Correction osteotomy of distal radius malunion stabilised with dorsal locking plates without grafting

Functional outcome of 2-D- and 3-D-guided corrective forearm osteotomies: a systematic review

We performed a systematic review to compare conventional (2-D) versus 3-D-guided corrective osteotomies regarding intraoperative results, patient-reported outcome measures, range of motion, incidence of complications and pain score. PubMed (MEDLINE), Embase and Cochrane CENTRAL were searched, and 53 articles were included, reporting 1257 patients undergoing forearm corrective osteotomies between 2010 and 2022. 3-D-guided surgery resulted in a greater improvement in median Disabilities of the Arm, Shoulder and Hand (DASH) score (28, SD 7 vs. 35, SD 5) and fewer complications (12% vs. 6%). Pain scores and range of motion were similar between 3-D-guided and conventional surgery. 3-D-guided corrective osteotomy surgery appears to improve patient-reported outcomes and reduce complications compared to conventional methods. However, due to the limited number of comparative studies and the heterogeneity of the studies, a large randomized controlled trial is needed to draw definitive conclusions.Level of evidence: III.

Corrective osteotomy of the distal radius with palmar locking plate osteosynthesis without bone grafting and without cortical contact

The aim of this study was to assess bone healing and secondary fracture displacement after corrective osteotomy of the distal radius without any cortical contact using palmar locking plates without bone grafting. Between 2009 and 2021, 11 palmar corrective osteotomies of extra-articular malunited distal radius fractures and palmar plate fixations without the use of bone grafts and without cortical contact, were assessed. All patients showed complete osseous restoration and significant improvement in all radiographic parameters. Except for one patient, there were no secondary dislocations or loss of reduction in the postoperative follow-up. Bone grafts may not be mandatory for bone healing and prevention of secondary fracture displacement after palmar corrective osteotomy without cortical contact and fixation with palmar locking plate.Level of evidence: IV.

Managing the Extra-Articular Distal Radius Malunion

Distal radius fractures are common injuries. Satisfactory outcomes are typically achieved with appropriate nonoperative or operative treatment. A proportion of these injuries develop symptomatic malunions, which may be treated surgically with distal radius corrective osteotomy. A thorough understanding of the anatomy, biomechanics, radiographic parameters, and indications is needed to provide appropriate treatment. Factors, including surgical approach, osteotomy type, use of bone graft, fixation construct, management of associated tendon and/or nerve conditions, soft tissue contracture releases, and need for ulnar-sided procedures, should be considered. A comprehensive evaluation is necessary to guide understanding for when salvage procedures may be preferred.

Total Wrist Arthroplasty as a Motion-Sparing Option for Distal Radius Malunion in a Patient of Advanced Age: A Case Report

CASE

A 62-year-old woman presented with wrist pain secondary to a distal radius fracture malunion 4 months after a fall onto an outstretched hand. She was not an ideal candidate for osteotomy and bone graft because of the degree of displacement and osteoporosis, so after nonoperative treatment was unsuccessful, she was offered total wrist arthroplasty (TWA) or arthrodesis and opted for TWA.

CONCLUSION

At 14-month follow-up, the patient reported significant improvement in her pain and function. The current generation of TWA implants may allow use in the management of symptomatic distal radius malunions in older, low-demand patients.

Dorsally and volarly angulated extra-articular malunions of the distal radius treated with volar corrective osteotomy and volar locking plate fixation. A case series of 19 patients with a long-term follow-up

BACKGROUND AND AIM

To date, different technique of corrective osteotomy for the treatment of distal radius extra-articular malunions are described. With this study, we present a case series of corrective osteotomy using volar plate fixation to treat volar and dorsal extra-articular malunions aiming to evaluate the effectiveness of corrective osteotomies through volar plate stabilization in these two types of extra-articular malunions.

METHODS

Between August 2008 and May 2017 all patients diagnosed with extra-articular malunion were included in the study. An extended volar Orbay approach and two types of dedicated volar locking plate (Medartis AG, Switzerland and Acumed, Hillsboro,OR) were used. Clinical and radiological parameters were evaluated. The DASH and PRWE scores and the VAS scale questionnaires were administered. The results were analyzed through statistical evaluations.

RESULTS

A retrospective analysis of 19 patients diagnosed with extra-articular malunion was carried out. Nine had a volar type deformity (group A), while the other 10 had a dorsal type deformity (group B). The active range of motion (aROM), radiographic parameters, grip strength and pinches in both groups were statistically improved, except for radial deviation in both groups, ulnar deviation in group A, and radial inclination in group B.  The grip strength and pinches values were slightly better in group A. DASH, PRWE scores and VAS scale showed a significant improvement.

CONCLUSION

Corrective osteotomy through volar fixation is an effective technique to treat both extra-articular dorsally and volarly angulated malunions. Statistically significant benefits are present in both types of deformities, with better outcomes in the group of volar deformities.

Distal Radius Malunion

Malunion remains the most common complication of nonsurgical treatment of fractures of the distal radius and represents a common clinical entity. Symptomatic treatment often involves corrective osteotomy. Surgical correction is a challenging problem with unpredictable clinical outcomes. Prevention of malunion of a distal radius fracture is the best course of action. With maintenance of volar cortical contact and the use of volar fixed-angle devices, bone grafting may not be necessary in certain cases of malunion correction. New technologies such as 3-dimensional modeling and computer-generated osteotomy guides are likely to have a positive impact on the outcomes of surgical treatment.

Distal radius correction osteotomy with tricortical bone graft is a successful method in heavy smokers

BACKGROUND

Corrective osteotomy is a technically challenging surgical option to improve wrist function in tilted distal radius malunions. However fracture healing in smokers is adversely affected. The aim of this study was to evaluate the clinical and radiological effect of cigarettes on bone union in heavy-smokers who underwent corrective osteotomy with a triangular bone graft harvested from the iliac crest.

METHOD

Fifteen patients, who were treated using trapezoidal block grafts taken from the iliac crest, who were smokers of 20 or more cigarettes daily (heavy smokers) with no chronic disease, and who consented to participate in the study. Fifteen non-smoker patients of the same age group were determined as the control group. Radiological measurements were made to include radial inclination and ulnar variance in pre-operative and post-operative radiographs. Functional evaluation was performed using Q-DASH and MAYO hand-wrist scores.

RESULTS

In both groups, the mean age of the patients was 49,1 ± 3,92 years. Smokers group the bone union in the osteotomy line was observed after 16,63 (12-24 h) weeks, non-smokers grup 14.1 (12-24) weeks (p = 0.06). Range of motion is found similar clinic between in groups (p > 0.05). Q-DASH for group smokers was 17.54 ± 1.85, nonsmokers 17.20 ± 1.24 (p = 0,878); MAYO was 82.27 ± 6.06 for 82.00 ± 7.74 (p = 0.874). for group B. No statistically significant difference was noted between the groups.

CONCLUSION

Our study showed that cigarette smoking did not have negative effect on union time in the metaphyseal region after correction osteotomy. The time of bone-union in heavy-smokers was 2.5 weeks more than that of non-smokers.

Outcomes and Complications Following Volar and Dorsal Osteotomy for Symptomatic Distal Radius Malunions: A Comparative Study

PURPOSE

To compare patient-reported outcomes, functional outcomes, radiographic alignment, and complications of volar versus dorsal corrective osteotomies as the treatment for symptomatic distal radius malunions.

METHODS

We performed a retrospective review of all patients who underwent a distal radius corrective osteotomy with either a volar or dorsal approach and plating at 1 of 3 institutions between 2005 and 2017. Demographic data, type of surgical treatment, and radiographs were examined. Outcomes were Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) function scores and radius union scoring system as well as major and minor complications.

RESULTS

We included 53 cases (37 volar osteotomies and 16 dorsal osteotomies). Postoperative follow-up from the time of surgery to last QuickDASH score was 84.6 months (range, 12-169.4 months). Compared with the dorsal osteotomy group, the volar osteotomy group demonstrated a better postoperative flexion-extension arc (94.9° vs 72.9°, respectively), pronation-supination arc (146.2° vs 124.9°, respectively), and last QuickDASH scores (6.65 vs 12.87), respectively. Radiographically, there was no difference noted in radial height, radial inclination, or volar tilt in the immediate postoperative and last radiographs. There was a higher rate of complications in the dorsal osteotomy group (8 cases [50% of patients]) compared with the volar osteotomy group (7 cases [18.9% of patients]), including a higher rate of hardware removal.

CONCLUSIONS

For patients with symptomatic malunions of the distal radius, the volar and dorsal approaches both resulted in improvement in QuickDASH scores and range of motion. Volar plating resulted in slightly better QuickDASH scores and fewer complications compared with dorsal plating.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The Vascularity and Osteogenesis of a Vascularized Flap for the Treatment of Scaphoid Nonunion: The Pedicle Volar Distal Radial Periosteal Flap

Background: Vascularized periosteal flaps from the distal radius have been previously proposed. The purpose of this study was to investigate the vascularity and osteogenic potential of a vascularized volar distal radial periosteal flap for the treatment of scaphoid nonunion. Methods: In 5 fresh frozen cadavers, a rectangular periosteal flap was elevated from the distal radius with the pedicle just proximal to the watershed line. Latex dye was injected into the radial artery proximally and the vascularity of the flap characterized by microscopic evaluation. Patients with scaphoid nonunion were then treated with open reduction, internal fixation, and distal radius cancellous bone graft. Two groups of patients with midwaist nonunion scaphoid were then evaluated. The first group received the vascularized periosteal flap and the second group received a nonvascularized periosteal flap. A third group of proximal pole nonunions also received the vascularized flap. Results: Cadaveric dissections revealed that all of the injected flaps demonstrated vascularity to the distal edge of the flap. Vascularized flaps formed visible bone on imaging in 55% of cases. None of the nonvascularized flaps formed visible bone. In group 1, 12/12 midwaist nonunions united. In group 2, union was achieved in 6/6 of patients who completed the follow-up. In group 3, 6/7 proximal pole fractures united. Conclusions: Previously proposed vascularized periosteal flaps from the distal radius appear to possess notable osteogenic potential that may be of interest to surgeons treating scaphoid nonunion.

Extra-articular Corrective Osteotomy With Bone Grafting to Achieve Lengthening and Regain Alignment for Distal Radius Fracture Malunion

Surgical correction of the distal radius fracture malunion is challenging because of the 3-dimensional deformity. We propose a method by using the Kapandji intrafocal pinning in corrective osteotomy for treatment of the distal radius fracture malunion to facilitate the alignment correction while using the bone graft to restore the radial length. The surgery was started with the osteotomy from a volar approach, and the osteotomy gap was expanded gradually. Then, allobone grafting was performed to maintain the corrected radial length. We used the Kapandji intrafocal pinning dorsally to provide dorsal supporting force and radially to correct the radial inclination. Finally, a volar plate was used to buttress and push the distal fragment to fit as to regain the correct volar tilt. We enrolled 10 patients of distal radius fracture malunion with a mean age of 59.3 years. All patients had bone healing within 3 months after surgery. The mean lengthened distance was 5 mm. The radial inclination and volar tilt could be corrected with improved functional results.

Carpal Tunnel Syndrome Following Corrective Osteotomy for Distal Radius Malunion: A Rare Case Report and Review of the Literature

BACKGROUND

Although median nerve neuropathy and carpal tunnel syndrome (CTS) are known complications of both untreated and acutely treated distal radius fracture, median neuropathy after correction of distal radius malunion is not commonly reported in hand surgery literature. We describe a patient with severe CTS after corrective osteotomy, open reduction internal fixation (ORIF) with a volar locking plate (VLP), and bone grafting for distal radius malunion.

METHODS

We report a case of severe acute CTS as a complication of corrective osteotomy with bone grafting for distal radius malunion.

RESULTS

The patient was treated with surgical exploration of the median nerve and carpal tunnel release.

CONCLUSION

The authors report a case of acute CTS after ORIF with VLP for a distal radius malunion warranting surgical exploration and carpal tunnel release. Treatment teams must be aware of this potential complication so that the threshold for reoperation is low and irreversible damage to the median nerve is prevented.

Corrective osteotomy is an effective method of treating distal radius malunions with good long-term functional results

INTRODUCTION

Malunion occurs in approximately 23% of non-operatively treated and 11% of operatively treated distal radius fractures. The decision whether to correct a malunion is primarily based on functional impairment and wrist pain. The purpose of this study was to assess the long-term functional outcomes of corrective osteotomies for symptomatic malunited distal radius fractures.

METHODS

All consecutive corrective osteotomies of the distal radius performed in one centre between January 2009 and January 2016 were included. The primary outcome was the functional outcome assessed with the Disability of the Arm, Shoulder and Hand (DASH) and the Patient-Rated Wrist Evaluation (PRWE) score. Secondary outcomes were range of motion, grip strength, pain as indicated on the Visual Analogue Scale (VAS) before and after corrective osteotomy, radiological parameters, time to union and complications. Additionally, we aimed to determine if there were any difference in graft versus no graft usage.

RESULTS

A total of 48 patients were included. The median age was 54.5 years (IQR 39-66) and 71% was female. The median time to follow-up was 27 months. The median DASH and PRWE score were respectively 10.0 (IQR 5.8-23.3) and 18.5. (6.5-37.0). Except for pronation and supination, range of motion and grip strength of the injured wrist were significantly less compared to the uninjured side. Palmar and dorsal flexion and radial and ulnar deviation of the injured wrist were significantly less compared with the uninjured side. VAS pain scores decreased significantly from 6.5 preoperative to 1.0 postoperative. The median time to union was 23 weeks (IQR 12-29.5). Eighteen patients (38%) had a complication for which additional treatment was required. Except for a significant difference in radial inclination and length after the corrective osteotomy in favour of graft usage, there were no significant differences between graft an no graft usage.

CONCLUSIONS

Corrective osteotomy is an effective method of treating symptomatic distal radius malunions with good long-term functional results, measured with the DASH and PRWE score, and improvement in radiographic parameters and pain scores. Additionally, no differences in functional outcomes were found between graft and no graft usage.

Minimally invasive osteotomy for distal radius malunion: A preliminary series of 9 cases

The rate of malunion after distal radius fractures is 25% after conservative treatment and 10% after surgery. Their main functional repercussion related to ulno-carpal conflict is loss of wrist motion. We report a retrospective clinical series of minimally invasive osteotomies. The series consisted of 9 cases of minimally invasive osteotomies with volar locking plate fixation. All osteotomies healed. The average pain was 5.3/10 preoperatively and 2.1/10 at last follow-up. The mean Quick DASH was 55.4/100 preoperatively and 24.24/100 at last follow-up. Compared to the opposite side, the average wrist flexion was 84.11%, the average wrist extension was 80.24%, the average pronation was 95.33% and the average supination was 93.9%. With similar results to those of the literature, our short series confirms the feasibility of minimally invasive osteotomy of the distal radius for extra-articular malunion. TYPE: Case-series.

LEVEL OF EVIDENCE

IV.

Is Bone Grafting Necessary in the Treatment of Malunited Distal Radius Fractures?

Background Open wedge osteotomy with bone grafting and plate fixation is the standard procedure for the correction of malunited distal radius fractures. Bone grafts are used to increase structural stability and to enhance new bone formation. However, bone grafts are also associated with donor site morbidity, delayed union at bone-graft interfaces, size mismatch between graft and osteotomy defect, and additional operation time. Purpose The goal of this study was to assess bone healing and secondary fracture displacement in the treatment of malunited distal radius fractures without the use of bone grafting. Methods Between January 1993 and December 2013, 132 corrective osteotomies and plate fixations without bone grafting were performed for malunited distal radius fractures. The minimum follow-up time was 12 months. Primary study outcomes were time to complete bone healing and secondary fracture displacement. Preoperative and postoperative radiographs during follow-up were compared with each other, as well as with radiographs of the uninjured side. Results All 132 osteotomies healed. In two cases (1.5%), healing took more than 4 months, but reinterventions were not necessary. No cases of secondary fracture displacement or hardware failure were observed. Significant improvements in all radiographic parameters were shown after corrective osteotomy and plate fixation. Conclusion This study shows that bone grafts are not required for bone healing and prevention of secondary fracture displacement after corrective osteotomy and plate fixation of malunited distal radius fractures. Level of evidence Therapeutic, level IV, case series with no comparison group.

Non-union in 3 of 15 osteotomies of the distal radius without bone graft

BACKGROUND AND PURPOSE

Open-wedge osteotomies of the distal radius create a void that is usually filled with either iliac crest bone graft or bone substitute. Previous studies have suggested that this is unnecessary. We investigated the safety of omitting the filling procedure.

PATIENTS AND METHODS

We included 15 patients with a dorsal malunion of a distal radius fracture. A palmar approach and angle-stable plates were used. The patients were followed until there was radiographic and clinical healing.

RESULTS

Non-union occurred in 3 of the 15 patients. The study, which had been planned to include 25 patients, was then discontinued. 6 osteotomies created a trapezoid void (no cortical contact); 3 of these did not unite after the index procedure (p = 0.04), but did subsequently, after autogenous bone grafting. A trapezoid void was significantly associated with non-union (p = 0.04).

INTERPRETATION

When a trapezoid defect is created, one should consider bone substitute or autogenous bone graft. This has been shown to be safe in other studies.

Management of complications of distal radius fractures

Treating a fracture of the distal radius may require the surgeon to make a difficult decision between surgical treatment and nonsurgical management. The use of surgical fixation has recently increased because of complications associated with conservative treatment. However, conservative action may be necessary depending on certain patient factors. The treating surgeon must be aware of the possible complications associated with distal radius fracture treatments to prevent their occurrence. Prevention can be achieved with a proper understanding of the mechanism of these complications. This article discusses the most recent evidence on how to manage and prevent complications following a fracture of the distal radius.