Corrective Osteotomy of Distal Radius Malunion---New Horizons · TIMING OF SURGERY-absence of trophic changes-acceptable bone quality-adequate wrist function as soon as possible,

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Corrective Osteotomy of Distal Radius Malunion---New Horizons

I certify that, to the best of my knowledge, no aspect of my current personalor profession situation might reasonably be expected to affect significantlymy views on the subject on which I am presenting.

1. LOSS OF REDUCTION

2. DELAYED UNION AND NONUNION

3. MALUNION

4. DISTAL RADIOULNAR JOINT

WRIST FRACTURES

OSTEOARTICULAR COMPLICATIONS• Carpal ligaments

• Carpal fractures

• Nerves

• Tendons

• Combined soft tissues

• Vascular, compartment syndrome

ASSOCIATED LESIONS COMPLICATIONS

Carpal instability

Nonunion, malalignment

Neuropathy

Tendinitis, ruptures

Multifactorialfunctional deficit

RSD, Complex RegionalPain syndrome

WRIST FRACTURES

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TIMING OF SURGERY

-absence of trophic changes-acceptable bone quality-adequate wrist function

as soon as possible, provided there is: NASCENT MALUNION

- immature callus

- established deformity (5 – 8 weeks

post-fracture )

MATURE MALUNION

- remodelled callus

- 4 to 6 months or morepost-fracture

ADVANTAGES OF EARLY CORRECTION

•easiness of radial and DRUJ re-alignment

•less soft tissue contractures and DRUJ dysfunction

•no need of structural corticocancellous bone graft

•considerably decrease of total disability

•early return to work

Jupiter JB, Ring D:A comparison of early and late r econstruction of malunited fracturesof the distal end of the radius. JBJS 78A: 739-

748, May 1996

corrective osteotomy of malunited Colles fracturesthrough a dorsal approach

preoperative planning is based on the radiographicmeasurements of the opposite wrist:

-ulnar inclination-ulnar variance-volar tilt

(for rotational deformity: comparative CT-scans)

Bindra RR,Cole RJ et al: Quantification of the radial torsion angle withcomputerized tomography in cadaver specimens JBJS 79A:833-837, 1997

SURGICAL TECHNIQUE

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preoperative planning dorsal approach

2.4 distal radius locking plates

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correction of malunited Colles`fracturesthrough a volar approach:

SURGICAL TECHNIQUE

- Open wedge osteotomy, interpositional bone graftand volar plate fixation (U. Lanz, J.Orbay)

- Close wedge osteotomy, Darrach procedure andK-wire fixation (Posner, Garcia-Elias)

- Close wedge osteotomy and ulnar shortening

- Close wedge osteotomy and ulnar head prosthesis (D.L.Fernandez)

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open wedge osteotomy, bone graft and volar plate fi xation

Prommersberger KJ Lanz U.: Corrective osteotomy for malunited Colles‘fractures. Orthop Trauma 6: 75-87 , 1998.

Orbay JL, Indriago I, Badia A, Khouri RK, Gonzalez E, Fernandez DL: Corrective osteotomy of dorsally malunited fractures of the distal radiusvia the extended FCR approach.J Hand Surg 28B (Suppl 1): 2 ,2003

Lanz U, Kron W: Neue Technik zur Korrektur in Fehlstellung verheilterRadiusfrakturen. Handchir Mikrochir Plast Chir 8:203-206, 1976

L

Rsurgical technique

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post-opx-rays

12 weekspost-op

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3-dimensional image aquisition and 3-D planning

SNF Nr.258337: Fürnstahl P, Schweizer A, Székely G, Nagy L

Osteotomy ReportCutting: 22.014 mm (from distal) to distalCut is performed at 22.014 mm (from distal)Osteotomy result:First: Rotation around axis 2 by 15.868 degreesSecond: Rotation around axis 1 by 26.756 degreesThird: Rotation around axis 0 by 9.2067 degreesFourth: Translation by 0.93842 (axis 0),0.7939 (axis 1),-11.642 (axis 2) mm

SNF Nr.258337: Fürnstahl P, Schweizer A, Székely G, Nagy L

Osteotomy ReportCutting: 22.014 mm (from distal) to proximalCut is performed at 22.014 mm (from distal)Osteotomy result:First: Rotation around axis 2 by 15.868 degreesSecond: Rotation around axis 1 by 26.756 degreesThird: Rotation around axis 0 by 9.2067 degreesFourth: Translation by 0.93842 (axis 0),0.7939 (axis 1),-11.642 (axis 2) mm

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CONV. PLATE DRILLING JIG

SETTING GAUGE

SA 39

SA 39 SA 39

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SA 39 SA 39

SA 39

Osteotomy result:First: Rotation around axis 2 by 3.2372°Second: Rotation around axis 1 by -15.076°Third: Rotation around axis 0 by -7.8848°Fourth: Translation by0.33353 mm, 0.66308 mm,-4.9765 mm

SA 39

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SA 39 SA 39

SA 39 SA 39

Skyline view

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SA 39 6W

INTRARTICULAR MALUNION

intra-articular malunion results after failure to r ecognize

potentially unstable articular disruption, or insuf ficient

reduction and fixation during surgical treatment

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The indication of osteotomy for an intra-articularmalunion depends on:

1) the fracture pattern

2) the extent of cartilage damage

3) the chronology

4) presence of fixed carpal malalignment

5) the soft tissue condition

INTRA-ARTICULAR OSTEOTOMIES

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CONTRAINDICATIONS

1) severe cartilage damage

2) radiographic degenerative changes

3) chronic synovitis

4) significant soft tissue andcapsular contractures (post RSD)

5) complex fracture pattern andfixed carpal malalignment

TREATMENT RECOMMENDATIONS

- simple intra-articular disruption

- as soon as possible

- minimal cartilage damage (chondromalacia)

- adequate pre-operative function

- complient, cooperative patient

otherwise a limited carpal fusion (RSL or RL) is preferable

INTRA-ARTICULAR MALUNION

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ARTHROSCOPIC ASSISTED TREATMENT OF DISTAL RADIUS MALUNION

Francisco del Piñal et al: Arthroscopically guided osteotomyfor management of intra-articular distal radius malunions.

J Hand Surg 35A: 392-397, 2010

del Piñal, F , Garcia Bernal FJ, et al: Correction of malunited intra-articular distal radius fractures with an inside-out

osteotomy technique. J Hand Surg 31A: 1029-1034, 2006

Courtesy: Dr Francisco del Piñal, Santander,Spain

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Combined Intra- and Extra-Articular Distal Radius Malunion

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Geert A. Buijze, MDKarl-Josef Prommersberger, MDJuan González del Pino, MD PhDDiego L. Fernandez, MDJesse B. Jupiter, MD

Corrective Osteotomy for Combined Intra- and Extra-Articular Distal Radius Malunion

Study Aims MethodsPatient Inclusion

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MethodsPatient Inclusion

MethodsPatient Characteristics

Surgical TechniqueExtra-Articular Malunion

Surgical TechniqueIntra-Articular Malunion

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Surgical Technique

1

1

2

3

3

2

Surgical Technique

Surgical Technique Surgical Technique

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Eleven years FU CONCLUSIONS

- malunion remains the most common complication of closed reduction and plaster immobilisation of unst able

extra-articular fractures

- intra-articular malunion results after failure to recognize potentially unstable articular disruption, or insuf ficient

reduction and fixation during surgical treatment

- if symptomatic extra-articular malunion occurs, ra dialosteotomy offers better function,improves the exter nal

appearance and normalizes carpal kinematics

-intra-articular malunion deserves early correction in orderto restore the functional – anatomic integrity of th e jointbefore the onset of symptoms and cartilage damage

-our experience has shown that with:

careful patient selection

correct indication and

refinements of surgical technique

over 80% of excellent and good results can be expected

CONCLUSIONS

Complications and failures are commonly caused eith erby technical errors, or by improper patient selecti on with:

degenerative changes

trophic disturbances

partial joint stiffness

severe osteoprosis

fixed type of DISI malaligment

and failure to assess and simultaneously treatassociated disorders of the distal radioulnar joint

CONCLUSIONS

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THANK YOU