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.

Outcomes of Ulnar Shortening Osteotomy with an Intramedullary Bone Graft for Idiopathic Ulnar Impaction Syndrome

Background

Although several techniques for the treatment of ulnar impaction syndrome (UIS) have been introduced, there have still been reports on various complications such as delayed union, nonunion, refracture, wrist pain, plate irritation, and chronic regional pain syndrome. This study aimed to compare the differences in radiological and clinical outcomes of patients in which intramedullary bone grafting was performed in addition to plate stabilization with those without additional bone grafting during ulnar shortening osteotomies (USOs).

Methods

Between November 2014 and June 2021, 53 wrists of 50 patients with idiopathic UIS were retrospectively reviewed. Patients were divided into 2 groups according to whether intramedullary bone grafting was performed. Among the 53 wrists, USO with an intramedullary bone graft was performed in 21 wrists and USO without an intramedullary bone graft was performed in 32 wrists. Demographic data and factors potentially associated with bone union time were analyzed.

Results

There was no significant difference between the 2 groups when comparing postoperative radioulnar distance, postoperative ulnar variance, amount of ulnar shortening, and postoperative Disabilities of the Arm, Shoulder and Hand score. Compared to the without-intramedullary bone graft group, bone union time of the osteotomy site was significantly shortened, from 8.8 ± 3.0 weeks to 6.7 ± 1.3 weeks in the with-intramedullary bone graft group. Moreover, there were no cases of nonunion or plate-induced symptoms. Both in univariable and multivariable analyses, intramedullary bone grafting was associated with shorter bone union time.

Conclusions

USO with an intramedullary bone graft for idiopathic UIS has favorable radiological and clinical outcomes. The advantage of this technique is the significant shortening of bone union time.

Arthroscopic wafer procedure versus ulnar shortening osteotomy for ulnar impaction syndrome: a systematic review and meta-analysis

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.

Is ulnar shortening osteotomy effective for the treatment of ulnar styloid impaction syndrome compared to ulnar impaction syndrome?

PURPOSE

This study aimed at evaluating the outcomes of ulnar shortening osteotomy (USO) for the treatment of ulnar styloid impaction syndrome (USIS) and to compare them with those of USO for the treatment of ulnar impaction syndrome (UIS).

METHODS

We enrolled 144 patients who underwent USO between March 2015 and October 2021. The patients were divided into a UIS group (group I, n = 93) and a USIS group (group II, n = 51). Clinical and radiological parameters, including Disabilities of the Arm, Shoulder, and Hand (DASH) score, ulnar variance, ulnar styloid length, and ulnar styloid process index (USPI), were collected pre-operatively and one year post-operatively, and a comparative analysis was performed.

RESULTS

The DASH score showed significant improvement in both groups (p < .001 and p < .001), and there was no significant difference between the two groups one year after surgery (p = .143). The USPI was significantly different between the two groups (p < .001). The ulno-lunate and ulno-triquetrum distances showed significant increases in both groups, with significant differences between the two groups (p = .020, and p < .001, respectively). The incidence of post-operative arthritic changes in the distal radioulnar joint was significantly greater in the UIS group than that in the USIS group (21 vs 3, respectively; p = .017). No remarkable differences were observed in the post-operative evidence of chondromalacia at the last follow-up between the two groups.

CONCLUSION

The USO, which was performed as a treatment for USIS showed reliable outcomes compared to the USO for the treatment of UIS. Therefore, USO is a viable option for the treatment of USIS.

Is metaphyseal ulnar shortening osteotomy superior to diaphyseal ulnar shortening osteotomy in the treatment of ulnar impaction syndrome? A meta-analysis

BACKGROUND

Although metaphyseal ulnar shortening osteotomy (MUSO) is safer for the treatment of ulnar impaction syndrome (UIS) than diaphyseal ulnar shortening osteotomy (DUSO), DUSO is widely used for UIS treatment.

AIM

To evaluate the effectiveness of DUSO and MUSO for UIS treatment and determine the factors that should be considered when choosing surgical treatment for UIS.

METHODS

Articles comparing the effectiveness of DUSO and MUSO for UIS treatment were systematically retrieved from MEDLINE (Ovid), PubMed, EMBASE, and Cochrane Library. The demography, incidence of complications, secondary operation rate, postoperative DASH score, wrist pain on the visual analogue scale, and grip strength improvement were also evaluated. In addition, the correlation between the improvement of grip strength and the shortening of osteotomy length of ulna was analyzed. The outcome of the patient was discontinuous, and the odds ratio, risk ratio (RR), and 95%CI were calculated and analyzed via RevMan5.3 software.

RESULTS

Six studies, including 83 patients receiving MUSO (experimental group) and 112 patients receiving DUSO (control group), were included in the meta-analysis. The second operation rate was significantly higher after DUSO than after MUSO. The DASH scores were slightly lower in the MUSO group than in the DUSO group. The patients receiving MUSO had slightly better pain relief effect than patients receiving DUSO. However, the incidence of complications and improvement of grip strength were not significantly different between the two groups.

CONCLUSION

Although DUSO and MUSO provide similar effects for UIS, MUSO is associated with a lower secondary operation rate, slightly lower postoperative DASH scores and slightly better pain relief effect than DUSO, indicating that MUSO can effectively be used for UIS treatment.

Impaction Syndromes About the Wrist

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.

Results of isolated ulnar shaft shortening osteotomy in the treatment of idiopathic ulnocarpal impaction syndrome

The objective of this study was to evaluate the results of isolated ulnar shaft shortening osteotomy (USSO) in the treatment of idiopathic ulnocarpal impingement syndrome. This was a two-center retrospective study. All patients older than 18 years who underwent isolated USSO for idiopathic ulnocarpal impingement syndrome between 2006 and 2016 were included. The outcome measures were: patient satisfaction, decrease in pain intensity, change in occupation, QuickDASH and PRWE functional scores, secondary palliative surgery suggesting failure of the ulnar shaft shortening osteotomy, and postoperative ulnar variance. The main complications were analyzed. Thirty-one patients were included. Twenty-six (84%) were satisfied with the procedure. At an average follow-up of 62 months, there was no secondary palliative surgery. Mean pain intensity on VAS was 7/10 (range, 2-10) and 1.7/10 (range, 0-6) preoperatively and postoperatively, respectively, for a mean decrease of 5.3 ± 2.6 points; this decrease was statistically significant (p &lt; 0.001). None of the manual workers had to alter their work. Mean postoperative QuickDASH score was 19.6/100 (range, 0-79.55) and mean postoperative PRWE score was 23/100 (range, 1-85). Mean postoperative ulnar variance was -0.5 mm. As for complications, 61% of patients (n = 19/31) had discomfort related to the plate; 9.7% (n = 3/31) had distal radioulnar osteoarthritis; 4% (n = 1/19) had a fracture after hardware removal; 13% (n = 4/31) had non-union. Despite a high rate of complications, the study confirmed the effectiveness, in terms of pain, of isolated USSO in the treatment of idiopathic ulnocarpal impingement syndrome. LEVEL OF EVIDENCE: IV; retrospective cohort.

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.

Bone Morphology in Ulnar Impaction Syndrome: A Radiographic Evaluation

Background: Positive ulnar variance (UV) may be associated with a higher incidence of ulnar impaction syndrome (UIS). However, neutral and/or negative UV has also been associated with the development of UIS; therefore, other risk factors may be involved. The purpose of this study was to compare radiological bone morphology in patients with UIS and asymptomatic controls. Methods: Between 2009 and 2018, posteroanterior wrist radiographs of 47 wrists in 45 patients diagnosed with UIS were compared with those of 163 wrists in 93 asymptomatic patients from the control group. The following parameters were obtained: ulnar variance (UV); ulnar head top-fovea distance (UTFD); capitate-triquetrum distance (CTD); radio-lunate distance (RLD) and lunate coverage ratio (LCR). The morphology of the lunate was classified based on the absence (type I) or presence (type II) of a medial facet that articulates with the hamate. The radiographic parameters and lunate types were compared between the two groups. We then divided the groups into two subgroups: the positive UV subgroup and the neutral/negative UV subgroup. In each subgroup, the radiographic parameters and lunate types were compared between the UIS and control groups. Results: In the UIS group, the UV and UTFD were significantly increased compared to those in the control group. The proportion of type II lunates was significantly higher in the UIS group than in the control group. In addition, the type II lunate was more common in the UIS group in both the positive UV and negative UV groups. Conclusions: Our study suggests that in addition to positive UV, ulnar head morphology with an increased UTFD and type II lunate morphology may be associated with the development of ulnar impaction syndrome. Level of Evidence: Level III (Diagnostic).

Comparing radial lengthening osteotomy with ulnar shortening osteotomy to treat ulnar impaction syndrome after distal radius fracture malunion

INTRODUCTION

Distal radius mal-unions often cause radius shortening and ulnar impaction syndrome. The modern treatments of ulnar impaction syndrome following distal radius mal-union are ulnar shortening osteotomy (USO) and distal radius lengthening osteotomy (DRLO). However, there are few studies to compare long-term outcomes of these two treatments. This study compares isolated USO to DRLO for the treatment of ulnar impaction syndrome following distal radius mal-union.

MATERIALS AND METHODS

We retrospectively reviewed 68 patients with extra-articular distal radius mal-unions treated by isolated USO in 36 patients and DRLO in 32 patients. Pain visual analog scale (VAS), wrist motion, grip strength, radiographic parameters including sigmoid inclination, DASH score, and perioperative complications were analyzed. Mean follow-up was 62.6 months.

RESULTS

The postoperative VAS scores for pain on exertion were less in the DRLO group than the USO group (1.2 vs. 2.8, p = 0.02). The DASH scores were 16.7 and 29.8 in the DRLO and USO groups, respectively (p = 0.02). The reduction of pain and improvement of function showed significantly better in the DRLO group. The mean operative time was shorter in the USO group. Most of the sigmoid inclinations were changed in DRLO. There were two re-operations following USO for painful nonunion and two patients had subsequent DRUJ osteoarthritis at the last follow-up.

CONCLUSION

Although both treatments improved range of motion, grip strength, and VAS for pain, DRLO was found in better reduction of pain and improvement of function. USO is a simpler procedure with a shorter operative time but it has an increased potential to cause subsequent osteoarthritis of the DRUJ as its incongruity of DRUJ after USO especially in reverted inclination. DRLO can be a preferred method for treating USWP in relevant distal radial mal-union.

Outcomes of ulna shortening osteotomy: a cohort analysis of 106 patients

Background

Ulna shortening osteotomy (USO) for ulnar impaction syndrome (UIS) aims to improve pain and function by unloading the ulnar carpus. Previous studies often lack validated patient-reported outcomes or have small sample sizes. The primary objective of this study was to investigate patient-reported pain and hand function at 12 months after USO for UIS. Secondary objectives were to investigate the active range of motion, grip strength, complications, and whether outcomes differed based on etiology.

Materials and methods

We report on 106 patients with UIS who received USO between 2012 and 2019. In 44 of these patients, USO was performed secondary to distal radius fracture. Pain and function were measured with the Patient Rated Wrist/Hand Evaluation (PRWHE) before surgery and at 3 and 12 months after surgery. Active range of motion and grip strength were measured before surgery and at 3 and 12 months after surgery. Complications were scored using the International Consortium for Health Outcome Measurement Complications in Hand and Wrist conditions (ICHAW) tool.

Results

The PRWHE total score improved from a mean of 64 (SD = 18) before surgery to 40 (22) at 3 months and 32 (23) at 12 months after surgery (P  < 0.001; effect size Cohen’s d = −1.4). There was no difference in the improvement in PRWHE total score (P = 0.99) based on etiology. Also, no clinically relevant changes in the active range of motion were measured. Independent of etiology, mean grip strength improved from 24 (11) before surgery to 30 (12) at 12 months (P  = 0.001). Sixty-four percent of patients experienced at least one complication, ranging from minor to severe. Of the 80 complications in total, 50 patients (47%) had complaints of hardware irritation, of which 34 (32%) had their hardware removed. Six patients (6%) needed refixation because of nonunion.

Conclusion

We found beneficial outcomes in patients with UIS that underwent USO, although there was a large variance in the outcome and a relatively high number of complications (which includes plate removals). Results of this study may be used in preoperative counseling and shared decision-making when considering USO.

Level of evidence

Therapeutic III.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10195-021-00621-8.

Influence of TFCC foveal tear on the location of lunate chondromalacia in ulnar impaction syndrome

OBJECTIVE

The purpose of this study was to identify the location of lunate chondromalacia and to compare the difference in location according to presence or absence of triangular fibrocartilage complex (TFCC) foveal tear, which induces distal radioulnar joint (DRUJ) instability.

METHODS

We performed a retrospective study of 97 patients (102 wrists) who were diagnosed with and treated for idiopathic ulnar impaction syndrome (UIS) between 2014 and 2018. Subjects were divided into two groups according to presence or absence of TFCC foveal tear with DRUJ instability. Group I had UIS without a TFCC foveal tear (52 wrists, mean age of 43.2 years), while Group II had UIS with a TFCC foveal tear (50 wrists, mean age of 45.3 years). There was no significant difference in age, sex, or duration of symptoms between the two groups. All patients underwent wrist MR Arthrography (MRA) in the same gantry, and all scanned coronal sections of the lunate were standardized into 10 slices, including the whole anteroposterior width of the lunate. Each slice was sequentially numbered from dorsal to volar side, and the location of chondromalacia was marked in each numbered section. Radiological parameters including ulnar variance and ulnolunate distance (ULD), which indicated the distance between the ulnar head and lunate, were measured in the wrist series.

RESULTS

The most frequent location of lunate chondromalacia was slightly to the volar side of the lunate in both groups. Group I showed a higher frequency of chondromalacia in the volar side of the lunate. In Group II, chondromalacia was identified with high frequency not only on the volar side of the lunate but also on the dorsal side. In other words, Group II showed broader chondromalacia in the lunate. There was no significant difference in ulnar variance (Group I, 3.19 ± 1.42 mm; Group II, 2.76 mm ± 1.67 mm) or ulnolunate distance (Group I, 1.66 ± 0.94 mm; Group II, 2.05 mm ± 0.87 mm). The average ULD decreased during radial deviation but increased during ulnar deviation.

CONCLUSION

This study showed that lunate chondromalacia associated with idiopathic ulnar impaction syndrome occurs more frequently on the volar side of the lunate. Also, TFCC foveal tear, which causes DRUJ instability, leads to broader lunate chondromalacia in idiopathic ulnar impaction syndrome. Therefore, further analysis of the pattern of lunate chondromalacia can provide a clue for DRUJ instability.

Tips and tricks to achieve osteotomy healing and prevent refracture after ulnar shortening osteotomy

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.

Ulna shortening osteotomy versus arthroscopic wafer procedure in the treatment of ulnocarpal impingement syndrome

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.

Clinical and Epidemiological Features Among Patients with Wrist Arthroscopy Surgery: A Hospital-based Study in China

Propose

To analyze the clinical and epidemiological features of patients who underwent wrist arthroscopy procedures.

Methods

This is a cross‐sectional epidemiological study. The study included a cohort of patients who underwent wrist arthroscopy procedures in a national orthopaedic referral center from 1 February, 2014 to 1 February, 2019. The medical records, diagnosis, and every wrist arthroscopy procedure of all the patients were collected and reviewed. The epidemiological features, detail of the diagnoses, and the procedures of all the patients were systemically analyzed. All the patients were divided into two groups: trauma and non‐trauma conditions. The complexity of the wrist arthroscopy procedure was classified into simple procedures (exploration or debridement) and complex procedures (repair or reconstruction). χ² test was used to compare proportions between the procedures of different complexity and the two groups of patients.

Results

A total of 533 patients (332 males and 201 females) were included in this study. More than half (56%) of the patients were in the age group 21–40 and nearly two thirds (62%) of all the 533 patients were male. The diagnoses of all the patients could be classified into eight categories: (i) TFCC injury; (ii) ulnar impactions syndrome; (iii) carpal trauma (carpal bone fractures and/or carpal ligament injures); (iv) distal radius fractures; (v) carpal bone cyst or necrosis; (vi) ganglion cyst; (vii) wrist arthritis; and (viii) disorders of small joint of the hand. The most common conditions treated with wrist arthroscopy were TFCC injury (172 cases), followed by carpal trauma (125 cases) and ulnar impaction syndrome (84 cases). The simple arthroscopic procedures (exploration or debridement) account for 53% of all the procedures while complex reparative or reconstructive procedures account for 47%. There was a significant difference in the proportion between simple procedures and complex procedures in both trauma and non‐traumatic patients. Repair or reconstruction procedures were more frequently performed for wrist trauma patients, whereas exploration or debridement procedures were more frequently performed for non‐trauma patients.

Conclusions

The largest group of patients who underwent wrist arthroscopy surgery are those who complained of ulnar‐sided wrist pain and the commonly conducted wrist arthroscopy procedures have evolved from simple exploration/debridement to the more complex repair or reconstruction procedures in China.

Ulnar shortening osteotomy as a treatment of symptomatic ulnar impaction syndrome after malunited distal radius fractures

A malunited distal radius fracture can lead to symptomatic ulnar impaction syndrome, which is a common cause for ulnar-sided wrist pain. If conservative treatment fails and symptoms persist after an arthroscopic ulnocarpal debridement, ulnar shortening osteotomy (USO) is the treatment of choice. Since the first USO described by Milch in 1941 after a malunited Colles fracture, many techniques have been described varying in surgical approach, type of osteotomy and osteosynthesis material used. Many studies demonstrated good to very good functional results after USO, reporting, however, a delayed union or non-union rate up to 18%. A modern, low profile, locking plate showed in our short-term study very good functional results and no implant-associated complications, in particular no non-union.

Comparative Study of Dorsal and Volar Plating for Ulnar Shortening Osteotomy

Background: Postoperative results of ulnar shortening osteotomy for ulnar abutment syndrome were compared between groups of patients in whom the plate was placed on the volar side and those in whom the plate was placed on the dorsal side. Methods: A total of 35 wrists of 14 males and 21 females were evaluated. The average age of patients at surgery was 44.3 years, and the average follow-up period was 66.2 months. After transverse osteotomy was performed, the ulna was fixed using a 6-hole LC-LCP or a LC-DCP on the dorsal (group D) or the volar (group V) side, respectively. Imaging and clinical results, rates and reasons for implant removal were evaluated. Results: There were 27 patients in group D and 8 in group V. A significant difference was observed only in the postoperative grip strength compared with that of the unaffected side between groups V and D (102% and 87%, respectively). Implant removal was performed in 18 (64%) patients in group D and in 7 (88%) in group V, and the main reasons for this were pain in group V and discomfort in group D. Re-fracture occurred after implant removal in one patient in group D. Conclusions: There were no differences in the imaging and clinical results depending on the plate position. It is preferable to avoid implant removal by placing the lower profile plate on the dorsal side.

Outcomes of ulnar shortening osteotomy using a new compression plate

Ulnar impaction syndrome (UIS) is a frequent cause of ulnar-sided wrist pain. Several open and arthroscopic surgery techniques have been described. Ulnar shortening osteotomy (USO) is often the method of choice. It has the advantage of leveling the distal radioulnar joint extra-articularly while maintaining the integrity of the soft tissues that stabilize the joint. This retrospective study reports the short-term outcomes of 20 patients who underwent surgery between 2013 and 2015. USO was performed with a locked plate and a new compression device (Alians®, Newclip™, Haute Goulaine, France). Preoperative and postoperative ulnar variance were measured on wrist X-rays in neutral pronation-supination. Functional outcomes were evaluated with the QuickDASH score and the pain on VAS (visual analog scale). Postoperative range of motion and grip strength were compared to those of the contralateral wrist. The average follow-up was 16 months (4 to 28 months). Preoperative ulnar variance was positive with an average of 4mm (1-11mm). The average length of the final ulna shortening was 3.5mm (1.5-6mm); the mean time to union was 4 months (3-12 months). The average QuickDASH was 12 and pain had decreased 2.4mm on the VAS. The results achieved with this new compression plate designed specifically for USO are similar to those described in the literature. This kind of device has an easily reproducible technique and can reduce the operative time. LEVEL OF EVIDENCE: IV.

Comparison of clinical outcomes after ulnar shortening osteotomy for ulnar impaction syndrome with or without arthroscopic debridement

Forty-four patients who had been diagnosed with ulnar impaction syndrome and who were scheduled to undergo ulnar shortening osteotomy were randomized into two groups, one treated by ulnar shortening osteotomy alone and the other treated by ulnar shortening osteotomy combined with arthroscopic debridement. The response to treatment, including the pain numeric rating scale in an ulnar provocation test and the Disability of the Arm, Shoulder and Hand score was assessed at 3 and 12 months after surgery. The mean pain and disability scores showed significant clinical improvement at the 12-month follow-up in both groups. The pain scores at 3 months of follow-up were significantly better in the ulnar shortening osteotomy with arthroscopic debridement group. However, no significant differences were observed between the two groups in the disability scores at 3 and 12 months, or in the pain scores at 12-month follow-up. We conclude that similar improvements in symptom severity and hand function occurred in the long term in patients both with and without concomitant arthroscopic debridement. This information regarding concomitant arthroscopy could be used in the informed consent discussion with patients scheduled for ulnar shortening osteotomy. Level of evidence: II.

During forearm rotation the three-dimensional ulnolunate distance is affected more by translation of the ulnar head than change in ulnar variance

Ulnolunate abutment has been thought to be aggravated by pronation because of an increase in ulnar variance. We hypothesized that the ulnolunate distance might be greater in pronation because the ulnar head is dorsally translated. Twenty-one three-dimensional reconstructions of computed tomographic scans of wrists taken in supination and pronation were investigated. The ulnolunate distance was measured in each position, and the change in ulnolunate distance from supination to pronation was calculated. The changes in ulnar variance from supination to pronation and the amount of translation of the ulnar head were measured directly by superimposing three-dimensional reconstructions. The mean ulnolunate distance in pronation was significantly greater than in supination. There was no significant correlation between the changes in ulnolunate distance and in the ulnar variance. The change in ulnolunate distance had a significant positive linear relationship with the amount of translation of the ulnar head. The change in ulnolunate distance during forearm rotation is determined by the amount of translation of the ulnar head rather than by change in ulnar variance. Level of evidence: IV.

Lunotriquetral coalition and ulnar impaction syndrome: a pictorial essay

Lunotriquetral coalition and ulnar impaction syndrome are among the spectrum of pathology encountered at the medial wrist. The co-existence of these entities in the same wrist is rare. The purpose of this pictorial essay is to present the etiology, clinical course, imaging findings, and treatment of lunotriquetral coalition and ulnar impaction syndrome, and co-existing disease.

Solitary ulnar shortening osteotomy for malunion of distal radius fractures: experience of a centre in the UK and review of the literature

INTRODUCTION

Isolated ulnar shortening osteotomies can be used to treat ulnocarpal abutment secondary to radial shortening following distal radius fractures. Given the increase of fragility distal radius fractures awareness of treating the sequelae of distal radius fractures is important. We present the largest reported case series in the UK of ulnar shortening osteotomies for this indication.

MATERIALS AND METHODS

Twenty patients with previous distal radial fractures were included, who presented with wrist pain and radiologically evident positive ulnar variance secondary to malunion of the distal radius with no significant intercalated instability. Patients were treated with a short oblique ulnar shortening osteotomy, using a Stanley jig and small AO compression plate system. Pre- and postoperative radiographical measurements of inclination, dorsal/volar angulation and ulnar variance were made. Patients were scored pre- and postoperatively using the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and Patient-Rated Wrist Evaluation scores by two orthopaedic surgeons. Mean follow-up was 24 months after surgery.

RESULTS

Radiographical analysis revealed a change in the ulnar variance with an average reduction of 5.74 mm. Mean preoperative scores were 61.1 (range 25-95.5) for QuickDASH and 70.4 (range 33-92) for Patient-Rated Wrist Evaluation. At the latest follow-up, mean postoperative QuickDASH scores were 10.6 (range 0-43.2) and 17.2 (range 0-44) for Patient-Rated Wrist Evaluation. Differences in scores after surgery for both QuickDASH and Patient-Rated Wrist Evaluation were statistically significant (P < 0.01).

CONCLUSIONS

The ulnar shortening osteotomy is a relatively simple procedure compared with corrective radial osteotomy, with a lower complication profile. In our series, patients showed significant improvement in pain and function by correcting the ulnar variance thus preventing ulna-carpal impaction.

Lunate morphology as a risk factor of idiopathic ulnar impaction syndrome

AIMS

Positive ulnar variance is an established risk factor for idiopathic ulnar impaction syndrome (UIS). However, not all patients with positive ulnar variance develop symptomatic UIS and other factors, including the morphology of the lunate, may be involved. The aim of this study was to clarify the relationship between lunate morphology and idiopathic UIS.

PATIENTS AND METHODS

A cohort of 95 patients with idiopathic UIS (UIS group) was compared with 95 asymptomatic controls with positive ulnar variance. The shape of the lunate was measured using the capitate-triquetrum distance (CTD), ulnar coverage ratio (UCR), radiolunate distance and radiolunate angle. The association of radiographic parameters and lunate types with the development of UIS was investigated in univariable and multivariable analyses. Receiver operating characteristic curves were used to estimate a cutoff for any statistically significant variables.

RESULTS

The proportion of type II lunates, which have a medial hamate facet, were significantly higher in the UIS group than in the control group in the univariable analysis (p = 0.001). CTD (odds ratio (OR) 1.52; 95% confidence interval (CI) 1.11 to 2.06; p = 0.008) and UCR (OR 44.78; 95% CI 5.35 to 374.90; p = 0.002) showed a positive association with UIS in the multivariable analysis. Estimated cutoff values were 2.5 mm for the CTD (area under the curve (AUC) = 0.65) and 0.4 for the UCR (AUC = 0.64).

CONCLUSION

The proportion of type II lunates was greater in the UIS group than in the control group. A large UCR, which represents the broad base of the lunate, was positively associated with the development of idiopathic UIS. Cite this article: Bone Joint J 2017;99-B:1508-14.

Ulnar Shortening Osteotomy: Are Complications Under Reported?

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.

Positive or negative ulnar variance after ulnar shortening for ulnar impaction syndrome: a retrospective study

Background

The goal of this study was to compare simple radiographic findings and clinical results according to residual ulnar variance following ulnar shortening for ulnar impaction syndrome.

Methods

Forty-five cases of ulnar impaction syndrome, which were treated with ulnar shortening from 2005 to 2008, were studied retrospectively. Group I included 13 cases with positive residual variance after ulnar shortening and group II included 32 cases with negative variance after shortening. The presence of a lunate cystic lesion both preoperatively and at final follow-up and assessments of wrist function based on the modified Mayo wrist score, the disabilities of the arm, shoulder, and hand (DASH) score, as well as the Chun and Palmer score were evaluated.

Results

A cystic lesion of the lunate was present in 4 cases preoperatively and the size decreased in 2 cases at final follow-up in group I, and in 10 and 5 cases, respectively, in group II. No statistical difference was observed between the groups. The modified Mayo wrist score, DASH score, as well as the Chun and Palmer score improved significantly in both groups. No significant differences were observed between the two groups in terms of the proportion of positive cystic lesions at final follow-up or the functional scores.

Conclusions

After ulnar shortening, the degree of radiological change in the cystic lunate lesions and clinical improvement did not differ significantly between the groups with unintended residual positive and negative variance after shortening.

A comparison of ulnar shortening osteotomy alone versus combined arthroscopic triangular fibrocartilage complex debridement and ulnar shortening osteotomy for ulnar impaction syndrome

Background

This study compared the results of patients treated for ulnar impaction syndrome using an ulnar shortening osteotomy (USO) alone with those treated with combined arthroscopic debridement and USO.

Methods

The results of 27 wrists were reviewed retrospectively. They were divided into three groups: group A (USO alone, 10 cases), group B (combined arthroscopic debridement and USO, 9 cases), and group C (arthroscopic triangular fibrocartilage complex [TFCC] debridement alone, 8 cases). The wrist function was evaluated using the modified Mayo wrist score, disabilities of the arm, shoulder and hand (DASH) score and Chun and Palmer grading system.

Results

The modified Mayo wrist score in groups A, B, and C was 74.5 ± 8.9, 73.9 ± 11.6, and 61.3 ± 10.2, respectively (p < 0.05). The DASH score in groups A, B, and C was 15.6 ± 11.8, 19.3 ± 11.9, and 33.2 ± 8.5, respectively (p < 0.05). The average Chun and Palmer grading score in groups A and B was 85.7 ± 8.9 and 84.7 ± 6.7, respectively. The difference in the Mayo wrist score, DASH score and Chun and Palmer grading score between group A and B was not significant (p > 0.05).

Conclusions

Both USO alone and combined arthroscopic TFCC debridement with USO improved the wrist function and reduced the level of pain in the patients treated for ulnar impaction syndrome. USO alone may be the preferred method of treatment in patients if the torn flap of TFCC is not unstable.