Cylindrical corrective osteotomy for Madelung deformity using a computer simulation: case report

Radial Osteotomy With Callus Distraction for the Correction of Severe Madelung Deformity

We report a case of an 11-year-old girl with bilateral severe Madelung deformity who underwent radial osteotomy with callus distraction. The distal radial articulation was corrected at surgery, and a unilateral fixator was subsequently used for callus distraction. No postoperative complication was noted. The patient did not need any additional surgeries for correction of the deformity. Forty-three months after surgery, the patient had a nearly full range of motion without any pain. Forearm deformity was not noticeable, except for surgical scar on both wrists.

Results of primary radial corrective osteotomy in Madelung's deformity

INTRODUCTION

The purpose of this study was the evaluation of surgical outcomes in a series of wrists with Madelung's deformity treated with radial corrective osteotomy. We hypothesize that this surgical technique is a suitable and safe way of treatment.

MATERIALS AND METHODS

A retrospective review of patients with Madelung's deformity treated with radial corrective osteotomy between January 2001 and June 2017 at a single large department of hand surgery in Germany was performed. Patients who met the inclusion criteria were invited for follow-up and outcome variables including pain, range of motion, patient-rated outcome measures, and radiographic measurements were obtained for comparison with preoperative data collected from the patients' medical records.

RESULTS

14 wrists were included. The average age at the time of surgery was 21.9 years, and the average follow-up was 7.2 years. The average visual analog pain scale at rest decreased from preoperative 2.6 points to postoperative 0.7 points. Under strain, the average VAS declined from 7.4 to 4.9 points. The mean DASH Score decreased from 42.9 before surgery to 22.0 points after surgery. Range of motion improved slightly in five out of six directions of motion, with the greatest increase seen in average supination from preoperative 68.5° to postoperative 82.0°. Averages of all five measured McCarroll's parameters and ulnar variance decreased, as expected from corrective surgery. Four wrists (26.8%) needed subsequent procedures.

CONCLUSION

Radial corrective osteotomy was a suitable treatment of Madelung's deformity in our collective, although surgical outcomes are not yet fully satisfying.

Shelf Osteotomy for Madelung's Deformity in Adults: A Novel Technique

Background  Madelung's deformity (MD) comprises increased volar and ulnar tilt of the distal radius joint facet, secondary to an idiopathic physeal dysplasia. Such change causes radial shortening and a consequent distal ulnar prominence, along with wrist pain and loss of motion. Classic surgical techniques are problematic for adults, as they are specific for children and adolescents whose distal radial physis is still open. Description of Technique  It is suggested a new treatment method for MD in skeletally mature patients: a distal radius osteotomy and joint realignment are performed through a volar approach to increase the support area of the lunate bone. The rotation and lengthening of the distal epiphysis of the radius generate support and cover to the lunate bone, with improvement of both radiocarpal and distal radioulnar joints. Patients and Methods  We describe the technique in details and report the treatment of a 25-year-old female patient. Results  Early clinical and radiographic outcomes are encouraging for the treatment of symptomatic patients. Conclusion  There is a plethora on the literature about conflicting opinions on the best treatment options and surgical techniques are quite variable, although usually with good results. Besides, the technique here described is indicated during a specific stage of disease presentation, consisting of young adults without any wrist-degenerative changes. Having said that, it is possible to claim that MD treatment with shelf osteotomy is a concept change. Our main goal is to reconstruct the diseased segment and improve wrist stability.

Dual Corrective Osteotomy of the Radius and Ulna for Mature Madelung Deformity Using CT-based 3D Simulation: A Case Report

We report a patient with mature Madelung deformity who underwent radial and ulnar corrective osteotomy using three-dimensional (3D) simulation. An osteotomy model was created using the computer-aided design (CAD) software based on the computed tomography (CT) data. After correcting the ulna, the osteotomy angle of the radius was determined using the location of the lunate as a landmark in the 3D plane created by the longitudinal axis of the corrected ulna. Consequently, the ulna was flexed 3° and shortened by 5 mm, and the radius was extended at 36° and ulna deviated at 25° by open wedge osteotomy. The radial inclinations, volar tilt and ulnar variance were 25°, 45° and 5 mm preoperatively, and improved to 22°, 10° and 0 mm after surgery. At the 18-month follow-up, the patient reported no pain even during sports activity. The preoperative 3D simulation enabled precise preoperative planning and accurate correction of the Madelung deformity. Level of Evidence: Level V (Therapeutic).

Use of a 3D Model for the Correction of a Complex Madelung Deformity in a Teenager: A Case Report

CASE

The aim of the article is to report on a case of a teenager affected by Madelung deformity treated with a double osteotomy, planned by means of a 3D model. Using a custom-made cutting guide, the radial osteotomy was performed, and after the reorientation, a shortening ulnar osteotomy completed the procedure. Postoperative clinical assessment showed a normal alignment of the ulna with increased range of motion wrist motion.

CONCLUSIONS

Using a 3D model when planning a multidirectional correction of a Madelung deformity may be advantageous to achieve a more accurate and precise realignment of the carpus and distal radioulnar joint.

Madelung Deformity: Diagnosis and Treatment Options

Madelung deformity (MD) comprises an increased volar and ulnar tilt of the joint facet of the distal radius, secondary to an idiopathic physeal dysplasia. Such change causes radial shortening and consequent distal ulnar prominence, along with wrist pain and loss of motion. Surgery becomes an option in patients with severe deformity that do not respond to conservative treatment.

The classic surgical techniques are problematic for adults, as they are specific for children and adolescents, whose radial physis is still open. Very few papers discuss the treatment of adult patients; furthermore, most are focused on the distal radioulnar joint, and thus do not approach the origin of the pathology.

When analyzing computed tomography scans with tridimensional reconstruction, a feature of MD, growth arrest of the volar and ulnar portions of the distal radius, is noted, causing the typical distal radius deformity that leads to lack of coverage of the lunate bone. That leads to palmar subluxation of the lunate bone and consequent radiocarpal instability.

We herein describe the possibilities of treatment in different stages of evolution, summarizing the authors' view on MD.

Reverse wedge osteotomy for Madelung's deformity in a high school student: A case report

Madelung deformity is a congenital disorder with the malformation of anterior ulnar bowing of radius and a dorsally protruding ulnar head caused by premature growth disturbance at the medial volar aspect of the distal radius. This report describes a bilateral idiopathic Madelung deformity in a 17-year-old woman treated successfully using reverse wedge osteotomy of the distal radius in a symptomatic left wrist. Reverse wedge osteotomy can orient the radial joint surface while correcting the whole radius length by reversely putting the wedge bone removed from the distal metaphysis of radius, the base of which is cut from the surplus of the radial and dorsal cortical bone in the hypotrophic portion. We corrected the palmar subluxation of the carpus, restored her good function, and relieved her wrist pain.

Open Wedge Osteotomy with Ulnar Shortening for Madelung Deformity Using a Computer-Generated Template

A variety of osteotomies have been reported to correct Madelung deformity using plain radiographs. However, evaluation of the deformity using 2-dimensional plain radiography is difficult because of its complex 3-dimensional nature. Therefore, we performed corrective osteotomy using recently developed 3D simulation technology on an adult woman with Madelung deformity, and achieved an excellent outcome. In this study, we calculated the amount of parallel displacement as well as the rotational angle for more precise correction, and performed open wedge osteotomy. Furthermore, we performed concurrent ulnar shortening. An exaggerated radial inclination was observed in the posteroanterior radiograph. A palmar shift of the carpus and dorsal dislocation of the ulnar head were observed in the lateral radiograph. In the preoperative findings, radial inclination (RI), volar tilt (VT), and ulnar variance (UV) were 35°, 40°, and 12 mm, respectively. The wrist showed improvement, with an RI of 25°, VT of 14°, and UV of 0 mm. At present, 14 months after surgery, there has been no loss of correction, instability of the ulnar head, or pain on the ulnar side. The procedure resulted in improvements in the protrusion and pain in the ulnar portion of the patient's wrist. Based on this result, we believe that accurate corrective osteotomy with ulnar shortening should be performed for Madelung deformity.

Madelung's Deformity of the Wrist-Current Concepts and Future Directions

Madelung's deformity of the wrist arises from premature closure of the medial and volar aspect of the distal radial physis. True Madelung deformities reveal the presence of a "Vickers" ligament which is a short, volar, radioulnar ligament. Clinically, patients report increasing deformity, pain, and poor range of motion. Radiological features include increased radial inclination, volar tilt of the distal radius, and a positive ulnar variance. Surgical intervention usually comprises either a "Vickers" ligament release and distal radius physiolysis or a radial dome osteotomy. In future, EOS Imaging could aid diagnosis by providing more detailed images of the deformity while minimizing radiation exposure. Furthermore, three-dimensional printing and computer-navigated deformity correction could revolutionize management by facilitating simulation training, expediting surgery, and reducing intraoperative error.

Madelung's deformity: capitate-related versus ulna-related measurement methods

Several investigators have defined measurements for Madelung's deformity based on the distal radius or on the longitudinal ulnar axis to avoid the distorted distal radius and its lunate fossa. However, errors may occur in severe cases because of ulnar deformity and displacement. We quantified seven established measurements for Madelung's deformity relying on the central axis of the capitate. The inter- and intrarater reliability of the capitate-related and the ulna-related techniques were compared. We observed a higher inter- and intrarater reliability for the capitate-related method than for the ulna-related method. Better agreement was also observed for measurements of distance than for measurements of angles. However, the palmar tilt angle measurement method was neither reliable nor reproducible. The capitate-related technique can help to accurately determine the severity of Madelung's deformity, assist in surgical planning and identify the prognosis. Level of evidence: III.

Computer-Assisted Three-Dimensional Corrective Osteotomy for Malunited Fractures of the Distal Radius Using Prefabricated Bone Graft Substitute

BACKGROUND

Three-dimensional computed tomography (3D-CT) imaging has enabled more accurate preoperative planning. The purpose of this study was to investigate the results of a novel, computer-assisted, 3D corrective osteotomy using prefabricated bone graft substitute to treat malunited fractures of the distal radius.

METHODS

We investigated 19 patients who underwent the computer-assisted 3D corrective osteotomy for a malunited fracture of the distal radius after the operation was stimulated with CT data. A prefabricated bone graft substitute corresponding to the patient's bone defect was implanted and internal fixation was performed using a plate and screws. We compared postoperative radiographic parameters of the patient's operated side with their sound side and analyzed clinical outcomes using Mayo wrist score.

RESULTS

All patients achieved bone union on X-ray imaging at final follow-up. The mean differences of palmar tilt, radial inclination and ulnar variance between the operation side and the sound side were 4.3°, 2.3° and 1.2 mm, respectively. The Mayo wrist score was fair in 4 patients and poor in 15 patients before surgery. At the final follow-up after surgery, the scores improved to excellent in 3 patients, good in 11 patients and fair in 5 patients. There were two patients with correction loss at the final follow-up, but no patient complained of hand joint pain.

CONCLUSIONS

We believe that computer-assisted 3D corrective osteotomy using prefabricated bone graft substitute achieved good results because it worked as a guide to the accurate angle.

Anatomy and injuries of the pediatric wrist: beyond the basics

Ligamentous injuries of the pediatric wrist, once thought to be relatively uncommon, are increasingly recognized in the context of acute high-energy mechanism trauma and chronic axial loading, including those encountered in both recreational and high-performance competitive sports. Recent advances in MR-based techniques for imaging the pediatric wrist allow for sensitive identification of these often radiographically occult injuries. Detailed knowledge of the intrinsic and supportive extrinsic ligamentous complexes, as well as normal developmental anatomy and congenital variation, are essential to accurately diagnose injuries to these structures. Early identification of ligamentous injury of the pediatric wrist is essential within the conservative treatment culture of modern pediatric orthopedics because treatment of these lesions often necessitates surgery, and outcomes often depend on early and sometimes aggressive intervention. In this article, we review MR arthrogram technique and pediatric wrist anatomy, and correlate appearances on MR and selected ligamentous pathologies of the pediatric wrist.

Positioning error of custom 3D-printed surgical guides for the radius: influence of fitting location and guide design

PURPOSE

Utilization of 3D-printed patient-specific surgical guides is a promising navigation approach for orthopedic surgery. However, navigation errors can arise if the guide is not correctly positioned at the planned bone location, compromising the surgical outcome. Quantitative measurements of guide positioning errors are rarely reported and have never been related to guide design and underlying bone anatomy. In this study, the positioning accuracy of a standard and an extended guide design with lateral extension is evaluated at different fitting locations (distal, mid-shaft and proximal) on the volar side of the radius.

METHODS

Four operators placed the surgical guides on 3D-printed radius models obtained from the CT scans of six patients. For each radius model, every operator positioned two guide designs on the three fitting locations. The residual positioning error was quantified with a CT-based image analysis method in terms of the mean target registration error (mTRE), total translation error ([Formula: see text]) and total rotation error ([Formula: see text]) by comparing the actual guide position with the preoperatively planned position. Three generalized linear regression models were constructed to evaluate if the fitting location and the guide design affected mTRE, [Formula: see text] and [Formula: see text].

RESULTS

mTRE, [Formula: see text] and [Formula: see text] were significantly higher for mid-shaft guides ([Formula: see text]) compared to distal guides. The guide extension significantly improved the target registration and translational accuracy in all the volar radius locations ([Formula: see text]). However, in the mid-shaft region, the guide extension yielded an increased total rotational error ([Formula: see text]).

CONCLUSION

Our study demonstrates that positioning accuracy depends on the fitting location and on the guide design. In distal and proximal radial regions, the accuracy of guides with lateral extension is higher than standard guides and is therefore recommended for future use.

Rapid prototyping for patient-specific surgical orthopaedics guides: A systematic literature review

There has been a lot of hype surrounding the advantages to be gained from rapid prototyping processes in a number of fields, including medicine. Our literature review aims objectively to assess how effective patient-specific surgical guides manufactured using rapid prototyping are in a number of orthopaedic surgical applications. To this end, we carried out a systematic review to identify and analyse clinical and experimental literature studies in which rapid prototyping patient-specific surgical guides are used, focusing especially on those that entail quantifiable outcomes and, at the same time, providing details on the guides’ design and type of manufacturing process. Here, it should be mentioned that in this field there are not yet medium- or long-term data, and no information on revisions. In the reviewed studies, the reported positive opinions on the use of rapid prototyping patient-specific surgical guides relate to the following main advantages: reduction in operating times, low costs and improvements in the accuracy of surgical interventions thanks to guides’ personalisation. However, disadvantages and sources of errors which can cause patient-specific surgical guide failures are as well discussed by authors. Stereolithography is the main rapid prototyping process employed in these applications although fused deposition modelling or selective laser sintering processes can also satisfy the requirements of these applications in terms of material properties, manufacturing accuracy and construction time. Another of our findings was that individualised drill guides for spinal surgery are currently the favourite candidates for manufacture using rapid prototyping. Other emerging applications relate to complex orthopaedic surgery of the extremities: the forearm and foot. Several procedures such as osteotomies for radius malunions or tarsal coalition could become standard, thanks to the significant assistance provided by rapid prototyping patient-specific surgical guides in planning and performing such operations.

Madelung Deformity

Madelung deformity of the wrist is more common in females and is often associated with Leri Weill dyschondrosteosis, a mesomelic form of dwarfism. Patients with Madelung deformity often report wrist deformity resulting from the prominence of the relatively long ulna. The typical Madelung deformity is associated with a Vickers ligament that creates a tether across the volar-ulnar radial physis that restricts growth across this segment. The distal radius deforms in the coronal (increasing radial inclination) and the sagittal (increasing volar tilt) planes. There is lunate subsidence and the proximal carpal row adapts to the deformity by forming an upside-down pyramid shape or triangle. Treatment depends on the age at presentation, degree of deformity, and magnitude of symptoms. Mild asymptomatic deformity warrants a period of nonsurgical management with serial x-ray examinations because the natural history is unpredictable. Many patients never require surgical intervention. Progressive deformity in the young child with considerable growth potential remaining requires release of Vickers ligament and radial physiolysis to prevent ongoing deterioration Concomitant ulnar epiphysiodesis may be necessary. Advanced asymptomatic deformity in older children with an unacceptable-appearing wrist or symptomatic deformity are indications for surgery. A dome osteotomy of the radius allows 3-dimensional correction of the deformity. Positive radiographic and clinical results after dome osteotomy have been reported.