Three-Dimensional Surgical Planning and Patient-Specific Osteotomy Guide in the Management of Chronic Monteggia Fracture: A Case Report

Introduction

Monteggia fracture-dislocations involve a fracture of the proximal ulna with dislocation of the radial head [1] and are commonly seen in pediatric patients but can also occur in adults [2]. While acute cases in adults are typically managed with open reduction and internal fixation, delayed diagnoses or non-anatomical reduction of the proximal ulna fracture may lead to chronic Monteggia lesions characterized by radial head dislocation, ulnar malunion, progressive joint dysfunction, and disabilities [2, 3].

Corrective osteotomy remains the cornerstone of treatment for chronic Monteggia injuries [4, 5]. In recent years, the application of three-dimensional (3D) technology encompassing virtual surgical planning, patient-specific cutting guides, and custom implants has gained popularity in complex deformity correction across various anatomical sites [6, 7].

Here, we report a case of chronic Monteggia fracture-dislocation in an adult patient successfully managed using 3D-assisted pre-operative planning and a patient-specific osteotomy guide, adding to the emerging evidence on the role of this technology in upper-limb malunions.

Case Report

A 24-year-old male presented with a 1-year history of persistent right forearm pain. He had sustained a Monteggia fracture of the right forearm approximately 1 year prior, initially managed at another institution with open reduction and internal fixation with small dynamic compression plate fixation (Fig. 1a) and subsequently implant removal after fracture union (Fig. 1b). Despite these interventions, he continued to experience pain and dysfunction. Clinical evaluation (Fig. 1c) revealed limited elbow flexion and pronation. The patient, however, experienced pain and discomfort while performing daily activities. The radiographs revealed malunion of the proximal ulna with anterior dislocation of the radial head, consistent with a chronic Monteggia fracture-dislocation (Bado type I) of the right elbow [8].

Discussion

Chronic Monteggia fracture-dislocations remain a formidable challenge in orthopedic practice due to delayed diagnosis, malunion of the ulna, and persistent radial head dislocation. These lesions, particularly Bado type I injuries, often present with pain, limited range of motion, and joint instability, significantly impairing function [9]. In such cases, reconstructive strategies must address both osseous deformity and soft tissue imbalance to restore normal biomechanics and prevent long-term complications.

The cornerstone of surgical management in chronic Monteggia lesions is corrective ulnar osteotomy [5]. However, traditional techniques often rely on intraoperative judgment and fluoroscopic guidance, which may lead to suboptimal alignment or increased operative time. Historically, corrective osteotomy for chronic Monteggia lesions was performed freehand, using fluoroscopic landmarks to estimate the osteotomy plane and angulation [2,10]. Techniques such as closing-wedge, dome, or step-cut osteotomies have been described, but their success depends heavily on intraoperative experience and remains susceptible to residual malalignment or recurrent subluxation [2,11]. The overarching goal in managing these injuries is to restore ulnar length and alignment to allow stable reduction of the radial head with congruent radiocapitellar articulation [3]. The conventional treatment algorithm begins with ulnar osteotomy and fixation, followed by assessment of radial head stability. If reduction is unstable, adjunctive procedures such as annular ligament reconstruction or temporary transcapitellar pinning are employed [12]. In enduring or irreducible cases, salvage options such as radial head excision or prosthetic replacement may be considered, though they are reserved for refractory cases due to concerns about long-term joint function [3,13].

In this case, we utilized three-dimensional (3D) technology to overcome the limitations of traditional management. In recent years, 3D-assisted techniques have been increasingly applied in upper-limb deformity correction, particularly for distal radius, forearm, and humeral malunions [7]. Pre-operative CT data can be converted into virtual models, enabling accurate assessment of deformity and simulation of corrective osteotomies. Patient-specific guides allow precise transfer of the surgical plan to the operative field, reducing reliance on intraoperative estimation and fluoroscopy. Several series have demonstrated that 3D planning improves accuracy of correction, reduces operative time, and facilitates early functional recovery compared to conventional freehand osteotomies [14,15 16].

Although the application of 3D printing has been increasingly reported in the correction of upper extremity deformities, such as distal radius and forearm malunions, there is a relative paucity of literature focusing specifically on chronic Monteggia fracture-dislocations [11,12]. Only a small number of prior reports, most notably a two-case series describing custom-made surgical guides for malunited forearm fractures with associated radial head dislocation [16], have specifically addressed 3D-assisted correction in this injury pattern. Unlike these prior reports, the present case combines a patient-specific osteotomy guide with a custom-matched bone plate and concurrent annular ligament reconstruction within a single reconstructive strategy for a chronic Monteggia lesion, specifically, a combination not previously described for this injury. Our case supports its potential role in improving anatomical accuracy, joint congruency, and overall functional outcomes in this challenging subset of elbow pathology.

Despite the initial success, our patient developed oligotrophic non-union at the osteotomy site. This was likely multifactorial, with the patient’s continued smoking being a significant contributor. Smoking is well-established as a negative modulator of bone healing, and its impact in the context of osteotomy should not be underestimated [17]. Revision surgery with repeat autologous bone grafting ultimately led to union and satisfactory functional recovery. Thus, this case also underscores the importance of addressing modifiable risk factors, such as tobacco use, during pre-operative counseling and post-operative follow-up.

Furthermore, our case incorporated a comprehensive surgical approach combining osteotomy, annular ligament reconstruction, and temporary radiocapitellar pinning. This multimodal strategy likely contributed to early stability and radial head relocation. The use of radiocapitellar pinning, although debated in the literature, provided temporary stabilization, and facilitated ligament healing in our patient [18,19]. An additional aspect highlighted by this case is the importance of interdisciplinary cooperation between surgeons and biomedical engineers in the application of 3D technology. The accurate design of patient-specific guides and implants relies on meticulous communication of clinical requirements to engineers, while surgeons must interpret and validate the virtual plan for feasibility in the operative field. Prior studies in orthopedic oncology and complex limb reconstruction have emphasized that such collaborative workflows improve accuracy, reduce intraoperative uncertainty, and ultimately translate into better functional outcomes for patients [7,14,15].

Conclusion

The successful outcome in this case suggests that 3D-assisted surgical planning may be particularly beneficial in chronic Monteggia injuries where conventional alignment techniques may fall short due to prior surgical alterations or complex deformity, achieving anatomical ulnar alignment and successful radiocapitellar relocation through precise pre-operative simulation and a patient-specific guide. However, the subsequent development of a post-operative non-union in this patient, who continued smoking throughout treatment, underscores that personalized surgical guides must be coupled with strict adherence to biological optimization, particularly tobacco cessation, to achieve reliable union. As 3D printing becomes increasingly accessible and cost-effective, its role in upper-limb reconstruction, particularly in individualized deformity correction, is likely to expand, though larger studies and long-term follow-up are needed to validate its routine use and assess cost-effectiveness compared to standard methods.

Clinical Message

Patient-specific 3D surgical planning and osteotomy guides can improve the precision of corrective ulnar osteotomy and radial head reduction in chronic Monteggia fracture-dislocation. This technical precision must nonetheless be paired with rigorous biological optimization, particularly pre-operative and post-operative tobacco cessation, to achieve reliable bone union.

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About the Authors

• 

  Dr. Abhishet Varama

• 

  Dr. Chittawee Jiamton

• 

  Dr. Natthaphat Viriya

• 

  Dr. Chedtha Puncreobutr

• 

  Dr. Boonrat Lohwongwatana