I'm going to give it about a minute or two here before we get started. All right, I'm going to go ahead and get started here guys. All right, good evening everybody. On behalf of the American Society for Surgery of the Hand, I'd like to welcome everybody to the webinar on Complex Forearm Reconstruction, Treatment of Malunion, Nonunion, and Synostosis. I'm Jerry Huang from University of Washington, and I'm really excited to be joined by outstanding faculty with Dr. Bauer from Boston Children's Hospital, Dr. Richer from Duke University, and Dr. Wong from University of Utah. Just a couple of announcements of housekeeping items. Your audio will be muted during the presentations. The webinar is being recorded and will be emailed out to all the participants. As far as the questions and answers, please use the Q&A section of the Zoom chat box to submit your questions. We'll either answer them via the chat box or live during the discussions between the speakers. If you have any technical difficulties, please contact webinarsupport at assh.org. To claim your CME, they will be available on Thursday, April 27th, so please visit www.assh.org and log in. You can go to your dashboard and claim your CMEs. And again, really thank you everybody for joining us today. I'm really excited to learn from Dr. Bauer, Dr. Wong, and Dr. Richard. We can start off with Dr. Wong, who will teach us about Formal Unions, Osteotomies, and 3D Guides. Let me just get my screen going. Okay, sorry. It worked when I just did it, and let's see if I can get it to go. Okay, is that looking okay there? That's good. All right. So, thanks everyone for joining us, and thank you, Dr. Wong, for the opportunity. I think this is a really interesting and unusual topic, and I actually hope to be learning a lot from this as well. So, my topic is Formal Union, Osteotomy, and Use of 3D Guides. I'm going to be speaking about this condition in the adult population, which I think is actually a little bit less common. I think typically I see this in a younger population, just barely skeletally mature, and I think Dr. Bauer is going to talk about sort of what leads up to this in the pediatric population. I don't have anything to disclose relevant to this talk. So, just starting out with a quick review of anatomy for the forearm. We all know it's comprised of the radius and ulna, and there's really three things we have to think about here for the forearm moving as a unit. Proximally, the proximal radial ulnar joint and its soft tissue attachment, mostly the annular ligament, which supports this. The interosseous membrane, we all know that the central portion of which is the most important part, and distally, the distal radial ulnar joint, along with its soft tissue support, namely the TFCC and the associated structures. So, we all know from our training, and it's true because OrthoBullet says so, right, that adult forearm fractures are always treated pretty much with open reduction and internal fixation. And we know that we have to restore the normal anatomy of the forearm and all the planes of both bones in order for the forearm to have full rotation. And indeed, this is probably one of the most satisfying cases we do in upper extremity trauma. We're always fighting for it from the trauma surgeons. But so, both bones forearm plating is pretty much the standard of treatment for this fracture in adults. So, what makes this complicated is the forearm anatomy. In order for the radius to rotate around the ulna, it has to maintain its bow. So, the radial bow that we all know exists around the mid shaft of the radius. And the ulna is usually diagrammed as a straight axis around which the radius rotates. But we also know that it's not really straight. So, approximately the ulna takes about a 20 degree varus bow around the proximal third. So, you have to maintain both of these complex, not quite straight bones in order for the forearm rotation to occur properly. So, when I was talking about how I see this sort of as a sequela of pediatric forearm fractures and how common is it, this is kind of a nice review looking at malunion of pediatric forearm diaphysial fractures. And there's actually quite a high incidence of this. So, between 15, 35 to 39 percent in children up to 15 years of age. Fortunately, due to the remodeling potential of children, the incidence decreases. So, the malunion rate decreases from about 2 to 13 percent up to about 13 and a half years from injury. So, it does lessen with time. And despite the prevalence of residual deformity, a lot of pediatric patients don't have clinical complaints related to this. So, only about 1 percent of these will go on to a symptomatic malunion. And indeed, my own son has a both bones forearm malunion, so bad that he could rock his forearm back and forth on a table. But it doesn't bother him. And I'm sort of afraid to x-ray it. But a lot of times, patients' perceived disability does not correlate directly with the radiographic malunion. Okay. So, that having been said, malunited forearm fractures can cause limitation of rotation and pain and instability anywhere along the forearm. I think we tend to see it mostly at the wrist, I think, because the soft tissue supports are not as robust as at the elbow. So, when you have limitations of rotation, it will tend to toggle more at the wrist and cause pain and snapping there. I think there's a somewhat limited role for non-operative measures. Although, you know, the first time you see a patient, it's always worth considering this, particularly if their complaints may be mild. You could consider some wrist splinting. You could consider some therapy for possibly something like proprioception and strengthening. And you could consider a diagnostic injection. I don't do this a lot. But if you were, for example, unsure if you have some ECU subluxation versus actual distal radial ulnar joint subluxation, you could try a diagnostic injection in that area. So, if you've decided that the forearm fracture is symptomatic to the point where you're considering reconstruction, it can be very technically demanding. And this is because you need to simultaneously correct in multiple planes of one and possibly both bones to restore both ulnar variance as well as usually the DRUJ congruity and stability. And conventional planning using radiographs or a CT scan may not fully recognize the complex 3D deformity, especially with regard to rotational management. And so, there have been advances in medical imaging over the past 15 years or so that have made it more easy to compare the affected side to the contralateral normal side. And then the 3D planning has enabled planning for osteotomy as well as sometimes custom-made implants and plating for your osteotomies. So, we're going to talk a little bit about 2D versus 3D and, you know, when you should use one or the other. When I was talking to my partners about these cases and asking if they had some, my older partner said, nah, I only use regular x-rays. I'm an old fart. And this is what I do. And I'm well on my way to being an old fart as well. So, I'm going to show you one of my cases, which was just a 2D osteotomy. This is a 15-year-old male, right hand dominant, pain and snapping for about four years at the wrist. He did have a fracture at age 11. This was treated in a cast. Mom says they knew it was a little bit off, but the patient wanted, the physician wanted to treat it closed, hoping for some remodeling. But since then, he's more skeletally mature, has a lot of popping in the wrist with twisting many times a day, and as painful as the day progresses. On physical exam, he has significant generalized ligamentous laxity. And I actually think this is a very important point. I think a lot of the patients that I see that present with this have generalized ligamentous laxity, and that maybe predisposes them to having symptoms with this, with the malunions. So, on both elbows, he hyperextends a little bit more on the symptomatic side and the wrist with supination, subluxus volare. These are his injury films on the left. You can see he's skeletally immature here, not too bad, a little bit of translation and a little bit of loss of the radial inclination. You can see how he's remodeled in the next one, where, you know, it actually doesn't look too bad in the AP. You can see pretty much that he's got the Apex volare angulation here, which is probably going to be responsible for his symptoms, and then a forearm view. I just need to hide myself here. A forearm view, you can see again, this seems to be most of the problem right here on the radius. Probably a little bit of a loss of a bow here, but, you know, pretty clear, I think that that's where the problem was, since that's what I thought. So, for this case, I decided to do just a regular corrective osteotomy. This is just a regular standard plate and a uniplanar osteotomy. You can see it's better aligned here. He did, oops, sorry. He did, however, continue to have just roast instability of the distal radial ulnar joint, so he ended up getting a soft tissue reconstruction as well, but even with restoring the alignment, he was so lax that the distal radial ulnar joint subluxated both dorsally and bolarly after we had corrected it. So, 3D modeling was first described in the hand literature, sorry, the upper extremity literature about 2013 by this group, Oka from Japan, and this is where they described using computer modeling to compare the affected side to the normal side. So, this is from their actual original article showing in color the malunited bone compared to the contralateral normal bone, and then planning for corrections in three planes. There's still some factors that are variable with the 3D modeling, and that's you can use either standard plates to, right now they also have, you can get patient-specific plates printed to go with the jigs and fit on the bone, and then a question about whether or not single bone versus double osteotomies, sometimes the entire correction can be done through just the radius versus double if you have a more complex case. So, the second case is a 3D modeling case, and this is my partner's case. It's a 22-year-old female with left wrist pain, similar story trauma about 10 years ago when she was skeletally immature, tumbling, snapped her arm in a few places. She also has ulnar wrist pain worsening with activity. This bothers her to the point where she interferes with activities, and about four out of seven days a week she's in a lot of pain. So, she had it seen by a few people. One doctor told her it was pretty invasive surgery to fix it, and so he didn't want to have any part of that. Another doctor, the one who originally managed her fracture, got an MRI and said it looked okay and didn't recommend anything else, and so she came for a third opinion. On exam here, she also has bilateral laxity with hyperextension at the elbows, tenderness to palpation on the ulnar side, and instability with supination. So, her supination is somewhat limited, and when she gets to the end of supination, the distal ulna will clunk, and this is a little hard to see, but you can see with this, that's the snap right there, and you kind of lose a little bit of that contour of the distal ulna. Here, you can see also the ulna almost dimpling as she supinates, so a little hard to see on video, but right there it kind of dimples. Just advance this, okay. These are her x-rays, and they're actually pretty subtle, so I think in cases where the deformity is not as obvious, this is where the 3D modeling is helpful. You can see on the AP radiographs, her affected side is the left side. The right one almost looks more abnormal. She almost looks like she has more widening of the DRUJ on the right, sorry, and on the lateral, you know, it doesn't really look too bad on the wrist views. When you get to the forearm views, you can see something a little funkier, so there's a little, it looks a little bit close together at the proximal diaphysis, and there's some apex anterior slight angulation here, so this is obviously a more complex malunion, I think, than the previous one. Other studies that we checked, they did get an ultrasound to just check to make sure it wasn't her ECU tendon that was subluxating, and it was not. They did review the prior doctor's MRI, and that was unremarkable, and they got a CT scan, and a little bit hard to tell if the forearms are in the same position on the gantry, but I think this looks pretty similar if you look at the shape of the distal radius, and on the affected side on the left, you can see that the distal radius is you can see that the distal head of the ulna is subluxated volarly compared to on the right. So this patient underwent the 3D modeling, remodeling, sorry, modeling to plan for the osteotomy, and this is what it looks like. Again, the normal side in white, and the affected malunion side in the color. They will send you the plan where they actually plan the osteotomy. This is just a diagram of the potential rotation, and then a computer simulation of how it looks after the osteotomy with the hardware in place. So that's what she had done, and you can see this is her post-op films, and these are standard plates, not custom plates. The wrist films, again, look pretty similar to how they did, but if you look at the pre-op and post-op forearm films, you can see that there's a lot more space between the two bones, sort of about this proximal area, and better alignment as well on the lateral. So, and this is her, again, hard to see, but she doesn't have that clunking anymore with her forearm rotation. It's a much smoother rotation of the forearm there. This is just a different system. A couple systems are out there. They vary in price. I think the top of the line is probably about $5,000, and then decreasing from there, depending on which system you use. So how do these do? And this is just a study looking at the accuracy of the correction, and they found that it was very accurate. Generally, they were able to achieve the planned correction to between just a few degrees of difference, and clinically, the patients all had improvement of their range of motion and VAS grip strength and dash scores. This is kind of an interesting study just looking at corrective osteotomies also using 3D computer. Interestingly, they found slightly better correction with closing wedge than opening wedge. However, this difference was minimal, and it didn't affect their healing. If you're comparing 2D and 3D, there's only a few cases in the literature, a few series in the literature out there. This is a retrospective study comparing corrective osteotomy versus 2D versus 3D. They had similar outcomes, but they did find that the operating time was shorter in the computer assisted group, I'd imagine, because everything is planned out for you. And this is not in the form, but it's a similar study done in the distal radius malunion, again, comparing 3D to 2D. And they found pretty similar outcomes. They didn't find any change in the duration and similar complication rates. So they felt that there was a trend in favor of 3D, but it wasn't significant, likely due to insufficient power. So I think in summary, I think it's a useful tool, definitely for a more complex malunion. I'm not sure that it's always necessary, but I think it's a nice thing to have in your arsenal. And that's it for this section. All right. Thank you so much, Angela. I really enjoy your talk. As Dr. Wang mentioned, these are definitely a lot more common in the pediatric population from oftentimes a missed injury or a cast immobilization. So we're going to switch gears to Dr. Bauer, who's going to teach us about pediatric malunions and how we consider the physis and growth as far as looking at treatment options for these patients. Great. Thank you. Thanks for having me. Let's see if I can share successfully here. All right. Can you hear me and see this? Good. All right. So yeah, again, thank you for having me and nice segue. So we're going to start by talking about what's acceptable. So if a lot of these start in childhood, how do we not start them? How do we know that we're getting acceptable reductions for forearm fractures in kids? And then we'll talk a little bit about physio injuries, how to monitor them and who to monitor for arrest after physio injury, and then how to treat it if it happens, and lastly, I do have another case example of a malunion again just highlighting the power of those 3D corrections. So first off, you know, back to principle. So we know that sagittal and coronal plane remodeling can occur, but malrotation cannot, and the amount of remodeling depends on both the proximity of the fracture to the phisis and the age of the child, and typically when we get into trouble, it's because the fracture in any bone really in children is far away from the phisis, and when the child is perhaps physiologically older than we realize. And then on top of this, healing is quicker in children than adults. There's abundant blood supply. We have shorter mobilization times, shorter healing times, but you also need to make those decisions quickly and get correction quickly before things start to heal. The distal ulnar phisis closes around age 16 for girls and 17 for boys, and the radial physis is about six months after that, and remember that the distal physis provide 80% of forearm growth. So when we talk about these physial fractures, we're really talking for the most part about wrist fractures, distal radial and ulnar fractures. The nice thing about pediatric forearm fractures is, you know, although it's fun to fix those adult both bone forearm fractures, most of the time these are able to be treated non-operatively. They have rapid healing. They have that potential for remodeling. Really we're trying to facilitate the union of the fracture and restore functional range of motion, especially in pronation and supination, and what I think is interesting about what Dr. Wang said earlier, that parents often don't realize the disability. You know, we're looking as hand surgeons to maximize complete return of pronation and supination, even if our patients themselves don't realize that they have a lack of motion. Notice that ulnar alignment and the straight ulnar border is important for cosmesis, and what's great for the trainees listening is that this is a case where the ER treatment can be the only treatment that the child needs, and that's pretty powerful for, you know, a junior resident to be the only treatment that this child needs. I love showing things like this, you know, the acceptable displacement in a young child. This Crawford study from 2012 had great photos. There's other great photos out there, but again, these are young children, and close to the physis is when we can get such great remodeling. So in this study, all of these kids were under 10 years old, and you can see that, you know, you'd never know that there was a problem. So what will remodel? So in those young kids, under 10, when there's still a lot of growth remaining, they haven't gone through their preadolescent growth spurt, we can accept up to 20 degrees of midshaft angulation and bayonet apposition, but still, even in a young child, no rotation. In patients who are over 10, those numbers start to shrink, so a 12-year-old kid might look pretty young, but at the midshaft, we can only accept 10 degrees of angulation as and as we get more proximal, maybe even less, and again, no rotation. Back to whether the patient notices the difference or not, some articles and some numbers that you'll see on the internet or in textbooks are really looking at the functional result of malunion, so not what will remodel to straight, but what can the patient tolerate, and papers, you know, from a little while ago would say things like, well, kids get relatively good functional results, and that's been reported up to 10 to 15 degrees of angulation at the midshaft, maybe even 45 degrees of rotation and bayonet apposition, but that doesn't mean that that child would have full pronation and supination on your exam. It just means that they are happy with the results. So when we think about fissile arrest, you know, it's well-known that throughout the pediatric skeleton, repeated efforts at reduction of a fissile fracture are probably going to do more harm than good, and these injuries, you know, we have such good blood supply in that area, they're going to unite even more quickly, and so the attempts to correct the malposition after a week are liable to do more damage than good, and so we really think about correcting fissile injuries within the first couple days and not remanipulating them after seven days for sure. Even with our best treatment, fissile arrest does happen in about 3 to 4% of distal radial fissile fractures. There's progressive deformity that then leads to abnormal risk mechanics, pain, stiffness, onocarpal impaction, TFCC tears, DREJ instability, the whole gamut of onocytic risk problems, and you can see in this picture they can be quite significant, and here is someone whose ulna is just going to keep going because the ulna is not done still, and so they can lead to quite significant onocarpal impaction and overgrowth of the ulna. That number of 4% came from this Candada paper in 2003 in the Journal of Orthopedic Trauma, and of this, there were 157 fissile fractures of the distal radius, only 6 fissile fractures of the distal ulna, so those numbers are still a little hard to suss out, but 7 of the 157 radius fractures had a growth arrest. Three of the 6 ulnar fractures had a growth arrest, making us think that that rate is much higher, but I think it's just we don't really know that number because there were so few in this study. We do know that interarticular fractures have a higher risk, so at a case series out of Boston Children's, looking at just Salter-Harris 3 and 4 fractures, 41% of those went on to growth arrest. So, although we have this number of 4% that's out there in the literature, clearly, depending on what trauma the fissus actually saw, that risk will vary widely, and the bottom line, I think, as of 2023, when we still don't know exactly which ones need to be followed, really all distal radial fissile fractures should be followed until there's normal growth, until we know that we've had resumption of normal growth. My personal preference is to see those kids at 6 to 9 months after the fracture with x-rays, looking to see that there's no change in the ulnar variance, that we don't see a bar, and that we see resumption of normal growth, that they've actually had some skeletal growth since the fracture. And what are we looking for, what are we going to do when we find something? So, if there's an incomplete fissile arrest, which is rare, you can evaluate by CT or MRI to establish the area of the bar and consider a bar resection. More commonly, we'll find a larger area that may be incomplete, but still too large to do a bar resection, and so we might do a completion epiphysioidesis of both bones. And then if there's a complete fissile arrest, if it's caught early, then we can do an ulnar epiphysioidesis. If it's later, then we might need to consider ulnar shortening or radius lengthening, which is what we're trying to avoid by following kids in those earlier months. So surgical options, like we talked about, depending on the pattern of arrest, the degree of deformity, and how much skeletal growth is remaining. So even in a case where you need to do an ulnar shortening, we can't forget to do the ulnar epiphysioidesis as well if the ulnar fissus is still open. So this is just a simple case, Salter-Harris 2, distal radius, you know, looks relatively innocuous. The kid was 15, but did not have any follow-up after CAST treatment, and then at age 17 came back with ulnar-sided wrist pain, and so underwent an ulnar shortening. And that's really what we're trying to avoid by following kids more closely. So turning to malunions, you know, as Dr. Wang talked about, the role of nonoperative management is really just understanding and accepting the deformity. So we can follow children throughout childhood, maximize the remodeling potential, and then understand the functional limitations, and people may choose that those are just not too big of a deal for them, and they don't want surgery. When it comes to operative treatment, this is typically osteotomy, and that can be done either freehand or computer-assisted. There are a lot of commercial products, and you probably have them on your PAC system, maybe even if you've never gone looking for them, if you just want to do a digital templating. So you know, when I was a resident, and I don't think I'm too old, we would actually print out the x-rays and cut them out with scissors. You don't need to do that anymore. I think pretty much everyone still using the CORA technique, still using those standard geometric techniques, you can translate that at least onto planning in the computer, and most of them, most of the PAC systems will have that. You're still doing a freehand surgical technique in the OR, but at least you have a plan going in, you know, how big is the angle you're trying to correct, where do you want to make your osteotomy, and things like that. The next step up would be to make a 3D-printed model that you could hold in your hand, or perhaps a 3D PDF that you could spin around on a computer screen. There are commercial 3D printing companies that do this. You know, lots of people have 3D printers these days, so at Boston Children's, we can build these bone models in-house. I think a lot of hospitals are doing that. My third grader's school has a 3D printer. He could probably do this at school. And if you have the MRI or the CT files, you can just print off of that. These are great for pre-op planning. If it's just a deformity that you can't wrap your head around, even on the 3D model in the PAC system, sometimes it's nice to be able to hold it in your hand. You could even practice, you know, if it's someone that you're taking through a case, like how are you going to make that closing-mudge osteotomy, or sometimes with, you know, maybe a more complicated articular osteotomy you could practice. Again, you're still using your freehand surgical technique in the OR. When you're building a bone model, you're just more prepared. And then finally, this is similar to the case that Dr. Wang showed. You can get through various engineering companies custom guides. And so, these are then 3D printed jigs that you can put onto the bone. And here, you're no longer doing a freehand technique in the OR. It can be slightly terrifying to just, you know, put this guide on, drill your holes, and hope for the best before you make the osteotomies. But this is, you know, based on your pre-op plan. And then all you're doing in the OR is carrying out the plan that you did on the computer preoperatively. In order to make that work, you do need to get a thin-cut CT scan of both arms and then work with an engineer over the computer, either usually virtual meetings, or over email and things like that. The drill guides and the cutting jigs are created in the engineer, so nothing is freehand in the OR. I would say that in the pediatric world, there are systems here that are now FDA-approved. And the time, because children are growing, the time between the CT scan and the surgery is actually regulated by the FDA. So, in the case that I'm going to show you, we had only three weeks from the time that he was scanned until the time we had to use the jigs in the OR by the FDA. So, that's just an important thing to keep in mind if you're using this type of system on children. So, this is the child, an 11-year-old boy who fell playing football. He had this proximal radius and ulna fracture. He was treated with a closed reduction. And you can see, although there's really a great AP view here, the lateral view, there's a significant amount of angulation here. And I think when we get into the proximal radius, sometimes it's difficult to appreciate if you're not looking at these and making these decisions about how displaced is too displaced on a routine basis. I think these can get missed. And one of the things I sent out in the handout is the article by Price about the crossover sign and that we really should not be seeing the radius crossing over here to that degree on the lateral x-ray. And so, you know, that's something to keep in mind when you're looking at these proximal form x-rays. And so, he then just went on to heal like that and was sent to me at six months after injury because he had zero supination. So, he had full pronation and supination only to neutral. And you can see that's quite a bit of angulation on the x-ray. And for me, you know, this is something that's really helpful to then put through the 3D process because you can see that degree. Like, I think it's, you know, in hindsight, right, this is obvious. But it's really obvious when you look at it in 3D. And you can see how far off that proximal radius really is. And so, we know that this is beyond the limits of what we can accept. And this is the reason that he's not rotating. And so, you know, we did this closing wedge, this plan to do two closing wedge osteotomies to correct the radius and ulna. I think this is, again, where the 3D printing and planning comes into play that if I were doing this freehand, I probably would have only corrected the radius. And I think I would have gotten a good outcome but probably not as good of an outcome as when, you know, doing both of these. Even though there wasn't much of a change to the ulna, it really fine-tunes the process. And so, we did closing wedge osteotomies in the radius and the ulna. I'm just showing the radius here just for space on the slide. And then, doing the case of two closing wedge osteotomies in the proximal radius and ulna took us 90 minutes of tourniquet time. And I only got x-rays once at the end. You know, maybe, Angela, your senior partner is really good at doing it freehand, but I'm not that good at doing it freehand. So, definitely much shorter OR time and less radiation for all of us in the room. And these were the final floros showing, you know, especially in the lateral, that improvement in that proximal radius angulation. And these were the... I'll play this little show. So, this is where he was beforehand having full pronation and no supination. You can see kind of the angulation just looking at his forearm. And then, here he was afterwards. And so, you know, still maintaining pronation, but now going all the way into supination. So, you know, that's something. To be able to do that that smoothly, I think, is the benefit of all that preoperative planning. Sorry. So, just in conclusion here. So, we can accept a lot in young kids at the distal forearm. Be careful accepting imperfect reductions if the imperfection is in the rotational plane and if it's proximal. And particularly as kids get closer to skeletal maturity. Phyceal arrest, we use this number of 4%, but we know that can vary depending on the trauma to the phyces. My preference is to do x-ray follow-up at six to nine months after Salter-Harris fractures with the treatment then based on the extent of the arrest and the growth remaining. And then, finally, the best way to treat a malunion is to not cause one and understand the acceptable deformity and then consider computer-assisted techniques for difficult deformities. Thank you. That was a great talk, Andy. Thank you so much. Just want to remind attendees, please use the Q&A function if you have any questions for Dr. Bauer, Dr. Wang, or Dr. Richard later on as well. And one thing I want to ask during the discussion later is for both of you, kind of timing of the pediatric forearm fracture that's a malunion, when do you time the osteotomy? And also, you talked about 3D versus 2D. And when is it too complex for 2D versus using 3D into cost consideration? So we'll talk about that later. But great talks. Thank you. I'm going to have Dr. Richard teach us more about forearm nonunions. Mark, thank you. Thanks, Jerry. And great talk so far. I think I've got Siri on, I'm sorry. I am going to talk to us about forearm nonunion and kind of take 15 minutes to roll through simple bone grafting, mascalade technique, and that kind of in between, and then vascularized bone grafting, and when I use each. So disclosures, but nothing really relevant to nonunions in and of themselves. Introduction, I totally agree with Angela that the forearm is a functional unit. And I love when many of your peers and colleagues kind of have the same thoughts parallel to you, but it's a joint, or it should be treated as a joint. And it's got five structures, the radius and the ulna, and then the proximal radial and their joint, the distal radial and the joint, and the interosseous membrane. And all five of those have to be considered to preserve the function of the forearm unit. So we're going to talk about nonunion and nothing this crazy. But like the talk that Andy just gave, the best way to prevent nonunion is to do it right the first time. So we do have to spend a slide or two on choice of fixation. Union rates for radius and ulna are reported in the literature as 98 and 96% respectively. We do see bone defects. We're going to talk about managing that. Now, the biological environment matters, fracture displacement, multiple injuries, polytraumas when they're all revved up in a hypermetabolic state, location of the fracture matters, junction of the middle and distal thirds of the ulnar shaft, particularly have a watershed area because of the termination of the descending branch of the nutrient artery. But those are all things that can knock us down from that very high union rate. Choice of fixation, classically compression plating, and as plates have evolved dynamic compression plates, I think we all agree that semi-tubular plates and recon plates are insufficient. There are high torsional and rotational forces on the forearm, on the whole upper limb. And those plates simply aren't strong enough to resist those forces and will very predictably lead to non-union. As far as screw density, a lot of this is dogma. To be quite honest, there is an old study by Peter Stern looking at increasing screws, decreasing non-union rates. I think dogmatically, a lot of us say six cortices on either side of the fracture. Three good bi-cortical screws, but materials matter, screw size matters, bone size matters, screw density, spacing. There's a lot of different things to go into there. And I don't think that we're ever going to get to one particular answer about that. I talked about plate selection. This is an example. I always want to just be clear. These were sent in for the corrective operation, but recon plate insufficient to resist those rotational forces, as is a one-third tubular plate. And you can see the sequelae when those are used, usually non-union and ultimate plate breakage. So what do we do to take care of the non-union when we get it? This is a classic paper by Ring and Jupiter, 2004. I can't believe this was 20 years old, but they looked at segmental defects between one centimeter and six centimeters. And spoiler alert coming up, I know everybody knows this, but six centimeters is where we start thinking about vascularized bone graft. And that's why that was the upper limit here. They had 35 patients treated with autogenous cancellous bone graft only, so nothing structural. And they had union in all of their cases by six months. So here's just a representative case from the paper. Injury on the left, cancellous bone graft and fixation of the fracture with six cortices on each side of the fracture, cancellous only, nothing structural, and then gradual incorporation into union. And very good outcomes. I will show you some of my cases. I still have a hard time not putting something structural in there, but it is good to know that it can be done. We'll start simple. This is a 43-year-old woman with polytrauma who somehow got some of her other injuries fixed and then was supposed to follow up with me afterwards to do this as an outpatient. She had a hard time following up. She had one show up to the ER where they got x-rays but couldn't capture her at three months. And then she finally showed up at four and a half months. So it's probably really more of a nascent malunion, but I'm counting it as a nonunion for an example. Still have a reasonable ability to tell fracture position, alignment. It's a very simple fracture. I think that callus ends up being a good source of local bone graft. So in this case, we're going to harvest that when we take it down. And you can see a beaver blade there just taking that soft callus down and trying to localize the fracture site and get a dental pick or a beaver blade into the fracture site and save that callus as your local bone graft. Anytime you're dealing with a non-union or any kind of corrective, I would put the malunions in this too. You wanna recannulate the medullary canal. If it's been previously operated and has a plate and screws and you're gonna have pedestal around those screws and you really wanna rev up that intramedullary canal and that endosteal ability to contribute to fracture healing. So I'll take a drill and just cannulate up and down. You can see the lobster claw in there doing that. And then this is new enough that it is able to get a reasonable read with a clearing of the fracture site. I show here on the right, the Hinterman compression distraction set that our foot and ankle partners use a lot. It can be very helpful for either compression or distraction. In this case, we're gonna try and use it for compression. It holds some out of plane provisional reduction and lets you generate some pretty good compression along there. So I use that in a lot of my non-unions and mal-unions of these long bones. Alignment, there's an old saying that straight plates curve bones for the radius to recognize that unique geometry. Now we have some anatomic plates. So if you have an anatomic plate, it should be curved plate, curved bone. But this, you can see if I'm using an anatomic plate, I wanna make sure that I match that plate to restore the anatomy. If I had a straight LCDC plate, I would make sure the bone was a little bit curved around there. So trying to make sure we get our reduction, which can be a little bit hard in the mal-unions and the non-unions. Don't forget about the laterals curved in two planes. So there's a dorsal bow realigned as well. Always when you do these cases and you're messing with those bones and the interosseous membrane, you want to be respectful of the five components that make the joint that we talked about. So always look at the wrist and the elbow, confirm that you haven't done something to change or alter the DRUJ or the PRUJ. So these are just representative films looking that the DRUJ is not crazy or we haven't shortened so much that we've dislocated the DRUJ or anything crazy like that. Just a clinical look at it, very straightforward case. And I think we're all used to doing this. And if you do it, you can confirm rotation with pronation supination. This is her final follow-up whenever that was and she's healed and has a very reasonable functional range of motion at the end. So let's move on to the slightly bigger defects and the induced membrane technique described by Alain Mascalet from France. And you can see here's a tibia, but there's a cement spacer in place. And he has very good series of literature that shows that the pseudosynovial membrane that forms in response to the cement spacer is helpful for a number of reasons. It is one rich in growth factors, specifically VEGF, TGF beta one, and then the osteoinductive factor BMP2. So that membrane does really two things for us. It provides a mechanical and biologic support of the cancellous bone graft. So if you go back to that Ring and Jupiter paper, you can simply pack that densely with cancellous bone graft and expect that to heal. And the membrane helps both mechanically and biologically. And it also provides a barrier to minimize graft resorption so that that bone graft stays where you put it and it does not fall away once you close the wound and get the patient up and mobilized. The last thing that I think it does is it keeps important structures that you don't want to be falling down into that defect from falling down into that defect. So when you come back to do your secondary bone graft, you have a preserved space that you can work in and out of very easily. And as long as you're within that space, you're not getting into any of the structures that are going to be nearby and at risk. We'll talk a little bit about antibiotics. I think the majority of us put antibiotics in our cement when we do this. And for open wounds, I have to admit, I do. I've been reviewing some of Mascalet's work. I've gotten away from doing it in primary settings and I'll share his thoughts on it and why that influenced me coming up. And I usually grab either the Gent or Tober cement when I use antibiotics, and then I add my own Vanco to it. And you don't need to pressurize this. It is simply mixed in a bowl, made into that doughy format, and then you're making a match area for the defect that you're trying to preserve the space for. So this is Pearls and Pitfalls by Alain Mascalet in JOT relatively recently. So he is the expert and I'm going to share the summary of his thoughts on this. He is very much against putting antibiotics into the cement for three reasons. One, he says the antibiotic may be inactive on the germ and is likely to increase biological resistance of germs, reasonable thought. Some active antibiotics can affect the characteristics of the membrane and all of his studies looking at the biologic properties of the membrane were done without antibiotics. So we don't actually know that it has the same biologic properties when antibiotics are present. And then finally, he says that if you're trying to do the bone grafting at a time when you don't have current infection, the absence of antibiotics and the absence of infection at that time should make you feel better that you have a clean wound and you're going to have a better chance at healing. All very reasonable thoughts. The shape of the spacer, you want to make it as large as possible without compromising the soft tissues or the skin. It should overlap the ends of the bone. It should be slightly larger than the defect. And when you make it, you want to avoid the thermal necrosis that can occur by just packing it in and letting it have its exothermic phase of PMMA that we all know that you get with it in vivo. You want to do that ex vivo and then place it into the defect. So I'll usually have us make three different sets. I'll make one, fellow will make one, resident will make one, and we'll try to make one what we think the size is, one bigger, one smaller. So we have some options after you get through that exothermic phase. As far as fixation, plates, nails, X-Fix is all suitable. You want to avoid too rigid of a construct if you're doing cancellous only because you don't want to stress shield that in that induced membrane technique. And he's got cases in the literature of up to something like 26 centimeters in the lower extremity being treated with a cancellous bone graft alone. I'm not brave enough to do that. And you'll see, as we get to the last part of this, but it is described in the literature, but you do have to be very thoughtful about the carpentry that you do and the mechanics of the construct that you're going to provide to allow that to incorporate. And then lastly, timing, you want to do it at maturation of the soft tissue envelope, which is typically around six weeks. Growth factors peak at four weeks. So when they looked at the retrieval studies in sheep, when they did this, the growth factors were at their peak at four weeks, but there's no difference in union or outcome related to duration between first and second stage. So if you have to wait 10 weeks, 12 weeks for the soft tissue to mature, you're fine to do so. And then I guess really lastly, bone graft. Cancellous bone graft, ideally from a very biologically active area like the iliac crest bone. He advises against cortical cancellous or cortical bone graft due to the inability to revascularize. It doesn't revascularize the same way cancellous does. I'll show you some of my cases where I use that structural graft and I think it works just fine. If there's a volume issue because you're trying to fill a large space, consider via or mixing with cancellous allograft, but not greater than one to three. So you do need some autograft in there. Cancellous allograft alone is not suitable. And when I was a resident at BU, we had a lower extremity series looking at this and the only ones that did not heal were the two or three that were pure allograft. So you do need some autograft in there, preferably all if you can. You want to tightly pack that into the space to fill the defect. And there you can see it's going around. This is a tibial nail just being packed in and closed around. So let's go over maybe two cases with the masculates, a 30-year-old right-hand dominant male who has a gunshot wound to the right upper extremity. Two pack per day smoker, works as an electrician. Here's his injury film shortened on the radius. We're looking at that whole form as a unit and he's got some shortening of the radius with this gunshot wound. He's got not the worst soft tissue defect, but here we're plating them out to length and we're going to use our wrist and elbow as a reference. And then we're going to put a cement spacer into that area to preserve it for delayed bone grafting. So this is a clinical picture of the exposure. You can see the plate there. You do want to try to keep the spacer in the place. So we've all had these where the spacer spits out and you're halfway through your, between your stages and you've got the spacer in the soft tissues, which is not so ideal. So this is, we were talking about skiing later before we started this, is like a little gondola with the hooks going around through one of those plate holes just to keep that cement spacer in place is what it looks like radiographically. And then once the soft tissue heals, you can see he's back in clinic now with x-rays. We're going to take him back and do the bone grafting. I still, with the majority of the time, will put a structural piece of bone graft in there and then pack my cancellous graft around the edges. So I'll still use that Mascalet in the active biomembrane, but I'll put a couple of unicornical screws in that segment. And here he is at five months with reasonable incorporation and there he is with a good range of motion. And that's the last time, last time I got to see him. One more with the Mascalet and then we'll finish with vascularized bone graft. 62 year old male, bicycle accident, open both bone form fracture. He was treated by one of my friends elsewhere and had some recurrent infection. I'm just going to get to the Mascalet part. He asked me just to do, to do this part, just to change things up a little bit. He's a very good surgeon. Hardware removal infection was cleared. He did the Mascalet and made a very nice spacer that fit the defect. And then I did his, his bone grafting. So this is just intra-op, what it looks like. You can see in the picture on the right, that's a beautiful membrane and the opportunity to have a graft that can fit right in there. You could do that totally with cancellous graft. I already gave you my bias. I like a little bit of structural graft. And I like to make that little trapezoid, put my plate on the long side of the trapezoid. So when I compress, I wedge that structural piece into there. And that's what I go for on these, but a cancellous graft is just fine. Here is a structural piece of iliac crest. You see, I've built my barrier around there so that this is not going to go flying away because I unfortunately admit I've lost a graft or two before. So I try to make this a safe space to do this carpentry in the back table. There's a cancellous graft and we're going to pack that up and down the medullary canal that we've recannulated, fill the surrounding part of the biomembrane with that. And then we're going to put our structural graft in and plate it. So here is the plate going in. You can see a little bit of a trapezoidal shape to that to get some compression and wedge it in. And you got to do something different. He already had one plate, so he's going to get two plates. Also provides a little buttress on the orthogonal side to prevent escape of that. And then this is him post-op. And I don't have his latest follow-up because he's following up back with my friend who took care of him first. Last couple of slides here, defect greater than six centimeters deserves vascularized bone grafting. And for the trainees, that is still the board answer. And the free vascularized fibular graft is the one of choice. It is the perfect shape for the long bones of the forearm. And that's our go-to. So this is a woman, this is a sad story. She's going, she was separated or divorced and had a custody issue with her ex-husband. And when they were exchanging the kids for the custody days, he ended up shooting her through the, so she was pregnant and he shot her. So it created some timing issues with some of her cases, some of her surgeries. But this is her at her initial, through the radius, through the ulna, soft tissue defect. And in a very comminuted ulna, she got washed out, X-fixed by the trauma team. You always need skin and soft tissue in these. So we did an osteocutaneous free fib for this one into the defect. There's the radius being plated kind of from stem to stern. You can see the radius, the free fib, sorry, and the defect greater than six centimeters there. I like, if I don't know what's going on in the ulna, I'll put a nail in. So it lets me adjust the length and not commit to a length. Super comminuted there. So we did the radius. I don't know why I have X-rays of her lower leg, but I did, so I put it in just to show. Here she is incorporating the free fib, but she's not incorporating the ulna around that and unlocked nail, but she was also pregnant. So we let her give birth and get through that side of things. And then we came back and just, you can see eight months there, she's got one non-union site. So we go back and do a typical structural graft, not anything vascularized for this, whatever it is, one or two centimeter defect. You see the nail coming out, there's a defect. Back to her iliac crest for a structural piece. And then there's the plating with the revision. There's her healed final follow-ups of radius and ulna. And there is her motion. It's not perfect, but it's functional. And it was a tough injury for her and some timing issues. So in summary, treat the forearm like a joint, choose appropriate plates and resist the torsion and rotational forces that we know are significant. The induced membrane technique is a very useful tool. It enriches the local biologic environment for delayed bone grafting. It also preserves the space and the shape for the delayed bone grafting, creates that barrier against resorption. If your defect is less than six centimeters, non-vascularized bone graft is fine. If it's greater than six centimeters, I still consider vascularized bone graft and specifically for the forearm, free vascularized fibular graft. Thank you very much. That was great, Mark. Great cases, great talk, and kind of a whirlwind tour through non-unions. Thank you so much. Thank you. So again, remind the attendees, any questions for Dr. Rich or Dr. Byron Wong, please use the Q&A function. So now we're gonna switch gears, gonna go from bony deformity and not enough bone to too much bone. So we're gonna talk about post-traumatic radial ulnar synostosis. These are my disclosures. And we know that post-traumatic radial ulnar synostosis is actually fairly common, incidence up to 5% or 6%. It's much more common with open fractures or high energy trauma, and certainly a lot more common at approximately one third fraction of the forearm. Patients with a common head injury, you can see HO up to 33% of these patients, and technique does matter. I think you really wanna avoid violating the interosseous membrane, wanna remove any loose bony fragments, and really kind of be careful when you have bone grafting you do, and keep it out of the interosseous space. As far as classification, really divide it based on anatomy, distal, type one is distal synostosis, type two is in the shaft, type three is more proximal. And Jupiter and Rhea in 1998 subdivided the type three proximal PRUJ synostosis into a 3A, which is more distal to the bicepital tuberosity, and 3B over the tuberosity, and 3C is more proximal involving the radial capitellar joint. As far as what to do, these are three examples of patients with severe synostosis involving the PRUJ, kind of interosseous space over the shaft, and then distally over the DRUJ. Hastings and Graham divided up into really six areas in this paper. Area one and two is more proximal. This is where you have not just synostosis, but joint destruction, where you really can't salvage the joints. You're looking at some type of arthroplasty of the ulnar-herobrine joint, and perhaps a radial head excision versus arthroplasty. What's more kind of proximal, one-third over the mid-shaft region, you're probably looking at some type of excision of the atrial interposition material of some kind of surgeon choice. And we'll go over some of that option later on in the talk. And distally over the DRUJ, especially if, oftentimes, you not just have DRUJ synostosis, but post-traumatic changes involving the sigmoid notch on her head. So you're probably looking at either a salve compongi procedure or a fairly proximal DERA resection. So I'm gonna go over a couple of cases. Case one, this is a 55-year-old female, high-speed MVA with a head injury, multiple orthopedic injuries, had an open left proximal radius ulnar fracture. So she was initially treated by the Orthopedic Trauma Service with IND or IF of the left radius ulna. These are initial injury radiographs showing just amount of displacement, high-energy trauma, amount of combination, and multiple loose bony fragments. Two weeks post-op, so you can see they had a really nice reduction, but even initial fixation, you can see there's some loose bony fragments due to amount of combination in that interosseous space more approximately. This is a patient at two months post-op. You can see further maturation and growth of the heterotopic bone between the proximal radius and proximal ulna. This is a patient at six months post-op. She's really gone on to a complete synostosis over the PREJ. So now she's about six months out. She was referred to our clinic and presented to my clinic with forearm stiffness, pronation zero degrees, supination 15 degrees, more over her carpus rather than her wrist or her forearm. She's been working with therapy fairly diligently with really no progress. She's got a fixed contracture. She works as a hairdresser, really can't do her job due to her forearm stiffness. So question becomes, if you look at initial presentation, chances of 55-year-old high-energy trauma, MVA with a head injury, should there have been initial prophylaxis? Now that she's formed a synostosis, what's the best timing of surgery? What's her surgical approach? Should interposition material be used? And then after the HO takedown, should there be some type of prophylaxis for this patient? As far as HO prophylaxis and allergia, we're looking at really two main modalities, endomethicin for four weeks. The main concern is GI bleeding. Multiple studies has also shown that despite putting patients on a endomethicin protocol, the compliance is actually not very good, probably less than 50% compliance. Radiation treatment, a single dose, 700 to 800 centigrade has also been described with concerns of wound healing, neuritis, and risk of sarcoma. There's actually a randomized prospective study at three centers looking at XRT acutely after elbow trauma that may be a high risk of HO. The study was actually terminated fairly early on due to a high complication rate, 38% nonunion rate. And the ones that did go on to complete the study, HO rate was actually similar with or without HRT. So based on this, radiation was actually not recommended and I don't routinely do radiation after acute elbow trauma. So what about timing of HO release? I think traditionally in the 80s and 90s, we're looking for a cold bone scan. We know that early on hypervascularity, you do have a very hot bone scan, but it takes about 12 to 18 months to get there. As far as patients return to function, return to work, definitely a prolonged process. So more recently, there's quite a bit of literature supporting this, including the call of 1997 and Randy Vaila and Doug Kahn in 1990 had looked at excision in about six to eight months. And their recommendations are, once you have tissue equilibrium, fractures healed, scar is supple, soft tissue beds quieted down, there's no progression of HO, it's quite mature. And patients plateau with therapy, they try everything they can, that's when it's time. So case one, this patient did not have NSAIDs, did not have XRT due to risk of a nonunion. Also with open fracture, concerns of wound healing issues. So by the time she got to me, the fracture was healed, the scar was supple, She's really plateaued with therapy. So felt that was the right timing for surgery. I do routinely get XRT. Typically these are scheduled in the afternoon. They see the radon service a day of surgery in the morning for a single dose of XRT right over the surgical site. How do you get there? Really three standard approaches. Looking at the lateral approach to the elbow, Kaplan between ECRL, EDC, Cochrane between EC inconeus and the Boy-Anderson approach, which is more posterior along the subcutaneous border of the proximal ulna. So these are standard approaches. Again, the Kaplan approach on the far left and the Cochrane approach on the right, which is much more posterior. You're staying just posterior to the lateral collateral a little bit more complex. The Boy-Anderson approach is probably my go-to majority PRUJ, synostosis takedown. Certainly taught to me by my senior partner, Dr. Hannel. You're basically going along the subcutaneous border of the proximal ulna. The inconeus EC is reflected anteriorly to get you right down to the proximal ulna and proximal radius. You can incise the supinator as posteriorly as possible, or you can simply just take your perioste to elevate or really try a subperioste to elevate the muscle along the proximal ulna until it gets to the area of the HO and the synostosis. It's really important to keep in mind any type of dissection in this region, whether you're doing a Kaplan, a Boy-Anderson, or a Cochrane approach, keep it foreign pronated. The PI is about 50 to 55 millimeters distal to the joists, so much more distal. But if you're in a supinated position, the PI is much more proximal and more at risk with any work around the bicep or tuberosity. As far as approaches for me, a type 3, a 3B over the tuberosity, my go-to is probably more of a Boy-Anderson approach. If you're looking at directly over the radial head, though, I do like to go Kaplan, get directly on the radial head. Again, keep in mind, keep it foreign pronated and probably stop short of the tuberosity if I could help it, or if I'm gonna go beyond the tuberosity, make sure the PI is dissected free and protected as well. This is a case series by Jupiter and Ring, 18 limbs, 17 patients, type A, B, and C. In their case series, no XRT, no endosymbiont form rotation was 139 degrees. So the patients did quite well with only one case recurrence. They did recommend initially doing interposition in a fat graft that's not vascularized, but they have cases where extruded. So in their discussion, they actually do not recommend any type of interposition material in the PRUJ. A couple of different options that are out there that have been described. So my colleagues here at Harborview, Jeff Friedrich, Doug Cano, described using TFL as an interposition graft at 13 patients, and actually had really good, excellent outcomes at 10 out of 13 with form rotation more than 100 degrees. So I do like having something in between there. The literature does not support any type of interposition material, but for me, this makes sense. This is my go-to for interposition. Dipofascial flaps are also described. Neil Jones has a case report. A couple of other case series out there looking at adipose flaps to try and again, buffer that interface between that raw bone between the proximal radius and proximal ulna. So this patient had two weeks post-op, HO take down, and TFL interposition. Again, we did do a pre-op XRT, a single shot. Three months post-op, she came in, supination is 80 pronation was actually zero degrees to neutral. Interesting, you try and passively rotate her forearm. She was tied not over the elbow, but over the DREJ, preferably tied more distally. So I actually took her back to the OR for a revision contracture release. PREJ actually released it over the dorsal DREJ capsule. I think she had prolonged contracture. So the DREJ joint capsule was actually quite tight. So entropically, we were able to reach full pronation supination. So at six weeks post-op after revision surgery, quite happy, went back to work as a hairdresser. So really kind of keep that in mind, the initial pathology injury could be more proximally, but patients who have a fixed contracture can develop contracture and capsular synchrony over the DREJ as well. Cases where you have a destruction of the radial head as well as the capitella might want to consider radial arthroplasty. And in cases where you really don't have a lot of tissue planes to work with, this is essentially a reverse salvicopology. You're essentially performing a fusion of the PREJ more proximally and do segmental excisions at proximal radius, about one centimeter segment to create a pseudo joint of the PREJ. And I'm gonna go out to the second case, 62 year old female, or I have dysphagia on the Ethiopia about two years ago. Came in to us, form is fixed in 20 degrees of pronation, quite a bit of pain over the wrist as well. Wrist flexion 20, extension 30 degrees. As the patient that came to us initially, again, you can see synostosis between the radius ulna just proximal to the segment notch. Did a dorsal ulnar approach over the fifth dorsal compartment, used a saw to remove the HO in between. In this case, actually put a Achilles interposition graft in between her radius ulna and kind of docked it in place using suture anchors in the radial shaft. Alarm splint for six weeks and supination. Two weeks post-op, three months post-op, pronation 40, supination 10. So still very, very, very limited form rotation. She had quite a bit of pain, which made therapy quite difficult for her, but we got into about 40 of pronation, 30 of supination. So unfortunately she came back. Worsening wrist pain, eight out of 10. No new trauma, but severe pain over her distal ulna. Pronation is 45, supination 20. And this is her January, 2021. You can see there's a fracture through her distal ulnar shaft. It's really unknown if this is related to the interposition graft and kind of any type of scalloping there. She had to work up her infection. It was negative. Tried to treat this in a cast. So two months with cast immobilization, she had resorption over her ulnar shaft. So that area's kind of melted away. So now we're looking at DHE arthritis. All the fracture going on to nine union. So for me, I think the main options are a DERA resection, a very, very aggressive DERA. That's quite proximal versus saliviculopalgy since she essentially has created a segmental defect in ulnar shaft as well. But with the concerns of kind of rehab process, I really want to do a saliviculopalgy. I think concerns of a union, maybe not happening. So she actually ended up with a DREA arthroplasty with a prosthesis. She's now a one-year post-op, still in pain, unfortunately, but her rotation is excellent. So pronation is 60, supination is 70. Her pain is actually managed quite well with the anti-inflammatories. So in summary, synostosis is quite common, especially with a proximal, both from fracture and high-energy trauma, especially with a head injury. I think as far as timing of surgery, the scar is mature. The fracture is healed. You can proceed with HO takedown. You might want to consider a pre-op XRT and periodic synostosis. And for me, if it's more proximal, it's a Kaplan approach, more distal vitubrosity, a Boy Anderson approach. In case of joint destruction, consider some type of arthroplasty, either proximally or distally. Yeah, that's all I have. All right, let's see if there are any questions from the Q&A. I don't think there are any there. So I have a couple of questions for Dr. Wang and Dr. Bauer. So now you kind of mentioned, this is a lot more common to pediatric population versus adults. So in the pediatric population, how do you decide between going ahead, doing osteotomy and waiting for skeletal maturity? And also, when do you go after the physis? When do you kind of wait it out? I'm gonna start with, I guess, Dr. Wang and Dr. Bauer. Andy, do you want to talk about the physio part first? Sure. Yeah, I mean, I think that's a great question. And I think it's one that the longer I'm in practice, the more it comes up and I don't know the answer. I think that just because of physio, I think the first step is to screen everybody at six to nine months after a physio fracture. I think the kids who get into trouble, just like Dr. Wang was talking about, the kids with ligamentous laxity having more trouble with malunions. I think that's absolutely true. I think it's the tall kids that have more trouble with physio fractures. So, it's the 14, 15-year-old who then is gonna grow a ton still in those teenage years. I think the physis is more vulnerable as it's closing. Perhaps that's a more difficult injury for the physis to overcome than like a 10-year-old soldier hair is too. And then if those kids, if I had that fracture, it would not have been a problem for me. I was done growing at 14 or 15, but the kids who continue to grow until 17, I think those are the ones that are an issue. And so, when I do those checks, I look at their growth chart too. And so, if I see one of those kids back, the physis are still open and they haven't grown since the fracture, actually, even though it's been six months, I might consider seeing them back again. The other thing that I think is really helpful is looking at the change in variance. So, I always pull up the past x-ray. And so, even if they're at a neutral variance, but they used to be on a negative, again, that might be somebody that'll fall for an additional six months. And sometimes it's just a blip. The physis will seem like it's not growing and you see them again in six months and it's resumed. I think, because I will continue to follow them until I know that there's a problem, but I think there's a lot of ways it can go from that six-month time point still. Great, thank you. I think for the young adult or the older adolescent, it does also have to deal with how much growth they have left. But most of these osteotomies are gonna be diaphysial. So, I won't worry as much about it if it's a diaphysial problem. If it's closer to the growth plate, I might give them a little bit more time. But the first case I showed, he was 15. So, probably not totally done, but most of the way there. Yeah, it's a little tricky to predict when they're still growing. But if the osteotomy is gonna be in the diaphysis, I don't think it's as much of an issue. If you do an osteotomy on a kid that's almost done growing, let's say you do a initiative radial osteotomy, do you proceed with a epiphysiodesis just to make sure you don't have continued abnormal growth between the radius and ulna? What's your approach for that? I think it depends how far off they are. If it's pretty close, I probably won't within a few millimeters. If it's obvious, then yeah. Or even a ulnar shortening osteotomy if you're talking about something more uneven at the wrist. And one of the questions actually for all three of you, how do you decide between freehand versus a 3D guide? I think the guides are so good now. The 3D model is so good. Certainly makes it easier, but cost is a consideration, especially with insurance companies. How do you guys decide between, is it based on amount of deformity, based on something that's both rotational so angular deformity as well? How do you decide in your own practice? I mean, I think for me, it's really the site of the body. If it's something where a geographic operation is appropriate, proximal humerus, distal humerus, where you could have a significant amount of translation at your osteotomy site and it's gonna be fine, you're just going for a geographically straight part of the body, then I think 2D is much simpler. I tend to gravitate towards the 3D and the forearm because a geographic operation is not okay. We're looking for precision there. And I think that's where it's just, it's very helpful and it's so much faster. I think you're easily saving $5,000 of OR time to cover the $5,000 case fee. What about you, Mark? Yeah, I totally agree with that. I think it used to be very dichotomous for me, like whatever this means, the easy ones, no, the hard ones, whatever that means, right? But there was very little gray zone probably, and it was a small bucket of the hard ones, but the more of those that I've done, the more I have realized that, I'll speak for myself, I'm not as good as I thought I was at doing that. So I've gone more towards the 3D ones because I think you do make up some of the time in the OR, like every single one of these I've done has been one tourniquet. And I think that that is something, especially when you have the forearm fileted open for so long on some of these cases, the precision is exactly what we're going for, like Andy said. And when there's rotation involved, I think the literature that Angela was showing is exactly right, where the two-dimensional stuff we're pretty good at, the third dimension we're not very good at. So if rotation is really important to the outcome of the case, I'm much more likely to do 3D planning at the very least. That's great. And Andy, you mentioned your case, just only a single fluoro shot, 90 minutes of tourniquet time for a double osteotomy. That certainly saves a lot of OR time, a lot of anxiety and sweat in the OR as well. Yeah, and Jerry, I would say that I think the surgeon's investment in time is probably similar because you're doing all your thinking outside of the OR, but it's much more peaceful. You can be doing it while wearing your pajamas at home instead of scrubbed in with racing the tourniquet and racing anesthesia, racing all the other stresses of the OR. So it's still a thinking person's operation, but you're taking that to an area that is, you can talk to friends, you can talk to colleagues, you can think twice about things and be okay with it. So I'm gonna, if it's okay, Megha, I'm gonna do the cases really fast, kind of rapid fire through the faculty. I have two cases, one is a malunion, one is a non-union just to kind of see what they would do really fast. Okay. So I'll kind of rapid fire this for you guys. Can I see the screen there? So this is very similar to Dr. Wang's case earlier. It's 15-year-old high school kid, so same age, presented popping over the outer head, fell off a horse two years ago, had cast treatment of a left wrist fracture. And last year, his symptoms got worse with popping and DREJ weakness and instability. This is a patient two years ago, you can see a distal radius fracture, maybe a salter too, that's now gone on to a malunion with apex vullar angulation and DREJ instability. So kind of for kind of the group, what do you think as far as more imaging? What would you think as far as management at this stage? Patient's 15, the last couple of years it's gotten worse. His physis is wide open. Would you wanna wait it out or would you look at treatment at this stage? Dr. Wang. I think he looks close enough to skeletal maturity that I would probably go for it if he's symptomatic. And also I think that you could stay far away from the physis for any growth that's left. So I would treat him now. So interesting, so three days later after being seen by actually a colleague, so he came to me as a third opinion, but three days later he fell and now has a radial shaft fracture. That's more proximal. So it's pretty mainly displaced. Do you treat this or do you leave it alone? I would say- You all look good. What would you do? Andy, what do you think? I would just say this, when you showed the first one, it's like, oh, that seems pretty simple. And then you showed this and I'm like, okay, that really messes it up. So I think you're probably leaning towards fixing him before he did this. And now I think this absolutely buys him a procedure. Would you guys plate the radial shaft that's an acute fracture now? Or would you let that heal and then deal with everything at the same time? I think I would plate it and then try to correct his malunion at the same time. Like I would just do it now with the acute fracture. But also try to correct the original problem, yeah. Yes. So you would try and do both at the same time? Yeah, I think I would wait and then try to do both at the same time. But yeah, I think you try to avoid two operations for this. Yeah, so he came to me actually four weeks after he broke it. So that was at the outside hospital. So this is him now. So question becomes, do you do the surgery now? And what do you want to do as far as corrective osteotomy? Do you do this freehand? Do you get to be put to guide? And then should there be epiphyseal desens performed at the same time? He's almost closed his visors, but not quite there. So vote for 3D guide. I do. Do you guys, would you wait longer for him to grow? He's 15 now, going on 16. Okay. No. I think so. All right. So just for sake of time, kind of a ballistic injury, Marcat went earlier. I got you a couple of them with a big forearm wound, decreased sensation. Actually went through the EDC muscle belly as well. Extensive disruptive EDC muscle. Segmental defect of the PIN as well. Or I have the left forearm. So they actually went in there, remove all the bony fragments. They use the anatomic plate. So question for the faculty, when is the defect too big for Mascalet versus a vascularized bone grafting? What would you guys do for this? I think Mascalet would say nothing is too big for a Mascalet technique. Higher arm. Exactly. This would be a free fib for me. It sounds like it's soft tissue injury. So you can make up for some of that defect with an osteocutaneous fibula. It's much more peaceful to see that structural bone there than to watch that other bone incorporate and think it's not structurally sounding up like that regenerate bone that you worry about. So I would do a free fib with the skin paddle, of course. And then probably tendon transfer. If his EDC and his PIN are both out, he's gonna get tendon transfers later. So I wouldn't even worry about the nerve, I think. How about you, Angela? Would this be a Mascalet in your hands or do you think you would lean towards vascularized bone grafting for this one as well? I do a free fibula with the skin on this. Yeah, I think the soft tissue defect, a pretty large defect certainly came into play for this particular patient. So wound back multiple times. You can see how he looks now. And by the time they did multiple back changes, actually not as bad as far as the soft tissue defect, but still not great. So kind of for respecting everybody's time. So did end up with a vascularized fibula. This was done by my colleague, Dr. Miller, with the skin paddle, as you guys mentioned. And kind of intraoperatively, they actually hooked it up to read artery more proximally and kind of inserted it in there. Unfortunately, I don't have kind of post-op clinical photos, but this is what the patient looks like now. Well, thank you so much, Dr. Bauer, Dr. Richer, and Dr. Wang for joining us this evening and taking time to teach us about malunion and nonunion. Really appreciate you joining us. Thank you. Thank you. Thank you very much. I'm gonna double check the Q&A. I think otherwise. Yeah, the only question that came up on the Q&A is just recommendation for timeline for therapy. I think for me, certainly, once you get stable fixation after a synostosis, I recommend doing therapy pretty early on, typically two weeks at the latest, maybe one week post-op. Thank you again. Have a great evening, guys. Thank you so much. See you guys. All right.

orthopedic surgeons

treatment

malunion

nonunion

children

adults

3D imaging

corrective osteotomies

decision-making process

treatment options

Masque Lay technique

vascularized bone grafts