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Name:
Distal Radius Osteotomy - For Malunited Fracture
Description:
Distal Radius Osteotomy - For Malunited Fracture
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Duration:
T00H33M37S
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https://cadmoreoriginalmedia.blob.core.windows.net/37707884-28ac-405a-9723-ecdc455771f8/Distal Radius Osteotomy - for malunited Fracture.mp4?sv=2019-02-02&sr=c&sig=4Q5iHoSLOLfs6eC8oo1n7cfy%2BtufCa96md6DNAy4wWU%3D&st=2024-11-21T20%3A41%3A11Z&se=2024-11-21T22%3A46%3A11Z&sp=r
Upload Date:
2024-06-01T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
BIJAYENDRA SINGH: Hello, everyone. I'm going to demonstrate a distal radius corrective osteotomy. So a 32-year-old female who had a fracture of her right distal radius which was manipulated and purcutaned and fixed with percutaneous k-wires. And then three months later, she came to me with pain and stiffness in her wrist,
BIJAYENDRA SINGH: and as you can see, this has healed in shortened and dorsally angulated position. The CT scan confirms this malunion with a fair amount of dorsiflexion as well as shortening, she also unfortunately developed some CRPS which improved with intensive hand therapy.
BIJAYENDRA SINGH: When she came to me, we decided to proceed with surgery after the hand therapy and this is her EUA just before the surgery was taken. As you can see, she has very little to no supination from the mid-prone position. Dorsiflexion and palmar flexion were also limited,
BIJAYENDRA SINGH: but they were within the functional range of movement. So this patient is under anesthetic, arm tourniquet, and use the dorsal approach using the 3/4 plane.
BIJAYENDRA SINGH: So I generally tend to use a disposable tourniquet which provides excellent exsanguination as well as hemostasis at the same time. It also reduces the amount of tourniquet time.
BIJAYENDRA SINGH: Skin is incised just ulna to the listers tubercle, although in this case, it's a bit difficult to identify the landmarks because of the fresh malunion identifying the small veins. Thankfully, there isn't any major neurovascular bundle on this approach.
BIJAYENDRA SINGH: Now identifying the retinaculum, make a small nick into the extensor retinaculum of the full thickness and then extend it proximally and distally so that I get the right depth and you don't end up making multiples cuts in the retinaculum. Here it's tough because of the scarring from the fracture as well as the k-wire insertion.
BIJAYENDRA SINGH: You may choose to open the third extensor compartment and release and move the EPL out, which you can see here. Uh, this will allow for adequate exposure.
BIJAYENDRA SINGH: Need to take extra care that the tendons don't get accidentally injured when doing this dissection as they can be quite stuck down.
BIJAYENDRA SINGH: And now I'm removing that spicular bone that was seen on the CT scan A2A my placement of the plate and also relieve any pressure onto the uh, tendon. Avoid any tendon rupture at a later date.
BIJAYENDRA SINGH: Once I've reached the sub-periosteal dissection, I use a needle to identify the joint line to allow me assessment of the level of the osteotomy. Once the needle has been placed, take a image intensifier, snap to see the location and once I'm happy with the position of that, I would use a k-wire at a level where I think the right level of osteotomy would be.
BIJAYENDRA SINGH: Once this is done, just do a quick image x-rays to see the position of the wire and the level of osteotomy. Ideally want it to be at the same level as the correction needed. In this case, it's a bit proximal, not quite metaphyseal the level of the deformity and I'm happy with the position of the wire.
BIJAYENDRA SINGH: Once I'm happy with the position of the wire, I use a saw to perform the osteotomy. Be careful that the bone will be sclerotic and because it's uneven, you need to make sure you have a steady hand to perform the osteotomy. This is performed
BIJAYENDRA SINGH: through almost most of the cortex, leaving a thin sliver of the wall of cortex intact and I use a small osteotome to break this. Once I've done the full osteotomy and this device allows use of different types of wedges to get the appropriate thickness and the size, which will allow proper placement and sizing of the graft
BIJAYENDRA SINGH: as you can see here. I'll split this wedge and then do a check radiographs, which shows a good correction, and you can change the different sizes till you are happy with the size that you want.
BIJAYENDRA SINGH: You do another X-ray. Now I can see that I managed to achieve good correction. Then I would get the appropriate size foam wedge and then insert the graft into the correct performed osteotomy.
BIJAYENDRA SINGH: Sometimes you may be able to manage it by just pulling onto the ends. Although in pictures it looks easy, but in real life because of the soft tissue tension and contracts with this becomes quite difficult. So in that situation, you may have to use k-wires. Here I'm trying to see if I can generally nudge the graft into it's position. As you can see, I can manage to get most of it, but it's not going all the way through up to the wall of cortex.
BIJAYENDRA SINGH: I'll try and use another technique to see if I can insert the graft. Be careful that these grafts, although fairly strong in compression, they are fragile and too much forceful tapping can crack and break the graft.
BIJAYENDRA SINGH: So this is not getting to a satisfactory position and I've decided to use a spreader which is commonly used by the foot surgeons in their osteotomies. And this allows us to put two the k-wires and to hold the osteotomy opened up.
BIJAYENDRA SINGH: Once my wires are in, I use this spreader to open up the osteotomy. You just need to be careful that this does not cause any angulation in a different plane and you need to check before you insert the graft. You can see there is some translation and this is what one needs to be careful about. So once I've distracted enough, I wrench the graft input in situ.
BIJAYENDRA SINGH: Then you can remove the k-wires and then use a tamp to gently settle in the bone graft. Once I'm happy with the position, then getting the two plates, I would certainly recommend two plates or two planar plates for any distal radius osteotomy as using just one plate
BIJAYENDRA SINGH: still leaves it with some instability and I've seen some of these go into delayed and nonunion as well as implant failure. So getting the primary fixation, initial screw into the proximal fragment, I tend to put it in the oval hole so that I can move the plate around to the appropriate height.
BIJAYENDRA SINGH:
BIJAYENDRA SINGH: Do a check x-ray to check the height as well as the angulation of the plate. As you can see, I'm not happy with the alignment of the lateral plane and hence I've decided to contour this plate to align to the angle that I would like.
BIJAYENDRA SINGH: Start to insert the screw back again into the proximal part of the radial shaft.
BIJAYENDRA SINGH: Once I'm happy with the position, then go to the locking screws in the distal fragment to get the primary fix here with the first dorsal plate.
BIJAYENDRA SINGH: I've then gone on to apply the second plate, which is on the radial side to provide that rotational stability.
BIJAYENDRA SINGH: And putting one screw on either side of the plate, adjusting the height and the orientation of the plate on the second plate. I think this is quite vital to provide additional support for the osteotomy.
BIJAYENDRA SINGH: Important thing to remember is that the second plate is mainly to provide rotational stability and does not need to have all the screws fixed. After the initial fixation, do another check so that the position of both the plates and the osteotomies checked and at this time also check the movement. And I'm happy that she has regained almost full supination on table. The element, which is because of the soft tissue contracture can be difficult to
BIJAYENDRA SINGH: judge and to completely improve. At this stage now you can fill in a few more screws on board the plates, ensuring that these are not over tightened, sorry, overfilled with too many screws to make it over stiff.
BIJAYENDRA SINGH:
BIJAYENDRA SINGH: Some final screws being placed into both the distal and the proximal fragment on both the plates to finish off this procedure.
BIJAYENDRA SINGH: Once I'm happy with the final screws, want to check the movement and assess what we have achieved. So you can see here her supination is almost 70 to 80 degrees. Dorsiflexion is about 40, palmar flexion is virtually full and the wrist is in pronation, forearm is in pronation so this has corrected
BIJAYENDRA SINGH: what we aimed for and these are some of the final intra op images. I would have liked to get it a bit more radial on the radial plate but sometimes it's very difficult. I always try and close the extensor retinaculum, even if it means putting a couple of opposing sutures. This will then hold it in place rather than make it too lax.
BIJAYENDRA SINGH: I routinely release the tourniquet, perform adequate hemostasis before the final closure in layers. We tend to use subcuticular monocryl for the skin. Patients immobilized in a backslab for the two weeks, followed by mobilization under supervision in a splint with the hand therapists. These are her post-op radiographs at six weeks, which shows the osteotomy to have nearly healed.
BIJAYENDRA SINGH: Good overall alignment achieved. Please subscribe to the channel for keeping yourself up to date with common upper limb problems. Leave your feedback, please. [VIDEO ENDS]
Segment:0 .
BIJAYENDRA SINGH: Hello, everyone. I'm going to demonstrate a distal radius corrective osteotomy. So a 32-year-old female who had a fracture of her right distal radius which was manipulated and purcutaned and fixed with percutaneous k-wires. And then three months later, she came to me with pain and stiffness in her wrist,
BIJAYENDRA SINGH: and as you can see, this has healed in shortened and dorsally angulated position. The CT scan confirms this malunion with a fair amount of dorsiflexion as well as shortening, she also unfortunately developed some CRPS which improved with intensive hand therapy.
BIJAYENDRA SINGH: When she came to me, we decided to proceed with surgery after the hand therapy and this is her EUA just before the surgery was taken. As you can see, she has very little to no supination from the mid-prone position. Dorsiflexion and palmar flexion were also limited,
BIJAYENDRA SINGH: but they were within the functional range of movement. So this patient is under anesthetic, arm tourniquet, and use the dorsal approach using the 3/4 plane.
BIJAYENDRA SINGH: So I generally tend to use a disposable tourniquet which provides excellent exsanguination as well as hemostasis at the same time. It also reduces the amount of tourniquet time.
BIJAYENDRA SINGH: Skin is incised just ulna to the listers tubercle, although in this case, it's a bit difficult to identify the landmarks because of the fresh malunion identifying the small veins. Thankfully, there isn't any major neurovascular bundle on this approach.
BIJAYENDRA SINGH: Now identifying the retinaculum, make a small nick into the extensor retinaculum of the full thickness and then extend it proximally and distally so that I get the right depth and you don't end up making multiples cuts in the retinaculum. Here it's tough because of the scarring from the fracture as well as the k-wire insertion.
BIJAYENDRA SINGH: You may choose to open the third extensor compartment and release and move the EPL out, which you can see here. Uh, this will allow for adequate exposure.
BIJAYENDRA SINGH: Need to take extra care that the tendons don't get accidentally injured when doing this dissection as they can be quite stuck down.
BIJAYENDRA SINGH: And now I'm removing that spicular bone that was seen on the CT scan A2A my placement of the plate and also relieve any pressure onto the uh, tendon. Avoid any tendon rupture at a later date.
BIJAYENDRA SINGH: Once I've reached the sub-periosteal dissection, I use a needle to identify the joint line to allow me assessment of the level of the osteotomy. Once the needle has been placed, take a image intensifier, snap to see the location and once I'm happy with the position of that, I would use a k-wire at a level where I think the right level of osteotomy would be.
BIJAYENDRA SINGH: Once this is done, just do a quick image x-rays to see the position of the wire and the level of osteotomy. Ideally want it to be at the same level as the correction needed. In this case, it's a bit proximal, not quite metaphyseal the level of the deformity and I'm happy with the position of the wire.
BIJAYENDRA SINGH: Once I'm happy with the position of the wire, I use a saw to perform the osteotomy. Be careful that the bone will be sclerotic and because it's uneven, you need to make sure you have a steady hand to perform the osteotomy. This is performed
BIJAYENDRA SINGH: through almost most of the cortex, leaving a thin sliver of the wall of cortex intact and I use a small osteotome to break this. Once I've done the full osteotomy and this device allows use of different types of wedges to get the appropriate thickness and the size, which will allow proper placement and sizing of the graft
BIJAYENDRA SINGH: as you can see here. I'll split this wedge and then do a check radiographs, which shows a good correction, and you can change the different sizes till you are happy with the size that you want.
BIJAYENDRA SINGH: You do another X-ray. Now I can see that I managed to achieve good correction. Then I would get the appropriate size foam wedge and then insert the graft into the correct performed osteotomy.
BIJAYENDRA SINGH: Sometimes you may be able to manage it by just pulling onto the ends. Although in pictures it looks easy, but in real life because of the soft tissue tension and contracts with this becomes quite difficult. So in that situation, you may have to use k-wires. Here I'm trying to see if I can generally nudge the graft into it's position. As you can see, I can manage to get most of it, but it's not going all the way through up to the wall of cortex.
BIJAYENDRA SINGH: I'll try and use another technique to see if I can insert the graft. Be careful that these grafts, although fairly strong in compression, they are fragile and too much forceful tapping can crack and break the graft.
BIJAYENDRA SINGH: So this is not getting to a satisfactory position and I've decided to use a spreader which is commonly used by the foot surgeons in their osteotomies. And this allows us to put two the k-wires and to hold the osteotomy opened up.
BIJAYENDRA SINGH: Once my wires are in, I use this spreader to open up the osteotomy. You just need to be careful that this does not cause any angulation in a different plane and you need to check before you insert the graft. You can see there is some translation and this is what one needs to be careful about. So once I've distracted enough, I wrench the graft input in situ.
BIJAYENDRA SINGH: Then you can remove the k-wires and then use a tamp to gently settle in the bone graft. Once I'm happy with the position, then getting the two plates, I would certainly recommend two plates or two planar plates for any distal radius osteotomy as using just one plate
BIJAYENDRA SINGH: still leaves it with some instability and I've seen some of these go into delayed and nonunion as well as implant failure. So getting the primary fixation, initial screw into the proximal fragment, I tend to put it in the oval hole so that I can move the plate around to the appropriate height.
BIJAYENDRA SINGH:
BIJAYENDRA SINGH: Do a check x-ray to check the height as well as the angulation of the plate. As you can see, I'm not happy with the alignment of the lateral plane and hence I've decided to contour this plate to align to the angle that I would like.
BIJAYENDRA SINGH: Start to insert the screw back again into the proximal part of the radial shaft.
BIJAYENDRA SINGH: Once I'm happy with the position, then go to the locking screws in the distal fragment to get the primary fix here with the first dorsal plate.
BIJAYENDRA SINGH: I've then gone on to apply the second plate, which is on the radial side to provide that rotational stability.
BIJAYENDRA SINGH: And putting one screw on either side of the plate, adjusting the height and the orientation of the plate on the second plate. I think this is quite vital to provide additional support for the osteotomy.
BIJAYENDRA SINGH: Important thing to remember is that the second plate is mainly to provide rotational stability and does not need to have all the screws fixed. After the initial fixation, do another check so that the position of both the plates and the osteotomies checked and at this time also check the movement. And I'm happy that she has regained almost full supination on table. The element, which is because of the soft tissue contracture can be difficult to
BIJAYENDRA SINGH: judge and to completely improve. At this stage now you can fill in a few more screws on board the plates, ensuring that these are not over tightened, sorry, overfilled with too many screws to make it over stiff.
BIJAYENDRA SINGH:
BIJAYENDRA SINGH: Some final screws being placed into both the distal and the proximal fragment on both the plates to finish off this procedure.
BIJAYENDRA SINGH: Once I'm happy with the final screws, want to check the movement and assess what we have achieved. So you can see here her supination is almost 70 to 80 degrees. Dorsiflexion is about 40, palmar flexion is virtually full and the wrist is in pronation, forearm is in pronation so this has corrected
BIJAYENDRA SINGH: what we aimed for and these are some of the final intra op images. I would have liked to get it a bit more radial on the radial plate but sometimes it's very difficult. I always try and close the extensor retinaculum, even if it means putting a couple of opposing sutures. This will then hold it in place rather than make it too lax.
BIJAYENDRA SINGH: I routinely release the tourniquet, perform adequate hemostasis before the final closure in layers. We tend to use subcuticular monocryl for the skin. Patients immobilized in a backslab for the two weeks, followed by mobilization under supervision in a splint with the hand therapists. These are her post-op radiographs at six weeks, which shows the osteotomy to have nearly healed.
BIJAYENDRA SINGH: Good overall alignment achieved. Please subscribe to the channel for keeping yourself up to date with common upper limb problems. Leave your feedback, please. [VIDEO ENDS]
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