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.

Surgical outcome of angular deformity correction of lower limbs in rickets: a cross-sectional study.

PURPOSE: This study aims to compare the functional and radiological outcomes following both guided growth surgery (GGS) and acute corrective osteotomy (ACO) correction of angular deformities in children with rickets. METHODS: A total of 8 and 7 children who had gradual GGS and ACO correction, respectively, for angular deformities due to rickets from 2002 to 2022 were recalled for follow-up. Demographic data, types of rickets, data on pharmacological treatment, biochemical parameters, recurrence of angular deformity and postoperative complications were obtained from the medical records. A radiographic evaluation of the leg was performed to determine the tibiofemoral angle. For functional evaluation, the Active Scale for Kids (ASK) and Lower Extremity Functional Scale (LEFS) instruments were used for children below and above 15 years old, respectively. RESULTS: In terms of the tibiofemoral angle, the GGS group documented greater angle changes compared to the ACO group, but the difference was not significant. In terms of functional outcomes, the overall score percentage of both groups was comparable with the GGS group showing a trend of higher score percentage compared to the ACO group. The GGS group presented no complication while 2 neurovascular injuries and 1 implant failure were recorded in the ACO group. CONCLUSION: Both GGS and ACO procedures resulted in similar radiographic and functional outcomes for the treatment of rickets in children. GGS may be advantageous in terms of reducing complications of surgery. Nevertheless, the choice of surgical intervention should be made based on the patient's circumstances and the surgeon's preference.

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.

Results of primary radial corrective osteotomy in Madelung's deformity.

INTRODUCTION: The purpose of this study was the evaluation of surgical outcomes in a series of wrists with Madelung's deformity treated with radial corrective osteotomy. We hypothesize that this surgical technique is a suitable and safe way of treatment. MATERIALS AND METHODS: A retrospective review of patients with Madelung's deformity treated with radial corrective osteotomy between January 2001 and June 2017 at a single large department of hand surgery in Germany was performed. Patients who met the inclusion criteria were invited for follow-up and outcome variables including pain, range of motion, patient-rated outcome measures, and radiographic measurements were obtained for comparison with preoperative data collected from the patients' medical records. RESULTS: 14 wrists were included. The average age at the time of surgery was 21.9 years, and the average follow-up was 7.2 years. The average visual analog pain scale at rest decreased from preoperative 2.6 points to postoperative 0.7 points. Under strain, the average VAS declined from 7.4 to 4.9 points. The mean DASH Score decreased from 42.9 before surgery to 22.0 points after surgery. Range of motion improved slightly in five out of six directions of motion, with the greatest increase seen in average supination from preoperative 68.5° to postoperative 82.0°. Averages of all five measured McCarroll's parameters and ulnar variance decreased, as expected from corrective surgery. Four wrists (26.8%) needed subsequent procedures. CONCLUSION: Radial corrective osteotomy was a suitable treatment of Madelung's deformity in our collective, although surgical outcomes are not yet fully satisfying.

Delayed aortic injury after thoracic corrective osteotomy: a case report.

PURPOSE: To present a case of delayed aortic perforation due to a nondisplaced fracture of the 9th rib after vertebral osteotomy for degenerative kyphoscoliosis in patients with osteoporosis. METHODS: A 78-year-old female patient with osteoporosis had undergone T9-iliac correction surgery for degenerative kyphoscoliosis. After 2 years, the patient underwent T10 pedicle subtraction osteotomy for a T10 vertebral fracture and progression of kyphosis. Postoperatively, the patient had been doing well for 3 weeks; however, just before the day of discharge, she died following a cardiopulmonary arrest. An autopsy was performed with the consent of her family. RESULTS: Autopsy revealed a large amount of blood and a clot in the left thoracic cavity. Aortic perforation was found just in front of a nondisplaced fracture of the left 9th rib. CONCLUSION: This report describes a new critical complication after spinal correction surgery. Even without pedicle screw malposition, aortic injuries can happen to patients with osteoporosis after corrective osteotomy for degenerative kyphoscoliosis due to positional change of aorta and fragility of the ribs. The spine surgeon should be aware of this type of complication, and rib fractures around the aorta after vertebral osteotomy should not be neglected even when there is no displacement.

Intra-articular opening wedge osteotomy for varus ankle arthritis with computer-assisted planning and patient-specific surgical guides: a retrospective case series.

BACKGROUND: Computer-assisted preoperative planning, combined with PSI has become an effective technique for treating complex limb deformities. The purpose of this study was to evaluate the efficacy and safety of the novel technique in corrective osteotomy for intra-articular varus ankle deformities associated with osteoarthritis and ankle instability. METHODS: Nineteen patients with intra-articular varus ankle arthritis were reviewed between April 2017 and June 2019, including ten men and nine women with a mean age of 58.3 ± 9.9 years (range, 38 to 76 years). All patients underwent intra-articular opening wedge osteotomy assisted by 3D virtual planning and PSI. Weight-bearing radiographs were used to assess the radiographic results, including TAS angle, TT angle, TMM angle, TC angle, TLS angle, opening-wedge angle, and wedge height. Functional outcomes were assessed by the AOFAS score, VAS score, and ROM of the ankle. RESULTS: The average follow-up time was 32.2 ± 9.0 months (range, 22 to 47 months). The average union time was 4.4 ± 0.9 months (range, 3.0 to 6.5 months). The TAS angle significantly changed from 84.1 ± 4.6° preoperatively to 87.7 ± 3.1° at the 1-year follow-up and 86.2 ± 2.6° at the latest follow-up. Similarly, the TT angle, TMM angle and TC angle changed significantly at the 1-year follow-up compared with the preoperative assessment and remained stable until the last follow-up. However, the TLS was not corrected significantly. The postoperative obtained opening-wedge angle, and wedge height showed no significant change with preoperative planning. The overall complication rate was 15.8%. The mean VAS score improved from 5.3 ± 0.6 to 2.7 ± 0.7. The mean AOFAS score improved from 56.2 ± 7.6 to 80.6 ± 4.6. However, the ROM showed no significant change. CONCLUSIONS: Accurate correction and satisfactory functional recovery were attained with computer-assisted planning and PSI in the corrective osteotomy of intra-articular varus ankle deformities.

Seven phenotypes of varus osteoarthritic knees can be identified in the coronal plane.

PURPOSE: Recommendations for resecting distal femur and proximal tibia in mechanical and anatomical alignment techniques are standardized. Kinematic alignment propagates individualizing resection planes. Whether significant variation exists, to warrant departure from standardized resection planes, has not been shown thus far in a large cohort of knees and with a wide range of varus deformity. The null hypothesis of this study was that there was no phenotypic variation in varus osteoarthritic knees. The aim of this paper was to determine whether distinct phenotypes could be identified, based on variations in coronal femoral and tibial morphology, which could aid in surgical planning and categorizing varus knees for future studies. METHODS: 2129 full-leg weightbearing radiographs were analyzed (1704 preoperative; 425 of contralateral arthritic knee). Measurements made were of HKA (hip-knee-ankle angle), VCA (valgus correction angle), mLDFA (lateral mechanical distal femoral angle), aLDFA (lateral anatomical distal femoral angle), MPTA (medial proximal tibial angle), MNSA (medial neck shaft angle), TAMA (angle between tibial mechanical and anatomical axes), and TPDR (percentage length of tibia proximal to extra-articular deformity). RESULTS: Seven distinct types were identified covering 2021 knees, reducible to 4 broad phenotypes: 11% were Type 1 'Neutral' knees showing values close to reported normal knees (mean VCA 5.5°, mLDFA 87°, aLDFA 81°). 38% were Type 2 'Intra-articular varus' with medial intra-articular bone loss (mean mLDFA 90.9°, MPTA 85.4°, VCA of 5.7°). 41% were Type 3 'Extra-articular varus' with extra-articular deformity (EAD). Type 3a had proximal tibial EAD; Type 3b had tibial diaphyseal EAD; Type 3c had femoral EAD (mean VCA 8.7°, HKA 166°), and severe medial bone loss (mean mLDFA 92°, MPTA 83°). 9% were Type 4 'Valgoid type' with features of valgus knees: Type 4a had medial femoral bowing (mean VCA 2.9°); Type 4b had significant distal femoral valgus (mean mLDFA 85.3°, aLDFA 78.6°). CONCLUSIONS: The null hypothesis that there was no phenotypic variation in varus osteoarthritic knees was rejected as considerable variation was found in coronal morphology of femur and tibia. Four broad phenotypic groups could be identified. Plane of the knee joint articular surface was quite variable. This has relevance to planning and performance of corrective osteotomies, unicompartmental and total knee arthroplasty. LEVEL OF EVIDENCE: III, retrospective cohort study.

Differences in Synovial Cytokine Profile Associated with Long-Term Clinical Outcomes in Patients with Knee Osteoarthritis Undergoing Corrective Osteotomy with Platelet-Rich Plasma or Stromal Vascular Fraction Post-Treatments.

Functional outcomes and synovial fluid (SF) cytokine concentrations in response to platelet-rich plasma (PRP) or stromal vascular fraction (SVF) post-treatments following open wedge high tibial osteotomy (HTO) in 20 patients with knee osteoarthritis (OA) were examined. Six weeks after surgery, the knees of 10 patients were injected with autologous PRP (PRP subgroup), while another 10 patients were injected with autologous SVF (SVF subgroup) and monitored for 1.5 years. Pain assessment (VAS score) and functional activity (KOOS, KSS, Outerbridge, and Koshino scores) were applied. PRP subgroup performed better compared with the SVF subgroup according to KOOS, KSS, and VAS scores, while the SVF subgroup demonstrated better results according to Outerbridge and Koshino testing and produced more pronounced cartilage regeneration in the medial condyle and slowed down cartilage destruction in its lateral counterpart. SF was collected before and one week after PRP or SVF injections and tested for concentrations of 41 cytokines (Multiplex Assay). In the PRP subgroup, a significant decrease in IL-6 and CXCL10 synovial concentrations was accompanied by an increase in IL-15, sCD40L, and PDGF-AB/BB amounts. The SVF subgroup demonstrated a significant decrease in synovial TNFα, FLT-3L, MIP-1ß, RANTES, and VEGF concentrations while SF concentrations of MCP-1 and FGF2 increased. Both post-treatments have a potential for increased tissue regeneration, presumably due to the downregulation of inflammation and augmentation of synovial growth factor concentrations.

[Clinical and functional outcomes of valgus osteotomy in patients with medial gonarthrosis (preliminary results)]. / Rezul'taty val'giziruyushchei osteotomii u patsientov s medial'nym gonartrozom (predvaritel'nye rezul'taty).

OBJECTIVE: To analyze gait biomechanics before and after corrective osteotomies around the knee joint in patients with medial gonarthrosis. MATERIAL AND METHODS: The study recruited 5 patients (6 surgeries) with medial gonartrosis and varus knee deformity. Gait biomechanics was analyzed in preoperative period and 6 months later. The control group consisted of 20 healthy people. RESULTS: Knee joint biomechanics was almost normal in postoperative period. Amplitude of knee joint flexion was increased. Moreover, hip joint flexion-extension amplitude was increased on both sides and often exceeded normal values. Clinical results showed significant increase in IKS (from 55 to 89.6) and VAS score (from 7.7 to 2.3). Postoperative correction angle varied within 1.5-2° of valgus. CONCLUSION: Corrective osteotomy around the knee joint is effective for medial gonarthrosis. We obtained favorable clinical results and limb axis correction after surgery without significant hypercorrection. Gait biomechanics was also improved.

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.

Malunited calcaneal fracture: the role and technique of osteotomy-a systematic review.

PURPOSE: The research is aimed to introduce various corrective osteotomies utilized in treating calcaneal malunions in published papers, to further analyze the results, and to summarize recommended indications. METHODS: The relevant research screening was conducted on the following search engines: the Cochrane Library, Web of Science, PubMed, Embase, Medline, and Academic Search Premier. Key words input included "calcaneal/calcaneus", "malunion," and "malunited fracture(s)" with Boolean operators "AND" and "OR." The inclusion criteria were researches containing surgical procedures treating calcaneal malunion with corrective osteotomy and published in the English language. For included research article, such information was extracted and analyzed: the type of calcaneal malunion, the time from initial injury to corrective surgery, the method of osteotomy, outcomes of each osteotomy (score systems, Bohler angle, talocalcaneal height and width of calcaneus, etc.), the function of the affected limb, post-operative complications, and patients' satisfaction. For included review, descriptive, commentary, or indicative sentences about corrective osteotomy were highlighted, analyzed, and summarized. RESULTS: Ten research articles (170 patients with 184 feet) and nine reviews were included in this review, presenting seven types of corrective osteotomies (lateral wall exostectomy, Dwyer osteotomy, lateral wedge opening osteotomy, Romash osteotomy, tongue osteotomy, sagittal resection osteotomy, and modified Dwyer osteotomy). CONCLUSION: A different corrective osteotomy with/without arthrodesis is recommended to be utilized based on the classification of the malunion and the condition of the cartilage in treating malunited calcaneal fractures. With adequate postoperative care and rehabilitation, the results of treatment could be associated with patients' satisfaction and good function.

The impact of limb loading and the measurement modality (2D versus 3D) on the measurement of the limb loading dependent lower extremity parameters.

BACKGROUND: Deformity assessment and preoperative planning of realignment surgery are conventionally based on weight-bearing (WB) radiographs. However, newer technologies such as three-dimensional (3D) preoperative planning and surgical navigation with patient-specific instruments (PSI) rely on non-weight bearing (NWB) computed tomography (CT) data. Additionally, differences between conventional two-dimensional (2D) and 3D measurements are known. The goal of the present study was to systematically analyse the influence of WB and the measurement modality (2D versus 3D) on common WB-dependent measurements used for deformity assessment. METHODS: 85 lower limbs could be included. Two readers measured the hip-knee-ankle angle (HKA) and the joint line convergence angle (JLCA) in 2D WB and 2D NWB radiographs, as well as in CT-reconstructed 3D models using an already established 3D measurement method for HKA, and a newly developed 3D measurement method for JLCA, respectively. Interrater and intermodality reliability was assessed. RESULTS: Significant differences between WB and NWB measurements were found for HKA (p < 0.001) and JLCA (p < 0.001). No significant difference could be observed between 2D HKA NWB and 3D HKA (p = 0.09). The difference between 2D JLCA NWB and 3D JLCA was significant (p < 0.001). The intraclass correlation coefficient (ICC) for the interrater agreement was almost perfect for all HKA and 3D JLCA measurements and substantial for 2D JLCA WB and 2D JLCA NWB. ICC for the intermodality agreement was almost perfect between 2D HKA WB and 2D HKA NWB as well as between 2D HKA NWB and 3D HKA, whereas it was moderate between 2D JLCA WB and 2D JLCA NWB and between 2D JLCA NWB and 3D JLCA. CONCLUSION: Limb loading results in significant differences for both HKA and JLCA measurements. Furthermore, 2D projections were found to be insufficient to represent 3D joint anatomy in complex cases. With an increasing number of surgical approaches based on NWB CT-reconstructed models, research should focus on the development of 3D planning methods that consider the effects of WB on leg alignment.

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.

Functional outcome after corrective osteotomy for malunion of the distal radius: a randomised, controlled, double-blind trial.

PURPOSE: The purpose of this randomised, controlled, double-blind trial was to evaluate functional outcome during the first year after corrective osteotomy for malunited distal radius fractures, with or without filling the osteotomy void. METHOD: Patients were randomised to receive a HydroSet bone substitute or no graft. Cortical contact was maintained and stabilisation of the osteotomy was carried out with a DiPhos R- or RM Plate. To evaluate subjective functional outcome, the Patient-Rated Wrist Evaluation (PRWE), the Quick Disabilities of the Arm, Shoulder and Hand Questionnaire (Q-DASH), the Canadian Occupational Performance Measure (COPM) and the RAND-36 were used. Moreover, range of motion and grip strength were measured by blinded evaluators. Evaluations were made pre-operatively and three, six and 12 months post-operatively. RESULTS: There were no significant differences between the groups at any time point post-operatively with respect to any of the PROMs that were used or range of motion or grip strength (p > 0.05). In both groups, there was a significant improvement at the 12-month follow-up compared with pre-operatively for the PRWE, the Q-DASH and the COPM satisfaction scores. The RAND-36 revealed no significant differences except for two domains, in which there was an improvement in the treatment group (p < 0.05). For grip strength and for range of motion in all movement directions, except dorsal extension, there was a significant improvement in both groups (p < 0.05). CONCLUSION: There is no significant difference in functional outcome during the first year after corrective open-wedge distal radius osteotomy, where cortical contact is maintained, regardless of whether or not bone substitute to fill the void is used.

Corrective osteotomy after malunited distal radius fractures.

Posttraumatic malunion or secondary dislocation can cause wrist joint incongruency. Uncorrected malalignment increases the risk of secondary degenerative changes and chronic pain. Therefore, early correction using the available fixed-angle devices, cancellous bone grafting only becomes necessary in larger bony defects. Premounting the plate through a palmar approach with regard to the desired correction angles leads to predictable results by precise correction. In case of posttraumatic growth arrest with larger discrepancy of the radius and the ulna, a two-staged procedure is advisable.

Posttraumatic Bifid Ulna in a Pediatric Galeazzi-Equivalent Forearm Fracture.

We report an unusual clinical presentation and surgical treatment of a Galeazzi-equivalent fracture in which initial closed treatment failed. This case was unique and challenging secondary to the formation of a neoulna volar to an unreduced periosteal sleeve injury, resulting in a bifid radiographic appearance.

Chronic anterior sternoclavicular instability: technique and results of corrective clavicular osteotomy.

BACKGROUND: Chronic anterior sternoclavicular (SC) instability is a rare but potentially disabling condition. It can arise in conjunction with trauma or hyperlaxity, or both. Numerous surgical techniques have been described, but no gold standard exists. SC instability is often position-dependent and can be reduced with the arm in a specific position. METHODS: To directly address this issue, we used a technique of corrective osteotomy of the clavicle with the goal to reorient the articular portion of the medial end of the clavicle so that it remains stable in all functional positions of the arm. To illustrate the technique and the correction in space, we performed postoperative 3-dimensional computed tomography analyses of the shoulder girdle of 4 patients. Clinical scores were obtained at the final follow-up and compared with preoperative scores. RESULTS: Mean follow-up was 64 months (range, 19-191 months). The mean Constant score improved from 58 (range, 45-68) preoperatively to 73 (range, 69-84) postoperatively and the Subjective Shoulder Value from 42 (range, 15-80) to 79 (range, 50-100). All patients reported good or very good stability of the SC joint at the last follow-up. We recorded no intraoperative or direct postoperative complications. During follow-up, 3 patients underwent removal of the plate, 1 of them for plate breakage. The mean postoperative correction for combined rotations is given as a 3-dimensional angle and averaged 28.0° (range, 8.6°-39.7°). CONCLUSION: In this pilot study, medial corrective clavicular osteotomy using the described technique treated anterior SC instability with improvement of clinical shoulder function scores and good patient satisfaction. The technique appears simple and safe and deserves further evaluation.

Standardization of torsional CT measurements of the lower limbs with threshold values for corrective osteotomy.

INTRODUCTION: Re-establishing anatomic rotational alignment of shaft fractures of the lower extremities remains challenging. Clinical evaluation in combination with radiological measurements is important in pre- and post-surgical assessment. Based on computed tomography (CT), a range of reference values for femoral torsion (FT) and tibial torsion (TT) have historically been reported, which require standardization to optimize the significant intra- and inter-observer variability. The aims of this study were (re-)evaluation of the reference FT and TT angles, determination of the normal intra-individual side-to-side torsional differences to aid the surgical decision-making process for reoperation, and development of a novel 3D measurement method for FT. MATERIALS AND METHODS: In this retrospective study, we included 55 patients, without any known torsional deformities of the lower extremities. Two radiologists, independently, measured the rotational profile of the femora using the Hernandez and Weiner CT methods for FT, and the tibiae using the bimalleolar method for TT. The intra-individual side-to-side difference in paired femora and paired tibiae was determined. A 3D technique for FT assessment using InSpace® was designed. RESULTS: FT and TT demographic values were lower than previously reported, with mean FT values of 5.1°-8.8° and mean TT values of 25.5°-27.7°. Maximal side-to-side differences were 12°-13° for FT and 12° for TT. The Weiner method for FT was less variable than the Hernandez method. The new 3D method was equivocal to the conventional CT measurements. CONCLUSION: The results from this study showed that the maximal side-to-side tolerance in asymptomatic normal adult lower extremities is 12°-13° for FT and 12° for TT, which could be a useful threshold for surgeons as indication for revision surgery (e.g., derotational osteotomy). We developed a new 3D CT method for FT measurement which is similar to 2D and could be used in the future for virtual 3D planning.

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.

Rotational Corrective Osteotomy for Malunited Distal Diaphyseal Radius Fractures in Children and Adolescents.

PURPOSE: To report our method of computer-planned rotational corrective osteotomy for malunited distal diaphyseal radius fractures in children and adolescents using a custom jig and to review the results of 4 cases. METHODS: Four patients (mean age, 13 years; range, 11-16 years) underwent computer-planned rotational corrective osteotomy for malunited distal diaphyseal radius fracture using a custom jig. We retrospectively evaluated their radiographic and clinical data. RESULTS: In patients who had marked restriction of forearm supination before osteotomy, the mean arc of forearm supination improved from 5° before surgery to 79° after surgery. Angular deformity on x-ray, range of forearm rotation, and grip strength all improved after surgery. Mild and moderate pain reported by 1 and 2 patients, respectively, was resolved after surgery. CONCLUSIONS: Computer-planned rotational corrective osteotomy for malunited distal diaphyseal radius fracture in children and adolescents using a custom jig is a strategy that facilitates the surgical procedure by accurately correcting both rotational and angular deformities on 1 plane in a single procedure. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.