Corrective Osteotomy of Distal Radius Malunion-- …

1 5/11/20131 Corrective Osteotomy of Distal Radius malunion ---New HorizonsI certify that, to the best of my knowledge, no aspect of my current personalor profession situation might reasonably be expected to affect significantlymy views on the subject on which I am LOSS OF REDUCTION2. DELAYED UNION AND NONUNION3. malunion 4. Distal RADIOULNAR JOINTWRIST FRACTURESOSTEOARTICULAR COMPLICATIONS Carpal ligaments Carpal fractures Nerves Tendons Combined soft tissues Vascular, compartment syndromeASSOCIATED LESIONSCOMPLICATIONSC arpal instabilityNonunion, malalignmentNeuropathyTendinitis, rupturesMultifactorialfunctional deficitRSD, Complex RegionalPain syndromeWRIST FRACTURES5/11/20132 TIMING OF SURGERY-absence of trophic changes-acceptable bone quality-adequate wrist functionas soon as possible, provided there is.

2 NASCENT malunion - immature callus- established deformity (5 8 weeks post-fracture)MATURE malunion -remodelled callus- 4 to 6 months or morepost-fractureADVANTAGES OF EARLY CORRECTION easiness of radial and DRUJ re-alignment less soft tissue contractures and DRUJ dysfunction no need of structural corticocancellous bone graft considerably decrease of total disability early return to workJupiter JB, Ring D:A comparison of early and late reconstruction of malunited fracturesof the Distal end of the Radius . JBJS 78A: 739-748, May 1996corrective Osteotomy of malunited Colles fracturesthrough adorsal approachpreoperative planning is based on the radiographicmeasurements of the opposite wrist:-ulnar inclination-ulnar variance-volar tilt(for rotational deformity: comparative CT-scans)Bindra RR,Cole RJ et al: Quantification of the radial torsion angle withcomputerized tomography in cadaver specimens JBJS 79A:833-837, 1997 SURGICAL TECHNIQUE5/11/20133preoperative planningdorsal Distal Radius locking plates5/11/201345/11/201355/11/201365/11 /20137correction of malunited Colles`fracturesthrough a volar approach:SURGICAL TECHNIQUE-Open wedge Osteotomy , interpositional bone graftand volar plate fixation (U.)

3 Lanz, )- Close wedge Osteotomy , Darrach procedure andK-wire fixation (Posner, Garcia-Elias)- Close wedge Osteotomy and ulnar shortening - Close wedge Osteotomy and ulnar head prosthesis ( )5/11/201385/11/201395/11/2013105/11/201 3115/11/201312open wedge Osteotomy , bone graft and volar plate fixationPrommersberger KJ Lanz U.: Corrective Osteotomy for malunited Colles fractures. Orthop Trauma 6: 75-87 , JL, Indriago I, Badia A, Khouri RK, Gonzalez E, Fernandez DL: Corrective Osteotomy of dorsally malunited fractures of the Distal radiusvia the extended FCR Hand Surg 28B (Suppl 1): 2 ,2003 Lanz U, Kron W: Neue Technik zur Korrektur in Fehlstellung verheilterRadiusfrakturen. Handchir Mikrochir Plast Chir 8:203-206, 1976 LRsurgical technique5/11/201313post-opx-rays12 weekspost-op5/11/2013143-dimensional image aquisition and 3-D planningSNF : F rnstahl P, Schweizer A, Sz kely G, Nagy LOsteotomy ReportCutting: mm (from Distal ) to distalCut is performed at mm (from Distal ) Osteotomy result:First: Rotation around axis 2 by degreesSecond: Rotation around axis 1 by degreesThird: Rotation around axis 0 by degreesFourth: Translation by (axis 0), (axis 1), (axis 2) mmSNF : F rnstahl P, Schweizer A, Sz kely G, Nagy LOsteotomy ReportCutting: mm (from Distal ) to proximalCut is performed at mm (from Distal ) Osteotomy result:First.

4 Rotation around axis 2 by degreesSecond: Rotation around axis 1 by degreesThird: Rotation around axis 0 by degreesFourth: Translation by (axis 0), (axis 1), (axis 2) mm5/11/201315 CONV. PLATEDRILLING JIGSETTING GAUGESA 39SA 39SA 395/11/201316SA 39SA 39SA 39 Osteotomy result:First: Rotation around axis 2 by Second: Rotation around axis 1 by Third: Rotation around axis 0 by Fourth: Translation mm, mm, mmSA 395/11/201317SA 39SA 39SA 39SA 39 Skyline view5/11/201318SA 39 6 WINTRARTICULAR malunion intra-articular malunion results after failure to recognize potentially unstable articular disruption, or insufficient reduction and fixation during surgical treatment5/11/2013195/11/2013205/11/2013 215/11/2013225/11/2013235/11/2013245/11/ 2013255/11/201326 The indication of Osteotomy for an intra-articularmalunion depends on.

5 1) the fracture pattern2) the extent of cartilage damage3) the chronology4) presence of fixed carpal malalignment5) the soft tissue conditionINTRA-ARTICULAR OSTEOTOMIES5/11/201327 CONTRAINDICATIONS1) severe cartilage damage2) radiographic degenerative changes3) chronic synovitis4) significant soft tissue andcapsular contractures (post RSD)5) complex fracture pattern andfixed carpal malalignmentTREATMENT RECOMMENDATIONS-simple intra-articular disruption- as soon as possible- minimal cartilage damage (chondromalacia)- adequate pre-operative function- complient, cooperative patientotherwise a limited carpal fusion (RSL or RL) is preferableINTRA-ARTICULAR MALUNION5/11/201328 ARTHROSCOPIC ASSISTED TREATMENT OF Distal Radius MALUNIONF rancisco del Pi al et al: Arthroscopically guided osteotomyfor management of intra-articular Distal Radius Hand Surg 35A: 392-397, 2010 del Pi al, F , Garcia Bernal FJ, et al: Correction of malunited intra-articular Distal Radius fractures with an inside-out Osteotomy technique.

6 J Hand Surg 31A: 1029-1034, 2006 Courtesy: Dr Francisco del Pi al, Santander,Spain5/11/201329 Combined Intra- and Extra-Articular Distal Radius Malunion5/11/2013301181195/11/201331 Geert A. Buijze, MDKarl-Josef Prommersberger, MDJuan Gonz lez del Pino, MD PhDDiego L. Fernandez, MDJesse B. Jupiter, MDCorrective Osteotomy for Combined Intra- and Extra-Articular Distal Radius MalunionStudy AimsMethodsPatient Inclusion5/11/201332 MethodsPatient InclusionMethodsPatient CharacteristicsSurgical TechniqueExtra-Articular MalunionSurgical TechniqueIntra-Articular Malunion5/11/201333 Surgical Technique112332 Surgical TechniqueSurgical TechniqueSurgical Technique5/11/201334 Eleven years FUCONCLUSIONS- malunion remains the most common complication of closed reduction and plaster immobilisation of unstableextra-articular fractures- intra-articular malunion results after failure to recognize potentially unstable articular disruption.

7 Or insufficientreduction and fixation during surgical treatment- if symptomatic extra-articular malunion occurs, radialosteotomy offers better function,improves the externalappearance and normalizes carpal kinematics-intra-articular malunion deserves early correction in orderto restore the functional anatomic integrity of the jointbefore the onset of symptoms and cartilage damage-our experience has shown that with:careful patient selectioncorrect indication andrefinements of surgical techniqueover 80% of excellent and good resultscan be expectedCONCLUSIONSC omplications and failures are commonly caused eitherby technical errors, or by improper patient selection with:degenerative changestrophic disturbancespartial joint stiffnesssevere osteoprosisfixed type of DISI malaligmentand failure to assess and simultaneously treatassociated disorders of the Distal radioulnar jointCONCLUSIONS5/11/201335 THANK YOU