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Pre-osteotomy plate application technique for ulnar shortening
ARTICLE IN PRESS
PRE-OSTEOTOMY PLATE APPLICATION TECHNIQUE FOR ULNAR SHORTENING R. CHENNAGIRI and P. BURGE From the Nuffield Orthopaedic Centre, Headington, Oxford OX3 7LD, UK
The self-compressing mode of the AO/ASIF LC-DC plate can be harnessed to close and compress modest osteotomy gaps that are created after provisional application of the plate with two screw holes on either side of the osteotomy. The oblique osteotomy cuts are made through 70% of the bone diameter and the actual osteotomy width is measured. After provisional plate application and removal, the cuts are completed and the plate is re-applied. Eccentric drilling of up to five holes of a 6-hole plate using the 3.5 mm universal drill guide allows closure and compression of osteotomy gaps of up to 4 mm. An interfragmentary screw is placed across the oblique osteotomy through the remaining hole. The technique is simple but requires careful planning and execution. Journal of Hand Surgery (British and European Volume, 2004) 29B: 5: 453–457 Keywords: ulna, shortening, osteotomy, technique, abutment
and then harnesses its dynamic compression mode to close the osteotomy gap.
INTRODUCTION Ulnar shortening osteotomy is widely used in the management of the ulnar abutment syndrome. The average shortening achieved varies between 2 and 4 mm (Chun and Palmer, 1993; Jain et al., 2000; Labosky and Waggy, 1996; Loh et al., 1999; Minami and Kato, 1998; Mizuseki et al., 2001; Rayhack et al., 1993; Wehbe and Cautilli, 1995), which is consistent with the biomechanical evidence that shortening by 2.5 mm reduces the proportion of radiocarpal load borne by the ulna from 18% to 4% (Werner et al., 1986). It is difficult to control the smooth bone ends accurately and surprisingly easy to achieve an imperfect reduction and/or inadequate compression when performing the technique freehand (i.e. cutting the osteotomy and then applying the plate). Although the plate can be applied to one end prior to osteotomy, it is still difficult to control and reduce the other fragment accurately. Application of a small external distraction device (Wehbe and Cautilli, 1995) can control the fragments, though this technique requires that the osteotomy is transverse and necessitates four additional pin holes through the ulna at right angles to the line of the plate. Jigs devised by Rayhack et al. (1993) and Loh et al. (1999), are fixed to the bone through screw holes that will be used subsequently for plate fixation, and provide slots to guide the osteotomy saw cuts. By drilling two holes on each side prior to osteotomy, accurate reduction is assured as the plate is applied. However, these devices tend to obscure the ulna once they are applied and necessitate the purchase of equipment that may only be used infrequently. We describe a method of ulnar shortening that assures accurate reduction by fixing the plate to the intact bone with two screws on each side of the proposed osteotomy
METHOD The dynamic compression plate achieves longitudinal compression of fracture fragments by movement of an eccentrically-drilled screw down the spherical sloping edge of the plate hole. The same principle can be used to close the gap of an ulnar shortening osteotomy. The Synthes (AO/ASIF) (Stratec Medical Ltd., Welwyn Garden City, UK) 6-hole 3.5 mm low contact dynamic compression plate (LC-DCP) (catalogue no. 223.560) has oval screw holes 7 mm in length. Movement of the bone beneath the plate is achieved by drilling the screw hole eccentrically within the plate hole. Use of the Universal Drill Guide (catalogue no. 323.360) in compression mode places the screw shank against the edge of the plate hole and achieves 1 mm movement of the bone in relation to the plate as the screw head engages the sloping edge of the plate hole (Fig 1a and b). A gap of 2.5 mm then remains between the screw shank and the opposite edge of the plate hole. If a second eccentric screw is placed in another hole on the same side of the osteotomy, the first screw moves a further 1 mm, leaving a 1.5 mm gap between its shank and the opposite edge of its plate hole. Insertion of a third eccentric screw moves the first screw another 1 mm, of which 0.5 mm leaves the first screw head flush with the plate hole while the second 0.5 mm takes it up the sloping edge of the hole so that it sits slightly proud of the plate (Fig 1c and d). Sequential eccentric drilled holes on one side of the osteotomy can therefore produce 2.5 mm of bone movement relative to the plate before the first screw-head rides up the opposite edge of its screw hole. 453
ARTICLE IN PRESS
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Fig 1
THE JOURNAL OF HAND SURGERY VOL. 29B No. 5 OCTOBER
2004
A screw inserted eccentrically (a) moves 1 mm with respect to the plate as it is tightened (b). As another eccentrically-placed screw is tightened in another hole in the plate, the first screw moves a further 1 mm (c). Insertion of a third eccentric screw moves the first screw another 1 mm, of which the second 0.5 mm takes the screw head up the sloping edge of the hole so that it sits slightly proud of the plate (d). A total screw movement of 2.5 mm is therefore possible before the first screw head begins to ride up in its hole.
The problem is how to drill enough eccentric holes before the osteotomy has been cut. In order to define the position of the plate with respect to the intact bone, two holes must be drilled on either side of the proposed osteotomy. But it will be evident that if the plate is held against the bone and two eccentric screw holes are drilled on the same side of the osteotomy, only 1 mm of bone movement will result – the holes are effectively in the same position and their effect is not additive. There is no possibility of drilling a ‘‘more eccentric’’
hole. Two millimetre total movement can be produced by eccentric drilling of screw holes on either side of the osteotomy if the four holes are drilled before the osteotomy is cut, and if one hole is to be used for a lag screw across the osteotomy, only one hole of the sixhole plate remains for an eccentric screw after cutting the osteotomy; thus the maximum total movement is 3 mm. The pre-osteotomy drilling sequence described below allows 3 mm movement to be built in prior to osteotomy.
ARTICLE IN PRESS
ULNAR SHORTENING TECHNIQUE
455
OPERATIVE TECHNIQUE
enforce an accurate reduction of the osteotomy. Screw holes 1, 2 and 5 will move the bone with respect to the plate and close the osteotomy. Additional movement will be obtained, if necessary, with hole 4. The osteotomy cuts are completed and the surfaces inspected to ensure that they are smooth and flat (Fig 3). The plate is applied and screws inserted in the sequence 1, 2, 5, and 6. As each of screws 1, 2 and 5 are tightened, it will be seen that the osteotomy gap closes by 1 mm. The osteotomy is then inspected. If the ends are firmly in contact and no further compression is needed, screw 4 is inserted centrally and screw 6 is replaced with a full length screw. If further closure of the osteotomy is required, screw 4 is inserted eccentrically but its head is left proud of the plate (Fig 4). Before it can be tightened, it is necessary to remove screw 6, which would otherwise abut on the edge of its screw hole as it is carried towards the osteotomy by movement of the bone beneath the plate. Screw 5 is loosened and screw 4 is tightened, taking care to avoid excessive compression that could lead to fracture of one of the osteotomy surfaces. It will now be apparent that the position of hole 6 will not allow a screw to be inserted to its full depth because the drill hole is too close to the osteotomy side of the plate hole. Therefore, a new drill hole is made in the far cortex, ignoring the hole in the near cortex. This screw will have purchase in only the far cortex, but its hold should be good and there will be fixation in five cortices on this side of the osteotomy. Finally, an interfragmentary screw is placed across the osteotomy through hole 3.
The desired amount of shortening is estimated from the radiographs. The level of the osteotomy is marked and an oblique saw cut is made, angled proximally and cutting through about 70% of the bone. A saw blade is placed into the cut to act as a guide and a parallel second cut is made an appropriate distance away, again cutting only 70% of the bone. The actual width of the osteotomy cut is now measured and recorded, and it may be slightly different from the pre-determined width. This is unlikely to affect ulnocarpal loading significantly, but it is the actual width that determines the number of plate holes at which compression will be required in order to close the osteotomy gap (Fig 2). The plate is then placed on the bone so that the proximal osteotomy cut is level with distal edge of hole 3 in the plate. Hole 1 is drilled eccentrically and the screw inserted, ensuring that its head is tight up against the edge of the plate hole away from the osteotomy when it is fully seated. This can be achieved by pulling the plate towards the osteotomy as the screw is tightened. Hole 6 is then drilled eccentrically through the near cortex only and a uni-cortical screw is inserted, leaving its head just proud of the plate. Hole 2 is drilled eccentrically but no screw is inserted at this stage. Loosening of screw 1 and tightening of screw 6 then moves the plate to the right by 1 mm and allows another eccentric screw hole to be drilled at position 5. Now the two screw holes on either side of the osteotomy have fixed the relationship of the plate to the bone, and will
Fig 2 (a) After making a double incomplete osteotomy and measuring the width in the axis of the bone, screw 1 (neutral) and screw 6 (eccentric, short) are inserted. (b) Eccentric hole is drilled at position 2. (c) Screw 1 is loosened and screw 6 is tightened, thus moving the plate 1 mm to the right. (d) Hole 5 is drilled eccentrically and the plate is removed.
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Fig 3 The osteotomy is completed and the plate reapplied. As screw 1 is tightened, the gap is narrowed by 1 mm (a) and by a further 1 mm as screw 2 is tightened (b). Screw 6 (neutral) and screw 5 are inserted and 1 mm of gap closure results from tightening screw 5 (c).
Fig 4 A further 1 mm closure is obtained, if necessary by an eccentric screw at position 4 (a), but before it is tightened screw 6 must be removed (b). The far cortex of hole 6 is drilled and a full length neutral screw is inserted. The osteotomy is compressed by a lag screw at position 3 (c).
DISCUSSION Jigs facilitate cutting of an osteotomy with exactly parallel surfaces and insertion of screws at positions which should ensure correct fitting of the plate. Our technique provides better visualisation of the ulna during the procedure and does not entail the purchase of equipment that may only be used infrequently. It will be apparent that screws 1, 2, 4 and 5 are ‘‘compression’’ screws that cause the underlying segments of bone to move and close the osteotomy. The function of screw 6 is merely to allow the plate to be positioned correctly, bearing in mind that there must always be at least one screw securing the plate to the bone on either side of the proposed osteotomy prior to cutting the osteotomy itself, and that two screw holes must be made in each fragment prior to osteotomy in order to ensure subsequent accurate alignment of the plate and bone ends. The correct order of screw insertion is not intuitive. The surgeon may wish to practice the technique on a
plastic bone or piece of wood, using a discarded plate and screws, and also to have a copy of the instructions available in the operating room. If an error is made in measurement of the osteotomy or in the screw insertion sequence, the bone movement provided by the four compression screws may be insufficient to close the osteotomy gap. There are then two options. Firstly, the plate can be replaced by a seven hole plate so as to introduce an additional screw beyond screw 1. We may call this screw 0. Its hole is drilled eccentrically, but before the screw is tightened it will be necessary to loosen screw 2 and remove screw 1. An attempt can then be made to drill a new hole for screw 1 (as for screw 6, to which it is now equivalent). If the proximity of the original hole precludes a secure grip in either cortex for the new screw 1, then the hole could be left unfilled as the four cortex fixation on this side of the osteotomy should suffice. The second option is to remove the plate and apply it to a different surface of the bone, though this will result in an undesirable excess of holes.
ARTICLE IN PRESS
ULNAR SHORTENING TECHNIQUE
Strong osteotomy compression forces can be applied by eccentric drilling. Once the osteotomy surfaces have made contact, no more than 1 mm of compression should be applied, so as to minimize the risk of fracture.
References Chun S, Palmer AK (1993). The ulnar impaction syndrome: follow-up of ulnar shortening osteotomy. Journal of Hand Surgery, 18A: 46–53. Jain R, Hudak P, Bowen CV (2000). Health status following recessional ulnar osteotomy. Hand Surgery, 5(1): 11–17. Labosky DA, Waggy CA (1996). Oblique ulnar shortening osteotomy by a single saw cut. Journal of Hand Surgery, 21A: 48–59. Loh YC, Van Den Abbeele K, Stanley JK, Trail IA (1999). The results of ulnar shortening for ulnar impaction syndrome. Journal of Hand Surgery, 24B(3): 316–320. Minami A, Kato H (1998). Ulnar shortening for triangular fibrocartilage complex tears associated with ulnar positive variance. Journal of Hand Surgery, 23A: 904–908.
457 Mizuseki T, Tsuge K, Ikuta Y (2001). Precise ulna-shortening osteotomy with a new device. Journal of Hand Surgery, 26A: 931–939. Rayhack JM, Gasser SI, Latta LL, Ouellette EA, Milne EL (1993). Precision oblique osteotomy for shortening of the ulna. Journal of Hand Surgery, 18A: 908–918. Wehbe MA, Cautilli DA (1995). Ulnar shortening using the AO small distractor. Journal of Hand Surgery, 20A: 959–964. Werner FW, Glisson RR, Murphy DJ, Palmer AK (1986). Force transmission through the distal radioulnar carpal joint: effect of ulnar lengthening and shortening. Handchirurgie Mikrochiurgie Plastische Chirurgie, 18: 304–308.
Received: 8 September 2003 Accepted after revision: 7 April 2004 Peter Burge FRCS, Nuffield Orthopaedic Centre, Headington, Oxford OX3 7LD, UK. Tel.: +44-1865-227477; fax: +44-1865-227740; E-mail: [email protected] r 2004 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhsb.2004.04.007 available online at http://www.sciencedirect.com
PRE-OSTEOTOMY PLATE APPLICATION TECHNIQUE FOR ULNAR SHORTENING R. CHENNAGIRI and P. BURGE From the Nuffield Orthopaedic Centre, Headington, Oxford OX3 7LD, UK
The self-compressing mode of the AO/ASIF LC-DC plate can be harnessed to close and compress modest osteotomy gaps that are created after provisional application of the plate with two screw holes on either side of the osteotomy. The oblique osteotomy cuts are made through 70% of the bone diameter and the actual osteotomy width is measured. After provisional plate application and removal, the cuts are completed and the plate is re-applied. Eccentric drilling of up to five holes of a 6-hole plate using the 3.5 mm universal drill guide allows closure and compression of osteotomy gaps of up to 4 mm. An interfragmentary screw is placed across the oblique osteotomy through the remaining hole. The technique is simple but requires careful planning and execution. Journal of Hand Surgery (British and European Volume, 2004) 29B: 5: 453–457 Keywords: ulna, shortening, osteotomy, technique, abutment
and then harnesses its dynamic compression mode to close the osteotomy gap.
INTRODUCTION Ulnar shortening osteotomy is widely used in the management of the ulnar abutment syndrome. The average shortening achieved varies between 2 and 4 mm (Chun and Palmer, 1993; Jain et al., 2000; Labosky and Waggy, 1996; Loh et al., 1999; Minami and Kato, 1998; Mizuseki et al., 2001; Rayhack et al., 1993; Wehbe and Cautilli, 1995), which is consistent with the biomechanical evidence that shortening by 2.5 mm reduces the proportion of radiocarpal load borne by the ulna from 18% to 4% (Werner et al., 1986). It is difficult to control the smooth bone ends accurately and surprisingly easy to achieve an imperfect reduction and/or inadequate compression when performing the technique freehand (i.e. cutting the osteotomy and then applying the plate). Although the plate can be applied to one end prior to osteotomy, it is still difficult to control and reduce the other fragment accurately. Application of a small external distraction device (Wehbe and Cautilli, 1995) can control the fragments, though this technique requires that the osteotomy is transverse and necessitates four additional pin holes through the ulna at right angles to the line of the plate. Jigs devised by Rayhack et al. (1993) and Loh et al. (1999), are fixed to the bone through screw holes that will be used subsequently for plate fixation, and provide slots to guide the osteotomy saw cuts. By drilling two holes on each side prior to osteotomy, accurate reduction is assured as the plate is applied. However, these devices tend to obscure the ulna once they are applied and necessitate the purchase of equipment that may only be used infrequently. We describe a method of ulnar shortening that assures accurate reduction by fixing the plate to the intact bone with two screws on each side of the proposed osteotomy
METHOD The dynamic compression plate achieves longitudinal compression of fracture fragments by movement of an eccentrically-drilled screw down the spherical sloping edge of the plate hole. The same principle can be used to close the gap of an ulnar shortening osteotomy. The Synthes (AO/ASIF) (Stratec Medical Ltd., Welwyn Garden City, UK) 6-hole 3.5 mm low contact dynamic compression plate (LC-DCP) (catalogue no. 223.560) has oval screw holes 7 mm in length. Movement of the bone beneath the plate is achieved by drilling the screw hole eccentrically within the plate hole. Use of the Universal Drill Guide (catalogue no. 323.360) in compression mode places the screw shank against the edge of the plate hole and achieves 1 mm movement of the bone in relation to the plate as the screw head engages the sloping edge of the plate hole (Fig 1a and b). A gap of 2.5 mm then remains between the screw shank and the opposite edge of the plate hole. If a second eccentric screw is placed in another hole on the same side of the osteotomy, the first screw moves a further 1 mm, leaving a 1.5 mm gap between its shank and the opposite edge of its plate hole. Insertion of a third eccentric screw moves the first screw another 1 mm, of which 0.5 mm leaves the first screw head flush with the plate hole while the second 0.5 mm takes it up the sloping edge of the hole so that it sits slightly proud of the plate (Fig 1c and d). Sequential eccentric drilled holes on one side of the osteotomy can therefore produce 2.5 mm of bone movement relative to the plate before the first screw-head rides up the opposite edge of its screw hole. 453
ARTICLE IN PRESS
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Fig 1
THE JOURNAL OF HAND SURGERY VOL. 29B No. 5 OCTOBER
2004
A screw inserted eccentrically (a) moves 1 mm with respect to the plate as it is tightened (b). As another eccentrically-placed screw is tightened in another hole in the plate, the first screw moves a further 1 mm (c). Insertion of a third eccentric screw moves the first screw another 1 mm, of which the second 0.5 mm takes the screw head up the sloping edge of the hole so that it sits slightly proud of the plate (d). A total screw movement of 2.5 mm is therefore possible before the first screw head begins to ride up in its hole.
The problem is how to drill enough eccentric holes before the osteotomy has been cut. In order to define the position of the plate with respect to the intact bone, two holes must be drilled on either side of the proposed osteotomy. But it will be evident that if the plate is held against the bone and two eccentric screw holes are drilled on the same side of the osteotomy, only 1 mm of bone movement will result – the holes are effectively in the same position and their effect is not additive. There is no possibility of drilling a ‘‘more eccentric’’
hole. Two millimetre total movement can be produced by eccentric drilling of screw holes on either side of the osteotomy if the four holes are drilled before the osteotomy is cut, and if one hole is to be used for a lag screw across the osteotomy, only one hole of the sixhole plate remains for an eccentric screw after cutting the osteotomy; thus the maximum total movement is 3 mm. The pre-osteotomy drilling sequence described below allows 3 mm movement to be built in prior to osteotomy.
ARTICLE IN PRESS
ULNAR SHORTENING TECHNIQUE
455
OPERATIVE TECHNIQUE
enforce an accurate reduction of the osteotomy. Screw holes 1, 2 and 5 will move the bone with respect to the plate and close the osteotomy. Additional movement will be obtained, if necessary, with hole 4. The osteotomy cuts are completed and the surfaces inspected to ensure that they are smooth and flat (Fig 3). The plate is applied and screws inserted in the sequence 1, 2, 5, and 6. As each of screws 1, 2 and 5 are tightened, it will be seen that the osteotomy gap closes by 1 mm. The osteotomy is then inspected. If the ends are firmly in contact and no further compression is needed, screw 4 is inserted centrally and screw 6 is replaced with a full length screw. If further closure of the osteotomy is required, screw 4 is inserted eccentrically but its head is left proud of the plate (Fig 4). Before it can be tightened, it is necessary to remove screw 6, which would otherwise abut on the edge of its screw hole as it is carried towards the osteotomy by movement of the bone beneath the plate. Screw 5 is loosened and screw 4 is tightened, taking care to avoid excessive compression that could lead to fracture of one of the osteotomy surfaces. It will now be apparent that the position of hole 6 will not allow a screw to be inserted to its full depth because the drill hole is too close to the osteotomy side of the plate hole. Therefore, a new drill hole is made in the far cortex, ignoring the hole in the near cortex. This screw will have purchase in only the far cortex, but its hold should be good and there will be fixation in five cortices on this side of the osteotomy. Finally, an interfragmentary screw is placed across the osteotomy through hole 3.
The desired amount of shortening is estimated from the radiographs. The level of the osteotomy is marked and an oblique saw cut is made, angled proximally and cutting through about 70% of the bone. A saw blade is placed into the cut to act as a guide and a parallel second cut is made an appropriate distance away, again cutting only 70% of the bone. The actual width of the osteotomy cut is now measured and recorded, and it may be slightly different from the pre-determined width. This is unlikely to affect ulnocarpal loading significantly, but it is the actual width that determines the number of plate holes at which compression will be required in order to close the osteotomy gap (Fig 2). The plate is then placed on the bone so that the proximal osteotomy cut is level with distal edge of hole 3 in the plate. Hole 1 is drilled eccentrically and the screw inserted, ensuring that its head is tight up against the edge of the plate hole away from the osteotomy when it is fully seated. This can be achieved by pulling the plate towards the osteotomy as the screw is tightened. Hole 6 is then drilled eccentrically through the near cortex only and a uni-cortical screw is inserted, leaving its head just proud of the plate. Hole 2 is drilled eccentrically but no screw is inserted at this stage. Loosening of screw 1 and tightening of screw 6 then moves the plate to the right by 1 mm and allows another eccentric screw hole to be drilled at position 5. Now the two screw holes on either side of the osteotomy have fixed the relationship of the plate to the bone, and will
Fig 2 (a) After making a double incomplete osteotomy and measuring the width in the axis of the bone, screw 1 (neutral) and screw 6 (eccentric, short) are inserted. (b) Eccentric hole is drilled at position 2. (c) Screw 1 is loosened and screw 6 is tightened, thus moving the plate 1 mm to the right. (d) Hole 5 is drilled eccentrically and the plate is removed.
ARTICLE IN PRESS
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THE JOURNAL OF HAND SURGERY VOL. 29B No. 5 OCTOBER
2004
Fig 3 The osteotomy is completed and the plate reapplied. As screw 1 is tightened, the gap is narrowed by 1 mm (a) and by a further 1 mm as screw 2 is tightened (b). Screw 6 (neutral) and screw 5 are inserted and 1 mm of gap closure results from tightening screw 5 (c).
Fig 4 A further 1 mm closure is obtained, if necessary by an eccentric screw at position 4 (a), but before it is tightened screw 6 must be removed (b). The far cortex of hole 6 is drilled and a full length neutral screw is inserted. The osteotomy is compressed by a lag screw at position 3 (c).
DISCUSSION Jigs facilitate cutting of an osteotomy with exactly parallel surfaces and insertion of screws at positions which should ensure correct fitting of the plate. Our technique provides better visualisation of the ulna during the procedure and does not entail the purchase of equipment that may only be used infrequently. It will be apparent that screws 1, 2, 4 and 5 are ‘‘compression’’ screws that cause the underlying segments of bone to move and close the osteotomy. The function of screw 6 is merely to allow the plate to be positioned correctly, bearing in mind that there must always be at least one screw securing the plate to the bone on either side of the proposed osteotomy prior to cutting the osteotomy itself, and that two screw holes must be made in each fragment prior to osteotomy in order to ensure subsequent accurate alignment of the plate and bone ends. The correct order of screw insertion is not intuitive. The surgeon may wish to practice the technique on a
plastic bone or piece of wood, using a discarded plate and screws, and also to have a copy of the instructions available in the operating room. If an error is made in measurement of the osteotomy or in the screw insertion sequence, the bone movement provided by the four compression screws may be insufficient to close the osteotomy gap. There are then two options. Firstly, the plate can be replaced by a seven hole plate so as to introduce an additional screw beyond screw 1. We may call this screw 0. Its hole is drilled eccentrically, but before the screw is tightened it will be necessary to loosen screw 2 and remove screw 1. An attempt can then be made to drill a new hole for screw 1 (as for screw 6, to which it is now equivalent). If the proximity of the original hole precludes a secure grip in either cortex for the new screw 1, then the hole could be left unfilled as the four cortex fixation on this side of the osteotomy should suffice. The second option is to remove the plate and apply it to a different surface of the bone, though this will result in an undesirable excess of holes.
ARTICLE IN PRESS
ULNAR SHORTENING TECHNIQUE
Strong osteotomy compression forces can be applied by eccentric drilling. Once the osteotomy surfaces have made contact, no more than 1 mm of compression should be applied, so as to minimize the risk of fracture.
References Chun S, Palmer AK (1993). The ulnar impaction syndrome: follow-up of ulnar shortening osteotomy. Journal of Hand Surgery, 18A: 46–53. Jain R, Hudak P, Bowen CV (2000). Health status following recessional ulnar osteotomy. Hand Surgery, 5(1): 11–17. Labosky DA, Waggy CA (1996). Oblique ulnar shortening osteotomy by a single saw cut. Journal of Hand Surgery, 21A: 48–59. Loh YC, Van Den Abbeele K, Stanley JK, Trail IA (1999). The results of ulnar shortening for ulnar impaction syndrome. Journal of Hand Surgery, 24B(3): 316–320. Minami A, Kato H (1998). Ulnar shortening for triangular fibrocartilage complex tears associated with ulnar positive variance. Journal of Hand Surgery, 23A: 904–908.
457 Mizuseki T, Tsuge K, Ikuta Y (2001). Precise ulna-shortening osteotomy with a new device. Journal of Hand Surgery, 26A: 931–939. Rayhack JM, Gasser SI, Latta LL, Ouellette EA, Milne EL (1993). Precision oblique osteotomy for shortening of the ulna. Journal of Hand Surgery, 18A: 908–918. Wehbe MA, Cautilli DA (1995). Ulnar shortening using the AO small distractor. Journal of Hand Surgery, 20A: 959–964. Werner FW, Glisson RR, Murphy DJ, Palmer AK (1986). Force transmission through the distal radioulnar carpal joint: effect of ulnar lengthening and shortening. Handchirurgie Mikrochiurgie Plastische Chirurgie, 18: 304–308.
Received: 8 September 2003 Accepted after revision: 7 April 2004 Peter Burge FRCS, Nuffield Orthopaedic Centre, Headington, Oxford OX3 7LD, UK. Tel.: +44-1865-227477; fax: +44-1865-227740; E-mail: [email protected] r 2004 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhsb.2004.04.007 available online at http://www.sciencedirect.com