Malunion of a clavicle fracture caused thoracic outlet syndrome in a professional violinist.

Clavicle fractures are a common injury in adults. Most patients are treated non-operatively. In this case report, a 53-year-old professional violinist had a midt shaft clavicula fracture and was treated non-operatively. The fracture healed, but the patient developed thoracic outlet syndrome (TOS) and a venous thrombosis when playing violin. Surgery with restoration of the normal anatomy alleviated the symptoms and six months later she was symptom free and playing violin again. TOS is a rare complication to clavicle fractures and the treating doctors should be aware of the diagnosis.

Improving standard volar plate fixation in 3D-guided corrective osteotomy of the distal radius: evaluation of a shim instrument.

Standard volar plates often do not fit the surface of the malunited distal radius after osteotomy, necessitating an offset angle for accurate volar tilt correction. The correction can be achieved if the plate is held at the correct angle when the distal screws are locked. With the advantage of 3D surgical planning and patient-specific instruments, we developed a shim instrument to assist the surgeon in securing the plate at the intended angle when locking the distal screws, and evaluated radiological results. Five female patients aged 63-74 with dorsally angulated extra-articular malunions underwent surgery using 3D-printed guides and the shim instrument. The plate position, drilling guide alignment, screw placements, and distal radius correction on postoperative CTs were compared with the surgical plans. Errors were measured using an anatomical coordinate system, and standard 2D radiographic measures were extracted. Preoperative dorsal tilt ranged from 16° to 35°, and postoperative volar tilt from 1° to 11°. 3D analysis revealed mean absolute correction errors of 6.1° in volar tilt, 1.6° in radial inclination, and 0.6 mm in ulnar variance. The volar tilt error due to the shim instrument, indicated by the mean angle error of the distal screws to the plate, was 2.1° but varied across the five patients. Settling of the distal radius, due to tension during and after reduction, further contributed to a mean loss of 3.5° in volar tilt. The shim instrument helped with securing plates at the intended angle; however, further correction improvements should consider the tension between the fragments of osteoporotic bone.

Intramedullary nailing of femoral shaft fractures: an analysis of rotational malunions using 3D EOS.

PURPOSE: Rotational malalignment and leg length discrepancy after intramedullary nailing of femoral shaft are frequent. This study has three objectives: evaluate the rate of femoral rotational malalignment and leg length discrepancy using EOS imaging after antegrade intramedullary nailing of femoral shaft fracture, find a relevant clinical examination to detect malrotation and identified risk factors. METHODS: We performed a retrospective single-centre study between January 2014 and January 2022. Fifty-eight patients were clinically and radiographically assessed at a minimum of three months. RESULTS: The femoral rotation of the operated side was significantly greater by a mean of 15.4° in internal rotation compared to the healthy side. There was no statically significant difference for the femoral length (p = 0.08). CONCLUSION: When using EOS stereography following antegrade intramedullary nailing of post-traumatic diaphyseal femur fractures, a statistically significant difference of more than 15.4° in internal rotation was found for femoral rotation on the operated side compared to the healthy side.Please confirm if the author names are presented accurately and in the correct sequence (given name, middle name/initial, family name). Author 1 Given name: [B. Poirot] Last name [Seynaeve]. Also, kindly confirm the details in the metadata are correct.The last name of the first author was corrected : Given name = B. and last name = Poirot Seynaeve The details in matadata are correct LEVEL OF EVIDENCE: III.

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.

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.

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.

Corrective Open-wedge Valgus Proximal Humerus Lengthening Osteotomy. Technique and Case Series.

Symptomatic varus malunion after proximal humeral fractures is associated with weakness and painful limitation of shoulder range of motion. When there is conformity of the articular surface and no avascular necrosis, a head-preserving procedure is best indicated. Arthroscopic arthrolysis, subacromial decompression, and tuberoplasty have been described for the treatment of mild deformity. In cases with more severe deformity, corrective extracapsular lateral closing wedge valgus osteotomy has been reported as a reliable treatment option, in terms of both pain relief and improved function. While this procedure adequately restores rotator cuff tensioning, it is associated with a shortening of the lever arm to the deltoid muscle, secondary to a loss of humeral length. We describe our technique and results with a vascular-sparing, medial open-wedge osteotomy, using a structural allograft and lateral locking plate. In our opinion, this procedure is safe and effective, with the potential to improve functional outcomes in young and active patients.

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.

[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.

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.

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.

[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.

[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.

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.

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.

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.

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.

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).

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.