Corrective osteotomy for malunited, volarly displaced fractures of the distal end of the radius

A meta-analysis comparing complications of anterior versus dorsal osteotomy and plating for distal radial malunions

This systematic review and meta-analysis compare the incidences of complications, reoperations and hardware removal between anterior and dorsal plating after corrective osteotomy for dorsally angulated distal radial malunions. A total of 403 patients were included; 253 patients underwent anterior corrective osteotomy and 150 underwent dorsal corrective osteotomy. Mean follow-up was 30 months. Anterior plating was associated with fewer reoperations (9% vs. 28%), less hardware removal (3% vs. 18%) and comparable major complications (5% vs. 6%) compared to dorsal plating. The adjusted model showed a significant reduction (approximately 85%) in the odds of reoperation and hardware removal in the anterior group. There was no difference in major or minor complications between the groups. Surgeons should be fully aware of the increased risks when using dorsal plate fixation after corrective osteotomy for dorsally angulated distal radial malunions.

Intra-Articular Corrective Osteotomy for Distal Radial Intra-Articular Malunion Using Patient-Matched Instruments: A Prospective, Multicenter, Open-Label, Single-Arm Trial

Background

Corrective osteotomy for intra-articular malunion is a challenging procedure. However, recent advancements, including patient-matched instruments created on the basis of preoperative computer simulation, enable accurate intra-articular correction. We hypothesized that intra-articular corrective osteotomy using patient-matched instruments for the treatment of distal radial intra-articular malunion would reduce intra-articular deformity and restore wrist function at 12 months of follow-up.

Methods

This prospective study included 12 patients with distal radial intra-articular malunion who underwent intra-articular corrective osteotomy external to the joint using patient-matched instruments. The primary end point was the maximum step-off on the articular surface of the distal radius, measured with use of computed tomography (CT), with an expected postoperative value of ≤1.5 mm. The secondary end points included the gap of the articular surface; range of motion; grip strength; pain evaluated using a visual analog scale (VAS); patient satisfaction; Disabilities of the Arm, Shoulder and Hand (DASH) score; and Patient-Rated Wrist Evaluation (PRWE) score. A mean postoperative step-off of ≤1.5 mm for the primary end point was assessed with use of the 1-sample t test. The secondary end points were assessed with use of the Dunnett multiple comparison test.

Results

The average step-off significantly improved from 3.75 ± 1.04 mm preoperatively to 0.51 ± 0.40 mm at the 52-week postoperative follow-up and was maintained within 1.5 mm. The average wrist and forearm range of motion, VAS score, grip strength, DASH score, and PRWE score significantly improved. Eleven patients were either very satisfied or satisfied with their outcomes.

Conclusions

The use of patient-matched instruments could contribute to improving postoperative outcomes of intra-articular corrective osteotomy procedures involving the distal radius.

Level of Evidence

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

Z-Corrective Osteotomy in Malunited Extra-Articular Fractures of Distal Radius

PURPOSE

We sought to assess clinical, radiological, and functional outcomes following treatment of extra-articular malunions of the distal radius using a multiplanar z-corrective osteotomy.

METHODS

Fifteen patients with extra-articular distal radius malunions (13 dorsal and 2 volar) underwent z-corrective osteotomy and volar plate fixation without bone grafting. Correction and maintenance of each deformity was evaluated in terms of various radiographic indices (radial height; volar and radial tilt); osteotomy union; pain (visual analog scale); grip strength; range of motion; Disabilities of the Arm, Shoulder, and Hand scores; and Mayo wrist scores.

RESULTS

The mean follow-up was 16.4 months. The mean radial height was corrected from -1.3 mm to 4.9 mm. The mean ulnar variance improved from 4.3 mm to -0.4 mm. The sagittal radial tilt and radial inclination were restored from a mean of -17.9° (dorsal) to 3.3° (volar) and from 12.0° to 17.2°, respectively. The Disabilities of the Arm, Shoulder, and Hand and Mayo wrist scores improved from means of 36 and 56 preoperatively to 24.8 and 73.3, respectively, at 6 months and further to 20.6 and 77.6, respectively, at the last follow-up. There were no nonunions or tendon-related problems. The mean pain score decreased from 4.1 preoperatively to 1.0 at 6 months and 0.8 at the last follow-up. The mean grip strength improved from 5.6 kg preoperatively to 15.6 kg at 6 months and 19.7 kg at the last follow-up. There was a statistically significant improvement in range of motion at the wrist.

CONCLUSIONS

The z-osteotomy provides correction of deformity in all 3 planes, along with restoration of radial height. It also maintains a broad area of bone contact between the 2 osteotomized bone fragments, facilitating bony union and eliminating the need for bone grafting.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Patient-reported outcomes after corrective osteotomy for a symptomatic malunion of the distal radius

AIMS

The primary aim of this study was to describe patient satisfaction and health-related quality of life (HRQoL) following corrective osteotomy for a symptomatic malunion of the distal radius.

METHODS

We retrospectively identified 122 adult patients from a single centre over an eight-year period who had undergone corrective osteotomy for a symptomatic malunion of the distal radius. The primary long-term outcome was the Patient-Rated Wrist Evaluation (PRWE) score. Secondary outcomes included the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, the EQ-5D-5L score, complications, and the Net Promoter Score (NPS). Multivariate regression analysis was used to determine factors associated with the PRWE score.

RESULTS

Long-term outcomes were available for 89 patients (72%). The mean age was 57 years (SD 15) and 68 were female (76%). The median time from injury to corrective osteotomy was nine months (interquartile range (IQR) 6 to 13). At a mean follow-up of six years (1 to 11) the median PRWE score was 22 (IQR 7 to 40), the median QuickDASH score was 11.4 (IQR 2.3 to 31.8), and the median EQ-5D-5L score was 0.84 (IQR 0.69 to 1). The NPS was 69. Multivariate regression analysis showed that the presence of an associated ulnar styloid fracture was the only significant independent factor associated with a worse PRWE score when adjusting for confounding variables (p = 0.004).

CONCLUSION

We found that corrective osteotomy for malunion of the distal radius can result in good functional outcomes and high levels of patient satisfaction. However, the presence of an ulnar styloid fracture may adversely affect function. Level of Evidence: III (cohort study). Cite this article: Bone Joint J 2020;102-B(11):1542-1548.

Complications of Corrective Osteotomies for Extra-Articular Distal Radius Malunion

PURPOSE

Osteotomy of the distal radius for a fracture malunion is a challenging procedure. The purpose of this study was to review a series of osteotomies to determine the type and risk of complications.

METHODS

A retrospective cohort study was performed, including all Kaiser Permanente Southern California patients who were aged 18 years or older between January 1, 2007, and September 25, 2015, and underwent osteotomy for an extra-articular distal radius fracture malunion. Charts were reviewed for demographic data, comorbidities, osteotomy type (hinged vs distraction), implant, and bone graft type. Complications including infection, nonunion, loss of reduction, implant failure, nerve injury, tendon injury, and complex regional pain syndrome were recorded.

RESULTS

There were 60 patients who underwent extra-articular osteotomy of the distal radius for malunion during the study period. The mean age was 54 years (range, 21-83 years). There were 24 distraction-type (intervening bone graft) and 36 hinge-type (volar cortical contact maintained) osteotomies. Twenty-five of 60 patients had complications related to the procedure requiring 13 subsequent procedures. There were 7 nonunions and 3 cases of delayed healing at the osteotomy site. One extensor carpi radialis longus tendon laceration resulted from the use of an osteotome. There were 3 delayed extensor pollicis longus (EPL) tendon ruptures after surgery. The distraction-type osteotomy was associated with a greater risk of major complications including nonunion and delayed union.

CONCLUSIONS

A complication rate of nearly 50% was observed in distal radius osteotomies. Surgeons should be aware of the risk of injury to, or delayed rupture of the EPL tendon associated with these procedures. The risk of nonunion or delayed union is higher in distraction-type compared with hinge-type osteotomies. Low surgeon volume with this procedure may be a contributing factor to the high rate of complications.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Three-Dimensional Corrective Osteotomy for Malunited Fractures of the Upper Extremity Using Patient-Matched Instruments: A Prospective, Multicenter, Open-Label, Single-Arm Trial

BACKGROUND

Medical image processing has facilitated simulation of 3-dimensional (3-D) corrective osteotomy, and 3-D rapid prototyping technology has further enabled the manufacturing of patient-matched surgical guides and implants (patient-matched instruments, or PMIs). However, 3-D corrective osteotomy using these technologies has not been the standard procedure. We aimed to prospectively verify the efficacy and safety of PMIs in corrective osteotomy for deformities of the upper extremity.

METHODS

We enrolled 16 patients with a total of 17 bone deformities in the upper extremity. Eight patients had distal radial malunion; 5, distal humeral malunion; and 3, forearm diaphyseal malunion. All cases underwent 3-D corrective osteotomy with PMIs. The primary end point was the residual maximum deformity angle (MDA), which was calculated from 2 deformity angles-1 on the anteroposterior and 1 on the lateral postoperative radiograph. Secondary end points included the deformity angle on radiographs, 3-D error between the preoperative planning model and the postoperative result, range of motion, grip strength, pain measured with a visual analog scale (VAS), patient satisfaction, and Disabilities of the Arm, Shoulder and Hand (DASH) score.

RESULTS

The average MDA significantly improved from 25.5° preoperatively to 3.3° at the final follow-up (p < 0.001). The angular deformity was within 5° in all cases, except for 1 with distal radial malunion who had a higher angle on the anteroposterior radiograph. The error between the correction seen on the postoperative 3-D bone model and the planned correction was <1° and <1 mm. Flexion and extension of the wrist and pronation of the forearm of the patients treated for distal radial malunion improved significantly, and pronation improved for those treated for forearm diaphyseal malunion. The average VAS score, grip strength, and DASH score significantly improved as well. Of the 16 patients, 15 were very satisfied or satisfied with the outcomes.

CONCLUSIONS

Corrective osteotomy using PMIs achieved accurate correction and good functional recovery in the upper extremity. Although our study was limited to cases without any deformity on the contralateral side, 3-D corrective osteotomy using PMIs resolved treatment challenges for complex deformities in upper extremities.

LEVEL OF EVIDENCE

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

Improving accuracy of opening-wedge osteotomies of distal radius using a patient-specific ramp-guide technique

BACKGROUND

Opening-wedge osteotomies of the distal radius, performed with three-dimensional printed patient-specific instruments, are a promising technique for accurate correction of malunions. Nevertheless, reports of residual malalignments and discrepancies in the plate and screw position from the planned fixation exist. Consequently, we developed a patient-specific ramp-guide technique, combining navigation of plate positioning, osteotomy cutting, and reduction. The aim of this study is to compare the accuracy of navigation of three-dimensional planned opening-wedge osteotomies, using a ramp-guide, over state-of-the-art guide techniques relying solely on pre-drilled holes.

METHODS

A retrospective analysis was carried out on opening-wedge osteotomies of the distal radius, performed between May 2016 and April 2017, with patient-specific instruments. Eight patients were identified in which a ramp-guide for the distal plate fixation was used. We compared the reduction accuracy with a control group of seven patients, where the reduction was performed with pre-drilled screw holes placed with the patient-specific instruments. The navigation accuracy was assessed by comparing the preoperative plans with the postoperative segmented, computed tomography scans. The accuracy was expressed using a 3D angle and in measurements of all six degrees of freedom (3 translations, 3 rotations), with respect to an anatomical coordinate system.

RESULTS

The duration of the surgery of the ramp-guide group was significantly shorter compared to the control group. Significantly less rotational and translational residual malalignment error was observed in the open-wedged osteotomies, where patient-specific instruments with ramp-guides were used. On average, a residual rotational malalignment error of 2.0° (± 2.2°) and a translational malalignment error of 0.6 mm (± 0.2 mm) was observed in the ramp-guide group, as compared to the 4.2° (± 15.0°) and 1.0 mm (± 0.4 mm) error in the control group. The used plate was not significantly positioned more accurately, but significantly fewer screws (15.6%) were misaligned in the distal fragment compared to the control group (51.9%).

CONCLUSION

The use of the presented ramp-guide technique in opening-wedge osteotomies is improving reduction accuracy, screw position, and surgical duration, compared to the existing patient-specific instrument based navigation methods.

Complex angular and torsional deformities (distal femoral malunions)

Objective: To describe the surgical technique of complex distal femoral deformity correction with the aid of stereolithography apparatus (SLA) biomodels, stabilized with locking plate fixation.

Methods: Full-size replica epoxy bone bio-models of the affected femurs (4 dogs/5 limbs) were used as templates for surgical planning. A rehearsal procedure was performed on the biomodels aided by a guide wire technique and stabilized with locking plate fixation. Surgery performed in all dogs was guided by the rehearsal procedure. All pre-contoured implants were subsequently used in the definitive surgical procedure with minimal modification.

Results: All dogs had markedly improved, with near normal functional outcomes; all but one had a mild persistent lameness at the final in-hospital follow-up examination (mean: 54.4 weeks; range: 24–113 weeks after surgery). All femurs healed without complications (mean: 34 weeks, median: 12 weeks; range: 8–12 weeks for closing osteotomies, and 26–113 weeks for opening wedge osteotomies). Long-term follow-up examination (mean: 28.6 months; range: 5–42 months) revealed all but one owner to be highly satisfied with the outcome. Complications were observed in two dogs: prolonged tibiotarsal joint decreased flexion that resolved with physical therapy. In one of these dogs, iatrogenic transection of the long digital extensor tendon was repaired, and the other had a peroneal nerve neurapraxia.

Clinical significance: Stereolithography apparatus biomodels and rehearsal surgery simplified the definitive surgical corrections of complex femoral malunions and resulted in good functional outcomes.

Online supplementary material is available for this paper at: http://dx.doi.org/10.3415/VCOT-15-08-0145

[Over-reduction after distal radius fracture pinning in young active patients: Prevention by multiple mixed pinning]

Over-reduction is a classical complication following pinning of distal radius fractures. Indeed, the pinning techniques derived from Kapandji's technique do not allow anterior stabilization. A literature review and our experience show that it is an underestimated complication that can affect up to one-third of cases, but that is well tolerated if the anterior tilt is less than 20°. Excessive angulation of the dorsal intrafocal K-wires becomes a significant risk factor beyond 60°. Volar comminution of the fracture is an obvious predisposing factor. We will outline our ideas on the topic and present a new pinning technique, which has reduced the over-reduction rate to below 3 %: multiple mixed pinning combines two dorsal intrafocal K-wires with two trans-styloid K-wires along the anterior and posterior cortices of the radius to provide true sagittal stabilization of the fracture. This technique is suitable for fractures without major instability or associated anterior comminution-Milliez types 1 and 2 are its best indications. In our practice, there still is a place for pinning of non-complex fractures in young active subjects. More than 20° malunion in flexion can lead to symptoms; in this instance, isolated opening osteotomy of the radius is the most suitable technique.

Staged Reconstruction for Malunited Fractures of the Distal Radius

This prospective study assessed the outcomes of 26 symptomatic malunited distal radial fractures which were treated with an opening wedge corrective osteotomy and bone grafting with rigid fixation. An ulnar shortening osteotomy was subsequently required as a second-stage operation in five cases to restore normal ulnar variance. A wrist arthroscopy was indicated as a third stage procedure with persistent ulnar sided wrist pain in order to address central tears of the triangular fibrocartilage.

Satisfactory functional scores were achieved by 20 of the 26 patients after distal radial osteotomy alone and, 24 of the 26 after subsequent ulnar shortening osteotomies and arthroscopy when necessary. The one, two or three stage concept of reconstructing the malunited distal end radius could optimise the outcome rather than using a single-stage strategy.

Effect of Volarly Angulated Distal Radius Fractures on Forearm Rotation and Distal Radioulnar Joint Kinematics

PURPOSE

To examine the effect of volar angulation deformities of the distal radius with and without triangular fibrocartilage complex (TFCC) rupture on forearm range of motion and the kinematics of the ulnar head at the distal radioulnar joint (DRUJ) during simulated active forearm rotation.

METHODS

Volar angulation deformities of the distal radius with 10° and 20° angulation from the native orientation were created in 8 cadaveric specimens using an adjustable apparatus. Active supination and pronation were performed using a forearm motion simulator. Pronation and supination range of motion was quantified with each deformity. In addition, changes in the dorsovolar position of the ulnar head relative to the radius were calculated after simulating each distal radial deformity. Testing was performed with the TFCC intact and sectioned.

RESULTS

Volar angulation deformities of 20° decreased the supination range with preservation of pronation. There was no effect of TFCC status on the range of forearm rotation. With the TFCC intact, volar angulation deformities translated the ulna slightly dorsally in pronation and volarly in supination. After sectioning the TFCC, volar angulation deformities of 10° and 20° translated the ulna dorsally throughout forearm rotation.

CONCLUSIONS

Volar angulation deformities reduce supination range and alter the DRUJ kinematics. The increased tension in the intact TFCC caused by volar angulation deformities likely prevented the expected dorsovolar displacement at the DRUJ and restricted supination. Dividing the TFCC released the constraining effect on the DRUJ and allowed the ulna to translate dorsally. However, supination remained limited, presumably because of impediment from the dorsally subluxated ulna.

CLINICAL RELEVANCE

This study demonstrated the importance of correcting volar angulation deformities of the distal radius to less than 20° in order to maintain normal range of forearm rotation and to less than 10° to maintain normal DRUJ kinematics when the TFCC is ruptured.

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.

Is it really necessary to restore radial anatomic parameters after distal radius fractures?

Small variations within normal range of radiographic parameters, except ulnar variance and volar tilt, do not influence the final functional outcome in distal radius fractures.

INTRODUCTION

There are many reports in the literature on the relationship between radiographic variables and their influence on the final outcome of distal radius fractures. Most authors report that a good functional result depends on anatomical restoration of the articular surface and extra-articular alignment. The aim of this study was to verify if it is really necessary to restore anatomic radiographic parameters to obtain satisfactory functional outcome in distal radius fractures treated with volar plate.

MATERIALS AND METHODS

We retrospectively evaluated 51 patients treated with volar locked plate for articular unstable distal radius fractures from December 2006 to March 2009. Each fracture was evaluated according to the AO classification. The average follow-up was 40.5 months. Radiological measurements were performed considering radial height, radial inclination, volar tilt and ulnar variance, both preoperatively and postoperatively, to estimate the correction value. We examined range of motion (ROM), grip strength with a Jamar(®) dynamometer and Disabilities of the Arm, Shoulder and Hand (DASH) score. The τ Student test was performed for statistical analysis.

RESULTS

The persistence of articular step-off was assessed in 35.3% of patients. Normal radial inclination (21-25°) was restored in 74.5% of patients (range 15-27.5°). Normal radial height (10-13 mm) was restored in 66.6% of patients (range 6.8-17.3mm). Normal volar tilt (7-15°) was achieved in 90.2% of patients (range 3-17°). Normal ulnar variance (0.7-1.5mm) was restored in 86.3% of patients (range 0.7-4.1mm). There was a statistically significant difference between the preoperative and postoperative radiographic values (p<0.01). The majority of patients showed complete recovery of ROM, with no statistically significant difference (p>0.05) in extension, flexion, supination and pronation compared with the contralateral hand. Eight patients who had postoperative volar tilt and/or ulnar variance out of range had a statistically significant difference (p<0.05) in ROM compared with the non-operated side. At final follow-up, all patients had a statistically significant difference (p<0.05) in grip strength compared with the contralateral side, even with good strength values. The mean DASH score was 12.2 (range 0-61).

DISCUSSION AND CONCLUSION

Our experience suggests that ulnar variance and volar tilt are the most important radiographic parameters to be restored to obtain good functional outcome in distal radius fracture. Small variations of other radiographic parameters seem to not affect the final outcome at minimum 3 years' follow-up.

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.

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.

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.

The role of bone allografts in the treatment of angular malunions of the distal radius

PURPOSE

Two cohorts of patients who had corrective osteotomies and volar platings for malunited fractures of the distal radius were compared retrospectively to determine whether the time to union and the outcome were affected by bone allograft.

METHODS

Patients in the first group (n = 14) did not receive any bone graft; patients in the second group (n = 14) had allograft bone chips following volar plating. Indications for surgery, surgical technique, and postoperative rehabilitation were the same in both groups. Volar cortical contact was maintained using a volar locking plate in all patients. Radiographic parameters of deformity correction, time to union, wrist and forearm range of motion, grip strength, patient-rated wrist evaluation and Disabilities of the Arm, Shoulder, and Hand questionnaire were used to evaluate the outcome before and after the surgery. Average follow-up time was 36 weeks. Patients who had diabetes, who smoked, who had a body mass index of more than 35, and who required lengthening for deformity correction were excluded from the study.

RESULTS

Osteotomies in both groups healed without loss of surgical correction. Final outcome and time to union revealed no significant differences, clinically or statistically, between the 2 groups. The Disabilities of the Arm, Shoulder, and Hand score was improved in both groups.

CONCLUSIONS

When volar cortical contact was maintained using a volar locked plate, bone allograft at the osteotomy site did not improve the final outcome.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

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.

Corrective osteotomy of the malunited distal radius fracture: use of periosteal bed may reduce the extent of postoperative graft resorption

The aim of this study was to compare osteotomy for malunited distal radius fracture with embedment of a corticospongious graft into a periosteal flap of the recipient bone (test) with the standard procedure (control) with respect to graft resorption. A retrospective assessor-blind analysis of consecutive patients (test: n = 19, control: n = 30) was performed. Ulnar tilt, palmar tilt and capitate-ulna distance were assessed from radiographs taken before, two to four days after and over three months after the surgery to determine loss of correction achieved by the surgery and estimate graft resorption during the postoperative period. In both unadjusted and adjusted comparisons, loss of correction of all parameters was lower in the test group (P < 0.05). The odds of "none to mild" resorption were greater in the test group with an adjusted odds ratio of 5.43 (95% confidence interval: 1.32-26.5, P = 0.025). Total graft collapse occurred in five of 30 controls and in none of 19 test patients. Graft embedment into the periosteum may improve its preservation.

Management of post-traumatic malunion of fractures of the distal radius

Distal radius malunions are a common cause of patient morbidity. This review of the literature surrounding distal radius malunion covers the demographics, pathologic anatomy, and indications for surgery, surgical techniques, and salvage options. Particular emphasis is placed on subject areas that have not been reviewed as extensively in previous articles, including: intra-articular malunion, computer-assisted techniques, bone graft alternatives, and volar fixed-angle plate osteosynthesis.

Corrective osteotomy for volarly malunited distal radius fracture

PURPOSE

To retrospectively analyze consecutive cases with opening wedge corrective osteotomy of the volarly malunited distal radius with iliac bone graft, including preoperative and postoperative comparison of symptoms, visual analog scale (VAS), Japanese Society for Surgery of the Hand version of the Disabilities of the Arm, Shoulder, and Hand (DASH-JSSH) questionnaires, radiographic indices, clinical results as evaluated by modified Mayo wrist score, and complications.

METHODS

Subjects were 28 patients with volarly malunited distal radius fracture treated by transverse opening wedge osteotomy with oblique iliac bone graft. Preoperative symptoms included wrist deformity, weakness of grip strength, and marked restriction of supination range. Postoperative symptoms, radiographic parameters, clinical results, and complications were analyzed at an average of 25 months of follow-up. We also analyzed the union period of the radius in younger patients (< or =45 years old) and older patients (>45 years old).

RESULTS

Mean preoperative visual analog scale was 45, improving significantly to 3 postoperatively. Range of wrist motion improved in all 28 patients, with supination range improving from 16 degrees preoperatively to 80 degrees postoperatively. Mean preoperative DASH-JSSH score was 55, improving to 9 postoperatively. Radiography revealed that volar tilt improved from 32 degrees preoperatively to 10 degrees postoperatively, and radial inclination increased from 17 degrees to 21 degrees . Preoperative ulnar variance of +5.9 mm was corrected to -0.1 mm postoperatively. All 28 wrists demonstrated bony union at the osteotomy site after an average of 52 days (younger patients, 51 days; older patients, 54 days). No complications, significant radiographic correction loss, or nonunion were seen after at least 2 years of follow-up. Modified Mayo wrist score was excellent in 16 patients, good in 10 patients, and fair in 2 patients.

CONCLUSIONS

Opening wedge osteotomy for volarly malunited distal radius fracture restored bony configuration of the distal radius, decreased pain, and improved grip strength and range of wrist motion, particularly for forearm supination. No complications or noteworthy correction loss were noted after surgery, even in older patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Three-dimensional corrective osteotomy of malunited fractures of the upper extremity with use of a computer simulation system

BACKGROUND

Three-dimensional anatomical correction is desirable for the treatment of a long-bone deformity of the upper extremity. We developed an original system, including a three-dimensional computer simulation program and a custom-made surgical device designed on the basis of simulation, to achieve accurate results. In this study, we investigated the clinical application of this system using a corrective osteotomy of malunited fractures of the upper extremity.

METHODS

Twenty-two patients with a long-bone deformity of the upper extremity (four with a cubitus varus deformity, ten with a malunited forearm fracture, and eight with a malunited distal radial fracture) participated in this study. Three-dimensional computer models of the affected and contralateral, normal bones were constructed with use of data from computed tomography, and a deformity correction was simulated. A custom-made osteotomy template was designed and manufactured to reproduce the preoperative simulation during the actual surgery. When we performed the surgery, we placed the template on the bone surface, cut the bone through a slit on the template, and corrected the deformity as preoperatively simulated; this was followed by internal fixation. All patients underwent radiographic and clinical evaluations before surgery and at the time of the most recent follow-up.

RESULTS

A corrective osteotomy was achieved as simulated in all patients. Osseous union occurred in all patients within six months. Regarding cubitus varus deformity, the humerus-elbow-wrist angle and the anterior tilt of the distal part of the humerus were an average of 2 degrees and 28 degrees, respectively, after surgery. Radiographically, the preoperative angular deformities were nearly nonexistent after surgery. All radiographic parameters for malunited distal radial fractures were normalized. The range of forearm rotation in patients with forearm malunion and the range of wrist flexion-extension in patients with a malunited distal radial fracture improved after surgery.

CONCLUSIONS

Corrective osteotomy for a malunited fracture of the upper extremity with use of computer simulation and a custom-designed osteotomy template can accurately correct the deformity and improve the clinical outcome.

Malunited fractures of the distal radius treated with corrective osteotomy using volar locking plate and a corticocancellous bone graft following immediate mobilisation

We describe our experience of using a volar locking plate for corrective osteotomy and bone grafting combined with early mobilisation in the treatment of distal radius malunions. Corrective osteotomy of the distal radius was performed through a volar approach, and fixated by a volar locking plate associated with corticocancellous iliac bone grafting in three patients aged 16, 71 and 75 years. Two patients had had volarly displaced malunion and one dorsally displaced malunion. Wrist motion was started immediately after surgery. The average follow-up was 15 months (range, 12-20 months). All osteotomies healed at an average 5.7 weeks post-operatively, resulting in a total arc of wrist motion of 133 degrees, forearm rotation of 167 degrees, and grip strength of 70% of that of the contralateral side. This treatment method proved to be effective and safe.

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.

Gradual reduction of distal radial malunion using distraction osteogenesis

PURPOSE

To evaluate gradual distraction lengthening or distraction osteogenesis as a technique for treating malunions of the distal radius.

METHODS

Twenty patients with clinical and radiographic evidence of distal radius malunion were treated with osteotomy of the distal radius using distraction osteogenesis. At the follow-up evaluation each patient was evaluated for healing rates, complications, resolution of pain, and radiographic alignment. Surgical treatment consisted of an application of a nonbridging external fixator that could be distracted to correct the deformity. A loosely set screw that connected the distal pins to the fixator served as a hinge and allowed the distal radius to rotate into a corrected position. Gradual distraction via distraction osteogenesis was initiated 1 week after surgery.

RESULTS

Seventeen osteotomies healed uneventfully in an average of 9 weeks. Complications included 9 pin track infections. Two nonunions required bone grafting. One patient inadvertently compressed rather than distracted the fixator, leading to premature healing of the osteotomy. One patient ruptured the extensor pollicis longus. All complications resolved with additional intervention. Overall the patients showed radiographic and symptomatic improvement.

CONCLUSIONS

An external fixator and distraction lengthening through distraction osteogenesis is a viable alternative to plate fixation and bone grafting. In 18 of 20 of our patients, the technique eliminated the need for bone grafting and the need for a second surgical procedure to remove a dorsal plate.

Management of post-traumatic malunion of fractures of the distal radius

Distal radius malunions are a common cause of patient morbidity. This review of the literature surrounding distal radius malunion covers the demographics, pathologic anatomy, and indications for surgery, surgical techniques, and salvage options. Particular emphasis is placed on subject areas that have not been reviewed as extensively in previous articles, including: intra-articular malunion, computer-assisted techniques, bone graft alternatives, and volar fixed-angle plate osteosynthesis.

Malunion of the distal radius

Fractures of the distal radius are common injuries. Acceptable results typically can be obtained with appropriate surgical or nonsurgical management. However, a small percentage of these fractures can progress to symptomatic malunion, which traditionally has been treated with osteotomy of the distal radius. Proper understanding of anatomy, biomechanics, indications, and contraindications can help guide patient selection for surgery. In formulating a treatment plan, the surgeon also must consider such technical variables as the type of osteotomy, the use of bone graft or bone-graft substitute, and the means of fixation to stabilize the osteotomy. Simultaneous implementation of an ulnar-side procedure, an intra-articular osteotomy, and soft-tissue releases also may be necessary. Some cases may be more appropriate for wrist fusion or other salvage procedures.

Outcomes using an internal osteotomy and distraction device for corrective osteotomy of distal radius malunions requiring correction in multiple planes

PURPOSE

Many different methods have been proposed for correction of distal radius malunions; however, precise correction of a severe malunion that requires simultaneous adjustment of displacement, angulation, and rotation in multiple planes is difficult. This prospective study measured radiographic and functional outcomes using an adjustable osteotomy, distraction, and fixation system for distal radius malunions that required correction in multiple planes.

METHODS

Five consecutive patients with symptomatic distal radius malunions requiring correction in multiple planes were recruited into this study. All patients had correction of the malunion with an adjustable osteotomy, distraction, and fixation device. Radiographic parameters and objective and subjective functional outcomes were measured before surgery and at 3 months, 6 months, and 1 year after surgery.

RESULTS

All radiographic measurements improved after surgery. Grip strength, pinch strength, and the Jebsen-Taylor test showed only marginal improvement. Ulnar deviation of the wrist and forearm pronation-supination improved, but the wrist extension-flexion arc did not. The Michigan Hand Outcomes Questionnaire showed improvement in all domains, and significant improvement was seen in the overall, work, aesthetic, and satisfaction domains. The Michigan Hand Outcomes Questionnaire, however, also indicated a substantial amount of residual impairment in all domains, including activities of daily living and pain.

CONCLUSIONS

Corrective osteotomy with the adjustable osteotomy, distraction, and fixation device resulted in improvement in distal radius anatomy and function. However, not all improvements were statistically significant, and anatomy and function did not returned to baseline levels. Despite residual disability, patients noted substantial improvement in subjective outcomes. This system is useful for improving anatomy and function in distal radius malunions that require correction in multiple planes, but patients should be informed that they cannot expect to regain normal anatomy or function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Corrective osteotomies in malunions of the distal radius: do we get what we planned?

Fifteen patients with symptomatic malunions of the distal radius were treated with osteotomies, corticocancellous bone grafting, and plate and screw fixation. We investigated the ability of precise preoperative planning of the size and shape of the corticocancellous bone graft to restore alignment of the radius to within 5 degrees angular deformity and 2 mm ulnar variance as compared with the opposite uninjured wrist. Only six of 15 patients (40%) satisfied these criteria. Inter-rater reliability of radiographic assessment was greater than 0.85. Five patients had residual radial inclination or sagittal tilt greater than 10 degrees with respect to the uninvolved wrist. Four patients had a residual ulnar variance greater than 2 mm with respect to the uninvolved wrist. Residual shortening (three of four patients), but not residual angulation, was associated with unsatisfactory pain and stiffness an average of 19.5 months after osteotomy (range, 11-32 months). We conclude that a distal radius osteotomy using a precisely planned and measured interpositional corticocancellous graft does not restore distal radius alignment in most patients, and that failure to restore length is associated with continued pain and stiffness.

LEVEL OF EVIDENCE

Therapeutic study, Level IV (case series).

A histologic analysis of the effects of stainless steel and titanium implants adjacent to tendons: an experimental rabbit study

PURPOSE

The current trend is to treat distal radius fractures with open reduction and internal fixation with either titanium or stainless steel plates. Both provide stable fixation; however, there is minimal evidence concerning the soft-tissue response to these materials. Our objective was to evaluate the response of adjacent extensor tendons to titanium and stainless steel in a rabbit in vivo model and to evaluate the influence of time.

METHODS

Forty rabbits were divided into 5 groups of 8 rabbits each. Groups I and II had unilateral osteotomy of the distal radius followed by dorsal fixation with titanium and stainless steel plates, respectively. Groups III and IV had fixation with titanium and stainless steel, respectively, but without osteotomy. Group V had surgical dissection without osteotomy or plates. Two animals per group were killed at 1, 4, 12, and 24 weeks. The specimens (distal radius, plate, overlying soft tissue, and extensor tendon) were harvested en bloc for histologic analysis. For interface preservation between implant and tissues the specimens were embedded in methylmethacrylate, sectioned, and stained with hematoxylin-eosin.

RESULTS

Histologic analysis showed a fibrous tissue layer formed over both implants between the plate and the overlying extensor tendons in the groups treated with plating independently of the material and the presence or absence of osteotomy. This fibrous layer contained the majority of debris. Metallic particles were not observed in the tendon or muscle substance of any animals; however, they were visualized in the tenosynovium. Hematoxylin-eosin-stained sections of groups I through IV showed proliferative fibroblasts and metallic particles; however, this layer was not observed in group V. Statistical analysis did not show differences between the groups regarding the number of cells or metallic particles.

CONCLUSIONS

Our results indicate that both implants generated adjacent reactive inflammatory tissue and particulate debris. There was no difference in cell or particle number produced by both materials. There is a statistically significant increase in inflammatory cells with increasing time of implantation.

[Functional outcome after corrective osteotomy of the distal radius]

BACKGROUND

Malunited fractures of the distal radius frequently show disabling and painful reductions in active range of motion (AROM) of the wrist and forearm with reduced grip strength. Shortening and three-dimensional torsion of the distal radius occur with relative ulnar lengthening. Corrective osteotomy of the distal radius is indicated in these conditions.

METHODS

We examined 24 of 30 patients after corrective osteotomy with respect to AROM, grip strength, DASH, and pain perception (visual analogue scale). The mean age of the population was 49 years (18-69 years), and the mean follow-up period was 22 months (6-63 months).

RESULTS

Preoperative extension/flexion was 65 degrees , postoperative 92 degrees (p<0.05). Forearm rotation improved from 129 degrees preoperative to 160 degrees postoperative (p<0.01). The DASH score could be reduced from 40 (n=9) to 18 (n=24). Grip strength increased from 17 kg to 27 kg postoperative (p<0.01). Radioulnar inclination increased from 15 degrees preoperative to 24 degrees postoperative (p<0.05). Relative ulnar lengthening could be minimized from 4.3 mm to 0.7 mm (p<0.05).

CONCLUSION

Data show that reconstruction of the distal radius improves grip strength and range of motion significantly with simultaneous reduction of pain perception and DASH scores.

Influence of distal radioulnar joint subluxation on restricted forearm rotation after distal radius fracture

PURPOSE

To analyze the influence of subluxation of the distal radioulnar joint (DRUJ) on restricted forearm rotation after distal radius fracture.

METHODS

Twenty-two cases of healed unilateral distal radial fracture with restricted forearm rotation were included in the study. The subluxation of the DRUJ was evaluated using helical computed tomography scan at neutral, maximum pronation, and maximum supination and presented as the percent displacement of the ulnar head in both the injured and uninjured sides. The radiographic parameters of palmar tilt, radial inclination, dorsal shift, radial shift, and ulnar variance were measured on plain x-ray films and the rotational deformity of the distal radius was evaluated from the computed tomography scan. The differences of each radiographic parameter from the uninjured side were calculated. The relationships between the restricted forearm rotation and the percent displacement of the ulnar head and each of the radiographic parameters were analyzed statistically.

RESULTS

When forearm pronation was restricted the ulnar head was located palmarly at neutral, maximum supination, and maximum pronation with severe dorsal tilt of the distal radius. When supination was restricted the ulnar head was located dorsally at maximum supination with severe ulnar-positive variance.

CONCLUSIONS

The subluxation of the DRUJ was related to restricted forearm rotation. The radiographic parameters of palmar tilt and ulnar variance showed an adverse influence on the position of the ulnar head at the DRUJ, which might lead to restricted forearm rotation after distal radial fracture.

Use of an ulnar head endoprosthesis for treatment of an unstable distal ulnar resection: review of mechanics, indications, and surgical technique

Resection of the distal ulna for post-traumatic arthritis can lead to an unstable forearm joint through loss of the normal articular contact through the distal radioulnar joint and loss of soft tissue constraint. The resulting convergence instability can lead to residual pain, weakness, and loss of function. Restabilization of the forearm joint with implantation of an ulnar head endoprosthesis can re-establish the mechanical continuity of the forearm, reducing pain and improving strength and function. The anatomy, mechanics,rationale, and indications for surgical replacement of the distal ulna are presented. Important tenets of proper ulnar head implant insertion are given to provide a guide for use of the implant. Preliminary results after 2 years of clinical experience are encouraging.

Extra-articular distal radial fracture malunion

With the increase in surgical options for the treatment of distal radius fractures, the authors anticipate that distal radial fracture malunions will be a less frequently seen problem. Nevertheless, they will still occur. Although patient selection has been weighted toward the younger patient, we believe that surgery should be based on patient activity level, functional needs, and disability related to the malunion. With advances in biotechnology and improved anesthetics, surgical intervention even in the older and osteopenic population is now more promising. Surgical intervention still requires appropriate patient selection, careful preoperative planning, and meticulous surgical technique. The appropriate surgical procedure should be tailored to the patient's symptoms, age, needs, and radiographic findings.

Treatment of the neglected distal radius fracture

Operative treatment of inadequately or imperfectly treated fractures of the distal radius can improve wrist and hand function substantially, but rarely restores the limb to normal. Patients with malunion of the distal radius present either with poor radiographic alignment before complete healing of the fracture (nascent malunion) or with functional problems that may be related to inadequate alignment of a healed fracture (mature malunion). Corrective osteotomy is offered to patients who have sufficient malalignment that the surgeon thinks problems are inevitable or to patients in whom the functional deficit can be related clearly to the malunion. Ununited fractures are associated with painful instability of the wrist and very poor hand function. Operative treatment has proved successful even when the distal fragment is small. Operative treatment for reconstruction of the distal radius has been facilitated by the introduction of plates with angular stable screws (screws that lock into the plate). Painful arthritis is salvaged with arthrodesis.

Corrective osteotomy of the distal radius through volar approach

Operative correction through the malunion has become a well-accepted reconstructive procedure for symptomatic malunited extra-articular fractures of the distal radius over the last 3 decades. Now that newer plates designed specifically for the volar fixation of dorsally unstable distal radius fractures by incorporating buttress pins and screws that lock to the plate are available, more and more surgeons prefer volar fixation of dorsally unstable distal radius fractures. In the mid 1970s, the senior author (U.B.L.) developed a technique for corrective osteotomy of dorsally tilted malunions of the distal radius using a radiovolar approach and a special plate. This technique was proved to be efficient in more than 400 patients.

Nonunion of distal radius fractures

Nonunion of a distal radius fracture is extremely uncommon. Healing problems in the distal radius seem to be related to unstable situations, such as concomitant fracture of the distal radius and ulna, and to an inadequate period of immobilization. Nonunion should be suspected if there is continuing pain after remobilization of the wrist in combination with a progressing deformity. The diagnosis may be confirmed by showing movement at the fracture site on lateral radiographs of the wrist in flexion and extension. Because of the rarity of distal radius fracture nonunion, it is not surprising that there is no consensus on the optimum mode of operative treatment. Based on our experience with reconstruction surgery in 23 patients, we think that most nonunions of the distal radius are amenable to attempts to re-align and heal the fracture even when the distal fragment is small. Therefore, surgeons should try to preserve even a small amount of wrist motion and reserve wrist fusion as a final resort.

Computer-assisted distal radius osteotomy

PURPOSE

To establish the accuracy, precision, and clinical feasibility of a novel technique of computer-assisted distal radius osteotomy for the correction of symptomatic distal radius malunion.

METHODS

Six patients underwent a computer-assisted distal radius osteotomy and were followed-up for an average of 25 months. Objective radiographic measurements and functional outcomes, as measured by clinical examination including grip strength and range of motion, and Disability of the Arm, Shoulder and Hand (DASH) questionnaires, were used.

RESULTS

The mean radiographic parameters included an increase of radial inclination to 21 degrees from 12 degrees (normal, 23 degrees ). Dorsal and volar tilt (malunion) were corrected to 9 degrees from -30 degrees and 21 degrees, respectively (normal, 10 degrees ). Ulnar variance was corrected to 1.9 mm from 7.5 mm (normal, +1.5 mm). Normal is defined as the average of the contralateral limb radiographs. The mean clinical outcome measures at an average of 25 months included a DASH global score of 14, a DASH individual item average score of 1.6, and an average affected side grip strength of 79% when compared with the unaffected side.

CONCLUSIONS

The results of the computer-assisted technique were comparable with published results of traditional non-computer-assisted opening wedge osteotomy techniques. This technique allows a surgeon to accurately and precisely recognize and correct 3-dimensional deformities of the distal radius including axial malalignment (supination). The technique has the added benefit of reducing radiation exposure to the patient and surgical team because fluoroscopy is not used during the procedure. Additional benefits of the computer-assisted technique include the ability to perform multiple surgical simulations to optimize the alignment plan, and it serves as an excellent teaching tool for less-experienced surgeons.

Sliding osteotomy for deformity correction following malunion of volarly displaced distal radial fractures

OBJECTIVE

To determine the outcome after a sliding osteotomy for deformity correction following malunion of volarly displaced distal radius fractures.

DESIGN

Retrospective review of a consecutive patient series.

SETTING

A university-affiliated, tertiary-care center.

PATIENTS/INTERVENTION

Ten patients with symptomatic distal radius malunion following a volarly displaced distal radial fracture (Smith's fracture) were treated with an oblique sliding osteotomy and plate fixation, through a volar approach, without using an iliac crest bone graft. Five men and five women with an average age of 41.9 years were followed for an average of 2.7 years postoperatively.

MAIN OUTCOME MEASUREMENTS

Range of motion, grip strength, Fernandez wrist score, radiographic parameters.

RESULTS

At latest follow-up, wrist extension improved from an average of 37 degrees preoperatively to 70 degrees postoperatively (P = 0.002), wrist flexion improved from an average of 40 degrees to 65 degrees (P = 0.012), and supination improved from an average of 31 degrees to 68 degrees (P = 0.002). Postoperative radiographs revealed an average deformity correction of 10.6 degrees of volar tilt, 7.7 degrees of radial inclination, 5.8 mm of ulnar variance, and 10.4 mm of volar translation. Using the Fernandez point score (0-20) system, the average overall score improved from 10.5 preoperatively to 17.6 postoperatively (P = 0.0001). Functional outcome was rated as excellent or good in 9 of 10 patients and fair in 1 patient (who experienced residual problems due to persistent ulnar-sided pain). There were two reoperations (one hardware removal, one distal ulnar hemiresection).

CONCLUSIONS

This method reliably restores distal radial anatomy, decreases pain, and improves supination without requiring iliac crest bone grafting.

Corrective osteotomy for malunion of the distal radius in young and middle-aged patients: an outcome study

INTRODUCTION

We report the outcome of osteotomy for malunion of the distal radius.

MATERIAL AND METHODS

Twenty-one wrists in 21 patients (mean age 38 years) with a malunion of the distal radius were treated with an osteotomy. An opening wedge osteotomy was performed when the distal radioulnar joint (DRUJ) could be saved; a closing wedge osteotomy was done when the DRUJ was treated with resection (Darrach) or arthrodesis (Sauvé-Kapandji). The clinical and radiographic outcomes were evaluated together with the DASH score (disability of shoulder and hand).

RESULTS

Extension improved to an average of 48 degrees in the Smith-type group and flexion improved to an average of 51.8 degrees in the Colles-type group. The postoperative DASH-score averaged, respectively, 17.3 and 33. There were four poor, four fair, seven good and six excellent scores on the scale of Fernandez and there were four poor, seven fair, three good and seven very good results on the Fernandez point score. Grip strength postoperatively averaged 70% of the contralateral side. Radiographically, there was a correction of increased volar tilt of the articular surface from 30.6 to 4.0 degrees in the Smith-type group and a correction of increased dorsal tilt of the articular surface of 24.6 degrees (from -21.3 to 3.3 degrees) in the Colles-type group. Nine patients had surgery on the distal ulna at the time of the radial correction. Their average DASH score was 16.8 compared to the 33.97 average DASH score of those with radial correction without ulnar surgery.

CONCLUSION

Osteotomy of the distal radius in cases of malunion gives favorable outcomes. Treatment of the DRUJ is mandatory.

Outcome after corrective osteotomy for malunited fractures of the distal end of the radius

This retrospective study evaluated the outcome of corrective osteotomy for malunited distal radial fractures and investigated the influence of the radiological result on the clinical outcome. Twenty-nine patients underwent corrective osteotomy for malunited, dorsally tilted fractures of the distal radius and 20 underwent corrective osteotomy for malunited, palmarly angulated distal radial fractures. All were surveyed at an average of 18 months after surgery and assessed for: pain; grip strength; range of motion; radial tilt; radial inclination; and ulnar variance. Postoperative radial tilt, radial inclination and ulnar variance were significantly improved by corrective osteotomy. Patients with no, or only minor residual deformity after corrective osteotomy had significantly better results than those with gross residual deformity.