An Original Technique in Madelung’s Deformity

Abstract

Objective/Hypothesis: Madelung’s deformity results from a growth defect in the ventral and medial part of the growth plate of the distal extremity of the radius, causing a disorientation of the ulnar part of radial glenoid. Surgical procedures to improve aesthetics and function for Madelung’s deformity are numerous and difficult to assess because the disease is uncommon. We propose and evaluate an original technique in a retrospective study of 19 wrists: the reverse wedge osteotomy (RWO) of the distal radius. Materials and Methods: Twelve women and 1 man Madelung’s deformity were treated from 1992 to 2016. The wrists (6 bilateral, 7 unilateral) were reviewed by an independent examiner at an average follow-up of 6 years (6 months-22 years). Surgery was motivated by aesthetic and functional discomfort at the average age of 23 years, before any complication. RWO was developed to reorient the radial joint surface while reducing overall radius length as little as possible. Osteotomy was performed through an anteroradial or radial approach with an average time under 2 h. The bone wedge was harvested from the excess cortical on the dorsal and radial aspect of the radius. The circumferential wedge was then removed, reversed, and put back into the osteotomy to ensure closing on cortical excess and lengthening on the opposite side. Fixation was achieved by an anterior locking plate in all cases. An associated osteotomy of the ulna was necessary to avoid an ulnocarpal conflict for 4 cases with severe deformity. Objective (morphology of the wrist, range of motion, and grip strength) and subjective (Quick Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation scores) data were analyzed. Radiological settings were taken from McCarroll’s criteria. A vector model of the procedure was established to estimate osteotomy angles from 2 indexes from McCarroll. The nonparametric Wilcoxon test ( P < .05) was used for statistical analysis. Results: All cases achieved fusion at 3 months. Eight of the 19 wrists had the plate removed. There was no complication except for hypoesthesia on the radial side of the thenar eminence in 2 cases. Aesthetics and range of motion improved. Improvement was significant for flexion, pronation, and supination with preserving the grip strength, as well as the radiological parameters of McCarroll: significant correction of the palmar and ulnar deviation of the radial epiphysis, as well as rising of the lunate and palmar displacement of the carpus. Average Quick Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation scores were less than 30 out of 100 at review. All patients were satisfied aesthetically and functionally. Conclusions: The corrective power of RWO is well adapted to the severe radial epiphyseal dystrophy of Madelung’s deformity. Clinical and radiological results are convincing and meet patients’ expectations. RWO has a special place among the techniques proposed so far. The flattening of the dorsal aspect of the wrist is hoped to provide long-term protection against extensor tendon tear. Vector model allows preoperative planning and optimizes the realization.