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

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.

Surgical Technique of Corrective Osteotomy for Malunited Distal Radius Fracture Using the Computer-Simulated Patient Matched Instrument

The conventional corrective osteotomy for malunited distal radius fracture that employs dorsal approach and insertion of a trapezoidal bone graft does not always lead to precise correction or result in a satisfactory surgical outcome. Corrective osteotomy using a volar locking plate has recently become an alternative technique. In addition, the use of patient-matched instrument (PMI) via computed tomography simulation has been developed and is expected to simplify surgical procedures and improve surgical precision. The use of PMI makes it possible to accurately position screw holes prior to the osteotomy and simultaneously perform the correction and place the volar locking plate once the osteotomy is completed. The bone graft does not necessarily require a precise block form, and the problem of the extensor tendon contacting the dorsal plate is avoided. Although PMI placement and soft tissue release technique require some degree of specialized skill, they comprise a very useful surgical procedure. On the other hand, because patients with osteoporosis are at risk of peri-implant fracture, tandem ulnar shortening surgery should be considered to avoid excessive lengthening of the radius.

[Are there any indications for surgery of distal radius malunion in elderly patients?]

Malunions of the distal radius are associated most of the time with disturbances of the distal radioulnar (DRU) joint. While a corrective osteotomy of the distal radius is a well-known procedure in younger patients, manual workers and active patients, is it justified in independent elderly patients above 70 years of age? These techniques improve function, reorient the articular surfaces, protect against complications such as degenerative osteoarthritis and stiffness of the wrist, and they improve DRU balance. Osteotomies performed with bone or artificial grafts have comparable outcomes. Either a volar or dorsal approach can be used depending on the orientation of the carpal articular surface of the radius and the need to lengthen the radius. If the patient is active and independent, the clinical benefit is higher when an osteotomy is done for significant malunions; urgent treatment of these older patients brings about additional costs and unclear benefits.

Variable-angle locking plate with or without double-tiered subchondral support procedure in the treatment of intra-articular distal radius fracture

Background

Double-tiered subchondral support (DSS) procedure is two-row fixation in which proximal screws support the dorsal subchondral bone, whereas distal screws support the volar central subchondral bone, using the volar variable-angle locking plate to achieve better anatomical reduction. We examined whether DSS improves clinical outcome, complication rate, and loss of correction for dorsally displaced Arbeitsgemeinschaft für Osteosynthesefragen (AO) type C3 distal radius fractures.

Materials and methods

We reviewed dorsally displaced intra-articular AO C3-type distal radius fractures treated at our institutions with a variable-angle volar locking plate. We assessed 49 patients (27 DSS; 22 non-DSS) treated with volar locking plates, with a mean age of 59.9 years and average follow-up of 20.2 months (range 12–56 months). We evaluated differences in functional outcome, complication rates, and loss of correction between groups using radiographic parameters.

Result

There were no differences in clinical outcome and complications. Final volar tilt and ulnar variance were better maintained in the DSS group (P = 0.01 and 0.03). Change in volar tilt of the non-DSS group was more than that of the DSS group (P = 0.00).

Conclusion

Though there were no significant differences in clinical outcomes, we identified a significant reduction in final volar tilt, ulnar variance, and change in volar tilt. DSS procedure is useful to avoid correction loss when treating unstable C3 distal radius fractures and thus would reduce posttraumatic arthrosis.

Level of evidence

Level IV.

Opening wedge osteotomy for distal radius malunion: dorsal or palmar approach?

Background There are various technical variations to consider when performing a corrective osteotomy of a distal radius malunion. We chose two of the more commonly reported techniques and compared the results of volar (palmar) osteotomy and fixation with dorsal osteotomy and fixation. Method Within a continuous cohort of patients who had undergone corrective osteotomy for a malunited Colles fracture, two groups could be identified retrospectively. In 8 patients a dorsal approach was used. A structural trapezoidal graft, subtending the amount of correction, was inserted into the osteotomy gap and stabilization was performed with a thin round-hole mini-fragment plate. In 14 patients a palmar approach and a palmar fixed-angle plate was used for correction of the malunion and for angular stable rigid fixation of the two fragments. The osteotomy gap was loosely filled with nonstructural cancellous bone chips. A retrospective comparison of the two groups was performed to see whether the outcome was affected by the use of either operative technique.The demographics, the preoperative amount of deformity, range of motion, pain, and force were comparable for both groups. All osteotomies healed without loss of correction. After a minimal follow-up of one year, radiographic appearance, objective functional parameters were assessed and subjective data (Disabilities of the Arm, Shoulder, and Hand [DASH] score and special pain and function questionnaire) obtained. Results These data did not show statistical difference for the two groups except for the amount of final wrist flexion. This parameter was significantly better in patients who had palmar approaches and fixed-angle plates. Conclusion Corrective osteotomies of distal radius malunions can be done in either way. It might result in some better flexion, if performed volarly.

Three-dimensional deformity analysis of malunited distal radius fractures and their influence on wrist and forearm motion

Little information exists about three-dimensional (3-D) deformity patterns of malunited distal radius fractures including axial deformity. The current study aimed to clarify the 3-D deformity pattern of malunited distal radius fractures and reveal the influence of osseous deformities, including axial rotation deformity, on wrist and forearm motion. The deformity of 20 dorsally tilted malunions were evaluated using 3-D computer models created from CT data, and correlations between deformity components and range of motion were assessed. The 3-D deformity analysis showed that axial malalignment in pronation, which showed a correlation with the degree of radial tilt deformity, was very common. A radial tilt deformity of > 5° was observed in only 45% of cases. Although the range of wrist flexion and extension showed a correlation with dorsal tilt deformity, the range of forearm pronation and supination did not correlate with distal radius deformities.

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.

Distal radius osteotomy with volar locking plates based on computer simulation

BACKGROUND

Corrective osteotomy using dorsal plates and structural bone graft usually has been used for treating symptomatic distal radius malunions. However, the procedure is technically demanding and requires an extensive dorsal approach. Residual deformity is a relatively frequent complication of this technique.

QUESTIONS/PURPOSES

We evaluated the clinical applicability of a three-dimensional osteotomy using computer-aided design and manufacturing techniques with volar locking plates for distal radius malunions.

PATIENTS AND METHODS

Ten patients with metaphyseal radius malunions were treated. Corrective osteotomy was simulated with the help of three-dimensional bone surface models created using CT data. We simulated the most appropriate screw holes in the deformed radius using computer-aided design data of a locking plate. During surgery, using a custom-made surgical template, we predrilled the screw holes as simulated. After osteotomy, plate fixation using predrilled screw holes enabled automatic reduction of the distal radial fragment. Autogenous iliac cancellous bone was grafted after plate fixation.

RESULTS

The median volar tilt, radial inclination, and ulnar variance improved from -20°, 13°, and 6 mm, respectively, before surgery to 12°, 24°, and 1 mm, respectively, after surgery. The median wrist flexion improved from 33° before surgery to 60° after surgery. The median wrist extension was 70° before surgery and 65° after surgery. All patients experienced wrist pain before surgery, which disappeared or decreased after surgery.

CONCLUSIONS

Surgeons can operate precisely and easily using this advanced technique. It is a new treatment option for malunion of distal radius fractures.