Biomechanical Study on the Stress Distribution of the Knee Joint After Tibial Fracture Malunion with Residual Varus-Valgus Deformity.

OBJECTIVE: To investigate the effect of residual varus and valgus deformity on the stress distribution of the knee joint after tibial fracture malunion. METHODS: Fourteen adult cadaver specimens were selected to establish the models of tibial fractures, which were fixed subsequently at neutral position (anatomical reduction) and malunion positions (at 5°, 10°, and 15° valgus positions, and 5°, 10°, and 15° varus positions). The stress distribution on the medial and lateral plateau of the tibia was quantitatively measured using ultra-low-pressure sensitive film technology. The changes in the stress distribution of the knee joint after tibial fracture malunion and the relationship between the stress values and the residual varus or valgus deformity were analyzed. RESULTS: Under 400 N vertical load, the stress values on the medial and lateral plateau of the tibia at the neutral position were 1.137 ± 0.139 MPa and 1.041 ± 0.117 MPa, respectively. When compared with the stress values measured at the neutral position, the stress on the medial plateau of the tibia was significantly higher at varus deformities and lower at valgus deformities, and the stress on the lateral plateau was significantly higher at valgus deformities and lower at varus deformities (all P < 0.05). The stress values on the medial plateau of the tibia were significantly higher than the corresponding data on the lateral plateau at neutral and 5°, 10°, and 15° varus deformities, respectively (all P < 0.05), and significantly lower than the corresponding data on the lateral plateau at 5°, 10°, and 15° valgus deformities, respectively (all P < 0.05). CONCLUSION: Residual varus and valgus deformity after tibial fracture malunion can lead to obvious changes of the stress distribution of the knee joint. Therefore, tibial fractures should be reduced anatomically and fixed rigidly to avoid residual varus-valgus deformity and malalignment of lower limbs.

Symptomatic malunion after midshaft clavicle fracture in an adolescent patient: a case report of surgical deformity correction using a 3D printed model.

A 14-year-old boy underwent surgery for symptomatic malunion of the clavicle. This complication, which is uncommon in adults and adolescents, occurred after a displaced midshaft clavicle fracture that had been treated conservatively. Surgery may be considered if functional impairment, pain, weakness, fatigability and neurological symptoms persist in the presence of significant clavicular deformity. Our case was unusual because the patient had a symptomatic malunion and lost range of movement of his shoulder despite a minor degree of clavicular shortening. We adopted an approach used in lower limb deformity correction but not described for the clavicle in which corrective osteotomy was planned and practised using a three-dimensional printed model of the malunited clavicle. A three-dimensional printed model of the mirror image of the opposite clavicle served as a template of normal. Three-dimensional models were printed from the computed tomography data. The patient's symptoms resolved and he recovered full range of movement and shoulder function following the corrective osteotomy.

Ulnar shortening osteotomy as a treatment of symptomatic ulnar impaction syndrome after malunited distal radius fractures.

A malunited distal radius fracture can lead to symptomatic ulnar impaction syndrome, which is a common cause for ulnar-sided wrist pain. If conservative treatment fails and symptoms persist after an arthroscopic ulnocarpal debridement, ulnar shortening osteotomy (USO) is the treatment of choice. Since the first USO described by Milch in 1941 after a malunited Colles fracture, many techniques have been described varying in surgical approach, type of osteotomy and osteosynthesis material used. Many studies demonstrated good to very good functional results after USO, reporting, however, a delayed union or non-union rate up to 18%. A modern, low profile, locking plate showed in our short-term study very good functional results and no implant-associated complications, in particular no non-union.

Salvage procedure after malunited distal radius fractures and management of pain and stiffness.

Indications for surgical treatment of distal radius fractures (DRF) remain controversial in the literature, especially in elderly patients. Complication rates after operatively treated DRF are low and well documented. These include malunion, degenerative osteoarthritis in the radiocarpal joint and subsequently pain and impaired hand function. If conservative treatment fails then salvage procedures are necessary. This review summarizes the therapeutic options available to treat degenerative osteoarthritis after malunited distal radius fractures, regardless of the initial operative or conservative treatment.

Revision strategy for malunited tibial plateau fracture caused by failure of initial treatment.

OBJECTIVE: The aim of this study was to evaluate our treatment algorithm and results in revision surgery of malunited tibial plateau fracture after failure of initial treatment. METHODS: Our revision strategy was as follows: First, we determined the presence of any infection. Second, we determined whether the patient required total knee arthroplasty (TKA). Third, based on the characteristics of the tibial plateau fracture malunion, patients underwent one of the following surgical methods to achieve reduction: original fracture line osteotomy, tibial tubercle + original fracture line osteotomy, fibula head + original fracture line osteotomy, and metaphyseal open window reduction rod technique. The results was assessed with healing time, Rasmussen score, knee range of motion and complication rates. RESULTS: A total of 25 patients 16 men and 9 women; Mean age: 47.4 years (range: 35-63 years) underwent tibial plateau fracture revision operation. The time interval between the two surgeries was 2-24 months. The follow-up time was 12-30 months, and the operation time was 120-300 min. All patients received bone union at the last follow-up. The healing time was 3-6 months. The postoperative Rasmussen score was 19-29 (mean 23.8) compared with 14.4 points before the operation (p < 0.05). The postoperative knee joint activity was 60-110° (mean 95.0°), compared with 57.8° before the operation (p < 0.05). Six patients still had a 2-mm collapse on the articular surface, and 4 patients still had slight valgus (<5°). Except for 2 TKA cases, fracture reduction was excellent in 15 cases and good in 8 cases, with a good rate of 100%. Superficial wound infections occurred in 3 patients. CONCLUSION: Because revision of tibial plateau fracture malunion caused by failure of initial treatment is difficult, it is necessary to create a detailed surgical plan before the operation. Satisfactory clinical effects can be obtained if the correct revision strategy is used. The key to success is adopting a proper revision strategy according to the unique characteristics of the patient's tibial plateau fracture malunion. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Is there a relationship between preoperative diagnosis and clinical outcomes in reverse shoulder arthroplasty? An experience in 699 shoulders.

BACKGROUND: The influence of diagnosis on outcomes after reverse shoulder arthroplasty (RSA) is not completely understood. The purpose of this study was to compare clinical outcomes of different pathologies. METHODS: A total of 699 RSAs were performed for the following diagnoses: (1) rotator cuff tear arthropathy (RCA), (2) massive cuff tear (MCT) with osteoarthritis (OA), (3) MCT without OA, (4) OA, (5) acute proximal humeral fracture, (6) malunion, (7) nonunion, and (8) inflammatory arthropathy. All patients had minimum 2-year clinical follow-up (mean, 47 months; range, 24-155 months). Range of motion, Simple Shoulder Test scores, American Shoulder and Elbow Surgeons scores, visual analog scale scores for function, and health-related quality-of-life measures were obtained preoperatively and postoperatively. RESULTS: The RCA, MCT-with-OA, MCT-without-OA, and OA groups all exhibited significant improvements in all outcome scores and in all planes of motion from preoperatively until a minimum of 2 years postoperatively. The malunion, nonunion, and inflammatory arthropathy groups showed improvements in American Shoulder and Elbow Surgeons scores, Simple Shoulder Test scores, forward flexion, and abduction. The average changes for all other outcomes and planes of motions were also positive but did not reach statistical significance. After adjustment for age and compared with RCA, female patients with malunion had significantly poorer forward flexion (P < .05), those with OA had significantly better abduction (P < .05), and those with fractures had significantly worse patient satisfaction (P < .05). Among male patients, those with MCTs without OA had significantly worse satisfaction (P < .05). CONCLUSION: RSA reliably provides improvement regardless of preoperative diagnosis. Although subtle differences exist between male and female patients, improvements in clinical outcome scores were apparent after RSA.

Treatment of fractures of the tibial plateau (Schatzker VI) with external fixators versus plate osteosynthesis.

INTRODUCTION: The purpose of this study was to determine the effectiveness of circular external fixation (CEF) as a definitive treatment option for patients with complex tibial plateau fractures (Schatzker VI) compared with the outcomes of a fixed angle locking plates' group. METHODS: Level III evidence. Retrospective, comparative study in a Level I Trauma Center. Fourteen patients treated with CEF (Group A) were compared to fourteen patients treated with minimal invasive angle locking plates (Group B). The mean time from fractures to surgery was 19 days for Group A with a mean ISS of 24 and 7 days for Group B with a mean ISS of 14. The main outcome measures were clinical and radiographic. RESULTS: Complete union was obtained in Group A at an average of 22 weeks and at 17 weeks in Group B. Two patients developed non-union, one in each group. Normal alignment was observed in both groups, no statistical differences were observed in Paley's anatomical posterior proximal tibial angle (aPPTA) and mechanical medial proximal tibial angle (mMPTA) between two groups. Results based on the Association for the Study and Application of the Method of Ilizarov criteria for Group A: 71% excellent and 29% good as far as bone outcomes are concerned and as 57% excellent, 37% good, and 7% fair for functional outcomes. CONCLUSIONS: Definitive fixation with circular external fixator is effective in complex Schatzker VI tibial plateau fractures. Advantages include maintaining the frame till union, reduced risk of infection, early mobilization, restoration of the normal lower extremity alignment, versatility, and improved union rate in patients with multiple traumatic injuries, infection, and soft tissue injuries.

Corrective Osteotomy with Autogenous Bone Graft with Callus after Malunion of Distal Radius Fracture.

Corrective osteotomy with callus filling at fracture site for malunion after distal radius fracture is a rare technique, but it achieved a favorable postoperative outcome. The patient, 66-year-old female, visited our hospital 4 months after distal radius fracture. Corrective osteotomy of the distal radius was planned aiming at improving the wrist joint function, and was performed using a volar locking plate, then the bone defect was filled with callus as autogenous bone grafting. At 12 months after surgery, left wrist joint pain and the range of motion have improved, and the Mayo wrist score was excellent. To our knowledge, there has been no study on the treatment of bone defects by filling with callus. Since favorable bone fusion was achieved with callus, this treatment method may overcome the disadvantages of autogenous bone graft, such as pain at the donor region.

In Vivo Three-Dimensional Analysis of Malunited Forearm Diaphyseal Fractures with Forearm Rotational Restriction.

BACKGROUND: The aim of this study was to clarify the mechanisms of rotational restriction in malunited forearm diaphyseal fractures. METHODS: We retrospectively analyzed the cases of 18 patients with malunited forearm diaphyseal fractures and rotational restriction. All patients underwent bilateral computed tomography (CT) of the forearm in maximum supination, pronation, and neutral positions. From these images, we created 3-dimensional (3-D) bone surface models. We quantified the 3-D deformities, identified instances of osseous impingement between the radius and the ulna during forearm rotation, calculated the path length of the central band (CB) of the interosseous membrane, and measured forearm range of motion. RESULTS: Sixteen patients had extension deformity of the radius (the RE group) and 2 had flexion deformity (the RF group). In the RE group, extension deformity of the radius and valgus deformity of the ulna had significant negative correlation with pronation range of motion (R = -0.50, p = 0.046) and supination range of motion (R = -0.63, p = 0.027), respectively. Osseous impingement was mainly observed during pronation (15 of 16 patients). The CB path with the largest changes in length originated from the distal CB attachment area of the radius and ran toward the proximal area of the ulna (the transverse CB). The transverse CB significantly increased in length in supination compared with that in pronation (p < 0.001). Therefore, tightness of the transverse CB appeared to cause supination restriction in the RE group. In the RF group, osseous impingement caused supination restriction. The greatest increases in the transverse CB length were observed in pronation in the RF group, which appeared to cause pronation restriction. CONCLUSIONS: In the RE group, pronation restriction was associated with osseous impingement that was due to extension deformity of the radius, and supination restriction was associated with CB tightness that was due to valgus deformity of the ulna. In the RF group, our results suggested that pronation restriction was caused by CB tightness and that supination restriction was caused by osseous impingement. CLINICAL RELEVANCE: Three-dimensional corrective osteotomy for extension deformity of the radius in malunited forearm diaphyseal fractures would improve rotational restriction by relieving osseous impingement during pronation and CB tightness during supination.

Morphology and kinematics studies of the upper extremity and its clinical application in deformity correction.

Morphological and kinetic studies using computer-generated bone models are helpful for determining normal articular movements and various pathological conditions of the wrist joints, forearms, and elbow joints. Previous studies consisted of kinetic analyses that were carried out by superimposing three-dimensional bone models created on a computer on the basis of CT data obtained by scanning the limbs in several different positions. We applied the techniques used in such studies and have discovered a method for carrying out surgical procedure simulations aimed at correcting upper limb deformities. In addition, we have developed a system aimed at assisting surgical procedures conducted in accordance with simulations by using patient-matched guides (patient-matched instruments, PMI) and custom-made osteosynthesis plates. Our system has allowed for accurate anatomical corrections to be carried out three-dimensionally during a simple surgical procedure. The system was clinically used in the treatment of cubitus varus as well as malunited distal radial fractures and forearm fractures. As a result, accurate correction and favorable clinical outcomes have been achieved. Together with the development of therapeutic techniques, we have also simultaneously developed the related technological system, which consists of imaging protocols aimed at reducing the amount of radiation exposure and creating statistical shape models, as well as web-based tools for communication between physicians and engineers.

Corrective osteotomy of distal radius malunions using three-dimensional computer simulation and patient-specific guides to achieve anatomic reduction.

Malunion is a common complication of distal radius fractures, especially those treated conservatively. In clinical studies, a significant correlation between anatomic reduction and wrist function has been shown. Corrective osteotomy is the preferred treatment for symptomatic cases, notwithstanding the technical challenges. The use of computer simulation improves pre-operative understanding of the three-dimensional deformity. Patient-specific surgical guides, based on precise pre-operative planning, lead to superior perioperative accuracy and reproducibility. The pre-operative planning and surgical technique of distal radius corrective surgery using three-dimensional computer technology are described in detail. The preliminary results demonstrate the excellent clinical and radiographic outcome of this technique.

Association Between Distal Radial Fracture Malunion and Patient-Reported Activity Limitations: A Long-Term Follow-up.

BACKGROUND: The long-term effect of distal radial fracture malunion on activity limitations is unknown. Between 2001 and 2002, we conducted a prospective cohort study of all patients with distal radial fracture treated with casting or percutaneous fixation in northeast Scania in Sweden. In that original study, the patients completed the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire at baseline and at 2 years. We performed a long-term follow-up study of patients who were 18 to 65 years of age at the time of the fracture to investigate the association between fracture malunion and activity limitations. METHODS: In this long-term follow-up, patients who had participated in the original study completed the DASH questionnaire and a visual analog scale (VAS) for pain and for satisfaction (scored, 0 [best] to 100) and underwent radiographic and physical examinations at 12 to 14 years after the fracture. We defined malunion as dorsal angulation of ≥10°, ulnar variance of ≥3 mm, and/or radial inclination of ≤15°. We also assessed the presence of radiocarpal osteoarthritis and ulnar styloid nonunion. The primary outcome was the change in DASH score from baseline. Secondary outcomes were DASH, pain, and satisfaction scores, wrist range of motion, and grip strength at the time of the follow-up. RESULTS: Of 85 eligible patients, 63 (74%) responded to the questionnaires and underwent examinations. Malunion was found in 25 patients, osteoarthritis was found in 38 patients, and styloid nonunion was found in 9 patients. Compared with patients without malunion, those with malunion had significantly worse DASH scores from baseline to 12 to 14 years (p = 0.002); the adjusted mean difference was 11 points (95% confidence interval [CI], 4 to 17 points). Similarly, follow-up scores were significantly worse among patients with malunion; the adjusted mean difference was 14 points (95% CI, 7 to 22 points; p < 0.001) for DASH scores, 10 points (95% CI, 0 to 20 points; p = 0.049) for VAS pain scores, and 26 points (95% CI, 11 to 41 points; p = 0.001) for VAS satisfaction scores. No differences were found in range of motion or grip strength. Osteoarthritis (mostly mild) and styloid nonunion had no significant association (p > 0.05) with DASH scores, VAS pain or satisfaction scores, or grip strength. CONCLUSIONS: Patients who sustain a distal radial fracture at the age of 18 to 65 years and develop malunion are more likely to have worse long-term outcomes including activity limitations and pain. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Effectiveness of an Arthroscopic Technique to Correct Supination Losses of 90° or More.

PURPOSE: To present a new arthroscopic method for treating supination losses. METHODS: Six patients (15-71 y) were eligible for this study. All had a history of trauma to the wrist more than 6 months previously. Five of them had sustained a distal radius fracture: 3 had been treated with a volar plate (1 of them for an extra-articular malunion), 1 with an external fixator and K-wires, and 1 had been treated in a cast. One of these patients underwent a further operation for correcting an intra-articular malunion. The last patient underwent an open reduction of a transscaphoid perilunate dislocation. During a standard radiocarpal arthroscopy, a curved periosteal elevator was inserted through the 6R portal into the volar-radial corner of the triangular fibrocartilage complex and advanced proximally gliding on the anterior ulnar head surface. The volar capsule was then distended with the periosteal elevator and by means of gentle sweeping motion adherences between them, the volar capsule and the ulnar head were freed. Finally, the arthroscopic release was combined with a gentle passive supination force applied by the surgeon. Full supination was maintained in an orthosis for 2 to 3 days. Afterward, regular physical therapy was instituted. Concomitant surgery, arthroscopic or open, was performed in all to treat associated conditions. RESULTS: Full supination (90°) was achieved in all intraoperatively. At a mean follow-up of 3.3 years, mean supination was 76° in the latest follow-up (range, 50° to 90°). Mean improvement in supination was 80° (range, 50° to 100°). No distal radioulnar instability or other complications were noted. CONCLUSIONS: The method presented proved effective in severe forms of supination deficits. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Effect of decrease in radial inclination of distal radius fractures on distal radioulnar joint stability: a biomechanical study.

We investigated the relationship between the radial inclination of the distal radius and distal radioulnar joint stability. Six fresh-frozen upper extremities were used. Radial inclination was decreased by 10° and 20° and increased by 10° from the original radial inclination. Distal radioulnar joint stiffness was assessed with an intact radioulnar ligament and after partial and then complete sectioning of the radioulnar ligament. Radial angulation deformities significantly increased distal radioulnar joint stiffness when the radioulnar ligament is totally or partially attached to the ulnar fovea. After complete sectioning of the radioulnar ligament, distal radioulnar joint stiffness decreased significantly; additional radial angulation deformity slightly increased distal radioulnar joint stiffness, but the distal radioulnar joint never recovered to the original stiffness. Based on the results, radial angulation deformities of the distal radius should be corrected within 10° when the radioulnar ligament is intact, to reduce the risk of symptomatic distal radioulnar joint instability.

Outcomes of Isolated Radial Osteotomy for Volar Distal Radioulnar Joint Instability Following Radial Malunion in Children.

PURPOSE: The radius bone has a slight dorsoradial bow that allows for full forearm pronosupination around the ulna. However, radial malunion can lead to reversal of the radial bow and subsequent volar instability of the distal radioulnar joint (DRUJ), predominantly in supination. This study assessed the outcomes of corrective radial osteotomy for volar DRUJ instability after radial malunion in children. METHODS: The charts of 7 children (2 boys and 5 girls) treated with corrective radial osteotomy for volar DRUJ instability after a radius fracture or deformity were reviewed. Demographic, diagnostic, treatment, and complication information was collected for each patient. Radiographs at initial injury, fracture union, diagnosis of DRUJ instability, and final follow-up were reviewed for radiographic measurements of radial deformity and subsequent correction. RESULTS: Fractures included 4 distal radius, 2 proximal radius, and 1 plastic deformation of the radial shaft. Volar DRUJ instability was diagnosed an average of 2.7 years (range, 1-6 years) after fracture at an average age of 13.6 years (range, 12-17 years). Two of 7 patients had persistent symptoms despite having undergone previous soft tissue surgery for DRUJ instability. Radial osteotomy was performed on all patients (3 dorsal and 4 volar approaches), with an average sagittal plane correction of 23° ± 10° (range, 14° to 40°). Osteotomy site varied (3 proximal third, 1 middle third, and 3 distal third) based on the apex of maximal deformity. Patients were observed an average of 2.3 years (range, 1.0-5.7 years). At final follow-up, all patients had a stable DRUJ and no patient required soft tissue stabilization. CONCLUSIONS: Apex volar malunion of radial fractures may result in volar instability of the DRUJ. Radial osteotomy restored the normal apex dorsal radial bow and effectively stabilized the DRUJ without the need for soft tissue repair. Osteotomy should be tailored to the specific site of radiographic deformity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Ulnar Shortening Versus Distal Radius Corrective Osteotomy in the Management of Ulnar Impaction After Distal Radius Malunion.

BACKGROUND: Distal radius malunions lead to functional deficits. This study compares isolated ulnar shortening osteotomy (USO) to distal radius osteotomy (DRO) for the treatment of ulnar impaction syndrome following distal radius malunion. METHODS: We retrospectively reviewed 11 patients with extra-articular distal radius malunions treated for ulnar impaction with isolated USO. This group was compared to a 1:1 age- and sex-matched cohort treated with isolated DRO for the same indication. Pain visual analog scale (VAS), wrist motion, grip strength, radiographic parameters, and perioperative complications were analyzed. Mean follow-up was 14.8 months. RESULTS: VAS scores improved. Wrist range of motion improved in both cohorts with the exception of radial deviation, pronation, and supination in the USO cohort, which decreased from a mean of 17°-16°, 67°-57°, and 54°-52°, respectively. There was no significant difference between groups in regard to change in pain or range of motion, with the exception of pronation and ulnar deviation. The mean tourniquet time was shorter in the USO group. The final ulnar variance was 1.8 mm negative in the USO group and 1.1 mm positive in the DRO group. There was 1 reoperation following USO for painful nonunion, while there were 2 reoperations following DRO for persistent ulnar impaction. CONCLUSIONS: An improvement in range of motion, grip strength, and VAS with restoration of the radioulnar length relationship was observed in both cohorts. USO is a simpler procedure with a shorter tourniquet time that can be an attractive alternative to DRO for ulnar impaction syndrome after distal radius malunions.

Working length and proximal screw constructs in plate osteosynthesis of distal femur fractures.

BACKGROUND: The study purpose is to evaluate the working length, proximal screw density, and diaphyseal fixation mode and the correlation to fracture union after locking plate osteosynthesis of distal femoral fractures using bridge-plating technique. METHODS: A four-year retrospective review was performed to identify patients undergoing operative fixation of distal femur fractures with a distal femoral locking plate using bridge-plating technique for the metadiaphyseal region. Primary variables included fracture union, secondary surgery for union, plate working length, and diaphyseal screw technique and configuration. Multiple secondary variables including plate metallurgy and coronal plane fracture alignment were also collected. RESULTS: Ninety-six patients with distal femur fractures with a mean age 60 years met inclusion criteria. None of the clinical parameters were statistically significant indicators of union. Likewise, none of the following surgical technique parameters were associated with fracture union: plate metallurgy, the mean working length, screw density and number of proximal screws and screw cortices. However, diaphyseal screw technique did show statistical significance. Hybrid technique had a statistically significant higher chance of union when compared to locking (p=0.02). All proximal locking screw constructs were 2.9 times more likely to lead to nonunion. CONCLUSIONS: Plating constructs with all locking screws used in the diaphysis when bridge-plating distal femur locking plates were 2.9 times more likely to incur a nonunion. However, other factors associated with more flexible fixation constructs such as increased working length, decreased proximal screw number, and decreased proximal screw density were not significantly associated with union in this study.

Computer-Assisted Corrective Osteotomy of Malunited Pediatric Radial Neck Fractures-Three-Dimensional Postoperative Accuracy and Clinical Outcome.

Neglected or incorrect treatment of pediatric radial neck fractures may lead to symptomatic malunions. Computer-assisted corrective osteotomies with patient-specific guides have been proposed as a promising technique for the reconstruction of malunited long bone deformities. The aim of this study was to evaluate the accuracy and clinical outcome of this technique in children with malunited fractures of the radial neck. Four children [2 boys, 2 girls; mean age 12 (10-16) years] underwent computer-assisted closing wedge osteotomy of the radial neck. The contralateral uninjured side was used as a reconstruction template. Computed tomography were performed 8 weeks postoperatively to confirm bony consolidation and to quantify residual 3D rotational and translational displacement error. Clinical outcome [pain, range of motion (ROM)] and overall satisfaction were documented. Preoperative subluxation of the radial head could be corrected in 2 of 3 patients. One patient had to be revised because of secondary traumatic loss of reduction. At the last follow-up [mean 16 (range, 12-24) months], all patients were pain free for activities of daily living (preoperative pain: visual analog scale 6). Pain during sport activities could be substantially reduced (visual analog scale 8→2). Although the procedure failed to improve ROM, none of the patients had limitations regarding work, daily, or sports activities. Yet, restricted ROM was considered as a cosmetic problem in 1 patient. Full consolidation of the osteotomy site, with no signs of avascular necrosis of the radial head, was achieved in all patients. The deformity could be substantially reduced, from a 3D angle of 13-40 degrees to 3-7 degrees (58%-89% deformity correction). Computer-assisted corrective osteotomy is a novel technique for the treatment of radial neck malunions that led to adequate pain reduction and 3D accuracy of deformity correction in our small case series. Despite the lack of improved ROM, all patients were satisfied and would undergo the same procedure again.

Effects of short malunion of the clavicle on in vivo scapular kinematics.

BACKGROUND: Short malunion of the clavicle after fracture can change scapular kinematics and alter clinical outcome. However, the effects of malunion on kinematics and outcomes remains poorly understood because there have been no in vivo studies measuring changes during active motion with malunion. This study aimed to measure and to compare in vivo 3-dimensional (3D) scapular kinematics between normal shoulders and shoulders with short malunion using 3D-2-dimensional model image registration techniques. METHODS: Fifteen patients with clavicle fracture who had been treated conservatively were enrolled in this study. In these patients, the angle of scapular upward rotation, posterior tilting, and external rotation were compared between shoulders with short malunion and contralateral, normal shoulders. A 3D-2-dimensional model image registration technique was used to determine the 3D orientation of the scapula. RESULTS: Scapular upward rotation increased following increase of the arm elevation angle and also showed a significant difference by arm elevation in both groups (P = .04). Posterior tilting of the scapula gradually increased as the arm abduction angle increased, and this varied significantly between groups (P = .01). Shoulders with short malunion also showed a more internally rotated position than the contralateral, normal shoulders between 100° and the maximum abduction angle (P = .04). CONCLUSION: Our results suggest that clavicle shortening of >10% greatly affects scapular kinematics in vivo. Further studies will be needed to determine the clinical implications of short malunion of the clavicle.

Near-anatomical correction using a CT-guided technique of a forearm malunion in a 15-year-old girl: A case report including surgical technique.

BACKGROUND: In this case report, we describe a left-arm both-bone forearm fracture in a 15-year-old girl who fell off a swing. Conservative treatment with an above-elbow cast failed, resulting in a malunion with functional impairment. The pro- and supination were 90/0/10, respectively. The patient complained of difficulties performing daily activities. For this pediatric case, a corrective osteotomy was proposed using a CT-guided technique aiming for maximum anatomical and functional outcome. It was the first time this technique was used in our hospital. METHODS: A corrective osteotomy of the patient's left arm was performed using 3D printed templates to guide the osteotomy orientation. These templates were produced using specialized software in which CT images of her malunited left forearm were overlaid with the mirrored images of her healthy right forearm. RESULTS: The postoperative CT-scan showed a near-anatomical reduction with close to 1° correction in all three planes, as compared to the preoperative planning. Three months after surgery, the patient had regained full function of her left forearm. CONCLUSION: Although this was the first time this technique was used in our hospital, it resulted in excellent anatomical and functional outcomes making it a safe, reliable and precise treatment option that may be useful for even more complex corrections. LEVEL OF EVIDENCE: Level V.