Introduction
Distal radius fractures (DRF) account for up to 18% of adult fractures, with malunion occurring in up to 25% of conservatively managed cases and 10% of surgically managed cases. Symptomatic malunion can lead to significant morbidity, including loss of forearm rotation, adaptive carpal instability, and arthritis. Corrective osteotomy is a key surgical intervention, yet there is no consensus on the optimal surgical approach, fixation technique, or necessity of bone grafting. The purpose of this systematic review is to evaluate surgical outcomes of distal radius osteotomy for extra-articular malunion, compare volar and dorsal approaches, and assess the need for bone grafting.
Methods
A search of PubMed (2000-2023) was conducted using predefined search terms to identify relevant studies. Seventeen studies met inclusion criteria, which required primary data on DRF malunion correction, comparative analyses of volar versus dorsal approach, bone graft necessity, and patient-reported outcomes. Data on complication rates, patient satisfaction, and clinical questionnaire scores were analyzed.
Results
Ten studies assessed volar plate fixation outcomes, with five using bone grafting and five without. Both groups demonstrated significant improvement in PROMs, radiographic measures, and grip strength. Four studies without bone grafting reported zero cases of nonunion, while one study was discontinued due to persistent malunion in 20% of cases. Bone grafting, including autologous and synthetic options, was associated with similar functional and radiographic outcomes. Two studies directly compared volar and dorsal approaches. Both approaches demonstrated significant improvements in range of motion and patient-reported outcomes. However, the volar approach resulted in significantly greater wrist flexion (p=0.012) and fewer hardware-related complications compared to dorsal plating. Three studies assessed the necessity of bone grafts and showed mixed results. While some demonstrated successful outcomes without grafting, others reported improved union rates with cancellous grafts. One study found no difference between autologous and synthetic grafts.
Conclusion
Corrective osteotomy for DRF malunion significantly improves patient outcomes, with volar plate fixation trending towards better outcomes over dorsal plating. Bone grafting may not be essential for all cases, particularly when stable fixation is achieved with cortical bony contact. Further high-quality comparative studies are needed to refine surgical decision-making.
