- Email: [email protected]
Isolated Wedge Osteotomy of the Ulna for Mild Madelung’s Deformity
Isolated Wedge Osteotomy of the Ulna for Mild Madelung’s Deformity Yann Glard, MD, André Gay, MD, Franck Launay, MD, Didier Guinard, MD, Régis Legré, MD From the Department of Plastic and Reconstructive Surgery, Hôpital de la Conception, Marseille, France; and the Department of Pediatric Orthopaedic Surgery, Hôpital d’Enfants de la Timone, Marseille, France.
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. (J Hand Surg 2007;32A:1037–1042. Copyright © 2007 by the American Society for Surgery of the Hand.) Type of study/level of evidence: Therapeutic IV. Key words: Madelung’s deformity, ulnar osteotomy.
adelung’s deformity has various degrees of severity and functional impairment.1 Madelung’s deformity is a rare condition without any available assessment of its incidence or prevalence in the literature.2 It is defined as a characteristic pattern of anterior-ulnar bowing of the radius and a dorsally prominent ulnar head3 with a complex incongruency of the distal radioulnar joint (Fig. 1A, B; Fig. 2). The term anterior bowing is inappropriate, because in the pronated position, the direction of the bowing might be posterior. Nevertheless, it is commonly used in the literature. A partial closure of the distal radial growth plate may cause this specific deformity.4,5 It may be isolated or part of a syndrome such as dyschondrosteosis.6 – 8 It may be inherited with autosomal dominance and variable penetrance9,10 or may be sporadic.10 Clinical features are a dorsal prominence of the ulnar head and a certain degree of functional impairment.10,11 Range of
M
motion is decreased in flexion-extension, radial and ulnar deviation, and forearm rotation.10,11 The age of onset of the disease is reported to be late childhood or teenage years.11 Conservative treatment is not effective, failing to control or correct the deformity.11–13 Our aim is to describe a surgical procedure (isolated anterior angulation and shortening osteotomy of the ulna) to improve the appearance of the wrist and to relieve pain if present without compromising the function of the wrist in selected patients with mild forms of Madelung’s deformity who complain mainly about the appearance of their wrists. We report a short series of 4 wrists in 3 consecutive patients, with 24 months follow-up.
Materials and Methods The study design was retrospective. To be included in our series, patients had to meet the following criteria: to The Journal of Hand Surgery
1037
1038
The Journal of Hand Surgery / Vol. 32A No. 7 September 2007
extensor carpi ulnaris was dissected respecting a rectangular flap with a radial base in the dorsal carpal ligament for further dorsal stabilization. The ulnar shaft was shortened 6 cm proximal to the base of the styloid process and fixed using a contoured dynamic compression plate after anterior angulation and shortening osteotomy of the ulna (Fig. 3B). The amount of ulnar resection was planned on preoperative x-rays to bring the ulnar variance close to 0. A slight anterior tilt was performed to attempt a reduction of the distal radioulnar joint. The extensor carpi ulnaris was stabilized using the rectangular flap previously dissected. A protective cast preventing the forearm rotation was applied for 3 weeks. The plate was removed after the ulnar union was achieved. A postoperative view is shown in Figure 4A, B. In each patient, the following items were recorded: age at surgery, gender, involved side, preoperative and 24-months postoperative clinical and radiologic evaluation. The clinical evaluation was assessed preoperatively and postoperatively as follows: active pain-free range of motion in pronation, supination, flexion, extension, radial deviation, and ulnar deviation. Pain was assessed preoperatively and postoperatively using a personal pain score derived from the system described by Jiranek et al,14 modified from Cooney et al.15 In this comprehensive rating system, the pain is assessed using a 30-point score (Table 1). All of the patients completed the pain score 2 times: once prior to their surgery and another time at 24 months follow-up evaluation. Even-
Figure 1. Preoperative radiograph in a patient with Madelung’s deformity: (A) AP view, (B) lateral view.
be diagnosed with a mild form of Madelung’s deformity (with no lunate dislocation, but with volar tilt of the distal radius on the lateral radiograph of the wrist and with increased radial inclination on the anteroposterior radiograph of the wrist), to be skeletally mature, to have been operated on using the technique described in the current document, and to have a follow-up of at least 2 years. Four wrists in 3 consecutive patients were included. There were 1 man and 2 women. The mean age at surgery was 29 years, ranging from 27 to 32 years. Surgical Procedure All of the patients had the same surgical procedure. The distal third of the ulna and the radioulnar joint were reached through a dorsal approach, respecting the dorsal ulnar cutaneous nerve (Fig. 3A). The dislocated
Figure 2. Clinical preoperative appearance of the wrist in Madelung’s deformity (patient 2).
Glard et al / Ulnar Osteotomy in Madelung’s Deformity
1039
Figure 3. Intraoperative view (patient 2). (A) Dorsal approach of the distal ulnar third and the radioulnar joint. (B) Fixation using a contoured plate after anterior angulation and shortening osteotomy of the ulna.
tually, a tenderness at the distal ulna and at the distal radioulnar joint was looked for preoperatively and postoperatively. The radiologic evaluation was assessed preoperatively and postoperatively as follows: the distal radioulnar joint incongruency was assessed based on anteroposterior (AP) and lateral views of the involved wrist. On the lateral view, the distal radioulnar joint was defined as subluxated if less than 50% of the surface of the ulnar head was superimposed with the distal radius. A subluxated joint was noted “⫹,” and a nonsubluxated and nondislocated joint was noted “⫺.” The ulnar variance was assessed preoperatively and postoperatively according to the “project a line” technique described by Steyers and Blair.16 The angle of the distal ulna at the osteotomy site was assessed postoperatively on the lateral view. Satisfaction of patients postoperatively was assessed on the basis of their perception of the cosmetic result according to a personal rating system derived from the system described by Gangopadyay and Packer.17 Patients were asked to grade their wrists with a score between 0 and 10, based on the following factors: (a) length of the scar, (b) prominence of the radial head, (c) interference with activities of daily living, (d) how noticeable the deformity was to them, and (e) how noticeable the deformity was to others. Each item is rated as 0 (poor), 1 (medium), or 2 (good). A score of between 9 and 10 was classified as excellent, between 7
and 8 as good, between 5 and 6 as fair, and below 5 as poor. The comparison was made based on preoperative and 24 months follow-up data. Because of the very small size of the sample, a simple description without any statistical test was performed.
Results Overall results are shown in Table 2. The data indicated out that, at 24 months follow-up evaluation, the active pain-free range of motion in pronation and supination improved. Conversely, the active pain-free range of motion in flexion, extension, radial deviation, and ulnar deviation did not improve but did not worsen. The pain score was higher postoperatively (meaning an improvement in pain). A tenderness at the distal ulna and at the distal radioulnar joint was found in all cases preoperatively but in none postoperatively. The subluxation rate of the distal radioulnar joint was 100% preoperatively
Table 1. Pain Score Narcotic medication needed Pain every day Pain during gripping or impact loading Aching after heavy work Aching more than once a month Aching once a month or less No pain 0 ⫽ poor; 30 ⫽ excellent.
0 6 10 16 22 26 30
1040
The Journal of Hand Surgery / Vol. 32A No. 7 September 2007
Figure 4. Postoperative radiograph in patient 2 with Madelung’s deformity: (A) AP view, (B) lateral view.
and 0% at 24 months follow-up. The ulnar variance averaged ⫹4 mm preoperatively and ⫺1 mm postoperatively. The mean angle of the distal ulna at the osteotomy site was 17°. All of the patients were satisfied with the appearance of their wrists and their forearms at 24 months follow-up. At follow-up, all of the patients rated their wrists as good according to our personal satisfaction scale. The results of our personal satisfaction scale are given in Table 3.
Discussion The natural history of Madelung’s deformity toward osteoarthritis is not clear.11,18 Patients may suffer from osteoarthritis late in their lives.11,19 Nevertheless, the functional complaint is not common in patients with Madelung’s deformity. In these patients, the main motivation to have surgery is the appearance of the wrist.11 Conservative treatment is not effective, failing to control or correct the deformity.11–13 Many surgical procedures were described in the literature. Dobyns et al1 defined 3 groups of procedures in grown patients: radial procedures,20,21 ulnar procedures,22–26 and combined radial and ulnar procedures.20,22–28 Nevertheless, few procedures have been separately validated with a clinical series in the literature. To date, we found only 6 series in which postoperative results in patients with Madelung’s deformity are clearly given.10,11,20,23,24,29 The surgical procedure used is homogenous in only 3 of these series. Bruno et al20
published a retrospective series of 9 adult patients. All of them were suffering from ulnar-sided wrist pain. They all had the same procedure: an ulnar shortening osteotomy (without any attempt to reduce the distal radioulnar joint subluxation). The authors reported postoperative improvement in pain in all cases without any notable changes in the range of motion. The appearance of the wrist was not assessed in this work. dos Reis et al published a large series of 25 wrists in 18 patients.11 In 9 patients, the surgery was performed due to pain and disability. For the other 9 patients, it was done due to appearance. The procedure used was a radial wedge osteotomy, combined with an ulnar shortening. The authors showed a notable postoperative improvement in pain, appearance, forearm rotation and grip strength, and a slight improvement in the flexionextension range of motion. More recently, Harley et al published a series of 26 wrists in 18 patients.29 The surgical procedure used has been described in a previous work.30 It was a surgical release of the Vickers ligament (abnormal thickened volar ligament that tethers the lunate and the triangular fibrocartilage complex to the abnormal area of the volar-ulnar radial epiphysis and metaphysis) associated with a dome osteotomy of the distal radius. The authors showed improvement in pain, appearance of the wrist, forearm supination and wrist extension, with no loss of pronation or flexion. In
Glard et al / Ulnar Osteotomy in Madelung’s Deformity
Table 2. Overall Results Showing Range of Motion of the Wrist Pre- and Post-Operatively Patient
Pronation Preop Postop Supination Preop Postop Flexion Preop Postop Extension Preop Postop Radial deviation Preop Postop Ulnar deviation Preop Postop Pain Preop Postop Radioulnar dislocation Preop Postop
1
2
3
4
45 70
50 60
55 70
60 65
35 70
40 60
40 70
45 75
61 59
72 73
65 60
70 75
32 30
36 49
40 35
41 40
0 5
5 5
4 5
6 5
15 20
17 14
20 19
22 23
10 26
16 22
16 26
16 26
1 0
1 0
1 0
1 0
Preop, preoperatively; Postop, postoperatively.
the other 3 series available (Ranawat et al,23 Nielsen,24 and Murphy et al10), both radial and ulnar procedures were variably associated causing some confusion about the exact postoperative results. Our series is made of selected patients with mild forms of Madelung’s deformity without completely dislocated lunate bone. Pain was not a criterion for inclusion. Nevertheless, we do not perform pure cosmetic bone surgery. Therefore, all of the patients experienced some kind of wrist pain preoperatively, as shown in Table 1 (even if it was not their primary motivation to have surgery). All of the patients preoperatively had an ulnar-sided wrist pain and tenderness at the distal ulna and at the distal radioulnar joint. In these patients who complain mainly about the appearance of their wrists, we chose to perform a reduction osteotomy of the ulna diaphysis with anterior angulation aiming to reduce the radioulnar incongruency and thereby improve the appearance of the wrist. The exaggerated palmar and ulnar tilt of the distal radial joint surface is left undisturbed. The aim was not to restore the whole anatomy of the carpus but only to improve the distal radioulnar joint anatomy, appearance, and function. Our work assessed 4 points. Our results showed that
1041
there was a partial postoperative improvement in the range of motion, with a forearm rotation improvement, but without any effect on radial deviation, ulnar deviation, or flexion-extension. There was a postoperative improvement of the pain, there was a radiologic postoperative improvement of the distal radioulnar joint congruency, and overall there was an improvement of the appearance of the wrist without any deterioration of the appearance of the forearm at the osteotomy site. This simple procedure seems to be safe and reliable in selected patients with a mild form of Madelung’s deformity. Union occurred within 4 months in all cases. Although this was not the primary goal of this study, we observed that no remodeling of the osteotomy site of the ulna occurred during the follow-up period, and there was no change in the radiographic relationship of the radius and the ulna. Our series should not be compared with those of dos Reis et al11 and Harley et al,29 because our operative procedure focuses only on the distal ulna for Madelung’s deformity, whereas dos Reis et al11 used a combined radial and ulnar procedure and Harley et al29 used a radial osteotomy associated with a release of the Vickers ligament. Thus, the only series available in the literature giving some postoperative results after isolated ulnar procedure for comparison is the one by Bruno et al.20 For the function of the wrist, our procedure seems to have some similar outcomes than the one described by Bruno et al20: there is no dramatic postoperative change in the range of motion, but the pain is relieved. Our work assessed the cosmetic outcomes, which Bruno et al20 did not, and patients in our series were satisfied with the appearance of their wrists. The restricted range of motion in flexion-extension is not the main complaint in these selected patients. We think that this procedure may be useful in selected patients with a mild form of Madelung’s deformity who complain mostly about the appearance of their wrists but are satisfied with its function. It is very important to highlight that this simple procedure is suitable for mild Table 3. Satisfaction Scale Patient
Length of the scar Prominence of the radial head Interference with activities of daily living How noticeable the deformity is to the patient How noticeable the deformity is to others Total
1
2
3
4
0 2
1 2
1 1
0 2
2
2
2
2
2
1
1
2
2 8
2 8
2 7
2 8
1042
The Journal of Hand Surgery / Vol. 32A No. 7 September 2007
forms of Madelung’s deformity, and we do not recommend performing it in case of severe Madelung’s deformity with a completely dislocated lunate. We have the feeling that these patients mainly complain about the prominence of their ulnar head. They do not want to know if the distal radioulnar joint is dislocated or subluxated. The only thing they see is that their wrist has a hump on the ulnar side, and they want it off. We have the feeling that the operation we are reporting addresses this issue without compromising the function of the wrist. Further investigations with a larger sample of patients must be performed to assess the clinical effectiveness of this procedure, but this preliminary study indicated that our procedure seems to be safe and has not generated any postoperative joint stiffness or pain at 24 months follow-up in these patients with mild Madelung’s deformity.
11.
12.
13. 14.
15.
16. 17.
18. Received for publication January 19, 2007; accepted in revised form May 17, 2007. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Corresponding author: Dr. Yann Glard, Department of Plastic and Reconstructive Surgery, Hôpital de la Conception, 147 Bd Baille, 13005 Marseille, France; e-mail: [email protected]. Copyright © 2007 by the American Society for Surgery of the Hand 0363-5023/07/32A07-0015$32.00/0 doi:10.1016/j.jhsa.2007.05.015
References 1. Dobyns JH, Doyle JR, Von Gillern TL, Cowen NJ. Congenital anomalies of the upper extremity. Hand Clin 1989;5: 321–342; discussion 339 –340. 2. Flatt AE. A test of a classification of congenital anomalies of the upper extremity. Surg Clin North Am 1970;50:509 –516. 3. Arora AS, Chung KC, Otto W. Madelung and the recognition of Madelung’s deformity. J Hand Surg 2006;31A:177– 182. 4. Vickers D, Nielsen G. Madelung deformity: surgical prophylaxis (physiolysis) during the late growth period by resection of the dyschondrosteosis lesion. J Hand Surg 1992; 17B:401– 407. 5. Munns CF, Glass IA, LaBrom R, Hayes M, Flanagan S, Berry M, et al. Histopathological analysis of Leri-Weill dyschondrosteosis: disordered growth plate. Hand Surg 2001;6:13–23. 6. Felman AH, Kirkpatrick JA Jr. Madelung’s deformity: observations in 17 patients. Radiology 1969;93:1037–1042. 7. Golding JS, Blackburne JS. Madelung’s disease of the wrist and dyschondrosteosis. J Bone Joint Surg 1976;58B:350 – 352. 8. Gelberman RH, Bauman T. Madelung’s deformity and dyschondrosteosis. J Hand Surg 1980;5A:338 –340. 9. Mohan V, Gupta RP, Helmi K, Marklund T. Leri-Weill syndrome (dyschondrosteosis): a family study. J Hand Surg 1988;13B:16 –18. 10. Murphy MS, Linscheid RL, Dobyns JH, Peterson HA. Ra-
19.
20.
21.
22.
23.
24.
25. 26. 27.
28.
29.
30.
dial opening wedge osteotomy in Madelung’s deformity. J Hand Surg 1996;21A:1035–1044. dos Reis FB, Katchburian MV, Faloppa F, Albertoni WM, Laredo Filho J Jr. Osteotomy of the radius and ulna for the Madelung deformity. J Bone Joint Surg 1998;80B:817– 824. Henry A, Thorburn MJ. Madelung’s deformity. A clinical and cytogenetic study. J Bone Joint Surg 1967;49B: 66 –73. Lamb D. Madelung deformity. J Hand Surg 1988;13B:3– 4. Jiranek WA, Ruby LK, Millender LB, Bankoff MS, Newberg AH. Long-term results after Russe bone-grafting: the effect of malunion of the scaphoid. J Bone Joint Surg 1992; 74A:1217–1228. Cooney WP, Bussey R, Dobyns JH, Linscheid RL. Difficult wrist fractures. Perilunate fracture-dislocations of the wrist. Clin Orthop Relat Res 1987:136 –147. Steyers CM, Blair WF. Measuring ulnar variance: a comparison of techniques. J Hand Surg 1989;14A:607– 612. Gangopadhyay S, Packer G. A comparative study between longitudinal and “T” incisions for dorsal plating of the distal radius. J Hand Surg 2003;28B:568 –570. Mansat M, Lebarbier P, Cahuzac JP, Gay R, Pasquie M. [Madelung’s disease. A study of nine wrists operated on (author’s transl)]. Ann Chir 1979;33:669 – 675. Schmidt-Rohlfing B, Schwobel B, Pauschert R, Niethard FU. Madelung deformity: clinical features, therapy and results. J Pediatr Orthop B 2001;10:344 –348. Bruno RJ, Blank JE, Ruby LK, Cassidy C, Cohen G, Bergfield TG. Treatment of Madelung’s deformity in adults by ulna reduction osteotomy. J Hand Surg 2003;28A:421– 426. Fernandez DL, Capo JT, Gonzalez E. Corrective osteotomy for symptomatic increased ulnar tilt of the distal end of the radius. J Hand Surg 2001;26A:722–732. Darrow JC Jr, Linscheid RL, Dobyns JH, Mann JM III, Wood MB, Beckenbaugh RD. Distal ulnar recession for disorders of the distal radioulnar joint. J Hand Surg 1985; 10A:482– 491. Ranawat CS, DeFiore J, Straub LR. Madelung’s deformity. An end-result study of surgical treatment. J Bone Joint Surg 1975;57A:772–775. Nielsen JB. Madelung’s deformity. A follow-up study of 26 cases and a review of the literature. Acta Orthop Scand 1977;48:379 –384. Matev I, Karagancheva S. The Madelung deformity. Hand 1975;7:152–158. Watson HK, Pitts EC, Herber S. Madelung’s deformity. A surgical technique. J Hand Surg 1993;18B:601– 605. White GM, Weiland AJ. Madelung’s deformity: treatment by osteotomy of the radius and Lauenstein procedure. J Hand Surg 1987;12A:202–204. Salon A, Serra M, Pouliquen JC. Long-term follow-up of surgical correction of Madelung’s deformity with conservation of the distal radioulnar joint in teenagers. J Hand Surg 2000;25B:22–25. Harley BJ, Brown C, Cummings K, Carter PR, Ezaki M. Volar ligament release and distal radius dome osteotomy for correction of Madelung’s deformity. J Hand Surg 2006;31A: 1499 –1506. Harley BJ, Carter PR, Ezaki M. Volar surgical correction of Madelung’s deformity. Tech Hand Up Extrem Surg 2002;6: 30 –35.
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. (J Hand Surg 2007;32A:1037–1042. Copyright © 2007 by the American Society for Surgery of the Hand.) Type of study/level of evidence: Therapeutic IV. Key words: Madelung’s deformity, ulnar osteotomy.
adelung’s deformity has various degrees of severity and functional impairment.1 Madelung’s deformity is a rare condition without any available assessment of its incidence or prevalence in the literature.2 It is defined as a characteristic pattern of anterior-ulnar bowing of the radius and a dorsally prominent ulnar head3 with a complex incongruency of the distal radioulnar joint (Fig. 1A, B; Fig. 2). The term anterior bowing is inappropriate, because in the pronated position, the direction of the bowing might be posterior. Nevertheless, it is commonly used in the literature. A partial closure of the distal radial growth plate may cause this specific deformity.4,5 It may be isolated or part of a syndrome such as dyschondrosteosis.6 – 8 It may be inherited with autosomal dominance and variable penetrance9,10 or may be sporadic.10 Clinical features are a dorsal prominence of the ulnar head and a certain degree of functional impairment.10,11 Range of
M
motion is decreased in flexion-extension, radial and ulnar deviation, and forearm rotation.10,11 The age of onset of the disease is reported to be late childhood or teenage years.11 Conservative treatment is not effective, failing to control or correct the deformity.11–13 Our aim is to describe a surgical procedure (isolated anterior angulation and shortening osteotomy of the ulna) to improve the appearance of the wrist and to relieve pain if present without compromising the function of the wrist in selected patients with mild forms of Madelung’s deformity who complain mainly about the appearance of their wrists. We report a short series of 4 wrists in 3 consecutive patients, with 24 months follow-up.
Materials and Methods The study design was retrospective. To be included in our series, patients had to meet the following criteria: to The Journal of Hand Surgery
1037
1038
The Journal of Hand Surgery / Vol. 32A No. 7 September 2007
extensor carpi ulnaris was dissected respecting a rectangular flap with a radial base in the dorsal carpal ligament for further dorsal stabilization. The ulnar shaft was shortened 6 cm proximal to the base of the styloid process and fixed using a contoured dynamic compression plate after anterior angulation and shortening osteotomy of the ulna (Fig. 3B). The amount of ulnar resection was planned on preoperative x-rays to bring the ulnar variance close to 0. A slight anterior tilt was performed to attempt a reduction of the distal radioulnar joint. The extensor carpi ulnaris was stabilized using the rectangular flap previously dissected. A protective cast preventing the forearm rotation was applied for 3 weeks. The plate was removed after the ulnar union was achieved. A postoperative view is shown in Figure 4A, B. In each patient, the following items were recorded: age at surgery, gender, involved side, preoperative and 24-months postoperative clinical and radiologic evaluation. The clinical evaluation was assessed preoperatively and postoperatively as follows: active pain-free range of motion in pronation, supination, flexion, extension, radial deviation, and ulnar deviation. Pain was assessed preoperatively and postoperatively using a personal pain score derived from the system described by Jiranek et al,14 modified from Cooney et al.15 In this comprehensive rating system, the pain is assessed using a 30-point score (Table 1). All of the patients completed the pain score 2 times: once prior to their surgery and another time at 24 months follow-up evaluation. Even-
Figure 1. Preoperative radiograph in a patient with Madelung’s deformity: (A) AP view, (B) lateral view.
be diagnosed with a mild form of Madelung’s deformity (with no lunate dislocation, but with volar tilt of the distal radius on the lateral radiograph of the wrist and with increased radial inclination on the anteroposterior radiograph of the wrist), to be skeletally mature, to have been operated on using the technique described in the current document, and to have a follow-up of at least 2 years. Four wrists in 3 consecutive patients were included. There were 1 man and 2 women. The mean age at surgery was 29 years, ranging from 27 to 32 years. Surgical Procedure All of the patients had the same surgical procedure. The distal third of the ulna and the radioulnar joint were reached through a dorsal approach, respecting the dorsal ulnar cutaneous nerve (Fig. 3A). The dislocated
Figure 2. Clinical preoperative appearance of the wrist in Madelung’s deformity (patient 2).
Glard et al / Ulnar Osteotomy in Madelung’s Deformity
1039
Figure 3. Intraoperative view (patient 2). (A) Dorsal approach of the distal ulnar third and the radioulnar joint. (B) Fixation using a contoured plate after anterior angulation and shortening osteotomy of the ulna.
tually, a tenderness at the distal ulna and at the distal radioulnar joint was looked for preoperatively and postoperatively. The radiologic evaluation was assessed preoperatively and postoperatively as follows: the distal radioulnar joint incongruency was assessed based on anteroposterior (AP) and lateral views of the involved wrist. On the lateral view, the distal radioulnar joint was defined as subluxated if less than 50% of the surface of the ulnar head was superimposed with the distal radius. A subluxated joint was noted “⫹,” and a nonsubluxated and nondislocated joint was noted “⫺.” The ulnar variance was assessed preoperatively and postoperatively according to the “project a line” technique described by Steyers and Blair.16 The angle of the distal ulna at the osteotomy site was assessed postoperatively on the lateral view. Satisfaction of patients postoperatively was assessed on the basis of their perception of the cosmetic result according to a personal rating system derived from the system described by Gangopadyay and Packer.17 Patients were asked to grade their wrists with a score between 0 and 10, based on the following factors: (a) length of the scar, (b) prominence of the radial head, (c) interference with activities of daily living, (d) how noticeable the deformity was to them, and (e) how noticeable the deformity was to others. Each item is rated as 0 (poor), 1 (medium), or 2 (good). A score of between 9 and 10 was classified as excellent, between 7
and 8 as good, between 5 and 6 as fair, and below 5 as poor. The comparison was made based on preoperative and 24 months follow-up data. Because of the very small size of the sample, a simple description without any statistical test was performed.
Results Overall results are shown in Table 2. The data indicated out that, at 24 months follow-up evaluation, the active pain-free range of motion in pronation and supination improved. Conversely, the active pain-free range of motion in flexion, extension, radial deviation, and ulnar deviation did not improve but did not worsen. The pain score was higher postoperatively (meaning an improvement in pain). A tenderness at the distal ulna and at the distal radioulnar joint was found in all cases preoperatively but in none postoperatively. The subluxation rate of the distal radioulnar joint was 100% preoperatively
Table 1. Pain Score Narcotic medication needed Pain every day Pain during gripping or impact loading Aching after heavy work Aching more than once a month Aching once a month or less No pain 0 ⫽ poor; 30 ⫽ excellent.
0 6 10 16 22 26 30
1040
The Journal of Hand Surgery / Vol. 32A No. 7 September 2007
Figure 4. Postoperative radiograph in patient 2 with Madelung’s deformity: (A) AP view, (B) lateral view.
and 0% at 24 months follow-up. The ulnar variance averaged ⫹4 mm preoperatively and ⫺1 mm postoperatively. The mean angle of the distal ulna at the osteotomy site was 17°. All of the patients were satisfied with the appearance of their wrists and their forearms at 24 months follow-up. At follow-up, all of the patients rated their wrists as good according to our personal satisfaction scale. The results of our personal satisfaction scale are given in Table 3.
Discussion The natural history of Madelung’s deformity toward osteoarthritis is not clear.11,18 Patients may suffer from osteoarthritis late in their lives.11,19 Nevertheless, the functional complaint is not common in patients with Madelung’s deformity. In these patients, the main motivation to have surgery is the appearance of the wrist.11 Conservative treatment is not effective, failing to control or correct the deformity.11–13 Many surgical procedures were described in the literature. Dobyns et al1 defined 3 groups of procedures in grown patients: radial procedures,20,21 ulnar procedures,22–26 and combined radial and ulnar procedures.20,22–28 Nevertheless, few procedures have been separately validated with a clinical series in the literature. To date, we found only 6 series in which postoperative results in patients with Madelung’s deformity are clearly given.10,11,20,23,24,29 The surgical procedure used is homogenous in only 3 of these series. Bruno et al20
published a retrospective series of 9 adult patients. All of them were suffering from ulnar-sided wrist pain. They all had the same procedure: an ulnar shortening osteotomy (without any attempt to reduce the distal radioulnar joint subluxation). The authors reported postoperative improvement in pain in all cases without any notable changes in the range of motion. The appearance of the wrist was not assessed in this work. dos Reis et al published a large series of 25 wrists in 18 patients.11 In 9 patients, the surgery was performed due to pain and disability. For the other 9 patients, it was done due to appearance. The procedure used was a radial wedge osteotomy, combined with an ulnar shortening. The authors showed a notable postoperative improvement in pain, appearance, forearm rotation and grip strength, and a slight improvement in the flexionextension range of motion. More recently, Harley et al published a series of 26 wrists in 18 patients.29 The surgical procedure used has been described in a previous work.30 It was a surgical release of the Vickers ligament (abnormal thickened volar ligament that tethers the lunate and the triangular fibrocartilage complex to the abnormal area of the volar-ulnar radial epiphysis and metaphysis) associated with a dome osteotomy of the distal radius. The authors showed improvement in pain, appearance of the wrist, forearm supination and wrist extension, with no loss of pronation or flexion. In
Glard et al / Ulnar Osteotomy in Madelung’s Deformity
Table 2. Overall Results Showing Range of Motion of the Wrist Pre- and Post-Operatively Patient
Pronation Preop Postop Supination Preop Postop Flexion Preop Postop Extension Preop Postop Radial deviation Preop Postop Ulnar deviation Preop Postop Pain Preop Postop Radioulnar dislocation Preop Postop
1
2
3
4
45 70
50 60
55 70
60 65
35 70
40 60
40 70
45 75
61 59
72 73
65 60
70 75
32 30
36 49
40 35
41 40
0 5
5 5
4 5
6 5
15 20
17 14
20 19
22 23
10 26
16 22
16 26
16 26
1 0
1 0
1 0
1 0
Preop, preoperatively; Postop, postoperatively.
the other 3 series available (Ranawat et al,23 Nielsen,24 and Murphy et al10), both radial and ulnar procedures were variably associated causing some confusion about the exact postoperative results. Our series is made of selected patients with mild forms of Madelung’s deformity without completely dislocated lunate bone. Pain was not a criterion for inclusion. Nevertheless, we do not perform pure cosmetic bone surgery. Therefore, all of the patients experienced some kind of wrist pain preoperatively, as shown in Table 1 (even if it was not their primary motivation to have surgery). All of the patients preoperatively had an ulnar-sided wrist pain and tenderness at the distal ulna and at the distal radioulnar joint. In these patients who complain mainly about the appearance of their wrists, we chose to perform a reduction osteotomy of the ulna diaphysis with anterior angulation aiming to reduce the radioulnar incongruency and thereby improve the appearance of the wrist. The exaggerated palmar and ulnar tilt of the distal radial joint surface is left undisturbed. The aim was not to restore the whole anatomy of the carpus but only to improve the distal radioulnar joint anatomy, appearance, and function. Our work assessed 4 points. Our results showed that
1041
there was a partial postoperative improvement in the range of motion, with a forearm rotation improvement, but without any effect on radial deviation, ulnar deviation, or flexion-extension. There was a postoperative improvement of the pain, there was a radiologic postoperative improvement of the distal radioulnar joint congruency, and overall there was an improvement of the appearance of the wrist without any deterioration of the appearance of the forearm at the osteotomy site. This simple procedure seems to be safe and reliable in selected patients with a mild form of Madelung’s deformity. Union occurred within 4 months in all cases. Although this was not the primary goal of this study, we observed that no remodeling of the osteotomy site of the ulna occurred during the follow-up period, and there was no change in the radiographic relationship of the radius and the ulna. Our series should not be compared with those of dos Reis et al11 and Harley et al,29 because our operative procedure focuses only on the distal ulna for Madelung’s deformity, whereas dos Reis et al11 used a combined radial and ulnar procedure and Harley et al29 used a radial osteotomy associated with a release of the Vickers ligament. Thus, the only series available in the literature giving some postoperative results after isolated ulnar procedure for comparison is the one by Bruno et al.20 For the function of the wrist, our procedure seems to have some similar outcomes than the one described by Bruno et al20: there is no dramatic postoperative change in the range of motion, but the pain is relieved. Our work assessed the cosmetic outcomes, which Bruno et al20 did not, and patients in our series were satisfied with the appearance of their wrists. The restricted range of motion in flexion-extension is not the main complaint in these selected patients. We think that this procedure may be useful in selected patients with a mild form of Madelung’s deformity who complain mostly about the appearance of their wrists but are satisfied with its function. It is very important to highlight that this simple procedure is suitable for mild Table 3. Satisfaction Scale Patient
Length of the scar Prominence of the radial head Interference with activities of daily living How noticeable the deformity is to the patient How noticeable the deformity is to others Total
1
2
3
4
0 2
1 2
1 1
0 2
2
2
2
2
2
1
1
2
2 8
2 8
2 7
2 8
1042
The Journal of Hand Surgery / Vol. 32A No. 7 September 2007
forms of Madelung’s deformity, and we do not recommend performing it in case of severe Madelung’s deformity with a completely dislocated lunate. We have the feeling that these patients mainly complain about the prominence of their ulnar head. They do not want to know if the distal radioulnar joint is dislocated or subluxated. The only thing they see is that their wrist has a hump on the ulnar side, and they want it off. We have the feeling that the operation we are reporting addresses this issue without compromising the function of the wrist. Further investigations with a larger sample of patients must be performed to assess the clinical effectiveness of this procedure, but this preliminary study indicated that our procedure seems to be safe and has not generated any postoperative joint stiffness or pain at 24 months follow-up in these patients with mild Madelung’s deformity.
11.
12.
13. 14.
15.
16. 17.
18. Received for publication January 19, 2007; accepted in revised form May 17, 2007. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Corresponding author: Dr. Yann Glard, Department of Plastic and Reconstructive Surgery, Hôpital de la Conception, 147 Bd Baille, 13005 Marseille, France; e-mail: [email protected]. Copyright © 2007 by the American Society for Surgery of the Hand 0363-5023/07/32A07-0015$32.00/0 doi:10.1016/j.jhsa.2007.05.015
References 1. Dobyns JH, Doyle JR, Von Gillern TL, Cowen NJ. Congenital anomalies of the upper extremity. Hand Clin 1989;5: 321–342; discussion 339 –340. 2. Flatt AE. A test of a classification of congenital anomalies of the upper extremity. Surg Clin North Am 1970;50:509 –516. 3. Arora AS, Chung KC, Otto W. Madelung and the recognition of Madelung’s deformity. J Hand Surg 2006;31A:177– 182. 4. Vickers D, Nielsen G. Madelung deformity: surgical prophylaxis (physiolysis) during the late growth period by resection of the dyschondrosteosis lesion. J Hand Surg 1992; 17B:401– 407. 5. Munns CF, Glass IA, LaBrom R, Hayes M, Flanagan S, Berry M, et al. Histopathological analysis of Leri-Weill dyschondrosteosis: disordered growth plate. Hand Surg 2001;6:13–23. 6. Felman AH, Kirkpatrick JA Jr. Madelung’s deformity: observations in 17 patients. Radiology 1969;93:1037–1042. 7. Golding JS, Blackburne JS. Madelung’s disease of the wrist and dyschondrosteosis. J Bone Joint Surg 1976;58B:350 – 352. 8. Gelberman RH, Bauman T. Madelung’s deformity and dyschondrosteosis. J Hand Surg 1980;5A:338 –340. 9. Mohan V, Gupta RP, Helmi K, Marklund T. Leri-Weill syndrome (dyschondrosteosis): a family study. J Hand Surg 1988;13B:16 –18. 10. Murphy MS, Linscheid RL, Dobyns JH, Peterson HA. Ra-
19.
20.
21.
22.
23.
24.
25. 26. 27.
28.
29.
30.
dial opening wedge osteotomy in Madelung’s deformity. J Hand Surg 1996;21A:1035–1044. dos Reis FB, Katchburian MV, Faloppa F, Albertoni WM, Laredo Filho J Jr. Osteotomy of the radius and ulna for the Madelung deformity. J Bone Joint Surg 1998;80B:817– 824. Henry A, Thorburn MJ. Madelung’s deformity. A clinical and cytogenetic study. J Bone Joint Surg 1967;49B: 66 –73. Lamb D. Madelung deformity. J Hand Surg 1988;13B:3– 4. Jiranek WA, Ruby LK, Millender LB, Bankoff MS, Newberg AH. Long-term results after Russe bone-grafting: the effect of malunion of the scaphoid. J Bone Joint Surg 1992; 74A:1217–1228. Cooney WP, Bussey R, Dobyns JH, Linscheid RL. Difficult wrist fractures. Perilunate fracture-dislocations of the wrist. Clin Orthop Relat Res 1987:136 –147. Steyers CM, Blair WF. Measuring ulnar variance: a comparison of techniques. J Hand Surg 1989;14A:607– 612. Gangopadhyay S, Packer G. A comparative study between longitudinal and “T” incisions for dorsal plating of the distal radius. J Hand Surg 2003;28B:568 –570. Mansat M, Lebarbier P, Cahuzac JP, Gay R, Pasquie M. [Madelung’s disease. A study of nine wrists operated on (author’s transl)]. Ann Chir 1979;33:669 – 675. Schmidt-Rohlfing B, Schwobel B, Pauschert R, Niethard FU. Madelung deformity: clinical features, therapy and results. J Pediatr Orthop B 2001;10:344 –348. Bruno RJ, Blank JE, Ruby LK, Cassidy C, Cohen G, Bergfield TG. Treatment of Madelung’s deformity in adults by ulna reduction osteotomy. J Hand Surg 2003;28A:421– 426. Fernandez DL, Capo JT, Gonzalez E. Corrective osteotomy for symptomatic increased ulnar tilt of the distal end of the radius. J Hand Surg 2001;26A:722–732. Darrow JC Jr, Linscheid RL, Dobyns JH, Mann JM III, Wood MB, Beckenbaugh RD. Distal ulnar recession for disorders of the distal radioulnar joint. J Hand Surg 1985; 10A:482– 491. Ranawat CS, DeFiore J, Straub LR. Madelung’s deformity. An end-result study of surgical treatment. J Bone Joint Surg 1975;57A:772–775. Nielsen JB. Madelung’s deformity. A follow-up study of 26 cases and a review of the literature. Acta Orthop Scand 1977;48:379 –384. Matev I, Karagancheva S. The Madelung deformity. Hand 1975;7:152–158. Watson HK, Pitts EC, Herber S. Madelung’s deformity. A surgical technique. J Hand Surg 1993;18B:601– 605. White GM, Weiland AJ. Madelung’s deformity: treatment by osteotomy of the radius and Lauenstein procedure. J Hand Surg 1987;12A:202–204. Salon A, Serra M, Pouliquen JC. Long-term follow-up of surgical correction of Madelung’s deformity with conservation of the distal radioulnar joint in teenagers. J Hand Surg 2000;25B:22–25. Harley BJ, Brown C, Cummings K, Carter PR, Ezaki M. Volar ligament release and distal radius dome osteotomy for correction of Madelung’s deformity. J Hand Surg 2006;31A: 1499 –1506. Harley BJ, Carter PR, Ezaki M. Volar surgical correction of Madelung’s deformity. Tech Hand Up Extrem Surg 2002;6: 30 –35.