Comparative Analysis of Radial Corrective Osteotomy and Sauvé-Kapandji Procedure for Malunited Distal Radius Fractures in Older Adults.

PURPOSE: Malunited distal radius fractures frequently occur in the older population, posing a dilemma in selecting ideal management for symptomatic patients. Radial corrective osteotomy (RCO) and the Sauvé-Kapandji procedure (SK) have been used to treat this challenging condition. However, it remains unknown which approach is better for the older population. The objective of this study was to compare the outcomes of RCO with those of SK for the treatment of symptomatic distal radius malunion in older adults. METHODS: Thirty-three patients aged ≥60 years, with malunited distal radius fractures, were randomized to be treated with either RCO or SK and followed for a minimum of 2 years. The primary evaluation parameter was grip strength, and secondary outcome parameters were surgical time, range of motion of the wrist, exercise-related wrist pain assessment using visual analog scale scores, radiographic results, patient-reported outcomes evaluated using the Disability of the Arm, Shoulder, and Hand (DASH), and Patient-Related Wrist Evaluation (PRWE) scores. RESULTS: The average follow-up duration was 36.7 ± 10.2 months. The grip strength was significantly higher in the RCO group. The surgical time was shorter in the SK group than in the RCO group. The postoperative wrist range of motion and visual analog scale scores for exercise-related pain alleviation were similar in both groups. The ulnar variance decreased in both groups and was similar when compared with the postoperative images. The DASH and PRWE scores were similar between the RCO and SK groups. CONCLUSIONS: Radial corrective osteotomy and SK surgeries have similar clinical and functional outcomes in patients aged ≥60 years. Grip strength is higher in the RCO group than in the SK group. However, the operating time to accomplish SK is shorter than RCO. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

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).

Comparing radial lengthening osteotomy with ulnar shortening osteotomy to treat ulnar impaction syndrome after distal radius fracture malunion.

INTRODUCTION: Distal radius mal-unions often cause radius shortening and ulnar impaction syndrome. The modern treatments of ulnar impaction syndrome following distal radius mal-union are ulnar shortening osteotomy (USO) and distal radius lengthening osteotomy (DRLO). However, there are few studies to compare long-term outcomes of these two treatments. This study compares isolated USO to DRLO for the treatment of ulnar impaction syndrome following distal radius mal-union. MATERIALS AND METHODS: We retrospectively reviewed 68 patients with extra-articular distal radius mal-unions treated by isolated USO in 36 patients and DRLO in 32 patients. Pain visual analog scale (VAS), wrist motion, grip strength, radiographic parameters including sigmoid inclination, DASH score, and perioperative complications were analyzed. Mean follow-up was 62.6 months. RESULTS: The postoperative VAS scores for pain on exertion were less in the DRLO group than the USO group (1.2 vs. 2.8, p = 0.02). The DASH scores were 16.7 and 29.8 in the DRLO and USO groups, respectively (p = 0.02). The reduction of pain and improvement of function showed significantly better in the DRLO group. The mean operative time was shorter in the USO group. Most of the sigmoid inclinations were changed in DRLO. There were two re-operations following USO for painful nonunion and two patients had subsequent DRUJ osteoarthritis at the last follow-up. CONCLUSION: Although both treatments improved range of motion, grip strength, and VAS for pain, DRLO was found in better reduction of pain and improvement of function. USO is a simpler procedure with a shorter operative time but it has an increased potential to cause subsequent osteoarthritis of the DRUJ as its incongruity of DRUJ after USO especially in reverted inclination. DRLO can be a preferred method for treating USWP in relevant distal radial mal-union.

An image fusion system for corrective osteotomy of distal radius malunion.

BACKGROUND: To provide surgical support for corrective osteotomy, we developed an image fusion system for three-dimensional (3D) preoperative planning and fluoroscopy. To assess the utility of this image fusion system, we evaluated the reproducibility of preoperative planning for corrective osteotomy of dorsally angulated distal radius malunion using the system and compared reproducibility without using the system. METHODS: Ten wrists from 10 distal radius malunion patients who underwent corrective osteotomy were evaluated. 3D preoperative planning and the image fusion system were used for the image fusion group (n = 5). Only 3D preoperative planning was used for the control group (n = 5). 3D preoperative planning was performed for both groups in order to assess reduction, placement, and the choice of implants. In the image fusion group, the outline of the planned image was displayed on a monitor and overlapped with fluoroscopy images during surgery. Reproducibility was evaluated using preoperative plan and postoperative 3D images. Images were compared with the 3D coordinates of the radial styloid process (1), the volar and dorsal edges of the sigmoid notch (2) (3), and the barycentric coordinates of the three reference points. The reproducibility of the preoperative plan was evaluated by the distance of the coordinates between the plan and postoperative images for the reference points. RESULTS: The distances between preoperative planning and postoperative reduction in the image fusion group were 2.1 ± 1.1 mm, 1.8 ± 0.7 mm, 1.9 ± 0.9 mm, and 1.4 ± 0.7 mm for reference points (1), (2), (3), and the barycenter, respectively. The distances between preoperative planning and postoperative reduction in the control group were 3.7 ± 1.0 mm, 2.8 ± 2.0 mm, 1.7 ± 0.8 mm, and 1.8 ± 1.2 mm for reference points (1), (2), (3), and the barycenter, respectively. The difference in reference point (1) was significantly smaller in the image fusion group than in the control group (P < 0.05). CONCLUSION: Corrective osteotomy using an image fusion system will become a new surgical support method for fracture malunion. Trial registration Registered as NCT03764501 at ClinicalTrials.gov.

Approaching "Elective" Surgery in the Era of COVID-19.

The coronavirus disease 2019 pandemic created unprecedented challenges for the health care system. To meet capacity demands, hospitals around the world suspended surgeries deemed to be elective. In hand surgery, numerous pathologies are treated on an elective basis, but a delay or absence of care may result in poorer outcomes. Here, we present an ethical framework for prioritizing elective surgery during a period of resource scarcity. Instead of using the term "elective," we define procedures that can be safely delayed on the basis of 3 considerations. First, a safe delay is possible only if deferral will not result in permanent injury. Second, a delay in care will come with tolerable costs and impositions that can be appropriately managed in the future. Third, a safe delay will preserve the bioethical principle of patient autonomy. In considering these criteria, 3 case examples are discussed considering individual patient characteristics and the pathophysiology of the condition. This framework design is applicable to ambulatory surgery in any period of crisis that may strain resources, but further considerations may be important if an operation requires hospital admission.

Outcomes and Complications Following Volar and Dorsal Osteotomy for Symptomatic Distal Radius Malunions: A Comparative Study.

PURPOSE: To compare patient-reported outcomes, functional outcomes, radiographic alignment, and complications of volar versus dorsal corrective osteotomies as the treatment for symptomatic distal radius malunions. METHODS: We performed a retrospective review of all patients who underwent a distal radius corrective osteotomy with either a volar or dorsal approach and plating at 1 of 3 institutions between 2005 and 2017. Demographic data, type of surgical treatment, and radiographs were examined. Outcomes were Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) function scores and radius union scoring system as well as major and minor complications. RESULTS: We included 53 cases (37 volar osteotomies and 16 dorsal osteotomies). Postoperative follow-up from the time of surgery to last QuickDASH score was 84.6 months (range, 12-169.4 months). Compared with the dorsal osteotomy group, the volar osteotomy group demonstrated a better postoperative flexion-extension arc (94.9° vs 72.9°, respectively), pronation-supination arc (146.2° vs 124.9°, respectively), and last QuickDASH scores (6.65 vs 12.87), respectively. Radiographically, there was no difference noted in radial height, radial inclination, or volar tilt in the immediate postoperative and last radiographs. There was a higher rate of complications in the dorsal osteotomy group (8 cases [50% of patients]) compared with the volar osteotomy group (7 cases [18.9% of patients]), including a higher rate of hardware removal. CONCLUSIONS: For patients with symptomatic malunions of the distal radius, the volar and dorsal approaches both resulted in improvement in QuickDASH scores and range of motion. Volar plating resulted in slightly better QuickDASH scores and fewer complications compared with dorsal plating. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Three-Dimensional Versus Radiographic Measurements for Analyzing Extra-Articular Distal Radius Malunion.

PURPOSE: To compare the accuracy of evaluating deformity in distal radius malunions using plain radiographic measurements compared with a 3-dimensional method involving 3-dimensional computer bone models. METHODS: Consecutive patients who had an extra-articular distal radius malunion were included. Standard radiographs and computed tomography scans of both wrists were performed. Palmar tilt, radial tilt, and ulnar variance were measured on radiographs. The computed tomography scan data were sent to a workstation and 3-dimensional bone surface models of the radius were created. The 3-dimensional palmar tilt, 3-dimensional radial tilt, 3-dimensional ulnar variance, and axial rotational deformity were calculated. RESULTS: Thirteen patients, mean age 40 years (range, 22-57 years) were included. The 3 3-dimensional values were positively correlated with their corresponding radiographic values. Nevertheless, the 3-dimesional palmar tilt and 3-dimensional radial tilt values were slightly smaller than the radiographic palmar tilt and radial tilt. The quantitative difference between the 3-dimensional method and plain radiographs was on average 2° for the dorsal deformity group and 3° for the palmar deformity group. The 3-dimensional ulnar variance was significantly higher than the radiographic ulnar variance by an average of +1.3 mm for malunions with dorsal tilt and +0.6 mm for malunions with palmar tilt. The 3-dimensional method allowed us to measure the extent of the axial rotational deformity, which was 9° on average (range, 2° to 21°). CONCLUSIONS: Despite small differences, measurements made on both plain radiographs and 3-dimensional computer bone models are accurate for evaluating the deformity in extra-articular distal radius malunions. Our 3-dimensional method seems to provide a more accurate measurement of ulnar variance, particularly for dorsally angulated cases, and is helpful for measuring rotational malalignment. CLINICAL RELEVANCE: In this study, we found that either a 3-dimensional computer bone model or plain radiographs can be used as a benchmark to evaluate the deformity of extra-articular distal radius malunion. The 3-dimensional method can also be used to define axial rotational deformity.

Effect of Radial Lengthening on Distal Forearm Loading Following Simulated In Vitro Radial Shortening During Simulated Dynamic Wrist Motion.

PURPOSE: To evaluate the effect of radial length change on distal forearm loading during simulated dynamic wrist motion. METHODS: A custom-built adjustable radial implant was used to simulate up to 4 mm of distal radius shortening (-4 mm) and 3 mm of lengthening (+3 mm). Load cells were placed in the distal radius and ulna in cadavers to measure their respective axial loads. The specimens were mounted on a wrist motion simulator that produced active wrist motion via tendon actuation. To simulate radial lengthening osteotomy following radial shortening from malunion, the radius was sequentially lengthened by 1-mm intervals from -4 mm to +3 mm. Radial and ulnar loads were measured during simulated wrist flexion, ulnar deviation (UD), and flexion dart throw (DT) at each interval of radial lengthening up to +3 mm. RESULTS: During wrist flexion and UD, for each millimeter of radial lengthening from -4 mm to the native length, there was a significant increase in distal radial loads. No significant change in radial load was observed beyond the native length during flexion and UD. There was no change in distal radial loads during DT for each interval of radial lengthening from -4 mm to +3 mm. A sequential decrease in ulnar loads was observed as the radius was lengthened from -4 mm to +3 mm for all wrist motions evaluated. CONCLUSIONS: Radial lengthening beyond the native length was not detrimental to radial loading and further reduced distal ulnar loading; achieving at least native ulnar variance seems to be appropriate to restore normal biomechanical loading based on this in vitro study. CLINICAL RELEVANCE: Lengthening of the radius beyond native variance in the setting of ulnar impaction syndrome, distal radius malunion, or distal radioulnar instability may not result in excessive loading of the distal radius and further reduces loading on the distal ulna. Surgeons should obtain contralateral wrist x-rays to serve as a template when performing distal radius osteotomies.

Complications of Corrective Osteotomies for Extra-Articular Distal Radius Malunion.

PURPOSE: Osteotomy of the distal radius for a fracture malunion is a challenging procedure. The purpose of this study was to review a series of osteotomies to determine the type and risk of complications. METHODS: A retrospective cohort study was performed, including all Kaiser Permanente Southern California patients who were aged 18 years or older between January 1, 2007, and September 25, 2015, and underwent osteotomy for an extra-articular distal radius fracture malunion. Charts were reviewed for demographic data, comorbidities, osteotomy type (hinged vs distraction), implant, and bone graft type. Complications including infection, nonunion, loss of reduction, implant failure, nerve injury, tendon injury, and complex regional pain syndrome were recorded. RESULTS: There were 60 patients who underwent extra-articular osteotomy of the distal radius for malunion during the study period. The mean age was 54 years (range, 21-83 years). There were 24 distraction-type (intervening bone graft) and 36 hinge-type (volar cortical contact maintained) osteotomies. Twenty-five of 60 patients had complications related to the procedure requiring 13 subsequent procedures. There were 7 nonunions and 3 cases of delayed healing at the osteotomy site. One extensor carpi radialis longus tendon laceration resulted from the use of an osteotome. There were 3 delayed extensor pollicis longus (EPL) tendon ruptures after surgery. The distraction-type osteotomy was associated with a greater risk of major complications including nonunion and delayed union. CONCLUSIONS: A complication rate of nearly 50% was observed in distal radius osteotomies. Surgeons should be aware of the risk of injury to, or delayed rupture of the EPL tendon associated with these procedures. The risk of nonunion or delayed union is higher in distraction-type compared with hinge-type osteotomies. Low surgeon volume with this procedure may be a contributing factor to the high rate of complications. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

A comparison of corrective osteotomies using dorsal and volar fixation for malunited distal radius fractures.

PURPOSE: This study aimed to compare clinical results and to restore radiographic parameters of corrective osteotomy for malunited distal radius fracture using a volar locking plate with a dorsal plate. METHODS: We retrospectively studied 28 consecutive patients with symptomatic malunited distal radius fractures followed up for more than 12 months who underwent corrective osteotomy with a dorsal buttress plate (n = 9) or a volar locking plate (n = 19). Volar tilt (VT), radial inclination (RI), and ulnar variance (UV) were radiographically evaluated. Clinical examination parameters included pain, wrist and forearm ranges of motion (ROM), grip strength, and Mayo Modified Wrist Score (MMWS). RESULTS: The volar group had a significantly greater VT undercorrection for - 9.4° than did the dorsal group for - 1.2° (p < 0.001). Major complications requiring plate removal occurred in six of nine patients in the dorsal group and two of 19 patients in the volar group. The complication ratio was significantly greater in the dorsal group than in the volar group (p < 0.05). Improvements in forearm and wrist ROM, grip strength, and MMWS did not differ significantly between groups. CONCLUSIONS: Opening wedge osteotomy of the radius using a volar locking plate is preferable to dorsal buttress fixation in terms of surgical and technical demands and frequency of complications, but VT correction is insufficient. Surgeons should be aware of the mismatch between the plate and the volar surface of the malunited distal radius.

A Simple 3-Dimensional Printed Aid for a Corrective Palmar Opening Wedge Osteotomy of the Distal Radius.

The reconstruction of malunited distal radius fractures is often challenging. Virtual planning techniques and guides for drilling and resection have been used for several years to achieve anatomic reconstruction. These guides have the advantage of leading to better operative results and faster surgery. Here, we describe a technique using a simple implant independent 3-dimensional printed drill guide and template to simplify the surgical reconstruction of a malunited distal radius fracture.

Forearm rotation improves after corrective osteotomy in patients with symptomatic distal radius malunion.

Objectives: Distal radius malunion can result in pain and functional complaints. One of the functional problems that can affect daily life is impaired forearm rotation. The primary aim of this study was to investigate the effect of corrective osteotomy for distal radius malunion on forearm rotation at 12 months after surgery. We secondarily studied the effect on grip strength, radiological measurements, and patient-reported outcome measurements (PROMs). Patients and methods: This cohort study analysed prospectively collected data of adult patients with symptomatic distal radius malunion. All patients underwent corrective osteotomy for malunion and were followed for 1 year. We measured forearm rotation (pronation and supination) and grip strength and analysed radiographs. PROMs consisted of the Patient-Rated Hand/Wrist Evaluation (PRWHE) questionnaire, Visual Analogue Scale for pain, and satisfaction with hand function. Results: Preoperative total forearm rotation was 112° (SD: 34°), of which supination of 49° (SD: 25°) was more impaired than pronation of 63° (SD: 17°). Twelve months after surgery, an unpaired Student's t-test showed a significant improvement of total forearm rotation to 142° (SD: 17°) (p < 0.05). Pronation improved to 72° (SD: 10°), and supination to 69° (SD: 13°) (p < 0.05). Grip strength, PROMs, as well as inclination and volar tilt on radiographs improved significantly during the first year after surgery (p < 0.05). Conclusion: In patients with reduced forearm rotation due to distal radius malunion, corrective osteotomy is an effective treatment that significantly improves forearm rotation. In addition, this intervention improves grip strength, the PRWHE-score, pain, and satisfaction with hand function.

Vascularized graft from the metatarsal base for reconstructing major osteochondral distal radius defects.

PURPOSE: To present our experience of reconstructing distal radius articular defects with a vascularized osteochondral graft from the metatarsal base and to present the mid-term outcomes. METHODS: Seven patients (average age, 36 y; range, 26-55 y) who had reconstruction of major defects of the articular surface of the radius are presented. In 5, the lunate facet and sigmoid notch were reconstructed; in 1, an isolated defect on the surface of the lunate facet was reconstructed; and in 1, the scaphoid facet was reconstructed. In 6, the base of the third metatarsal was transferred, and in 1, the base of the second was transferred. RESULTS: All flaps survived without complications. At the latest follow-up (range, 20 mo to 8 y), the flexion-extension arc improved an average of 50°, and the pain on a visual analog scale decreased from 8 to 1 on average. Disabilities of the Arm, Shoulder, and Hand score improved from 54 to 11 on average. One patient did not improve. No major complaints related to the donor site were mentioned (average American Orthopedic Foot and Ankle Society score of 96/100). CONCLUSIONS: Our mid-term results are promising; however, the decision-making process and the operation are complex. The operation is not indicated when the carpals are devoid of cartilage or when the defect involves the whole radius surface.

What Surgical Technique to Perform for Isolated Ulnar Shortening Osteotomy After Distal Radius Malunion: A Systematic Review.

BACKGROUND: Unstable fractures of the distal radius fractures (DRFs) may result in malunion, usually consisting of subsequent shortening and angular deviations. Ulnar shortening osteotomy (USO) is assumed to be a simpler procedure than radial correction osteotomy, resulting in fewer complications and comparable outcomes. The aim of this study was to identify the best surgical technique to perform USO to restore distal radioulnar joint congruency after DRF malunion. METHODS: A systematic review of the literature is performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines in February 2022 to identify studies reporting outcomes and surgical technique for isolated USO. The primary outcome was complication rates. Secondary outcomes included functional, radiologic, and patient-rated outcomes. The methodological index for nonrandomized studies criteria were used to assess the quality of evidence. RESULTS: Included were 12 cohorts (185 participants). Due to substantial heterogeneity, a meta-analysis could not be performed. The overall complication rate was 33% (95% confidence interval, 16% to 51%). The most reported complication was implant irritation (22%), often requiring removal of the implant (13%). Only 3% nonunions were mentioned. Functional and patient-rated outcomes improved in most patients after USO. Quality of evidence of the papers was low to very low. Common methodological flaws were related to retrospective research. CONCLUSION: No evident differences in complication rates and functional outcomes between the surgical techniques were observed. Based on this literature, most complications are related to implant irritation. Nonunion and infection rates were rare. Therefore, a surgical technique with a buried implant might be preferred. This hypothesis requires further investigation.

Reconstruction of intraarticular distal radius malunion with 3D printed guide and arthroscopic assisted intraarticular osteotomy.

INTRODUCTION: Distal radius fractures are one the most common upper extremity injuries, accounting for 25 % of pediatric fractures and up to 18 % of elderly fractures. Intraarticular malunion is one major complication of distal radius fractures and was reported in 0 to 33 % of total cases. It usually causes pain, deformity, limited range of motion (ROM), and loss of strength. Therefore, proper surgical management to satisfactorily unite the fragment is necessary. Case Illustrations: This is a case series of three adult male and female patients diagnosed with intraarticular distal radius fracture with malunion. They had been diagnosed based on clinical and radiological examinations. Preoperative and postoperative QuickDASH and ROM were measured. Three-dimensional printing was created for planning the osteotomy. Osteotomy was performed using arthroscopy. All patients showed QuickDASH and ROM improvement in all wrist movements. DISCUSSION: The primary goal of the procedure was to restore normal anatomic alignment to improve wrist function and reduce pain. Osteotomy guided by arthroscopy planned by 3D printed surgical guide successfully reduced the malunion fracture. CONCLUSION: Osteotomy assisted by arthroscopy combined with the 3D-printed surgical guide is a promising technique to restore challenging intraarticular distal radius malunion.

Acute on Chronic Distal Radius Fracture: A Case Series and Technique Description.

Purpose: Distal radius fractures are the most common fractures in adults. Because of the prevalence of these injuries, patients may present with a repeat distal radius fracture on the same wrist through the site of a malunion. We clinically refer to this as an acute on chronic distal radius fracture. In this setting, the restoration of acceptable alignment can be challenging. There is little guidance in the literature for the management of these fractures. We report our experience with acute on chronic distal radius fractures. The secondary fracture plane was used to correct the prior deformity, and the construct was fixated with a fixed angle volar locking plate. Methods: Records of patients with malunion of the distal radius who experienced an acute fracture of the ipsilateral distal radius were reviewed. Inclusion required treatment with open reduction internal fixation using a distal fragment first technique and a volar locking plate through the extended flexor carpi radialis approach. Clinical outcomes and complications were collected. Results: Across 13 patients, the mean follow-up term was 13 months (range, 6-40 months). Radiographic union was noted in all patients. The mean visual analog scale score for pain was 1.8, and the mean Quick Disabilities of the Arm, Shoulder, and Hand score was 21.9. There were no recorded complications. Conclusion: Our results and described technique provide reproducible guidance for the management of acute on chronic distal radius fractures. These cases can be managed using the secondary fracture plane, a distal fragment first technique, and a volar locking plate to correct the preexisting deformity. Type of study/level of evidence: Therapeutic IV.

Case Report of Customized Distal Radius Prosthesis Replacement: An Alternative Treatment for Post-traumatic Unreconstructable Intraarticular Distal Radius Malunion.

Severely comminuted intraarticular distal radius malunion can significantly affect a patient's quality of life. To date, there is no ideal solution. We propose customized distal radius prosthesis replacement as a treatment option. A 33-year-old policeman presented with left wrist deformity and loss of motion for five months following a distal radius fracture AO (Arbeitsgemeinschaft für Osteosynthesefragen) type-C3 which had been fixed with a volar locking plate incorporate with external fixation and Kirschner wire (K-wire) augmentation for two months. He needed to rely on wrist motion for work. Therefore, we fabricated a customized distal radius prosthesis based on his contralateral normal anatomy to replace the malunion site. The patient was satisfied and able to return to work two months after the operation. Thirty months later, the range of motion had improved from fixed 40° flexion and fixed 70° pronation deformity to 73° flexion, 79° extension, 75° supination, and 85° pronation. His DASH (Disabilities of the Arm, Shoulder, and Hand) score had improved from 80 to 14.2. His pain score, as measured by the visual analog scale, improved from eight preoperatively to two. Unreconstructable intraarticular malunion of the distal radius is a challenging problem with no treatment consensus. Customized distal radius prosthesis may provide a successful treatment option. Future research should elucidate long-term outcomes.

Early Correction of Distal Radius Partial Articular Malunion Leads to Good Long-term Functional Recovery at Mean Follow-up of 4 Years.

Background: Distal radius articular step-off or deformity may cause posttraumatic arthritis and poor functional outcome. The purpose of this study was to evaluate pain and functional outcomes in patients with malunited partial articular distal radius fractures who underwent corrective osteotomy. We hypothesized that anatomic restoration of distal radius articular surface after a malunited partial articular distal radius fracture results in improvement in pain and functional measures and delays the development of posttraumatic arthritis. Methods: Seven consecutive patients with mean age of 38 years underwent corrective osteotomy via either a standard dorsal approach or combined dorsal and volar approach. Mean time from injury to corrective osteotomy was 10 weeks. Patients were assessed with respect to Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), forearm and wrist range of motion, pain, and grip strength. Results: At mean follow-up of 44 months, significant improvements in pain scores (7.1-0.9, P < .001), QuickDASH (38.7-11.6, P < .001), grip strength (21.4-30.0 kg, P = .01) were achieved. All range of motion measurements demonstrated significant improvements except forearm pronation. One patient demonstrated radiographic evidence of osteoarthritis but had no pain at final follow-up. No patients required secondary surgery for removal of symptomatic hardware. Conclusions: Based on these findings, we recommend that early corrective osteotomies should be considered in young patients with intra-articular distal radius malunions before considering salvage procedures such as partial or complete wrist arthrodesis.

Computer-assisted 3D preoperative planning of corrective osteotomy for extra-articular distal radius malunion: A 16-patient case series.

The aim of this prospective study was to describe the surgical procedure and to report outcomes of computer-assisted 3D preoperative planning of corrective osteotomy for extra-articular distal radius malunions. Sixteen consecutive patients were enrolled. CT scans of both wrists were performed, and 3D bone surface models of the radii were created. Software was used to simulate the osteotomy and the reorientation of the distal radial articular surface. Patient-specific cutting and drilling guides for intraoperative guidance of the osteotomy as well as bone graft templates were also simulated. At a mean follow-up of 12 months (range 6-27) after surgery, pain was reduced from 3 to 0.3 at rest and 6.8 to 1.5 during effort according to a visual analog scale. The average wrist flexion-extension was 145° and pronation-supination was 155°. Grip strength was 91% of the contralateral side. All patients achieved primary bone union in a mean of 10 weeks (range, 7-18). Using our 3D analysis method, preoperative 3D values showed no significant difference with radiographic measurement. Moreover, there was no significant difference between the postoperative radiographic values in term of correction. This procedure provides satisfactory clinical and radiological results with minimal residual malalignment. LEVEL OF EVIDENCE: III.

Implementation of a semiautomatic method to design patient-specific instruments for corrective osteotomy of the radius.

PURPOSE: 3D-printed patient-specific instruments (PSIs), such as surgical guides and implants, show great promise for accurate navigation in surgical correction of post-traumatic deformities of the distal radius. However, existing costs of computer-aided design and manufacturing process prevent everyday surgical use. In this paper, we propose an innovative semiautomatic methodology to streamline the PSIs design. METHODS: The new method was implemented as an extension of our existing 3D planning software. It facilitates the design of a regular and smooth implant and a companion guide starting from a user-selected surface on the affected bone. We evaluated the software by designing PSIs starting from preoperative virtual 3D plans of five patients previously treated at our institute for corrective osteotomy. We repeated the design for the same cases also with commercially available software, with and without dedicated customization. We measured design time and tracked user activity during the design process of implants, guides and subsequent modifications. RESULTS: All the designed shapes were considered valid. Median design times ([Formula: see text]) were reduced for implants (([Formula: see text]) = 2.2 min) and guides (([Formula: see text]) = 1.0 min) compared to the standard (([Formula: see text]) = 13 min and ([Formula: see text]) = 8 min) and the partially customized (([Formula: see text]) = 6.5 min and ([Formula: see text]) = 6.0 min) commercially available alternatives. Mouse and keyboard activities were reduced (median count of strokes and clicks during implant design (([Formula: see text]) = 53, and guide design (([Formula: see text]) = 27) compared to using standard software (([Formula: see text]) = 559 and ([Formula: see text]) = 380) and customized commercial software (([Formula: see text]) = 217 and ([Formula: see text]) = 180). CONCLUSION: Our software solution efficiently streamlines the design of PSIs for distal radius malunion. It represents a first step in making 3D-printed PSIs technology more accessible.