Metaphyseal ulnar shortening osteotomy for the treatment of ulnocarpal abutment syndrome using distal ulna hook plate: case series

A modified partial wedge-shaped metaphyseal ulnar osteotomy for the treatment of ulnar impaction syndrome with reverse oblique sigmoid notch

We describe a modified metaphyseal ulnar osteotomy to treat ulnar impaction syndrome with a reverse oblique sigmoid notch. Based on a computational analysis of radiographs, a modified wedge metaphyseal ulnar osteotomy was devised with its apex positioned at the ulnar styloid base to avoid impaction between the sigmoid notch and ulnar head. Subsequently, nine patients with ulnar impaction syndrome and a reverse oblique sigmoid notch underwent this operation, combined with arthroscopic exploration and transosseous triangular fibrocartilage complex repair. The mean follow-up was 14 months. All patients achieved bone union within 5 weeks, with no degenerative changes being observed during the follow-up assessments. The final follow-up assessments revealed decreases in ulnar variance and in the scores for Visual Analogue Scale, Quick Disabilities of the Arm, Shoulder and Hand questionnaire and the Patient-Rated Wrist Evaluation. All patients achieved excellent or good grades on the Modified Mayo Wrist Score. This technique is effective in treating the ulnar impaction syndrome with a reverse oblique sigmoid notch.Level of evidence: IV.

Antegrade Fixation of Distal Metaphyseal Ulnar Shortening Osteotomy

The ulnar shortening osteotomy (USO) is a common procedure used to treat ulnar impaction syndrome secondary to static or dynamic ulnar-positive variance. There are many described techniques for the USO. The distal metaphyseal ulnar shortening osteotomy (DMUSO) with retrograde cannulated screw fixation was described to reduce complications seen with other techniques. Biomechanical analysis of fixation constructs demonstrates 2-screw constructs are significantly stiffer than 1 screw and antegrade constructs have similar or greater stiffness when compared with retrograde constructs. Here, we describe a technique of antegrade cannulated screw fixation for DMUSO that obviates the need for the disruption of the distal radioulnar joint for intra-articular exposure of the ulnar head. Similar to the traditional retrograde DMUSO technique, this construct may also decrease the risk of delayed union, symptomatic implants associated with diaphyseal osteotomies, and disruption of triangular fibrocartilaginous complex in wafer procedures.

Comparison of diaphyseal and metaphyseal ulnar shortening osteotomies for the treatment of ulnar impaction syndrome

BACKGROUND

Ulnar shortening osteotomy (USO) is a common surgical procedure for the treatment of ulnar impaction syndrome (UIS). The purpose of this study was to compare the results of metaphyseal and diaphyseal USO.  METHODS: This retrospective study compared the clinical outcomes and complications of 32 patients who underwent diaphyseal step-cut USO (n = 10), diaphyseal oblique USO (n = 12), or metaphyseal USO (n = 10).

RESULTS

Patient characteristics, ulnar variance, wrist range of motion, preoperative pain, grip strength, and functional scores (quick disability of the arm, shoulder, and hand and patient-rated wrist evaluation) were comparable. Both operation time (79.5 vs. 138/139 min) and incision length (7.80 vs. 9.67/13.00 cm) were shorter in the metaphyseal USO than in the diaphyseal oblique/step-cut USO. Compared with diaphyseal oblique/step-cut USO, metaphyseal osteotomies were associated with greater improvement in the pain on postoperative day 3 and shorter bone healing time. The requirements for implant removal were the same among the three groups. No complications were observed in any group.

CONCLUSION

Compared with diaphyseal USO, metaphyseal USO has advantages for operation time and incision length, early postoperative pain, bone healing in UIS management. The results suggested that metaphyseal USO could be widely applied to the surgical treatment of UIS. However, the long-term outcomes of these techniques still require further evaluation using more large-scale, randomized clinical trials.

Distal Metaphyseal Ulnar Shortening Osteotomy Fixation: A Biomechanical Analysis

PURPOSE

Ulnar shortening osteotomy can be used to treat ulnar impaction syndrome and other causes of ulnar wrist pain. Distal metaphyseal ulnar shortening osteotomy (DMUSO) is one technique that has been proposed to reduce the complications seen with a diaphyseal USO or a wafer resection. However, to our knowledge, the optimal fixation construct for DMUSO has not been studied. We sought to characterize the biomechanical stiffness and rotational stability of different DMUSO constructs.

METHODS

A DMUSO was performed on 40 human cadaveric ulnas using 4 different fixation constructs (10 specimens per group): one 3.0 mm antegrade screw; two 2.2 mm antegrade screws; one 3.0 mm retrograde screw; and two 2.2 mm retrograde screws. Biaxial testing using axial load and cyclical axial torque was performed until failure, defined as 10° of rotation or 2 mm displacement. Specimens were assessed for stiffness at failure. Bone density was assessed using the second metacarpal cortical percentage.

RESULTS

Bone density was similar between all 4 testing groups. Of the 4 groups, the 2 antegrade screw group exhibited the highest rotational stiffness of 232 ± 102 Nm/deg. In paired analysis, this was significantly greater than 1 retrograde screw constructs. In multivariable analysis, 2-screw constructs were significantly stiffer than 1 screw and antegrade constructs were significantly stiffer than retrograde. Maximum failure torque did not differ with orientation, but 2 screws failed at significantly higher torques.

CONCLUSION

Using 2 screws for DMUSO fixation constructs may provide higher stiffness and maximum failure torque, and antegrade screw constructs may provide more stiffness than retrograde constructs.

CLINICAL RELEVANCE

Antegrade screw fixation using 2 screws may provide the strongest construct for DMUSO. Antegrade fixation may be preferred because it avoids violating the distal radioulnar joint capsule and articular surface of the ulna.

The Combined Procedure of Ulnar Metaphyseal Shortening Osteotomy With Triangular Fibrocartilage Complex Foveal Knotless Repair

Ulnar impaction syndrome (UIS) and triangular fibrocartilage complex (TFCC) tear are common causes of ulnar-sided wrist pain. As a standard surgical treatment, ulnar-shortening osteotomy (USO) and TFCC repair are used respectively. Patient spectrums of UIS accompanied by distal radioulnar joint instability or traumatic TFCC foveal tear with UIS symptoms exist, and both USO and TFCC repair are necessary for treating some of these patients. However, there have been few reports on the procedure for performing these 2 operations concurrently. We introduce a combined procedure to concurrently perform USO and TFCC repair. We performed a USO in the ulnar metaphysis using a locking plate and open TFCC knotless repair using a suture anchor at the ulnar fovea. In this technique, USO is conducted in the metaphysis, which is favorable to union, using a small plate that is easy to handle, and knotless TFCC repair can be performed simultaneously through a single small incision.

Surgical treatment of posterior cruciate ligament tibial avulsion fractures using a locking compression hook plate: A case series

OBJECTIVE

This study aimed to evaluate the results of surgical treatment of tibial avulsion injuries of the posterior cruciate ligament (PCL) with a 3.5-mm locking compression hook plate (LCHP).

METHODS

From June 2012 to June 2015, 16 consecutive patients (10 males and 6 females, mean age: 38 (range: 19-57) years) presented with isolated tibial avulsion injuries of the PCL. We used a 3.5-mm LCHP and lag screws for open reduction and internal fixation (ORIF) through the posterior medial approach. The operation time, quantity of bleeding, visual analog scale (VAS) scores, stability of posterior drawer test (PDT) results, and fracture healing time were studied to assess clinical efficacy. At the 12-month follow-up, a functional evaluation using knee range of motion (ROM) and the Lysholm knee scoring system (LKSS) was performed.

RESULTS

The data from a mean follow-up of 24.1 (range: 14-33) months from 16 patients were recorded. No neurovascular complications, incision infections, or delayed union or nonunion were observed. The mean operation time was 61.4 (range: 45-80) min. The mean quantity of bleeding was 41.6 (range: 25-66) mL. The mean bone healing time was 11.8 (range: 45-80) weeks. The mean VAS score was 1.63 (range: 0-3) after surgery. The average LKSS and ROM of the knee were 51.75±7.67 and 50.94°±10.19° before surgery and 92.75±5.46 and 127.75°±6.13° at 1 year, respectively. The outcomes were judged to be excellent for 11 patients, good for 4, and fair for 1 (excellent and good rates: 93.8% for 15/16). At the final follow-up (≥1 year), the PDT scores returned to normal.

CONCLUSION

The results showed that 3.5-mm LCHP provided reliable fixation following ORIF of isolated PCL tibial avulsion fractures and was a safe, simple, and effective procedure. This procedure may reduce complications and improve functional recovery relative to those of other procedures.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR-1900022920. Registered on 3 May 2019.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Distal Metaphyseal Osteotomy Allows for Greater Ulnar Shortening Compared to Diaphyseal Osteotomy for Ulnar Impaction Syndrome: A Biomechanical Study

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.

Determinants of Pain and Predictors of Pain Relief after Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

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.

Distal Ulnar Metaphyseal Wedge Osteotomy for Ulnar Abutment Syndrome

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.

Metaphyseal Versus Diaphyseal Ulnar Shortening Osteotomy for Treatment of Ulnar Impaction Syndrome: A Comparative Study

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.

Treatment of symptomatic non-unions of the base of the ulnar styloid with plate osteosynthesis

The purpose of this prospective case series was to assess the efficacy of plate osteosynthesis using a low profile distal ulna plate for the management of persistently symptomatic non-unions of the base of the ulnar styloid. Six consecutive patients underwent resection of the non-union and plate osteosynthesis with a 2.0 mm distal ulna hook plate. Post-operative measurements of mean pain scores, QuickDASH scores, grip strength, and range of motion parameters showed significant improvements compared with the pre-operative values. No complications were reported at a mean follow-up of 25 months. The present study presents an alternative method for treating symptomatic ulnar styloid non-unions that provides stable fixation with low risk of implant removal.

LEVEL OF EVIDENCE

Therapeutic IV.

Influence of Plate Size and Design upon Healing of Ulna-Shortening Osteotomies

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.

Operative treatment of ulnar impaction syndrome: a systematic review

This article critically and systematically reviews the surgical treatments for ulnar impaction syndrome. Three types of treatments currently exist: arthroscopic wafer procedure, open wafer procedure, and ulna shortening osteotomy. A total of 36 articles were included from searching the electronic databases PubMed MEDLINE, Ovid MEDLINE, and Ovid EMBASE. Studies were evaluated for quality using the Modified Detsky Score. Of these, 14 articles had a Modified Detsky Score of 6/10 or higher. Satisfaction rates were 100% for arthroscopic wafer procedure, 89% for open wafer procedure, and 84% for ulna shortening osteotomy. The percentage of participants reporting an excellent or good outcome was 82% for arthroscopic wafer procedure, 87% for open wafer procedure, and 76% for ulna shortening osteotomy. In conclusion, available evidence shows that arthroscopic wafer procedure and open wafer procedure may be viable alternatives to the more popular ulna shortening osteotomy, but clinical superiority is yet to be established. Future research should focus on prospective cohort methods and should report participant outcomes using validated scoring methods.

Ulnar Shortening Osteotomy After Distal Radius Fracture Malunion: Review of Literature

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.

The AO Ulnar Shortening Osteotomy System Indications and Surgical Technique

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.

Distal ulna hook plate: angular stable implant for fixation of distal ulna

Distal ulna fractures, especially styloid injuries, classically have not been repaired, and only recently have these injuries been considered important. Certain fracture patterns of the distal ulna contribute to distal radioulnar joint (DRUJ) incongruity and potential instability. Appropriate fixation of the distal ulna is frequently difficult for several reasons: (1) high incidence of osteoporois in the affected patient population, (2) proximity of the injury to articular surfaces, and (3) lack of a proper implant to treat these injuries. The 2.0-mm locking compression distal ulna plate (LC-DUP) is an anatomically contoured implant with a low profile and fixed angle that provides proper stability to treat injuries of the distal ulna. The plate was designed for the treatment of distal ulna fractures, but its success has led to an extension of its indications to be used in treating symptomatic basistyloid ulnar nonunions and in ulnar shortening osteotomy for ulnocarpal abutment syndrome. The authors' description of the techniques used for each indication as well as their perspectives in the treatment of distal ulna injuries are described in detail in this report.