Corrective Osteotomy of Distal Radius Malunion---New Horizons · TIMING OF SURGERY-absence of...
Transcript of Corrective Osteotomy of Distal Radius Malunion---New Horizons · TIMING OF SURGERY-absence of...
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Corrective Osteotomy of Distal Radius Malunion---New Horizons
I certify that, to the best of my knowledge, no aspect of my current personalor profession situation might reasonably be expected to affect significantlymy views on the subject on which I am presenting.
1. LOSS OF REDUCTION
2. DELAYED UNION AND NONUNION
3. MALUNION
4. DISTAL RADIOULNAR JOINT
WRIST FRACTURES
OSTEOARTICULAR COMPLICATIONS• Carpal ligaments
• Carpal fractures
• Nerves
• Tendons
• Combined soft tissues
• Vascular, compartment syndrome
ASSOCIATED LESIONS COMPLICATIONS
Carpal instability
Nonunion, malalignment
Neuropathy
Tendinitis, ruptures
Multifactorialfunctional deficit
RSD, Complex RegionalPain syndrome
WRIST FRACTURES
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TIMING OF SURGERY
-absence of trophic changes-acceptable bone quality-adequate wrist function
as soon as possible, provided there is: NASCENT MALUNION
- immature callus
- established deformity (5 – 8 weeks
post-fracture )
MATURE MALUNION
- remodelled callus
- 4 to 6 months or morepost-fracture
ADVANTAGES OF EARLY CORRECTION
•easiness of radial and DRUJ re-alignment
•less soft tissue contractures and DRUJ dysfunction
•no need of structural corticocancellous bone graft
•considerably decrease of total disability
•early return to work
Jupiter JB, Ring D:A comparison of early and late r econstruction of malunited fracturesof the distal end of the radius. JBJS 78A: 739-
748, May 1996
corrective osteotomy of malunited Colles fracturesthrough a dorsal approach
preoperative planning is based on the radiographicmeasurements of the opposite wrist:
-ulnar inclination-ulnar variance-volar tilt
(for rotational deformity: comparative CT-scans)
Bindra RR,Cole RJ et al: Quantification of the radial torsion angle withcomputerized tomography in cadaver specimens JBJS 79A:833-837, 1997
SURGICAL TECHNIQUE
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preoperative planning dorsal approach
2.4 distal radius locking plates
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correction of malunited Colles`fracturesthrough a volar approach:
SURGICAL TECHNIQUE
- Open wedge osteotomy, interpositional bone graftand volar plate fixation (U. Lanz, J.Orbay)
- Close wedge osteotomy, Darrach procedure andK-wire fixation (Posner, Garcia-Elias)
- Close wedge osteotomy and ulnar shortening
- Close wedge osteotomy and ulnar head prosthesis (D.L.Fernandez)
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open wedge osteotomy, bone graft and volar plate fi xation
Prommersberger KJ Lanz U.: Corrective osteotomy for malunited Colles‘fractures. Orthop Trauma 6: 75-87 , 1998.
Orbay JL, Indriago I, Badia A, Khouri RK, Gonzalez E, Fernandez DL: Corrective osteotomy of dorsally malunited fractures of the distal radiusvia the extended FCR approach.J Hand Surg 28B (Suppl 1): 2 ,2003
Lanz U, Kron W: Neue Technik zur Korrektur in Fehlstellung verheilterRadiusfrakturen. Handchir Mikrochir Plast Chir 8:203-206, 1976
L
Rsurgical technique
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post-opx-rays
12 weekspost-op
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3-dimensional image aquisition and 3-D planning
SNF Nr.258337: Fürnstahl P, Schweizer A, Székely G, Nagy L
Osteotomy ReportCutting: 22.014 mm (from distal) to distalCut is performed at 22.014 mm (from distal)Osteotomy result:First: Rotation around axis 2 by 15.868 degreesSecond: Rotation around axis 1 by 26.756 degreesThird: Rotation around axis 0 by 9.2067 degreesFourth: Translation by 0.93842 (axis 0),0.7939 (axis 1),-11.642 (axis 2) mm
SNF Nr.258337: Fürnstahl P, Schweizer A, Székely G, Nagy L
Osteotomy ReportCutting: 22.014 mm (from distal) to proximalCut is performed at 22.014 mm (from distal)Osteotomy result:First: Rotation around axis 2 by 15.868 degreesSecond: Rotation around axis 1 by 26.756 degreesThird: Rotation around axis 0 by 9.2067 degreesFourth: Translation by 0.93842 (axis 0),0.7939 (axis 1),-11.642 (axis 2) mm
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CONV. PLATE DRILLING JIG
SETTING GAUGE
SA 39
SA 39 SA 39
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SA 39 SA 39
SA 39
Osteotomy result:First: Rotation around axis 2 by 3.2372°Second: Rotation around axis 1 by -15.076°Third: Rotation around axis 0 by -7.8848°Fourth: Translation by0.33353 mm, 0.66308 mm,-4.9765 mm
SA 39
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SA 39 SA 39
SA 39 SA 39
Skyline view
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SA 39 6W
INTRARTICULAR MALUNION
intra-articular malunion results after failure to r ecognize
potentially unstable articular disruption, or insuf ficient
reduction and fixation during surgical treatment
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The indication of osteotomy for an intra-articularmalunion depends on:
1) the fracture pattern
2) the extent of cartilage damage
3) the chronology
4) presence of fixed carpal malalignment
5) the soft tissue condition
INTRA-ARTICULAR OSTEOTOMIES
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CONTRAINDICATIONS
1) severe cartilage damage
2) radiographic degenerative changes
3) chronic synovitis
4) significant soft tissue andcapsular contractures (post RSD)
5) complex fracture pattern andfixed carpal malalignment
TREATMENT RECOMMENDATIONS
- simple intra-articular disruption
- as soon as possible
- minimal cartilage damage (chondromalacia)
- adequate pre-operative function
- complient, cooperative patient
otherwise a limited carpal fusion (RSL or RL) is preferable
INTRA-ARTICULAR MALUNION
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ARTHROSCOPIC ASSISTED TREATMENT OF DISTAL RADIUS MALUNION
Francisco del Piñal et al: Arthroscopically guided osteotomyfor management of intra-articular distal radius malunions.
J Hand Surg 35A: 392-397, 2010
del Piñal, F , Garcia Bernal FJ, et al: Correction of malunited intra-articular distal radius fractures with an inside-out
osteotomy technique. J Hand Surg 31A: 1029-1034, 2006
Courtesy: Dr Francisco del Piñal, Santander,Spain
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Combined Intra- and Extra-Articular Distal Radius Malunion
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Geert A. Buijze, MDKarl-Josef Prommersberger, MDJuan González del Pino, MD PhDDiego L. Fernandez, MDJesse B. Jupiter, MD
Corrective Osteotomy for Combined Intra- and Extra-Articular Distal Radius Malunion
Study Aims MethodsPatient Inclusion
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MethodsPatient Inclusion
MethodsPatient Characteristics
Surgical TechniqueExtra-Articular Malunion
Surgical TechniqueIntra-Articular Malunion
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Surgical Technique
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Surgical Technique
Surgical Technique Surgical Technique
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Eleven years FU CONCLUSIONS
- malunion remains the most common complication of closed reduction and plaster immobilisation of unst able
extra-articular fractures
- intra-articular malunion results after failure to recognize potentially unstable articular disruption, or insuf ficient
reduction and fixation during surgical treatment
- if symptomatic extra-articular malunion occurs, ra dialosteotomy offers better function,improves the exter nal
appearance and normalizes carpal kinematics
-intra-articular malunion deserves early correction in orderto restore the functional – anatomic integrity of th e jointbefore the onset of symptoms and cartilage damage
-our experience has shown that with:
careful patient selection
correct indication and
refinements of surgical technique
over 80% of excellent and good results can be expected
CONCLUSIONS
Complications and failures are commonly caused eith erby technical errors, or by improper patient selecti on with:
degenerative changes
trophic disturbances
partial joint stiffness
severe osteoprosis
fixed type of DISI malaligment
and failure to assess and simultaneously treatassociated disorders of the distal radioulnar joint
CONCLUSIONS
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