Risk Factors for Complications in Ulnar Shortening Osteotomies: A Multicenter Retrospective Review.

PURPOSE: Ulnar shortening osteotomy (USO) is commonly performed to alleviate pathologies causing ulnar-sided wrist pain. Surgical complications include nonunion and hardware removal, with rates up to 18% and 45%, respectively. The primary objective of the study was to report the overall complication rate of USO. The secondary objective was to identify risk factors for complications. METHODS: A retrospective multicenter cohort review was undertaken, including six Canadian cities over a 6-year period (January 2013-December 2018). Chart review was used to collect demographic data, surgical technique, implant used, and postoperative complications. Descriptive statistics of demographics and operative characteristics, including plate positioning, type of osteotomy, plate type, and ulnar variance (mm), were analyzed. Univariate analyses were used to select predictor variables for nonunion and hardware removal. These predictor variables were then entered into an adjusted multivariable logistic regression model. RESULTS: A total of 361 USOs were performed. Mean age was 46 ± 16 years (60.7% men). The overall complication rate was 37.1%, hardware removal rate was 29.6%, and nonunion rate was 9.4%. There was a workers' compensation claim associated with 21.6% of all complications, and it was a risk factor for both hardware removal (odds ratio [OR] = 3.81) and nonunion (OR = 2.88). Neither smoking nor diabetes was associated with complication rates. Seventy percent of plates were placed volarly, 25.5% dorsally, and 3.9% directly ulnar. Osteotomies were oblique in 83.7% of cases and transverse in 15.5%. Adjusted multivariate regression analysis revealed that younger age (OR = 0.98) was a risk factor for hardware removal and male sex (OR = 2.49) was a risk factor for nonunion. A surgical factor associated with hardware removal was direct ulnar plate placement (OR = 9.93). No surgical factors were associated with nonunions. CONCLUSIONS: There are substantial rates of complications with USOs. Direct ulnar plate placement should be avoided. Patients should be thoroughly counseled on the risks of complications prior to proceeding with USO. LEVEL OF EVIDENCE: Therapeutic IV.

Distal Metaphyseal Ulnar Shortening Osteotomy Fixation: A Biomechanical Analysis.

PURPOSE: Ulnar shortening osteotomy can be used to treat ulnar impaction syndrome and other causes of ulnar wrist pain. Distal metaphyseal ulnar shortening osteotomy (DMUSO) is one technique that has been proposed to reduce the complications seen with a diaphyseal USO or a wafer resection. However, to our knowledge, the optimal fixation construct for DMUSO has not been studied. We sought to characterize the biomechanical stiffness and rotational stability of different DMUSO constructs. METHODS: A DMUSO was performed on 40 human cadaveric ulnas using 4 different fixation constructs (10 specimens per group): one 3.0 mm antegrade screw; two 2.2 mm antegrade screws; one 3.0 mm retrograde screw; and two 2.2 mm retrograde screws. Biaxial testing using axial load and cyclical axial torque was performed until failure, defined as 10° of rotation or 2 mm displacement. Specimens were assessed for stiffness at failure. Bone density was assessed using the second metacarpal cortical percentage. RESULTS: Bone density was similar between all 4 testing groups. Of the 4 groups, the 2 antegrade screw group exhibited the highest rotational stiffness of 232 ± 102 Nm/deg. In paired analysis, this was significantly greater than 1 retrograde screw constructs. In multivariable analysis, 2-screw constructs were significantly stiffer than 1 screw and antegrade constructs were significantly stiffer than retrograde. Maximum failure torque did not differ with orientation, but 2 screws failed at significantly higher torques. CONCLUSION: Using 2 screws for DMUSO fixation constructs may provide higher stiffness and maximum failure torque, and antegrade screw constructs may provide more stiffness than retrograde constructs. CLINICAL RELEVANCE: Antegrade screw fixation using 2 screws may provide the strongest construct for DMUSO. Antegrade fixation may be preferred because it avoids violating the distal radioulnar joint capsule and articular surface of the ulna.

Is ulnar shortening osteotomy effective for the treatment of ulnar styloid impaction syndrome compared to ulnar impaction syndrome?

PURPOSE: This study aimed at evaluating the outcomes of ulnar shortening osteotomy (USO) for the treatment of ulnar styloid impaction syndrome (USIS) and to compare them with those of USO for the treatment of ulnar impaction syndrome (UIS). METHODS: We enrolled 144 patients who underwent USO between March 2015 and October 2021. The patients were divided into a UIS group (group I, n = 93) and a USIS group (group II, n = 51). Clinical and radiological parameters, including Disabilities of the Arm, Shoulder, and Hand (DASH) score, ulnar variance, ulnar styloid length, and ulnar styloid process index (USPI), were collected pre-operatively and one year post-operatively, and a comparative analysis was performed. RESULTS: The DASH score showed significant improvement in both groups (p < .001 and p < .001), and there was no significant difference between the two groups one year after surgery (p = .143). The USPI was significantly different between the two groups (p < .001). The ulno-lunate and ulno-triquetrum distances showed significant increases in both groups, with significant differences between the two groups (p = .020, and p < .001, respectively). The incidence of post-operative arthritic changes in the distal radioulnar joint was significantly greater in the UIS group than that in the USIS group (21 vs 3, respectively; p = .017). No remarkable differences were observed in the post-operative evidence of chondromalacia at the last follow-up between the two groups. CONCLUSION: The USO, which was performed as a treatment for USIS showed reliable outcomes compared to the USO for the treatment of UIS. Therefore, USO is a viable option for the treatment of USIS.

Distal radius malunion: outcomes following an ulnar shortening osteotomy.

PURPOSE: Positive ulnar variance following a distal radius malunion can lead to ulnar-sided wrist pain, loss of grip strength, and distal radioulnar joint impingement. The primary aim of this study is to describe upper limb-specific functional outcomes following ulnar shortening osteotomy (USO) for ulnar-sided wrist pain associated with malunion of the distal radius. METHODS: We retrospectively identified 40 adult patients from a single centre over a 9-year period that had undergone an USO for symptomatic malunion of the distal radius. The primary outcome was the patient-rated wrist evaluation (PRWE). Secondary outcomes were the QuickDASH, EQ-5D-5L, complications, and net promoter score (NPS). RESULTS: Outcomes were available for 37 patients (93%). The mean age was 56 years and 25 patients were female (68%). At a mean follow-up of 6 years (range 1-10 years) the median PRWE was 11 (IQR 0-29.5), the median QuickDASH 6.8 (IQR 0-29.5), and the median EQ-5D-5L index was 0.88 (IQR 0.71-1). The NPS was 73. Complications occurred in nine patients (24%) and included non-union (n = 4), early loss of fixation requiring revision surgery (n = 1), superficial wound infection (n = 2), neurological injury (n = 1), and further surgery for symptomatic hardware removal (n = 1). CONCLUSIONS: For patients with a symptomatic distal radius malunion where the predominant deformity is ulnar positive variance, this study has demonstrated that despite 1 in 4 patients experiencing a complication, USO can result in excellent patient reported outcomes with high levels of satisfaction. LEVEL OF EVIDENCE: III (Cohort Study).

Return to Usual Work Following an Ulnar Shortening Osteotomy: A Sample of 111 Patients.

PURPOSE: The primary aim of this study was to analyze the median time until patients performed their usual work following an ulnar shortening osteotomy (USO). The secondary aim was to identify factors influencing the median time until return to their usual work. METHODS: We used a retrospective cohort of patients with ongoing data collection from our institution in the Netherlands. Patients with paid employment who underwent USO were invited to complete a return-to-work questionnaire at 6 weeks, 3 months, 6 months, and 12 months after surgery. The probability of and median time until return to usual work were assessed using an inverted Kaplan-Meier analysis. Factors influencing the return to usual work were evaluated using multivariable Cox proportional hazard regression. RESULTS: In total, 111 patients who underwent USO were included, with a mean age of 46 years. The probability of returning to usual work in the first year was 92%, and the median time was 12 weeks. The type of work was independently associated with a return to work, with median times of 8, 12, and 14 weeks for light, moderate, and heavy physical work, respectively. We did not find differences in return to usual work based on age, sex, duration of complaints until surgery, treatment side, smoking status, the preoperative Patient-Rated Wrist Evaluation score, or whether the osteotomy was performed freehand or with an external cutting device. CONCLUSIONS: Half of the patients that underwent USO fully performed their usual work by 12 weeks following surgery. We found that 92% of the patients performed their usual work within 1 year after surgery. We found a large variation in the time until a return to work based on the type of work. Surgeons can use this data to inform patients on the rehabilitation phase after USO. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Radiographic Determination of the Distal Ulnar Diaphyseal Angle.

PURPOSE: Characterizing the distal ulnar diaphyseal angle (DUDA) may be important for anatomic recreation of the distal ulna during ulnar shortening osteotomy procedures using conventional straight plates. This study characterized the DUDA and determined side-to-side, age, and sex effects on DUDA magnitudes and locations. METHODS: Retrospective analyses of bilateral wrist radiographs were performed on 60 patients. The DUDA was defined as the angle of intersection between a line passing through the center of the distal ulnar metadiaphyseal region, in line with the landmarked long axis of the ulna, on a lateral radiograph. This inflection point was measured from the most distal aspect of the ulnar head and recorded as the DUDA tip-to-apex distance (TAD). Rater reliability was determined using the intraclass correlation coefficient. RESULTS: We found DUDAs in 94% of radiographs. The mean DUDA angle was 5.6° ± 2.6° and the mean TAD was 45.3 ± 9.5 mm. The Pearson correlation coefficients for side-to-side comparisons were 0.47 for the DUDA angle and 0.69 for the TAD. For male and female patients, the mean DUDAs were 5.4° ± 2.3° and 5.9° ± 2.9°, respectively, and the mean TADs were 47.8 ± 9.7 mm and 41.7 ± 7.9 mm, respectively. The DUDA angle and TAD had negligible associations with age (r = -0.15 and -0.08, respectively). At 0.74 (95% CI, 0.58-0.85), interrater reliability was good. At 0.93 (95% CI, 0.88-0.96), intrarater reliability was excellent. CONCLUSIONS: We demonstrated DUDAs, representing valgus deviations from the center axis and anteroposterior views of the ulna. Contralateral lateral wrist radiographs are moderate to strongly reliable in determining a DUDA. Rater reliability was good to excellent. CLINICAL RELEVANCE: Re-creation of the DUDA may benefit procedures such as ulnar shortening osteotomy, fractures, or malunion by contributing to knowledge of distal radioulnar joint biomechanics.

Comparing radial lengthening osteotomy with ulnar shortening osteotomy to treat ulnar impaction syndrome after distal radius fracture malunion.

INTRODUCTION: Distal radius mal-unions often cause radius shortening and ulnar impaction syndrome. The modern treatments of ulnar impaction syndrome following distal radius mal-union are ulnar shortening osteotomy (USO) and distal radius lengthening osteotomy (DRLO). However, there are few studies to compare long-term outcomes of these two treatments. This study compares isolated USO to DRLO for the treatment of ulnar impaction syndrome following distal radius mal-union. MATERIALS AND METHODS: We retrospectively reviewed 68 patients with extra-articular distal radius mal-unions treated by isolated USO in 36 patients and DRLO in 32 patients. Pain visual analog scale (VAS), wrist motion, grip strength, radiographic parameters including sigmoid inclination, DASH score, and perioperative complications were analyzed. Mean follow-up was 62.6 months. RESULTS: The postoperative VAS scores for pain on exertion were less in the DRLO group than the USO group (1.2 vs. 2.8, p = 0.02). The DASH scores were 16.7 and 29.8 in the DRLO and USO groups, respectively (p = 0.02). The reduction of pain and improvement of function showed significantly better in the DRLO group. The mean operative time was shorter in the USO group. Most of the sigmoid inclinations were changed in DRLO. There were two re-operations following USO for painful nonunion and two patients had subsequent DRUJ osteoarthritis at the last follow-up. CONCLUSION: Although both treatments improved range of motion, grip strength, and VAS for pain, DRLO was found in better reduction of pain and improvement of function. USO is a simpler procedure with a shorter operative time but it has an increased potential to cause subsequent osteoarthritis of the DRUJ as its incongruity of DRUJ after USO especially in reverted inclination. DRLO can be a preferred method for treating USWP in relevant distal radial mal-union.

The Combined Procedure of Ulnar Metaphyseal Shortening Osteotomy With Triangular Fibrocartilage Complex Foveal Knotless Repair.

Ulnar impaction syndrome (UIS) and triangular fibrocartilage complex (TFCC) tear are common causes of ulnar-sided wrist pain. As a standard surgical treatment, ulnar-shortening osteotomy (USO) and TFCC repair are used respectively. Patient spectrums of UIS accompanied by distal radioulnar joint instability or traumatic TFCC foveal tear with UIS symptoms exist, and both USO and TFCC repair are necessary for treating some of these patients. However, there have been few reports on the procedure for performing these 2 operations concurrently. We introduce a combined procedure to concurrently perform USO and TFCC repair. We performed a USO in the ulnar metaphysis using a locking plate and open TFCC knotless repair using a suture anchor at the ulnar fovea. In this technique, USO is conducted in the metaphysis, which is favorable to union, using a small plate that is easy to handle, and knotless TFCC repair can be performed simultaneously through a single small incision.

Inevitable nonunion after ulnar shortening osteotomy in patients with ulnar impaction syndrome and breast cancer under bisphosphonate treatment.

BACKGROUND: Nonunion after ulnar shortening osteotomy (USO) was observed at a high rate in patients undergoing long-term bisphosphonate (BP) maintenance treatment after breast cancer surgery. Here, we report the unique features of these nonunions. METHODS: In total, 485 patients who had undergone USO between March 2008 and September 2017 were screened for inclusion based on the following criteria: (1) definitive nonunion after USO; (2) prior history of or ongoing BP therapy after the diagnosis of breast cancer; and (3) no evidence of metastasis in the ulna treated with USO, as determined based on the radiological evaluation. RESULTS: Five patients with histories of breast cancer and subsequent BP treatment were identified; all (100%) of these patients showed definitive nonunion after USO. The mean age was 56.2 years, and all ulnae were on the contralateral side to that of the original breast cancer. Intravenous Ibandronate® and Zolendronate® were administrated to one and four patients, respectively. The mean period of administration was 67.8 months. Three patients exhibited suspicious lesions impending atypical fracture on their femurs, and the other two patients were treated by intramedullary nailing after the occurrence of atypical fractures. Radiological evaluation revealed no evidence of a metastatic lesion, including in the musculoskeletal system, in any patient. Osteosynthesis was performed with cancellous iliac bone graft and mean of 4.3 months after osteosynthesis, union in all cases was achieved. CONCLUSIONS: Problems associated with BP treatment are well known. Even in cases in which the agent is essential for preventing bony metastasis of breast cancer, the normal bony physiology, including bone turnover and healing, is likely to be compromised. In addition to atypical fractures of the femur and ulna, procedures such as USO are likely to be affected by BP. Furthermore, not only a primary iliac bone graft but also other method (oblique osteotomy) should be needed to avoid nonunion during plating in USO. LEVEL OF EVIDENCE: IV, Retrospective case series.

Ulnar shortening osteotomy as a treatment of symptomatic ulnar impaction syndrome after malunited distal radius fractures.

A malunited distal radius fracture can lead to symptomatic ulnar impaction syndrome, which is a common cause for ulnar-sided wrist pain. If conservative treatment fails and symptoms persist after an arthroscopic ulnocarpal debridement, ulnar shortening osteotomy (USO) is the treatment of choice. Since the first USO described by Milch in 1941 after a malunited Colles fracture, many techniques have been described varying in surgical approach, type of osteotomy and osteosynthesis material used. Many studies demonstrated good to very good functional results after USO, reporting, however, a delayed union or non-union rate up to 18%. A modern, low profile, locking plate showed in our short-term study very good functional results and no implant-associated complications, in particular no non-union.

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

PURPOSE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

An In Vitro Study to Determine the Effect of Ulnar Shortening on Distal Forearm Loading During Wrist and Forearm Motion: Implications in the Treatment of Ulnocarpal Impaction.

PURPOSE: To evaluate the effect of ulnar shortening on distal forearm loading following simulated dynamic motion. METHODS: Ulnar shortening was simulated using a custom-built adjustable implant to simulate up to 4 mm of ulnar shortening (-4 mm) in 9 cadaveric extremities. Load cells were placed in the distal ulna and radius to quantify axial loading. Using a wrist and forearm motion simulator, absolute and percentage loads were measured during dynamic flexion, ulnar deviation (UD), flexion dart throw (DT), and pronation. RESULTS: There was a significant decrease in absolute and percentage distal ulnar loads at each interval of ulnar shortening during flexion, UD, DT, and pronation. The distal ulna bore no compressive loads, and in fact, tensile loads were measured in the ulna at 2 mm of ulnar shortening during DT and pronation, at 3 mm during flexion, and at 4 mm during UD. CONCLUSIONS: A progressive decrease in distal ulnar loads with generation of tensile loads was observed with sequential ulnar shortening. CLINICAL RELEVANCE: Ulnar shortening greater than 2 mm can result in tensile loading in the distal ulna. When managing ulnar impaction syndrome, excessive shortening may not be required to provide relief of symptoms.

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

PURPOSE: To compare the clinical and radiographic outcomes and complication rates of diaphyseal and metaphyseal ulnar shortening osteotomies for the treatment of ulnar abutment syndrome. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The Outcomes of Arthroscopic Repair Versus Debridement for Chronic Unstable Triangular Fibrocartilage Complex Tears in Patients Undergoing Ulnar-Shortening Osteotomy.

PURPOSE: The aim of this study was to compare the results of arthroscopic peripheral repair (AR) and arthroscopic debridement (AD) for the treatment of chronic unstable triangular fibrocartilage complex (TFCC) tears in ulnar-positive patients undergoing ulnar-shortening osteotomy (USO). METHODS: A total of 31 patients who underwent arthroscopic treatments combined with USO for unstable TFCC tears and were followed-up at a minimum of 24 months were included in this retrospective cohort study. Fifteen patients were treated with AR, and 16 patients were treated with AD while at the same time undergoing a USO. Outcome measures included wrist range of motion, grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) and Patient-Rated Wrist Evaluation (PRWE) scores, and overall outcomes according to the modified Mayo wrist scoring system. In addition, a stress test to assess distal radioulnar joint (DRUJ) stability was performed before and after surgery to compare the 2 cohorts. RESULTS: Both respective cohorts showed significant improvements in grip strength and subjective scores at the final follow-up. Grip strength, DASH, and PRWE scores were better in the AR group than in the AD group. The recovery rate from DRUJ instability observed during the preoperative examination was superior in the AR group. CONCLUSIONS: Both AD and AR of the TFCC combined with USO are reliable procedures with satisfactory clinical outcomes for unstable TFCC tears in ulnar-positive patients. However, AR of the TFCC is suggested if DRUJ stability is concomitantly compromised. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

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

PURPOSE: To examine potential risk factors for the development of delayed or nonunion following elective ulnar shortening osteotomy using a dedicated osteotomy plating system. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Soft tissue complications of dorsal versus volar plating for ulnar shortening osteotomy.

PURPOSE: To compare the results and complications of fixed-angle dorsal locking plate fixation for ulnar shortening osteotomy (USO) with the conventional technique of volar plating. METHODS: We performed a retrospective review of 32 patients undergoing USO on 34 wrists and compared the outcomes of 16 consecutive cases with dorsal 2.4/2.7-mm fixed-angle plating and 18 consecutive cases with volar 3.5-mm plating. A minimum of 12 months' follow-up was used to assess outcomes. Primary outcomes were painful hardware and removal of symptomatic implants. Secondary outcomes were pain, Patient-Rated Wrist Evaluation, range of motion, time to union, grip strength, and complications. RESULTS: There were no significant differences in Patient-Rated Wrist Evaluation, pain score, range of motion, or time to union. Relative grip strength compared with the contralateral upper extremity in the dorsal group was higher than the volar group. After adjusting for hand dominance, dorsal plating was significantly associated with higher relative grip strength. There were 2 complications in the dorsal group, including one case with painful hardware. This was significantly lower than in the volar group, which had 10 complications including 2 nonunions and 6 cases of hardware-related soft tissue irritation. CONCLUSIONS: Both volar and dorsal plating techniques for USO yielded good functional outcomes. There was a higher incidence of painful hardware requiring removal of implants in the volar group. Based on these findings, we advocate dorsal plate position using a smaller fixed-angle plate for USO in ulnar impaction syndrome. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Functionality after arthroscopic debridement of central triangular fibrocartilage tears with central perforations.

PURPOSE: To investigate functional and subjective outcome parameters after arthroscopic debridement of central articular disc lesions (Palmer type 2C) and to correlate these findings with ulna length. METHODS: Fifty patients (15 men; 35 women; mean age, 47 y) with Palmer type 2C lesions underwent arthroscopic debridement. Nine of these patients (3 men; 6 women; mean static ulnar variance, 2.4 mm; SD, 0.5 mm) later underwent ulnar shortening osteotomy because of persistent pain and had a mean follow-up of 36 months. Mean follow-up was 38 months for patients with debridement only (mean static ulnar variance, 0.5 mm; SD, 1.2 mm). Examination parameters included range of motion, grip and pinch strengths, pain (visual analog scale), and functional outcome scores (Modified Mayo Wrist score [MMWS] and Disabilities of the Arm, Shoulder, and Hand [DASH] questionnaire). RESULTS: Patients who had debridement only reached a DASH questionnaire score of 18 and an MMWS of 89 with significant pain reduction from 7.6 to 2.0 on the visual analog scale. Patients with additional ulnar shortening reached a DASH questionnaire score of 18 and an MMWS of 88, with significant pain reduction from 7.4 to 2.5. Neither surgical treatment compromised grip and pinch strength in comparison with the contralateral side. We identified 1.8 mm or more of positive ulnar variance as an indication for early ulnar shortening in the case of persistent ulnar-sided wrist pain after arthroscopic debridement. CONCLUSIONS: Arthroscopic debridement was a sufficient and reliable treatment option for the majority of patients with Palmer type 2C lesions. Because reliable predictors of the necessity for ulnar shortening are lacking, we recommend arthroscopic debridement as a first-line treatment for all triangular fibrocartilage 2C lesions, and, in the presence of persistent ulnar-sided wrist pain, ulnar shortening osteotomy after an interval of 6 months. Ulnar shortening proved to be sufficient and safe for these patients. Patients with persistent ulnar-sided wrist pain after debridement who had preoperative static positive ulnar variance of 1.8 mm or more may be treated by ulnar shortening earlier in order to spare them prolonged symptoms. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Forearm transplantation osteosynthesis using modified ulnar shortening osteotomy technique.

One of the challenges of forearm-level hand transplantation surgery is the achievement of osseous union of the ulna given the substantial soft tissue dissection, the use of immune modulating medications, and the diaphyseal level of osseous coaptation. Modification of the conventional surgical technique for an elective ulnar shortening osteotomy provides the advantages of precise osteotomy alignment, a large contact surface oblique osteotomy, and lag screw and compression plating technique. A step-by-step description of the developed modification is provided with a case example.

Comparison of compression screw and perpendicular clamp in ulnar shortening osteotomy.

PURPOSE: To biomechanically quantify 2 techniques, compression screw and perpendicular clamp, for generating compression during ulnar shortening osteotomy (USO) in order to promote reliable primary bone healing. METHODS: Fourteen fresh-frozen cadaveric human forearms were randomly assigned to 1 of 2 groups. Group I (n = 7) underwent USO according to the traditional AO plate fixation technique using a screw placed eccentrically in an oblong hole to generate compression at the osteotomy site. Group II (n = 7) underwent USO with a commercially available USO plating system using a clamp placed perpendicular to the osteotomy site to generate compression. Both techniques involved a 2-mm resection osteotomy performed with cutting jigs to minimize variability and an interfragmentary lag screw to augment compression. A digital pressure sensor measured contact area at the osteotomy site and average pressure in the observed contact area; these values were used to calculate force across the osteotomy site. Measurements were obtained after the following steps: reduction of osteotomy, compression screw placement (group 1 only), lag screw placement, and final construct with all clamps removed. RESULTS: Group II demonstrated significantly greater force than group I, and lag screw placement resulted in significantly increased force independent of fixation technique. The effect of the lag screw on force was maintained after clamp removal. Although technique of fixation did not significantly influence contact area, lag screw placement significantly increased contact area independent of fixation method. However, this effect was not maintained after clamp removal. Average pressure in the observed contact area was not significantly influenced by fixation technique or stage of fixation. CONCLUSIONS: Perpendicular clamp compression significantly increased force as compared with traditional compression screw technique, and lag screw placement significantly increased force in both constructs. CLINICAL RELEVANCE: Larger compressive forces across the osteotomy may promote primary bone union and decrease the rates of delayed union or nonunion.

Ulnar impaction syndrome: incidence of lunotriquetral ligament degeneration and outcome of ulnar-shortening osteotomy.

PURPOSE: We hypothesized that most patients with ulnar impaction syndrome have degenerative changes of the proximal lunotriquetral (LT) membrane and that ulnar-shortening osteotomy is an effective procedure in these patients. METHODS: We retrospectively reviewed 50 wrists of 49 patients with idiopathic ulnar impaction syndrome who underwent an arthroscopic evaluation at the time of ulnar-shortening osteotomy, and subsequently at plate removal. Based on the Geissler classification, patients were divided into group A, normal, and group B, grades I to IV. The degree of degeneration of the proximal LT membrane at first-look arthroscopy was compared with that at second-look arthroscopy. RESULTS: After ulnar-shortening osteotomy, both groups improved significantly in wrist range of motion and grip strength. According to the Mayo wrist score, 29, 18, and 3 patients showed excellent, good, and fair results, respectively. Of the 50 wrists, 25 had degenerative changes (group B) in the proximal LT membrane at the time of first-look arthroscopy. Of the 25 wrists in group B, 11 wrists improved based on the Geissler grade, 9 wrists showed no changes, and 2 wrists became worse. Clinically, patients demonstrated improvement after ulnar-shortening osteotomy regardless of the degree of degenerative LT ligament changes. CONCLUSIONS: Degenerative LT membrane changes that were seen in about half of our patients were mostly of a mild nature, and the clinical outcomes of ulnar-shortening osteotomy were acceptable. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.