Wall Lindley B, Calhoun Valeri, Roberts Summer, Goldfarb Charles A
Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO; Shriners Hospital for Children, St. Louis, MO.
Shriners Hospital for Children, St. Louis, MO.
J Hand Surg Am. 2017 Jun;42(6):473.e1-473.e7. doi: 10.1016/j.jhsa.2017.03.002. Epub 2017 Apr 4.
In the amyoplasia type of arthrogryposis, a reverse pronated grasp pattern is often seen. We hypothesized that repositioning the hands, through distal humerus external rotation osteotomies (DHO), would allow for palm-to-palm grasp without arm cross-over and would improve function and parent/patient satisfaction.
The medical records of all patients treated surgically for arthrogryposis were reviewed at the Shriners Hospital for Children, St. Louis, MO. From 2012 to 2014, 9 patients (14 extremities) had undergone a DHO. All patients had preoperative and postoperative video recordings of functional activities and we assessed functional changes after osteotomies. Preoperative upper extremity position was graded as 1, palms facing midline; 2, palm facing posterior; and 3, palms facing away from midline. Postoperative Pediatric Outcomes Data Collection Instrument (PODCI) questionnaires were obtained and parent satisfaction was evaluated.
Mean patient age at the time of surgery was 6.5 years. Five patients underwent bilateral DHOs. All patients had 3 or fewer additional procedures on an upper extremity during the study period. All patients had an improved resting posture of the upper extremity after DHO surgery, with a mean change of 51° (range, 15°-90°). Grasp pattern was altered in 13 extremities; there was a change in hand position of at least 1 grade and 5 had complete change from 3 to 1, palms facing away from midline to facing toward midline. There was a wide range in postoperative PODCI scores for function, but Happiness scores were high, mean 89 (range, 60-100). Parents universally stated the procedure improved the child's function "a great deal." There were 2 complications: 1 periprosthetic humerus facture with recurrence of the internal rotation and 1 patient with scarring of the triceps requiring tenolysis.
The DHO is an effective procedure for correcting the internal rotation position of the upper extremity in arthrogryposis and the surgery improves hand opposition with minimal complications. Universally, there was perceived improved function with high postoperative PODCI Happiness scores.
TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.
在先天性多发性关节挛缩症的肌张力缺失型中，常可见到反向旋前抓握模式。我们推测，通过肱骨远端外旋截骨术（DHO）重新定位手部，可实现手掌对掌抓握且手臂不交叉，并能改善功能以及提高家长/患者的满意度。
在密苏里州圣路易斯市的施莱宁儿童医院，对所有接受先天性多发性关节挛缩症手术治疗的患者病历进行了回顾。2012年至2014年期间，9例患者（14个肢体）接受了肱骨远端外旋截骨术。所有患者均有术前和术后功能活动的视频记录，我们评估了截骨术后的功能变化。术前上肢位置分为1级，手掌朝向中线；2级，手掌朝向后侧；3级，手掌背离中线。获取术后儿童结局数据收集工具（PODCI）问卷，并评估家长满意度。
手术时患者的平均年龄为6.5岁。5例患者接受了双侧肱骨远端外旋截骨术。在研究期间，所有患者在上肢进行的额外手术均不超过3次。所有患者在肱骨远端外旋截骨术后上肢的静息姿势均有改善，平均变化为51°（范围为15° - 90°）。13个肢体的抓握模式发生了改变；手部位置至少改变了1级，5个肢体从3级完全改变为1级，即从手掌背离中线变为朝向中线。术后PODCI功能评分范围较广，但满意度评分较高，平均为89分（范围为60 - 100分）。家长们一致表示该手术极大地改善了孩子的功能。有2例并发症：1例假体周围肱骨骨折伴内旋复发，1例患者三头肌瘢痕形成需要进行肌腱松解术。
肱骨远端外旋截骨术是矫正先天性多发性关节挛缩症上肢内旋位置的有效手术，该手术可改善手部对掌功能，并发症最少。总体而言，术后PODCI满意度评分较高，功能得到了改善。
研究类型/证据水平：治疗性研究V。
