Long-term Outcomes of Ulnar Shortening Osteotomy for Idiopathic Ulnar Impaction Syndrome: At Least 5-Years Follow-up

Background

There have been few outcomes studies with follow-up after performing ulnar shortening osteotomy for ulnar impaction syndrome. We investigated the long-term clinical and radiological outcomes of ulnar shortening osteotomy for the treatment of idiopathic ulnar impaction syndrome.

Methods

We retrospectively reviewed 36 patients who had undergone ulnar shortening osteotomy for idiopathic ulnar impaction syndrome for a mean follow-up of 79.1 months (range, 62 to 132 months). The modified Gartland and Werley scores were measured pre- and postoperatively. The radiographic parameters for the assessment of the distal radioulnar joint (DRUJ) as well as the relationship between these radiographic parameters and the clinical and radiological outcomes were determined.

Results

The average modified Gartland and Werley wrist score improved from 65.5 ± 8.1 preoperatively to 93.4 ± 5.8 at the last follow-up visit. The average preoperative ulnar variance of 4.7 ± 2.0 mm was reduced to an average of -0.6 ± 1.4 mm postoperatively. Osteoarthritic changes of the DRUJ were first seen at 34.8 ± 11.1 months follow-up in 6 of 36 wrists (16.7%). Those who had osteoarthritic changes in the DRUJ had significantly wider preoperative ulnar variance, a longer distal radioulnar distance and a greater length of ulnar shortening, but the wrist scores of the patients who had osteoarthritic changes in the DRUJ were comparable to those who did not have osteoarthritic changes in the DRUJ.

Conclusions

The clinical outcomes are satisfactory for even more than 5 years after ulnar shortening osteotomy for treating idiopathic ulnar impaction syndrome despite the osteoarthritic changes of the DRUJ. The patients who need a larger degree of ulnar shortening may develop DRUJ arthritis.     

Do triangular fibrocartilage complex foveal injuries affect the clinical outcome of ulnar shortening osteotomy for ulnar impaction syndrome?

BackgroundUlnar shortening osteotomy (USO), as its name implies, is used to shorten the ulna. It subsequently tightens the triangular fibrocartilage complex (TFCC) and ulnar wrist. TFCC foveal insertion is a primary stabilizer of the distal radioulnar joint. It is unclear whether USO is effective in TFCC foveal injuries. The purpose of this study was to review the clinical outcomes of ulnar shortening osteotomies with and without TFCC foveal injuries.MethodsWe retrospectively reviewed patients with ulnar wrist pain treated with USO and wrist arthroscopy including the distal radioulnar joint (DRUJ). Sixty-five patients were included in this study. An algorithm was used to guide surgical decision-making. After arthroscopic confirmation of ulnar impaction syndrome, we performed USO with a locking compression plate (mean length of shortening, 2.7 mm; range, 1–7.5 mm). The flattened TFCC disc due to ulnar shortening was confirmed arthroscopically. If the DRUJ was unstable after USO, we repaired the TFCC foveal insertion.ResultsThere were 32 post-traumatic and 33 idiopathic cases. We detected TFCC disc injuries in 34 wrists and TFCC foveal injuries in 33 wrists; both types were found in 15 wrists. TFCC foveal injuries were not significantly correlated with patient age, history of trauma, or clinical outcome. Most patients showed good clinical outcomes; 31 of 65 patients had preoperative DRUJ instability, with a significant number having foveal but not disc injuries.ConclusionUSO achieved reasonable outcomes, even in patients with TFCC foveal injuries. In cases demonstrating ulnar impaction, USO should be prioritized over TFCC repair.     

Ulnar shortening osteotomy for ulnar ideopathic impaction syndrome.

Twenty-eight patients were treated by ulnar shortening osteotomy for static or dynamic ulnar impaction syndrome. Ulnar variance was measured on a true anteroposterior radiograph. There were 25 wrists that were too long, two neutral, and one that was short. Bones were shortened by a mean of 3.5 mm. Mean follow-up time was 29 months (range 7-60), all with confirmed consolidation. At final follow-up mean grip strength had improved from 67% to 75%, mean Disabilities of the Arm, Shoulder, and Hand (DASH) score from 40 (range 12-83) to 26 (range 0-61) and mean range of movement from 80% (range 40%-100%) to 88% (range 50%-100%). Smoking, age at operation, type of osteotomy (transverse or oblique), dominance of hand, and sex did not influence consolidation or functionality. Special attention was paid to the anatomy of the distal radioulnar joint and the inclination of the sigmoid notch of the radius. There was no correlation between the anatomy and the functional outcome scores. Mean consolidation time (10 months) (range 2-32) and return to work were longer than in similar studies. Our findings confirm the usefulness of ulnar shortening osteotomy in the relief of ulnocarpal impingement symptoms.     

Treatment of Madelung's deformity in adults by ulna reduction osteotomy

PURPOSE: Adult patients with Madelung's deformity may present with ulnar-sided wrist pain. Treatment often involves addressing the distal radial deformity. If there is focal wrist pathology and a positive ulnar variance, however, then an isolated ulnar-shortening osteotomy may provide symptomatic relief in these patients. The purpose of this study was to report our results of ulnar-shortening osteotomy without radial osteotomy in adult patients with Madulung's deformity. METHODS: From 1988 to 2001 9 wrists in 9 adult patients with Madelung's deformity and ulnar-sided wrist pain underwent ulnar-shortening osteotomy. The distal radius abnormality was not addressed. All of the patients were women and the average age at the time of surgery was 34 years (range, 29-45 y). Two of the individuals were mesomelic dwarfs and the remaining 7 patients were otherwise normal. Surgery was performed after the patients failed at least 6 months of nonsurgical management. RESULTS: All patients had improvement of their symptoms at an average follow-up evaluation of 42 months (range, 6-112 mo). All of the osteotomies united. One patient required replating for a delayed union. There were no infections and no ulnar carpal subluxation. Ulnar-positive variance correction averaged 4.4 mm. Postoperative range of motion and grip strength were equivalent to the contralateral wrist. CONCLUSIONS: Ulnar-shortening osteotomy is a safe and reliable surgical procedure that can relieve ulnar-sided wrist pain in adult patients with symptomatic Madelung's deformity and positive ulnar variance.     

Ulnar shortening osteotomy with a premounted sliding-hole plate

BACKGROUND: Ulnar shortening osteotomy represents a common procedure for various ulnar-sided wrist disorders but is still associated with complications like malrotation, angulation, or nonunion because of incomplete closure of the osteotomy gap. We describe the use of a newly developed palmarly placed sliding-hole dynamic compression plate that allows fixation of the ulna before the oblique osteotomy is carried out. METHODS: We performed ulnar shortening osteotomy on 27 consecutive patients. The indication was ulnar impaction syndrome in 25 patients and symptomatic ulnar plus variance secondary to malunited distal radial fracture in 2 patients. The mean preoperative ulnar variance was +2.1 mm (range, +1 mm to +8 mm). All patients were evaluated before and after surgery and graded with the Disability of Arm-Shoulder-Hand (DASH) scoring system. RESULTS: All 27 osteotomies healed uneventfully over an average of 9.2 +/- 2.1 weeks. The mean postoperative ulnar variance was -2.1 mm (range, -3.1 mm to 0 mm). There were significant improvements in DASH score, pain, and grip strength at an average follow-up of 8.1 months. Six patients complained of plate irritation. CONCLUSION: Favorable results suggest that ulnar shortening osteotomy using an oblique osteotomy and a premounted sliding-hole compression plate avoids malrotation and angulation and is associated with satisfactory outcomes. This device does not require an assisting device, which minimizes the surgical exposure of the ulna. Palmar placement of the plate seems to reduce hardware irritation.     

Ulnar shortening osteotomy for ulnar ideopathic impaction syndrome

Twenty-eight patients were treated by ulnar shortening osteotomy for static or dynamic ulnar impaction syndrome. Ulnar variance was measured on a true anteroposterior radiograph. There were 25 wrists that were too long, two neutral, and one that was short. Bones were shortened by a mean of 3.5 mm. Mean follow-up time was 29 months (range 7–60), all with confirmed consolidation. At final follow-up mean grip strength had improved from 67% to 75%, mean Disabilities of the Arm, Shoulder, and Hand (DASH) score from 40 (range 12–83) to 26 (range 0–61) and mean range of movement from 80% (range 40%–100%) to 88% (range 50%–100%). Smoking, age at operation, type of osteotomy (transverse or oblique), dominance of hand, and sex did not influence consolidation or functionality. Special attention was paid to the anatomy of the distal radioulnar joint and the inclination of the sigmoid notch of the radius. There was no correlation between the anatomy and the functional outcome scores. Mean consolidation time (10 months) (range 2–32) and return to work were longer than in similar studies. Our findings confirm the usefulness of ulnar shortening osteotomy in the relief of ulnocarpal impingement symptoms.     

Distal ulnar recession for disorders of the distal radioulnar joint

Thirty-six wrists of 35 patients were treated with distal ulnar recession for pain and limitation of motion associated with chondromalacia of the ulnar head, triangular fibrocartilage complex tears, ulnocarpal impingement, and instability of the distal radioulnar joint. Contributing factors were positive ulnar variance in 31 wrists, fracture of the distal radius in five, sprains in 14, premature closure of the distal radial epiphysis in five, and lax ligamentous habitus in five. The ages of the patients averaged 33 years. Clinical findings were local tenderness, crepitus, and instability evident by a positive "piano key" effect. Roentgenographic findings were positive ulnar variance (29 of 36), zero ulnar variance (four), negative ulnar variance (three), positive arthrogram (11 of 19), and "forme fruste" Madelung's deformity (two). The surgical procedure is a modification of the Milch cuff resection with the use of a dynamic compression plate. Recession ranged from 2 to 13 mm (average of 4 mm). Findings at surgery included chondromalacia of the ulnar head (19), tears of the triangular fibrocartilage complex (11), and excessive mobility of the ulnar head (10). At an average follow-up of 24.5 months, results were excellent in 7 wrists, good in 21, fair in four, and poor in four. Poor results in two wrists were upgraded to good after osteosynthesis of a nonunion in one and recessional osteotomy of the radial sigmoid notch in the other. Ulnar recession offers a less destructive alternative to disorders of the distal radioulnar joint than the Darrach resection.     

Corrective osteotomy for symptomatic increased ulnar tilt of the distal end of the radius

Twelve wrists in 10 patients with a mean age of 23.6 years were treated for symptomatic increased ulnar inclination of the joint surface with corrective osteotomy of the radius. Diagnoses included mild ulnar dysplasia, posttraumatic deformity, Madelung's disease, and multiple hereditary exostosis. All patients had radial-sided wrist pain and an ulnarly displaced arc of radioulnar deviation. Preoperative radiographs showed excessive ulnar inclination of the distal radius, ulnar carpal translation, adaptive carpal malalignment, and frequent distal radioulnar joint incongruency. The patients had decreased pain and improved wrist function at a mean of 5.1 years (range, 2-10 years) after surgery. Average radial deviation changed from 3 degrees to 16 degrees and ulnar deviation from 48 degrees to 29 degrees; flexion/extension and pronosupination remained unchanged. Realignment of the wrist was shown radiographically by a change of ulnar inclination of the radius from 33 degrees to 21 degrees, an increase in scaphoid height from 16.4 to 20.4 mm, and reversal of ulnar carpal translation as shown by an increase in lunate-covering ratio of 64% to 77%. Reduction of the ulnar inclination to normal values by corrective radial osteotomy restores a more physiologic range of motion, decreases symptomatic wrist pain, reverts adaptive carpal changes to normal, increases lunate coverage, and may prevent abnormal cartilage overload in the ulnar compartment of the wrist.     

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.     

The ulnar impaction syndrome

The ulnar impaction syndrome can be defined as the impaction of the ulnar head against the triangular fibrocartilage complex and ulnar carpus resulting in progressive degeneration of those structures. The differential diagnosis in patients who present with ulnar wrist pain and limitation of motion can also include ulnar impingement syndrome and arthrosis or incongruity of the distal radioulnar joint. Structural abnormalities involving the distal radioulnar joint, distal radius, and ulnar carpus must be carefully elucidated prior to developing a treatment plan. When such abnormalities are identified and appropriately addressed, surgical treatment can be expected to be effective in the majority of cases. It is important to remember that in the absence of obvious structural abnormalities, the ulnar impaction syndrome may result from daily activities that result in excessive intermittent loading of the ulnar carpus. In this group of patients, treatment is directed at decreasing ulnar load by shortening the distal ulna in any of several ways. If relative instability of the ulnar ligamentous complex is a factor, then ulnar shortening by recession is the treatment of choice. Malunion of the distal radius resulting in ulnar impaction syndrome is best treated by addressing the deformity; that is, corrective radial osteotomy. Patients who present with a combination of ulnar impaction syndrome along with distal radioulnar joint, abnormalities must have both of these abnormalities addressed at the time of surgery. The matched ulnar resection and the hemiresection interposition arthroplasty are both effective procedures; however, the Suave-Kapandji procedure also can be used to address relative ligamentous laxity at the ulnar aspect of the wrist. The Darrach procedure is presently not recommended as a first-line treatment in these cases; however, when used as a salvage procedure, satisfactory results can be obtained in properly selected patients. Careful preoperative evaluation and planning are therefore the key to successful treatment of the ulnar impaction syndrome.     

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.     

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.     

Arthroscopic treatment of ulnar impaction syndrome

Ulnar impaction syndrome occurs in the setting of a central traumatic or degenerative defect in the triangular fibrocartilage complex in patients with ulnar positive variance. Chondral and subchondral edema, mechanical impingement of the articular disc, and chondromalacia of the distal ulna, proximal lunate, and proximal triquetrum produce symptoms with activity that do not improve with rest. Decreasing ulnocarpal load-sharing across the wrist with recession of the distal ulna is necessary to relieve symptoms in the majority of patients. Arthroscopic treatment with triangular fibrocartilage complex debridement and arthroscopic ulnar wafer resection is an effective treatment for ulnar impaction syndrome. It affords a single-stage, minimally invasive approach, with similar efficacy and fewer complications than open wafer resection or ulnar shortening osteotomy.     

Ulnar shortening osteotomy

Objective  Ulnar shortening to unload the ulnocarpal ligamentous complex. Indications  Clinically relevant ulnar impaction syndrome, be it congenital or posttraumatic. Contraindications  Concomitant pronounced malunion of the radius. Osteoarthritis of the distal radioulnar joint. Surgical Technique  Ulnopalmar approach. Oblique osteotomy of the ulna in its distal third. Removal of a bony wafer of predetermined thickness. Internal fixation with a 7-hole LD-DC plate or special plate and lag screw. Results  29 patients (14 men, 15 women, average age 42 years) underwent an ulnar shortening osteotomy for a therapyresistant ulnar impaction syndrome. Follow-up after an average of 25(7–37) months. Average amount of shortening 4.5 (1.5–13) mm. 72% reduction of pain as determined with a visual analog scale. The range of motion was improved by 7% in extension/flexion, by 8% in abduction/adduction, and by 11% in pronation/supination. Grip strength measured with a vigorimeter (balloon size 5) increased by 12%. Complications: three malunions, effectively treated by revision of internal fixation.     

青年桡骨远端陈旧性骨折继发下尺桡关节重度脱位的手术治疗

目的 探讨青年桡骨远端陈旧性骨折继发下尺桡关节重度脱位的手术治疗方法.方法 采用短缩尺骨、重建下尺桡关节法,对7例桡骨陈旧性骨折、短缩,下尺桡关节重度脱位患者进行治疗.术后对患者腕关节外形、功能进行随访.结果 所有患者外形恢复良好,功能评价优6例,良1例.结论 短缩尺骨、重建下尺桡关节法是治疗桡骨陈旧性骨折、短缩,下尺桡重度脱位的有效方法.     

Results of ulnar shortening osteotomy for ulnocarpal impaction syndrome in wrists with neutral or negative ulnar variance

Ulnocarpal impaction syndrome was diagnosed in six wrists of five patients with neutral or negative ulnar variance. All underwent ulnar shortening with satisfactory results. The average grip strength increased from 53% to 78% and the range of flexion-extension increased from 82% to 93%, the mean Cooney's score improved from 25 to 83. These cases show that ulnocarpal impaction syndrome can occur in wrists with zero or negative ulnar variance, and that ulnar shortening is an effective treatment for such wrists.     

Die Ulnaverkürzungsosteotomie

Objective Ulnar shortening to unload the ulnocarpal ligamentous complex. Indications Clinically relevant ulnar impaction syndrome, be it congenital or posttraumatic. Contraindications Concomitant pronounced malunion of the radius.Osteoarthritis of the distal radioulnar joint. Surgical Technique Ulnopalmar approach. Oblique osteotomy of the ulna in its distal third. Removal of a bony wafer of predetermined thickness. Internal fixation with a 7-hole LD-DC plate or special plate and lag screw. Results 29 patients (14 men, 15 women, average age 42 years) underwent an ulnar shortening osteotomy for a therapy-resistant ulnar impaction syndrome.Follow-up after an average of 25 (7–37) months. Average amount of shortening 4.5 (1.5–13) mm. 72% reduction of pain as determined with a visual analog scale. The range of motion was improved by 7% in extension/flexion, by 8% in abduction/adduction and by 11% in pronation/supination. Grip strength measured with a vigorimeter (balloon size 5) increased by 12%.Complications: three malunions, effectively treated by revision of internal fixation.     

Corrective osteotomy for malunion of the distal radius

Positive ulnar variance due to inadequate correction of radial length is a common disorder after radial corrective osteotomy. To avoid this complication we performed a combination of ulnar-shortening osteotomy and radial corrective osteotomy in 6 of 22 radial corrections. The indication for the combined procedure was a relative ulnar length of minimally 6 mm. The functional outcome was fair in 1 and good in 5 cases with combined osteotomy. Overall, the functional results were good in 17 cases, and pain in the distal radioulnar joint was observed in 3 of 22 patients. Positive ulnar variance was the reason for pain in only 1 patient. Eventually, 2 hemiresections of the ulnar head (Bower's arthroplasty) were performed. It appears that a combination of ulnar shortening and radial osteotomy is a reliable technique, which can reduce symptoms and need for secondary operations on the ulnar side of the wrist.     

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.     

Silicone rubber replacement of the severely fractured radial head

Ten patients, at an average of 3.4 years after Swanson silicone rubber radial head replacement following acute trauma, were evaluated for pain, motion, and grip strength. Three had excellent results, one had a fair result, and two had poor results. Three patients had arthritis at the distal radioulnar joint. The arthritis was correlated with a positive ulnar variance in the uninjured wrist. Degenerative arthritis at the elbow was present in 56% (five out of nine). Ulnar variance was increased significantly in the wrists on the injured side, compared with the opposite wrist and to a control group. A 20-kg grip stress radiograph analysis showed the silicone rubber prostheses to deform and wrist subluxation to occur. A biomechanical study of six human cadaver upper extremities indicated that the flexible implants transferred minimal forces across the radiocapitellar joint. A radial head replacement with a modulus of elasticity similar to bone showed a more physiologic loading at the elbow. Both the clinical and biomechanical studies indicated that the silicone rubber prostheses is unable to transmit physiologic forces from the proximal radius to the capitellum. A less flexible radial head prosthesis should provide more normal physiologic stresses and may lead to improved clinical results.