Surgical management of ulnocarpal impaction syndrome

Refracture after plate removal following ulnar shortening osteotomy for ulnar impaction syndrome - a retrospective case-control study

LEVEL OF EVIDENCE

Level III, case-control study.

Time-Dependent Recovery of Outcome Parameters in Ulnar Shortening for Positive Ulnar Variance: A Prospective Case Series

BACKGROUND

This study evaluates the results of ulnar shortening using the ulna osteotomy locking plate system (UOL; I.T.S. GmbH, Graz, Austria) with special regard to the time-dependent recovery of subjective and objective outcome parameters and surgeons' experiences.

METHODS

Ulnar shortening using the UOL was performed on 11 patients (3 men, 8 women) with an average age of 47 ± 19.6 years. Range of motion (ROM) and grip strength were compared with the contralateral hand. Patient-rated outcomes were measured using a visual analogue scale (VAS) for pain and the Disability of the Arm, Shoulder and Hand (DASH) and the Patient Rated Wrist Evaluation (PRWE) survey for subjective outcomes. Ulnar variance and bony union were assessed using conventional wrist radiographs. The surgeons evaluated intraoperative handling through a standardized feedback form.

RESULTS

ROM improved and grip strength increased significantly between preoperative values and final follow-up. Flexion and supination improved significantly between weeks 8 and 12 and grip strength from week 8 onward. Patient-rated outcomes changed significantly with a final DASH score of 14.2 ± 12.4 and a PRWE score of 24.3 ± 17.0. Pain levels improved significantly with no pain at rest and a mean VAS of 0.8 ± 1.2 during activity. The average amount of shortening was 4.0 ± 1.9 mm with a final ulnar variance of 0.2 ± 1.8 mm. All osteotomies healed with 2 cases of delayed union.

CONCLUSIONS

In ulnar shortening with the UOL, wrist function recovered after an initial decrease from week 8 onward. Subjective outcome parameters showed early recovery and improved continuously over time.

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

BACKGROUND

Ulnar shortening osteotomy (USO) is a widely adopted procedure with excellent outcomes. However, delayed union or nonunion has occasionally been observed. The purpose of this retrospective case-control study was to identify variables affecting osseous consolidation after USO in patients with ulnar impaction syndrome.

METHODS

The study included 325 patients who had undergone USO between March 2008 and March 2014. We evaluated the association between union and basic demographic factors as well as preoperative pain (assessed on a visual analog scale [VAS]), range of wrist motion, grip strength, and modified Mayo wrist score. We also assessed the association of union with radiographic variables such as the degree of dorsal subluxation of the ulna, preoperative and postoperative ulnar variance, morphological type of the distal radioulnar joint, gap at the osteotomy site, and presence of newly developed arthritic changes during the follow-up period. Finally, variables associated with operative conditions, such as degeneration of the triangular fibrocartilage complex, use of a parallel double-blade saw, type of plate used for fixation, number of screws, and plate position on the volar or dorsal ulnar surface were investigated.

RESULTS

Ulnar union was achieved in 294 patients (group 1), and 31 patients had delayed union or nonunion (group 2). On univariate and multivariate analyses, smoking, low bone mineral density (BMD), a decreased range of motion of the wrist, and use of a double-blade saw were found to be significant factors for an adverse radiographic outcome (nonunion or delayed union).

CONCLUSIONS

Delayed union or nonunion occurred in about 10% of patients treated with USO. We suggest that it may be preferable to perform USO in nonsmokers, patients with normal bone density, and those without restricted wrist motion. Also, we recommend the use of a single-blade saw when performing the osteotomy.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Ulnar Shortening Osteotomy After Distal Radius Fracture Malunion: Review of Literature

Malunion of distal radius fracture is often complicated with shortening of the radius with disturbed radio- ulnar variance, frequently associated with lesions of triangular fibrocartilage complex and instability of the distal radioulnar joint. Positive ulnar variance may result in wrist pain located in ulnar part of the joint, limited ulnar deviation and forearm rotation with development of degenerative changes due to the overloading that occurs between the ulnar head and corresponding carpus. Ulnar shortening osteotomy (USO) is the standard procedure for correcting positive ulnar variance. Goal of this procedure is to minimize the symptoms by restoring the neutral radio - ulnar variance. In this paper we present a variety of surgical techniques available for ulnar shorthening osteotomy, their advantages and drawbacks. Methods of ulnar shortening osteotomies are divided into intraarticular and extraarticular. Intraarticular method of ulnar shortening can be performed arthroscopically or through open approach. Extraarticular methods include subcapital osteotomy and osteotomy of ulnar diaphysis, which depending on shape can be transverse, oblique, and step cut. All of those osteotomies can be performed along wrist arthroscopy in order to dispose and treat possibly existing triangular fibrocartilage complex injuries. At the end we described surgical procedures that can be done in case of ulnar shorthening osteotomy failure.

Results of ulnar shortening osteotomy with a new plate compression system

PURPOSE

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Persistent ulnar-sided wrist pain after treatment of triquetral dorsal chip fracture: six cases related to triangular fibrocartilage complex injury

INTRODUCTION

Persistent ulnar-sided wrist pain after treatment of triquetral dorsal chip fracture even after union is a matter of concern. There could be various reasons for this persistent pain like arthritis, instability, fractures and non-union. We correlate our findings of physical examination and wrist arthroscopy as triangular fibrocartilage complex injury to be one of the causes of this persistent pain.

PATIENTS

Six subjects who had persistent ulnocarpal joint pain and tenderness after triquetral dorsal chip fracture, despite 2 months of conservative treatment, were subjected to physical tests. If the physical examination yields positive results, then magnetic resonance imaging followed by arthroscopic treatment was performed. The six patients were then evaluated using the visual analogue scale, the Mayo modified wrist score, and the grip strength test.

RESULTS

Triangular fibrocartilage complex (TFCC) injury was observed in all six cases and partial TFCC resection and synovectomy were performed. Analysis of the visual analogue scale, Mayo modified wrist score, and grip strength test data revealed statistically significant improvements (P < 0.05).

CONCLUSION

In addition to several causes reported in the published literature, TFCC injury can be a cause of persistent ulnar pain after treatment of triquetral dorsal chip fracture. Arthroscopic partial TFCC resection can be considered to be a suitable treatment for such cases.