Ulnar Shortening Research Articles

Interosseous membrane reconstruction with a suture-button construct for treatment of chronic forearm instability

The purpose of this study was to report outcomes of interosseous membrane (IOM) reconstruction with a suture-button construct for treatment of chronic longitudinal forearm instability. We performed a retrospective review with prospective follow-up of patients who underwent ulnar shortening osteotomy and IOM reconstruction with the Mini TightRope device from 2011 through 2014. Bivariate statistical analysis was used for comparison of preoperative and postoperative Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, range of motion, grip strength, and ulnar variance. Complications and patient satisfaction were also recorded. Ten patients (mean age, 45.3 years) satisfied inclusion criteria: 8 treated for post-traumatic sequelae of Essex-Lopresti-type injuries, 1 for forearm instability secondary to previous elbow surgery, and 1 for instability secondary to trauma and multiple elbow surgeries. Surgeries were performed an average of 28.6 months from initial injury. At mean follow-up of 34.6 months after surgery, significant improvement was observed in elbow flexion-extension arc (+23° vs. preoperatively; P = .007), wrist flexion-extension arc (+22°; P = .016), QuickDASH score (-48; P = .000), and ulnar variance (-3.3 mm; P = .006). Three patients required additional surgery: 1 revision ulnar shortening osteotomy for persistent impingement, 1 revision ulnar osteotomy and Mini TightRope removal for lost forearm supination, and 1 fixation of a radial shaft fracture after a fall. IOM reconstruction using a suture-button construct is an effective treatment option for chronic forearm instability.

Suture-Button Reconstruction of the Interosseous Membrane.

Reconstruction of the interosseous membrane (IOM) may play a role in the treatment of acute and chronic longitudinal forearm instability. Several reconstruction techniques have been proposed. Suture-button reconstruction is attractive because it obviates donor site morbidity and is relatively easy to perform. How this method compares to its alternatives, however, is unknown. We review literature describing reconstruction of the forearm axis. We describe how we perform suture-button reconstruction of the IOM, summarize our previously published biomechanical data on the subject, and offer a case report. A suture-button is implanted so as to approximate the course of the interosseous ligament. This may be accomplished percutaneously, or when grafting is desired, through an open approach. Data informing the choice of one reconstruction technique over another consist mostly of biomechanical studies and a small number of case reports. Suture-button reconstruction of the IOM may encourage anatomic healing of acute forearm axis injuries especially as an adjunct to radial head replacement or repair. Chronic injuries may benefit from a combination suture-button graft construct and ulnar shortening osteotomy.

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.

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.

Radiographic Criteria for Undergoing an Ulnar Shortening Osteotomy in Madelung Deformity: A Long-term Experience From a Single Institution.

There are no established guidelines on the age or the severity of deformity for which an ulna shortening osteotomy or ulna epiphysiodesis should be performed in children and adolescents with Madelung deformity. The purpose of this study was to identify radiographic criteria associated with the eventual performance for an ulna shortening procedure in this patient population. We retrospectively identified 41 wrists in 31 Madelung patients (mean±SD age 13.8±3.2 y) subjected to surgical correction of their deformity between 1999 and 2013. We assessed established radiographic criteria (ulnar tilt, lunate subsidence, palmar carpal displacement, ulnar variance) at preoperative and postoperative visits. Univariate and multivariate analyses were carried out to determine which radiographic criteria were associated with the performance of an "ulnar shortening procedure" at the first (index) surgical procedure. Eleven wrists were subjected to an ulna shortening osteotomy at the index and 5 at subsequent procedures; 10 cases received an ulnar epiphysiodesis (mean age 13.4±1.5 y). Ulnar shortening at the index procedure was associated with significantly higher preoperative lunate subsidence, ulnar variance, and palmar carpal displacement. Ulnar variance of >5 mm and lunate subsidence >4 mm resulted in a respective 67% and a 53% likelihood of undergoing ulnar shortening osteotomy; palmar carpal displacement over 22 mm resulted in a 50% likelihood for ulnar shortening. Patients who required a subsequent procedure (n=8) showed a significant increase in palmar displacement between surgeries. None of the 10 cases with a primary ulnar epiphysiodesis received a subsequent ulnar shortening; none of those undergoing late ulnar shortenings had an ulna epiphysiodesis at their index procedure (at 10.3±4.3 y). Lunate subsidence, ulnar variance, and palmar carpal displacement were significant radiographic criteria for undergoing an ulnar shortening osteotomy at our institution. A shortening osteotomy may be prevented by early ulna epiphysiodesis in skeletally immature children older than 10 years of age. Therapeutic level IV-case series.

Gradual ulnar lengthening in children with multiple exostoses and radial head dislocation: results at skeletal maturity.

PurposeDeformities of the forearm and shortening of the ulna occur in 30 % of patients with hereditary multiple exostoses (HME), leading to radial head dislocation and loss of movement. Several surgical techniques have been described for treatment, and the aim of our study was to present clinical and radiographic results at skeletal maturity in 15 children that underwent the surgical procedure of ulnar lengthening with external fixators.MethodsWe evaluated 15 patients with ulnar shortening and radial head dislocation that underwent external fixation procedures. Radiographic assessment included measurement of radial articular angle, carpal slip, and ulnar shortening. Clinical evaluation included range of motion, MAYO Elbow Score, assessment function of the extremity as described by Stanton, the visual analog scale (VAS) for pain, and SF-12 to evaluate quality of life.ResultsThe average follow-up period was 77 months and took place when each patient had reached skeletal maturity. MAYO Elbow Score improved from 34.7 to 93.3 points, while the average preoperative functional assessment criteria score was 1.6 points and improved to 4.4. The preoperative average VAS ranged from 8.2 to 2.3, while the SF-12 in its physical (PCS) and mental (MCS) components resulted, respectively, as 53.3 and 54.2. Pronation and supination improved from a preoperative average value of 35.6° and 51.3° to 70° and 80.6°, respectively, at the most recent follow-up visit. Flexion and extension ranged, respectively, from 143° and 2° to 146.7° and 3°. Ulnar shortening improved from 24 mm preoperative to 3 mm, and radial articular angle varied from 37.7° preoperative to 26° at the last follow-up. Only one complication occurred in our group, and one patient completely healed from a case of nonunion of the ulna.ConclusionsUlnar lengthening is a safe and reliable procedure for the treatment of HME that provides good to excellent results and reduces radial head dislocation.

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.

Ulnocarpal Impingement and Triangular Fibrocartilage Complex Tears

Ulnocarpal impingement syndrome is a common reason for ulnar-sided wrist pain in athletes. Clinical history, imaging, and physical examination are important when diagnosing and formulating a management plan. Gymnasts and baseball and racket playing athletes are at higher risk for ulnocarpal (UC) impingement because of repetitive wrist pronation and gripping. Overloading of the UC joint can progress to ulnar head chondromalacia, triangular fibrocartilage complex tears, and lunotriquetral ligament damage. Treatment options for UC impingement range from rest and splinting to operative intervention. Splints that limit wrist pronation and supination prevent the ulna from being driven distally into the lunate. Ulnar shortening osteotomy remains the gold standard for UC joint unloading, but other interventions including arthroscopic debridement with the ulnar wafer procedure can be effective. Recovery time and complication rates vary between each operative procedure and should be taken into consideration when managing athletes.

Successful bone healing of nonunion after ulnar shortening osteotomy treated with teriparatide: a case report

Successful bone healing of nonunion after ulnar shortening osteotomy treated with teriparatide: a case report

Simultaneous Radial Lengthening and Ulnar Shortening for a Delayed Presentation of Radius Distal Physeal Arrest: A Case Report

Simultaneous Radial Lengthening and Ulnar Shortening for a Delayed Presentation of Radius Distal Physeal Arrest: A Case Report

Variables Prognostic for Delayed Union and Nonunion Following Ulnar Shortening Fixed With a Dedicated Osteotomy Plate

To examine potential risk factors for the development of delayed or nonunion following elective ulnar shortening osteotomy using a dedicated osteotomy plating system. We performed a retrospective review of all patients who underwent elective ulnar shortening using the TriMed single osteotomy dynamic compression plating system by 1 of 2 fellowship-trained hand surgeons over a 5-year period. Demographic data and medical, surgical, and social histories were reviewed. Time to bony union was determined radiographically by a blinded reviewer. Bivariate statistical analysis was performed to examine the effect of explanatory variables on the time to union and the incidence of delayed or nonunion. Those variables associated with the development of delayed or nonunion were used in a multivariate logistic regression model. Complications, including the need for additional surgery, were also recorded. Seventy-two ulnar shortening osteotomy procedures were performed in 69 patients. Delayed union, defined as ≥ 6 months to union, occurred in 8 of 72 cases (11%). Of 72 surgeries, 4 (6%) resulted in nonunions, all of which required additional surgery. Hardware removal was performed in 13 of 72 (18%) of the cases. Time to union was significantly increased in smokers (6 ± 3 months) versus nonsmokers (3 ± 1 months). On multivariable analysis, diabetics and active smokers demonstrated a significantly higher risk of developing delayed union or nonunion. Patient age, sex, body mass index, thyroid disease, worker's compensation status, alcohol use, and amount smoked daily did not have an effect on the time to union or the incidence of delayed or nonunion. Despite the use of an osteotomy-specific plating system, smokers and diabetics were at significantly higher risk for both delayed union and nonunion following elective ulnar shortening osteotomy. Other known risk factors for suboptimal bony healing were not found to have a deleterious effect.

Treatment of Madelung's deformity

Treatment of Madelung's deformity is still controversial. We reviewed retrospectively 19patients with Madelung's deformity (two bilateral, 21cases) who underwent surgery to the radius and ulna to improve range of motion, decrease pain and improve appearance of the wrist. Nineteen patients underwent 21distal radial osteotomy procedures using three different techniques: subtraction, addition or dome osteotomy. Ulnar shortening and redirection of the distal ulna was performed in 12cases; a long oblique osteotomy was used in 10 of these cases. The Sauvé-Kapandji technique was performed in five cases, an ulnar distal epiphysiodesis in two cases and a combination of osteotomy and epiphysiodesis in one case. The aim was to reduce the distal radial slope and to restore the orientation and congruity of the distal radio-ulnar joint and to improve its function. Pain was reduced as a result of the procedure: more than 75% of the cases had no or intermittent pain at the review. Pronation improved from 63° to 68° (P=0.467, not significant) and supination improved from 48° to 72° on average (P=0.034, significant). Grip strength increased from 11 to 18kgf (P=0.013, significant). Madelung's deformity is not always a benign condition and it responds well to corrective osteotomies.

Stabilizing Effect of Ulnar Shortening Procedure for DRUJ Instability

Ulnar shortening is widely indicated for ulnocarpal abutment syndrome with positive-variance wrist. It also stabilizes the distal radioulnar joint (DRUJ) because of tightening effect on the triangular fibrocartilage complex (TFCC), as long as either the dorsal or palmar portion of the radioulnar ligament (RUL) is attached to the ulnar fovea. In clinical practice, it is very important to check the condition of the RUL through DRUJ arthroscopy, when the ulnar shortening was indicated for DRUJ instability cases. We retrospectively analyzed our case series.

Commentary for “Distal Radioulnar Joint Reaction Force Following Ulnar Shortening: Diaphyseal Osteotomy Versus Wafer Resection”

Commentary for “Distal Radioulnar Joint Reaction Force Following Ulnar Shortening: Diaphyseal Osteotomy Versus Wafer Resection”

Distal Radioulnar Joint Reaction Force Following Ulnar Shortening: Diaphyseal Osteotomy Versus Wafer Resection

To compare how ulnar diaphyseal shortening and wafer resection affect distal radioulnar joint (DRUJ) joint reaction force (JRF) using a nondestructive method of measurement. Our hypothesis was that ulnar shortening osteotomy would increase DRUJ JRF more than wafer resection. Eight fresh-frozen human cadaveric upper limbs were obtained. Under fluoroscopic guidance, a threaded pin was inserted into the lateral radius orthogonal to the DRUJ and a second pin was placed in the medial ulna coaxial to the radial pin. Each limb was mounted onto a mechanical tensile testing machine and a distracting force was applied across the DRUJ while force and displacement were simultaneously measured. Data sets were entered into a computer and a polynomial was generated and solved to determine the JRF. This process was repeated after ulnar diaphyseal osteotomy, ulnar re-lengthening, and ulnar wafer resection. The JRF was compared among the 4 conditions. Average baseline DRUJ JRF for the 8 arms increased significantly after diaphyseal ulnar shortening osteotomy (7.2 vs 10.3 N). Average JRF after re-lengthening the ulna and wafer resection was 6.9 and 6.7 N, respectively. There were no differences in JRF among baseline, re-lengthened, and wafer resection conditions. Distal radioulnar joint JRF increased significantly after ulnar diaphyseal shortening osteotomy and did not increase after ulnar wafer resection. Diaphyseal ulnar shortening osteotomy increases DRUJ JRF, which may lead to DRUJ arthrosis.

Hardware Location and Clinical Outcome in Ulna Shortening Osteotomy.

Background:The purpose of this study was to investigate the influence of plate location during ulna shortening osteotomy on the incidence of hardware irritation and clinical outcome.Methods:Forty patients (17 women, 23 men; mean age, 47 years) who underwent a shortening osteotomy of the ulna due to idiopathic ulna impaction syndrome were examined after a mean of 36 months. All complications and secondary procedures were extracted from the patients’ records.Results:The rate of hardware removal was higher in patients who had a dorsal placement of the plate in comparison with ulnar or palmar placements, although this difference was not statistically significant. Apart from hardware irritation, there were 4 nonunions, 1 secondary osteoarthritis of the distal radioulnar joint, and 1 case of chronic irritation of the dorsal branch of the ulnar nerve, which required secondary surgery. The incidence of secondary surgery other than hardware removal was not significantly related to the original location of the plate.Conclusions:Secondary surgery after ulnar shortening osteotomy is common. However, we found no difference in clinical outcomes based on plate location.

Freehand technique with the predrilled hole method for ulnar-shortening osteotomy

BackgroundUlnar shortening is a common and useful method for treating ulnar wrist pain from many causes. Many devices used to perform osteotomy have been introduced in the literature; however, the devices are not universally available. The standard freehand technique is still commonly used in clinical practice; however, it is associated with several complications and is time-consuming. We present a freehand technique for ulnar-shortening osteotomy using a predrilled hole method. MethodsFrom 2011 to 2013, we performed the predrilled hole method for ulnar shortening in 18 cases using the six-hole limited-contact dynamic compression plate (LC-DCP) and in two cases using the Acumed six-hole Locking Midshaft Ulna Plate. ResultsAll patients had uneventful union, and the average operative time was 39.7 minutes (range, 32–50 minutes). The average follow-up period was 21 months (range, 12–30 months). There were no complications except in three patients in the LC-DCP group who complained of implant irritation. Good functional outcomes were achieved with this method. ConclusionOur technique is easy and quick to use and can minimize soft-tissue manipulation. The union rate is high and complications are few.

Buying Time: Long-term Results of Wrist Denervation and Need for Revision Surgery: Level 4 Evidence

Buying Time: Long-term Results of Wrist Denervation and Need for Revision Surgery: Level 4 Evidence

Ulnar Abutment Syndrome

With regard to the published article “arthroscopic curettage of intraosseous ganglions of lunate bone” in the last journal edition, it is time to review ulnar abutment syndrome with similar clinical and radiologic findings (1). The main cause of this syndrome is the overload of carpal bones, especially lunate bone related to positive ulnar variance. In normal wrist, 20% of the load is transmitted to ulna whereas 2 mm positive ulnar variance increases this load up to 40%. This problem may even happen in normal wrists because of ulnar variance changes during forearm rotation (2). Other predisposing factors are radial shortening after healed distal radius fractures, scapholunate dissociation, lunatotriquetral dissociation and triangular fibrocartilage complex (TFCC) tears. Most of these patients have pain in ulnar side of wrist associated with dorsoulnar wrist tenderness and positive Nakamura's ulnar stress test (ulnar side wrist pain during flexion and extension of ulnar deviated and pronated and axially loaded wrist). Differential diagnoses are lunate ganglion cysts, vascular grooves and Kienbock’s disease. Routine X-ray and MRI are useful for diagnosis. Radiologic findings are positive ulnar variance associated with lunate sclerosis and sometimes lunate cysts. Pronated grip view may better define ulnar impactions. Diagnostic MRI findings are TFCC degenerative tears and lunate chondromalacia. First line of treatment is nonoperative, including decreasing wrist load and using pain killers. In the absence of good response, operative treatment may be indicated. The most prevalent surgical treatment is ulnar shortening osteotomy to unload lunate bone (3). Alternative option is wafer distal ulna resection (removal of 2 4 mm of distal ulna below TFCC). In Palmers types 2a through 2D, (4) salvage procedures are distal ulna resection in low demand patients (Darrach procedure), Sauve-Kapandji procedure in manual laborers, distal ulnar hemi-resection arthroplasty, and finally ulnar head replacement.

The Clinical Outcome of Anatomical Reattachment of the TFCC to the Ulnar Fovea using an ECU Half-Slip and an Interference Screw.

We developed an original reattachment technique using a half-slip of the extensor carpi ulnaris (ECU) tendon with a very small titanium interference screw for chronic foveal avulsion of the TFCC. The clinical outcome of 66 wrists with foveal detachment of the TFCC treated by this procedure was examined.A distally based ECU half-slip was harvested, inserted into the TFCC, sutured to the remnant of the TFCC, and pulled out through a 2.5-mm bone tunnel at the centre of the fovea. The ECU half-slip was subsequently anchored to the ulnar fovea with a small titanium interference screw. We evaluated 66 wrists of 65 patients with a minimum follow-up of 1 year. Ulnar variance was neutral in 47 wrists, negative in 5 and positive in 14 wrists. Causes of injury were falls in 34 patients, traffic accidents in 12, sports activities in 9, labour in 2 and unknown in 8 patients. In the positive variance wrists, ulnar shortening was performed before the reattachment. The clinical outcome was evaluated using our original DRUJ evaluating system.Preoperatively, severe wrist pain was reported in 50 wrists and moderate pain in 16 wrists. Severe no-endpoint DRUJ instability was noted in 65 wrists, while 1 wrist demonstrated moderate DRUJ instability. Only 2 wrists had supination loss by 20 degrees. At the final follow-up, no pain was felt in 55 wrists, mild pain in 3 wrists, and 8 patients had moderate pain. One wrist exhibited a 30-degree loss of supination. The DRUJ was stable in 55 wrists, mildly unstable in 3, moderately unstable in 4 and severely unstable in 4 wrists. There were 50 excellent, 9 good, 3 fair and 4 poor results.The technique of anatomical reattachment of the TFCC to the ulnar fovea using an ECU half-slip tendon is effective for chronic foveal avulsion of the TFCC with severe DRUJ instability.