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Meesters AML, Assink N, IJpma FFA. Functional outcome of 2-D- and 3-D-guided corrective forearm osteotomies: a systematic review. J Hand Surg Eur Vol 2024; 49:843-851. [PMID: 37747738 DOI: 10.1177/17531934231201962] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
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.
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Affiliation(s)
- Anne M L Meesters
- Department of Trauma Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
- 3D Lab, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Nick Assink
- Department of Trauma Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
- 3D Lab, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Frank F A IJpma
- Department of Trauma Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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Ray S, Manske MC. Pediatric Forearm Malunions. Hand Clin 2024; 40:35-48. [PMID: 37979989 DOI: 10.1016/j.hcl.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
The aim of this article is to review the evaluation and management of pediatric forearm malunions. Acceptable parameters for nonoperative management of pediatric forearm fractures are reviewed, followed by clinical and imaging workups of malunions and decision-making points for treatment. The landscape of available technology for planning and execution of corrective osteotomy is discussed. Several cases of pediatric forearm malunion are presented, along with surgical and functional outcomes. Recommendations are given regarding the authors' preferred approach for management of pediatric forearm malunions.
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Affiliation(s)
- Shea Ray
- Department of Orthopedic Surgery, Shriners Hospital for Children Northern California, Sacramento, CA, USA
| | - M Claire Manske
- Department of Orthopedic Surgery, Shriners Hospital for Children Northern California, Sacramento, CA, USA; Department of Orthopedic Surgery, University of California Davis, 4860 Y Street, Suite 3800, Sacramento, CA 95817, USA.
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Kuiper RJA, Colaris JW, Stockmans F, van Es EM, Viergever MA, Seevinck PR, Weinans H, Sakkers RJB. Impact of bone and cartilage segmentation from CT and MRI on both bone forearm osteotomy planning. Int J Comput Assist Radiol Surg 2023; 18:2307-2318. [PMID: 37219804 PMCID: PMC10632286 DOI: 10.1007/s11548-023-02929-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 04/19/2023] [Indexed: 05/24/2023]
Abstract
INTRODUCTION The use of MRI scans for pre-operative surgical planning of forearm osteotomies provides additional information of joint cartilage and soft tissue structures and reduces radiation exposure in comparison with the use of CT scans. In this study, we investigated whether using 3D information obtained from MRI with and without cartilage information leads to a different outcome of pre-operative planning. METHODS Bilateral CT and MRI scans of the forearms of 10 adolescent and young adult patients with a unilateral bone deformation were acquired in a prospective study. The bones were segmented from CT and MRI, and cartilage only from MRI. The deformed bones were virtually reconstructed, by registering the joint ends to the healthy contralateral side. An optimal osteotomy plane was determined that minimized the distance between the resulting fragments. This process was performed in threefold: using the CT and MRI bone segmentations, and the MRI cartilage segmentations. RESULTS Comparison of bone segmentation from MRI and CT scan resulted in a 0.95 ± 0.02 Dice Similarity Coefficient and 0.42 ± 0.07 mm Mean Absolute Surface Distance. All realignment parameters showed excellent reliability across the different segmentations. However, the mean differences in translational realignment between CT and MRI bone segmentations (4.5 ± 2.1 mm) and between MRI bone and MRI bone and cartilage segmentations (2.8 ± 2.1 mm) were shown to be clinically and statistically significant. A significant positive correlation was found between the translational realignment and the relative amount of cartilage. CONCLUSION This study indicates that although bone realignment remained largely similar when using MRI with and without cartilage information compared to using CT, the small differences in segmentation could induce statistically and clinically significant differences in the osteotomy planning. We also showed that endochondral cartilage might be a non-negligible factor when planning osteotomies for young patients.
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Affiliation(s)
- Ruurd J A Kuiper
- Department of Orthopaedics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Joost W Colaris
- Department of Orthopaedics and Sports Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Filip Stockmans
- Muscles & Movement, Department of Development and Regeneration, KU Leuven Campus Kulak, Kortrijk, Belgium
| | - Eline M van Es
- Department of Orthopaedics and Sports Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Max A Viergever
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter R Seevinck
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Harrie Weinans
- Department of Orthopaedics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Ralph J B Sakkers
- Department of Orthopaedics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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The Flipping-Wedge Osteotomy: How 3D Virtual Surgical Planning (VSP) Suggested a Simple and Promising Type of Osteotomy in Pediatric Post-Traumatic Forearm Deformity. J Pers Med 2023; 13:jpm13030549. [PMID: 36983730 PMCID: PMC10058750 DOI: 10.3390/jpm13030549] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 03/22/2023] Open
Abstract
(1) Background: The application of computer-aided planning in the surgical treatment of post-traumatic forearm deformities has been increasingly widening the range of techniques over the last two decades. We present the “flipping-wedge osteotomy”, a promising geometrical approach to correct uniapical deformities defined during our experience with virtual surgical planning (VSP); (2) Methods: a case of post-traumatic distal radius deformity (magnitude 43°) treated with a flipping-wedge osteotomy in an 11-year-old girl is reported, presenting the planning rationale, its geometrical demonstration, and the outcome of the procedure; (3) Results: surgery achieved correction of both the angular and rotational deformities with a neutral ulnar variance; (4) Conclusions: flipping-wedge osteotomy may be a viable option to achieve correction in forearm deformities, and it deserves further clinical investigation.
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Manske MC, Pham C, Taylor SL, James MA. Long-Term Outcomes of Biceps Rerouting for Flexible Supination Contractures in Children With Brachial Plexus Birth Injuries. J Hand Surg Am 2023; 48:37-45. [PMID: 34953599 DOI: 10.1016/j.jhsa.2021.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 08/14/2021] [Accepted: 10/13/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Forearm supination contractures occur in 7% of children with brachial plexus birth injuries (BPBI). Biceps rerouting is proposed when pronation has deteriorated but is passively correctable to at least 0° (neutral). The purpose of this investigation was to evaluate long-term outcomes of biceps rerouting for this indication, including magnitude and maintenance of correction, complications, and subsequent osteotomy. METHODS We conducted a retrospective review of all children with BPBI and forearm supination contractures treated with biceps rerouting alone, for the above indications, from 1993 to 2017 with at least 2 years follow-up. Demographic information, BPBI characteristics, surgical details, and ranges of motion were obtained from medical records. Pre- and postoperative active pronation (AP) and supination (AS), elbow flexion contracture, and arc of forearm rotation (Arc) were analyzed using linear mixed-effect models. RESULTS Twenty-five children (13 females; 13 left forearms; 15 global BPBI) underwent biceps rerouting at age 7 ± 3 years and were followed for 6 ± 3 years. Before surgery, the mean AP and AS were 6° ± 29° and 62° ± 27°, respectively. At the final follow-up, the mean AP, AS, and Arc were 39° ± 36°, 18° ± 34°, and 57° ± 42°, respectively. AP was significantly improved and AS was significantly decreased by 2 years after surgery and at the final follow-up. Neither Arc nor elbow flexion contracture changed significantly. Two of 25 (8%) children underwent subsequent forearm osteotomy. CONCLUSIONS Biceps rerouting in children with BPBI improves the forearm position when pronation is deteriorating by shifting the arc from supination to pronation without decreasing the arc of motion or worsening elbow flexion contractures. There is a low risk of complications and a limited need for subsequent forearm osteotomy. These results are maintained over time. When performed before passive pronation is reduced beyond neutral, this procedure may prevent severe supination contractures and reduce the need for forearm osteotomy. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- M Claire Manske
- Department of Orthopedic Surgery, Shriners Hospital for Children Northern California, Sacramento, CA; Department of Orthopedic Surgery, University of California Davis Sacramento, CA.
| | - Cory Pham
- San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, CA
| | - Sandra L Taylor
- Department of Public Health Sciences, University of California Davis, Sacramento, CA
| | - Michelle A James
- Department of Orthopedic Surgery, Shriners Hospital for Children Northern California, Sacramento, CA; Department of Orthopedic Surgery, University of California Davis Sacramento, CA
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Accuracy of 3D Corrective Osteotomy for Pediatric Malunited Both-Bone Forearm Fractures. CHILDREN (BASEL, SWITZERLAND) 2022; 10:children10010021. [PMID: 36670572 PMCID: PMC9856311 DOI: 10.3390/children10010021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/08/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022]
Abstract
Re-displacement of a pediatric diaphyseal forearm fracture can lead to a malunion with symptomatic impairment in forearm rotation, which may require a corrective osteotomy. Corrective osteotomy with two-dimensional (2D) radiographic planning for malunited pediatric forearm fractures can be a complex procedure due to multiplanar deformities. Three-dimensional (3D) corrective osteotomy can aid the surgeon in planning and obtaining a more accurate correction and better forearm rotation. This prospective study aimed to assess the accuracy of correction after 3D corrective osteotomy for pediatric forearm malunion and if anatomic correction influences the functional outcome. Our primary outcome measures were the residual maximum deformity angle (MDA) and malrotation after 3D corrective osteotomy. Post-operative MDA > 5° or residual malrotation > 15° were defined as non-anatomic corrections. Our secondary outcome measure was the gain in pro-supination. Between 2016−2018, fifteen patients underwent 3D corrective osteotomies for pediatric malunited diaphyseal both-bone fractures. Three-dimensional corrective osteotomies provided anatomic correction in 10 out of 15 patients. Anatomic corrections resulted in a greater gain in pro-supination than non-anatomic corrections: 70° versus 46° (p = 0.04, ANOVA). Residual malrotation of the radius was associated with inferior gain in pro-supination (p = 0.03, multi-variate linear regression). Three-dimensional corrective osteotomy for pediatric forearm malunion reliably provided an accurate correction, which led to a close-to-normal forearm rotation. Non-anatomic correction, especially residual malrotation of the radius, leads to inferior functional outcomes.
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Schmitt S, Eisa A, Radosavljevic J, van Schoonhoven J. Dynamic palmar dislocation of the ulnar head at the distal radioulnar joint (DRUJ) after radius shaft malunion. Arch Orthop Trauma Surg 2022; 143:2781-2787. [PMID: 36346445 DOI: 10.1007/s00402-022-04684-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/26/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Palmar instability of the distal radioulnar joint (DRUJ) is a rare condition, which is, in contrast to the dorsal dislocation, scarcely represented in the literature. This palmar instability can result from a dorsally angulated malunion of the radial shaft after forearm fracture in childhood. Treating such a condition is controversial in the literature and was described in small case series. This study represents the largest case series in the literature that dealt with this condition, alongside a review of the key papers in the English literature. MATERIALS AND METHODS This is a retrospective case series. Ten patients were operated between 2007 and 2014. Six patients could be followed up clinically and radiologically after radius corrective osteotomy at the site of malunion with a mean time of 5.6 years. Patient history revealed a conservatively treated forearm fracture in childhood, a symptom-free period of several years [mean of 21.5 (min-max: 9.4-26.5) years] and a minor trauma as a trigger for clinical symptoms. All patients had clinically a DRUJ instability with palmar luxation of the ulnar head at supination. A diagnostic key feature is a radiograph of the whole forearm, revealing malunion of the radius at shaft level. Retrospective patient history, diagnostic imaging, operative technique and clinical results (DASH, modified Mayo Wrist Score, pain, grip strength, range of motion) were analyzed. RESULTS Four patients were lost to follow-up. In all patients, a radius corrective osteotomy could stabilize the DRUJ. In one patient, the osteosynthesis was revised due to metal failure after one month. In all the six patients, bony union of the osteotomy was achieved. In another patient, an additional ulnar shortening osteotomy was done one year later due to a positive ulnar variance. Postoperative range of motion of the wrist had an average of 136° in extension/flexion and 149° in pronation/supination, and grip strength was 89% of the opposite side. With an average of 12.5 points at the DASH score and 82 at the modified Mayo Wrist Score, patients rated their hand function as good. CONCLUSIONS In this patient cohort, a simple corrective osteotomy of the radial shaft at the malunion site was adequate to treat the dynamic palmar instability of DRUG. A soft tissue procedure was not required. Forearm radiographs are the mainstay of diagnostic tools.
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Affiliation(s)
- Stefanie Schmitt
- Clinic for Hand Surgery, Rhoen Klinikum Campus Bad Neustadt, Von-Guttenberg-Straße 11, 97616, Bad Neustadt an der Saale, Germany. .,, Robert-Koch-Str. 18, 77815, Buehl, Germany.
| | - Amr Eisa
- Clinic for Hand Surgery, Rhoen Klinikum Campus Bad Neustadt, Von-Guttenberg-Straße 11, 97616, Bad Neustadt an der Saale, Germany
| | - Jelena Radosavljevic
- Clinic for Hand Surgery, Rhoen Klinikum Campus Bad Neustadt, Von-Guttenberg-Straße 11, 97616, Bad Neustadt an der Saale, Germany
| | - Joerg van Schoonhoven
- Clinic for Hand Surgery, Rhoen Klinikum Campus Bad Neustadt, Von-Guttenberg-Straße 11, 97616, Bad Neustadt an der Saale, Germany
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Li TP, Wollstein A, Sabharwal S, Nayar SK, Sabharwal S. Malunion of Pediatric Forearm Shaft Fractures: Management Principles and Techniques. Curr Rev Musculoskelet Med 2022; 15:427-437. [PMID: 35876970 PMCID: PMC9789287 DOI: 10.1007/s12178-022-09783-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Clinically significant malunion of forearm diaphyseal fractures is an uncommon but potentially disabling condition amongst children and adolescents. We present the preoperative evaluation, including imaging, and discuss surgical indications and contemporary approaches to manage such patients, including an illustrative case. RECENT FINDINGS While advances in three-dimensional (3D) simulation, modeling, and patient-specific instrumentation have expanded the surgical armamentarium, their impact on long-term outcomes compared to traditional methods remains unknown. Successful outcome following surgical correction of malunion following a both-bone forearm fracture can be achieved with careful patient selection, appropriate indications, and a well-planned surgical execution.
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Affiliation(s)
- T. Peter Li
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Adi Wollstein
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Samir Sabharwal
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Suresh K. Nayar
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Sanjeev Sabharwal
- Department of Orthopaedic Surgery, University of California San Francisco, Benioff Children’s Hospital, Oakland, CA USA
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Roth KC, van Es EM, Kraan GA, Verhaar JAN, Stockmans F, Colaris JW. Outcomes of 3-D corrective osteotomies for paediatric malunited both-bone forearm fractures. J Hand Surg Eur Vol 2022; 47:164-171. [PMID: 34260312 PMCID: PMC8801669 DOI: 10.1177/17531934211029511] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Closed treatment of paediatric diaphyseal forearm fractures carries the risk of re-displacement, which can lead to symptomatic malunions. This is because growth will not correct angulation deformity as it does in metaphyseal fractures. The purpose of this prospective cohort study was to evaluate the outcomes after 3-D-planned corrective osteotomy with patient-specific surgical guides for paediatric malunited forearm fractures causing impaired pro-supination. Our primary outcome measure was the gain in pro-supination at 12 months follow-up. Fifteen patients with a mean age at trauma of 9.6 years and time until osteotomy of 5.9 years were included. Preoperatively, patients displayed a mean pro-supination of 67° corresponding to 44% of the contralateral forearm. At final follow-up, this improved to 128°, achieving 85% of the contralateral side. Multivariate linear regression analysis revealed that predictors of greater functional gain after 3-D corrective osteotomy are severe preoperative impairment in pro-supination, shorter interval until 3-D corrective osteotomy and greater angulation of the radius.Level of evidence: III.
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Affiliation(s)
- Kasper C. Roth
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands,Kasper C. Roth, Department of Orthopaedics and Sports Medicine, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Postbus 2040, 3000 CA Rotterdam, The Netherlands.
| | - Eline M. van Es
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Gerald A. Kraan
- Department of Orthopaedics, Reinier HAGA Orthopaedic Centre, Zoetermeer, The Netherlands
| | - Jan A. N. Verhaar
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | | | - Joost W. Colaris
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Patient-Specific Guided Osteotomy to Correct a Symptomatic Malunion of the Left Forearm. CHILDREN-BASEL 2021; 8:children8080707. [PMID: 34438598 PMCID: PMC8394506 DOI: 10.3390/children8080707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/10/2021] [Accepted: 08/13/2021] [Indexed: 12/02/2022]
Abstract
We present a case report of a 12-year old female with a midshaft forearm fracture. Initial conservative treatment with a cast failed, resulting in a malunion. The malunion resulted in functional impairment for which surgery was indicated. A corrective osteotomy was planned using 3D analyses of the preoperative CT-scan. Subsequently, patient-specific guides were printed and used during the procedure to precisely correct the malunion. Three months after surgery, the radiographs showed full consolidation and the patient was pain-free with full range of motion and comparable strength in both forearms. The current case report shows that a corrective osteotomy with patient-specific guides based on preoperative 3D analyses can help surgeons to plan and precisely correct complex malunions resulting in improved functional outcomes.
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