Ulnar Osteotomy Research Articles

A finite element model to investigate the effect of ulnar variance on distal radioulnar joint mechanics.

Ulnocarpal impaction syndrome involves excessive loading of the ulnocarpal joint. Ulnar shortening osteotomies are an effective way to reduce ulnocarpal loading but alter contact mechanics at the distal radioulnar joint (DRUJ). This study used a computational model to investigate the relationship between ulnar length and DRUJ mechanics. Detailed, finite element models of the radius and ulna bones were constructed from magnetic resonance imaging data. The length of the ulna bone model was increased and decreased up to 5 mm in 1 mm increments. A computational model was used to predict joint contact at the DRUJ for each ulnar length. Lengthening the ulna caused a slight decrease in DRUJ contact pressure, with a more substantial decrease in contact area. Shortening the ulna caused a substantial increase in contact area, with a smaller increase in DRUJ contact pressure. The location of contact on the radial sigmoid notch changed with 2 mm lengthening and 3 mm shortening. The results of this study demonstrate the sensitivity of DRUJ contact to ulnar length changes, which may explain the DRUJ cartilage degeneration that often follows ulnar osteotomies. The joint contact model implemented in this study allowed the relationship between ulnar length and DRUJ contact to be examined systematically, in a way that is difficult to achieve through cadaveric experimentation. The results confirmed published experimental data showing an increased DRUJ contact pressure with ulnar shortening. It is important that clinicians consider the influence of ulnar osteotomies, not only on ulnocarpal loading but also on DRUJ mechanics. Copyright © 2016 John Wiley & Sons, Ltd.

Successful Strategies for Managing Monteggia Injuries.

Monteggia fracture-dislocations refer to traumatic ulnar fractures associated with proximal radioulnar and radiocapitellar joint instability. Careful clinical and radiographic evaluation of the entire limb in the acutely injured child is critical for timely diagnosis and appropriate treatment. Treatment principles include restoring and maintaining both ulnar length and alignment as well as radiocapitellar joint reduction. Recent information suggests that surgical treatment of acute injuries associated with complete ulnar fractures is safe and effective in maintaining bone and joint alignment. In cases of late presentation or missed diagnoses, chronic reconstruction may be considered in symptomatic patients with preserved radiocapitellar morphology. Although challenging, ulnar osteotomy and open joint reduction with or without ligament reconstruction may restore joint congruity in the majority of patients.

Transverse Ulna Osteotomy for Revision Total Elbow Arthroplasty: Surgical Technique and Outcomes

Transverse Ulna Osteotomy for Revision Total Elbow Arthroplasty: Surgical Technique and Outcomes

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

Purpose Ulna-shortening osteotomy is one of the most established and most frequent operations in hand surgery. However, bone union is not always achieved and the use of plates implies potential risks and problems. The traditional points of criticism are the duration of bone healing, the incidence of nonunion, and the necessity of hardware removal due to the soft tissue irritation by the plate or the screws. These shortcomings have been addressed by an increasing standardization of the procedure and finally specific instruments and implants. The aim of this retrospective study was to compare a new LCP (locking compression plate) Ulna Osteotomy System 2.7 mm (Synthes, Paoli, PA) with the former 3.5-mm LCDCP (limited-contact dynamic compression plate) (Synthes) regarding consolidation, complications, and rate of plate removal. Methods To investigate the effect of an implant and technique specifically designed for this purpose, we have compared the course of healing and the result in 72 patients who have undergone ulnar shortening osteotomy using general instruments and applying a standard osteosynthesis plate (Synthes, 3.5-mm LCDCP) to a consecutive cohort of 40 patients who had ulnar shortening using the new dedicated ulna-shortening osteotomy system plate (Synthes, 2.7-mm LCP). Clinical and radiologic evaluation was performed 8 weeks, 3 months, 6 months, and 1 year postoperatively in all patients. Results The latter displayed shorter bone healing time, suggesting an advantage of an oblique osteotomy. There was no significant difference in rate of plate removal. Ultimate complication and consolidation rate was not different. Conclusion Using the new LCP 2.7 implant, time to consolidation was shorter and oblique osteotomies healed faster than transverse ones. However, in spite of the smaller plate, screws, and tapered design, the plate did not cause less local problems and failed to decrease the necessity of plate removal. Furthermore, the cost of the implant is higher than the LCDPC 3.5. Type of Study Retrospective comparative study. Therapeutic evidence Level III.

Ulnar impaction syndrome: Managed by wrist arthroscopy.

Background:The development of handicraft industry and increase of various such works that need a large amount of repeated wrist ulnar deviation strength, the incidence of ulnar impaction syndrome (UIS) is increasing, but the traditional simple ulnar shortening osteotomy has more complications. This study aimed to explore the early diagnostic criteria of UIS and its wrist arthroscopic treatment experience.Materials and Methods:9 UIS patients were enrolled in this study. According to magnetic resonance imaging, X-ray and endoscopic features, the diagnostic criteria of UIS were summarized and the individualized treatment schedule was made. If the ulnar positive variance was less than 4 mm, the arthroscopic wafer resection was performed. If the ulnar positive variance was more than 4 mm, the arthroscopic resection of injury and degenerative triangular fibrocartilage complex and ulnar osteotomy were conducted.Results:In all patients, the wound healed without any complications. All patients returned to normal life and work, with no ulnar wrist pain again. One patient had wrist weakness. There was a significant difference of the wrist activity between the last followup and before operation (P < 0.05). According to the modified wrist function scoring system of Green and O’Brien, there were 6 cases of excellent, 2 cases of good and 1 case of appropriate and the overall excellent and good rate was 92.3%.Conclusion:In the treatment of UIS, the arthroscopy can improve the diagnosis rate, optimize the treatment plan, shorten the treatment cycle, with good treatment results.

Bi-Oblique Dynamic Proximal Ulnar Osteotomy: Surgical Technique and Clinical Outcome in 86 Dogs.

To describe the technique of bi-oblique dynamic proximal ulnar osteotomy (BODPUO) and report the clinical outcome in a series of dog with medial compartment disease and other developmental elbow diseases. Retrospective case series. Dogs (n=86; 120 elbows) treated for elbow disease with BODPUO. Medical records and diagnostic images were reviewed. Type and frequency of complications and treatment required were recorded. Force plate data were reported in dogs for which data had been recorded preoperatively and at follow-up. Mean (standard deviation) final follow-up was 23.4 (35.6) weeks. There were minor complications in 15 elbows (12%, 14 dogs). There were no major complications. The caudo-cranial and latero-medial mean osteotomy angles were 55° (7°) and 48° (10°), respectively. The most caudo-proximal point of the osteotomy was located at a mean of 39% (5%) of the total ulnar length from the olecranon. Sixty of 68 elbows (88%) were considered healed by 4 months postoperative based on radiographs. Subjective lameness scores were significantly decreased by final follow-up for all dogs. For dogs treated with BODPUO alone for medial compartment disease, peak vertical force was significantly higher at 6 months postoperative. Dogs with medial compartment disease undergoing BODPUO showed clinical improvement in the 6 month follow-up. No complications required surgical intervention.

Effect of the Proximal Abducting Ulnar Osteotomy on Intra-Articular Pressure Distribution and Contact Mechanics of Congruent and Incongruent Canine Elbows Ex Vivo.

To determine the effects of the Proximal Abducting Ulnar Osteotomy (PAUL) on contact pressures of congruent and incongruent (short radius) canine elbows. Ex vivo biomechanical study. Unpaired normal cadaveric canine forelimbs (n=16). A servohydraulic testing frame and thin-film sensors were utilized to measure intra-articular contact area (CA), mean contact pressure (mCP), and peak contact pressure (pCP) for medial and lateral elbow compartments. Percent contribution of the medial compartment relative to the whole (%Med) was also examined. Baseline data were collected in 9 congruent elbows and 7 incongruent elbows where the radius was shortened. Both sets of elbows were tested following ulnar osteotomy and sequential placement of 2 and 3 mm PAUL plates and paw repositioning (to account for any medial to lateral shift of transarticular forces). Paired t-tests compared sequential procedural steps. P<.05 was significant. For congruent elbows, the 2 mm PAUL plate decreased CA in both compartments compared to baseline; lateral pCP increased with subsequent paw repositioning. Induction of radio-ulnar incongruity decreased CA and increased mCP medially, decreased pCP laterally, and increased %MedCA and %MedmCP compared to baseline. Both PAUL plates decreased mCP and pCP medially, with no effect laterally. Paw repositioning had no effect. The PAUL procedure had no effect on medial compartment pressure in the congruent elbow. It may ameliorate increased medial compartment pressure in the incongruent elbow. This change does not result from a medial to lateral compartmental shift and deserves further investigation.

Ulna Rotation Osteotomy in Complete Dislocation of the Distal Radioulnar Joint

Background Complete dislocation of the distal radioulnar joint (DRUJ) is a rare injury. Dislocation can present as uni- or multidirectional, acute or chronic, reducible or irreducible. It can occur due to isolated loss of ligamentous restraints or more frequent in Galeazzi - or Essex-Lopresti-type fractures. Case Description A 28-year-old man sustained a distal radius fracture and presented after conservative treatment with blocked supination. Examination revealed a malunion of the distal radius in combination with an irreducible dorsal dislocation of the DRUJ. Corrective osteotomy of the distal radius was performed, the DRUJ was reduced, and the ulnar avulsed triangular fibrocartilage complex (TFCC) refixed with transosseous sutures. Redislocation occurred 8 weeks later. Revision surgery showed a palmar dislocated TFC fixed in a palmar scar formation along the distal interosseous membrane (DIOM). The scar was released and a rotation osteotomy of the distal ulna was performed. At follow-up, the patient was pain-free, had good range of motion, and returned to work and sport activities. Literature Review For reconstruction of chronic complete dislocations of the DRUJ, ligament plasty procedures are described. In case of additional cartilage damage, salvage procedures are recommended. Clinical Relevance We report a procedure in which the rotation of the distal ulna is corrected to restore DRUJ congruity in chronic dislocations. The rotation osteotomy described is useful in gross ligamentous instability following loss of constraint by the TFCC and the DIOM.

Odanacatib increases mineralized callus during fracture healing in a rabbit ulnar osteotomy model

ABSTRACTThe effects of the cathepsin K inhibitor odanacatib (ODN) on fracture healing were monitored for ∼6 and 15 weeks post‐fracture in two separate studies using the unilateral transverse mid‐ulnar osteotomy model in skeletally mature female rabbits. Rabbits were pre‐treated for 3–4 weeks with vehicle (Veh), ODN (2 mg/kg, po, daily), or alendronate (ALN) (0.3 mg/kg, sc, twice‐weekly) prior to osteotomy. In Study 1, the animals were maintained on the same respective treatment for ∼6 weeks. In Study 2, the animals were also continued on the same therapy or switched from Veh to ODN or ODN to Veh for 15 weeks. No treatment‐related impairment of fracture union was seen by qualitative histological assessments in the first study. Cartilage retention was detected in the calluses of ALN‐treated rabbits at week‐6, while calluses in the ODN and Veh groups contained bony tissue with significantly less residual cartilage. ODN treatment also markedly increased the number of cathepsin K‐(+) osteoclasts in the callus, indicating enhanced callus remodeling. From the second study, ex vivo DXA and pQCT confirmed that ODN treatment pre‐ and post‐osteotomy increased callus bone mineral content and bone mineral density (BMD) versus Veh (p < 0.001) and discontinuation of ODN post‐surgery returned callus BMD to Veh. Peak load of ODN‐ or ALN‐treated calluses were comparable to Veh. ODN increased callus yield load (20%, p = 0.056) and stiffness (26%, p < 0.05) versus Veh. These studies demonstrated that ODN increased mineralized callus during the early phase of fracture repair without impairing callus formation or biomechanical integrity at the fracture site. © 2015 The Authors. Journal of Orthopaedic Research published by Wiley Periodicals, Inc. on behalf of the Orthopaedic Research Society. J Orthop Res 34:72–80, 2016.

Ulnar Rotation Osteotomy for Congenital Radial Head Dislocation

To evaluate an ulnar rotation osteotomy for congenital anterior dislocation of the radial head. Nine patients (5 boys and 4 girls aged 6 to 13 years) with congenital anterior dislocation of the radial head were treated with ulnar rotation osteotomy. Magnetic resonance imaging of the elbow showed the proximal radioulnar joint on the anterior-lateral side of the ulna rather than on the lateral side in patients with congenital anterior dislocation of the radial head. On the basis of this finding, we performed an osteotomy on the ulna and laterally rotated the proximal radioulnar joint achieving radial head reduction and restoring the anatomical relationship between the radial head and the capitellum. Clinical and radiographical evaluation of the elbow was performed before surgery and at postoperative follow-up. All patients were followed for 13 to 45 months after surgery. Elbow radiography showed that the radiocapitellar joint was reduced in all patients at the last follow-up visit and that the carrying angle was decreased relative to that in the preoperative condition. Elbow stability and the range of elbow flexion motion were improved at the last follow-up. We did not observe ulnar osteotomy site nonunion or elbow osteoarthritis in these patients. Furthermore, radial head dislocation did not recur. At early follow-up, ulnar rotation osteotomy was a safe and effective method for the treatment of congenital anterior dislocation of the radial head. Therapeutic IV.

Outcomes after surgical treatment of missed Monteggia fractures in children.

Chronic dislocation of the radial head treatment in Monteggia fracture dislocation is still controversial. We present a large series of patients treated in our Institution. The outcome of 22 children treated surgically between 1988 and 2011 for post-traumatic chronic radial head dislocation is reported. There were 12 girls and 10 boys with a mean age at surgery of 7.2 years (4.1-13.6). The mean interval between injury and treatment was 15.7 months (1-128). Nine patients underwent open reduction with removal of interposed tissue and repair (7) or Bell-Tawse reconstruction (2) of the annular ligament. Ten patients underwent osteotomy, gradual lengthening and angulation of the ulna by external fixation. Two patients underwent angular osteotomy of the proximal ulna with open wedge, open reduction in the radial head and reconstruction of the annular ligament. One patient admitted to the hospital 10 years after injury underwent radial head excision at 13.7 years of age. After a mean follow-up of 5.5 years (1-24.3), the radial head stayed reduced in 15 patients and subluxated in 5. In one case, redislocation occurred. All patients but five were pain-free. The elbow performance score (Kim score) was excellent in 14 cases, good in four and fair in four, with a mean score of 91, corresponding to a good result. Complications included a transient posterior interosseus nerve palsy (1), and one non-union of the ulna. Chronic Monteggia lesions must be treated. The clinical outcomes are usually better than the congruency of the radiocapitellar joint.

Neglected Monteggia fracture dislocations in children: a systematic review.

Monteggia fractures are uncommon and frequently missed injuries in children. This article aims to study, in a systematic manner, the surgical management and complications of treatment of chronic radial head dislocations. After screening of relevant abstracts, a total of 28 studies were included in the systematic review. A narrative synthesis of various treatment modalities has been discussed. This article concludes that open reduction should be attempted unless dysmorphism of the radial head restricts it. Open reduction with ulnar osteotomy with or without annular ligament reconstruction is the most commonly performed procedure and is expected to result in reduced pain and elbow deformity.

Ulnaire osteotomie als behandeling van een losse processus anconeus bij een jonge mastino napoletano

Een losse processus anconeus, onderdeel van het elleboogdysplasiecomplex, is een frequent voorkomende orthopedische ontwikkelingsstoornis bij snelgroeiende jonge honden behorend tot grote en chondrodystrofe rassen. Proximale ulnaire osteotomie is een van de mogelijke behandelingsmethoden, op voorwaarde dat het dier nog niet volwassen is. Deze ingreep is gericht op het herstellen van de lengteverhouding tussen radius en ulna, waardoor de opwaartse kracht, die de losse processus anconeus veroorzaakt, opgeheven wordt. Door de osteotomie is tevens een kanteling van het olecranon mogelijk, waardoor de losse processus anconeus alsnog kan fusioneren en het manken verdwijnt. Wanneer een proximale ulnaire osteotomie succesvol uitgevoerd wordt, zonder bijkomende articulaire chirurgie, wordt er minder osteoartrose gevormd en is het resultaat op lange termijn gunstiger. In dit artikel wordt de behandeling door middel van ulnotomie bij een jonge mastino napoletano besproken en worden de resultaten van de behandeling toegelicht.

Treatment of severe radial club hand by distraction using an articulated mini-rail fixator and transfixing pins

IntroductionTreatment of severe radial club hand is difficult. Several authors have emphasized the importance of preliminary soft-tissue distraction before centralization. HypothesisTreatment of severe radial club hand by articulated mini-rail allowing prior soft-tissue distraction improves results. Material and methodsThirteen patients were treated sequentially, with an initial step of distraction and a second step of centralization. The first step consisted in fitting 2 mini-fixators, one in the concavity and the other in the convexity of the deformity. Four transfixing wires through the ulna and metacarpal bone connected the 2 fixators. After this preliminary distraction, the fixator was removed and a centralization wire was introduced percutaneously, with ulnar osteotomy if necessary. Sagittal and coronal correction was measured on the angle between forearm and hand. ResultsMean age at treatment was 37.5months (range, 9–120months). Mean distraction time was 53.2days (26–90days). Ulnar osteotomy was required in 8 cases (61%). There were no major complications requiring interruption of distraction. Sagittal and coronal correction after centralization reduced mean residual forearm/hand angulation to<12°. DiscussionSoft-tissue distraction in the concavity ahead of centralization is essential to good correction, avoiding extensive soft-tissue release and hyperpressure on the distal ulnar growth plate. There have been several studies of distraction; the present technique, associating 2 mini-fixators connected by threaded K-wires, provided sufficient distraction in the concavity of the deformity to allow satisfactory correction in all cases. Subsequent complications (breakage or displacement of the centralization wires) testify to the complexity of long-term management. ConclusionThe present study confirms the interest of a preliminary soft-tissue distraction step in treating severe radial club hand. Level of evidenceIV.

One-stage rotational osteotomy for congenital radioulnar synostosis.

We report the results of a one-stage rotational osteotomy of the proximal third of the ulna and distal third of the radius with segmental bone resection for treating congenital radioulnar synostosis. We retrospectively reviewed 25 patients (28 forearms) treated by operation. Patients were divided into two groups according to the method of internal fixation at the osteotomy sites. In Group 1 the ulnar osteotomy was stabilized with an intramedullary pin and in Group 2 no fixation was used. The average forearm position improved from 47° pronation before surgery, to 27° supination after surgery. There were no statistically significant differences between the two groups in surgical outcomes. One-stage rotational osteotomy of the proximal third of the ulna and distal third of the radius with segmental bone resection is a simple and safe treatment for patients with congenital radioulnar synostosis. Internal fixation at the osteotomy site seems to be unnecessary. Level of evidence: Level 4.

CHRONIC RADIAL HEAD DISLOCATION IN CHILDREN. TREATMENT BY OPEN REDUCTION AND ULNAR OSTEOTOMY

Purpose: To present the results of open reduction and angulating-distraction ulnar osteotomy in children with chronic radial head dislocation. Material and Methods: This is a retrospective review of 4 children (3 girls, one boy) with chronic radial head dislocation treated in our hospital between 2009 and 2012. The average age at the time of surgery was 6.6 (4.2 – 9.1 years).The interval between initial trauma and surgery was from 2 to 25 months. Three of the patients had a plastic deformation of the ulna with a positive “ulnar bow sign” and one was with missed radial head dislocation after an equivalent injury. The surgical strategy in all patients included proximal ulnar osteotomy with angulation and distraction and open reduction of the dislocated radial head without annular ligament reconstruction or pinning. Osteotomy was fixed with a prebent one-third tubular plate and a tricortical bone graft. Results: The mean follow-up was 4 years (range 2.5 - 5.5). Radial head remained reduced and stable in all cases. All ulnar osteotomies healed without any complications. The postoperative range of motion was improved in all of the patients. Functional outcomes assessed by Elbow Performance Score were excellent in three and good in one of the patients. Conclusions:The treatment of an unrecognized radial head dislocation in children continues to pose a therapeutic challenge. The osteotomy of the proximal ulna with both angulation and elongation allows stable radial head reduction without necessity of annular ligament reconstruction in most of the cases.

Shortening of the distal ulna to correct ulnar variance in osteoporotic wrist fractures treated with intra-focal pining.

The aim of this study is to correct the ulnar variance in severe osteoporotic wrist fracture treated with intra-focal pining of the distal radius, with shortening osteotomy of the distal ulna. Thirteen patients, 12 females and one male, 61-83years old, 6-year follow-up, were treated by intra-focal pining (kapandji). When preoperatively the ulnar variance did not return to a normal value comparing to the opposite wrist, a shortening osteotomy of the ulna was performed in one stage, 4cm proximal to the ulnar head. The fractures healed 6-8weeks with stability and normal motion: flexion 70°, extension 60° and pronation/supination 140°. There was no pain upon palpation of distal ulna and no sign of radial impingement. Concerning the ulnar variance and starting with nine neutral values at the normal wrist, we obtained eight negative and one neutral ulnar variance after surgery. In four cases of negative variance at normal wrist, we obtained four negative ulnar variances after surgery and two cases of ulnar non-union. In cases of dorsal comminution in wrist fracture with severe osteoporosis, intra-focal pining technique is able to restore all the radiological parameters, but it could not correct the inversion of ulnar variance relative to shortening of the radius. Avoiding secondary interventions, acute shortening osteotomy of the ulna performed is a procedure which allows restoring the ulnar variance without affecting carpal stability and the mobility.

Chronic anterior monteggia lesions in children: report of 4 cases treated with closed reduction by ulnar osteotomy and external fixation.

Chronic, subacute, and chronic Monteggia fracture dislocations of the elbow are challenging problems. The literature generally recommends complex open reconstructive procedures. We present an alternative, minimally invasive, percutaneous method with external fixation. This was a retrospective review of 4 cases presenting with chronic Monteggia lesions with anterior dislocation of the radial head. Reduction of the radiocapitellar joint was successfully achieved in all patients after ulnar osteotomy and gradual correction using the Ilizarov external fixation. Open reduction or reconstruction of the radio-ulnar-capitellar joint and/or ligament was not undertaken. The patients were between 9 and 11 years of age at the time of injury. The time from injury to treatment was between 3 and 56 months. At follow-up of an average of 3.5 years (range, 2 to 6 y), all patients had full movement of the elbow and normal function of the forearm. Radiographically, all radial heads were well reduced and the ulnar osteotomy showed remodeling. The technique is relatively simple and avoids the risks and technical challenges of open osteotomies, open reduction, and ligament reconstruction. Gradual reduction of the radial head with the aid of an external fixation is a safe and effective method of treatment for chronic Monteggia lesions.

Proximal ulnar osteotomy in the treatment of neglected childhood Monteggia lesion

IntroductionThe aim of our study was to analyze medium and long-term results of proximal ulnar osteotomy with and without ligament injury in neglected Monteggia injury in children. Material and methodsThis retrospective, multicenter study included 28 patients. Clinical criteria concerned the range of motion, pain and MEPI score, and radiologic criteria comprised of Storen line, head-neck ratio, radial neck angle, and signs of osteoarthritic remodeling. ResultsTwenty-eight patients were reviewed, at a mean 6 years’ follow-up (range, 2–34y). Sixteen had proximal ulnar osteotomy without ligament reconstruction, and 12 had associated ligamentoplasty. Both groups showed significant clinical and radiological improvement, with no significant difference. Patients operated within less than 1 year had better clinical and radiographic results. There was no correlation between age at surgery and quality of results. The 5 patients who underwent condyloradial pinning showed early recurrence of dislocation and osteoarthritic remodeling. The three cases of Bado type-3 lesion had early recurrence of dislocation. DiscussionProximal ulnar osteotomy gives good long-term results in Bado type-1 lesions, regardless of age, if performed before 1 year, in the absence of osteoarthritic remodeling. Associated ligamentoplasty does not seem to be useful. Level of evidenceIV (retrospective).

"Sliding angulation osteotomy": preliminary report of a novel technique of treatment for chronic radial head dislocation following missed Monteggia injuries.

Neglected anterior radial head dislocation in type I Monteggia lesions leads to restriction of movement, deformity and instability of the affected elbow. If left untreated this leads to a painful arthritic elbow due to secondary degenerative changes. This is a difficult problem to manage and many intra-articular, extra-articular and combined procedures have been described with variable results. We report a new technique of sliding angulation osteotomy for this condition, which allows both lengthening and angulation of the ulna. A novel technique of sliding angulation osteotomy of the proximal ulna was done to achieve reduction of the radial head. Four patients with persistent anterior radial head dislocation were treated at our institution with this technique. All of them had good clinical and radiological outcomes at final follow-up. Sliding angulation osteotomy is a technically simple procedure, which achieves lengthening and angulation of the ulna simultaneously in the sagittal plane and reduces the radial head.