Surgical and Protocolized Management of Distal Radius Nonunion

Résumé

Introduction Nonunion of the distal radius is an extremely rare and serious complication with unpredictable outcomes. The aim of the present study is to analyze the radiological and functional results after a protocolized surgical treatment. Material and Methods A retrospective review of case series of patients with diagnosis of nonunion of the distal radius surgically treated from 2010 to 2016. The diagnosis of nonunion was made at 6 months without signs of consolidation. According to computed tomography (CT) scan images, we propose a classification of this complication as type I: no deformity or mild deformity, with subchondral metaphyseal bone stock beneath lunate facet greater than 10 mm, with no degenerative changes at the distal radioulnar joint (DRUJ); type II: moderate deformity or degenerative changes in the DRUJ, distinguishing between IIA and IIB based on the subchondral metaphyseal bone stock; and type III: degenerative changes at the midcarpal joint. In all cases, a reconstructive technique consisting of volar locking plate osteosynthesis with autologous tailored iliac crest graft was performed, hence none of the cases were classified as type III. Results In total, six cases were included. Mean follow-up: 58 months (range: 30–108 months). Consolidation was achieved in a mean period of 5 months (range: 3–9 months). Average active range of motion: flexion: 54° (range: 10°–80°); extension: 40° (range: 10°– 85°); supination: 82.5° (range: 75°–85°); pronation 80° (range: 55–85°); radial deviation: 15° (range: 5°–20°); and ulnar deviation 15° (range: 5–20°). Mean strength: 24.15 Kg (6.9– 35 Kg). The average score on the Visual Analog Scale (VAS) at rest was of 0.6 (0–2), and with movement, it was of 1.8 (0–4). The mean postoperative score on the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was of 18.48 (range: 0–50.8). Average radial height: 9.65 mm (range: 7–12 mm); average radial angulation: 17° (10°–20°); volar tilt: 8.36° (range: 0.2°–21°); average ulnar variance: 1.52 mm (range: 0–3.5 mm). Complications: persistent nonunion, superficial wound infection, acquired residual ulnar club hand deformity, radiocarpal arthritis, and midcarpal arthritis. Nevertheless, no salvage techniques were needed or requested during the follow-up, with all patients in an active work situation or living an active life in complete normality. Conclusions The protocolized surgical treatment of pseudoarthrosis of the the distal radius, based on our proposed classification, offers good functional outcomes in the long-term follow-up.