Ulnar shortening osteotomy for malunited distal radius fractures: results of a 7-year follow-up with special regard to the grade of radial displacement and post-operative ulnar variance

Managing the Extra-Articular Distal Radius Malunion

Distal radius fractures are common injuries. Satisfactory outcomes are typically achieved with appropriate nonoperative or operative treatment. A proportion of these injuries develop symptomatic malunions, which may be treated surgically with distal radius corrective osteotomy. A thorough understanding of the anatomy, biomechanics, radiographic parameters, and indications is needed to provide appropriate treatment. Factors, including surgical approach, osteotomy type, use of bone graft, fixation construct, management of associated tendon and/or nerve conditions, soft tissue contracture releases, and need for ulnar-sided procedures, should be considered. A comprehensive evaluation is necessary to guide understanding for when salvage procedures may be preferred.

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).

Corrective Osteotomy with Volar and Dorsal Fixation for Malunion of Intra-Articular Fracture of the Distal Radius: A Retrospective Study

OBJECTIVES

Although corrective osteotomy with volar or dorsal plate fixation can treat malunion of distal radius fractures, each has its own disadvantages. Little is currently known on whether dorsal fixation combined with volar fixation may further improve recovery. This study aimed to evaluate the clinical value of corrective osteotomy combined with volar and dorsal plate fixation in patients with malunion of intra-articular fractures of the distal radius.

METHODS

Seventeen patients with malunion of intra-articular fractures of the distal radius treated with corrective osteotomy with volar and dorsal plate fixation from 1 January 2016 to 31 November 2018 were retrospectively analyzed. The enrolled patients included seven males and 10 females with an average age of 54.9 years (range: 36-70 years). The radiographic parameters, including the radial length, the radial inclination angle, the ulnar variance, and the volar tilt, as well as clinical outcomes, including wrist and forearm range of motion (ROM), grip strength, the Mayo Modified Wrist Score (MMWS), and the disabilities of the Arm, Shoulder, and Hand (DASH) score, were examined at 3 months and 18 months after operation and compared with the preoperative state. The paired t-test was used for statistical analysis.

RESULTS

After corrective osteotomy combined with volar and dorsal plate fixation, all included patients were followed up for 18 months, and there was no surgical site infection. Patients reported postoperative pain due to the irritation of extensor tendon (two cases) and wrist arthritis (two cases). The radial length increased from 1.34 ± 2.34 mm to 9.25 ± 2.65 mm and 9.03 ± 2.47 mm at 3 months and 18 months postoperatively (t = 8.257, 7.954, all p < 0.05). The radial inclination angle increased from 6.45° ± 0.76° to 19.35° ± 3.43° and 19.03° ± 3.63° at 3 and 18 months (t = 12.517, 12.122, all p < 0.05). The ulnar variance decreased from 5.11 ± 0.23 mm to 1.32 ± 0.31 mm and 1.54 ± 0.62 mm at 3 and 18 months (t = 4.214, 4.895, all p < 0.05). The volar tilt was corrected from 4.47° ± 3.46° to 15.51° ± 2.72° and 14.12° ± 2.41°, respectively (t = 11.247, 10.432, all p < 0.05). Moreover, wrist ROM increased from 42.53° ± 8.99° to 98.70° ± 7.61° and 101.24° ± 7.66° (t = 41.433, 46.627, all p < 0.05), while forearm ROM was increased from 94.82° ± 6.54° to 134.47° ± 5.06° and 137.24° ± 5.52°, respectively (t = 31.507, 32.584, all p < 0.05). Similarly, grip strength, MMWS, and DASH were also remarkably improved. There were no significant differences in the wrist and forearm ROM, grip strength, MMWS, and DASH scores between follow-up at 3 and 18 months (all p > 0.05).

CONCLUSIONS

Corrective osteotomy with volar and dorsal fixation can improve recovery of volar tilt, relieve wrist pain, restore wrist and forearm function, and increase grip strength of patients with malunion of intra-articular fractures of the distal radius.

Ulnar Epiphysiodesis: Success of the Index Procedure

INTRODUCTION

Premature radial physeal closure is a relatively rare occurrence in children. When isolated growth arrest of the radius with continued ulnar growth occurs, the resulting ulnar positive deformity leads to altered wrist mechanics and pain. Timely epiphysiodesis of the distal ulna with and without ulnar shortening osteotomy can address these issues, but continued ulnar overgrowth is a possible complication. We seek to evaluate the success rate of the primary epiphysiodesis of the ulna and associated clinical outcomes.

METHODS

A chart review was conducted at 2 children's hospitals from 2008 to 2019. Patients between the ages of 6 and 18 years old, with premature distal radius physeal closure, with or without positive ulnar variance, and >2 months follow-up were included. We evaluated the following characteristics for each patient: demographics, initial cause of premature radial physeal closure, ulnar variance, additional procedures performed during epiphysiodesis, preoperative and postoperative pain, range of motion, instability. Summary statistics were conducted and expressed as proportions, medians and means. A paired t test evaluated change in ulnar variance for those who had an ulnar shortening osteotomy performed.

RESULTS

Thirty-one wrists among 30 patients were identified, and the median age at the time of surgery was 12.2 years (interquartile range: 3.4). Ulnar shortening osteotomies were performed in 53.1% of cases and distal radius osteotomy in 15.6%. Bone graft was utilized in 25.8% of the epiphysiodesis procedures. There were 2 failures of primary epiphysiodesis indicating an index success rate of 93.7%. The average ulnar variance correction was 3.1 mm (95% confidence interval: 1.9, 4.4). The mean physeal time to closure was 134 days. Preoperative symptoms were resolved for 90.6% cases at final follow-up.

CONCLUSION

Ulnar epiphysiodesis successfully terminates ulnar physeal growth in 93.7% of cases. Preoperative symptoms were completely resolved with a median physeal closure of just over 4 months. Ulnar variance was corrected on average by 4.1 mm when a radial or ulnar shortening osteotomy was performed at the time of epiphysiodesis.

LEVEL OF EVIDENCE

Level IV-case series.

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.

Outcomes of ulna shortening osteotomy: a cohort analysis of 106 patients

Background

Ulna shortening osteotomy (USO) for ulnar impaction syndrome (UIS) aims to improve pain and function by unloading the ulnar carpus. Previous studies often lack validated patient-reported outcomes or have small sample sizes. The primary objective of this study was to investigate patient-reported pain and hand function at 12 months after USO for UIS. Secondary objectives were to investigate the active range of motion, grip strength, complications, and whether outcomes differed based on etiology.

Materials and methods

We report on 106 patients with UIS who received USO between 2012 and 2019. In 44 of these patients, USO was performed secondary to distal radius fracture. Pain and function were measured with the Patient Rated Wrist/Hand Evaluation (PRWHE) before surgery and at 3 and 12 months after surgery. Active range of motion and grip strength were measured before surgery and at 3 and 12 months after surgery. Complications were scored using the International Consortium for Health Outcome Measurement Complications in Hand and Wrist conditions (ICHAW) tool.

Results

The PRWHE total score improved from a mean of 64 (SD = 18) before surgery to 40 (22) at 3 months and 32 (23) at 12 months after surgery (P  < 0.001; effect size Cohen’s d = −1.4). There was no difference in the improvement in PRWHE total score (P = 0.99) based on etiology. Also, no clinically relevant changes in the active range of motion were measured. Independent of etiology, mean grip strength improved from 24 (11) before surgery to 30 (12) at 12 months (P  = 0.001). Sixty-four percent of patients experienced at least one complication, ranging from minor to severe. Of the 80 complications in total, 50 patients (47%) had complaints of hardware irritation, of which 34 (32%) had their hardware removed. Six patients (6%) needed refixation because of nonunion.

Conclusion

We found beneficial outcomes in patients with UIS that underwent USO, although there was a large variance in the outcome and a relatively high number of complications (which includes plate removals). Results of this study may be used in preoperative counseling and shared decision-making when considering USO.

Level of evidence

Therapeutic III.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10195-021-00621-8.

Temporary epiphysiodesis in adolescent patients with ulnocarpal impaction syndrome: a preliminary case series of seven wrists

Adolescents with ulnar positive variance can develop ulnocarpal symptoms due to ulnocarpal impaction syndrome. Common treatment methods are conservative therapy, distal ulna epiphysiodesis or eventually ulnar shortening osteotomy. The aim of this preliminary case series was to investigate a recently described, new therapeutic approach using a reversible, temporary epiphysiodesis technique, following the principles of guided growth. Seven cases with the diagnosis of a painful ulnar positive variance, which underwent a temporary epiphysiodesis, were retrospectively evaluated. These cases consisted of four individual patients who received an intraoperatively customized plate fixation to slow down growth. The following parameters were collected: diagnosis, age at surgery, age at explantation, growth plate status at explantation, ulnar variance before and after surgery, complications and any clinical and radiological abnormalities. The radiological measurements of ulnar variance were performed according to the Gelbermann method. The seven investigated cases (average age at surgery 12.4 years; average age at explantation 14.7 years), in which a temporary epiphysiodesis was performed, showed an average ulnar variance of +3.9 mm (range: from +1.9 mm to +6.1 mm) before the start of therapy. After explantation, an average ulnar variance of +0.1 mm (range: from -3.2 mm to +5.0 mm) was observed, which corresponds to an average reduction/improvement of -3.8 mm (range: from -0.5 mm to -9.3 mm). The ulnocarpal wrist complaints were significantly reduced after the intervention. One case needed a secondary ulnar shortening osteotomy. The described method of a temporary, reversible epiphysiodesis is an elegant, less invasive technique to correct the ulnar positive variance without irreversibly closing the growth plate. In case of therapy failure, a secondary ulna shortening osteotomy is still possible.

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.

[Treatment of the ulnar impingement syndrome in the distal radioulnar joint]

Ligamentous stability and joint congruity are prerequisites for a physiological function of the distal radioulnar joint (DRUJ). Impingement of the ulnar head may be caused by a congenital ulna-minus variance or by an iatrogenically excessive ulna shortening osteotomy. This impingement is detected by a positive 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.

[Diagnosis and treatment of degenerative disc lesions of the wrist]

BACKGROUND

The triangular fibrocartilage complex (TFCC) widens the radiocarpal joint and takes part in load transmission from the carpus to the forearm. It is thereby prone to degenerative changes. The painful situation that can accompany degeneration is called ulnar impaction.

DIAGNOSIS

Clinical examination helps differentiate between various causes of ulnar-sided wrist pain. Standard X‑rays are needed to determine ulnar variance and stress radiographs can depict narrowing of the ulnocarpal joint space under load. MRI may prove degeneration of the TFCC itself or may indirectly confirm ulnar impaction in the presence of bone marrow edema in the ulnar head or at the proximal ulnar aspect of the lunate.

TREATMENT

If conservative treatment fails to alleviate symptoms, arthroscopy may be indicated. On the one hand, this completes the diagnostic cascade, and, on the other hand, allows decompression of the ulnocarpal joint space by resection of the TFCC with partial resection of the ulnar head (wafer resection). In the case of ongoing pain, ulnar shortening sufficiently alleviates ulnar-sided wrist pain. Thereby, modern standardized operation techniques are safe enough to ensure bone healing at the osteotomy site. The aim of alleviating ulnar-sided wrist pain is mostly achieved if the correct treatment option is chosen.

[Surgical treatment of ulnar impaction syndrome : Ulnar shortening osteotomy through the ulnopalmar approach using a low-profile, locking plate]

OBJECTIVE

Extra-articular shortening of the distal ulna in order to decompress the ulnocarpal joint.

INDICATIONS

Congenital or posttraumatic, symptomatic ulnar impaction syndrome.

CONTRAINDICATIONS

Osteoarthritis or deformation of the distal radioulnar joint.

SURGICAL TECHNIQUE

Exactly defined oblique osteotomy in the distal third of the ulna using the saw guide, closing of the osteotomy gap using the compression spindle, osteosynthesis with the locking plate.

POSTOPERATIVE MANAGEMENT

Palmar forearm thermoplastic cast or splint for 3 weeks, load bearing after bony union.

RESULTS

Between June 2016 and March 2018 ulnar shortening was performed in 17 patients using the new locking plate. In all, 15 patients were reevaluated with complete follow-up data. Postoperatively patients experienced significant pain reduction (Visual Analog Scale 0-10) by 65% (7 before and 2.5 after surgery; p < 0.05) and a significant improvement of function (Disabilities of Arm, Shoulder and Hand 0-100) by 49% (47 before and 24 after surgery; p < 0.05). Bony union was observed in all patients after a mean time of 4 months. Overall patient satisfaction was high.

The severity of ulnar variance compared with contralateral hand: its significance on postoperative wrist function in patients with distal radius fracture

The aim of this study was to detect the severity of ulnar variance (UV) compared with contralateral hand on postoperative wrist function in patients with distal radius fracture. 116 cases with unilateral distal radius fracture were retrospectively analyzed and divided into high or low UV severity groups (Dividing value = 2.5 mm). The following parameters were used to evaluate the effect: palmar tilt, radial inclination, VAS score, DASH score and wrist function. The severity of UV existed widely, accounting for 93.1% (108 cases). The severity of UV correlated with palmar tilt, radial inclination, grip strength, VAS score, DASH score and the wrist function (P < 0.05). Log-rank analysis showed that the severity of UV, palmar tilt, radial inclination were important factors influencing the joint function postoperatively (P < 0.0 5). Multivariate analysis confirmed that the severity of UV was an independent and significant factor on wrist function (P = 0.010). And the palmar tilt was also an important factor influencing wrist function (P = 0.047). The severity of ulnar variance compared with contralateral hand is an independent and significant factor on wrist function, which should be considered as an important step during preoperative plan.

Solitary ulnar shortening osteotomy for malunion of distal radius fractures: experience of a centre in the UK and review of the literature

INTRODUCTION

Isolated ulnar shortening osteotomies can be used to treat ulnocarpal abutment secondary to radial shortening following distal radius fractures. Given the increase of fragility distal radius fractures awareness of treating the sequelae of distal radius fractures is important. We present the largest reported case series in the UK of ulnar shortening osteotomies for this indication.

MATERIALS AND METHODS

Twenty patients with previous distal radial fractures were included, who presented with wrist pain and radiologically evident positive ulnar variance secondary to malunion of the distal radius with no significant intercalated instability. Patients were treated with a short oblique ulnar shortening osteotomy, using a Stanley jig and small AO compression plate system. Pre- and postoperative radiographical measurements of inclination, dorsal/volar angulation and ulnar variance were made. Patients were scored pre- and postoperatively using the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and Patient-Rated Wrist Evaluation scores by two orthopaedic surgeons. Mean follow-up was 24 months after surgery.

RESULTS

Radiographical analysis revealed a change in the ulnar variance with an average reduction of 5.74 mm. Mean preoperative scores were 61.1 (range 25-95.5) for QuickDASH and 70.4 (range 33-92) for Patient-Rated Wrist Evaluation. At the latest follow-up, mean postoperative QuickDASH scores were 10.6 (range 0-43.2) and 17.2 (range 0-44) for Patient-Rated Wrist Evaluation. Differences in scores after surgery for both QuickDASH and Patient-Rated Wrist Evaluation were statistically significant (P < 0.01).

CONCLUSIONS

The ulnar shortening osteotomy is a relatively simple procedure compared with corrective radial osteotomy, with a lower complication profile. In our series, patients showed significant improvement in pain and function by correcting the ulnar variance thus preventing ulna-carpal impaction.

Simultaneous correction of radius and ulna for secondary ulnar impaction syndrome with radial physeal arrest in adolescent: A case report and review of literatures

•

Distal radius physeal fractures are common in pediatric patients.

•

Distal radius physeal fracture can lead to physeal arrest.

•

Forearm bone length discrepancy occurs, it is often asymptomatic.

•

Surgical correction of symptomatic forearm bone discrepancy can provide a satisfactory result.

Introduction

Distal radius physeal fractures are common in pediatric patients. Although most of these fractures heal without complication, some result in significant physeal arrest. If significant physeal arrest occurs, the various treatment methods can be applied depending on the severity of deformity and remaining growth of the patient.

Presentation of case

We present a 16-year old female with distal radial physeal arrest who presented four years after initial injury. Radiologically, forearm bone length discrepancy was 7 mm. But, she had a secondary ulnar impaction syndrome. She underwent open wedge corrective osteotomy of distal radius on volar side and ulnar shortening osteotomy, simultaneously. Early mobilization and rehabilitation were started soon after the surgery. At 18 months postoperatively, the ROM was assessed to be almost identical as the unaffected side and the patient presented with no significant symptoms.

Discussion

Distal radial fracture is one of the most common fractures in pediatric population. And distal radial physis is often involved in these fracture, which can lead to physeal arrest. However, even if forearm bone length discrepancy occurs, if the difference is within 1 cm, it is often asymptomatic. In this case, the forearm bone length discrepancy was mild, but due to symptom, we performed surgical treatment.

Conclusion

Distal radial physeal arrest due to distal radial fracture is relatively common in children, and long-term follow-up is needed. Moreover, relatively mild deformity caused by physeal arrest may also cause symptoms, so careful observation is needed.

A novel surgical approach for treating distal radial extraarticular malunion: Oblique osteotomy with buttress plate stabilization

PURPOSE

Distal radial extraarticular malunions are not uncommon. However, requirements of surgical correction depend on multiple conditions. Traditionally, surgical techniques include closing or opening wedge osteotomies. Each has unique advantages and disadvantages. An oblique osteotomy was developed to simplify the revision surgery.

METHODS

Forty-eight consecutive adult patients with 48 malunions were surgically treated. An oblique osteotomy of 45° vertical to the radial longitudinal axis was performed from medio-distally to latero-proximally. Consequently, the osteotomized fragments were compressed with a bone clamp. The proximal part of the distal fragment was pushed backward to correct the dorsal tilt. A 7-hole buttress plate was inserted volarly and cancellous bone graft was packed. Postoperatively, a short-arm splint or brace without restriction of all five metacarpophalangeal joints was applied for 6 weeks.

RESULTS

Forty-one patients were followed for an average of 2.8 years (range, 1.1-5.8 years). All malunions healed within 6 weeks. The union rate was 100% and no complications occurred. Radiographically, ulnar variance, volar tilt of radial articulation, and radial inclination restored to acceptable criteria in all patients. Patients with Modified Mayo Wrist Score (MMWS) improved from 17% to 80% ( p < 0.001) and Disability of Arm, Shoulder and Hand (DASH) Score improved from 0% to 80% ( p < 0.001). The relationship between MMWS and DASH Score was highly correlated (correlation coefficient = -0.90).

CONCLUSION

The described approach may be an excellent alternative for treating distal radial extraarticular malunions. The technique is not difficult but the satisfactory rate is high.

The distal radial decompression osteotomy for ulnar impingement syndrome

INTRODUCTION

The decompression of the distal radioulnar joint (DRUJ) is performed by ulnar translation of the radial shaft proximal to the sigmoid notch, i.e. detensioning of the distal part of the interosseous membrane (DIOM) while containment of the DRUJ is achieved by closed wedge osteotomy of the radius. The osteotomy shortens the radius which entails detensioning of the triangular fibrocartilage complex (TFCC).

SURGICAL TECHNIQUE

Facilitating the modified Henry approach to the distal palmar radius a radial based wedge osteotomy is applied. The proximal osteotomy is proximal to the ulnar head and distal osteotomy is proximal to the sigmoid notch to prevent iatrogenic impingement. Ulnar translation of the radial shaft is performed to loosen the DIOM. The closed wedge osteotomy reduces radial inclination which will foster containment of the DRUJ.

CONCLUSION

Distal radial decompression osteotomy of the DRUJ preserves DRUJ function while relieving painful impingement. Further surgical interventions are not compromised in case of failure.

Ulna-Shortening Osteotomy: Outcome and Repercussion of the Distal Radioulnar Joint Osteoarthritis

BACKGROUND

Ulnocarpal impaction syndrome occurs mostly in patients with positive ulnar variance. Ulnar-shortening osteotomy is a commonly used method to correct it, but degenerative changes may appear in the distal radioulnar joint. The authors evaluated outcome after ulnar-shortening osteotomy, particularly the impact of distal radioulnar joint osteoarthritis.

METHODS

A 10-year study was performed of patients who underwent ulnar-shortening osteotomy.

RESULTS

Forty-six patients were available for clinical examination and radiography. Twenty-nine wrists showed worsening or new osteoarthritis. A difference of preulnar variance and resection was noted: 4.64 mm and 4.48 mm, respectively, in the osteoarthritis group versus 3.50 mm and 3.38 mm in the group without osteoarthitis. Comparison of patients with osteoarthritis revealed a significant limitation of range of motion in flexion-extension (p = 0.009) and pronosupination (p = 0.028): 102 degrees and 138 degrees, respectively, in the osteroarthritis group versus 124 degrees and 155 degreees in the group without osterarthritis. The type of distal radioulnar joint differed significantly (p = 0.038), with a predominance of type I in the osterarthritis group and type II in the group without osterarthritis. Functional outcome was significantly worse in the osterarthritis group versus the group without osteoarthritis concerning the Patient-Rated Wrist Evaluation score (39.07 versus 22.59, p = 0.031), the Quick Disabilities of the Arm, Shoulder, and Hand score (27.38 versus 19.59, p = 0.017), and the modified Gartland-Werley score (76.72 versus 85.14, p = 0.027).

CONCLUSIONS

Ulnar-shortening osteotomy modifies the congruence of the distal radioulnar joint, and the type I joint may be at increased risk of arthrosis. Osteoarthritis has a clinical impact, and the amount of ulnar shortening should be limited to what is needed to avoid altering the functional outcome.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Can Total Wrist Arthroplasty Be an Option for Treatment of Highly Comminuted Distal Radius Fracture in Selected Patients? Preliminary Experience with Two Cases

We present two case reports of successful primary shortening of the forearm and total wrist arthroplasty (TWA) using the new angle-stable Maestro Wrist Reconstructive System (WRS) for treatment of highly comminuted distal radius fracture in selected autonomous patients. In a 56-year-old male patient with adequate bone stock, insertion of the noncemented Maestro WRS was combined with ulnar shortening osteotomy. In an 84-year-old female patient with poor osteoporotic bone stock, insertion of the radial cemented Maestro WRS was combined with ulnar head resection. Both patients could resume their work without additional surgery after TWA. At the 1-year follow-up, there were no changes in position of either implant without signs of loosening, no impingement, and no instability of the distal radioulnar joint or the distal ulna stump. All clinical parameters (DASH score, pain through VAS, and grip strength) were satisfactory. Both patients reported that they would have the same procedure again. Further experience is needed to validate this concept.

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.

[Standard wrist arthroscopy: technique and documentation]

OBJECTIVE

Minimally invasive approach to the wrist in order to diagnose and treat different wrist pathologies.

INDICATIONS

Diagnosis of unclear chronic pain syndromes, cartilage status, intra-articular ligament structures as well as post-traumatic and inflammatory conditions of the wrist. Treatment of ulnar impaction syndrome, dorsal ganglia and also in fracture treatment and various different wrist interventions.

CONTRAINDICATIONS

Soft tissue infections around the wrist, severe scarring may impede access to the joint.

SURGICAL TECHNIQUE

Supine position with the forearm upright and in neutral position, the elbow flexed by 90°, axial traction of 3-4 kg. Superficial stab incision, blunt preparation through joint capsule, insertion of optic through 3-4 portal and probe through 4-5 portal, and radial and ulnar midcarpal portals, respectively. Either sodium chloride, CO2 or air is used as arthroscopy medium. Diagnostic round with standardized examination of all parts of the joint. Standardized written and high quality photo and/or video documentation to facilitate understandability of the findings.

POSTOPERATIVE MANAGEMENT

Forearm cast for 1 week, limited load for 2 more weeks, then load is increased to normal.

The AO Ulnar Shortening Osteotomy System Indications and Surgical Technique

Ulnar shortening osteotomy is an established and frequently performed surgical procedure in wrist surgery. The technical aspects of the procedure have continued to develop in recent years, with instruments and implants being developed specifically for this purpose. Ulnar shortening osteotomy is required for different clinical indications and situations. These varying indications demand different amounts of shortening, but all must be precise and accurate. Controversy exists as to how this can best be achieved in terms of the location for osteotomy, the surgical approach and geometry of the osteotomy, as well as which implant to use to provide optimal stability. The goal of all techniques (besides successfully resolving the underlying problem) is to achieve reliable and rapid bone union without compromising early functional rehabilitation and also to avoid hardware complications. The AO Hand Expert Group has developed a specialized instrumentation system with dedicated and specifically designed implants to ensure exact and accurate cutting with precise and rigid stabilization of the ulna. The matched drill guides and double-blade saws allow accurate completion of the planned amount of shortening together with precise coaptation of the osteotomy fragments. The specific ulnar osteotomy LCP (locking compression plate) combines maximum stability with minimum bulk and soft tissue irritation. The features of the implant, its surgical technique, and early results are described.