Segmental femoral fracture malunion: evidence and prognostic analysis of medical intervention in the third century BC.

We examined the remains of an individual who was unearthed from the Tuchengzi site and was believed to be from the Warring States period in China. The remains exhibited segmental femoral fracture. We aimed to deduce the cause of fracture, medical interventions, healing process, and motion behavior after fracture healing using several techniques, including macroscopic observation, computed tomography (CT), and finite element analysis. Based on the morphology of the long bones, it appeared that the individual was male. The fractures resulted in an adduction angle of 5.47° and an anterior flexion angle of 21.34° in the proximal femur, while the femoral neck anteversion angle had been replaced by a retroversion angle of 10.74°. Additionally, the distal femur formed an abnormal anterior convex angle of 144.60°. CT revealed mature callus formation and visible trabecular bundles. The finite element analysis indicated that the maximum von Mises stress in the femur was 17.44 MPa during standing and 96.46 MPa during walking. We suggest that medical practitioners in the Warring States period possessed a good knowledge of thigh anatomy, enabling them to perform fracture reduction and fixation. Reasonable medical intervention facilitated fracture healing and load recovery. Satisfactory fracture healing ensured that the individual could engage in normal standing and walking activities after rehabilitation.

3D-assisted corrective osteotomies of the distal radius: a comparison of pre-contoured conventional implants versus patient-specific implants.

PURPOSE: There is a debate whether corrective osteotomies of the distal radius should be performed using a 3D work-up with pre-contoured conventional implants (i.e., of-the-shelf) or patient-specific implants (i.e., custom-made). This study aims to assess the postoperative accuracy of 3D-assisted correction osteotomy of the distal radius using either implant. METHODS: Twenty corrective osteotomies of the distal radius were planned using 3D technologies and performed on Thiel embalmed human cadavers. Our workflow consisted of virtual surgical planning and 3D printed guides for osteotomy and repositioning. Subsequently, left radii were fixated with patient-specific implants, and right radii were fixated with pre-contoured conventional implants. The accuracy of the corrections was assessed through measurement of rotation, dorsal and radial angulation and translations with postoperative CT scans in comparison to their preoperative virtual plan. RESULTS: Twenty corrective osteotomies were executed according to their plan. The median differences between the preoperative plan and postoperative results were 2.6° (IQR: 1.6-3.9°) for rotation, 1.4° (IQR: 0.6-2.9°) for dorsal angulation, 4.7° (IQR: 2.9-5.7°) for radial angulation, and 2.4 mm (IQR: 1.3-2.9 mm) for translation of the distal radius, thus sufficient for application in clinical practice. There was no significant difference in accuracy of correction when comparing pre-contoured conventional implants with patient-specific implants. CONCLUSION: 3D-assisted corrective osteotomy of the distal radius with either pre-contoured conventional implants or patient-specific implants results in accurate corrections. The choice of implant type should not solely depend on accuracy of the correction, but also be based on other considerations like the availability of resources and the preoperative assessment of implant fitting.

Distal radial fractures: a nationwide register study on corrective osteotomies after malunion.

The aim of the present study was to explore the incidence of corrective osteotomies after conservatively treated distal radial fracture and the risk for late correction depending on the patient's age. Based on data from the Finnish National Care Register of Health Care, Specialist Care, on all corrective osteotomies carried out in Finland during 2015-2019 in adults aged ≥20 years, we calculated the mean annual incidence rates per 100,000 person-years, standardized with the European Standard Population 2013. Using multivariable logistic regression, we calculated the risk of corrective osteotomies in various age groups. In total, 41,418 distal radial fractures were identified. Of those, 10,577 received surgical treatment in the acute phase. The incidence rate of primary operations for distal radial fractures was 47.9 per 100, 000 person-years. A total of 321 conservatively treated fractures needed corrective osteoteomy, with a surprisingly low mean annual incidence rate of 1.5 per 100,000 person-years. The risk for this was highest in patients in their fourth or fifth decade.Level of evidence: III.

Malunions following lower extremity fractures in veterans with a spinal cord injury/disorder.

BACKGROUND: Nearly 50% of all persons with a spinal cord injury/disorder (SCI/D) will sustain an osteoporotic fracture sometime in their life, with lower extremity fractures being the most common. There are a number of complications that can occur post fracture, including fracture malunion. To date, there have been no dedicated investigations of malunions among persons with SCI/D. OBJECTIVES: The primary objective of this study was to identify risk factors associated with fracture malunion among fracture-related (type of fracture, fracture location, initial fracture treatment) and SCI/D-related factors. Secondary objectives were to describe treatment of fracture malunions and complications following these malunions. METHODS: Veterans with SCI/D with an incident lower extremity fracture and subsequent malunion from Fiscal Year (FY) 2005-2015 were selected from the Veteran Health Administration (VHA) databases using International Classification of Diseases, 9th edition (ICD-9) codes for lower extremity fractures and malunion. These fracture malunion cases underwent electronic health record (EHR) review to abstract information on potential risk factors, treatments and complications for malunion. Twenty-nine cases were identified with a fracture malunion with 28 of them successfully matched with Veterans with a lower extremity fracture during FY2005-FY2014 without a malunion (matched 1:4) based on having an outpatient utilization date of care within 30 days of the fracture case. There was trend towards more nonsurgical treatment in the malunion group (n = 27, 96.43%) compared to the control group (n = 101, 90.18%) (P = 0.05), though fracture treatment proved not to be not associated with developing a malunion in univariate logistic regression analyses (OR = 0.30; 95% CI: 0.08-1.09). In multivariate analyses, Veterans with tetraplegia were significantly less likely (approximately 3-fold) to have a fracture malunion (OR = 0.38; 95% CI: 0.14-0.93) compared to those with paraplegia. Fracture malunion was significantly less likely to occur for fractures of the ankle (OR = 0.02; 95% CI: 0-0.13) or the hip (OR = 0.15; 95% CI: 0.03-0.56) compared to femur fractures. Fracture malunions were rarely treated. The most common complications following malunions were pressure injuries (56.3%) followed by osteomyelitis (25.0%). CONCLUSIONS: Persons with tetraplegia as well as fractures of the ankle and hip (compared to the femur) were less likely to develop a fracture malunion. Attention to prevention of avoidable pressure injuries following a fracture malunion is important.

Corrective osteotomy of the distal radius with palmar locking plate osteosynthesis without bone grafting and without cortical contact.

The aim of this study was to assess bone healing and secondary fracture displacement after corrective osteotomy of the distal radius without any cortical contact using palmar locking plates without bone grafting. Between 2009 and 2021, 11 palmar corrective osteotomies of extra-articular malunited distal radius fractures and palmar plate fixations without the use of bone grafts and without cortical contact, were assessed. All patients showed complete osseous restoration and significant improvement in all radiographic parameters. Except for one patient, there were no secondary dislocations or loss of reduction in the postoperative follow-up. Bone grafts may not be mandatory for bone healing and prevention of secondary fracture displacement after palmar corrective osteotomy without cortical contact and fixation with palmar locking plate.Level of evidence: IV.

The treatment of a malunited posterior pilon fracture with talar dislocation: A staged surgical treatment protocol.

BACKGROUND: Malunited posterior pilon fractures with talus dislocation (mPPFtd) are rare and there are no appropriate treatment strategies. The purpose of this study was to introduce a stepped strategy featuring preliminary soft tissue management according to the Ilizarov principle and delayed open reduction and internal fixation (ORIF) through a modified posteromedial approach to overcome rigid soft tissue contracture. METHOD: From February 2015 to August 2021, 12 selected patients with mPPFtd who were treated with the staged protocol (Group A) were retrospectively analysed. The clinical and radiographic outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, the visual analogue scale (VAS) score, and the Burwell-Charnley score. Moreover, this case series was compared with some cases of fresh fracture (Group B) in patients that had the same baseline data from our previous study. RESULTS: In Group A, the average length of time between the date of injury and the date of surgery was 4.8 ± 3.3 months. The average time to external fixator distraction, as the first-stage treatment, was 13.4 ± 1.0 days. In the second stage of ORIF, the posterosuperior dislocation of the talus was corrected with osteotomy and leverage manoeuvres. According to the Burwell-Charnley score system, the reduction quality was excellent in 9 cases and good in 3 cases. After a mean follow-up of 3.8 ± 2.1 years, there were no infections, wound healing problems, or nerve injuries in our cohort, and union was observed in all fractures without a loss of reduction. The baseline data of the two groups were not significantly different (p>0.05). The mean AOFAS score in Group A was 85.0 ± 10.5 and that in Group B was 95.4 ± 6.1 (p<0.05). The mean VAS score in Group A was 1.7 ± 1.4 and that in Group B was 0.7 ± 0.9 (p<0.05). CONCLUSION: A staged surgical treatment strategy characterized by soft tissue management will improve the treatment of mPPFtd and produce satisfactory clinical outcomes. LEVEL OF EVIDENCE: Level IV, retrospective case series.

[Malunion of the distal radius: 3D planning and performance of intra- and extra-articular corrective osteotomy]. / Malunion der distalen Radiusfraktur: 3-D-Planung und Durchführung von intra- und extraartikulären Korrekturosteotomien.

OBJECTIVE: Restoration of the original anatomy with reduction of both current symptoms and risk of posttraumatic osteoarthritis. INDICATIONS: Symptomatic intra- or extra-articular malunion due to limitation of movement and/or painful function, intra-articular step of > 1 mm, instability of the distal radioulnar joint. CONTRAINDICATIONS: Minimal deformity. Pre-existing osteoarthritis Knirk and Jupiter II or higher. Simpler surgical alternative, e.g., ulna shortening osteotomy. Smoking or advanced age are not contraindications. SURGICAL TECHNIQUE: Preoperative assessment and performance of a bilateral computed tomography (CT). Three-dimensional (3D) malposition analysis and calculation of the correction. Planning of the corrective osteotomy on the 3D model and creation of patient-specific drilling and sawing guides. Performing the 3D-guided osteotomy. POSTOPERATIVE MANAGEMENT: Early functional unloaded mobilization with the splint for 8 weeks until consolidation control with CT. RESULTS: Significant reduction of the step to < 1 mm (p ≤ 0.05) can be achieved with intra-articular corrections. In extra-articular corrective osteotomies, a mean residual rotational malalignment error of 2.0° (±â€¯2.2°) and a translational malalignment error of 0.6 mm (±â€¯0.2 mm) is achieved. Single-cut osteotomies in the shaft region can be performed to within a few degrees for rotation (e.g., pronation/supination 4.9°) and for translation (e.g., proximal/distal, 0.8 mm). After surgery, a mean residual 3D angle of 5.8° (SD 3.6°) was measured. Furthermore, surgical time for 3D-assisted surgery is significantly reduced compared to the conventional technique (140 ± 37 vs 108 ± 26 min; p < 0.05). Thus, the progression of osteoarthritis can be reduced in the medium term and improved mobility and grip strength are achieved. The clinical outcome parameters based on patient-rated wrist evaluation (PRWE) and the disabilities of the arm, shoulder and hand (DASH) scores are roughly comparable.

[Carpal Malalignment in Malunited Fractures of the Distal Radius]. / Konstellationen des karpalen Gefüges bei fehlverheilten extraartikulären distalen Radiusfrakturen.

PURPOSE: To evaluate and classify carpal alignment in malunited fractures of the distal radius. MATERIALS AND METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Corrective Osteotomy of Malunited Forearm Fractures for Volar Distal Radioulnar Joint Instability: A Case Report.

CASE: A 6-year-old girl who had midshaft forearm fractures treated conservatively had volar distal radioulnar joint (DRUJ) instability caused by radial malunion at the 1-year follow-up. Corrective osteotomy was planned using computer-aided design (CAD) software based on computed tomography images. According to the analysis, the radial bone had an 8° apex volar deformation in the sagittal plane. Corrective osteotomy was performed based on preoperative planning. After surgery, the patient regained full function of her right forearm without volar DRUJ instability. CONCLUSION: This case report shows that corrective osteotomy with 3D CAD analysis can help surgeons plan and accurately correct malunion.

Minimal Invasive Corrective Osteotomy with the Ilizarov Mini-Fixator for Malunited Fractures of Proximal Phalanges in Adolescence: Report of Three Cases and a Review of the Literature.

Posttraumatic malunion with combination of angular, rotational, and shortening deformity of the proximal phalanx may cause scissoring of a finger and impairment of hand function. Cosmetic disfigurement and severe dysfunction of fingers require surgical correction, most often via open corrective osteotomies and rigid fixation with a plate or screws. However, such an approach requires a longer incision, inevitably results in a scar, and has a higher potential for extensor tendon adhesion. Also, abruption of the periosteum and plating of the phalange requires longer bone healing time. Thus, we devised a technique of minimally invasive correction of phalangeal malunion using an external mini-fixator. We presented representative three cases of malunited fractures of phalanges treated with the Ilizarov mini-fixator in adolescence and review reports of similar cases. The usage of Ilizarov mini-fixator provided excellent outcomes for posttraumatic malunion of three fingers.

Change in capitate shift after osteotomy for distal radial fracture malunion.

Loss of anterior tilt after a distal radial fracture can lead to carpal malalignment, which may cause functional impairment. The aim of this study was to establish whether distal radial osteotomy for malunion, which primarily restores the dorsal tilt, will also improve carpal malalignment as measured by capitate shift. Radiographs of 67 patients who underwent osteotomy after malunion of a distal radial fracture were reviewed. Measurements of capitate shift and dorsal tilt were recorded. Linear regression modelling was used to assess the relationship between dorsal tilt and capitate shift. Change in capitate shift was strongly associated with change in dorsal tilt following osteotomy. This relationship was maintained on long-term radiographs. Capitate shift is strongly related to dorsal tilt following a distal radial fracture. Correcting the dorsal tilt during an osteotomy, therefore, will improve capitate shift and carpal malalignment. Capitate shift is unrelated to age, sex and is easy to visually assess.Level of evidence: IV.

[Calcaneal V-shaped osteotomy combined with subtalar arthrodesis for Stephens â ¡ and â ¢ calcaneal fractures malunion].

Objective: To investigate the effectiveness of calcaneal V-shaped osteotomy combined with subtalar arthrodesis in the treatment of Stephens Ⅱand Ⅲ calcaneal fracture malunion. Methods: The clinical data of 24 patients with severe calcaneal fracture malunion treated by calcaneal V-shaped osteotomy combined with subtalar arthrodesis between January 2017 and December 2021 were retrospectively analyzed. There were 20 males and 4 females with an average age of 42.8 years (range, 33-60 years). Conservative treatment of calcaneal fracture failed in 19 cases and operation failed in 5 cases. Stephens classification of calcaneal fracture malunion was type Ⅱ in 14 cases, and type Ⅲ in 10 cases. Preoperative Böhler angle of calcaneus was 4.0°-13.5° (mean, 8.6°), Gissane angle was 100°-152° (mean, 119.3°). The time from injury to operation was 6-14 months (mean, 9.7 months). American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score and visual analogue scale (VAS) score were used to evaluate the effectiveness before operation and at last follow-up. Bone healing was observed and the healing time was recorded. The talocalcaneal height, talus inclination angle, Pitch angle, calcaneal width, and hindfoot alignment angle were measured. Results: Necrosis of the cuticle edge of the incision occurred in 3 cases, which were cured by dressing change and oral administration of antibiotic therapy. The other incisions healed by first intention. All the 24 patients were followed up 12-23 months, with an average of 17.1 months. The foot shape of the patients recovered well, the shoes were restored to the size before injury, and there was no anterior ankle impingement. Bone union was achieved in all patients, and the healing time ranged from 12 to 18 weeks, with an average of 14.1 weeks. At last follow-up, no adjacent joint degeneration occurred in all patients; 5 patients had mild foot pain during walking, which had no significant impact on daily life and work; no patient needed revision surgery. The AOFAS ankle and hindfoot score was significantly higher than that before operation ( P<0.001), the results were excellent in 16 cases, good in 4 cases, and poor in 4 cases, and the excellent and good rate was 83.3%. The VAS score, talocalcaneal height, talus inclination angle, Pitch angle, calcaneal width, and hindfoot alignment angle were significantly improved after operation ( P<0.001). Conclusion: Calcaneal V-shaped osteotomy combined with subtalar arthrodesis can effectively relieve hindfoot pain, correct talocalcaneal height, restore talus inclination angle, and reduce the risk of nonunion after subtalar arthrodesis.

Neglected Metatarsophalangeal Joint Dislocation of the Lesser Toe with Associated Metatarsal Fracture Malunion in a 4-Year-Old Child: A Case Report.

CASE: A 4-year-old girl presented with a 5-week-old, neglected fourth metatarsophalangeal (MTP) joint dislocation with malunion of the fourth metatarsal. A previous attempt at closed reduction had failed. The reduction was hindered by dynamic stabilizing of soft tissues around the MTP joint. Open reduction of the fourth MTP joint dislocation and corrective osteotomy of the fourth metatarsal was performed. The patient was pain-free without any cosmetic deformity at the 1-year follow-up. CONCLUSION: Prompt recognition of a MTP dislocation is vital. The long extensor tendon to the toe can hinder the closed reduction of the MTP dislocation. Osteotomy of the metatarsal malunion is necessary for stable reduction. LEVEL OF EVIDENCE: 4.

Multiple Reconstructive Osteotomy Treating Malunited Calcaneal Fractures Without Subtalar Joint Fusion.

OBJECTIVE: Various surgical techniques have been reported in treating calcaneal malunions over the decades, while the operations on single plane were accompanied by respective limitations. The purpose of this study is to evaluate the efficacy of a novel multiple reconstructive osteotomy for treating malunited calcaneal fractures without subtalar joint fusion. METHODS: From March 12, 2010, to August 17, 2017, 10 patients (10 feet) with malunited calcaneal fractures were treated with multiple reconstructive osteotomy with subtalar joint-preserving operations. All patients were treated with a corrective osteotomy, joint realignment, soft tissue balancing, and secondary internal fixation at a mean of 5.6 ± 2.41 months since the initial injury. With the utilization of the multiple reconstructive osteotomy, the posterior facet was restored to preserve the subtalar joint. All patients were evaluated clinically and radiographically at a mean follow-up of 3.04 ± 1.21 years. RESULTS: All patients were subjectively satisfied with the treatment. The average time to union was 12.2 ± 1.11 weeks. The American Orthopedic Foot and Ankle (AOFAS) ankle and hind foot score was 86.3 ± 4.45 (t = 27.64, P < 0.0001, paired t-test), which was significantly higher than the preoperative assessment. Postoperative radiographic assessment revealed great improvement in Böhler's angle (from 25.4° to 86.3°), talocalcaneal height (65.15-72.68 mm) and Calcaneus-talus angle (from 34.46° to 39.7°). One patient had mild discomfort after a 1-h brisk walk. One patient was suspected to have early posttraumatic arthritis of the subtalar joint based upon radiographic evidence during the follow-up, but the patients could walk normally for a long time without pain. CONCLUSION: Multiple reconstructive osteotomy is an effective way to restore the calcaneal morphology and preserve the subtalar joint for selected calcaneal malunion.

Shortening dome osteotomy for correction of severe cubitus varus secondary to malunited supracondylar fractures in children.

The results of conventional corrective procedures remain suboptimal for severe cubitus varus deformities (> 30°) in children. We present the results of shortening dome osteotomy for the correction of such deformities. PATIENTS AND METHODS: We present retrospective review of prospectively collected data of 18 patients (11 boys and 7 girls) who underwent shortening dome osteotomy between January 2011 and December 2019 for severe cubitus varus deformities (> 30°) secondary to malunited supracondylar fracture. The procedure involved the removal of convexo-concave bone (5-8 mm wide) between the two domes. Humero-ulnar angles, lateral condylar prominence index (LCPI), and elbow range of movements were recorded preoperatively and postoperatively. RESULTS: Mean age was 7.5 years (range 5 years-11 years). Indication for surgery was poor cosmesis in all the patients and tardy ulnar nerve symptoms in three patients. Mean preoperative humero-ulnar angle was 26.1° varus (range 22°-34°), while it was 7.1° valgus (range 0°-12°) for contralateral normal elbow. They were followed for a mean duration of 2.2 years (range 12 months-5.8 years). The mean postoperative valgus angle achieved was 7.3° (range 2°-12°) as total angular correction achieved was 34.4° (range 30°-44°) (p < 0.001). Radiological healing was observed in all the patients at mean duration of 7.1 weeks (range 5 weeks-9 weeks). Mean preoperative and postoperative LCPI were - 2.4 (range +4.7 to - 10.5) and - 1.7 (range +4.5 to - 5.1), respectively (p = 0.595). Three patients had pin tract infections and two of them responded to aseptic dressings and oral antibiotics, while another required early pin removal and additional protection in splint. All patients regained preoperative arc of motion within 6 months after the procedure. CONCLUSION: Shortening dome osteotomy is a safe and effective method for correcting severe cubitus varus deformities (> 30°) secondary to malunited supracondylar fracture in children.

Staged Ilizarov distraction histogenesis and corrective reconstruction for severe malunited calcaneal fractures.

PURPOSE: Severe calcaneal malunion is a clinical conundrum for the difficulty of calcaneal reconstruction without soft tissue complications. The aim of this study is to introduce the treatment strategy and preliminary results of staged Illizarov distraction histogenesis and corrective reconstruction for severe malunion of calcaneal fractures. METHODS: From June 2014 to May 2020, 14 patients with severe calcaneal malunion treated with the staged strategy were retrospectively analyzed. At the first stage, calcaneal osteotomy and external fixation with Ilizarov frame were performed. The restoration of the approximate configuration of calcaneus and the expansion of contractural soft tissue were achieved by gradual calcaneal distraction. At the second stage, corrective reconstruction was performed and autogenous iliac crest bone graft was used. Clinical and radiographic outcomes were evaluated at final follow-up. RESULTS: The average time of Ilizarov distraction and total fixation was 21.4 days and 41.0 days at first-stage treatment. At a mean follow-up of 33.1 months, the average American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score increased significantly from 24.0 to 72.4 (p < 0.01). And the mean visual analogue scale (VAS) score had improved remarkably from 8.2 to 2.4 (p < 0.01). Radiographs showed that talocalcaneal height, calcaneal width, calcaneal tuberosity height, hindfoot alignment angle, and talar declination angle were improved to a great extent (p < 0.01). Only one patient had minor pin site infection at first-stage treatment and one got superficial wound infection after second-stage surgery. No wound dehiscence, skin necrosis, or deep infection occurred. CONCLUSION: Staged Ilizarov distraction histogenesis and corrective reconstruction is a safe and effective treatment strategy for reducing soft tissue complications and improving reconstruction results in surgical correction of severe calcaneal malunion.

Distal radius malunion: outcomes following an ulnar shortening osteotomy.

PURPOSE: Positive ulnar variance following a distal radius malunion can lead to ulnar-sided wrist pain, loss of grip strength, and distal radioulnar joint impingement. The primary aim of this study is to describe upper limb-specific functional outcomes following ulnar shortening osteotomy (USO) for ulnar-sided wrist pain associated with malunion of the distal radius. METHODS: We retrospectively identified 40 adult patients from a single centre over a 9-year period that had undergone an USO for symptomatic malunion of the distal radius. The primary outcome was the patient-rated wrist evaluation (PRWE). Secondary outcomes were the QuickDASH, EQ-5D-5L, complications, and net promoter score (NPS). RESULTS: Outcomes were available for 37 patients (93%). The mean age was 56 years and 25 patients were female (68%). At a mean follow-up of 6 years (range 1-10 years) the median PRWE was 11 (IQR 0-29.5), the median QuickDASH 6.8 (IQR 0-29.5), and the median EQ-5D-5L index was 0.88 (IQR 0.71-1). The NPS was 73. Complications occurred in nine patients (24%) and included non-union (n = 4), early loss of fixation requiring revision surgery (n = 1), superficial wound infection (n = 2), neurological injury (n = 1), and further surgery for symptomatic hardware removal (n = 1). CONCLUSIONS: For patients with a symptomatic distal radius malunion where the predominant deformity is ulnar positive variance, this study has demonstrated that despite 1 in 4 patients experiencing a complication, USO can result in excellent patient reported outcomes with high levels of satisfaction. LEVEL OF EVIDENCE: III (Cohort Study).

Virtual surgical planning and mirrored, 3-dimensionally printed guides for corrective clavicle osteotomies in clavicle malunions and nonunions.

BACKGROUND: The objective of this study was to retrospectively review clinical and radiographic outcomes of patients who underwent corrective osteotomies for clavicle malunion and internal fixation for nonunion using a combination of virtual surgical planning, patient-specific 3-dimensional (3D)-printed clavicles, and 3D-printed cutting guides manufactured at the point of care. METHODS: Between 2015 and 2021, 18 patients underwent corrective osteotomy for a clavicle malunion (7 shoulders) or internal fixation for a clavicle nonunion (11 shoulders). There were 11 male and 7 female individuals with an average patient age of 43.9 (range 19-76) years. All patients underwent computed tomography evaluation of both clavicles. The DICOM files were manually segmented, virtual surgical planning was performed selectively using commercially available software, and a mirrored version of the normal clavicle was 3D printed along with a 3D-printed replica of the affected clavicle. Three-dimensionally printed mirrored clavicles were used in all cases to ensure adequate restoration of the shape and length of the clavicle and to precontour fixation plates. Virtual surgical planning and 3D-printed cutting guides for osteotomy were used in 4 of 18 (22%) patients. Either cancellous or structural intercalary bone grafting was used in 15 of 18 (83%) cases. Patients were contacted postoperatively to determine clinical outcome scores. Preoperative, early postoperative, and late postoperative radiographs were reviewed to assess for union and complications. The average follow-up time was 24.9 months. RESULTS: Radiographic evaluation at the most recent follow-up demonstrated adequate restoration of length and successful union for all shoulders. There were no complications or reoperations. Postoperative patient-reported outcomes could be obtained in 16 of 18 (88.9%) patients. At the most recent follow-up, the mean visual analog scale for pain was 2.38 points (range, 1-7), the mean shoulder American Shoulder and Elbow Surgeons score was 73.2 points (range, 25-100), and the mean Patient-Reported Outcome Measurement Information System Upper Extremity score was 26 points (range, 7-35). All (100%) the patients were satisfied with their outcome (9 very satisfied, 7 satisfied), and their mean subjective shoulder value was 73% (range, 10%-100%). However, 2 patients complained of hardware-related symptoms, and 1 patient had return of preoperative symptoms after an interim 2 years of pain relief. CONCLUSION: The use of mirrored 3D-printed clavicles combined with virtual surgical planning and patient-specific 3D guides provides a reliable technique for restoring native anatomy when performing corrective osteotomies for clavicle malunion or internal fixation for clavicle nonunion, with a high rate of satisfactory clinical and radiographic outcomes.

Inconclusive evidence that arthroscopic techniques yield better outcomes than open techniques for subtalar arthrodesis-A systematic review.

IMPORTANCE: Open in situ subtalar arthrodesis (ISTA) has been a standard procedure for treating subtalar arthritis for varied etiologies with good outcomes. There has been a paradigm shift from ISTA to arthroscopic subtalar arthrodesis (ASTA) over the past two decades due to increase in number of surgeons performing arthroscopy worldwide. However, there is only limited evidence in the existing literature to substantiate the benefit of this change with regards to patient benefit. To our knowledge, there are also no systematic reviews comparing the results of the two techniques for subtalar arthrodesis (STA). AIM: Our systematic review aims to determine the superior technique for performing STA by comparing the outcomes, union rates, and complications between open and arthroscopic approach for in situ STA. We hypothesised that both procedures would have similar outcomes, union rates, time to union, and complication rate for in-situ STA. EVIDENCE REVIEW: Three databases, MEDLINE/PubMed, the Cochrane Library, and Google Scholar, were searched using predefined inclusion and exclusion criteria to compare the two procedures. Risk of bias assessment was done using The Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I) tool for assessing the risk of bias in the included studies. Weighted mean averages were computed for all parameters and tabulated separately for ASTA and ISTA. FINDINGS: We included a total of 22 studies with a total of 978 (ASTA-310, ISTA-668) patients in the review. The most common indication for both techniques was post traumatic subtalar arthritis due to malunited calcaneal fracture in both groups (54.5%). The American Orthopaedic Foot & Ankle Society score was better in the ASTA group with a weighted average improvement of 43.4, while the weighted average improvement was 31.1 in the ISTA group, respectively. Patients undergoing ASTA had a weighted average union rate of 95.5% (standard deviation [SD]-3.6) with a weighted average time to union of 12.2 weeks (SD-2.4) while the ISTA group reported 90.7% (SD-6) union rate with a weighted average time to union of 15.5 weeks (SD-8.4). The weighted overall average complication rate was 13.1% (SD-8.9) in ASTA group and 20.3% (SD-16.2) in the ISTA group with hardware-related complications being the most common in both the groups. CONCLUSION: From the existing literature, our review suggests that both ASTA and ISTA techniques are effective procedures for STA. However, there is no conclusive evidence to recommend one technique over another. High quality randomised studies may be further required to clearly define the superiority of one technique over another LEVEL OF EVIDENCE: level III.

Distance mapping in three-dimensional virtual surgical planning in hand, wrist and forearm surgery: a tool to avoid mistakes.

PURPOSE: Three-dimensional planning in corrective surgeries in the hand and wrist has become popular throughout the last 20 years. Imaging technologies and software have improved since their first description in the late 1980s. New imaging technologies, such as distance mapping (DM), improve the safety of virtual surgical planning (VSP) and help to avoid mistakes. We describe the effective use of DM in two representative and frequently performed surgical interventions (radius malunion and scaphoid pseudoarthrosis). METHODS: We simulated surgical intervention in both cases using DM. Joint spaces were quantitatively and qualitatively displayed in a colour-coded fashion, which allowed the estimation of cartilage thickness and joint space congruency. These parameters are presented in the virtual surgical planning pre- and postoperatively as well as in the actual situation in our cases. RESULTS: DM had a high impact on the VSP, especially in radius corrective osteotomy, where we changed the surgical plan due to the visualization of the planned postoperative situation. The actual postoperative situation was also documented using DM, which allowed for comparison of the VSP and the achieved postoperative situation. Both patients were successfully treated, and bone healing and clinical improvement were achieved. CONCLUSION: The use of colour-coded static or dynamic distance mapping is useful for virtual surgical planning of corrective osteotomies of the hand, wrist and forearm. It also allows confirmation of the correct patient treatment and assessment of the follow-up radiological documentation.