5/11/2013

1

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

5/11/2013

2

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

5/11/2013

3

preoperative planning dorsal approach

2.4 distal radius locking plates

5/11/2013

4

5/11/2013

5

5/11/2013

6

5/11/2013

7

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)

5/11/2013

8

5/11/2013

9

5/11/2013

10

5/11/2013

11

5/11/2013

12

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

5/11/2013

13

post-opx-rays

12 weekspost-op

5/11/2013

14

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

5/11/2013

15

CONV. PLATE DRILLING JIG

SETTING GAUGE

SA 39

SA 39 SA 39

5/11/2013

16

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

5/11/2013

17

SA 39 SA 39

SA 39 SA 39

Skyline view

5/11/2013

18

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

5/11/2013

19

5/11/2013

20

5/11/2013

21

5/11/2013

22

5/11/2013

23

5/11/2013

24

5/11/2013

25

5/11/2013

26

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

5/11/2013

27

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

5/11/2013

28

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

5/11/2013

29

Combined Intra- and Extra-Articular Distal Radius Malunion

5/11/2013

30

118

119

5/11/2013

31

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

5/11/2013

32

MethodsPatient Inclusion

MethodsPatient Characteristics

Surgical TechniqueExtra-Articular Malunion

Surgical TechniqueIntra-Articular Malunion

5/11/2013

33

Surgical Technique

1

1

2

3

3

2

Surgical Technique

Surgical Technique Surgical Technique

5/11/2013

34

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

5/11/2013

35

THANK YOU