Case report 277
Percutaneous corrective osteotomy for Kirner’s deformity: a case report Kazushige Gamoa, Kohji Kuriyamab, Ayako Uesugib, Takanobu Nakaseb, Masayuki Hamadab and Hideo Kawaic Kirner’s deformity is a rare skeletal deformity first described in Germany in 1927. It is characterized by progressive palmar–radial curvature of the distal phalanx of the small finger. Here, we present the case of a 15-year-old boy with Kirner’s deformity in both little fingers, who was treated with percutaneous corrective osteotomy. This was followed by a successful outcome after 36 c 2014 Wolters months. J Pediatr Orthop B 23:277–281 Kluwer Health | Lippincott Williams & Wilkins.
Keywords: Kirner’s deformity, minimally invasive surgery, percutaneous corrective osteotomy a Department of Orthopaedic Surgery, Bell Land General Hospital, bDepartment of Orthopaedic Surgery, Hoshigaoka Koseinenkin Hospital and cDepartment of Rehabilitation, Shijonawate Gakuen University, Osaka, Japan
Correspondence to Kazushige Gamo, MD, PhD, Department of Orthopaedic Surgery, Bell Land General Hospital, 500-3 Higashiyama, Naka-ku, Sakai-shi, Osaka 599-8247, Japan Tel: + 81 72 234 2001; fax: + 81 72 234 2003; e-mail: [email protected]
Journal of Pediatric Orthopaedics B 2014, 23:277–281
Introduction Kirner’s deformity is a rare skeletal deformity characterized by progressive palmar–radial curvature of the distal phalanx of the small finger; this condition was first described in 1927 by Kirner [1]. Pronounced convexity of the nails may also cause a ‘parrot beak’ disfiguration [2]. Although the etiology of Kirner’s deformity is unknown, it may be inherited as an autosomal dominant trait with incomplete penetrance or it may occur sporadically. The deformity develops in late childhood or adolescence with initial swelling along the dorsum of the distal phalanx. Subsequently, a palmar–radial curvature of the distal fingertip develops over time. Once established, the deformity is stable. Several treatment options have been reported previously, including observation, splinting, and corrective osteotomy. To our knowledge, all of the
reported corrective osteotomy procedures were performed by exposing the terminal phalanx. Here, we present the case of a patient who underwent percutaneous corrective osteotomy for Kirner’s deformity.
Case report A 15-year-old boy presented to our hand clinic because he was concerned about the appearance of the little finger on both of his hands and complained of pain in the paronychia of his left little finger. The terminal parts of both little fingers were curved symmetrically into the palmar and radial side. The nail body was also curved, resembling a parrot beak (Fig. 1). Radiographs are shown in Fig. 2. He showed no other abnormalities on clinical examination. There was no family history of limb
Fig. 1
(a) Preoperative appearance of the dorsal aspect of both hands. (b, c) Lateral view of the fifth finger showing incurving into the palmar and radial side. c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 1060-152X
DOI: 10.1097/BPB.0000000000000042
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
278 Journal of Pediatric Orthopaedics B 2014, Vol 23 No 3
abnormalities. At the age of 8 years, he had noticed the deformities of both little fingers and he gradually became anxious about the deformities. The flexor and extensor mechanisms all functioned normally. Treatment options were discussed with the patient and his parents. They were extremely eager for bilateral correction of the deformities in the same session. After discussing the possible treatment options, risks, and benefits, we
obtained informed consent for treating the Kirner’s deformity with percutaneous corrective osteotomy. We planned an opening wedge volar osteotomy. The operation was performed bilaterally using a minimally invasive technique under general anesthesia. The surgical procedure was facilitated by the use of C-arm fluoroscopy to monitor the performance of some of the steps. The nail
Fig. 2
Preoperative radiographs of the fifth finger of each hand. (a, b) Right finger. (c, d) Left finger.
Fig. 3
Surgical procedure for the left little finger. (a) Multiple predrilling was performed with a 1.0 mm K-wire at the distal osteotomy site from the radial side percutaneously. (b) The distal osteotomy site was cut, using a 1.8 mm K-wire as an osteotome, percutaneously from the radial side. The distal curvature of the phalanx was manually corrected and the volar cortex was wedged open. (c, d) Proximal osteotomy was performed in the same fashion and the entire curvature of the phalanx was manually corrected. (e) Fixation through the distal interphalangeal joint was accomplished using an axial 1.0 mm K-wire. K-wire, Kirschner wire.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Percutaneous osteotomy for Kirner’s deformity Gamo et al. 279
Fig. 4
(a, b) The left little finger just after percutaneous corrective osteotomy. The nail bed was dented (arrow). (c, d) To avoid damage, the nail bed was covered with the removed nail.
Fig. 5
Postoperative radiographs. (a, b) Right finger. (c, d) Left finger.
plate was removed to ease the correction of the curvature after the osteotomy. The distal osteotomy site was predrilled percutaneously at multiple locations from the radial side with a 1.0 mm Kirschner wire (K-wire) (Fig. 3a). The osteotomy was then performed percutaneously
through the predrilling site from the radial side, leaving the dorsal cortex intact, with a 1.8 mm K-wire as an osteotome (Fig. 3b). The volar cortex was manually wedged open. At the proximal site, predrilling, osteotomy, and manual correction were performed in the same manner as
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
280
Journal of Pediatric Orthopaedics B 2014, Vol 23 No 3
that in the distal site (Fig. 3c and d). The osteotomy sites were then stabilized using a 1.0 mm K-wire, which was inserted from the fingertip and passed across the distal interphalangeal joint (Figs 3e, 4, and 5). Both nail beds were dented; we were concerned that this would lead to nail deformities (Fig. 4a and b). To avoid damage, the nail bed was covered with the removed nail for 4 weeks (Fig. 4c and d). The K-wire and nail cover were removed 8 weeks after surgery. Bone union was achieved at 6 weeks after surgery. At 36 months after surgery, when the patient was 17 years and 9 months of age, nail deformations were not
present, and the patient was satisfied with the surgical results (Figs 6 and 7).
Discussion Kirner’s deformity is a very rare condition. The incidence is 0.15% [3] to 0.25% [4], and females are affected twice as frequently as males [5]. Inheritance has been described as an autosomal dominant trait with incomplete penetrance. However, many cases arise sporadically. No specific genetic linkage has been identified.
Fig. 6
Radiographs obtained at 36 months after surgery. (a, b) Right finger. (c, d) Left finger.
Fig. 7
(a) Dorsal aspect of both hands at 36 months after surgery. (b, c) Lateral view of the fifth finger showing good cosmetic results.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Percutaneous osteotomy for Kirner’s deformity Gamo et al. 281
Although various theories have been discussed, the precise etiology of Kirner’s deformity is unknown. Suggested causes include osteochondrosis, osteochondritis, imbalance of the flexor and extensor tendons, osteomalacia, and aseptic necrosis [6]. Dykes [7] reported that splinting the small finger into extension was effective for relieving discomfort in the early swelling stage of the deformity, although no benefit was obtained in prevention or correction of the deformity. However, Freiberg and Forrest [2] reported a case where 16 months of serial splinting was useful in correcting the deformity when applied in the early stages and before completion of growth. In 1970, Carstam and Eiken [8] reported the opening wedge volar osteotomy with mid lateral incision, and recently, this has become a common procedure. There are several other surgical options. These may include dorsal closing wedge osteotomy [9], distraction lengthening [10], hemiepiphysiodesis [11], and distal detachment of the flexor digitorum profundus tendon [12]. As the present case had passed the early stage at the initial visit, we chose surgical treatment. Although all of the reported surgical procedures were performed by exposing the terminal phalanx to a varying degree, we used a minimally invasive percutaneous approach for preservation of blood flow to the osteotomized bones and the surrounding tissue to prevent pseudoarthrosis. We also expected a reduction in the operating time and the possibility of performing the procedure bilaterally with fewer complications. For the minimally invasive osteotomy, a 1.8 mm K-wire was used as a small sharp osteotome. The deformity consists of a three-dimensional palmar– radial deviation of the distal phalanx, but it appears difficult to correct the radial deformity completely. In the present case, the palmar deformity was well corrected, but there was residual radial deformity in both little fingers. The difficulties in correcting the radial deformity may be a weakness of this technique. The main disadvantage of this procedure is that the patient and surgeon are exposed to radiation as it is a C-arm fluoroscopy-dependent surgery. We believe that corrective osteotomy should be performed just before the physeal closure in consideration of osseous healing and
the possibility of physeal injury during the surgical procedure. Kirner’s deformities have been considered to cause little functional disturbance. The indication for surgery is primarily restoration of finger appearance. Therefore, these surgeries have rarely been performed. In the present case, we performed a minimally invasive procedure and obtained a good result at 36 months after surgery. Percutaneous corrective osteotomy has potential advantages over commonly used open techniques and provides a viable alternative to traditional open techniques for the treatment of Kirner’s deformity.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1
Kirner J. Doppelseitige Verkrummungen des Kleinfingerendglieds als selbstandiges Krankheitsbild. Fortschr Geb D Roentgenst 1927; 36: 804–886. 2 Freiberg A, Forrest C. Kirner’s deformity: a review of the literature and case presentation. J Hand Surg Am 1986; 11:28–32. 3 Sugiura Y. Polytopic dystelephalangy of the fingers. Pediatr Radiol 1989; 19:493–495. 4 David TJ, Burwood RL. The nature and inheritance of Kirner’s deformity. J Med Genet 1972; 9:430–433. 5 Kay SP, McCombe DB, Kozin SH. Deformities of the hand and fingers. In: Wolfe SWW, Hotchkiss RN, Pederson WC, Kozin SH, editors. Green’s operative hand surgery. 6th ed. Philadelphia: Elsevier/Churchill Livingstone; 2011. pp. 1357–1358. 6 Staheli LT, Clawson DK, Capps JH. Bilateral curving of the terminal phalanges of the little fingers. Report of two cases. J Bone Joint Surg Am 1966; 48:1171–1176. 7 Dykes RG. Kirner’s deformity of the little finger. J Bone Joint Surg Br 1978; 60:58–60. 8 Carstam N, Eiken O. Kirner’s deformity of the little finger. Case reports and proposed treatment. J Bone Joint Surg Am 1970; 52:1663–1665. 9 Luppino T, Vaccari A. Acrodisplasia metadiafisaria bilaterale congenita del mignolo (deformita´ di Kirner [Congenital bilateral metadiaphyseal acrodysplasia of the little finger (Kirner’s deformity)]). Chir Organi Mov 1971; 60:133–141. 10 Moser N, Rosslein R. A new method for treating the Kirner deformity with the SM-Fix phalangeal distractor. Handchir Mikrochir Plast Chir 1996; 28: 34–38. 11 Niederwieser E, Segmuller G. Kirner-Deformita¨t: eine isolierte Fehlbildung der Kleinfingerenphalanx [Kirner’s deformity: an isolated malformation of the third phalanx of the little finger]. Schweiz Med Wochenschr 1979; 109:1023–1027. 12 Benatar N. Kirner’s deformity treated by distal detachment of the flexor digitorum profundus tendon. Handchir Mikrochir Plast Chir 2004; 36: 166–169.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Percutaneous corrective osteotomy for Kirner’s deformity: a case report Kazushige Gamoa, Kohji Kuriyamab, Ayako Uesugib, Takanobu Nakaseb, Masayuki Hamadab and Hideo Kawaic Kirner’s deformity is a rare skeletal deformity first described in Germany in 1927. It is characterized by progressive palmar–radial curvature of the distal phalanx of the small finger. Here, we present the case of a 15-year-old boy with Kirner’s deformity in both little fingers, who was treated with percutaneous corrective osteotomy. This was followed by a successful outcome after 36 c 2014 Wolters months. J Pediatr Orthop B 23:277–281 Kluwer Health | Lippincott Williams & Wilkins.
Keywords: Kirner’s deformity, minimally invasive surgery, percutaneous corrective osteotomy a Department of Orthopaedic Surgery, Bell Land General Hospital, bDepartment of Orthopaedic Surgery, Hoshigaoka Koseinenkin Hospital and cDepartment of Rehabilitation, Shijonawate Gakuen University, Osaka, Japan
Correspondence to Kazushige Gamo, MD, PhD, Department of Orthopaedic Surgery, Bell Land General Hospital, 500-3 Higashiyama, Naka-ku, Sakai-shi, Osaka 599-8247, Japan Tel: + 81 72 234 2001; fax: + 81 72 234 2003; e-mail: [email protected]
Journal of Pediatric Orthopaedics B 2014, 23:277–281
Introduction Kirner’s deformity is a rare skeletal deformity characterized by progressive palmar–radial curvature of the distal phalanx of the small finger; this condition was first described in 1927 by Kirner [1]. Pronounced convexity of the nails may also cause a ‘parrot beak’ disfiguration [2]. Although the etiology of Kirner’s deformity is unknown, it may be inherited as an autosomal dominant trait with incomplete penetrance or it may occur sporadically. The deformity develops in late childhood or adolescence with initial swelling along the dorsum of the distal phalanx. Subsequently, a palmar–radial curvature of the distal fingertip develops over time. Once established, the deformity is stable. Several treatment options have been reported previously, including observation, splinting, and corrective osteotomy. To our knowledge, all of the
reported corrective osteotomy procedures were performed by exposing the terminal phalanx. Here, we present the case of a patient who underwent percutaneous corrective osteotomy for Kirner’s deformity.
Case report A 15-year-old boy presented to our hand clinic because he was concerned about the appearance of the little finger on both of his hands and complained of pain in the paronychia of his left little finger. The terminal parts of both little fingers were curved symmetrically into the palmar and radial side. The nail body was also curved, resembling a parrot beak (Fig. 1). Radiographs are shown in Fig. 2. He showed no other abnormalities on clinical examination. There was no family history of limb
Fig. 1
(a) Preoperative appearance of the dorsal aspect of both hands. (b, c) Lateral view of the fifth finger showing incurving into the palmar and radial side. c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 1060-152X
DOI: 10.1097/BPB.0000000000000042
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
278 Journal of Pediatric Orthopaedics B 2014, Vol 23 No 3
abnormalities. At the age of 8 years, he had noticed the deformities of both little fingers and he gradually became anxious about the deformities. The flexor and extensor mechanisms all functioned normally. Treatment options were discussed with the patient and his parents. They were extremely eager for bilateral correction of the deformities in the same session. After discussing the possible treatment options, risks, and benefits, we
obtained informed consent for treating the Kirner’s deformity with percutaneous corrective osteotomy. We planned an opening wedge volar osteotomy. The operation was performed bilaterally using a minimally invasive technique under general anesthesia. The surgical procedure was facilitated by the use of C-arm fluoroscopy to monitor the performance of some of the steps. The nail
Fig. 2
Preoperative radiographs of the fifth finger of each hand. (a, b) Right finger. (c, d) Left finger.
Fig. 3
Surgical procedure for the left little finger. (a) Multiple predrilling was performed with a 1.0 mm K-wire at the distal osteotomy site from the radial side percutaneously. (b) The distal osteotomy site was cut, using a 1.8 mm K-wire as an osteotome, percutaneously from the radial side. The distal curvature of the phalanx was manually corrected and the volar cortex was wedged open. (c, d) Proximal osteotomy was performed in the same fashion and the entire curvature of the phalanx was manually corrected. (e) Fixation through the distal interphalangeal joint was accomplished using an axial 1.0 mm K-wire. K-wire, Kirschner wire.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Percutaneous osteotomy for Kirner’s deformity Gamo et al. 279
Fig. 4
(a, b) The left little finger just after percutaneous corrective osteotomy. The nail bed was dented (arrow). (c, d) To avoid damage, the nail bed was covered with the removed nail.
Fig. 5
Postoperative radiographs. (a, b) Right finger. (c, d) Left finger.
plate was removed to ease the correction of the curvature after the osteotomy. The distal osteotomy site was predrilled percutaneously at multiple locations from the radial side with a 1.0 mm Kirschner wire (K-wire) (Fig. 3a). The osteotomy was then performed percutaneously
through the predrilling site from the radial side, leaving the dorsal cortex intact, with a 1.8 mm K-wire as an osteotome (Fig. 3b). The volar cortex was manually wedged open. At the proximal site, predrilling, osteotomy, and manual correction were performed in the same manner as
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
280
Journal of Pediatric Orthopaedics B 2014, Vol 23 No 3
that in the distal site (Fig. 3c and d). The osteotomy sites were then stabilized using a 1.0 mm K-wire, which was inserted from the fingertip and passed across the distal interphalangeal joint (Figs 3e, 4, and 5). Both nail beds were dented; we were concerned that this would lead to nail deformities (Fig. 4a and b). To avoid damage, the nail bed was covered with the removed nail for 4 weeks (Fig. 4c and d). The K-wire and nail cover were removed 8 weeks after surgery. Bone union was achieved at 6 weeks after surgery. At 36 months after surgery, when the patient was 17 years and 9 months of age, nail deformations were not
present, and the patient was satisfied with the surgical results (Figs 6 and 7).
Discussion Kirner’s deformity is a very rare condition. The incidence is 0.15% [3] to 0.25% [4], and females are affected twice as frequently as males [5]. Inheritance has been described as an autosomal dominant trait with incomplete penetrance. However, many cases arise sporadically. No specific genetic linkage has been identified.
Fig. 6
Radiographs obtained at 36 months after surgery. (a, b) Right finger. (c, d) Left finger.
Fig. 7
(a) Dorsal aspect of both hands at 36 months after surgery. (b, c) Lateral view of the fifth finger showing good cosmetic results.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Percutaneous osteotomy for Kirner’s deformity Gamo et al. 281
Although various theories have been discussed, the precise etiology of Kirner’s deformity is unknown. Suggested causes include osteochondrosis, osteochondritis, imbalance of the flexor and extensor tendons, osteomalacia, and aseptic necrosis [6]. Dykes [7] reported that splinting the small finger into extension was effective for relieving discomfort in the early swelling stage of the deformity, although no benefit was obtained in prevention or correction of the deformity. However, Freiberg and Forrest [2] reported a case where 16 months of serial splinting was useful in correcting the deformity when applied in the early stages and before completion of growth. In 1970, Carstam and Eiken [8] reported the opening wedge volar osteotomy with mid lateral incision, and recently, this has become a common procedure. There are several other surgical options. These may include dorsal closing wedge osteotomy [9], distraction lengthening [10], hemiepiphysiodesis [11], and distal detachment of the flexor digitorum profundus tendon [12]. As the present case had passed the early stage at the initial visit, we chose surgical treatment. Although all of the reported surgical procedures were performed by exposing the terminal phalanx to a varying degree, we used a minimally invasive percutaneous approach for preservation of blood flow to the osteotomized bones and the surrounding tissue to prevent pseudoarthrosis. We also expected a reduction in the operating time and the possibility of performing the procedure bilaterally with fewer complications. For the minimally invasive osteotomy, a 1.8 mm K-wire was used as a small sharp osteotome. The deformity consists of a three-dimensional palmar– radial deviation of the distal phalanx, but it appears difficult to correct the radial deformity completely. In the present case, the palmar deformity was well corrected, but there was residual radial deformity in both little fingers. The difficulties in correcting the radial deformity may be a weakness of this technique. The main disadvantage of this procedure is that the patient and surgeon are exposed to radiation as it is a C-arm fluoroscopy-dependent surgery. We believe that corrective osteotomy should be performed just before the physeal closure in consideration of osseous healing and
the possibility of physeal injury during the surgical procedure. Kirner’s deformities have been considered to cause little functional disturbance. The indication for surgery is primarily restoration of finger appearance. Therefore, these surgeries have rarely been performed. In the present case, we performed a minimally invasive procedure and obtained a good result at 36 months after surgery. Percutaneous corrective osteotomy has potential advantages over commonly used open techniques and provides a viable alternative to traditional open techniques for the treatment of Kirner’s deformity.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1
Kirner J. Doppelseitige Verkrummungen des Kleinfingerendglieds als selbstandiges Krankheitsbild. Fortschr Geb D Roentgenst 1927; 36: 804–886. 2 Freiberg A, Forrest C. Kirner’s deformity: a review of the literature and case presentation. J Hand Surg Am 1986; 11:28–32. 3 Sugiura Y. Polytopic dystelephalangy of the fingers. Pediatr Radiol 1989; 19:493–495. 4 David TJ, Burwood RL. The nature and inheritance of Kirner’s deformity. J Med Genet 1972; 9:430–433. 5 Kay SP, McCombe DB, Kozin SH. Deformities of the hand and fingers. In: Wolfe SWW, Hotchkiss RN, Pederson WC, Kozin SH, editors. Green’s operative hand surgery. 6th ed. Philadelphia: Elsevier/Churchill Livingstone; 2011. pp. 1357–1358. 6 Staheli LT, Clawson DK, Capps JH. Bilateral curving of the terminal phalanges of the little fingers. Report of two cases. J Bone Joint Surg Am 1966; 48:1171–1176. 7 Dykes RG. Kirner’s deformity of the little finger. J Bone Joint Surg Br 1978; 60:58–60. 8 Carstam N, Eiken O. Kirner’s deformity of the little finger. Case reports and proposed treatment. J Bone Joint Surg Am 1970; 52:1663–1665. 9 Luppino T, Vaccari A. Acrodisplasia metadiafisaria bilaterale congenita del mignolo (deformita´ di Kirner [Congenital bilateral metadiaphyseal acrodysplasia of the little finger (Kirner’s deformity)]). Chir Organi Mov 1971; 60:133–141. 10 Moser N, Rosslein R. A new method for treating the Kirner deformity with the SM-Fix phalangeal distractor. Handchir Mikrochir Plast Chir 1996; 28: 34–38. 11 Niederwieser E, Segmuller G. Kirner-Deformita¨t: eine isolierte Fehlbildung der Kleinfingerenphalanx [Kirner’s deformity: an isolated malformation of the third phalanx of the little finger]. Schweiz Med Wochenschr 1979; 109:1023–1027. 12 Benatar N. Kirner’s deformity treated by distal detachment of the flexor digitorum profundus tendon. Handchir Mikrochir Plast Chir 2004; 36: 166–169.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
