闭口式尺桡骨双侧截骨术治疗桡骨远端畸形愈合的病例对照研究

Case-control study on two osteotomy techniques for the treatment of distal radial malunion

目的 ：比较传统桡骨开口截骨植骨术与闭口式截骨术治疗桡骨远端畸形愈合的临床和影像学结果。方法：对2004年1月至2012年12月采取矫形截骨治疗的47例桡骨远端关节外骨折畸形愈合患者的临床资料进行回顾性研究,4例失访,1例死亡,共42例纳入研究,分为桡骨开口式截骨植骨术组（A组）和闭口式尺桡骨截骨术组（B组）。A组22例,其中男5例,女17例,年龄25~75岁;B组20例,其中男4例,女16例,年龄19~79岁。根据放射学结果和功能评估结果评估临床效果,包括腕关节活动度、握力、疼痛分级评估,Mayo腕关节评分及DASH评分。结果：A组患者平均随访36个月（12~101个月）,B组患者平均随访28个月（12~87个月）。A组掌倾角由术前（27±8）°（20°~38°）改善至术后（14±6）°（9°~22°）,B组掌倾角由术前（26±5）°（20°~32°）改善至术后（10±5）°（3°~15°）。A组尺骨变异术前（7±2）mm（0~10 mm）,术后减小至（3±2）mm（-1~7 mm）;B组由术前（6±2）mm（1~8 mm）减小至术后（0.2±0.7）mm（-1~2 mm）;B组尺骨变异恢复优于A组。腕关节屈伸活动度A组由术前（74±30）°（30°~142°）提高至术后（108±23）°（65°~159°）,B组由术前（95±35）°（30°~175°）提高至术后（154±16）°（115°~180°）,B组腕关节屈伸活动度改善优于A组。术后Mayo腕关节评分A组78±10（55~100分）,B组86±7（70~95分）,B组优于A组;术后DASH评分A组14±12（0~44分）,B组13±14（1~60分）,两组差异无统计学意义。结论 ：闭口式尺桡骨双侧截骨术能有效治疗桡骨远端关节外骨折畸形愈合,并在恢复尺骨变异、腕关节屈伸活动度和Mayo评分方面优于开口式截骨术。

Objective ： Radial corrective osteotomy is an established but challenging treatment for distal radial malunion. There is an ongoing discussion about whether an opening or closing-wedge osteotomy between should employed. The purpose of the present study was to retrospectively compare the clinical and radio graphic results between conventional opening-wedge os- teotomy and closing-wedge technique. Methods：From January 2004 and December 2012,42 patients with extra-articular distal radial malunion were managed with corrective osteotomy and were followed for a minimum of one year. Twenty-two patients （5 males and 17 females,ranging in age from 25 to 75 years old） were managed with radial opening-wedge osteotomy and im- planting of interpositional bone graft or bone-graft substitute, and twenty patients （4 males and 16 females, ranging in age from 19 to 79 years） were managed with simultaneous radial closing-wedge and ulnar shortening osteotomy without bone graft. The selection of the surgical procedure was determined by the surgeon. Each patient was evaluated on the basis of objective radio graphic measurements, and functional outcomes were determined on the basis of clinical examinations, including range of wrist motion, grip strength, pain-rating score, Mayo wrist score, and Disabilities of the Arm, Shoulder and Hand （DASH） score. Re- suits：The mean duration of follow-up was 36 months （ranged, 12 to 101 months） for the opening-wedge cohort and 28 months （ranged, 12 to 87 months） for the closing-wedge cohort. The two techniques were comparable in terms of complications. Post- operative volar tilt and ulnar variance were improved significantly in each cohort. The ulnar variance was more frequently re- stored to within defined criteria （22.5 to 0.5 mm） in the closing-wedge cohort than that in the opening-wedge cohort. The post- operative mean extension-flexion arc of the wrist and Mayo wrist score were significantly better in the closing-wedge cohort.Differences in the pronation-supination arc, grip strength, pain-rating score, and DASH scores between these two cohorts were not significant. Conclusion：The closing wedge osteotomy technique is an effective reconstructive procedure for the treatment of extra-articular distal radial malunion. It is significantly better than the opening-wedge osteotomy technique in terms of the restoration of ulnar variance, the extension-flexion arc of wrist motion, and the Mayo wrist score.