Isolated Lunotriquetral Ligament Tears Treated With Ulnar Shortening Osteotomy

SCIENTIFIC ARTICLE

Isolated Lunotriquetral Ligament Tears Treated With Ulnar Shortening Osteotomy Ather Mirza, MD, Justin B. Mirza, DO, Alexander Y. Shin, MD, Daniel J. Lorenzana, BA, Brian K. Lee, BS, Brett Izzo, MD

Purpose To evaluate outcomes in a single-surgeon series of ulnar shortening osteotomy for the treatment of traumatic isolated tears to the lunotriquetral interosseous ligament (LTIL). Methods This study includes 53 consecutive cases of posttraumatic isolated LTIL tears treated with ulnar shortening osteotomy with minimum 1-year follow-up (range, 1.0 –10.6 y). We confirmed all LTIL tears via arthroscopy before performing a precision 2.5-mm oblique osteotomy using a modified Rayhack technique. We assessed outcomes using grip strength measurements and Chun and Palmer’s modified Gartland Werley wrist scoring system, which includes subjective and objective outcome measures. Results Preoperatively, 45 cases were graded as fair (28%; n ⫽ 15) or poor (57%; n ⫽ 30) on the modified Gartland Werley score. There were insufficient data to calculate grades in 8 cases (15%). At final follow-up, most patients exhibited excellent (51%; n ⫽ 27) or good (32%; n ⫽ 17) scores, some scored fair (17%; n ⫽ 9), and none scored as poor. All subjective and objective variables significantly improved over a mean follow-up of 36 months (range, 12–127 mo). Mean grip strength increased from a value of 23 kg before surgery to 33 kg over the same period, a 41% increase. All patients achieved clinical and radiographic union by 10 months. Osteotomy plates were removed routinely in most cases (89%; n ⫽ 47) at a mean of 17 months. Conclusions Ulnar shortening osteotomy reduced symptoms of posttraumatic isolated LTIL tears in this single-surgeon series. (J Hand Surg 2013;38A:1492–1497. Copyright © 2013 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Lunotriquetral, ligament, instability, ulnar shortening osteotomy. ligamentous injuries of the carpus, symptomatic and isolated tears of the lunotriquetral interosseous ligament (LTIL) are not commonly reported. Multiple mechanisms of traumatic etiology have been proposed and include hypothenar loading in a reversal of the lesser arc pattern

R

ELATIVE TO OTHER

From the Department of Hand and Microsurgery, St. Catherine of Siena Medical Center; and the North ShoreSurgi-Center,Smithtown;andtheDepartmentofOrthopaedics,PlainviewHospital,NorthShore– Long Island Jewish, Plainview, NY; the Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN; the Keck School of Medicine, University of Southern California, Los Angeles, CA; and the Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI. Received for publication November 20, 2012; accepted in revised form May 20, 2013. The authors acknowledge the North Shore Surgi-Center staff for their dedication in treating patients; Patricia A Meyer, MA, OTR/CHT, for exceptional occupational therapy work and postoperative evaluations; and Evan Finger for diligent efforts during data collection phases.

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perilunate injury,1–3 dorsal overloading with flexion,4 and presenting as a forme fruste of perilunate dislocations.5,6 Patients with a symptomatic, isolated LTIL tear typically present with unresolved ulnar-sided wrist pain after a traumatic event.1 For patients unresponsive to No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Ather Mirza, MD, Department of Hand and Microsurgery, St. Catherine of Siena Medical Center, 290 East Main Street, Suite 200, Smithtown, NY 11787; e-mail: [email protected]. 0363-5023/13/38A08-0005$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.05.024

ISOLATED LTIL TEARS TREATED WITH USO

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conservative treatment, traditional surgical interventions aim to directly stabilize the lunotriquetral joint through ligament repair, ligament reconstruction, or lunotriquetral arthrodesis.7 Most studies suggest that these procedures resolve pain symptoms in a majority of cases, albeit with high complication and re-operation rates. For example, Shin et al7 reported 5-year reoperation rates of 31%, 77%, and 78% for ligament reconstruction, ligament repair, and arthrodesis, respectively. Those authors also reported a high complication rate of 82% and a re-operation rate of 64% owing to nonunion, failed repair, and ulnocarpal impingement. Ulnar shortening osteotomy may reduce symptoms of LTIL tears without an intracarpal surgical procedure through tightening the distal extension of the triangular fibrocartilage complex (TFCC) and relevant extrinsic ligaments.8 –10 A biomechanical analysis by Gupta et al11 suggests that USO reduces relative motion of the lunate and triquetrum by increasing strain in the ulnolunate and ulnotriquetral ligaments, while leaving lunotriquetral strain relatively unchanged. The purpose of this study was to retrospectively evaluate the outcomes of a single-surgeon series of USO in this patient population. MATERIALS AND METHODS We retrospectively identified patients who underwent USO, performed by the senior author (A.M.). Patients with arthroscopically verified isolated LTIL tears of traumatic origin and minimum follow-up of 12 months were included in the study. Isolated traumatic LTIL tears were identified using the following criteria: arthroscopic visualization of LTIL damage with no degenerative changes outside the lunotriquetral joint, history of trauma consistent with a ligamentous tear, and the absence of concurrent damage to the TFCC or scapholunate ligament, as well as no indication of ulnar impaction syndrome via radiograph or arthroscopy. Exclusion criteria consisted of preexisting injuries or subsequent unrelated injuries to the ipsilateral hand or wrist that would affect clinical outcomes. We obtained informed consent to publish non-identifiable patient data from all study participants before inclusion in the study. Patient evaluation Physical examination included strength testing with a Jamar dynamometer (Sammons Preston, Bolingbrook, IL) visual assessment of bilateral ranges of motion, palpation for tenderness, and the Reagan ballottement testing for lunotriquetral instability.1 During the initial consultation, x-rays of the wrist were obtained in neutral posterior anterior (PA), oblique PA, lateral, and gripping PA in pronation with

FIGURE 1: Measurement of ulnar variance by the method of perpendiculars. Arrows indicate the distal ulnar aspect of the radius and the distal cortical rim of the ulna.

elbow flexed 90°. We used radiographs to assess ulnar variance and any disruption of carpal alignment. Ulnar variance was measured to the nearest 0.5 mm from PA radiographs by the method of perpendiculars12 (Fig. 1). Any indication of volar intercalated segment instability deformity was considered a contraindication for this procedure. Patients were asked to subjectively assess function, pain, and motion according to the modified Gartland and Werley wrist grading system of Chun and Palmer.13 A wrist grade was assigned after each clinical examination using these subjective responses as well as objective range of motion and grip strength data. We also reviewed patient records for mechanism of injury, handedness, patient account of symptoms, complications, and any subsequent operations. Initial treatment approach All patients were initially managed conservatively with a wrist orthosis and nonsteroidal anti-inflammatory drugs. Patients included in this study failed to respond to this conservative treatment and underwent Technetium-99m triple-phase bone scans and arthrograms to assess the integrity of the TFCC and carpal ligaments.

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Arthrography was performed preoperatively on all patients with fluoroscan, on a routine basis, before arthroscopy. Suspected LTIL tears were diagnosed via arthroscopy before USO. We used the bone scans as part of an algorithm for the diagnosis of ulnar-sided wrist pain. A magnetic resonance imaging (MRI) study was not part of the protocol; however, MRI studies that were examined were provided by referring physicians. Surgical technique In all cases, the senior author conducted an oblique osteotomy using guides to ensure a precise shortening of 2.5 mm, regardless of ulnar variant with the intent of tightening the distal extension of the TFCC and relevant extrinsic ligaments. Under a regional block, the hand was suspended with 4.7 kg traction for the arthroscopy, which was reduced to 2 kg for the USO procedure. The appearance of the LTIL, scapholunate ligament, and TFCC were noted in all cases, and the degree of LTIL dissociation using the Geissler classification was recorded in the latter 41 cases.14 An 11-cm incision was made 4 cm proximal to the ulnar styloid on the subcutaneous border of the ulna. The osteotomy jig was placed on the volar surface of the ulna and the surgeon performed the osteotomy in accordance with the Rayhack technique with some modifications.15 The compression plate was placed on the volar surface of the ulna in most cases, which was thought to be flatter and to more easily accommodate the compression plate (Fig. 2). The wrist was postoperatively immobilized with a short-arm orthosis. An ulnar gutter orthosis was fabricated 8 to 10 days postoperatively, at which point occupational therapy began and continued in most cases for 3 months. The patient was allowed to take the orthosis off to accommodate hygiene and home exercise programs until 12 weeks postoperatively. Subsequently, the orthosis was worn only for high-risk activity. Statistical analysis We assessed differences between numerical preoperative and postoperative grip strength using Student’s t-test for paired data. Although they are presented as numerical values, we analyzed overall wrist grades and subscores as ordinal data using the Wilcoxon signedranks test. All statistical tests were 2-tailed tests with significance at P ⬍ .05. RESULTS Demographics We identified 416 USO procedures performed by the senior author between April 1991 and September 2011.

FIGURE 2: Postoperative radiographic imaging. A Immediately after surgery. B Healed osteotomy site 19 months later.

These included 72 cases with isolated, traumatic tears of the LTIL, of which we included 64 cases with clinical follow-up of at least 12 months. We excluded 4 patients with preexisting carpal fusions or injuries to the hand or wrist that affected their clinical outcomes and 3 patients with subsequent unrelated injuries to the hand or wrist that affected our evaluation. Furthermore, 1 patient declined to participate in the study and 1 patient was noncompliant in keeping occupational therapy appointments. This patient was not consistent in follow-up examination, and we could not collect data for the modified Gartland-Werley scores. Two patients were lost to follow-up. Thus, the study included 53 cases (52 patients) of arthroscopically verified isolated LTIL tears treated with a USO technique between October 1992 and April 2010 and with a minimum 1-year follow-up (Table 1). Patient presentation In all cases, the presenting problem was unresolved ulnar-sided wrist pain after a traumatic event. In some cases, patients reported radiating pain to the ring and little fingers and proximally up the ulnar border of the forearm. The most frequently seen mechanisms of injury were falls on an outstretched hand and motor vehicle accidents. Other mechanisms of injury included sports injuries, twisting injuries, wrist flexion trauma, lifting injuries, and other trauma (Table 1).

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TABLE 1.

Demographics

Age, y (mean ⫾ SD)

43.4 ⫾ 7.6

TABLE 2. Comparison of Chun and Palmer Wrist Grade Distribution Before Surgery and at Final Follow-Up

Sex Preoperative

Final

0

27 (51%)

0

17 (32%)

15 (28%)

9 (17%)

Male

27 (52%)

Female

25 (48%)

Excellent

Fall on outstretched hand

16 (30%)

Fair

Motor vehicle accident

13 (25%)

Poor

30 (57%)

0

8 (15%)

0

Mechanism

Good

Sports

4 (8%)

Twisting

4 (8%)

Palmar flexion

3 (5%)

Lifting

2 (3%)

Other

11 (21%)

Preoperatively, ulnar variance was positive in 27 cases (51%; range, 1–3 mm; mean, 1.7 mm; SD, 0.6 mm), neutral in 22 cases (42%; range, 0 – 0 mm; mean, 0.0 mm; SD, 0.0 mm), and negative in 4 cases (8%; range, ⫺2 to ⫺1 mm; mean, ⫺1.8 mm; SD, 0.5 mm). Most cases displayed ulnar variance of 1 mm or less (70%, n ⫽ 36; range, ⫺2 to 1 mm; mean, 0.3 mm; SD, 1.1 mm). All radiographs, including gripping views, were negative for volar intercalated segment instability patterns, and there was no appreciable disruption of the Gilula lines. Bone scans were positive for uptake in the lunotriquetral area in 45 cases (85%) in the lunate or triquetrum, or sometimes in both. In 8 cases, bone scans were negative (15%). Forty-two cases (79%) were positively diagnosed on arthrography. Geissler classifications were made intraoperatively in the latter 41 cases: 11 cases (27%) were grade 3 tears, and 30 cases (73%) were grade 4. Surgical outcomes The mean time to evidence of radiographic bone healing, which we then clinically assessed, was 18 weeks (range, 8 –39 wk) after osteotomy. Ulnar variance was reduced from a preoperative mean of 0.9 mm (range, ⫺2.0 to ⫹3.0 mm) to a postoperative mean of ⫺1.0 mm (range, ⫺5.0 to 1.0). Table 2 lists preoperative and postoperative modified Gartland-Werley wrist grade classifications. All subjective and objective variables significantly improved on average by final follow-up (Table 3). Complications and additional procedures We observed 6 complications (11%), including 4 cases of delayed union (8%), 1 of transient distal radioulnar joint stiffness, and 1 of transient lateral epicondylitis.

No grade

The case of transient distal radioulnar joint stiffness exhibited limited supination, which improved over the course of occupational therapy with no functional impairment by final follow-up. The case of transient lateral epicondylitis also resolved non-surgically during occupational therapy within the follow-up period. Both of these cases were graded good at final follow-up, with modified Gartland-Werley scores of 83 and 85, respectively. There were no cases of nonunion, infection, or wound dehiscence. Radiographic and clinical evidence of union took longer than 6 months in 4 cases, which qualified as delayed healing under the modified Gartland-Werley grading system. Each of these cases achieved radiographic and clinical union in less than 10 months without further intervention. We removed osteotomy plates in 89% of cases because of persistent tenderness in the plate area that was unresponsive to conservative management. Hardware removal was the sole reason for reoperation in this series. DISCUSSION Whereas the mechanism and treatment of radial-sided ligamentous injuries have been extensively studied, the corresponding ligamentous injuries on the ulnar side of the wrist are not as well understood. In 1980, Mayfield et al5 performed a classic study of radial-sided perilunate injuries in cadaveric wrists loaded to failure in extension, ulnar deviation, and intercarpal supination, and proposed 4 distinct stages of progressive ligamentous injuries arising on the radial side of the wrist and progressing around the lunate. In 1984, Reagan et al1 proposed that a reversal of such a mechanism could account for isolated LTIL tears and other ulnar-sided perilunate injuries. Since then, our understanding of LTIL pathophysiology has been advanced by numerous authors,2,4 including Viegas et al,16 who proposed 3 stages of ulnar-sided perilunate injuries, beginning with an isolated LTIL tear.

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TABLE 3.

ISOLATED LTIL TEARS TREATED WITH USO

Grip Strength and Wrist Grade Subscores Preoperative (Mean ⫾ SD)

Postoperative (Mean ⫾ SD)

P Value

Grip strength, kg

23 ⫾ 15

33 ⫾ 14

⬍ .010*

Wrist score

63 ⫾ 7

89 ⫾ 8

⬍ .001

7⫾2

16 ⫾ 4

⬍ .001

Subjective function

6⫾2

17 ⫾ 4

⬍ .001

Subjective motion

5⫾3

9⫾1

⬍ .001

Objective motion

7⫾3

10 ⫾ 2

⬍ .001

Objective strength

8⫾3

9⫾2

⬍ .001

Subjective pain

Data comparing grip strength measurements and Chun and Palmer subscores before surgery and at final follow-up. *t-test. All others were analyzed using Wilcoxon signed-rank test.

Murray et al3 correlated biomechanical cadaveric testing with clinical findings and proposed a discrete 3-stage mechanism of ulnar-sided perilunate injuries. Based on impact to the hypothenar eminence, those authors put forward 3 stages beginning with isolated disruption of the LTIL and progressing to dorsal perilunate dislocation. We believe that this pattern may account for most injuries observed in our study; a majority of patients reported loading injuries that may have been ulnar-sided, including falls on the outstretched hand and motor vehicle accidents while grasping the steering wheel. Nonetheless, we report other mechanisms of injury that may not be accounted for by this pattern, including twisting and wrist flexion injuries. We concur with Shin et al17 that these injuries likely arise from more than 1 mechanism. We suspect that the relative scarcity of isolated LTIL injuries reported in the literature may result in part from underdiagnosis. In our study population, LTIL tears were initially dismissed as wrist sprains and were only referred to our practice after persistent pain and functional impairment. Once reported, these injuries may also be missed because of diagnostic difficulty. Of note is that a negative MRI may give the practitioner a false sense of security: A recent study found 3.0-T wrist MRIs to have diagnostic sensitivity for LTIL tears of 25% to 75%, in contrast to 72% to 95% sensitivity for TFCC tears.18 Although sensitive, bone scans were highly nonspecific for LTIL tears, whereas arthrograms were more specific, especially the midcarpal arthrogram. Instead, we recommend relying on lunotriquetral ballottement followed by arthrography before arthroscopy. Shin et al7 found that 65% of confirmed isolated LTIL tears demonstrated a positive lunotriquetral ballottement test. In another study, Omokawa et al19 found that all 11 cases of confirmed LTIL tears also demon-

strated positive lunotriquetral ballottement. Ultimately, we relied on the same diagnostic criteria for isolated LTIL tears used by both of these studies: arthroscopic confirmation. In cases of isolated LTIL tears that do not respond to conservative treatment, surgical interventions include ligament repair, ligament reconstruction, dorsal capsulodesis, and lunotriquetral arthrodesis. Unfortunately, these interventions are not always successful in relieving pain and restoring function.7,20 –24 In a retrospective review of 57 isolated LTIL tears treated with arthrodesis, repair, or reconstruction, Shin et al7 noted a 5-year reoperation rate of 57% after ligament repair or reconstruction and 1-year complication rates greater than 20% for both procedures. Yet, even with these complication rates, those researchers concluded that both ligament repair and reconstruction resulted in better patient outcomes than arthrodesis. Several authors have speculated that USO may reduce symptoms of symptomatic LTIL tears through tightening the distal extension of the TFCC and extrinsic ligaments.8 –10,15 In a biomechanical analysis of USO, Gupta et al11 concluded that relative motion of the lunate and triquetrum was lessened by increased strain on secondary restraints, specifically the ulnotriquetral and ulnolunate ligaments. This analysis provides a possible explanation for the clinical improvement observed in this study. Mean grip strength in the present study improved by a mean of 9.5 kg (41%) by final follow-up, which compares favorably with published outcomes of 7.7 kg (42%) for ligament reconstruction, 3.7 kg (14%) for ligament repair, and 5 kg (20%) in a case series of capsulodesis.7,19 Moreover, the complication rate in the present study (11%) compares favorably with complication rates of greater than 20% for intracarpal procedures and is comparable to

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complication rates of USO for other indications.7,25 Although the present study includes a high reoperation rate (89%), these secondary procedures were for the purpose of hardware removal, necessitated by patients’ reports of hardware tenderness. Any suspicion of damage to the ulnolunate or ulnotriquetral ligaments may undermine the efficacy of USO to treat isolated LTIL tears. Thus, we consider suspicion of damage to these secondary restraints as a contraindication for this procedure. This includes volar triquetral avulsion fractures, which Smith and Murray26 found to be associated with injuries to the ulnotriquetral ligament. This study has several limitations. Although longitudinal subjective assessment was performed over a mean follow-up of 3 years, we did not use patient-rated outcome measures. We also lacked contralateral strength assessments and range of motion measurements, which were evaluated directly using the modified Gartland Werley scale, so numerical analysis was not possible. Furthermore, this study was not a comparative or randomized study. It is only of limited use for comparison of USO with alternative procedures. Nonetheless, our study includes subjective and objective outcome data on all patients who met basic inclusion criteria, allowing us to address our stated goal of evaluating USO to treat isolated, traumatic LTIL tears in a single-surgeon series. This study suggests that USO may be an effective primary treatment option for addressing traumatic LTIL tears, but further study is necessary to draw more definitive conclusions.

7.

8. 9. 10.

11.

12.

13. 14.

15.

16.

17. 18.

19.

20. 21.

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