Corrective osteotomy of the distal radius through volar approach

Clinical, functional and radiological outcomes of the use of fixed angle volar locking plates in corrective distal radius osteotomy for fracture malunion

Background and aim:

Fractures of the distal radius are a common injury and mal-union can occur in those managed non-operatively. This can cause significant functional limitations along with pain. A corrective osteotomy with the use of a volar locking plate aims to restore articular surface congruency and improve outcomes. We present our local experience with clinical, functional and radiological outcomes of corrective osteotomy using a fixed angle volar locking plate and bone graft for management of distal radius mal-union.

Methods:

Retrospective study. All adult patients. Both pre and post operatively clinical range of motion was recorded. Post operative PROMS was measure by DASH, MAYO and SF-12 and pain by means of a VAS measured from 0-10. Mean follow up period was at 15 months.

Results:

32 patients underwent the studied procedure. 24F-8F. Mean age: 56. Radiological union of corrective osteotomy: 28 (88%) of patients. 4 patients required further operative treatment to achieve corrective union. No other reported complications post-op. Post-operatively flexion improved by 24 and extension 20. Pronation was improved by 24 and supination 22. Pain was improved from an average VAS pre-operative of 5.6 to 1.6 post-operatively. Mean DASH scored improved from 57.8 to 16.2 post-operatively and MAYO 38.5 to 58.6. The mean post-operative SF-12 score was 46.2 from 31.

Conclusions:

In this series of 32 patients (the biggest reported in the literature in our knowledge) a corrective osteotomy with fixed-angle volar locking plate for mal-united distal radius has shown to improve both clinical-radiological and patient reported outcomes and provide good results of the very few complications’ treatments. (www.actabiomedica.it)

The Dorsal Periosteal Curtain for Distal Radius Osteotomy Via the Volar Approach

Volar wedge osteotomy and angle stable volar plating is now considered a standard approach for correction of distal radius malunion. In previous descriptions of the technique, soft tissue release has been performed with periosteal incision in line with the bony osteotomy. We present a technique whereby the dorsal periosteum is incised more proximally creating a dorsal vascularized periosteal "curtain." Our technique has several advantages including systematic release of restraining soft tissues to allow better distraction and reduction of the malunion; a dorsal periosteal curtain of vascular tissue with which to contain bone graft, protect extensor tendons and expedite healing; and better access to locally available bone graft. The previously described rotation-advancement of pronator quadratus is also used for plate coverage. We have found this technique straightforward to execute and teach, and useful in mitigating against some of the potential risks of the standard technique.

International Survey: Factors Associated With Operative Treatment of Distal Radius Fractures and Implications for the American Academy of Orthopaedic Surgeons' Appropriate Use Criteria

OBJECTIVES

Through an international survey, we assessed whether deciding to operatively treat an intra-articular distal radius fracture (DRF) is guided by identifiable patient and surgeon factors. In addition, we compared surgeons' treatment decisions with the American Academy of Orthopaedic Surgeons' Appropriate Use Criteria (AUC) treatment recommendations.

METHODS

This cross-sectional survey asked 224 surgeons to operatively or nonoperatively treat 28 hypothetical patients with radiographs of an intra-articular DRF. We randomized patient age (50/70 years), gender, mechanism of injury, activity level, and OTA/AO fracture type. We classified 6 fractures as "nonclinically significant displacement" and 22 as "potentially clinically significant displacement." Multilevel logistic regression analysis was performed. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported. Statistical significance was P < 0.05.

RESULTS

Patient factors independently associated with surgery included younger age (OR 6.7, P = 0.003), clinically significant fracture displacement (type B: OR 122, CI, 20-739, P < 0.001; type C: OR 59, CI, 12-300, P < 0.001), normal activity level (OR 5.0, P < 0.001), and high-energy mechanisms (OR 1.3, P = 0.002). Surgeon factors associated with recommending surgery included practicing outside the United States (Europe: OR 2.6, P < 0.001; "other": OR 4.8, P < 0.001). Hand surgeons most often selected surgery, as compared to orthopaedic trauma surgeons (OR 2.3, P = 0.001) and "other orthopaedists" (OR 2.2, P = 0.022). Thirty-seven percent of treatment decisions for patients with normal activity levels were rated by AUC recommendations as "rarely appropriate," which included 91% disagreement for 70-year-olds with nonclinically significant displacement.

CONCLUSIONS

Surgeons use patient age and fracture displacement to make treatment recommendations for intra-articular DRF. We recommend that the AUC be updated to include these clinical factors as essential components in its algorithm.

LEVEL OF EVIDENCE

Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Best Approaches in Distal Radius Fracture Malunions

PURPOSE OF REVIEW

Malunion remains a common complication in the treatment of distal radius fractures. The purpose of this review was to discuss the various approaches in planning and surgical management for extra- and intra-articular distal radius malunions.

RECENT FINDINGS

Several recent studies have reported good results with surgical correction of distal radius malunions utilizing a number of preoperative planning methods and surgical approaches. Three-dimensional models and custom cutting guides have recently become more popular, but their benefit in comparison to other methods remains unclear. Regardless of preoperative planning method or surgical approach, good results can be achieved with correction of distal radius malunion with careful attention to patient selection, indications, and surgical technique.

Surgical Technique of Corrective Osteotomy for Malunited Distal Radius Fracture Using the Computer-Simulated Patient Matched Instrument

The conventional corrective osteotomy for malunited distal radius fracture that employs dorsal approach and insertion of a trapezoidal bone graft does not always lead to precise correction or result in a satisfactory surgical outcome. Corrective osteotomy using a volar locking plate has recently become an alternative technique. In addition, the use of patient-matched instrument (PMI) via computed tomography simulation has been developed and is expected to simplify surgical procedures and improve surgical precision. The use of PMI makes it possible to accurately position screw holes prior to the osteotomy and simultaneously perform the correction and place the volar locking plate once the osteotomy is completed. The bone graft does not necessarily require a precise block form, and the problem of the extensor tendon contacting the dorsal plate is avoided. Although PMI placement and soft tissue release technique require some degree of specialized skill, they comprise a very useful surgical procedure. On the other hand, because patients with osteoporosis are at risk of peri-implant fracture, tandem ulnar shortening surgery should be considered to avoid excessive lengthening of the radius.

Distal Radius Fractures in the Elderly

Distal radius fractures are common in elderly patients, and the incidence continues to increase as the population ages. The goal of treatment is to provide a painless extremity with good function. In surgical decision making, special attention should be given to the patient's bone quality and functional activity level. Most of these fractures can be treated nonsurgically, and careful closed reduction should aim for maintenance of anatomic alignment with a focus on protecting fragile soft tissues. Locked plating is typically used for fracture management when surgical fixation is appropriate. Surgical treatment improves alignment, but improvement in radiographic parameters may not lead to better clinical outcomes. Treatment principles, strategies, and clinical outcomes vary for these injuries, with elderly patients warranting special consideration.

[Are there any indications for surgery of distal radius malunion in elderly patients?]

Malunions of the distal radius are associated most of the time with disturbances of the distal radioulnar (DRU) joint. While a corrective osteotomy of the distal radius is a well-known procedure in younger patients, manual workers and active patients, is it justified in independent elderly patients above 70 years of age? These techniques improve function, reorient the articular surfaces, protect against complications such as degenerative osteoarthritis and stiffness of the wrist, and they improve DRU balance. Osteotomies performed with bone or artificial grafts have comparable outcomes. Either a volar or dorsal approach can be used depending on the orientation of the carpal articular surface of the radius and the need to lengthen the radius. If the patient is active and independent, the clinical benefit is higher when an osteotomy is done for significant malunions; urgent treatment of these older patients brings about additional costs and unclear benefits.

Extensor Pollicis Longus Ruptures Following Distal Radius Osteotomy Through a Volar Approach

PURPOSE

To investigate the cause and pathological process of extensor pollicis longus (EPL) ruptures after correction of distal radius malunion through a volar approach.

METHODS

We included patients with EPL ruptures who underwent distal radius osteotomies performed through a volar approach. Data were pooled from members of the International Wrist Investigators Workshop. Patient demographics, initial injury parameters, imaging studies, preoperative and postoperative examination, intraoperative findings, surgical technique, and outcomes were compared and analyzed. Preoperative and postoperative radiographic images were evaluated and compared.

RESULTS

We evaluated 6 cases from 5 surgeons in 4 institutions. Length of follow-up ranged from 1 to 5 years. On initial radiographic evaluation all malunions were healed with dorsal angulation (20° to 60°) and with positive ulnar variance. Deformity correction in the sagittal plane was 25° to 55°. Osteotomies were fixed with volar locking plates with autologous bone graft except for one patient who received calcium phosphate-based bone void filler. Postoperative x-rays suggested prominent osteotomy resection edges, osteophytes, or dorsal bony prominence resulting from healed callus. Average time from osteotomy to EPL rupture was 10 weeks (range, 2-17 weeks). Two patients initially refused to undergo tendon transfers. One was pleased with the outcome despite the ruptured EPL. The other patient ruptured 2 more tendons and chose to have tendon transfers. One patient also ruptured the transferred tendon after 2 months and underwent successful tendon grafting.

CONCLUSIONS

In the absence of screw prominence and technical flaws, it is likely that dorsal callus, prominent osteotomy resection edges, and osteophytes may contribute to attritional rupture of the EPL tendon after a corrective osteotomy through a volar approach. Exposure and debridement of excessive callus, dorsal ridge, or a prominent Lister tubercle performed during the osteotomy may reduce subsequent EPL rupture.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.

Median neuropathy in malunited fractures of the distal radius

PURPOSE

Irritation of the median nerve is a well-characterized complication after acute fractures of the distal radius, but there is limited literature on median neuropathy in malunited fractures. The aims of our prospective study were to estimate the prevalence of the median neuropathy, explore the relationship between radiographic findings and the condition, and investigate whether corrective osteotomy without carpal tunnel release was a sufficient treatment.

METHODS

Thirty consecutive patients, who were referred to us for treatment of symptomatic distal radial malunion, underwent nerve conduction studies of both wrists by one board-certified neurologist under standardized conditions. Test results were correlated with conventional radiographic parameters (radial tilt, radial inclination, palmar shift, ulnar variance, radiolunate and capitolunate angle) and computer tomography (CT) based measurements of the cross-sectional area of the carpal tunnel. After corrective osteotomy without carpal tunnel release, 10 of 13 patients with unilateral preoperative median neuropathy agreed to an electrodiagnostic re-examination by the same neurologist.

RESULTS

Nineteen patients demonstrated abnormal test results, but only seven patients complained about paresthesias of median-innervated fingers. There was no correlation between median neuropathy and conventional radiographic parameters. Surprisingly, the cross-sectional area of the carpal canal was significantly greater for patients with median neuropathy. Symptoms resolved in all patients after corrective osteotomy. Postoperatively, six of ten patients demonstrated improved nerve conduction studies, although only four patients demonstrated normal test results.

DISCUSSION

There is a high rate of subclinical median neuropathy in malunited distal radial fractures that cannot be predicted by conventional radiographic parameters. Corrective osteotomy without carpal tunnel release is a sufficient treatment for neuropathy in malunited distal radius fractures.

Anterolateral surgical approach to the malunited distal radius fracture for corrective osteotomy and bone-graft harvest

The most common complication after distal radius fractures is union with deformity. When symptomatic, distal radial malunions may require operative intervention. Numerous approaches to the distal radius have been described. Most volar approaches involve sectioning the brachioradialis and opening the first extensor compartment to permit adequate exposure. When bone graft is required, this may necessitate a separate incision and further add to the morbidity. We present an alternative anterolateral surgical approach to the distal radius, which allows for excellent exposure, and minimal trauma to the tendons while permitting harvest of local bone graft through the same incision.

Opening wedge osteotomy for distal radius malunion: dorsal or palmar approach?

Background There are various technical variations to consider when performing a corrective osteotomy of a distal radius malunion. We chose two of the more commonly reported techniques and compared the results of volar (palmar) osteotomy and fixation with dorsal osteotomy and fixation. Method Within a continuous cohort of patients who had undergone corrective osteotomy for a malunited Colles fracture, two groups could be identified retrospectively. In 8 patients a dorsal approach was used. A structural trapezoidal graft, subtending the amount of correction, was inserted into the osteotomy gap and stabilization was performed with a thin round-hole mini-fragment plate. In 14 patients a palmar approach and a palmar fixed-angle plate was used for correction of the malunion and for angular stable rigid fixation of the two fragments. The osteotomy gap was loosely filled with nonstructural cancellous bone chips. A retrospective comparison of the two groups was performed to see whether the outcome was affected by the use of either operative technique.The demographics, the preoperative amount of deformity, range of motion, pain, and force were comparable for both groups. All osteotomies healed without loss of correction. After a minimal follow-up of one year, radiographic appearance, objective functional parameters were assessed and subjective data (Disabilities of the Arm, Shoulder, and Hand [DASH] score and special pain and function questionnaire) obtained. Results These data did not show statistical difference for the two groups except for the amount of final wrist flexion. This parameter was significantly better in patients who had palmar approaches and fixed-angle plates. Conclusion Corrective osteotomies of distal radius malunions can be done in either way. It might result in some better flexion, if performed volarly.

Corrective osteotomy of distal radial deformities: a new method of guided locking fixed screw positioning

Corrective osteotomy for distal radial malunion is a valuable but at times technically challenging operation. We have developed a new device to aid in the performance of the operation. We compared clinical use of the new technique with the standard technique. In 11 patients treated with the new technique the volar locking plate needed repositioning only once. With the standard technique in 17 patients the plate was repositioned in nine cases and needed bending in six cases. The new method corrected radial inclination (SD of 3° vs. 9°) and ulnar variance (SD of 0.9 mm vs. 1.4 mm) more predictably than the standard technique but there was no advantage in correction of volar tilt (SD of 6° vs. 4°). In our experience the new device makes corrective osteotomy of the distal radius easier and more reliable.

Correction of dorsally-malunited extra-articular distal radial fractures using volar locked plates without bone grafting

Malunion is the most common complication of the distal radius with many modalities of treatment available for such a problem. The use of bone grafting after an osteotomy is still recommended by most authors. We hypothesised that bone grafting is not required; fixing the corrected construct with a volar locked plate helps maintain the alignment, while metaphyseal defect fills by itself. Prospectively, we performed the procedure on 30 malunited dorsally-angulated radii using fixed angle volar locked plates without bone grafting. At the final follow-up, 22 wrists were available. Radiological evidence of union, correction of the deformity, clinical and functional improvement was achieved in all cases. Without the use of bone grafting, corrective open wedge osteotomy fixed by a volar locked plate provides a high rate of union and satisfactory functional outcomes.

Malunion of the distal radius

Fractures of the distal radius are extremely common injuries, which are steadily becoming a public health issue. One of the most common complications following distal radius fractures is still malunion of the distal radius. This review of the literature surrounding distal radius malunion covers the biomechanics of distal radial malunion, treatment options, indications for surgery, surgical techniques, and results.

Corrective osteotomy after damage of the distal radial physis in children: surgical technique and results

Distal radial physis closure in children can develop severe wrist deformity (radial shortening). These patients can be treated using a single-step surgery. It was carried out in the form of a corrective osteotomy adopting the volar approach, with fixed-angle volar plate fixation and bone grafting from the iliac crest. There have been few descriptions of the use of this technique in the management of deformities related to early epiphysiodesis in distal radius. The use of fixation systems for the radius, using fixed-angle locking plates, allows radius lengthening adjusted to demand after osteotomy, using the combination of the plate and distal locking pins as spacer-with custom-sized tricortical iliac crest grafting within the defect. The freeing of soft parts such as the dorsal periosteum and brachioradialis muscle tendon allows adequate bone lengthening in a single-surgical step.

OSTEOTOMY OF THE DISTAL RADIUS USING A FIXED-ANGLE VOLAR PLATE

OBJECTIVE

Skewed consolidation of the distal radius, due to sequelae of fractures, may cause functional incapacity, thus leading such patients to present pain, loss of strength and diminished mobility. Based on the excellent results obtained from surgical treatment of unstable fractures of the distal radius through a volar approach and use of rigid fixation with a fixed-angle volar plate, we started to use the same method for osteotomy of the distal radius.

METHODS

A retrospective review was conducted, and 20 patients treated between February 2002 and October 2009 were found. The mean length of follow-up was 43.9 months (range: 12 to 96 months). The surgical indications were persistent pain, deformity and functional limitation subsequent to a dorsally displaced fracture.

RESULTS

The mean preoperative deformity was 27° of dorsal tilt of the distal radius, 87° of ulnar tilt, and 7.3 mm of shortening of the radius. All the osteotomies consolidated and the final mean volar tilt was 6.2°, with ulnar tilt of 69.3° and shortening of 1 mm. The mean mobility of the wrist increased by 19.9° (flexion) and by 24° (extension). Mean forearm supination increased by 23.5° and pronation by 21.7°. Grip strength increased from 13.4 to 34.5 pounds.

CONCLUSION

Use of a fixed-angle volar plate for a volar approach towards osteotomy of the distal radius enables satisfactory correction of the deformities and eliminates the need for removal of the synthesis material caused by tendon complications.

Long-term outcomes of corrective osteotomy for the treatment of distal radius malunion

Corrective osteotomy is an established but challenging treatment for distal radius malunion. Short- and intermediate-term results have been previously published while long-term results have not. The long-term results of 22 patients treated with corrective osteotomy for symptomatic distal radius malunion are presented (range 6-24 years, mean 13 years). All patients completed the DASH questionnaire and the modified Gartland and Werley, and Green and O'Brien scores postoperatively. Wrist alignment was assessed through standard wrist radiographs. Average wrist flexion-extension was 72.5% of the contralateral limb. Grip strength averaged 71%. The DASH score averaged 16 points corresponding to mild perceived disability. Results were categorized as fair on both the Gartland and Werley score (average 9 points) and the modified Green and O'Brien score (average 67 points). Wrist alignment was maintained over time but 13 patients presented mild to moderate symptomatic wrist arthritis. The outcome presented may be a reflection of the use of stricter evaluation instruments or reflect the development of post-traumatic arthritis.

Sagittal rotational malunions of the distal radius: the role of pure derotational osteotomy

Sagittal rotational malunion after distal radius fractures was identified in eight patients by the presence of a "hinge" point on the volar cortex on the lateral radiograph, and the ulnar head being shorter than the anterior lip of the radius on the posterior-anterior radiograph. The surgical correction consisted of preplating the distal fragment with a volar locking plate before an osteotomy through the "hinge" point, and correcting the dorsal tilt of the distal fragment. Any dorsal defect was filled with cancellous bone graft from the olecranon. Pain, range of motion and grip all improved. Disabilities of arm, shoulder and hand score changed from 54 to six. Dorsal sagittal tilt improved by 26 degrees , from -23 degrees to +3 degrees . Ulnar variance improved by 3 mm, from +1.5 to -1.5 mm, becoming identical to the opposite side. A pure derotational osteotomy corrected the apparent shortening of the radius and restored the volar tilt.

Tricalcium phosphate bone substitute in corrective osteotomy of the distal radius

AIM

To evaluate the outcome of using tricalcium phosphate (TCP) as void filler and structural support in corrective opening-wedge osteotomy of the distal radius.

METHODS

A consecutive series of 17 patients with malunited dorsally angulated distal radius fracture underwent corrective osteotomy using plates, screws and TCP blocks. Results were evaluated postoperatively with DASH at 6 months with radiography at 8-12 weeks and 0.5-3.5 years.

RESULTS

Mean DASH score improved from 52 (S.D. 22) preoperatively to 30 (S.D. 22) postoperatively. There was one non-union. There was also a mean loss of radial length of 1.1mm (S.D. 1.0mm) between the first postoperative radiograph and final follow-up. Radiolucent zones were observed around the TCP grafts after 6-8 weeks in 10/14 cases, but could not be statistically correlated with the slight loss of reduction.

CONCLUSIONS

TCP seems to be an alternative to iliac crest bone grafting in corrective osteotomies of the distal radius. The shortening observed over time may be attributable to inflammation induced by the TCP.

Corrective osteotomy for deformity of the distal radius using a volar locking plate

Dorsally angulated malunions of the distal radius have historically been corrected with an opening wedge osteotomy fixed with a dorsal plate. Volar locking plates may facilitate a less morbid approach to corrective osteotomies of the wrist. Eight consecutive patients with an average age of 40 years (range, 15-52 years) underwent correction of a distal radius deformity through a volar approach. Clinical follow-up averaged 17.4 months (range, 7-41 months). Preoperative radiographs revealed an average of 24 degrees of dorsal tilt in patients with dorsal deformity. Postoperatively, their average measurement was <3 degrees of volar tilt. Patients were initially ulnar-positive with an average of 4 mm ulnar-positive variance (range, 2-7 mm). This corrected to less than 1 mm postoperatively. Postoperative disabilities of the arm, shoulder, and hand (DASH), SF-12, and Mayo Wrist scores averaged 10.8, 40.5, and 82.5, respectively. There were no nonunions, and no plates required removal. Distal radius deformity can be effectively addressed through a volar approach with the use of a locking plate.