Ulnar shortening osteotomy with a new sliding-hole plate

Ulnar shortening osteotomy represents a common procedure for surgical treatment of the ulnar impaction syndrome but is still associated with complications like malrotation, angulation, or malunion because of incomplete closure of the osteotomy gap. Therefore, the authors developed a special 7-hole compression plate that allows fixation of the ulna before the osteotomy is carried out to prevent rotation. With this plate, a shortening of up to 10 mm is possible and the compression holes allow closure of the osteotomy gap. The plate has been used in 23 ulnar shortening cases at their center with good results. The authors describe the technique and report their results of ulnar shortening with this device.     

Die Ulnaverkürzungsosteotomie mit der neuen 7-Loch-Gleitplatte

BACKGROUND: Ulna shortening osteotomy is a common procedure for the surgical treatment of ulna impaction syndrome, but it is still associated with complications such as rotation malalignment, and delayed or non-union due to of incomplete closure of the osteotomy gap. METHODS: We have developed a 7-hole titanium compression plate that provides fixation of the ulna before the osteotomy is carried out. With this plate, which has been in use for 4 years, a shortening of up to 10 mm is possible using two gliding holes, with the compression holes enabling the closure of the osteotomy gap. We report the results of 70 patients undergoing 70 ulna shortening procedures, with a follow-up of between 5 and 18 months. Two patient groups underwent follow-up clinical examination as well as completing the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire for evaluation. RESULTS AND CONCLUSIONS: There was no occurrence of delayed or non-union. The DASH score averaged 19 points in the prospective and 23 points in the retrospective group, representing a good functional result with only minor impairment. This study indicates that ulnar shortening using this gliding compression plate and performing an oblique osteotomy is associated with a minimal complication rate and highly satisfactory clinical outcome.     

Simultaneous radial closing wedge and ulnar shortening osteotomies for distal radius malunion

PURPOSE: Closing wedge osteotomies are an attractive treatment option for distal radius malunion in patients with osteopenia; however, they require an ulnar head resection to accommodate closure of corrective osteotomy and to address the issue of ulnocarpal abutment. The literature contains little information on concomitant ulnar shortening osteotomy despite a physiologic solution. We report the functional and radiographic outcomes of 5 patients treated for symptomatic distal radius malunion with simultaneous radial closing wedge and ulnar shortening osteotomies. METHODS: All 5 patients were women aged 52 to 69 years (average, 61 years). Four patients had extra-articular radius fractures with dorsal angulation (20-22 degrees ) and shortening (3-7/mm); the other had the fracture with volar angulation (24 degrees ) and shortening (11 mm). Through a volar approach an appropriate amount of bone wedge was removed from the distal radius. A small volar T-plate was used to secure the osteotomized bone fragment. Six to 11 mm of ulnar shortening osteotomy was performed by using transverse osteotomy and compression plating technique with an AO compression device. RESULTS: In all 5 wrists healing of radial and ulnar osteotomies occurred less than 3 months after surgery. There were no postsurgical complications. Postsurgical radiographs showed that the volar tilt angle of the radius was reduced to normal range (range, 8-15 degrees ) in all wrists. The ulnar variance was 0 mm in 4 wrists and 2 mm in 1 wrist. There were significant improvements in pain, function, and range of motion at an average follow-up evaluation of 17 months. The average grip strength as a percentage of the opposite side improved from 30% before to 73% after surgery. CONCLUSIONS: This study showed that closing wedge osteotomy of the radius concomitant with ulnar shortening osteotomy is technically and functionally adequate. Our procedure is indicated for patients with osteopenia for whom opening wedge osteotomy of the radius is inadequate.     

Mid-Term Results Following Ulna Shortening Osteotomy

Background

Successful short-term results of diaphyseal ulna shortening osteotomy are documented in both idiopathic and post-traumatic ulnar impaction.

Questions/Purposes

The purpose of this study was to evaluate the mid-term outcomes of ulnar shortening osteotomy with respect to radiographic assessment of corrected alignment and healing as well as patient satisfaction, pain, and function assessed using the Disability of the Arm, Shoulder, and Hand (DASH) score.

Patients and Methods

This retrospective case series included follow-up of 33 patients with ulnar impaction syndrome following ulna shortening osteotomy at a minimum of 5 years. Patient-rated outcomes included satisfaction, pain assessment, and DASH score. Pre- and postoperative radiographs were reviewed to quantify ulnar variance and osteotomy union rates. Subsequent operations were also recorded.

Results

Average follow-up was 10 years (range, 5–20 years). Eighty-eight percent of patients reported they were either satisfied or very satisfied with the procedure and 91% reported they would have the same procedure again. Average pain rating was 2 out of 10 at final follow-up. The mean DASH score was 11 (range, 0–39). Removal of hardware was performed in 10 patients (30%). The overall rate of reoperation was 45%.

Conclusions

Ulna shortening osteotomy yields reliable midterm satisfaction and pain relief in patients with idiopathic and post-traumatic ulnar impaction syndrome. Reoperation is frequent. Consistent with results of short-term follow-up, plate irritation requiring removal remains the most common cause for reoperation over time.     

Ulna shortening osteotomy using a compression device

PURPOSE: To report the functional and radiographic outcomes of a cohort of patients treated for ulnar impaction syndrome with a single technique of ulnar shortening osteotomy. METHOD: We performed ulnar shortening osteotomy on 18 consecutive patients over a 10-year period by using an oblique osteotomy and compression plating technique with an AO compression device (Synthes, Paoli, PA). There were 11 men and 7 women in the series, with an average age of 32.7 years. All patients were graded before and after surgery with the modified wrist grading system of Chun and Palmer. RESULTS: All 18 osteotomies healed over an average of 6-8 weeks. There were significant improvements in pain, function, strength, and range of motion at an average follow-up of 3 years. Thirteen wrists were graded excellent, 3 good, and 2 fair. There were no postoperative complications, however, 8 patients ultimately required plate removal for local discomfort. CONCLUSIONS: This study showed that ulnar shortening osteotomy using an oblique osteotomy and an AO compression device is easy to execute and is associated with satisfactory outcomes. Healing time is rapid and postoperative cast immobilization is not required.     

Radial osteotomy for Kienböck disease

Of various surgical treatments, radial shortening for patients with negative ulnar variance and radial wedge osteotomy (radial closing osteotomy) for patients with 0 or positive ulnar variance are widely accepted for the treatment of Kienb?ck disease. Long-term follow-up studies have shown more than 10 years lasting satisfactory pain relief, as well as an increase in wrist range of motion and grip strength. As representative surgical procedures, the techniques of radial shortening by transverse osteotomy, using a locking compression plate for internal fixation, and radial wedge osteotomy by step-cut osteotomy, using a small dynamic compression plate or locking compression plate, are described. One important point of radial wedge osteotomy is that resection of simple wedge bone yields a decrease in ulnar variance; therefore, we recommend trapezoidal bone resection with ulnar height of 1 mm for transverse osteotomy at the metaphysis and ulnar height of 2 mm for step-cut osteotomy at the distal fourth of the radius.     

Oblique ulnar shortening osteotomy with a new plate and compression system

Ulnocarpal abutment or the ulnocarpal impaction syndrome occurs when excessive loads exist between the distal ulna and ulnar carpus. This overloading occurs as a result of the distal ulnar articular surface being more distal than the ulnar articular surface of the distal radius. This situation has been termed positive ulnar variance, and it can quickly lead to ulnar-sided wrist degenerative changes and functional losses. Patients often have vague, ulnar-sided complaints of chronic pain and swelling with an insidious onset that does not correlate with any specific traumatic event. Many procedures have been developed to alleviate this condition, but the gold standard for correcting positive ulnar variance is the ulnar shortening osteotomy. The goals of the shortening procedure are to relieve pain and prevent arthritis by reestablishing a neutral or slightly negative ulnar variance. We describe a new plate and compression system in which an oblique ulnar diaphyseal osteotomy is both completed and stabilized through the same jig-based system.     

Ulnar Shortening Osteotomy: Are Complications Under Reported?

Ulnar shortening osteotomy is an accepted treatment for ulnar impaction syndrome and numerous techniques for have been described in the literature. We present our single surgeon case series over 10 years of oblique ulnar shortening osteotomy using a jig technique. A review of the current literature with reference to the risk of complications is included. All patients undergoing ulnar shortening osteotomy from 2001 to 2011 were identified and case-notes were reviewed retrospectively. Risks of complications included metalwork irritation (51 %), non-union (6.3 %), refracture (1.6 %) and chronic regional pain syndrome (1.6 %). Oblique ulnar osteotomy using a jig technique is reliable and reproducible in shortening the ulna and maintaining alignment, rotation and compression at the osteotomy site. Symptoms improved in the majority of patients. However, the morbidity associated with the procedure may be underestimated as highlighted by our complication rates. Surgeons should counsel patients appropriately when offering ulnar shortening osteotomy.     

Ulnar shortening

Ulnar shortening is a procedure that has steadily grown in popularity over the past decade. This technique was originally introduced to treat ulnar impaction following a displaced distal radial fracture. However, indications for ulnar shortening have increased over the years to include luno-triquetral tears and early degenerative arthritis at the distal radial-ulnar joint. Today the operation is more precisely performed due to technologic advances in surgical equipment. These advances include a specialized saw guide that allows the creation of perfectly parallel surfaces at known widths, a compression device that permits the osteotomy surfaces to be easily approximated with the plate already positioned on the ulna, and a specialized ulnar slotted plate that allows an interfragmentary screw to be placed through the plate at a 22 degrees angle. In addition to stainless steel, titanium plates are available to coordinate with standard screw sets that are made of titanium. Healing of the osteotomy is very reliable with the advent of precision oblique cuts. The major drawback to ulnar shortening is the potential need to remove the plate due to its palpable position along the ulnar subcutaneous border.     

Ulnar shortening osteotomy in idiopathic ulnar impaction syndrome

BACKGROUND: Idiopathic ulnar impaction syndrome can be defined as a degenerative condition of the ulnar aspect of the wrist in patients with congenital or dynamic positive ulnar variance without a history of fracture or premature physeal arrest. The purpose of this study was to evaluate the clinical features of idiopathic ulnar impaction syndrome and the outcomes of ulnar shortening osteotomy for this group of patients. METHODS: Thirty-one wrists in twenty-nine patients with idiopathic ulnar impaction syndrome were treated with an ulnar shortening osteotomy. Ulnar variance was measured on an anteroposterior radiograph of the wrist, and radioulnar distance was measured on a lateral radiograph, with the forearm in neutral rotation, to evaluate any displacement of the ulnar head from the distal aspect of the radius. All patients were followed clinically and radiographically for a mean of thirty-two months. RESULTS: An average preoperative ulnar variance of +4.6 mm (range, 2 to 7.5 mm) was reduced to an average of -0.7 mm (range, -4 to +1 mm) postoperatively. Preoperatively, the modified Gartland and Werley score was an average (and standard deviation) of 69.5 +/- 7.6, with twenty-four wrists rated poor and seven rated fair. Postoperatively, the score improved to an average of 92.5 +/- 8.0, with twenty-four wrists rated excellent; five, good; one, fair; and one, poor. Dorsal subluxation of the distal aspect of the ulna was found concomitantly in nine wrists, and it was found to be reduced by the shortening osteotomy. Seven patients had cystic changes in the carpal bones preoperatively, but these were not evident one to two years after the operation. CONCLUSIONS: Ulnar shortening osteotomy improved wrist function in patients with idiopathic ulnar impaction syndrome and reduced the subluxation of the distal radioulnar joint, which is commonly found in these patients. Degenerative cystic changes of the ulnar carpal bones appear to resolve following the shortening osteotomy.     

Simultaneous radial closing wedge and ulnar shortening osteotomy for distal radius malunion

Closing wedge osteotomies are an attractive treatment option for distal radius malunion in patients with osteopenia. It does not require a separate-site bone graft, result-ing in decreased morbidity. However, this procedure has always been performed in combination with ulnar head resection to accommodate closure of corrective osteotomy and to address the issue of ulnocarpal abutment. Because ulnar shortening osteotomy is more physiological solution, it seemed advantageous to us to combine radial closing wedge osteotomy and ulnar shortening osteotomy. In this article, we present in detail our technique for treating patients with distal radius malunion. The patients are potentially osteopenic such as women aged over 45 years and are active at home, work, and/or recreation but are not involved in heavy physical work. Through volar approach an appropriate bone wedge is removed from the distal radius. A small volar T-plate is used to secure the osteotomized bone fragments. The aim of the radial osteotomy is to correct the dorsal angulation in the sagittal plane within a normal range of 1 degree to 2 degrees with reference to that of opposite wrist. Ulnar shortening osteotomy is performed by using transverse osteotomy and compression plating technique with an AO compression device. The ulnar variance is adjusted to neutral. Although the technique presented requires the surgeons to use careful plate and screw technique, early results have been encouraging, and patients with osteopenia can be treated successfully. Decreased grip strength which may be provoked by shorting of the forearm is acceptable.     

Mar shortening osteotomy in posttraumatic ulnar impaction syndrome

Twenty-eight patients (average age 45 years) with posttraumatic ulnar impaction syndrome underwent ulnar shortening osteotomy of 3–15 mm. Contributing factors were malunited fractures of the distal radius in 20, diaphyseal fractures of the ulna and radius in 6, resection of the radial head and a traumatic tear of the triangular fibrocartilage in 1 patient each. Evaluation at an average follow-up of 20 months showed a high rate of satisfied patients (89%), but according to Chun's modification of the Gartland-Werley score there were 1 excellent (3.5%), 11 good (39.5%), 11 fair (39.5%) and 5 poor (17.5%) results. Degenerative changes of the distal radioulnar joint were associated with fair and poor results, and ulnar shortening osteotomy is only recommended in ulnocarpal impaction with an intact distal radioulnar joint. Osteotomy fixation with 3.5 mm dynamic compression plates enabled immediate postoperative mobilisation and resulted in a low complication rate. There was no advantage for the technically more demanding oblique as compared with a transverse osteotomy.     

Clinical and experimental study of shortening osteotomy of forearm bone(s) in Kienb?ck's disease

Sixty-nine patients with Kienb?ck's disease were surgically treated from 1972 to 1987. Eleven patients with ulnar minus variance, 48 with neutral variance and 10 with ulnar plus variance were treated with shortening osteotomy of the radius. Ten patients with ulnar plus variance were treated with shortening osteotomy of both the radius and ulna. All cases were followed up from one to eleven years. Satisfactory improvement was attained in 85% of cases. Radiologic evaluation showed revascularization of the lunate in 94%. Collapse of the lunate did not progress in 60%. In 14 wrists of adult Japanese monkeys, ulnar minus and plus variants were created, and radial-ulna compression force was measured with intraarticular pressure sensors. Intraarticular forces were then measured following shortening osteotomy of the forearm bone(s). These procedures uniformly decreased pressure in the radial-ulna joint.     

Step-cut distal ulnar-shortening osteotomy

PURPOSE: Several techniques for ulnar-shortening osteotomies have been described in recent years, reflecting the difficulties that sometimes are encountered in what seems to be a relatively simple procedure. We describe the use of a simple step-cut ulnar-shortening osteotomy stabilized with a lag screw and a palmarly placed 3.5-mm neutralization plate. METHODS: Twenty-nine patients had the surgery. The indication was ulnar-impaction syndrome in 23 patients and symptomatic ulnar-plus variance secondary to trauma in 6 patients (4 with previous distal radius fractures, 2 with Essex-Lopresti injuries). The preoperative ulnar variance ranged from +1 mm to +6 mm. RESULTS: The mean follow-up period was 34 months. All osteotomies healed uneventfully. The mean postoperative ulnar variance was +0.2 mm (range, -1 mm to +1.5 mm). Three patients had hardware removal. CONCLUSIONS: The step-cut osteotomy resulted in solid union in all patients. It provides ample bone-to-bone contact and easier control of rotation, and no special instrumentation is necessary. Stable fixation permitted early mobilization of the wrist and palmar placement of the plate minimized the need for plate removal. This is a simple and effective technique for ulnar shortening.     

Isolated wedge osteotomy of the ulna for mild Madelung's deformity

PURPOSE: Madelung's deformity is a characteristic pattern of anterior-ulnar bowing of the radius and a dorsally prominent ulnar head. Even if this deformity is associated with a certain degree of functional impairment, patients are satisfied with their function and mainly complain about the appearance of their wrists. The purpose of this study was to report a new surgical procedure (shortening combined with a slight anterior angulation osteotomy of the ulna) aiming to improve the appearance of the wrist and to relieve pain if present without compromising the function of the wrist. This technique is suitable for mild cases of Madelung's deformity. METHODS: This is a retrospective study of 4 wrists in 3 patients. All patients had a mild form of Madelung's deformity (without any dislocation of the lunate). Even if it was not their primary motivation to have surgery, all of the patients preoperatively experienced some wrist pain. An anterior angulation and shortening osteotomy of the ulna shaft was performed through a dorsal medial approach and fixed with a dynamic compression plate. RESULTS: At 24 months follow-up, all of the patients were satisfied with the appearance of their wrists and forearms. The distal radioulnar joint was congruent radiologically in all cases, and the range of active pain-free forearm rotation improved. CONCLUSIONS: This technique seems to be safe and reliable in mild cases of Madelung's deformity.     

Surgical treatment for chronic radial head dislocation

BACKGROUND: The treatment of chronic radial head dislocation remains controversial. High rates of redislocation and complications have been reported after surgery. In our view, correction of malalignment with ulnar osteotomy is the key to a good surgical result. METHODS: Since 1975, twenty-two patients were treated surgically for chronic radial head dislocation at our hospital. The procedure consisted of open reduction of a dislocated radial head followed by radial and/or ulnar osteotomy, with or without reconstruction of the annular ligament or by reconstruction of the annular ligament alone. The ages of the patients ranged from four to twenty years. In 1991, we modified the surgical technique by performing an oblique ulnar osteotomy with angulation and elongation and rigid plate fixation. Bone-grafting at the osteotomy site was also performed if necessary. A cast was applied with the forearm in neutral rotation and was worn for two to four weeks. Nine patients were treated with this modified technique. RESULTS: The mean interval between the initial injury and the reconstructive surgery was ten months. There were no serious surgical complications. Of the thirteen patients treated before 1991, four had a good reduction and seven had redislocation. Seven patients had restricted forearm rotation postoperatively. Of the nine patients treated with the modified osteotomy since 1991, seven had a good reduction. Two patients, who had had slight radial head deformity preoperatively, had subluxation postoperatively. Two patients had restricted forearm rotation. CONCLUSIONS: Since we modified our technique for ulnar osteotomy, good reduction of the radial head has been achieved without causing serious contracture. Both angulation and elongation of the ulna are required to allow the radial head to reduce.     

Radial head dislocation due to gigantic solitary osteochondroma of the proximal ulna: case report and literature review

Developmental anterior dislocation of the radial head resulting from a congenital solitary osteochondroma of the proximal ulna is an extremely rare condition. We present a case of a 4-year-old girl with this condition affecting her right elbow, which was treated by a trapezoidal shortening osteotomy at the radial neck following an oblique ulnar osteotomy with angulation and elongation after a complete resection of the tumor mass. The child remained asymptomatic with symmetric carrying angles during 2.5 years of follow-up post-surgery. We discuss the nature of this condition and review the literature.     

Ulnar shortening with the ulna osteotomy locking plate

Objective

Ulnar shortening for ulnocarpal unloading using a new device enabling parallel osteotomy, rotation-secured compressive shortening, lag screw placement and hybrid stabilization combined in a solely locking plate construct.

Indications

Idiopathic ulnar impaction syndrome. Posttraumatic radial shortening without major tilting of the radius in the sagittal or frontal plane, rotation deformity and/or translation of the distal fragment.

Contraindications

Advanced arthritis of the distal radioulnar joint (DRUJ), DRUJ type?III according to Tolat, malunion of the distal radius with major tilting of the radius in the sagittal or frontal plane, rotation deformity and/or translation of the distal fragment.

Surgical technique

Mounting of the UOL plate system on the palmar surface of the ulna using standard ulnopalmar exposure. Two parallel 45° osteotomies are performed using an osteotomy guide followed by rotation secured shortening and compression. Stabilization is gained by inserting an interfragmentary lag screw perpendicular to the osteotomy site and applying locking and compression screws.

Postoperative management

Lower arm cast for 4?weeks until radiological signs of bone healing become apparent. To limit negative influence of rotational forces during bone healing, patients were instructed to limit forearm rotation up to 30° in pro-/supination.

Results

Sixteen ulnar shortening osteotomies were performed in 15?patients (6?men, 9?women, average age 49?years) and evaluated retrospectively. In 10?cases a trauma-related pathology was the indication for the procedure. The average follow-up time was 53?weeks (range 12?C93?weeks). Bone union was observed at a median of 10?weeks (range 6?C33?weeks). Overall good clinical results could be achieved with an average shortening of 3.7?mm (range 2.1?C16?mm). In this series, there was one nonunion.     

Ulnar shortening osteotomy for malunited distal radius fractures: results of a 7-year follow-up with special regard to the grade of radial displacement and post-operative ulnar variance

Introduction

The treatment of ulnar-sided wrist pain after malunited distal radius fractures remains controversial. Radial corrective osteotomy can restore congruity in the distal radioulnar joint (DRUJ) as well as adequate length of the radius. Ulnar shortening osteotomies leave the radius’ angular deformities unchanged, risking secondary DRUJ osteoarthritis. We supposed that, even within the widely accepted limit of 20°, a greater angulation of the radius in the sagittal plane correlates with a higher rate of DRUJ osteoarthritis. Furthermore, we suspected worse results from an ulna shortened to a negative rather than a neutral or positive ulnar variance.

Materials and methods

For this retrospective study, we reviewed 23 patients a mean 7.2 (range 5.6–8.5) years after ulnar shortening osteotomy for malunion of distal radius fractures. We compared 14 patients with up to 10° dorsal or palmar displacement from the normal palmar tilt of 10° to 9 patients with more than 10° displacement, and 15 patients whose post-operative ulnar variance was neutral or positive to 8 who had a negative one.

Results

Ulnar-sided wrist pain decreased enough to satisfy 21 of the 23 patients. Clinical results tended to be better when radial displacement was minor and when post-operative ulnar variance was positive or neutral. A shorter ulna significantly increased the rate of DRUJ osteoarthritis, whereas a greater degree of radial displacement only increased the rate slightly.

Conclusions

Radial corrective osteotomy should be discussed as alternative when displacement of the radius in the sagittal plane exceeds 10°. The ulna should be shortened moderately to reduce the risk of osteoarthritis in the distal radioulnar joint.     

Comparison of ulnar shortening osteotomy and the wafer resection procedure as treatment for ulnar impaction syndrome

A retrospective review was performed that compared the results of 2 different surgical treatments for ulnar impaction syndrome in 22 patients over a 6-year period. Ulnar shortening osteotomy and wafer distal ulna resection (wafer resection procedure) were each performed in 11 patients based on the preference of 3 individual hand surgeons. All patients presented with ulnar wrist pain and positive ulnar variance on either neutral rotation or pronated-grip x-rays and each failed conservative management. At a minimum follow-up time of 18 months, 9 patients had good to excellent results following ulnar shortening osteotomy compared with 8 following the wafer resection procedure. This difference was not statistically significant. All patients regained functional wrist motion and 21 of the 22 patients had satisfactory pain relief. There was 1 poor result in the wafer group that required revision to complete resection of the distal ulna. Five secondary procedures were required in the osteotomy group to remove painful hardware and union was delayed in 2 patients. Although ulnar shortening osteotomy provides effective treatment for ulnar impaction syndrome, the wafer resection procedure provides favorable pain relief and restoration of function but without the potential for nonunion or hardware removal. (J Hand Surg 2000; 25A:55-60.