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Orthogonal Plate Fixation With Corrective Osteotomy for Treatment of Distal Radius Fracture Malunion
SCIENTIFIC ARTICLE
Orthogonal Plate Fixation With Corrective Osteotomy for Treatment of Distal Radius Fracture Malunion Michael P. Gaspar, MD,* Jenniefer Y. Kho, MD,*† Patrick M. Kane, MD,* Hesham M. Abdelfattah, MD,*‡ Randall W. Culp, MD*
Purpose To report outcomes of patients with distal radius fracture malunions treated with corrective osteotomy and orthogonal volar and radial “90-90” plate fixation. Methods We performed a retrospective review of all patients who underwent distal radius corrective osteotomy and 90-90 fixation from January 2008 through December 2014. Demographic data, injury history, prior treatments, and clinical examination values were recorded. Preoperative radiographic measurements were used to classify the type and severity of deformity. The outcomes were patient-reported pain levels, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) functional scores, and radiographic outcomes. Secondary outcomes, including complications and the need for additional surgeries, were also noted. Results Thirty-nine cases (31 extra-articular, 8 combined intra- and extra-articular) were included. At mean postoperative follow-up interval of 4 years, significant improvements were observed clinically in wrist flexion-extension arc, grip strength, pain, and Quick Disabilities of the Arm, Shoulder, and Hand scores. Radiographically, significant postoperative improvements were noted in ulnar variance, radial inclination, intra-articular stepoff, and radial tilt, with volarly and dorsally angulated malunions corrected to 9 and 7 of volar tilt, respectively. Twelve patients (31%) underwent additional surgery, the most common being plate removal in 7 patients, 3 of which involved removal of the radial plate. Conclusions For patients with symptomatic malunion of the distal radius, corrective osteotomy with 90-90 plate fixation is an effective treatment option for improving pain and restoring function for both volarly and dorsally angulated malunions, including malunions with an intraarticular component. (J Hand Surg Am. 2017;42(1):e1ee10. Copyright Ó 2017 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Chronic deformity, corrective osteotomy, distal radius fracture malunion, orthogonal 90-90 plate fixation, radial- and volar-sided plating.
From *The Philadelphia Hand Center, PC, Department of Orthopedic Surgery, Thomas Jefferson University Hospitals; the ‡Department of Orthopaedic Surgery and Sports Medicine, Temple University Health System, Philadelphia, PA; and the †Division of Orthopedic Surgery, Sutter Gould Medical Foundation, Modesto, CA. Received for publication January 28, 2016; accepted in revised form October 23, 2016. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Michael P. Gaspar, MD, The Philadelphia Hand Center, PC, The Franklin, Suite G114, 834 Chestnut St., Philadelphia, PA 19107; e-mail: michaelpgaspar@ gmail.com. 0363-5023/17/4201-0013$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2016.10.012
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among the most commonly occurring of all fractures and are responsible for considerable public health and economic burden.1e7 Over recent decades, as implant technologies and fixation techniques have continued to evolve, the number of DRF treated surgically has increased.8 However, despite these advances, the risk of developing complications following initial treatment of DRF persists, most notably including posttraumatic arthritis, median nerve compression, symptomatic hardware, tendon rupture, and fracture malunion.9e14 ISTAL RADIUS FRACTURES (DRF) ARE
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DISTAL RADIUS MALUNION 90-90 PLATING
Malunions can occur following either nonsurgical management or failed surgical treatment, and may result in progressive pain and disability.15e21 For those patients with symptomatic DRF malunions, surgical intervention with corrective osteotomy is generally the treatment of choice. A variety of surgical approaches and osteotomy techniques with generally favorable outcomes have been reported in the setting of DRF malunions.22e33 However, the generalizability of such techniques remains unclear because most techniques are described to address malunions of a specific fracture pattern. The primary goal of this study is to report outcomes of distal radius corrective osteotomy with 90-90 fixation for treatment of symptomatic fracture malunion.
administered, along with standard preoperative antibiotics. A pneumatic tourniquet was used. An 8-cm incision was made over the flexor carpi radialis tendon beginning at the wrist crease and carried proximally, utilizing the previous incision for those patients who had previously undergone surgical fixation. The interval between the flexor carpi radialis and the radial artery was identified. The pronator quadratus was released along its distal and radial borders for later repair, followed by release of the brachioradialis from the radial styloid. For cases involving an intra-articular component, an osteotomy was performed parallel to the long axis of the radius, beginning with a microsagittal saw, followed by a small osteotome and mallet for completion of the osteotomy. The depressed intraarticular fragment was then elevated to restore articular congruity and temporarily fixed with 0.045 K-wire. Attention was then turned to the extra-articular malunion as a separate opening wedge osteotomy was performed parallel to the joint line at the level of the previous fracture. For dorsally angulated malunions, a dorsal opening wedge osteotomy was performed (Fig. 1A), while a volar opening wedge osteotomy was created for volarly angulated malunions. Once the osteotomy was created, a volar locking plate was fixed first to the distal fragment only, allowing use of the plate as a joystick to reduce the distal fragment to the radial shaft via the proximal portion of the plate (Fig. 1B). When alignment appeared satisfactory following this reduction maneuver, a cortical screw was provisionally placed through the proximal plate into the radius to maintain reduction. At this point, alignment was confirmed fluoroscopically, and the volar plate was affixed to the radius by completing standard screw placement including through the intra-articular fragment, if present. Once the volar plate was in place, the osteotomy site was visualized fluoroscopically as the wrist was gently ranged in flexion-extension, radialto-ulnar deviation, and pronosupination. With attention then turned to the radial aspect of the osteotomy, the tendons of the first dorsal extensor compartment were elevated subperiosteally and protected via the same surgical incision, although a formal release of the compartment was not routinely performed. Branches of the superficial radial nerve were similarly identified and protected. The radial-sided locking plate was positioned at 90 from the volar plate in the axial plane, with bicortical nonlocking screws placed proximally and unicortical locking screws distally to position the plate in buttress mode (Fig. 1C). Proper alignment was again confirmed fluoroscopically, and
MATERIALS AND METHODS This study was approved by our institutional review board. Using our departmental electronic billing database search for Current Procedural Terminology codes 25350 (Osteotomy, distal third of radius), 25400 (Repair of nonunion or malunion, radius OR ulna; without graft), and 25405 (Repair of nonunion or malunion, radius OR ulna; with iliac or other autograft), we identified all patients who underwent corrective osteotomy of the distal radius with volarand radial-sided orthogonal (90-90) fixation at our institution from January 2008 through December 2014. All surgeries were performed by the senior author (R.W.C.), a fellowship-trained orthopedic hand and upper extremity surgeon. Surgical indications Patients were considered surgical candidates if (1) they exhibited pain and disability consistent with the observed malunion, (2) they had no appreciable radiocarpal arthrosis on preoperative radiographs, and (3) their deformity met at least 1 of the following radiographic criteria: (a) radial inclination less than 15 , (b) volar tilt greater than 25 or dorsal tilt greater than 20 , (c) ulnar variance greater than 5 mm, or (d) intra-articular stepoff greater than 2 mm. In addition to these radiographic guidelines, patients’ bone quality and the age of the fracture malunion were used in the decision to perform 90-90 fixation. From our prior experience, we found that, in addition to radiographic deformity, poor bone quality and longstanding malunions (> 6 months from injury) were most predictive of failure of volar plating alone. Surgical technique and postoperative protocol The patient was placed in the supine position and general anesthesia with regional blockade was J Hand Surg Am.
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DISTAL RADIUS MALUNION 90-90 PLATING
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FIGURE 1: Schematic representation of a malunited distal radius fracture treated with corrective osteotomy and 90-90 plate fixation. A Before surgery, the patient presents with ulnar positivity owing to shortening of the radius and dorsal angulation. A microsagittal saw and osteotome are used to re-create the fracture at the malunion site. B With the plate first fixed distally only, the surgeon can then maneuver the proximal portion of the plate (green arrows) in order to rotate the distal fragment (orange arrows) and correct the deformity in both the anteroposterior and lateral planes. C With the deformity corrected, the reduction is maintained by completing screw fixation through the volar plate. Next, the radial-sided locking plate is positioned at 90 from the volar plate, typically using bicortical nonlocking screws proximally and unicortical locking screws distally.
the wrist flexion-extension and forearm rotation arcs were examined to rule out impingement secondary to hardware placement. At that time, the bone graft or substitute of choice was placed into the osteotomy site through the volar-radial interval formed between the 2 plates. Nonstructural bone graft or substitute was used in all index surgeries (1 case of recalcitrant nonunion required revision during which structural autograft was used, and is discussed later). Following bone graft or graft substitute placement, repair of the pronator quadratus was performed. After surgery, the patient was placed in a bulky volar orthosis and transitioned to a forearm-based wrist orthosis at the time of suture removal, generally at 10 to 14 days from surgery. At that time, formal therapy was initiated with gentle passive range of motion exercises of the wrist progressing to active range of motion over the next 4 to 6 weeks. At 6 to 8 J Hand Surg Am.
weeks, strengthening exercises were incorporated into the rehabilitation regimen. Data collection Demographic data for study patients was obtained from departmental records including patient age, gender, handedness, and medical comorbidities. Information regarding the initial injury or condition was also recorded, including injury mechanism, initial treatment, and the time interval from initial treatment to reevaluation at our center. Patient-reported variables obtained via chart review were visual analog scale (VAS) erated pain levels (0 ¼ no pain, 10 ¼ worst pain imaginable) and Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) scores. Clinical examination measurements were wrist flexionextension arc (WFE), forearm rotation arc (FR), and grip strength measured by Jamar dynamometer r
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DISTAL RADIUS MALUNION 90-90 PLATING
FIGURE 2: A Preoperative anteroposterior, oblique, and lateral radiographs of the dominant right wrist of a 63-year-old woman who sustained a distal radius fracture after falling out of a chair more than 4 years prior to presentation at our clinic. B Owing to the longstanding nature of her malunion, radial tilt could only be corrected to neutral, as evident on immediate postoperative radiographs. C The patient ultimately underwent removal of her symptomatic hardware, as seen on her radiographs taken 58 months after corrective osteotomy.
(Lafayette Instrument Company, Inc., Lafayette, IN). Per our institution standards, grip strength was documented as the mean of 3 attempts on settings II and III for females and males, respectively. Surgical details including the type of bone graft used and concomitant procedures were recorded. Radiographic data including direction and degree of radial tilt, radial inclination, ulnar variance, and articular stepoff (for those malunions with an intra-articular component) were recorded from standard posteroanterior and lateral radiographs, as measured by a fellowshiptrained attending orthopedic hand surgeon who was not the treating surgeon. For the purpose of data analysis, patients were classified according to the direction of radial tilt measured on the preoperative lateral radiographs into either volar or dorsal J Hand Surg Am.
subgroups (Fig. 2). Patients were contacted by telephone and invited to return to our clinic for follow-up, where interval history, VAS-rated pain and QuickDASH outcomes, repeat examination, and follow-up radiographs were prospectively obtained. For the patients who were unable to return to clinic, VAS-rated pain levels, QuickDASH scores, and interval histories were obtained over the phone, and clinical examination and radiographic measures from their most recent visits were used in analysis. Statistical analysis Descriptive statistics were obtained for the patient cohort as a whole and for the volar and dorsal subgroups. Bivariate analysis with paired t testing was utilized to compare pre- and postoperative VAS, r
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QuickDASH, WFE, FR, and grip strength, as well as degree of tilt and ulnar variance. Secondary outcomes included the development of complications and the need for additional or revision surgery.
TABLE 1. Demographic and Descriptive Data for the Study Cohort
RESULTS Descriptive Analysis Forty-eight cases of orthogonal plating of the distal radius were identified via chart review, of which 9 were excluded for the following reasons: 4 cases were DRF nonunions that were revised with the addition of the radial-sided plate, 2 cases were for correction of Madelung deformities, 2 cases were for treatment of acute DRF, and 1 case was a revision of a refracture through a giant cell tumor of the distal radius. The remaining 39 patients (mean age, 53 14 years) met the inclusion criteria, of which 32 patients returned to clinic for in-person evaluation. The 7 patients who were not able to return to clinic completed follow-up over the telephone. Twenty-four cases were performed in females and 15 in males. Twenty-one cases involved the nondominant extremity. The median time interval from initial treatment to surgery for all patients was 7 months (range, 3e143 months), and the mean follow-up duration was 48 24 months (range, 13e89 months). The primary reason for seeking surgery for all 39 patients was pain. Seven patients also complained of median nerveerelated symptoms before surgery and underwent a carpal tunnel decompression at the time of their osteotomy. All patients were seen as secondary referrals to our institution; initial management of their injury had been performed elsewhere. Thirty patients presented with dorsal angulation on lateral preoperative radiographs, and the remaining 9 were volarly angulated. Thirty-one malunions were extra-articular involving the metaphysis alone, and the remaining 8 had both an extra-articular and an intra-articular component. The mean preoperative ulnar variance was 4.5 2.7 mm (Table 1). Significant improvements were demonstrated in WFE, grip strength as measured by dynamometer, VAS pain scores, and mean QuickDASH scores (Table 2). Ulnar variance decreased significantly across the full cohort, whereas radial inclination increased significantly in the dorsal malunion subgroup only (Table 3). Radial tilt demonstrated significant in both malunion subgroups. For the 8 patients with preoperative articular incongruency, intra-articular stepoff was significantly improved by a mean of 2.5 mm (P < .05). Although no patients had signs of radiocarpal degeneration on preoperative
Age (y)
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Variable
All Fracture Malunions (n ¼ 39) 53 14
Gender Male
15
Female
24
Dominant extremity? Yes
18
No
21
Direction of angulation Dorsal
30
Volar
9
Joint involvement Extra-articular only Combined intra-/extra-articular
31 8
Initial treatment Nonsurgical
23
Surgical
16
ORIF
10
CRPP
4
Ex-fix
1
ORIF þ Ex-fix
1
CRPP, closed reduction with percutaneous pinning; Ex-fix, external fixation; ORIF, open reduction internal fixation.
radiographs, 6 had mild-to-moderate degeneration on follow-up. Twelve patients underwent at least 1 subsequent operation at mean interval of 7 4 months from the index 90-90 fixation procedure. Eleven of those patients required 1 additional surgery, and 1 patient required 2 separate operations due to nonunion at his osteotomy site (Table 4). That patient was a 39-year old man who was referred to our center with a malunited distal radius in 30 of dorsal tilt and positive ulnar variance of 5 mm. After corrective osteotomy with 90-90 fixation and placement of autologous cancellous iliac crest bone graft (ICBG), serial follow-up imaging demonstrated radiographic signs of hardware failure and progressive loss of reduction. At 5 months after surgery, revision 90-90 plating with placement of corticocancellous ICBG and osteogenic protein-1 was performed. Subsequently, although the hardware remained intact and alignment of the osteotomy was maintained on radiographs, there were no signs of bony healing. At that time, the patient disclosed a longstanding 2 pack-per-day smoking r
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DISTAL RADIUS MALUNION 90-90 PLATING
TABLE 2.
Pre- and Postoperative Comparison of Clinical Outcomes for the Full Study Cohort
Variable
Preoperative
WFE ( ) FR ( )
Postoperative
P Value
85 22
103 23
< .05
140 40
153 24
.054
Grip strength (pounds)
38 26
56 24
< .05
VAS
6.9 1.6
2.9 1.0
< .05
QuickDASH
55 16
20 9
< .05
TABLE 3. Pre- and Postoperative Comparison of Radiographic Measures Based on Direction of Preoperative Fracture Malunion Dorsally Angulated Malunions (n ¼ 30) Radiographic Variable Tilt ( )*
Preoperative
Postoperative
e25 9
Volarly Angulated Malunions (n ¼ 9)
P Value
Preoperative
75
< .05
31 8
Postoperative
P Value
94
Radial inclination ( )
17 5
22 3
< .05
24 9
25 2
Ulnar variance (mm)
4.6 2.3
e0.3 1.4
< .05
4.3 3.7
e1.1 1.8
< .05 .84 < .05
*Preoperative dorsal tilt is represented by a negative value.
TABLE 4.
Postoperative Complications and Subsequent Surgeries for Entire Study Cohort Complication
Procedure
Number Performed
Symptomatic hardware
Removal of hardware Volar only Radial only Volar and radial
7 4 2 1
Ulnar impingement
Ulnar-shortening osteotomy
3
De Quervain syndrome
First extensor compartment release
3
Wrist contracture
Wrist capsulectomy
2
Flexor tendon adhesions
Tenolysis
2
Recurrent carpal tunnel syndrome
Revision carpal tunnel release
2
Mild, persistent wound drainage
Irrigation and debridement, wound closure
2
DRUJ instability
DRUJ reconstruction with palmaris longus tendon autograft
1
1. Hardware failure, osteotomy nonunion 2. Osteotomy nonunion
1. Revision volar plating with nonunion takedown 2. Revision volar and radial plating with nonunion takedown and placement of cancellous ICBG
1*
DRUJ, distal radioulnar joint. *Last patient underwent 2 consecutive revision surgeries.
the final revision surgery. In 2 additional patients, drainage from 0.5-cm areas of wound dehiscence were noted after surgery. Although neither patient developed any clinical signs or symptoms of infection, both patients were returned to the operating room for formal irrigation and wound closure; they healed uneventfully afterward.
history. Despite aggressive attempts at smoking cessation and use of a bone stimulator, no appreciable signs of healing were seen on serial radiographs, and a second revision was performed 11 months from index 90-90 fixation with addition of autologous cancellous ICBG, osteogenic protein-1; this eventually demonstrated full bone union at 10 months from
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TABLE 5.
Study
Summary Comparing Prior Recent Investigations of Corrective Osteotomy of Distal Radius Fracture Malunions
Design/ Methods
Approach, Technique and Plating Configurations studied
Fracture Pattern(s)
Patients Studied (n)
Mean Patient Age, y (range)
Mean Injury to Surgery Interval, mo (range)
Mean FollowUp, mo (range)
Prior Treatment Course
Outcomes*
Complications
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Retrospective chart review with prospective follow-up Single surgeon
39 31 extra(15 M, 24 articular, F) 8 Extra- þ intraarticular Volar and dorsal angulated
53 (18e86)
14 Median ¼ 7 (3e143)
48 (13e89)
23 Nonsurgical 16 Surgical
(See Table 3 for Improved: details) WFE Grip strength Ulnar variance Volar/dorsal angulation Radial inclination Articular incongruity Mean VAS pain Mean QuickDASH
Buijze et al, 201228†
18 All 18 extra- þ Highly variable Retrospective intra-articular (11 M, 7 F) chart review Dorsal and/or volar approach Volar and dorsal with angulated Single- or doubleprospective plate fixation follow-up 4 Surgeons from 4 centers
43 (20e67)
9 Median ¼ 7 (3e29)
78 (24e134)
Unclear
Hardware Improved: removed in 10 WFE patients Wrist pronosupination De Quervain in 3 patients Radial/ulnar (managed deviation nonsurgically) Grip strength Extensor tendon Ulnar variance rupture in 1 Volar/dorsal patient w/ angulation double dorsal Articular plating incongruity Mean postoperative VAS, 1 Mean postoperative DASH, 11
Sato et al, 200926
Retrospective chart review; multiple surgeons
28 (17 M, 11 F)
41 (13e80)
11 (2e96)
25 (12-60)
19 Nonsurgical 9 Surgical
Improved: WFE Wrist pronosupination Grip strength Ulnar variance
Orthogonal volar þ radial plating
Volar plating with All 28 extraopening wedge articular osteotomy All volarly angulated
DISTAL RADIUS MALUNION 90-90 PLATING
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Current study
1 Patient with transient median nerve symptoms
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(Continued)
Study
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TABLE 5.
Summary Comparing Prior Recent Investigations of Corrective Osteotomy of Distal Radius Fracture Malunions (Continued)
Design/ Methods
Approach, Technique and Plating Configurations studied
Fracture Pattern(s)
Patients Studied (n)
Mean Patient Age, y (range)
Mean Injury to Surgery Interval, mo (range)
Mean FollowUp, mo (range)
Prior Treatment Course
Outcomes*
Complications
Volar angulation Mean VAS pain Mean JSSH-DASH
Ring et al, 200527†
Highly variable Retrospective chart review Dorsal and/or volar Approach with Screw, K-wire or prospective plate fixation follow-up Surgeons from 4 centers
Volar plating with All 4 extraopening wedge articular osteotomy All dorsally angulated
4M
12 (3e30)
14 (9e23)
3 Nonsurgical 1 Surgical
1 Periprosthetic Improved‡: fracture after a Volar tilt fall Note: Quantitative improvements in WFE pronosupination grip strength, DASH scores, VAS pain, radial inclination, and ulnar variance not shown to be of statistical significance, likely due in part to small sample size
37 (18e67)
6 (3e14)
38 (24e102)
14 Nonsurgical 9 Surgical
Improved: WFE Wrist pronosupination Radial/ulnar deviation Grip strength Ulnar variance Articular incongruity
r
57 (16e76)
Vol. 42, January 2017 23 17 Intra(16 M, 7 F) articular 6 Extra- þ intraarticular; Volar and dorsal angulated
DASH, Disabilities of the Arm, Shoulder, and Hand; JSSH, Japanese Society for Surgery of the Hand. *Outcomes are listed as “improved” if they were reported to be statistically significant by the study authors. †The later study by Buijze et al, 2012,28 includes the 6 patients with combined intra- and extra-articular malunions from Ring et al in 2005.27 ‡These are based off our own analysis of the authors’ provided data, using Mann-Whitney U testing to compare pre- and postoperative nonparametric outcomes.
None specified Progression of radiocarpal arthrosis in 10 patients
DISTAL RADIUS MALUNION 90-90 PLATING
Retrospective chart review
J Hand Surg Am.
Malone et al, 200629
DISTAL RADIUS MALUNION 90-90 PLATING
DISCUSSION Distal radius fracture malunions continue to represent a troublesome subset of complications often requiring further surgical intervention.15e21 Although malunion following DRF has been reported in as many as onequarter of those treated nonsurgically, the risk of malunion after surgical treatment also remains surprisingly high, with reported incidences ranging from 4% to 10%.34 Surgical treatment options for DRF malunions are numerous and depend largely on the pattern and severity of underlying deformity as well the presence or absence of articular involvement.22e33 Thus, although prior studies of corrective osteotomies for DRF malunions demonstrate mostly positive outcomes, those that utilized a single standard technique tended to treat 1 specific pattern.22e30 Similarly, those studies involving more heterogeneous patterns of DRF malunions did not generally utilize a standard approach (Table 5). Conversely, we have found that the technique we describe here allows for treatment of a wider range of malunion patterns than other methods of internal fixation, despite using a standard volar approach and the same plate configuration. Thus, although our outcomes were not superior to those of previous DRF corrective osteotomy studies, the ability to utilize the same plate configuration via standard volar approach regardless of the malunion orientation or articular involvement may be an attractive option to surgeons. Although not previously discussed in the setting of DRF malunion correction, the utility of the 90-90 radial-volar construct has been demonstrated clinically for the treatment of acute DRF with a radial column/styloid component or severe comminution.35e37 In all 3 reported series, the authors performed a volar approach and first plated the fractures volarly, adding the styloid plate only if reduction was inadequate with volar plating alone. Thus, despite their positive outcomes, it is difficult to assess their results without a control group treated with volar plating alone. In addition, limited, biomechanical testing of this construct has been supportive to date, with studies demonstrating that the 90-90 construct as significantly stiffer, stronger, and more resistant to fragment displacement than volar plating alone.38,39 The clinical importance of this increased stiffness is debatable, but it is likely to serve a role particularly when structural bone graft is not utilized. Plate removal was the most commonly performed secondary surgery, of which 3 cases (8%) involved De Quervainetype symptoms related to the radial-sided plate. We did not elect to release the first extensor
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compartment at the time of osteotomy fixation owing to concerns that the tendons may become irritated by direct contact with the radial-sided plate. Given that all 3 cases resolved with a first extensor compartment release and plate removal, performing a first compartment release as a standard prophylactic measure at the time of 90-90 fixation may warrant consideration, although it is difficult to predict if doing so would predispose the tendons to irritation from the plate. This study has a number of notable limitations, including its retrospective nature, which requires that we rely on clinical documentation. Another notable limitation was that 7 patients were unable to followup in person. Although outcomes were obtained via telephone, these data are less likely to be reliable than if obtained in person. Furthermore, because some data could not be obtained on the phone, there is the possibility that values obtained previously regarding range of motion, grip strength, and radiographic parameters had changed in the interim. These drawbacks would be remedied by a prospective study. Another limitation is the use of plain radiographs to measure preoperative deformity and subsequent correction, particularly when determining intraarticular stepoff, which is obscured by hardware. Furthermore, because it is not possible to blind the reviewer to pretreatment versus posttreatment radiographs, there is potential for bias in measuring these outcomes. Finally, the most important limitation is likely the lack of a control group. Without this comparison group of patients treated with volar plating alone, it is difficult to determine if outcomes following 90-90 plating warrant the additional risk of symptoms related to the radial plate. Despite the limitations of this study, we feel that the results show that corrective osteotomy of the distal radius with 90-90 fixation effectively treats pain and restores function in patients with symptomatic volarly or dorsally angulated malunions of the distal radius, with or without an intra-articular component. Future studies that directly compare this method with existing techniques of DRF malunion correction are needed to determine if it warrants use in larger populations. REFERENCES 1. Karl JW, Olson PR, Rosenwasser MP. The epidemiology of upper extremity fractures in the United States, 2009. J Orthop Trauma. 2015;29(8):e242ee244. 2. Ootes D, Lambers KT, Ring DC. The epidemiology of upper extremity injuries presenting to the emergency department in the United States. Hand (N Y). 2012;7(1):18e22.
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DISTAL RADIUS MALUNION 90-90 PLATING
23. Lozano-Calderon S, Moore M, Liebman M, Jupiter JB. Distal radius osteotomy in the elderly patient using angular stable implants and Norian bone cement. J Hand Surg Am. 2007;32(7): 976e983. 24. Tarng YW, Yang SW, Hsu CJ. Palmar locking plates for corrective osteotomy of latent malunion of dorsally tilted distal radial fractures without structural bone grafting. Orthopedics. 2011;34(6):178. 25. Mahmoud M, El Shafie S, Kamal M. Correction of dorsallymalunited extra-articular distal radial fractures using volar locked plates without bone grafting. J Bone Joint Surg Br. 2012;94(8): 1090e1096. 26. Sato K, Nakamura T, Iwamoto T, Toyama Y, Ikegami H, Takayama S. Corrective osteotomy for volarly malunited distal radius fracture. J Hand Surg Am. 2009;34(1):27e33. 33.e1. 27. Ring D, Prommersberger KJ, González del Pino J, Capomassi M, Slullitel M, Jupiter JB. Corrective osteotomy for intra-articular malunion of the distal part of the radius. J Bone Joint Surg Am. 2005;87(7):1503e1509. 28. Buijze GA, Prommersberger KJ, González Del Pino J, Fernandez DL, Jupiter JB. Corrective osteotomy for combined intraand extra-articular distal radius malunion. J Hand Surg Am. 2012;37(10):2041e2049. 29. Malone KJ, Magnell TD, Freeman DC, Boyer MI, Placzek JD. Surgical correction of dorsally angulated distal radius malunions with fixed angle volar plating: a case series. J Hand Surg Am. 2006;31(3): 366e372. 30. Del Piñal F, Garcia-Bernal FJ, Studer A, Regalado J, Cagigal L. Sagittal rotational malunions of the distal radius: the role of pure derotational osteotomy. J Hand Surg Eur Vol. 2009;34(2): 160e165. 31. Thivaios GC, McKee MD. Sliding osteotomy for deformity correction following malunion of volarly displaced distal radial fractures. J Orthop Trauma. 2003;17(5):326e333. 32. Kunz M, Ma B, Rudan JF, Ellis RE, Pichora DR. Image-guided distal radius osteotomy using patient-specific instrument guides. J Hand Surg Am. 2013;38(8):1618e1624. 33. Schweizer A, Fürnstahl P, Nagy L. Three-dimensional correction of distal radius intra-articular malunions using patient-specific drill guides. J Hand Surg Am. 2013;38(12):2339e2347. 34. Margaliot Z, Haase SC, Kotsis SV, Kim HM, Chung KC. A metaanalysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures. J Hand Surg Am. 2005;30(6): 1185e1199. 35. Helmerhorst GT, Kloen P. Orthogonal plating of intra-articular distal radius fractures with an associated radial column fracture via a single volar approach. Injury. 2012;43(8):1307e1312. 36. Tang P, Ding A, Uzumcugil A. Radial column and volar plating (RCVP) for distal radius fractures with a radial styloid component or severe comminution. Tech Hand Up Extrem Surg. 2010;14(3): 143e149. 37. Jacobi M, Wahl P, Kohut G. Repositioning and stabilization of the radial styloid process in comminuted fractures of the distal radius using a single approach: the radio-volar double plating technique. J Orthop Surg Res. 2010;5:55. 38. Grindel SI, Wang M, Gerlach M, McGrady LM, Brown S. Biomechanical comparison of fixed-angle volar plate versus fixedangle volar plate plus fragment-specific fixation in a cadaveric distal radius fracture model. J Hand Surg Am. 2007;32(2): 194e199. 39. Cheng HY, Lin CL, Lin YH, Chen AC. Biomechanical evaluation of the modified double-plating fixation for the distal radius fracture. Clin Biomech (Bristol, Avon). 2007;22(5):510e517.
3. Thompson PW, Taylor J, Dawson A. The annual incidence and seasonal variation of fractures of the distal radius in men and women over 25 years in Dorset, UK. Injury. 2004;35(5):462e466. 4. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am. 2001;26(5):908e915. 5. DeNoble PH, Marshall AC, Barron OA, Catalano LW III, Glickel SZ. Malpractice in distal radius fracture management: an analysis of closed claims. J Hand Surg Am. 2014;39(8):1480e1488. 6. Shauver MJ, Yin H, Banerjee M, Chung KC. Current and future national costs to Medicare for the treatment of distal radius fracture in the elderly. J Hand Surg Am. 2011;36(8):1282e1287. 7. Farner S, Malkani A, Lau E, Day J, Ochoa J, Ong K. Outcomes and cost of care for patients with distal radius fractures. Orthopedics. 2014;37(10):e866ee878. 8. Chung KC, Shauver MJ, Birkmeyer JD. Trends in the United States in the treatment of distal radial fractures in the elderly. J Bone Joint Surg Am. 2009;91(8):1868e1873. 9. Soong M, van Leerdam R, Guitton TG, Got C, Katarincic J, Ring D. Fracture of the distal radius: risk factors or complications after locked volar plate fixation. J Hand Surg Am. 2011;36(1):3e9. 10. Yu YR, Makhni MC, Tabrizi S, Rozental TD, Mundanthanam G, Day CS. Complications of low-profile dorsal versus volar locking plates in the distal radius: a comparative study. J Hand Surg Am. 2011;36(7):1135e1141. 11. Esenwein P, Sonderegger J, Gruenert J, Ellenrieder B, Tawfik J, Jakubietz M. Complications following palmar plate fixation of distal radius fractures: a review of 665 cases. Arch Orthop Trauma Surg. 2013;133(8):1155e1162. 12. Arora R, Lutz M, Hennerbichler A, Krappinger D, Espen D, Gabl M. Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate. J Orthop Trauma. 2007;21(5): 316e322. 13. Ring D. Treatment of the neglected distal radius fracture. Clin Orthop Relat Res. 2005;431:85e92. 14. MacKenney PJ, McQueen MM, Elton R. Prediction of instability in distal radial fractures. J Bone Joint Surg Am. 2006;88(9):1944e1951. 15. Adams BD. Effects of radial deformity on distal radioulnar joint mechanics. J Hand Surg Am. 1993;18(3):492e498. 16. Bronstein AJ, Trumble TE, Tencer AF. The effects of distal radius fracture malalignment on forearm rotation: a cadaveric study. J Hand Surg Am. 1997;22(2):258e262. 17. Werner FW, Palmer AK, Fortino MD, Short WH. Force transmission through the distal ulna: effect of ulnar variance, lunate fossa angulation, and radial and palmar tilt of the distal radius. J Hand Surg Am. 1992;17(3):423e428. 18. Park MJ, Cooney WP III, Hahn ME, Looi KP, An KN. The effects of dorsally angulated distal radius fractures on carpal kinematics. J Hand Surg Am. 2002;27(2):223e232. 19. Kihara H, Palmer AK, Werner FW, Short WH, Fortino MD. The effect of dorsally angulated distal radius fractures on distal radioulnar joint congruency and forearm rotation. J Hand Surg Am. 1996;21(1): 40e47. 20. Baratz ME, Jardins Des J, Anderson DD, Imbriglia JE. Displaced intra-articular fractures of the distal radius: the effect of fracture displacement on contact stresses in a cadaver model. J Hand Surg Am. 1996;21(2):183e188. 21. Jupiter JB, Ring D. A comparison of early and late reconstruction of malunited fractures of the distal end of the radius. J Bone Joint Surg Am. 1996;78(5):739e748. 22. Wada T, Isogai S, Kanaya K, Tsukahara T, Yamashita T. Simultaneous radial closing wedge and ulnar shortening osteotomies for distal radius malunion. J Hand Surg Am. 2004;29(2):264e272.
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Orthogonal Plate Fixation With Corrective Osteotomy for Treatment of Distal Radius Fracture Malunion Michael P. Gaspar, MD,* Jenniefer Y. Kho, MD,*† Patrick M. Kane, MD,* Hesham M. Abdelfattah, MD,*‡ Randall W. Culp, MD*
Purpose To report outcomes of patients with distal radius fracture malunions treated with corrective osteotomy and orthogonal volar and radial “90-90” plate fixation. Methods We performed a retrospective review of all patients who underwent distal radius corrective osteotomy and 90-90 fixation from January 2008 through December 2014. Demographic data, injury history, prior treatments, and clinical examination values were recorded. Preoperative radiographic measurements were used to classify the type and severity of deformity. The outcomes were patient-reported pain levels, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) functional scores, and radiographic outcomes. Secondary outcomes, including complications and the need for additional surgeries, were also noted. Results Thirty-nine cases (31 extra-articular, 8 combined intra- and extra-articular) were included. At mean postoperative follow-up interval of 4 years, significant improvements were observed clinically in wrist flexion-extension arc, grip strength, pain, and Quick Disabilities of the Arm, Shoulder, and Hand scores. Radiographically, significant postoperative improvements were noted in ulnar variance, radial inclination, intra-articular stepoff, and radial tilt, with volarly and dorsally angulated malunions corrected to 9 and 7 of volar tilt, respectively. Twelve patients (31%) underwent additional surgery, the most common being plate removal in 7 patients, 3 of which involved removal of the radial plate. Conclusions For patients with symptomatic malunion of the distal radius, corrective osteotomy with 90-90 plate fixation is an effective treatment option for improving pain and restoring function for both volarly and dorsally angulated malunions, including malunions with an intraarticular component. (J Hand Surg Am. 2017;42(1):e1ee10. Copyright Ó 2017 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Chronic deformity, corrective osteotomy, distal radius fracture malunion, orthogonal 90-90 plate fixation, radial- and volar-sided plating.
From *The Philadelphia Hand Center, PC, Department of Orthopedic Surgery, Thomas Jefferson University Hospitals; the ‡Department of Orthopaedic Surgery and Sports Medicine, Temple University Health System, Philadelphia, PA; and the †Division of Orthopedic Surgery, Sutter Gould Medical Foundation, Modesto, CA. Received for publication January 28, 2016; accepted in revised form October 23, 2016. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Michael P. Gaspar, MD, The Philadelphia Hand Center, PC, The Franklin, Suite G114, 834 Chestnut St., Philadelphia, PA 19107; e-mail: michaelpgaspar@ gmail.com. 0363-5023/17/4201-0013$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2016.10.012
D
among the most commonly occurring of all fractures and are responsible for considerable public health and economic burden.1e7 Over recent decades, as implant technologies and fixation techniques have continued to evolve, the number of DRF treated surgically has increased.8 However, despite these advances, the risk of developing complications following initial treatment of DRF persists, most notably including posttraumatic arthritis, median nerve compression, symptomatic hardware, tendon rupture, and fracture malunion.9e14 ISTAL RADIUS FRACTURES (DRF) ARE
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DISTAL RADIUS MALUNION 90-90 PLATING
Malunions can occur following either nonsurgical management or failed surgical treatment, and may result in progressive pain and disability.15e21 For those patients with symptomatic DRF malunions, surgical intervention with corrective osteotomy is generally the treatment of choice. A variety of surgical approaches and osteotomy techniques with generally favorable outcomes have been reported in the setting of DRF malunions.22e33 However, the generalizability of such techniques remains unclear because most techniques are described to address malunions of a specific fracture pattern. The primary goal of this study is to report outcomes of distal radius corrective osteotomy with 90-90 fixation for treatment of symptomatic fracture malunion.
administered, along with standard preoperative antibiotics. A pneumatic tourniquet was used. An 8-cm incision was made over the flexor carpi radialis tendon beginning at the wrist crease and carried proximally, utilizing the previous incision for those patients who had previously undergone surgical fixation. The interval between the flexor carpi radialis and the radial artery was identified. The pronator quadratus was released along its distal and radial borders for later repair, followed by release of the brachioradialis from the radial styloid. For cases involving an intra-articular component, an osteotomy was performed parallel to the long axis of the radius, beginning with a microsagittal saw, followed by a small osteotome and mallet for completion of the osteotomy. The depressed intraarticular fragment was then elevated to restore articular congruity and temporarily fixed with 0.045 K-wire. Attention was then turned to the extra-articular malunion as a separate opening wedge osteotomy was performed parallel to the joint line at the level of the previous fracture. For dorsally angulated malunions, a dorsal opening wedge osteotomy was performed (Fig. 1A), while a volar opening wedge osteotomy was created for volarly angulated malunions. Once the osteotomy was created, a volar locking plate was fixed first to the distal fragment only, allowing use of the plate as a joystick to reduce the distal fragment to the radial shaft via the proximal portion of the plate (Fig. 1B). When alignment appeared satisfactory following this reduction maneuver, a cortical screw was provisionally placed through the proximal plate into the radius to maintain reduction. At this point, alignment was confirmed fluoroscopically, and the volar plate was affixed to the radius by completing standard screw placement including through the intra-articular fragment, if present. Once the volar plate was in place, the osteotomy site was visualized fluoroscopically as the wrist was gently ranged in flexion-extension, radialto-ulnar deviation, and pronosupination. With attention then turned to the radial aspect of the osteotomy, the tendons of the first dorsal extensor compartment were elevated subperiosteally and protected via the same surgical incision, although a formal release of the compartment was not routinely performed. Branches of the superficial radial nerve were similarly identified and protected. The radial-sided locking plate was positioned at 90 from the volar plate in the axial plane, with bicortical nonlocking screws placed proximally and unicortical locking screws distally to position the plate in buttress mode (Fig. 1C). Proper alignment was again confirmed fluoroscopically, and
MATERIALS AND METHODS This study was approved by our institutional review board. Using our departmental electronic billing database search for Current Procedural Terminology codes 25350 (Osteotomy, distal third of radius), 25400 (Repair of nonunion or malunion, radius OR ulna; without graft), and 25405 (Repair of nonunion or malunion, radius OR ulna; with iliac or other autograft), we identified all patients who underwent corrective osteotomy of the distal radius with volarand radial-sided orthogonal (90-90) fixation at our institution from January 2008 through December 2014. All surgeries were performed by the senior author (R.W.C.), a fellowship-trained orthopedic hand and upper extremity surgeon. Surgical indications Patients were considered surgical candidates if (1) they exhibited pain and disability consistent with the observed malunion, (2) they had no appreciable radiocarpal arthrosis on preoperative radiographs, and (3) their deformity met at least 1 of the following radiographic criteria: (a) radial inclination less than 15 , (b) volar tilt greater than 25 or dorsal tilt greater than 20 , (c) ulnar variance greater than 5 mm, or (d) intra-articular stepoff greater than 2 mm. In addition to these radiographic guidelines, patients’ bone quality and the age of the fracture malunion were used in the decision to perform 90-90 fixation. From our prior experience, we found that, in addition to radiographic deformity, poor bone quality and longstanding malunions (> 6 months from injury) were most predictive of failure of volar plating alone. Surgical technique and postoperative protocol The patient was placed in the supine position and general anesthesia with regional blockade was J Hand Surg Am.
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DISTAL RADIUS MALUNION 90-90 PLATING
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FIGURE 1: Schematic representation of a malunited distal radius fracture treated with corrective osteotomy and 90-90 plate fixation. A Before surgery, the patient presents with ulnar positivity owing to shortening of the radius and dorsal angulation. A microsagittal saw and osteotome are used to re-create the fracture at the malunion site. B With the plate first fixed distally only, the surgeon can then maneuver the proximal portion of the plate (green arrows) in order to rotate the distal fragment (orange arrows) and correct the deformity in both the anteroposterior and lateral planes. C With the deformity corrected, the reduction is maintained by completing screw fixation through the volar plate. Next, the radial-sided locking plate is positioned at 90 from the volar plate, typically using bicortical nonlocking screws proximally and unicortical locking screws distally.
the wrist flexion-extension and forearm rotation arcs were examined to rule out impingement secondary to hardware placement. At that time, the bone graft or substitute of choice was placed into the osteotomy site through the volar-radial interval formed between the 2 plates. Nonstructural bone graft or substitute was used in all index surgeries (1 case of recalcitrant nonunion required revision during which structural autograft was used, and is discussed later). Following bone graft or graft substitute placement, repair of the pronator quadratus was performed. After surgery, the patient was placed in a bulky volar orthosis and transitioned to a forearm-based wrist orthosis at the time of suture removal, generally at 10 to 14 days from surgery. At that time, formal therapy was initiated with gentle passive range of motion exercises of the wrist progressing to active range of motion over the next 4 to 6 weeks. At 6 to 8 J Hand Surg Am.
weeks, strengthening exercises were incorporated into the rehabilitation regimen. Data collection Demographic data for study patients was obtained from departmental records including patient age, gender, handedness, and medical comorbidities. Information regarding the initial injury or condition was also recorded, including injury mechanism, initial treatment, and the time interval from initial treatment to reevaluation at our center. Patient-reported variables obtained via chart review were visual analog scale (VAS) erated pain levels (0 ¼ no pain, 10 ¼ worst pain imaginable) and Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) scores. Clinical examination measurements were wrist flexionextension arc (WFE), forearm rotation arc (FR), and grip strength measured by Jamar dynamometer r
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DISTAL RADIUS MALUNION 90-90 PLATING
FIGURE 2: A Preoperative anteroposterior, oblique, and lateral radiographs of the dominant right wrist of a 63-year-old woman who sustained a distal radius fracture after falling out of a chair more than 4 years prior to presentation at our clinic. B Owing to the longstanding nature of her malunion, radial tilt could only be corrected to neutral, as evident on immediate postoperative radiographs. C The patient ultimately underwent removal of her symptomatic hardware, as seen on her radiographs taken 58 months after corrective osteotomy.
(Lafayette Instrument Company, Inc., Lafayette, IN). Per our institution standards, grip strength was documented as the mean of 3 attempts on settings II and III for females and males, respectively. Surgical details including the type of bone graft used and concomitant procedures were recorded. Radiographic data including direction and degree of radial tilt, radial inclination, ulnar variance, and articular stepoff (for those malunions with an intra-articular component) were recorded from standard posteroanterior and lateral radiographs, as measured by a fellowshiptrained attending orthopedic hand surgeon who was not the treating surgeon. For the purpose of data analysis, patients were classified according to the direction of radial tilt measured on the preoperative lateral radiographs into either volar or dorsal J Hand Surg Am.
subgroups (Fig. 2). Patients were contacted by telephone and invited to return to our clinic for follow-up, where interval history, VAS-rated pain and QuickDASH outcomes, repeat examination, and follow-up radiographs were prospectively obtained. For the patients who were unable to return to clinic, VAS-rated pain levels, QuickDASH scores, and interval histories were obtained over the phone, and clinical examination and radiographic measures from their most recent visits were used in analysis. Statistical analysis Descriptive statistics were obtained for the patient cohort as a whole and for the volar and dorsal subgroups. Bivariate analysis with paired t testing was utilized to compare pre- and postoperative VAS, r
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QuickDASH, WFE, FR, and grip strength, as well as degree of tilt and ulnar variance. Secondary outcomes included the development of complications and the need for additional or revision surgery.
TABLE 1. Demographic and Descriptive Data for the Study Cohort
RESULTS Descriptive Analysis Forty-eight cases of orthogonal plating of the distal radius were identified via chart review, of which 9 were excluded for the following reasons: 4 cases were DRF nonunions that were revised with the addition of the radial-sided plate, 2 cases were for correction of Madelung deformities, 2 cases were for treatment of acute DRF, and 1 case was a revision of a refracture through a giant cell tumor of the distal radius. The remaining 39 patients (mean age, 53 14 years) met the inclusion criteria, of which 32 patients returned to clinic for in-person evaluation. The 7 patients who were not able to return to clinic completed follow-up over the telephone. Twenty-four cases were performed in females and 15 in males. Twenty-one cases involved the nondominant extremity. The median time interval from initial treatment to surgery for all patients was 7 months (range, 3e143 months), and the mean follow-up duration was 48 24 months (range, 13e89 months). The primary reason for seeking surgery for all 39 patients was pain. Seven patients also complained of median nerveerelated symptoms before surgery and underwent a carpal tunnel decompression at the time of their osteotomy. All patients were seen as secondary referrals to our institution; initial management of their injury had been performed elsewhere. Thirty patients presented with dorsal angulation on lateral preoperative radiographs, and the remaining 9 were volarly angulated. Thirty-one malunions were extra-articular involving the metaphysis alone, and the remaining 8 had both an extra-articular and an intra-articular component. The mean preoperative ulnar variance was 4.5 2.7 mm (Table 1). Significant improvements were demonstrated in WFE, grip strength as measured by dynamometer, VAS pain scores, and mean QuickDASH scores (Table 2). Ulnar variance decreased significantly across the full cohort, whereas radial inclination increased significantly in the dorsal malunion subgroup only (Table 3). Radial tilt demonstrated significant in both malunion subgroups. For the 8 patients with preoperative articular incongruency, intra-articular stepoff was significantly improved by a mean of 2.5 mm (P < .05). Although no patients had signs of radiocarpal degeneration on preoperative
Age (y)
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Variable
All Fracture Malunions (n ¼ 39) 53 14
Gender Male
15
Female
24
Dominant extremity? Yes
18
No
21
Direction of angulation Dorsal
30
Volar
9
Joint involvement Extra-articular only Combined intra-/extra-articular
31 8
Initial treatment Nonsurgical
23
Surgical
16
ORIF
10
CRPP
4
Ex-fix
1
ORIF þ Ex-fix
1
CRPP, closed reduction with percutaneous pinning; Ex-fix, external fixation; ORIF, open reduction internal fixation.
radiographs, 6 had mild-to-moderate degeneration on follow-up. Twelve patients underwent at least 1 subsequent operation at mean interval of 7 4 months from the index 90-90 fixation procedure. Eleven of those patients required 1 additional surgery, and 1 patient required 2 separate operations due to nonunion at his osteotomy site (Table 4). That patient was a 39-year old man who was referred to our center with a malunited distal radius in 30 of dorsal tilt and positive ulnar variance of 5 mm. After corrective osteotomy with 90-90 fixation and placement of autologous cancellous iliac crest bone graft (ICBG), serial follow-up imaging demonstrated radiographic signs of hardware failure and progressive loss of reduction. At 5 months after surgery, revision 90-90 plating with placement of corticocancellous ICBG and osteogenic protein-1 was performed. Subsequently, although the hardware remained intact and alignment of the osteotomy was maintained on radiographs, there were no signs of bony healing. At that time, the patient disclosed a longstanding 2 pack-per-day smoking r
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DISTAL RADIUS MALUNION 90-90 PLATING
TABLE 2.
Pre- and Postoperative Comparison of Clinical Outcomes for the Full Study Cohort
Variable
Preoperative
WFE ( ) FR ( )
Postoperative
P Value
85 22
103 23
< .05
140 40
153 24
.054
Grip strength (pounds)
38 26
56 24
< .05
VAS
6.9 1.6
2.9 1.0
< .05
QuickDASH
55 16
20 9
< .05
TABLE 3. Pre- and Postoperative Comparison of Radiographic Measures Based on Direction of Preoperative Fracture Malunion Dorsally Angulated Malunions (n ¼ 30) Radiographic Variable Tilt ( )*
Preoperative
Postoperative
e25 9
Volarly Angulated Malunions (n ¼ 9)
P Value
Preoperative
75
< .05
31 8
Postoperative
P Value
94
Radial inclination ( )
17 5
22 3
< .05
24 9
25 2
Ulnar variance (mm)
4.6 2.3
e0.3 1.4
< .05
4.3 3.7
e1.1 1.8
< .05 .84 < .05
*Preoperative dorsal tilt is represented by a negative value.
TABLE 4.
Postoperative Complications and Subsequent Surgeries for Entire Study Cohort Complication
Procedure
Number Performed
Symptomatic hardware
Removal of hardware Volar only Radial only Volar and radial
7 4 2 1
Ulnar impingement
Ulnar-shortening osteotomy
3
De Quervain syndrome
First extensor compartment release
3
Wrist contracture
Wrist capsulectomy
2
Flexor tendon adhesions
Tenolysis
2
Recurrent carpal tunnel syndrome
Revision carpal tunnel release
2
Mild, persistent wound drainage
Irrigation and debridement, wound closure
2
DRUJ instability
DRUJ reconstruction with palmaris longus tendon autograft
1
1. Hardware failure, osteotomy nonunion 2. Osteotomy nonunion
1. Revision volar plating with nonunion takedown 2. Revision volar and radial plating with nonunion takedown and placement of cancellous ICBG
1*
DRUJ, distal radioulnar joint. *Last patient underwent 2 consecutive revision surgeries.
the final revision surgery. In 2 additional patients, drainage from 0.5-cm areas of wound dehiscence were noted after surgery. Although neither patient developed any clinical signs or symptoms of infection, both patients were returned to the operating room for formal irrigation and wound closure; they healed uneventfully afterward.
history. Despite aggressive attempts at smoking cessation and use of a bone stimulator, no appreciable signs of healing were seen on serial radiographs, and a second revision was performed 11 months from index 90-90 fixation with addition of autologous cancellous ICBG, osteogenic protein-1; this eventually demonstrated full bone union at 10 months from
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TABLE 5.
Study
Summary Comparing Prior Recent Investigations of Corrective Osteotomy of Distal Radius Fracture Malunions
Design/ Methods
Approach, Technique and Plating Configurations studied
Fracture Pattern(s)
Patients Studied (n)
Mean Patient Age, y (range)
Mean Injury to Surgery Interval, mo (range)
Mean FollowUp, mo (range)
Prior Treatment Course
Outcomes*
Complications
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Retrospective chart review with prospective follow-up Single surgeon
39 31 extra(15 M, 24 articular, F) 8 Extra- þ intraarticular Volar and dorsal angulated
53 (18e86)
14 Median ¼ 7 (3e143)
48 (13e89)
23 Nonsurgical 16 Surgical
(See Table 3 for Improved: details) WFE Grip strength Ulnar variance Volar/dorsal angulation Radial inclination Articular incongruity Mean VAS pain Mean QuickDASH
Buijze et al, 201228†
18 All 18 extra- þ Highly variable Retrospective intra-articular (11 M, 7 F) chart review Dorsal and/or volar approach Volar and dorsal with angulated Single- or doubleprospective plate fixation follow-up 4 Surgeons from 4 centers
43 (20e67)
9 Median ¼ 7 (3e29)
78 (24e134)
Unclear
Hardware Improved: removed in 10 WFE patients Wrist pronosupination De Quervain in 3 patients Radial/ulnar (managed deviation nonsurgically) Grip strength Extensor tendon Ulnar variance rupture in 1 Volar/dorsal patient w/ angulation double dorsal Articular plating incongruity Mean postoperative VAS, 1 Mean postoperative DASH, 11
Sato et al, 200926
Retrospective chart review; multiple surgeons
28 (17 M, 11 F)
41 (13e80)
11 (2e96)
25 (12-60)
19 Nonsurgical 9 Surgical
Improved: WFE Wrist pronosupination Grip strength Ulnar variance
Orthogonal volar þ radial plating
Volar plating with All 28 extraopening wedge articular osteotomy All volarly angulated
DISTAL RADIUS MALUNION 90-90 PLATING
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Current study
1 Patient with transient median nerve symptoms
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Study
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TABLE 5.
Summary Comparing Prior Recent Investigations of Corrective Osteotomy of Distal Radius Fracture Malunions (Continued)
Design/ Methods
Approach, Technique and Plating Configurations studied
Fracture Pattern(s)
Patients Studied (n)
Mean Patient Age, y (range)
Mean Injury to Surgery Interval, mo (range)
Mean FollowUp, mo (range)
Prior Treatment Course
Outcomes*
Complications
Volar angulation Mean VAS pain Mean JSSH-DASH
Ring et al, 200527†
Highly variable Retrospective chart review Dorsal and/or volar Approach with Screw, K-wire or prospective plate fixation follow-up Surgeons from 4 centers
Volar plating with All 4 extraopening wedge articular osteotomy All dorsally angulated
4M
12 (3e30)
14 (9e23)
3 Nonsurgical 1 Surgical
1 Periprosthetic Improved‡: fracture after a Volar tilt fall Note: Quantitative improvements in WFE pronosupination grip strength, DASH scores, VAS pain, radial inclination, and ulnar variance not shown to be of statistical significance, likely due in part to small sample size
37 (18e67)
6 (3e14)
38 (24e102)
14 Nonsurgical 9 Surgical
Improved: WFE Wrist pronosupination Radial/ulnar deviation Grip strength Ulnar variance Articular incongruity
r
57 (16e76)
Vol. 42, January 2017 23 17 Intra(16 M, 7 F) articular 6 Extra- þ intraarticular; Volar and dorsal angulated
DASH, Disabilities of the Arm, Shoulder, and Hand; JSSH, Japanese Society for Surgery of the Hand. *Outcomes are listed as “improved” if they were reported to be statistically significant by the study authors. †The later study by Buijze et al, 2012,28 includes the 6 patients with combined intra- and extra-articular malunions from Ring et al in 2005.27 ‡These are based off our own analysis of the authors’ provided data, using Mann-Whitney U testing to compare pre- and postoperative nonparametric outcomes.
None specified Progression of radiocarpal arthrosis in 10 patients
DISTAL RADIUS MALUNION 90-90 PLATING
Retrospective chart review
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Malone et al, 200629
DISTAL RADIUS MALUNION 90-90 PLATING
DISCUSSION Distal radius fracture malunions continue to represent a troublesome subset of complications often requiring further surgical intervention.15e21 Although malunion following DRF has been reported in as many as onequarter of those treated nonsurgically, the risk of malunion after surgical treatment also remains surprisingly high, with reported incidences ranging from 4% to 10%.34 Surgical treatment options for DRF malunions are numerous and depend largely on the pattern and severity of underlying deformity as well the presence or absence of articular involvement.22e33 Thus, although prior studies of corrective osteotomies for DRF malunions demonstrate mostly positive outcomes, those that utilized a single standard technique tended to treat 1 specific pattern.22e30 Similarly, those studies involving more heterogeneous patterns of DRF malunions did not generally utilize a standard approach (Table 5). Conversely, we have found that the technique we describe here allows for treatment of a wider range of malunion patterns than other methods of internal fixation, despite using a standard volar approach and the same plate configuration. Thus, although our outcomes were not superior to those of previous DRF corrective osteotomy studies, the ability to utilize the same plate configuration via standard volar approach regardless of the malunion orientation or articular involvement may be an attractive option to surgeons. Although not previously discussed in the setting of DRF malunion correction, the utility of the 90-90 radial-volar construct has been demonstrated clinically for the treatment of acute DRF with a radial column/styloid component or severe comminution.35e37 In all 3 reported series, the authors performed a volar approach and first plated the fractures volarly, adding the styloid plate only if reduction was inadequate with volar plating alone. Thus, despite their positive outcomes, it is difficult to assess their results without a control group treated with volar plating alone. In addition, limited, biomechanical testing of this construct has been supportive to date, with studies demonstrating that the 90-90 construct as significantly stiffer, stronger, and more resistant to fragment displacement than volar plating alone.38,39 The clinical importance of this increased stiffness is debatable, but it is likely to serve a role particularly when structural bone graft is not utilized. Plate removal was the most commonly performed secondary surgery, of which 3 cases (8%) involved De Quervainetype symptoms related to the radial-sided plate. We did not elect to release the first extensor
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compartment at the time of osteotomy fixation owing to concerns that the tendons may become irritated by direct contact with the radial-sided plate. Given that all 3 cases resolved with a first extensor compartment release and plate removal, performing a first compartment release as a standard prophylactic measure at the time of 90-90 fixation may warrant consideration, although it is difficult to predict if doing so would predispose the tendons to irritation from the plate. This study has a number of notable limitations, including its retrospective nature, which requires that we rely on clinical documentation. Another notable limitation was that 7 patients were unable to followup in person. Although outcomes were obtained via telephone, these data are less likely to be reliable than if obtained in person. Furthermore, because some data could not be obtained on the phone, there is the possibility that values obtained previously regarding range of motion, grip strength, and radiographic parameters had changed in the interim. These drawbacks would be remedied by a prospective study. Another limitation is the use of plain radiographs to measure preoperative deformity and subsequent correction, particularly when determining intraarticular stepoff, which is obscured by hardware. Furthermore, because it is not possible to blind the reviewer to pretreatment versus posttreatment radiographs, there is potential for bias in measuring these outcomes. Finally, the most important limitation is likely the lack of a control group. Without this comparison group of patients treated with volar plating alone, it is difficult to determine if outcomes following 90-90 plating warrant the additional risk of symptoms related to the radial plate. Despite the limitations of this study, we feel that the results show that corrective osteotomy of the distal radius with 90-90 fixation effectively treats pain and restores function in patients with symptomatic volarly or dorsally angulated malunions of the distal radius, with or without an intra-articular component. Future studies that directly compare this method with existing techniques of DRF malunion correction are needed to determine if it warrants use in larger populations. REFERENCES 1. Karl JW, Olson PR, Rosenwasser MP. The epidemiology of upper extremity fractures in the United States, 2009. J Orthop Trauma. 2015;29(8):e242ee244. 2. Ootes D, Lambers KT, Ring DC. The epidemiology of upper extremity injuries presenting to the emergency department in the United States. Hand (N Y). 2012;7(1):18e22.
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