg Am 1984;9:718–24. [4] Matev IB. Thumb reconstruction after amputation at the metacarpophalangeal joint by bone-lengthening. A preliminary report of three cases. J Bone Joint Surg Am 1970;52:957–65. [5] Kessler I, Baruch A, Hecht O. Experience with distraction lengthening of digital rays in congenital anomalies. J Hand Surg Am 1977;2:394–401. [6] Matev I. The distraction method in reconstructive surgery of the thumb and fingers. Handchirurgie 1979;11:153–6. [7] Manktelow RT, Wainwright DJ. A technique of distraction osteosynthesis in the hand. J Hand Surg Am 1984;9:858–62. [8] Houshian S, Ipsen T. Metacarpal and phalangeal lengthening by callus distraction. J Hand Surg Br 2001;26:13–6. [9] 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 2002;84:986–91. [10] 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 2004;29:712–9. [11] Ko¨mu¨rcu¨ M, Ku¨rklu¨ M, Demiralp B, Atesalp AS, Alsancak S, Basbozkurt M. First ray reconstruction with distraction osteogenesis. Prosthet Orthot Int 2008;32:50–6. [12] Seitz Jr WH, Dobyns JH. Digital lengthening. With emphasis on distraction osteogenesis in the upper limb. Hand Clin 1993;9:699–706. [13] Velazquez RJ, Bell DF, Armstrong PF, Babyn P, Tibshirani R. Complications of use of the Ilizarov technique in the correction of limb deformities in children. J Bone Joint Surg Am 1993;75:1148–56. [14] Seitz Jr WH, Froimson AL. Digital lengthening using the callotasis technique. Orthopedics 1995;18:129–38. [15] Masada K, Fujita S, Fuji T, Ohno H. Complications following metatarsal lengthening by callus distraction for brachymetatarsia. J Pediatr Orthop 1999;19:394–7. [16] Seitz Jr WH, Bley LA. Distraction lengthening in the hand using the principle of callotasis. Atlas Hand Clin 2000;5:31–9. [17] Song HR, Oh CW, Kyung HS, Kim SJ, Guille JT, Lee SM, et al. Fourth brachymetatarsia treated with distraction osteogenesis. Foot Ankle Int 2003;24: 706–711.
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[18] Aydinlioglu A, Akpinar F, Tosun N. Mathematical relations between the lengths of the metacarpal bones and phalanges: surgical significance. Tohoku J Exp Med 1998;185:209–16. [19] Moy OJ, Peimer CA, Sherwin FS. Reconstruction of traumatic or congenital amputation of the thumb by distraction lengthening. Hand Clin 1982;8:57–62. [20] Zimmermann R, Sailer R, Pechlaner S, Gabl M. Functional outcome with special attention to the DASH questionnaire following callus distraction and phalangization of the thumb after traumatic amputation in the middle onethird. Arch Orthop Trauma Surg 2003;123:521–6. [21] Matev IB. Thumb reconstruction through metacarpal bone lengthening. J Hand Surg Am 1980;5:482–7. [22] Finsen V, Russwurm H. Metacarpal lengthening after traumatic amputation of the thumb. J Bone Joint Surg Br 1996;78:133–6. [23] Toh S, Narita S, Arai K, Nakashima K, Tsubo K. Distraction lengthening by callotasis in the hand. J Bone Joint Surg Br 2002;84:205–10. [24] Sen C, Kocaoglu M, Eralp L, Cinar M. Bone lengthening of congenitally short metacarpus and metatarsus by the callus distraction technique. Acta Orthop Traumatol Turc 2003;37:154–61 [in Turkish].
[25] Kato H, Minami A, Suenaga N, Iwasaki M, Kimura T. Callotasis lengthening in patients with brachymetacarpia. J Pediatr Orthop 2005;22:497– 500. [26] Bozan ME, Altinel L, Kuru I, Maralcan G, Acar M, Durmaz H. Factors that affect the healing index of metacarpal lengthening: a retrospective study. J Orthop Surg 2006;14:167–71. [27] Erdem M, Sen C, Eralp L, Kocaoglu M, Ozden V. Lengthening of short bones by distraction osteogenesis – results and complications. Int Orthop 2009;33: 807–13. [28] Hette K, Lemke T, Knaepler H. Distraction of the first metacarpal bone for thumb reconstruction. Unfallchirurg 1992;95:294–7. [29] Joist A, Neuber M, Frebel T, Joosten U. Callus distraction of the first metacarpal bone for thumb reconstruction after traumatic amputation. Unfallchirurg 2000;103:1073–8. [30] Zimmermann R. Phalangization des daumens nach traumatischer amputation. Oper Orthop Traumatol 2002;4:280–9. [31] Matev I. Thumb metacarpal lengthening. Tech Hand Up Extrem Surg 2003;7:157–63.