Whether there is pure malrotation in the sagittal plane, or a combination with shortening or loss of radial tilt, I always use a volar approach as initially described by Lanz [24]. The time honoured dorsal approach, championed by Diego Fernández (osteotomy, cortico-cancellous interpositional bone graft and dorsal plating) [8], although compared to the former, is an easier technique, has the major drawback of requiring a plate to be applied on the dorsal surface. The latter runs an increased risk of extensor tendon damage. In addition, a second operation for plate removal is more likely.

Conversely, plating volarly is more technically demanding, as it allows no alterations once the plate is fixed distally. On the other hand, it rarely requires plate removal, as tendinitis is unusual (provided the appropriate length of screws is used). The initial problems with Lanz’s technique, related to the implant size and the lack of stability of the construct when length was also corrected, have been overcome with modern fixed-angle plates. As a matter of fact, the exact application of these plates to the malunited epiphysis will automatically correct any malunion. Furthermore, the stability provided by the plate allows immediate rehabilitation, without the need of structural bone graft [25]. Last but by no means least, placement of the plate volarly will spontaneously correct any malrotation of the distal fragment in the axial plane.

Again when planning the procedure we would recommend a technique described by Fernandez [8]. Measurements are taken from the lateral radiographs. The key point is to fix the distal component of the plate, forming an angle (“correction” angle) with the diaphysis equal to the preoperative measured dorsiflexion plus 5°, in order to achieve some physiologic palmar tilt (Fig. 7.5).

The operation is performed under axillary block, on an outpatient basis. The arm was exsanguinated and a tourniquet applied. Bone from the olecranon is harvested through a 2.5 cm transverse incision. The cavity is then filled with Surgicel® and the wound closed in a single layer, using a 3/0 subcuticular nylon.

Access to the malunion site is through a 6–8 cm incision, radial to the flexor carpi radialis sheath (FCR), with a 10 mm radially directed back cut at the proximal wrist crease. By dissecting with a knife on the radial aspect of the FCR sheath, the sheath can usually be preserved intact, but, more importantly, the radial artery will stay safely lateral. The space between the FCR and radial vessels is developed. A large constant branch from the radial vessels to the radial aspect of the pronator quadratus should be identified and coagulated. This muscle is then sharply elevated subperiostically and reflected ulnarly. Proximally, some fibres of the flexor pollicis longus are reflected ulnarly. This will expose the malunion site, the distal epiphysis and the radial shaft. Dissection now proceeds on the dorsum of the radius, going superficial to the brachioradialis, which is left undisturbed, except in cases of major radius shortening. The whole layer of thickened-scarred periosteum is elevated on block and then divided by making several transverse cuts, proximal to the extensor tendon compartments, until the tendons themselves are exposed. Unless this is done, proper reduction of the epiphyseal fragment would not be attainable, as this scarred tissue acts as a check-rein to volar tilting of the distal fragment.

At this moment the fixation plate is applied volarly, prior to the osteotomy, as recommended by Lanz [18, 24]. The transverse part of the plate is placed as distally as possible and always distal to the hinge point of the malunion. Guide K-wires are invaluable to ascertain that the distal pegs will be subchondral, as this will guarantee a strong hold. If the surgeon is satisfied with the fluoroscopy image, all the distal screws and pegs are inserted. As mentioned previously, at the end of this part of the operation, the plate should form an angle with the radial shaft (correction angle) equivalent to the amendment needed in the sagittal plane. To avoid the loss of any volar cortical bone by the cut of the saw, the osteotomy is performed using a 1 mm diameter K-wire. A series of perforations parallel to the articular surface, to the dorsal cortex, are made along the exact hinge point of the malunion (Fig. 7.6). Once the osteotomy is completed, the surgeon applies force dorsally to the distal-radius and plate to produce an osteoclasis of the weakened volar cortex. Quite frequently several attempts are needed and in some cases an oscillating saw is required to cut the very sturdy medial (ulnar) cortex. The distal-radius/plate block is then reduced to the shaft of the radius, by pushing volarly with the fingers on the distal fragment, as in a closed Colles’ reduction. The use of a lamina spreader to distract the collapsed dorsal space greatly helps achieve reduction. Other manoeuvres, such as the use of bone clamps to bring the stem of the plate to the shaft of the radius, are to be avoided as this may cause the screws to be pulled out of the bone. Once the plate adapts to the volar shaft cortex without undue force, it is held temporarily by two bone clamps. It is now critical to perfectly reduce the volar cortex, as otherwise shortening and incomplete volar tilt correction will ensue. Once this has been checked radiologically the rest of the screws are inserted and a bone graft applied. Thereafter pronator quadratus is closed, if possible, over the plate, by preplacing three resorbable stitches and tightening them in pronation. The skin is closed with subcuticular 3/0 nylon. In every case a standard exploratory dry arthroscopy follows the osteotomy [26]. Synovectomy, soft tissue procedures and/or ulnar styloid excision is undertaken as required (Fig. 7.7) (see “Ulnar side procedures” later).

A bandage and volar splint are applied and then the tourniquet is released, maintaining some pressure over the surgical area for 5 min for haemostasis. At the first preoperative visit, 24–48 h later, a removable splint is applied, encouraging self-directed active range of motion exercises. After the 4th-6th week patients are weaned off the splint. No formal therapy is prescribed. Protection of the elbow for 4–6 weeks with skateboard splints is also recommended.

In cases of true concomitant shortening (and angulation) the technique is slightly modified or Wada’s operation (see next section) is undertaken. The dorsal tilt is first corrected, with the plate inserted distally and then reduced to the shaft of the radius. With the help of a laminar spreader at the osteotomy site, the radius is distracted as required. Then, the screws are inserted into the longitudinal stem of the plate, to lock it. It is important, when shortening exists, to step-cut the brachioradialis as otherwise it will limit correction. The tails of the Z-plastied tendon are sutured at the end of the operation. The appropriate graft size is interposed; the graft itself, typically being cortico-cancellous, can be taken from the iliac crest. Modern plates allow the insertion of cancellous bone graft or even bone substitutes. It is, however, quite difficult to correct more than 10–15 mm of radial shortening by an open wedge procedure as proposed previously [8, 27] (see next section). Finally, severe shortening of the radius, more than 3 cm, requires distraction of the radius.

To avoid the need for bone graft and the risk of non-union, Posner and Ambrose [28] proposed a volar closing wedge osteotomy of the radius, combined with a Darrach procedure to address the distal radio-ulnar joint. The operation is less involved for the patient, as no bone graft is required and for fixation, the better-tolerated volar plate can be used. Despite good results reported at 5 years in a relatively young patient group (40-y-o), most hand surgeons would consider sacrificing a healthy/preservable distal radio-ulnar joint as a disservice to the patient. By the same token, however, when the DRUJ is irreversibly damaged, there is not much point in restoring the radial length. In these cases a Posner-Ambrose procedure, or a closing wedge radial osteotomy combined with a Sauvé-Kapandji, or an ulnar head replacement, are the options of choice.

Wada et al. in 2004 [29] popularized the concept of combining a closing wedge osteotomy of the radius and an open ulnar shortening, rather than a destructive procedure on the ulnar side. Initially they recommend it for the elderly or less demanding patients [29]. However, due to their good results they have now extended their indications to all ages [30].