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Treatment of radioulnar synostosis by radical excision and interposition of a radial forearm adipofascial flap
Treatment of Radioulnar Synostosis by Radical Excision and Interposition of a Radial Forearm Adipofascial Flap Neil F. Jones, MD, Adil Esmail, MD, Eon K. Shin, MD, Los Angeles, CA
A patient had radical excision of type II diaphyseal radioulnar synostosis and interposition of a radial forearm adipofascial flap. Neither adjuvant nonsteroidal anti-inflammatory medications nor radiation therapy were used. Three years after surgery the patient showed 90° of pronation and 90° of supination without any evidence of recurrence. (J Hand Surg 2004;29A:1143–1147. Copyright © 2004 by the American Society for Surgery of the Hand.) Key words: Radioulnar synostosis, radial forearm flap.
The functional limitation resulting from posttraumatic radioulnar synostosis can be substantial and multiple treatment options have been advocated. There seems to be a potential for recurrence after excision alone.1,2 Therefore interposition of foreign or biologic materials has been recommended including bone wax,3 silicone,1,4 –7 or soft tissue such as muscle, fat, or fascia.8 –14 Additionally nonsteroidal anti-inflammatory medications and postoperative low-dose radiation have been recommended to decrease the likelihood of recurrence.15,16 With regard to soft-tissue interposition, nonvascularized abdominal fat grafts, free vascularized fascio–fat flaps, a posterior interosseous flap, and various muscle flaps have been reported.8 –14 We describe a patient with a fixed type II diaphFrom the Department of Orthopedic Surgery and the Division of Plastic and Reconstructive Surgery, University of California Los Angeles, Los Angeles, CA. Received for publication November 10, 2003; accepted July 21, 2004. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Neil F. Jones, MD, UCLA Hand Center, 200 UCLA Medical Plaza, Suite 140, Los Angeles, CA 90095. Copyright © 2004 by the American Society for Surgery of the Hand 0363-5023/04/29A06-0025$30.00/0 doi:10.1016/j.jhsa.2004.07.017
yseal radioulnar synostosis treated with radical bony excision and radial forearm adipofascial flap interposition who regained normal range of forearm rotation with no recurrence 3 years after surgery.
Case Report A 49-year-old right-handed salesman and semiprofessional pianist was involved in a motor vehicle accident, sustaining burns to the right forearm, hand, and face. In addition he sustained an unrecognized nondisplaced fracture of the midshaft of the right ulna, which resulted in a complete type II diaphyseal synostosis between the radius and ulna (Fig. 1). Examination revealed healed split-thickness skin grafts on the extensor surface of the right forearm. The forearm was held in neutral rotation with no active or passive pronation or supination. Because the patient was a pianist the lack of pronation forced him to compensate with increased shoulder abduction and internal rotation. After the risks and benefits of excision alone, excision with radiation or nonsteroidal anti-inflammatory medications, or excision with softtissue interposition were discussed the patient elected to undergo excision and radial forearm flap interposition. Longitudinal anterior and posterior incisions were used. Through the anterior incision the radial nerve The Journal of Hand Surgery
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Figure 1. (A) Plain radiograph and (B) computed tomography scan showing type II radioulnar synostosis of the right forearm.
and its branches were identified proximally and protected. A dorsal approach also was used to isolate the radioulnar synostosis. With the radial nerve protected, subperiosteal exposure of the radius and ulna was performed through both incisions to define the synostosis (Fig. 2). The synostosis was excised radically and bone wax was placed on the exposed bony surfaces (Fig. 3). Then the skin was elevated off the subcutaneous tissues of the distal third of the forearm and a radial forearm adipofascial flap was harvested based proximally on the radial artery (Fig. 4A). The flap was transposed proximally and interposed from palmar to dorsal between the radius and ulna in the region of the resected synostosis (Fig. 4B). With the flap interposed there was still full passive pronation and supination. The proximal stump of the radial artery now lay in the dorsal incision and was reconstructed to the distal stump of the radial artery at the wrist by using a reversed saphenous vein graft using
standard microsurgical techniques. Both incisions were closed primarily. The patient started active range of motion exercises 5 days after surgery. Three years after surgery the patient has 90° of pronation and 90° of supination and no evidence of recurrent synostosis (Fig. 5). The radial artery remains patent on Allen testing.
Figure 2. Surgical exposure identifying the synostosis.
Figure 3. After radical excision of the synostosis.
Discussion Radioulnar synostosis can result from burns, trauma, after repair of distal biceps tendon rupture, or after surgical treatment of forearm fractures. There still is controversy as to the optimal treatment of posttraumatic radioulnar synostosis—whether recurrence develops after excision of the synostosis alone and whether this can be prevented by interposition of materials, tissue, or by adjuvant therapy. Vince and Miller1 classified 28 patients with ra-
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Figure 4. (A) Elevation and (B) interposition of the radial forearm adipo-fascial flap.
dioulnar synostosis. Type I occurred in the distal intra-articular area of the radius and ulna, type II occurred in the middle third or nonarticular area of the radius and ulna, and type III occurred in the proximal third of the radius and ulna. Overall 5 of 17 synostoses recurred after excision alone, however, there were no recurrences after excision alone of the 10 type II synostoses. Three patients achieved an excellent result with greater than 160° of forearm rotation and 4 patients achieved a good result with an arc of forearm rotation between 60° and 160°. Silicone sheeting was interposed in 2 patients with type II synostoses, 1 patient had an excellent result and 1 patient had a fair result. Failla et al2 reported 20 patients with proximal type III radioulnar synostoses over a 42-year period. Nine patients achieved a poor result with less than 30° of total forearm rotation. Of the 9 patients who had interposition of silicone rubber sheeting, 4 patients achieved good or excellent results; but 2 patients who had interposition of muscle and 1 patient who had interposition of fat and fascia achieved only fair or poor results. In contrast Jupiter and Ring3 described 18 patients with proximal type III radioulnar synostosis treated by resection but without postoperative radiation therapy or anti-inflammatory medications. One patient, the only patient with an associated closed head injury, developed a recurrence. The first 7 patients had a nonvascularized fat graft interposed after excision of the synostosis but the graft dislodged into the subcutaneous tissues in the eighth patient and because the patient did not develop a recurrence the interposition of a fat graft consequently was discontinued in the remaining 10 patients. Those patients who had excision and interposition of a fat graft achieved a mean arc of 138° of forearm rotation compared with those patients who had excision alone who achieved a mean arc of 141° of forearm rotation.
They concluded that a satisfactory result could be achieved by surgical resection of proximal type III radioulnar synostoses without requiring postoperative radiation therapy or anti-inflammatory medications. Several interpositional materials have been recommended to prevent reformation of bone between the raw surfaces of the radius and ulna after resection of radioulnar synostosis. Schneider and Leyva4 first reported using siliconized mesh after excision of a recurrent radioulnar synostosis. Several investigators1,2,5–7 subsequently have described interposition of thin silicone sheeting between the radius and ulna. Nonbiological materials have been superceded by the use of fascia, fat, and muscle. Yong-Hing and Tschang8 first suggested the interposition of a nonvascularized abdominal fat graft, but Jupiter and Ring3 were unable to show any advantages to interposition of abdominal fat grafts in proximal type III radioulnar synostoses. It has been shown conclusively, however, in an experimental dog laminectomy model that fat grafts prevent scar formation better than any foreign material and vascularized pedicled fat grafts are better than nonvascularized fat grafts.17 Breit9 described interposition of the muscle bellies of the abductor pollicis longus and the extensor pollicis longus, and Watson and Eaton,6 in addition to using silicone sheeting, interposed the muscle belly of the flexor digitorum superficialis of the small finger. Bell and Banger10 treated 3 patients with posttraumatic type III radioulnar synostoses by interposition of an anconeus muscle flap and early mobilization with a forearm rotation assist splint. Wraparound pedicled brachioradialis muscle flaps have been reported for prevention of recurrent proximal radioulnar synostoses and pedicled flexor carpi ulnaris muscle flaps have been described for recurrent midshaft synostoses.11 More recently vascularized pedicled and free flaps
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patients with radioulnar synostoses caused by burns, which are acknowledged to be associated with a more severe form of radioulnar synostosis and a higher rate of recurrence. The arc of rotation of anconeus or brachioradialis muscle flaps will allow them only to be interposed into a proximal type III synostosis. Free lateral arm adipofascial flaps require specialist microsurgical expertise and a posterior interosseous flap requires meticulous dissection. In contrast a radial forearm adipofascial flap is simple and easy to harvest from the distal third of the forearm and can be elevated from beneath a skingrafted forearm. The radial artery probably does not need to be reconstructed but by doing so there is essentially no morbidity to this flap donor site because the patient still will have normal arterial inflow to the hand and normal skin coverage of the distal forearm. Finally adjuvant treatment with radiation therapy or anti-inflammatory medication also has been recommended after excision. Abrams et al15 treated 2 patients and Cullen et al16 treated 4 patients with low-dose radiation. No patients developed a recurrence or any problems with wound healing. The need for any adjuvant therapy with postoperative radiation or anti-inflammatory medications, however, has been disputed in proximal type III radioulnar synostoses.3
References Figure 5. Radiograph showing no recurrence of the radioulnar synostosis 3 years after surgery.
have been advocated for interposition. Sugimoto et al12 described transposition of a pedicled posterior interosseous forearm flap after resection of a type III radioulnar synostosis. Kanaya and Ibaraki13 described a free vascularized fascio–fat graft using an ipsilateral lateral arm flap based on the posterior radial collateral artery after resection of congenital proximal radioulnar synostoses in 7 children with no recurrences. Kawaguchi et al14 confirmed the efficacy of a free lateral arm flap for interposition after resection of 1 posttraumatic and 1 congenital proximal radioulnar synostosis. There are only 3 large series1–3 detailing treatment of radioulnar synostoses and 2 of them only included patients with proximal type III radioulnar synostoses. The defect after resection of a proximal radioulnar synostosis may be too small to allow interposition of flap tissue. In addition none of these 3 series included
1. Vince KG, Miller JE. Cross-union complicating fracture of the forearm. Part I: adults. J Bone Joint Surg 1987;69A:640 – 653. 2. Failla JM, Amadio PC, Morrey BF. Post-traumatic proximal radio-ulnar synostosis. Results of surgical treatment. J Bone Joint Surg 1989;71A:1208 –1213. 3. Jupiter JB, Ring D. Operative treatment of post-traumatic proximal radioulnar synostosis. J Bone Joint Surg 1998;80A: 248 –257. 4. Schneider CF, Leyva S. Silconized Dacron interposition for traumatic radio-ulnar synostosis. J Med Assoc Alabama 1964;33:185–188. 5. Carstam N, Eiken O. The use of silastic sheet in hand surgery. Scand J Plast Reconstr Surg 1971;5:57– 61. 6. Watson FM Jr, Eaton RG. Post-traumatic radio-ulnar synostosis. J Trauma 1978;18:467– 468. 7. Maempel FZ. Post-traumatic radioulnar synostosis. A report of two cases. Clin Orthop 1984;186:182–185. 8. Yong-Hing K, Tchang SPK. Traumatic radio-ulnar synostosis treated by excision and a free fat transplant. A report of two cases. J Bone Joint Surg 1983;65B:433– 435. 9. Breit R. Post-traumatic radioulnar synostosis. Clin Orthop 1983;174:149 –152. 10. Bell SN, Benger D. Management of radioulnar synostosis with mobilization, anconeus interposition, and a forearm rotation assist splint. J Shoulder Elbow Surg 1999;8:621– 624.
Jones, Esmail, and Shin / Radioulnar Synostosis 11. Fernandez DL, Joneschild E. “Wrap around” pedicled muscle flaps for the treatment of recurrent forearm synostosis. Tech Hand Upper Extremity Surg 2004;8:102–109. 12. Sugimoto M, Masada K, Ohno H, Hosoya T. Treatment of traumatic radioulnar synostosis by excision, with interposition of a posterior interosseous island forearm flap. J Hand Surg 1996;21B:393–395. 13. Kanaya F, Ibaraki K. Mobilization of a congenital proximal radioulnar synostosis with use of a free vascularized fasciofat graft. J Bone Joint Surg 1998;80A:1186 –1192. 14. Kawaguchi S, Kitamura M, Usui M. Proximal radioulnar
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synostosis treated with a free vascularised fascio-fat graft— report of two cases. J Hand Surg 2000;5:161–164. 15. Abrams RA, Simmons BP, Brown RA, Botte MJ. Treatment of posttraumatic radioulnar synostosis with excision and low-dose radiation. J Hand Surg 1993;18A:703–707. 16. Cullen JP, Pellegrini VD Jr, Miller RJ, Jones JA. Treatment of traumatic radioulnar synostosis by excision and postoperative low-dose irradiation. J Hand Surg 1994;19A:394 – 401. 17. Gill GG, Sakovich L, Thompson E. Pedicle fat grafts for the prevention of scar formation after laminectomy. An experimental study in dogs. Spine 1979;4:176 –186.
A patient had radical excision of type II diaphyseal radioulnar synostosis and interposition of a radial forearm adipofascial flap. Neither adjuvant nonsteroidal anti-inflammatory medications nor radiation therapy were used. Three years after surgery the patient showed 90° of pronation and 90° of supination without any evidence of recurrence. (J Hand Surg 2004;29A:1143–1147. Copyright © 2004 by the American Society for Surgery of the Hand.) Key words: Radioulnar synostosis, radial forearm flap.
The functional limitation resulting from posttraumatic radioulnar synostosis can be substantial and multiple treatment options have been advocated. There seems to be a potential for recurrence after excision alone.1,2 Therefore interposition of foreign or biologic materials has been recommended including bone wax,3 silicone,1,4 –7 or soft tissue such as muscle, fat, or fascia.8 –14 Additionally nonsteroidal anti-inflammatory medications and postoperative low-dose radiation have been recommended to decrease the likelihood of recurrence.15,16 With regard to soft-tissue interposition, nonvascularized abdominal fat grafts, free vascularized fascio–fat flaps, a posterior interosseous flap, and various muscle flaps have been reported.8 –14 We describe a patient with a fixed type II diaphFrom the Department of Orthopedic Surgery and the Division of Plastic and Reconstructive Surgery, University of California Los Angeles, Los Angeles, CA. Received for publication November 10, 2003; accepted July 21, 2004. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Neil F. Jones, MD, UCLA Hand Center, 200 UCLA Medical Plaza, Suite 140, Los Angeles, CA 90095. Copyright © 2004 by the American Society for Surgery of the Hand 0363-5023/04/29A06-0025$30.00/0 doi:10.1016/j.jhsa.2004.07.017
yseal radioulnar synostosis treated with radical bony excision and radial forearm adipofascial flap interposition who regained normal range of forearm rotation with no recurrence 3 years after surgery.
Case Report A 49-year-old right-handed salesman and semiprofessional pianist was involved in a motor vehicle accident, sustaining burns to the right forearm, hand, and face. In addition he sustained an unrecognized nondisplaced fracture of the midshaft of the right ulna, which resulted in a complete type II diaphyseal synostosis between the radius and ulna (Fig. 1). Examination revealed healed split-thickness skin grafts on the extensor surface of the right forearm. The forearm was held in neutral rotation with no active or passive pronation or supination. Because the patient was a pianist the lack of pronation forced him to compensate with increased shoulder abduction and internal rotation. After the risks and benefits of excision alone, excision with radiation or nonsteroidal anti-inflammatory medications, or excision with softtissue interposition were discussed the patient elected to undergo excision and radial forearm flap interposition. Longitudinal anterior and posterior incisions were used. Through the anterior incision the radial nerve The Journal of Hand Surgery
1143
1144
The Journal of Hand Surgery / Vol. 29A No. 6 November 2004
Figure 1. (A) Plain radiograph and (B) computed tomography scan showing type II radioulnar synostosis of the right forearm.
and its branches were identified proximally and protected. A dorsal approach also was used to isolate the radioulnar synostosis. With the radial nerve protected, subperiosteal exposure of the radius and ulna was performed through both incisions to define the synostosis (Fig. 2). The synostosis was excised radically and bone wax was placed on the exposed bony surfaces (Fig. 3). Then the skin was elevated off the subcutaneous tissues of the distal third of the forearm and a radial forearm adipofascial flap was harvested based proximally on the radial artery (Fig. 4A). The flap was transposed proximally and interposed from palmar to dorsal between the radius and ulna in the region of the resected synostosis (Fig. 4B). With the flap interposed there was still full passive pronation and supination. The proximal stump of the radial artery now lay in the dorsal incision and was reconstructed to the distal stump of the radial artery at the wrist by using a reversed saphenous vein graft using
standard microsurgical techniques. Both incisions were closed primarily. The patient started active range of motion exercises 5 days after surgery. Three years after surgery the patient has 90° of pronation and 90° of supination and no evidence of recurrent synostosis (Fig. 5). The radial artery remains patent on Allen testing.
Figure 2. Surgical exposure identifying the synostosis.
Figure 3. After radical excision of the synostosis.
Discussion Radioulnar synostosis can result from burns, trauma, after repair of distal biceps tendon rupture, or after surgical treatment of forearm fractures. There still is controversy as to the optimal treatment of posttraumatic radioulnar synostosis—whether recurrence develops after excision of the synostosis alone and whether this can be prevented by interposition of materials, tissue, or by adjuvant therapy. Vince and Miller1 classified 28 patients with ra-
Jones, Esmail, and Shin / Radioulnar Synostosis
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Figure 4. (A) Elevation and (B) interposition of the radial forearm adipo-fascial flap.
dioulnar synostosis. Type I occurred in the distal intra-articular area of the radius and ulna, type II occurred in the middle third or nonarticular area of the radius and ulna, and type III occurred in the proximal third of the radius and ulna. Overall 5 of 17 synostoses recurred after excision alone, however, there were no recurrences after excision alone of the 10 type II synostoses. Three patients achieved an excellent result with greater than 160° of forearm rotation and 4 patients achieved a good result with an arc of forearm rotation between 60° and 160°. Silicone sheeting was interposed in 2 patients with type II synostoses, 1 patient had an excellent result and 1 patient had a fair result. Failla et al2 reported 20 patients with proximal type III radioulnar synostoses over a 42-year period. Nine patients achieved a poor result with less than 30° of total forearm rotation. Of the 9 patients who had interposition of silicone rubber sheeting, 4 patients achieved good or excellent results; but 2 patients who had interposition of muscle and 1 patient who had interposition of fat and fascia achieved only fair or poor results. In contrast Jupiter and Ring3 described 18 patients with proximal type III radioulnar synostosis treated by resection but without postoperative radiation therapy or anti-inflammatory medications. One patient, the only patient with an associated closed head injury, developed a recurrence. The first 7 patients had a nonvascularized fat graft interposed after excision of the synostosis but the graft dislodged into the subcutaneous tissues in the eighth patient and because the patient did not develop a recurrence the interposition of a fat graft consequently was discontinued in the remaining 10 patients. Those patients who had excision and interposition of a fat graft achieved a mean arc of 138° of forearm rotation compared with those patients who had excision alone who achieved a mean arc of 141° of forearm rotation.
They concluded that a satisfactory result could be achieved by surgical resection of proximal type III radioulnar synostoses without requiring postoperative radiation therapy or anti-inflammatory medications. Several interpositional materials have been recommended to prevent reformation of bone between the raw surfaces of the radius and ulna after resection of radioulnar synostosis. Schneider and Leyva4 first reported using siliconized mesh after excision of a recurrent radioulnar synostosis. Several investigators1,2,5–7 subsequently have described interposition of thin silicone sheeting between the radius and ulna. Nonbiological materials have been superceded by the use of fascia, fat, and muscle. Yong-Hing and Tschang8 first suggested the interposition of a nonvascularized abdominal fat graft, but Jupiter and Ring3 were unable to show any advantages to interposition of abdominal fat grafts in proximal type III radioulnar synostoses. It has been shown conclusively, however, in an experimental dog laminectomy model that fat grafts prevent scar formation better than any foreign material and vascularized pedicled fat grafts are better than nonvascularized fat grafts.17 Breit9 described interposition of the muscle bellies of the abductor pollicis longus and the extensor pollicis longus, and Watson and Eaton,6 in addition to using silicone sheeting, interposed the muscle belly of the flexor digitorum superficialis of the small finger. Bell and Banger10 treated 3 patients with posttraumatic type III radioulnar synostoses by interposition of an anconeus muscle flap and early mobilization with a forearm rotation assist splint. Wraparound pedicled brachioradialis muscle flaps have been reported for prevention of recurrent proximal radioulnar synostoses and pedicled flexor carpi ulnaris muscle flaps have been described for recurrent midshaft synostoses.11 More recently vascularized pedicled and free flaps
1146
The Journal of Hand Surgery / Vol. 29A No. 6 November 2004
patients with radioulnar synostoses caused by burns, which are acknowledged to be associated with a more severe form of radioulnar synostosis and a higher rate of recurrence. The arc of rotation of anconeus or brachioradialis muscle flaps will allow them only to be interposed into a proximal type III synostosis. Free lateral arm adipofascial flaps require specialist microsurgical expertise and a posterior interosseous flap requires meticulous dissection. In contrast a radial forearm adipofascial flap is simple and easy to harvest from the distal third of the forearm and can be elevated from beneath a skingrafted forearm. The radial artery probably does not need to be reconstructed but by doing so there is essentially no morbidity to this flap donor site because the patient still will have normal arterial inflow to the hand and normal skin coverage of the distal forearm. Finally adjuvant treatment with radiation therapy or anti-inflammatory medication also has been recommended after excision. Abrams et al15 treated 2 patients and Cullen et al16 treated 4 patients with low-dose radiation. No patients developed a recurrence or any problems with wound healing. The need for any adjuvant therapy with postoperative radiation or anti-inflammatory medications, however, has been disputed in proximal type III radioulnar synostoses.3
References Figure 5. Radiograph showing no recurrence of the radioulnar synostosis 3 years after surgery.
have been advocated for interposition. Sugimoto et al12 described transposition of a pedicled posterior interosseous forearm flap after resection of a type III radioulnar synostosis. Kanaya and Ibaraki13 described a free vascularized fascio–fat graft using an ipsilateral lateral arm flap based on the posterior radial collateral artery after resection of congenital proximal radioulnar synostoses in 7 children with no recurrences. Kawaguchi et al14 confirmed the efficacy of a free lateral arm flap for interposition after resection of 1 posttraumatic and 1 congenital proximal radioulnar synostosis. There are only 3 large series1–3 detailing treatment of radioulnar synostoses and 2 of them only included patients with proximal type III radioulnar synostoses. The defect after resection of a proximal radioulnar synostosis may be too small to allow interposition of flap tissue. In addition none of these 3 series included
1. Vince KG, Miller JE. Cross-union complicating fracture of the forearm. Part I: adults. J Bone Joint Surg 1987;69A:640 – 653. 2. Failla JM, Amadio PC, Morrey BF. Post-traumatic proximal radio-ulnar synostosis. Results of surgical treatment. J Bone Joint Surg 1989;71A:1208 –1213. 3. Jupiter JB, Ring D. Operative treatment of post-traumatic proximal radioulnar synostosis. J Bone Joint Surg 1998;80A: 248 –257. 4. Schneider CF, Leyva S. Silconized Dacron interposition for traumatic radio-ulnar synostosis. J Med Assoc Alabama 1964;33:185–188. 5. Carstam N, Eiken O. The use of silastic sheet in hand surgery. Scand J Plast Reconstr Surg 1971;5:57– 61. 6. Watson FM Jr, Eaton RG. Post-traumatic radio-ulnar synostosis. J Trauma 1978;18:467– 468. 7. Maempel FZ. Post-traumatic radioulnar synostosis. A report of two cases. Clin Orthop 1984;186:182–185. 8. Yong-Hing K, Tchang SPK. Traumatic radio-ulnar synostosis treated by excision and a free fat transplant. A report of two cases. J Bone Joint Surg 1983;65B:433– 435. 9. Breit R. Post-traumatic radioulnar synostosis. Clin Orthop 1983;174:149 –152. 10. Bell SN, Benger D. Management of radioulnar synostosis with mobilization, anconeus interposition, and a forearm rotation assist splint. J Shoulder Elbow Surg 1999;8:621– 624.
Jones, Esmail, and Shin / Radioulnar Synostosis 11. Fernandez DL, Joneschild E. “Wrap around” pedicled muscle flaps for the treatment of recurrent forearm synostosis. Tech Hand Upper Extremity Surg 2004;8:102–109. 12. Sugimoto M, Masada K, Ohno H, Hosoya T. Treatment of traumatic radioulnar synostosis by excision, with interposition of a posterior interosseous island forearm flap. J Hand Surg 1996;21B:393–395. 13. Kanaya F, Ibaraki K. Mobilization of a congenital proximal radioulnar synostosis with use of a free vascularized fasciofat graft. J Bone Joint Surg 1998;80A:1186 –1192. 14. Kawaguchi S, Kitamura M, Usui M. Proximal radioulnar
1147
synostosis treated with a free vascularised fascio-fat graft— report of two cases. J Hand Surg 2000;5:161–164. 15. Abrams RA, Simmons BP, Brown RA, Botte MJ. Treatment of posttraumatic radioulnar synostosis with excision and low-dose radiation. J Hand Surg 1993;18A:703–707. 16. Cullen JP, Pellegrini VD Jr, Miller RJ, Jones JA. Treatment of traumatic radioulnar synostosis by excision and postoperative low-dose irradiation. J Hand Surg 1994;19A:394 – 401. 17. Gill GG, Sakovich L, Thompson E. Pedicle fat grafts for the prevention of scar formation after laminectomy. An experimental study in dogs. Spine 1979;4:176 –186.