Ulnar Osteotomy Research Articles

Lesión de Monteggia inveterada. Resultados con la técnica de Bell-Tawse modificada en tres casos

Purpose Monteggia injuries are a rare occurrence (2% of all elbow fractures), and inveterate cases are extremely unusual. We present 3 cases treated by means of open reduction and reconstruction of the annular ligament with a strip of triceps fascia. Case reports The mean age of the 3 patients was 7 years (range: 5–9). Two of them were male and all presented with type 1 Bado injuries on the right side. All 3 were treated by means of the Bell-Tawse technique as modified by Lloyd-Roberts and Bucknill; one of the patients was also subjected to ulnar osteotomy. Results There were no complications. After a mean follow-up of 35 months (range: 9–84) all patients achieve a functional flexion-extension range. They experienced a slight loss of pronosupination but they reported no restrictions to their activities of daily living or any functional impairment. Conclusions The modified Bell-Tawse technique is an effective method, even if it leads to a slight loss of mobility, especially in terms of pronosupination. The long-term results of this technique are better than those achieved with a late excision of the dislocated radial head.

Ulnar osteotomy tar ulnar impaction syndrome following distal radius fracture

Objective To evaluate the effect and influential factor of ulnar-shortening procedure for ulnar impaction syndrome after distal radius fracture. Methods From January 2002 to December 2006, 28 cases who had been diagnosed as ulnar impaetion syndrome following distal radius fracture received ul-nar-shortening procedure. The therapeutic effect for the injured wrist was assessed by the modified Gartland and Werley scoring system of wrist function. The relation between the operative outcome and the length of shortening was analyzed. Results Carpal anteroposterior X-ray film revealed 23 cases of ulnar positive variance, 3 cases of neutral variance and 2 cases of negative variance preoperatively, but 3 positive, 4 neutral and 21 negative ulnar variance postoperatively. The average ulnar variance was (3.1±2.3 )mm before ulnar-shortening procedure and (0.9±1.4) mm after operation. The modified Gartland and Wedey wrist function score was 62.6±4.3 preoperatively and 92.2±7.8 postoperatively. Before operation 21 cases were evaluated as fair and 7 as poor, but after operation 22 cases were evaluated as excellent, 3 fine, 2 fair and 1 poor. The radioulnar ligaments (RUL) were abscised in 3 cases and partly cut off in 4 cases. Ulnar-carpal dorsal semiluxation was found in 6 cases, but the deformity was redressed after ul-nar-shortening procedure. Conclusions The ulnar-shortening procedure may improve earpal function scores and clinical symptoms markedly in patients with ulnar impaction syndrome secondary to distal radius fractures. But the operative effectiveness can be affected by excessive ulnar-shortening which leads to increased pressure on the distal ulnoradial joint facets. Key words: Ulna; Osteotomy; Radius fractures; Operative procedure

Early Clinical Experience with Osteochondral Autograft Transfer for Treatment of Osteochondritis Dissecans of the Medial Humeral Condyle in Dogs

To establish whether osteochondral autograft transfer (OAT) procedures for osteochondritis dissecans (OCD) of the canine elbow would restore articular contour, resurface osteochondral defects with hyaline cartilage, and resolve lameness in the short term. Case series. Dogs (n=27) with medial humeral condylar OCD. After arthroscopic assessment, the medial humeral condyle was exposed by arthrotomy. Medial coronoid disease (MCD) was managed by subtotal coronoid ostectomy, then the OCD lesion debrided and OATS instrumentation used for resurfacing the defect with osteochondral core grafts collected from the stifle. Recipient sockets were created to maximally resurface OCD lesions. Six elbows also had proximal ulnar osteotomy. Outcomes measures included subjective clinical, radiographic, and arthroscopic examination at 12-18 weeks. Of 33 treated elbows, 30 also had MCD. Accurate reconstruction of the medial humeral condylar surface was achieved in all joints. Lameness resolved in 3-13 weeks in 26 of 31 limbs with follow-up. Arthroscopic outcomes for elbows with concomitant MCD but without proximal ulnar osteotomy were variable (14/24 good, 5/24 intermediate, 5/24 poor). Short-term outcome for OCD without MCD (n=2) and when proximal ulnar osteotomy (n=5) was performed were positive. Long-term assessments of 7 dogs suggested minimal donor site morbidity. OAT procedures are technically feasible in the canine elbow. In elbows with concurrent MCD, proximal ulnar osteotomy may improve likelihood of positive clinical outcome. OAT procedures warrant further evaluation as a treatment option for selected cases of OCD involving the canine medial humeral condyle.

Missed Monteggia fracture in children: Is annular ligament reconstruction always required?

Background:Chronic (neglected) radiocapitellar joint dislocation is one of the feared complications of Monteggia fractures especially when associated with subtle fracture of the ulna bone. Many treatment strategies have been described to manage chronic Monteggia fracture and the need for annular ligament reconstruction is not always clear. The purpose of this study is to highlight the management of missed Monteggia fracture with particular emphasis on utility of annular ligament reconstruction by comparing the two groups of patients.Materials and Methods:In a prospective study 12 patients with mean age of 7.4 years, who presented with neglected Monteggia fractures, were studied. All children underwent open reduction of the radiocapitellar joint. Five children (Group A) were treated with angulation-distraction osteotomy of ulna and annular ligament reconstruction and six cases (Group B) required only angulation-distraction osteotomy of ulna without ligament reconstruction. In one case an open reduction of the radiocapitellar joint was sufficient to reduce the radial head and this was included in Group B. The gap between injury and presentation was from 3 months to 18 months (mean 9 months). Ten patients were classified as Bado I, and one each as Bado II and III respectively. We used the Kim's criteria to score our results.Result:The mean follow-up period was 22 months. All ulna osteotomies healed uneventfully. The mean loss of pronation was 15 degree in Group A and 10 degree in Group B. Elbow flexion improved from the preoperative range and no child complained of pain, deformity and restriction of activity. The elbow score was excellent in 10 cases, and good in two cases.Conclusion:Distraction-angulation osteotomy of the ulna suffices in most cases of missed monteggia fracture and the need for annular ligament reconstruction is based on intraoperative findings of radial head instability.

Treatment of Neglected Monteggia Fracture-Dislocation in Children

Purpose: Our purpose is to evaluate the results of the operative treatment in neglected Monteggia fracture-dislocation in children. Materials and Methods: We retrospectively analyzed 10 elbows in 10 patients who underwent surgery. All patients were classified as Bado type I, except one with type III. The mean duration of follow up was 2 years and 5 months. The mean age at the time of operation was 10 years and the mean time from injury to operation was 7 months. All 10 patients underwent open reduction of the radial head and reconstruction of annular ligament. Ulnar osteotomy was performed in 9 cases. Clinical assessment was done by Bruce et al.'s rating system. Results: All 10 patients gained a mean of of extension-flexion arc, however lost a mean of of pronation-supination arc. And there were three complications, including dislocation of radial head in two patients and breakage of transarticular K-wire in one patient. According to Bruce et al.'s rating system, there were 4 excellent, 1 good, 3 fair, and 2 poor results. Conclusion: We found that the effect of the operative treatment of neglected Monteggia fracturedislocation in children was limited in majority of the patients. Particularly, the loss of pronation-supination arc was noticed postoperatively in most patients.

Effect of amino acids lysine and arginine on fracture healing in rabbits: A radiological and histomorphological analysis

Background:Amino acids like arginine and lysine have been suggested to hasten the process of fracture healing by improving the local blood supply, supplementing growth factors, and improving collagen synthesis. We studied the role of lysine and arginine in the fracture repair process with regard to the rate of healing, probable mechanisms involved in the process, and mutual synergism between these agents.Materials and Methods:In an experimental study, 40 rabbits were subjected to ulnar osteotomy. They were distributed in control (14) and test groups (26). Twenty-six animals in the test group were fed with a diet rich in lysine and arginine. Both the groups were followed radiologically and histologically till union.Results:There was better healing of osteotomy in terms of better vascularization, callus formation, and mineralization in the test group. The time of healing in the test group was reduced by a period of 2 weeks.Conclusion:We conclude that amino acids like arginine and lysine may hasten fracture healing.

Radial head dislocation with ulnar plastic deformation in children: An osteotomy within the middle third of the ulna

This retrospective study includes 6 patients (average age, 8.7 years) with a dislocation of the radial head and ulnar plastic deformation. All were Monteggia fractures, Bado type I equivalents. The maximum ulnar bow was near the midulna. Five patients underwent an ulnar osteotomy, with elongation and reduction of the angulation within the middle third of the ulna, and open reduction of the radial head. One patient underwent an ulnar osteotomy with only elongation. The osteotomy sites were stabilized by a plate and screws or Kirschner wires. Mean follow-up was 3.4 years. Postoperatively, the average elbow range of motion was extension to 0 degrees, flexion to 138 degrees, forearm supination to 90 degrees, and forearm pronation to 88 degrees. Results in all patients were rated as excellent. One nonunion occurred. An osteotomy performed within the middle third of the ulna, combined with open reduction of the radial head, resulted in excellent clinical outcomes.

Anatomic Reduction of Old Displaced Lateral Condylar Fractures of the Humerus in Children via a Posterior Approach With Olecranon Osteotomy

We questioned the principle of treatment of late lateral condylar fracture of a pediatric elbow. We report the results of treating this condition using a different approach. We treated six children with type 3 late lateral condylar fractures. The average age was 4.5 years old. The time delay from injury to surgery averaged at 3.8 months. All the displaced lateral condyles were Milch type 2 with significant rotation away from the trochlea. The articular anatomic reduction of the lateral condyles was achieved via ulnar osteotomy in all six cases. We fixed both the fracture and the osteotomy with Kirschner wires buried under the skin. No strenuous passive physical therapy was needed. All lateral condylar fractures and ulnar osteotomies were united within 3 months. Five out of six children had regained full range of motion and symmetric carrying angles at the latest follow-up 2 to 11 years later. Complications included transient physeal change and lateral bump. Based on our results, we recommend olecranon osteotomy via a posterior approach as one of the options in treating late cases of type 3 lateral condylar fracture of the elbow with significant displacement in children.

Cartilage-retaining wafer resection osteotomy of the distal ulna.

Ulnar-sided wrist pain resulting from ulnar impaction is common. We describe a new cartilage-retaining wafer resection osteotomy designed to keep the cartilage intact and decompress the ulnocarpal articulation without requiring internal fixation. We retrospectively reviewed seven patients with ulnar impaction who had the procedure. The minimum followup was 14 months (mean, 30 months; range, 14-38 months). The mean change in ulnar variance was -1.29 mm. Patients showed radiographic healing by a mean of 11 weeks. Our preliminary results suggest the cartilage-retaining wafer resection osteotomy may be an effective way to unload the ulnocarpal joint without requiring internal fixation or destruction of the distal ulna cartilage. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Surgical treatment of missed Monteggia lesions in children

The treatment of an unrecognized Monteggia lesion continues to pose a therapeutic challenge, as evidenced by the variety of surgical techniques described. Moreover, there are high complication and redislocation rates following surgery. This report concerns a surgical technique to reduce a chronic dislocation of the radial head utilizing an ulnar osteotomy and internal fixation. Six consecutive cases of missed Monteggia lesions were treated in our institution between August 2001 and September 2003. Patient mean age was 6.5 (range 4-8) years, and the mean interval between injury and surgical procedure was 17 (range 1-49) months. Surgery consisted of an ulnar osteotomy with angulation and lengthening, bone grafting at the osteotomy site, and internal fixation. Open reduction of the radial head, repair or reconstruction of the annular ligament or temporary fixation of the radial head with a transarticular wire was not undertaken. Cast immobilization with the forearm in neutral rotation was maintained for 2 weeks. There was one case of nonunion. At an average follow-up of 3 (range 1.5-4.4) years, all patients had regained painless function of the forearm, good range of elbow and forearm motion, and maintenance of the radial head reduction. Both angulation and elongation of the ulna are required to allow for reduction of the radial head. We do not see any indication for procedures directed at the radio-capitellar joint.

A primarily overlooked and incorrectly treated Essex-Lopresti injury: what can this lead to?

What result can one expect in treating an Essex-Lopresti lesion--a rare complex combination injury of the forearm consisting of a radial head fracture and a rupture of the interosseous membrane--which failed to be identified at first? We report on a 45-year-old poly traumatized patient in which a primary Essex-Lopresti injury was overlooked following a dislocated radial head fracture. A radial head resection followed by an ulna-shortening osteotomy was performed with disastrous consequences at another clinic. As a result of persistent instability in the distal radioulnar joint, we implanted a mono-polar radial head prosthesis, which was subsequently changed as a result of a loosening of the prosthesis and persistent complex instability and pain in the area of the entire forearm, while an ulna osteotomy had to be carried out to correct this. This prosthesis also loosened, which destroyed the capitulum humeri. It was only after a specially designed modular radial head prosthesis with a capitulum shield was implanted and an elapse of 5(1/2) years of the illness that permanent stability could be achieved on the forearm and the pain experienced by the patient eliminated while at the same time the patient regained a moderate degree of functioning and grip strength. An overlooked primary and ultimately initially incorrectly treated Essex-Lopresti injury can degenerate into a real therapeutic disaster. Years of illness and multiple corrective operations which only serve to limit the collateral damage caused by the wrong therapy strategy and ultimately only lead to restoration of moderate function. The crucial factor is an early diagnosis. Then a radial head prosthesis should first be implanted in an operation in order to prevent an additional proximal migration of the radius and to move the distal radioulnar joint into the proper anatomical position.

The effects of the short-term administration of low therapeutic doses of anti-COX-2 agents on the healing of fractures

We have evaluated the effect of the short-term administration of low therapeutic doses of modern COX-2 inhibitors on the healing of fractures. A total of 40 adult male New Zealand rabbits were divided into five groups. A mid-diaphyseal osteotomy of the right ulna was performed and either normal saline, prednisolone, indometacin, meloxicam or rofecoxib was administered for five days. Radiological, biomechanical and histomorphometric evaluation was performed at six weeks. In the group in which the highly selective anti-COX-2 agent, rofecoxib, was used the incidence of radiologically-incomplete union was similar to that in the control group. All the biomechanical parameters were statistically significantly lower in both the prednisolone and indometacin (p = 0.01) and in the meloxicam (p = 0.04) groups compared with the control group. Only the fracture load values were found to be statistically significantly lower (p = 0.05) in the rofecoxib group. Histomorphometric parameters were adversely affected in all groups with the specimens of the rofecoxib group showing the least negative effect. Our findings indicated that the short-term administration of low therapeutic doses of a highly selective COX-2 inhibitor had a minor negative effect on bone healing.

Isolated Madelung's deformity: long-term follow-up study of five patients treated surgically

Five patients with isolated Madelung's deformity were reviewed with an average follow-up of 34 years after surgery. All the patients were female and their average age at surgery was 12.7 years, whereas the average age at follow-up was 53 years. The deformity was bilateral in four patients and unilateral in one, for a total of nine deformities. At diagnosis, in all the patients the typical radial deviation of the hand was observed, with dorsal prominence of the distal end of the ulna. Pain and limitation of the range of motion were present in all the wrists except two, which were painless but presented marked functional impairment. In no patient did we observe growth disorders of the other bones or deformities typical of osteochondrodysplasias. Surgical correction was sought by both the families and the patients mainly for functional reasons, although cosmetic improvement was also expected. The operation consisted of closing-wedge osteotomy of the distal radial metaphysis and either shortening osteotomy or resection of the distal ulna. At follow-up, the range of motion of the wrists was improved, and all the patients were pain-free and satisfied with the final results. No significant radiographic osteoarthritis was present in any of the operated wrists, although four of the five patients were above 50 years of age.

Treatment of ununited anconeal process in 8 dogs by osteotomy and dynamic distraction of the proximal part of the ulna

A surgical technique for the treatment of ununited anconeal process in dogs treated by osteotomy and dynamic distraction of the proximal part of the ulna using a linear external skeletal fixator was evaluated. In all cases the osteotomy was distracted 1mm each day after the surgery until desired distraction had been achieved. Eight dogs and 9 joints diagnosed with ununited anconeal process were treated. The success of the procedure was determined by comparing clinical signs of lameness and degree of arthrosis at the time of diagnosis to 6 months after the surgical intervention. Radiographic union occurred in 88.9% of the affected joints between 21 and 42 days after the surgical procedure. Clinically, six elbows were classified as good, two as satisfactory and one as unsatisfactory. Six months after surgery two elbows had no arthrosis, one had Grade 1, two Grade 2 and one Grade 3. It is concluded the combination of ulnar osteotomy and dynamic distraction of the olecranon by a linear external skeletal fixator is a feasible procedure for the treatment of ununited anconeal process in dogs.

CASE REPORT:Late Radial Head Dislocation with Radial Head Fracture and Ulnar Plastic Deformation

Type II Monteggia lesion equivalents produced by plastic deformation of the ulna are rare. Radial head fractures in skeletally immature patients are also uncommon. We report a late presentation of a Type II Monteggia equivalent injury with a fracture of the radial head and neck and plastic deformation of the ulna in an 11-year-old boy. The radial head was located on the initial injury radiographs and subsequently dislocated in a posterior direction. The radial head fracture was misdiagnosed as a coronoid fracture at presentation. The plastic deformation of the ulna was diagnosed several weeks after the injury when the dislocation was first noted. Magnetic resonance imaging was used to establish the diagnosis of a radial head fracture at the same time. The patient was treated successfully with an open reduction and internal fixation of the radial head combined with a dorsal closing-wedge ulnar osteotomy.

Transverse Ulnar Bone Transport Osteogenesis: A New Technique for Limb Salvage for the Treatment of Distal Radial Osteosarcoma in Dogs

To develop instrumentation and a technique for transverse ulnar bone transport osteogenesis in dogs. Cadaveric study and in vivo validation (1 dog). Paired cadaveric antebrachii (n=10 dogs) and 1 live dog. Circular fixator constructs were applied and fitted with reeling or linear motors designed to transport an ulnar segment transversely into a defect created by excising the distal 50% of the ipsilateral radius. A longitudinal osteotomy of the adjacent ulna was created and the segment was transported across the radial defect. Pre- and post-distraction CT scans were used to compare the efficacy of each construct. The procedure was performed unilaterally in a live dog using the reeling motor (RM) construct. Both constructs effectively transported the ulnar segment into the defect. Subjectively, the RMs were easier to apply and operate. No significant differences were observed in the objective measures of efficacy between the 2 construct types. The live dog produced viable regenerate bone after transverse ulnar bone transport. Transverse ulnar bone transport should be considered a potential method for limb salvage in dogs with osteosarcoma (OSA) of the distal radius. The RMs were effective and clinically applicable. Transverse ulnar bone transport osteogenesis affords the benefits of longitudinal radial bone transport osteogenesis, allowing resolution of large longitudinal radial defects in a substantially less time as a result of shortening the transport distance. This would be beneficial when treating conditions such as OSA where minimizing convalescence and maximizing quality of life is a priority.

Osteochondral Shortening Osteotomy for the Treatment of Ulnar Impaction Syndrome

A new technique for ulna shortening is described. It is a modification of the open-wafer procedure that preserves the distal ulna's articular surface. A 4- to 5-mm chondral-cortical bone block is removed at the distal ulna articular-metaphysis junction. Closing the bone gap results in the osteotomy site proximal to the sigmoid notch. The distal ulna chondral-cortical fragment is secured with 1 or 2 headless compression screws, which permit early motion and results in solid healing. Similar to Feldon's previously described open-wafer procedure, this new technique reduces the ulna carpal load by reducing the distal ulna carpal length at the distal radioulnar joint. This new technique eliminates the exposure of the radiocarpal joint to continuous bleeding from the distal ulna's trabecular bone as seen in Feldon's open-wafer procedure and avoids all the inherent problems associated with plating the ulna for a typical distal ulna osteotomy, such as delayed union and painful hardware.

Surgical treatment of chronic isolated radial head dislocation in children with proximal ulnar osteotomy

目的 评估采用尺骨近端截骨治疗少年陈旧性单纯桡骨头脱位的临床疗效.方法 回顾性研究了采用尺骨近端截骨治疗陈旧性单纯桡骨头脱位的6例患者,手术时的年龄从7～12岁,从受伤到接受手术治疗的时间间隔为6个月～4年,平均为[(19.3±16.5)个月,x-±s,下同],其中2例患者同时缝合了环状韧带,1例患者进行了桡侧侧副韧带的重建.重点分析了术后功能恢复情况和术前、术后的影像学改变.结果 本组6例术后随访时间平均为(16.5±8.7)个月.所有患者截骨部位均达骨性愈合,无异位骨化或其他较为严重的并发症,也无肘关节疼痛和桡骨头再脱位.肘关节屈伸活动度为(140.0±7.1)°,前臂旋转活动度为(129.0±18.4)°,患侧握力占健侧握力的百分比为(96.9±3.5)%.术后影像学提示随着随访时间的延长,尺骨的再塑形非常明显,表现为截骨所致的向后成角逐渐圆滑,最终成角消失,以及损伤所致的尺骨弓征逐渐纠正.结论 对于少年陈旧性单纯桡骨头脱位如果无明显桡骨头畸形,采用尺骨近端截骨治疗可以取得较为满意的疗效。

Open reduction and corrective ulnar osteotomy for missed radial head dislocations in children

The treatment of chronic radial head dislocation remains controversial. Open reduction of the radial head in combination with correction of malalignment with ulnar osteotomy can be the key to a good surgical result. Between 2001 and 2006, 9 (6 female, 3 male, average age 8.4 (5-11) years) patients were treated surgically for chronic radial head dislocation by one surgeon. The time between trauma and surgery was 7 (1.5-14) months. The procedure consisted of open reduction of the dislocated radial head and reconstruction of the annular ligament in combination with an ulnar osteotomy. An upper arm cast was applied with the forearm in neutral rotation for six weeks. Plates were removed in all patients. Clinical and radiological evaluation took place preoperatively and after an average of 23 (10-49) months. At radiograph 8/9 showed a reduced radial head; in one an anterior subluxation was seen. The range of motion remained the same in 4 patients who had a full range of motion preoperatively. In 2/5 patients with loss of range of motion preoperatively, improvement was seen. There were no serious surgical complications beside one infection. Open reduction and corrective ulnar osteotomy shows good results for missed radial head dislocations in children.

Chronic Posttraumatic Anterior Dislocation of the Radial Head in Children: Thirteen Cases Treated by Open Reduction, Ulnar Osteotomy, and Annular Ligament Reconstruction Through a Boyd Incision

Chronic Posttraumatic Anterior Dislocation of the Radial Head in Children: Thirteen Cases Treated by Open Reduction, Ulnar Osteotomy, and Annular Ligament Reconstruction Through a Boyd Incision