Derotational Pronation-Producing Osteotomy of the Radius and Biceps Tendon Rerouting for Supination Contractures
Casey M. DeDeugd, MD1; William J. Shaughnessy, MD1; Alexander Y. Shin, MD2; (1)Mayo Clinic, Rochester, MN, (2)Division of Hand Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
Background: Forearm supination contractures can occur as a result of neurologic derangement of the upper extremity. Primarily, this is observed in patients with neonatal brachial plexus birth palsy (NBPBP). The contractures develop slowly over time and become problematic in childhood as forearm pronation becomes necessary for activities of daily living including typing on a keyboard, holding utensils and writing. To correct this deformity, a radial osteotomy to realign the forearm in resting pronation is combined with a biceps tendon rerouting to prevent recurrence. We present the largest case series to date describing the outcomes of this technique.
Patients and Methods: A retrospective review identified patients who had a radial osteotomy and biceps rerouting for supination contracture between 2006 and 2016. Inclusion criteria included forearm supination contracture caused by NBPBP, patients <18 years of age, and at least 6 months of clinical and radiographic follow-up. Demographic and surgical variables, clinical outcomes, complications, reoperations and revision were documented.
Results: There were 22 patients identified who met inclusion criteria. The mean follow-up was 3 years (range, 6 months – 9 years). There was a statistically significant difference in resting forearm position from an average of 70° arc of motion from an average of 56° of supination preoperatively to 14° of pronation postoperatively (p < 0.001). Correspondingly, there was an increase in passive forearm pronation from 0° preoperatively to 66° postoperatively (p <0.01) and expected decrease in passive forearm supination from 78° preoperatively to 41° postoperatively (p<0.01). In total, there were no complications. Excluding revisions, there were 15 reoperations in 14 patients (63%) including 14 for hardware removals and 1 FCU to ECRB tendon transfer for the flexion contracture of the wrist. There were 2 revisions for osteotomy nonunion, both of which went onto eventual union. Overall survivorship free from revision surgery was 95% at 12 month, 88% at 24 months and 88% at 60 months.
Conclusions: These are results of a novel surgical solution for forearm supination contracture through the combination of derotational osteotomy of the radius and biceps tendon rerouting. Our results show a significant benefit in forearm positioning and passive pronation with excellent survivorship. This is the first study, and thus the largest series to date, to document and report outcomes after surgical intervention for supination contracture using this technique.
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