We're going to demonstrate today a radial shortening osteotomy, which tends to be done through a volar-based standard incision, which is on top of the flexor carpi radialis tendon. You can also do it dorsally, however, there tend to be a bit more problems with the extensor tendons. Some things you want to think about is you want to feel where the radius and the ulna are to line up your skin incision in a distal proximal fashion. You want to make sure the end of this plate is below the distal radial ulna joint, because we don't want to have the plate have any risk of impingement at the joint after you shorten it. So in general, the plate will sit something in this location here with the distal radius and the ulna being present. I always draw these out, and then sure enough, you always need a little extra to get the plate on. Make some hash marks so when you're closing the skin, you can close it appropriately. There are two ways you can really do a shortening osteotomy. You can make it just a transverse osteotomy, which is what we're going to do today, affix the plate distally after you've done your osteotomy, taken it out, and then compress the bones together and put these two screws, number four and number five screw, in compression with the number six screw being in neutral. These three screws are in neutral. They're put in first in neutral because there's no compression component. When you do this technique, you have to have perfectly flush surfaces. You have to be very careful and meticulous about your osteotomy technique. You generally want to pre-bend the plate just a little bit. That means bend the plate so it's standing off the bone just a hair in the mid-portion of the plate, which will compress the opposite cortex a little bit more vigorously. The other technique is to use an oblique osteotomy. It does have the advantage of having some additional rotational stability to the radius after the osteotomy is compressed. Here again, you would make your osteotomy, again, parallel cuts. You want to fix the plate on one side, and then what you're going to do is you're going to jam this corner of the unfixed radius into this angled hook. It's going to hook its way in, and it's going to force that corner in in a compression mode so that you have a nice tight fit here. You're basically compressing this against the crotch of the plate and the radius where it's already been fixed. If you're off a little bit on these cuts, you can have an open end on the opposite side, so sometimes you can also pre-bend this just a little bit. The other thing to think about is this one screw here that you're going to put in compression. If your cut is too oblique, you're going to potentially go across the fracture site here or the osteotomy site, so you want to make sure you align this up correctly so that this screw comes out on a cortex, a good cortex to tighten up, or you can put this screw at an angle and go across the osteotomy site, which some people like, and then they use a seven-hole plate, so they put three screws, an oblique screw through the osteotomy, and then three screws approximately. You want to get good cuts parallel to each other regardless of their orientation and get good compression. We're going to start with our incision here over the flexor carpi radialis. We're just going to go down through the skin, and obviously the thing you want to watch in the beginning is any sensory branch of the radial nerves that might come into play. There are lots of different ways to approach this. I tend to go cut right down onto the flexor carpi radialis tendon right through the sheath. People prefer to take it ulnarly. Some people prefer to take it radially. I don't think it makes much difference. The nice thing about taking it radially is the radial artery is a little further away. You do have to make sure you're not going to disrupt the palmar cutaneous branch of the median nerve, which generally comes out about five centimeters proximal to the wrist crease, so in this area, the palmar cutaneous branch of the median nerve might be present, so you've just got to be mindful of that. Now normally there's a nice sheath here on the bottom of the FCR tendon, which you have to open the floor of the sheath, and that's what you're going to close when you're done with the surgery. You can really do a lot of this dissection bluntly with your fingertip, going down through the FPL tendon and having the flexor tendons on one side. Take your little dissecting scissors. Try to use your whole incision, whatever you cut, go from end to end. Don't start making it smaller as you go deeper, which tends to be a common problem. So here's our pronator quadratus up here. I'm going to put a little center tractor in here, and again, you don't want to go crazy here because you don't want to injure the median nerve. Here we see our distal radius. This is actually the bone right here, and this is the beginning of the pronator quadratus. Normally here we can take the pronator quadratus off. You don't need as much as you do for doing a distal radius plating for a fracture. So sometimes you can just peel off just the proximal portion. I'm going to take a little bit of this pronator, peel it off the skin. It's always nice to try to close this to some degree because it covers the plate, keeps the flexor tendons from rubbing on the screws. That's easier said than done. It tends to be a little bit more difficult in practice because it tends to be very thin tissue and you don't have a lot of tissue on this side to close it to, and you score your periosteum, open up the periosteum here. You don't have to go all the way around the periosteum here. All you need to do is expose the area where the plate's going to lie on the bone. In fact, you probably don't want to disrupt the periosteum around it. You only want to disrupt the periosteum around it where the actual osteotomy occurs. We're going to take our little plate and we'll just slide it down on the bone and see if our alignment's pretty good here so we've got a nice alignment on the distal radius. And our osteotomy's going to go between the third and the fourth hole. Now we're going to want to have this plate sit off the bone a little bit. Just pre-bend this plate a little bit so you're going to want to bow it away from the bone like this. Bow it away from the bone so the mid-portion of the plate is just going to rest off the bone about a millimeter. So this is not flat anymore so when you put it on the bone itself there's a little space right here where it's touching at the ends. The first step here is really just to put the three neutral screws, which are going to be the distal screws. This is the long part of the bone so you always want to fix your distal part first because you don't want to have any chance of needing to slide the plate up into the distal radius region. If you're going to have to slide something you want to slide the proximal part of the form into a fixed unit. I would only put in one of these screws, let's say this one here. I'd put it in, get my alignment, take off the plate, take out the one screw, and I'd leave these two, or vice versa, put in this screw and leave these two virgin so that when I put the plate back on, and I'll show you that step, these are fresh bites and they stay on. They're put in one time and they don't get taken out. And you just use your finger and line this up. We're going to take the green guide as for neutral if the arrow goes towards the osteotomy. So we want this screw in a neutral position, hold it in the appropriate placement, put our drill guide in, drill one cortex and two cortex. Sometimes there's a lot of bone graft in these drill bits and it seems like a trivial thing but I have the scrub take out the graft, she just scoops this out in between all of these individual drill areas and we put that in a little cup. And the reason we do that is because when you take the LCDCP plate and you look at it from the side, there's these little cutouts. And this cutout happens to be right between the third and fourth screws, always between the screws. So at the end of the case, your osteotomy is going to be right at this little cutout and you can stuff that little bit of bone graft right underneath the plate, underneath the plate in this little cutout on both sides. So we're going to make sure our plate's appropriately aligned, take our depth gauge here and feel our depth and this looks like it's a 16mm screw and this is towards the middle so it's going to sink down so I'm going to use a 14mm screw because it was in between the two screws. You can see there's a cutting guide there in the end of the hole so I'm only going to put in one screw in this case, I don't want to put in all three screws because I don't want to have to re-cut these. We've got our plate in here, now what we want to do is we want to mark our osteotomy sites and essentially you're going to know where the osteotomy site's going to be because it's going to be right between the third and fourth screw. Sometimes this is a little bit narrow here so I take a little bit of periosteum off between the third and fourth screw here and I'm just going to mark it on both sides where I want that osteotomy to be so I know I have good cortex here to drill and I'm going to draw along the side of the plate too for rotation. So now we're just going to take out this one screw, we're going to go roughly in this direction here between this third and fourth hole, try to make sure it's perpendicular to the long axis of the bones. This is a sagittal saw, it's nice to use a sagittal saw which means the blade comes straight in line with the power device rather than at a 90 degree angle because if you use the 90 degree angle you tend to hit the forearm with the saw itself and you can't get all the way through. Here you're coming from the top so you can go all the way through nice and easy. Another trick to this is you can mount several blades in a row on this. You can put three or four blades and you measure it, make sure it's two millimeters and you basically stack them all together and then it's one cut. The rules here are you want to maintain your alignment both this way, you want to be perpendicular so you want to be right here, perpendicular to the long axis of the radius and you want to be perpendicular this way. You don't want to shift it either way. In this picture you're perfectly 90 degree angle up and down and you're also perfectly rotated this way. You want to make sure you constantly irrigate. So when you start this, just start off the bone a little bit, get it going, make a little score in the bone without water so you know you've got a little guide that you can use. And now we're going to stabilize it and finish our osteotomy. There's our cut. We're all the way through. We've maintained our alignment. We made sure while we were cutting that we didn't rotate. We didn't start angling like this. Keep it nice and aligned. And now the trick is you want to measure where your second cut's going to be. We don't have a ruler so we're going to use the back of this knife handle. Now there's a little bit of a girth that you took out from the width of the cut of the blade. I tend to measure two millimeters and I ignore the amount of the girth of the blade. So it tends to be like a two and a half millimeter, sometimes a three millimeter shortening. But you can include that if you prefer. So I'm going to measure out two millimeters here and we just go proximal to that. We're going to draw another little line and I tend to just eyeball the incision so it looks nice and parallel. And now we're just going to cut it again and we apply the same principles of staying parallel to the bone and in both planes. Now we've taken out our wafer and one way to check to see if you actually did a decent job is to look at your wafer. If the surfaces are parallel, like this one, you did a pretty decent job. If it looks like a trapezoid, then you've got a little bit of a problem. It's better to go back and try to flush it out. Now we put our plate back on. We see our hole there because this is self-tapping which I didn't realize so I'm going to actually use a 16 instead of the 14 I had because I do think generally it won't get the bite that I'd like on the opposite cortex. And now we're going to put the other two screws distally. Now the reason we're doing these after the osteotomy again is because we're using self-tapping screws. These are in neutral so if they're in neutral you can drill them both at the same time. You don't have to do them in a stepwise fashion because they're neutral screws. You have to do one at a time. So here we're going to measure the opposite cortex, pull up on that, and this looks like it's going to be a 14 and this one looks like it's going to be a 16. I think I'm going to actually take a 16 instead of the 14 and the reason is, again, that distal bite on these self-tapping screws is not real great. So if I have to air I'd like to be a little long rather than a little short, but not too long so that you impinge into the tendons or anything like that. So these are neutral screws so the plate's not going to slide or anything, it's just going to sort of stay where it is. And as you do this you want to just keep an eye on the alignment of the plate relative to the bone. You don't want to put your plate on in an oblique fashion, you want it to be perfectly longitudinal to the axis of the radius. I'm going to slide this down so that plate is now neutral and I tend to just tighten these guys up, make sure we're nice and tight. Now you basically push the bones together, you're going to get these bones so there's some compression. Your incision's always maybe a little bit short so I'm just going to make this a little longer so we can see. Hold this bone together, sometimes it helps to have a little Hohmann retractor which you put around it because you can lift the bone up to the plate itself like that. And we look at our rotational alignment, make sure that looks good. And now this first screw is going to go into a compression and again the compression, you want the arrow of the drill guide to be pointing towards the osteotomy or towards the fracture. Come in here again and drill our screw. Now we only do one because we're compressing and then we're going to go back and compress it again. So you can see this hole is eccentric, it's not in the middle of the hole so as you tighten the screw down it's going to force the bone into the other end of the radius that we cut. So we'll take that 16, place it in the hole and this is going to catch the bone and once that screw head starts hitting the lip of the plate it's going to start forcing the bones together as it pulls it tighter. Now we're going to put a second compression screw here. Usually you can always do two compressed screws, sometimes if it's not that tight the first time you can go three compressed screws. Slide this down, that looks like it's a 14 but again we're just off the lip so again with the self-tapping I'm going to go a little bit longer and again this is an eccentric screw. Now the trick here is you've got to have the plate has to slide on the bone but we've already locked this screw down so when this screw that we're putting in right now, when the lip engages the plate so the plate won't slide, won't lose it's rotation right here, it's just engaging, it's not tightened, it hasn't slid but it's engaged, we're going to loosen this one up just a hair because we want the plate to slide. Now as we tighten up this screw it gives the plate just that extra amount to slide away and then we retighten this first screw. The last hole can be put in neutral so the arrow goes towards the osteotomy again, depth gauge, that's definitely a 14 and this one's not going to compress so we're not going to undo any of the other screws. And so there you have your completed radial shortening osteotomy. You want to use a floor scan to check that you've actually accomplished the shortening at the radius that you're aiming for and you also want to make sure that when you look down here with your mini floor scan that the two bones are well opposed and you want to check that the lengths of the screws are the appropriate lengths. This is the place where I would take a little bit of that bone graft that I spaced and I would stick it right here, right underneath this little trough cut out in the plate, right where the osteotomy is, stuff it in there and stuff it in on the other side. And then we're going to put all the tissues back, we'll repair this pronator quadratus as best we can over the plate itself, close the sheath that's underneath the FCR and then close your skin up. I generally don't cast these if the plate went on fine and there's no big problem. I will just put them in a volar splint, a soft dressing for 7 to 10 days, see them back, take out the stitches and then if it's an unruly patient that you don't trust, maybe put them in a short arm cast for a few weeks just to keep them out of trouble. If it's a fairly compliant patient, I think you can put an orthoplast splint on that can be removed so that they can take showers and start early range of motion. So here we have our radial shortening osteotomy on the x-ray. The screws, I like the five screws distally. They're sticking out a little bit more than you would for a non-self-tapping screw but not really where it's going to cause any trouble. That last screw, the neutral screw, I think I would replace, get a little longer screw so it got a good bicortical bite. You can see that's well aligned with the bone and then if we look at the wrist here, now we've created a radial negative variance whereas in a Keenbox patient, non-cadaver specimen, they would have an ulnar minus variance, you would be neutral. So we do look like we've shortened it about two millimeters if you look at the end of the ulna and the end of the radius. So we've accomplished what we want.

radial shortening osteotomy

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osteotomy techniques