Corrective osteotomy of malunited distal radius fractures

The malunion of the distal radius may result in shortening, radial impaction, volar angulation, dorsal displacement or rotatory deformity. For restoration, the anatomy and kinematics of the distal radioulnar joint and the triangular fibrocartilaginous complex (TFCC) are of importance. This nonunion consists of the articular disk, a meniscus homologue, the ulnar collateral ligament, and the dorsal and palmar radioulnar ligaments. Malunion of the distal radioulnar joint leads to an increase in loading on the individual parts, as well as pain and a decrease in supination and pronation. Osteotomy is indicated if the angulation of the malunion is more than 20 degrees in the frontal or sagittal plane. Corrective osteotomy requires detailed preoperative planning with calculation of the correct position in all planes. The most common operation that has proved to be effective is osteotomy of the radius, insertion of a trapezoidal bone graft in place, and internal fixation with a dorsal or volar plate.     

Dome-shaped osteotomy for distal radius fracture malunions

After having hinted to the various component of the malformity caused by malunions of the distal radius fracture, the various possibilities of correcting this deformity are described. The difficulty to correct all the components of the deformity are considered. Then a Dome-shaped osteotomy of the distal radius is described that allows to correct all the deformities in all the directions as the gliding plane of the osteotomy is spherical. The ulnar plus and the DRUJ alterations are corrected by means of an added Sauvé-Kapandji procedure that guarantees against any painful movement of the DRUJ preserving effective prono-supination.     

Corrective osteotomy for malunited fracture of the glenoid cavity: a case report

Fractures of the glenoid cavity that are substantially displaced are rare. A patient with shoulder pain and dysfunction caused by a severely malunited fracture of the glenoid cavity was treated successfully with corrective osteotomy and bone grafting. Functional results 2 years after surgery were satisfactory, and radiographs showed no evidence of degenerative change. Although appropriate initial management should prevent the development of symptomatic malunion, results of the current study suggest that later reconstruction of the glenoid cavity restores satisfactory function, even if so much time has elapsed that glenoid osteotomy must be done to achieve reduction.     

Outcome after corrective osteotomy for malunited fractures of the distal end of the radius

This retrospective study evaluated the outcome of corrective osteotomy for malunited distal radial fractures and investigated the influence of the radiological result on the clinical outcome. Twenty-nine patients underwent corrective osteotomy for malunited, dorsally tilted fractures of the distal radius and 20 underwent corrective osteotomy for malunited, palmarly angulated distal radial fractures. All were surveyed at an average of 18 months after surgery and assessed for: pain; grip strength; range of motion; radial tilt; radial inclination; and ulnar variance. Postoperative radial tilt, radial inclination and ulnar variance were significantly improved by corrective osteotomy. Patients with no, or only minor residual deformity after corrective osteotomy had significantly better results than those with gross residual deformity.     

Correction of malunited intra-articular distal radius fractures with an inside-out osteotomy technique

PURPOSE: To present an inside-out osteotomy technique under arthroscopic guidance to correct an intra-articular malunion. METHODS: The joint is explored with a 2.7-mm arthroscope through the standard portals without infusing any water. To allow room to introduce the curettes and the osteotomes (4-mm wide), the instrumentation portals are made slightly larger than usual. Malunited fragments are cut with the osteotomes from inside the joint and advanced out. Fragments are mobilized, and granulating tissue and/or new bone is removed with curettes and synoviotomes. After disimpaction and reduction, fixation with plates or screws via the appropriate open approach is performed under arthroscopic control. No water is used throughout the procedure except at the end of the surgery to clear out debris. RESULTS: Steps were corrected to 0 mm in all patients. Gaps of less than 1 mm were common. CONCLUSIONS: This procedure allows us to define each cartilage-containing fragment and to re-create the original articular fracture line without the fear of creating new fracture lines on the articular surface. This technique can be used for patients with irregularly defined fragments that are not amenable to classic techniques. The key to the procedure is to perform the arthroscopic exploration without water infusion (dry technique).     

An assessment of the results of corrective osteotomy for malunited fractures of the distal radius

INTRODUCTION: Malunion is the most common and serious complications after fracture of the distal radius. Alterations of the normal biomechanics affect function of the wrist, which is associated with pain, disability and, in longer perspective, with arthrosis. Reestablishment of the normal anatomic relationships by corrective osteotomy is one of the most effective ways to prevent this scenario. PATIENTS AND METHODS: Twenty-five consecutive patients, 19 women and 6 men with the mean age of 50 years with malunited fractures of the distal radius underwent corrective osteotomy. Operations were performed at mean of 8 months after precipitated fracture and indications included pain, reduction of wrist movement, loss of grip strength and wrist deformity. Regarding to direction of the dislocation, operations were done through a dorsal (20 patients) or volar (5 patients) approach, post-osteotomy defect in the distal radius was flied with cancellous bone graft form the iliac crest in 20 patients or allogenous bone graft in 5 patients and bone fixation was done with K-wires In 18 patients or with T-plate in 7 patients. The results were assessed at mean of 2 years with two standardized questionnaires: Gartland-Werley and DASH. RESULTS: The average pre-operative DASH score was of 115 points (range 76-132) indicated severe disability of the hand. At the last follow-up assessment it decreased to a mean of 47 points (range 30-100) indicating statistically significant improvement the hand function. In Gartland-Werley scale, 9 patients (36%) achieved excellent, 11 (44%) good, 3 (12%) fair and 2 patients (8%) poor result. Two cases of poor results were caused by complications. Failure of the K-wires bone fixation with concomitant infection caused dislocation of the bone graft and collapse of the distal radius. In the second case, an allogenous bone graft did not heal, but disintegrated, what resulted in the total deformation of the distal radius.     

Radial osteotomy and Bowers arthroplasty for malunited fractures of the distal end of the radius

Radial osteotomy and hemiresection arthroplasty was performed in fifteen patients who had malunion of a fracture of the distal end of the radius with symptoms predominantly in the radio-ulnar joint and limited rotation of the forearm. Postoperatively, all of the patients had improved rotation and stability of the distal radio-ulnar joint, as well as satisfactory relief of pain. Over-all, grip strength increased an average of 30 per cent, and every patient had substantial improvement in function. The result was very good in four patients, good in eight, and fair in three.     

The importance of the distal radioulnar joint for reconstructive procedures in the malunited distal radius fracture

Clinically most patients complain about ulnar sided wrist pain and limited forearm rotation following malunited distal radius fractures. Possible bony reasons consist of intraarticular incongruency, malalignment of the sigmoid notch of the distal radius or the ulna-plus-situation at the wrist level. A persisting luxation of the distal radioulnar joint (DRUJ) will present itself with complete loss of forearm rotation. The ligamentous or bony detachment of the triangular fibrocartilage complex (TFCC) will lead to instability of the DRUJ. Uncorrected, each of these components will lead to arthrosis of the DRUJ. The presence of arthrosis only allows salvage procedures for the DRUJ and will lead to functional loss. Reconstructive options consist of radius correction osteotomy, ulnar shortening osteotomy, reposition of a luxation and refixation of the TFCC. To chose the necessary reconstructive procedure, the individual pathological situation has to be analysed.     

Corrective osteotomy for malunited intra-articular fracture of the distal radius using a custom-made surgical guide based on three-dimensional computer simulation: case report

We report a case of malunited intra-articular fracture of the distal radius successfully treated with corrective osteotomy through an extra-articular approach using a custom-made surgical guide that was designed based on preoperative three-dimensional computer simulation.     

Locking plates for corrective osteotomy of malunited dorsally tilted distal radial fractures: a biomechanical study

The purpose of the study was to compare the biomechanical properties of five different palmar fixation plate designs in a distal radius osteotomy cadaver model. A 1cm metaphyseal osteotomy gap was made to simulate a corrective osteotomy and the osteotomy plated. Axial load was applied to the distal end of each construct by a material testing machine under control of a motion analysis video system. The specimens were arranged into five implant groups of eight specimens each. No test group developed deformity and movement of the fracture gap greater than 2mm with a load of 100N. Increasing the load to 250N revealed statistically significant differences in stiffness and failure load between the different plates. Axial failure strength and stiffness were greater for the radial correction plates than for the other implants. The former may provide enough stability for corrective osteotomy of dorsally angulated distal radial malunions, even when the osteotomy gap is only filled with cancellous bone graft instead of cortical bone graft.     

桡骨远端骨折畸形愈合的截骨矫正:利用骨膜瓣减少术后植骨吸收

桡骨远端骨折畸形愈合后,临床常用截骨术进行矫正,但术后植骨块吸收、短缩等并发症影响矫形效果及功能恢复.为此,克罗地亚萨格勒布大学的Kovianic等提出,应用近端蒂骨膜瓣包绕植骨块的改良截骨矫形法,期望能减少植骨块的吸收以提高功能,恢复效果.     

Corrective osteotomy of the malunited distal radius fracture: use of periosteal bed may reduce the extent of postoperative graft resorption

The aim of this study was to compare osteotomy for malunited distal radius fracture with embedment of a corticospongious graft into a periosteal flap of the recipient bone (test) with the standard procedure (control) with respect to graft resorption. A retrospective assessor-blind analysis of consecutive patients (test: n = 19, control: n = 30) was performed. Ulnar tilt, palmar tilt and capitate-ulna distance were assessed from radiographs taken before, two to four days after and over three months after the surgery to determine loss of correction achieved by the surgery and estimate graft resorption during the postoperative period. In both unadjusted and adjusted comparisons, loss of correction of all parameters was lower in the test group (P < 0.05). The odds of “none to mild” resorption were greater in the test group with an adjusted odds ratio of 5.43 (95% confidence interval: 1.32–26.5, P = 0.025). Total graft collapse occurred in five of 30 controls and in none of 19 test patients. Graft embedment into the periosteum may improve its preservation.     

循原骨折线截骨矫正跟骨骨折畸形愈合

目的 探讨循原骨折线截骨矫正跟骨骨折畸形愈合方法的可行性.方法 2004年8月至2007年5月,跟骨骨折畸形愈合患者25例28足,男23例26足,女2例2足;年龄22～56岁,平均31岁;受伤至手术时间1.5～12个月,平均4.6个月.采用循原骨折线截骨术进行治疗.按照Zwipp和Rammelt跟骨骨折畸形愈合的分类方法进行分类,其中Ⅲ型11例12足,Ⅳ型14例16足.术前均摄双足跟骨侧位、轴位X线片及行CT检查,12例患者(14足)行三维CT重建.根据Sander及Essex-Lopresti分类,参考原始X线片对不同骨折类型制定截骨线,重现原始骨折.根据CT轴位载距突及外侧骨块所带关节面的宽度和轴位骨折线的斜度从前外上到后内下斜行截骨,恢复跟骨的高度,将后关节骨折块向后上撬起,使塌陷的后关节面骨块复位.骨缺损处,用劈下的跟骨外侧壁填塞植骨,或取自体髂骨植骨,最后用钢板螺钉固定.结果 24例26足获得随访,随访时间10～16个月,平均12个月.骨折愈合时间10～14周,平均12周.2例发生伤口感染,经抗生素治疗后10周取出钢板伤口愈合.无一例发生钢板螺钉断裂和骨折再移位.按照Maryland足部评分标准,优10足,良12足,可4足,优良率84%.结论 循原骨折线截骨重现原始骨折,可恢复跟骨的骨性结构,能更好地矫正跟骨各方位畸形,同时保留距下关节,减少了手术对足踝功能的影响,近期疗效满意.     

Percutaneous bridge plating of extra-articular distal fibular fracture for the management of distal tibia type III open fracture

PurposeThe aim of this study is to conduct clinical and radiographic evaluations of the use of percutaneous bridge plating for distal fibular fractures combined with distal tibia type III open fractures.MethodsThirty-four patients with acute distal third fibular shaft fractures (4F2A_(c) and 4F2B_(c) according to the AO/OTA classification) combined with distal tibia type III open fractures were enrolled. Concurrent fibular fractures were fixed with the percutaneous bridge plating simultaneously, while distal tibia open fractures were temporally stabilized with a spanning external fixator. Clinical and radiographic outcomes were evaluated using the Lower Extremity Functional Scale (LEFS), the proportional length difference of the fibula, the talocrural angle, the union rate of the fibula and tibia, the operation time, and complications at the final follow-up.ResultsAll fibular fractures healed with an average bone healing time of 20.7 ± 6.3 weeks (range, 16–35). The mean proportional length difference was 0.492 ± 0.732% compared with that in the uninjured fibula. The functional assessment result according to the LEFS was 74.0 ± 3.70 points (range, 57–80). No cases of fibula fracture infection developed throughout the follow-up period in any of the patients. Iatrogenic postoperative superficial peroneal nerve injury was not found in any of the patients.ConclusionWith the perspective of minimizing soft tissue problems due to high-energy trauma, the application of percutaneous bridge plating for the treatment of distal fibular fractures can be an alternative to conventional treatment methods.