Anthony J. Lauder, M.D., Douglas P. Hanel, M.D., Thomas E. Trumble, M.D.

American Society for Surgery of the Hand, Chapter 18, Copyright ASSH 2006

Lauder, A J, MD, Trumble, T E, MD

UW Medicine Department of Orthopaedics and Sports Medicine 2006 Research Report, 50-53.

The ulnar shortening osteotomy has become the gold standard for correcting positive ulnar variance. Ulnar variance is defined as the difference in length between the distal ulnar corner of the radius and the distal most aspect of the dome of the ulnar head. Positive ulnar variance occurs when the dome of the distal ulna is more distal than the ulnar corner of the distal radius. This positive variance leads to ulnar sided wrist pain and degenerative processes due to the overloading that occurs between the ulnar head and the ulnar capus. Thus, the goals of the shortening procedue are to relieve pain and prevent arthritis by reestablishing a neutral or slightly negative ulnar variance. The typical incidations for the osteotomy include ulnar impaction syndrom, non repairable tears of the triangular fibrocartilage complex (TFCC), previous radial head excision and associated Essex-Lopresti lesions, attritional luno-triquetral ligament tears, ulnar nonunions, radial malunions, and early post-traumatic distal radioulnar joing (DRUJ) arthritis. Numerous authors have introduced methods and systems for performing, and hopefully simplifying, the osteotomy. This study compared the resuls of shortening ulnas with a new plate and compresssion system to a previously described and accepted method.

Luria, S, MD, Lauder, A J, MD, Trumble, T E, MD

The Journal of Hand Surgery, Vol. 33A, November 2008, Page 1493-1497

Purpose: Ulnar-shortening osteotomy has become common in the treatment of symptomatic positive ulnar variance. Our goal was to evaluate prospectively a new dynamic compression plating system in comparison with a commonly used dynamic comopression system. In contrast with other systems, the new system uses a slotted hole that enable fixation of the plate to the bone prior to performing the osteotomy, a fitted compression clamp, and a lag screw. Cutting guides that attached directly to plate eliminate the need for freehand osteotomies.

Methods: Thirty-seven patients were treated with a 3.5-mm, 6-hole dynamic compression plate with distraction device (Synthes, Paoli, PA) and compared with 17 patients treated with a new dynamic compression system manufactured by TriMed (Valencia, CA). Procedure lenght was recorded. The patients were evaluated for amount of shortening, pain, range of motion, grip strenght, time to union, and return to work as well as with validated outcome measures.

Results: Improvement was found in all measured although no difference was found between the 2 groups other than significantly shorter lenght of operation with the TriMed System (a mean of 2 hours with the Synthes syste vs 1 hour with the TriMed System). Ten plates were removed in the Synthes group and 4 plates were removed in the TriMed group because of symptomatic prominence of the plate. There were not infections, delayed unions, or nonunions in either group.

Conclusions: The new TriMed plating system for ulnar shortening was found to be as effective as the Synthes system and with shorter procedure time. This may be related to the different measuring periods, although years of practive with the Synthes technique preceded this study. We believe the shortened procedure time for the TriMed system is due to its technical advantages.

Type of study / level of evidence: Therapeutic III

Isaacs, J., MD, Howard, S., OTR/L, CHT, Gulkin, D., MD

HAND (2010) 5:148–154, Article, September 2009

Abstract: Extra-articular ulnar shortening osteotomy, in principle, is an accepted treatment option for symptomatic degenerative and traumatic triangular fibrocartilage complex (TFCC) tears. Despite the benefits of this surgical approach, potential disadvantages include risk of nonunion, soft tissue irritation, and the need for future hardwar removal. A recently introduced low profile ulna shortening system was designed to decrease these potential complications. A single-surgeon prospective study was performed to evaluate this system. Ten consecutive patients undergoing ulna shortening for ulnar-sided wrist pain compatible with TFCC pathology participated in the study. Subjective, objective, and radiographic assessments were performed preoperatively and up to 24 weeks postoperatively. Based on visual analog scale (VOS) ratings (0 to 10), pain socres significantly improved (p<0.05) and average patient satisfaction was 8.7. DASH and PRWE scores improved at three month follow-up (p<0.05). Osteotomy healing time averaged 10.3 weeks, and there were no nonunions. Average discomfort associated with palpation of the plate at final follow-up was 3.3 (using VOS), and one patient requested removal of the hardware. In this short-term follow-up study, the assessed ulna shortening system appears effective and, in general, well tolerated.

Ahsan ZS, Song Y, Yao J

Journal of Hand Surgery; Volume 38, Number 8, August 2013, Pages 1520-1523

Purpose: To evaluate the outcomes of patients with ulnar impaction syndrome treated with a jig-facilitated, oblique, diaphyseal ulnar shortening osteotomy and fixed with a TriMed (Santa Clarita, CA) ulnar osteotomy compresson plate.

Methods: A retrospective chart review of patients with ulnar impaction syndrome identified 38 patients who had had ulnar shortening osteotomy and fixation with the TriMed dynamic compression system. The following clinical data were obstained: patient age, sex, follow-up range of motion, grip strength, and complications. After a minimum of 2 years after surgery, patients reported complications and completed a Disabilities of the Arm, Shoulder, and Hand questionnaire.

Results: Eight patients were lost to follow-up. Compared to the opposite limb at an average of 8 months after surgery, the remaining 30 patients attained 92% to 97% of wrist and forearm motion and 71% of grip strength. The average Disabilities of the Arm, Shoulder, and Hand score was 12 after a minimum of 2 years following surgery. Four patients required plate removal due to irritation. Two patients reported persistent ulnar-sided pain, and 2 other patients developed atrophic nonunions and required autologous bone grafting. There were no infections.

Conclusions: Ulnar shortening osteotomy using the TriMed system yielded good clinical outcomes that are comparable to those previously documented using other sytems.

Type of study / level of evidence: Therapeutic IV

Isaacs J, Frankenhoff J

A Master Skills Publication; Ed. Greenberg J, 2013; Chapter 13, Pages 137-148, 2013

Ulnar impaction syndrome (UIS), also known as ulnar abutment syndrome, is a painful degenerative process affecting the ulnar side of the wrist presumably in response to chronic ulnar-carpal overload. Initially recognized as sequela of radial shortening following malunited wrist fractures, eventually the role of atraumatic etiologies was recognized, as well. Though a higher incidence of UIS is noted in patients with a positive ulnar variance, the exact role of this anatomic variation in the development of ulnar-sided wrist pain is not completely understood. Regardless, both biomechanical and clinical data strongly supports the effectiveness of surgically “unloading” the ulnar side of the wrist in the treatment of this disorder. While this can be achieved through either an pen or arthroscopic resection of several millimeters of the distal ulnar articular surface and ulnar head, extraarticular ulnar shortening is the most commonly reported surgical treatment strategy. Through there is little agreement as to the best way to technically perform the ulna-shortening osteotomy, the adherence to well-established principle will improve the likelikehood of achieving a favorable outcome.

Higgins J, Shores J, Katz R, Lee WPA, Wolock B

Journal of Hand Surgery; 2014, January, Volume 39, Number 1, Pages 134-142

One of the challenges of forearm-level hand transplantation surgery is the achievement of osseos union of the ulna given the substantial soft tissue dissection, the use of immune modulating medications, and the diaphyseal level of osseos 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 compressiong plating technique. A step-by-step description of the developed modification is provided with a case example.

Pouliot M, Yao J

Techniques in Hand & Upper Extremity Surgery, 18(2), 72–76. March 2014

Abstract: Ulnar impaction syndrome (UIS) is a degenrative condition of the ulnar wrist typically seen in patients with statis or dynamic ulnar-positive variance. Impactions of the distal ulna on the proximal lunate and triquetrum leads to degenerations of the triangular fibrocartilage complex and/or the chondral surfaces of the lunate and triquetrum. Patients with UIS present with pain in the ulnar aspect of the wrist. In cases of UIS refractory to nonperative treatment, several surgical techniqes have been described, including arthroscopic triangular fibrocartilage complex debrideent, arthroscopic wafer procedure, and ulnar shortening osteotomy (USO). USO has gained favor as a reliable technique to offload the forces seen at the ulnar wrist extra-articularly while preserving the distal radioulnar joint stabilizing structures. We describe a technique utilizing a jig-facilitated, oblique, diaphyseal USO and fixed with a TriMed ulnar osteotomy compression plate. This system allows for precise measured ulnar shortening and reliable compression across the osteotomy site, and has been shown to decrease operative times and achieve to high union rates. Plate prominence is minimized by utilizing the volar surface of the ulna, although plate prominence and subsequent need for hardware removal remain a relatively common complication.

Martin D, Zlotolow D, Russo S, Kozin S

Journal of Hand Surgery; Volume 39, Number 8, August 2014, Pages 1558-64

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 or 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 valued were used to calculate force across the osteotomy site. Measurements were obtained after the following steps: reduction of osteotomy, compression screw placement (Group I 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 the technique of fixation did not signficantly influence contact area, lag screw placement significantly increased contact area independent of the 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 of stage of fixation.

Conclusions: Perpendicular clamp compression significantly increased force as compared with the 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.