Dorsal Malunion Research Articles

Association of dorsal malunion in distal radius fractures with wrist osteoarthritis: Alterations of bone density and stress-distribution patterns in relation to deformation angles

Distal radius fractures (DRFs) with dorsal malunion increase the risk of osteoarthritis (OA), although the cause of post-DRF OA is yet to be elucidated. To clarify the abnormal effects of a post-DRF dorsal radius deformity, we evaluated the bone density (BD) and stress-distribution patterns of the articular surface in dorsally malunited DRFs. In 36 cases of dorsally malunited DRFs following extra-articular fractures, we generated three-dimensional computerized models of the malunited distal radius from computed tomography data and extracted the subchondral bones of the radiocarpal joint (RCJ) and distal radioulnar joint (DRUJ). Both BD and stress distribution in the subchondral bones were quantitatively evaluated by comparing the affected and normal sides. Correlations of alterations in high-BD distribution and deformation angles were analyzed. The center of high-BD distribution from the center of the RCJ in the volar(-)-dorsal(+) direction was dorsal (0.56±0.72mm) on the affected side compared with the normal side (-0.15±0.63mm) [95% CI: 0.43, 1.00, P<0.0001]. The maximum stress distribution was also dorsal on the affected side (2.34±3.52mm) compared with the normal side (-2.49±1.62mm) [95% CI: 0.89, 1.79, P<0.0001]. The alterations in BD and stress distribution correlated with the dorsiflexion and radial deviation angles. In the DRUJ, there was no significant difference in BD between the affected and normal sides. In dorsally malunited DRFs, the alignment change of the RCJ resulted in high BD-concentration areas and stress distribution on the dorsal side of the radius, which may constitute a precursor for OA.

Influence of ulnar styloid fracture with concurrent extra-articulardistal radius fracture on forearm rotations

Introduction: This study was conducted to evaluate the relation between extra articular distal radius fracture associated with and without ulnar styloid fracture and the rotational movements of wrist and forearm. Materials and Methods: This retrospective study was performed on 86 unilateral, extra articular distal radius fracture, treated conservatively. Associated ulnar styloid fracture was present in 42 (48.8%) group Aand 44 (51.2%) with intact ulnar styloid group B. Men were 54 (62.8%) and women 32 (37.2%). Distal radius fracture involving right, dominant side were 56 (65.1%). All patients were treated by one surgeon with close reduction under anaesthesia with plaster immobilisation. Long arm cast was applied with forearm in supination wrist in ulnar volar flexion and after 2 weeks changed to below elbow cast with wrist in neutral rotation. Results: The mean limitation of supination was 7.82 ± 5.19 for group 1 (intact styloid) and 23.82±14.41 for group 2 (fractured styloid). The mean limitation of pronation was 4.72 ± 3.68 for group 1 (intact styloid) and 3.29 ± 2.79 for group 2 (fractured styloid). The difference between the two groups was statistically significant regarding the limitation of supination, but not about the 0 0 0 limitation of pronation. The average pronation deformity was 120 (range 60 to 190 ) in patients with dorsal malunion and 110 0 (range 50 to 210) in volar malunion. The supination deformity averaged at about 80° (range 40° to 140°) in dorsal and 120 0 0 (range 80 to 170 ) in volarly angulated distal radius malunion. Conclusion: The association of extra articular distal radius fracture with fracture ulnar styloid at two year follow up causes restriction of supination and pronation of forearm

Carpal Malalignment in Malunited Fractures of the Distal Radius

To evaluate and classify carpal alignment in malunited fractures of the distal radius. On standardized lateral radiographs of the involved wrist of 72 patients with a symptomatic extra-articular malunion of the distal radius, 43 with a dorsal and 29 with a palmar angulation, radius tilt (RT), radiolunate (RL) and lunocapitate angle were measured. Malposition of the radius was defined as RT plus 11° in dorsal malunion and RT minus 11° in palmar malunion. A palmar tilt of the radius was marked with a minus sign. At the time of corrective osteotomy 9 dorsal malunions underwent for different reasons evaluation of the scapholunate ligament with 4 having a complete scapholunate ligament disruption. With respect to the RL-angle, carpal malalignment was categorized as follows: type P with a RL-angle less than -12°, type K with a RL-angle between -12 and 10°, type A with a RL-angle more than 10°, but less than the malposition of the radius, type D with a RL-angle greater than the malposition of the radius. All types of carpal malalignment were found in both, dorsally and palmarly tilted malunion. Type A carpal alignment was identified as the leading type in dorsal malunion (25 out of 43 patients), whilst in palmar malunion colinear subluxation of the carpus (type C) was the dominant type (12 out of 29 patients). To return the hand to a neutral position the rotation of the lunate was compensated by a contrarotation of the capitate in the dorsal malunion. In the palmar malunion a dorsal extension of the capitate returned the hand to a neutral position. In 4 of the 5 patients with type D carpal alignment, who had scapholunate ligament evaluation, a complete ligament tear was found. In this study four different types of carpal alignment in malunited extra-articular fractures of the distal radius were identified. Based on this data we suspect that type D carpal alignment in dorsal malunion may be associated with a scapholunate ligament tear. Therefore, we recommend wrist arthroscopy for this group of patients.

Rigid Internal Fixation of Proximal Crescentic Metatarsal Osteotomy in Hallux Valgus Correction.

The purpose of this study was to evaluate outcomes utilizing a low-profile titanium plate and screw construct for rigid fixation of first ray proximal crescentic osteotomies in the treatment of hallux valgus. Forty-eight patients (53 feet) with mild to severe hallux valgus were prospectively enrolled and completed 12-month follow-up. All were treated with a proximal crescentic osteotomy, fixed with a low-profile titanium plate, distal soft tissue correction, with or without an Akin osteotomy. Recorded outcomes included change in first ray dorsiflexion angles, need for hardware removal, radiographic and clinical evaluation, pain, and American Orthopaedic Foot & Ankle Society (AOFAS) scores. All patients achieved radiographic union of their osteotomy. An Akin osteotomy was performed in 83% of patients. Seventeen feet (32%) had hardware removed. First ray dorsiflexion angles increased from a mean of 1.6 degrees preoperatively to 5.0 degrees postoperatively (P < .001). Dorsal malunion, defined as change in dorsiflexion angle greater than 1 standard deviation above the mean, occurred in 7 feet. The mean hallux valgus angle improved from 29 to 9 degrees (P < .001). The mean 1-2 intermetatarsal angle decreased from 14 to 6 degrees (P < .001). The first metatarsophalangeal joint range of motion decreased from 77 to 59 degrees (P < .001). The mean visual analog scale score improved from 4 to 0.7 (P < .0001). The mean AOFAS score improved from 55 to 89 points (P < .001). Proximal crescentic metatarsal osteotomy, fixed with a low-profile titanium plate and screw construct, with distal soft tissue repair, and Akin osteotomy as indicated, was a safe and reliable method for operative treatment of hallux valgus. Level IV, retrospective case series.

Distal Radius Malunion: A Cheap Surgery Case Report

Introduction: Malunion is a common complication of distal radius fractures. The incidence after conservative treatment is 25% and after surgery is 10% (1). After distal radius malunion, different surgical procedures have been described, such as fixation with K wire, plate, use of external fixator and frequent locking plate application (2-3). Case Report: In our case 32 year old patient who was operated by neurosurgery after traffic accident. Two months after the operation, the patient came to the orthopedics clinic. Distal radius dorsal angle malunion was detected after x-ray control.we choose dorsal aproach and using only k wire in surgery. Conclusion: In this case we understand that ,in distal radius extra articular malunion surgery, prefering dorsal approach and using only k wire can be good results like the other syrgery procedures.

CaP cement is equivalent to iliac bone graft in filling of large metaphyseal defects: 2 year prospective randomised study on distal radius osteotomies

The purpose of this prospective randomised study was to compare the clinical and radiological outcomes of injectable CaP bone cement with corticocancellous bone graft used to fill voids after corrective opening wedge osteotomies in the distal radius. 17 women/3 men, median age 56 (51.3; 61.0), underwent an open-wedge osteotomy of a dorsal malunion in the distal radius randomised to filling the defect either with bone graft (10) or CaP bone cement (10). Dorsal titanium locking plates were used and the wrist was plastered for 8 weeks. Follow-ups for 24 months included X-rays, CT scans, VAS on wrist and iliac crest, grip strength, ROM, Quick-DASH and Gartland & Werley scores. No difference was found between the 2 groups as to clinical outcome or radiological results with no loss of reduction. One bone graft patient developed a pseudarthrosis and one CaP patient suffered a plate fracture 6 months post-operatively. CaP bone cement is a good alternative to bone graft as a void filler in open-wedge osteotomies of the distal radius. The procedure is shorter, easier with the post-operative advantage of no donor site pain.Level of Evidence Randomised controlled trial. Level I evidence.

Surgical correction of distal radius malunions using an anatomic radial locking plate.

Correction of a distal radius fracture malunion is challenging technically. These malunions most classically deform dorsally, but often the deformity involves three planes. Using an anatomically designed radial plate that takes into consideration the three planes, correction of the deformity can be obtained. In this video we see a patient with a classic dinner fork deformity that is associated with a dorsal malunion involving the distal radius. Correction of a distal radius malunion can be performed using a radial approach and an anatomic radial plate. The authors have used this technique for difficult distal radius fracture malunions and have achieved superb correction, returning patients to early range of motion and an active lifestyle. Careful mobilization of the branches of the lateral antebrachial cutaneous nerve and the superficial branch of the radial nerve is required. This technique affords the surgeon excellent access to three sides of the radius to help perform this complex surgery.

Non-union in 3 of 15 osteotomies of the distal radius without bone graft

Background and purpose — Open-wedge osteotomies of the distal radius create a void that is usually filled with either iliac crest bone graft or bone substitute. Previous studies have suggested that this is unnecessary. We investigated the safety of omitting the filling procedure.Patients and methods — We included 15 patients with a dorsal malunion of a distal radius fracture. A palmar approach and angle-stable plates were used. The patients were followed until there was radiographic and clinical healing.Results — Non-union occurred in 3 of the 15 patients. The study, which had been planned to include 25 patients, was then discontinued. 6 osteotomies created a trapezoid void (no cortical contact); 3 of these did not unite after the index procedure (p = 0.04), but did subsequently, after autogenous bone grafting. A trapezoid void was significantly associated with non-union (p = 0.04).Interpretation — When a trapezoid defect is created, one should consider bone substitute or autogenous bone graft. This has been shown to be safe in other studies.

Evidence-based review of Colles’ fracture

Background A Colles’ fracture occurs as a transverse fracture of the metaphyseal region of the distal radius, approximately 25–40 mm proximal to the radio-carpal joint, and is associated with dorsal displacement and angulation of the distal fragment. Other features include radial shortening and palmar tilt. Key radiological measurements usually noted are that of radial length (normally 11 mm), dorsal angulation of the distal radius (normally 10° volar angulation) and radial inclination (normally 22°). A Colles’ fracture is one of the most common types of osteoporotic fractures seen, especially in females above the age of 50. Incidence of men vs. women over the age of 35 was 9/10,000 vs. 37/10,000, respectively. Management Conservative management is commonly an option in stable or minimally displaced fractures which are described as ≤2 mm loss of radial height, ≤5° change in radial inclination and ≤10° of dorsal angulation. This can be managed in a plaster cast for five to six weeks. Furthermore, age of &gt;60 years was found to be the most important factor in predicting whether a reduced unstable fracture would redisplace. Kirschner-wire fixation is a useful and simple operative method to help stabilise fragments that are not severely comminuted. This option was found to be better than plaster cast management alone, but was associated with surgical complications such as infection and nerve injuries. A more common management option utilised for unstable fractures today is open reduction and internal fixation using either dorsal or volar plates. Dorsal plates are less commonly used due to increased risk of volar collapse and tendon rupture with up to a 22% removal of implant rate due to tendon irritation. Volar plates are more popular as they allow a more stable fixation and thus early mobilisation with a better radiological outcome when compared against K-wire fixation. They are also associated with a lower incidence of tendon complications. External fixation management options may either be bridging or nonbridging in regards to the radio-carpal joint. Immobilising the wrist with a bridging external fixation device can be an option when managing a severely comminuted fracture without a large enough distal fragment to secure a distal pin. However, dorsal malunion was six times more likely when compared against a nonbridging option. Though studies showed external fixation devices provided better radiological outcomes when compared to conservative management, there is insufficient evidence to conclude that long-term functional outcomes are also improved. Prevention Often a fracture of this nature is considered as one of the first signs of osteoporosis in a middle-aged adult. Hormone replacement therapies and use of bisphosphonate therapy have been proven to reduce the risk of osteoporotic fractures with alendronate being found to significantly reduce the risk of spine, hip and wrist fractures in postmenopausal women with a mean age of 70 years. Incorporation of other health care professionals such as physiotherapists and occupational therapists is also of vital importance to ensure osteoporotic patients are at a lower risk of sustaining falls.

Die fehlverheilte distale Radiusfraktur – Langzeit­ergebnisse nach extraartikulärer Korrekturosteotomie

Numerous reports on short- and mid-term results demonstrate the value of corrective osteotomies for malunion of the distal radius. However, only long-term results can show whether a procedure has stood the test of time. Therefore the main questions to be answered in this article are: (i) are clinical and radiological improvements, recorded at short- and mid-term follow-up, long lasting? (ii) are consecutive procedures required, especially salvage procedures?; and (iii) what about the development of post-traumatic osteoarthritis? The study is based on the prospective data of 17 patients who underwent an extraarticular corrective osteotomy of the distal radius for symptomatic malunion (13 dorsal and 4 palmar malunions) between August 1992 and August 2003. The corrective osteotomy was performed as an opening wedge osteotomy filling the gap with an iliac crest bone graft and stabilisation of the radius with a plate. In 16 patients the radius was approached from palmar, in one patient the approach was dorsal. Preoperative, at short-term and at long-term postoperative follow-up clinical and radiological examinations were performed. In dorsal malunion the mean short-term follow-up was 17±10 (range: 7-44) months, and the mean long-term follow-up was 157±51 (120-254) months. In palmar malunion, the short-term follow-up averaged 13±6 (7-20) months, and the long-term follow-up 150±10 (138-166) months. All osteotomies showed bony union. One patient had to be excluded from the long-term evaluation due to wrist fusion and ulnar head hemiresection after 15 years. After dorsal malunion the long-term results showed a lasting improvement for all parameters. A comparison of short-term and long-term results revealed no deterioration of the results but a further statistically significant improvement in grip strength. 7 patients had no osteoarthritis, 3 osteoarthritis 1°, 1 osteoarthritis 2°, and 1 osteoarthritis 3°. After palmar malunion improvements occurred and lasted in the long-term run, but were not statistically significant. In this group no osteoarthritis was present. Corrective osteotomy for malunion of the distal radius has stood the test of time even in the long-term course. Even from this point of view, it can be recommended.

Reply to comments by Wu et al. regarding our manuscript titled: A minimally invasive technique for surgical treatment of hallux valgus: simple, effective, rapid, inexpensive (SERI)

Reply to comments by Wu et al. regarding our manuscript titled: A minimally invasive technique for surgical treatment of hallux valgus: simple, effective, rapid, inexpensive (SERI)

Mechanical Comparison of Two Types of Fixation for Ludloff Oblique First Metatarsal Osteotomy

The Ludloff oblique metatarsal osteotomy is an effective method to correct hallux valgus deformity, although a number of problems have been associated with it, including inherent instability, delayed union, dorsal malunion, and fixation failure. The purpose of the present study was to compare the mechanical characteristics of fixation of the Ludloff osteotomy in 20 identical synthetic bone models, 10 fixated using 2 screws (group I) and 10 fixated using 2 screws augmented with a mini locking plate (group II). Each specimen was loaded to failure, and the mean average load to failure, stiffness, and absorbed energy to failure were compared using unpaired Student’s t test. The mean average stiffness of the Ludloff osteotomy fixed with 2 screws (group I) and with the supplementary mini locking plate (group II) was 172.7 ± 31.7 N/mm and 193.3 ± 39 N/mm, respectively ( p = .21). The mean average load to failure for groups I and II was 278.4 ± 64.4 N and 356.2 ± 77.9 N, respectively ( p = .025). The mean average energy absorbed before failure for groups I and II was 506.7 ± 206.4 Nmm and 769.8 ± 339.4 Nmm, respectively ( p = .05). The use of a medially applied supplementary mini locking plate offers a simple and effective method to improve the mechanical stability of the Ludloff oblique osteotomy.

Biomechanical comparison of hallux valgus correction using the proximal chevron osteotomy fixed with a medial locking plate and the Ludloff osteotomy fixed with two screws

Background For moderate-to-severe hallux valgus deformities with a 1–2 intermetatarsal angle in excess of 15°, a proximal first metatarsal osteotomy is indicated. The ideal osteotomy has yet to be defined, but should inherently limit the incidence of dorsal malunion and allow for early ambulation. The present study evaluates the mechanical integrity of two popular first metatarsal osteotomies. Methods Ten matched pairs of fresh-frozen cadaveric first metatarsals were harvested. In one metatarsal from each pair, a Ludloff osteotomy was created and fixed with two cannulated 3.5 mm screws. In the contralateral first metatarsal, a proximal chevron osteotomy was performed and subsequently fixed with a medially applied locking plate. All specimens were mounted within an Instron 1321 servohydraulic materials testing machine and subjected to a plantar-to-dorsal cantilever bending protocol for 1000 cycles. Findings Two of ten Ludloff osteotomies failed prior to completion of 1000 loading cycles by fracture at the distal screw site, whereas six of ten proximal chevrons failed prior to the 1000th cycle. The mode of failure in this group was by cut-out of the plantar-proximal screw. The bending stiffness of the Ludloff osteotomy exceeded that of the proximal chevron at all measurement points between the 1st and 200th load cycles ( P < 0.05). After 200 cycles, an inadequate number of plate constructs survived to allow statistical comparison. Interpretation The results of the present study indicate that the proximal chevron osteotomy fixed with a medially based locking plate exhibits mechanical properties inferior to those of the Ludloff osteotomy under the tested conditions.

Do young patients with malunited fractures of the distal radius inevitably develop symptomatic post-traumatic osteoarthritis?

Fractures of the distal radius occurring in young adults are treated increasingly by open surgical techniques, partly because of concern that failure to restore the alignment of the fracture accurately may cause symptomatic post-traumatic osteoarthritis in future years. We reviewed 106 adults who had sustained a fracture of the distal radius between 1960 and 1968 and who were below the age of 40 years at the time of injury. We carried out a clinical and radiological assessment at a mean follow-up of 38 years (33 to 42). No patient had required a salvage procedure. While there was radiological evidence of post-traumatic osteoarthritis after an intra-articular fracture in 68% of patients (27 of 40), the disabilities of the arm, shoulder and hand (DASH) scores were not different from population norms, and function, as assessed by the Patient Evaluation Measure, was impaired by less than 10%. Ordinal logistic regression analysis showed a significant relationship between narrowing of the joint space and extra-articular malunion (dorsal angulation and radial shortening) as well as intra-articular injury. Multivariate analysis revealed that grip strength had fallen to 89% of that of the uninjured side in the presence of dorsal malunion, but no measure of extra-articular malunion was significantly related to either the Patient Evaluation Measure or DASH scores. While anatomical reduction is the principal aim of treatment, imperfect reduction of these fractures may not result in symptomatic arthritis in the long term, and this should be considered when counselling patients on the risks and benefits of the many treatment options available.

Early Results of the Mau Osteotomy for Correction of Moderate to Severe Hallux Valgus: A Review of 24 Cases

In our retrospective study, we report the objective results of the Mau osteotomy in the treatment of hallux valgus. We reviewed the results of 24 cases of moderate to severe hallux valgus deformities corrected with the Mau osteotomy of the first metatarsal combined with a distal soft-tissue procedure. Follow-up was possible in 24 cases. Preoperatively the mean hallux valgus and first intermetatarsal angles were 31.3 degrees and 16.6 degrees respectively, and were corrected postoperatively to an average of 13.00 degrees+/-7.15 degrees and 9.80 degrees+/-2.43 degrees respectively (P< .001). In the sagittal plane, the first metatarsal was shortened by an average of 2.00 mm. Two (8.3%) cases had dorsal elevation of the osteotomy fragment. Complications included 3 recurrences of the deformity, 1 frank nonunion, 8 dorsal cortical nonunions, 5 cases of undercorrection, and 1 case of broken hardware that was present in the nonunion that went on to revision. There were no superficial or deep infections, and no cases of transfer metatarsalgia were noted. In this series, the use of an oblique first metatarsal osteotomy with a dorsal shelf resulted in reliable and powerful correction of the first intermetatarsal angle in patients with moderate to severe hallux valgus. Particular attention should be paid to severe IM angles and the possibility of undercorrections. Despite ambulation postoperatively, the Mau osteotomy minimized dorsal malunion and the incidence of transfer metatarsalgia. 4.

Osteotomy of dorsally displaced malunited fractures of the distal radius: No loss of radiographic correction during healing with a minimally invasive fixation technique and an injectable bone substitute

Background and purpose Malunion after a distal radius fracture can be treated with an osteotomy of the distal radius. Often autologous iliac crest bone graft is used to fill the gap, but this is associated with donor site morbidity. Instead of bone graft, we have used a slow-resorbing bone substitute in combination with a minimally invasive fixation technique.Patients and methods 25 consecutive patients with a dorsal malunion after a distal radius fracture underwent an osteotomy. A TriMed buttress pin and a radial pin plate were used for fixation, and Norian SRS as bone substitute. The patients were followed for a minimum of 1 year and range of motion, grip strength, DASH scores, and the radiographic correction were measured.Results Forearm rotation improved from 137° to 155°, flexion/extension from 102° to 120°, and radioul-nar deviation from 32° to 43°. Grip strength increased from 62% of the contralateral hand to 82%. DASH scores decreased from 36 to 23. Radiographically, all osteotomies but 1 healed and the radiographic correction achieved was consistent over the first year.Interpretation Osteotomy of the distal radius is effective in increasing motion and grip strength after a malunited distal radial fracture. Patient satisfaction is high and subjective results measured with DASH are good. Using a bone substitute, the operation can be performed as an outpatient procedure and donor-site pain avoided. No loss of the radiographic correction achieved was noted during osteotomy healing.

Bridging and non‐bridging external fixation in the treatment of unstable fractures of the distal radius: A retrospective study of 588 patients

Background and purpose Bridging external fixation is used more frequently than non‐bridging fixation in the management of unstable distal radius fractures, despite evidence from randomized controlled trials of better outcome with the latter technique. This study was designed to investigate the generalizability of the technique of non‐bridging external fixation, and to define the indications for the use of each technique and their complications.Methods 641 patients with unstable displaced fractures of the distal radius were treated with bridging or non‐bridging external fixation. Non‐bridging external fixation was used where there was space for pins in the distal fragment. 52 patients were lost to follow‐up, leaving 588 patients available for study. Complete data from radiographic measurements after fracture healing were available for 546 patients. 59 % of fractures were treated with the non‐bridging technique.Results Fractures treated with bridging external fixation had a 6 times increased risk of dorsal malunion (p < 0.001) and a 2.5 times increased risk of radial shortening (p < 0.001) after adjusting for confounding factors (95% CI for odds ratio: 3–13 and 1.5–4, respectively) compared to non‐bridging techniques. Minor pin tract infections were more common in the non‐bridging group.Interpretation Non‐bridging external fixation of the distal radius is a generalizable technique, and reduces the risk of dorsal malunion compared with bridging external fixation. Major complication rates are low and the technique is applicable to most unstable fractures of the distal radius. We recommend that non‐bridging external fixation be used where there is space for the pins in the distal fragment.

Distal radial osteotomy for malunion using non–bridging external fixation

Background and purpose Symptomatic malunion of the distal radius is a common problem and is treated by distal radial osteotomy. Plating is commonly used but has a high rate of plate removal. This study is a report of the functional and radiographic outcome of a prospective series of distal radial osteotomies using non‐bridging external fixation.Methods 23 patients with a median age of 60 (18-84) years underwent distal radial osteotomy using non‐bridging external fixation and bone grafting for dorsal malunion of a fracture of the distal radius. There were no cases of intraarticular malunion. Radiographic, functional, and patient‐assessed outcomes were assessed preoperatively and until 6 months after surgery.Results The mean preoperative dorsal angle of 20 (5-40) degrees was corrected to over 5 (0-15) degrees of volar tilt (p < 0.001) and the mean preoperative positive ulnar variance of 3.9 (0-8) mm was corrected to 2.5 (0-8) mm (p = 0.005). Carpal alignment was restored in 22 of the 23 patients. 5 patients required simultaneous ulnar surgery, 1 required ulnar shortening, and 4 required modified Bower's procedures. By 6 months postoperatively, all measures of function except extension and key grip strength showed statistically significant improvements in their means. The SF36 showed statistical improvements in two domains, role physical and bodily pain. There were 2 patients with extensor pollicis longus ruptures and 13 with minor pin‐track infections.Interpretation Distal radial osteotomy for dorsal malunion of the distal radius using non‐bridging external fixation is a successful technique for correction of deformity and restoration of function, with the advantages of being less invasive and not requiring further surgery for removal of metalwork.

Proximal Oblique Slide Closing Wedge Metatarsal Osteotomy With Plate Fixation for Severe Hallux Valgus Deformities

Proximal metatarsal osteotomies are generally recommended for severe hallux valgus deformities. The most common problems encountered with these osteotomies are overcorrection, that is, hallux varus and dorsal malunion because of either technical errors or fixation failure. We report our first 12 cases of severe hallux valgus deformities treated with a modified proximal metatarsal osteotomy fixed with angular stable plates, with an average American Orthopaedic Foot and Ankle Society preoperative score of 50 points, average intermetatarsal angle of 15 degrees, and metatarsophalangeal angle of 36 degrees. The osteotomy was performed from the dorsal to the plantar aspect of the bone, removing a small bone wedge laterally as determined in the preoperative planning, and translating laterally the distal fragment. In this way, rotation and lateral displacement of the distal fragment was performed until intraoperative parallelism between the first and second metatarsal bone was obtained. The osteotomy was fixed with an angular stable plate, with 2 locked screws proximally and 3 distal nonlocked screws. The geometric model of the osteotomy, preoperative planning, technique, early results, and complications are shown.

Effect of First Metatarsal Shortening and Dorsiflexion Osteotomies on Forefoot Plantar Pressure in a Cadaver Model

Metatarsalgia of the second ray is a common problem associated with disorders of the first metatarsal. It also occurs after the operative treatment of those disorders. Plantar pressure changes from alteration of the static and dynamic structure of the forefoot may be associated with this condition. This study evaluated changes in plantar forefoot pressure especially under the second metatarsal head after three operative procedures on the first ray. Each of 12 cadaver foot specimens was cyclically loaded on the servohydraulic MTS Mini Bionix test frame (MTS Systems Corp., Eden Prairie, MN) with traction on the Achilles tendon. Plantar forefoot pressure was measured by the F-scan system (Tekscan, Inc., S. Boston, MA) with the foot intact, after a first metatarsal base dorsal closing-wedge osteotomy with 5-mm base length to simulate dorsal malunion, and after 5-mm and 10-mm metatarsal shortening procedures. Paired Student t-test analysis was used to compare data for the intact foot with data after each intervention. One form of Bonferroni's correction was done to establish a new alpha level to tighten the analysis and to compensate for multiple paired Student t-tests. The significance level was calculated to be 0.016 based on an original alpha level of 0.05. As compared with the intact foot, all three procedures on the first metatarsal resulted in significant decreases in plantar pressure under the first metatarsal head (p < 0.016). Plantar pressure under the second metatarsal head increased significantly as compared with the intact foot (p < 0.016) after all three procedures. Pressures under the third-fourth metatarsal heads increased significantly compared with the intact foot after the 5-mm and 10-mm shortenings (p < 0.016). Plantar pressure under the fifth metatarsal did not change significantly after any of the three procedures. Dorsiflexion osteotomy and shortening of the first metatarsal are associated with significant forefoot plantar pressure changes in a cadaver model.