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Comparison of ulnar shortening osteotomy and the wafer resection procedure as treatment for ulnar impaction syndrome
Comparison of Ulnar Shortening Osteotomy and the Wafer Resection Procedure as Treatment for Ulnar Impaction Syndrome Kostas J. Constantine, MD, Matthew M. Tomaino, MD, James H. Herndon, MD, Dean G. Sotereanos, MD, Pittsburgh, PA A retrospective review was performed that compared the results of 2 different surgical treatments for ulnar impaction syndrome in 22 patients over a 6-year period. Ulnar shortening osteotomy and wafer distal ulna resection (wafer resection procedure) were each performed in 11 patients based on the preference of 3 individual hand surgeons. All patients presented with ulnar wrist pain and positive ulnar variance on either neutral rotation or pronated-grip x-rays and each failed conservative management. At a minimum follow-up time of 18 months, 9 patients had good to excellent results following ulnar shortening osteotomy compared with 8 following the wafer resection procedure. This difference was not statistically significant. All patients regained functional wrist motion and 21 of the 22 patients had satisfactory pain relief. There was 1 poor result in the wafer group that required revision to complete resection of the distal ulna. Five secondary procedures were required in the osteotomy group to remove painful hardware and union was delayed in 2 patients. Although ulnar shortening osteotomy provides effective treatment for ulnar impaction syndrome, the wafer resection procedure provides favorable pain relief and restoration of function but without the potential for nonunion or hardware removal. (J Hand Surg 2000;25A:55– 60. Copyright © 2000 by the American Society for Surgery of the Hand.) Key words: Ulnar osteotomy, wafer resection, ulnar impaction syndrome.
Ulnar impaction syndrome is a common cause of ulnar wrist pain. Excessive loading at the ulnocarpal joint causes degeneration of the triangular fibrocartilage complex (TFCC), chondromalacia of the lunate and ulnar head, and lunotriquetral (LT) ligament disruption.1,2 While there are numerous reports on this subject,2–11 the most recent addressing treatment From the Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA. Received for publication December 28, 1998; accepted in revised form September 27, 1999. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Matthew M. Tomaino, MD, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA 15213. Copyright © 2000 by the American Society for Surgery of the Hand 0363-5023/00/25A01-0020$3.00/0
discuss the results of either ulnar shortening osteotomy or the wafer resection procedure.8 –11 We compare ulnar shortening osteotomy with the wafer resection procedure.
Materials and Methods A retrospective review of all patients undergoing surgery on our upper extremity service between 1990 and 1996 revealed 31 patients who had surgery for ulnar impaction syndrome. Nine patients were excluded because their impaction was secondary to distal radius fracture malunion (7 patients) or because of other major wrist pathology (Kienbo¨ck’s disease and wrist fusion each in 1 patient). Of the 22 remaining patients ulnar shortening osteotomy and the wafer resection procedure were each performed The Journal of Hand Surgery 55
56 Constantine et al / Ulnar Osteotomy Versus Wafer Resection
in 11 patients based on the treatment preference of the 3 surgeons. Patients ranged in age from 15 to 69 years, with a mean age of 35 years for the osteotomy group and 46 years for the wafer group (p ⱕ .05). There were 14 females (6 had osteotomy and 8 had wafer resection) and 8 males (5 had osteotomy and 3 had wafer resection). Eight patients had work-related injuries (5 had osteotomy and 3 had wafer resection). The follow-up period ranged from 18 to 85 months, with a mean of 46 months following osteotomy and 26 months following the wafer resection procedure (p ⱕ .05)). Fifteen of 22 patients related the onset of symptoms to a distinct injury, usually a fall. All 3 treating surgeons (M.M.T., J.H.H., and D.G.S.) used the same criteria to establish the diagnosis of ulnar impaction syndrome. These included a painful ulnar stress test,12 tenderness at the ulnocarpal joint, positive ulnar variance on either neutral rotation13 or pronated-grip x-rays,14 and the absence of distal radioulnar joint or pisotriquetral arthritis or extensor carpi ulnaris tendinitis. Previous treatments included splinting, modification of activities, injections, and nonsteroidal anti-inflammatory medicines. Ulnar variance was measured using the method of perpendiculars to the nearest 0.5 mm.15 On neutral rotation x-rays ulnar variance averaged ⫹2.5 mm for the osteotomy group (range, 1–5 mm) and ⫹1.5 mm for the wafer group (range, 0 – 4 mm; p ⱕ .05). In 3 patients in the wafer group, neutral ulnar variance increased to ⫹2 mm in 2 and ⫹3 mm in 1 on the pronated-grip x-ray. Nine patients had arthrograms (2 in the wafer resection group and 7 in the osteotomy group) and 6 had magnetic resonance imaging scans (all 6 in the wafer resection group). Arthrography showed TFCC tears in all 9 wrists and an LT ligament tear in 1. Magnetic resonance imaging showed TFCC tears in 3 wrists. Arthroscopy was performed in 4 patients at the same setting as the wafer resection procedure and showed both TFCC and LT tears in 1 wrist only. Two patients in the wafer resection group and 1 in the osteotomy group had TFCC tears arthroscopically diagnosed and debrided before referral. At the time of osteotomy neither the TFCC nor the LT ligament was exposed; hence, further debridement was not performed. In the wafer resection group 8 TFCC tears were identified during surgery and debrided. The LT tear previously mentioned was not debrided. Two of the wafer resection procedures were performed because of unsuccessful pain relief following
Table 1. Criteria for Grading Results20 Excellent Good Fair
Poor
Full range of motion compared with opposite wrist and no pain or limitation of function Mild discomfort with strenuous use and mild limitation of motion compared with opposite wrist Moderate discomfort with use, moderate limitation of motion in more than 1 direction, and limitation of function sufficient to prevent full return to work Persistent pain, limitation of motion sufficient to prevent return to gainful employment, and/or nonunion
previous arthroscopic TFCC debridement. Two of the osteotomy patients had undergone previous procedures, including a carpal tunnel release and a metacarpal boss and ganglion excision each in 1. Objective assessment at the final follow-up visit was performed by 1 of us (K.J.C.) based on physical examination for 15 patients and chart review and telephone conversation for the remaining 7. Postoperative wrist range of motion and grip strength were measured with a goniometer and a Jamar dynamometer (Asimow Engineering, Los Angeles, CA), respectively. Follow-up physical examination included the ulnar stress test,12 palpation of the extensor carpi ulnaris tendon and the incision, and an assessment of stability and tenderness at the distal radioulnar joint. Union (for the osteotomy patients) and postoperative ulnar variance were measured using a neutral rotation x-ray.13 The number and type of secondary procedures were also reviewed. Assessment of subjective outcome included inquiry regarding pain relief and return to work status. Results were scored using criteria described by Darrow et al16 (Table 1). For continuous variables, comparisons of the means were performed using Student’s t-test. The chi-square test was used to determine statistical significance for differences between categorical variables. Differences were considered statistically significant at p ⱕ .05.
Operative Technique Ulnar shortening osteotomy was performed by 2 surgeons (J.H.H., 1 patient; D.G.S., 10 patients). An incision based on the distal subcutaneous border of the ulna was used, protecting the dorsal sensory branches of the ulnar nerve. A 6-hole AO/ASIF 3.5 LC-DCP plate (Synthes, Paoli, PA) was contoured to the distal ulna and a distal an-
The Journal of Hand Surgery / Vol. 25A No. 1 January 2000 57
Figure 1. (A) Preoperative zero rotation posteroanterior radiograph of the wrist showing ulnar positive variance. (B) Postoperative zero rotation posteroanterior radiograph of the wrist showing correction after ulnar shortening osteotomy.
choring screw was predrilled. The edges of the osteotomy were marked to control rotation. An oscillating saw was used to make a transverse osteotomy of the ulna, removing a 2- to 3-mm portion of bone to correct the ulnar variance to at least neutral. The holes in the plate were then filled, placing compression at the osteotomy site. The forearm was then rotated to make sure there was no impingement. The distal radioulnar joint was not exposed and the TFCC and LT ligament were not assessed during surgery. Patients were placed in a long arm splint for 2 weeks, then casted for 2 to 4 additional weeks (Fig. 1). The wafer resection procedure was performed by one surgeon (M.M.T.). A dorsal approach to the distal ulna was used. The extensor retinaculum was
divided between the fifth and sixth dorsal compartments. A longitudinal capsulotomy was made to expose the ulnar head. Cartilage and bone were resected to result in neutral variance based on the measurement on the pronated-grip x-ray. The ulnar styloid and the TFCC attachments were preserved by making a back cut rather than extending the transverse cut all the way ulnarly. The LT ligament was never exposed. The TFCC was debrided if a tear was present or if undersurface fibrillation was identified.17 The dorsal capsule and retinaculum were repaired in separate layers, and a sugar tong splint immobilized the forearm in supination for 2 weeks followed by a long arm cast in neutral rotation for 2 additional weeks. Range of motion exercises and grip strengthening were then started (Fig. 2).
58
Constantine et al / Ulnar Osteotomy Versus Wafer Resection
Figure 2. (A) Preoperative pronated-grip posteroanterior radiograph of the wrist showing ulnar positive variance. (B) Postoperative pronated-grip posteroanterior radiograph of the wrist showing correction after the wafer procedure.
Results Following ulnar shortening osteotomy 9 patients had excellent or good results compared with 8 after the wafer resection procedure (p ⱕ .05) (Table 2). Two patients in each group had a fair result, but these were all skewed by co-morbid factors, such as shoulder and elbow injuries (2 patients), weakness secondary to a stroke (1 patient), and pending litigation (1 patient). One patient who underwent the wafer
Table 2. Summary of Results Excellent Good Fair Poor
Osteotomy
Wafer
2 7 2 0
2 6 2 1
resection procedure had a poor result secondary to residual pain at the distal radioulnar joint. She underwent complete resection of the distal ulna without improvement. Compared with the nonoperative side, postoperative grip strength averaged 98% in the osteotomy group and 85% in the wafer resection group; however, the differences were not statistically significant when corrected for age. No patient in either treatment group lost more than 10° of motion in any plane. Postoperative examination revealed minimal pain with the ulnar stress test, shucking of the distal radial ulnar joint, and palpation of the incision or the extensor carpi ulnaris tendon in 21 of 22 patients. The patient noted above with a poor result was involved in a workers’ compensation case and continued to have symptomatic ulnar wrist pain even after revision surgery. Nine of the 11 patients in the osteotomy
The Journal of Hand Surgery / Vol. 25A No. 1 January 2000 59
group and 8 of the 11 patients in the wafer resection group returned to their previous level of employment. After surgery ulnar variance averaged 1.0 mm for both treatment groups. Ulnar shortening osteotomy resulted in a mean resection of 3.0 mm compared with 2.0 mm in the wafer resection group (p ⱕ .05), but the former group of wrists had increased ulnar variance before surgery compared with the latter. For the patients in the osteotomy group mean time to union was 3 months, but in 2 it took greater than 4 months. Five of 11 patients required plate removal because of extensor carpi ulnaris irritation. Of the remaining 6 patients, 2 continued to have some mild cold sensitivity.
Discussion Because ulnar variance affects load transfer across the wrist,18 surgical procedures that shorten the ulna may provide effective treatment for ulnar impaction syndrome.4 –7,9,11 Our experience with both ulnar shortening osteotomy and the wafer resection procedure has allowed us to compare the efficacy of each. Ulnar shortening osteotomy has been the gold standard for many years with favorable outcome9,11 but the procedure is also associated with many potential complications, including delayed union, nonunion, hardware discomfort, prolonged immobilization, and a larger scar. This may have prompted Feldon et al8 to use the wafer resection procedure. Early results have shown good or excellent results in 71% to 100% of patients.8,10 However, no previous study has attempted to compare the results of both procedures. Our results are similar to what has been reported previously in the literature regarding the efficacy of both ulnar shortening osteotomy and the wafer resection procedure. We observed no significant differences in outcome between the 2 treatment groups with respect to range of motion, age-corrected grip strength, pain relief, or return to work status. The length of the follow-up period was significantly longer for the osteotomy group. Nevertheless, the minimum follow-up interval of 18 months was sufficient enough to allow a fair assessment of pain relief and restoration of function following the wafer resection procedure. Although the osteotomy patients had a younger mean age than the wafer resection patients (p ⱕ 05), this was slightly misleading since there was 1 patient in the wafer group who was much older (69 years).
Our study has limitations. First, a larger number of patients would have been beneficial to improve the statistical power of our study. Because it is retrospective, a consistent preoperative work-up and postoperative assessment protocol were not used. This has prevented us from addressing the incidence of TFCC and LT tears, particularly in the osteotomy group, or the need for debridement, since few wrists underwent either arthroscopy or open exploration. Second, wafer resection procedures were performed in patients with less ulnar variance than those who underwent ulnar shortening osteotomy. Therefore, notwithstanding our observation that both procedures were successful, we are unable to conclude that they can be used interchangeably until a comparison is made in patients with similar ulnar variance. Although our patient numbers are small, the study is retrospective, and the follow-up is relatively short, the wafer resection procedure seems to be a viable alternative for the treatment of ulnar impaction syndrome with potentially less morbidity than ulnar shortening osteotomy. These patients usually appreciated pain relief as early as 6 to 8 weeks after surgery and regained near complete or complete forearm rotation by 3 months. The authors thank Molly Vogt, PhD, for assisting in the statistical analysis of our results.
References 1. Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg 1989;14A:594 – 606. 2. Friedman SL, Palmer AK. The ulnar impaction syndrome. Hand Clin 1991;7:295–310. 3. Milch H. Cuff resection of the ulna for malunited Colles’ fracture. J Bone Joint Surg 1941;23:311–313. 4. Dingman PVC. Resection of the distal end of the ulna. An end-result study of 24 cases. J Bone Joint Surg 1952;34A: 893–900. 5. Sauve K. Nouvelle technique traitement chirurgical des luxations recidivantes isolees de l’extremite inferieure du cubitus. J Chir 1936;47:589 –594. 6. Bowers WH. Distal radioulnar joint arthroplasty: the hemiresection-interposition technique. J Hand Surg 1985; 10A:169 –178. 7. Watson HK, Ryu J, Burgess RC. Matched distal ulna resection. J Hand Surg 1986;11A:812– 817. 8. Feldon P, Terrono AL, Belsky MR. Wafer distal ulna resection for triangular fibrocarilage tears and/or ulna impaction syndrome. J Hand Surg 1992;17A:731–736. 9. Chun S, Palmer AK. The ulnar impaction syndrome: follow-up of ulnar shortening osteotomy. J Hand Surg 1993; 18A:46 –53.
60 Constantine et al / Ulnar Osteotomy Versus Wafer Resection 10. Schuurman AH, Bos KE. The ulno-carpal abutment syndrome: follow-up of the wafer procedure. J Hand Surg 1995;20B:171–177. 11. Loh YC, Van Den Abbele K, Stanley JK, Trail IA. The results of ulnar shortening for ulnar impaction syndrome. J Hand Surg 1999;24B:316 –320. 12. Nakamura R, Horii E, Imaeda T, Nakao E, Kato H, Watanabe K. The ulnocarpal stress test in the diagnosis of ulnar-sided wrist pain. J Hand Surg 1997;22B:719 – 723. 13. Palmer AK, Glisson RR, Werner FW. Ulnar variance determination. J Hand Surg 1982;7:376 –379. 14. Tomaino MM, Rubin DA. The value of the “pronated grip
15. 16.
17.
18.
radiograph” in assessing for dynamic ulnar positive variance: a case report. Am J Orthop 1999;3:180 –181. Steyers CM, Blair WF. Measuring ulnar variance: a comparison of techniques. J Hand Surg 1989;14A:607– 612. Darrow JC Jr, Linscheid RL, Dobyns JH, Mann JM III, Wood MB, Beckenbaugh RD. Distal ulnar recession for disorders of the distal radioulnar joint. J Hand Surg 1985; 10A:482– 491. Tomaino MM. Ulnar impaction syndrome in the ulnar negative and neutral wrist. J Hand Surg 1998;23B:754 – 757. Palmer AK, Werner FW. Biomechanics of the distal radioulnar joint. Clin Orthop 1984;187:26 –35.
Ulnar impaction syndrome is a common cause of ulnar wrist pain. Excessive loading at the ulnocarpal joint causes degeneration of the triangular fibrocartilage complex (TFCC), chondromalacia of the lunate and ulnar head, and lunotriquetral (LT) ligament disruption.1,2 While there are numerous reports on this subject,2–11 the most recent addressing treatment From the Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA. Received for publication December 28, 1998; accepted in revised form September 27, 1999. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Matthew M. Tomaino, MD, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA 15213. Copyright © 2000 by the American Society for Surgery of the Hand 0363-5023/00/25A01-0020$3.00/0
discuss the results of either ulnar shortening osteotomy or the wafer resection procedure.8 –11 We compare ulnar shortening osteotomy with the wafer resection procedure.
Materials and Methods A retrospective review of all patients undergoing surgery on our upper extremity service between 1990 and 1996 revealed 31 patients who had surgery for ulnar impaction syndrome. Nine patients were excluded because their impaction was secondary to distal radius fracture malunion (7 patients) or because of other major wrist pathology (Kienbo¨ck’s disease and wrist fusion each in 1 patient). Of the 22 remaining patients ulnar shortening osteotomy and the wafer resection procedure were each performed The Journal of Hand Surgery 55
56 Constantine et al / Ulnar Osteotomy Versus Wafer Resection
in 11 patients based on the treatment preference of the 3 surgeons. Patients ranged in age from 15 to 69 years, with a mean age of 35 years for the osteotomy group and 46 years for the wafer group (p ⱕ .05). There were 14 females (6 had osteotomy and 8 had wafer resection) and 8 males (5 had osteotomy and 3 had wafer resection). Eight patients had work-related injuries (5 had osteotomy and 3 had wafer resection). The follow-up period ranged from 18 to 85 months, with a mean of 46 months following osteotomy and 26 months following the wafer resection procedure (p ⱕ .05)). Fifteen of 22 patients related the onset of symptoms to a distinct injury, usually a fall. All 3 treating surgeons (M.M.T., J.H.H., and D.G.S.) used the same criteria to establish the diagnosis of ulnar impaction syndrome. These included a painful ulnar stress test,12 tenderness at the ulnocarpal joint, positive ulnar variance on either neutral rotation13 or pronated-grip x-rays,14 and the absence of distal radioulnar joint or pisotriquetral arthritis or extensor carpi ulnaris tendinitis. Previous treatments included splinting, modification of activities, injections, and nonsteroidal anti-inflammatory medicines. Ulnar variance was measured using the method of perpendiculars to the nearest 0.5 mm.15 On neutral rotation x-rays ulnar variance averaged ⫹2.5 mm for the osteotomy group (range, 1–5 mm) and ⫹1.5 mm for the wafer group (range, 0 – 4 mm; p ⱕ .05). In 3 patients in the wafer group, neutral ulnar variance increased to ⫹2 mm in 2 and ⫹3 mm in 1 on the pronated-grip x-ray. Nine patients had arthrograms (2 in the wafer resection group and 7 in the osteotomy group) and 6 had magnetic resonance imaging scans (all 6 in the wafer resection group). Arthrography showed TFCC tears in all 9 wrists and an LT ligament tear in 1. Magnetic resonance imaging showed TFCC tears in 3 wrists. Arthroscopy was performed in 4 patients at the same setting as the wafer resection procedure and showed both TFCC and LT tears in 1 wrist only. Two patients in the wafer resection group and 1 in the osteotomy group had TFCC tears arthroscopically diagnosed and debrided before referral. At the time of osteotomy neither the TFCC nor the LT ligament was exposed; hence, further debridement was not performed. In the wafer resection group 8 TFCC tears were identified during surgery and debrided. The LT tear previously mentioned was not debrided. Two of the wafer resection procedures were performed because of unsuccessful pain relief following
Table 1. Criteria for Grading Results20 Excellent Good Fair
Poor
Full range of motion compared with opposite wrist and no pain or limitation of function Mild discomfort with strenuous use and mild limitation of motion compared with opposite wrist Moderate discomfort with use, moderate limitation of motion in more than 1 direction, and limitation of function sufficient to prevent full return to work Persistent pain, limitation of motion sufficient to prevent return to gainful employment, and/or nonunion
previous arthroscopic TFCC debridement. Two of the osteotomy patients had undergone previous procedures, including a carpal tunnel release and a metacarpal boss and ganglion excision each in 1. Objective assessment at the final follow-up visit was performed by 1 of us (K.J.C.) based on physical examination for 15 patients and chart review and telephone conversation for the remaining 7. Postoperative wrist range of motion and grip strength were measured with a goniometer and a Jamar dynamometer (Asimow Engineering, Los Angeles, CA), respectively. Follow-up physical examination included the ulnar stress test,12 palpation of the extensor carpi ulnaris tendon and the incision, and an assessment of stability and tenderness at the distal radioulnar joint. Union (for the osteotomy patients) and postoperative ulnar variance were measured using a neutral rotation x-ray.13 The number and type of secondary procedures were also reviewed. Assessment of subjective outcome included inquiry regarding pain relief and return to work status. Results were scored using criteria described by Darrow et al16 (Table 1). For continuous variables, comparisons of the means were performed using Student’s t-test. The chi-square test was used to determine statistical significance for differences between categorical variables. Differences were considered statistically significant at p ⱕ .05.
Operative Technique Ulnar shortening osteotomy was performed by 2 surgeons (J.H.H., 1 patient; D.G.S., 10 patients). An incision based on the distal subcutaneous border of the ulna was used, protecting the dorsal sensory branches of the ulnar nerve. A 6-hole AO/ASIF 3.5 LC-DCP plate (Synthes, Paoli, PA) was contoured to the distal ulna and a distal an-
The Journal of Hand Surgery / Vol. 25A No. 1 January 2000 57
Figure 1. (A) Preoperative zero rotation posteroanterior radiograph of the wrist showing ulnar positive variance. (B) Postoperative zero rotation posteroanterior radiograph of the wrist showing correction after ulnar shortening osteotomy.
choring screw was predrilled. The edges of the osteotomy were marked to control rotation. An oscillating saw was used to make a transverse osteotomy of the ulna, removing a 2- to 3-mm portion of bone to correct the ulnar variance to at least neutral. The holes in the plate were then filled, placing compression at the osteotomy site. The forearm was then rotated to make sure there was no impingement. The distal radioulnar joint was not exposed and the TFCC and LT ligament were not assessed during surgery. Patients were placed in a long arm splint for 2 weeks, then casted for 2 to 4 additional weeks (Fig. 1). The wafer resection procedure was performed by one surgeon (M.M.T.). A dorsal approach to the distal ulna was used. The extensor retinaculum was
divided between the fifth and sixth dorsal compartments. A longitudinal capsulotomy was made to expose the ulnar head. Cartilage and bone were resected to result in neutral variance based on the measurement on the pronated-grip x-ray. The ulnar styloid and the TFCC attachments were preserved by making a back cut rather than extending the transverse cut all the way ulnarly. The LT ligament was never exposed. The TFCC was debrided if a tear was present or if undersurface fibrillation was identified.17 The dorsal capsule and retinaculum were repaired in separate layers, and a sugar tong splint immobilized the forearm in supination for 2 weeks followed by a long arm cast in neutral rotation for 2 additional weeks. Range of motion exercises and grip strengthening were then started (Fig. 2).
58
Constantine et al / Ulnar Osteotomy Versus Wafer Resection
Figure 2. (A) Preoperative pronated-grip posteroanterior radiograph of the wrist showing ulnar positive variance. (B) Postoperative pronated-grip posteroanterior radiograph of the wrist showing correction after the wafer procedure.
Results Following ulnar shortening osteotomy 9 patients had excellent or good results compared with 8 after the wafer resection procedure (p ⱕ .05) (Table 2). Two patients in each group had a fair result, but these were all skewed by co-morbid factors, such as shoulder and elbow injuries (2 patients), weakness secondary to a stroke (1 patient), and pending litigation (1 patient). One patient who underwent the wafer
Table 2. Summary of Results Excellent Good Fair Poor
Osteotomy
Wafer
2 7 2 0
2 6 2 1
resection procedure had a poor result secondary to residual pain at the distal radioulnar joint. She underwent complete resection of the distal ulna without improvement. Compared with the nonoperative side, postoperative grip strength averaged 98% in the osteotomy group and 85% in the wafer resection group; however, the differences were not statistically significant when corrected for age. No patient in either treatment group lost more than 10° of motion in any plane. Postoperative examination revealed minimal pain with the ulnar stress test, shucking of the distal radial ulnar joint, and palpation of the incision or the extensor carpi ulnaris tendon in 21 of 22 patients. The patient noted above with a poor result was involved in a workers’ compensation case and continued to have symptomatic ulnar wrist pain even after revision surgery. Nine of the 11 patients in the osteotomy
The Journal of Hand Surgery / Vol. 25A No. 1 January 2000 59
group and 8 of the 11 patients in the wafer resection group returned to their previous level of employment. After surgery ulnar variance averaged 1.0 mm for both treatment groups. Ulnar shortening osteotomy resulted in a mean resection of 3.0 mm compared with 2.0 mm in the wafer resection group (p ⱕ .05), but the former group of wrists had increased ulnar variance before surgery compared with the latter. For the patients in the osteotomy group mean time to union was 3 months, but in 2 it took greater than 4 months. Five of 11 patients required plate removal because of extensor carpi ulnaris irritation. Of the remaining 6 patients, 2 continued to have some mild cold sensitivity.
Discussion Because ulnar variance affects load transfer across the wrist,18 surgical procedures that shorten the ulna may provide effective treatment for ulnar impaction syndrome.4 –7,9,11 Our experience with both ulnar shortening osteotomy and the wafer resection procedure has allowed us to compare the efficacy of each. Ulnar shortening osteotomy has been the gold standard for many years with favorable outcome9,11 but the procedure is also associated with many potential complications, including delayed union, nonunion, hardware discomfort, prolonged immobilization, and a larger scar. This may have prompted Feldon et al8 to use the wafer resection procedure. Early results have shown good or excellent results in 71% to 100% of patients.8,10 However, no previous study has attempted to compare the results of both procedures. Our results are similar to what has been reported previously in the literature regarding the efficacy of both ulnar shortening osteotomy and the wafer resection procedure. We observed no significant differences in outcome between the 2 treatment groups with respect to range of motion, age-corrected grip strength, pain relief, or return to work status. The length of the follow-up period was significantly longer for the osteotomy group. Nevertheless, the minimum follow-up interval of 18 months was sufficient enough to allow a fair assessment of pain relief and restoration of function following the wafer resection procedure. Although the osteotomy patients had a younger mean age than the wafer resection patients (p ⱕ 05), this was slightly misleading since there was 1 patient in the wafer group who was much older (69 years).
Our study has limitations. First, a larger number of patients would have been beneficial to improve the statistical power of our study. Because it is retrospective, a consistent preoperative work-up and postoperative assessment protocol were not used. This has prevented us from addressing the incidence of TFCC and LT tears, particularly in the osteotomy group, or the need for debridement, since few wrists underwent either arthroscopy or open exploration. Second, wafer resection procedures were performed in patients with less ulnar variance than those who underwent ulnar shortening osteotomy. Therefore, notwithstanding our observation that both procedures were successful, we are unable to conclude that they can be used interchangeably until a comparison is made in patients with similar ulnar variance. Although our patient numbers are small, the study is retrospective, and the follow-up is relatively short, the wafer resection procedure seems to be a viable alternative for the treatment of ulnar impaction syndrome with potentially less morbidity than ulnar shortening osteotomy. These patients usually appreciated pain relief as early as 6 to 8 weeks after surgery and regained near complete or complete forearm rotation by 3 months. The authors thank Molly Vogt, PhD, for assisting in the statistical analysis of our results.
References 1. Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg 1989;14A:594 – 606. 2. Friedman SL, Palmer AK. The ulnar impaction syndrome. Hand Clin 1991;7:295–310. 3. Milch H. Cuff resection of the ulna for malunited Colles’ fracture. J Bone Joint Surg 1941;23:311–313. 4. Dingman PVC. Resection of the distal end of the ulna. An end-result study of 24 cases. J Bone Joint Surg 1952;34A: 893–900. 5. Sauve K. Nouvelle technique traitement chirurgical des luxations recidivantes isolees de l’extremite inferieure du cubitus. J Chir 1936;47:589 –594. 6. Bowers WH. Distal radioulnar joint arthroplasty: the hemiresection-interposition technique. J Hand Surg 1985; 10A:169 –178. 7. Watson HK, Ryu J, Burgess RC. Matched distal ulna resection. J Hand Surg 1986;11A:812– 817. 8. Feldon P, Terrono AL, Belsky MR. Wafer distal ulna resection for triangular fibrocarilage tears and/or ulna impaction syndrome. J Hand Surg 1992;17A:731–736. 9. Chun S, Palmer AK. The ulnar impaction syndrome: follow-up of ulnar shortening osteotomy. J Hand Surg 1993; 18A:46 –53.
60 Constantine et al / Ulnar Osteotomy Versus Wafer Resection 10. Schuurman AH, Bos KE. The ulno-carpal abutment syndrome: follow-up of the wafer procedure. J Hand Surg 1995;20B:171–177. 11. Loh YC, Van Den Abbele K, Stanley JK, Trail IA. The results of ulnar shortening for ulnar impaction syndrome. J Hand Surg 1999;24B:316 –320. 12. Nakamura R, Horii E, Imaeda T, Nakao E, Kato H, Watanabe K. The ulnocarpal stress test in the diagnosis of ulnar-sided wrist pain. J Hand Surg 1997;22B:719 – 723. 13. Palmer AK, Glisson RR, Werner FW. Ulnar variance determination. J Hand Surg 1982;7:376 –379. 14. Tomaino MM, Rubin DA. The value of the “pronated grip
15. 16.
17.
18.
radiograph” in assessing for dynamic ulnar positive variance: a case report. Am J Orthop 1999;3:180 –181. Steyers CM, Blair WF. Measuring ulnar variance: a comparison of techniques. J Hand Surg 1989;14A:607– 612. Darrow JC Jr, Linscheid RL, Dobyns JH, Mann JM III, Wood MB, Beckenbaugh RD. Distal ulnar recession for disorders of the distal radioulnar joint. J Hand Surg 1985; 10A:482– 491. Tomaino MM. Ulnar impaction syndrome in the ulnar negative and neutral wrist. J Hand Surg 1998;23B:754 – 757. Palmer AK, Werner FW. Biomechanics of the distal radioulnar joint. Clin Orthop 1984;187:26 –35.