This is a review from 4 institutions on the results of corrective osteotomy for intra-articular malunion of the distal part of the radius. Twenty-three skeletally mature patients were evaluated in an average of 38 months (range, 24 to 102 months) after the injury. The indications for osteotomy included articular incongruity in the coronal plane with subluxation of the radial carpal joint in 14 patients, and articular incongruity of greater than 2-mm as measured on the posteroanterior radiograph in 17 patients. The average maximum articular step-off prior to operation was 4-mm. There were 16 men and 7 women with an average age of 37 years (range, 18 to 67 years). There were 12 Type B fractures and 11 Type C fractures. The initial treatment was closed manipulation and casting in 14 patients and operative internal fixation in 9 patients. The operative technique included a dorsal approach in 13 patients, volar in 9 patients and both dorsal and volar in 1 patient. An osteotome was used to recreate the fracture line. Bone was resected until the articular portion of the fracture could be accurately reduced. The osteotomy was secured with screws alone in 7 patients, Kirschner wires alone in 2 patients and a plate and screws in 14 patients. Autologous bone graft was applied in 17 patients. One patient with a dorsal 2.0 mm plate had a rupture of the EPL which was treated with an EIP transfer, one had a Sauve-Kapandji procedure to address arthrosis of the distal radial ulnar joint, one had a radio-scapholunate fusion and a hemi-resection arthroplasty of the distal radial ulnar joint to address arthrosis of the radial carpal and distal radial ulnar joints and one had an ulnar shortening osteotomy. Implants were removed at an average of 7 months after the first operation in 7 patients. Wrist extension improved from an average of 37 degrees to 56 degrees, wrist flexion improved from 44 degrees to 56 degrees, pronation improved from 64 degrees to 80 degrees, supination improved from 57 degrees to 81 degrees, radial deviation improved from 14 degrees to 22 degrees, ulnar deviation improved from 17 degrees to 33 degrees. Grip strength improved from 50% to 85% of that of the contralateral hand. The intra-articular step-off or gap averaged 4-mm (range, 2 to 15-mm) preoperatively and improved to 0.4 mm (range, 0 to 3-mm) with 6 patients having incongruity of greater than 1 mm. There was significant improvement in ulnar variance and articular incongruity. Ten patients had radiographic signs of radial carpal arthrosis. The average score according to the Fernandez system was 16 points (range, 12 to 20 points) with 6 excellent, 13 good and 3 fair results. According to the system of Gartland and Werley, the average demerit score was 5 points (range, 0 to 15 points) with 7 excellent, 12 good and 3 fair results. According to the modified system of Green and O’Brien, the average score was 76 points (range, 15 to 95 points) with 2 excellent, 8 good and 11 fair results and 1 poor result. All osteotomies healed without evidence of osteonecrosis.
The results of this study indicate that intra-articular osteotomies of malunited distal radius fractures may result in improved radiographic parameters, clinical range of motion and reasonable outcome scores. However, 10 of 23 patients exhibited radiographic signs of radiocarpal arthrosis, despite the operative interventions being performed on average 6 months from the injury. In addition, 60% of the results were fair or poor according to the modified Green and O’Brienrating scale which indicates that the osteotomy for malunited articular fractures of
the distal part of the radius rarely restores normal or near normal wrist function. However, the low incidence of fair or poor results according to the Fernandez aswell as the Gartland and Werley rating systems emphasizes that useful wrist function can be restored with this reconstructive procedure. The authors recommend that articular osteotomy be performed as early as possible after it is identified following the index procedure. They caution however that not all intra-articular malunions necessitate osteotomy, especially with nonunions in relatively non-articular areas such as between the scaphoid and lunate facet of the distal part of the radius. Although intra-articular osteotomies may be useful for improving and prolonging the wrist function of healthy active patients, it cannot be expected
to restore a normal wrist.
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J. Bone and Joint Surgery