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Liu Y, Li X, Su X, Yin H, Xu W, Shen Y. A modified partial wedge-shaped metaphyseal ulnar osteotomy for the treatment of ulnar impaction syndrome with reverse oblique sigmoid notch. J Hand Surg Eur Vol 2024:17531934241252302. [PMID: 38780140 DOI: 10.1177/17531934241252302] [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: 05/25/2024]
Abstract
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.
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Affiliation(s)
- Yuchen Liu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
- Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital, Shanghai, People's Republic of China
| | - Xiucun Li
- Department of Hand and Foot Surgery, The Second Hospital of Shandong University, Jinan, Shandong, People's Republic of China
| | - Xiangmeng Su
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
- Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital, Shanghai, People's Republic of China
| | - Huawei Yin
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
- Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital, Shanghai, People's Republic of China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
- NHC Key Laboratory of Hand Reconstruction, Fudan University, Shanghai, People's Republic of China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, People's Republic of China
- Institute of Hand Surgery, Fudan University, Shanghai, People's Republic of China
| | - Wendong Xu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
- Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital, Shanghai, People's Republic of China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
- NHC Key Laboratory of Hand Reconstruction, Fudan University, Shanghai, People's Republic of China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, People's Republic of China
- Institute of Hand Surgery, Fudan University, Shanghai, People's Republic of China
| | - Yundong Shen
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
- Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital, Shanghai, People's Republic of China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
- NHC Key Laboratory of Hand Reconstruction, Fudan University, Shanghai, People's Republic of China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, People's Republic of China
- Institute of Hand Surgery, Fudan University, Shanghai, People's Republic of China
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Ku S, Zhuang T, Shapiro LM, Richard MJ, Ruch DS, Kamal RN. Cost-Effectiveness Analysis of Early versus Late Debridement of Superficial Triangular Fibrocartilage Complex Tears. J Hand Microsurg 2024; 16:100009. [PMID: 38854387 PMCID: PMC11127526 DOI: 10.1055/s-0042-1757179] [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: 11/05/2022] Open
Abstract
Background While initial nonoperative management is the conventional approach for superficial triangular fibrocartilage complex (TFCC) tears, a substantial portion of these cases go on to require surgery, and the optimal duration of nonoperative treatment is unknown. In this study, we evaluate the cost-effectiveness of early versus late arthroscopic debridement for the treatment of superficial TFCC tears without distal radioulnar joint (DRUJ) instability. Methods We created a decision tree to compare the following strategies from a healthcare payer perspective: immediate arthroscopic debridement versus immobilization for 4 or 6 weeks with late debridement as needed. Costs were obtained from the Centers for Medicaid and Medicare Services and a national administrative claims database. Probabilities and health-related quality-of-life measures were obtained from published sources. We conducted sensitivity analyses on model inputs, including a probabilistic sensitivity analysis consisting of 10,000 Monte Carlo simulations. Results Immobilization for 6 weeks while reserving arthroscopic debridement for refractory cases was both the least costly and most effective strategy. Immediate arthroscopic debridement became cost-effective when success rates of immobilization for 4 or 6 weeks were less than 7.7 or 10.5%, respectively. Our probabilistic sensitivity analysis showed that immobilization for 6 weeks was preferred 97.6% of the time, and immobilization for 4 weeks was preferred 2.4% of the time. Conclusion Although various early and late debridement strategies can be used to treat superficial TFCC tears without DRUJ instability, immobilization for 6 weeks while reserving arthroscopic debridement for refractory cases is the optimal strategy from a cost-effectiveness standpoint.
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Affiliation(s)
- Seul Ku
- Department of Orthopaedic Surgery, Stanford University, VOICES Health Policy Research Center, Redwood City, California, United States
| | - Thompson Zhuang
- Department of Orthopaedic Surgery, Stanford University, VOICES Health Policy Research Center, Redwood City, California, United States
| | - Lauren M. Shapiro
- Department of Orthopaedic Surgery, Stanford University, VOICES Health Policy Research Center, Redwood City, California, United States
| | - Marc J. Richard
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, United States
| | - David S. Ruch
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, United States
| | - Robin N. Kamal
- Department of Orthopaedic Surgery, Stanford University, VOICES Health Policy Research Center, Redwood City, California, United States
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Waris E, Höglund T, Sippo R, Aspinen S. Association of ulnar variance with three-dimensional carpal alignment and demographics in asymptomatic volunteers. Acta Radiol 2023; 64:3009-3014. [PMID: 37774688 DOI: 10.1177/02841851231204875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
BACKGROUND Several carpal pathologies are considered to be related to ulnar variance. Recently, computer-aided computed tomography (CT) analysis software was introduced to quantify three-dimensional (3D) carpal alignment with high accuracy and reliability. PURPOSE To determine the association of ulnar variance with 3D carpal alignment and demographics. MATERIAL AND METHODS A wrist of 121 asymptomatic volunteers (69 men, 52 women; mean age = 38 ± 10.4 years) was imaged in the neutral wrist position with cone-beam CT. Computer-aided CT analysis software (Bonelogic), based on segmentation and numerical modelling, was used to define ulnar variance and standardized 3D axes for all carpal bones. The association of ulnar variance with 3D carpal alignment, age of the volunteer, and side and dominance of the imaged wrist was assessed. RESULTS The mean ulnar variance was -1.6 ± 1.5 mm (range = -5.3 to 2.4 mm). The mean ulnar variance was -1.9 mm and -1.1 mm in men and women (P = 0.007), respectively. Of the imaged 121 wrists, 18 (15%) had positive and 103 (85%) negative ulnar variance. There was no association between ulnar variance and any of the radio- or intercarpal angle values in either the sagittal or coronal plane (ρ = -0.16…0.17, r = -0.13….0.12). The ulnar variance showed no association with side (P = 0.51) or dominance (P = 0.27) of the imaged wrist. CONCLUSION 3D carpal alignment is not affected by ulnar variance. The association of ulnar variance with sex may in part explain the difference in reported prevalence of some carpal pathologies, such as ulnar impaction syndrome and Kienböck's disease.
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Affiliation(s)
- Eero Waris
- Department of Hand Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Mehiläinen Helsinki Hospital, Helsinki, Finland
| | - Theresa Höglund
- Department of Hand Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Robert Sippo
- Department of Hand Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Samuli Aspinen
- Department of Hand Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Shin EK. Impaction Syndromes About the Wrist. Curr Rev Musculoskelet Med 2022; 16:1-8. [PMID: 36435859 PMCID: PMC9839928 DOI: 10.1007/s12178-022-09809-9] [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] [Accepted: 11/01/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Impaction syndromes are frequently a source of ulnar-sided wrist pain and patient disability. Differentiating between these entities can be difficult due to significant overlap in their clinical presentations. This manuscript reviews the diagnosis and treatment of three different impaction syndromes: (1) ulnar impaction syndrome, (2) hamate arthrosis lunotriquetral ligament syndrome, and (3) triquetrohamate impaction syndrome. RECENT FINDINGS While non-operative treatment is always recommended upon initial presentation, the duration and extent of treatment are poorly defined. Diagnostic wrist arthroscopy usually confirms the clinical diagnosis and facilitates appropriate surgical management. Pain from ulnar impaction syndrome can be effectively treated with an ulnar shortening osteotomy, which unloads the ulnar aspect of the carpus, but complications have been reported secondary to hardware prominence and nonunion at the osteotomy site. Hamate arthrosis lunotriquetral ligament syndrome can be addressed by arthroscopically or openly excising the proximal pole of the hamate, while triquetrohamate impaction syndrome demands a debridement procedure with partial excision of the impinging triquetrum or hamate. In summary, impaction syndromes are underappreciated clinical entities but are known causes of ulnar-sided wrist pain. Maintaining a high index of suspicion will help to expedite appropriate non-operative and operative treatment. Surgical intervention-if needed-is often curative.
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Affiliation(s)
- Eon K Shin
- Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia Hand to Shoulder Center, 1203 Langhorne-Newtown Road, Suite 335, Langhorne, PA, 19047, USA.
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Abstract
Ulnar abutment (ulnocarpal impaction) syndrome may be a source of ulnar-sided wrist pain in the athlete. This condition results from excessive load transfer across the triangular fibrocartilage complex and ulnocarpal joints with characteristic degenerative changes. It frequently occurs in patients with either static or dynamic ulnar positive variance. Treatment is tailored to the athlete and their sporting demands. Surgical treatment focuses on addressing ulnar variance to unload the ulnocarpal joint, with multiple surgical options, including the metaphyseal closing wedge osteotomy achieving this goal. This review focuses on the presentation, biomechanics, and treatment options for ulnar abutment syndrome in the athlete.
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Affiliation(s)
- Thomas R Acott
- The Core Institute, 9321 W Thomas Road, Suite 205, Phoenix, AZ 85037
| | - Jeffrey A Greenberg
- Indiana Hand to Shoulder Center, 8501 Harcourt Road, Indianapolis, IN 46260, USA.
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