Surgical management of posttraumatic distal radial growth arrest in adolescents

Thirty adolescents underwent surgery for progressive deformity after posttraumatic distal radial growth arrest at the average age of 14.8 years. Patients underwent ulnar epiphysiodesis (n = 11), ulnar-shortening osteotomy (n = 18), radial osteotomy (n = 7), and combined radial and ulnar epiphysiodesis (n = 3) procedures. A modification of the Mayo Wrist Score (maximum 100) was used to assess functional outcome at an average follow-up of 21 months. Average wrist scores in 24 symptomatic patients improved from 82 to 98 after surgical treatment. All six asymptomatic patients maintained scores of 100. Of 18 patients who underwent ulnar shortening, average ulnar variance was corrected from 4.5-mm positive to neutral. Complications included one case of radial osteotomy displacement and two cases of continued ulnar overgrowth. Surgery for posttraumatic distal radial growth arrest can improve pain and loss of motion in symptomatic adolescents and prevent symptoms in asymptomatic patients with progressive deformity.     

Volar ligament release and distal radius dome osteotomy for correction of Madelung's deformity

PURPOSE: Madelung's deformity is usually recognized near the completion of skeletal growth and corrective osteotomy of the radius is frequently performed to treat the deformity and reduce pain. This study reviewed the clinical and radiographic results of a volar approach, ligament release, and dome osteotomy technique for treatment of this deformity. METHODS: Between 1990 and 2000, 26 wrists in 18 patients were treated with a volar ligament release and dome osteotomy of the distal radius. The average age of the patients at the time of surgery was 13 years. All patients were available for review at an average of 23 months after surgery. Radiographs before surgery and at final follow-up evaluation were analyzed for the extent of correction. RESULTS: All patients treated with this corrective osteotomy reported a reduction in pain and improved appearance. Patients showed improvements in forearm supination and wrist extension, with no loss of pronation or flexion. Improvements in the radiographic parameters of radial inclination and lunate subsidence also were observed. Four wrists required concurrent ulnar-sided surgery, and 3 additional wrists required staged ulnar shortening. One patient required a Darrach resection 3 years after the index procedure. CONCLUSIONS: The results of volar dome osteotomy provide improved range of motion, improved appearance, radiographic correction, and pain relief while preserving soft-tissue support for radial rotation around the distal ulna. Long-term follow-up evaluation is ongoing.     

Corrective osteotomy for symptomatic increased ulnar tilt of the distal end of the radius

Twelve wrists in 10 patients with a mean age of 23.6 years were treated for symptomatic increased ulnar inclination of the joint surface with corrective osteotomy of the radius. Diagnoses included mild ulnar dysplasia, posttraumatic deformity, Madelung's disease, and multiple hereditary exostosis. All patients had radial-sided wrist pain and an ulnarly displaced arc of radioulnar deviation. Preoperative radiographs showed excessive ulnar inclination of the distal radius, ulnar carpal translation, adaptive carpal malalignment, and frequent distal radioulnar joint incongruency. The patients had decreased pain and improved wrist function at a mean of 5.1 years (range, 2-10 years) after surgery. Average radial deviation changed from 3 degrees to 16 degrees and ulnar deviation from 48 degrees to 29 degrees; flexion/extension and pronosupination remained unchanged. Realignment of the wrist was shown radiographically by a change of ulnar inclination of the radius from 33 degrees to 21 degrees, an increase in scaphoid height from 16.4 to 20.4 mm, and reversal of ulnar carpal translation as shown by an increase in lunate-covering ratio of 64% to 77%. Reduction of the ulnar inclination to normal values by corrective radial osteotomy restores a more physiologic range of motion, decreases symptomatic wrist pain, reverts adaptive carpal changes to normal, increases lunate coverage, and may prevent abnormal cartilage overload in the ulnar compartment of the wrist.     

Ulnar shortening osteotomy with a premounted sliding-hole plate

BACKGROUND: Ulnar shortening osteotomy represents a common procedure for various ulnar-sided wrist disorders but is still associated with complications like malrotation, angulation, or nonunion because of incomplete closure of the osteotomy gap. We describe the use of a newly developed palmarly placed sliding-hole dynamic compression plate that allows fixation of the ulna before the oblique osteotomy is carried out. METHODS: We performed ulnar shortening osteotomy on 27 consecutive patients. The indication was ulnar impaction syndrome in 25 patients and symptomatic ulnar plus variance secondary to malunited distal radial fracture in 2 patients. The mean preoperative ulnar variance was +2.1 mm (range, +1 mm to +8 mm). All patients were evaluated before and after surgery and graded with the Disability of Arm-Shoulder-Hand (DASH) scoring system. RESULTS: All 27 osteotomies healed uneventfully over an average of 9.2 +/- 2.1 weeks. The mean postoperative ulnar variance was -2.1 mm (range, -3.1 mm to 0 mm). There were significant improvements in DASH score, pain, and grip strength at an average follow-up of 8.1 months. Six patients complained of plate irritation. CONCLUSION: Favorable results suggest that ulnar shortening osteotomy using an oblique osteotomy and a premounted sliding-hole compression plate avoids malrotation and angulation and is associated with satisfactory outcomes. This device does not require an assisting device, which minimizes the surgical exposure of the ulna. Palmar placement of the plate seems to reduce hardware irritation.     

Isolated wedge osteotomy of the ulna for mild Madelung's deformity

PURPOSE: Madelung's deformity is a characteristic pattern of anterior-ulnar bowing of the radius and a dorsally prominent ulnar head. Even if this deformity is associated with a certain degree of functional impairment, patients are satisfied with their function and mainly complain about the appearance of their wrists. The purpose of this study was to report a new surgical procedure (shortening combined with a slight anterior angulation osteotomy of the ulna) aiming to improve the appearance of the wrist and to relieve pain if present without compromising the function of the wrist. This technique is suitable for mild cases of Madelung's deformity. METHODS: This is a retrospective study of 4 wrists in 3 patients. All patients had a mild form of Madelung's deformity (without any dislocation of the lunate). Even if it was not their primary motivation to have surgery, all of the patients preoperatively experienced some wrist pain. An anterior angulation and shortening osteotomy of the ulna shaft was performed through a dorsal medial approach and fixed with a dynamic compression plate. RESULTS: At 24 months follow-up, all of the patients were satisfied with the appearance of their wrists and forearms. The distal radioulnar joint was congruent radiologically in all cases, and the range of active pain-free forearm rotation improved. CONCLUSIONS: This technique seems to be safe and reliable in mild cases of Madelung's deformity.     

Corrective osteotomy for malunion of the distal radius

Positive ulnar variance due to inadequate correction of radial length is a common disorder after radial corrective osteotomy. To avoid this complication we performed a combination of ulnar-shortening osteotomy and radial corrective osteotomy in 6 of 22 radial corrections. The indication for the combined procedure was a relative ulnar length of minimally 6 mm. The functional outcome was fair in 1 and good in 5 cases with combined osteotomy. Overall, the functional results were good in 17 cases, and pain in the distal radioulnar joint was observed in 3 of 22 patients. Positive ulnar variance was the reason for pain in only 1 patient. Eventually, 2 hemiresections of the ulnar head (Bower's arthroplasty) were performed. It appears that a combination of ulnar shortening and radial osteotomy is a reliable technique, which can reduce symptoms and need for secondary operations on the ulnar side of the wrist.     

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.     

Step-cut distal ulnar-shortening osteotomy

PURPOSE: Several techniques for ulnar-shortening osteotomies have been described in recent years, reflecting the difficulties that sometimes are encountered in what seems to be a relatively simple procedure. We describe the use of a simple step-cut ulnar-shortening osteotomy stabilized with a lag screw and a palmarly placed 3.5-mm neutralization plate. METHODS: Twenty-nine patients had the surgery. The indication was ulnar-impaction syndrome in 23 patients and symptomatic ulnar-plus variance secondary to trauma in 6 patients (4 with previous distal radius fractures, 2 with Essex-Lopresti injuries). The preoperative ulnar variance ranged from +1 mm to +6 mm. RESULTS: The mean follow-up period was 34 months. All osteotomies healed uneventfully. The mean postoperative ulnar variance was +0.2 mm (range, -1 mm to +1.5 mm). Three patients had hardware removal. CONCLUSIONS: The step-cut osteotomy resulted in solid union in all patients. It provides ample bone-to-bone contact and easier control of rotation, and no special instrumentation is necessary. Stable fixation permitted early mobilization of the wrist and palmar placement of the plate minimized the need for plate removal. This is a simple and effective technique for ulnar shortening.     

Sliding osteotomy for deformity correction following malunion of volarly displaced distal radial fractures

OBJECTIVE: To determine the outcome after a sliding osteotomy for deformity correction following malunion of volarly displaced distal radius fractures. DESIGN: Retrospective review of a consecutive patient series. SETTING: A university-affiliated, tertiary-care center. PATIENTS/INTERVENTION: Ten patients with symptomatic distal radius malunion following a volarly displaced distal radial fracture (Smith's fracture) were treated with an oblique sliding osteotomy and plate fixation, through a volar approach, without using an iliac crest bone graft. Five men and five women with an average age of 41.9 years were followed for an average of 2.7 years postoperatively. MAIN OUTCOME MEASUREMENTS: Range of motion, grip strength, Fernandez wrist score, radiographic parameters. RESULTS: At latest follow-up, wrist extension improved from an average of 37 degrees preoperatively to 70 degrees postoperatively (P = 0.002), wrist flexion improved from an average of 40 degrees to 65 degrees (P = 0.012), and supination improved from an average of 31 degrees to 68 degrees (P = 0.002). Postoperative radiographs revealed an average deformity correction of 10.6 degrees of volar tilt, 7.7 degrees of radial inclination, 5.8 mm of ulnar variance, and 10.4 mm of volar translation. Using the Fernandez point score (0-20) system, the average overall score improved from 10.5 preoperatively to 17.6 postoperatively (P = 0.0001). Functional outcome was rated as excellent or good in 9 of 10 patients and fair in 1 patient (who experienced residual problems due to persistent ulnar-sided pain). There were two reoperations (one hardware removal, one distal ulnar hemiresection). CONCLUSIONS: This method reliably restores distal radial anatomy, decreases pain, and improves supination without requiring iliac crest bone grafting.     

Madelung deformity: isolated ulnar wedge osteotomy

OBJECTIVES: Madelung deformity is defined as a partial closure of the medial half of the distal radial growth plate, with anatomical consequences (wrist deformity), and functional impairment (decrease range of motion, loss of grip strength, and wrist pain). We report a new surgical procedure including a shortening of the ulna combined with slight anterior flexion osteotomy aiming to correct the radio-ulnar dislocation and to improve the range of forearm rotation, without correcting the global deformity. METHODS: This was a retrospective study of four symptomatic wrists in three patients. The follow-up was 24 months. Patients were assessed clinically and radiologically pre and post operatively. The ulnar shaft was shortened and anteriorly flexed through a dorsal and ulnar approach and fixed with a fitted internal DCP plate. The aim of this osteotomy was to reduce the dislocated distal radio-ulnar joint. RESULTS: At 24 months follow-up, the function was considerably improved with a correction of the ulno-carpial conflict. The range of painfree forearm rotation improved. The post-operative views showed a correction of the dorsal dislocation of the ulnar head. CONCLUSION: This technique seemed to be safe and demonstrated good results in these four wrists. It should be proposed in patients with Madelung deformity and assessed prospectively.     

Ulnar impaction

Ulnar impaction syndrome is a common source of ulnar-sided wrist pain. It is a degenerative condition that occurs secondary to excessive load across the ulnocarpal joint, resulting in a spectrum of pathologic changes and symptoms. It may occur in any wrist but is usually associated with positive ulnar variance, whether congenital or acquired. The diagnosis of ulnar impaction syndrome is made by clinical examination and is supported by radiographic studies. Surgery is indicated if nonoperative treatment fails. Although a number of alternatives exist, the 2 primary surgical options are ulnar-shortening osteotomy or partial resection of the distal dome of the ulna (wafer procedure). This article discusses the etiology of ulnar impaction syndrome, and its diagnosis and treatment.     

Plate removal after ulnar-shortening osteotomy

PURPOSE: Ulnar-shortening osteotomy using plate and screw fixation is a reliable method for treating various wrist disorders. In some patients the plate remains as a source of discomfort even after the osteotomy has healed and the preoperative complaints have resolved. There is not a large body of information to guide the surgeon in the timing of plate removal should it be needed to address persistent forearm complaints caused by prominent hardware. This study investigated the outcome of patients who had removal of the plate because of persistent symptoms after undergoing ulnar-shortening osteotomy once radiographic healing was apparent. METHODS: A consecutive series of 40 ulnar shaft-shortening osteotomies was performed in which 14 patients requested removal of the plate because of persistent tenderness despite nonsurgical management. There were 12 Rayhack (11 titanium, 1 stainless steel) and 2 Synthes 3.5-mm dynamic compression titanium plates used. Before removal radiographic union was documented by 2 sets of films taken in multiple planes at least 4 weeks apart. The average time to plate removal was 6.6 months. RESULTS: All patients had resolution of the ulnar forearm pain after hardware removal. There were no repeated surgeries and all patients returned to their prior levels of activity or employment. Patients were followed-up for an average of 17 months after plate removal. There was 1 refracture in an osteoporotic patient when she fell down a flight of stairs 7 months after plate removal. CONCLUSIONS: When used for fixation after ulnar shaft-shortening for ulnar-sided wrist pain of various causes 3.5-mm compression plates seem to be removable at 6 to 9 months in symptomatic patients with a low risk for refracture when sequential sets of x-rays confirm healing of the osteotomy site according to this small series of patients.     

Results of the operative treatment in Madelung's deformity]

Nine wrists in eight patients were treated surgically between 1988 and 2003 for symptomatic Madelung's deformity. The pain of involved wrist followed by forearm deformation fulfilled criteria for surgery. Closing wedge osteotomy of the distal radius were carried out eight times accompanied by shortening of the ulna (four patients), excision of the distal ulna (one patient), and no ulnar surgery (three patients). Pain relieved after surgery. The follow up period ranged from 1 to 9.5 years. No pour results were stated in subjective patient's estimation during final check up. Wrist appearance were stated to be satisfactory. Limitation of the range of motion concerning supination and pronation of the forearm were stated invariably. X-ray retrospective assessment of the inclination angle, lunate coverage and presence of arthritic changes were conducted. Time and method of surgical treatment for Madelung's deformity should be considered individually.     

Staged reconstruction for malunited fractures of the distal radius

This prospective study assessed the outcomes of 26 symptomatic malunited distal radial fractures which were treated with an opening wedge corrective osteotomy and bone grafting with rigid fixation. An ulnar shortening osteotomy was subsequently required as a second-stage operation in five cases to restore normal ulnar variance. A wrist arthroscopy was indicated as a third stage procedure with persistent ulnar sided wrist pain in order to address central tears of the triangular fibrocartilage. Satisfactory functional scores were achieved by 20 of the 26 patients after distal radial osteotomy alone and, 24 of the 26 after subsequent ulnar shortening osteotomies and arthroscopy when necessary. The one, two or three stage concept of reconstructing the malunited distal end radius could optimise the outcome rather than using a single-stage strategy.     

Simultaneous radial closing wedge and ulnar shortening osteotomies for distal radius malunion

PURPOSE: Closing wedge osteotomies are an attractive treatment option for distal radius malunion in patients with osteopenia; however, they require an ulnar head resection to accommodate closure of corrective osteotomy and to address the issue of ulnocarpal abutment. The literature contains little information on concomitant ulnar shortening osteotomy despite a physiologic solution. We report the functional and radiographic outcomes of 5 patients treated for symptomatic distal radius malunion with simultaneous radial closing wedge and ulnar shortening osteotomies. METHODS: All 5 patients were women aged 52 to 69 years (average, 61 years). Four patients had extra-articular radius fractures with dorsal angulation (20-22 degrees ) and shortening (3-7/mm); the other had the fracture with volar angulation (24 degrees ) and shortening (11 mm). Through a volar approach an appropriate amount of bone wedge was removed from the distal radius. A small volar T-plate was used to secure the osteotomized bone fragment. Six to 11 mm of ulnar shortening osteotomy was performed by using transverse osteotomy and compression plating technique with an AO compression device. RESULTS: In all 5 wrists healing of radial and ulnar osteotomies occurred less than 3 months after surgery. There were no postsurgical complications. Postsurgical radiographs showed that the volar tilt angle of the radius was reduced to normal range (range, 8-15 degrees ) in all wrists. The ulnar variance was 0 mm in 4 wrists and 2 mm in 1 wrist. There were significant improvements in pain, function, and range of motion at an average follow-up evaluation of 17 months. The average grip strength as a percentage of the opposite side improved from 30% before to 73% after surgery. CONCLUSIONS: This study showed that closing wedge osteotomy of the radius concomitant with ulnar shortening osteotomy is technically and functionally adequate. Our procedure is indicated for patients with osteopenia for whom opening wedge osteotomy of the radius is inadequate.     

Treatment of distal radioulnar disorders

Twenty-nine wrists of 29 patients were treated with three procedures: distal ulnar resection (Darrach's procedure), distal ulnar recession, or hemiresection-interposition arthroplasty. The indications were pain and limitation of motion associated with primary osteoarthritis of the distal radioulnar joint, derangement after distal forearm bone fracture, Madelung's deformity, and distal radioulnar sprain. The age of the patients averaged 48.3 years. Follow-up averaged 1 year and 9 months. Radiographic evaluations were done preoperatively and postoperatively. Relief of pain was good in the wrists treated by Darrach's procedure; however, diminished grip strength and wrist instability occurred. Relief of pain in the wrists treated by distal ulnar recession and hemiresection-interposition arthroplasty was inferior to that of Darrach's procedure; however, postoperative grip strength increased and wrist instability did not occur.     

Oblique ulnar shortening osteotomy with a new plate and compression system

Ulnocarpal abutment or the ulnocarpal impaction syndrome occurs when excessive loads exist between the distal ulna and ulnar carpus. This overloading occurs as a result of the distal ulnar articular surface being more distal than the ulnar articular surface of the distal radius. This situation has been termed positive ulnar variance, and it can quickly lead to ulnar-sided wrist degenerative changes and functional losses. Patients often have vague, ulnar-sided complaints of chronic pain and swelling with an insidious onset that does not correlate with any specific traumatic event. Many procedures have been developed to alleviate this condition, but the gold standard for correcting positive ulnar variance is the ulnar shortening osteotomy. The goals of the shortening procedure are to relieve pain and prevent arthritis by reestablishing a neutral or slightly negative ulnar variance. We describe a new plate and compression system in which an oblique ulnar diaphyseal osteotomy is both completed and stabilized through the same jig-based system.     

尺骨短缩术治疗桡骨骨折后尺骨撞击综合征

目的 评价尺骨短缩术治疗尺骨撞击综合征的效果及其影响因素. 方法 2002年1月至2006年12月对28例诊断为腕部尺骨撞击综合征患者给予尺骨截骨短缩治疗,采用改良的Gartland and Werley腕关节功能评分系统判定治疗效果;分析尺骨短缩数量与手术效果的关系. 结果 本组术前尺骨阳性变异23例,中件变异3例,阴性变异2例;术后阳性变异3例,中性变异4例,阴性变异21例.尺骨变异术前平均(3.1±2.3)mm,术后平均(0.9±1.4)mm,差异有统计学意义(t=4.32,P<0.05).按改良的Gartland and Werley评分:术前平均为(62.6±4.3)分,可21例,差7例;术后评分改善到平均为(92.2±7.8)分,优22例,良3例,可2例,差1例,腕关节功能评分术前与术后比较差异有统计学意义(t=10.45,P<0.05).3例切断尺桡远端韧带,4例部分切断尺桡远端韧带.6例术前存在远端尺腕部背侧半脱位,尺骨短缩术后明显改善. 结论 尺骨短缩术能显著改善桡骨远端骨折后继发尺骨撞击综合征的功能评分和临床症状;但尺骨短缩过多,远侧尺桡关节间压力增大,则影响手术效果.     

闭口式尺桡骨双侧截骨术治疗桡骨远端畸形愈合的病例对照研究

目的:比较传统桡骨开口截骨植骨术与闭口式截骨术治疗桡骨远端畸形愈合的临床和影像学结果.方法:对2004年1月至2012年12月采取矫形截骨治疗的47例桡骨远端关节外骨折畸形愈合患者的临床资料进行回顾性研究,4例失访,1例死亡,共42例纳入研究,分为桡骨开口式截骨植骨术组(A组)和闭口式尺桡骨截骨术组(B组).A组22例,其中男5例,女17例,年龄25～75岁;B组20例,其中男4例,女16例,年龄19～79岁.根据放射学结果和功能评估结果评估临床效果,包括腕关节活动度、握力、疼痛分级评估,Mayo腕关节评分及DASH评分.结果:A组患者平均随访36个月(12～101个月),B组患者平均随访28个月(12～87个月).A组掌倾角由术前(27±8)°(20°～38°)改善至术后(14±6)°(9°～22°),B组掌倾角由术前(26±5)°(20°～32°)改善至术后(10±5)°(3°～15°).A组尺骨变异术前(7±2) mm(0～10 mm),术后减小至(3±2) mm(-1～7 mm);B组由术前(6±2)mm(1～8 mm)减小至术后(0.2±0.7)mm(-1～2 mm);B组尺骨变异恢复优于A组.腕关节屈伸活动度A组由术前(74±30)°(30°～142°)提高至术后(108±23)°(65°～159°),B组由术前(95±35)°(30°～175°)提高至术后(154±16)°(115°～180°),B组腕关节屈伸活动度改善优于A组.术后Mayo腕关节评分A组78±10(55～100分),B组86±7(70～95分),B组优于A组;术后DASH评分A组14±12(0～44分),B组13±14(1～60分),两组差异无统计学意义.结论:闭口式尺桡骨双侧截骨术能有效治疗桡骨远端关节外骨折畸形愈合,并在恢复尺骨变异、腕关节屈伸活动度和Mayo评分方面优于开口式截骨术.     

Ulnar shortening osteotomy for malunited distal radius fractures: results of a 7-year follow-up with special regard to the grade of radial displacement and post-operative ulnar variance

Introduction

The treatment of ulnar-sided wrist pain after malunited distal radius fractures remains controversial. Radial corrective osteotomy can restore congruity in the distal radioulnar joint (DRUJ) as well as adequate length of the radius. Ulnar shortening osteotomies leave the radius’ angular deformities unchanged, risking secondary DRUJ osteoarthritis. We supposed that, even within the widely accepted limit of 20°, a greater angulation of the radius in the sagittal plane correlates with a higher rate of DRUJ osteoarthritis. Furthermore, we suspected worse results from an ulna shortened to a negative rather than a neutral or positive ulnar variance.

Materials and methods

For this retrospective study, we reviewed 23 patients a mean 7.2 (range 5.6–8.5) years after ulnar shortening osteotomy for malunion of distal radius fractures. We compared 14 patients with up to 10° dorsal or palmar displacement from the normal palmar tilt of 10° to 9 patients with more than 10° displacement, and 15 patients whose post-operative ulnar variance was neutral or positive to 8 who had a negative one.

Results

Ulnar-sided wrist pain decreased enough to satisfy 21 of the 23 patients. Clinical results tended to be better when radial displacement was minor and when post-operative ulnar variance was positive or neutral. A shorter ulna significantly increased the rate of DRUJ osteoarthritis, whereas a greater degree of radial displacement only increased the rate slightly.

Conclusions

Radial corrective osteotomy should be discussed as alternative when displacement of the radius in the sagittal plane exceeds 10°. The ulna should be shortened moderately to reduce the risk of osteoarthritis in the distal radioulnar joint.