Ulnar shortening osteotomy for distal radius malunion

Distal radius malunion: outcomes following an ulnar shortening osteotomy

PURPOSE

Positive ulnar variance following a distal radius malunion can lead to ulnar-sided wrist pain, loss of grip strength, and distal radioulnar joint impingement. The primary aim of this study is to describe upper limb-specific functional outcomes following ulnar shortening osteotomy (USO) for ulnar-sided wrist pain associated with malunion of the distal radius.

METHODS

We retrospectively identified 40 adult patients from a single centre over a 9-year period that had undergone an USO for symptomatic malunion of the distal radius. The primary outcome was the patient-rated wrist evaluation (PRWE). Secondary outcomes were the QuickDASH, EQ-5D-5L, complications, and net promoter score (NPS).

RESULTS

Outcomes were available for 37 patients (93%). The mean age was 56 years and 25 patients were female (68%). At a mean follow-up of 6 years (range 1-10 years) the median PRWE was 11 (IQR 0-29.5), the median QuickDASH 6.8 (IQR 0-29.5), and the median EQ-5D-5L index was 0.88 (IQR 0.71-1). The NPS was 73. Complications occurred in nine patients (24%) and included non-union (n = 4), early loss of fixation requiring revision surgery (n = 1), superficial wound infection (n = 2), neurological injury (n = 1), and further surgery for symptomatic hardware removal (n = 1).

CONCLUSIONS

For patients with a symptomatic distal radius malunion where the predominant deformity is ulnar positive variance, this study has demonstrated that despite 1 in 4 patients experiencing a complication, USO can result in excellent patient reported outcomes with high levels of satisfaction.

LEVEL OF EVIDENCE

III (Cohort Study).

Comparing radial lengthening osteotomy with ulnar shortening osteotomy to treat ulnar impaction syndrome after distal radius fracture malunion

INTRODUCTION

Distal radius mal-unions often cause radius shortening and ulnar impaction syndrome. The modern treatments of ulnar impaction syndrome following distal radius mal-union are ulnar shortening osteotomy (USO) and distal radius lengthening osteotomy (DRLO). However, there are few studies to compare long-term outcomes of these two treatments. This study compares isolated USO to DRLO for the treatment of ulnar impaction syndrome following distal radius mal-union.

MATERIALS AND METHODS

We retrospectively reviewed 68 patients with extra-articular distal radius mal-unions treated by isolated USO in 36 patients and DRLO in 32 patients. Pain visual analog scale (VAS), wrist motion, grip strength, radiographic parameters including sigmoid inclination, DASH score, and perioperative complications were analyzed. Mean follow-up was 62.6 months.

RESULTS

The postoperative VAS scores for pain on exertion were less in the DRLO group than the USO group (1.2 vs. 2.8, p = 0.02). The DASH scores were 16.7 and 29.8 in the DRLO and USO groups, respectively (p = 0.02). The reduction of pain and improvement of function showed significantly better in the DRLO group. The mean operative time was shorter in the USO group. Most of the sigmoid inclinations were changed in DRLO. There were two re-operations following USO for painful nonunion and two patients had subsequent DRUJ osteoarthritis at the last follow-up.

CONCLUSION

Although both treatments improved range of motion, grip strength, and VAS for pain, DRLO was found in better reduction of pain and improvement of function. USO is a simpler procedure with a shorter operative time but it has an increased potential to cause subsequent osteoarthritis of the DRUJ as its incongruity of DRUJ after USO especially in reverted inclination. DRLO can be a preferred method for treating USWP in relevant distal radial mal-union.

Extra-articular Corrective Osteotomy With Bone Grafting to Achieve Lengthening and Regain Alignment for Distal Radius Fracture Malunion

Surgical correction of the distal radius fracture malunion is challenging because of the 3-dimensional deformity. We propose a method by using the Kapandji intrafocal pinning in corrective osteotomy for treatment of the distal radius fracture malunion to facilitate the alignment correction while using the bone graft to restore the radial length. The surgery was started with the osteotomy from a volar approach, and the osteotomy gap was expanded gradually. Then, allobone grafting was performed to maintain the corrected radial length. We used the Kapandji intrafocal pinning dorsally to provide dorsal supporting force and radially to correct the radial inclination. Finally, a volar plate was used to buttress and push the distal fragment to fit as to regain the correct volar tilt. We enrolled 10 patients of distal radius fracture malunion with a mean age of 59.3 years. All patients had bone healing within 3 months after surgery. The mean lengthened distance was 5 mm. The radial inclination and volar tilt could be corrected with improved functional results.

Ulnar Shortening Versus Distal Radius Corrective Osteotomy in the Management of Ulnar Impaction After Distal Radius Malunion

BACKGROUND

Distal radius malunions lead to functional deficits. This study compares isolated ulnar shortening osteotomy (USO) to distal radius osteotomy (DRO) for the treatment of ulnar impaction syndrome following distal radius malunion.

METHODS

We retrospectively reviewed 11 patients with extra-articular distal radius malunions treated for ulnar impaction with isolated USO. This group was compared to a 1:1 age- and sex-matched cohort treated with isolated DRO for the same indication. Pain visual analog scale (VAS), wrist motion, grip strength, radiographic parameters, and perioperative complications were analyzed. Mean follow-up was 14.8 months.

RESULTS

VAS scores improved. Wrist range of motion improved in both cohorts with the exception of radial deviation, pronation, and supination in the USO cohort, which decreased from a mean of 17°-16°, 67°-57°, and 54°-52°, respectively. There was no significant difference between groups in regard to change in pain or range of motion, with the exception of pronation and ulnar deviation. The mean tourniquet time was shorter in the USO group. The final ulnar variance was 1.8 mm negative in the USO group and 1.1 mm positive in the DRO group. There was 1 reoperation following USO for painful nonunion, while there were 2 reoperations following DRO for persistent ulnar impaction.

CONCLUSIONS

An improvement in range of motion, grip strength, and VAS with restoration of the radioulnar length relationship was observed in both cohorts. USO is a simpler procedure with a shorter tourniquet time that can be an attractive alternative to DRO for ulnar impaction syndrome after distal radius malunions.

Can Total Wrist Arthroplasty Be an Option for Treatment of Highly Comminuted Distal Radius Fracture in Selected Patients? Preliminary Experience with Two Cases

We present two case reports of successful primary shortening of the forearm and total wrist arthroplasty (TWA) using the new angle-stable Maestro Wrist Reconstructive System (WRS) for treatment of highly comminuted distal radius fracture in selected autonomous patients. In a 56-year-old male patient with adequate bone stock, insertion of the noncemented Maestro WRS was combined with ulnar shortening osteotomy. In an 84-year-old female patient with poor osteoporotic bone stock, insertion of the radial cemented Maestro WRS was combined with ulnar head resection. Both patients could resume their work without additional surgery after TWA. At the 1-year follow-up, there were no changes in position of either implant without signs of loosening, no impingement, and no instability of the distal radioulnar joint or the distal ulna stump. All clinical parameters (DASH score, pain through VAS, and grip strength) were satisfactory. Both patients reported that they would have the same procedure again. Further experience is needed to validate this concept.