Ulnar Shortening Research Articles

Reconstructing the Interosseous Membrane

Reconstruction of the interosseous membrane is an emerging procedure designed to help restore anatomic and biomechanical relationships within the forearm after a longitudinal instability injury. The indication for this reconstruction is proven acute or chronic longitudinal instability of the forearm. This technique uses a synthetic braided graft tied over endobuttons at radial and ulnar tunnels. It can also be combined with other procedures such as radial head replacement, wafer procedures, and even ulnar shortening osteotomies for comprehensive management of the condition. Early results indicate that this reconstruction can produce clinical improvement in some patients. Further follow-up is required to determine the long-term durability of the construct, but early results are encouraging in a complex patient population.

A comparison of diaphyseal and metaphyseal techniques of ulna shortening

The aim of this retrospective study was to compare two techniques of ulna shortening for ulnocarpal abutment. The technique performed initially was diaphyseal osteotomy. Subsequently, a metaphyseal osteotomy was performed to avoid the drawbacks related to the plate. The study group consisted of 29 patients: 13 with diaphyseal and 16 with metaphyseal osteotomies. The pre-operative diagnosis was ulnocarpal abutment in all cases. The results were graded according to the scoring system of Chun and Palmer and patients' self-assessment. Both rankings were related to indications, age, gender, occupation, and surgery. Final follow-up occurred at a median of 54 (range 15-144) months after surgery. There was no delayed union or non-union, necrosis of the ulnar head, or infection. Pain relief was the main benefit. Both techniques gave similar outcomes for pain relief, satisfaction, and objective results. The shortening was significantly greater in the metaphyseal group without any apparent consequence on function or pain. No screw removal was needed after metaphyseal osteotomy; in contrast, plate removal was required in all patients. We conclude that both techniques are valuable alternatives for treating ulnocarpal abutment.

Ulnar Shortening for Adolescent Ulnar Impaction Syndrome: Radiological and Clinical Outcomes

To determine the amount of shortening needed in an ulna to achieve final neutral ulnar variance in adolescents with ulnar impaction syndrome. Radiological and clinical outcomes were evaluated after ulnar shortening and after growth had stopped. From February 2006 to February 2009, we prospectively followed 16 consecutive patients treated with a shortening osteotomy for positive ulnar variance. The study group included 10 boys and 6 girls with an average age of 16.1 years. The closed medial half-side of the physis of the distal radius was used to measure the variance as a reference for the ulna. Based on the radius without any growth potential, the amount of shortening was determined for the ulna with potential for further growth. The preoperative, postoperative, and final ulnar variances were evaluated. The clinical results were compared before surgery and at the time of growth termination. Preoperative ulnar variance was 3.4 mm ± 0.6 mm and the amount to be shortened was 6.1 mm ± 1 mm. The final ulnar variance was 0.2 mm ± 0.3 mm. The mean visual analog scale pain score improved from 6.6 ± 1.0 before surgery to 2.2 ± 0.5 after surgery. The mean range of forearm rotation increased from 132° ± 11° before surgery to 170° ± 16° at final follow-up. In addition, grip strength was 15.3 kg ± 7.6 kg (71% of grip strength on the unaffected side) before surgery and 19.8 kg ± 4.9 kg (90% of grip strength on the unaffected side) at final follow-up. The modified Mayo Wrist Score was 85 ± 8 at the final follow-up. No cases of complications or treatment failure occurred. Ulnar shortening was considered a useful procedure for adolescents with ulnar impaction syndrome, particularly if the measurement for the shortening amount was determined using the physis of the distal radius and ulna.

Clinical, Radiographic, and Arthroscopic Outcomes After Ulnar Shortening Osteotomy: A Long-Term Follow-Up Study

Previous studies have investigated the long-term outcomes of ulnar shortening osteotomy (USO) in the treatment of ulnocarpal abutment syndrome (UCA), but none have used arthroscopic assessments. The purpose of this study was to investigate the long-term clinical outcomes of USO with patient-based, arthroscopic, and radiographic assessments. We retrospectively reviewed 30 patients with UCA after a minimum follow-up of 5 years, with arthroscopic evaluations at the time of both USO and plate removal. We confirmed the initial diagnosis of UCA by radiography and arthroscopy. Mean age at the time of index surgery was 37 years. Mean duration of follow-up was 11 years (range, 5-19 y). We obtained Disabilities of the Arm, Shoulder, and Hand and Hand20 self-assessments postoperatively for all patients. Bony spur formation was evaluated postoperatively from plain radiographs. We detected triangular fibrocartilage complex (TFCC) disc tear in 13 wrists arthroscopically at the time of USO. Of these, 10 showed no evidence of TFCC disc tear at second-look arthroscopy. The remaining 17 cases showed no TFCC disc tear at either first- or second-look arthroscopy. Follow-up radiography revealed that bony spurs at the distal radioulnar joint had progressed in 13 wrists. Disabilities of the Shoulder, Arm, and Hand and Hand20 scores did not significantly correlate with the presence of bony spurs or TFCC disc tears. Range of motion decreased significantly with age only. Lower grip strength correlated with bony spur and lower radial inclination. Triangular fibrocartilage complex tear, male sex, and advanced age were associated with lower Disabilities of the Shoulder, Arm, and Hand and Hand20 scores. Ulnar shortening osteotomy achieved excellent long-term results in most cases. Most TFCC disc tears identified at the initial surgery had healed by long-term arthroscopic follow-up. We suggest that UCA with a TFCC disc tear is a good indication for USO.

Arthroscopic Repair of Ulnar-Sided Triangular Fibrocartilage Complex (Palmer Type 1B) Tears: A Comparison Between Short- and Midterm Results

To compare short- and midterm functional and subjective outcomes of arthroscopically repaired Palmer 1B tears. At 2 time points, we evaluated 49 patients with Palmer 1B tears who underwent arthroscopic repair. We examined 46 patients (23 males and 23 females) in the short-term at an average of 11 months (range, 6-23 mo) postoperatively. In a second midterm follow-up, we examined 40 patients (20 males and 20 females) an average of 4.8 years (range, 4.2-5.9 y) after repair. Between short- and midterm follow-ups, 6 patients underwent an ulnar-shortening osteotomy to alleviate persistent ulnar-sided symptoms. Objective and subjective evaluation included the determination of range of motion, grip strength, pain, and wrist scores (modified Mayo wrist score and Disabilities of Arm, Shoulder, and Hand score). Compared with short-term repair results, midterm outcomes showed a further improvement in pain, wrist scores, grip strength, and motion. Neither static nor dynamic ulnar variance was correlated to preoperative and postoperative Disabilities of the Arm, Shoulder, and Hand scores, short-term modified Mayo wrist scores, or need for ulnar-shortening osteotomy. Five patients improved only after having received an ulnar shortening osteotomy. After repair of Palmer 1B lesions, patients continued to improve in function and comfort at least into the second year, although some needed to have the ulna shortened to achieve this result.

Long-Term Subjective Satisfaction after Ulna Shortening Osteotomy for Ulnar Impaction Syndrome: Level 4 Evidence

Long-Term Subjective Satisfaction after Ulna Shortening Osteotomy for Ulnar Impaction Syndrome: Level 4 Evidence

Management of forearm deformities with ulnar shortening more than 15 mm caused by hereditary multiple osteochondromas

Treatment for forearm deformities caused by hereditary multiple osteochondromas is still controversial. The purpose of the study was to describe the outcome of treatment with the combined use of ulnar lengthening and excision of osteochondromas. Fourteen patients with hereditary multiple osteochondromas had forearm deformities which belongs to type I Masada deformity. The mean relative ulnar shortening was 19.9 mm (range, 16-23). All patients ranging from 4 to 15 years old had operative treatment. Clinical evaluation involving the assessment of pain, activities of daily living, and range of motion of the wrist and forearm was performed. The radiographic evaluation was relative ulnar shortening (RUS), radial articular angle (RAA), carpal slip (CS), and radial bowing. Besides, we also evaluated the amount of ulnar lengthening, external fixation time, and external fixation index. The mean EFT was 101 days (range, 84-133), and the mean external fixation index was 44.4 days/cm (range, 33.6-51.2). During the mean 43.1 months follow-up, four patients had mild pain and two patients had mild restriction of daily activities. The rotation of forearm and motion of wrist had increased except in Case 3. The RAA, CS, and radial bowing had been improved except in Case 6 and 7. In all patients, relative ulnar shortening had been corrected. According to the functional evaluation criteria recommended by Krimmer, there were ten excellent and four good. The combined use of ulna lengthening and excision of osteochondromas is a proper and effective treatment method to the type I Masada deformity with the relative ulnar shortening more than 15 mm.

Ulnar shortening with the ulna osteotomy locking plate

Ulnar shortening for ulnocarpal unloading using a new device enabling parallel osteotomy, rotation-secured compressive shortening, lag screw placement and hybrid stabilization combined in a solely locking plate construct. Idiopathic ulnar impaction syndrome. Posttraumatic radial shortening without major tilting of the radius in the sagittal or frontal plane, rotation deformity and/or translation of the distal fragment. Advanced arthritis of the distal radioulnar joint (DRUJ), DRUJ typeIII according to Tolat, malunion of the distal radius with major tilting of the radius in the sagittal or frontal plane, rotation deformity and/or translation of the distal fragment. Mounting of the UOL plate system on the palmar surface of the ulna using standard ulnopalmar exposure. Two parallel 45° osteotomies are performed using an osteotomy guide followed by rotation secured shortening and compression. Stabilization is gained by inserting an interfragmentary lag screw perpendicular to the osteotomy site and applying locking and compression screws. Lower arm cast for 4weeks until radiological signs of bone healing become apparent. To limit negative influence of rotational forces during bone healing, patients were instructed to limit forearm rotation up to 30° in pro-/supination. Sixteen ulnar shortening osteotomies were performed in 15patients (6men, 9women, average age 49years) and evaluated retrospectively. In 10cases a trauma-related pathology was the indication for the procedure. The average follow-up time was 53weeks (range 12-93weeks). Bone union was observed at a median of 10weeks (range 6-33weeks). Overall good clinical results could be achieved with an average shortening of 3.7mm (range 2.1-16mm). In this series, there was one nonunion.

Metaphyseal Ulnar Shortening Osteotomy for the Treatment of Ulnocarpal Abutment Syndrome Using Distal Ulna Hook Plate: Case Series

To determine the efficacy of a transverse ulnar-shortening osteotomy at the metaphysis in combination with osteosynthesis using a low-profile, 2.0-mm, locking compression distal ulna plate for the treatment of ulnocarpal abutment syndrome. We enrolled into this prospective case series 6 patients with symptomatic ulnocarpal abutment syndrome without distal radioulnar joint ligamentous instability, who had previously failed conservative treatment. We recorded Quick Disability of Arm, Shoulder, and Hand score; wrist range of motion; and visual analog scale score for pain before and after surgery for statistical comparisons. All parameters improved after the surgery. The Quick Disabilities of the Arm, Shoulder, and Hand improved from a mean of 65 to 17, and the visual analog score improved from a mean of 7 to 2. No hardware removal was required and no complications were reported. Metaphyseal ulnar-shortening osteotomy provided the functional advantages of a midshaft ulnar-shortening osteotomy with the potential for improved bone healing and the reduced risk for complications. This technique was a useful alternative for treatment of ulnocarpal abutment syndrome, especially in patients with more than 2 mm ulnar positive variance. Therapeutic IV.

The Distal Interosseous Membrane: Current Concepts in Wrist Anatomy and Biomechanics

The distal interosseous membrane (DIOM) of the forearm acts as a secondary stabilizer of the distal radioulnar joint (DRUJ) when the dorsal and palmar radioulnar ligaments of the triangular fibrocartilage complex are cut. Recent anatomical studies revealed that thickness of the DIOM varies widely among specimens and the distal oblique bundle (DOB) exists within the DIOM in 40% of specimens. The DOB originates from the distal one-sixth of the ulnar shaft and runs distally to insert on the inferior rim of the sigmoid notch of the radius. The mean thickness of the DIOM without a DOB was 0.4 mm, which was significantly thinner than 1.2 mm with a DOB. Biomechanical studies have shown that the DOB is an isometric stabilizer of the forearm during pronosupination. The presence of a DOB was shown to have a significant impact on DRUJ stability. Innate DRUJ laxity in the neutral forearm position was greater in the group without a DOB than in the group with a DOB. Ulnar shortening with the osteotomy performed proximal to the attachment of the DIOM had a more favorable effect on stability of the DRUJ compared with the effect of distal osteotomy, especially in the presence of a DOB. The longitudinal resistance to ulnar shortening was significantly greater in proximal shortening than in distal shortening. It also suggested that the DIOM is of great importance in the management of concomitant ulnar-side injuries in distal radius fracture.

Modified Ilizarov technique for the treatment of forearm deformities in multiple cartilaginous exostoses: case series and literature review

The aim of this study is to evaluate the results of gradual ulnar correction and lengthening using the modified Ilizarov technique for the treatment of forearm deformities in patients with multiple cartilaginous exostoses. We retrospectively reviewed 23 forearms in 16 patients. Three different types of operative procedures were performed: (1) corrective osteotomy and gradual lengthening of the ulna, (2) corrective osteotomy of the radius, and (3) excision of exostoses. We evaluated the radiographs; range of motion of the wrist, forearm, and elbow; and functional status using a questionnaire before and after operation. During the clinical interview, post-operative functional status was significantly improved than pre-operative functional status, 12 patients stated that they had no difficulty in performing daily activities, 11 patients stated that they had no pain, and 11 patients stated that the post-operative appearance of the operated forearm was satisfactory. At time of final follow-up, the mean range of motion of the wrist in ulnar/radial deviation, forearm pronation/supination was significantly improved. Also, the radiographic parameters including radial articular angle, carpal slip, radial bowing, and ulnar variance were significantly improved at time of final follow-up. In conclusion, we achieved successful clinical and radiological outcomes in our patients with forearm deformities after treatment with the modified Ilizarov method. However, there could be a recurrence of ulnar shortening and deformity during growth periods in skeletally immature patients.

Corrective Radial and Ulnar Osteotomies for Distal Radial Fracture Malunion.

We describe a technique consisting of simultaneous radial closing-wedge and ulnar shortening osteotomy to treat malunion of distal radial fractures. Plan the radial closing-wedge osteotomy to correct the volar tilt angle to 8.5° to 15.5° and the ulnar shortening osteotomy to restore ulnar variance to -2.5 to 0.5 mm. Remove the wedge of bone from the radius and reduce the distal fragment, keeping the dorsal cortex as a hinge. Resect the section of the ulna equivalent to the positive ulnar variance with transverse osteotomies. Hold together the two fragments of the radius with a Kirschner wire and fix the osteotomy site with a volar locking plate. Evaluate residual ulnar positive variance with fluoroscopy and restore the ulnar variance to within a normal range by removing additional bone from the proximal fragment. Use a compression device to close and fix the ulnar osteotomy site. Allow early motion immediately after the operation. We retrospectively evaluated forty-two patients at a minimum of one year after treatment of an extra-articular distal radial malunion with a radial corrective osteotomy. IndicationsContraindicationsPitfalls & Challenges.

Results of ulnar shortening osteotomy with a new plate compression system

The gold standard for treatment of ulnar impaction has become ulnar shortening osteotomy. Previous reports in the literature have shown not only good results with relief of ulnar-sided wrist pain but also significant nonunion rates and painful hardware necessitating further surgery and potentially, metal removal. The purpose of this paper is to review the success rate of ulnar shortening osteotomy utilizing a low profile compression plate designed specifically for ulnar shortening osteotomy. Ninety-three patients with ulnar abutment syndrome underwent ulnar shortening osteotomy with the low profile osteotomy plate. There were 47 males and 46 females. The Acumed's ulnar shortening system was utilized in all cases. The patients were evaluated for pain, range of motion, grip strength, return to work, time to union, and hardware removal. The patients' results were validated using the Mayo Wrist Score. There was a 100% union rate in the 93 patients. There were no nonunions or delayed unions, or any hardware removal. All patients noted an improvement in their ulnar-sided wrist pain. Utilizing the Mayo wrist classification, the average postoperative score was 84.5. The average preoperative Mayo score was 49.4, for an average increase of 35.1 points. The Acumed's low-contact plate designed specifically for ulnar shortening osteotomy demonstrated 100% union rate and no implant removal in our series. This is the largest study to our knowledge of a series of ulnar shortening osteotomies and successful healing without the removal of any implants. Furthermore, the specifically designed ulnar shortening osteotomy plate significantly simplifies the procedure for the surgeon and improves patient outcomes with relief of ulnar-sided wrist pain.

Radiographic Appearance and Patient Outcome After Ulnar Shortening Osteotomy for Idiopathic Ulnar Impaction Syndrome

Radiographic carpal chondromalacia (RCC) was defined as the presence of cortical sclerosis or subchondral changes, such as a lucent defect or cystic changes in a carpal on plain radiographs. The purpose of this study was to investigate the factors associated with the occurrence of RCC in idiopathic ulnar impaction syndrome and to determine the efficacy of ulnar shortening osteotomy on patient outcome and RCC. Thirty-nine patients (42 wrists) with idiopathic ulnar impaction syndrome were treated with either ulnar shortening osteotomy or arthroscopic wafer resection. Patients were divided into 2 groups according to the presence (RCC group; 17 patients, 19 wrists) or absence (non-RCC group: 22 patients, 23 wrists) of RCC on preoperative radiographs. To determine the factors associated with RCC, a comparative analysis of these 2 groups was performed with respect to sex, age, duration of symptoms, positive ulnar variance, pain scores, and Chun and Palmer grading system. The RCC area was measured on serial radiographs taken during follow-up. Progressive changes of RCC area and clinical outcomes were evaluated. Patients in the RCC group were older, exhibited greater positive ulnar variance, and demonstrated a significantly higher mean pain score before surgery. The RCC was found to reverse over the year following ulnar shortening osteotomy and did not recur up to 2 years after surgery. In 3 wrists, RCC had completely disappeared at the last follow-up. All patients showed improved clinical outcomes. The RCC changes correlated with older age, a positive ulnar variance, and preoperative pain severity. The RCC progressively reversed after ulnar shortening osteotomy, and this reversal of radiographic changes correlated with clinical improvements. Therapeutic IV.

Outcome analysis of ulnar shortening osteotomy for ulnar impaction syndrome

Ulnar-sided wrist pain is a common problem in the upper extremity. It affects a broad patient population and can be difficult to treat. Ulnar impaction syndrome (UIS) is major cause of ulnar-sided wrist pain and a number of different operations have been used to correct it, including ulnar shortening osteotomy (USO). To retrospectively review functional outcomes and complication rates of USO for UIS at the Hand and Upper Limb Centre (London, Ontario) over a two-year period. Twenty-eight patients who underwent USO between 2007 and 2009 participated in the present study. Ulnar variance pre- and post-surgery was assessed using standard radiographic examination. Patient-rated outcomes were measured using a visual analogue scale (VAS) for pain and the Disabilities of the Arm, Shoulder and Hand (DASH) survey for functional outcomes. Objective grip strength and range of motion were compared with the contralateral extremity. On average, USO achieved a 3.11 mm reduction in ulnar variance. Nonunion occurred in five patients and required a secondary bone grafting procedure. All USO eventually healed. Overall, pain improved by 47.2% and the mean DASH score after surgery was 37.21. Flexion, extension and supination range of motion decreased by 10° compared with the unaffected side. Eleven patients (39%) elected to undergo a second surgery for hardware removal. Patients receiving compensation from the Workplace Safety and Insurance Board experienced significantly higher residual pain (VSA 5.24 versus 1.97) and disability levels (DASH 60.23 versus 25.70). Smokers also experienced worse outcomes in terms of pain (VSA 4.43 versus 2.36) and disability (DASH 51.06 versus 29.67). In this cohort, smoking was not associated with a higher rate of nonunion. USO is effective in reducing pain in UIS and improves disability, at the price of a small decrease in range of motion. Smokers and people receiving compensation from the Workplace Safety and Insurance Board, however, have significantly worse subjective outcomes (VAS and DASH), but similar objective outcomes (range of motion).

Positive or Negative Ulnar Variance after Ulnar Shortening for Ulnar Impaction Syndrome: A Retrospective Study

BackgroundThe goal of this study was to compare simple radiographic findings and clinical results according to residual ulnar variance following ulnar shortening for ulnar impaction syndrome.MethodsForty-five cases of ulnar impaction syndrome, which were treated with ulnar shortening from 2005 to 2008, were studied retrospectively. Group I included 13 cases with positive residual variance after ulnar shortening and group II included 32 cases with negative variance after shortening. The presence of a lunate cystic lesion both preoperatively and at final follow-up and assessments of wrist function based on the modified Mayo wrist score, the disabilities of the arm, shoulder, and hand (DASH) score, as well as the Chun and Palmer score were evaluated.ResultsA cystic lesion of the lunate was present in 4 cases preoperatively and the size decreased in 2 cases at final follow-up in group I, and in 10 and 5 cases, respectively, in group II. No statistical difference was observed between the groups. The modified Mayo wrist score, DASH score, as well as the Chun and Palmer score improved significantly in both groups. No significant differences were observed between the two groups in terms of the proportion of positive cystic lesions at final follow-up or the functional scores.ConclusionsAfter ulnar shortening, the degree of radiological change in the cystic lunate lesions and clinical improvement did not differ significantly between the groups with unintended residual positive and negative variance after shortening.

Oblique Step Ulnar Shortening Osteotomy for Management of Posttraumatic Ulnar Impaction

We describe an oblique step-cut osteotomy technique for ulnar shortening. The technique requires no special instrumentation. It requires only an eight-hole 3.5-mm low-contact dynamic compression plate for fixation. Sixteen patients with posttraumatic ulnar impaction syndrome were treated. The average patient age was 40 years. The mean followup duration was 8 (range, 3 to 28) months. No nonunions occurred. Two patients required hardware removal for symptomatic hardware. Fourteen of the 16 patients reported persistence of occasional pain with some activities, but only 10 had any pain elicited at the time of examination. One patient required revision of the ulnar shortening procedure for persistence of symptoms. Functional outcomes were comparable with ulnar shortening performed by other methods. However, this technique might offer improved union rates compared with those described in the literature and is applicable to treat ulnar impaction syndrome arising from other causes.

Acute Ulnar Shortening for Delayed Presentation of Distal Radius Growth Arrest in an Adolescent

Distal radius physeal fractures are common in children and adolescents. However, posttraumatic growth arrest is uncommon. The management of posttraumatic growth arrest is dependent on the severity of the deformity and the remaining growth potential of the patient. Various treatment options exist. We present a 17-year-old male with distal radius growth arrest who presented four years after the initial injury. He had a symptomatic 15 mm positive ulnar variance managed with an ulnar shortening osteotomy with the use of the AO mini distractor intraoperatively. To the best of our knowledge, an acute ulnar shortening of 15 mm is the largest reported.

Outcome analysis of ulnar shortening osteotomy for ulnar impaction syndrome

Outcome analysis of ulnar shortening osteotomy for ulnar impaction syndrome

The Stabilizing Effect of the Distal Interosseous Membrane on the Distal Radioulnar Joint in an Ulnar Shortening Procedure: A Biomechanical Study

The Stabilizing Effect of the Distal Interosseous Membrane on the Distal Radioulnar Joint in an Ulnar Shortening Procedure: A Biomechanical Study