Minimally invasive osteotomy for distal radius malunion: A preliminary series of 9 cases

Total Wrist Arthroplasty as a Motion-Sparing Option for Distal Radius Malunion in a Patient of Advanced Age: A Case Report

CASE

A 62-year-old woman presented with wrist pain secondary to a distal radius fracture malunion 4 months after a fall onto an outstretched hand. She was not an ideal candidate for osteotomy and bone graft because of the degree of displacement and osteoporosis, so after nonoperative treatment was unsuccessful, she was offered total wrist arthroplasty (TWA) or arthrodesis and opted for TWA.

CONCLUSION

At 14-month follow-up, the patient reported significant improvement in her pain and function. The current generation of TWA implants may allow use in the management of symptomatic distal radius malunions in older, low-demand patients.

Technique, Indications and Limitations of a Minimally Invasive Approach to Treat Distal Radius Fractures and Malunions

The minimally invasive flexor carpi radialis approach can be used for volar locking plate fixation of distal radius fractures. It offers the advantage of preserving ligamentotaxis, which facilitates the reduction and the small size of the scar improves the esthetic result of the procedure. It is indicated for extra-articular fractures of the distal radius. In the case of an intra-articular fracture, an arthroscopy may be associated. In the case of a proximal diaphyseal extension of the fracture, a second proximal approach can be added in order to use a longer plate. Relative contraindications are comminuted articular fractures in elderly osteoporotic patients. Functional and radiological results are comparable to those obtained with the extented flexor carpi radialis approach. A conversion of the procedure for a larger incision is always possible in the case of a difficult reduction.

Mini-invasive Osteotomy for Pediatric Distal Radius Malunion

Although most malunions after pediatric distal radius fractures will remodel as the child grows, adolescent patients with severe malunion and limited growth require reduction to restore alignment. The authors technique for a mini-invasive osteotomy is presented. The apex of the malunion is approached from a single 2 cm volar incision through the flexor carpi radialis sheath. Open wedge osteotomy is performed. The osteosynthesis is secured with an individually contoured T-plate. The procedure was used to correct a severe visible malunion in a 12-year-old girl. Normal alignment was achieved with no nerve or tendon injury or irritation, infection, refracture, or any other complication. Mini-invasive osteotomy with a volar plate is a feasible method for experienced hand surgeons for the treatment of distal radius malunion in adolescents.

A 3D printed cast for minimally invasive transfer of distal radius osteotomy: a cadaver study

Purpose

In corrective osteotomy of the distal radius, patient-specific 3D printed surgical guides or optical navigation systems are often used to navigate the surgical saw. The purpose of this cadaver study is to present and evaluate a novel cast-based guiding system to transfer the virtually planned corrective osteotomy of the distal radius.

Methods

We developed a cast-based guiding system composed of a cast featuring two drilling slots as well as an external cutting guide that was used to orient the surgical saw for osteotomy in the preoperatively planned position. The device was tested on five cadaver specimens with different body fat percentages. A repositioning experiment was performed to assess the precision of replacing an arm in the cast. Accuracy and precision of drilling and cutting using the proposed cast-based guiding system were evaluated using the same five cadaver arms. CT imaging was used to quantify the positioning errors in 3D.

Results

For normal-weight cadavers, the resulting total translation and rotation repositioning errors were ± 2 mm and ± 2°. Across the five performed surgeries, the median accuracy and Inter Quartile Ranges (IQR) of pre-operatively planned drilling trajectories were 4.3° (IQR = 2.4°) and 3.1 mm (IQR = 4.9 mm). Median rotational and translational errors in transferring the pre-operatively planned osteotomy plane were and 3.9° (IQR = 4.5°) and 2.6 mm (IQR = 4.2 mm), respectively.

Conclusion

For normal weight arm specimens, navigation of corrective osteotomy via a cast-based guide resulted in transfer errors comparable to those using invasive surgical guides. The promising positioning capabilities justify further investigating whether the method could ultimately be used in a clinical setting, which could especially be of interest when used with less invasive osteosynthesis material.

Minimally invasive anterior plate osteosynthesis of the distal radius: A 710 case-series

INTRODUCTION

Since the 2000s, internal fixation of distal radius fracture by volar locking plate on an extended flexor carpi radialis (FCR) approach has become the gold standard.

OBJECTIVE

The present study aimed to assess medium-term results of minimally invasive plate osteosynthesis (MIPO) in distal radius fracture.

MATERIAL AND METHODS

The series comprised of 710 cases (512 female; mean age, 58 years). The 15mm approach was on the lateral edge of the FCR. The plate was slipped under the pronator quadratus. Closure used intradermal running suture without drain or orthosis.

RESULTS

At a mean 7 months' follow-up, mean scar length was 17mm (range, 10-40mm), pain 1.13/10 (0-8), Quick-DASH 13.28 (0-86.36), and patient-rated wrist evaluation (PRWE) 11.48 (0-91). Compared to contralateral values, mean flexion was 87.23%, extension 88.52%, pronation 96.17%, supination 93.41%, and grip strength 79.68%. Hardware was removed in 45.92% of cases. There were 16 cases of secondary displacement, with 4 revision procedures, one of sepsis at 6 months, 10 of complex regional pain syndrome, and 14 of median nerve paresthesia, with 4 carpal tunnel release procedures.

DISCUSSION

The minimally invasive FCR approach can be used for volar plate fixation of distal radial fracture. It has the advantage of conserving ligamentotaxis, facilitating reduction and improving scar esthetics. The incision can be extended if need be.

LEVEL OF EVIDENCE

III; single-centre retrospective study.

Distal radius fracture malunion in an adolescent patient treated with osteotomy and autologous iliac bone grafting: A case report

RATIONALE

Adolescent wrist trauma can cause epiphyseal dysplasia and even distal radius deformity malunion. At present, there is no uniform treatment standard for the malunion of the distal radius of adolescents. Osteotomy and autologous bone grafting are currently one of the effective ways to treat the disease. We treated an adolescent patient with distal radius deformity malunion, and used this surgical method to treat the patient and achieved satisfactory results.

PATIENT CONCERNS

A 16-year-old boy suffered from a serious distal radius deformity after trauma of the left wrist 8 years ago.

DIAGNOSES

Physical examination, X-rays examination, high-resolution computed tomography scan, and 3-dimensional reconstruction images of the affected limb helped us diagnose the distal radius fracture malunion.

INTERVENTIONS

The fracture malunion was treated by osteotomy and autologous iliac bone grafting.

OUTCOMES

At the 2-year follow-up, wrist flexion returned to 68°, wrist dorsiflexion to 55°, radial deviation to 14°, ulnar deviation to 12°, forearm pronation to 75°, supination to 67°. Grip strength increased to 35.1 kg after 2 years of operation, recovered to 87% of the uninjured side. Quick DASH score at 2-year follow-up was 9. No complication, such as nonunion or infection, was observed.

LESSONS

This rare case provides valuable insights for hand surgeons. High-resolution computed tomography scan and 3-dimensional reconstruction can help us effectively diagnose wrist diseases. Small lesions on the articular surface of the distal radius will change the position and function of the wrist joint, and cause traumatic arthritis of the wrist joint. Therefore, it is very important to reconstruct the normal structure of the distal radius articular surface. Osteotomy and autologous iliac bone grafting are effective treatments for serious distal radius fracture malunion in the adolescent patient. During the operation, care should be taken to protect the osteoepiphysis to avoid bone dysplasia.

Minimally Invasive Plate Osteosynthesis for a Distal Radius Fracture with Forearm Skin Problem

In this study, we performed osteosynthesis for a distal radius fracture using a minimally invasive approach for a patient with skin disorder of the forearm and obtained favorable results. This case report may provide new findings confirming the usefulness of this surgical approach for distal radius fractures. Blister formation on the right forearm was observed in a 53-year-old female who was diagnosed with a distal fracture of the right radius and underwent splinting in a local hospital, and she was referred to our hospital 2 days after the injury. Minimally invasive locking plate osteosynthesis was performed, and there was no skin lesion at this incision site. Postoperatively, there were no complications in soft tissues and the operative scar was almost unrecognizable. We reported volar locking plate osteosynthesis using the minimally invasive approach in a patient with skin disorder of the forearm. Such patients are rarely encountered. However, this minimally invasive approach is extremely useful for utilizing the advantages of volar locking plate fixation without being affected by the soft tissue environment.

Distal radius fracture fixation with a volar locking plate and endoscopic carpal tunnel release using a single 15mm approach: Feasibility study

Distal radius fractures (DRF) may trigger, reveal or decompensate acute carpal tunnel syndrome (CTS) in 0.5-21% of cases. Internal fixation and median nerve release must then be carried out urgently. Less invasive approaches have been described for both the median nerve release using an endoscopic device and for the DRF fixation using a volar locking plate. We assessed the feasibility of DRF fixation and median nerve release through a single, minimally-invasive 15mm approach on a series of 10 cases. We reviewed retrospectively 10 consecutive cases of DRF associated with symptomatic CTS in 8 women and 2 men, aged 57 years on average. CTS was diagnosed clinically. All patients were treated during outpatient surgery with a volar locking plate and endoscopic carpal tunnel release using a single 15mm minimally-invasive approach. In one case, arthroscopic scapholunate repair was also required. Six months after the procedure, all patients were reviewed with a clinical examination and a radiological evaluation. The average values for the clinical and radiological outcomes were as follows: pain on VAS 1.5/10; QuickDASH 14.3/100; flexion 90%; extension 90.6%; pronation 95.6%; supination 87.9%; grip strength 90.1%; 2PD test 5.2mm (4-8mm). Five complications occurred: two cases of temporary dysesthesia in the territory of the median nerve and one case of temporary hypoesthesia of the palmar branch of the median nerve, which had all completely recovered; two cases of complex regional pain syndrome type I, which were still active at 6 months. Despite its methodological weaknesses, our study is the only one to describe the technical feasibility of a single 15mm minimally-invasive approach for both internal fixation using a volar locking plate and endoscopic nerve release, with no serious complications. This technique should be added to the surgical toolbox of minimally-invasive procedures for the hand and wrist.

A novel surgical approach for treating distal radial extraarticular malunion: Oblique osteotomy with buttress plate stabilization

PURPOSE

Distal radial extraarticular malunions are not uncommon. However, requirements of surgical correction depend on multiple conditions. Traditionally, surgical techniques include closing or opening wedge osteotomies. Each has unique advantages and disadvantages. An oblique osteotomy was developed to simplify the revision surgery.

METHODS

Forty-eight consecutive adult patients with 48 malunions were surgically treated. An oblique osteotomy of 45° vertical to the radial longitudinal axis was performed from medio-distally to latero-proximally. Consequently, the osteotomized fragments were compressed with a bone clamp. The proximal part of the distal fragment was pushed backward to correct the dorsal tilt. A 7-hole buttress plate was inserted volarly and cancellous bone graft was packed. Postoperatively, a short-arm splint or brace without restriction of all five metacarpophalangeal joints was applied for 6 weeks.

RESULTS

Forty-one patients were followed for an average of 2.8 years (range, 1.1-5.8 years). All malunions healed within 6 weeks. The union rate was 100% and no complications occurred. Radiographically, ulnar variance, volar tilt of radial articulation, and radial inclination restored to acceptable criteria in all patients. Patients with Modified Mayo Wrist Score (MMWS) improved from 17% to 80% ( p < 0.001) and Disability of Arm, Shoulder and Hand (DASH) Score improved from 0% to 80% ( p < 0.001). The relationship between MMWS and DASH Score was highly correlated (correlation coefficient = -0.90).

CONCLUSION

The described approach may be an excellent alternative for treating distal radial extraarticular malunions. The technique is not difficult but the satisfactory rate is high.

The minimally invasive approach for distal radius fractures and malunions

This article reviews the author's currently used minimal invasive approach for volar plating of distal radius fractures. A single longitudinal incision of 1.5 cm is drawn on the lateral aspect of the flexor carpi radialis tendon in order to insert a plate under the pronator quadratus. With the wrist flexed, the plate is applied on the anterior cortex of the radius to reduce the fracture. This approach offers the advantage of preserving ligamentotaxis, which facilitates the reduction, and the small scar improves the cosmetics. It is mainly indicated for extra-articular and simple intra-articular fractures of the distal radius. Relative contraindications are comminuted articular fractures in elderly osteoporotic patients. Functional and radiological results are comparable with those obtained with an extended flexor carpi radialis approach. My colleagues and I have used it for more than 2000 cases since 2012. This technique requires practise. Attempted conversion to a larger incision is possible in case of difficulty, but this is seldom necessary.

Possibility of Fixation of a Distal Radius Fracture With a Volar Locking Plate Through a 10 mm Approach

The management of distal radius fractures has dramatically improved due to the development of a locking plate system. In addition, mini-invasive surgery has been performed in a lot of surgical fields in recent years. The aim of the present study is to investigate the possibility of fixation of a distal radius fracture with a volar locking plate through a 10 mm approach. Eighteen patients with distal radius fracture (mean age: 66 y; range, 28 to 88 y; 8 males and 10 females) were operated on using a volar locking plate. The incision for plating was always 10 mm long. The clinical, cosmetic, and radiologic outcomes were investigated. At 3 months' follow-up, the range of motion of the wrist joint was 67.5 degrees in flexion, 65.6 degrees in extension, 88.3 degrees in pronation, and 88.3 degrees in supination. The % grip strength compared to the healthy side ranged from 35% to 100%. The VAS, Q-DASH, and modified Mayo scores were 0.7, 8.5, and 93.3, respectively (excellent in all 18 patients). Bone union was achieved on plain x-ray radiography and cosmetic problems were satisfied in all patients. Our results suggest that it is possible to achieve fixation of a distal radius fracture with a volar locking plate through a 10 mm approach. However, its applicability to surgery must be carefully examined. If any difficulties in plate installation or approach occur during this intervention, it will be necessary to consider switching to a conventional approach. We believe that surgeons must not adhere to a mini-invasive approach.

Minimally invasive hardware removal after minimally invasive distal radius plate osteosynthesis (MIPO): Feasibility study in a 388 case series

HYPOTHESIS

The aim of the present study was to assess the technical feasibility of minimally invasive volar plate removal following distal radius fracture.

MATERIAL AND METHODS

Three hundred and eighty-eight plates removed from 387 patients (357 females: mean age, 50 years) were assessed retrospectively. The incision used the primary minimally invasive approach and was closed after plate removal by intradermal continuous suture, without drainage or immobilization.

RESULTS

Mean scar size was 22.2mm preoperatively, and the incision was 19.8mm at start and 21.4mm at end of procedure, these differences being non-significant. The scar was enlarged by accidental skin tear in 13 cases and intentionally by lancet in 11 cases. There were 29 screw-related complications, 1 bone crack without clinical impact, and 1 plate fracture. There were no postoperative complications.

DISCUSSION

The present results demonstrate the feasibility of removing a volar plate on the distal radius via a 20-mm approach. These findings should be confirmed on a future study comparing minimally invasive plate ablation and conventional approaches.