American Association for Hand Surgery
Theme: Beyond Innovation

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An Original Technique in Madelung's Deformity: the Reverse Wedge Osteotomy (RWO) of the Distal Radius
Florence Mallard, MD; Jérôme Jeudy, MD; Bruno Cesari, MD; Guy Raimbeau, MD; Yann Saint-Cast, MD
Hand Center, Angers-Trélazé, France

Introduction
Madelung's deformity results from a growth defect in the ventral and medial part of the growth plate of the distal radius, causing a disorientation of the ulnar part of radial glenoid. Surgical procedures to improve aesthetics and function for Madelung's deformity are numerous and difficult to assess because the disease is uncommon. We propose and evaluate an original technique.
Materials and Methods
Twelve women and one men with bilateral Madelung's deformity were treated from 1992 to 2016. The 19 cases (6 bilateral, 7 unilateral) were reviewed at an average follow-up of 6 years [6 months to 22 years]. Surgery was motivated by aesthetic and functional discomfort at the average age of 23 years, before any complication. Reverse wedge osteotomy was developed to reorient the radial joint surface while reducing overall radius length as little as possible. Osteotomy was performed through an antero-radial or radial approach. The bone wedge was harvested from the excess cortical on the dorsal and radial aspect of the radius. The circumferential wedge was then removed, reversed, and put back into the osteotomy to ensure closing on cortical excess and lengthening on the opposite side. Fixation was achieved by an anterior locking plate. An associated osteotomy of the ulna was necessary to avoid an ulnocarpal conflict for 4 cases with severe deformity. Objective and subjective (Quick-DASH and PRWE scores) data were analyzed. Radiological settings were taken from McCarroll's criteria. A vector model of the procedure was established to estimate osteotomy angles from 2 indexes from McCarroll. The nonparametric Wilcoxon test (p<0.05) was used for statistical analysis.
Results
All cases achieved fusion at 3 months. Eight of the 19 patients had the plate removed. There was no complication except for hypoesthesia on the radial side of the thenar eminence in 2 cases. Aesthetics and range of motion improved. Improvement was significant for flexion, pronation, and supination with preserving the grip strength, as well as the radiological parameters of McCarroll. Average scores were less than 30/100 at review. All patients were satisfied aesthetically and functionally.
Conclusions
The corrective power of reverse wedge osteotomy is well adapted to the severe radial epiphyseal dystrophy of Madelung's deformity. Clinical and radiological results are convincing and meet patients' expectations. Reverse wedge osteotomy has a special place among the techniques proposed so far. The ?attening of the dorsal aspect of the wrist is hoped to provide long-term protection against extensor tendon tear.


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