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Acta Orthop. Belg., 2012, 78, 317-323 ORIGINAL STUDY

Ulna-shortening osteotomy : subjective appreciation and

long-term functional outcome

Alexandra CHERCHEL, Sophie VAnDEnDUnGEn, Jean-Pierre MOERMAnS, Pascal LEDOUx

From the Clinique du Parc Léopold, Brussels, Belgium

Ulna-shortening osteotomy is a therapeutic option for fracture, physeal injury, or Essex-Lopresti injury. It
ulnar impaction syndrome. We aimed to assess the may also be idiopathic, or present only during
long-term subjective and functional outcome after power grip, particularly when it is combined with
ulna-shorteming osteotomy. We conducted a retro- forearm pronation (7).
spective study of 18 patients presenting with ulnar The principle behind the treatment of ulnar
impaction syndrome of various aetiologies, with an
impaction syndrome is ulno-carpal decompression.
average follow-up of 5.9 ± 3.4 years. Seventeen
patients (94.4%) were satisfied and would undergo
Frequently used surgical treatment alternatives for
the operation again. Although most patients reported ulnar impaction syndrome are the wafer procedure
residual complaints (83.3%) such as weakness (38%) and ulna-shortening osteotomy (9). The technique of
or pain under given specific circumstances, objective ulna-shortening osteotomy was originally described
measurements of wrist function were good. The aver- by Milch in 1941 ; it then consisted in performing
age Mayo Wrist Score was 75.9 ± 13.4 (n = 16) and an oblique osteotomy fixated with a wire (11). The
the average DASH score was 18.0 ± 13 (n = 12). goal of the current study was to assess the long-
Comparison of the operated and healthy limb did not term subjective and functional outcome after ulna-
show any significant difference in strength or range shortening osteotomy.
of motion, except for significantly reduced flexion on
the operated side (p < 0.05). In this study, ulna-short-
ening osteotomy provided a good functional outcome
and high subjective satisfaction over the long term.
Keywords : ulnar impaction syndrome ; ulna-shortening
osteotomy. ■ Alexandra Cherchel, MD, Plastic Surgery Resident.
Plastic Surgery Department, CHU Brugmann, Free
University of Brussels, Belgium.
■ Sophie Vandendungen, MD, Staff Orthopaedic Surgeon.
INTRODUCTION ■ Jean-Pierre Moermans, MD, PhD, Professor and Staff
Plastic Surgeon.
Ulnar impaction syndrome is the degenerative ■ Pascal Ledoux, MD, Staff Orthopaedic Surgeon.
■ Hand Surgery Center, Parc Léopold Clinic, Brussels,
process which affects the ulnocarpal joint when it
Belgium.
undergoes a chronic overload of compressive Correspondence : Dr. Alexandra Cherchel, CHU Brugmann,
forces. Ulnar-positive variance increases ulno- Département de Chirurgie, Place A. Van Gehuchten, 4,
carpal loading and is thus a risk factor for ulnar 1020 Laeken, Belgium.
impaction syndrome. An ulnar-positive variance E-mail : [email protected]
may be acquired from radial shortening after wrist © 2012, Acta Orthopædica Belgica.

No benefits or funds were received in support of this study Acta Orthopædica Belgica, Vol. 78 - 3 - 2012
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318 A. CHERCHEL, S. VAnDEnDUnGEn, J.-P. MOERMAnS, P. LEDOUx

MATERIALS AND METHODS

Recruitment of patients was performed by entering

the search term “ulna” in a patient database of the
Clinique du Parc Léopold, covering the years 1998 to
2009. Forty seven patients whose operation label was
«ulna-shortening osteotomy» were retrieved. We were
able to obtain a consultation and clinical examination for
19 of those patients. One patient was excluded, as he is
officially an invalid since the initial accident which
caused a wrist fracture. Seven different surgeons operat-
ed on the patients selected for this study.
The initial medical history and operative data were
gathered from the medical records. During the consulta-
tion, any information missing in the history was added,
the patients underwent a clinical examination, and addi-
tional questions were asked. We sought to find out about
a b
the patients’ subjective appreciation of the operation and
whether they would go through the operation again. We
Fig. 1. — Preoperative wrist radiograph of a 48-year-old man
inquired about any changes in sports or hobby perform- showing a positive ulnar variance of 2 mm and immediate post-
ance and finally, we asked the patients to state any cur- operative view.
rent complaints and answer with “yes” or “no” to the
presence or absence of the following set of complaints :
ulnar-sided wrist pain, clicking, wrist popping, weak-
ness, stiffness or swelling. The clinical examination, in type of trauma included a fracture in 38.9% of cases
addition to inspection and palpation, included range of (7/18), or did not involve any bony lesion in 33.3%
motion measurement and Jamar strength testing. The of cases (6/18). In 4 patients (22.2%), the ulnar
standardized outcome tests used were the DASH and the impaction syndrome was idiopathic, and in a single
Mayo Wrist Score. Antero-posterior (AP) radiographs of case, it was secondary to epiphysiodesis (5.6%).
the wrist were taken, as well as AP and lateral views of In terms of prior surgeries aiming to treat ulnar-
the forearm. Ulnar variance was then measured accord- sided wrist pain, two patients in our series had
ing to the technique of perpendiculars (16). undergone arthroscopy prior to the ulna-shortening
Statistical analysis was performed using the
osteotomy. In both cases, an arthroscopic shaving
nCSS97™ software (number Cruncher Statistical
Systems, Kaysville, Utah). Strength testing and all range
was performed, and in one of them, an arthroscopic
of motion measurements except pronation and supina- wafer resection followed three months later. In
tion were compared using Student’s t-test. P values addition, the patient who suffered a physeal damage
< 0.05 were considered statistically significant. had undergone radial distraction prior to the ulna-
shortening osteotomy.
RESULTS Fixation of the ulna osteotomy was with a plate
and screws in 17 patients (94.4%) (Fig. 1), while an
The total population studied included 18 patients. intramedullary nail was used in only one patient.
Ten patients were male (55.6%) and eight were Plate fixation was supplemented by a bone graft in
female (44.4%). The average age was 51.9 ± 33.3% of cases (6/18) and by Chronos™ bone graft
14.5 years and the average age at surgery was substitute in one patient (5.6%).
46.0 ± 14.1 years. In half of the patients, the operat- The average ulnar variance prior to operation
ed hand was the dominant hand. The average was +3.6 ± 2.5 mm (n = 9). According to operation
follow-up duration was 5.9 ± 3.4 years. notes, the median resection length was 3 mm
In 77.8% of cases (14/18), the aetiology of the (range : 2-11 mm) (n = 18). The current average
ulnar impaction syndrome was post-traumatic. The ulnar variance was -0.4 ± 2.1 mm (n = 18).

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ULnA-SHORTEnInG OSTEOTOMy 319

The only complication found in the series was Table I. — Types of complaints reported by patients
delayed healing of the osteotomy in a patient with Complaint n % (n = 18)
psoriatic arthritis, who was being treated with anti- Weakness 7 38.9
TnF medication.
Pain (unspecified) 4 22.2
The fixation material was removed in 12 patients.
Pain upon leaning on hand 4 22.2
This was done as a systematic measure in 4 patients ;
Stiffness 4 22.2
in the others, the hardware was removed because of
complaints consisting of various combinations of Decreased range of motion 4 22.2
discomfort, pain and swelling. Barometric pressure pain 3 16.7
When asked whether they would go through the Pain during specific activity 2 11.1
operation again or not, 94.4% (17/18) of the Scar pain 2 11.1
patients said that they would. Only one patient said Swelling 2 11.1
that he would not choose to be operated again. «Popping» 2 11.1
Although he presented no striking anomalies on
clinical examination or on test scores (DASH score
5.6, Mayo Wrist Score 75), the patient complained
of stiffness, reduced range of motion and inability Of the 12 patients who have a particular sport or
to bear weight on a flat open hand, thus forcing him hobby, 41.7% were able to resume their activity of
to rest on his fist instead. choice undisturbed. The others either had to adapt
In our series, only 3 patients had strictly no com- or refrain from engaging in their sport/hobby.
plaint regarding the operated limb (16.7%). Among The average Mayo Wrist score was 75.9 ± 13.4
the complaints currently reported by our patients, (n = 16). Two patients were excluded from this
weakness was present in 7/18 patients, making it measurement due to contralateral pathology. The
the most common complaint. It is noteworthy that DASH score was available only for 12 patients. The
in all of those patients, the aetiology of the ulnar two above mentioned patients were excluded, as
impaction syndrome was traumatic, whether with were three other patients who answered less than
or without fracture. Other types of complaints the required 27 items on the test (5), and one patient
include scar pain, pain in a various circumstances, who declined to take the test. While it was offered
stiffness, swelling, and «popping» of the wrist to her in her native language, she was not literate in
(Table I). that language and was thus unable to answer. The
Only 17 patients were submitted to clinical average DASH score was 18.0 ± 13.9. Where appli-
examination comparing Jamar strength testing and cable, the optional DASH modules were calculated.
range of motion of the operated limb to that of The median sport/music DASH module score was
the healthy limb. One patient was excluded due 28.15 (range 0-100) (n = 8), and the median work
to severe contralateral limb pathology. The only DASH module score was 25.0 (range 0-68.8) (n =
parameter that was significantly different between 11).
both limbs was flexion (p < 0.05), which was limit-
ed in the affected limb (Table II). DISCUSSION
Regarding pronation, only one patient presented
with a pronation deficit of 20° compared to the This retrospective study involved a small number
contralateral wrist. Five patients out of 17 present- of patients. However, the average follow-up on
ed with a supination deficit (29.4%). The average our patients at 5.9 years is longer than in previous
supination in that subgroup was measured at similar studies, in which it was between
48 ± 29.5°. All those patients had post-traumatic 18.5 months (15) and at best 51 months (3).
ulnar impaction syndrome, and a supination deficit Ulna-shortening osteotomy for ulnar impaction
had been documented pre-operatively in three of syndrome has provided a high level of subjective
them. satisfaction in a number of other studies. In the

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320 a.  CHERCHEl,  S. vaNDENDUNGEN,  j.-P.  mOERmaNS,  P.  lEDOUx

Table II. — Comparison of strength and wrist range of motion between the operated limb and the healthy limb
Parameter Operated limb Healthy limb Difference
(average) (average)
Grip strength (kg)  31.4 ± 13.2 35.1 ± 16.0 NS
Flexion (°) 54.7 ± 14.4 65 ± 12.1 p < 0.05
Extension (°) 62.4 ± 13.9 61.8 ± 13.3 NS
Flexion-extension range (°) 117.1 ± 24.6 126.8 ± 22.2 NS
Radial inclination (°) 20.3 ± 7.8 22.8 ± 6.8 NS
Ulnar inclination (°) 39.4 ± 12.1 40.6 ± 9.5 NS
Inclination range (°) 59.1 ± 14.1 62.6 ± 10.3 NS

study  by  Fricker  et al on  26  patients  with  post- When  considering  the  surgical  history  of  our
t raumatic  ulnar  impaction  syndrome,  23 patients patients, it appears that we have made use of thera-
stated that they were satisfied with the operation at peutic  arthroscopy  in  proportions  similar  to  Chun
an average follow-up of 21 months (6). Petersen et and Palmer (3) and Fricker (6) but much less so than
al studied  a  similar  population  composed  of a number of other authors who performed a thera-
16 patients  followed  for  a  median  time  of peutic  arthroscopic  action  in  at  least  half  of  their
18.5 months ; 13 patients would undergo the opera- patients (10,12,14,15).
tion again and 75% of them experienced significant With  an  average  DaSH  score  of  18,  we  have  a
pain relief (15). In the population of loh et al, a sig- slightly  better  result  than  moermans  et al, whose
nificant  reduction  in  pain  as  assessed  by  a  visual final DaSH score was 26 at an average follow-up
analogue scale was found at an average follow-up time  of  29  months.  Nonetheless,  the  result  in  that
of 33.1 months (10). as our results demonstrate, this series represents a statistically significant improve-
satisfaction appears to be maintained over time.  ment on the preoperative DaSH which the authors
In  spite  of  subjective  improvement,  we  have had  measured  at  40 (12). The  score  that  we  have
found that most patients do have one or more com- obtained  illustrates  a  good  functional  outcome
plaints  relative  to  the  affected  wrist.  None  of  the which persists on the longer term. 
complaints in our series have required further surgi- The  Gartland  and  Werley  score  has  also  been
cal management. However, some cases reported in used  by  other  authors  to  evaluate  the  outcome  of
the  literature  have  required  subsequent  aggressive ulna-shortening  osteotomy.  Their  results  have
management  such  as  a  Sauvé-Kapandji  proce- shown  a  significant  postoperative  improvement  in
dure (12), a new osteotomy, or a wafer procedure (15). subjective  pain  score,  subjective  and  objective
all  corrections  were  indicated  for  persistent  pain. range  of  motion  scores,  strength  score,  and  mean
Complaints otherwise related to the fixation materi- wrist score (1,3).
al appear to be common (10,12,15). Significant improvement in the range of motion
We have found a single case of delayed union in is also noted in the study by moermans et al (12). The
our series of 18 patients. This complication is pres- retrospective nature of our study did not allow us to
ent  in  almost  similar  proportions  in  the  series  of gather  sufficient  data  for  extensive  pre-  and  post -
moermans  et al (2/28  patients) (12) and  Fricker operative  range  of  motion  comparison.  How ever,
(2/26  patients) (6), while  the  rate  is  higher  in  the comparison between the operated and healthy limb
series of Oskam (2/10 patients) (14). Other types of has  allowed  us  to  see  that  both  limbs  are  equally
complications reported by multiple authors include strong and mobile, except for flexion, which is sig-
non-union (10,12,15),  reflex  sympathetic  dystro- nificantly more limited on the operated side. 
phy (1,10) and  symptoms  of  damage  to  the  dorsal Constantine et al have compared ulna-shortening
ulnar nerve branch (6,10,12,15). osteotomy  and  wafer  resection  in  two  groups  of

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ULnA-SHORTEnInG OSTEOTOMy 321

11 patients each. Darrow’s criteria yielded a subjec- Our results are comparable to those of the wafer
tive outcome which was rated excellent for procedure in terms of subjective appreciation and
9 patients in the ulnar-shortening osteotomy group, objective outcome. We have reported a more varied
and good for 8 patients in the wafer resection group. set of residual complaints in our series than in the
no significant difference was found in grip strength studies reviewed on wafer procedures (13,17).
or range of motion analysis between the two groups. Residual pain appears to be present in a fairly
However, there were significant differences between greater proportion of our patients. The aforemen-
the two populations in terms of age, follow-up, ulnar tioned studies have an average follow-up ranging
variance and resection length. The authors conclude between 27 and 32 months, which is somewhat less
that both methods can treat ulnar impaction syn- than half of our average follow-up.
drome successfully, however, they are cautious The complications of ulnar-shortening osteoto-
about stating that the techniques are interchange- my are directly related to the osteotomy in the form
able, due to the difference in ulnar variance (4). of non-union (10,12,14) or delayed union (6,12,14) as
Subjective satisfaction with the wafer resection in our series, whereas the comlications of the wafer
is also high in other series of patients. Feldon et al, procedure tend to target surrounding tissues which
who initially described the procedure, has obtained are more subject to damage than those encountered
69% excellent results and 31% good results during an ulnar-shortening osteotomy.
according to Darrow’s criteria for his series of Proponents of the wafer resection cite the
12 patients (5). In a group of 11 patients, nagle and absence of hardware-related complications risk and
Bernstein have obtained 64% excellent results the absence of bone union requirements as an
using the same criteria, and 18% each of good, fair, advantage of the wafer osteotomy (13,17). While no
and poor results (13). Tomaino and Shah’s study bone healing or hardware removal is necessary for
yielded equally positive results with 23/26 patients a wafer resection, the ulna-shortening osteotomy
being rated as completely satisfied based on a visu- offers the advantage of minimally altering the wrist
al analogue scale. The other 3 patients presented compartment by preserving the cartilaginous edge
persistent pain, one of them actually requiring revi- of the ulna. Barry and Macksound have proposed a
sion to a distal ulnar resection (17). cartilage-retaining open wafer resection technique.
Objective evaluations of the wafer resection are They present a retrospective study of 7 patients
generally favourable. Grip strength appears to be followed for an average of 30 months ; in 5 patients
maintained (5,17). In terms of range of motion, some available for a longer follow-up, they report a
studies report a maximum loss of range of motion good improvement on a visual analog scale pain
of 10 degrees in any plane (4,5). Tomaino and Shah score and preserved range of motion. They report
report preservation of forearm rotation and wrist one case of complex regional pain syndrome and
flexion and extension in 64% and 68% of their one case of extensor carpi ulnaris tendonitis (2).
patients, respectively ; they also report a maximum This technique could potentially offer a compro-
average loss of motion of 20° for pronation and 13° mise, reconciling the advantages of both tech-
for supination. The authors specify that the residual niques.
range of motion was within the functional range for In conclusion, the high satisfaction rate and good
all patients at final follow-up. functional outcome in our patient series suggest that
Complaints reported by patients after a wafer ulna-shortening osteotomy is a valid therapeutic
procedure essentially consist of residual pain (13,17), option several years after surgery. However, we
usually in a small number of patients. A frequently recognize that this study has some weaknesses due
reported complication is tendonitis, most particular- to its retrospective nature. The preoperative data
ly extensor carpi ulnaris tendonitis (5,13, 17). Other that could be gathered was scarce, and unfortu-
types of complications include an ulno-carpal scar nately, many patients were lost to follow-up so that
requiring débridement, a dorsal wrist ganglion, and only a small population of patients was available
portal site erythema treated by antibiotics (13). for analysis.

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322 A. CHERCHEL, S. VAnDEnDUnGEn, J.-P. MOERMAnS, P. LEDOUx

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