Forearm Osteotomy

[admin]

Anyone know about this for oversupination? What age can it be done at? What does it help? Do kids lose function with this? Does it help elbow contractures? Does it help improve pronation? Is the child still able to supinate after this surgery?

[admin]

I would think that some of these answers depend on why the child is oversupinating in the first place. This is a good question to ask the doctor who will be doing the osteotomy.

[katep]

Guest,

I'll try to get some references posted for you later today.

I agree that the ultimate answers to your questions need to come from the doctor. However, as with practically everything else in BPI, there are multiple approaches and opinions on treatments. Each doctor will typically only talk about, and recommend, what they personally believe is the best course. In my experience, it can be pretty difficult to get some doctors to discuss alternatives even if you do ask. If you don't even know enough to ask, you may NEVER know that other doctors use different approaches. We would never have know about the possiblity of primary surgery, for instance, if we'd stayed with the first ortho surgeon we saw and didn't do our own research. Once I researched it myself, though, I was finally (after two months of seeing him) able to ask the right questions and find out that he was *significantly* uninformed about that surgery.

It helps to be an "informed consumer".

Kate

[katep]

Guest,

Sorry this took so long. Here are a few papers and excerpts. I tried to quote relevant parts for you; I don't know enough about the various doctors or history of procedures for supination problems to judge anything written here, so please don't take any of these quotes as endorsements! But hopefully these will help provide some background and basis for more discussion with your doctor(s).

Kate

SURGICAL STRATEGY FOR IMPROVING FOREARM AND
HAND FUNCTON IN LATE OBSTETRIC BRACHIAL PLEXUS PALSY

Plast Reconstr Surg. 2002 May;109(6):1934-46

David Chwei-Chin Chuang, M.D., Hae-Shya Ma, Loren J.
Borud, and Hung-Chi Chen, M.D.
Taipei, Taiwan, and Boston, Mass.

http://www.ncbi.nlm.nih.gov/entrez/quer ... s=11994597

Abstract:

For the purpose of treatment, obstetric brachial plexus
palsy can be subdivided into two distinct phases: initial
obstetric brachial plexus palsy, and late obstetric brachial
plexus palsy. In the latter, nerve surgery is no longer
practical, and treatment often requires palliative surgery
to improve function of the shoulder, elbow, forearm, and
hand. Late obstetric brachial plexus palsy in the forearm
and hand includes weakness or absence of wrist or metacarpophalangeal
or interphalangeal joint extension;
weakness or absence of finger flexion; forearm supination,
or less commonly pronation contracture; ulnar deviation
of the wrist; dislocation of the radial or ulnar head; thumb
instability; or sensory disturbance of the hand. Palliative
reconstruction for these forearm and hand manifestations
is more difficult than for the shoulder or elbow because
of the lack of powerful regional muscles for transfer. This
report reviews the authors’ experience performing more
than 100 surgical procedures in 54 patients over a 9-year
period (between 1988 and 1997) with a minimum of 2
years’ follow-up. Surgical treatment is highly individualized,
but the optimal age for forearm and hand reconstruction
is usually later than for shoulder and elbow
reconstruction because of the requirement for a preoperative
exercise program. Multiple procedures for forearm
and hand function were often performed on any
given patient. Frequently, these were done simultaneously
with reconstructive procedures for improving shoulder
and/or elbow function. Traditional tendon transfer techniques
do not provide satisfactory reconstruction for those
deformities. Many of the authors’ patients required more
complex techniques such as nerve transfer and functioning
free-muscle transplantation to augment traditional
techniques of tendon and/or bone management. Sensory
disturbance of the forearm and hand in late obstetric
brachial plexus palsy seems a minor problem and further
sensory reconstruction is unnecessary.


EXCERPTS

From Surgery section

"Correction of Forearm Supination Contracture

Forearm supination contracture (37 percent
[performed in 20 out of 54 surgical patients])
varies in severity in late obstetric brachial
plexus palsy. In mild cases in which the interosseous
membrane is not yet fixed, rerouting
of the biceps as described by Zancolli4 is
sufficient [16 of our patients (30 percent)]
(Figs. 1 and 2 and 6 through 8). However,
when severe supination contracture of 90 degrees
or more associated with a fixed interosseous
membrane is present, additional procedures
are required. In four patients in our
series, in addition to the classic biceps rerouting,
detaching the supinator insertion over the
radius and rerouting it (passing under the radius
bone) to act as a pronator, extensive separation
of the interosseous membrane including
the distal radioulnar joint, and rotational
osteotomy of the radius or humerus are required
simultaneously to correct severe supination
contracture."

From Results section:

"Correcting Forearm Supination Contracture

Rerouting of the biceps for forearm pronation
(Zancolli procedure) was very useful, increasing
forearm pronation range of motion
from an average of 24.5 degrees (range, 0 to 80
degrees) up to an average of 77.5 degrees
(range, 0 to 90 degrees) (Figs. 1, 2, and 6). If
the supination deformity is severe (greater than 90 degrees),
the biceps rerouting is insufficient
when used alone. In these cases, the procedure
should be used in addition to detachment of
the supinator from the radius, separation of
the interosseous membrane, release of the distal
radioulnar joint, and rotational osteotomy
of the radius or humerus (Fig. 7)."

From the Discussion section:

"Most authors argue that the best age for reconstruction
of the late obstetric brachial plexus
palsy deformity is at age 4 or older4,5,8,22 because
of the lack of severe contracture, the ability of the
patient to cooperate in rehabilitation, and easier
clinical evaluation. Preoperative evaluation of
each donor muscle is critically important for a
successful transfer. Children should be placed on
a preoperative exercise program to strengthen
donor muscles. Patients or patients’ parents must
be enlisted to manage and encourage the preoperative
preparation. In addition, shoulder and
elbow muscles always recover earlier and more
completely than forearm and hand function in
late obstetric brachial plexus palsy. The muscles
in the forearm or hand usually demonstrate paresis
(incomplete palsy with weak motor
strength), paralysis (complete palsy with atro-
phy), or sometimes contracture because of muscle
imbalance or aberrant reinnervation. Patients
with birth palsy, most often Erb palsy with rupture
of upper and/or middle trunk, will lead to
misdirection of regenerated axons (aberrant reinnervation)
and cause significant deformities of
the shoulder and elbow.3,22 However, the phenomenon
of aberrant reinnervation is less significant
in the forearm and hand because of less
ruptured cases in the lower trunk, but there is
more avulsion (incomplete or complete) of the
C8 and T1 roots. Tendon transfer in the forearm
and hand cannot be based solely on contracture
release and transfer to augment the paretic muscles
as seen in the shoulder and elbow. Therefore,
although the treatment is highly individualized,
shoulder and elbow reconstruction should
usually be performed before addressing the forearm
and hand. There is usually a lack of powerful
muscles in the forearm and hand for transfer in
late obstetric brachial plexus palsy. Continuous
physical therapy with a rehabilitation program to
optimize the residual muscle strength in the forearm
and hand is vital for later management.
From our experience, the optimum age for forearm
and hand reconstruction is during schoolage
years, 6 to 13 years old; whereas the optimum
age for shoulder and elbow reconstruction is during
the preschool years, 4 to 6 years old."


SURGICAL CORRECTION OF SUPINATION DEFORMITY IN
CHILDREN WITH OBSTETRIC BRACHIAL PLEXUS PALSY

J Hand Surg [Br]. 2002 Feb;27(1):20-3

J. BAHM and A.GILBERT
From the Institute de la Main, Paris, France

http://www.ncbi.nlm.nih.gov/entrez/quer ... s=11895340


Abstract:

We present a series of 40 children who were operated
on for supination contracture following severe
obstetric brachial plexus palsy. Surgery was
done at an average age of 7 years and the mean
postoperative follow-up was 4 years. In the 23
cases treated by an open or closed radial osteotomy,
the mean intraoperative derotation was 78 degrees, the
immediate postoperative position was 29 degrees
pronation and it stabilized at follow-up at
17 degrees pronation. Biceps rerouting was performed in 17
cases without any recurrence of supination deformity
and the final position was 228 pronation.
Some active forearm rotation was obtained in a
few cases. These surgical corrections are part of an
overall treatment plan and allow the ‘‘begging hand’’
to be corrected to a more functional and less
noticeable position.

Excerpts:

"Pathophysiology:

Supination contracture results from muscle imbalance
and shrinkage of the interosseous membrane. When the
median nerve (C6–8) isnot functioning, the two
pronatorsare paralysed and the forearm becomes
supinated. The interosseous membrane may then
shorten and an irreducible supination contracture may
develop.
The growing radial head is affected by muscle forces
acting on the proximal radioulnar joint. Muscular
imbalance due to an obstetric plexus palsy may lead to
deformation or even posterior dislocation of the radial
head (Aitken, 1952). A biceps contrac ture can produce
an anterior subluxation of the radial head. Furthermore,
as the biceps is also a supinator, the supination
deformity may be aggravated."



"Surgical Techniques"

"Open radial osteotomy was performed in older
children with restricted motion or fixed supination,
when there wasbone deformity or anterior dislocation
of the radial head. In such cases, a primary biceps
rerouting would be ineffectual, but could be required
after the osteotomy. The osteotomy was done through a
lateral approach at the junction of the distal and middle
thirds of the diaphysis where a good blood supply
ensures rapid bone healing.

Biceps rerouting was possible in young children with
mobile joints, no radial head displacement and no fixed
contracture. It wasinit ially described by Grilli (1959)
who detached the distal biceps tendon and the lacertus
fibrosus, which were then reattached more laterally on
the radius. We prefer the Zancolli modification (1967)
with a Z-type lengthening tenotomy and a ‘‘wraparound’’
of the distal tendon, maintaining its bony
insertion (Fig 2).

During the above open procedures, the interosseous
membrane may be sectioned when there is a fixed
deformity."

"Results"

"There were seven recurrences of supination deformity,
two after osteoclasis and five after open radial osteotomies.
Four of these were operated on again. A further
osteotomy was performed in three cases with successful
results.The other case underwent a dynamic biceps
rerouting procedure. In four children, osteotomy was
combined with bicepsrerout ing. In one case, both
procedures were performed at the same operation."

"The surgical correction of a supination contracture
enhances function by improving the position of the hand
in space and also gives a better appearance. Active wrist
extension is necessary before correction, otherwise
gravity will cause wrist flexion and the hand will adopt
the typical posture of a radial palsy. Therefore, previous
or concomitant transfer of the flexor carpi ulnaris to the
wrist extensors is mandatory."


SURGERY ABOUT THE ELBOW FOR BRACHIAL PALSY

J Pediatr Orthop. 2000 Nov-Dec;20(6):781-5

M. Mark Hoffer, M.D., and Gary J. Phipps, M.D.
Study conducted at Orthopaedic Hospital, Los Angeles, California, and Rancho Los Amigos Medical Center,
Downey, California, U.S.A.

http://www.ncbi.nlm.nih.gov/entrez/quer ... s=11097254

Summary: The results of surgical procedures performed on 21
children to improve their elbow function were reviewed. Five
flexor-plasties were performed in children with weak elbow
flexors. In five patients with anterior dislocations of the radial
head and supination contractures, transfers of the biceps to the
ulna were performed. In eight patients with supination contractures
and located radial heads, turnabout transfers to make the
biceps a pronator were performed. Four of the five children
with flexor-plasties had significant functional gains. All five
biceps to ulna transfers had increased ability to flex without the
necessity of supinating. The eight patients who had the turnabout
procedure of the biceps had excellent flexion with the
ability to pronate the forearm. Key Words: Brachial palsy—
Elbow.


From Materials and Methods:

"The indications for procedures to manage the supination
contracture were a supination contracture that did
not permit any pronation past neutral in a patient with a
functional hand. These were children with posterior cord
or mixed palsies. When patients with this contracture
also had an anterior dislocation of the radial head, a
transfer of the biceps insertion to the ulna was carried
out. The goal in these children is active flexion in neutral
rotation. A long arm cast, with the forearm in neutral
rotation and elbow flexed at 90°, was used for 6 weeks,
after which a bivalve cast was utilized and therapy carried
out in active flexion. The splint was discontinued
and extension allowed when the transfer was grade 4 or
better.

If, there was a supination contracture and the radial
head was not dislocated, then a rerouting transfer of the
biceps, first described by Zancolli (8) but modified to
exclude a release of the contracture itself, was carried
out. Here the goal was to achieve active pronation. This
was performed through a zig-zag incision in the antecubitum.
A Z-plasty of the tendon was performed at the
biceps insertion with the middle limb of the Z at least 1.5
inches in length. The inserting portion of the Z was
turned about the radial neck to create a pronating force
and then sutured together to the remaining tendon. The
forearm was pronated as much as possible. A long arm
cast was placed. If inadequate pronation was obtained,
the cast was changed at 2 weeks under general anesthesia
and the forearm manipulated into further pronation until
at least 50° of pronation was obtained. The cast remained
for 6 weeks after surgery, after which a bivalved cast was
used and therapy carried out into active pronation and
flexion. When the grade of the transferred tendon muscle
unit was 4 or greater, then the splint was discontinued
and extension allowed.


From Discussion:

"The biceps turnabout procedure (1) that we used was
performed without the extensive release of supination
contracture described by Zancolli. This was possible in
these children for two reasons. The first is that these
children did not have severe contractures into supination.
The second is that postoperative regimen allowed progressive
manipulation of these forearms into pronation.
In one case (patient 18), there was a prior osteotomy of
both bones that resulted in a recurrence of the contracture,
but it was not as severe as the initial deformity; that
patient still required the turnabout procedure that, we
believe, should have been performed before any osteotomy
or manipulation."

A SURGICAL TECHNIQUE FOR PEDIATRIC FOREARM PRONATION:
BRACHIORADIALIS REROUTING WITH INTEROSSEOUS MEMBRANE RELEASE

J Hand Surg 2004;29A:22–27

Turker Ozkan, MD, Atakan Aydin, MD, Istanbul, Turkey,
Kagan Ozer, MD, Louisville, KY, Kahraman Ozturk, MD,
Hayati Durmaz, MD, Safiye Ozkan, Istanbul, Turkey

http://www.ncbi.nlm.nih.gov/entrez/quer ... s=14751098

Purpose: In this study we used a tendon transfer technique
(consisting of rerouting of the brachioradialis
with interosseous membrane release) to restore
active forearm pronation in patients with
supination deformity secondary to brachial plexus birth palsy.

Methods: Four children (3 with flexible supination
deformities, 1 with a fixed supination deformity)
whose ages ranged between 5 and 9 years had
brachioradialis rerouting with interosseous
membrane release.

Results: Mean active forearm rotation was improved
from 28° supination before surgery to 49°
pronation after surgery. No patient developed elbow
contracture during a minimum of 12 months
of follow-up evaluation (40 months in 2 patients,
14 months in 1 patient, 12 months in 1 patient).

Conclusions: These results suggest that
brachioradialis rerouting combined with interosseous membrane
release may be a successful means to correct
supination deformity of the forearm.


"One of the most commonly used surgical techniques
today involves rerouting the biceps tendon
around the radial head and releasing the interosseous
membrane. This is usually done at an early stage to
restore the active pronation and to correct the deformity.
The procedure is not recommended in cases in
which the triceps is paralyzed because it can cause
elbow flexion contracture.1 Biceps rerouting also is
not practical in cases in which the radial head has
been resected.

The current study presents an alternative tendon
transfer technique (brachioradialis rerouting with interosseous
membrane release) that is designed to
restore active pronation of the forearm without jeopardizing
elbow function. Unlike biceps rerouting,
brachioradialis rerouting can be used for reconstruction
purposes in patients with triceps paralysis and in
those in whom the radial head has been resected. We
report the results of this technique in 4 children."

"...Unlike biceps rerouting, brachioradialis
rerouting can be used for reconstruction
in cases of triceps paralysis and radial head resection
provided that the proximal radioulnar joint is stable."

[ksass]

My daughter is unable to go palm down/pronate
If she has the forearm osteotomy to help her pronate will she lose the ability to supinate/palm up?