A comparison of corrective osteotomies using dorsal and volar fixation for malunited distal radius fractures

Clinical and Radiographic Outcomes of Gap Osteotomy Versus Dorsal Opening Wedge Osteotomy for Extra-Articular Distal Radius Malunion and Internal Fixation Using a Volar Locking Plate Without Bone Graft

Purpose

Metaphyseal corrective osteotomy and fixed-angle volar locking plate fixation have reduced the need for additional bone grafting in symptomatic distal radius malunions. This study evaluated the outcomes of gap versus dorsal opening wedge and locking plate fixation without bone grafts for distal radius malunions and the correlation between the osteotomy defect and the osteotomy's distance from the articular surface with the union time.

Methods

We retrospectively reviewed 62 patients who underwent corrective osteotomy between 2010 and 2021. Gap osteotomy (n = 44) was performed to correct the coronal deformity predominantly, whereas an opening wedge osteotomy (n = 18) was performed to correct the sagittal deformity. No bone graft was used in any patient. Radiological outcomes comprised of correction of radial height, inclination, ulnar variance, volar tilt and the correlation between the osteotomy defect and the distance from the distal radial articular surface with the union time. The functional assessment comprised the disabilities of arm, shoulder, and hand questionnaire and the patient-rated wrist evaluation scores.

Results

All patients had a union of the osteotomy and statistically significant improvement in the radial height, inclination, ulnar variance, and tilt, irrespective of the osteotomy technique (P < .05). The mean defect length of the osteotomy, the time to the union, and the distance of the osteotomy were 4.7 mm (1-8.3 mm), 11.7 weeks (5-24 weeks), and 13.9 mm (1.6-35.8 mm), respectively. Time taken for union showed a weak positive correlation with the defect length of the osteotomy and no correlation with the distance of the distal osteotomy site from the articular surface. Opening wedge osteotomies took less time than the gap osteotomies. The mean postoperative disabilities of arm, shoulder, and hand questionnaire and the patient-rated wrist evaluation scores were 6.89 and 12.18, respectively.

Conclusions

Corrective osteotomy and fixed-angle volar plate fixation for distal radius malunion provide satisfactory union rates and clinical and radiological outcomes even without bone graft, irrespective of the osteotomy type, size, or location. However, length of the osteotomy defect influenced the union time.

Type of study/level of evidence

Therapeutic IV.

Comparative Analysis of Radial Corrective Osteotomy and Sauvé-Kapandji Procedure for Malunited Distal Radius Fractures in Older Adults

PURPOSE

Malunited distal radius fractures frequently occur in the older population, posing a dilemma in selecting ideal management for symptomatic patients. Radial corrective osteotomy (RCO) and the Sauvé-Kapandji procedure (SK) have been used to treat this challenging condition. However, it remains unknown which approach is better for the older population. The objective of this study was to compare the outcomes of RCO with those of SK for the treatment of symptomatic distal radius malunion in older adults.

METHODS

Thirty-three patients aged ≥60 years, with malunited distal radius fractures, were randomized to be treated with either RCO or SK and followed for a minimum of 2 years. The primary evaluation parameter was grip strength, and secondary outcome parameters were surgical time, range of motion of the wrist, exercise-related wrist pain assessment using visual analog scale scores, radiographic results, patient-reported outcomes evaluated using the Disability of the Arm, Shoulder, and Hand (DASH), and Patient-Related Wrist Evaluation (PRWE) scores.

RESULTS

The average follow-up duration was 36.7 ± 10.2 months. The grip strength was significantly higher in the RCO group. The surgical time was shorter in the SK group than in the RCO group. The postoperative wrist range of motion and visual analog scale scores for exercise-related pain alleviation were similar in both groups. The ulnar variance decreased in both groups and was similar when compared with the postoperative images. The DASH and PRWE scores were similar between the RCO and SK groups.

CONCLUSIONS

Radial corrective osteotomy and SK surgeries have similar clinical and functional outcomes in patients aged ≥60 years. Grip strength is higher in the RCO group than in the SK group. However, the operating time to accomplish SK is shorter than RCO.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

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.

Functional outcome of 2-D- and 3-D-guided corrective forearm osteotomies: a systematic review

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.

3D-assisted corrective osteotomies of the distal radius: a comparison of pre-contoured conventional implants versus patient-specific implants

PURPOSE

There is a debate whether corrective osteotomies of the distal radius should be performed using a 3D work-up with pre-contoured conventional implants (i.e., of-the-shelf) or patient-specific implants (i.e., custom-made). This study aims to assess the postoperative accuracy of 3D-assisted correction osteotomy of the distal radius using either implant.

METHODS

Twenty corrective osteotomies of the distal radius were planned using 3D technologies and performed on Thiel embalmed human cadavers. Our workflow consisted of virtual surgical planning and 3D printed guides for osteotomy and repositioning. Subsequently, left radii were fixated with patient-specific implants, and right radii were fixated with pre-contoured conventional implants. The accuracy of the corrections was assessed through measurement of rotation, dorsal and radial angulation and translations with postoperative CT scans in comparison to their preoperative virtual plan.

RESULTS

Twenty corrective osteotomies were executed according to their plan. The median differences between the preoperative plan and postoperative results were 2.6° (IQR: 1.6-3.9°) for rotation, 1.4° (IQR: 0.6-2.9°) for dorsal angulation, 4.7° (IQR: 2.9-5.7°) for radial angulation, and 2.4 mm (IQR: 1.3-2.9 mm) for translation of the distal radius, thus sufficient for application in clinical practice. There was no significant difference in accuracy of correction when comparing pre-contoured conventional implants with patient-specific implants.

CONCLUSION

3D-assisted corrective osteotomy of the distal radius with either pre-contoured conventional implants or patient-specific implants results in accurate corrections. The choice of implant type should not solely depend on accuracy of the correction, but also be based on other considerations like the availability of resources and the preoperative assessment of implant fitting.

Corrective Osteotomy with Volar and Dorsal Fixation for Malunion of Intra-Articular Fracture of the Distal Radius: A Retrospective Study

OBJECTIVES

Although corrective osteotomy with volar or dorsal plate fixation can treat malunion of distal radius fractures, each has its own disadvantages. Little is currently known on whether dorsal fixation combined with volar fixation may further improve recovery. This study aimed to evaluate the clinical value of corrective osteotomy combined with volar and dorsal plate fixation in patients with malunion of intra-articular fractures of the distal radius.

METHODS

Seventeen patients with malunion of intra-articular fractures of the distal radius treated with corrective osteotomy with volar and dorsal plate fixation from 1 January 2016 to 31 November 2018 were retrospectively analyzed. The enrolled patients included seven males and 10 females with an average age of 54.9 years (range: 36-70 years). The radiographic parameters, including the radial length, the radial inclination angle, the ulnar variance, and the volar tilt, as well as clinical outcomes, including wrist and forearm range of motion (ROM), grip strength, the Mayo Modified Wrist Score (MMWS), and the disabilities of the Arm, Shoulder, and Hand (DASH) score, were examined at 3 months and 18 months after operation and compared with the preoperative state. The paired t-test was used for statistical analysis.

RESULTS

After corrective osteotomy combined with volar and dorsal plate fixation, all included patients were followed up for 18 months, and there was no surgical site infection. Patients reported postoperative pain due to the irritation of extensor tendon (two cases) and wrist arthritis (two cases). The radial length increased from 1.34 ± 2.34 mm to 9.25 ± 2.65 mm and 9.03 ± 2.47 mm at 3 months and 18 months postoperatively (t = 8.257, 7.954, all p < 0.05). The radial inclination angle increased from 6.45° ± 0.76° to 19.35° ± 3.43° and 19.03° ± 3.63° at 3 and 18 months (t = 12.517, 12.122, all p < 0.05). The ulnar variance decreased from 5.11 ± 0.23 mm to 1.32 ± 0.31 mm and 1.54 ± 0.62 mm at 3 and 18 months (t = 4.214, 4.895, all p < 0.05). The volar tilt was corrected from 4.47° ± 3.46° to 15.51° ± 2.72° and 14.12° ± 2.41°, respectively (t = 11.247, 10.432, all p < 0.05). Moreover, wrist ROM increased from 42.53° ± 8.99° to 98.70° ± 7.61° and 101.24° ± 7.66° (t = 41.433, 46.627, all p < 0.05), while forearm ROM was increased from 94.82° ± 6.54° to 134.47° ± 5.06° and 137.24° ± 5.52°, respectively (t = 31.507, 32.584, all p < 0.05). Similarly, grip strength, MMWS, and DASH were also remarkably improved. There were no significant differences in the wrist and forearm ROM, grip strength, MMWS, and DASH scores between follow-up at 3 and 18 months (all p > 0.05).

CONCLUSIONS

Corrective osteotomy with volar and dorsal fixation can improve recovery of volar tilt, relieve wrist pain, restore wrist and forearm function, and increase grip strength of patients with malunion of intra-articular fractures of the distal radius.

Corrective Osteotomy of Malunited Fractures of the Distal Radius Using a Combined Surgical Approach

Background: Malunited distal radius (DR) fractures following conservative treatment range from 6% to 80% of clinical observations. Surgical treatment is used to return the articular surface of the radius to original anatomical position and to restore the natural transfer of strength, wrist kinematics, and function of the entire hand. The aim of this research was to study and analyze the results of corrective osteotomy of malunited distal radius fractures using a combined approach. Methods: From 2008 to 2018, 43 patients with malunited DR fractures who underwent surgery using a combined approach were followed up. Long-term results (1 year after surgery) were studied in detail in 32 patients. Indications for surgery were determined taking into account, first, complaints of severe pain in the wrist during exertion, decreased hand strength, and limited mobility of the wrist. Results: Five patients (15.6%) reported a number of minor complications: intra-articular screw placement (2), incorrect reposition (1), transient neuropathy of the superficial branch of the radial nerve (1), and delayed fracture consolidation (1). In addition, another 5 patients reported the progression of wrist arthritis. Suppurations of the surgical wound and malunited fragments were not reported. Conclusions: During reconstructive interventions, a combined approach with palmar plating provides optimal conditions for corrective osteotomy, adequate reposition and plastic repair of the bone defect, and minimization of the number of complications.

Distal radius malunion in adults

Distal radius malunion (DRMU) consists in a non-anatomical consolidation of a distal radius fracture. The resulting alteration of the articular or extra-articular radial anatomy impairs wrist function to a greater or lesser degree: Restricted ranges of motion, loss of strength, pain. There may also be nerve or tendon involvement. Adaptive carpal malalignment and ulnar-carpal impingement are also possible. Imaging assessment should at least include X-ray and CT; CT-arthrography is essential in intra-articular DRMU, which regularly progresses toward radiocarpal osteoarthritis. Surgical indications are guided by clinical assessment. Restoring distal radial anatomy requires osteotomy, according to type of DRMU: anterior or posterior opening or closing wedge. Bone or bone-substitute graft may need to be associated. Computerisation has improved planning and should be implemented, whenever possible. Ulnar osteotomy may be performed, isolated or associated to distal radial osteotomy. Palliative partial fusion or bone resection is possible in case of joint involvement or in patients with low functional demand.

Functional and radiological outcome of distal radius fractures stabilized by volar-locking plate with a minimum follow-up of 1 year

INTRODUCTION

Distal radius fractures (DRF) are the most common fractures of the upper extremities and incidence is expected to continue rising as life expectancy increases. Palmar locking plate stabilizing has since become the standard treatment for dorsally displaced DRF. Main aim of this study was to investigate correlation between radiological and clinical outcome in patients stabilized by palmar locking plate with a minimum follow-up of one year.

METHODS

A total of 524 patients with DRF, stabilized using palmar angular stable locking plate fixation were included in the study. Of these, 117 patients had to be excluded and another 177 were not accessible. The study group thus compromised 230 patients who returned for the follow-up investigation and were followed-up clinically and radiologically with a mean follow-up interval of 20 months. Outcome was evaluated using pain, range of motion (ROM) and grip strength parameters. In addition, self-assessment by patients was registered on the QuickDASH, PRWE and Mayo Score. The immediate postoperative and final checkup radiographs were scrutinized for alignment and intra-articular step-off.

RESULTS

Bivariant correlation analysis showed a significant correlation between ulnar variance and QuickDASH (r = 0.18, p = 0.01), grip strength (r = - 0.18, p = 0.04) and Mayo Score (r = - 0.23, p = 0.001). No significant differences could be found between an unacceptable (> 2 mm) and acceptable (< 2 mm) ulnar variance in respect of pain, ROM, grip strength and patient-reported outcome measurements. Age, gender, additional fracture to the ulnar styloid, or type of postoperative immobilization showed no significant or clinical important impact on the final patient-reported outcome. No significant differences in incidence of complications, ROM or loss of reduction could be found in any patients over or under 65 years of age.

CONCLUSIONS

Stabilization of DRF by palmar angular stable locking plate is a safe form of treatment and results in a good clinical and radiological outcome with low complication rate. Ulnar variance showed a significant correlation to grip strength, QuickDASH and Mayo Score, but an unacceptable ulnar variance (> 2 mm) was not associated with a worse clinical important outcome. Age (< 65/> 65 years), gender and type of immobilization had no impact on the complication rate or in the final functional or radiological outcome.