Osteotomy for malunited fractures of the distal radius: a comparison of structural and nonstructural autogenous bone grafts

Korrektureingriffe nach distaler Radiusfraktur

After a fracture of the distal radius, especially with malunion, many patients complain of a decreased range of forearm rotation and pain on the ulnar side of the wrist. The purpose of this article is to describe the therapeutic options available in such cases. Decision making as to whether there is an indication for corrective surgery or not is based on the patient's symptoms and the clinical findings, whereas the decision as to which surgery to perform must take into account the radiological findings. If possible, reconstruction of the anatomy using a distal radius osteotomy should be carried out.

Management of post-traumatic malunion of fractures of the distal radius

Distal radius malunions are a common cause of patient morbidity. This review of the literature surrounding distal radius malunion covers the demographics, pathologic anatomy, and indications for surgery, surgical techniques, and salvage options. Particular emphasis is placed on subject areas that have not been reviewed as extensively in previous articles, including: intra-articular malunion, computer-assisted techniques, bone graft alternatives, and volar fixed-angle plate osteosynthesis.

Immediate mobilisation following corrective osteotomy of distal radius malunions with cancellous graft and volar fixed angle plates

The purpose of the study was to examine the reliability with which a specific technique of corrective osteotomy of malunions of the distal radius combined with early mobilisation could both restore the normal anatomic parameters of the radius and achieve a functional range of motion with good strength. Corrective osteotomy of the distal radius was performed through a volar approach using a fixed angle volar plate and cancellous bone graft from the iliac crest in 19 patients of mean age 50 years with initial malunions with a mean dorsal tilt of 36 degrees and 7 mm of ulnar variance. An immediate mobilisation programme was started. All healed at a mean of less than 12 weeks (including two heavy smoking patients who required repeat cancellous bone grafting to achieve final union) to achieve a total arc of wrist motion around 120 degrees, forearm rotation of 158 degrees and grip strength which was 80% of contralateral. This treatment strategy was judged to be straightforward and effective.

Malunion of the distal radius

Fractures of the distal radius are common injuries. Acceptable results typically can be obtained with appropriate surgical or nonsurgical management. However, a small percentage of these fractures can progress to symptomatic malunion, which traditionally has been treated with osteotomy of the distal radius. Proper understanding of anatomy, biomechanics, indications, and contraindications can help guide patient selection for surgery. In formulating a treatment plan, the surgeon also must consider such technical variables as the type of osteotomy, the use of bone graft or bone-graft substitute, and the means of fixation to stabilize the osteotomy. Simultaneous implementation of an ulnar-side procedure, an intra-articular osteotomy, and soft-tissue releases also may be necessary. Some cases may be more appropriate for wrist fusion or other salvage procedures.

Outcomes using an internal osteotomy and distraction device for corrective osteotomy of distal radius malunions requiring correction in multiple planes

PURPOSE

Many different methods have been proposed for correction of distal radius malunions; however, precise correction of a severe malunion that requires simultaneous adjustment of displacement, angulation, and rotation in multiple planes is difficult. This prospective study measured radiographic and functional outcomes using an adjustable osteotomy, distraction, and fixation system for distal radius malunions that required correction in multiple planes.

METHODS

Five consecutive patients with symptomatic distal radius malunions requiring correction in multiple planes were recruited into this study. All patients had correction of the malunion with an adjustable osteotomy, distraction, and fixation device. Radiographic parameters and objective and subjective functional outcomes were measured before surgery and at 3 months, 6 months, and 1 year after surgery.

RESULTS

All radiographic measurements improved after surgery. Grip strength, pinch strength, and the Jebsen-Taylor test showed only marginal improvement. Ulnar deviation of the wrist and forearm pronation-supination improved, but the wrist extension-flexion arc did not. The Michigan Hand Outcomes Questionnaire showed improvement in all domains, and significant improvement was seen in the overall, work, aesthetic, and satisfaction domains. The Michigan Hand Outcomes Questionnaire, however, also indicated a substantial amount of residual impairment in all domains, including activities of daily living and pain.

CONCLUSIONS

Corrective osteotomy with the adjustable osteotomy, distraction, and fixation device resulted in improvement in distal radius anatomy and function. However, not all improvements were statistically significant, and anatomy and function did not returned to baseline levels. Despite residual disability, patients noted substantial improvement in subjective outcomes. This system is useful for improving anatomy and function in distal radius malunions that require correction in multiple planes, but patients should be informed that they cannot expect to regain normal anatomy or function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Corrective osteotomies in malunions of the distal radius: do we get what we planned?

Fifteen patients with symptomatic malunions of the distal radius were treated with osteotomies, corticocancellous bone grafting, and plate and screw fixation. We investigated the ability of precise preoperative planning of the size and shape of the corticocancellous bone graft to restore alignment of the radius to within 5 degrees angular deformity and 2 mm ulnar variance as compared with the opposite uninjured wrist. Only six of 15 patients (40%) satisfied these criteria. Inter-rater reliability of radiographic assessment was greater than 0.85. Five patients had residual radial inclination or sagittal tilt greater than 10 degrees with respect to the uninvolved wrist. Four patients had a residual ulnar variance greater than 2 mm with respect to the uninvolved wrist. Residual shortening (three of four patients), but not residual angulation, was associated with unsatisfactory pain and stiffness an average of 19.5 months after osteotomy (range, 11-32 months). We conclude that a distal radius osteotomy using a precisely planned and measured interpositional corticocancellous graft does not restore distal radius alignment in most patients, and that failure to restore length is associated with continued pain and stiffness.

LEVEL OF EVIDENCE

Therapeutic study, Level IV (case series).

A histologic analysis of the effects of stainless steel and titanium implants adjacent to tendons: an experimental rabbit study

PURPOSE

The current trend is to treat distal radius fractures with open reduction and internal fixation with either titanium or stainless steel plates. Both provide stable fixation; however, there is minimal evidence concerning the soft-tissue response to these materials. Our objective was to evaluate the response of adjacent extensor tendons to titanium and stainless steel in a rabbit in vivo model and to evaluate the influence of time.

METHODS

Forty rabbits were divided into 5 groups of 8 rabbits each. Groups I and II had unilateral osteotomy of the distal radius followed by dorsal fixation with titanium and stainless steel plates, respectively. Groups III and IV had fixation with titanium and stainless steel, respectively, but without osteotomy. Group V had surgical dissection without osteotomy or plates. Two animals per group were killed at 1, 4, 12, and 24 weeks. The specimens (distal radius, plate, overlying soft tissue, and extensor tendon) were harvested en bloc for histologic analysis. For interface preservation between implant and tissues the specimens were embedded in methylmethacrylate, sectioned, and stained with hematoxylin-eosin.

RESULTS

Histologic analysis showed a fibrous tissue layer formed over both implants between the plate and the overlying extensor tendons in the groups treated with plating independently of the material and the presence or absence of osteotomy. This fibrous layer contained the majority of debris. Metallic particles were not observed in the tendon or muscle substance of any animals; however, they were visualized in the tenosynovium. Hematoxylin-eosin-stained sections of groups I through IV showed proliferative fibroblasts and metallic particles; however, this layer was not observed in group V. Statistical analysis did not show differences between the groups regarding the number of cells or metallic particles.

CONCLUSIONS

Our results indicate that both implants generated adjacent reactive inflammatory tissue and particulate debris. There was no difference in cell or particle number produced by both materials. There is a statistically significant increase in inflammatory cells with increasing time of implantation.

Corrective osteotomy for intra-articular malunion of the distal part of the radius. Surgical technique

BACKGROUND

Corrective osteotomy is an appealing treatment for malunited articular fractures of the distal part of the radius since articular incongruity may be the factor most strongly associated with arthrosis and diminished function after such fractures. Enthusiasm for osteotomy has been limited by concerns regarding the difficulty of the technique and the potential for additional injury, osteonecrosis, and nonunion.

METHODS

Twenty-three skeletally mature patients were evaluated at an average of thirty-eight months after corrective osteotomy for an intra-articular malunion of the distal part of the radius. The indication for the osteotomy included dorsal or volar subluxation of the radiocarpal joint in fourteen patients and articular incongruity of >/=2 mm as measured on a posteroanterior radiograph in seventeen patients. Six patients had combined intra-articular and extra-articular malunion. The average interval from the injury to the osteotomy was six months. The average maximum step-off or gap of the articular surface prior to the operation was 4 mm.

RESULTS

One patient had a subsequent partial wrist arthrodesis because of radiocarpal arthrosis, and three patients had additional surgery because of dysfunction of the distal radioulnar joint. One patient had a rupture of the extensor pollicis longus, which was treated with a tendon transfer. The final articular incongruity averaged 0.4 mm, and the final grip strength averaged 85% of that on the contralateral side. The rate of excellent or good results was 83% according to the rating systems of Fernandez and of Gartland and Werley, and 43% according to a modification of the rating system of Green and O'Brien.

CONCLUSIONS

The results of corrective osteotomy for the treatment of intraarticular malunion are comparable with those of osteotomy for the treatment of extra-articular malunion. Intra-articular osteotomy can be performed with acceptable safety and efficacy, it improves wrist function, and it may help to limit the need for salvage procedures such as partial or total wrist arthrodesis.

Surgical correction of dorsally angulated distal radius malunions with fixed angle volar plating: a case series

PURPOSE

To report our experience using a fixed-angle volar plate in conjunction with a corrective osteotomy and cancellous bone graft for the treatment of distal radius malunions with dorsal angulation in 4 patients.

METHODS

Four consecutive patients had a volarly based opening wedge osteotomy with a fixed angle volar plate and cancellous bone grafting for the treatment of a dorsally angulated distal radius malunion. Data collected retrospectively included a visual analog pain scale, grip strength, range of motion, radiographic parameters, and each patient's subjective functional outcomes as measured by the Disabilities of the Arm, Shoulder, and Hand questionnaire. Motion, strength, and radiographic values were compared with the contralateral arm for each patient.

RESULTS

The average time from initial fracture to corrective osteotomy was 346 days. The average length of follow-up evaluation was 13.5 months. The flexion-extension arc of motion increased an average of 21 degrees to a value of 84% of the contralateral side; the pronation-supination arc of motion increased an average of 20 degrees to a value of 98% of the contralateral side. The average tilt of the radius improved from 26 degrees extension to 2 degrees extension; the average radial inclination improved from 22 degrees to 24 degrees; the average ulnar variance excluding the 1 patient who had a distal ulna resection improved from 5 mm to 1 mm. The average retrospective Disabilities of the Arm, Shoulder, and Hand score improved from 30 to 7; the average retrospective visual analog pain scale score improved from 4.5 to 1. The average grip strength increased from 20 to 29 kg, which corresponded to 73% of the contralateral extremity.

CONCLUSIONS

The rigid characteristics of fixed angle volar plates can provide an alternative to the traditional techniques of distal radius osteotomy including structural bone grafting and dorsal plate fixation or external fixation. In addition these plates are strong enough to allow for early postoperative motion.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic, Level IV.

Extra-articular distal radial fracture malunion

With the increase in surgical options for the treatment of distal radius fractures, the authors anticipate that distal radial fracture malunions will be a less frequently seen problem. Nevertheless, they will still occur. Although patient selection has been weighted toward the younger patient, we believe that surgery should be based on patient activity level, functional needs, and disability related to the malunion. With advances in biotechnology and improved anesthetics, surgical intervention even in the older and osteopenic population is now more promising. Surgical intervention still requires appropriate patient selection, careful preoperative planning, and meticulous surgical technique. The appropriate surgical procedure should be tailored to the patient's symptoms, age, needs, and radiographic findings.

Treatment of the neglected distal radius fracture

Operative treatment of inadequately or imperfectly treated fractures of the distal radius can improve wrist and hand function substantially, but rarely restores the limb to normal. Patients with malunion of the distal radius present either with poor radiographic alignment before complete healing of the fracture (nascent malunion) or with functional problems that may be related to inadequate alignment of a healed fracture (mature malunion). Corrective osteotomy is offered to patients who have sufficient malalignment that the surgeon thinks problems are inevitable or to patients in whom the functional deficit can be related clearly to the malunion. Ununited fractures are associated with painful instability of the wrist and very poor hand function. Operative treatment has proved successful even when the distal fragment is small. Operative treatment for reconstruction of the distal radius has been facilitated by the introduction of plates with angular stable screws (screws that lock into the plate). Painful arthritis is salvaged with arthrodesis.

Early corrective osteotomy for a malunited Colles' fracture using volar approach and calcium phosphate bone cement: a case report

We report a case of malunion of the distal radius after a Colles' fracture treated with osteotomy using a volar approach combined with calcium phosphate bone cement grafting of the dorsal defect via a drill hole from the volar cortex 6 weeks after the injury. One year and 4 months after surgery range of motion and grip strength were improved and x-rays of the wrist showed complete union of the distal radius with progressive absorption of the calcium phosphate bone cement.

Corrective osteotomy of malunited distal radius fractures using carbonated hydroxyapatite as an alternative to autogenous bone grafting

PURPOSE

The purpose of the present study was to report on the author's experience using carbonated hydroxyapatite as a bony substitute in distal radius corrective osteotomies.

METHODS

Six patients had a corrective osteotomy for a malunited distal radius fracture using carbonated hydroxyapatite as an alternative to an autogenous bone graft. Internal fixation of the osteotomy was achieved by using 2 or 3 K-wires.

RESULTS

At an average follow-up evaluation of 33 months (range, 22-45 mo) all the osteotomies united. Wrist flexion-extension motion improved from 75 degrees to 110 degrees , forearm rotation increased from 116 degrees to 157 degrees , and grip strength had an average increase of 140% at the time of the final follow-up evaluation. All patients were satisfied and there were no reports of persistent pain. Radiographic evaluation showed an average volar tilt improvement from a preoperative dorsal angulation shifting into a neutral position in the sagittal plane; radial lengthening improved from an average of 4 mm (range, 2-6 mm) before surgery to 7 mm (range, 5-9 mm) after surgery, ulnar plus deformity improved by 5 mm. Radiographically the carbonated hydroxyapatite material was integrated completely into the bone tissue with evidence of progressive re-absorption and bony calcification over time. The Mayo wrist score system, according to Cooney and Krimmer modifications, improved by an average of 88 and 98 points (0-100 points), respectively.

CONCLUSIONS

On the basis of this preliminary experience it is reasonable to consider carbonated hydroxyapatite as a viable alternative to bone grafting in conjunction with surgical correction of a distal radius malunion. It must be augmented, however, with internal fixation.

Corrective osteotomy of the distal radius through volar approach

Operative correction through the malunion has become a well-accepted reconstructive procedure for symptomatic malunited extra-articular fractures of the distal radius over the last 3 decades. Now that newer plates designed specifically for the volar fixation of dorsally unstable distal radius fractures by incorporating buttress pins and screws that lock to the plate are available, more and more surgeons prefer volar fixation of dorsally unstable distal radius fractures. In the mid 1970s, the senior author (U.B.L.) developed a technique for corrective osteotomy of dorsally tilted malunions of the distal radius using a radiovolar approach and a special plate. This technique was proved to be efficient in more than 400 patients.

Nonunion of distal radius fractures

Nonunion of a distal radius fracture is extremely uncommon. Healing problems in the distal radius seem to be related to unstable situations, such as concomitant fracture of the distal radius and ulna, and to an inadequate period of immobilization. Nonunion should be suspected if there is continuing pain after remobilization of the wrist in combination with a progressing deformity. The diagnosis may be confirmed by showing movement at the fracture site on lateral radiographs of the wrist in flexion and extension. Because of the rarity of distal radius fracture nonunion, it is not surprising that there is no consensus on the optimum mode of operative treatment. Based on our experience with reconstruction surgery in 23 patients, we think that most nonunions of the distal radius are amenable to attempts to re-align and heal the fracture even when the distal fragment is small. Therefore, surgeons should try to preserve even a small amount of wrist motion and reserve wrist fusion as a final resort.