Surgical treatment outcome of wrist flexion contracture in children with cerebral palsy through temporary extra-articular arthrodesis

Abstract

Background. The surgical approaches adopted for the treatment of wrist flexion contracture can be categorized into soft tissue intervention (such as lengthening or transplantation of tendons) and bone operations that stabilize the wrist joint. We developed a technique for temporary arthrodesis of the wrist joint to combine the main advantages of both the approaches, that is, the stability of arthrodesis by the installed metal construction and the possibility of active movements in the wrist joint after removal of the structure.
 Aim. To compare the effectiveness of a new method of surgical treatment of wrist flexion contracture in children with cerebral palsy, such as temporary extra-articular arthrodesis and transplantation of the hand flexors to the extensors, according to Green.
 Materials and methods. We conducted a comparative analysis of the treatment outcomes between the following 2 groups of patients: group 1 (n = 13) patients underwent a tendon transplantation of m. flexor carpi ulnaris on m. extensor carpi radialis brevis/longus (Green operation), while group 2 (n = 13) patients underwent temporary arthrodesis of the wrist joint with a bone plate for a period of 1 year. The patients in group 2, after the removal of metal structures, underwent a 14-day course of rehabilitation before evaluation of their treatment outcomes. A comparative analysis of the treatment results between the groups 1 and 2 was performed 1 year after arthrodesis and plate removal and at 1 year after muscle transplantation. The range of active and passive movements in the wrist joint was analyzed throughout. In addition, the functionality of the upper limb was assessed with reference to the international classification system of MACS 2002 and the Block and Box test.
 Results. In the group 1 patients, an increase in the passive range of motion (+9.7) was noted. In both the groups, a significant increase was recorded in the amplitude of active movements (31.9 in group 1 and 45.7 in group 2). The upper limb functionality index MACS, on evaluating the condition of the arm as a whole, appeared to be almost identical in both the groups. In the group 1 patients, the average dynamics of the Block and Box test as a result of treatment was 8 additional cubes, while it was only 1.6 in the group 2 patients.
 Conclusion. The Green operation was less effective in comparison with the operation of temporary arthrodesis as a method of correcting the flexion contracture of the wrist joint. However, the functional performance of the Green operation was higher. The choice of the optimal surgical treatment technique can be determined as follows. In children with a high functional perspective, the Green operation is preferred. However, in children with doubtful functional prospects where the correction of severe contracture is the main aim, temporary arthrodesis may be preferable.