Bayne Lg Klug Ms Long-term Review of the Surgical Treatment of Radial Deficiencies J Hand Surg

Abstract

Introduction. In 1733, Petit first described the deformation of the forearm, congenital radial clubhand. A large number of modifications in the surgical treatment of this deformation have been developed. In the available literature, there is no comparative assay of the applied designs of the sections.

Aim. The goal is a comparative analysis of the effectiveness of the utilize of dorsal rotation flap past Evans, and incision designs by Bayne, in the correction of built radial clubhand in children.

Material and methods. Between 2013 and 2016, block randomization of 40 children with built radial clubhand was used and grouped by procedures. Surgical correction was performed using two different incision designs (the first grouping by Bayne and the 2nd past Evans). The analysis of the early postoperative complications was performed. The evaluation in the belatedly postoperative period of soft tissue condition of the forearm using a pinch test, Vancouver scale, and a visual analog scale was carried out.

Results. Based upon gender, patients were divided with male person predominance in both groups with seven girls and 13 boys in the first group, and 8 girls and 12 boys in the second group. In the immediate postoperative period, marginal necrosis was observed in the showtime grouping (35%). In the late postoperative catamenia, the study showed an advantage of using dorsal rotation flap by Evans versus the incision designs past Bayne.

Conclusion. Using incision designs past Evans with the formation of a dorsal rotation flap provided a more than aesthetic and functional effect.

Keywords

Full Text

Introduction

The kickoff mention of congenital radial clubhand was noted in 1733 when Petit described the bilateral deformity of the forearm and the hand in a stillborn male person fetus. Many authors have pointed out the characteristic clinical signs of congenital radial clubhand: saber-similar deformity of the forearm, palmar-radial deviation of the paw, hypoplasia of the first finger, aberration of development of the three-phalangeal fingers [1]. Nevertheless, the land of soft tissues, namely, the skin, was non taken into consideration.

For more than a century subsequently its first mention, no publications emerged on the methods of the surgical handling of congenital radial clubhand. In 1894, Sayre published a detailed article describing the causes of radial clubhand. He proposed a basic technique of surgery consisting of fixing of a paw on an ulnar bone. This was accomplished by forming a depression in the bones of the proximal row of the wrist bones, excision of the soft tissue interpanat, partial resection of the distal segment of the ulnar bone, and fixing them with each other. Subsequent methods proposed for surgery were in near cases different modifications of the 1 described by Sayre [2-4].

With the development of paw surgery, new methods have been described in the treatment of built radial clubhand. Blauth (1969) demonstrated his experience in the treatment of 89 patients past analyzing the anatomical features and demonstrating the results of surgical treatment [4]. Still, the incision fabricated in this case did non differ significantly; linear access was also employed, but with a different length. The continuation of the incision to the dorsal surface of the mitt as described past Sayre was not performed. In the writer's stance, such access is optimal for the visualization of anatomical structures. Correction of the excess of soft tissues forth the ulnar margin of the forearm was not performed [4].

According to Lamb (1979), the making of a linear incision restricts the view of the surgical field. The proposed arc-shaped incision allowed a more than user-friendly access [5]. Buck-Gramcko concurs by performing an S-shaped access on the rear surface of the forearm [2].

At the same time, the pattern of the incisions was adult, which enabled the displacement or correction of backlog skin on the ulnar margin of the forearm. According to Watson, Z-grafting on the radial and ulnar margins leads to a decrease in tension and tissue redistribution [6]. All the same, Bayne and Klug disagree and implement the Z-grafting on the radial surface of the forearm in combination with the excision of excess pare along the ulnar margin [vii].

A completely new technique of skin redistribution was suggested by Evans (1995). He used the method of dorsal rotation flap developed by Esser [8]. In this technique, the first rotation flap was formed along the ulnar margin in the projection of skin backlog, and the 2d was formed on the dorsal surface of the hand, with the continuation of the incision in the transverse direction to the radial surface, to the area of the skin deficiency [9].VanHeest and Grierson (2007) described a modification of the rotation flap of the dorsal surface of the forearm. The rotation flap was formed mainly on the dorsal surface with transition to the ulnar surface. The remaining excess pare was excised [iii, ten]. This did not enable the adequate employ of existing tissues to supplement the skin deficit along the radial margin of the forearm. Vuillermin et al. (2015) modified the Evans flap by forming it on the inner surface of the forearm and unfolding information technology by 180°. The deviation was in the position of the second rotation flap located on the forearm, but not on the hand [xi].

The analysis of the accesses used by different authors to perform the centering or radialization of the hand enabled to categorize incision designs into 2 groups having fundamental differences. Group ane consisted of incisions that provided access to just anatomical structures. Grouping 2 was formed past incisions ensuring the redistribution of backlog soft tissue located along the ulnar margin of the forearm. However, bachelor literature does not provide a comparative analysis of various methods that aid in assessing the efficacy of the proposed designs described higher up.

In the present study, our aim was the comparative analysis of efficacy of the dorsal rotation flap past Evans and the incision design past Bayne for the correction of congenital radial clubhand in children.

Materials and methods

This written report was conducted in the department of manus reconstructive microsurgery and surgery of the Turner Scientific and Research Constitute for Children's Orthopedics between 2013 and 2016. Cake randomization of xl children with built radial clubhand of Four degree into 2 groups (nomenclature by Bayne and Klug) was performed. All patients (or their representatives) voluntarily signed and provided an informed consent for participating in this study and for undergoing surgical intervention. For patients in grouping 1, the incision blueprint proposed by Bayne was used (Fig. 1). For patients in group 2, the incision design described past Evans was used to form the dorsal rotation flap (Fig. ii).

Fig. one. Incision Designs as proposed past Bayne

Fig. two. Incision Designs every bit proposed by Evans for the germination of a dorsal rotation flap

In both groups, the age of patients at the time of surgical handling ranged from 11 months to 2 years (the mean value was one.2 ± 0.5 years).

There was a preponderance of male patients, with 13 boys and vii girls in group 1. There were 12 boys and 8 girls in group ii. The follow-upwardly period was from six months to five years (mean value was two.4 ± 0.7 years).

The condition of the soft tissue of the forearm and hand was evaluated in the immediate postoperative period and at to the lowest degree vi months after the surgical intervention. In the firsthand postoperative flow, all patients were assessed for evidence of marginal necrosis of the displaced flaps; the area of necrosis was as well measured.

On long-term follow-upward, the state of soft tissues was assessed past controlling the peel mobility on the radial margin of the forearm by performing a pinch test. The researcher pinched a fold of the patient's skin using the tips of the first and second fingers in a transverse direction to the axis of the forearm of the patient. The exam was evaluated as positive in cases where it was possible to make a skin fold, and in other cases it was evaluated every bit negative.

To assess the condition of postoperative scars, the Vancouver scale was used. Four criteria were studied: pigmentation (0–3 points), elasticity (0–5 points), peak (0–3 points), and vascularization (0–3 points).

The assessment of satisfaction with the cosmetic result afterward the deformity correction was performed using a visual analog scale (Fig. 3). This was carried out with the assistance of parents, who were asked to assess the cosmetic country of postoperative scars, but not the extent of deformity correction itself. This was because parents may be satisfied with the correction of radial difference of the hand, merely not with the corrective state of postoperative scars. The minimum score indicated satisfaction with the event.

Fig. 3. Visual analog scale

Results of the study

The main purpose of the incisions performed is to ensure optimal access to the underlying structures. In both groups, the incision designs provided sufficient visualization necessary to perform the correction of congenital radial clubhand.

The cess of the condition of the displaced flaps in the immediate postoperative period revealed marginal necrosis in 7 patients (35%) of grouping one, whereas in group 2 information technology was noted only in 2 patients (x%). The area of necrosis varied from ii to 8 cm2 (mean 4 ± 0.9 cm2). There were no significant differences noted in the areas of necroses in both groups; nonetheless, this was more frequent in grouping ane (p < 0.05).

On long-term postoperative follow-up period, a control exam was performed for evaluation of the skin and postoperative scars, followed past photographic documentation.

Assessment of skin mobility on the radial margin of the forearm showed a positive compression test in iii patients and negative in 17 patients in group 1. In grouping 2, this test was positive in 16 cases and negative in iv patients.

The full number of points on the Vancouver scale in assessing the status of the scars varied in group 1 from three to 8 points (mean value 5 ± ii.iv), and in group 2 it was from 0 to vii points (mean value 3 ± ane.seven), p < 0.05. A detailed analysis of the assessment of the condition of postoperative scars by the Vancouver scale in grouping i showed that the mean score values amounted to the following: pigmentation of the scar, 0.viii; elasticity, two.7; height of the scar, 1.1; and vascularization, 0.2. In grouping 2, these indicators differed toward decrease every bit follows: pigmentation of the scar, 0.75; elasticity, 0.9; height of the scar, 0.3; and vascularization, 0.2.

Satisfaction with the cosmetic appearance of postoperative scars was assessed using a visual analog scale, with the assist of parents. In group 1, the score varied from 5.ii to 8.4 (hateful value 7.4 ± i.five), while in group 2 it varied from ii.1 to 4.vii (hateful value 2.5 ± 0.7), p < 0.05.

The clinical example of the employ of the incision design past Bayne is provided below.

The marking was made on the radial surface, in the projection of maximum tension. Fig. 4 demonstrates built radial clubhand in a patient aged 1 year. The hand is located in the palmar-radial departure, and along the ulnar margin there is marked peel excess. The first stage eliminates the tension along the radial margin of the hand with the help of Z-grafting. After moving the mitt to the central position, the amount of skin to be excised along the ulnar margin is accurately determined. In the firsthand postoperative flow, no marginal necrosis of the displaced flaps was detected. One yr after the surgical correction of the deformity, a deficiency of soft tissues was noted: the pinch test showed negative results. When assessing the condition of the scar on the Vancouver calibration, scar pigmentation was not detected; elasticity was 2 points, the scar height in some places exceeded two mm, and vascularization was 0 points (Fig. 5). Satisfaction with the esthetic state of the postoperative scars was 4.vii points, which was acquired by the condition of the postoperative scar palpable in some areas in the form of a dense band.

Fig. 4. Appearance of the paw and forearm with the incision pattern by Bayne earlier surgical treatment

Fig. 5. Appearance of the scar 1 year after the surgery

A clinical case of the application of a rotation flap by Evans in a 3-twelvemonth-old with thrombocytopenia with absent-minded radius (TAR) syndrome is presented below. This syndrome is characterized with a marked deficiency of pare forth the ulnar margin of the forearm, palmar-radial divergence of the hand, and preserved starting time ray of the hand (Fig. 6). In the firsthand postoperative period, no marginal necrosis was noted. Evaluation of the state of soft tissue was performed 6 months afterwards the surgery. The pinch test showed positive results. When assessing the condition of the scar on the Vancouver scale, scar pigmentation was not observed, the elasticity was 1 signal, the peak of the scar was at the same level with the skin, and vascularization was i point (Fig. seven). Satisfaction with the esthetic land of the postoperative scars was 3.two points, which was caused by persistent vascularization due to incomplete germination.

Fig. vi. Appearance of the hand and forearm with mark of the dorsal rotation flap by Evans earlier the surgical treatment

Fig. 7. Outcome 6 months after the awarding of the dorsal rotation flap past Evans in a patient with TAR syndrome

Word

Radial clubhand is a congenital malformation of the upper limb, characterized by longitudinal hypoplasia of the forearm and mitt on the radial surface [i]. Characteristic signs, every bit described previously [two, 5, 7], include saber-like deformity of the forearm and palmar-radial deviation of the hand. This, in our opinion, is also an indirect sign of skin deficit forth the radial margin of the forearm.

Group 1 showed a high incidence of marginal necrosis in the immediate postoperative flow. This is caused by the existing skin deficiency and tension on pare flaps, despite Z-grafting. The author of this technique does not describe this type of complication [9].

In group ane, all patients had a subtract in soft tissue tension along the radial margin of the forearm, but the skin deficit persisted, whereas in patients of group two, in that location was no soft tissue deficiency. Evans indicates a uniform distribution of peel with the utilize of a dorsal rotation flap [9], which was likewise noted in patients of group 2 and was confirmed past the pinch test.

Analysis of postoperative scars using the Vancouver calibration indicated the changes in elasticity and acme of postoperative scars in grouping i. The formation of scars in group 1 was of the hypertrophic type. The reason for this is the frequency of marginal necrosis in the immediate postoperative period, caused past impaired claret flow in the displaced flaps due to tension.

Most parents were satisfied with the overall results of surgical correction of existing deformities. However, when assessing the corrective state of postoperative scars, satisfaction was significantly college in the group using the Evans incision, which corresponds to the results reported in the studies by Evans, merely does non concur with the data reported by Bayne and Klug [7, 9].

Conclusions

The land of the skin in children with congenital radial clubhand is characterized by a deficiency along the radial margin of the forearm and peel backlog along the ulnar margin.
Local Z-grafting in the projection of soft tissue tension does not allow full correction of the skin deficiency. Uncomplicated excision of excess skin forth the ulnar margin aligns only the outline of the forearm.
A number of postoperative complications, accompanied by edge necrosis of the displaced flaps, prevailed in the patients of group 1 and resulted in unsatisfactory cosmetic results.
Awarding of the incision blueprint proposed by Evans allowed the effective employ of excess skin on the ulnar margin and its uniform redistribution to the forearm.

Thus, the present study demonstrated high efficiency in the application of the dorsal rotation flap by Evans in comparison with the incision design by Bayne.

Funding and conflict of interest

The work was performed on the basis of and with the support of the Turner Scientific and Research Institute for Children's Orthopedics, the Ministry of Health of Russia. The authors declare no obvious and potential conflicts of interest related to the publication of this article.

About the authors

Anton V. Govorov

The Turner Scientific and Research Institute for Children'southward Orthopedics

Author for correspondence.
Email: agovorov@yandex.ru

Dr., PhD, inquiry acquaintance of the department of reconstructive microsurgeryand mitt surgery.

Russian Federation, Saint petersburg

Natalia V. Avdeychik

The Turner Scientific and Enquiry Institute for Children's Orthopedics.

Electronic mail: natali_avdeichik@mail.ru

MD, orthopedic surgeon of the department of reconstructive microsurgery and hand surgery

Russian Federation, Saint Petersburg

Andrey Five. Safonov

The Turner Scientific and Research Institute for Children's Orthopedics

Email: safo125@gmail.com

Doctor, PhD, chief of the department of reconstructive microsurgery and mitt surgery

Russia, Saint Petersburg

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Source: https://journals.eco-vector.com/turner/article/view/6754