Corrective Osteotomy for Malunited Fractures of the Distal Radius Using Internal Fixation With Locking Plates

Abstract

Objectives: Symptomatic malunion is still a major complication of distal radius fractures, which requires a surgical treatment. The corrective extra-articular or intra-articular osteotomy restores the anatomy of the distal radius and improves the wrist function. The purpose of this study was to evaluate the results and complications of the corrective osteotomy and locked plating for malunited extra-articular and intra-articular fractures of the distal radius. Methods: Out of 175 patients with malunions of the distal radius treated surgically in the period from July 2001 to July 2015, 147 were evaluated. There were 45 males and 102 females with the average age of 42.9 years (15-75). The time interval between the injury and surgery was from 1 to 31 months (approximately 2.2 months). According to the Arbeitsgemeinschaft für Osteosynthesefragen (AO)/ Association for the Study of Internal Fixation (ASIF)-classification, there were 77 A (52.4%), 18 B (12.2%), and 52 C (35.4%) type fractures. In 133 cases, we performed a corrective wedge osteotomy of the distal radius with the iliac bone graft transfer (38), distal radius graft (11), and bone substitute—“ChronOs”/“Orthos” (34/1). In 10 patients with B and C malunited fractures, we performed the intra-articular osteotomy, and in 4 cases, we did the combined (intra-articular and extra-articular) procedure; we used the preoperative computer tomography and intraoperative fluoroscopy during the operations. The locking volar or dorsal plates were employed for the osteosynthesis via palmar (87), dorsal (48), and combined (12) approaches. The immediate mobilization of the wrist began on the second postoperative day. The mean follow-up was 24 months (6 months-8 years). We examined 147 patients after operation with the respect of the radiological parameters, active range of motion (AROM), grip strength, Disability of the Arm, Shoulder and Hand (DASH) questionnaire, Cooney-Krimmer score, and Martini score. Statistical Analysis was done using SPSS 21, paired t test, and paired Wilcoxon test. Results: In a year after the operation, 121 patients (82.3%) showed excellent and good outcomes on Cooney-Krimmer score, and 108 patients (73.5%) did the same on Martini score. The rates of DASH questionnaire prior to the operation were on average 57.43 ± 3.90 points; after the surgery −15.31 ± 2.54 points ( P < .001). The preoperative total AROM of the wrist and forearm was 50.22 ± 3.46% of the other side, and the postoperative one was 81.65 ± 2.19% ( P < .001). The preoperative grasping power was 24.45 ± 6.21%, and the postoperative one made up 88.55 ± 4.15% ( P < .001) of the contralateral hand. The radioulnar inclination increased from preoperative 11.56 ± 0.64° to postoperative 23.15 ± 2.34°( P = .005). The palmar inclination increased from preoperative −17 ± 0.09° (−45° to 37.5°) to postoperative 4.9 ± 0.24° ( P = .020). The preoperative ulnar variance of +4.18 ± 0.29 mm was corrected to 1.06 ± 0.31 mm ( P = .001) postoperatively. Intra-articular steps were corrected from 2.35 ± 0.16 to 0.86 ± 0.05 mm ( P < .001). Complications (17.3%) included 2 nonunions and 2 malunions after bone substitute, 3 postoperative carpal tunnel syndrome (CTS) 1 De Quervain syndrome, 1 superficial radial nerve injury, 5 posttraumatic arthroses, and 5 hardware failures. Fixators were removed from 17 patients (11.6%). Conclusions: Corrective extra-articular and intra-articular osteotomy is an effective and reliable method of the distal radius configuration restoration. The use of the locking plates ensures the rigid fixation of distal radius fragments, immediate postoperative mobilization, and improvement of the wrist function.