Baltimore, MD — On New Year’s Eve in 2016, Juan and Alma Mota swaddled their precious new deliveries in pink and counted 30 perfect toes and 29 perfect fingers. Of their beautiful triplet daughters, Julianna was born with a rare congenital anomaly known as radial longitudinal deficiency (RDL) or club hand, in which the radius bone of her forearm failed to develop normally. The result of this for Julianna was a shortened forearm, with her hand folded inward at the wrist and an under developed thumb.
The triplets’ birth came just ten days after surgeons at MedStar Union Memorial Hospital’s Curtis National Hand Center in Baltimore performed the first surgery of its kind in the U.S., for the treatment of RDL on a 7-year old boy. Dr. James Higgins, chief of the Curtis National Hand Center and Dr. Ryan Katz, attending hand surgeon, used a bone with growth plates taken from the child’s toe, to construct a full-length radius. In a single surgery, Drs. Katz and Higgins were able to lengthen the boy’s forearm, correct the posture of his hand, and promote the potential for future growth. This novel procedure garnered national and international attention.
The unique approach differs from traditional RDL surgical treatments, which focus primarily on improving the appearance of the hand, but do not address function or allow for growth. One classic method of treatment fuses the hand to the forearm in a straight position. This classic approach removes the ability to move the hand at the wrist and does not stand the test of time – often resulting in the hand curving inward again as the child grows.
After finding national news coverage of the case online, the Mota family, determined to find the best treatment for Julianna, set out on 1600-mile journey from Ft. Morgan, Colorado to the Curtis National Hand Center in Baltimore.
Helping Julianna achieve optimum use and an aesthetic result was a three-part process that began in September. Doctors applied a distraction device to lengthen and straighten the curved forearm, and to create space in the joint for the anticipated transfer of her toe. With this device, the forearm was lengthened over a course of six weeks.
In October, the next and most complex procedure was performed to harvest Julianna’s second toe and transplant the bone into her forearm. Using high powered microscopes in the operating room, and sutures thinner than human hair, Drs. Katz and Higgins surgically reconnected the tiny vessels of the bone’s blood supply into the space created by the lengthening device, to construct a partial radius bone. Transplanting the bone with its own vascular system and growth plates ensures Julianna’s arm will grow, remain straight, and have motion.
This is a technically challenging surgery where two attending surgeons and their teams operate simultaneously: One prepares the hand to receive the transfer, and one works at the foot to remove the toe, while carefully preserving the blood supply.
“Both aspects of the case are very challenging,” Dr. Katz said. “At the hand, the normal anatomy is not there, and you have to preserve the important structures and the blood flow to the hand, prepare the site for a boney inset, a tendon transfer and ultimately, revascularization of the toe. We have to get it alive again.
“At the toe, you have to raise everything you’re going to use. We prepared tendon, nerve, bone and skin. Ultimately, you have to protect the critically important artery and vein.”
Additionally, and most innovatively, Drs. Katz and Higgins “banked” a piece of bone which otherwise would be discarded, by vascularizing it into Julianne’s hand. “Here it will remain safe and alive in her own body, until her parents are ready to move forward with surgery to construct a functioning thumb,” said Dr. Katz. “By banking the bone, there is potential for future reconstructive thumb surgery. It would require a tendon transfer, but we’ve laid the foundation for a novel reconstruction option.’
In November, the Mota family returned to MedStar Union Memorial Hospital to remove the hardware scaffolding that kept her little arm immobilized an ensure proper healing. Now in a cast, Julianna’s hand is upright, her forearm is straight, and will grow as she grows. She recovered quickly from the foot surgery; is walking and running without difficulty – challenging her sisters to keep up.
For more information on the Curtis National Hand Center or the MedStar Union Memorial Hospital, please visit medstarunionmemorial.org.
About The Curtis National Hand Center
Since 1975, people all over the world have placed their hands in ours – The Curtis National Hand Center. From repairing traumatic injuries to treating repetitive motion injuries, arthritic conditions and congenital differences, our goal is to restore the patient's use of the hand, wrist, arm, elbow and shoulder to the greatest degree possible. Our long history of experience, outstanding medical staff, and state-of-the-art facilities combine to create a treatment center that is the first choice in caring for the hand or arm, no matter how common or complex.
Today, The Curtis National Hand Center is recognized as the largest, most experienced hand center in the nation. In fact, the hand center was designated by Congress as the National Center for the Treatment of the Hand and Upper Extremity.
About MedStar Union Memorial Hospital
MedStar Union Memorial Hospital is a not-for-profit, 223-bed acute care teaching hospital with a strong emphasis on cardiac care, orthopaedics and sports medicine. With roots stemming back to 1854, MedStar Union Memorial has provided high quality care for 160 years. As one of the region's top specialty hospitals, MedStar Union Memorial is home to: The Curtis National Hand Center, the only hand center designated by Congress as The National Center for the Treatment of Hand and Upper Extremity; MedStar Heart & Vascular Institute, a premier cardiovascular program in the mid-Atlantic, aligned with Cleveland Clinic Heart and Vascular Institute, the nation’s #1 heart program; and MedStar Union Memorial Orthopaedics and Sports Medicine, the oldest hospital based Sports Medicine Program in Maryland (founded in 1979). In addition, MedStar Union Memorial offers a comprehensive range of inpatient and outpatient services including oncology, diabetes and endocrinology, general surgery, thoracic surgery, vascular surgery and palliative care.
MedStar Union Memorial is accredited by The Joint Commission (TJC). It is the first hospital in Baltimore to receive spine certification by TJC, and the first in the state of Maryland to receive advanced certification for palliative care. MedStar Union Memorial is also TJC-certified in hip and knee replacement, CARF-accredited in inpatient rehabilitation and Curtis Work Rehabilitation Services, and has been designated as a Primary Stroke Center and the Hand Trauma Center for Maryland.
MedStar Union Memorial is a proud member of MedStar Health, a non-profit, regional health care system with 10 hospitals and more than 20 other health-related services in the Maryland and Washington, D.C., area.
For more information, visit MedStarUnionMemorial.org.