Updates on Ulnar Impaction Syndrome / 대한정형외과학회잡지

Ulnar impaction syndrome is one of the common causes of ulnar-sided wrist pain. The pain is usually aggravated by ulnar deviation during a power grip, especially when the forearm is in a pronated position. The most common predisposing factor of ulnar impaction syndrome is ulnar positive variance, which is an increased ulnar length relative to the radius of the radiocarpal joint. However, it can also occur in patients with ulnar neutral or negative variance because ulnar variance can increase during functional activities, including pronation and power gripping. In these patients, the triangular fibrocartilage complex (TFCC) may be thickened. If conservative treatments—lifestyle modification, medication, or wrist splinting—are unsuccessful, surgical treatments, such as wafer procedure or ulnar shortening osteotomy can be considered. The wafer procedure is an effective treatment for ulnar impaction syndrome. It removes the distal 2 to 4 mm of the ulnar head, while preserving the ulnar styloid process from fracturing via a limited open or an arthroscopic approach. The advantages of the wafer procedure are that it does not require bone healing or internal fixation and provides direct access to TFCC. However, it is a technically demanding procedure and is contraindicated in patients with distal radio-ulnar joint (DRUJ) instability, lunotriquetral instability, ulnar minus variance, and with an ulnar positive variance of more than 4 mm. Ulnar shortening osteotomy is the most popular method for the treatment of ulnar impaction syndrome. It can effectively relieve ulnar impaction symptoms and stabilize DRUJ. However, an excessive amount of shortening may increase the peak pressure at DRUJ, which results in DRUJ arthritis. There is also a possibility of delayed union or nonunion in the osteotomy site. To prevent delayed union or nonunion, we should make an effort to decrease the gap in the osteotomy site during surgery. A serial follow-up is also recommended to evaluate the occurrence of arthritis in DRUJ after ulnar shortening.

Long-term Outcomes of Ulnar Shortening Osteotomy for Idiopathic Ulnar Impaction Syndrome: At Least 5-Years Follow-up

BACKGROUND: There have been few outcomes studies with follow-up after performing ulnar shortening osteotomy for ulnar impaction syndrome. We investigated the long-term clinical and radiological outcomes of ulnar shortening osteotomy for the treatment of idiopathic ulnar impaction syndrome. METHODS: We retrospectively reviewed 36 patients who had undergone ulnar shortening osteotomy for idiopathic ulnar impaction syndrome for a mean follow-up of 79.1 months (range, 62 to 132 months). The modified Gartland and Werley scores were measured pre- and postoperatively. The radiographic parameters for the assessment of the distal radioulnar joint (DRUJ) as well as the relationship between these radiographic parameters and the clinical and radiological outcomes were determined. RESULTS: The average modified Gartland and Werley wrist score improved from 65.5 +/- 8.1 preoperatively to 93.4 +/- 5.8 at the last follow-up visit. The average preoperative ulnar variance of 4.7 +/- 2.0 mm was reduced to an average of -0.6 +/- 1.4 mm postoperatively. Osteoarthritic changes of the DRUJ were first seen at 34.8 +/- 11.1 months follow-up in 6 of 36 wrists (16.7%). Those who had osteoarthritic changes in the DRUJ had significantly wider preoperative ulnar variance, a longer distal radioulnar distance and a greater length of ulnar shortening, but the wrist scores of the patients who had osteoarthritic changes in the DRUJ were comparable to those who did not have osteoarthritic changes in the DRUJ. CONCLUSIONS: The clinical outcomes are satisfactory for even more than 5 years after ulnar shortening osteotomy for treating idiopathic ulnar impaction syndrome despite the osteoarthritic changes of the DRUJ. The patients who need a larger degree of ulnar shortening may develop DRUJ arthritis.

A Comparison of Ulnar Shortening Osteotomy Alone Versus Combined Arthroscopic Triangular Fibrocartilage Complex Debridement and Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

BACKGROUND: This study compared the results of patients treated for ulnar impaction syndrome using an ulnar shortening osteotomy (USO) alone with those treated with combined arthroscopic debridement and USO. METHODS: The results of 27 wrists were reviewed retrospectively. They were divided into three groups: group A (USO alone, 10 cases), group B (combined arthroscopic debridement and USO, 9 cases), and group C (arthroscopic triangular fibrocartilage complex [TFCC] debridement alone, 8 cases). The wrist function was evaluated using the modified Mayo wrist score, disabilities of the arm, shoulder and hand (DASH) score and Chun and Palmer grading system. RESULTS: The modified Mayo wrist score in groups A, B, and C was 74.5 +/- 8.9, 73.9 +/- 11.6, and 61.3 +/- 10.2, respectively (p 0.05). CONCLUSIONS: Both USO alone and combined arthroscopic TFCC debridement with USO improved the wrist function and reduced the level of pain in the patients treated for ulnar impaction syndrome. USO alone may be the preferred method of treatment in patients if the torn flap of TFCC is not unstable.

Ulnar Shortening Osteotomy for the Treatment of Ulnar Impaction Syndrome

PURPOSE: To compare the clinical outcomes of the ulnar shortening osteotomy alone and the ulnar shortening osteotomy with arthroscopic debridement in the idiopathic ulnar impaction syndrome with positive ulnar variance. MATERIALS AND METHODS: Twenty seven cases, who underwent the ulnar shortening osteotomy with or without arthroscopic debridement for treatment of the idiopathic ulnar impaction syndrome with positive ulnar variance, were included. The mean age was 40.3 years (range, 21 to 63 years) and the mean follow-up period was 20.6 months (range, 12 to 60 months). The ulnar shortening osteotomy alone and the ulnar shortening osteotomy with arthroscopic debridement were performed in 14 and 13 cases respectively. Pre- and postoperative functional results of the wrist were evaluated by the modified Mayo wrist score. RESULTS: The ulnar variance was corrected from 4.61 mm (range, 1.8~10 mm) to -0.06 mm (range, -3.3~3.1 mm) in the ulnar shortening osteotomy alone group and from 3.01 mm (range, 1.2~7.6 mm) to -0.74 mm (range, -1.8~0 mm) in the ulnar shortening osteotomy with arthroscopic debridement group. The final results of the ulnar shortening osteotomy alone were excellent in 4 cases, good in 5 cases, and fair in 5 cases. Those of the ulnar shortening osteotomy with arthroscopic debridement group were excellent in 6 cases, good in 2 cases, fair in 1 case, and poor in 2 cases. The modified Mayo wrist score at the last follow-up were 83.57(range, 75~100) in the ulnar shortening osteotomy alone group and 83.35(range, 40~100) in the ulnar shortening osteotomy with arthroscopic debirdement group. No statistically significant difference was demonstrated between two groups (p=0.43). CONCLUSION: The ulnar shortening osteotomy is valuable treatment for the idiopathic ulnar impaction syndrome with positive ulnar variance. The combined arthroscopic debridment does not appear to have positive influence to the final results.

Treatment of Ulnar Impaction Syndrome using Arthroscopy and Ulnar Shortening Osteotomy / 대한정형외과학회잡지

PURPOSE: To retrospectively analyze the follow-up results of patients with ulnar impaction syndrome, who were treated with arthroscopic debridement, thermal shrinkage and a simultaneous ulnar shortening osteotomy. MATERIALS AND METHODS: Eleven wrists from ten patients with ulnar impaction syndrome, which were diagnosed by the clinical history, physical examination, radiological evaluation and arthroscopic findings, and were treated by arthroscopic debridement, thermal shrinkage and ulnar shortening osteotomy were enrolled in this study. The minimum duration of the follow-up was one year. The ulnar variance was measured using Kreder's method, and the follow-up results were analyzed radiographically as well as clinically using the Chun and Palmer wrist score. RESULTS: According to the wrist scoring system, seven wrists were fair and four poor preoperatively. However, after surgery, eight wrists were excellent and three good. The average wrist score increased from 62 preoperatively to 93 at the last follow-up. The mean ulnar variance decreased from +3.3 mm (+0.4-+6.4 mm) preoperatively to +0.1 mm (-0.8-+1.3 mm) at the last follow-up. Radiological union of the osteotomy site was achieved after an average of 12 weeks. There were no cases of nonunion or malunion. CONCLUSION: When ulnar impaction syndrome is diagnosed by the clinical, radiological and arthroscopic findings, arthroscopic debridement, thermal shrinkage and simultaneous ulnar shortening osteotomy are useful treatments for relieving the patients symptoms.

Arthroscopy of the Wrist and Ulnar Shortening Osteotomy for the Treatment of the Ulnar Impaction Syndrome / 대한정형외과학회잡지

PURPOSE: This is a retrospective analysis of patients with ulnar impaction syndrome, who were diagnosed by wrist arthroscopy and treated by simultaneous ulnar shortening osteotomy. MATERIALS AND METHODS: Six patients with ulnar impaction syndrome, in whom there was an arthroscopic diagnostic confirmation of the disease had an arthroscopic debridement and ulnar shortening osteotomy. Conservative treatment over a period of more than six months had failed in each patient. The minimum duration of the follow up was one year. The ulnar variance was measured using Kreder's method, and the results were clinically analysed using Chun and Palmer's wrist score as well as radiographically. RESULTS: The Palmer's stages of TFCC injury were 2A (one), 2B (four), 2C (one) on arthroscpic finding. The results were excellent in 4 and good in 2 (preoperative: 3 were fair, and 3 were poor). The wrist score increased from 63 to 94. The ulnar variance changed from +3 mm to -1 mm. CONCLUSION: When an ulnar impaction syndrome is suspected on clinical grounds and by radiographic findings, the pathoanantomy should be assessed arthroscopically. If the arthroscopy reveals Palmer's stages 2A, 2B, 2C, arthroscopic debridement and ulnar shortening osteotomy is a useful method for the treatment of ulnar impaction syndrome.