Gradual reduction of distal radial malunion using distraction osteogenesis

Bifocal osteosynthesis to treat radial shortening deformity with dislocation of the inferior radioulnar joint

Background

Several methods have been reported to correct deformity and shortening of the distal radius. However, the results are not entirely satisfactory. The results of bifocal osteosynthesis were retrospectively analyzed in this study.

Methods

Eight patients treated with bifocal osteosynthesis were evaluated retrospectively. Pre-operative and post-operative clinical and radiographic examinations were performed. Subjective symptoms and objective joint function were assessed. Radiographic data of the extent of radial lengthening and distal radial articular angle were collected.

Results

The mean follow-up period was 46 months (37–68 months). Satisfactory wrist appearance and radial lengthening was achieved in all patients. All patients were satisfied with the wrist appearance and willing to undergo the same treatment again. The range of motion (ROM) of the forearm and wrist was significantly improved. Pin-track infections occurred in two patients, for which they received wound care and oral antibiotics. Complications such as fixation device failure, tendon rupture, fracture of regenerated bone or nerve impairment did not occur. The duration of lengthening depended on the shortening of the radius. Delayed union in the docking site was observed in two patients and union was achieved after bone grafting.

Conclusions

Bifocal osteosynthesis using the Ilizarov method provides a useful method for correction of radial shortening deformity with dislocation of the inferior radioulnar joint. Despite the fact that we did not validate pre-and post-operation functional outcome scores, all patients were satisfied with the wrist appearance and function.

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.

Corrective Radial and Ulnar Osteotomies for Distal Radial Fracture Malunion

Introduction

We describe a technique consisting of simultaneous radial closing-wedge and ulnar shortening osteotomy to treat malunion of distal radial fractures.

Step 1 Preoperative Planning

Plan the radial closing-wedge osteotomy to correct the volar tilt angle to 8.5° to 15.5° and the ulnar shortening osteotomy to restore ulnar variance to -2.5 to 0.5 mm.

Step 2 Radial Closing-Wedge Osteotomy

Remove the wedge of bone from the radius and reduce the distal fragment, keeping the dorsal cortex as a hinge.

Step 3 Distal Ulnar Shortening Osteotomy

Resect the section of the ulna equivalent to the positive ulnar variance with transverse osteotomies.

Step 4 Plate Fixation of the Radial Osteotomy Site

Hold together the two fragments of the radius with a Kirschner wire and fix the osteotomy site with a volar locking plate.

Step 5 Proximal Ulnar Shortening Osteotomy

Evaluate residual ulnar positive variance with fluoroscopy and restore the ulnar variance to within a normal range by removing additional bone from the proximal fragment.

Step 6 Plate Fixation of the Ulnar Osteotomy Site

Use a compression device to close and fix the ulnar osteotomy site.

Step 7 Postoperative Management

Allow early motion immediately after the operation.

Results

We retrospectively evaluated forty-two patients at a minimum of one year after treatment of an extra-articular distal radial malunion with a radial corrective osteotomy.

What to Watch For

IndicationsContraindicationsPitfalls & Challenges.

Clinical outcomes of corrective osteotomy for distal radial malunion: a review of opening and closing-wedge techniques

BACKGROUND

Radial corrective osteotomy is an established but challenging treatment for distal radial malunion. There is ongoing discussion over whether an opening or closing-wedge osteotomy should be employed. The purpose of the present study was to retrospectively compare the clinical and radiographic results of conventional opening-wedge osteotomy with those of our closing-wedge technique.

METHODS

We retrospectively evaluated forty-two patients with extra-articular distal radial malunion who were managed with corrective osteotomy and were followed for a minimum of one year. Twenty-two patients were managed with radial opening-wedge osteotomy and interpositional bone graft or bone-graft substitute, and twenty were managed with simultaneous radial closing-wedge and ulnar shortening osteotomy without bone graft. The selection of the surgical procedure was determined by the surgeon. Each patient was evaluated on the basis of objective radiographic measurements and functional outcomes as determined on the basis of clinical examination, including range of wrist motion, grip strength, pain-rating score, Mayo wrist score, and Disabilities of the Arm, Shoulder and Hand (DASH) score.

RESULTS

The mean duration of follow-up was thirty-six months (range, twelve to 101 months) for the opening-wedge cohort and twenty-eight months (range, twelve to eighty-seven months) for the closing-wedge cohort. The two techniques were comparable in terms of complications. Postoperative volar tilt and ulnar variance improved significantly compared with the preoperative status in each cohort (p < 0.05). Restoration of ulnar variance to within defined criteria (-2.5 to 0.5 mm) was significantly more frequent in the closing-wedge cohort than in the opening-wedge cohort (p < 0.001). The postoperative mean extension-flexion arc of the wrist (p < 0.001) and Mayo wrist score (p = 0.008) were significantly better in the closing-wedge cohort. Differences between the two cohorts in terms of the pronation-supination arc, grip strength, pain-rating score, and DASH scores were not significant.

CONCLUSIONS

The closing-wedge osteotomy technique is an effective reconstructive procedure for the treatment of extra-articular distal radial malunion. It is significantly better than the opening-wedge osteotomy technique in terms of the restoration of ulnar variance, the extension-flexion arc of wrist motion, and the Mayo wrist score.

Palmar locking plates for corrective osteotomy of latent malunion of dorsally tilted distal radial fractures without structural bone grafting

The purpose of this retrospective study was to investigate the clinical and radiological outcomes following corrective osteotomy for nascent malunion of distal radial fractures with dorsal tilt using palmar-locking plates without using autologous structural bone grafting for dorsal cortex support. The fractures were dorsally angulated distal radial fractures (AO types A2, A3, and C1) with neglected or delayed treatment for 5 to 8 weeks. Fractures were repaired using 2.4-mm palmar locking plates. Dorsal cortical defects at the osteotomy sites were filled with incipient healing callus. Radiographs were obtained before correction and at 2 and 6 weeks and 3, 4.5, 6, and 12 months postoperatively. Palmar tilt, radial inclination, and ulnar variance were measured. There were no cases of loss reduction, implant failure, or delayed fracture union without structural bone graft and casting. Clinical assessments included active range of motion of the wrist and function based on the Mayo Wrist Score. Even with wrist immobilization for >1 month preoperatively, all patients had excellent Mayo Wrist Scores at 4.5 months due to early postoperative rehabilitation. No further changes were apparent between 4.5- and 12-month follow-up.The palmar locking plates provided sufficient stability for corrective osteotomy within 8 weeks of injury without the need for structural bone grafting. Furthermore, casting immobilization was also unnecessary, and a good wrist range of motion was restored early after rehabilitation.

Computed tomographic assessment of reduction of the distal radioulnar joint by gradual lengthening of the radius

Congruency of the distal radioulnar joint was assessed by computed tomography after gradual lengthening of the radius in patients with considerable ulnar positive variance of mean 12 (range 10-17) mm and chronic dislocation of the distal radioulnar joint. Six patients of mean age 25 years were treated by radial osteotomy and subsequent gradual lengthening using either a single-rod or a half-ring external fixator, which was applied for a mean of 81 days. The causes of deformity were distal radial epiphyseal injury in four, malunion of a radius shaft fracture in one and Madelung deformity in one. Computed tomography scans taken at 1 year postoperatively demonstrated that all patients had a congruent distal radioulnar joint. All patients achieved symptom and radiographic parameter improvements at a mean follow-up of 40 months. A disadvantage was unattractive scars on a cosmetically important surface of the forearm. Given a relatively intact bony contour of the distal radioulnar joint, congruent reduction of the distal radioulnar joint can be obtained by gradual lengthening of the radius.