Introduction

The use and development of new technologies has been a hallmark of our Hand Service. As an example we will present our utilization of newly-designed angular stable plates with Norian bone cement to improve our ability to surgically correct distal radius malunions in the elderly.

Union with deformity is the most common complication following a distal radius fracture.(1) This deformity can be intra-articular, affecting either the radiocarpal or radioulnar joints; extra-articular characterized by metaphyseal angulation and loss of length, or it may be a combination of both.(2-6)

Corrective osteotomies have been proven to be an effective treatment for symptomatic malunion.(1, 7)

A variety of techniques have been used, however there has remained concern regarding the indications for surgical intervention in the presence of underlying osteoporosis as well as the recognized morbidity associated with autogenous iliac crest bone grafting.(8-10)

Technical advances including the use of precontoured internal fixation devices with angular stable fixation, as well as the use of osteointegration biomaterials have offered some advantages.

The former facilitates osteosynthesis characterized by higher stability even in osteopenic bone and in altered bone architecture as it is seen in osteoporosis.(11-17) These implants afford osseous fixation that allows early motion and rehabilitation.( 18) Also their precontoured shape maintains desirable patterns of alignment, congruency and inclination of the distal radius after corrective osteotomy because of their ability to ensure angular and axial stability.(18-20) These properties reduce the probabilities of screw loosening and consequent loss of reduction.(4, 20)

Following osteotomy and achievement of proper angulation and alignment, there will exist a three-dimensional defect that must be filled in order to adequately support the bone fragments.(21-25) Autogenous bone grafts have been widely used for this purpose. They have a recognized potential for donor site morbidity, in particular those involving corticocancellous variants.(8, 10, 26) Materials such as polymethylmethacrylate (PMMA) and osteoconductive biomaterials such as Norian Skeletal Repair System (Norian SRS)? offer structural support eliminating effects of donor site morbidity.(21-25) Experience with polymethylmethacrylate (PMMA) has shown lack of osseous integration.(24, 25) In contrast, prospective randomized trials demonstrated good clinical and radiological results with osteoconductive synthetic materials such as Norian SRS.(21-25)

We believe this operative technique to be safe and predictable. Additional benefits such as the use in osteoporotic patients and the elimination of donor site morbidity also support the practice of this technique.

INDICATION FOR THIS SURGICAL TECHNIQUE

We consider this technique indicated and ideal in the elderly patient, who is experiencing symptoms and disability caused by a malunion of a previous distal radius fracture. This surgery is appropriate to treat these patients, whose bone quality is not adequate to tolerate any type of implant due to the presence of osteopenia or osteoporosis.

MATERIALS AND METHODS

Between 2002 and 2004, 11 patients, 7 female and 4 male with an average age of 55 years (range: 44 to 74 years), were treated at Massachusetts General Hospital, Orthopaedic Hand Surgery Service by a single orthopaedic hand surgeon (J.B.J). (Table 1)

The patients presented at 8 months post trauma (range: 1 to 14 months) with symptomatic distal radius malunion. Preoperative clinical and radiological evaluations were done to assess range of motion, grip and pinch strength and characterize radiologically the malunion.

Four patients were classified as “Dorsal” malunion. This pattern was typified as severe dorsal tilt of the radius in the lateral plane. (Fig 1) The physical exam of these patients consistently presented excessive wrist extension and lack or impairment of wrist flexion. Seven patients were classified as “Volar” malunion. These were characterized as deformities with marked volar tilt of the distal radius on the pre-operative radiography lateral view. (Fig 2) In contrast, these patients had a lack of wrist extension and greater wrist flexion when compared to the opposite limb).

The osteotomy was performed trough dorsal approach in four patients and via volar approach in five; two had a combined approach due to excision of previously placed internal fixation as well as the need for median nerve decompression. Two corrections included an intraarticular osteotomy.

All cases were performed under regional block anesthesia. For internal fixation five patients were treated with volar locking 2.4 mm T plates and six with dorsal 2.4 mm. T, L and/or radial column locking plates. Following the osteotomy and internal fixation, the created defect was filled with Norian SRS cement?. X-rays were taken to evaluate quality of reduction and fixation after the osteotomy. At 10 to 14 days of postoperative immobilization, all patients started active motion exercises.

Pre and postoperative range of motion and grip strength were measured by an independent observer. Wrist and forearm mobility were objectively quantified with a goniometer (Orthofix, USA). Excellent range of motion was defined as 100% of wrist and forearm motion of the contralateral limb. Good results as between 75% and 99%; fair between 50% and 74% and bad when achieved motion was less than 50% of the uninvolved limb. Grip strength was tested also pre and postoperatively, using a hydraulic hand dynamometer (Baseline? FEI, Irvington, N.Y. 10533, USA) with the elbow set at the third station (elbow at ninety degrees of flexion and the wrist and forearm in neutral). Postoperatively, all patients were measured according to the Modified Mayo wrist score and the modified Gartland and Werley score to evaluate outcomes in terms of pain, ability to return to work, mobility, grip strength, residual deformities and complications. The DASH questionnaire was also completed at the postoperative visit.

Ulnar inclination, volar tilt, radial length and ulnar variance were measured in pre and postoperative radiographs according to the standard technique for radiographic measurement in the radius. Percentage improvement and averages were calculated for each patient.

RESULTS

Corrective osteotomies were performed an average of 8 months after the initial injury (range: 1 – 14 months). There were no perioperative complications. All osteotomies healed. At an average follow up of 17 months (range: 6 to 22), 8 patients of the 11 have completed the evaluation. An average wrist and forearm motion of 78% of the opposite side was achieved. Average achieved wrist and forearm motion was 47° degrees of flexion, 43° of extension, 75° of supination, 86° of pronation, 20° of radial deviation and 35° of ulnar deviation.



The Modified Mayo wrist score scale was used to measure grip strength. The total of 8 patients were rated as good strength (strength between 75% and 99%). The grip strength on average was 88% when compared to the uninvolved hand. The average grip was 69.8 pounds.

According to the Modified Mayo Wrist Score, two patients rated as good result (75-89pts) and six as a fair outcome (50- 74pts). There were no patients scoring a bad result (less than 50pts). The average Modified Mayo Wrist Score was 71 points of a hundred (range: 65-85).(Table 2)

When using the Modified Gartland and Werley Score, one patient rated as excellent outcome (0-2pts.); four as good results (3-8pts); and three as a fair result (9-20pts). There were no poor results (more than 21 pts). The average Gartland and Werley score was 7.8 points, ranging from 1 to 18 points. (Table 2)

The average DASH score was 21.5 points, ranging from 0 to 41. (Table 2)

One patient required a Darrach’s procedure at 6 months to increase motion and management of pain at the distal radio ulnar joint. Two patients required plate removal due to pain and limitation in movement. These patients have not completed their final follow up.

In terms of X ray evaluation the average pre operative volar tilt was 19.4° in extension in the dorsal deformity group and 25° in flexion in the volar deformity group. Postoperatively, the average palmar tilt was 12.9° in the former and 12.5° in the latter group. The average improvement after surgery was 24.6° degrees in patients with dorsal deformity and 14.1° in those with volar deformity. Pre operative ulnar variance was on average 4.1 mm, after surgery it corrected to 2.54 mm (50%). Ulnar inclination averaged 14.5° preoperatively, after treatment it averaged 22° presenting an improvement of 7.5°. Lastly, with the exception of one patient, restoration after surgery achieved acceptable clinical outcomes and radiologic parameters. Assessment for posttraumatic arthritis was negative in every case at the time of follow up.

DISCUSSION

A corrective osteotomy in the older patient is more difficult because of the associated osteopenia as well as the limited autogenous bone graft to be obtained from the iliac crest. Several technological advances have made this procedure more predictable. The first is the development of low profile implants with angular stable screw fixation. This osteosynthesis system device has shown good results in maxillofacial and spine surgery, where stability is required without bicortical screw purchase.(13, 16, 17)

The locking compression system offers a similar mechanism of action with the mechanical advantage of multiple points of screw fixation when compared to fixed angle devices. It is a point of crucial importance in fractures with long working lengths, short periarticular fragments and the absence of osseous support on the contralateral side where the plate is placed.(13) The angle fixed constructs do not affect the blood supply to the bone and do not require good bone quality to proportionate stability. In this system, threads on the screw heads lock into the corresponding threads on the screw hole of the plate, eliminating therefore toggling. Forces are transmitted then from the bone to the plate across the threaded connection converting compression unnecessary to get stability. This lack of compression preserves the blood supply to the bone improving conditions for healing. Disadvantages of this system include no tactile feedback to the surgeon while tightening the screws. Previous reduction is needed before application of the device, once the locked screw is placed below or above of the fracture site no further reduction is possible unless the construct is totally removed.(27-30) Clinical trials have verified the efficacy of fixed angled plates for the treatment of distal radius fractures. (27-30) Functional outcomes are promising and the rate of complications low, making this implant desirable also for the stabilization of osteotomies for the treatment of distal radius malunion.

The second technical advance is the use of cement and biomaterials that can support and put together fragments of bone, and that can fill defects after severe comminution or osteotomies. The role of this material is particularly important in osteoporotic bone that cannot tolerate adequately constructs and that needs support while consolidation process takes place. Norian SRS Cement offers biocompatibility and osteointegration; high compressive strength, even higher than cancellous bone; fast-setting that cures in vivo at physiological pH and temperature avoiding local damage tissue characteristic of PMMC use; and lastly injectable consistency that allows percutaneous as well as open-technique application.(24)

Additionally, advantages in imaging under fluoroscopy and X rays have been proved.(9, 31)

Two prospective randomized studies (Sanchez-Sotelo et al and Cassidy et al) evaluating the use of Norian showed good results.(21, 24) Clinical outcomes were significantly better than the standard care; however, none of them defined what type of fractures gets benefit from this particular approach with cement and percutaneous fixation. Recent research has demonstrated comparable results between percutaneous fixation and open reduction and internal fixation for extra articular and non-complex intraarticular fractures(30), therefore, the role of Norian? cement in distal radius fractures in previous studies must be related with bone quality, in other words, osteoporosis and osteopenia.

According to the mechanism of action and previous description of these two surgical advances, we consider them extremely useful for the treatment of malunions in osteopenic patients that suffered a distal radius fracture concluding in malunion or mal-alignment. We find this technique useful and safe to treat malunion.

CONCLUSION

This series reports the results of treatment of distal radius malunion with osteotomy plus internal fixation with locking compression plates and Norian SRS?. Our purpose is to present this technique as an alternative in these complex cases where we have to face the elderly patient with osteoporotic bone.

Santiago A. Lozano-Calderón, MD is a Research Fellow, Orthopaedic Surgery Service, Harvard Medical School, Massachusetts General Hospital, Boston, MA.
Jesse B. Jupiter, MD is Chief Orthopaedic Hand Surgery Service, Harvard Medical School, Massachusetts General Hospital, Boston, MA.

Address correspondence to:

Jesse Jupiter, M.D.
Massachusetts General Hospital
55 Fruit St., YAW2
Boston, MA 02114

References:

1. Fernandez DL, Ring D, Jupiter JB. Surgical management of delayed union and nonunion of distal radius fractures. J Hand Surg [Am]. 2001 Mar;26(2):201-9.
2. Shea K, Fernandez DL, Jupiter JB, Martin C, Jr. Corrective osteotomy for malunited, volarly displaced fractures of the distal end of the radius. J Bone Joint Surg Am. 1997 Dec;79(12):1816-26.
3. Martini AK. Secondary arthrosis of the wrist joint in malposition of healed and un-corrected fracture of the distal radius. Aktuelle Traumatol. 1986 Aug;16(4):143-8.
4. Miyake T, Hashizume H, Inoue H, Shi Q, Nagayama N. Malunited Colles’ fracture. Analysis of stress distribution. J Hand Surg [Br]. 1994 Dec;19(6):737-42.
5. Pogue DJ, Viegas SF, Patterson RM, Peterson PD, Jenkins DK, Sweo TD, et al. Effects of distal radius fracture malunion on wrist joint mechanics. J Hand Surg [Am]. 1990 Sep;15(5):721-7.
6. Villar RN, Marsh D, Rushton N, Greatorex RA. Three years after Colles’ fracture. A prospective review. J Bone Joint Surg Br. 1987 Aug;69(4):635-8.
7. Jupiter JB, Fernandez DL. Complications Following Distal Radial Fractures. Journal of Bone and Joint Surgery. 2001 August;83-A(8):1244-65.
8. Hill NM, Horne JG, Devane PA. Donor site morbidity in the iliac crest bone graft. Aust N Z J Surg. 1999 Oct;69(10):726-8.
9. Kopylov P, Jonsson K, Thorngren KG, Aspenberg P. Injectable calcium phosphate in the treatment of distal radial fractures. J Hand Surg [Br]. 1996 Dec;21(6):768-71.
10. Silber JS, Anderson DG, Daffner SD, Brislin BT, Leland JM, Hilibrand AS, et al. Donor site morbidity after anterior iliac crest bone harvest for single-level anterior cervical discectomy and fusion. Spine. 2003 Jan 15;28(2):134-9.
11. Ring D, Jupiter JB, Brennwald J, Buchler U, Hastings H, 2nd. Prospective multicenter trial of a plate for dorsal fixation of distal radius fractures. J Hand Surg [Am]. 1997 Sep;22(5):777-84.
12. Gesensway D, Putnam MD, Mente PL, Lewis JL. Design and biomechanics of a plate for the distal radius. J Hand Surg [Am]. 1995 Nov;20(6):1021-7.
13. Haidukewych GJ. Innovations in locking plate technology. J Am Acad Orthop Surg. 2004 Jul-Aug;12(4):205-12.
14. Frigg R, Appenzeller A, Christensen R, Frenk A, Gilbert S, Schavan R. The development of the distal femur Less Invasive Stabilization System (LISS). Injury. 2001 Dec;32 Suppl 3:SC24-31.
15. Koval KJ, Hoehl JJ, Kummer FJ, Simon JA. Distal femoral fixation: a biomechanical comparison of the standard condylar buttress plate, a locked buttress plate, and the 95-degree blade plate. J Orthop Trauma. 1997 Oct;11(7):521-4.
16. Richter M, Wilke HJ, Kluger P, Claes L, Puhl W. Biomechanical evaluation of a newly developed monocortical expansion screw for use in anterior internal fixation of the cervical spine. In vitro comparison with two established internal fixation systems. Spine. 1999 Feb 1;24(3):207-12.
17. Herford AS, Edward EI. Use of a Locking Reconstrucion Bone Plate/Screw System for Mandibular Surgery. J Oral Maxillofac Surg. 1998;56:1261-5.
18. Jupiter JB. Complex Articular Fractures of the Distal Radius: Classification and Management. J Am Acad Orthop Surg. 1997 May;5(3):119-29.
19. Simic PM, Weiland AJ. Fractures of the distal aspect of the radius: changes in treatment over the past two decades. Instr Course Lect. 2003;52:185-95.
20. Trumble TE, Randall C. Intra-articular fractures of the Distal Aspect of the Radius. The Journal of Bone and Joint Surgery. 1998 April 1998;80-A(4):582-600.
21. Sanchez-Sotelo J, Munuera L, Madero R. Treatment of fractures of the distal radius with a remodellable bone cement: a prospective, randomised study using Norian SRS. J Bone Joint Surg Br. 2000 Aug;82(6):856-63.
22. Constantz BR, Ison IC, Fulmer MT, Poser RD, Smith ST, VanWagoner M, et al. Skeletal repair by in situ formation of the mineral phase of bone. Science. 1995 Mar 24;267(5205):1796-9.
23. Larsson S, Bauer TW. Use of injectable calcium phosphate cement for fracture fixation: a review. Clin Orthop. 2002 Feb(395):23-32.
24. Cassidy C, Jupiter JB, Cohen M, Delli-Santi M, Fennell C, Leinberry C, et al. Norian SRS cement compared with conventional fixation in distal radial fractures. A randomized study. J Bone Joint Surg Am. 2003 Nov;85-A(11):2127-37.
25. Cohen MS, Whitman K. Calcium phosphate bone cement--the Norian skeletal repair system in orthopedic surgery. Aorn J. 1997 May;65(5):958-62.
26. Ahlmann E, Patzakis M, Roidis N, Shepherd L, Holtom P. Comparison of anterior and posterior iliac crest bone grafts in terms of harvest-site morbidity and functional outcomes. J Bone Joint Surg Am. 2002 May;84-A(5):716-20.
27. Orbay JL. Volar plate fixation of distal radius fractures. Hand Clin. 2005 Aug;21(3):347-54.
28. Orbay JL. The treatment of unstable distal radius fractures with volar fixation. Hand Surg. 2000 Dec;5(2):103-12.
29. Orbay JL, Fernandez DL. Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient. J Hand Surg [Am]. 2004 Jan;29(1):96-102.
30. Kreder HJ, Hanel DP, McKee M, Jupiter J, McGillivary G, Swiontkowski MF. Consistency of AO fracture classification for the distal radius. J Bone Joint Surg Br. 1996 Sep;78(5):726-31.
31. Jupiter JB, Winters S, Sigman S, Lowe C, Pappas C, Ladd AL, et al. Repair of five distal radius fractures with an investigational cancellous bone cement: a preliminary report. J Orthop Trauma. 1997 Feb-Mar;11(2):110-6.

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