|Year : 2013 | Volume
| Issue : 1 | Page : 61-65
Modified Ilizarov technique in Madelung’s deformity
Osama Ghali1, Mahmoud Hadhoud2
1 Department of Orthopedic Surgery, Health Insurance Hospital, Cairo, Egypt
2 Department of Orthopedic Surgery, Faculty of Medicine, Menoufiya University, Menufia, Egypt
|Date of Submission||21-Aug-2011|
|Date of Acceptance||20-Oct-2011|
|Date of Web Publication||19-Jul-2014|
Mokatam Hospital for Health Insurance, 32511 Cairo
Source of Support: None, Conflict of Interest: None
Madelung’s deformity is caused by arrest of growth on the ulnar side of the distal epiphysis of the radius. It results in palmar and ulnar tilt of the articular surface, volar translation of the hand and wrist, shortening of the radius, and dorsal subluxation of the ulnar head with incongruity of the distal radioulnar joint.
Patients and methods
Six patients with Madelung’s deformity were treated with the Ilizarov method at the Orthopedic Department of health insurance hospitals. Correction was undertaken for pain in the case of two patients, because of impaired function in two, and because of bad cosmoses in another two patients. The cause of the deformity was congenital in four cases and acquired in two after fractures. The patients included five girls and one boy. The ages of the patients varied from 11 to 17 years, with an average age of 14.6 years.
All patients were free from pain at follow-up. Supination improved by a mean of 30π and pronation by a mean of 10π. The mean improvement in flexion was 20π. Extension did not change. Radial and ulnar deviations were increased by a mean of 5 and 10π, respectively, and lengthening of the radius by a mean of 12 mm (6–25). Radiological measurement showed that the mean volar angulation had been reduced from 20 to 10π and ulnar inclination from 40 to 25π. The most common problem was minor pin-tract infection in all cases, which was treated with antibiotics. No loosening of pins or bone fracture occurred. There were no deep pin-tract infections or neurovascular injury.
The Ilizarov technique should be considered for the surgical treatment of Madelung’s deformity in patients suffering from persistent pain when gradual correction and lengthening is indicated. The Ilizarov method is useful for obtaining correction of forearm deformity.
Keywords: correction, Ilizarov, Madelung’s deformity
|How to cite this article:|
Ghali O, Hadhoud M. Modified Ilizarov technique in Madelung’s deformity. Egypt Orthop J 2013;48:61-5
| Introduction|| |
Madelung’s deformity can result in pain and decreased function of the wrist and hand. It is caused by arrest of growth on the ulnar side of the distal epiphysis of the radius. It results in palmar and ulnar tilt of the articular surface, volar translation of the hand and wrist, shortening of the radius, and dorsal subluxation of the ulnar head with incongruity of the distal radioulnar joint. These anatomical changes alter the biomechanics of the wrist and associated structures, resulting in a decreased range of movement, especially ulnar deviation and extension, decreased grip strength, and pain 1.
Madelung’s deformity presents as a spectrum. It may affect the entire radius or it may affect only the distal radius. Extremities with involvement of the entire radius have a shorter radius and ulna, decreased length, and a more severe deformity compared with extremities with involvement of only the distal radius 2. Ulnar tilt, lunate subsidence, and palmar carpal displacement are considered reliable and reproducible measurements for quantifying the severity of Madelung’s deformity on radiographs 3.
The deformity presents in late childhood or adolescence, is more common in the female population, and is often bilateral. The deformity was classified by Henry and Thorburn 4 into four different etiological groups: (a) idiopathic or primary; (b) secondary, after trauma, infection, or tumor; (c) dysplastic, including dyschondrosteosis, hereditary multiple osteochondromatosis, Ollier’s disease, and achondroplasia; and (d) chromosomal or genetic such as in Turner’s syndrome.
Conservative methods of treatment are often ineffective and do not prevent progression of the deformity. A number of surgical techniques have been developed 5–7. Dobyns et al. 7 divided these into three broad groups: first, those applied to the radius such as epiphysiodesis, corrective osteotomy, and physiolysis; second, those applied to the ulna such as epiphysiodesis, excision of the head, shortening osteotomy, and creation of a pseudarthrosis with or without fusion to the radius; and third, combined techniques in which both bones are dealt with usually by one of the above-mentioned methods. None of the surgical techniques available has been shown consistently to improve grip strength, range of movement, or relieve pain.
The Ilizarov method permits for combined axis correction and/or distraction or compression. This is the method of choice for the treatment of nonunion of the forearm with concomitant shortening and axis deformity 8. We have evaluated the results of osteotomy of the distal radius with subsequent bone lengthening and deformity correction by the Ilizarov technique in cases of Madelung’s deformity.
| Patients and methods|| |
Between January 2006 and March 2008, six patients with Madelung’s deformity were treated with the Ilizarov method at the Orthopedic Department of health insurance hospitals. They were not satisfied with the result of conservative treatment and underwent surgical correction using the Ilizarov technique. In two patients correction was undertaken for pain, in two because of impaired function, and in another two because of bad cosmoses. The cause of the deformity was congenital in four cases and acquired in two after fractures. The patients included five girls and one boy.
The ages of the patients varied from 11 to 17 years, with an average age of 14.6 years. The mean duration of follow-up after the operation was 16 months (9–26 months).
The Ilizarov apparatus was applied under general anesthesia in the operating room. A modified Ilizarov frame was constructed with two half-rings connected by threaded rods. Threaded half-pins were used: two in the proximal radius and two distal to the planned osteotomy close and parallel to the radiocarpal joint [Figure 1]. The frame was mounted to the pins with rancho cube fixation clamps. Transverse osteotomy was performed in the distal third of the radius, after which the frame was reassembled. Distraction and correction began on the seventh postoperative day. The rate of distraction was different and depended on radiographic evidence of regeneration and pain tolerability of the patients, ranging from 0.25 to 1 mm/day. In three cases we were forced to discontinue distraction temporarily, usually for 1–2 weeks, because of pain. After reaching the required length we stopped lengthening of the ulnar side and continued lengthening of the radial side to correct the palmar and ulnar deformities [Figure 2] and [Figure 3]. After gaining full correction of the deformity, the frame was kept in place until consolidation of the gap. Patients were encouraged to perform exercises to mobilize the fingers, wrist, and forearm. They were advised to clean the frame and provide care to the pin site insertion. The frame was removed without anesthesia. Physiotherapy was advised after removal of the frame until full function had been regained.
|Figure 1. Photographs showing the Ilizarov frame applied intraoperatively.|
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|Figure 2. (a) A 12-year-old girl with Madelung’s deformity. (b–d) Radiographs showing follow-up of correction using the Ilizarov frame. (e) A radiograph showing complete consolidation after frame removal. (f) Photographs showing full correction of the deformity.|
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|Figure 3. A 15-year-old boy with Madelung’s deformity. (a) Photographs showing Madelung’s deformity. (b) A radiograph showing Madelung’s deformity. (c) Photographs showing the Ilizarov frame applied intraoperatively. (d) Radiograph showing follow-up of correction using the Ilizarov frame. (e) Radiograph showing complete consolidation after frame removal. (f) Photographs showing full correction of the deformity.|
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We assessed the patients for pain, grip strength, and goniometry of the wrist and forearm before and at follow-up. Supination and pronation were measured with the elbow at 90° and the shoulder in the neutral position. The range of movement of the wrist was measured with the patient seated; the elbow flexed to 90° and the forearm pronated 9. From radiographs, the angle of the articular surface of the distal radius in relation to the long axis of the radius, carpal malalignment, and the degree of shortening of the radius were measured before and after operation. The patients were also asked whether the pain and appearance had improved and whether they were satisfied with the cosmetic and functional results.
| Results|| |
All patients were free from pain at follow-up. Supination improved by a mean of 30° and pronation by a mean of 10°. Flexion improved in four cases. The mean improvement in flexion was 20°. Extension did not change. Radial and ulnar deviation had increased by a mean of 5 and 10°, respectively, and lengthening of the radius by a mean of 12 mm (6–25). The mean duration of correction was 24 days. The mean period of consolidation was 39 days (25–55). Radiological measurement showed that the mean volar angulation had been reduced from 20 to 10° and ulnar inclination from 40 to 25°. The mean carpal malalignment (volar translation) was reduced from 8 to 3 mm. However, slight deformity and malalignment remained in two patients.
The most common problem was minor pin-tract infection, which was seen in all cases and which was treated with antibiotics. No loosening of pins or bone fracture occurred. There were no deep pin-tract infections or neurovascular injury. The rate of lengthening had to be reduced to half of the lengthening speed for 1 week in three cases because of pain. After the pain had subsided, normal elongation was continued. No patient needed a bone graft. Overall, patients tolerated the procedure well and five patients were satisfied with the improvement in the appearance of their wrist [Figure 2] and [Figure 3].
| Discussion|| |
A number of anatomical changes occur in Madelung’s deformity that result in biomechanical alterations leading to decreased range of movement, decreased grip strength, and often pain. Correction after skeletal maturity or towards the end of skeletal growth decreases the likelihood of recurrence of the deformity 10.
However, nonoperative management is ineffective in treating painful wrists and does not prevent progression of the deformity. Several surgical methods of treatment have been proposed, including early resection of the tether band before closure of the epiphysis 10 and early resection of the ulnar zone of the epiphysis of the distal radius and replacement with an autologous fat graft 11. Resection of the head of the ulna may be needed once the epiphysis has fused. Excision of the distal ulna alone has also been reported 12–14 but may leave the carpus unstable. Ranawat et al. 15 used the Darrach procedure, with or without associated radial osteotomy, and Murphy et al. 1 studied patients who underwent had radial opening wedge osteotomy and observed no change in range of movement or grip. Procedures that involve resection of the ulnar head should be avoided in young patients as ulnar deviation and carpal dislocation may result 1.
White and Weiland 16 described a volar closing wedge osteotomy combined with a distal radioulnar arthrodesis and ulnar pseudarthrosis proximal to the arthrodesis (the Kapandji procedure). With this technique, relief from pain was significant but the range of movement did not improve. Harley et al. 17 described volar dome osteotomy.
Techniques involving physiolysis 10,11 obviously require an open growth plate. Surgery before closure of the physis may lessen the development of secondary changes in the carpus and allow some remodeling.
Osteotomy of the radius combined with shortening of the ulna has been reported 18. It generally involves a biplane osteotomy with either a closing or opening wedge to correct the position of the surface of the joint or shortening of the ulna. As a consequence of the disease, the forearm is shortened in most patients, and therefore further shortening of the forearm bones is undesirable. The technique of shortening combined with a slight anterior angulation osteotomy of the ulna aiming to improve the appearance of the wrist and to relieve pain if present without compromising the function of the wrist is suitable only for mild cases of Madelung’s deformity 19–24.
Bagatur et al. 25 found that lengthening of the forearm results in improved upper-extremity function, especially in activities requiring equal arm length, as well as in better cosmetic appearance if adequate soft tissue is preserved. The Ilizarov technique is an effective method for lengthening the ulna in children with radial longitudinal deficiency 26. Villa et al. 27 and Lacher et al. 28 used a modified Ilizarov method, and both teams of researchers as well as de Billy et al. 29 have used the technique to lengthen an opening wedge osteotomy gradually. In both studies, Kirschner wires were used for fixation.
Houshian et al. 30,31 treated seven patients with Madelung’s deformity by radial osteotomy with subsequent lengthening and angular correction using the Ilizarov technique. Frames consisted of three half-rings and 4 mm threaded half-pins. Hinges were at the axis of the proposed osteotomy, ∼2 cm proximal to the radial articular surface. Lengthening was performed, followed by angular correction. All patients were pain free at follow-up. Supination improved by a mean of 34°, pronation by a mean of 9°, and flexion by a mean of 15° 30,31.
In our work we made osteotomy more proximal in the radius, unlike in the series of Houshian et al. 31. This gave enough space for pin insertion, and hence there was no loosening or fracture of the distal fragment. The Ilizarov technique restores the anatomy of the wrist to almost normal by repositioning the radioulnar joint and thereby reversing some of the biomechanical changes caused by the ulnar and volar shift of the carpus. However, there are still slight deformities and malalignments in the joints in some of the patients. Further, the carpal bones are deformed in long-standing Madelung’s disease 31.
The use of half-pins instead of transfixation Kirschner wires allows a near-normal movement of the forearm and wrist during the prolonged period of external fixation 31. The Ilizarov method offers the advantage of a minimally invasive technique with minimal dissection and therefore decreased risk of neurovascular and soft-tissue injury and infection; it is also adjustable 32.
The Ilizarov technique allows correction of the deformity in two planes, controlled by radiographs. There is no need for bone graft and the pins are removed without anesthesia. The slow correction by gradual lengthening allows the ligament complex of the distal radioulnar joint to adjust to the lengthened radius, thereby contributing to the stability of the joint. This may be the keystone for relief from pain. In our series, not only were pain, shortening, and deformity of the forearm reduced but function also improved considerably. The Ilizarov method is useful in obtaining corrections of forearm deformity.
| Conclusion|| |
The Ilizarov technique should be considered for the surgical treatment of Madelung’s deformity in patients suffering from persistent pain when gradual correction and lengthening is indicated.
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[Figure 1], [Figure 2], [Figure 3]