Laser-assisted arthroscopic ulnar shortening

Is ulnar shortening osteotomy or the wafer procedure better for ulnar impaction syndrome?: A systematic review and meta-analysis

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.

Ulnar shortening osteotomy vs. wafer resection for ulnar impaction syndrome: A systematic review and meta-analysis

BACKGROUND

Ulnar shortening osteotomy (USO) is the most common operation to treat ulnar impaction syndrome (UIS). An alternative to USO is the arthroscopic wafer procedure (AWP). Few studies have directly compared USO and AWP in patients with UIS. This study compared ulnar shortening osteotomy (USO) versus arthroscopic wafer procedure (AWP) for UIS treatment.

MATERIALS AND METHODS

PubMed, EMBASE, the Cochrane Library, Wanfang, and CNKI were systematically searched for reports published before March 2021. The outcomes included Modified Mayo Wrist Score, Darrow's Criteria, Disability of Arm, Shoulder, and Hand (DASH), grip strength, visual analog scale (VAS) score, and time to resume manual occupation.

RESULTS

Seven studies (133 and 118 patients with USO and AWP, respectively) were included. There were no differences in combined Darrow's Criteria or Modified Mayo Wrist Score, Modified Mayo Wrist Score, Darrow's Criteria, revision rate, DASH score, VAS score, and time to resume manual occupation. Grip strength was better with AWP (SMD = -0.73, 95%CI: -1.36, -0.11, P = 0.022). Differences were seen for ulna positive variation, favoring USO (WMD = -2.75, 95%CI: -5.17, -0.33, P = 0.026).

CONCLUSIONS

In the surgical treatment of UIS, AWP might be associated with improved grip strength, while USO seems to show better results in treating pronounced ulna positive variation. Only evidence of moderate quality could be included in this meta-analysis.

Arthroscopic Anatomy of the TFCC with Relevance to Function and Pathology

Introduction  The authors present a new comprehensive arthroscopic anatomical description of the fibrocartilage complex "TFCC" which is related to the current TFCC functional and pathological knowledge. Methods  Our description of the TFCC is based on an arthroscopic view from the 3-4 portal as observed in more than 100 wrist arthroscopies in fresh cadavers and more than 1000 diagnostic and/or therapeutic wrist arthroscopies. Results  TFCC is considered as a 3-D-3-part box-like structure (Reins, Wall and Disc). The first TFCC component ("R") corresponds to 2 strong radio-ulnar ligamentous Reins, one dorsal (DRUL) and one palmar (PRUL). This "V-shaped" RUL reins diverge from the fovea and ulnar styloid to the volar and dorsal edges of the sigmoid notch. It is a main stabilizer of the DRUJ. The second TFCC component ("W") is a continuous, radially concave Peripheral Capsular Wall attached and perpendicular to the RUL reins. It surrounds the ulnar aspect of the ulno-carpal interval while attaching to the RUL reins proximally and to the medial carpus distally. Along with the radiocarpal ligaments, the TFCC peripheral capsular wall contributes to the stability of the carpus with respect to the radius-ulna entity. This is especially true for the thick volar TFCC capsular wall. The third TFCC component ("D") is the disc proper which is a static and dynamic shock absorber intercalated between the ulnar head and the medial proximal row in the coronal/sagittal planes and between the two strands of the RUL in the axial plane. Its pathology is influenced and related to the ulnar variance. Discussion  This new arthroscopic description of the TFCC provides a comprehensive anatomical, functional ant pathological background for TFCC disorders analysis and treatment. Currently known disorders are included as "R 1,2,3,4", "W 1, 2, 3, 4", and "D 1, 2". Combined TFCC disorders and further new pathology descriptions may be included in this open classification.

A Dorsal Approach for Ulnar Shortening Osteotomy

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.

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.

Minimally invasive approaches to ulnar-sided wrist disorders

Ulnar-sided wrist pain is a common cause of pain and disability, which has long been a diagnostic and therapeutic dilemma for hand surgeons. A thorough understanding of the anatomy, clinical examination, and radiographic evaluation is essential to establish a focused differential diagnosis, with the cause of disability often being multifactorial. Arthroscopy is particularly well suited to both directly visualize and treat multiple causes of ulnar-sided wrist pain, including pathology of the TFCC, UIS, LTIL tears, and hamate arthrosis.

Arthroscopy during ulnar shortening for idiopathic ulnar impaction syndrome

Arthroscopy during ulnar shortening osteotomy for ulnar impaction syndrome is subject to debate regarding its clinical usefulness. The purposes of this study were to analyze the arthroscopic findings in patients who underwent ulnar shortening osteotomy and to assess the role of arthroscopic evaluation during osteotomy. Medical records and arthroscopic findings of 50 consecutive patients who had been diagnosed with idiopathic ulnar impaction syndrome were retrospectively evaluated. Pathologic changes of the articular disk of the triangular fibrocartilage complex (TFCC), chondromalacia of the lunate and triquetrum, and tears of the lunotriquetral interosseous ligament (LTIL) were evaluated during arthroscopy. Palmer’s classification was used to classify the TFCC lesions. Perforation of the TFCC was observed in 20 patients, and central tears were observed in 10. Thirty-eight patients exhibited chondromalacia of the lunate, including 4 unstable cartilage flaps. Partial tears of the LTIL were detected in 24 patients, including 9 unstable flap tears. In 21 (42%) of 50 patients, arthroscopic findings were not appropriate to define the disease stage with Palmer’s original description. Eight wrists exhibited tears or perforations of the TFCC without evidence of chondromalacia. Seven patients had an LTIL tear without perforation of the TFCC. Lunotriquetral interosseous ligament tears without lunate chondromalacia were found in 7 patients. Arthroscopic debridement was performed in 23 patients based on the clinical judgment that the procedure would help alleviate symptoms postoperatively. Arthroscopy during ulnar shortening osteotomy addresses intra-articular pathologies and may be helpful for symptom improvement.

Arthroscopic treatment of ulnar impaction syndrome

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

Current concepts in wrist arthroscopy

The purpose of this article is to review the recent literature on arthroscopic treatment of distal radius fractures (DRFs), triangular fibrocartilage complex injuries, intercarpal ligament injuries, and ganglion cysts, including the use of electrothermal devices. A major advantage of arthroscopy in the treatment of DRFs is the accurate assessment of the status of the articular surfaces and the detection of concomitant injuries. Nonrandomized studies of arthroscopically assisted reduction of DRFs show satisfactory results, but there is only 1 prospective randomized study showing the benefits of arthroscopy compared with open reduction-internal fixation. Wrist arthroscopy plays an important role as part of the treatment for DRFs; however, the treatment for each practitioner and each patient needs to be individualized. Wrist arthroscopy is the gold standard in the diagnosis and treatment of triangular fibrocartilage complex injuries. Type 1A injuries may be successfully treated with debridement, whereas the repair of type 1B, 1C, and 1D injuries gives satisfactory results. For type 2 injuries, the arthroscopic wafer procedure is equally effective as ulnar shortening osteotomy but is associated with fewer complications in the ulnar positive wrist. With interosseous ligament injuries, arthroscopic visualization provides critical diagnostic value. Debridement and pinning in the acute setting of complete ligament tears are promising and proven. In the chronic patient, arthroscopy can guide reconstructive options based on cartilage integrity. The preliminary results of wrist arthroscopy using electrothermal devices are encouraging; however, complications have been reported, and therefore, their use is controversial. In dorsal wrist ganglia, arthroscopy has shown excellent results, a lower rate of recurrence, and no incidence of scapholunate interosseous ligament instability compared with open ganglionectomy. Arthroscopy in the treatment of volar wrist ganglia has yielded encouraging preliminary results; however, further studies are warranted to evaluate the safety and efficacy of arthroscopy.

Factors affecting results of ulnar shortening for ulnar impaction syndrome

Although ulnar shortening osteotomy is the most frequently performed operation for ulnar impaction syndrome, little attention has been given to detect certain preoperative factors affecting clinical outcomes of this procedure. We asked whether preoperative factors influenced the postoperative score of ulnar shortening osteotomy combined with arthroscopic debridement of the triangular fibrocartilage complex. We retrospectively reviewed 51 patients (53 wrists) with ulnar impaction syndrome treated with this procedure. There were 28 males and 23 females ranging in age from 14 to 67 years (mean, 37.5 years). The minimum followup was 12 months (mean, 26.3 months; range, 12-95 months). At last followup, we determined a modified Mayo wrist score for each patient. Preoperative factors affecting the clinical score were identified using multiple regression analysis. The clinical score ranged from 40 to 100 points (mean, 84.5 points). A long duration of symptoms and workers' compensation predicted worse clinical scores. We recommend considering these two factors when deciding whether to perform this procedure.

[The arthroscopic "wafer procedure" in degenerative disc ulnocarpal tears with ulnocarpal compression syndrome. Techniques, indications, results]

The wafer procedure is a technique involving the partial resection of the distal ulna for the treatment of patients with symptomatic tears of the TFCC, for ulnar abutment syndrome or both. The TFCC-tears are classified as Palmer type 2. The wafer procedure can be performed as an open procedure or arthroscopically. It is an alternative to a shortening osteotomy of the ulna and decompresses the ulnocarpal joint. In ten cases with long-term follow-up, the preferability of the arthroscopic method is demonstrated: a minimally invasive technique, optimal assessment of all lesions, maximum protection of all uninjured structures in comparison to the open method, single stage procedure, and low complication rate. The long-term results are predominantly positive, so that the arthroscopic wafer procedure should be performed more often than it is today.