Dr Ashok Johari – A Unique Journey of a Paediatric Orthopaedic Surgeon- Part II

Volume 2 | Issue 2 | May-Aug 2016 | Page 3-10| Ashok N. Johari

Authors :Ashok N. Johari [1]

[1] Director of The Enable International Center for Paediatric Musculoskeletal Care, India.

Address of Correspondence
Dr Ashok N Johari
Email ID: drashokjohari@hotmail.com

The Price of Greatness is Responsibility
– Winston Churchill –

This interview with Dr Ashok Johari (ANJ) was conducted in Hotel Le Meredian. The interview was conducted by Dr Sandeep Patwardhan (SP) and Dr Ashok Shyam (AKS) on the second day of Pune Orthopaedic Society Annual Meeting in Pune, India.
The purpose of this interview is to know more about the journey of Dr Ashok Johari who is a pioneer in paediatric orthopaedics in India and in the world. This interview aims to catch a glimpse of his life and times and also showcase the rise of paediatric orthopaedic as an independent faculty in India. A broader objective is to attract people to paediatric orthopaedics and to have pride in our own people who have done exceptionally well in reaching international acclaim in respective fields. Presenting the part II of the interview

AKS: Continuing from the part I, we were talking about you starting private practice in Paediatric Orthopaedics
ANJ: When I came back, because of my paediatric background and since I worked a lot in paediatrics, I was interested in doing exclusive paediatric orthopaedic practice. I went and asked my bosses that I want to do paediatric orthopaedics. They all unanimously told me, ‘do you want to Starve’. But I did start my private practice as paediatric orthopaedic surgeon. Early on adult patients also came and I continued this divided practice of adult and paediatric continued for two years after which I started exclusive paediatric practice. Practice was good even in early years, I started in 1989 and by 1992 I was quite busy and operating every day. When I was in Sion I was earning Rs 1800 as a tutor and my wife was also full time in BPT and we managed to earn around 4000 INR per month and we thought we were royalty and did not need any more! Same thought applied to private practice that if I was able to earn same amount in private, we would be good. Somehow I managed to earn half of this amount on my first day of practise. I had a home visit call where patient had a clavicle fracture and I did bandaging and got 400 rupees from him and then there were other patients that came along from reference from known people and I could earn 900 rupees on day one. It was a good and encouraging start. And I never looked back since then and had the confidence to become an exclusive paediatric ortho surgeon

AKS: Were there other people practising paediatric orthopaedic
ANJ: No one was practising exclusive paediatric orthopaedics at that time. Dr Chacko was Professor at Manipal. He was a general orthopaedic surgeon but had special interest in Perthes disease. Dr Sriram was attached to Children’S hospital in Chennai but was doing adult work also. Besides that there were very few, like Dr B Mukhopadhyay who was doing lot of work in clubfoot. Dr Benjamin was working in Dr Chacko’s unit which did paediatric work along with adult work. I think our unit in Sion hospital in 1986 was first to do exclusive paediatric work historically. It was a small unit but did exclusive paediatric orthopaedics.

AKS: How did the idea of Paediatric Orthopaedic Society of India (POSI) came into picture?
ANJ: I was meeting Dr Benjamin on and off in conferences and since both our papers were in paediatric orthopaedics we soon developed good rapport. We discovered that we are both very much interested in paediatric orthopaedics. While talking to each we realised that lot of general orthopaedic surgeons are interested in paediatric orthopaedics. We also realised that we need an organisation for paediatric orthopaedics in India. I knew Dr Benjamin earlier and had interaction with him in UK at Liverpool and other places. We had earlier discussed the idea a few times but it remained dormant.

Two Pillars of POSI Dr Ashok Johari and Dr Benjamin Joseph

Two Pillars of POSI
                    Dr Ashok Johari and Dr Benjamin Joseph

At that time the situation was very different in the country. It was a very hierarchical society. Knowledge was not freely available, there was no internet and libraries were available to select few. Books were difficult to buy. If you finished your MS and move out of college, you had no access to the library. Every senior was addressed as sir and there was wide gap between the seniors and juniors. We were lucky to have teachers like Dr Taraporewala who were very close to student. The environment outside was not so good with select few controlling associations like Indian Orthopaedic Association. So in this scenario we started POSI. We decided that Dr Benjamin will think about the constitution and membership criteria etc. and I would look into getting members and writing to orthopaedic surgeons to be part of the body. Because of the hierarchical structure, we had to involve seniors like Dr Chacko, Dr Taraporewala, and Dr Sriram. Ground work was done by me in getting the list of IOA members and writing a letter to them to get involved in paediatric orthopaedic society. We did the inaugural meeting of POSI in Mumbai, where we invited all seniors including Dr Mullaferoze who was already working as a paediatric orthopaedic surgeon, Dr Dholakia, Dr B Mukhopadhya (past president of IOA), Dr Taneja and Dr RL Mittal (IOA President) also came. This was in April 1994 and the conference was a two day conference. It started with review lectures as there was very less research at that time. The important part of this meeting was that we made members in this meeting and the society got the sanctity of seniors. The first meeting after the society was formed was organised by Dr Benjamin in Manipal. Dr Benjamin got foreign faculty from Sheffield, Dr Mike Bell and started the tradition for foreign faculties

SP: So POSI did not have much influence from foreign societies like POSNA or BSCOS? It feels more like a de novo idea.
ANJ: Yes it was more of a de novo idea as we didn’t even know about POSNA in those days and influence of American orthopaedics in India was very poor. In those days we used to look at Britain for everything and had very less contact with USA. The British Children’s Orthopaedic Society (BSCOS) was not an organised society and their annual meeting was a half day meeting where they met at some place in London and presented papers. When I was there in UK, BSCOS was in its fourth year and was a very patchy society with no structure. So when we formed POSI, there was nothing much to compare. The only example we had before us was the Spine society, ASSI (Association of Spine Surgeons of India). I remember talking to Dr Ingalhalikar who said he was going to meet Dr Dholakia as they were forming the ASSI. At that time Dr Ingalhalikar was my teacher and for him to think about making a society was fine but for juniors like us to start a society was quite unusual. But it all started with a good aim. In the first meeting there were 37 delegates and one or two foreign faculty and we were the Indian faculty. It was a very homely meeting and everyone knew everybody. I was then the secretary of POSI. The next meeting was held in Chennai since Dr Sriram was involved. In Chennai also we had few foreign faculty. Next meeting I think the meeting was in Chandigarh with Dr SS Gill who supported us a lot. Eventually the standard of the meetings started going up very fast, specially the delegates got to interact with foreign faculty. People were getting exposure to foreign faculty and lot of them started going abroad too. I remember young surgeons like Taral, Alaric, Manish Agarwal got to interact with people like Dr Kaye Wilkins. Dr Wilkins was a great entity and he brought the paediatric fracture course with him. Eventually many members went to visit these foreign faculties in their countries and thus a to and fro learning process started.

At 3rd POSICON at Chandigarh organised by Dr SS Gill. Dr Ashok Johari (then Secretary of POSI) with Dr Chacko (then President of POSI)

At 3rd POSICON at Chandigarh organised by Dr SS Gill. Dr Ashok Johari (then Secretary of POSI) with Dr Chacko (then President of POSI)

12th POSICON held at Ranchi, Jharkhand. Dr Ashok Johari as President of POSI insisted on POSICON being held in smaller towns to create awareness about the speciality of Pediatric Orthopaedics.

12th POSICON held at Ranchi, Jharkhand. Dr Ashok Johari as President of POSI insisted on POSICON being held in smaller towns to create awareness about the speciality of Pediatric Orthopaedics.

 

SP – The POSICON 2000 was really a landmark in itself
ANJ: Yes POSICON 2000 was a landmark in the sense that it had 13 foreign faculty. We had dedicated symposia involving all of them and many were able to interact with these faculties. People who are in their prime now like Taral, Rujuta, Alaric and others, were young pedipods at that time and all of them were very enthusiastic. We collected a lot of academic material and published them as proceedings of the meeting. We published titles like ‘Fracture Course’, ‘Ultrasound Hip Course’, ‘Pelvic Osteotomy Course’, ‘Cerebral Palsy Course’, ‘Spinal Instrumentation Course’ and ‘Post Graduate Instructional Course’. Mr. Macnicol had written a book on pelvic osteotomy and he sent us a copy which we could xerox and spiral bind them and distribute. Around 800 delegates came to this meeting and included not only paediatric orthopaedic surgeons but also general orthopaedic surgeons and therapists. We also conducted the postgraduate course that year. So many new things started in that POSICON

Dr Ashok Johari and Dr Benjamin Joseph in Kochi, Japan 1996, attending the Asia Pacific Orthopaedic Association meeting. They were invited fellows by the Japanese Paediatric Orthopaedic Association

Dr Ashok Johari and Dr Benjamin Joseph in Kochi, Japan 1996, attending the Asia Pacific Orthopaedic Association meeting. They were invited fellows by the Japanese Paediatric Orthopaedic Association

Copies of Instructional Books released during POSICON 2000 still preserved at Dr Johari’s Clinic

Copies of Instructional Books released during POSICON 2000 still preserved at Dr Johari’s Clinic

Gowerdhan Ingale: Sir, please share your childhood episode of ‘Sadhana’
ANJ: Ok so before I forget, I will share that story before we come back to POSI again. I was learning Indian classical music in my young age and was singing quite well. I had a good rank in all India exam and our teacher was encouraging us to do ‘Riyaz’ (practise). I wondered what riyaz was and asked my teacher to teach us riyaz. He agreed on one condition that I had to go and wake him up in morning and then he would come with me to my house and teach me to riyaz. So I used to get up at 3.00 am and get ready and go to his place in Mahim by 3.30 am and wake him up. He used to get ready and then come with me by around 5 am and then we did riyaz till 6.30 – 7 am. Then he would have breakfast with us and go at 7.30 am. My teacher was such a wise man, he didn’t say that I will come and teach you, but made me come to his house and get him and earn the riyaz. That discipline inculcated the feeling of devotion ‘Sadhana’ and that is what Gowerdhan reminded

In company of young orthopaedic surgeons, (L to R) Dr Kumar Dussa, Dr Tushar Agarwal, Dr Farokh Wadia, Dr Alaric Aroojis, Dr Ashok Johari and Dr Taral Nagda. Four of these 5 are now Paediatric Orthopaedic Surgeons

In company of young orthopaedic surgeons, (L to R) Dr Kumar Dussa, Dr Tushar Agarwal, Dr Farokh Wadia, Dr Alaric Aroojis, Dr Ashok Johari and Dr Taral Nagda. Four of these 5 are now Paediatric Orthopaedic Surgeons

AKS: Do you still sing?
ANJ: At times, when forced to, especially at POSICON’s! Actually a music guru comes to my house every Sunday since last two years. My son, my daughter in law and my wife learned from him and had a public program at Bhaidas hall. I couldn’t learn but my family could learn. Time is an issue and too many things to do

SP: Sir, between you becoming paediatric orthopaedic and our batch of paediatric group there was a gap of 15 years. Why such a long gap? Does this change happen in spurts?
ANJ: Yes probably my contemporaries were already doing their stuff in adult trauma and other fields. They were not really amenable to change mind-sets and were following their own teachers. I think it takes a generation forward to change the pattern. There few things that helped like Wadia posting in paediatric orthopaedics for KEM boys, where people like Atul Bhaskar, Durgesh Nagarkatti, Jayesh Trivedi, Sandeep Hemmadi, Nirmal Tejwani, Jwalant Mehta, Harish Hosalkar etc trained. Also lot of people worked at Haji Ali, Children’s Orthopaedic Hospital. Many did these posting but hardly stuck to paediatric orthopaedics

SP: Probably you were the catalyst in developing paediatric orthopaedic at least in this part of India. I think you made it clear that this is a financially viable branch to pursue.
ANJ: Yes, it was the thing of developing this specialty and that is why I shared the story of meeting my seniors who did not want me to do exclusive paediatric orthopaedics. They opined that a special interest in paediatric orthopaedic could be held but exclusive practise will fail.
Here I remember the life story of Dr Katrak who was a general surgeon who went and did his Orthopaedic surgery and also FRCS and MCh. He came back to India in 1929 and was the HOD in KEM Hospital and also Wadia in 1930. In KEM he was running the general surgery department. Wadia hospital started the orthopaedic department and wanted him to head it. This was much before the department of Orthopaedics at KEM which was formed in 1945 and this was in 1931. In his memoirs, he has written, that though he was part of general surgery, he would not see any general surgery patients but wanted to see only orthopaedic patients. He has noted many difficulties that he faced, struggling and surviving. His colleagues did not support him and patients were not sent to him. All other surgeons were doing predominantly general surgery and some orthopaedic work and he was the odd guy who wanted to do only orthopaedics. This took some time to change before the new generation of exclusive orthopaedic surgeons came up and almost 15 years later the department of orthopaedics was established in KEMH. I shared this to give an example of similar situation that happened and like Sandeep said it took a generation to build up. Inspiration goes from one generation to another. It’s very difficult to change the mind-set of contemporaries and it takes a new generation to establish new things.

In Japan for the second International Federation of Paediatric Orthopaedic Surgeons meeting: Dr Johari with Dr Sanjeev Sabharwal2nd International Federation of Paediatric Orthopaedic Societies Congress at Sendai: Dr. Johari with Dr. Sanjeev Sabharwal, Dr. Vrisha Madhuri and others

In Japan for the second International Federation of Paediatric Orthopaedic Surgeons meeting: Dr Johari with Dr Sanjeev Sabharwal2nd International Federation of Paediatric Orthopaedic Societies Congress at Sendai: Dr. Johari with Dr. Sanjeev Sabharwal, Dr. Vrisha Madhuri and others

SP: So where do you think the direction of paediatric orthopaedics in India is going?
ANJ: In our country the paediatric population is large and there are insufficient number of paediatric orthopaedic surgeon. General orthopaedic surgeons have to share the work with us, but they have limitations of their own. I think we can work on training the general orthopaedic surgeons to help them treat paediatric orthopaedic problems better. We also have to create and improve more paediatric ortho surgeons. Information about the speciality has to be established in peripheral and rural areas also. Till we can develop a strong team of paediatric orthopods, we can develop this system.
I would like to share another story about my time in UK. Dr Fixsen was a well-known paediatric orthopaedic surgeon at Great Ormond Street Hospital. He was also my MCh examiner and I visited him at GOS and used to go to meet him often in the mornings. Every afternoon he would disappear and when I inquired he said he visits St Bart’s Hospital and does joint replacement surgery there. I was surprised as he was the most prominent paediatric orthopaedic surgeon in UK. He said paediatric orthopaedic is not really a viable speciality in England anymore because their population was declining and he didn’t know anyone in England who did exclusive paediatric orthopaedics. So even in England there were no pure paediatric orthopaedic surgeons and everyone was doing additional adult work

SP: So how did the Americans’ develop the speciality of paediatric orthopaedic with dedicated hospitals and huge institutes? Was it a different thought process, was it philanthropy or they had history which was more than 100 years?
ANJ: We have to take this by understanding the backdrop of development of paediatric orthopaedics in India, UK and USA. British did not believe in developing specialities. They believe that they had now treated the child’s hip and in future when the child develops hip arthritis, they should be able to treat them in adulthood too.
In America, the first hospital in Orthopaedics was the Hospital for Special Surgery (HSS) which was then called the New York Hospital. It was started to look at special cases, like crippled children and those with skeletal anomalies. Then later it expanded to include other things. I think the scale of thought of Americans was large probably. I think they applied their mind to specialisation and specialist societies came up very fast. Why they would apply so, baffles me still. For example before POSNA there were precursors known as Paediatric Orthopaedic Society (1971) and Paediatric Orthopaedic Study Group [1974]. So they started quite early.

With Dr David Marks, Spine Surgeon from Birmingham, discussing early onset scoliosis

With Dr David Marks, Spine Surgeon from Birmingham, discussing early onset scoliosis

SP: Do you think philanthropy played an important role in USA. Like the DuPont Centre and Gillette Centre of Cerebral Palsy?
ANJ: May be and I think surely. Here in India, philanthropy is not really strong. Also priorities are different. As individuals we are very bothered of our children but collectively we are not. For example in 1987-1989, the Children’s Orthopaedic Hospital had a huge piece of land which I suggested to develop a Children’s orthopaedic centre. They were very much opposed to that idea. At that time, Mrs. Anita Garware, wife of Mr Garware, an industrialist, came on board of COH and she liked this idea. She tried different sources of philanthropy including Tata’s, Mahindra’s etc but ultimately it failed till recently. So even in the city of Bombay it was not possible through philanthropy. I think everything boils down to returns when compared to a cardiac hospital or a joint replacement hospital. So pure philanthropy did not come and I think this is failure of vision as it is an essential thing to take care of our children. At the same time big hospitals like Texas Scottish Rite Hospital for Children and others were coming up in USA. I am thinking hard of the reason but I think we were introduced to orthopaedic surgery much later when it had already developed into a branch catering to adults. Americans started orthopaedics to cater to children, so HSS also was started as a children’s centre. Probably this is one of the reason why paediatric orthopaedic developed fast and on a large scale in USA as traditionally they had children’s hospitals.
Returning back to POSI, I am happy that it has become a viable and vibrant body. I was secretary for first seven years from 1994 to 2001 by which time we had 300 members. We were never keen on big numbers but we wanted people who joined to be interested in paediatric orthopaedics. Dr Benjamin, when he first proposed the idea for POSI membership, included MS Ortho criteria, and experience in children orthopaedics for one year and also three publication in paediatric orthopaedic. It was difficult to convince him otherwise but finally we kept these criteria only for office bearers rather than members. This largely kept the body out of politics and maintained the academic flavour. I am happy that the body is growing very well academically and we have good meetings and good papers. The standards are going higher and higher every year.

Receiving award for his 17 years of service to POSI - At POSICON 2011 in Chandigarh

Receiving award for his 17 years of service to POSI – At POSICON 2011 in Chandigarh

AKS: Sir, please tell us about your work with JPO-B?
ANJ: I was on the editorial board of JPO-B much earlier. JPO-B was started by Henri Bensahel who was the founding editor from 1992 to 2006. The EPOS was the group which JPO-B was meant to represent. However, the journal was held by publisher Wolters- Kluwer and EPOS wanted to have its own journal. Bensahel stepped down for the same and publishers were searching for someone to replace him who had a good hold of academics, English and reviewing. Surprisingly I got a mail from the publisher inviting me to take up the job of Editor or recommend someone. I thought it was a good opportunity for us, especially for the Asian group. Although JPO-B was a European journal but I thought eventually it will extend to also represent Asia Pacific. Earlier the work load was not much and I worked for one year smoothly and they gave me a three year appointment and a second renewal was for additional 6 years. It has been good for us as it encourages publication from Asian side, also lot of European and American crowd still publishes in JPO-B. The number of articles has gone up exponentially, like in Jan and March this year (2016), I am processing around 200 articles. We can’t really cope with this load and have delays but the journal is going very strong.

AKS: Any advice for IJPO?
ANJ: I think IJPO has a different role to play. I think high level publications can go to journals like JPO-B specially when needed for promotions etc. I get desperate emails often for final result as promotions of authors hinge on these publications. But there is a need for a journal that is more practical and serves the general orthopaedic surgeon and educates them in good paediatric orthopaedic practices. IJPO can publish articles like technical notes and reviews which is very difficult in JPO-B as we have to give space to original articles.

AKS: Thanks sir, IJPO is planned on these lines to become a more practice based journal with practical knowledge. Also IJPO is now indexed as per MCI criteria and articles published in IJPO are considered for promotions by MCI.
ANJ: That is very good indeed

SP: Any ambition for the next 10 years?
ANJ: I simply want to review my work, publish more and do more research. Some of my own work is pending for years. I want to do something more for the younger generation in terms of education.

At POSICON 2012 - In a relaxed Mood

At POSICON 2012 – In a relaxed Mood

Unwinding at POSICON

Unwinding at POSICON

SP: Do you feel that subspecialties in paediatric orthopaedic will come up? Or even centres of paediatric orthopaedics, like Boston Children Hospital which has 34 paediatric orthopaedic surgeons working together
ANJ: Yes, subspecialization will happen over a period of time but it will happen only when there is broader spread of paediatric orthopaedics in the country. It may take more than 10 years to happen. About paediatric centres, it is something to do with our genetics or mind-set. I think people don’t actually trust each other in this country, may be because of bad experiences. People may be all for humanity but many a times people are very self-centric. Probably because nobody reciprocates. If people are self-centric, it is very difficult to come together and then centres like that will be difficult. Even multicentre work and research becomes difficult. We should aim for changing this environment. The future orthopaedic surgeons should be open about their work, results and should be honest with each other. IF we can create this environment, nobody can beat us with the workload that we have. With our research we should be able to answer our own clinical problems.
AKS: Sir, you have been part of many national and international bodies like IOA etc. What according to you is role of these bodies?
ANJ: I have been through many association and realised that people come together for an event, possibly just to take lime light. What I find lacking is group of people sincerely working behind the scenes to develop the organisation. AAOS is great today because people are working behind the scene. Everyone takes their post very seriously and they have a system of audit and regular appraisal. For example in IOA, every president was inducting more and more executive committee members and at one time we had more than 100 EC members. I felt this was not good when only handful people were working. When I was President of IOA, I reduced the number of people in EC and many were not happy. But I think that is the way forward. This can very well happen in smaller societies rather than in a large society like IOA.

Dr Johari as President of Indian Orthopaedic Association during IOACON 2010, Jaipur

Dr Johari as President of Indian Orthopaedic Association during IOACON 2010, Jaipur

Dr Johari as President of Indian Orthopaedic Association during IOACON 2010, Jaipur

Dr Johari as President of Indian Orthopaedic Association during IOACON 2010, Jaipur

AKS: What are your hobbies?
ANJ: Right now I don’t have much time (laughs) but in the past I had lot of hobbies. I was a President scout with a golden cord and 48 proficiency badges and was troop leader for Bombay. When we attained proficiency in a skill say like cooking, we received one badge. My shirt was full of badges. I had the jungle goph, meaning I could survive in a jungle. I was in NCC air wing for three years. I had a pilot’s license and I would fly under supervision. I had learnt music. I was editor of the college magazine and also Research Journal of Grant Medical College Research Society. I attended special workshop for journalism. Drawing, painting and cartooning were also there. I had lot of extracurricular activities at the right time. I also did live the campus life in college with socialising and was acting GS for Grant Medical College. I was also a historian of sorts and did work on the history of Grant Medical College and life of Sir Robert Grant. I spent lot of time, around 2 months, digging up all the papers and articles from the Government’s archives about how the Grant Medical College was started a 150 years ago. I went through letters that were send from here to queen Victoria etc.
I used to read lot of fiction in young age and used to finish books like Enid Blyton or Agatha Christie in a day. Also I was interested in philosophises like J Krishnamurti, Osho etc.

 

AKS: Any particular philosophy that has impacted you, of course they keep on changing, but do share your views
ANJ: I have been affected by many philosophies but even now sometimes I go back to writings of Vivekananda and I am really impressed by his writings. He is not talking of mysticism but of practical life. J Krishnamurti spoke in lot of abstract terms. As a child I had met him when he used to come to JJ School of Arts. I had also attended Osho’s meetings. They were very learned people, especially Osho for his breadth of knowledge. I have read them and have enjoyed reading them. Vivekananda’s eloquence is exceptional and his writings are as if he is directly speaking to you. But yes, no particular philosophy, If you take my personal philosophy you may say Humanism, that is, to be good to people around you.

AKS: I understand that you have been a very positive person, but do you have any regrets?
ANJ: It’s always been a problem of call of duty versus family obligations. For example, if I have made a commitment long back and at the time something comes up in family where I am needed, I have always chosen my commitments. I have always taken my commitments more seriously as I think in the family someone can represent me. In that sense my personal life has suffered but I know we can’t be at everyplace every time. But I feel where I can be represented I can go with the option, but where I have to give a talk, personally conveying my message is more important.

AKS: How do you cope with hectic schedules? How do you take care of your health?
ANJ: Well by taking everything out of every minute. And about health I really don’t take much care about it. Family is always worried as I never take care of health, never sleep well.

SP: If you look as Sir’s life he has lived it to the fullest. In the short span, the amount of accolades that he has gathered is so very impressive. Every minute he has made it count.
ANJ: Yes, I always felt that, it’s not how long you live that matters but how well you live. How well means that whatever you have in your mind you can realise, achieve and accomplish. Somehow my accomplishments are not in building hospital or anything else. Mine are more of clinical and academic accomplishments which is something that I understand.

AKS: How would you like the legacy of Dr Johari to be known as?
ANJ: I don’t know if I will leave a legacy at all! I have studied the lives of many people in the past and very few were fortunate enough to leave behind any legacy. They were all big people in orthopaedics and not common orthopaedic surgeons. I think good deeds are always forgotten. Like good you did for your patients will be forgotten, probably they will remember for their life time but nothing after that. I am a firm believer that our legacy is through our students who will remember you. They may or may not acknowledge it. Like when I started in paediatric orthopaedics, the spectrum of problems I saw, I had nowhere to fall back on. I hope I was able to create a fall back for my students through my work in academics. But it’s difficult to leave a legacy and shelf life of legacy is becoming shorter. Also because so much of advancement is taking place, older techniques are replaced by new ones. Best is to live life to the fullest and when your job is done, leave. But that doesn’t mean you leave your work, do it to the best of your abilities. Many things that you do are circumstantial, but you had taken up the opportunity and made it work.
SP: But even 100 years down the line people will remember you for starting paediatric orthopaedics in India and nurturing and developing it.
ANJ: Yes, probably, but that’s not important. It is important that you work, but others will say that you have created a legacy, and probably the coming generations will get inspired and join paediatric orthopaedics

AKS: The main purpose of this interview was to bring forth the efforts that likes of you have taken and be inspired by it. Like for example you told us about Dr Katrak today, of whom my generation has only heard about the Katrak oration in WIROC.
ANJ: Yes Dr Katrak has actually written it down in a letter to Dr B Mukhopadhya where he describes his struggles in life. He was senior to Dr B Mukhopadhya and they might have met during some meeting. Dr Katrak was a very reclusive person and rarely socialised, but he wrote a letter to Dr Mukhopadhya and I got hold of this letter indirectly. In the letter he describes his life and the struggles he had. He said no one would support him and he had to go by public transport even after being an FRCS. He also writes about his first car where he mentions that after two years of practice, he could get a loan and buy a car to travel. There were very few surgeons in Bombay but since he decided to do only orthopaedics he had to face lot of difficulties. If he had started his shop as a general surgeon he would have done very well, but he underwent a trial to establish himself as an orthopaedic surgeon. So there are people who have sacrificed a lot for the speciality and they should be remembered.

AKS: You must have come across certain misconceptions about ‘Yourself’ that are part of the folklore? Anything in particular you wish to comment on?
ANJ: Sometimes colleagues are upset about my traits of meticulousness and perfection but I firmly believe in those qualities. It definitely reduces your output but once a job is done, you do not have to look back and revise and from the patient’s point of view, this definitely works well in reducing complications.
AKS: What technical tips would you give for someone who has just embarked on his career as an Orthopaedic surgeon?
ANJ: To be a lifelong student of the science and art of Orthopaedics. We are very lucky to be working in this field which is both a science and an art and our lives should embody the best of both!

How to Cite this Article: AN Johari. Dr Ashok Johari – A Unique Journey of a Paediatric Orthopaedic Surgeon. International Journal of Paediatric Orthopaedics May-Aug 2016;2(2):2-7.

Dr Ashok N Johari

Dr Ashok N Johari

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IJPO – New Educational Initiatives

Volume 2 | Issue 3 | Sep – Dec 2016 | Page 1-2| Sandeep Patwardhan, Taral Nagda, Ashok Shyam

Authors :Sandeep Patwardhan [1], Taral Nagda [2], Ashok Shyam [1],[3]

[1]  Sancheti Instittue for orthopaedics and Rehabilitation, Pune, India.
[2] Institute of Pediatric Orthopedic Disorders Mumbai India.
[3] Indian Orthopaedic Research Group, Thane, India

Address of Correspondence
Dr Ashok Shyam
IORG House, Mantahn Apts, shreesh CHS, Hajuri Road, Thane
Email: dr ashokshyam@gmail.com

IJPO – New Educational Initiatives

International Journal of Paediatric Orthopaedics has successfully completed second year of regular publication and we thank our readers, reviewers, authors and editorial board members for their support. Now we are ready to undertake more serious roles in our academic endeavours. There two main focus of IJPO, Research and Education. Role of a journal as an Education portal has been limited since most journals currently focus on the new research and original articles. At IJPO we have kept our focus on the educational front from the very first issue
IJPO has the tradition of including a symposia in every issue and we have completed symposia on certain complex topics like paediatric supracondylar humerus fractures [1], neglected clubfoot [2] and radial club hand [3]. These symposia are written in an easy narrative review patterns and are written by authors that are actively involved in treatment of these diseases. The reviews have practical learning points and are most of the time case based, thus making it easier to read as well as relate. If the readers can relate to the journal and use the practical points in their clinical practice, that would be the greatest testimonial to IJPO. To that end we are trying to use the technology to make the content more user friendly. Videos have been shown to be more effective that text in terms of appeal for the users as well as the visual impact. We are trying to use this concept in three different ways for IJPO. From next issue we will be inviting the article summary in a PowerPoint format which will then be converted to a video to make up a video abstract and posted online. The concept of video abstract is absolutely novel and has just been introduced in our Journal of Orthopaedic Case Reports in Dec 2016 [4]. The world is rapidly advancing in terms of its technological tastes. The screens are getting smaller and many access the journals on mobile platform where reading text may be a problem. Video abstracts in PowerPoint format will help the reader get the summary of the paper in a nice video format which they can easily browse and play on the mobile devices. We shall in future ask the authors themselves to record themselves either presenting the PowerPoint or even directly talking to the readers summarising important points in their articles. This will also create a different kind of interaction among the authors and the readers. IJPO has the policy of including the author’s photographs in the article and with inclusion of video abstract with authors speaking to the readers, a new kind of interaction will be forged. Our second attempt will be focussed on including surgical technique videos in all our original articles that describe a surgical technique. We believe this will give readers an insight into the procedure that authors are performing and will help in forming clear perspective of the paper. Also many surgeons have certain tricks and minor improvisations in surgical techniques which will be helpful to many. Our section of surgical techniques will also be based on similar concept where demonstration of surgical techniques by experts will be included. This is specifically useful in learning practical clinical tips as suggested by recent randomised trial [5]. This approach may also help in accelerating the surgical learning curve for new procedures [6]. In addition we will also be partnering with Ortho TV portal for providing more exclusive and dynamic content to our readers. Ortho TV is an upcoming portal of Orthopaedic Research group that will have exclusive video content put online by various organisations and societies. We will also be putting content from IJPO specially the video abstracts on Ortho TV for listing. This will gain us a wider audience and will improve the outreach of the Journal.
We wish to keep IJPO as well as our other journals in forefront of technological developments and intend to use technology to its fullest. This will help us put forth the content is a more effective format as well as cater to the changing taste and times of the coming generation.
We wish IJPO to be an education as well as an Academic Portal. When we say portal, we mean the entire package of web portal and the print version. We solicit the support of the paediatric orthopaedic community to help us in realising this ambitious project. This is a huge task and cannot be done without the help of the paediatric orthopaedic community. We invite suggestions and comments from all of you to create a better Journal which is future ready
Thanks again for supporting IJPO and we look forward to an interactive 2017

References 

1. Patwardhan S, Nagda T. Editorial. International Journal of Paediatric Orthopaedics July-Sep 2015;1(1):1.
2. Agashe M. Neglected clubfoot: Patho-anatomy and clinical features. International Journal of Paediatric Orthopaedics Jan-Apr 2016;1(2):2-5
3. Mehta R. Editorial – Radial Hemimelia Par I. International Journal of Paediatric Orthopaedics May-Aug 2016;2(2):8.
4. Shyam A. Video Abstracts – A new approach to Academic Publications. Journal of Orthopaedic Case Reports 2016 Nov – Dec 6(4): 1-2.
5. Buch SV, Treschow FP, Svendsen JB, Worm BS. Video- or text-based e-learning when teaching clinical procedures? A randomized controlled trial. Adv Med Educ Pract. 2014 Aug 16;5:257-62.
6. Ibrahim AM, Varban OA, Dimick JB. Novel Uses of Video to Accelerate the Surgical Learning Curve. J Laparoendosc Adv Surg Tech A. 2016 Apr;26(4):240-2.

How to Cite this Article: Patwardhan S, Nagda T, Shyam AK. IJPO – New Educational Initiatives. International Journal of Paediatric Orthopaedics Sep – Dec 2016;2(3):1-2

Dr Sandeep Patwardhan

Dr Sandeep Patwardhan

Dr Taral Nagda

Dr Taral Nagda

Dr Ashok Shyam

Dr Ashok Shyam

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The Use of Distraction Techniques in Treating Radial Clubhand

Volume 2 | Issue 3 | Sep-Dec 2016 | Page 12-15| Milind Chaudhary

Authors : Milind Chaudhary [1]

[1] Director, Centre for Ilizarov Techniques, Chaudhary Hospital, Akola, Maharashtra, India

Address of Correspondence
Dr Milind Chaudhary
Director, Centre for Ilizarov Techniques, Chaudhary Hospital, Akola, Maharashtra, India
Email: milind.chaudhary@gmail.com

Abstract

Radial club hand is a complex anomaly and requires customised approach. Distraction techniques are useful as alternative and adjunctive procedures +in various stages of management of radial club hand. The main use of distraction is to lengthen the ulna and correct its deformity and distraction prior to centralisation of hand reduce tissue dissection. Distraction can also be used as a precursor to microvascular joint transfer, to correct residual deformities in radial clubhand and as an adjunct to the operation of ulnarization The present article details the use of distraction techniques in radial club hand and provides insight into its principles based on authors experience.
Keywords: Distraction, radial club hand.

Introduction

Radial club hand or radial hemimelia is a difficult congenital anomaly to treat. There is a severe manus valgus deformity at the wrist due to a partial or complete absence of the radius. Movements of the elbow and interphalangeal joints of fingers are restricted. There is a high incidence of aplasia and hypoplasia of the thumb [1,2].
Treatment aims to correct deformity at the wrist to improve the appearance and hopefully the function as well. Untreated patients adapt well to the deformities and have reasonable function. The shortened forearm and deformed wrist are unsightly. Distraction techniques help lengthen and correct deformities of the bones. Distraction lengthens the shortened and deficient soft tissues as a precursor to centralization of the wrist. External fixation and distraction help assist Ulnarization of the wrist.

For lengthening & deformity correction of the bones
The condition occasionally presents itself as a shortening of the Radius. Distraction lengthening of the distal radius equalizes length to that of the ulna to match it at the distal radial ulnar joint [3,4]. Though uncommon, it is the simplest of all treatment modalities(Fig1).

A monolateral fixator is easy to use with two half pins in the proximal and distal fragment each. An angulation translation osteotomy corrects the bowing deformity of the proximal ulna. A large deformity can be corrected percutaneously. In this situation, it is better to perform the surgery using the Ilizarov external fixator. A 5/8 th ring fixed proximally at the elbow is kept open anteriorly to allow flexion of the elbow joint. The distal ulnar ring can be a full one.
The hand is fixed with a ring with wires and half pins. Distraction in the concavity corrects the radial deviation deformity. The hand ring also prevents deformities that may arise with distraction.
Deformity at the carpus can be corrected with an angulation-translation osteotomy of the distal ulna without resorting to open surgery. Ulnar bow is corrected by angulating the distal ulnar fragment with medial translation. This helps buttress the wrist and improve the appearance of the hand (Fig. 2).


Lengthening of the radius equalizes radio –ulnar length in acquired clubhand due to growth arrest. The aim is to correct the length deficit as well as angular deformity of the lower end of radius and to try and match it to the distal ulna [5,6] . The physeal arrest must also be addressed on its merits and a physeal bar resection must be performed.

The use of distraction techniques as a precursor to Centralization
Deformity correction by centralization is popular and the aim is to get the ulna to be collinear with the lunate, capitate and third metacarpal. Extensive soft tissue release with resection of the capsule is needed to get the carpus in line with the ulna. The deficiency of the soft tissues as well as skin on the radial side makes this a difficult task. Many have also described the role of pre-centralization distraction. It is an attractive concept as it may help reduce the extensive soft tissue dissection needed to get the carpus on top of the ulna. The soft tissue deficit causes radial deviation and ulnar subluxation of the wrist. Gradual distraction of the soft tissues doesn’t merely stretch them but lengthens them according to the law of tension stress [7]. A monolateral or circular external fixator is applied to the hand and ulna. Soft tissue elongation allows the hand to be distracted out of radial deviation & volar subluxation to enable the third metacarpal to become collinear with the ulna [ 8,9,10,11,12]. The external fixator retains the lengthened position till soft tissues mature & prevents reshortening. This may reduce the extent of soft tissue dissection needed to achieve correction.
A K wire travels from the third metacarpal going down into the capitate, lunate and ulna. Some prefer to remove the K wire at 12 weeks and retain the correction by either tendon transfers or a brace. Some prefer to leave the K wire in situ. The K wire may be passed without making any preparatory changes in distal ulna. External fixation corrects the deformity maintains the position thereafter. The distal ulna flattens out to match the surfaces of the carpus. Preserved movement and improved appearance gives a good cosmetic and functional result.
The external fixator maintains position and stabilizes the wrist. Some surgeons create a notch in the proximal carpus and insert the distal ulna in it. The notch behaves like a multiplane joint to allow movement and prevents recurrence of deformity.

Distraction techniques as a precursor to Microvascular joint transfer
There is a complete deficit of the radial side of the wrist. Any positioning of the carpus on the distal ulna is therefore unstable. Distracting the carpus out of radial deviation and volar subluxation creates space on the radial side of the wrist. Microvascular technique is used to fill this space with the second metatarsal and metatarsophalangeal joint transfer. The bone is fixed to the ulna in a Y shaped manner [13,14]. The advantage of this method is that a proper joint is created and buttress support to the radial aspect of the wrist is permanent. However, long term studies are lacking on how these transfers perform. The microvascular technique itself is rather complex and such skills may not be available at all centres which makes their application rather limited.

Distraction techniques to correct residual deformities in Radial Clubhand
A common complication of centralization is recurrence of the deformity. Since K wires are removed after a few weeks (or may migrate proximally), recurrence of the deformity is likely due to re-shortening of the fibrotic and inelastic soft tissues. The extensive dissection of the distal ulna may damage its blood supply and result in distal ulnar growth arrest with deformities and shortening. In these situations, a circular external fixator [15,16,17] can easily correct the residual deformity by soft tissue distraction of the hand and wrist. The hand is brought out of the radial deviation and volar subluxation and repositioned on top of the distal ulna. Passing a K wire, or creating a trough for the ulna or by a wrist arthrodesis creates stability. Prolonged bracing may also help. Percutaneous osteotomy helps correct deformities at any level in the ulna. Proximal ulnar lengthening can be added as well. (Fig. 3)
Corticotomy lengthening and gradual correction of the angular deformity are possible in the proximal ulna. Compression between the distal ulna and carpus helps fuse the wrist.

Distraction as an adjunct to the operation of Ulnarization
Wrist and finger movement are more important than maintenance of hand forearm angle for long term hand function [18]. However, fingers are usually stiff to start with and cannot be influenced by surgery. Centralization or radialization reduce movement at the wrist even without fusion. Recurrence of the radial deviation and volar subluxation deformity of the wrist is common.
Creating a notch in the wrist with residual deformity may eventually need an arthrodesis. Combined with the restricted movements in the elbow and PIP and DIP joints of the fingers stiffness of the wrist can contribute to functional disability.
Paley described Ulnarization to correct the deformity, retain movement at the wrist and prevent its recurrence [19]. This is an advanced technique of reconstruction of the deformities of radial clubhand. It prevents the problems associated with the previous methods of treatment, namely: recurrence of the deformity, stiffness of the wrist and distal ulnar growth arrest.
Ulnarization shifts the wrist and hand from radial to the ulnar side of the distal ulna. The ulnar border of the distal ulna mechanically prevents radial deviation of the wrist. (Fig. 4).


The second part of the operation transfers the flexor carpi ulnaris tendon from the pisiform to the dorsal side of the wrist. The operation can be performed as early as 15-18 months of age. Magnification with a surgical loupe helps preserve small vessels in surgery in very young children. Pollicization of the index finger can be performed at a later date.
The incision begins at ulnar border of lower humerus, extends across the forearm, goes towards radial aspect wrist and then back along the wrist crease in a Z to open in the palm. The radial extension helps to create a pocket on the radial side of the distal forearm and wrist joint in which the distal ulna can be translocated. The blood supply to the distal ulnar epiphysis comes from the radial side and should be preserved while freeing the distal ulna from the wrist capsule. The tendons dorsal to ulna are released by sharp dissection from the distal ulna. Complete release of capsule from the radial, volar and dorsal sides helps mobilize the distal ulna.
Gentle dissection creates a pocket on the radial side of the distal forearm allowing the distal ulna to slide from the dorsum of the wrist towards its radial aspect. Care is taken to prevent subluxation of wrist and hand on the volar or dorsal side of distal ulna. It is fixed to the hand and wrist with a K-wire for a few weeks. Ilizarov fixator fine tunes position of the hand and wrist on the distal ulna. It may also be used for an osteotomy of the proximal ulna if grossly deformed. The distal ring is distracted to improve the tension in the soft tissues and transferred tendons.
Prominence of the distal ulna on the radial side of the wrist looks like a prominent radial styloid. The appearance of the entire forearm and hand is dramatically improved. The FCU is transferred to the dorsal ulnar side of the wrist to the base of the fifth metacarpal. The wrist can dorsiflex due to transferred action of flexor carpi ulnaris. Muscles on the radial side of the wrist are usually absent and unavailable for tendon transfers.
The author has performed five procedures in four patients over the last seven years. Age has ranged from 2 to 18 years of age. Follow-up has now ranged from a period of three years to eight years. A short period of bracing or casting was needed in two of our cases. The improved appearance of the hand was satisfactory for all of our patients. There was a mild recurrence of the volar flexion deformity at the wrist in 2 of five patients. There was very little recurrence of radial deviation deformity. Three had aplasia of the thumb for which they have not yet come for pollicisation. Poor hand function has been chiefly due to lack of the thumb and stiffness of the fingers.

Conclusion

Distraction techniques using monolateral and Ilizarov external fixators have an important role in the treatment of Congenital Radial club hand. They help lengthen the short radius and the shortened ulna along with deformity correction of the ulna either at the proximal or distal level. They ease the operations of centralization of the wrist by reducing the need for extensive soft tissue distraction. Recurrent deformities are easily corrected by distraction techniques. It aids displacement of the carpus to the ulnar border of distal ulna in Ulnarization.  This procedure improves appearance of the hand by correcting the deformity, prevents its recurrence but preserves the mobility of the wrist.

References 

1. Lamb DW. Radial club hand. A continuing study of sixty-eight patients with one hundred and seventeen club hands. J Bone Joint Surg Am. 1977 Jan;59(1):1-13.
2. Bora FW Jr, Osterman AL, Kaneda RR, Esterhai J. Radial club-hand deformity. Long-term follow-up. J Bone Joint Surg Am. 1981 Jun;63(5):741-5.
3. Tetsworth K, Krome J, Paley D. Lengthening and deformity correction of the upper extremity by the Ilizarov technique. Orthop Clin North Am. 1991;22: 689-713.
4. Takagi T, Seki A, Mochida J, Takayama S. Bone lengthening of the radius with temporary external fixation of the wrist for mild radial club hand. J Plast Reconstr Aesthet Surg. 2014 Dec;67(12):1688-93.
5. Zhang X, Duan L, Li Z, Chen X. Callus distraction for the treatment of acquired radial club-hand deformity after osteomyelitis. J Bone Joint Surg Br. 2007 Nov;89(11):1515-8
6. Hosny GA, Kandel WA. Treatment of posttraumatic radial club hand with distraction lengthening. Ann Plast Surg. 2013 Nov;71(5):489-92.
7. Ilizarov G.A. Clinical effect of the tension stress effect for limb lengthening. Clin. Orthop. Rel. Res.1990 Jan (250) 8: 26.
8. Sabharwal S, Finuoli AL, Ghobadi F. Pre-centralization soft tissue distraction for Bayne type IV congenital radial de¬ficiency in children. J Pediatr Orthop 2005;25(3):377-81.
9. Kanojia RK, Sharma N, Kapoor SK. Preliminary soft tissue distraction using external fixator in radial club hand. J Hand Surg Eur Vol. 2008 Oct;33(5):622-7.
10. Thirkannad SM, Burgess RC. A technique for using the Ilizarov fixator for primary centralization in radial clubhand. Tech Hand Up Extrem Surg. 2008 Jun;12(2):71-8.
11. Saini N, Patni P, Gupta S, Chaudhary L, Sharma V. Management of radial clubhand with gradual distraction followed by centralization. Indian J Orthop. 2009 Jul;43(3):292-300.
12. Bhat SB, Kamath AF, Sehgal K, Horn BD, Hosalkar HS. Multi-axial correction system in the treatment of radial club hand. J Child Orthop. 2009 Dec;3(6):493-8.
13. Vilkki SK. Distraction and microvascular epiphysis transfer for radial club hand. J Hand Surg Br. 1998 Aug;23(4):445-52.
14. de Jong JP, Moran SL, Vilkki SK. Changing paradigms in the treatment of radial club hand: microvascular joint transfer for correction of radial deviation and preservation of long-term growth. Clin Orthop Surg. 2012 Mar;4(1):36-44.
15. Kawabata H, Shibata T, Masatomi T, Yasui N. Residual deformity in congenital radial club hands after previous centralisation of the wrist. Ulnar lengthening and correction by the Ilizarov method. J Bone Joint Surg Br. 1998 Sep;80(5):762-5.
16. Damore E, Kozin SH, Thoder JJ, Porter S. The recurrence of deformity after surgical centralization for radial clubhand. J Hand Surg Am. 2000 Jul;25(4):745-51.
17. Shariatzadeh H, Jafari D, Taheri H, Mazhar FN. Recurrence rate after radial club hand surgery in long term follow up. J Res Med Sci. 2009 May;14(3):179-86.
18. Hand function in children with radial longitudinal deficiency Anna Gerber Ekblom, Lars B Dahlin, Hans-Eric Rosberg, Monica Wiig, Michael Werner, Marianne Arner BMC Musculoskeletal Disorders 2013, 14:116.
19. Paley D, Robbins CA. Ulnarization for treatment of radial club hand. Limb Lengthening & Reconstruction Surgery Case Atlas. Switzerland, Springer International 2015 Jan:1-11.

How to Cite this Article: Chaudhary M. The use of distraction techniques in treating radial clubhand. International Journal of Paediatric Orthopaedics Sep-Dec 2016;2(3):12-15.

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Ulna Osteotomy Role – Methods, Timing, Combo Procedures, Recurrences and Re- Osteotomy

Volume 2 | Issue 3 | Sep-Dec 2016 | Page 16-18| Premal Naik, Hitesh Chauhan

Authors : Premal Naik [1], Hitesh Chauhan [1]

[1] Rainbow Rainbow Super Speciality and Children Orthopaedic Hospital, Ahmedabad.

Address of Correspondence
Dr Premal Naik
Rainbow Rainbow Super Speciality and Children Orthopaedic Hospital, Ahmedabad.
Email: premalnaik@gmail.com

Abstract

Ulna bowing is common occurrence in radial club hand and depends on the severity of the deformity. Centralisation takes care of the wrist stability and deformity however ulna deformity if ignored may continue to progress and cause significant forearm deformity. Current recommendation it to perform Ulna osteotomy at the time of index procedure of centralisation, if the ulna deformity is more than 30 degrees. Current article describes the technique and methods of ulna osteotomy.
Keywords: Ulna osteotomy, radial club hand.

Introduction

Congenital radius deficiency, or radial hemimelia, is characterized by a hypoplasia or complete absence of the radius. In radial hemimelia, ulnar bowing plays a significant role in overall deformity. Severity of ulnar bowing is mostly proportional to severity of radial hypoplasia.
Centralization for correction of radial hemimelia was proposed in 1894 [8] and has been modified later on by many surgeons [1, 2, 6, 7, 10]. It has shown significant improvement in overall wrist function and strength but correction of forearm deformity i.e. correction of ulnar bow has not been given due importance.
Progressive ulnar bowing is an important late complication after centralization surgery, when forearm deformity is severe and is not corrected [1, 5, 9]. There remains a dilemma whether to correct ulna bowing during the index procedure or to perform it at a second stage.

Ulnar bowing – Current scenario
Ulnar bow is the angle formed by the intersection of the distal ulnar bisector line and a similar line drawn for the proximal ulna (Fig.1) [3]. Severity of forearm deformity depends on the severity of radial hypoplasia. Radial hemimelia with complete absence of radius (Bayne and Klug type III & IV) present with severe forearm deformity as compared to mild hypoplasia (Bayne and Klug type II).
According to Bayne and Klug and few other reports, ulnar bow was considered to be significant if angular deformity is more than 30°. They did not recommend corrective osteotomy of the ulna if the angular deformity was less than 30° [1] .
According to Geck MJ et.al ulnar osteotomy was performed for ulnar bow greater than 30° and for milder deformity of less than 30° it was done only if needed, to pass the transfixing pin[3].
Timing and method of ulna osteotomy is not defined clearly in literature and depends on surgeon’s preference. It is either performed during index procedure or can be done at a second stage[3, 9]. Few surgeons prefer to correct ulnar angulation at the time of lengthening[4].
In Geck MJ et.al series, 13 ulnar osteotomies were performed along with index procedure and 4 osteotomies were done as secondary procedure. The ulnar osteotomy was performed at the apex of deformity when deformity is more than 30° and in less severe deformity, it was performed wherever k wire could not be passed thorough ulnar shaft. Osteotomy was transfixed with same k wire, which is fixing the wrist. Wire was removed at 8 – 12 weeks. They noted no statistically significant difference of results between osteotomy done along with index procedure or as secondary procedure at the final follow-up. They could achieve statistically significant correction in ulnar bow from preoperative measurement to final follow-up measurement and found that Ulnar osteotomy did not have a deleterious effect on the correction of the wrist deformity [3].
H. Kawabata and colleagues recommended correction of congenital radial club hand by staged procedures. The first is centralization followed by lengthening of the ulna and correction of the angular deformity using the Ilizarov method. In their series mean angular deformity was 42°. Full correction of angular deformity was done in six out of seven patients but at final follow up mean correction was 57 % of initial correction [4].
Deformity recurrence and revision is an important issue in surgical correction of congenital radius deficiency. Revision surgery is mostly attributed to recurrent increased hand forearm angle or increased radial translation at wrist as compared to recurrence of ulnar bow[4, 9].
Due to poor growth potential of ulnar physis, recurrence of forearm deformity after correction is mostly not significant[4]. Geck MJ showed that there was no statistically significant difference between the postoperative and final follow up ulnar bow in patients with and without ulnar osteotomy[8].
According to H. Kawabata, recurrence of ulnar bowing was due to muscle imbalance which was exaggerated by the lengthening. The recurrence was least in a wrist with well-balanced muscle forces. So they proposed first centralization procedure is of great importance for further Illizarov correction[4] .

Authors preferred treatment
We routinely take ‘All In One’ approach for correction of radial club hand. This includes single stage, centralization with tendon transfer and Ulna Osteotomy. Addition of ulnar osteotomy adds very little time and obviates the need for second surgery. In our center we have operated 45 extremities in 40 patients till May 2016. We presented our experience of 24 extremities in 20 patients earlier (POSICON 2013). We could achieve statistically significant improvement in wrist forearm angle and ulnar angulation in all patients. Ulnar angulation was corrected from an average of 380 preoperatively to 130 postoperatively (p value – < 0.0001) and wrist forearm angle was corrected from an average of 410 preoperatively to 130 postoperatively (p value – < 0.0001). We did not have any significant problem related to ulnar osteotomy. We found ulnar osteotomy a useful adjunct in the treatment of radial hemimelia.

Surgical technique
We use either Ewan bilobed flap of lazy S incision. After exposing the wrist a provisional track is made with k wire from distal ulnar epiphysis till apex of deformity (Fig 2a, b). One K wire is then passed from 3rd MC head transfixing carpus over distal ulna and advanced in distal ulnar shaft till apex of deformity (in previously made tract).
Nail tip (at the apex of the deformity) is confirmed under image intensifier guidance. Apex of bow exposed subperiosteally (Fib 2 c) and horizontal osteotomy is done (Fig 2 d), k wire is then advanced in proximal fragment under vision and brought out through tip of olecranon (Fig 2 e). In severe deformities, minimal shortening is done to correct the deformity to avoid excessive stretch and injury to neurovascular bundle. After fixation of wrist and ulna osteotomy, tendon transfer is performed. AE cast is given for 6 weeks, followed by strict splinting. K wire is kept for at least 6 months post operatively. Fig. 2 describes the surgical technique
Illustrated Case: Two month old male child, presented with left radial hemimelia(Fig 3 a). On radiological evaluatoin, there was complete absence of radius with gross bowing of ulnawith pre operatively ulnar angulation of 400 (Fig 3 b) . He underwent ‘All In One correction’ at age of 10 months (Fig 3 c). Child under went pollicisation 1 year after primary surgery. After 4 year child is having good hand function and very good overall wrist and forearm allignment (Fig – 4). On follow up, ulnar angulation was 150 (Fig. – 5).

Conclusion

We have found ulnar osteotomy (along with centralisation and tendon transfer) a very useful and powerful tool in managing radial hemimelia. Ulnar osteotomy adds extra 20-300 correction in a significantly deformed upper limb.
Ulnar osteotomy is a simple procedure and does not add significant extra surgical time. We did not have any significant complications related ulnar osteotomy. We recommend ulnar ostetomy in all cases when angulaton is > 300 or when k wire can not be passed straight through the ulna.

References 

1. Bayne LG, Klug MS. Long-term review of the surgical treatment of radial deficiencies. The Journal of hand surgery. 1987;12:169-179.
2. Buck-Gramcko D. Radialization as a new treatment for radial club hand. The Journal of hand surgery. 1985;10:964-968.
3. Geck MJ, Dorey F, Lawrence JF, Johnson MK. Congenital radius deficiency: radiographic outcome and survivorship analysis. The Journal of hand surgery. 1999;24:1132-1144.
4. Kawabata H, Shibata T, Masatomi T, Yasui N. Residual deformity in congenital radial club hands after previous centralisation of the wrist. Bone & Joint Journal. 1998;80:762-765.
5. Lourie GM, Lins RE. Radial longitudinal deficiency. A review and update. Hand clinics. 1998;14:85-99.
6. Manske PR, McCarroll HR, Swanson K. Centralization of the radial club hand: an ulnar surgical approach. The Journal of hand surgery. 1981;6:423-433.
7. Riordan D. Congenital Absence Of The Radius-a 15-year Follow-up. In: Journal Of Bone And Joint Surgery-american Volume. Journal Bone Joint Surgery Inc 20 Pickering St, Needham, Ma 02192: 1963:1783-1783.
8. Sayre RH. A contribution to the study of club-hand. Trans Am Orthop Assoc. 1894;1:208-216.
9. Shariatzadeh H, Jafari D, Taheri H, Mazhar FN. Recurrence rate after radial club hand surgery in long term follow up. J Res Med Sci. 2009;14:179-186.
10.. Watson HK, Beebe RD, Cruz NI. A centralization procedure for radial clubhand. The Journal of hand surgery. 1984;9:541-547.

How to Cite this Article: Naik P, Chauhan H. Ulna Osteotomy Role – Methods, timing, combo procedures, recurrences and re- osteotomy. International Journal of Paediatric Orthopaedics Sep-Dec 2016;2(3):16-18.

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Percutaneous centralization for Radial Club Hand – A Technical Note

Volume 2 | Issue 3 | Sep-Dec 2016 | Page 19-23 | Sandeep Patwardhan, Kunal Aneja, Ashok Shyam

Authors : Sandeep Patwardhan [1] ,  Dr Kunal Aneja [1], Ashok Shyam [1]

[1]  Sancheti Instittue for orthopaedics and Rehabilitation, Pune, India.
[2] Indian Orthopaedic Research Group, Thane, India.

Address of Correspondence
Dr Sandeep Patwardhan
Sancheti Instittue for orthopaedics and Rehabilitation, Pune, India
Email: sandappa@gmail.com

Abstract

The treatment for radial club hand (Heikel Type III and IV) in stages of soft tissue distraction, followed by centralization of carpus over ulna and later pollicisation has been reported. Traditionally the described procedure for centralization of the carpus over the ulna has been by an open approach, involving placing the growing inferior end of ulna over center of carpus and maintaining it with a K wire. Open centralization procedure is fraught with dangers of damage to cartilage, scarring and stiffness of wrist joint, thus increasing morbidity of the procedure. We describe a new technique of percutaneous closed centralization, taking advantage of pliability of soft tissues achieved by distraction method, thus preserving the biology and function. This technique, to our knowledge, has not been reported earlier and we have found it to be a simple and effective method to achieve centralization for patients with radial club hand.
Keywords: Radial club hand, percutaneous centralisation, ulna osteotomy.

Introduction

Radial club hand is a relatively rare deformity with an incidence of 0.5 per 10,000 live births [1,2,3]. Petit was the first individual to record the first case of radial club hand in the year 1733[4]. Radial club hand is divided by Heikel[5] into four types out of which Type III and IV are considered to be the most common forms[5]. These cases also tend to be associated with the greatest amount of radial deviation of the wrist. Over the years, the management of radial club hand has undergone significant changes. In severe cases (Heikel[5] Type III and IV), requiring surgical intervention for deformity correction and improvement of function, historically various surgical treatment modalities have been performed like ulnar osteotomy and splitting the distal ulna for insertion of the carpus [6], serial casting and open centralisation[7] , ilizarov correction[8,9], reconstruction by a bone graft and non-vascularized epiphyseal transfer[10],vascularized proximal fibular epiphyseal transfer[11]and pollicization[12,13].We believe, a staged treatment of radial club hand involving soft tissue differential distraction, percutaneous centralization and pollicization offers a biological solution to this complex problem, for deformity correction and to enhance function.

Procedure : Staged surgical correction of radial club hand deformity is done in the following manner-

Stage 1 : Soft tissue differential distraction
Done by Using a Universal Mini External Fixator (UMEX fixator) to slowly distract the soft tissues and correct the radial deviation. (Fig. 2 a, b)
1. Under suitable anesthesia and under all aseptic precautions, painting and draping of affected upper limb is done.
2. Two K wires of 1.5 mm diameter each are passed at mid metacarpal level, parallel to each other and passing through all the metacarpals in the coronal plane.
3. Two K wires of 2 mm diameter each are passed parallel to each other at the apex of ulnar bowing, again in the coronal plane.
4. These are connected across carpus using universal mini external fixator for soft tissue distraction, such that one connecting rod is towards the concave (radial) and the other towards the convex (ulnar) side of the deformity. It is usually possible to passively accommodate these K wires in same plane. In case it is not possible to do so, additional frame may be constructed so that the distractors are placed in a coplanar fashion. (Fig. 2c)
5. After 2nd post operative day, differential distraction is started which involves distracting at rate of 1mm/day on radial side in 4 graduated turns of 1/4th mm each and 0.5mm/day on ulnar side in 2 graduated turns of 1/4th mm each. This is taught to the child’s parents for them to continue at home.
6. Adequate pin tract care is taken with regular pin tract dressing on alternate days. Weekly X-rays are taken to confirm centralization of carpus over ulna and distraction across carpus.
7. The guided differential distraction is continued for 4 weeks till the radial deviation of hand is obliterated and the hand is visibly angled slightly to ulnar side.
8. After this is achieved, distraction is stopped and the external fixator is kept in static mode for additional one week, to allow for the soft tissues to stretch. This stretching of soft tissues allows for passive correction of deformity.
Thereafter, as a second stage procedure, external fixator is removed and percutaneous centralization of carpus over ulna is done.
On removal of external fixator frame, it is observed that soft tissue pliability achieved by distraction allows the hand to be placed in over corrected position in relation to ulna. (Fig. 3)

Stage 2: Percutaneous centralization:
1. Neutralizing the hand in relation to forearm, such that there is no visible deviation of hand in both coronal and sagittal planes. This involves holding the hand in line with the forearm in antero posterior view and also ensuring that there is no visible volar deviation of wrist in lateral view. (Fig. 3)


2. After flexing the metacarpals to 90 degrees, to make the head of 3rd metacarpal more prominent and moving the base of the proximal phalynx away, a 2mm K wire is loaded on Jacobs chuck T handle and is advanced in retrograde fashion from head of 3rd metacarpal. It is passed through the distal end of 3rd metacarpal, into its body and exited from its proximal end. (Fig. 4) The positioning of K wire within the substance of 3rd metacarpal is important and hence checked under image intensifier in both anteroposterior and lateral views. (Fig. 5)


3. With manual traction and manipulation, K wire is then centralized over mid portion of distal end of ulnar epiphysis and progressed in a retrograde manner, under image intensifier guidance. The correct selection of entry point in ulna is important to maintain the hand in neutral corrected position in relation to the forearm. Checking it under antero-posterior and lateral views of C-arm ensures that the entry point is in the center of distal ulnar epiphysis. (Fig. 6)


4. In some cases, due to bowing of the ulnar shaft, K wire may hit the apex of ulnar deformity and hence may exit more distally (middle third) in the ulnar shaft. In such cases, to allow for the K wire to exit from proximal 1/3rd aspect of ulnar shaft, following methods can be used to straighten the ulna:
Closed plastic deformation of ulna (Fig. 7) : pressure is applied over the apex of the ulnar bow with the thumb and deformity is corrected under image intensifier guidance. K wire is then guided in a retrograde fashion into the straightened ulna. This K wire prevents the deformed ulna from regaining its original contour.

Percutaneous ulnar osteotomy (Fig 8) : If plastic deformation doesn’t help achieving a straightened ulna, ulnar osteotomy may be warranted. For this, a stab incision is taken over the apex of the ulnar bowing and percutaneous ulnar osteotomy is achieved by drilling with a drill bit. K wire is then guided into osteotomised ulna such that the coronal bowing is maximally corrected (Fig. 9)


Ideally the K wire should exit from the proximal third of ulnar shaft, as proximally as possible. In cases, where minimal bowing of ulna is there and apex of ulnar bowing lies in proximal 1/3rd of ulna, neither osteotomy nor plastic deformation is required and the ulna remodels as the patient grows.
5. K wire is then progressed further proximally through the ulna such that it exits from its proximal end, as proximally as possible. A small nick is made over the skin overlying the K wire, to expose the K wire.


6. K wire is pulled out from the proximal end of ulna with a nose plier till its distal end gets completely buried just within the head of the 3rd metacarpal, to allow for free movements of 3rd Metacarpo-phalangeal (MCP) joint which is checked intra operatively. (Fig.10)


7. Excessive length of the k wire is cut off, bending and burying the remaining portion under the skin and closing the skin incisions primarily with ethilon sutures.
8. To immobilize and externally support the fixation, above elbow scotch cast is given in 90 degrees of elbow flexion for a period of 4 weeks. (FIG 11)
9. After a month, cast is removed and removable brace in the form of PVC ulnar gutter splint is given to support the wrist and forearm in neutral position. (FIG 12)


10. Active and passive range of motion exercises are encouraged for the elbow and fingers of the involved hand.
11. The K wire is kept in situ for maintaining the alignment of carpal bones over the ulna, till the distal ulnar epiphysis widens to accommodate the carpal bones. This distal ulnar remodeling is assessed with radiographs obtained on regular 3 monthly follow up visits. (Fig. 13) We believe this biological plasticity of distal ulna is better served by a closed procedure. K wire is retained in situ for an average period of 1.5 to 2 years, after which it is removed. Pollicisation is done 3 months after centralization procedure.
12. For K wire removal, under image intensifier guidance, a small skin incision is taken over the proximal end of ulna, in line with the intraosseous K wire, and blunt dissection is done to expose the proximal end of K-wire. In those cases where the wire becomes buried under bone due to cortical bone covering it, overlying bone is nibbled out and then the K wire is exposed. K wire is then removed by withdrawing it proximally through this incision. After removal, skin is primarily closed with ethilon sutures.

Discussion

The aim of this technical note is to introduce and describe an innovative technique of percutaneous centralization in staged treatment of patients diagnosed with radial club hand. Advantage of this technique is that it being a closed procedure, involves minimal soft tissue dissection, thus reducing the chances of growth plate injury and is easily reproducible after a short learning curve. The current treatment method followed, where centralization is achieved by an open technique, involves extensive soft tissue dissection and has been associated with high rates of physeal injury [14], recurrent radial deviation [15], and wrist stiffness [16]. Iatrogenic physeal injury can hamper the growth potential of the already shortened forearm and can increase the limb length discrepancy [14]. Complications of the technique described here can be infection leading to K Wire loosening and back out or bending of K wire, recurrence of deformity [15] and restricted wrist range of motion after K Wire removal. Since this staged treatment involves usage of an UMEX external fixator for soft tissue distraction prior to centralization, many parents might be apprehensive with the usage of an external fixator for 6 weeks duration, hence reducing the acceptability of this staged procedure. Many authors have described the usage of an external fixator for radial club hand correction previously. On the other hand, in those patients in whom the radial deviation of hand is passively correctable prior to the start of treatment, primary objective, which is to maintain neutral hand forearm position, can be achieved by directly percutaneously centralizing the hand without soft tissue distraction. A long term follow up study of a large sample size is required to establish the efficacy of this technique and document the complications associated with it.
Summary: The technique of percutaneous centralization of carpal bones over radius is recommended as part of a staged procedure, following soft tissue distraction with UMEX fixator. It is an innovative biological approach relying on realignment of soft tissues and remodeling of distal ulnar physis. It has been described here for treatment of Type III and IV radial club hands and for patients with age equal to or less than 2 years at the time of primary surgical intervention. Advantage of this technique is that it involves minimal soft tissue dissection and is easily reproducible after a short learning curve.

Conclusion

Distraction techniques using monolateral and Ilizarov external fixators have an important role in the treatment of Congenital Radial club hand. They help lengthen the short radius and the shortened ulna along with deformity correction of the ulna either at the proximal or distal level. They ease the operations of centralization of the wrist by reducing the need for extensive soft tissue distraction. Recurrent deformities are easily corrected by distraction techniques. It aids displacement of the carpus to the ulnar border of distal ulna in Ulnarization.  This procedure improves appearance of the hand by correcting the deformity, prevents its recurrence but preserves the mobility of the wrist.

References 

1. McCarthy JJ, Kozin SH, Tuohy C, Cheung E, Davidson RS, Noonan K. External fixation and centralization versus external fixation and ulnar osteotomy: the treatment of radial dysplasia using the resolved total angle of deformity. J Pediatr Orthop 2009;29(7):797–803.
2. Saini N, Patni P, Gupta SP, Chaudhury L, Sharma V. Management of radial clubhand with gradual distraction followed by centralization. Indian J Orthop. 2009;43:292–300.
3. Ekblom AG, Laurell T, Arner M. Epidemiology of congenital upper limb anomalies in 562 children born in 1997 to 2007: a total population study from stockholm,sweden.J Hand Surg Am. 2010 Nov;35(11):1742-54.
4. Pardini AG Jr. Radial dysplasia. Clin Orthop Relat Res. 1968 Mar-Apr;57:153-77.
5. HEIKEL HV. Aplasia and hypoplasa of the radius: studies on 64 cases and on epiphyseal transplantation in rabbits with the imitated defect. Acta Orthop Scand Suppl. 1959;39:1-155.
6. Sayre RH. A contribution to the study of Club Hand. Trans Amer Ortho Assn. 1893;6:208–16.
7. M. Farzan. Congenital Radial Club Hand : Results of centralization in 10 cases Acta Medica Iranica,2005 Vol. 43, No. 1
8. Kawabata H, Yasui N, Ariga K, Shirata T. Bone lengthening with the Ilizarov apparatus for congenital club hands. Tech Hand Up Extrem Surg. 1998 Mar;2(1):72-7.
9. Kanojia RK, Sharma N, Kapoor SK. Preliminary soft tissue distraction using external fixator in radial club hand. J Hand Surg Eur Vol. 2008 Oct;33(5):622-7.
10. Albee FH. Formation of radius congenitally absent: condition seven years after implantation of bone graft. Ann Surg. 1928 Jan; 87(1): 105-10.
11. Medrykowski F, Barbary S, Gibert N, Lascombes P, Dautel G. Vascularized proximal fibular epiphyseal transfer: two cases. Orthop Traumatol Surg Res. 2012 Oct;98(6):728-32.
12. Ceulemans L, Degreef I, Debeer P, De Smet L. Outcome of index finger pollicisation. J Hand Microsurg. 2010 Jun;2(1):13-7.
13. Fujiwara M, Nakamura Y, Nishimatsu H, Fukamizu H. Strategic two-stage approach to radial club hand. J Hand Microsurg. 2010;2:33–7.
14. Sestero AM, Van Heest A, Agel J. Ulnar growth patterns in radial longitudinal deficiency. J Hand Surg Am 2006;31(6):960–967.
15. Damore E, Kozin SH, Thoder JJ, Porter S. The recurrence of deformity after surgical centralization for radial clubhand. J Hand Surg [Am]. 2000 Jul; 25(4):745-751.
16. Shariatzadeh H, Jafari D, Taheri H, Mazhar FN. Recurrence rate after radial club hand surgery in long term follow up. J Res Med Sci. 2009; 14(3):179-86.

How to Cite this Article: Patwardhan S, Aneja K, Shyam AK. Percutaneous centralization for Radial Club Hand – a technical note International Journal of Paediatric Orthopaedics Sep-Dec 2016;2(3):19-23.

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Complications of Surgical Management of Radial Club Hand

Volume 2 | Issue 3 | Sep-Dec 2016 | Page 24-27| Ratna Maheshwari, Rujuta Mehta, Ashok Johari

Authors : Ratna Maheshwari  [1], Rujuta Mehta [2], Ashok Johari [3]

[1] Consultant, Pediatric Orthopedics, Enable International Centre for Pediatric Musculoskeletal Care
[2] Head of Dept. Paediatric Orthopedics B J Wadia Hospital For Children.
[3] Head, Pediatric Orthopedics, Enable International Centre for Pediatric Musculoskeletal Care.

Address of Correspondence
Dr Ratna Maheshwari
Enable International Centre for Pediatric Musculoskeletal Care
Email: drratnajohari@gmail.com

Abstract

Radial club hand is a congenital deformity of the upper extremity which can present with a spectrum of hand and forearm anomalies ranging from mild radial hypoplasia to complete absence of the radius. The surgical treatment of radial club hand historically has attempted to create a centralized wrist, maintain wrist motion and improve hand function by placing the hand in a more outstretched position.Treatment for these patients has focused on the technique of centralization, in addition to ulnocarpal arthrodesis, ulna and radial lengthening, and microvascular toe transfer. In this paper we review the complications of various surgical interventions described so far for the treatment of this condition.
Keywords: Centralization, recurrence, physeal arrest.

Introduction

There are several treatment options for radial deficiency of the forearm, including nonsurgical management; centralization, radialization, or ulnarization; ulnocarpal arthrodesis; soft tissue procedures including distraction; ulnar lengthening; and vascularized second metatarsophalangeal joint transfer. The most common procedure performed currently is soft tissue distraction followed by a wrist realignment procedure such as a centralization, radialization, or ulnarization. While one-stage procedures subject the patient to a single operation, they are associated with the possible need for carpal resections, ulnar shortening, and sacrifice of the distal ulnar growth plate, stretch injury to the radial neurovascular structures, excessive swelling of the hand, and wound complications [1,2,3,4,5,6]

Centralization/radialization/ulnarization
This technique involves moving the carpus to a central position on the ulna as a means of obtaining correction of radial deviation and wrist subluxation. Unfortunately, this technique has been associated with a high rate of recurrent radial deviation, physeal injury and wrist stiffness [7,8]
Lamb et al [9] reported a recurrence of radial wrist deviation in 7 out of 15 patients.
Damore and colleagues reviewed 19 cases of recurrence after a centralization procedure. The surgery had corrected the radial deviation from a mean of 83 to 25.However at final follow- up (6.5 years), the deviation was back to an average of 63 [10].
Heikel [11] demonstrated in 1959 that the ulna in children with radial club hand may grow between one half to three quarters the length of the unaffected ulna. Centralization procedures, with concomitant ulnar osteotomy and transphyseal pins can all result in potential distal ulnar physeal injury resulting in further shortening of the forearm unit.
In their long-term outcome study, Goldfarb et al [12] noted total ulnar growth to average 12 cm in comparison to 15.4 cm in Vilkki’s series [13] of vasularised metatarsophalangeal joint transfer . While 3 cm may seem clinically insignificant, this must be taken in the context of a longer ulna in addition to a wrist that is in a more balanced position when compared to standard centralization procedures.


K-wire stabilisation is not free of complications: wire migration or breakage, skin ulcer, and changes may follow growth. Despite such repeated revision, correction loss is acceptable and the fixation finally stabilizes over growth. If K-wire tension appears excessive, distraction can be slowed down so as to allow the skin and capsule-ligamentous structures to relax progressively [14].

Ulnocarpal arthrodesis
This procedure is generally reserved for recurrence of deformity after centralization. The generally accepted indications for this procedure is radial angulation greater than 450, inability to actively extend the wrist to within 250 of neutral. Pike et al [15] described 12 patients with average age of 12.6 years treated with ulnocarpal arthrodesis for recurrence of deformity after centralization, that was performed at an average age of 2.4 years. The average time to union for 11 of the 12 patients was 4 months. Union was ultimately achieved in the 12th patient after a revision arthrodesis with a plate that was necessary because the initial arthrodesis hardware (K-wires) was removed early owing to concern about infection.

Ulnar lengthening
Farr and colleagues [16] reported on 8 cases in 6 patients and noted that initial postsurgical gains of radial deviation were not maintained. Radial deviation averaged 250 preoperatively and recurred to 230 at an average 4-year follow-up. Two major complications occurred, including an ulna fracture after frame removal and insufficient regenerate during lengthening.
Peterson and colleagues [17] described 9 children who underwent 13 lengthenings after previous centralization procedures. The average gain in length was 4.4 cm. All patients had at least 1 pin site infection that was treated with antibiotics. Furthermore 4 patients had additional procedures, including internal fixation and bone grafting for delayed union in 3 patients and wrist arthrodesis for recurrence in 1 patient.
Yoshida and colleagues [18] investigated the growth of the ulna after repeated lengthenings. After the initial lengthening, the average length improved from 57% to 89% of the normal side, but then regressed to 70%, whereas after the second lengthening the average length was 102% but regressed to 83%. Bone growth was found to be markedly decreased after the second lengthening. Therefore, if multiple lengthenings are performed, the second one should be performed after skeletal maturity.
Although successful in producing multi-planar deformity correction and an approximately 50% increase in ulnar length, the Ilizarov technique brings with it a steep clinician learning curve. Device application, cumbersome hardware, lengthy total treatment time, and relatively high risk of complications may prove problematic and has effectively limited the use of the device to adolescents and older children.

Radial lengthening
Matsuno and colleagues [19] described 4 cases of Bayne and Klug type II and III radial longitudinal deficiency treated with radial lengthening and simultaneous soft tissue distraction. Three of 4 patients required several lengthenings to correct the recurring discrepancy between the radius and ulna. Only 2 of the 4 patients had acceptable function and appearance after the multiple procedures. In 1 patient, lengthening was abandoned owing to severe bone absorption at the distal end of the radius. One patient died of cardiac disease after a lengthening.

Microvascular second toe transfer:
Vilkki [20] used a novel technique for treatment of Bayne type III and IV radial deficiency using the 2nd MTP joint as a vascularized graft to create a radial column within the wrist (see Fig. 1). The metatarsal and proximal phalanx of the 2nd toe are transferred to the forearm to create a Y shaped distal ulna with potential for growth at both limbs of “Y”. He used a monolateral external fixator in conjunction with this. With regard to the design of the external fixator, the author commented, ‘‘the lengthening device can still be improved and it should have the potential to correct angular deformities.’’ The author also acknowledged unpredictable growth of the transferred bone, cosmetic concerns of the transferred skin pedicle, and technical difficulties with microvascular transfer. Residual radial deviation of the wrist averaging 200 was noted at follow-up. One patient developed a traumatic fracture of the transplanted joint. Consequently the treatment protocol was adjusted to using the distraction device for at least nine weeks following MTP transfer.
Vilkki [13] reported the long term results of vascularized second metatarsophalangeal joint on 24 limbs with an average follow-up of 11 years. The average radial deviation at final follow- up was 280, the average active wrist total arc of motion was 830, and the average length of the ulna was 67% of the contralateral side. Complications were present in more than 50% of patients, including 5 cases of failure of the transfer, 2 of which were vascular in origin and 3 of which had necrosis or fracture leading to necrosis of the metatarsal head. Subluxation of the joint was present in 6 cases and several patients underwent subsequent osteotomies or joint transfer procedures. Distractor device complications was present in 2 patients, fracture of the MTP joint in 2 patients, delayed bony union of the metatarsal ulna interface in 2 patients and pseudoarthrosis at the MTP joint in 2 patients. Three children required late joint transport to lengthen MTP constructs that failed to grow adequately. Donor site morbidity was noted in only 4 patients with hallux valgus noted in one patient, prominent scarring in 2 and occasional pain noted in one other.
These findings of ulna length compares favorably with previous reports of Sestero et al. [7] who found that untreated limbs of patients with radial club hand grew to 64% of normal ulnar length, while surgically centralized limbs within their study grew to only 48-58% of normal ulnar length.
The evidence regarding treatment of radial deficiency of the forearm is limited to retrospective case series. The wide variation in types of operative treatment reflects the lack of a clearly superior procedure. All options have high rates of recurrence with the potential for multiple procedures, all of which have considerable complication rates.

Conclusion

Strategies suggested by the authors for preventing complications are as follows:
1. Good volar and radial skin release
2. Accurate reduction of carpus on ulna
3. Good soft tissue repair
4. Tendon balancing
5. Tightening of structures on ulnar side
6. Temporary stabilization of carpus on ulna
7. Distraction of carpus on ulna (when required with a careful watch to prevent physeal distraction)
8. Limited lengthening of ulna restricted to at the most 5 centimeters in one stage. Elbow stability is an important pre-operative consideration, given that sometimes there may be a co-existing shallow olecranon fossa.

References 

1. Flatt AE. The Care of Congenital Hand Anomalies, 2d ed. St Louis: Quality Medical Publishing, 1994:366–410.
2. Urban MA, Osterman LA. Management of radial dysplasia. Hand Clin. 1990;6:589–605.
3. Buck-Gramcko D. Radialization as a new treatment for radial club hand. J Hand Surg [Am]. 1985;10:964–968.
4. Lamb DW. Radial club hand. J Bone Joint Surg [Am]. 1977;59:1–13.
5. Watson HK, Beebe RD, Cruz NI. A centralization procedure for radial clubhand. J Hand Surg [Am]. 1984;9: 541–547.
6. Bayne LG, Klug MS. Long-term review of the surgical treatment of radial deficiencies. J Hand Surg [Am]. 1987;12: 169–179
7. Sestero AM, Van Heest A, Agel J. Ulnar growth patterns in radial longitudinal deficiency. J Hand Surg Am. 2006;31(6):960–967. [PubMed]
8. Shariatzadeh H, Jafari D, Taheri H, Mazhar FN. Recurrence rate after radial club hand surgery in long term follow up. J Res Med Sci. 2009;14(3):179–186
9. Lamb DW, Scott H, Lam WL, Gillespie WJ, Hooper G. Operativecorrection of radial club hand: a long-term followupof centralization of the hand on the ulna. J Hand Surg Br.1997;22(4):533-6.
10. Damore E, Kozin SH, Thoder JJ, Porter S. The recurrence of deformity after surgical centralization for radial clubhand. J Hand Surg Am. 2000;25(4):745e751
11. Heikel HV. Aplasia and hypoplasa of the radius: studies on 64 cases and on epiphyseal transplantation in rabbits with the imitated defect. ActaOrthopScand Suppl. 1959;39:1- 155.
12. Goldfarb CA, Klepps SJ, Dailey LA, Manske PR. Functional outcome after centralization for radius dysplasia. J Hand Surg Am. 2002;27(1):118–124.
13. Vilkki SK. Vascularised metatarsophalangeal joint transfer for radial hypoplasia. Semin Plastic Surgery.2008; 22(3): 195- 212
14. C. Romanaa, G. Ciaisa, F. Fitoussi. Treatment of severe radial club hand by distraction using an articulated mini-rail fixator and transfixing pins. Orthopaedics& Traumatology: Surgery & Research Volume 101, Issue 4, June 2015, Pages 495–500
15. Pike JM, Manske PR, Steffen JA, Goldfarb CA. Ulnocarpal epiphyseal arthrodesis for recurrent deformity after centralization for radial longitudinal deficiency. J Hand Surg Am. 2010;35(11): 1755- 1761.
16. Farr S, Petje G, Sadoghi P, Ganger R, Grill F, Girsch W. Radiographic early to midterm results of distraction osteogenesis in radial longitudinal deficiency. J Hand Surg Am. 2012;37(11): 2313-2319.
17. Peterson BM, McCarroll HR Jr, James MA. Distraction lengthening of the ulna in children with radial longitudinal deficiency. J Hand Surg Am. 2007;32 (9):1402-1407.
18. Yoshida K, Kawabata H, Wada M. Growth of the ulna after repeated bone lengthening in radial longitudinal deficiency. J PediatrOrthop. 2011;31(6):674e678.
19. Matsuno T, Ishida O, Sunagawa T, Suzuki O, Ikuta Y, Ochi M. Radius lengthening for the treatment of Bayne and Klug type II and III radial longitudinal deficiency. J Hand Surg Am 2006;31 (5): 822- 829
20. Vilkki SK. Distraction and microvascular epiphysis transfer for radial club hand. J Hand Surg [Br]. 1998;23: 445–452.

How to Cite this Article: Maheshwari R, Mehta R, Johari AN. Complications of Surgical Management of Radial Club Hand. International Journal of Paediatric Orthopaedics Sep-Dec 2016;2(3):24-27.

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