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Abstract:
Introduction: Madelung's deformity is a rare congenital anomaly of wrist. Corrective osteotomy of radius is a common method for treating symptomatic Madelung’s deformity. The purpose of this retrospective study is to evaluate if the location of wedge osteotomy of radius will influence the corrective outcomes.
Methods: Four cases of Madelung’s deformity were treated since 2002 to 2011. All patients were female with average age 15.5 (14-19) years and had received radial biplanar closing wedge corrective osteotomy at different level which was 5.4, 3.0, 2.3, and 1.4 cm from distal articular surface respectively. Range of motion and radiographic parameters, as ulna tilt, lunate subsidence, and distal radio-ulnar surface step off were measured preoperatively and postoperatively.
Results: At a mean follow-up of 7.5 (4-10) years, all patients had remarkable improvement in cosmetic outcome and wrist motion, particularly in extension (average from 35 to 60 degrees) and supination (average from 36.3 to 72.5 degrees). Ulnar tilts of all patients were also improved averagely from 23.5 to 44 degrees and the amount of improvement was correlated with the osteotomy level. Patients with wedge osteotomy level closer to radial articular surface demonstrated better correction of ulnar tilt.
Discussion: Radial biplanar wedge osteotomy for Madelung's deformity brings in good functional and radiographic outcome. Despite the limited case number, we found a trend that the radial corrective osteotomy performed more distally may allow better correction of ulnar tilt and avoid adverse effect on distal radio-ulnar joint.
Keywords:
Madelung’s deformity; radial wedge osteotomy; radial corrective osteotomy
Introduction:
Madelung’s deformity is considered as abnormal growth of the distal radial physis, which results in a volar and ulnar tilted distal radial articular surface, volar translation of the hand and wrist, and a dorsally prominent distal ulna. These anatomical variances influence biomechanical function of wrist, as decreased range of motion, particular ulnar deviation and extension, decreased grip strength and often elicit the pain(1).
Madelung's deformity is a rare anomaly, accounting for only 1.7% of hand anomalies in Flatt's series(2). It is more common in females, and produces visible deformity and cosmetic problem at adolescence (Figure 2a). The etiology of the abnormalities of distal radial growth plate is uncertain and various causes have been suggested. It is usually a part of Leri-Weill dyschondrosteosis, characterized by mesomelia, short stature, and bilateral Madelung’s deformity.
Conservative treatment is usually recommended initially for patients with minimal pain and excellent function. However, these methods are ineffective for severe cases and cannot prevent the progression of pain. Many authors proposed that radial open or closing wedge osteotomy to correct ulnar and volar tilting of distal radial articular surface in symptomatic cases(1;3-5).
Since 2002 to 2011, we treated four cases of Madelung’s deformity by radial biplanar closing wedge osteotomy for all and simultaneous ulnar shortening in three among them. In the follow-up, the biplanar wedge osteotomy of radius among these cases was noted to be performed at different distance from distal articular surfaces. The purpose of this retrospective study is to evaluate if the difference of wedge osteotomy level would influence the degree of correction.
Methods :
There were four cases of Madelung’s deformity were treated in our hospital since 2002 to 2011. All patients were female. The average age at the time of operation was 15.5 (14-19) years old. Case 1 and Case 2 were consistent with diagnosis of dyschondrosteosis with bilateral wrist involved, but the operation was performed only for left wrist which was more severe than right wrist. (Table 1)
Clinical and imaging evaluation
The range of motion of the involved limb including wrist flexion-extension, and the forearm pronation-supination were measured preoperatively and postoperatively 1 year. (Table 2)
For evaluating the preoperative severity of Madelung’s deformity and the postoperative improvement, three parameters, such as ulnar tilt, lunate subsidence, and distal radio-ulnar surface step off of these patients were routinely measured on radiograph of wrist as the method described by McCarroll et al (Figure 1) (6).
Surgical technique
Under general anesthesia, the procedure was carried out under an upper-arm tourniquet application. We measured the size of the biplanar wedge from distal radius according to anterior-posterior view and lateral view of X-ray to restore radial inclination and palmar tilt respectively within normal limits. Via dorso-radial incision in the distal third of forearm, the radius was exposed. A biplanar wedge osteotomy was made with the apex on the volar and radial aspect of radius to correct the palmar tilt and ulnar tilt respectively. The radial osteotomy was applied at a particular distance from distal radial articular surface in every patients (Table 2). Plating in Case 1 and 2 (Figure 2c and 3b) or pinning with K-wires in Case 3 and 4 was used for fixation (Figure 4b and 5b).
After fixing the radius, the pronation-supination of the operated wrist would be examined intraoperatively. Ulnar shortening osteotomy would be performed in the cases with limited supination and positive ulnar variance more than 4 mm (7) under fluoroscope in Case 1, 3, and 4. Through another dorso-ulnar incision to expose the ulnar bone, osteotomy was made at least 3 cm away from the ulnar styloid process to avoid distal radio-ulnar joint (DRUJ) injury. A segment of ulnar bone was excised for decreasing the positive ulnar variance and then fixed with semi-tubular plate (Figure 2c, 4b, and 5b).
Results :
During follow-up of 7.5 (4-10) years, all patients were satisfied with the improvement of grip strength and cosmetic outcome. The result of clinical and imaging evaluation is presented as Table 2. At the latest clinic for follow up, all patients got much improvement in range of motion after operation. Wrist extension improved averagely from 35 to 60 degrees and flexion from 73.8 to 80 degrees. Forearm supination increased from 36.3 to 72.5 degrees and pronation from 72.5 to 82.5 degrees in average.
In radiographic presentation, ulnar tilt of all wrists achieved remarkable correction with 20.5 degrees improvement in average (improved from 66.5 to 46 degrees).
The data revealed a negative correlation between correction of ulnar tilt and the level of radial wedge from distal radial articular surface (Figure 6). The patient with wedge osteotomy level closer to distal radial articular surface might get greater correction of ulnar tilt deformity. Apparent improvement of lunate subsidence also observed on Case 3 and 4. In Case 1, 3, and 4 who had received ulnar shortening, the distal radio-ulnar surface step off decreased 0.64 cm in average. There was no patient with recurrent deformity or arthritic change during follow-up.
Discussion
In treating Madelung’s deformity, there is no consensus about indication of surgical intervention. The following factors which include the presence of pain, age, limitations of daily activities, and cosmetic influence should be carefully considered before corrective surgery (8). Many authors preferably performed the surgical intervention for the patients of Madelung’s deformity after the adolescent growth spurt to lower the probability of recurrence(3;4;9). Vickers and Nielsen (8), however, proposed that the prophylactic procedure of the resection of Vickers’ ligament, a thickened radiolunate ligament which tethers the lunate and the triangular fibrocartilage complex to the deformed distal radius, as early as possible to prevent further progression of the deformity. In our series, all cases had corrective osteotomy in late adolescence or young adult with mature skeleton. There is no recurrence or progression of the deformity during follow-up.
Many surgeons brought up a number of techniques, which were proposed by Dobyns et al (10) into three groups according to :
1) Applied to the radius alone: epiphysiodesis, corrective osteotomy, physiolysis, or progressive lengthening (9);
2) Applied to the ulna alone: epiphysiodesis, excision of the head, shortening osteotomy and creation of a pseudarthrosis with or without fusion to the radius (9);
3) Combined techniques in both radius and ulna (9;11;12).
There is no sufficient evidence to support which surgical technique is prior or leads better long-term outcome(3-5;9). The ulnar head resection (Darrach procedure) or ulnar epiphysiodesis (Phemister procedure) to decrease the length discrepancy have the possibility of further ulnar translation of the carpus and limited improvement of radiocarpal congruence (13).
In radiocarpal or radioulnar arthrodesis (Sauvé-Kapandji procedure), wrist mobility is sacrificed (14).
Uniplanar or biplanar radial wedge osteotomy combined with arthroplasty of the distal ulna brings in good mobility and functional outcome; however, it might cause greater shortening of the forearm and instability of wrist (9;13). Dome osteotomy of radius may provide an alternative to biplanar wedge osteotomy to achieve 3-dimensional alteration and avoid the problem of shortening. Nevertheless, this method lacks long-term follow-up, also the postoperative congruency of DRUJ is still of concern (12).
In spite of the cost of forearm shortening, biplanar radial wedge osteotomy combined with ulnar shortening could re-establish the congruence of radiocarpal and distal radioulnar articular surface and improve good functional and cosmetic results after long-term follow-up (4;11).
In our series, we performed biplanar closing wedge osteotomy of radius in different level. Initially, we tried to make corrective osteotomy at the apex of the radial bow in Case 1 and to fix the fragments with plate. Nevertheless, we found the correction was limited because long moment arm of distal fragment resulted in diastasis of DRUJ while angular correction was done (Figure 2d). Then we performed osteotomy of radius in Case 2 closer to distal articular surface than Case 1 to decrease the influence of DRUJ (Figure 3b). The better outcome of correction in Case 2 encouraged us to locate the radial osteotomy more distally and fix the fragments with K-wires instead of previous plating in Case 3 and 4 (Figure 4b and 5b). There was a trend that the wedge osteotomy level on the operated radius would influence the degree of correction on the radiographic appearance.
Osteotomy close to distal radial surface could improve ulnar tilt and avoid the adverse effect to DRUJ, such as incongruity or instability. McCarroll HR et al (15) carried out a very distal radial osteotomy (VEDRO) for individual correction of the three components of Madelung’s deformity, including palmar tilt, ulnar tilt, and radial bowing. Plating was used for fixation of distal radius in McCarroll’s series. However, the design of traditional plate and screw system may not allow the stable fixation of very small fragments due to its limited purchase of screws. In Case 3 and 4, we used pinning with augmentation of casting for postoperative fixation, which may allow more distal osteotomy for greater correction of ulnar tilt of radial articular surface with adequate stability.
The additional advantage of this method is avoidance of further surgical intervention for implant removal. Undeniably, there are some confounding factors, such as the surgeon’s learning curve and confidence in increasing the amount of correction attempted. Larger case number is necessary to eliminate these factors in the future.
Interestingly, we found the proximal radius of Case 2 and Case 3 is deficient. To our best knowledge, this deformity has not been well described as a part of the dyschondrosteosis of Madelung’s deformity. According to preoperative clinical presentation and postoperative outcome in our series, the proximal radial deficiency might not cause significant loss of daily function. Further investigation is needed to clarify the related etiology and clinical pattern.
In conclusion, the radial biplanar closing wedge osteotomy combined with ulnar shortening achieved significant improvement in gross appearance, radiographic presentation, and wrist motion in our series with four-years minimum follow-up. Although the case number in this retrospective study is insufficient to make a strong recommendation, we found a trend that the radial wedge corrective osteotomy closer to the distal articular surface might allow greater correction of ulnar tilt and less influence of the DRUJ. Fixation of K-wires with augmentation casting provides an alternative to plating to perform the radial corrective osteotomy more distally.
Reference :
(1) dos Reis FB, Katchburian MV, Faloppa F, Albertoni WM, Laredo FJ, Jr. Osteotomy of the radius and ulna for the Madelung deformity. J Bone Joint Surg Br 1998 Sep;80(5):817-24.
(2) Flatt AE. Care of the congenital hand anomalies. 50. 1977. St. Louis: The C.V. Mosby Co.
Ref Type: Generic
(3) Murphy MS, Linscheid RL, Dobyns JH, Peterson HA. Radial opening wedge osteotomy in Madelung's deformity. J Hand Surg Am 1996 Nov;21(6):1035-44.
(4) Potenza V, Farsetti P, Caterini R, Tudisco C, Nicoletti S, Ippolito E. Isolated Madelung's deformity: long-term follow-up study of five patients treated surgically. J Pediatr Orthop B 2007 Sep;16(5):331-5.
(5) Laffosse JM, Abid A, Accadbled F, Knor G, Sales de GJ, Cahuzac JP. Surgical correction of Madelung's deformity by combined corrective radioulnar osteotomy: 14 cases with four-year minimum follow-up. Int Orthop 2009 Dec;33(6):1655-61
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(6) McCarroll HR, Jr., James MA, Newmeyer WL, III, Molitor F, Manske PR. Madelung's deformity: quantitative assessment of x-ray deformity. J Hand Surg Am 2005 Nov;30(6):1211-20.
(7) Geissler WB, Freeland AE, Weiss AP, Chow JC. Techniques of wrist arthroscopy. Instr Course Lect 2000;49:225-37.
(8) Vickers D, Nielsen G. Madelung deformity: surgical prophylaxis (physiolysis) during the late growth period by resection of the dyschondrosteosis lesion. J Hand Surg Br 1992 Aug;17(4):401-7.
(9) Ranawat CS, DeFiore J, Straub LR. Madelung's deformity. An end-result study of surgical treatment. J Bone Joint Surg Am 1975 Sep;57(6):772-5.
(10) Dobyns JH. Madelung's Deformity. 1993. New York: Churchill- Livingston.
Ref Type: Generic
(11) dos Reis FB, Katchburian MV, Faloppa F, Albertoni WM, Laredo FJ, Jr. Osteotomy of the radius and ulna for the Madelung deformity. J Bone Joint Surg Br 1998 Sep;80(5):817-24.
(12) Harley BJ, Brown C, Cummings K, Carter PR, Ezaki M. Volar ligament release and distal radius dome osteotomy for correction of Madelung's deformity. J Hand Surg Am 2006 Nov;31(9):1499-506.
(13) Kessler I, Hecht O. Present application of the Darrach procedure. Clin Orthop Relat Res 1970 Sep;72:254-60.
(14) Laffosse JM, Abid A, Accadbled F, Knor G, Sales de GJ, Cahuzac JP. Surgical correction of Madelung's deformity by combined corrective radioulnar osteotomy: 14 cases with four-year minimum follow-up. Int Orthop 2009 Dec;33(6):1655-61.
(15) McCarroll HR, Jr., James MA. Very distal radial osteotomy for Madelung's deformity. Tech Hand Up Extrem Surg 2010 Jun;14(2):85-93.
Figure legends
Figure 1a: Ulnar tilt on a PA x-ray is defined as the complement of the acute angle (angle a) between the longitudinal axis of the ulna and a line tangent to the proximal surfaces of the scaphoid and lunate.
Figure 1b: Lunate subsidence on a PA x-ray (distance b) is defined as the distance between the most proximal point of the lunate and a line perpendicular to the longitudinal axis of the ulna and through the distal articular surface. Distal radio-ulnar surface step off on a PA x-ray (distance c) is defined as the distance between the articular circumference of distal ulna and ulnar notch of distal radius.
Figure 2:
(a) Preoperative gross picture of Case 1
(b) Preoperative X-ray of Case 1
(c) Postoperative X-ray of Case 1
(d) X-ray of follow-up for 7 years
Figure 3:
(a) Preoperative X-ray of Case 2
(b) Postoperative X-ray of Case 2
Figure 4:
(a) Preoperative X-ray of Case 3
(b) Postoperative X-ray of Case 3
(c) Gross picture of forearm supination postoperative 3 years
(d) Gross picture of forearm pronation postoperative 3 years
Figure 5:
(a) Preoperative X-ray of Case 4
(b) Postoperative X-ray of Case 4
Figure 6: Linear relationship between correction of ulnar tilt and wedge osteotomy level from distal radial surface. The straight line indicates regression line with a regression equation.
Table 1. Patients list
Patient
number |
Gender |
Age at operation |
Involved/Operated side |
Dyschondrosteosis |
Occupation |
follow-up |
1 |
female |
15 y |
Bilateral/Left |
Y |
Student |
10y |
2 |
female |
14 y |
Bilateral/Left |
Y |
Student |
8y |
3 |
female |
19 y |
Right/Right |
N |
Student |
8y |
4 |
female |
14 y |
Right/Right |
N |
Student |
4y |
Table 2. Pre-operative and post-operative range of motion and radiographic data
*Radial wedge osteotomy combined with ulnar shortening
**Radial wedge osteotomy alone
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