Treatment of congenital proximal radioulnar synostosis using pedicle posterior interosseous perforator adipofascial flaps

Abstract

Objective To present the clinical result of a procedure using pedicle posterior interosseous perforator adipofascial flaps for the treatment of congenital proximal radioulnar synostosis (CPRUS). Methods Eight forearms (from eight patients) with CPRUS were treated by the operation during December 2013 to January 2018 at Beijing Jishuitan Hospital. The average age of the children are seven years old (range: five years old to twelve years old). There were six boys and two girls. Seven forearms were classified as the Cleary type Ⅲ, and one forearm was classified as the Cleary type Ⅱ. Five children were suffered with bilateral CPRUS, and three children were unilateral. The average fixed forearm pronation angle was 43° (range: 0° to 80°). The operating procedure: a dorsal incision from olecranon to the distal 1/3 part of the middle axial of forearm was designed. Then the pedicle posterior interosseous perforator adipofascial flap was harvested. Elevated the anconeus muscle retrogradely, and the location of the osseous synostosis was exposed. Then the radial volar Henry incision just below the elbow joint crease was designed, the insertion part of the biceps brachii was exposed and elevated. The osseous synostosis was exposed and removed with the help of burr at the dorsal side. The cartilage part of the radial head was remolded. A trapeziform osteotomy was made at the site of radial tubercle due to the deformity angle of the radial shaft to reduce the dislocated radial head, then the distal and proximal part of radius was reduced and fixed with plate and screw. The pronator quadratus and the adipofascial flap were pulled to the volar side, and sutured to the deep fascia. The tendon of the biceps brachii was pulled dorsally and reattached to the radial tubercle. Postoperatively, an above-the-elbow splint was applied to keep the elbow in 90° of flexion and the forearm in 80° of supination. Three days later, the other splint was used to keep the forearm in 80° of pronation. Two splints were worn every other day alternatively. At four weeks after the operation, the ROM exercises were initiated both actively and passively, with the splints worn every other night alternatively. The splint was worn for six months. Results All patients received follow-up, the average duration of follow-up was 27 months (average: 6-48 months). The space of the proximal radioulnar joint could be seen clearly in seven patients, without the sign of recurrence of the synostosis. The synostosis was occurred in one child. Removed the synostosis part and the implant six months after operation, and placed an allograft tendon ball as the interposition tissue simultaneously. The problem was resolved successfully after that. Fingers extension weakness was happened in two patients, and recovered spontaneously and completely in three months. Limitation of elbow extension was occurred in two patients (range: 15° and 20°). The average pronation was 32.5° (range: 10°-65°), and the average supination was 31.9° (range: 10°-70°). Conclusions Using the perforator adipofascial flap pedicled with posterior interosseous vessels to treat the CPRUS is an easier method compared with classical Kanaya method . It could prevent the recurrence of synostosis effectively, and the treatment result is satisfied. The possibility of injury of the deep branch of radial nerve may be the potential problem. Key words: Flaps; Osteotomy; Radioulnar synostosis