吻合血管的腓骨近端骨骺移植治疗儿童Ⅲ型先天性桡侧纵列缺如

Vascularized proximal fibular epiphyseal transfer for bayne and klug typeⅢradial longitudinal deficiency in children

目的探讨采用分期手术的治疗策略与吻合膝下外侧动脉的腓骨近端骨骺移植治疗儿童Ⅲ型先天性桡侧纵列缺如的可行性及有效性。方法2007年6月至2012年6月,中山大学附属第一医院显微创伤手外科收治BayneⅢ型先天性桡侧纵列缺如畸形患儿5例,男3例,女2例;年龄3.3~5.8岁,平均4.3岁。采取分期手术的治疗策略,一期手术行前臂与腕部桡侧软组织松解、外固定架固定及桡偏畸形的逐级矫形,酌情附加尺骨弯曲截骨、接骨板内固定术;二期手术行吻合血管的腓骨近端骨骺移植修复桡骨缺损、重建腕关节,腓骨近端骨骺移植物的血管蒂为膝下外侧动脉;三期手术行拇指畸形的矫形术。术后对患儿腕关节桡侧偏斜程度、前臂长度及肘关节、前臂、腕关节、手指活动度进行功能评价。结果本组5例患儿平均随访52.6个月(42~72个月)。移植腓骨平均长度为4.1 cm,全部存活并在3个月内与桡骨远端骨性愈合。最终随访时腕关节桡侧偏斜平均矫正28°;尺、桡骨平均长度分别为14.4、12.1 cm,占健侧长度的64.0%、56.3%;腕关节稳定性好,活动度为健侧的56%;前臂旋前为健侧的75%,旋后为健侧的45%,肘关节屈伸基本正常;平均手指活动度为103°,为健侧的39%。结论儿童Ⅲ型先天性桡侧纵列缺如采取分期手术的治疗策略,吻合膝下外侧动脉的腓骨近端骨骺移植能达到恢复桡骨长度、稳定腕关节的治疗目标,长期随访效果满意。

Objective For Bayne and Klug typeⅢradial longitudinal deficiency,the aim of the surgical methods is to create a centralized stable wrist and restore the length of the radius.The purpose of the current study was to validate the use of the staged procedures with vascularized proximal fibular epiphyseal transfer,based on a single vascular pedicle of the inferior lateral genicular artery to treat radius defects.Methods Between June 2007 and June 2012,five children with an averaged age of 4.3 years(range,3.3 to 5.8 years)who had a typeⅢradial longitudinal deficiency were identified.The staged procedures we performed for this patient consisted of:(1)soft tissue distraction of the wrist with an external distraction device to centralize the wrist and create a space for placement of the proximal fibular graft,ulnar osteotomy,and internal fixation to correct the bowing deformity of the ulna if necessary;(2)vascularized proximal fibular epiphysis transferred to repair the radius defect and to reconstruct the wrist;and(3)pollicization or thumb reconstruction to treat thumb deficiency.In all patients,the range of motion of the digits,wrist,forearm,and elbow;the length of the forearm;and the deviation of the wrist were evaluated.Results The averaged duration of follow-up was 52.6 months(range,42 to 72 months).All transplants survived and united with the host bone within 3 months postoperatively.An averaged correction of 28 degrees in the hand-forearm angle was obtained.At the final follow-up,the average ulna and radius lengths were 14.4 cm and 12.1 cm,respectively;the percentage length compared with the normal side was 64.0 and 56.3 percent,respectively.The overall range of wrist motion was approximately 56 percent of that of the contralateral extremity.The averaged pronation and supination were 75 and 45 percent of the normal side,respectively.The overall range of elbow motion was similar to the normal side.Conclusions The results of the present study indicated that vascularized proximal fibular epiphyseal transfer,based on the inferior lateral genicular artery,is a technically feasible method for treatment of Bayne and Klug typeⅢdeficiency,which restores the length of the radius and stabilized the wrist.