Forearm lengthening and prosthetic management in children with transverse congenital forearm deficiency.

In cases of transverse congenital forearm deficiency, achieving a good prosthesis fit during childhood remains a challenge. Ulnar lengthening is a treatment option for improving the prosthesis fit. The objective of this study was to evaluate surgical ulnar lengthening and the subsequent prosthesis fit. We reviewed four cases of ulnar lengthening in children with transverse congenital forearm deficiency. The procedure was evaluated in terms of the duration of lengthening, increase in ulnar length and healing index. The elbow range of motion, functional outcome (Prosthetic Upper Extremity Functional Index, PUFI) and time spent using the prosthesis per day were evaluated. The mean age at the time of the lengthening procedure was 3.5 years, the mean duration of lengthening was 58.3 days, the mean length gain was 21 mm, and the mean healing index was 70.1 days/cm. Elbow range of motion was restricted in one patient (100°-140°) and full in the other three patients. Based on the PUFI, 88.4% of activities were performed without the prosthesis. Children only used their prosthesis to perform specific tasks. Given the high complication rate and the lack of prosthesis use during daily activities, the main indication for forearm lengthening is a very short forearm that prevents prosthesis fitting. This procedure should be performed later in life - in adolescence.

Does inter-tibiofibular graft still have a role in the treatment of lower-limb non-union?

INTRODUCTION: Tibial non-union is a complication that poses a real challenge for surgeons. Several forms of treatment, depending on the type of non-union, have been described. The present study sought to assess results for treatment of tibial non-union by inter-tibiofibular graft (ITFG). MATERIAL AND METHOD: An exhaustive cohort study was performed on the files of 33 patients: 25 male, 8 female; mean age, 44years. Twenty cases involved high-energy trauma. Twenty-four were open fractures. Twenty-two concerned diaphyseal fracture, 10 of which were complex segmental. Eleven concerned distal fracture, including 4 complete articular fractures. There were 17 cases of septic non-union. There were no cases of severe bone defect. ITFG was performed at a mean 8.7 months post-trauma, as first-line treatment in 30 cases and in second line in 3. RESULTS: Thirty-one patients showed bone consolidation, at a mean 7.2 months. The 2 failures resulted from technical error. Trauma kinetics emerged as a risk factor for failure. DISCUSSION: ITFG remains a useful treatment option in tibial non-union, whether infected or not. The present results are comparable with those of the literature. Although the present series comprised only tight non-union, a study of the literature showed that ITFG can treat bone defects up to 4 or 5cm. Functional results showed tibiotalar joint stiffening, due more to immobilization and non-weight-bearing than to syndesmosis. ITFG thus remains relevant to the treatment of tibial non-union. LEVEL OF EVIDENCE: IV, retrospective study.

Use of an iliac crest growth plate for the development of a neo-articulation for congenital transverse deficiencies at the wrist.

PURPOSE: Terminal congenital transverse deficiencies of the wrist and hand are rare malformations. They are usually treated with prosthetic devices. We describe here a surgical technique to create a neo-articulation that could provide mobility distal to the forearm and help children with terminal transverse deficiencies use orthotic devices. METHODS: This procedure involved an autologous, nonvascularized graft from the immature iliac crest. The graft was placed with its cartilaginous side facing the radial and ulnar articular surfaces. We studied the clinical, radiological, and functional outcomes of this technique in 2 pediatric cases 5 and 14 years after this procedure. RESULTS: The x-rays showed a mobile graft distally in the forearm. Magnetic resonance imaging showed a space between the graft and the radius and an intermediate signal on either side of the space highly suggestive of articular cartilage. These various elements were organized into a neo-articulation between the forearm and the graft. The functional ability at follow-up was greater compared with the absence of a graft. CONCLUSIONS: The results of basic research work on cartilage and chondrocytes may help explain the presence of persistent cartilaginous tissue on the articulated part of the graft. The good functional outcome provided by our surgical procedure may translate into reduced need for prosthesis acceptance. Our surgical procedure does not restore limb length, but does add a new functional ability. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.