Persistent Radial or Midcarpal Malalignment after Corrective Osteotomy Does Not Affect Functional Outcome

Background: Distal radius malunion accompanied by increased dorsal angulation tends to alter wrist biomechanics, leading to a range of carpal malalignment patterns, which may affect both the radiocarpal (radiolunate) and midcarpal (capitolunate) joints. One type has radiocarpal malalignment with an aligned midcarpal joint, and the second type has midcarpal malalignment with an aligned radiocarpal joint. Previous studies have demonstrated that corrective osteotomy tends to restore normal radiocarpal and midcarpal alignment. However, we observed that radiocarpal and midcarpal malalignment persist in a subset of patients, despite appropriate correction of the malunited distal radius. The primary aim was to assess the effects of postoperative persistent carpal malalignment on functional outcomes by comparing the Patient-Rated Wrist Evaluation (PRWE) of patients with and without persistent radiocarpal or midcarpal malalignment following a corrective osteotomy of the distal radius. Methods: For this retrospective study, we screened all consecutive adult patients who had an extra-articular corrective osteotomy between January 2019 and 2024 for a distal radius malunion. Radiocarpal and midcarpal malalignment was assessed on pre- and postoperative radiographs by two researchers. The PRWE was evaluated during the standard postoperative follow-up. Results: This study showed that PRWE scores of patients with carpal malalignment did not differ from those of patients with normal carpal alignment, both preoperatively and postoperatively. Furthermore, the prevalence of all types of malalignment decreased following the corrective osteotomy, and all patients reported improved hand and wrist function, with a median improvement of 50 points on the PRWE. Conclusions: Midcarpal malalignment is common in distal radius malunions and may exist simultaneously with radiocarpal malalignment. Despite the presence of malalignment, all patients experienced improved function after the corrective osteotomy. Therefore, we conclude that persistent radial or midcarpal malalignment following a corrective osteotomy does not have an adverse effect on functional outcome. Level of evidence: Level III (Therapeutic).