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Mesas Aranda I, Haas-Lützenberger EM, Imam S, Giunta RE, Volkmer E. Algorithm-Guided Treatment of Ulna Impaction Syndrome: A 10-Year Follow-Up Study of Ulna Shortening Osteotomy and Wafer Procedure. J Clin Med 2024; 13:3972. [PMID: 38999536 PMCID: PMC11242476 DOI: 10.3390/jcm13133972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Revised: 06/28/2024] [Accepted: 07/02/2024] [Indexed: 07/14/2024] Open
Abstract
Background: Ulnar impaction syndrome (UIS) is a common degenerative wrist condition which results from positive ulnar variance, leading to an overload on the ulnar carpus. Ulnar shortening osteotomy (USO) and the arthroscopic wafer procedure (AWP) are established therapies for UIS if conservative management fails. This study assessed an algorithm-guided treatment of UIS over a period of 10 years. Methods: This prospective observational study compared the outcome of 54 patients who underwent either USO or AWP for UIS based on a predefined treatment algorithm. The mean follow-up period was 10 years. Primary outcome parameters were the visual analogue scale (VAS) for pain and the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH), whereas secondary outcome parameters were grip and pinch strength and range of motion. Results: The median preoperative ulnar variance was 2.6 mm in the USO group and 2.0 mm in the AWP group. The postoperative average ulnar variance was 0 mm in both groups. The preoperative pain at rest was 3.4 in the USO group and 2.3 in the AWP group. One year after surgery, there was a significant reduction to VAS 0.7 and 0.2, respectively. These results persisted to the 10-year follow-up (VAS 0.9 and 0.2). The pain in motion also decreased significantly in the first year (from 6.8 and 6.7 to 2.2 and 2.1), as well as after 10 years (2.4 and 1.0). The preoperative DASH score averaged 31.3 in the USO group and 35.8 in the AWP group. At the 10-year follow-up, the DASH of both groups decreased significantly to 4.35 in the AWP group compared to 12.7 in the USO group. Conclusions: Our data show that, when using our algorithm, both USO and AWP, two common operative treatment options of UIS, reliably reduce pain and significantly reduce the DASH score over at least a period of ten years. The results after 10 years differ from short-term results in so far as after one year, the USO group showed to some degree similar outcome parameters compared to AWP, whereas at the 10-year follow-up, AWP reached slightly better primary outcome parameters. The algorithm presented, thus, produced excellent short- and long-term outcomes. Our findings and the applied algorithm can assist in decision-making and patient education.
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Affiliation(s)
- Irene Mesas Aranda
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, 80336 Munich, Germany
| | | | - Sara Imam
- Division of Vascular Surgery, Helios Klinikum Munich West, 81241 Munich, Germany;
| | - Riccardo E. Giunta
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, 80336 Munich, Germany
| | - Elias Volkmer
- Department of Hand Surgery, Helios Klinikum Munich West, 81241 Munich, Germany
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Daoulas T, Bernard M, Dellestable A, Letissier H, Bacle G, Sos C. Consolidation rate in ulnar shortening osteotomy with the APTUS Wrist plate. HAND SURGERY & REHABILITATION 2024; 43:101682. [PMID: 38492803 DOI: 10.1016/j.hansur.2024.101682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/01/2024] [Accepted: 03/06/2024] [Indexed: 03/18/2024]
Abstract
INTRODUCTION Ulnocarpal impaction syndrome causes pain on the ulnar side of the wrist. Various surgical techniques have been described. Ulnar shortening osteotomy is now a standard treatment. However, it is associated with complications such as non-union of the osteotomy site. The main study objective was to report the rate of radiographic consolidation after ulnar shortening osteotomy with a cutting guide. MATERIAL AND METHODS This multicenter retrospective study of 30 cases reported clinical and radiographic criteria at a minimum 6 month's follow-up. RESULTS The non-union rate was 3.4%. One case presented non-union of the osteotomy site. 87% of patients were satisfied or very satisfied with the procedure. Mean VAS pain rating was 2.7 ± 2.4. Mean QuickDASH and PRWE scores were 24.7 ± 19.2 and 28.6 ± 25. Mean strength on Jamar dynamometer was 27.4 ± 8.9 kg. One patient developed complex regional pain syndrome. Five patients required plate removal for hardware-related discomfort. DISCUSSION Ulna shortening osteotomy with the Aptus Wrist plate provides a standardized approach to the surgical treatment of ulnocarpal impaction syndrome. Compared with other series in the literature, the procedure provided satisfactory consolidation and clinical results.
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Affiliation(s)
- Thomas Daoulas
- Service de Chirurgie Orthopédique, Traumatologique et Urgence Main, Boulevard Tanguy Prigent, CHU de la Cavale Blanche, 29200 Brest, France.
| | - Mathilde Bernard
- Service de Chirurgie de la Main et des Nerfs Périphériques, 2 Boulevard Tonnellé, 37000 Tours, France
| | - Arthur Dellestable
- Service de Chirurgie Orthopédique, Traumatologique et Urgence Main, Boulevard Tanguy Prigent, CHU de la Cavale Blanche, 29200 Brest, France
| | - Hoel Letissier
- Service de Chirurgie Orthopédique, Traumatologique et Urgence Main, Boulevard Tanguy Prigent, CHU de la Cavale Blanche, 29200 Brest, France
| | - Guillaume Bacle
- Service de Chirurgie de la Main et des Nerfs Périphériques, 2 Boulevard Tonnellé, 37000 Tours, France
| | - Clara Sos
- Service de Chirurgie de la Main et des Nerfs Périphériques, 2 Boulevard Tonnellé, 37000 Tours, France
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Cruz J, Gonçalves SB, Neves MC, Silva HP, Silva MT. Intraoperative Angle Measurement of Anatomical Structures: A Systematic Review. SENSORS (BASEL, SWITZERLAND) 2024; 24:1613. [PMID: 38475148 PMCID: PMC10934548 DOI: 10.3390/s24051613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 02/22/2024] [Accepted: 02/28/2024] [Indexed: 03/14/2024]
Abstract
Ensuring precise angle measurement during surgical correction of orientation-related deformities is crucial for optimal postoperative outcomes, yet there is a lack of an ideal commercial solution. Current measurement sensors and instrumentation have limitations that make their use context-specific, demanding a methodical evaluation of the field. A systematic review was carried out in March 2023. Studies reporting technologies and validation methods for intraoperative angular measurement of anatomical structures were analyzed. A total of 32 studies were included, 17 focused on image-based technologies (6 fluoroscopy, 4 camera-based tracking, and 7 CT-based), while 15 explored non-image-based technologies (6 manual instruments and 9 inertial sensor-based instruments). Image-based technologies offer better accuracy and 3D capabilities but pose challenges like additional equipment, increased radiation exposure, time, and cost. Non-image-based technologies are cost-effective but may be influenced by the surgeon's perception and require careful calibration. Nevertheless, the choice of the proper technology should take into consideration the influence of the expected error in the surgery, surgery type, and radiation dose limit. This comprehensive review serves as a valuable guide for surgeons seeking precise angle measurements intraoperatively. It not only explores the performance and application of existing technologies but also aids in the future development of innovative solutions.
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Affiliation(s)
- João Cruz
- IDMEC, Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais 1, 1049-001 Lisboa, Portugal; (J.C.); (S.B.G.)
| | - Sérgio B. Gonçalves
- IDMEC, Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais 1, 1049-001 Lisboa, Portugal; (J.C.); (S.B.G.)
| | | | - Hugo Plácido Silva
- IT—Instituto de Telecomunicações, Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais 1, 1049-001 Lisboa, Portugal;
| | - Miguel Tavares Silva
- IDMEC, Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais 1, 1049-001 Lisboa, Portugal; (J.C.); (S.B.G.)
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Shi H, Huang Y, Shen Y, Wu K, Zhang Z, Li Q. Arthroscopic wafer procedure versus ulnar shortening osteotomy for ulnar impaction syndrome: a systematic review and meta-analysis. J Orthop Surg Res 2024; 19:149. [PMID: 38378573 PMCID: PMC10880364 DOI: 10.1186/s13018-024-04611-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 02/01/2024] [Indexed: 02/22/2024] Open
Abstract
PURPOSE This study aimed to systematically compare the efficacy and safety of arthroscopic wafer procedure (AWP) versus ulnar shortening osteotomy (USO) for ulnar impaction syndrome (UIS) treatment. METHODS All the studies included in this meta-analysis compared the efficacy of AWP to USO for UIS and were acquired through a comprehensive search across multiple databases. The meta-analysis was performed by calculating the effect sizes with the Cochrane Collaboration's RevMan 5.4 software. RESULTS A total of 8 articles were included in this analysis, comprising 148 cases in the AWP group and 163 cases in the USO group. The pooled estimates indicated no significant differences in combined Darrow's Criteria or Modified Mayo Wrist Score, Modified Mayo Wrist Score, DASH scores, grip strength, VAS score, and postoperative ulnar variation. On the other hand, the patients in the AWP group exhibited fewer complications (OR = 0.17, 95%CI 0.05-0.54, P = 0.003) and a lower reoperation rate (OR = 0.12, 95%CI 0.05-0.28, P < 0.00001) than those in the USO group. CONCLUSIONS The two surgical techniques were both effective in treating UIS but the AWP group showed fewer complications and a lower reoperation rate. Therefore, AWP may present a superior alternative for UIS treatment.
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Affiliation(s)
- Haifeng Shi
- Department of Hand Surgery, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China.
| | - Yongjing Huang
- Department of Hand Surgery, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Yong Shen
- Department of Hand Surgery, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Ke Wu
- Department of Hand Surgery, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China.
| | - Zhihai Zhang
- Department of Hand Surgery, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Qian Li
- Department of Hand Surgery, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
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Hama S, Moriya K, Koda H, Tsubokawa N, Maki Y, Nakamura H. The Duration of Bone Healing and Nonunion Ratio After Ulnar Shortening Osteotomy Using a 5-Hole Forearm Compression Plate With Transverse Osteotomy. Hand (N Y) 2023:15589447231218402. [PMID: 38142408 DOI: 10.1177/15589447231218402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2023]
Abstract
BACKGROUND Ulnar shortening osteotomy using various osteotomy sites, osteotomy methods, and surgical techniques with a variety of implants has been reported, but nonunion rates and the duration of bone healing are not uniform by the authors. The purpose of this study was to investigate the duration of bone healing and nonunion ratio in patients who underwent ulnar shortening osteotomy by a 5-hole nonlocking plate with a simple transverse osteotomy for ulnar impaction syndrome and to determine the correlation between the gap length of the osteotomy site and the duration of bone healing. METHODS We assessed patients who underwent ulnar shortening osteotomy for ulnar impaction syndrome using a 5-hole nonlocking plate fixation followed by a simple transverse osteotomy between July 2012 and October 2021. This study was a case series study, and the level of evidence was IV. RESULTS A total of 80 patients were included. The mean age of the patients was 46.7 years, and 46 patients were men. The average bone union period was 41.8 ± 18.7 weeks. The correlation between the gap length of the osteotomy site and the duration of bone union of the osteotomy site was not significant. The nonunion ratio of our method was 2.5%. CONCLUSION The nonunion rate of our ulnar shortening osteotomy with a simple transverse osteotomy and a 5-hole nonlocking plate was comparable to that in previous reports, but our method required slightly longer periods for bone union. There was no correlation between the gap length of the osteotomy and the duration of bone union. LEVEL OF EVIDENCE Level IV (Case series).
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Affiliation(s)
- Shunpei Hama
- Niigata Hand Surgery Foundation, Japan
- Yodogawa Christian Hospital, Osaka, Japan
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Ha JW, Kwon YW, Lee S, Lim H, Lee J, Lim CK, Lee JK. Is ulnar shortening osteotomy or the wafer procedure better for ulnar impaction syndrome?: A systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e35141. [PMID: 37773809 PMCID: PMC10545262 DOI: 10.1097/md.0000000000035141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 08/18/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND Wrist pain on the ulnar side is often caused by ulnar impaction syndrome (UIS). Idiopathic UIS requires surgical treatment when conservative treatment fails. The 2 main surgical procedures used are the wafer procedure and ulnar shortening osteotomy (USO) of the metaphysis or diaphysis. This review aimed to analyze comparative studies of the 2 procedures in UIS to determine clinical outcomes and complications. METHODS One prospective and 5 retrospective comparison trials were retrieved from the PubMed, Embase, and Cochrane Library databases. The primary outcomes were treatment effectiveness; pain visual analog scale (VAS), disabilities of the arm, shoulder, and hand (DASH) score, Mayo wrist, and Darrow scores. The incidence of postoperative complications formed the secondary outcome. RESULTS The selected studies included 107 patients who underwent the wafer procedure (G1) and 117 patients who underwent USO (G2). The wafer procedure had the benefits of less postoperative immobilization and an early return to work. However, there were no significant differences in the postoperative pain improvement and functional scores. All 6 studies reported high total complication rates and reoperation with USO. The most frequent complication was implant-related discomfort or irritation; subsequent plate removal was the most common reason for a secondary operation. CONCLUSIONS There was no difference in pain improvement or the postoperative functional score between the groups. Nevertheless, postoperative complications were the major pitfalls of USO. As the specialized shortening system advances further, a high-level study will be necessary to determine the surgical option in UIS.
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Affiliation(s)
- Joong Won Ha
- Department of Orthopaedic Surgery, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Woo Kwon
- Department of Orthopedic Surgery, Uijeongbu Eulji Medical Center, Uijeongbu-si, Gyeonggi-do, South Korea
| | - Sujung Lee
- Medical Library, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| | - Hyunsun Lim
- Department of Research and Analysis, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| | - Jinho Lee
- Department of Orthopaedic Surgery, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chae Kwang Lim
- Department of Orthopaedic Surgery, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jun-Ku Lee
- Department of Orthopaedic Surgery, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
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Moeller RT, Mentzel M, Vergote D, Bauknecht S. [Ulnar Shortening Osteotomy - Two Weeks of Immobilization Sufficient]. HANDCHIR MIKROCHIR P 2022; 54:434-441. [PMID: 36037818 DOI: 10.1055/a-1894-7149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Diaphyseal ulnar shortening osteotomy (USO) as surgical treatment of ulnar impaction syndrome is standardized nowadays with good to very good results. In contrast, a wide spectrum of different postoperative treatment regimens can be found in the current literature. The results after USO with modern, angular stable implants with immobilization for 2 weeks are presented. PATIENTS AND METHODS A retrospective database analysis identified 49 patients (31 women, 18 men, mean age 37.6 years) with a total of 51 USO over a 13-year period and were followed up for 73.5 (15.9-192.9). All USO were obliquely sawed and stabilized with palmar locking implants. The wrist was immobilized postoperatively in 30° extension in a dorsal forearm splint for 2 weeks. RESULTS All USO showed load-stable consolidation signs after an average of 7.0 (SD 1.9; 4.9-14.1) weeks. Wrist range of motion was significantly improved in extension/flexion from 107.6° (60-155) preoperatively to 123.7° (80-160) postoperatively and in ulnar/radial deviation from 55.1° (25-90) to 60.8° (30-90) (p<0.05). Pain level was significantly reduced from 3.2 (0-8) to 0.1 (0-2) at rest and from 7.3 (4-10) to 1.2 (0-9) under weight bearing (p<0.01). A total of 5 complications (9.8%) were noted. Nonunion was not found. CONCLUSION By using angular stable implants to stabilize a USO, the duration of immobilization can be reduced to 2 weeks without compromising bone healing.
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Affiliation(s)
- Richard-Tobias Moeller
- Universitätsklinikum Ulm, Klinik für Unfall-, Hand-, Plastische und Wiederherstellungschirurgie
| | - Martin Mentzel
- Universitätsklinikum Ulm, Klinik für Unfall-, Hand-, Plastische und Wiederherstellungschirurgie
| | - Daniel Vergote
- Universitätsklinikum Ulm, Klinik für Unfall-, Hand-, Plastische und Wiederherstellungschirurgie
| | - Simon Bauknecht
- Universitätsklinikum Ulm, Klinik für Unfall-, Hand-, Plastische und Wiederherstellungschirurgie
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Roulet S, Gubbiotti L, Lakhal W, Chaves C, Marteau E, Laulan J, Bacle G. Ulna shortening osteotomy for ulnar impaction syndrome: Impact of distal radioulnar joint morphology on clinical outcome. Orthop Traumatol Surg Res 2021; 107:102970. [PMID: 34052512 DOI: 10.1016/j.otsr.2021.102970] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/02/2020] [Accepted: 09/14/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Treatment of ulnar impaction syndrome (UIS) is based on ulnocarpal decompression, which may be achieved by ulna shortening osteotomy. The aim is to restore zero or negative ulnar variance. Tolat et al. described 3 distal radioulnar joint (DRUJ) morphologic types: vertical, oblique and reverse. Joint type has been thought to influence the clinical result of shortening, especially in the reverse type. HYPOTHESIS DRUJ type does not influence clinical results in ulna shortening osteotomy. MATERIAL AND METHODS Twenty-nine wrists were operated on in 27 patients: 13 female, 14 male; mean age at surgery, 43 years (range, 18-72 years). In 20 cases, UIS was idiopathic and in 7 post-traumatic. Mean preoperative ulnar variance was 3.6mm (range, 2-18mm). The osteotomy was fixed by screwed plate. RESULTS Twenty-five patients (27 wrists) were assessed at a mean 64 months (range, 18 months to 13 years). There were no cases of infection or hematoma. DRUJ was type 1 (vertical) in 6 cases (22%), type 2 (oblique) in 14 (52%) and type 3 (reverse) in 7 (26%). Mean postoperative pain score on VAS was 0.7/10 (range, 0-4); 9 wrists remained painful. Mean Quick-DASH was 16.9 (range, 0-48) and mean PRWE 21.9 (range, 16.9-59). Thirteen patients were very satisfied, 11 satisfied, 1 moderately satisfied, and 2 dissatisfied. Mean postoperative ulnar variance was -0.1mm (range, -4 to +8mm). Three wrists developed osteoarthritis, all following traumatic UIS. There were no significant correlations between DRUJ type and other clinical or radiological parameters. DISCUSSION Ulna shortening osteotomy has proven efficacy in UIS. The literature reports excellent or good results in 75% of cases. In the present study, 96% of patients considered themselves cured or improved by surgery, and none reported worsening. Ulna shortening osteotomy can be used in all 3 DRUJ types; DRUJ coronal morphology does not impact clinical result. LEVEL OF EVIDENCE IV-retrospective study.
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Affiliation(s)
- Steven Roulet
- Département de chirurgie orthopédique, chirurgie de la main et des nerfs périphériques-centre Hospitalo-Universitaire Tours-université de médecine de Tours François Rabelais, Avenue de la République, 37000 Tours, France.
| | - Laura Gubbiotti
- Département de chirurgie orthopédique, chirurgie de la main et des nerfs périphériques-centre Hospitalo-Universitaire Tours-université de médecine de Tours François Rabelais, Avenue de la République, 37000 Tours, France
| | - Walid Lakhal
- Département de chirurgie orthopédique, chirurgie de la main et des nerfs périphériques-centre Hospitalo-Universitaire Tours-université de médecine de Tours François Rabelais, Avenue de la République, 37000 Tours, France
| | - Camilo Chaves
- Département de chirurgie orthopédique, chirurgie de la main et des nerfs périphériques-centre Hospitalo-Universitaire Tours-université de médecine de Tours François Rabelais, Avenue de la République, 37000 Tours, France
| | - Emilie Marteau
- Département de chirurgie orthopédique, chirurgie de la main et des nerfs périphériques-centre Hospitalo-Universitaire Tours-université de médecine de Tours François Rabelais, Avenue de la République, 37000 Tours, France
| | - Jacky Laulan
- Département de chirurgie orthopédique, chirurgie de la main et des nerfs périphériques-centre Hospitalo-Universitaire Tours-université de médecine de Tours François Rabelais, Avenue de la République, 37000 Tours, France
| | - Guillaume Bacle
- Département de chirurgie orthopédique, chirurgie de la main et des nerfs périphériques-centre Hospitalo-Universitaire Tours-université de médecine de Tours François Rabelais, Avenue de la République, 37000 Tours, France
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Kang JW, Cha SM, Kim SG, Choi IC, Suh DH, Park JW. Tips and tricks to achieve osteotomy healing and prevent refracture after ulnar shortening osteotomy. J Orthop Surg Res 2021; 16:110. [PMID: 33541409 PMCID: PMC7863478 DOI: 10.1186/s13018-021-02266-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 01/26/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Parallel osteotomy is essential for favorable osteotomy reduction and healing and technically challenging during diaphyseal ulnar shortening osteotomy (USO). This study aimed to evaluate the advantages of guided osteotomy for parallel osteotomy and reduction osteotomies, healing over freehand osteotomy. It also aimed to identify surgical factors affecting healing after diaphyseal USO. METHODS Between June 2005 and March 2016, 136 wrists that had undergone diaphyseal USO for ulnar impaction syndrome (UIS) were evaluated. The wrists were divided into two groups according to the osteotomy technique (group 1: freehand osteotomy, 74 wrists; group 2: guided osteotomy, 62 wrists). The osteotomy reduction gap and time to osteotomy healing (union and consolidation) were compared between the groups. A multiple regression test was performed to identify the surgical factors affecting healing. The cut-off length of the reduction gap to achieve osteotomy union on time and the cut-off period to decide the failure of complete consolidation were statistically calculated. RESULTS The baseline characteristics did not differ between the two groups. The osteotomy reduction gap and time to osteotomy union, and complete consolidation were shorter in group 2 than in group 1 (p = 0.002, < 0.001, 0.002). The osteotomy reduction gap was a critical surgical factor affecting both time to osteotomy union and complete consolidation (p < 0.001, < 0.001). The use of a dynamic compression plate affected only the time to complete consolidation (p < 0.001). The cut-off length of the osteotomy reduction gap to achieve osteotomy union on time was 0.85 mm. The cut-off period to decide the failure of complete consolidation was 23.5 months after osteotomy. CONCLUSIONS The minimal osteotomy reduction gap was the most important for timely osteotomy healing in the healthy ulna, and guided osteotomy was beneficial for reducing the osteotomy reduction gap.
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Affiliation(s)
- Jong Woo Kang
- Department of Orthopedic Surgery, Korea University Anam Hospital, Korea University College of Medicine, 73, Goryeodae-ro, Seongbuk-gu, Seoul, 02841 South Korea
| | - Soo Min Cha
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sang-gyun Kim
- Department of Orthopedic Surgery, Korea University Anam Hospital, Korea University College of Medicine, 73, Goryeodae-ro, Seongbuk-gu, Seoul, 02841 South Korea
| | - In Cheul Choi
- Department of Orthopedic Surgery, Anam Hospital, College of Medicine, Korea University, Seoul, Korea
| | - Dong Hun Suh
- Department of Orthopedic Surgery, Korea University Anam Hospital, Korea University College of Medicine, 73, Goryeodae-ro, Seongbuk-gu, Seoul, 02841 South Korea
| | - Jong Woong Park
- Department of Orthopedic Surgery, Anam Hospital, College of Medicine, Korea University, Seoul, Korea
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Auzias P, Delarue R, Camus EJ, Van Overstraeten L. Ulna shortening osteotomy versus arthroscopic wafer procedure in the treatment of ulnocarpal impingement syndrome. HAND SURGERY & REHABILITATION 2020; 40:156-161. [PMID: 33160084 DOI: 10.1016/j.hansur.2020.10.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 11/30/2022]
Abstract
Post-traumatic or constitutional ulnar impaction syndrome can be treated by shortening the ulna. This can be achieved by diaphyseal or metaphyseal osteotomy, or by arthroscopic epiphyseal resection. The objective of this study was to compare the results of the diaphyseal shortening osteotomy (USO) and arthroscopic wafer procedure (AWP) of the ulna in this indication. This was a retrospective case series of 33 patients operated for ulnar impaction syndrome by the same surgeon between 1997 and 2017. The diagnosis was made based on pain on the ulnar edge of the wrist with positive provocative tests. Radiographs were made and CT arthrography or MRI were used to confirm the diagnosis. Per-and post-operative assessments were functional (DASH and PRWE scores), clinical (pain, range of motion and grip strength) and radiographic. Diaphyseal ulnar shortening osteotomy (USO) was performed in 9 patients using a volar plate and a cutting guide. Twenty-four patients underwent an arthroscopic wafer procedure. Mean follow-up was 103 ± 8 months in the USO group versus 55 ± 4 months in the AWP group. There was no significant difference between groups in pain levels (1.2/10 in the USO group versus 0.9/10 in the AWP group, p = 0.88), grip strength (39 Kg in the USO group versus 34 Kg in the AWP group, p = 0.27) and PRWE score (5,8/100 in the USO group versus 11,2 in the AWP group, p = 0.34), and DASH score (25/100 in the USO group versus 28 in the AWP group, p = 0.63). The time away from work was long in the USO group than in the AWP group (7.86 months versus 3.75 months) (p = 0.002). Seven patients were reoperated in the USO group (5 plate removal, 1 nonunion and 1 delayed union) versus 3 in the AWP group (1 ECU stabilization, 1 ablation for painful ulnar styloid due to nonunion and 1 wrist denervation) (p = 0.0004). The study found no clinical differences between these two techniques except the return to work time. In our series, diaphyseal USO was associated with a greater number of reoperations than the AWP.
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Affiliation(s)
- P Auzias
- SEL chirurgie de la main et du pied, 94, avenue Gustave Delory, 59810 Lesquin, France.
| | - R Delarue
- CHRU de Lille, rue du Professeur Emile Laine, 59037 Lille, France
| | - E J Camus
- SEL chirurgie de la main et du pied, 94, avenue Gustave Delory, 59810 Lesquin, France
| | - L Van Overstraeten
- Hôpital Erasme ULB, route de Lennik, 1070 Bruxelles, Belgique; Hand and Foot Surgery Unit, Rue Pierre Caille 9, Tournai, Belgique
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Cha SM, Shin HD, Ahn BK. Refracture after plate removal following ulnar shortening osteotomy for ulnar impaction syndrome - a retrospective case-control study. J Plast Surg Hand Surg 2020; 55:48-55. [PMID: 33019843 DOI: 10.1080/2000656x.2020.1828900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
LEVEL OF EVIDENCE Level III, case-control study.
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Affiliation(s)
- Soo Min Cha
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hyun Dae Shin
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Byung Kuk Ahn
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
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12
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Abstract
Background: The primary purpose of our study was to identify factors associated with reoperation after ulna shortening osteotomy. Our secondary aims were to determine the rate and type of reoperation procedures. Methods: In this retrospective study, we included patients older than 18 years of age who underwent an ulna shortening osteotomy between January 2003 and December 2015. Medical records of patients were assessed for our explanatory variables, reoperations, and reporting of symptoms. We used bivariate and multivariable analyses to identify factors associated with reoperation after ulna shortening osteotomy. Results: Among 94 patients who underwent 98 ulna shortening osteotomies, there were 34 reoperations (35%). Nineteen patients (19%) underwent removal of hardware, 6 (6.1%) had a nonunion, and 9 (9.2%) underwent additional surgeries. Surgery on their dominant limb, trauma, and prior surgery to the ipsilateral wrist were associated with reoperation. In multivariable analysis, factors independently associated with reoperation were the dominant side being affected (odds ratio = 3.9; 95% confidence interval [CI] = 1.36-11) and traumatic origin (odds ratio = 3.4; 95% CI = 1.1-11). Bivariate analysis identified younger age and prior surgery of the affected wrist as factors associated with hardware removal. More operations for refixation due to nonunion of osteotomy were performed in patients with a transverse osteotomy compared with patients with an oblique osteotomy. Conclusions: One in 3 patients will undergo a reoperation after ulna shortening osteotomy, most often due to hardware irritation or nonunion of osteotomy. Awareness of these rates and predictive factors may be helpful for preoperative discussions and surgical decision making.
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Affiliation(s)
- Svenna H. W. L. Verhiel
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA,Svenna H. W. L. Verhiel, Research Fellow, Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Suite 2100, 55 Fruit Street, Boston, MA 02114, USA.
| | - Sezai Özkan
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kyle R. Eberlin
- Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Neal C. Chen
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Cardoso ANP, Viegas R, Gamelas P, Falcão P, Baptista C, Silva FS. Ulnar Shortening Osteotomy: Our Experience. Rev Bras Ortop 2020; 55:612-619. [PMID: 33093726 PMCID: PMC7575385 DOI: 10.1055/s-0040-1702959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 11/29/2019] [Indexed: 11/02/2022] Open
Abstract
Objective The objective of the present study was to evaluate the clinical and radiographic results of our series regarding ulnar shortening osteotomy, as well as to briefly review the pathology, indications and surgical options of ulnocarpal conflict. Methods We performed a retrospective analysis of consecutive patients who were treated with ulnar shortening osteotomy between January 2012 and June 2017 at our hospital. We clinically evaluated pain, articular range of motion, grip strength and functional outcomes using the quick-DASH questionnaire. We radiographically measured the pre- and postoperative ulnar variance and the shortening performed. Results We identified eight operated patients, and it was possible to evaluate seven of them. Pain decreased in this population (visual analogue scale [VAS] score changed from 7 to 2.6, p < 0.05), there was a decrease in quick-DASH (64 to 28, p < 0.05) and we found a decrease in the articular amplitude ∼ 7° for flexion ( p = 0.2), and of 5.5° for supination ( p = 0.3), as well as decreasing grip strength to about 86% on the contralateral side ( p = 0.07). The ulnar variance changed from a mean of + 5.5 mm to - 1.1 mm ( p < 0.05). Two out of 8 patients (25%) presented plaque-related symptoms and one of them underwent a new intervention to extract the material. Conclusions Ulnar shortening osteotomy is an effective surgical procedure both in the treatment of ulnocarpal conflict and in the discharge of the ulna. The results presented agreement with other results published in the literature, with good clinical and radiographic results.
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Affiliation(s)
| | - Rui Viegas
- Departamento de Ortopedia e Traumatologia, Hospital Beatriz Ângelo, Loures, Portugal
| | - Patrícia Gamelas
- Departamento de Ortopedia e Traumatologia, Hospital Beatriz Ângelo, Loures, Portugal
| | - Pedro Falcão
- Departamento de Ortopedia e Traumatologia, Hospital Beatriz Ângelo, Loures, Portugal
| | - Carolina Baptista
- Departamento de Ortopedia e Traumatologia, Hospital Beatriz Ângelo, Loures, Portugal
| | - Filipa Santos Silva
- Departamento de Ortopedia e Traumatologia, Hospital Beatriz Ângelo, Loures, Portugal
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Luo TD, De Gregorio M, Zuskov A, Khalil M, Li Z, Nuñez FA, Nuñez FA. Distal Metaphyseal Osteotomy Allows for Greater Ulnar Shortening Compared to Diaphyseal Osteotomy for Ulnar Impaction Syndrome: A Biomechanical Study. J Wrist Surg 2020; 9:100-104. [PMID: 32257610 PMCID: PMC7113004 DOI: 10.1055/s-0039-1695707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 07/15/2019] [Indexed: 10/26/2022]
Abstract
Purpose To compare the biomechanical characteristics between diaphyseal and metaphyseal ulnar-shortening osteotomy with respect to (1) maximal shortening achieved at each osteotomy site and (2) force required to achieve shortening at each site. Methods Nine fresh frozen cadaveric upper extremities were affixed through the proximal ulna to a wooden surgical board. A metaphyseal 20-mm bone wedge was resected from the distal ulna and sequential shortening was performed. A load cell was attached to a distal post that was clamped to the surgical board and used to measure the force required for each sequential 5-mm of shortening until maximal shortening was achieved. The resected bone was reinserted, and plate fixation was used to restore normal anatomy. A 20-mm diaphyseal osteotomy was performed, and force measurements were recorded in the same manner with (1) interosseous membrane intact, (2) central band released, and (3) extensive interosseous membrane and muscular attachments released. Results Metaphyseal osteotomy allowed greater maximal shortening than diaphyseal osteotomy with the interosseous membrane intact and with central band release but similar shortening when extensive interosseous membrane and muscle release was performed. Force at maximal shortening was similar between metaphyseal and diaphyseal osteotomy. Sequential soft tissue release at the diaphysis allowed for increased shortening with slightly decreased shortening force with sequential release. Conclusion Metaphyseal ulnar osteotomy allows greater maximal shortening but requires similar force compared with diaphyseal osteotomy. Sequential release of the interosseous membrane permits increased shortening at the diaphysis but requires extensive soft tissue release. Clinical Relevance Both sites of osteotomy can achieve sufficient shortening to decompress the ulnocarpal joint for most cases of ulnar impaction syndrome. The greater shortening from metaphyseal ulnar osteotomy may be reserved for severe cases of shortening, especially after distal radius malunion or in the setting of distal radius growth arrest in the pediatric population. Level of Evidence This is a Level V, basic science study.
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Affiliation(s)
- T. David Luo
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, North Carolina
| | - Michael De Gregorio
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, North Carolina
| | - Andrey Zuskov
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, North Carolina
| | - Mario Khalil
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, North Carolina
| | - Zhongyu Li
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, North Carolina
| | - Fiesky A. Nuñez
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, North Carolina
| | - Fiesky A. Nuñez
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, North Carolina
- Bon Secours Orthopaedic, Greenville, South Carolina
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Gire JD, Yao J. Surgical Techniques for the Treatment of Acute Carpal Ligament Injuries in the Athlete. Clin Sports Med 2020; 39:313-337. [PMID: 32115087 DOI: 10.1016/j.csm.2019.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The treatment of athletes with carpal ligament injuries provides many challenges. Our initial goals remain to make a timely and accurate diagnosis, provide treatment options, and create an environment for shared decision making. To optimize outcomes and facilitate return to play, early surgical intervention may be warranted. This article reviews common carpal ligament injury patterns in the athlete with a focus on both classic and newer surgical techniques.
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Affiliation(s)
- Jacob D Gire
- Robert A. Chase Hand and Upper Limb Center, Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway Street, MC 6342, Redwood City, CA 94063, USA
| | - Jeffrey Yao
- Robert A. Chase Hand and Upper Limb Center, Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway Street, MC 6342, Redwood City, CA 94063, USA.
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Nuñez FA, Marquez-Lara A, Newman EA, Li Z, Nuñez FA. Determinants of Pain and Predictors of Pain Relief after Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome. J Wrist Surg 2019; 8:395-402. [PMID: 31579549 PMCID: PMC6773568 DOI: 10.1055/s-0039-1692481] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 05/03/2019] [Indexed: 10/26/2022]
Abstract
Background The purpose of this study is to characterize patient- and surgery-specific factors associated with perioperative pain level in patients undergoing ulnar shortening osteotomy (USO) for ulnar impaction syndrome (UIS). We hypothesize that preoperative opiate consumption, tobacco utilization, and severity of ulnar variance will be associated with less postoperative pain relief. Methods All cases of USO between January 2010 and December 2016 for management of UIS were retrospectively reviewed. Patient demographics, smoking status, type of labor, and opioid utilization before surgery were recorded. Radiographic measurements for ulnar variance, radial tilt and inclination, as well as triangular fibrocartilage complex and distal radial-ulnar joint (DRUJ) morphology were assessed. Pre- and postoperative pain score were recorded. Regression analysis was performed to determine predictors of pain scores. Results A total of 69 patients were included for the final analysis with a mean age of 44 years (range 17-73 years). Seventeen patients reported use of daily opioid medications at the time of surgery (25%). Patients who used opioid analgesics daily, active laborers, smokers, and patients involved in worker compensation claims had significantly less pain relief after surgery. Patients with osteotomy performed at the metaphysis had significantly more pain relief than patients that had diaphyseal osteotomy. Regression analysis identified tobacco utilization and anatomic site of osteotomy as independent predictors of postoperative pain. Conclusion The results from this study identified smoking and location of osteotomy as independent predictors of postoperative pain relief. While smoking cessation is paramount to prevent delayed/nonunion it may also help improve pain relief following USO. The potential to achieve greater shortening with a metaphyseal osteotomy suggests that in addition to the mechanical unloading the carpus, pain relief after USO may also stem from tensioning the ulnar collateral ligaments of the wrist, the ECU subsheath, and the radioulnar ligaments. Level of Evidence This is a Level III, therapeutic study.
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Affiliation(s)
- Fiesky A. Nuñez
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Alejandro Marquez-Lara
- Department of Orthopaedic surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Elizabeth A. Newman
- Department of Orthopaedic surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Zhongyu Li
- Department of Orthopaedic surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Fiesky A. Nuñez
- Department of Orthopaedic surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Kubo N, Moritomo H, Arimitsu S, Nishimoto S, Yoshida T. Distal Ulnar Metaphyseal Wedge Osteotomy for Ulnar Abutment Syndrome. J Wrist Surg 2019; 8:352-359. [PMID: 31579542 PMCID: PMC6773578 DOI: 10.1055/s-0038-1677494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 11/26/2018] [Indexed: 10/27/2022]
Abstract
Background Ulnar shortening osteotomy of the diaphysis is a common and effective surgical procedure for ulnar abutment syndrome. However, this procedure has some disadvantages, such as a long period until union and a relatively high nonunion rate. To overcome these disadvantages, we have developed distal ulnar metaphyseal wedge osteotomy. The purpose of this article is to describe the technique and to report its clinical results. Patients and Methods Distal ulnar metaphyseal wedge osteotomy consists of resection of the wedge fragment at the distal ulnar metaphysis, compressing the distal fragment of the ulna toward the radial-proximal direction and fixation with a Herbert type headless screw. We performed this procedure for 58 patients with ulnar abutment syndrome, and the clinical data of 43 patients who were followed for > 6 months were analyzed. We evaluated range of motion, grip strength, and HAND20 which is a validated subjective scoring system in Japan. Results All patients experienced relief from their ulnar wrist pain, and bone union was achieved within an average of 2.6 months. The range of dorsiflexion improved from 63° preoperatively to 69° postoperatively, grip strength compared with the contralateral hand improved from 77% preoperatively to 87% postoperatively, and HAND20 improved from 41.3 points preoperatively to 22.4 points postoperatively. Discussion This procedure has advantages especially in early bone union. This procedure should be taken into consideration as one of the options to treat ulnar abutment syndrome.
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Affiliation(s)
- Nobuyuki Kubo
- Department of Orthopaedic Surgery, Kyouritsu Hospital, Kawanishi-shi, hyogo, Japan
| | - Hisao Moritomo
- Osaka Yukioka College of Health Science, Yukioka Hospital Hand Center, Osaka-shi, Osaka, Japan
| | - Sayuri Arimitsu
- Department of Orthopaedic Surgery, Yukioka Hospital, Osaka, Osaka Prefecture, Japan
| | - Shunsuke Nishimoto
- Department of Orthopaedic Surgery, Kansai Rosai Hospital, Amagasaki-shi, Hyogo, Japan
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Notermans BJW, Maarse W, Schuurman AH. A Dorsal Approach for Ulnar Shortening Osteotomy. J Wrist Surg 2018; 7:281-287. [PMID: 30302301 PMCID: PMC6172606 DOI: 10.1055/s-0037-1608636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 09/29/2017] [Indexed: 10/18/2022]
Abstract
Aim This study aims to evaluate the long-term complications, results, and patient satisfaction rates of a dorsally approached ulnar shortening osteotomy for ulnar impaction syndrome. Methods A retrospective chart review of 20 patients was performed. Primary outcomes of interest were subjective, measured using the Patient-Rated Wrist Evaluation (PRWE) score, Disability of the Arm, Shoulder, and Hand (DASH) score, and the third questionnaire about patient satisfaction, composed by the authors. Secondary outcomes included hardware removal due to irritation and other complications. Results Mean postoperative functional score of PRWE was 28 (standard deviation [SD], 30) and DASH 20 (SD, 26), respectively. Fifteen patients were satisfied with the operation. Removal of hardware was noted in six patients. In one patient plate breakage occurred. Conclusion Similar postoperative functional scores and complications were seen in patients undergoing an ulnar shortening osteotomy with a dorsally placed plate for ulnar impaction syndrome, compared with other plate placement localizations. The incidence of plate removal is also comparable to previously described results. As the dorsally placed plate and freehand technique, are relatively easy, we feel that it has a place in the treatment of ulnar impaction syndrome. Level of Evidence Level IV, retrospective cohort study.
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Affiliation(s)
- Bo J. W. Notermans
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, The Netherlands
| | - Wiesje Maarse
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, The Netherlands
| | - Arnold H. Schuurman
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, The Netherlands
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Elgammal A, Rozée B. Outcomes of the Ulnar Shortening Osteotomy Using a Dynamic Compression Plate on the Ulnar Surface of the Ulna. J Wrist Surg 2018; 7:344-349. [PMID: 30174994 PMCID: PMC6117180 DOI: 10.1055/s-0037-1608851] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 10/20/2017] [Indexed: 10/18/2022]
Abstract
Background The purpose of this study is to evaluate the results of patients with ulnar impaction syndrome treated with diaphyseal osteotomy using freehand technique and fixation with ulnar osteotomy compression plate placed on the ulnar surface of the ulna. Materials and Methods A retrospective chart review of patients with ulnar impaction syndrome between 2010 and 2014 identified 38 patients. The following clinical data were observed: patient age, sex, range of motion, grip strength, visual analog scale (VAS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, radiological assessment, and complications. The mean follow-up period is 30 months. Eleven patients were excluded from the study. Results Compared with the contralateral side, the 27 patients included in this study attained 93 to 96% of wrist and forearm motion and 81% of the grip strength. The average DASH score was 18 in a mean follow-up period of 30 months. Three patients required plate removal and one case showed nonunion and a further operation was needed. Two patients reported persistent ulnar-sided wrist pain. Conclusion We concluded that placing the ulnar osteotomy plate on the ulnar surface of the ulna is a quicker procedure, with less soft tissue dissection and irritation, and very high union rate. Level of Evidence Level IV.
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Affiliation(s)
- Ahmed Elgammal
- Department of Orthopedics, Ain Shams University Hospitals, Al Waili, Cairo, Egypt
- Department of Hand Surgery, Helios Kliniken, München, Germany
| | - Bernhard Rozée
- Department of Hand Surgery, Hessing Klinik, Augsburg, Germany
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20
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Schmidle G, Kastenberger T, Arora R. Time-Dependent Recovery of Outcome Parameters in Ulnar Shortening for Positive Ulnar Variance: A Prospective Case Series. Hand (N Y) 2018; 13:215-222. [PMID: 28391754 PMCID: PMC5950970 DOI: 10.1177/1558944717702465] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND This study evaluates the results of ulnar shortening using the ulna osteotomy locking plate system (UOL; I.T.S. GmbH, Graz, Austria) with special regard to the time-dependent recovery of subjective and objective outcome parameters and surgeons' experiences. METHODS Ulnar shortening using the UOL was performed on 11 patients (3 men, 8 women) with an average age of 47 ± 19.6 years. Range of motion (ROM) and grip strength were compared with the contralateral hand. Patient-rated outcomes were measured using a visual analogue scale (VAS) for pain and the Disability of the Arm, Shoulder and Hand (DASH) and the Patient Rated Wrist Evaluation (PRWE) survey for subjective outcomes. Ulnar variance and bony union were assessed using conventional wrist radiographs. The surgeons evaluated intraoperative handling through a standardized feedback form. RESULTS ROM improved and grip strength increased significantly between preoperative values and final follow-up. Flexion and supination improved significantly between weeks 8 and 12 and grip strength from week 8 onward. Patient-rated outcomes changed significantly with a final DASH score of 14.2 ± 12.4 and a PRWE score of 24.3 ± 17.0. Pain levels improved significantly with no pain at rest and a mean VAS of 0.8 ± 1.2 during activity. The average amount of shortening was 4.0 ± 1.9 mm with a final ulnar variance of 0.2 ± 1.8 mm. All osteotomies healed with 2 cases of delayed union. CONCLUSIONS In ulnar shortening with the UOL, wrist function recovered after an initial decrease from week 8 onward. Subjective outcome parameters showed early recovery and improved continuously over time.
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Affiliation(s)
- Gernot Schmidle
- Medical University of Innsbruck, Austria
- Gernot Schmidle, Division of Hand Surgery, Department of Trauma Surgery, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria.
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Finnigan T, Makaram N, Baumann A, Ramesh K, Mohil R, Srinivasan M. Outcomes of Ulnar Shortening for Ulnar Impaction Syndrome Using the 2.7 mm AO Ulna Shortening Osteotomy System. J Hand Surg Asian Pac Vol 2018; 23:82-89. [DOI: 10.1142/s242483551850011x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Ulnar shortening osteotomy is a well-established treatment for ulnar impaction syndrome. Controversy remains regarding the most effective system to achieve efficient bony union, whilst minimising incidence of complications, particularly hardware irritation. We present outcomes at 2 years using the recently released low profile AO osteotomy system.Methods: 32 consecutive patients with significant pain from ulnar impaction syndrome (idiopathic or post-traumatic), without degenerative changes of the distal radio-ulnar joint, were included. Time to union, range of motion, grip strength, pain and complications were recorded.Results: Median time to union was 10.14 weeks (9.27–11.01, 95%CI), with one nonunion. Visual Analogue Pain score, grip strength and range of motion improved significantly. No patient experienced hardware irritation. No plate required removal. Positive ulnar variance was reduced by 3.8 mm (mean).Conclusions: The low profile AO system appears effective in achieving bony union whilst minimising incidence of hardware irritation, at a follow up of 2 years
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Affiliation(s)
- T. Finnigan
- Department of Orthopaedics and Trauma, Royal Blackburn Hospital, Lancashire, UK
| | - N. Makaram
- Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
| | - A. Baumann
- Department of Orthopaedics and Trauma, Royal Blackburn Hospital, Lancashire, UK
| | - K. Ramesh
- Department of Orthopaedics and Trauma, Royal Blackburn Hospital, Lancashire, UK
| | - R. Mohil
- Department of Orthopaedics and Trauma, Royal Blackburn Hospital, Lancashire, UK
| | - M. Srinivasan
- Department of Orthopaedics and Trauma, Royal Blackburn Hospital, Lancashire, UK
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Oh WT, Kang HJ, Chun YM, Koh IH, An HMS, Choi YR. Arthroscopic Wafer Procedure Versus Ulnar Shortening Osteotomy as a Surgical Treatment for Idiopathic Ulnar Impaction Syndrome. Arthroscopy 2018; 34:421-430. [PMID: 29225020 DOI: 10.1016/j.arthro.2017.08.306] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 08/30/2017] [Accepted: 08/31/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare clinical and radiologic outcomes and complication rates of the arthroscopic wafer procedure (AWP) and ulnar shortening osteotomy (USO) for idiopathic ulnar impaction syndrome (UIS). METHODS From May 2009 to June 2014, 42 patients who were aged 45 years or older with idiopathic UIS underwent either the AWP or USO under the following identical surgical indications: (1) less than 4 mm of positive ulnar variance, (2) Palmer classification 2C or 2D lesion of the triangular fibrocartilage complex, (3) stable distal radioulnar joint (DRUJ) and/or lunotriquetral joint, and (4) no evidence of osteoarthritis of the DRUJ or ulnocarpal joint. The patient assignment was not randomized. Were used a visual analog scale for ulnar wrist pain; grip strength; range of motion; the Mayo Wrist Score (MWS); and the Disabilities of the Arm, Shoulder and Hand (DASH) score at 3, 6, 12, and 24 months after surgery to compare clinical outcomes. Ulnar variance, cystic changes of the lunate and triquetrum, and DRUJ arthritis on radiographs and operation-related complications were compared. RESULTS This study evaluated 19 patients after the AWP and 23 patients after USO. At 3 months, the AWP produced significantly better outcomes than USO regarding grip strength (79.6% ± 14.3% vs 62.7% ± 12.6%, P < .001), MWS (81.8 ± 7.9 points vs 71.3 ± 14.2 points, P = .005), and DASH score (19.4 ± 8.4 vs 31.5 ± 14.0, P = .001); clinical outcomes were similar at 6, 12, and 24 months. The complication rates were 34.8% for USO and 10.5% for the AWP; complications included DRUJ arthritis (n = 4), implant irritation (n = 6), and refracture after implant removal (n = 2) in the USO group and secondary surgery (n = 1) and tendinopathy (n = 1) in the AWP group. CONCLUSIONS The AWP and USO for idiopathic UIS with subtle positive ulnar variance achieved similar clinical and radiologic outcomes at 2 years after surgery. However, compared with USO, the AWP showed lower complication rates and better grip strength, MWS values, and DASH scores at 3 months after surgery. LEVEL OF EVIDENCE Level III, comparative trial.
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Affiliation(s)
- Won-Taek Oh
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ho-Jung Kang
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong-Min Chun
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Il-Hyun Koh
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hae-Mo-Su An
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yun-Rak Choi
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Haider T, Geisler D, Thalhammer G, Erhart J. Multiple drill-hole osteotomy in hand surgery - description of a novel application and proof of feasibility. BMC Musculoskelet Disord 2017; 18:529. [PMID: 29237432 PMCID: PMC5729239 DOI: 10.1186/s12891-017-1895-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 12/06/2017] [Indexed: 11/26/2022] Open
Abstract
Background Malunion of phalangeal and metacarpal bones are often associated with impairment of hand function and pose a challenging task for treating surgeons in most cases. When applicable, corrective osteotomy is the treatment of choice, where the affected bone is cut to correct malalignment using chisels or saws. The use of these instruments is associated with several drawbacks especially in hand surgery. We aimed to determine whether a multiple drill-hole (MDH) osteotomy technique was suitable for performing corrective osteotomies of metacarpal and phalangeal bones. Methods This case series included 11 patients with malalignments or malunions of phalangeal or metacarpal bones. Corrective osteotomy was performed with the MDH technique. Follow-up examinations included clinical evaluations and radiography at frequent intervals, between 2 and 22 months postoperatively. Results In all cases, planned osteotomies were technically feasible with the MDH technique. Apart from one case of a broken drillbit, no intraoperative or postoperative complication was recorded. All performed osteotomies healed within a mean of 6 weeks to radiological consolidation. In all cases, satisfactory results were achieved. Conclusion The present study was the first to test MDH osteotomy for hand surgery. We demonstrated that MDH was feasible for corrective osteotomies of metacarpal and phalangeal deformities. Advantages included excellent feasibility for osteotomies performed at varying angles, precise execution, reduced risk of collateral damage, and flexibility for performing intra-articular osteotomies.
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Affiliation(s)
- T Haider
- Department of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria.
| | - D Geisler
- Department of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - G Thalhammer
- Department of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - J Erhart
- Department of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
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Marquez-Lara A, Nuñez FA, Kiymaz T, Nuñez FA, Li Z. Metaphyseal Versus Diaphyseal Ulnar Shortening Osteotomy for Treatment of Ulnar Impaction Syndrome: A Comparative Study. J Hand Surg Am 2017; 42:477.e1-477.e8. [PMID: 28434833 DOI: 10.1016/j.jhsa.2017.03.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 02/16/2017] [Accepted: 03/09/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the clinical and radiographic outcomes and complication rates of diaphyseal and metaphyseal ulnar shortening osteotomies for the treatment of ulnar abutment syndrome. METHODS We performed a retrospective study comparing 35 patients who underwent either a metaphyseal (n = 14) or diaphyseal (n = 21) osteotomy. Radiographic and clinical outcomes were compared. Complication rates including infection, hardware removal, and reoperations were also assessed. RESULTS There were no differences in patient characteristics, ulnar variance, or pain and functional scores between groups. Metaphyseal osteotomy surgery time was shorter (45.5 vs 71.7 minutes) and resulted in greater ulnar shortening (4.8 vs 3.4 mm) compared with diaphyseal osteotomies. At an average 19.2-month follow-up, metaphyseal osteotomies were associated with greater improvement in pain and Quick-Disabilities of the Arm, Shoulder, and Hand questionnaire scores. The need for implant removal was the same in both groups. There were no complications in either group. CONCLUSIONS Results from this study suggest that metaphyseal osteotomies are a safe and effective alternative to diaphyseal osteotomies for the management of ulnar abutment syndrome. Although improved surgical time and postoperative outcomes are encouraging, further large-scale and properly powered studies with long-term outcomes will help characterize the benefit of one technique over another. Ultimately, the decision between a metaphyseal and diaphyseal osteotomy may be surgeon preference. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
| | - Fiesky A Nuñez
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC.
| | - Tunc Kiymaz
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Fiesky A Nuñez
- Hand and Upper Extremity Unit, Centro Medico Guerra Mendez, Valencia, Venezuela
| | - Zhongyu Li
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC
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Cha SM, Shin HD, Ahn KJ. Prognostic Factors Affecting Union After Ulnar Shortening Osteotomy in Ulnar Impaction Syndrome: A Retrospective Case-Control Study. J Bone Joint Surg Am 2017; 99:638-647. [PMID: 28419031 DOI: 10.2106/jbjs.16.00366] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ulnar shortening osteotomy (USO) is a widely adopted procedure with excellent outcomes. However, delayed union or nonunion has occasionally been observed. The purpose of this retrospective case-control study was to identify variables affecting osseous consolidation after USO in patients with ulnar impaction syndrome. METHODS The study included 325 patients who had undergone USO between March 2008 and March 2014. We evaluated the association between union and basic demographic factors as well as preoperative pain (assessed on a visual analog scale [VAS]), range of wrist motion, grip strength, and modified Mayo wrist score. We also assessed the association of union with radiographic variables such as the degree of dorsal subluxation of the ulna, preoperative and postoperative ulnar variance, morphological type of the distal radioulnar joint, gap at the osteotomy site, and presence of newly developed arthritic changes during the follow-up period. Finally, variables associated with operative conditions, such as degeneration of the triangular fibrocartilage complex, use of a parallel double-blade saw, type of plate used for fixation, number of screws, and plate position on the volar or dorsal ulnar surface were investigated. RESULTS Ulnar union was achieved in 294 patients (group 1), and 31 patients had delayed union or nonunion (group 2). On univariate and multivariate analyses, smoking, low bone mineral density (BMD), a decreased range of motion of the wrist, and use of a double-blade saw were found to be significant factors for an adverse radiographic outcome (nonunion or delayed union). CONCLUSIONS Delayed union or nonunion occurred in about 10% of patients treated with USO. We suggest that it may be preferable to perform USO in nonsmokers, patients with normal bone density, and those without restricted wrist motion. Also, we recommend the use of a single-blade saw when performing the osteotomy. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Soo Min Cha
- 1Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea
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Papatheodorou LK, Sotereanos DG. Step-Cut Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome. JBJS Essent Surg Tech 2017; 7:e3. [PMID: 30233938 DOI: 10.2106/jbjs.st.16.00062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction The step-cut ulnar shortening osteotomy for the treatment of ulnar impaction syndrome is a safe, reliable, and less expensive technique that uses a 7-hole 3.5-mm standard neutralization plate and a lag screw for fixation, thus avoiding the need for the special instrumentation that other ulnar shortening techniques require. Indications & Contraindications Step 1 Preoperative Planning Perform a physical examination and obtain imaging studies to identify all associated abnormalities. Step 2 Wrist Arthroscopy Video 1 Verify the diagnosis of ulnar impaction syndrome and treat concurrent intra-articular abnormalities. Step 3 Incision for the Ulnar Shortening Osteotomy Video 2 Make a longitudinal skin incision along the distal third of the ulna. Step 4 Design the Step-Cut Ulnar Shortening Osteotomy Video 2 Design the step-cut ulnar shortening osteotomy. Step 5 Perform the Step-Cut Ulnar Shortening Osteotomy Video 2 Create the step-cut ulnar shortening osteotomy using an oscillating saw. Step 6 Fixation of the Osteotomy Video 3 Fix the osteotomy with a lag screw and volar plate. Step 7 Wound Closure Meticulously close the wound in layers. Step 8 Postoperative Care Protect the affected arm for the first 6 weeks. Results In our original study, 164 patients with symptomatic ulnar impaction syndrome were treated with a step-cut ulnar shortening osteotomy using a volar 3.5-mm standard neutralization plate and a lag screw14. Pitfalls & Challenges
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Affiliation(s)
| | - Dean G Sotereanos
- Orthopaedic Specialists-UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania.,University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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27
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Benis S, Goubau JF, Mermuys K, Van Hoonacker P, Berghs B, Kerckhove D, Vanmierlo B. The Oblique Metaphyseal Shortening Osteotomy of the Distal Ulna: Surgical Technique and Results of Ten Patients. J Wrist Surg 2017; 6:39-45. [PMID: 28119794 PMCID: PMC5258128 DOI: 10.1055/s-0036-1585069] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 05/30/2016] [Indexed: 10/21/2022]
Abstract
Background Ulnocarpal abutment is a common condition following distal radius fractures. There are different surgical methods of treatment for this pathology: open and arthroscopic wafer procedure or an ulnar shortening osteotomy. We describe an oblique metaphyseal shortening osteotomy of the distal ulna using two cannulated headless compression screws. We report the results of 10 patients treated with this method. Materials and Methods Out of 17 patients, 10 could be reviewed retrospectively for this study. Patient-rated outcomes were measured using the VAS (visual analogue scale) for pain, PRWHE (patient-rated wrist and hand evaluation) survey, and Quick-DASH (disability of arm, shoulder and hand) survey for functional outcomes. At the review we measured the range of motion (ROM) of the wrist (extension and flexion, ulnar and radial deviation, pronation and supination). Grip strength, pronation, and supination strength of the forearm was measured using a calibrated hydraulic dynamometer. ROM and strength of the affected wrist was compared with ROM and strength of the unaffected wrist. Surgical Procedure Oblique long metaphyseal osteotomy of the distal ulna (from proximal-ulnar to distal-radial), fixed with two cannulated headless compression screws. Results The average postoperative VAS score for pain was 23.71 (standard deviation [SD] of 30.41). The average postoperative PRWHE score was 32.55 (SD of 26.28). The average postoperative Quick-DASH score was 28.65 (SD of 27.21). The majority of patients had a comparable ROM and strength between the operated side and the non-operated side. Conclusion This surgical technique has the advantage of reducing the amount of hardware and to decrease the potential hinder caused by it on medium term. Moreover, the incision remains smaller, and the anatomic metaphyseal localization of the osteotomy potentially allows a better and rapid healing.
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Affiliation(s)
- Szabolcs Benis
- Department of Orthopaedics and Traumatology, Upper Limb Unit, Orthoclinic Brugge, Bruges, Belgium
- Department of Orthopaedics and Traumatology, University Hospital Ghent, Ghent, Belgium
| | - Jean F. Goubau
- Department of Orthopaedics and Traumatology, Upper Limb Unit, Orthoclinic Brugge, Bruges, Belgium
- Department of Orthopaedics and Traumatology, University Hospital Brussels (VUB-Vrije Universiteit Brussel), Jette, Belgium
| | - Koen Mermuys
- Department of Radiology, AZ Sint-Jan AV Brugge-Oostende, Campus Brugge, Bruges, Belgium
| | - Petrus Van Hoonacker
- Department of Orthopaedics and Traumatology, Upper Limb Unit, Orthoclinic Brugge, Bruges, Belgium
| | - Bart Berghs
- Department of Orthopaedics and Traumatology, Upper Limb Unit, Orthoclinic Brugge, Bruges, Belgium
| | - Diederick Kerckhove
- Department of Orthopaedics and Traumatology, Upper Limb Unit, Orthoclinic Brugge, Bruges, Belgium
| | - Bert Vanmierlo
- Department of Orthopaedics and Traumatology, Upper Limb Unit, Orthoclinic Brugge, Bruges, Belgium
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Papatheodorou LK, Baratz ME, Bougioukli S, Ruby T, Weiser RW, Sotereanos DG. Long-Term Outcome of Step-Cut Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome. J Bone Joint Surg Am 2016; 98:1814-1820. [PMID: 27807114 DOI: 10.2106/jbjs.15.01111] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Extra-articular ulnar shortening osteotomy is a common procedure for the surgical treatment of ulnar impaction syndrome. Several techniques for this osteotomy have been developed to avoid the morbidity associated with a standard transverse osteotomy. However, these techniques require special instrumentation and are expensive. The purpose of this study was to evaluate the outcome of step-cut ulnar shortening osteotomy without special jigs for ulnar impaction syndrome. METHODS A retrospective study of 164 consecutive patients who underwent step-cut ulnar shortening osteotomy between 2000 and 2010 was performed. The long arm of the step-cut osteotomy was oriented in the coronal plane parallel to the long axis of the ulna. The short arms of the osteotomy were perpendicular to the long axis in the axial plane. Fixation was performed with a palmar 3.5-mm standard neutralization plate and a lag screw. The goal of the osteotomy was to reduce ulnar variance, which was assessed in all patients with pronated grip-view radiographs preoperatively and postoperatively. Preoperative ulnar variance ranged from +1 to +6 mm. RESULTS All patients were followed for at least 24 months. Union of the osteotomy site was achieved at a mean of 8.2 weeks. The union rate was 98.8%. There were 2 cases of nonunion, which required additional surgery. The mean postoperative ulnar variance was +0.2 mm (range, -1 to +1.5 mm) after a mean overall ulnar shortening of 2.5 mm. All patients returned to their previous work, in a mean of 4 months. The plate was removed from 12 patients because of plate-related symptoms. No other complications were encountered. CONCLUSIONS The step-cut ulnar shortening osteotomy provides ample bone-to-bone contact and simplifies control of rotation. Stable internal fixation with standard techniques allowed an early return to functional activities. Palmar placement of the plate diminishes the need for plate removal. This is a simple and less expensive technique for ulnar shortening that does not require the use of special instrumentation in patients with ulnar impaction syndrome. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Mark E Baratz
- University of Pittsburgh, Orthopaedic Specialists-UPMC, Pittsburgh, Pennsylvania
| | - Sofia Bougioukli
- University of Southern California, Keck School of Medicine, Los Angeles, California
| | - Tyler Ruby
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert W Weiser
- University of Pittsburgh, Orthopaedic Specialists-UPMC, Pittsburgh, Pennsylvania
| | - Dean G Sotereanos
- University of Pittsburgh, Orthopaedic Specialists-UPMC, Pittsburgh, Pennsylvania
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Jungwirth-Weinberger A, Borbas P, Schweizer A, Nagy L. Influence of Plate Size and Design upon Healing of Ulna-Shortening Osteotomies. J Wrist Surg 2016; 5:284-289. [PMID: 27777819 PMCID: PMC5074826 DOI: 10.1055/s-0036-1582430] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 03/03/2016] [Indexed: 10/21/2022]
Abstract
Purpose Ulna-shortening osteotomy is one of the most established and most frequent operations in hand surgery. However, bone union is not always achieved and the use of plates implies potential risks and problems. The traditional points of criticism are the duration of bone healing, the incidence of nonunion, and the necessity of hardware removal due to the soft tissue irritation by the plate or the screws. These shortcomings have been addressed by an increasing standardization of the procedure and finally specific instruments and implants. The aim of this retrospective study was to compare a new LCP (locking compression plate) Ulna Osteotomy System 2.7 mm (Synthes, Paoli, PA) with the former 3.5-mm LCDCP (limited-contact dynamic compression plate) (Synthes) regarding consolidation, complications, and rate of plate removal. Methods To investigate the effect of an implant and technique specifically designed for this purpose, we have compared the course of healing and the result in 72 patients who have undergone ulnar shortening osteotomy using general instruments and applying a standard osteosynthesis plate (Synthes, 3.5-mm LCDCP) to a consecutive cohort of 40 patients who had ulnar shortening using the new dedicated ulna-shortening osteotomy system plate (Synthes, 2.7-mm LCP). Clinical and radiologic evaluation was performed 8 weeks, 3 months, 6 months, and 1 year postoperatively in all patients. Results The latter displayed shorter bone healing time, suggesting an advantage of an oblique osteotomy. There was no significant difference in rate of plate removal. Ultimate complication and consolidation rate was not different. Conclusion Using the new LCP 2.7 implant, time to consolidation was shorter and oblique osteotomies healed faster than transverse ones. However, in spite of the smaller plate, screws, and tapered design, the plate did not cause less local problems and failed to decrease the necessity of plate removal. Furthermore, the cost of the implant is higher than the LCDPC 3.5. Type of Study Retrospective comparative study. Therapeutic evidence Level III.
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Affiliation(s)
| | - Paul Borbas
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Andreas Schweizer
- Division of Hand Surgery, Department of Orthopedics, University of Zurich, Zurich, Switzerland
| | - Ladislav Nagy
- Division of Hand Surgery, Department of Orthopedics, University of Zurich, Zurich, Switzerland
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30
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Chennagiri R, Burge P. Pre-Osteotomy Plate Application Technique for Ulnar Shortening. ACTA ACUST UNITED AC 2016; 29:453-7. [PMID: 15336748 DOI: 10.1016/j.jhsb.2004.04.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2003] [Accepted: 04/07/2004] [Indexed: 11/27/2022]
Abstract
The self-compressing mode of the AO/ASIF LC-DC plate can be harnessed to close and compress modest osteotomy gaps that are created after provisional application of the plate with two screw holes on either side of the osteotomy. The oblique osteotomy cuts are made through 70% of the bone diameter and the actual osteotomy width is measured. After provisional plate application and removal, the cuts are completed and the plate is re-applied. Eccentric drilling of up to five holes of a 6-hole plate using the 3.5 mm universal drill guide allows closure and compression of osteotomy gaps of up to 4 mm. An interfragmentary screw is placed across the oblique osteotomy through the remaining hole. The technique is simple but requires careful planning and execution.
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Affiliation(s)
- R Chennagiri
- Nuffield Orthopaedic Centre, Headington, Oxford OX3 7LD, UK
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31
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KÖPPEL M, HARGREAVES IC, HERBERT TJ. Ulnar Shortening Osteotomy for Ulnar Carpal Instability and Ulnar Carpal Impaction. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/s0266-7681(97)80265-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report the results of a retrospective review of 47 ulnar shortening osteotomies carried out for ulnar carpal impaction and/or ulnar carpal instability. The average follow-up was 18 months. Wrist function was graded preoperatively and postoperatively using an assessment system modified from Chun and Palmer (1993) . The results show that distal ulnar shortening osteotomy successfully reduces pain and improves wrist function both for ulnar carpal instability (UCI) and ulnar impaction syndrome (UIS) and is equally effective for those patients with combined UIS and UCI. Grip strength and wrist stability were significantly improved and range of wrist and forearm motion was little affected by the procedure. Oblique osteotomies were found to heal faster and to have a lower non-union rate than transverse osteotomies. Although radiographs did show adaptive changes of the distal radioulnar joint in a significant number of patients, there is no evidence (as yet) to suggest that this leads to the development of secondary osteoarthritis.
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Affiliation(s)
- M. KÖPPEL
- From St Luke’s Hospital Hand Unit, Sydney, Australia
| | | | - T. J. HERBERT
- From St Luke’s Hospital Hand Unit, Sydney, Australia
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32
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Canham CD, Schreck MJ, Maqsoodi N, Messing S, Olles M, Elfar JC. Distal Radioulnar Joint Reaction Force Following Ulnar Shortening: Diaphyseal Osteotomy Versus Wafer Resection. J Hand Surg Am 2015; 40:2206-12. [PMID: 26452758 PMCID: PMC5828165 DOI: 10.1016/j.jhsa.2015.07.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Revised: 07/08/2015] [Accepted: 07/08/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare how ulnar diaphyseal shortening and wafer resection affect distal radioulnar joint (DRUJ) joint reaction force (JRF) using a nondestructive method of measurement. Our hypothesis was that ulnar shortening osteotomy would increase DRUJ JRF more than wafer resection. METHODS Eight fresh-frozen human cadaveric upper limbs were obtained. Under fluoroscopic guidance, a threaded pin was inserted into the lateral radius orthogonal to the DRUJ and a second pin was placed in the medial ulna coaxial to the radial pin. Each limb was mounted onto a mechanical tensile testing machine and a distracting force was applied across the DRUJ while force and displacement were simultaneously measured. Data sets were entered into a computer and a polynomial was generated and solved to determine the JRF. This process was repeated after ulnar diaphyseal osteotomy, ulnar re-lengthening, and ulnar wafer resection. The JRF was compared among the 4 conditions. RESULTS Average baseline DRUJ JRF for the 8 arms increased significantly after diaphyseal ulnar shortening osteotomy (7.2 vs 10.3 N). Average JRF after re-lengthening the ulna and wafer resection was 6.9 and 6.7 N, respectively. There were no differences in JRF among baseline, re-lengthened, and wafer resection conditions. CONCLUSIONS Distal radioulnar joint JRF increased significantly after ulnar diaphyseal shortening osteotomy and did not increase after ulnar wafer resection. CLINICAL RELEVANCE Diaphyseal ulnar shortening osteotomy increases DRUJ JRF, which may lead to DRUJ arthrosis.
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Affiliation(s)
- Colin D. Canham
- Department of Orthopaedic Surgery, University of Rochester, Rochester, NY,Rochester Institute of Technology/University of Rochester Orthopaedic Biomechanics Laboratory, Rochester, NY
| | - Michael J. Schreck
- Department of Orthopaedic Surgery, University of Rochester, Rochester, NY,Rochester Institute of Technology/University of Rochester Orthopaedic Biomechanics Laboratory, Rochester, NY
| | - Noorullah Maqsoodi
- Rochester Institute of Technology/University of Rochester Orthopaedic Biomechanics Laboratory, Rochester, NY,Department of Manufacturing and Mechanical Engineering Technology, Rochester Institute of Technology, Rochester, NY
| | - Susan Messing
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY
| | - Mark Olles
- Rochester Institute of Technology/University of Rochester Orthopaedic Biomechanics Laboratory, Rochester, NY,Department of Manufacturing and Mechanical Engineering Technology, Rochester Institute of Technology, Rochester, NY
| | - John C. Elfar
- Department of Orthopaedic Surgery, University of Rochester, Rochester, NY,Rochester Institute of Technology/University of Rochester Orthopaedic Biomechanics Laboratory, Rochester, NY
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33
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Chan SKL, Singh T, Pinder R, Tan S, Craigen MA. Ulnar Shortening Osteotomy: Are Complications Under Reported? J Hand Microsurg 2015; 7:276-82. [PMID: 26578830 DOI: 10.1007/s12593-015-0201-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 09/14/2015] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Samuel K L Chan
- Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Birmingham, B31 2AP UK
| | - T Singh
- Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Birmingham, B31 2AP UK
| | - R Pinder
- Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Birmingham, B31 2AP UK
| | - S Tan
- Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Birmingham, B31 2AP UK
| | - M A Craigen
- Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Birmingham, B31 2AP UK
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Rajgopal R, Roth J, King G, Faber K, Grewal R. Outcomes and complications of ulnar shortening osteotomy: an institutional review. Hand (N Y) 2015; 10:535-40. [PMID: 26330791 PMCID: PMC4551633 DOI: 10.1007/s11552-014-9727-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Ulnar impaction syndrome (UIS) is a common cause of ulnar wrist pain. Patients may be candidates for surgical intervention if nonoperative options are ineffective. At our institution, ulnar shortening osteotomy is the preferred procedure to manage this disorder. The purpose of this study was to present patient reported outcomes and complication rates of ulnar shortening osteotomy (USO) at mid-term follow-up. METHODS A retrospective chart review of 72 patients (75 wrists) obtained from our institutional database was performed. At a mean 32 months postoperatively, telephone interviews (n = 53) were performed for all patients who were available for follow-up. The patient-rated wrist evaluation (PRWE), a validated outcome tool, was completed and complications were reviewed. RESULTS Patient-rated outcomes were favorable; however, complications were frequent and included: delayed union (10/75, 13.3 %), nonunion (6/75, 8 %), and complex regional pain syndrome (5/75, 6.7 %). Ten patients (13.3 %) required revision surgery. Thirty-four patients (45.3 %) required hardware removal with 4/30 (11.4 %) of these patients experiencing refracture. Smokers (mean PRWE 67.1) and patients with workers' compensation claims (mean PRWE 64.9) reported higher residual pain and disability than their counterparts (mean PRWE 28.0; 25.2). CONCLUSIONS General outcome measures were favorable. Smokers and patients with workers' compensation claims experienced significantly poorer outcomes. However, the incidence of nonunion and delayed union was higher than most reports in the literature. Furthermore, we demonstrated a high refracture rate (11.4 %) following removal of hardware.
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Affiliation(s)
- Raghav Rajgopal
- />Division of Orthopaedic Surgery, Western University, 339 Windermere Road, London, ON N6G 2V4 Canada
| | - James Roth
- />Division of Orthopaedic Surgery, Western University, 339 Windermere Road, London, ON N6G 2V4 Canada
- />The Roth | MacFarlane Hand and Upper Limb Centre, St. Joseph’s Health Centre, Suite D0-217, 268 Grosvenor Street, London, ON N6A 4L6 Canada
| | - Graham King
- />Division of Orthopaedic Surgery, Western University, 339 Windermere Road, London, ON N6G 2V4 Canada
- />The Roth | MacFarlane Hand and Upper Limb Centre, St. Joseph’s Health Centre, Suite D0-217, 268 Grosvenor Street, London, ON N6A 4L6 Canada
| | - Ken Faber
- />Division of Orthopaedic Surgery, Western University, 339 Windermere Road, London, ON N6G 2V4 Canada
- />The Roth | MacFarlane Hand and Upper Limb Centre, St. Joseph’s Health Centre, Suite D0-217, 268 Grosvenor Street, London, ON N6A 4L6 Canada
| | - Ruby Grewal
- />Division of Orthopaedic Surgery, Western University, 339 Windermere Road, London, ON N6G 2V4 Canada
- />The Roth | MacFarlane Hand and Upper Limb Centre, St. Joseph’s Health Centre, Suite D0-217, 268 Grosvenor Street, London, ON N6A 4L6 Canada
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Abstract
Chronic lunotriquetral (LT) injuries are less common than scapholunate ligament injuries and difficult to diagnose. They may be associated with positive ulnar variance. Clinical diagnostic tests elicit pain at the LT interval. Although radiographs are typically normal, MRI and wrist arthroscopy can help confirm the diagnosis. When conservative treatments fail, surgical options include LT ligament reconstruction, LT arthrodesis, and ulnar-shortening osteotomy (in patients with positive ulnar variance).
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Affiliation(s)
- Eric R Wagner
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Bassem T Elhassan
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Marco Rizzo
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Barbaric K, Rujevcan G, Labas M, Delimar D, Bicanic G. Ulnar Shortening Osteotomy After Distal Radius Fracture Malunion: Review of Literature. Open Orthop J 2015; 9:98-106. [PMID: 26157524 PMCID: PMC4484233 DOI: 10.2174/1874325001509010098] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 02/19/2015] [Accepted: 03/28/2015] [Indexed: 11/22/2022] Open
Abstract
Malunion of distal radius fracture is often complicated with shortening of the radius with disturbed radio- ulnar variance, frequently associated with lesions of triangular fibrocartilage complex and instability of the distal radioulnar joint. Positive ulnar variance may result in wrist pain located in ulnar part of the joint, limited ulnar deviation and forearm rotation with development of degenerative changes due to the overloading that occurs between the ulnar head and corresponding carpus. Ulnar shortening osteotomy (USO) is the standard procedure for correcting positive ulnar variance. Goal of this procedure is to minimize the symptoms by restoring the neutral radio - ulnar variance. In this paper we present a variety of surgical techniques available for ulnar shorthening osteotomy, their advantages and drawbacks. Methods of ulnar shortening osteotomies are divided into intraarticular and extraarticular. Intraarticular method of ulnar shortening can be performed arthroscopically or through open approach. Extraarticular methods include subcapital osteotomy and osteotomy of ulnar diaphysis, which depending on shape can be transverse, oblique, and step cut. All of those osteotomies can be performed along wrist arthroscopy in order to dispose and treat possibly existing triangular fibrocartilage complex injuries. At the end we described surgical procedures that can be done in case of ulnar shorthening osteotomy failure.
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Affiliation(s)
- Katarina Barbaric
- Department of Orthopaedic Surgery, Clinical Hospital Centre Zagreb, Salata 6, 10000, Zagreb, Croatia
| | - Gordan Rujevcan
- Department of Orthopaedic Surgery, General Hospital "Dr. Ivo Pedisic" Sisak, J. J. Strossmayera 59, 44000 Sisak, Croatia
| | - Marko Labas
- Department of Orthopaedic Surgery and Traumatology, General Hospital Varazdin, Ivana Mestrovica 2, 42000 Varazdin, Croatia
| | - Domagoj Delimar
- Department of Orthopaedic Surgery, University of Zagreb School of Medicine, Clinical Hospital Centre Zagreb, Salata 6-7, 10000 Zagreb, Croatia
| | - Goran Bicanic
- Department of Orthopaedic Surgery, University of Zagreb School of Medicine, Clinical Hospital Centre Zagreb, Salata 6-7, 10000 Zagreb, Croatia
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Das De S, Johnsen PH, Wolfe SW. Soft tissue complications of dorsal versus volar plating for ulnar shortening osteotomy. J Hand Surg Am 2015; 40:928-33. [PMID: 25721236 DOI: 10.1016/j.jhsa.2014.12.042] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 12/26/2014] [Accepted: 12/29/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the results and complications of fixed-angle dorsal locking plate fixation for ulnar shortening osteotomy (USO) with the conventional technique of volar plating. METHODS We performed a retrospective review of 32 patients undergoing USO on 34 wrists and compared the outcomes of 16 consecutive cases with dorsal 2.4/2.7-mm fixed-angle plating and 18 consecutive cases with volar 3.5-mm plating. A minimum of 12 months' follow-up was used to assess outcomes. Primary outcomes were painful hardware and removal of symptomatic implants. Secondary outcomes were pain, Patient-Rated Wrist Evaluation, range of motion, time to union, grip strength, and complications. RESULTS There were no significant differences in Patient-Rated Wrist Evaluation, pain score, range of motion, or time to union. Relative grip strength compared with the contralateral upper extremity in the dorsal group was higher than the volar group. After adjusting for hand dominance, dorsal plating was significantly associated with higher relative grip strength. There were 2 complications in the dorsal group, including one case with painful hardware. This was significantly lower than in the volar group, which had 10 complications including 2 nonunions and 6 cases of hardware-related soft tissue irritation. CONCLUSIONS Both volar and dorsal plating techniques for USO yielded good functional outcomes. There was a higher incidence of painful hardware requiring removal of implants in the volar group. Based on these findings, we advocate dorsal plate position using a smaller fixed-angle plate for USO in ulnar impaction syndrome. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.
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Affiliation(s)
- Soumen Das De
- Hand and Upper Extremity Service, Hospital for Special Surgery, New York, NY
| | - Parker H Johnsen
- Hand and Upper Extremity Service, Hospital for Special Surgery, New York, NY
| | - Scott W Wolfe
- Hand and Upper Extremity Service, Hospital for Special Surgery, New York, NY.
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Oteo J, Benavente P, Merino P. Acortamiento cubital. Contribución del sistema guiado para osteotomía y síntesis. REVISTA IBEROAMERICANA DE CIRUGÍA DE LA MANO 2015. [DOI: 10.1016/j.ricma.2015.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Objetivos: El acortamiento cubital es la técnica quirúrgica empleada más habitualmente para casos de impactación y dolor cubitocarpiano. Tradicionalmente el cúbito ha sido cortado sin guía y la osteosíntesis realizada con una placa no diseñada para esta intervención, pero han surgido sistemas que pretenden facilitar el trabajo al cirujano utilizando guías para la osteotomía y placas de compresión específicas, e intentar mejorar la evolución de los pacientes. El propósito de este estudio es determinar si con el uso de los sistemas guiados se consiguen mejorar los resultados de la técnica previa.Material y método: Entre 2004 y 2008 el acortamiento cubital se realizó en nuestro Centro sin utilizar una técnica guiada, a partir del 2008 se utilizó un sistema guiado. Se ha realizado un estudio descriptivo en 37 casos, 19 no guiados, 18 guiados, revisando el tiempo de duración de la cirugía, el rango de movimiento, el tiempo de consolidación y la retirada del material de osteosíntesis.Resultados: Tras realizar un análisis estadístico de los datos, se ha visto que hay una diferencia estadísticamente significativa en relación con la variable duración de la cirugía, siendo la cirugía guiada veinte minutos más corta que la no guiada. No se han visto diferencias estadísticamente significativas en los otros parámetros.Conclusión: En el acortamiento cubital el uso de los sistemas guiados para corte y osteosíntesis, consigue reducir el tiempo de la cirugía, sin ocasionar detrimento en los resultados en comparación con la técnica sin guía.
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Renfree KJ, Odgers RA. Stacked-blade, single-cut, ulnar-shortening osteotomy. Orthopedics 2015; 38:e80-7. [PMID: 25665123 DOI: 10.3928/01477447-20150204-53] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 04/30/2014] [Indexed: 02/03/2023]
Abstract
The authors reviewed a 10-year consecutive series of ulnar-shortening osteotomies using a freehand, single oblique cut with 2 or 3 stacked saw blades. Twenty-one patients (23 wrists) with chronic ulnar impaction syndrome (mean age, 45 years; range, 16 to 73 years) demonstrated an average preoperative ulnar variance of +2.1 mm (range, 0.0 to 4.0 mm). An oblique osteotomy was performed in the distal one-third of the ulnar diaphysis at an estimated 45° or 60° angle, relative to the ulnar axis, and was fixed with a 7-hole, 2.7- or 3.5-mm dynamic compression plate placed dorsally. Using a previously described formula, the authors estimated ulnar shortening on the basis of intraoperative measurement of kerf width and osteotomy angle as 3.3 mm (range, 2.3 to 4.7 mm). The actual measured average radiographic change in ulnar variance (preoperative to postoperative) was 2.8 mm (average 18% variance from intraoperative estimate). Final ulnar variance averaged -0.6 mm (range, -2.0 to 1.0 mm). Radiographic union occurred in all 23 (100%) osteotomies. Ten (43%) wrists required hardware removal for pain; 2 additional patients were symptomatic but declined removal. Ulnar-sided wrist pain was relieved in 22 wrists. This technique is simple, effective, and inexpensive. It can also be translated for use in shortening osteotomies for other long bones, although larger or smaller saw blades may be necessary for larger or smaller bones to achieve the desired amount of shortening. The authors' results also show it to be reasonably predictable, although the intraoperative use of a sterile goniometer for cut placement is recommended.
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Martin DE, Zlotolow DA, Russo SA, Kozin SH. Comparison of compression screw and perpendicular clamp in ulnar shortening osteotomy. J Hand Surg Am 2014; 39:1558-64. [PMID: 24969590 DOI: 10.1016/j.jhsa.2014.04.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 04/06/2014] [Accepted: 04/09/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To biomechanically quantify 2 techniques, compression screw and perpendicular clamp, for generating compression during ulnar shortening osteotomy (USO) in order to promote reliable primary bone healing. METHODS Fourteen fresh-frozen cadaveric human forearms were randomly assigned to 1 of 2 groups. Group I (n = 7) underwent USO according to the traditional AO plate fixation technique using a screw placed eccentrically in an oblong hole to generate compression at the osteotomy site. Group II (n = 7) underwent USO with a commercially available USO plating system using a clamp placed perpendicular to the osteotomy site to generate compression. Both techniques involved a 2-mm resection osteotomy performed with cutting jigs to minimize variability and an interfragmentary lag screw to augment compression. A digital pressure sensor measured contact area at the osteotomy site and average pressure in the observed contact area; these values were used to calculate force across the osteotomy site. Measurements were obtained after the following steps: reduction of osteotomy, compression screw placement (group 1 only), lag screw placement, and final construct with all clamps removed. RESULTS Group II demonstrated significantly greater force than group I, and lag screw placement resulted in significantly increased force independent of fixation technique. The effect of the lag screw on force was maintained after clamp removal. Although technique of fixation did not significantly influence contact area, lag screw placement significantly increased contact area independent of fixation method. However, this effect was not maintained after clamp removal. Average pressure in the observed contact area was not significantly influenced by fixation technique or stage of fixation. CONCLUSIONS Perpendicular clamp compression significantly increased force as compared with traditional compression screw technique, and lag screw placement significantly increased force in both constructs. CLINICAL RELEVANCE Larger compressive forces across the osteotomy may promote primary bone union and decrease the rates of delayed union or nonunion.
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Affiliation(s)
- Daniel E Martin
- Philadelphia Hand Center, Department of Orthopaedic Surgery, Division of Hand Surgery, Thomas Jefferson University, Philadelphia, PA; Upper Extremity Center of Excellence, Shriners Hospitals for Children, Philadelphia, PA; Biomechanics and Movement Science Program, University of Delaware, Newark, DE
| | - Dan A Zlotolow
- Philadelphia Hand Center, Department of Orthopaedic Surgery, Division of Hand Surgery, Thomas Jefferson University, Philadelphia, PA; Upper Extremity Center of Excellence, Shriners Hospitals for Children, Philadelphia, PA; Biomechanics and Movement Science Program, University of Delaware, Newark, DE
| | - Stephanie A Russo
- Philadelphia Hand Center, Department of Orthopaedic Surgery, Division of Hand Surgery, Thomas Jefferson University, Philadelphia, PA; Upper Extremity Center of Excellence, Shriners Hospitals for Children, Philadelphia, PA; Biomechanics and Movement Science Program, University of Delaware, Newark, DE
| | - Scott H Kozin
- Philadelphia Hand Center, Department of Orthopaedic Surgery, Division of Hand Surgery, Thomas Jefferson University, Philadelphia, PA; Upper Extremity Center of Excellence, Shriners Hospitals for Children, Philadelphia, PA; Biomechanics and Movement Science Program, University of Delaware, Newark, DE.
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Abstract
UNLABELLED Background Malunion is a common complication of distal radius fractures. Ulnar shortening osteotomy (USO) may be an effective treatment for distal radius malunion when appropriate indications are observed. Methods The use of USO for treatment of distal radius fracture malunion is described for older patients (typically patients >50 years) with dorsal or volar tilt less than 20 degrees and no carpal malalignment or intercarpal or distal radioulnar joint (DRUJ) arthritis. Description of Technique Preoperative radiographs are examined to ensure there are no contraindications to ulnar shortening osteotomy. The neutral posteroanterior (PA) radiograph is used to measure ulnar variance and to estimate the amount of ulnar shortening required. An ulnar, mid-sagittal incision is used and the dorsal sensory branch of the ulnar nerve is preserved. An USO-specific plating system with cutting jig is used to create parallel oblique osteotomies to facilitate shortening. Intraoperative fluoroscopy and clinical range of motion are checked to ensure adequate shortening and congruous reduction of the ulnar head within the sigmoid notch. Results Previous outcomes evaluation of USO has demonstrated improvement in functional activities, including average flexion-extension and pronosupination motions, and patient reported outcomes. Conclusion The concept and technique of USO are reviewed for the treatment of distal radius malunion when specific indications are observed. Careful attention to detail related to surgical indications and to surgical technique typically will improve range of motion, pain scores, and patient-reported outcomes and will reduce the inherent risks of the procedure, such as ulnar nonunion or the symptoms related to unrecognized joint arthritis. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Robin N. Kamal
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
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Abstract
Background Ulnar sided wrist pain is a commonly encountered complaint of the hand surgeon, and ulnar impaction is a common cause. Surgical treatment aims to reduce the force transmitted through the ulna and traditionally includes diaphyseal ulnar shortening osteotomy and the "wafer" procedure. These procedures have known shortcomings. We describe an alternative option known as the distal metaphyseal ulnar shortening osteotomy (DMUSO). Materials and Methods Retrospective review of eight procedures was undertaken to assess radiographic healing, objective measurements of wrist and forearm motion, grip and pinch strength, and subjective measures of Disabilities of the Arm, Shoulder, and Hand (DASH), Patient-Rated Wrist Evaluation (PRWE), and Michigan Hand Outcomes Questionnaire (MHQ) at a minimum of 12 months following surgery. Description of Technique A wedge osteotomy is made in the osteochondral region of the distal metaphysis of the ulna, and a headless compression screw is used for fixation. Results Five women and three men underwent DMUSO with average follow up at 13 months; the dominant wrist was affected in 7 of 8 patients. The affected wrist had less motion in all planes, and grip and pinch strength was also less in the affected wrist, but only wrist extension was significantly different from the contralateral side. These findings likely did not have an effect on the clinical outcome. Subjective outcomes included average DASH score of 13 (0-35), PRWE 19 (40-11), and MHQ score of 88 (85-100). Conclusions DMUSO is a viable option for patients with ulnar impaction syndrome. It requires intra-articular exposure of the distal radioulnar joint (DRUJ) but is less invasive then diaphyseal shortening. It permits early and reliable return of joint motion and function while avoiding the potential need for hardware removal by using a buried screw.
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Affiliation(s)
- Joseph S Khouri
- Division of Plastic Surgery, University of Rochester Medical Center, Rochester, New York
| | - Warren C Hammert
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York
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Ulnocarpal impaction syndrome: treatment with a transverse ulnar shortening osteotomy from an ulnodorsal approach. Arch Orthop Trauma Surg 2014; 134:881-5. [PMID: 24659305 DOI: 10.1007/s00402-014-1976-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Ulnocarpal impaction syndrome is a common cause of chronic ulnar-sided wrist pain. The distal ulnar shortening osteotomy addresses the often present positive ulnar variance and therefore relieves the excessive load on the ulnocarpal joint. In the present study, the results of a technique that uses an ulnodorsal approach with a compression device and a transverse osteotomy are presented and compared to other techniques. MATERIALS AND METHODS This retrospective study includes 92 wrists with an ulnocarpal impaction syndrome, which were treated with an ulnar shortening osteotomy. The mean duration of postoperative follow-up was 50 months. RESULTS The mean ulnar variance was 2.17 ± 1.56 mm preoperatively and after the ulnar shortening osteotomy -1.36 ± 1.67 mm (p < 0.05). Radiological consolidation of the osteotomy could be shown in 91 wrists 6 months postoperatively. Patients rated the preoperative pain level at a VAS 7.9 ± 1.7 which decreased to a of VAS 2.4 ± 2.5 (p < 0.05). 19 patients complained of mechanical irritation. There was no neurological irritation. CONCLUSION It could be shown that the distal ulnar shortening osteotomy by a transverse osteotomy using a compression device and an ulnodorsal approach has a low complication rate. It is comparable to the oblique osteotomy in effectiveness and safety.
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Nagy L, Jungwirth-Weinberger A, Campbell D, Pino JGD. The AO Ulnar Shortening Osteotomy System Indications and Surgical Technique. J Wrist Surg 2014; 3:91-97. [PMID: 25077046 PMCID: PMC4078186 DOI: 10.1055/s-0034-1375965] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Ulnar shortening osteotomy is an established and frequently performed surgical procedure in wrist surgery. The technical aspects of the procedure have continued to develop in recent years, with instruments and implants being developed specifically for this purpose. Ulnar shortening osteotomy is required for different clinical indications and situations. These varying indications demand different amounts of shortening, but all must be precise and accurate. Controversy exists as to how this can best be achieved in terms of the location for osteotomy, the surgical approach and geometry of the osteotomy, as well as which implant to use to provide optimal stability. The goal of all techniques (besides successfully resolving the underlying problem) is to achieve reliable and rapid bone union without compromising early functional rehabilitation and also to avoid hardware complications. The AO Hand Expert Group has developed a specialized instrumentation system with dedicated and specifically designed implants to ensure exact and accurate cutting with precise and rigid stabilization of the ulna. The matched drill guides and double-blade saws allow accurate completion of the planned amount of shortening together with precise coaptation of the osteotomy fragments. The specific ulnar osteotomy LCP (locking compression plate) combines maximum stability with minimum bulk and soft tissue irritation. The features of the implant, its surgical technique, and early results are described.
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Affiliation(s)
- Ladislav Nagy
- AO Hand Expert Group (HAEG), Davos, Switzerland
- Department of Orthopedics, University of Zürich, Balgrist, Zürich, Switzerland
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Abstract
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.
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Greenberg JA, Werner FW, Smith JM. Biomechanical analysis of the distal metaphyseal ulnar shortening osteotomy. J Hand Surg Am 2013; 38:1919-24. [PMID: 23978787 DOI: 10.1016/j.jhsa.2013.06.038] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Revised: 06/28/2013] [Accepted: 06/28/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the effect of a closing wedge osteotomy at the distal ulnar metaphysis on unloading the ulnar side of the wrist. METHODS Seven fresh frozen cadaver arms mounted in a wrist simulator were used for the analysis. A 6-degrees-of-freedom load cell was mounted on the distal radius and another on the distal ulna. Radioulnar carpal joint forces and transverse distal radioulnar joint (DRUJ) load were measured at static wrist positions and during dynamic wrist motions before and after the distal metaphyseal ulnar shortening osteotomy (DMUSO) was performed. RESULTS At each static position, significant decreases in ulnar load were noted after DMUSO. In addition, mean and maximum loads decreased for each dynamic wrist motion. There were no statistically significant differences in transverse forces across the DRUJ after DMUSO. CONCLUSION This study showed that DMUSO is an effective way to decrease the load across the ulnocarpal joint. The geometry of the osteotomy and resultant change in the position of the ulnar head did not increase transverse joint reaction forces. CLINICAL RELEVANCE This technique is an alternative to open diaphyseal techniques or methods that damage the articular surface of the distal ulna. Clinical studies will be necessary to associate the biomechanical correction noted in this study with clinical symptom improvement.
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Affiliation(s)
- Jeffrey A Greenberg
- Indiana Hand to Shoulder Center, Indianapolis, Indiana; SUNY Upstate Medical University, Syracuse, New York.
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Ahsan ZS, Song Y, Yao J. Outcomes of ulnar shortening osteotomy fixed with a dynamic compression system. J Hand Surg Am 2013; 38:1520-3. [PMID: 23830678 DOI: 10.1016/j.jhsa.2013.04.040] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 04/25/2013] [Accepted: 04/29/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the outcomes of patients with ulnar impaction syndrome treated with a jig-facilitated, oblique, diaphyseal ulnar shortening osteotomy and fixed with a TriMed (Santa Clarita, CA) ulnar osteotomy compression plate. METHODS A retrospective chart review of patients with ulnar impaction syndrome identified 38 patients who had had ulnar shortening osteotomy and fixation with the TriMed dynamic compression system. The following clinical data were obtained: patient age, sex, follow-up range of motion, grip strength, and complications. After a minimum of 2 years after surgery, patients reported complications and completed a Disabilities of the Arm, Shoulder, and Hand questionnaire. RESULTS Eight patients were lost to follow-up. Compared to the opposite limb at an average of 8 months after surgery, the remaining 30 patients attained 92% to 97% of wrist and forearm motion and 71% of grip strength. The average Disabilities of the Arm, Shoulder, and Hand score was 12 after a minimum of 2 years after surgery. Four patients required plate removal due to irritation. Two patients reported persistent ulnar-sided pain, and 2 other patients developed atrophic nonunions and required autologous bone grafting. There were no infections. CONCLUSIONS Ulnar shortening osteotomy using the TriMed system yielded good clinical outcomes that are comparable to those previously documented using other systems. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Zahab S Ahsan
- Indiana University School of Medicine, Indianapolis, IN, USA
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Mirza A, Mirza JB, Shin AY, Lorenzana DJ, Lee BK, Izzo B. Isolated lunotriquetral ligament tears treated with ulnar shortening osteotomy. J Hand Surg Am 2013; 38:1492-7. [PMID: 23849735 DOI: 10.1016/j.jhsa.2013.05.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 05/18/2013] [Accepted: 05/20/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate outcomes in a single-surgeon series of ulnar shortening osteotomy for the treatment of traumatic isolated tears to the lunotriquetral interosseous ligament (LTIL). METHODS This study includes 53 consecutive cases of posttraumatic isolated LTIL tears treated with ulnar shortening osteotomy with minimum 1-year follow-up (range, 1.0-10.6 y). We confirmed all LTIL tears via arthroscopy before performing a precision 2.5-mm oblique osteotomy using a modified Rayhack technique. We assessed outcomes using grip strength measurements and Chun and Palmer's modified Gartland Werley wrist scoring system, which includes subjective and objective outcome measures. RESULTS Preoperatively, 45 cases were graded as fair (28%; n = 15) or poor (57%; n = 30) on the modified Gartland Werley score. There were insufficient data to calculate grades in 8 cases (15%). At final follow-up, most patients exhibited excellent (51%; n = 27) or good (32%; n = 17) scores, some scored fair (17%; n = 9), and none scored as poor. All subjective and objective variables significantly improved over a mean follow-up of 36 months (range, 12-127 mo). Mean grip strength increased from a value of 23 kg before surgery to 33 kg over the same period, a 41% increase. All patients achieved clinical and radiographic union by 10 months. Osteotomy plates were removed routinely in most cases (89%; n = 47) at a mean of 17 months. CONCLUSIONS Ulnar shortening osteotomy reduced symptoms of posttraumatic isolated LTIL tears in this single-surgeon series. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Ather Mirza
- Department of Hand and Microsurgery, St. Catherine of Siena Medical Center, Smithtown, NY 11787, USA.
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Sennwald G, Della Santa D, Beaulieu JY. A comparison of diaphyseal and metaphyseal techniques of ulna shortening. J Hand Surg Eur Vol 2013. [PMID: 23204135 DOI: 10.1177/1753193412469126] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The aim of this retrospective study was to compare two techniques of ulna shortening for ulnocarpal abutment. The technique performed initially was diaphyseal osteotomy. Subsequently, a metaphyseal osteotomy was performed to avoid the drawbacks related to the plate. The study group consisted of 29 patients: 13 with diaphyseal and 16 with metaphyseal osteotomies. The pre-operative diagnosis was ulnocarpal abutment in all cases. The results were graded according to the scoring system of Chun and Palmer and patients' self-assessment. Both rankings were related to indications, age, gender, occupation, and surgery. Final follow-up occurred at a median of 54 (range 15-144) months after surgery. There was no delayed union or non-union, necrosis of the ulnar head, or infection. Pain relief was the main benefit. Both techniques gave similar outcomes for pain relief, satisfaction, and objective results. The shortening was significantly greater in the metaphyseal group without any apparent consequence on function or pain. No screw removal was needed after metaphyseal osteotomy; in contrast, plate removal was required in all patients. We conclude that both techniques are valuable alternatives for treating ulnocarpal abutment.
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Affiliation(s)
- G Sennwald
- Hand Surgery Unit, Medical School of Geneva, Geneva, Switzerland.
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Abstract
PURPOSE The gold standard for treatment of ulnar impaction has become ulnar shortening osteotomy. Previous reports in the literature have shown not only good results with relief of ulnar-sided wrist pain but also significant nonunion rates and painful hardware necessitating further surgery and potentially, metal removal. The purpose of this paper is to review the success rate of ulnar shortening osteotomy utilizing a low profile compression plate designed specifically for ulnar shortening osteotomy. METHODS Ninety-three patients with ulnar abutment syndrome underwent ulnar shortening osteotomy with the low profile osteotomy plate. There were 47 males and 46 females. The Acumed's ulnar shortening system was utilized in all cases. The patients were evaluated for pain, range of motion, grip strength, return to work, time to union, and hardware removal. The patients' results were validated using the Mayo Wrist Score. RESULTS There was a 100 % union rate in the 93 patients. There were no nonunions or delayed unions, or any hardware removal. All patients noted an improvement in their ulnar-sided wrist pain. Utilizing the Mayo wrist classification, the average postoperative score was 84.5. The average preoperative Mayo score was 49.4, for an average increase of 35.1 points. CONCLUSION The Acumed's low-contact plate designed specifically for ulnar shortening osteotomy demonstrated 100 % union rate and no implant removal in our series. This is the largest study to our knowledge of a series of ulnar shortening osteotomies and successful healing without the removal of any implants. Furthermore, the specifically designed ulnar shortening osteotomy plate significantly simplifies the procedure for the surgeon and improves patient outcomes with relief of ulnar-sided wrist pain.
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Affiliation(s)
- Sonya M. Clark
- East Tennessee Spine and Orthopedic Specialists, 2815 W. Andrew Johnson Hwy, Morristown, TN 37814 USA
| | - William B. Geissler
- The University of Mississippi Medical Center, 2500 North State Medical Tower 6th Floor, Jackson, MS 39216 USA
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