Osteotomia da ulna para correção cirúrgica de fratura de Monteggia negligenciada em criança com deformidade plástica da ulna. Relato de caso / Ulna osteotomy for surgical correction of neglected Monteggia fracture in a child with ulna bowing. Case report

Introdução: A luxação da cabeça do rádio com deformidade plástica da ulna, quando combinadas, configuram uma condição rara, e frequentemente não diagnosticada na urgência. Objetivo: Relatar um caso de fratura de Monteggia negligenciada em criança com defomidade plástica da ulna, tratada cirurgicamente com redução e fixação da cabeça dorádio, sem reconstrução do ligamento anular, e osteotomia da ulna. Relato do Caso: Paciente de 6 anos de idade, sexo masculino, vítima de queda ao solo com a mão espalmada, deu entrada em Unidade de Pronto Atendimento com queixa de dor no cotovelo direito. Paciente foi submetido à exames de imagem radiográficos do cotovelo interpretados peloexaminador como sem alterações. Duas semanas após, o paciente retornou mantendo dor, e foram solicitados exames de radiografia do antebraço, que evidenciaram presença de deformidade plástica da ulna associada à luxação da cabeça do rádio. Como tratamento, optou-se pela redução aberta e fixação da cabeça do rádio com fios metálicos, associado aosteotomia de flexão da ulna fixada com fio de Kirschnner. Evoluiu no pós operatório com consolidação da osteotomia, manutenção da redução da cabeça do rádio, e recuperação do arco de movimento total do cotovelo e antebraço. Conclusão: Pacientes pediátricos que se apresentam com dor no cotovelo, em decorrência de queda com a mão espalmada, devem ser minuciosamente avaliados quanto à possibilidade de deformidade plástica da ulna associada à luxação da cabeça do rádio. A osteotomia na ulna com fixação da cabeça do rádio, sem reconstrução do ligamento anular, trouxe bom resultado no tratamento de fratura de Monteggia negligenciada em criança com defomidade plástica da ulna. Palavras chave: Fratura de Monteggia, Ulna/deformidades, Fraturas da ulna, Osteotomia, Trauma, Criança, Pediatria Abstract Introduction: Dislocation of the radial head with ulna bowing, when combined, constitutes a rare condition, and often missed diagnosed. Objective: Report a case of neglected Monteggia fracture in a child with ulna bowing, treated surgically with reduction and fixation of the radial head, without reconstruction of the annular ligament, and osteotomy of the ulna. Case Report: A 6-year-old male patient, victim of falling to the ground, was admitted to the Emergency Department with complaints of pain in his right elbow. The patient was submitted to radiographic exams of the elbow, interpreted by the physician as normal. Two weeks later, the patient returned with pain, and radiographic exams of the forearm showed the presence of ulna bowing associated with dislocation of the radial head. As a treatment, we opted for open reduction and fixation of the radial head with metallic wires, associated with flexion osteotomy of the ulna. It evolved in the postoperative period with consolidation of the osteotomy, maintenance of the reduction of the radial head, and recovery of the total range of motion of the elbow and forearm. Conclusion: Pediatric patients who present with pain in the elbow, due to a fall, should be thoroughly evaluated for the possibility of ulna bowing associated with dislocation of the radial head. Ulna osteotomy with fixation of the radial head, without reconstruction of the annular ligament, brought good results in the treatment of neglected Monteggia fracture in a child with ulna bowing. Keywords: Monteggia fracture, Ulna/deformities, Ulna fractures, Osteotomy, Trauma, Child, Pediatrics

Canine developmental elbow disease part 2: surgical and non-surgical management

Developmental elbow disease is the term encompassing several abnormalities of the elbow joint, including fragmented medial coronoid process (FCP), osteochondrosis of the humerus (OC), ununited anconeal process (UAP), cartilage injuries and incongruity of the elbow joint. These disorders are associated with varying degrees of joint instability, inflammation, and loose fragments within the joint, which result in lameness and osteoarthrosis. Treatment should ideally involve correcting the underlying causes of the disease before significant joint damage has occurred. There are many surgical options for the treatment of developmental elbow disease which aim to unload the medial compartment, replace joint surfaces and manage pain. These include the sliding humeral osteotomy, proximal abducting ulna osteotomy, joint resurfacing and joint replacement. Studies evaluating the different treatments have low case numbers, variable outcome parameters, inconsistent diagnostic criteria and short follow-up times. Non-surgical manangement should always be part of the treatment plan to manage pain and symptoms as virtually all dogs with elbow disease will go on to develop osteoathritis.

Lengthening of the ulna by external fixation in children with congenital radial club hand

Background. Congenital radial club hand is characterized by the radial deviation of the hand, the longitudinal underdevelopment of the forearm, and the dysfunction of the upper limb. The shortening of the ulna is observed in all types of congenital radial club hand. The average shortening of the ulna surgical treatment was 33.3% compared to the intact contralateral side. Aim. This study aimed to evaluate the results of ulna elongation by the method of external fixation, depending on the level of osteotomy, in patients with congenital radial club hand type IIIIV. Materials and methods. The treatment results of 36 patients with congenital radial club hand type IIIIV from 1998 to 2018 were analyzed. The average age of the patients was 7.4 years 3.5 years. The patients were divided into three groups, depending on the level of ulnar osteotomy. Shortening of the ulna, correction of the angle of deformity of the ulna, radial deviation of the hand, period of correction, elongation obtained, index of fixation and osteosynthesis, and associated complications were analyzed. Results. The observation period was an average of 5.8 years. Before surgical treatment, the ulna was 33.3% shorter, while after surgery, it was 16%. Before surgery, the angle of deformation was 20.5 14.8, while after surgery, it was 7.4 5.6; this gives an angle of deformity correction of 63.9%. The elongation of the ulna was 3.2 1.1 cm. In patients who underwent proximal osteotomy, the resulting elongation was 32% and 18.4% more, respectively, than in patients who underwent an osteotomy in the middle and distal sections of the ulna. In group 1, the correction period was 24.4% and 28.9% more than in groups 2 and 3, respectively. The index of fixation in group 1 was 53.6%, which was 45.7% less than in groups 1 and 3. Postoperative complications included a false joint (15%), inflammation (10%), and forearm deformities (7.5%). Conclusions. In patients with congenital radial club hand type IIIIV, the optimal part of an ulna osteotomy is the proximal section. With a hand deviation of more than 20, osteotomy is performed in the distal section with simultaneous correction of the deformity.

Surgical treatment of chronic anterior radial head dislocations in missed Monteggia lesions in children: A rationale for treatment and pearls and pitfalls of surgery

Introduction The treatment of chronic radial head dislocations after Monteggia lesions in children can be challenging. This article provides a detailed description of the most frequently performed surgical technique: an ulna osteotomy followed by annular ligament reconstruction. Accordingly, we present the clinical and radiological results of 10 paediatric cases. Material and methods All paediatric patients that had a corrective osteotomy of the ulna for a missed Monteggia lesion between 2008 and 2014 were evaluated with standard radiographs and clinical examination. A literature search was performed to identify the relevant pearls and pitfalls of surgery. Primary outcome was range of motion. Results We included 10 patients, with a mean follow-up of 2.5 years. Postoperative range of motion generally improved 30.7°. Even in a patient with obvious deformity of the radial head, range of motion improved after surgery, without residual dislocation of the radial head. Conclusion Corrective proximal ulna osteotomy with rigid plate fixation and annular ligament reconstruction yields good results in patients with chronic radial head dislocation following a Monteggia lesion. Surgery should be considered regardless of patient age or time since trauma. Given substantial arguments in literature, we discourage surgery if a CT scan shows dome-shaped radial head dysmorphic features in work-up to surgery.

A 3D printed model for radius curvus surgical treatment planning in a dog

ABSTRACT: An 8 month-old, 10 kg male Azawakh dog was presented due to worsening forelimb gait and exercise intolerance. The right forelimb presented gross angular limb deformity with carpal valgus and radial procurvatum. Surgical planning based on radiographs allowed calculation of the centers of rotation and angularity (CORAs). The computer tomography data were used to generate 3D reconstructions of the antebrachium to aid the detection of the orthopaedic problems. With proper imaging software, the nature of the deformity and its degree were quantified using a previously unreported method based on the CORAs as a 3D printed model of anatomical area of interest. This 3D printed model was used by the surgeon to simulate the surgery with all orthopaedic steps, which included a partial ulna osteotomy and a double cuneiform osteotomy of the radius performed at the level of CORAs and stabilized with bone plates and screws. After 7 weeks, radiographs revealed bone union. At 8 months after surgery the animal presented a complete recovery of the involved forelimb. CORAs method combined with computed tomography and 3D model was useful to plan and simulate surgical procedures, including the corrective surgery of forelimb deformities in a dog which improved the surgical efficiency comparatively to the conventional pre-operative study.

Time-Dependent Recovery of Outcome Parameters in Ulnar Shortening for Positive Ulnar Variance: A Prospective Case Series

Background: This study evaluates the results of ulnar shortening using the ulna osteotomy locking plate system (UOL; I.T.S. GmbH, Graz, Austria) with special regard to the time-dependent recovery of subjective and objective outcome parameters and surgeons’ experiences. Methods: Ulnar shortening using the UOL was performed on 11 patients (3 men, 8 women) with an average age of 47 ± 19.6 years. Range of motion (ROM) and grip strength were compared with the contralateral hand. Patient-rated outcomes were measured using a visual analogue scale (VAS) for pain and the Disability of the Arm, Shoulder and Hand (DASH) and the Patient Rated Wrist Evaluation (PRWE) survey for subjective outcomes. Ulnar variance and bony union were assessed using conventional wrist radiographs. The surgeons evaluated intraoperative handling through a standardized feedback form. Results: ROM improved and grip strength increased significantly between preoperative values and final follow-up. Flexion and supination improved significantly between weeks 8 and 12 and grip strength from week 8 onward. Patient-rated outcomes changed significantly with a final DASH score of 14.2 ± 12.4 and a PRWE score of 24.3 ± 17.0. Pain levels improved significantly with no pain at rest and a mean VAS of 0.8 ± 1.2 during activity. The average amount of shortening was 4.0 ± 1.9 mm with a final ulnar variance of 0.2 ± 1.8 mm. All osteotomies healed with 2 cases of delayed union. Conclusions: In ulnar shortening with the UOL, wrist function recovered after an initial decrease from week 8 onward. Subjective outcome parameters showed early recovery and improved continuously over time.

Ανοσοϊστοχημική, απεικονιστική και εμβιομηχανική μελέτη βιολογικών φαινομένων σε πειραματικό μοντέλο διαταραχών πωρώσεως

Background: Fracture healing is a complex, well-orchestrated regenerative process, initiated in response to injury, resulting in optimal skeletal repair and restoration of skeletal function. Despite the progress accomplished towards the treatment of fractures in recent years, impaired healing in terms of delayed union and nonunion are still one of the most severe local complications, as they require a lengthy treatment. Most importantly, they represent a chronic clinical condition, which is difficult for patients to endure. Despite the effectiveness of treatments applied so far, no method has proven its efficacy regarding its reproducibility and cost justification. In this context, the field of Bone Tissue Engineering emerges as a promising alternative, accumulating and implementing knowledge from various disciplines and aiming at bone regeneration by use of biomimetic materials, growth factors and mesenchymal cells.Objective: The aim of this study was to investigate the efficacy of the implementation of biomimetic, naturally-derived and synthetic scaffolds alone or in combination with autologous growth factors and bone marrow stromal cells in terms of their ability to heal critical-size defects.Materials and Methods: Forty-eight NWZ rabbits weighing 2.9 to 3.5 kg were used for the purposes of the present study. An ulna osteotomy (15mm) was performed and the void was filled with naturally-derived and synthetic scaffolds alone or in combination with PRP and BMSCs. Imaging assessment of the regenerative process was made by use of x-rays at 4 and 8 weeks, as well as with CT and micro-CT at 8 weeks. After this time, all animals were sacrificed. Subsequently, the test samples were subjected to histological, imaging and biomechanical assessment.Results: All animals survived until the end of the study. No complications were encountered. The implemented scaffolds proved highly biocompatible and exerted a high degree of bone regenerative capacity, especially when they were seeded with growth factors and mesenchymal stem cells. Histological assessment revealed the existence of mature lamellar bone in all groups, with statistically significant superiority of those groups in which PRP and BMSCs were used concomitantly. Based on the 3D-histomorphometry, the synthetic biomimetic scaffold yielded superior results either alone or in combination with PRP and BMSCs.Conclusions: The implementation of biomimetic scaffolds is a safe alternative therapeutic approach in the treatment of nonunions. The seeding of biomimetic scaffolds with growth factors and stromal cells enhances their bone regenerative quantitative and the qualitative properties. The synthetic biomimetic scaffold used has proven superior, as compared to the naturally-derived one. This “on-site” strategy is safe, minimally invasive, and could be easily translated into the clinical field.