Delclaux S, Trang Pham T T, Bonnevialle N, Aprédoaei C, Rongières M, Bonnevialle P, Mansat P
Département de chirurgie orthopédique et traumatologique, hôpital Pierre-Paul-Riquet, CHU de Toulouse-Purpan, place du Dr-Baylac, 31059 Toulouse cedex 9, France.
Département de chirurgie orthopédique et traumatologique, hôpital Pierre-Paul-Riquet, CHU de Toulouse-Purpan, place du Dr-Baylac, 31059 Toulouse cedex 9, France.
Orthop Traumatol Surg Res. 2016 May;102(3):327-32. doi: 10.1016/j.otsr.2015.12.010. Epub 2016 Mar 3.
Distal radius malunion is a major complication of distal radius fractures, reported in 0 to 33% of cases. Corrective osteotomy to restore normal anatomy usually provides improved function and significant pain relief. We report the outcomes in a case-series with special attention to the potential influence of the initial management.
This single-centre retrospective study included 12 patients with a mean age of 35years (range, 14-60years) who were managed by different surgeons. There were 8 extra-articular fractures, including 3 with volar angulation, 2 anterior marginal fractures, and 2 intra-articular T-shaped fractures; the dominant side was involved in 7/12 patients. Initial fracture management was with an anterior plate in 2 patients, Kapandji intra-focal pinning in 5 patients, plate and pin fixation in 2 patients, and non-operative reduction in 3 patients. The malunion was anterior in 10 patients, including 2 with intra-articular malunion, and posterior in 2 patients. Corrective osteotomy of the radius was performed in all 12 patients between 2005 and 2012. In 11/12 patients, mean time from fracture to osteotomy was 168days (range, 45-180days). The defect was filled using an iliac bone graft in 7 patients and a bone substitute in 4 patients. No procedures on the distal radio-ulnar joint were performed.
All 12 patients were evaluated 24months after the corrective osteotomy. They showed gains in ranges not only of flexion/extension, but also of pronation/supination. All patients reported improved wrist function. The flexion/extension arc increased by 40° (+21° of flexion and +19° of extension) and the pronation/supination arc by 46° (+13° of pronation and +15° of supination). Mean visual analogue scale score for pain was 1.7 (range, 0-3). Complications recorded within 2years after corrective osteotomy were complex regional pain syndrome type I (n=1), radio-carpal osteoarthritis (n=3), and restricted supination due to incongruity of the distal radio-ulnar joint surfaces (n=3). This last abnormality should therefore receive careful attention during the management of distal radius malunion.
In our case-series study, 3 (25%) patients required revision surgery for persistent loss of supination. The main error in these patients was failure to perform a complementary procedure on the distal radio-ulnar joint despite postoperative joint incongruity. This finding and data from a literature review warrant a high level of awareness that distal radio-ulnar joint congruity governs the outcome of corrective osteotomy for distal radius malunion.
桡骨远端畸形愈合是桡骨远端骨折的主要并发症，报道发生率为0%至33%。通过截骨术恢复正常解剖结构通常能改善功能并显著缓解疼痛。我们报告一组病例系列的结果，特别关注初始治疗的潜在影响。
这项单中心回顾性研究纳入了12例患者，平均年龄35岁（范围14 - 60岁），由不同外科医生治疗。其中8例为关节外骨折，包括3例掌侧成角骨折、2例前缘骨折和2例关节内T形骨折；12例患者中有7例患侧为优势手。2例患者初始骨折治疗采用前路钢板，5例采用卡潘迪病灶内穿针，2例采用钢板和钢针固定，3例采用非手术复位。10例患者畸形愈合位于前方，其中2例为关节内畸形愈合，2例位于后方。2005年至2012年期间，对所有12例患者均进行了桡骨截骨矫正术。12例患者中有11例骨折至截骨的平均时间为168天（范围45 - 180天）。7例患者使用髂骨植骨填充骨缺损，4例患者使用骨替代物。未对桡尺远侧关节进行任何手术。
所有12例患者在截骨矫正术后24个月接受评估。他们不仅在屈伸活动度方面有所增加，旋前/旋后活动度也有所增加。所有患者均报告腕关节功能改善。屈伸弧度增加了40°（屈曲增加21°，伸展增加19°），旋前/旋后弧度增加了46°（旋前增加13°，旋后增加15°）。疼痛的视觉模拟量表平均评分为1.7（范围0 - 3）。截骨矫正术后2年内记录的并发症包括I型复杂性区域疼痛综合征（1例）、桡腕骨关节炎（3例）以及桡尺远侧关节面不匹配导致旋后受限（3例）。因此，在桡骨远端畸形愈合的治疗过程中，应特别关注这最后一种异常情况。
在我们的病例系列研究中，3例（25%）患者因旋后功能持续丧失需要翻修手术。这些患者的主要错误在于尽管术后关节不匹配，但未对桡尺远侧关节进行补充手术。这一发现以及文献综述的数据表明，应高度认识到桡尺远侧关节的匹配性决定了桡骨远端畸形愈合截骨矫正术的效果。
