Treatment of distal radius malunions with an intramedullary nail

Intramedullary nailing and plating osteosynthesis in the correction of post-traumatic deformity in late-diagnosed distal radius fractures: a retrospective comparison study

BACKGROUND

Various surgical modalities are available for correction of deformity in late-diagnosed distal radius fractures. This study compared surgical outcomes between intramedullary nailing and plating osteosynthesis in open-wedge osteotomy.

METHODS

We retrospectively reviewed 47 unilateral distal radius fractures that underwent open-wedge osteotomy at more than 4 weeks after injury between 2006 and 2011. A locally resected exuberant callus was used as the bone graft. Two types of fixation were used: intramedullary nail in 22 patients (group A) and locking plate in 25 patients (group B). Radiographic analysis including radial height, radial inclination, and volar tilt were performed preoperatively and 2-year postoperatively. The Modified Mayo Wrist Score (MMWS) was used for functional evaluation and a 10-point visual analog scale (VAS) for residual pain assessment. Patient satisfaction was self-reported as a 5-point scale. Radiographic data, functional outcomes, and surgical complications were compared between the two groups.

RESULTS

All fractures achieved bone union without major complications. The MMWS averaged 84.8 ± 9.7 in group A and 85.2 ± 8.4 in group B, without significant differences (p = 0.436). Instead, significant differences were found in mean wrist flexion (73.6 ± 7.9 vs. 69.6 ± 7.8 degrees; p = 0.042), patient satisfaction (3.6 ± 1.1 vs. 2.9 ± 1.2; p = 0.034), postoperative radial height (11.6 ± 2.6 vs. 10.2 ± 3 mm; p = 0.039) and inclination (20.8 ± 2.8 vs. 17.7 ± 4.1 degrees; p = 0.004), and implant-related complications (9% vs. 36%; p = 0.03). There were no significant differences in other assessment items including postoperative grip strength, pain scale, supination/pronation/extension, volar tilt, correction angles of all three parameters, and general complication rate. Four patients in group A (18%) and 2 in group B (8%) experienced postoperative paresthesia of the surgical hand; no significant difference was noted. All except one patient in group B had full recovery of neurological symptoms.

CONCLUSIONS

Open-wedge osteotomy with either an intramedullary nail or locking plate fixation yielded encouraging radiographic and functional outcomes. Intramedullary nail fixation may facilitate restoration of radial height and inclination with better wrist flexion, less implant-related complications, and greater patient satisfaction.

Complications of Intramedullary Fixation for Distal Radius Fractures in Elderly Patients: A Retrospective Analysis Using McKay's Complication Checklist

BACKGROUND

Intramedullary fixation for distal radius fractures is reported to be free of hardware irritation and less invasive than other fixation methods. Some specific complications associated with intramedullary fixation, such as radial nerve sensory neuritis, have been reported, but no study has focused on the complication rates of intramedullary fixation for distal radius fractures in the elderly population. Furthermore, no studies have analyzed common complications, such as carpal tunnel syndrome and flexor tenosynovitis including trigger finger, among patients with distal radius fractures treated by intramedullary fixation based on a comprehensive complication checklist.

METHODS

We reviewed the medical records of 52 elderly patients with distal radius fractures treated with intramedullary nail fixation. We investigated the postoperative complications in these patients using McKay's complication checklist.

RESULTS

5 patients experienced radial nerve sensory disorder, and one patients developed carpal tunnel syndrome. All neurological symptoms resolved spontaneously, and these neurological complications were categorized as mild. Further, 3 patients developed trigger finger at the A1 pulley and needed triamcinolone injections for symptomatic relief. There were no tendinous complications around the implanted hardware. All tendinous complications were categorized as moderate complications and resolved with steroid injection therapy. Among skeletal complications, 1 case of postoperative volar displacement resolved with good functional outcome without the need for corrective osteotomy. This was considered a mild complication. The total complication rate was 19.2%. All complications were categorized as mild or moderate, and no patients experienced severe complications that needed further surgery such as hardware removal.

CONCLUSIONS

Intramedullary fixation for distal radius fractures was free from tendinous complications such as tenosynovitis and tendon ruptures around the implant, which are frequently caused by volar locking plate fixation. However, this less invasive technique could not avoid common complications such as trigger finger and carpal tunnel syndrome associated with distal radius fractures.

A less invasive distal osteotomy of the radius for malunited dorsally displaced extra-articular fractures

A less invasive corrective osteotomy for symptomatic post-traumatic deformity of the distal radius was done in 12 patients. They were followed up for an average of 3.7 years. The indications for correction were based on the patients' level of activities, pain, functional limitations, loss of grip strength or deformity occurring with an extra-articular rotational malunion of the distal end of the radius. The procedure included a dorsal open wedge osteotomy through a dorsal incision in which the fulcrum of rotation, or hinge, was located at the palmar cortex, and stabilized with an extra- and intramedullary fixed angle device. The bone defect was replaced with autologous morsellized iliac bone graft. The final outcome was graded as very good in eight patients, good in two and fair in two. Level of evidence: IV.

Distal radius osteotomy with intramedullary fixation for the treatment of Kienbock disease

Symptomatic Kienbock disease with ulnar-negative variance is commonly treated with a distal radius shortening osteotomy. Traditionally, the osteotomy is stabilized using dorsal or volar plating. Use of an intramedullary implant to stabilize the osteotomy in the treatment of this condition is demonstrated in this article. In addition to changing the mechanical loading through the lunate, the technique also allows for core decompression the distal radial metaphyseal bone that may further help in restoring the vascularity to the lunate. The authors believe that this technique is a valuable method that demonstrates both clinical and technical improvements in the treatment of Kienbock disease.

Intramedullary fixation of distal radius fractures

Intramedullary fixation is the latest in a variety of techniques that have been developed to manage distal radius fractures. Intramedullary nailing of these fractures combines the soft-tissue advantages of a less invasive surgical approach with the biomechanical advantages of locking screw technology. These features may enable an accelerated postoperative rehabilitation and quicker return to function. Disadvantages associated with the intramedullary technique include the necessity of a closed or percutaneous reduction and the inability of the implant to adequately stabilize intraarticular or highly comminuted fractures. Consequently, intramedullary implants are primarily indicated for fixation of extra-articular or simple intraarticular split patterns and should not be employed for management of volar or dorsal shear fractures. Preliminary clinical data is emerging in the form of short-term follow-up studies with limited numbers of study participants.

Treatment of extra-articular distal radial malunions with an intramedullary implant

PURPOSE

Malunited distal radius fractures pose considerable problems, especially for young, active individuals. Surgical correction with osteotomy, bone grafting, and internal fixation with plates and screws has been the treatment of choice. Locked intramedullary fixation is an alternative technique to provide bony stability while minimizing soft tissue irritation in the management of acute distal radius fractures, with acceptable clinical results. The purpose of this study was to describe our experience with the use of an intramedullary device combined with grafting to repair distal radial malunions. This fixation device is inserted through the radial styloid and obtains distal fixation with 3 fixed-angle locking screws.

METHODS

Thirteen patients underwent distal radius malunion repair with an intramedullary implant and grafting. There were 6 male and 7 female participants with an average age of 51 years (range, 18-72 y). Patients were evaluated at an average follow-up of 24 months (range, 13-38 mo). Clinical outcome was measured by range of motion of the wrist and forearm, and grip strength, and by using the Disabilities of the Arm, Shoulder, and Hand questionnaire. We analyzed radiographs to determine time to union and adequacy of correction.

RESULTS

All of the malunions healed, with an average time to healing of 11 weeks. Patients' average range of motion at follow-up was 56 degrees of flexion, 66 degrees extension, 85 degrees pronation, and 84 degrees supination. Mean grip strength was 83% of the unaffected side, and the average Disabilities of the Arm, Shoulder, and Hand score was 21. Radiographs taken on the latest follow-up showed correction to the following average parameters: 20.6 degrees radial inclination, 11.0 mm radial height, +1.0 mm ulnar variance, and 2.1 degrees volar tilt.

CONCLUSIONS

The technique presented in this report demonstrates the effectiveness of an intramedullary nail combined with bone graft or graft substitute in repairing malunited fractures of the distal radius. The results show reliable correction of the deformity and good functional outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Biomechanical comparison of dorsal nail plate versus screw and K-wire construct for extra-articular distal radius fractures in a cadaver bone model

PURPOSE

The purpose of the study was to compare the biomechanical stability of distal radius fracture fixation with 2 new implants, the DNP (Hand Innovations LLC, Miami, FL), a dorsal locked hybrid of nail and plate, and the XSCREW (Zimmer, Freiburg, Germany), an implant combining a cannulated screw and K-wires, in a cadaver bone distal radius fracture model.

METHODS

Eight pairs of fresh-frozen cadaver radii were used. To simulate an extra-articular distal radius fracture, a 5-mm volar open wedge osteotomy was made. Axial loads of 10 to 100 N and torque loads of -1.5 to 1.5 Nm were applied by a testing machine to the intact radii and to the radii after each device was fixed as recommended by the manufacturer. One thousand cycles in torque and failure tests were performed.

RESULTS

With a median of 136.0 N/mm, the axial stiffness of XSCREW-fixed specimens was higher than that of DNP-fixed specimens, with a median of 69.5 N/mm, but differences were not statistically significant. With a median of 0.163 Nm/ degrees , the torque stiffness of XSCREW-fixed specimens was significantly higher than that of DNP-fixed specimens, with a median of 0.068 Nm/ degrees . The XSCREW-group reached 33% of the axial stiffness and 49% of the torque stiffness of the intact radii, and the DNP-group reached 14% of the axial stiffness and 20% of the torque stiffness of the intact radii.

CONCLUSIONS

In this human cadaver bone biomechanical study, the XSCREW provided more stability than the DNP in torque stiffness but not in axial stiffness.