Biplanar carpal wedge osteotomy in the treatment of the arthrogrypotic patients / Osteotomia intracárpica biplanar no tratamento de pacientes com artrogripose

ABSTRACT Objective: To describe the results of the surgical treatment of patients with congenital arthrogryposis with wrist deformity through biplanar carpal wedge osteotomy. Method: This study analyzed nine patients through a retrospective evaluation with severe deformity in flexion and ulnar deviation of the wrist in the period between January 2004 and December 2009. They were submitted to carpal osteotomy with a biplanar dorsal resection wedge, with a minimum evaluation of 48 months of postoperative evolution. In three patients the osteotomy was bilateral, totalling 12 cuffs analyzed. The indication for the technique described was deformity and stiffness for over six months, without improvement with the conservative treatment. Results: The mean age of the patients on the day of surgery was five years and eight months. The initial mean wrist mobility was 35°, and the joints presented a mean flexion of 72.5° in a resting position. Osteotomy union occurred in all patients at an average period of 5.7 weeks. The final position of the resting wrist was 12° of flexion and the mean mobility was 26.6°, slightly lower than preoperatively but in a much better position. No serious complications arising from surgery or in the immediate postoperative period were observed. Conclusions: Carpal osteotomy with biplanar dorsal resection wedge was useful and effective in helping to correct the deformities in flexion and ulnar deviation of the wrist, maintaining a reasonable mobility. It is a preservation surgery, which has low morbidity and avoids the progression of deformity and future degenerative changes.

RESUMO Objetivo: Descrever os resultados do tratamento cirúrgico de pacientes portadores de artrogripose congênita com deformidade do punho através da osteotomia intracárpica biplanar. Método: Por meio de uma avaliação retrospectiva, entre janeiro de 2004 e dezembro de 2009, o estudo avaliou nove pacientes com grave deformidade em flexão e desvio ulnar do punho por artrogripose submetidos a osteotomia intracárpica com cunha de ressecção dorsal biplanar, com avaliação mínima de 48 meses de evolução pós-operatória. Em três pacientes, a osteotomia foi bilateral, perfez 12 punhos analisados. A indicação da técnica descrita foi deformidade e rigidez havia mais de seis meses, sem melhoria com tratamento conservador. Resultados: A média de idade dos pacientes no dia da cirurgia foi de cinco anos e oito meses. A média de mobilidade inicial do punho foi de 35° e as articulações apresentavam 72,5° de flexão média em posição de repouso. Todas osteotomias consolidaram em um período médio de 5,7 semanas. A média da posição final do punho em repouso foi de 12° de flexão e a mobilidade média foi de 26,6°, ligeiramente inferior ao pré-operatório, porém mais bem posicionado. Não foram observadas complicações graves decorrentes da cirurgia ou no pós-operatório imediato. Conclusões: A osteotomia intracárpica com cunha de ressecção dorsal biplanar se mostrou útil e eficaz no auxílio da correção da deformidade em flexão e desvio ulnar do punho, com manutenção de uma mobilidade razoável. É uma cirurgia preservadora, com baixa morbidade e que evita a progressão da deformidade e alterações degenerativas futuras.

Biplanar carpal wedge osteotomy in the treatment of the arthrogrypotic patients.

OBJECTIVE: To describe the results of the surgical treatment of patients with congenital arthrogryposis with wrist deformity through biplanar carpal wedge osteotomy. METHOD: This study analyzed nine patients through a retrospective evaluation with severe deformity in flexion and ulnar deviation of the wrist in the period between January 2004 and December 2009. They were submitted to carpal osteotomy with a biplanar dorsal resection wedge, with a minimum evaluation of 48 months of postoperative evolution. In three patients the osteotomy was bilateral, totalling 12 cuffs analyzed. The indication for the technique described was deformity and stiffness for over six months, without improvement with the conservative treatment. RESULTS: The mean age of the patients on the day of surgery was five years and eight months. The initial mean wrist mobility was 35°, and the joints presented a mean flexion of 72.5° in a resting position. Osteotomy union occurred in all patients at an average period of 5.7 weeks. The final position of the resting wrist was 12° of flexion and the mean mobility was 26.6°, slightly lower than preoperatively but in a much better position. No serious complications arising from surgery or in the immediate postoperative period were observed. CONCLUSIONS: Carpal osteotomy with biplanar dorsal resection wedge was useful and effective in helping to correct the deformities in flexion and ulnar deviation of the wrist, maintaining a reasonable mobility. It is a preservation surgery, which has low morbidity and avoids the progression of deformity and future degenerative changes.

OBJETIVO: Descrever os resultados do tratamento cirúrgico de pacientes portadores de artrogripose congênita com deformidade do punho através da osteotomia intracárpica biplanar. MÉTODO: Por meio de uma avaliação retrospectiva, entre janeiro de 2004 e dezembro de 2009, o estudo avaliou nove pacientes com grave deformidade em flexão e desvio ulnar do punho por artrogripose submetidos a osteotomia intracárpica com cunha de ressecção dorsal biplanar, com avaliação mínima de 60 meses de evolução pós-operatória. Em três pacientes, a osteotomia foi bilateral, perfez 12 punhos analisados. A indicação da técnica descrita foi deformidade e rigidez havia mais de seis meses, sem melhoria com tratamento conservador. RESULTADOS: A média de idade dos pacientes no dia da cirurgia foi de cinco anos e oito meses. A média de mobilidade inicial do punho foi de 35° e as articulações apresentavam 72,5° de flexão média em posição de repouso. Todas osteotomias consolidaram em um período médio de 5,7 semanas. A média da posição final do punho em repouso foi de 12° de flexão e a mobilidade média foi de 26,6°, ligeiramente inferior ao pré-operatório, porém mais bem posicionado. Não foram observadas complicações graves decorrentes da cirurgia ou no pós-operatório imediato. CONCLUSÕES: A osteotomia intracárpica com cunha de ressecção dorsal biplanar se mostrou útil e eficaz no auxílio da correção da deformidade em flexão e desvio ulnar do punho, com manutenção de uma mobilidade razoável. É uma cirurgia preservadora, com baixa morbidade e que evita a progressão da deformidade e alterações degenerativas futuras.

OSTEOTOMY OF THE DISTAL RADIUS USING A FIXED-ANGLE VOLAR PLATE.

OBJECTIVE: Skewed consolidation of the distal radius, due to sequelae of fractures, may cause functional incapacity, thus leading such patients to present pain, loss of strength and diminished mobility. Based on the excellent results obtained from surgical treatment of unstable fractures of the distal radius through a volar approach and use of rigid fixation with a fixed-angle volar plate, we started to use the same method for osteotomy of the distal radius. METHODS: A retrospective review was conducted, and 20 patients treated between February 2002 and October 2009 were found. The mean length of follow-up was 43.9 months (range: 12 to 96 months). The surgical indications were persistent pain, deformity and functional limitation subsequent to a dorsally displaced fracture. RESULTS: The mean preoperative deformity was 27° of dorsal tilt of the distal radius, 87° of ulnar tilt, and 7.3 mm of shortening of the radius. All the osteotomies consolidated and the final mean volar tilt was 6.2°, with ulnar tilt of 69.3° and shortening of 1 mm. The mean mobility of the wrist increased by 19.9° (flexion) and by 24° (extension). Mean forearm supination increased by 23.5° and pronation by 21.7°. Grip strength increased from 13.4 to 34.5 pounds. CONCLUSION: Use of a fixed-angle volar plate for a volar approach towards osteotomy of the distal radius enables satisfactory correction of the deformities and eliminates the need for removal of the synthesis material caused by tendon complications.