Oblique Ulnar Shortening Osteotomy With a New Plate and Compression System

| D I S T A L R A D I O U L N A R J O I N T S Y M P O S I U M |

Oblique Ulnar Shortening Osteotomy Witha New Plate and Compression SystemAnthony J. Lauder, MDDepartment of Orthopaedic Surgery and RehabilitationUniversity of Nebraska College of MedicineOmaha, NE

Shai Luria, MDHand and Microvascular SurgeryUniversity of Washington Hand Surgery InstituteDepartment of Orthopaedics and Sports MedicineUniversity of WashingtonSeattle, WA

Thomas E. Trumble, MDUniversity of Washington Hand Surgery InstituteDepartment of Orthopaedics and Sports MedicineUniversity of WashingtonSeattle, WA

| ABSTRACT

Ulnocarpal abutment or the ulnocarpal impaction syn-

drome occurs when excessive loads exist between the

distal ulna and ulnar carpus. This overloading occurs as

a result of the distal ulnar articular surface being more

distal than the ulnar articular surface of the distal radius.

This situation has been termed positive ulnar variance,

and it can quickly lead to ulnar-sided wrist degenerative

changes and functional losses. Patients often have

vague, ulnar-sided complaints of chronic pain and

swelling with an insidious onset that does not correlate

with any specific traumatic event. Many procedures

have been developed to alleviate this condition, but the

gold standard for correcting positive ulnar variance is

the ulnar shortening osteotomy. The goals of the

shortening procedure are to relieve pain and prevent

arthritis by reestablishing a neutral or slightly negative

ulnar variance. We describe a new plate and compres-

sion system in which an oblique ulnar diaphyseal

osteotomy is both completed and stabilized through

the same jig-based system.

Keywords: ulnar shortening, osteotomy, impaction,

variance

| HISTORICAL PERSPECTIVE

Ulnar variance, defined as the difference in length

between the distal ulnar corner of the radius and

distalmost aspect of the dome of the ulnar head, is

positive when the dome of the distal ulna is more distal

than the ulnar corner of the distal radius (Fig. 1).

Generally, the radius receives 82% of the load borne

through the wrist, whereas the ulna receives 18% of the

force. However, Palmer and Werner1 showed that loads

through the distal ulna can change and are directly

related to ulnar variance. Increasing ulnar length by 2.5

mm raises ulnar loads to 42%, whereas a decrease in

length of 2.5 mm lowers the force seen at the distal ulna

to 4.3%. Furthermore, that same study revealed that

73% of wrists with triangular fibrocartilage complex

(TFCC) tears had either ulnar positive or neutral

variance. This indicates that overloading of the ulnar

wrist can ultimately lead to injury and degeneration of

the TFCC.

The ulnar shortening osteotomy was first described

by Milch2 in 1941 for a 17-year-old patient with an

ulnar positive wrist after a distal radius fracture. Milch’s

technique entailed resection of a portion of the distal

ulna with wire fixation at the osteotomy site. Since its

inception, numerous authors have described various

osteotomy types, including transverse,3,4 oblique (of

varying degrees),4Y8 sliding (long oblique),9 and step-

cut.10 Several commercially available systems have

Techniques in Hand and Upper Extremity Surgery 11(1):66–73, 2007 � 2007 Lippincott Williams & Wilkins, Philadelphia

Address correspondence and reprint requests to Anthony J. Lauder,MD, 981080 Nebraska Medical Center, Omaha, NE 68198-1080.E-mail: [email protected].

Techniques in Hand and Upper Extremity Surgery66

Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

been developed to facilitate bony contact, compression,

and rigid fixation at the osteotomy site.4,8,9

Attempting to elucidate which osteotomy provides

both stability and rapid healing potential, while remain-

ing easy to perform, can be an arduous task. Many

authors have reported good results with the osteotomy

methods mentioned. In 1995, Wehbe and Cautilli3

reported on their results for ulnar shortening using a

transverse osteotomy and the Arbeitsgemeinschaft fur

Osteosynthese (AO) small distractor. In their 24 patients

with ulnar impaction syndrome, they had no nonunions

and an average time to healing of 9.7 weeks. They did

have 3 delayed unions, but these reportedly healed

without incident by 28, 34, and 36 weeks.

In 2005, Darlis et al10 reported their results on 29

patients who underwent a step-cut osteotomy of the ulna

for various pathological conditions. Average time to

union was 8.3 weeks, and they had no delayed unions or

nonunions. Although these authors deem this a simple

technique, it does require more cuts than transverse or

oblique osteotomies.

Many surgeons today prefer an oblique osteotomy

based in large part on a 1993 study by Rayhack et al.4

That study compared 23 transverse osteotomies, in

which a specialized external compression device was

used, with 17 oblique osteotomies, in which a cutting

guide designed by the lead author was used. Average

healing time for the transverse osteotomies was 21

weeks compared with 11 weeks for the oblique group.

Furthermore, 1 nonunion was noted for the transverse

group. Importantly, Rayhack et al4 also reported on the

biomechanical differences between the 2 constructs.

Cadaveric data revealed no significant difference be-

tween the oblique or transverse cuts in regard to

anteroposterior or lateral bending strength. The oblique

osteotomy, however, was found to be significantly

stiffer in torsion.

The excellent results reported by Rayhack et al4 have

largely been substantiated by several other authors using

different systems for performing oblique osteotomies.

Reporting on 27 patients (30 osteotomies), Chun and

Palmer5 described their results for the oblique osteo-

tomy using a freehand technique. The wrists were graded

both preoperatively and postoperatively with a modified

Gartland and Werley11 system. Preoperatively, 28 wrists

were graded poor, and 2 fair. Postoperatively, 24 wrists

were graded excellent, 4 good, 1 fair, and 1 poor.

They had no nonunions. Chen and Wolfe6 also

reported good results for the oblique osteotomy using

a freehand technique and an AO compression device.

Preoperatively, 14 wrists were graded fair, and 4 poor,

whereas postoperatively, 13 were graded excellent,

3 good, and 2 fair. They also had no nonunions. Most

recently, Mizuseki et al8 reported their results for

24 oblique osteotomies created by their own device.

Healing time averaged 8.1 weeks, and they had no

nonunions.

| INDICATIONS/CONTRAINDICATIONS

The most common indication for implementing the

shortening osteotomy is pain stemming from an ulnar

impaction syndrome. Other less common indications

include nonrepairable tears of the TFCC, previous radial

FIGURE 1. Ulnar variance is the difference in lengthbetween the ulnar corner of the radius and the articulardome of the distal ulna. UV indicates ulnar variance.Reprinted with permission from Trumble TE. Distal radio-ulnar joint and triangular fibrocartilage complex. In:Trumble TE, ed. Principles of Hand Surgery and Therapy.Philadelphia, PA: WB Saunders; 1999:130.

FIGURE 2. Patients with overloading of the distal ulna orTFCC pathology will often have tenderness and/orswelling in an area just distal to the ulnar styloid.

Volume 11, Issue 1 67

A New System for Oblique Ulnar Shortening Osteotomy


head excision and associated Essex-Lopresti lesions,

attritional lunotriquetral ligament tears, ulnar nonun-

ions, radial malunions, and early posttraumatic distal

radioulnar joint arthritis. Importantly, the ulnar shorten-

ing osteotomy should not be performed in isolation for

radial malunions that include deformity other than just

shortening. Furthermore, the shortening should not be

performed alone in Essex-Lopresti situations, where the

radial head has been previously excised. In this instance,

continued shortening of the radius would be expected,

unless the osteotomy was performed in conjunction with

a radial head replacement.

A preoperative workup should include information

on antecedent trauma, duration of symptoms, and the

location of pain. Patients who benefit from an ulnar

shortening osteotomy generally relate a history of ulnar-

sided wrist pain that is exacerbated by pronation/

supination activities and forceful grip. Often, there will

be a history of prior trauma that led to an ulnar positive

wrist that now impacts on the ulnar carpus. On

examination, many patients will have swelling and

tenderness localized to the TFCC and distal ulna

(Fig. 2). The ulnar impaction maneuver, performed

FIGURE 4. A true PA view of the wrist. Note the ulnarand radial styloids, making up the outermost ulnar andradial portions on the radiograph.

FIGURE 3. The ulnar impaction ma-neuver is performed by ulnarly deviat-ing the wrist (A) and translating thecarpus in volar and dorsal directions(B). This maneuver is positive whenpain is elicited.

FIGURE 5. Intraoperative photograph demonstrating the15-cm incision and volar plate placement. Most often, thevolar surface is the broadest and flattest for plateapplication. Baby Homan retractors protect the underlyingsoft tissues.


Lauder et al


by moving an ulnarly deviated wrist in a volar and

dorsal direction, can help elicit pain that stems from

the TFCC and ulnar impaction (Figs. 3A, B).

Radiographic evaluation begins with plain postero-

anterior (PA) and lateral radiographs of the affected

wrist. The PA view should be taken with the shoulder

abducted to 90 degrees, elbow flexed to 90 degrees, and

the wrist in neutral rotation. A true PA view should have

the ulnar styloid at the far ulnar position (Fig. 4). The

importance of a true PA view stems from the fact that

rotation at the wrist can increase (pronation) or decrease

(supination) ulnar variance. Plain radiographs of the

contralateral wrist may be helpful for determining the

amount one wants to shorten the ulna. Contralateral

views are not as useful, however, when that wrist is also

ulnar positive. A magnetic resonance image or arthro-

gram may be a reasonable adjunct to the radiographic

evaluation when the surgeon suspects an acute, possibly

repairable, tear of the TFCC. Trumble et al12 combined

arthroscopic repairs of the TFCC with ulnar shortening

osteotomies. Their patients regained 83% of their total

range of motion and 81% of their grip strength when

compared with the contralateral side. In 19 of 21

patients, pain symptoms improved from complaints of

pain even with routine activities to having complete

relief of pain with all activities postoperatively. The

other 2 patients had decreased levels of pain after

surgery but continued to have occasional discomfort

with some heavy activities.

| TECHNIQUE

SetupThe required and optional equipment needed for the

ulnar shortening osteotomy is minimal. The procedure,

as described here, does require an ulnar shortening

system from Trimed (Valencia, Calif). Other equip-

ments required for this procedure include a radiolucent

lateral arm board, a fluoroscopy machine, a wire driver

and drill, a lobster claw reduction forceps, a set of

baby Homan retractors, and a sagittal saw and saw

blade (0.4-mm thick; 25-mm long). As previously stated,

other systems and techniques are available for comple-

tion of the osteotomy and shortening of the ulna.

In the supine position, the patient should have a

pneumatic tourniquet placed as high as possible onto the

arm. The arm in its entirety should rest comfortably on a

radiolucent hand table.

FIGURE 6. A, The plate is initially secured with 3 screwson the same side as the lag screw. On the other side, ascrew is inserted into the slot at the point farthest from thelag screw. Two 0.62-in Kirschner wires are insertedthrough the combination pin/drill guide in separate slotsat a point farthest from the lag screw. B, A close-up viewof the Kirschner wires being inserted at a point farthestfrom the lag screw. Inserting the Kirschner wires and slotscrew away from the lag screw will allow for in-linecompression after the osteotomy is completed.

FIGURE 7. The A and B guides for completing theosteotomies. Note that the A guides are available for 2-,3-, 4-, or 5-mm resections.




Surgical ExposureAfter exsanguinating the arm and inflating the tourni-

quet, a skin incision is made along the subcutaneous

border of the ulna. This incision should begin 1 to 2 cm

proximal to the ulnar styloid and continue proximally

for 15 cm. Incisions at or distal to the ulnar styloid must

be made carefully to avoid injury to the dorsal sensory

branch of the ulnar nerve. The incision is continued

between the interval separating the extensor carpi

ulnaris (ECU) and the flexor carpi ulnaris (FCU). The

periosteum of the ulna is then incised, and the FCU and

ECU are reflected using an elevator and baby Homan

retractors. Care must be taken to avoid injury to the

ulnar artery and nerve, which lie just radial to the FCU.

A substantial portion of each muscle must be reflected

to adequately visualize the ulna in preparation for the

osteotomy.

Initial Plate ApplicationWhenever possible, the plate should be applied to the

volar surface of the ulna (Fig. 5). Not only is there

FIGURE 8. A, Application of guide A that will determinethe amount of ulnar shortening. Note the guide slidesdirectly into the side of the plate. B, Completion of the firstosteotomy through guide A. C, Completion of the secondosteotomy through guide B and wafer removal.

FIGURE 9. A, Graphic depiction of the bone compressionclamp in position and compressing the osteotomy as theplate slides on the slot screw and Kirschner wires. B,Intraoperative photograph showing the compressionclamp in place before compressing the osteotomy. C,Intraoperative photograph demonstrating compression atthe osteotomy site while a lag screw is being inserted.


Lauder et al


more soft tissue padding, but this side also tends to be

the flattest surface of the ulna, allowing for the best

plate-to-bone contact. If the volar surface is not

practical, then the surgeon should choose the flattest

side that is still amenable to adequate soft tissue

coverage. Occasionally, it is necessary to use plate

benders to contour the plate to account for variations in

ulnar shape. Plates can also be bent to overcompensate

for the normal curvature of the ulna. This will help

prevent gapping at the osteotomy site at the time

compression is applied.

The position of the lag screw is dependent on both

the arm being operated on and the location of the plate.

For example, in a right-sided osteotomy with a volarly

placed plate, the lag screw hole will be distal to the

osteotomy site. If, however, the plate is set dorsally in a

right-sided osteotomy, then the lag screw hole will need

to be positioned proximal to the osteotomy. The

opposite is true for left-sided plates, with the lag screw

being placed proximally in volar plates and distally in

dorsal plates. Regardless of the orientation of the plate

or which ulna is being osteotomized, it is critical that

the 2 small holes on the side of the plate be easily

accessible for mounting of the cutting guides.

The plate is provisionally secured to the ulna with

the help of the ulnar plate clamp. Using the 2.3-mm drill

bit, 3.2-mm-diameter self-tapping screws are used to fix

the plate to the ulna on the same side as the lag screw.

When dealing with brittle bone, the 2.3-mm drill holes

can be tapped to precut screw threads. A fourth screw is

placed in the slotted screw hole to affix the plate both

proximal and distal to the planned osteotomy site. This

screw should be placed at the end of the slot farthest

from the lag screw. This allows for compression after

the osteotomy is completed. At this point, the combina-

tion pin/drill guide is applied. Two 0.62-in Kirschner

FIGURE 10. Graphic depiction of the hole preparation forthe lag screw. Note the compression across the osteotomysite with the bone compression clamp. The slotted screwhas been loosened, allowing the plate to slide proximally.

FIGURE 11. A, Preoperative radiographs demonstratingulnar positive variance in a patient with a long-standinghistory of ulnar-sided wrist pain. B and C, PostoperativeAP and lateral views illustrating a healed osteotomy andnegative ulnar variance.




wires are placed in the slots of the guide that are

away from the lag screw hole (Figs. 6A, B). The

shorter (50-mm) Kirschner wire is placed first,

followed by the longer (100-mm) wire. The differing

Kirschner wire lengths and the guide ensure that the

pins will remain parallel during insertion. The pin/

drill guide is now removed.

Ulnar OsteotomyCorrelating to measurements made from preoperative

radiographs for ulnar variance, a cutting guide is selected

for the intended amount of resection (2Y5 mm). In

general, the shortening should result in a neutral to

slightly negative ulnar variance. Marked A and B, these

cutting guides are designed with pegs that can only be

inserted so that the osteotomy cuts are made perpendic-

ular to the path of the planned lag screw. Guide A is

placed first. This guide defines the width of the

osteotomy and is marked as A-2, A-3, A-4, or A-5 mm

(Fig. 7). Five millimeters is usually the maximum

correction required, but it can be more in certain trauma

situations. After placing the baby Homan around the

ulna to protect the adjacent soft tissues, the osteotomy is

completed. Use of saline irrigation is recommended to

cool the saw blade and prevent thermal injury. Guide A

is then replaced with the cutting guide B. Once the

sequential osteotomies have been completed, the bone

wafer is detached from its soft tissue attachments and

excised (Figs. 8AYC). Of paramount importance for the

procedure is to keep the plate firmly fixed to the ulna to

ensure parallel osteotomy cuts. Therefore, screws should

be checked during the osteotomy and retightened as

necessary to prevent plate slippage.

Lag Screw Application and Plate StabilizationThe peg of the bone compression clamp is inserted into

the side of the plate. The cannulated portion of the

clamp is then used as a drill guide to place a third 0.062-

in Kirschner wire low on the bone between the slotted

hole and the 2 parallel Kirschner wires previously

inserted. The position of this third wire creates com-

pression forces perpendicular to the osteotomy. The

screw in the slotted hole is then loosened to allow

compression at the osteotomy using the bone compres-

sion clamp (Figs. 9AYC). Once compression has been

achieved, the slot screw should be retightened. At this

time, radiographs should be obtained to determine if the

ulnar variance has been corrected to neutral or slightly

negative. It is important to check that plate contact has

not changed because of a changing radius of curvature

of ulna from shortening. If this does occur, the plate

may need to be bent a second time to afford better

conformity and plate contact.

To insert the lag screw, the pin/drill guide can be

reapplied or the surgeon can freehand the trajectory of

the screw by using a standard drill guide. A 3.2-mm

drill bit is used first for the near cortex (Fig 10). This is

followed by the 2.3-mm drill bit, which is sent through

the far cortex. The lag screw should be tapped to

guarantee good purchase of the screw threads. Insert a

lag screw of appropriate length (normally 18Y20 mm).

The final 2 screws adjacent to the slotted hole are

inserted followed by removal of the drill guide,

compression clamp, and 3 Kirschner wires. Final radio-

graphs should be obtained to ensure proper screw

lengths (Figs. 11AYC).

The wound is then irrigated and the tourniquet is

released to check for active bleeding. Wound margins

can be injected with bupivacaine and epinephrine for

both hemostasis and postoperative analgesia. A drain is

placed in the fascial interval between the FCU and

ECU. This fascial interval is then closed to avoid

muscle herniations. The subcutaneous and skin layers

are closed separately with interrupted sutures. A long-

arm, well-padded splint is then applied.

| RESULTS

Seventeen patients were followed for a minimum of 12

months after an ulnar shortening osteotomy was

performed using the Trimed system. Bony union,

defined as bridging of the trabecular bone and cortical

margin blurring, was achieved at an average of 7.41

weeks. The average amount of shortening was 4.12 mm.

Preoperative and postoperative range of motion, grip

strength, pain, and Disabilities of the Arm, Shoulder,

and Hand scores are tallied in Table 1.

TABLE 1. Qualitative Outcomes of the Trimed System

Feature Preoperative Postoperative % Contralateral

Wrist flexion/extension (degrees) 110.00 116.47 98.26Wrist radial/ulnar deviation (degrees) 36.47 43.82 95.92Wrist pronation/supination (degrees) 133.24 136.76 96.70Grip strength (kg) 26.41 34.06 93.69Pain (visual analog scale 1Y10) 5.88 0.71 NADASH scores 65.4 10.4 NA

DASH indicates Disabilities of the Arm, Shoulder, and Hand; NA, not applicable.


Lauder et al


| COMPLICATIONS

In general, complications are few in a properly performed

shortening procedure. In our 17 patients who underwent

an osteotomy using the Trimed system, we found that the

most common complication was irritation over the plate

because of prominence. Four patients ultimately required

reoperation for plate removal. Although infection,

delayed union, nonunion, and nerve palsies are certainly

possible complications, we did not encounter any of these

situations in our series. Avoiding thermal injury during

the osteotomy and assuring good bony apposition will

help minimize any risk of delayed union or nonunion.

Surgeons should be cognizant of the path of the dorsal

sensory branch of the ulnar nerve, especially when

incisions are made distal to the ulnar styloid. Consistent-

ly, tenderness around the hardware has been the most

common adverse outcome in studies evaluating similar

plate and screw systems.6,8,10

| REHABILITATION

Patients are seen at 2 weeks for their first postoperative

visit. Sutures are removed, and compliant patients are

fitted with a removable long-arm splint fabricated by one

of our hand therapists. This allows for removal during

showers and commencement of elbow flexion and

extension exercises. Noncompliant patients are placed

into a long-arm cast. At 6 weeks, radiographs are

obtained, and gentle wrist range of motion is started if

there are early signs of bony consolidation. If there are

more signs of bony union at 9 weeks, then the patients are

instructed to begin gentle strengthening exercises.

| CONCLUSION

The ulnar shortening osteotomy has become the gold

standard for correcting ulnar-sided wrist symptoms

caused by positive ulnar variance. Fortunately, the

complications are minimal, with the most common

reason for reoperation being irritation because of

hardware prominence. Several systems and techniques

exist for performing the shortening, all with their own

advantages and disadvantages. We believe that this

new system presented here provides technical advan-

tages by eliminating the need for freehand cuts while

providing a means of compression through a unique

plate design.

| REFERENCES

1. Palmer AK, Werner FW. Biomechanics of the distal

radioulnar joint. Clin Orthop. 1984;187:26Y35.

2. Milch H. Cuff resection of the ulna for malunited Colles’

fracture. J Bone Joint Surg Am. 1941;23A:311Y313.

3. Wehbe MA, Mawr B, Cautilli DA. Ulnar shortening using

the AO small distractor. J Hand Surg [Am]. 1995;20A:

959Y963.

4. Rayhack JM, Gasser SI, Latta LL, et al. Precision oblique

osteotomy for shortening of the ulna. J Hand Surg [Am].1993;18A:908Y918.

5. Chun S, Palmer AK. The ulnar impaction syndrome:

follow-up of ulnar shortening osteotomy. J Hand Surg[Am]. 1993;18A:46Y53.

6. Chen NC, Wolfe SW. Ulna shortening osteotomy using

a compression device. J Hand Surg [Am]. 2003;28A:

88Y93.

7. Labosky DA, Waggy CA. Oblique ulnar shortening

osteotomy by a single saw cut. J Hand Surg [Am]. 1996;

21A:48Y59.

8. Mizuseki T, Tsuge K, Ikuta Y. Precise ulna-shortening

osteotomy with a new device. J Hand Surg [Am]. 2001;

26A:931Y939.

9. Horn PC. Long ulnar sliding osteotomy. J Hand Surg[Am]. 2004;29A:871Y876.

10. Darlis NA, Ferraz IC, Kaufmann RW, et al. Step-cut distal

ulnar-shortening osteotomy. J Hand Surg [Am]. 2005;

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11. Gartland JJ Jr, Werley CW. Evaluation of healed Colles’

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https://www.researchgate.net/publication/284877309_Cuff_resection_of_the_ulna_for_malunited_Colles'_fracture?el=1_x_8&enrichId=rgreq-0f22565e5756a111095ce88b52ae8fcd-XXX&enrichSource=Y292ZXJQYWdlOzYyOTg2NjY7QVM6MjAwNjA3ODk5MDk5MTM2QDE0MjQ4NDAwNTgyOTM=

Oblique Ulnar Shortening Osteotomy With a New Plate and Compression System

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