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Original article 1
Radial head resection and hemi-interposition arthroplasty in
patients with multiple hereditary exostoses: description of a
new surgical technique
Mark Flipsena, John S. Hama, Arnard L. van der Zwana and Konrad Maderb
Multiple hereditary exostoses (MHE) are a rare disorder
characterized by the growth of bony protrusions. Elbow
involvement is found in a considerable number of patients
and varies from the presence of a simple osteochondroma
to severe forearm deformities and radial head dislocation.
Patients encounter a variety of symptoms, for example, pain,
functional impairment, and cosmetic concerns. Several
types of surgical procedures, therefore, can be offered,
ranging from excision of symptomatic osteochondromas to
challenging reconstructions. In this paper, we will discuss
the essential basics of visualizing, planning, and treatment
options of forearm deformities in MHE. In more detail, we
will describe our current surgical technique as a salvage
procedure for Masada type II forearm deformities in patients
Introduction
Multiple hereditary exostoses (MHE) are a rare autosomal dominant disorder characterized by the presence of
multiple bony protrusions with a cartilage cap (osteochondromas). Osteochondromas in MHE occur as a result
of abnormal enchondral bone growth characterized by
metaphyseal protrusions of cartilage-capped bone [1].
These osteochondromas often result in pain, whereas the
disorder might lead to skeletal deformities, functional
impairment, and cosmetic complaints because of the
resulting deformities [2].
Forearm osteochondromas and/or deformities are reported
to occur in 50–85% of patients with MHE [3–5], which is
associated with greater loss of function than in any other
part of the body [6]. Osteochondromas in the forearm, as in
other long bones, most often develop at the site of the
growth plate that distributes most to the growth of the
specific bone. In the forearm, therefore, the site of predilection is in the distal ulna and radius. Osteochondromas
at this location may cause different symptoms including
pain and limiting motion because of impingement against
the opposite bone. In particular, osteochondromas might
obstruct unrestricted forearm rotation. Concomitant
deformities of the forearm are also often present and might
contribute toward further complaints and limitations in
daily living. In some cases, osteochondromas and the
resulting deformities in the elbow joint eventually lead to
Preliminary results have been presented internationally at the BLRS/BAPRAS
Annual Meeting (2016, Liverpool, UK), the SICOT Orthopaedic World Congress
(2016, Rome, Italy), and the DKOU Congress (2016, Berlin, Germany).
1060-152X Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
with MHE. J Pediatr Orthop B 00:000–000 Copyright © 2017
Wolters Kluwer Health, Inc. All rights reserved.
Journal of Pediatric Orthopaedics B 2017, 00:000–000
Keywords: elbow reconstruction, external elbow fixator, hemi-interposition,
Masada classification, Masada type II, multiple hereditary exostoses,
multiple osteochondromas, radial head resection
a
Department of Orthopaedics, OLVG, Amsterdam, The Netherlands and
Department of Orthopaedic, Trauma, and Spine Surgery, Section Upper
Extremity, Asklepios Klinik Altona, Hamburg, Germany
b
Correspondence to Konrad Mader, MD, PhD, Department of Orthopaedic,
Trauma, and Spine Surgery, Section Upper Extremity, Asklepios Klinik Altona,
22763 Hamburg, Germany
Tel: + 47 181 881 8239; e-mail: konrad.mader@outlook.com
radial head dislocation or subluxation, which can have an
additional negative effect on elbow and forearm function.
This combination of forearm deformity and radial head
dislocation is referred to as a Masada type II deformity
according to the classification system reported by Masada
and colleagues. In Masada type I, a combination of ulnar
shortening and bowing of the radius together with osteochondromas of the distal ulna is present. In Masada type
III, a relative radial shortening because of osteochondromas at the distal radius is present. In contrast to Masada
types I and III, the Masada type II deformities are further
specified on the basis of the presence of proximal radial
osteochondroma(s) in Masada type IIa or IIb. As a consequence of the radial head dislocation, the Masada type
II deformities demand a different approach because of
their complexity and their influence on the elbow. The
Masada classification is addressed in more detail later on in
this manuscript.
So far, there is no consensus with respect to indications
for surgery or optimal treatment regimens for forearm
osteochondromas and the different types of deformities.
Treatment protocols for visualizing, planning, and treatment for Masada type I deformities have been reported
before by our study group [7]. The aim of this manuscript
is to describe in more detail our treatment protocol
including a new surgical technique for Masada type II
deformities in MHE patients. The reported surgical
procedure has now been performed in 15 selected cases;
the results of this series will be analyzed and published in
a separate paper.
DOI: 10.1097/BPB.0000000000000496
Copyright r 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
2 Journal of Pediatric Orthopaedics B 2017, Vol 00 No 00
The (blinded for submission) multiple
hereditary exostoses database
The (blinded for submission) is attended as an expertise
center for MHE [7]. More than 600 patients with MHE
have been entered until this moment into a prospective
database for various studies, including a large series of
120 patients with forearm osteochondromas and deformities (140 forearms) who were surgically treated since
2002 by three senior orthopedic surgeons. Surgical procedures performed included excision of osteochondromas, gradual ulnar lengthening, and radial corrective
osteotomy (proximal and distal). Also, a combination of
these procedures was often performed for forearm
deformities, usually corrective osteotomy of the radius
and/or the ulna with plate fixation of the radius and
monolateral lengthening fixators for the ulna using
hydroxyapatite-coated fixator pins and a dedicated
lengthening and aftercare protocol. In most cases, these
extended reconstructive procedures were perfomed for
Masada type I defomities. In selected cases, the combination of surgical interventions was applied as a form of
leveling procedure of the forearm in case of a Masada
type II deformity in an attempt to reduce the (sub)luxated radial head, as was reported by Masada et al. [8].
Masada et al. [8] found improvements in range of motion
and radiographic findings in type II deformities treated
by excision of osteochondroma, ulnar lengthening, and
radial correction osteotomy. In one case, radial head
resection was performed and they concluded by recommending this procedure for type IIa deformities. For the
type IIb deformities, excision of osteochondroma, ulnar
lengthening, and radial correction osteotomy are recommended [8].
In selected cases of radial head (sub)luxation, redirectional proximal osteotomy of the radius with or without
the ulna was performed, similar to the procedure reported
for neglected Monteggia fractures. However, in persisting or recurrent radial head dislocation, despite leveling
or redirectional procedures, with complaints of pain and/
or severe functional impairment, a salvage procedure
including excision of the radial head and neck with a
hemi-interposition using a local tissue flap and lateral
ulnar collateral ligament (LUCL) graft reconstruction was
considered a feasible treatment option. To date, we have
performed this procedure in 15 MHE patients with a
Masada type II deformity. The main reason for the use of
this salvage procedure and not another form of treatment
in type II deformities was the problem that we encountered in all 15 patients, that is, the severe deformation of
the radial head, resulting in an inadequate and failing
radiocapitular articulation (Fig. 1). Because of chronic
(sub)luxation, large cartilage defects not only of the radial
head but often also of the capitulum had developed in all
cases. Because of this detoriation, reduction of the radial
head was considered undesirable. To the best of our
knowledge, this procedure has not been described before
Fig. 1
Severely deformed radial head with cartilage defects, shown after
resection.
in the treatment of MHE Masada type II deformity. For
other cases, such as inflammatory and post-traumatic
arthritis of the elbow, autograft and allograft interposition arthroplasty procedures have been reported in the
literature with satisfactory results [9–11]. The group of
attending orthopedic surgeons counseled all patients and
retrieved informed consent after presenting a structured
treatment plan.
Important basics in multiple hereditary
exostoses of the forearm
Since 1989, following the publication from Osaka by
Masada and colleagues, the Masada classification for MHE
deformity at the forearm level is generally used [7,8]. The
classification is based on the morphological characteristics
of the deformity on plain radiographs (Fig. 2). Three types
are identified:
(1) Type I: The main osteochondroma formation is
located in the distal portion of the ulna. The ulna is
shortened and there is bowing of the radius.
However, the radial head is not dislocated (this is,
according to Masada, the most common type: 55–61%
of cases).
(2) Type II: In addition to ulnar shortening, the radial
head is dislocated (22–33% of patients). Bowing of
the radius is less pronounced than in type I; this
could be an effect of the dislocation. In subtype IIA,
the radial head is dislocated because of an additional
Copyright r 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Radial head resection in MHE Flipsen et al. 3
Fig. 2
The Masada classification is based on the morphological characteristics
of the deformity on plain radiographs Modified from Masada et al. [8].
Adaptations are themselves works protected by copyright. So in order
to publish this adaptation, authorization must be obtained both from the
owner of the copyright in the original work and from the owner of
copyright in the translation or adaptation.
osteochondroma at the proximal metaphysis of the
radius. In subtype IIB, there is no osteochondroma
located in this region, but there is at the distal ulna.
Dislocation of the radial head in general leads to
rotational impairment, in particular, of pronation.
(3) Type III: The main osteochondroma formation is in
the metaphysis of the distal radius, and there is
relative shortening of the radius.
According to Masada et al. [8], this classification is quite
useful as it indicates both the severity of the forearm
deformity and the functional disabilities. Forearm rotation is most severely impaired in type I, whereas elbow
motion is normal. Type II shows restriction of both elbow
movement and forearm rotation. Radial deviation of the
wrist is severely restricted in both subtypes. Type III
retains almost normal forearm and elbow movement, but
ulnar deviation of the wrist is often restricted and painful.
Preoperative imaging and evaluation
Radiographs of the total forearm in full supination and
pronation as well as a total lateral view are taken: this is
considered necessary to (i) visualize the presence of
symptomatic and/or function limiting osteochondromas
as well as (ii) deformities in both forearm bones, (iii) for
imaging all four joints [elbow, wrist, distal, and proximal
radioulnar joints (PRUJs)], (iv) to determine the center of
rotation and angulation in case osteotomies have to be
planned, and (v) to locate the most appropriate site for
ulnar lengthening. Posteroanterior or anteroposterior
radiographs are obtained with the arm placed on the
imaging plate with the shoulder at 90° of abduction and
the elbow at 90° of flexion for as far this is tolerable with
patients’ range of motion. The beam is orthogonally
directed toward the forearm in a neutral position in the
posteroanterior direction. Several angles and other variables can be measured on the radiographs and form the
basis for follow-up of forearm deformities during growth
or outcome after forearm reconstruction. The most
important radiographic measurements are the radial
articular angle and the carpal slip.
At the elbow joint level, the length and grade of dislocation of the radial head and the amount of radial head
deformation are recorded. In addition, the congruency of
the humeroulnar joint is assessed. Furthermore,
the direction of the dislocation of the radial head (anterior
or posteroradial) is visualized on lateral radiographs.
Computed tomography with 3D reconstruction images are
generally used to further visualize the complex deformity
at the elbow level for planning of the location of radial
head resection and to counsel patient and relatives.
Computed tomographic imaging can also provide more
insight into the joint anatomy and may visualize (early)
degenerative changes. MRI was performed in selected
cases to assess the status of the cartilage of the radial head
and capitulum, and the presence and structural integrity of
the LUCL.
For evaluation of outcome, we used a prospective standardized protocol; pain scores, patients’ and/or parents’
complaints, restriction in daily living, preoperative and
postoperative function, both at the elbow and at the wrist
level, as well as elbow-ulnar and radioulnar joint (in)stability were recorded. Patient-specific outcome measures
were also obtainted, including DASH, PRWE, and
RAND36 questionnares.
Multiple hereditary exostoses study group
protocol
Indications for surgery
All surgeries were performed simultaneously by two
senior orthopedic surgeons (Initials blinded for submission). Indications for surgery included a Masada type II
deformity with PRUJ instability, chronic or recurrent
radial head dislocation, functional impairment, pain, and
severe deformation of the radial head with or without
degenerative changes of the radial head and capitulum
leading to unfavorable circumstances for reduction of the
Copyright r 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
4 Journal of Pediatric Orthopaedics B 2017, Vol 00 No 00
radial head. Cosmetic issues as a sole factor were not
accepted as an indication for surgery.
Procedures performed included radial head resection,
hemi-interposition using a local tissue flap, and LUCL
ligament graft reconstruction (most often indicated), followed by the application of a hinged elbow external
fixator for 6 weeks or a plaster cast to maintain the
optimal and most stable position of the elbow joint and to
protect the reconstructed ligament. Procedures were
most often performed after previous distal forearms procedures including excision of osteochondroma(s), ulnar
lengthening and/or radial correction osteotomy, or previous proximal correction osteotomy. The severity of the
deformity was determined on the basis of a radiological
assessment.
Operative technique
Surgical technique
The operative protocol was standardized. After induction
of general anesthesia, each patient was examined preoperatively for proximal radial and/or posterolateral
instability. A sterile tourniquet was placed at the most
proximal aspect of the arm. The patient remained supine
on the operating table with the arm placed on a hand
table. Before surgical exposure, the positions of the radial
head, the humeroulnar joint line, and other anatomic
landmarks were determined using fluoroscopy and drawn
on the skin using a sterile marker pen including a possible extension of the surgical approach proximal to the
dorsum of the distal triceps region for raising a possible
portion of the triceps humeri. The resection of the radial
head and capitullar interposition arthroplasty was performed through the central portion of the marked
approach by a 10 cm modified Kocher incision (Fig. 3).
The Kocher interval between the extensor carpi ulnaris
tendon and the anconeus muscle is typically defined by a
thin stripe of fat observed through the deep fascia. The
deep fascia was identified and incised along the supracondylar ridge, moving distally between the anconeus
muscle and the extensor carpi ulnaris muscle. The
extensor carpi ulnaris was reflected anteriorly with
the common extensor origin by using sharp dissection of
the underlying lateral collateral ligament complex. The
anconeus muscle was elevated posteriorly. The LUCL
complex was visualized, and its integrity and capacity to
stabilize against lateral and posterolateral forces were
documented to determine whether a tendon graft was
necessary in cases of insufficient stability or plain absence
of the ligament complex was noted (Fig. 4). After incision
of the elongated joint capsule, the radial head was fully
exposed and the morphology of the head and neck, the
deformity, and the cartilage status was documented by
photography. In cases with gross alteration of both morphology and cartilage radial head, resection was performed at the level of the radial neck. After reducing the
elbow in 110° of flexion using fluoroscopy in a true lateral
plane, the resection level was marked with a chisel in the
projection of the joint line of the PRUJ (Fig. 5).
Resection was performed using an oscillating saw while
protecting the surrounding soft tissues with Langenbeck
retractors. To raise the interposition flap, the inner part of
the elongated central joint capsule was dissected from
the undersurface of the common extensor origin by blunt
and sharp dissection to elevate a 4 × 6 cm proximally
rooted soft tissue flap (Fig. 6). Up to six bone anchors
(Mitek 3metric; DePuy Synthes, Oberdorf, Switzerland)
were placed after predrilling anterior and posterior at the
respective rim of the capitulum humeri and the interposition flap was sutured into the joint, creating a durable
interposition membrane (Fig. 7). In cases with sufficient
Fig. 3
Fig. 4
The proposed lateral skin incision (Kocher approach) is drawn using
anatomic landmarks (radial head and lateral epicondyle).
The lateral ulnar collateral ligament complex is visualized and its integrity
and capacity to stabilize against lateral and posterolateral forces is
documented to determine whether a tendon graft is necessary. a, radial
head; b, lateral ulnar collateral ligament.
Copyright r 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Radial head resection in MHE Flipsen et al. 5
Fig. 5
After reducing the elbow in 110° of flexion using fluoroscopy in a true
lateral plane, the resection level was marked with a chisel in projection
of the joint line of the proximal radioulnar joint.
Fig. 7
Up to six bone anchors (Mitek 3metric; DePuy Synthes, Switzerland)
were placed after predrilling anterior and posterior at the respective rim
of the capitulum humeri (a), and the interposition flap was sutured into
the joint, creating a durable interposition membrane. Proximal radial
osteotomy (b).
Fig. 8
Fig. 6
To raise the interposition flap, the inner part of the elongated central joint
capsule (a) was dissected from the undersurface of the common
extensor origin by blunt and sharp dissection to elevate a 4 × 6 cm
proximally rooted soft tissue flap.
LUCL complex, the joint capsule and the common
extensor origin were sutured using modified Mason Allen
sutures.
In cases of gross radial instability, a central triceps graft
was elevated (after proximal extension of the incision)
and a double-strand docking LUCL ligament graft
reconstruction using the technique published by Jones
et al. [12] was performed. The insertion site for the tendon graft was prepared by drilling two holes with a 4 mm
burr in the ulna in a manner that preserved a 2 cm
One hole was located near the tubercle on the supinator crest (a) and
the other hole was drilled ∼ 2 cm proximal to the first hole near the base
of the annular ligament (b).
osseous bridge or two cork-screws (Arthrex GmbH,
Munich, Germany) were inserted into this region. One
hole was located near the tubercle on the supinator crest
and the other hole was drilled ∼ 2 cm proximal to the first
hole near the base of the annular ligament (Fig. 8). A
curved awl was used to create an osseous tunnel between
these two drill holes, taking care not to violate the bony
bridge. The isometric point was determined and the
entry site for the graft was created using a 4 mm burr on
the humerus at this location, avoiding severing of possible open growth plates. The hole was drilled to a depth
of ∼ 15 mm. A dental drill with a small bit was used to
Copyright r 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
6 Journal of Pediatric Orthopaedics B 2017, Vol 00 No 00
create two small 15 mm exit punctures, separated by
1 cm, to allow for suture passage from the primary humeral tunnel. A suture passer was used from each of the
two exit punctures to pass a looped suture that was used
for later graft passage. The triceps tendon graft was
woven through the ulnar tunnel from an anterior-toposterior direction. The limb of the graft that was stitched in a Krackow manner was passed into the humeral
tunnel by shuttling the nonabsorbable sutures in the graft
along with the sutures stitched into the posteriorly
reflected capsule through the most posterior humeral
puncture holes. With the first limb of the graft docked
adequately into the humerus, the elbow was placed in
30°–40° of flexion and forced pronation. While tension
was maintained on the graft, the arm was cycled
(flexion–extension) to eliminate creep within the graft.
The final length of the graft was determined by placing
the free limb of the graft next to the humeral tunnel and
visually estimating the length of graft that was necessary
to adequately tension it within the humeral tunnel. This
ideal tension point on the graft was marked with a skin
marker and a no. 1 braided nonabsorbable suture was
stitched in a Krackow manner in the free graft limb. The
excess graft was excised carefully above the stitch and
the graft was docked securely in the humeral tunnel with
the sutures from the graft and the anteriorly reflected
capsule exiting the small humeral puncture holes. Final
graft tensioning was performed with the elbow positioned in 30°–40° of flexion and forced pronation. When
adequate tensioning was achieved, the four pairs of graft
sutures were tied over the osseous bridge on the lateral
epicondyle. The capsular sutures were tied first, followed
by the graft sutures. Closure was performed by
approximating the extensor carpi ulnaris and the anconeus muscles before final skin closure. In cases with gross
intraoperative instability and triceps grafting, a pediatric
or a standard elbow hinged fixator (Orthofix Srl,
Bussolengo VR, Italy) was applied using a standard
operative technique published in detail elsewhere
[13–15].
Postoperative management
Postoperatively, the arm was immobilized in a posterior
splint in full pronation and 90° of flexion for ∼ 10–14 days.
In cases where an elbow fixator was used, it was locked in
90° of flexion and the central unit of the fixator was
opened after 10–14 days to enable early active motion.
The initial phases of rehabilitation allowed ∼ 30° of
extension and 90° of flexion. These parameters were
increased gradually until full extension and flexion was
achieved. Range-of-motion exercises involving the wrist
and hand were allowed without limitations. Strengthening
exercises were generally initiated at 8–10 weeks postoperatively and full return to activity was permitted at
4–6 months depending on the specific activity. The
elbow fixator was removed at 6 weeks postoperatively as
an outpatient procedure without anesthesia in adults or
under general anesthesia in the operating room in children. Pin-site care was performed on a weekly basis using
a noncolored mild disinfectant.
Complications
This procedure was performed in a total of 14 patients.
The median age of the patients at surgery was 11.5 years
(range: 6.1–24.8 years). In nine cases, a previous leveling
procedure had been performed. In these cases, treatment
Fig. 9
Postoperative radiography of the elbow at the final follow-up in anteroposterior (a) and lateral (b) views.
Copyright r 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Radial head resection in MHE Flipsen et al. 7
with the new surgical technique was performed at a
median of 3.1 years (range: 0.6–6.5 years) after the initial
leveling procedure. The median follow-up duration for
the entire group was 4.8 years; of these, 10 cases achieved
skeletal maturity. A postoperative elbow radiography at
53 months of follow-up is shown in Fig. 9.
No major procedure-related complications were observed,
especially no external fixator-related radial nerve injures or
acute Essex Lopresti phenomenon. It is important to state
that at longer follow-up, a chronic slow proximal migration
of the radius (chronic Essex Lopresti phenomenon) might
occur with pain and functional deficit at the wrist level and
chronic valgus instability of the elbow with late ulnar
neuropathy. Proximal migration of the radius in these
series was observed in one case (n = 1, 7%) at a follow-up
of 21 months. At the final follow-up (68 months) at the age
of 12 years, proximal migration of the radius had further
progressed with bowing of the radius, but without pain
complaints or a decrease in range of motion. This phenomenon was not encountered in any of the other skeletally mature or immature patients. In another case,
superficial pin-site infection developed (n = 1, 7%). This
was treated successfully with pin care and oral antibiotics.
Acknowledgements
Conflicts of interest
There are no conflicts of interest.
References
1
2
3
4
5
6
7
8
9
On the basis of the observations during outpatient visits,
the new surgical technique seems to yield satisfactory
results in the postoperative pain score, range of motion,
elbow stability, patient satisfaction, and quality of life.
These outcomes will be analyzed in detail and prepared
for publication soon.
10
Conclusion
13
In MHE patients with a Masada type II deformity of the
forearm, radial head resection, hemi-interposition
arthroplasty, radiohumeral ligament augmentation, and
temporary stabilization with a hinged fixator can be used
as a salvage procedure. It is an optimal option for chronic
radial head dislocation at advanced stages with osteoarthritis in patients after leveling procedures of the forearm.
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