Ulnar Shortening Osteotomy Research Articles

Nonunion Rates Among Ulnar-Shortening Osteotomy for Ulnar Impaction Syndrome: A Systematic Review

The purpose of this study was to systematically review all available literature reporting nonunion rates of ulnar-shortening osteotomies (USO) used for the treatment of ulnar impaction syndrome (UIS) and to compare those rates among transverse versus oblique cuts for the osteotomy. Electronic databases including PubMed, EMBASE, and Cochrane Central Register of Controlled Trials were searched for studies that evaluated outcomes of both transverse and oblique USO for UIS. Level of evidence was determined by 2 independent reviewers. Studies were screened based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and inclusion and exclusion criteria were applied. A total of 37 studies (1,423 patients) were included in final analysis. The average rate of nonunion and delayed union for each group (transverse and oblique osteotomy) was calculated. The average rate of nonunion among all osteotomies was 4.0%. The average rate of nonunion was 4.16% and 3.86% in transverse osteotomies and oblique osteotomies, respectively. This difference was not statistically significant. The average rate of delayed union, in those studies that reported delayed union, was 5.7%. The average rate of delayed union was 7.41% and 4.1% in transverse osteotomies and oblique osteotomies, respectively. Based on our review of the literature, there is no difference in the rate of nonunion between transverse and oblique osteotomies. Therefore, the decision of which of the 2 surgical techniques should not be based on rate of nonunion. Therapeutic IV.

Triangular Fibrocartilage Complex Repair and Ulna Variance: A Systematic Review.

This purpose of the study was to conduct a systematic review of available literature regarding the association between ulnar variance and outcomes after repair of peripheral traumatic tears of the triangular fibrocartilage complex (TFCC). A systematic literature search of the medical literature about peripheral tears of the TFCC was performed. We selected seven studies comparing clinical outcome and ulnar variance in patients with peripheral TFCC tears. We evaluated quality of the articles using both the Structured Effectiveness Quality Evaluation Scale (SEQES) and Sackett's Level of Evidence (LOE). The outcomes were objective or self-assessment scoring systems for the function of the hand, wrist, or upper extremity. Seven articles were evaluated. The SEQES scores varied from 19 to 28, with a mean of 23. Five studies reported no association between ulnar variance and clinical outcome, and 2 studies reported an association. The studies reporting no association either excluded or did not mention the cases of unstable distal radioulnar joint (DRUJ). This systematic review did not demonstrate strong evidence regarding the association between ulnar variance and outcomes after TFCC repair. As most of the studies did not distinguish between capsular and foveal tears which can affect DRUJ stability, further studies looking at this point are necessary to determine whether ulnar shortening osteotomy has an added value for better outcomes after TFCC repair.

Chronic Longitudinal Instability of the Forearm Treated With a Combination of Ulnar Shortening Osteotomy, Pronator Teres Transfer, and Tightrope Technique.

Restoration of longitudinal stability of the forearm continues to pose a difficult challenge for the hand surgeon, and no technique has demonstrated success above others. Longitudinal stability to the forearm is conferred by 3 structures: the radial head, which acts as a primary stabilizer, the interosseous membrane, more specifically, the central band and, the distal radioulnar ligaments which are part of the triangular fibrocartilage complex. A combination of techniques is described in this article to address chronic longitudinal instability of the forearm: (1) ulnar shortening osteotomy to restore ulnar variance, (2) pronator teres transfer was used to reconstruct the central band of the interosseous membrane, and (3) tightrope augmentation was used to prevent elongation during the healing process.

Diagnosis and treatment of acute Essex-Lopresti injury: focus on terminology and review of literature

BackgroundAcute Essex-Lopresti injury is a rare and disabling condition of longitudinal instability of the forearm. When early diagnosed, patients report better outcomes with higher functional recovery. Aim of this study is to focus on the different lesion patterns causing forearm instability, reviewing literature and the cases treated by the Authors and to propose a new terminology for their identification.MethodsFive patients affected by acute Essex-Lopresti injury have been enrolled for this study. ELI was caused in two patients by bike fall, two cases by road traffic accident and one patient by fall while walking. A literature search was performed using Ovid Medline, Ovid Embase, Scopus and Cochrane Library and the Medical Subject Headings vocabulary. The search was limited to English language literature. 42 articles were evaluated, and finally four papers were considered for the review.ResultsAll patients were operated in acute setting with radial head replacement and different combinations of interosseous membrane reconstruction and distal radio-ulnar joint stabilization. Patients were followed for a mean of 15 months: a consistent improvement of clinical results were observed, reporting a mean MEPS of 92 and a mean MMWS of 90.8. One case complained persistent wrist pain associated to DRUJ discrepancy of 3 mm and underwent ulnar shortening osteotomy nine months after surgery, with good results.DiscussionThe clinical studies present in literature reported similar results, highlighting as patients properly diagnosed and treated in acute setting report better results than patients operated after four weeks. In this study, the definitions of “Acute Engaged” and “Undetected at Imminent Evolution” Essex-Lopresti injury are proposed, in order to underline the necessity to carefully investigate the anatomical and radiological features in order to perform an early and proper surgical treatment.ConclusionsFollowing the observations, the definitions of “Acute Engaged” and “Undetected at Imminent Evolution” injuries are proposed to distinguish between evident cases and more insidious settings, with necessity of carefully investigate the anatomical and radiological features in order to address patients to an early and proper surgical treatment.

Changes in Ulnar Variance after a Triangular Fibrocartilage Complex Tear.

Purpose The relationship between triangular fibrocartilage complex (TFCC) tear and ulnar impaction syndrome has not been fully understood. We hypothesized that a TFCC tear could change the ulnar variance, which may be the cause of ulnar impaction syndrome. Patients and Methods A total of 72 patients who underwent TFCC foveal repair between January 2011 and June 2016 were included in this retrospective study. Among them, 44 patients diagnosed with TFCC foveal tear with distal radioulnar joint instability and no ulnar impaction syndrome underwent TFCC foveal repair only (group A) and 28 patients diagnosed with TFCC foveal tear with ulnar impaction syndrome underwent TFCC foveal repair and ulnar shortening osteotomy simultaneously (group B). We measured their ulnar variances in preoperative, postoperative, and last follow-up plain radiography. We also compared them with the ulnar variance of the contralateral (uninjured) wrist. Postoperative clinical outcomes, such as range of motions of the wrist, the visual analog scale (VAS) for pain, grip strength, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, were assessed. Results Ulnar variance increased after TFCC tears compared with that on the uninjured side in both groups (group A: 0.98 vs. 0.52 mm, p = 0.013; group B: 2.71 vs. 2.13 mm, p = 0.001). Once the TFCC was repaired, ulnar variance decreased (group A: 0.98 to 0.01 mm, p < 0.01; group B: 2.71 to 0.64 mm, p < 0.01). However, it was increased on the last follow-up radiograph (group A: 0.01 to 0.81 mm, p < 0.01; group B: 0.64 to 1.05 mm, p = 0.004). There were no significant improvement of range of motion, except for pronation-supination motion ( p = 0.04). Mean grip strength increased from 56.8 to 70.8% of the contralateral unaffected hand at the last assessment ( p = 0.01). Mean VAS for pain decreased from 7.4 ± 2.5 preoperatively to 2.7 ± 2 postoperatively ( p = 0.001). The QuickDASH score significantly improved from 45 to 9 ( p = 0.001). Conclusion Ulnar variance may be changed after a TFCC tear. In our study, it decreased after TFCC foveal repair. However, as time went on, the ulnar variance increased again, which could be one of the causes of ulnar impaction syndrome and ulnar-sided wrist pain. Level of Evidence This is a therapeutic Level IV study.

Combined ulnar shortening osteotomy and elastic suspended fixation in treatment of ulnar impaction syndrome

To investigate the effectiveness of ulnar shortening osteotomy combined with elastic suspension fixation for ulnar impaction syndrome caused by relatively long ulna. Between October 2015 and August 2016, 3 cases of ulnar impaction syndrome were treated. One patient was male and 2 patients were females. The age was 32, 29, and 59 years, respectively. One patient was dislocation and impaction of distal radioulnar joint for more than 1 year after internal fixation due to ulnar and radial open fractures. Other patients had no trauma and surgery, but long-term manual history. The visual analogue scale (VAS) scores were 7, 5, and 5, respectively. Cooney wrist function scores were rated as poor. Preoperative X-ray measurements of the ulnar variance was 12.7, 9.0, and 8.7 mm, respectively. The ulna was transversely osteotomy and fixed with plate and screws. The distal radioulnar joint was elastic suspension fixed with mini plate. Postoperative X-ray film showed that the matching of the distal radioulnar joint had no significant difference compared with the contralateral side. All the incisions healed by first intention without complication such as neurovascular injury, infection, and dislocation of the distal radioulnar joint. The patients were followed up 27, 17, and 23 months, respectively. At last follow-up, X-ray film showed that all osteotomy segments achieved bony union without internal fixation failure. The VAS scores were 2, 0, and 1, respectively, and the Cooney wrist function scores were rated as excellent. The ulnar shortening osteotomy combined with elastic suspension fixation can correct the ulna variation, avoid the instability of the distal radioulnar joint caused by the extensive dissection of the tissue around the ulnar, and avoid stiffness of the joints caused by rigid fixation. It is an ideal treatment for ulna impaction syndrome.

Prognostic value of clinical and radiological findings for conservative treatment of idiopathic ulnar impaction syndrome

Ulnar impaction syndrome (UIS) is a common source of ulnar-sided wrist pain, yet not all cases of radiographic ulnar impaction are symptomatic. We retrospectively analyze clinical or radiologic factors that affect prognoses of conservative treatment for idiopathic UIS. A total of 114 patients who had been diagnosed with UIS were treated with 6 weeks of short arm orthosis followed by formal physiotherapy for 6 weeks, with lifestyle modification to limit aggravating movements. The response to treatment, including pain numeric rating scale on an ulnar provocation test, grip strength, Disability of the Arm, Shoulder, and Hand score (DASH), was assessed at 24-week follow-up. For the 24-week follow-up, 29 patients (25%) underwent ulnar shortening osteotomy due to persistent symptoms after conservative treatment, and 18 (16%) patients had pain scores of greater than 5, but they had not undergone surgery. After controlling for confounding variables, female gender (odds ratio (OR) 1.39), duration of symptom (OR 1.27), high pain NRS score on provocation test (OR 1.45), and enhanced carpal or distal ulna bone on MRI (OR 1.82) were associated with a higher likelihood of treatment failure. Knowledge of the factors offers physicians insight into predicting prognoses and helps patients set realistic expectations.

Treatment of the ulnar impingement syndrome in the distal radioulnar joint

Ligamentous stability and joint congruity are prerequisites for aphysiological function of the distal radioulnar joint (DRUJ). Impingement of the ulnar head may be caused by acongenital ulna-minus variance or by an iatrogenically excessive ulna shortening osteotomy. This impingement is detected by apositive compression test at the DRUJ. Radius correction osteotomy with shortening and correction of the radial inclination to restore the sigmoid notch may solve the problem by reducing the pressure between both joint partners and by promoting the remodelling of the DRUJ. This technique may restore the distal radioulnar joint and thus prevent the necessity of salvage procedures.

Does Distal Radio-ulnar Joint Configuration Affect Postoperative Functional Results after Ulnar Shortening Osteotomy?

Background:Reverse oblique distal radio-ulnar joint (DRUJ) configuration is assumed to show inferior postoperative results in ulnar-shortening osteotomy due to osteoarthritis, as the joint force pressure in the DRUJ may be increased. An evaluation and comparison of the postoperative functional results with regard to clinical and radiographic signs of arthritis among different DRUJ configurations was carried out retrospectively.Methods:Sixty-two patients after ulnar shortening osteotomy were included. The minimum follow-up was 5 years. Preoperative x-rays were assessed for the DRUJ configuration according to the Tolat classification, whereas postoperative radiographs were evaluated with regard to signs of osteoarthritis using the Kallgren-Lawrence-Score. Functional results were evaluated using the disabilities of the arm, shoulder and hand (DASH) and Mayo Wrist Score and measuring range of motion and grip strength.Results:Significantly better functional results were found in patients with parallel configuration of the DRUJ (Tolat type 1 configuration) with regard to DASH score, grip strength, and supination compared with nonparallel configurations. In the Tolat type 1, configurated DRUJ mean DASH score was 9 compared with 18 in the Tolat type 2 and 3 groups. Apart from supination, no differences were observed in range of motion among groups.Conclusion:Although long-term postoperative range of motion failed to display statistically significant differences between DRUJ configurations except for supination, better results regarding grip strength and DASH scores were seen in a parallel-aligned DRUJ configuration. Although onset of osteoarthritis does not seem to become apparent within the observation period, nonparallel aligned configuration predisposes to inferior results.

Chronic Essex-Lopresti injury: a systematic review of current treatment options.

Essex-Lopresti lesion (ELL) is a severe injury. Most of ELL is recognized in chronic phase representing a therapeutic challenge for orthopaedic surgeons. The aim of this systematic review is to highlight and criticize current concepts in the surgical treatment. The search was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guideline. A comprehensive research of Pubmed database was made using the following Mesh term: ((Essex-Lopresti injury) OR (Essex Lopresti) OR (distal radio ulnar dissociation) OR (distal radio ulnar dislocation) OR (longitudinal forearm instability)). Quality assessment of each article was performed according to Coleman score by two authors. Eight full articles were included to the systematic review. Surgical treatment was differentiated in five categories according to the most common procedure reported in clinical series. The mean Coleman Score was 51.13 ± 9.76. Case series reported in the literature include a limited number of patients with chronic ELL. Currently, salvage procedure devoted to treat a wrong diagnosis and an incorrect treatment is used. Radial head replacement together with ulnar shortening osteotomy and interosseous membrane reconstruction are the most common treatments of choice, but at present, there is not yet a shared scheme of management for patients with chronic ELL. According to current literature, a case-by-case treatment must always be considered. Further investigations, with higher level of evidence, quality of study design, and number of patients, are needed to better assess clinical results and complication of each technique. IV.

Outcomes of Ulnar Shortening for Ulnar Impaction Syndrome Using the 2.7 mm AO Ulna Shortening Osteotomy System.

Ulnar shortening osteotomy is a well-established treatment for ulnar impaction syndrome. Controversy remains regarding the most effective system to achieve efficient bony union, whilst minimising incidence of complications, particularly hardware irritation. We present outcomes at 2 years using the recently released low profile AO osteotomy system. 32 consecutive patients with significant pain from ulnar impaction syndrome (idiopathic or post-traumatic), without degenerative changes of the distal radio-ulnar joint, were included. Time to union, range of motion, grip strength, pain and complications were recorded. Median time to union was 10.14 weeks (9.27-11.01, 95%CI), with one nonunion. Visual Analogue Pain score, grip strength and range of motion improved significantly. No patient experienced hardware irritation. No plate required removal. Positive ulnar variance was reduced by 3.8 mm (mean). The low profile AO system appears effective in achieving bony union whilst minimising incidence of hardware irritation, at a follow up of 2 years.

Outcomes of the Ulnar Shortening Osteotomy Using a Dynamic Compression Plate on the Ulnar Surface of the Ulna.

Background The purpose of this study is to evaluate the results of patients with ulnar impaction syndrome treated with diaphyseal osteotomy using freehand technique and fixation with ulnar osteotomy compression plate placed on the ulnar surface of the ulna. Materials and Methods A retrospective chart review of patients with ulnar impaction syndrome between 2010 and 2014 identified 38 patients. The following clinical data were observed: patient age, sex, range of motion, grip strength, visual analog scale (VAS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, radiological assessment, and complications. The mean follow-up period is 30 months. Eleven patients were excluded from the study. Results Compared with the contralateral side, the 27 patients included in this study attained 93 to 96% of wrist and forearm motion and 81% of the grip strength. The average DASH score was 18 in a mean follow-up period of 30 months. Three patients required plate removal and one case showed nonunion and a further operation was needed. Two patients reported persistent ulnar-sided wrist pain. Conclusion We concluded that placing the ulnar osteotomy plate on the ulnar surface of the ulna is a quicker procedure, with less soft tissue dissection and irritation, and very high union rate. Level of Evidence Level IV.

Arthroscopic Wafer Procedure Versus Ulnar Shortening Osteotomy as a Surgical Treatment for Idiopathic Ulnar Impaction Syndrome

To compare clinical and radiologic outcomes and complication rates of the arthroscopic wafer procedure (AWP) and ulnar shortening osteotomy (USO) for idiopathic ulnar impaction syndrome (UIS). From May 2009 to June 2014, 42 patients who were aged 45years or older with idiopathic UIS underwent either the AWP or USO under the following identical surgical indications: (1) less than 4mm of positive ulnar variance, (2) Palmer classification 2C or 2D lesion of the triangular fibrocartilage complex, (3) stable distal radioulnar joint (DRUJ) and/or lunotriquetral joint, and (4) no evidence of osteoarthritis of the DRUJ or ulnocarpal joint. The patient assignment was not randomized. Were used a visual analog scale for ulnar wrist pain; grip strength; range of motion; the Mayo Wrist Score (MWS); and the Disabilities of the Arm, Shoulder and Hand (DASH) score at 3, 6, 12, and 24months after surgery to compare clinical outcomes. Ulnar variance, cystic changes of the lunate and triquetrum, and DRUJ arthritis on radiographs and operation-related complications were compared. This study evaluated 19 patients after the AWP and 23 patients after USO. At 3months, the AWP produced significantly better outcomes than USO regarding grip strength (79.6% ± 14.3% vs 62.7% ± 12.6%, P< .001), MWS (81.8 ± 7.9 points vs 71.3 ± 14.2 points, P= .005), and DASH score (19.4 ± 8.4 vs 31.5 ± 14.0, P= .001); clinical outcomes were similar at 6, 12, and 24months. The complication rates were 34.8% for USO and 10.5% for the AWP; complications included DRUJ arthritis (n= 4), implant irritation (n= 6), and refracture after implant removal (n= 2) in the USO group and secondary surgery (n= 1) and tendinopathy (n= 1) in the AWP group. The AWP and USO for idiopathic UIS with subtle positive ulnar variance achieved similar clinical and radiologic outcomes at 2years after surgery. However, compared with USO, the AWP showed lower complication rates and better grip strength, MWS values, and DASH scores at 3months after surgery. Level III, comparative trial.

A Dorsal Approach for Ulnar Shortening Osteotomy.

Aim This study aims to evaluate the long-term complications, results, and patient satisfaction rates of a dorsally approached ulnar shortening osteotomy for ulnar impaction syndrome. Methods A retrospective chart review of 20 patients was performed. Primary outcomes of interest were subjective, measured using the Patient-Rated Wrist Evaluation (PRWE) score, Disability of the Arm, Shoulder, and Hand (DASH) score, and the third questionnaire about patient satisfaction, composed by the authors. Secondary outcomes included hardware removal due to irritation and other complications. Results Mean postoperative functional score of PRWE was 28 (standard deviation [SD], 30) and DASH 20 (SD, 26), respectively. Fifteen patients were satisfied with the operation. Removal of hardware was noted in six patients. In one patient plate breakage occurred. Conclusion Similar postoperative functional scores and complications were seen in patients undergoing an ulnar shortening osteotomy with a dorsally placed plate for ulnar impaction syndrome, compared with other plate placement localizations. The incidence of plate removal is also comparable to previously described results. As the dorsally placed plate and freehand technique, are relatively easy, we feel that it has a place in the treatment of ulnar impaction syndrome. Level of Evidence Level IV, retrospective cohort study.

Treatment of Ulnar Impaction Syndrome with and without Central TFC Lesion.

Background Arthroscopic debridement of the triangular fibrocartilage (TFC) is well accepted in patients with ulnar impaction syndrome with central TFC lesions. Treatment remains controversial, however, when there is no such lesion from radiocarpal view. Purpose This study assessed the clinical outcome of arthroscopic central TFC resection and debridement and secondary ulnar shortening in patients with ulnar impaction with central TFC lesion compared with patients without TFC lesion. Patients and Methods Thirty-two consecutive patients with ulnar impaction syndrome were arthroscopically treated, 16 of whom had a central lesion of the TFC that was debrided. In the 16 patients with no lesion from the radiocarpal view, the TFC was centrally resected and debrided to decompress the ulnocarpal joint. Persisting symptoms necessitated ulnar shortening in four patients in each group. Two patients underwent repeat arthroscopic TFC debridement. All patients were examined at 3, 6, and 12 months, and at final follow-up (mean: 1.7 years) following arthroscopy, respectively ulnar shortening or hardware removal. Results In both groups, pain, Krimmer, and DASH scores significantly improved. Improvements of DASH scores were significantly higher in patients without lesion at 12 months and at final follow-up. For other parameters, no significant difference was found between the two groups. Conclusion In both situations, with and without central TFC lesion, resection and debridement sufficiently reduced the ulnar-sided wrist pain and improved function in three out of four patients, and therefore qualified as the first-line treatment of ulnar impaction syndrome as arthroscopy is performed, anyway. Those patients who complained of persisting or recurrent ulnar-sided wrist pain finally benefitted from ulnar shortening osteotomy as the secondary procedure. Level of Evidence Therapeutic III, case-control study.

Biomechanical study on ulnar shortening osteotomy for treatment of distal radius fracture malunion

Objective To investigate the effect on distal radioulnar joint (DRUJ) stability of ulnar shortening osteotomy for treatment of distal radius fracture malunion. Methods The model of distal radius fracture(AO type 23C1.2) malunion with radial shortening was created on 10 fresh adult upper limb cadaver specimens. The distal radius fracture was fixed with volar locking plate, and the oblique step ulnar shortening osteotomy was made. The changes of maximum pronation and supination torques from no internal fixation, Kirschner wires fixation and locking plate fixation for ulnar shorting osteotomy were compared. Results The maximum pronation and supination torques were (1.59±1.03) N•m and (1.85±1.21) N•m in the control model, (1.44±0.93) N•m and (1.63±1.18) N•m in the distal radius fracture model, (1.22±0.83) N•m and (1.20±0.83) N•m in the only ulnar shortening osteotomy model, (1.24± 0.78) N•m and (1.30±0.87) N•m in Kirschner wires fixation model, (1.37±0.85) N•m and (1.71±1.44) N•m in locking plate fixation model. Compared with the only ulnar shortening osteotomy model, there were no differences in the maximum pronation and supination torques of the Kirschner wires fixation model, while there were significant differences in that of the locking plate model fixation. There were significant differences in the maximum pronation torque and no differences in the maximum supination torque between the Kirschner wires and the locking plate fixation models. Conclusion The oblique step ulnar shortening osteotomy, similar to tenon-mortise structure, with no internal fixation or just percutaneous Kirschner wires fixation combined with external immobilization to control wrist rotation, is an effective method for treatment of ulnar-sided wrist pain caused by malunited distal radial fractures. Key words: Radius fractures; Biomechanics; Ulnar shortening osteotomy; Distal radioulnar joint

Metaphyseal Versus Diaphyseal Ulnar Shortening Osteotomy for Treatment of Ulnar Impaction Syndrome: A Comparative Study

To compare the clinical and radiographic outcomes and complication rates of diaphyseal and metaphyseal ulnar shortening osteotomies for the treatment of ulnar abutment syndrome. We performed a retrospective study comparing 35 patients who underwent either a metaphyseal (n= 14) or diaphyseal (n= 21) osteotomy. Radiographic and clinical outcomes were compared. Complication rates including infection, hardware removal, and reoperations were also assessed. There were no differences in patient characteristics, ulnar variance, or pain and functional scores between groups. Metaphyseal osteotomy surgery time was shorter (45.5 vs 71.7 minutes) and resulted in greater ulnar shortening (4.8 vs 3.4 mm) compared with diaphyseal osteotomies. At an average 19.2-month follow-up, metaphyseal osteotomies were associated with greater improvement in pain and Quick-Disabilities of the Arm, Shoulder, and Hand questionnaire scores. The need for implant removal was the same in both groups. There were no complications in either group. Results from this study suggest that metaphyseal osteotomies are a safe and effective alternative to diaphyseal osteotomies for the management of ulnar abutment syndrome. Although improved surgical time and postoperative outcomes are encouraging, further large-scale and properly powered studies with long-term outcomes will help characterize the benefit of one technique over another. Ultimately, the decision between a metaphyseal and diaphyseal osteotomy may be surgeon preference. Therapeutic IV.

Prognostic Factors Affecting Union After Ulnar Shortening Osteotomy in Ulnar Impaction Syndrome: A Retrospective Case-Control Study.

Ulnar shortening osteotomy (USO) is a widely adopted procedure with excellent outcomes. However, delayed union or nonunion has occasionally been observed. The purpose of this retrospective case-control study was to identify variables affecting osseous consolidation after USO in patients with ulnar impaction syndrome. The study included 325 patients who had undergone USO between March 2008 and March 2014. We evaluated the association between union and basic demographic factors as well as preoperative pain (assessed on a visual analog scale [VAS]), range of wrist motion, grip strength, and modified Mayo wrist score. We also assessed the association of union with radiographic variables such as the degree of dorsal subluxation of the ulna, preoperative and postoperative ulnar variance, morphological type of the distal radioulnar joint, gap at the osteotomy site, and presence of newly developed arthritic changes during the follow-up period. Finally, variables associated with operative conditions, such as degeneration of the triangular fibrocartilage complex, use of a parallel double-blade saw, type of plate used for fixation, number of screws, and plate position on the volar or dorsal ulnar surface were investigated. Ulnar union was achieved in 294 patients (group 1), and 31 patients had delayed union or nonunion (group 2). On univariate and multivariate analyses, smoking, low bone mineral density (BMD), a decreased range of motion of the wrist, and use of a double-blade saw were found to be significant factors for an adverse radiographic outcome (nonunion or delayed union). Delayed union or nonunion occurred in about 10% of patients treated with USO. We suggest that it may be preferable to perform USO in nonsmokers, patients with normal bone density, and those without restricted wrist motion. Also, we recommend the use of a single-blade saw when performing the osteotomy. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A study on functional and radiological outcome after corrective osteotomy and volar locked plate fixation for extra-articular malunion of distal radius

Background: Malunion is the most common complication following distal radius fractures occurring approximately 23% of non-surgically treated injuries and approximately 11% of operatively treated fractures. Malunion leads to functional limitation of affected wrist significantly requiring intervention. We report the functional and radiological outcome after corrective osteotomy of malunited distal radius using volar approach and fixation with a volar locked plate. Material and methods: Fifteen malunited distal radius in skeletally matured patients were treated with an osteotomy and iliac crest corticocancellous bone graft. Osteotomy was fixed in corrected position using a distal radius volar locking plate. Outcomes were evaluated using Modified Grahams criteria for acceptable healing, Fernandez scale, Modified Mayo wrist score and DASH questioner. Results: On radiological evaluation radial tilt was in the range of 9 degree dorsal to 20 degree volar. All osteotomies healed within acceptable limit by modified Graham’s radiographic criteria of acceptable healing of distal radius fractures. Functional evaluation by Fernandez scale shows excellent result in 3, good in 7, 5 fair and no poor result. Modified Mayo wrist score assessment shows 4 excellent, 6 good, 5 satisfactory and no poor result. The average score is 78.67 (range 65-90). DASH questioner analysis postoperatively revealed the average score is 15.93 improved from preoperative mean 50.8. One patient required concomitant ulnar shortening osteotomy. Conclusion: Corrective osteotomy and volar locked plate fixation of distal radius for symptomatic malunion gives favourable radiological and functional outcome and should be carried out in patients with high functional demand of the wrist joint.

The influence of cartilage thickness at the sigmoid notch on inclination at the distal radioulnar joint.

The aims of this study were: firstly, to investigate the influence of the thickness of cartilage at the sigmoid notch on the inclination of the distal radioulnar joint (DRUJ), and secondly, to compare the sensitivity and specificity of MRI with plain radiographs for the assessment of the inclination of the articular surface of the DRUJ in the coronal plane. Contemporaneous MRI images and radiographs of 100 wrists from 98 asymptomatic patients (mean age 43 years, (16 to 67); 52 male, 53%) with no history of a fracture involving the wrist or surgery to the wrist, were reviewed. The thickness of the cartilage at the sigmoid notch, inclination of the DRUJ and Tolat Type of each DRUJ were determined. The assessment using MRI scans and cortical bone correlated well with radiographs, with a kappa value of 0.83. The mean difference between the inclination using the cortex and cartilage on MRI scans was 12°, leading to a change of Tolat type of inclination in 66% of wrists. No reverse oblique (Type 3) inclinations were found when using the cartilage to assess inclination. These data revealed that when measuring the inclination of the DRUJ using cartilage, reverse oblique inclinations might not exist. The data suggest that performing an ulna shortening osteotomy might be reasonable even in distal radioulnar joints where the plain radiographic appearance suggests an unfavourable reverse oblique inclination in the coronal plane. We recommend using MRI to validate radiographs in those that appear to be reverse oblique (Tolat Type 3), as the true inclination might be different, thereby removing one possible contraindication to ulnar shortening. Cite this article: Bone Joint J 2017;99-B:369-75.