Hand Surgery and Rehabilitation 39 (2020) 275–283

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Original article

Computer-assisted 3D preoperative planning of corrective osteotomy

for extra-articular distal radius malunion: A 16-patient case series
Modélisation et planification préopératoires assistées par ordinateur de l’ostéotomie
correctrice des cals vicieux extra-articulaires de l’extrémité distale du radius:
à propos d’une série de 16 patients
L. Athlani a,*, A. Chenel b, R. Detammaecker a, Y.-K. De Almeida a, G. Dautel a
a
Service de chirurgie de la main, Chirurgie plastique et reconstructrice de l’appareil locomoteur, Centre Chirurgical Emile Gall, CHU de Nancy, 49, rue Hermite,
54000 Nancy, France
b
Newclip Technics, PSI Radius, 45, rue des Garottières, 44115 Haute-Goulaine, France

A R T I C L E I N F O A B S T R A C T

Article history: The aim of this prospective study was to describe the surgical procedure and to report outcomes of
Received 12 September 2019 computer-assisted 3D preoperative planning of corrective osteotomy for extra-articular distal radius
Received in revised form 27 January 2020 malunions. Sixteen consecutive patients were enrolled. CT scans of both wrists were performed, and 3D
Accepted 21 February 2020
bone surface models of the radii were created. Software was used to simulate the osteotomy and the
Available online 31 March 2020
reorientation of the distal radial articular surface. Patient-specific cutting and drilling guides for
intraoperative guidance of the osteotomy as well as bone graft templates were also simulated. At a mean
Keywords:
follow-up of 12 months (range 6–27) after surgery, pain was reduced from 3 to 0.3 at rest and 6.8 to
3D
Computer-assisted preoperative planning
1.5 during effort according to a visual analog scale. The average wrist flexion–extension was 1458 and
Corrective osteotomy pronation–supination was 1558. Grip strength was 91% of the contralateral side. All patients achieved
Distal radius malunion primary bone union in a mean of 10 weeks (range, 7–18). Using our 3D analysis method, preoperative 3D
values showed no significant difference with radiographic measurement. Moreover, there was no
significant difference between the postoperative radiographic values in term of correction. This
procedure provides satisfactory clinical and radiological results with minimal residual malalignment.
Level of evidence: III.
!C 2020 SFCM. Published by Elsevier Masson SAS. All rights reserved.

R É S U M É

Mots clés : L’objectif de cette étude prospective était de décrire la technique chirurgicale et de rapporter les résultats
3D de la planification préopératoire 3D assistée par ordinateur de l’ostéotomie correctrice des cals vicieux
Planification pré-opératoire assistée par extra-articulaires de l’extrémité distale du radius. Seize patients consécutifs ont été inclus. Une
ordinateur
tomodensitométrie des deux poignets étaient réalisée et des modèles virtuels 3D des radius étaient
Ostéotomie de correction
créés. Un logiciel était utilisé pour simuler l’ostéotomie et la réorientation de la surface articulaire distale
Cal vicieux de l’extrémité distale du radius
du radius. Des guides de forage et méchage spécifiques au patient pour le guidage peropératoire de
l’ostéotomie ainsi que des modèles de greffons osseux étaient également simulés. Au recul post
opératoire moyen de 12 mois (intervalle: 6-27 mois), la douleur était réduite significativement de 3 à 0,3/
10 au repos et de 6,8 à 1,5/10 lors de l’activité sur une échelle visuelle analogique. La flexion–extension
du poignet était en moyenne de 1458 et la pronation–supination de 1558. La force de préhension était de
91 % par rapport au côté opposé. Tous les patients avaient consolidé avec un délai moyen de 10 semaines
(intervalle: 6-16 semaines). En utilisant notre méthode d’analyse en 3D, les valeurs 3D préopératoires

* Corresponding author.
E-mail addresses: lionel.athlani@gmail.com (L. Athlani), achenel@newcliptechnics.com (A. Chenel), romain.detammaecker@hotmail.fr (R. Detammaecker),
dealmeida_yk@yahoo.fr (Y.-K. De Almeida), gillesdautel@mac.com (G. Dautel).

https://doi.org/10.1016/j.hansur.2020.02.009
2468-1229/! C 2020 SFCM. Published by Elsevier Masson SAS. All rights reserved.
276 L. Athlani et al. / Hand Surgery and Rehabilitation 39 (2020) 275–283
n’avaient montré aucune différence significative avec les mesures radiographiques. De même, il n’y avait
pas de différence significative entre les valeurs radiographiques postopératoires et les valeurs planifiées
3D préopératoires en termes de correction. Cette technique permet d’obtenir des résultats cliniques et
radiologiques satisfaisants avec un mauvais alignement résiduel minimisé.
Niveau de preuve. – III.
1. Introduction
Malunion of a distal radius fracture can result in chronic pain
and loss of function. Corrective osteotomy can improve wrist
function and reduce stiffness and pain [1]. Previous studies have
shown that an accurate anatomical reconstruction is important to
achieving optimal outcomes [2–4]. Therefore, preoperative plan-
ning and a precise surgical procedure are essential. Typically,
planning is performed using plain radiographs [5]. However, distal
radius malunion is usually a complex three-dimensional (3D)
deformity, which may not be fully appreciated on two-dimension-
al (2D) radiographs. Preoperative planning based on plain radio-
graphs may not be sufficiently accurate to ensure anatomical
correction [6]. Computer-assisted 3D planning techniques could be
an interesting solution to better analyze the deformity and to
improve the accuracy of bone alignment. With these techniques,
3D virtual bone models can be created of both the deformed and
contralateral unaffected radii. These models are then used to plan
the bone correction and the radius osteotomy preoperatively [7].
Recent studies have confirmed the possibility of creating 3D
bone models from CT scan data. They found a real benefit in terms
of quantifying the extent of the radius deformity [8,9]. However,
these studies mostly focused on 3D deformity analysis, 3D
osteotomy planning or the functional outcomes without properly
evaluating the correlation between 3D preoperative planning and
radiographic results. Computer-assisted 3D planning also makes it
possible to create patient-specific cutting and drilling guides. The
aim of this study was to describe the surgical procedure and to
report outcomes of computer-assisted 3D preoperative planning of
corrective osteotomy for extra-articular distal radius malunions.
2. Patients and methods
2.1. Patients
We conducted a prospective study, which was approved by our
hospital’s ethics committee. Between December 2016 and April
2019, 16 consecutive patients (7 men, 9 women) who had an extra-
articular distal radius malunion were enrolled after they provided
written informed consent. Their mean age was 45 years (17–74).
Five right wrists and 11 left were involved. Six of the involved
hands were dominant hands.
These patients had been referred to us because of wrist pain,
deformity, and/or limited pronation–supination. The malunion
diagnosis was confirmed by standard radiographs with antero-
posterior (AP) and lateral views. Initially, all patients had sustained
an extra-articular fracture and were treated by closed reduction
and cast immobilization. They had not previously undergone
surgery. The mean time between the injury event and malunion
diagnosis was 5 months (range, 3–10 months). Bone union was
achieved in every wrist. Based on their sagittal deformity, the
16 patients were divided into 8 cases of Pouteau-Colles fracture
pattern (malunion with dorsal tilt) and 8 cases of Goyrand-Smith
fracture pattern (malunion with volar tilt). Radiographs of the
asymptomatic contralateral wrist were used to verify that it had
not been previously fractured.
C 2020 SFCM. Publié par Elsevier Masson SAS. Tous droits réservés.
!
2.2. Preoperative 3D planning
Low-dose CT-scans (Aquilion ONE1; Canon Medical SystemsTM,
Otawara, Japan) of both the affected and the contralateral radius
(full length) were done. CT scan data were sent to a workstation in
standard DICOM format. The 3D bone surface models of the radii
were created using Simpleware1 software (Synopsys IncTM,
Mountain View, CA, USA) provided by Newclip TechnicsTM
(Haute-Goulaine; France). The locations of the relevant points
and axes were determined on the 3D bone surface models by a
single engineer specialized in biomechanics. For the affected and
contralateral wrists, the 3D palmar tilt (accuracy of 18), 3D radial
tilt (accuracy of 18), and 3D ulnar variance (accuracy of 0.1 mm)
were calculated based on these points using computer-aided
design software (3D Creo Parametric1, PTCTM, Boston, USA). The
radial styloid process and midway points were defined to minimize
the impact of the sagittal plane deformity when calculating 3D
radial tilt and 3D ulnar variance. The first point was placed at the
top of the radial styloid process and the second point was halfway
between the palmar and the dorsal ulnar margin points (Fig. 1).
The amount of residual deformity was defined for the three 3D
measurements as the difference between the two sides in the
coronal and sagittal planes. The axial rotational deformity was
analyzed by superimposing the 3D image of the affected radius
over the 3D mirror image of the contralateral normal radius. Then,
we evaluated the magnitude of the axial rotational deformity by
calculating the value, in degrees (accuracy of 18), between the two
axial planes defined for the two images superimposed proximally
to distally (Fig. 2).
Based on the 3D virtual models, the software was used to plan
the osteotomy on the affected wrist and simulate the reorientation
of distal radial epiphysis. The aim was to correct the 3D palmar tilt,
3D radial tilt, 3D ulnar variance and the axial rotational deformity
using the values of the normal contralateral limb (Fig. 3).
2.3. Patient-specific bone templates and cutting guides
Patient-specific cutting and drilling guides for intraoperative
guidance of the position and orientation of the osteotomy as well
as bone graft templates were also modelled. Similarly, positioning
of the fixation plate and screws as well as the bone hypertrophy
areas to remove to properly adjust the plate on the radius were
calculated (Fig. 4). For all patients, polyamide (PA 2200) bone
templates (affected radius and ideal bone graft) and cutting guides
were manufactured using a laser sintering 3D printer (Formiga
P1101, EOSTM, Maisach, Germany) and were sterilized before use
in the operating room (Fig. 5a).
2.4. Surgical procedure
The surgical procedures (Fig. 5) were performed by senior
surgeons. An anterior approach was used as described by Henry.
The pronator quadratus muscle was elevated to expose the distal
radius with the original fracture callus. The osteotomy guide was
positioned and stabilized with pins. One of them was placed in line
with the future osteotomy. Fluoroscopy was used to confirm the
 L. Athlani et al. / Hand Surgery and Rehabilitation 39 (2020) 275–283 277

Fig. 1. Deformity evaluation using 3D computer bone models. 3D palmar tilt (A) corresponds to the angle defined by a line perpendicular to the central long axis of the radius
and a line passing through the palmar ulnar margin point and the dorsal ulnar margin point. 3D radial tilt (B) corresponds to the angle defined by a line perpendicular to the
central long axis of the radius and the line passing through the radial styloid point and the midway point. 3D ulnar variance (C) corresponds to the distance between the line
perpendicular to the central long axis of the radius and tangent to the distal end of the ulnar head and then a line perpendicular to the radial shaft and passing through the
midway point. DUMP: dorsal ulnar margin point; MP: midway point; PUMP: palmar ulnar margin point; RSP: radial styloid point.

Fig. 2. Evaluation of axial rotational deformity using 3D computer bone models. Frontal planes for the contralateral normal radius (A) and the affected radius (B) pass
proximally through the center of the radial head and radial diaphysis, and distally through the radial styloid point and the midway point. The axial rotational deformity was
analyzed by superimposing the 3D image of the affected radius over a 3D mirror image of the contralateral normal radius (C). The magnitude of the deformity was evaluated
by calculating the value, in degrees, between the two axial planes defined for the two images superimposed proximally to distally (D). MP: midway point; RSP: radial styloid
point.

position of the osteotomy and correct it as needed. The holes for
the diaphyseal and epiphyseal screws were drilled. Using the same
guide, the radius osteotomy was performed with an oscillating
saw. The guide was then removed. The second step was bone graft
preparation using the 3D printed template. We used either a
corticocancellous iliac crest autograft or human allograft bone
(Biobank, Lieusaint, France or OstéopureTM, Clermont-Ferrand,
France). In the latter case, the allograft came as a cube of predefined
size, which allowed us to use the cutting guide to make the ideal
bone graft to match the virtual model. Next, the osteotomy site was
distracted, and the bone graft introduced. The third step was bone
fixation using an anatomic locking volar plate (Alians Distal
RadiusTM or Xpert Wrist 2.4TM, Newclip TechnicsTM, Haute-
Goulaine; France). The epiphyseal screws were first positioned
at the pilot holes and the metaphyseal screws thereafter.
Fluoroscopy was used again to confirm the malunion correction
with physiological restoration of distal radius anatomy. Correct
positioning of the fixation material and the bone graft was also
confirmed. If possible, the pronator quadratus was reattached. Skin
closure with drainage completed the procedure.
2.5. Postoperative protocol
Following surgery, the wrist was immobilized in a volar cast for
48 to 72 hours. Immobilization was extended for 4 weeks with a
short-arm fiberglass cast. Radiographs were made at this time, at
which point the patients began 1 month of self-directed
rehabilitation. Radiographs were made again at 8 weeks postop-
erative, after which physical therapy sessions were initiated. No
heavy loads could be placed on the wrist for the first 6 months
postoperatively.
Patients were reviewed in person every two weeks for 3 months
then, every month for 6 months and then every 6 months for
2 years. An independent examiner performed the clinical and
radiographic evaluations.
2.6. Clinical evaluation
Subjective and objective data were collected. Pain was
evaluated using a visual analog scale (VAS) (out of 10). Grip
strength in the operated and contralateral side was collected
using a Jamar1 hydraulic hand dynamometer (Performance
HealthTM, Charleville-Mézières, France). The active joint range
of motion (ROM) was measured in degrees during wrist flexion–
extension and pronation–supination (accuracy of 28). The number
of physical therapy sessions done, recovery of activities of daily
living (with the amount of time required) and return to work (with
time away from work) were also recorded. The functional
outcomes were evaluated using standardized questionnaires:
QuickDASH (The Disabilities of the Arm, Shoulder and Hand Score)
(out of 100) [10] and Patient-Rated Wrist Evaluation (PRWE) (out
of 100) [11].
278 L. Athlani et al. / Hand Surgery and Rehabilitation 39 (2020) 275–283

Fig. 3. Example of preoperative 3D planning. First, we corrected the 3D palmar tilt (A) in the sagittal plane and the 3D radial tilt (B) and 3D ulnar variance in the coronal plane
(C). We used the values from the healthy contralateral side as a reference. Next, we corrected the axial rotational deformity (D) to obtain a neutral value. The fixation plate was
applied to the bone (E).

Fig. 4. Example of preoperative 3D simulation for the screw positioning (A), the perfect bone graft model (B), the bone hypertrophy areas to be removed to properly adjust the
fixation plate (C) as well as the patient-specific cutting guides for radial osteotomy (D) and graft modelling (E).
 L. Athlani et al. / Hand Surgery and Rehabilitation 39 (2020) 275–283 279

Fig. 5. Photographs showing a case of extra-articular distal radius malunion treated by computer-assisted preoperative planning of the corrective osteotomy. Polyamide (PA
2200) bone models and cutting guides (A). Exposure of the distal radius malunion by an anterior approach (B). Positioning and stabilization of the osteotomy guide (C).
Fluoroscopy control to confirm the position of the future osteotomy (D). Radius osteotomy with an oscillating saw (E). Distraction of the osteotomy site (distractor from
Newclip TechnicsTM) (F). Introduction of the bone graft template to check the radius epiphyseal reorientation (G). Preparing the bone allograft so it matches the 3D printed
polyamide template (H). Introduction of the bone allograft in the osteotomy site (I). Fixation with an anatomic locking plate (Xpert Wrist 2.41, Newclip TechnicsTM) (J).
Postoperative radiographs: standard neutral PA (K1) and lateral (K2) views.

2.7. Radiographic evaluation
In preoperative period and at the follow-up visits, standard
radiographic views, standard neutral posterior-anterior (PA) and
lateral views, were taken in all patients. The digital radiographs
TM
were viewed on OsiriX! C (Pixmeo 2016, Geneva, Switzerland).
Palmar tilt, radial tilt (accuracy of 18) and ulnar variance (accuracy
of 0.1 mm) were calculated (Fig. 6). The absence of posterior ulnar
head subluxation was also verified in the lateral view, as described
by Ishikawa et al. [12]. Finally, we noted the time to bone union in
weeks.
2.8. Statistical methods
The recorded data were summarized using mean values and
ranges. The Wilcoxon signed rank test was used to compare the
means of each preoperative and postoperative measurement. The
significance level was set at P < 0.05.
3. Results
3.1. 3D planning before surgery
Between the normal and affected sides, the difference in 3D
values was 258 (range, 11 to 468) for the 3D palmar tilt, 68 (range,
0 to 228) for the 3D radial tilt and 3.4 mm (range, 1.3 to 5.5 mm) for
the 3D ulnar variance. Based on the sagittal deformity, the
difference in 3D palmar tilt was 308 (range, 158 to 468) for the
Pouteau-Colles group and 218 (range, 118 to 338) for the Goyrand-
Smith group.
The average axial rotational deformity was 118 (range, 2 to 288).
The mean value was 88 (range, 0 to 178) after 3D virtual correction
of the sagittal (palmar tilt) and coronal (radial tilt, ulnar variance)
deformities. However, in five cases, the axial rotational deformity
was greater than or equal to 108 and derotation was required. At
the end, the mean value was 48 (range, 0 to 98).
3.2. Clinical and functional outcomes
The mean follow-up after surgery was 12 months (range, 6–27).
The incisions healed within 2 weeks in all patients. All patients
were able to resume their activities of daily living after a mean of
3 weeks (range, 2–6). Six of the patients (37.5%) were retired and
10 were still working (62.5%). Among the working patients, all
were able to resume working in the same occupation. The mean
time away from work was 4 months (range, 2–6). On average,
30 physical therapy sessions were performed (range, 20–60).
The pain levels were significantly reduced at rest and during
effort (P < 0.001). Grip strength had improved relative to the
contralateral side: 48% preoperative versus 91% at follow-up. There
was also a significant improvement in the wrist’s ROM in flexion–
extension (P < 0.001) and pronation–supination (P < 0.001). The
DASH and PRWE scores were significantly better, with an
improvement of 40.5 points and 41 points, respectively (Table 1).
3.3. Radiographic outcomes
Preoperatively, there was no significant difference (P > 0.05)
between the mean palmar tilt, radial tilt and ulnar variance values
measured on radiographs and those measured on the both
(affected and contralateral wrists) 3D models (Table 2). For the
280 L. Athlani et al. / Hand Surgery and Rehabilitation 39 (2020) 275–283

Fig. 6. Measurement of palmar tilt, radial tilt, and ulnar variance on radiographs. Palmar tilt (A) was measured as the angle made by two lines on the lateral radiograph. A line
perpendicular to the central long axis of the radius and a line between the dorsal and palmar margins of the distal radial articular surface. Radial tilt (B) was measured as the
angle made by two lines on the posteroanterior radiographs. A line perpendicular to the central long axis of the radius and a line connected the radial styloid and ulnar margin
of the distal radial articular surface. Ulnar variance (C) was measured as the distance between two lines perpendicular to the central long axis of the radius. The first line was at
the ulnar margin of the distal radial articular surface and the second line was at the distal ulnar articular surface.

Table 1
Comparison of the clinical and functional outcomes (mean and range) for the study population (16 patients) between the preoperative period and last follow-up.

Parameters Preoperative Last follow-up P value

Pain at rest (VAS) (/10) 3.0 (1–5) 0.3 (0–2) < 0.001
Pain during effort (VAS) (/10) 6.8 (5–9) 1.5 (0–4) < 0.001
Grip strength (Kg.F) 20 (10–37) 42 contralateral 40 (16–55) 44 contralateral < 0.001
ROM F-E (8) 100 (70–150) 145 (130–175) < 0.001
ROM P-S (8) 105 (80–115) 155 (135–180) < 0.001
DASH (/100) 57 (34–82) 17 (0–45) < 0.001
PRWE (/100) 55 (23–73) 14 (0–47) < 0.001

VAS: visual analog scale; ROM F-E: range of motion in flexion-extension; ROM P-S: range of motion in pronation-supination; DASH: Disabilities of the Arm, Shoulder and
Hand; PRWE: patient rated wrist evaluation.

Table 2
Comparison of the preoperative radiographic measurements with the preoperative 3D values (mean and range) for the study population (16 patients).

Measurements Radiograph affected wrista 3D affected wrist Radiograph contralateral wristb 3D contralateral wrist

Palmar tilt (8) PC type (n = 8) +21 +20 "8 "7

(+5; +40) (+2; +37) ("3; "12) ("1; "12)
0.59 / 0.87 /
GS type (n = 8) "29 "27 "9 "8
("16; "39) ("19; "37) ("5; "11) ("4; "12)
0.19 / 0.47 /
Radial tilt (8) +19 +17 +23 +23
(+5; +27) (+2; +26) (+18; +25) (+18; +26)
0.12 / 0.42 /
Ulnar variance (mm) +2 +2.7 "1 "0.7
("0.5; +5.5) ("0.7; +5.5) ("2; 0) ("2; 0)
0.08 / 0.09 /

PC type: Pouteau-Colles fracture pattern; GS type: Goyrand-Smith fracture pattern.

a
P values shown in this column are results compared with 3D affected wrist.
b
P values are results compared with 3D contralateral wrist.
 L. Athlani et al. / Hand Surgery and Rehabilitation 39 (2020) 275–283 281

affected wrist, the quantitative difference between the 3D method
and plain radiographs was on average 18 for Pouteau-Colles group
and 28 for Goyrand-Smith group for palmar tilt. It was on average
28 for radial tilt and 0.7 mm for ulnar variance. 3D palmar tilt and
3D radial tilt had slightly smaller values than those of the
radiographic palmar tilt and radial tilt. 3D ulnar variance was
higher than the radiographic ulnar variance.
All patients achieved primary bone union confirmed by X-rays.
The mean union time was 10 weeks (range, 6–16). The mean time
to union was 8 weeks (range, 6–12) in the 5 patients who received
an iliac crest autograft and 12 weeks (range, 10–16) in the
11 patients who received allograft bone. The mean palmar tilt
(P < 0.001), radial tilt (P = 0.03) and ulnar variance (P < 0.001)
values measured on radiographs at the last follow-up were
significantly better than those measured preoperatively on the
virtual model of the involved wrist. There was no significant
difference (P > 0.05) between the mean values of these three
parameters postoperatively and the mean 3D values achieved after
computer-based planning of the correction on the virtual bone
model. Also, there was no significant difference (P > 0.05) between
the mean values of these three parameters postoperatively and the
3D values calculated using the virtual model of the healthy
contralateral wrist (Fig. 7) (Table 3). In all 16 wrists, the posterior
ulnar head subluxation was corrected.
3.4. Complications
There were no intraoperative or postoperative complications.
None of the patients reported symptoms of complex regional pain
syndrome.
4. Discussion
The aim of this study was to describe the surgical procedure and
report outcomes of computer-assisted 3D preoperative planning of
corrective osteotomy for extra-articular distal radius malunion.

Fig. 7. Clinical case. Radiographs showing a case of extra-articular distal radius malunion (A). 3D modelling (B). 3D preoperative planning (C). Radiographs at 4 months’
follow-up (D).

Table 3
Comparison of the postoperative radiographic outcomes with the preoperative 3D values (mean and range) for the study population (16 patients).

Measurements 3D affected wrista 3D contralateral wristb 3D preoperative planc Radiograph postoperative result

Palmar tilt (8) PC type (n = 8) +20 "7 "4 "3.3

(+2; +37) ("1; "12) ("1; "8) ("1; "8)
< 0.001 0.08 0.28 /
GS type (n = 8) "27 "8 "8.25 "9
("19; "37) ("4; "12) ("5; "10) ("8; "12)
< 0.001 0.58 0.18 /
Radial tilt (8) +17 +23 +21 +21
(+2; +26) (+18; +26) (+17; +25) (+18; +24)
0.03 0.07 0.39 /
Ulnar variance (mm) +2.7 "0.7 "0.4 "0.3
("0.7; +5.5) ("2; 0) ("1.6; +0.4) ("1.5; +0.5)
< 0.001 0.06 0.43 /

PC type: Pouteau-Colles fracture pattern; GS type: Goyrand-Smith fracture pattern.

a
P values shown in this column are results compared with radiograph postoperative result.
b
P values are results compared with radiograph postoperative result.
c
P values are results compared with radiograph postoperative result.
282 L. Athlani et al. / Hand Surgery and Rehabilitation 39 (2020) 275–283
The computer-assisted 3D planning technique led to significant
improvement in all affected radius positioning parameters. Indeed,
the palmar tilt, radial tilt and ulnar variance were systematically
corrected. Secondly, there was no significant difference between
the postoperative values and those of the contralateral normal
radius. Furthermore, the postoperative values and 3D preoperative
planning values did not differ. Moreover, the three preoperative 3D
values showed no significant difference with those of radiographs,
validating our 3D analysis method in terms of correlation.
However, our 3D method seems to be able to provide a more
accurate measurement of the frontal and sagittal plane deformities
and also adds the rotational deformity.
Vroemen et al. assessed the postoperative results after a 2D
planned corrective osteotomy using 3D imaging techniques
[14]. They found residual malalignment in 25 patients. In recent
years, 3D bone shape including rotation and twist can be assessed
in detail using CT image data and computer software. It has helped
surgeons carry out more accurate preoperative planning [1,6,14–
21]. Most authors report good results in terms of accuracy of
correction for palmar tilt, radial tilt and ulnar variance with a
significant improvement of mean values. We obtained similar
results with precise correction of the sagittal and coronal
deformity and also shortening.
Ulnar variance is an important parameter for assessing
shortening [4,5,13]. In all our patients, this parameter was
corrected. In many studies, the ulnar variance is used as an
indicator of clinical outcomes. Achieving a better relationship
between the radius and ulna is considered beneficial for patients
since a positive ulnar variance is negatively correlated with the
clinical outcome [22]. On the radiographic evaluations, we used
the ulnar margin of the volar rim of the radial articular surface as a
measuring point for ulnar variance. However, this point is not
usable in 3D models because the sagittal deformity (palmar or
dorsal) of the distal radius causes a measurement error. As a result,
we used a point midway between the volar and dorsal rims of the
ulnar margin of the radial articular surface as a reference
measuring point.
Distal malunions commonly have axial malalignment in
pronation [6]. As a result, we evaluated the axial rotational
deformity after 3D virtual correction of sagittal (3D palmar tilt) and
coronal (3D radial tilt, 3D ulnar variance) deformities. However, in
five cases, the residual deformity was greater than or equal to 108
and it was necessary to add derotation. In the end, all patients had a
value less than 108. Von Campe et al. pointed out that a residual
deformity of more than 108 could contribute to poor clinical results
[13].
All our patients had significant improvement of their ROM in
flexion–extension (1008 to 1458) and pronation–supination (1058
to 1558). Our postoperative results were similar to previous studies
with computer-assisted 3D planned corrective osteotomy. Walen-
kamp et al. evaluated 8 patients and found an average of 1598 in
flexion–extension and 1648 in pronation–supination after a mean
follow-up of 26 months [23]. Miyake et al. evaluated 20 patients
and reported a ROM of 1528 in pronation–supination after a mean
follow-up of 24 months [6].
Using 3D modelling software and a 3D printer, we created
patient-specific cutting and drilling guides that were used during
surgery. The aim was to transfer the preoperative 3D plan to the
patient’s bone. Patient-specific cutting guides have been success-
fully used before, and various teams have reported accurate
positioning of surgical instruments or implants with respect to
bony anatomy [16,24].
Moreover, the 3D model allowed us to simulate the ideal bone
graft, the best positioning of the fixation plate as well as the areas
of bone hypertrophy to remove. In most cases, we used a bone graft
substitute to avoid secondary pain and potential morbidity due to
surgery on the iliac crest. Furthermore, the surgical precision was
improved by fashioning bone grafts similar to the 3D model using
specific cutting guides and templates. However, the union time
was 1 month longer with allograft than with iliac crest bone graft.
This study has several limitations. Since the sample size was
relatively small (n = 16), the precision of all calculated average
values is limited. Moreover, although we found a good correlation
between our 3D measurements and radiographic analysis, no
patient had postoperative CT scan. As a result, we were unable to
compare the pre-operative planned 3D model with a postoperative
3D model at the last follow-up. Given the good clinical results and
patient satisfaction, none wished to undergo a CT scan of their
operated wrist.
Secondly, we investigated a method for planning a corrective
osteotomy of the distal radius that uses the contralateral healthy
radius as reference. Because of the large interpatient variability in
the average values for palmar tilt, radial tilt and ulnar variance, we
felt it was more logical to plan the correction of the deformed
radius using a model of the contralateral radius. In many studies
[15,16,19,25], the contralateral radius is used as reference since the
original radius length is unknown and no better reference is
available. Therefore, it is essential to have a CT scan of both wrists.
The drawbacks are the radiation exposure during CT scan, the need
for specialized computer software, and the time and effort required
for the computer-assisted 3D planning.
Thirdly, the 3D preoperative planning did not consider the soft
tissue problems that many of these deformed wrists have. The
initial trauma often causes scar formation in structures like the
interosseous membrane and can make the planned repositioning
difficult to carry out. In addition, complete geometric restoration of
bone structures can be impossible if there is too much stress on the
soft tissues. Therefore, in several case, some authors obtained only
partial correction [21,23] and others added an ulnar shortening
procedure to reduce risk of the failure [26]. Lastly, we focused on
extra-articular distal radius malunions; the results may differ for
intra-articular distal radius malunions.
5. Conclusion
Our computerized procedure allowed us to optimize the
preoperative 3D analysis of extra-articular distal radius malunions.
We obtained a preoperative 3D plan of the different steps of the
corrective surgery to minimize residual malalignment. For
accurate bone repositioning during corrective osteotomy, we
believe that using patient-specific bone models and cutting guides
provides a real benefit. Better precision in anatomical findings
appears to further optimize postoperative functional outcomes.
Advantages of our method are better reproducibility of the surgical
procedure and shorter operation time.
Funding statement
The authors received no financial support for the research,
authorship, and/or publication of this article.
Ethics approval
This study was approved by our institutional review board and
by the local ethics committee (Personal Protection Committee
Est-III, Vandoeuvre-les-Nancy, France).
Informed consent
Each author certifies that informed consent for participation in
the study was obtained.
 L. Athlani et al. / Hand Surgery and Rehabilitation 39 (2020) 275–283
Disclosure of interest
Audrey Chenel is employed by Newclip Technics. Lionel Athlani declares
a conflict of interest with Newclip Technics. The other authors declare that
they have no competing interest.
Acknowledgements
The authors wish to thank Dr Joanne Archambault for English
language editing assistance. The authors also acknowledge the
contribution of Newclip Technics for assisting in the 3D modelling.
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