Abstract
Background: The primary purpose of our study was to identify factors associated with reoperation after ulna shortening osteotomy. Our secondary aims were to determine the rate and type of reoperation procedures. Methods: In this retrospective study, we included patients older than 18 years of age who underwent an ulna shortening osteotomy between January 2003 and December 2015. Medical records of patients were assessed for our explanatory variables, reoperations, and reporting of symptoms. We used bivariate and multivariable analyses to identify factors associated with reoperation after ulna shortening osteotomy. Results: Among 94 patients who underwent 98 ulna shortening osteotomies, there were 34 reoperations (35%). Nineteen patients (19%) underwent removal of hardware, 6 (6.1%) had a nonunion, and 9 (9.2%) underwent additional surgeries. Surgery on their dominant limb, trauma, and prior surgery to the ipsilateral wrist were associated with reoperation. In multivariable analysis, factors independently associated with reoperation were the dominant side being affected (odds ratio = 3.9; 95% confidence interval [CI] = 1.36-11) and traumatic origin (odds ratio = 3.4; 95% CI = 1.1-11). Bivariate analysis identified younger age and prior surgery of the affected wrist as factors associated with hardware removal. More operations for refixation due to nonunion of osteotomy were performed in patients with a transverse osteotomy compared with patients with an oblique osteotomy. Conclusions: One in 3 patients will undergo a reoperation after ulna shortening osteotomy, most often due to hardware irritation or nonunion of osteotomy. Awareness of these rates and predictive factors may be helpful for preoperative discussions and surgical decision making.
Keywords: hardware removal, nonunion, prognostic factors, reoperation, ulna shortening osteotomy
Introduction
Ulna shortening osteotomy (USO) is performed to address ulna impaction syndrome and to treat pain and instability after injury to the triangular fibrocartilage complex (TFCC) or the lunotriquetral (LT) ligament. The goal of ulna shortening is to decrease the mechanical pressure of the ulnar head on the carpus, to correct subtle distal radioulnar joint (DRUJ) instability, and to correct LT instability in patients with higher grades of ulnar impaction syndrome.1-4 Many types of diaphyseal USO and fixation techniques are available, ranging from freehand transverse osteotomies and fixation with a dynamic compression plate to the use of advanced jigs and compression devices to achieve more precise oblique osteotomies and compression at the osteotomy site.5-13 The plate can be positioned on the dorsal, volar, or ulnar aspect of the ulna.9,14-18
The most common complications resulting from ulnar shortening osteotomy are tendon irritation due to plate positioning and nonunion of the ulna. Hardware irritation occurs in up to 55% of cases, and nonunion occurs in up to 18% of cases.9,17,19-22 Prior series suggest that tendon irritation may be associated with position and type of plate.13,17,18,23 Known risk factors for nonunion include higher age, poor nutrition, alcohol abuse, tobacco smoking, and diabetes.9,24-28
Most published data on USO are limited to relatively small retrospective series.9,11,18,29-31 Few studies report on predictors of reoperation.21,24,28 We studied the null hypothesis that there are no factors associated with reoperation after USO. Our secondary aims were to determine the rate and type of reoperation procedures.
Materials and Methods
This retrospective study was approved by our institutional review board. We used Current Procedural Terminology codes 25390 and 25360 to identify 102 adult patients who had a total of 106 USO procedures by searching our multi-institutional database covering all relevant orthopedic encounters at 3 regional hospitals: 2 level I trauma centers and 1 associated community hospital between January 2003 and December 2015. Indications for USO in our hospitals include ulnar impaction syndrome, irreparable tears of the TFCC, previous radial head excision, and associated Essex-Lopresti lesions that result in ulnar-positive variance, attritional lunotriquetral ligament tears, ulnar nonunions, radial malunions resulting in ulnar-positive variance, and early posttraumatic DRUJ arthritis.
We then reviewed medical records and collected data on age at surgery, sex, body mass index, reported alcohol or tobacco abuse, diagnosis of diabetes, occupation, workers’ compensation status, hand dominance, affected side, perception of traumatic or nontraumatic origin, prior surgery, prior nonsurgical treatment, magnetic resonance imaging evidence of TFCC tear, arthroscopy prior to surgery, osteotomy type, reduction, plate type, plate position, concomitant wrist procedure, and reoperations.
Eight patients were excluded: 4 due to inaccessible radiographs, 2 had inaccessible operative notes, and 2 had insufficient postoperative follow-up. This resulted in a final cohort of 94 patients who underwent 98 USO procedures. For follow-up, the median time from operation to the last clinical note was 13 months (interquartile range [IQR] = 6.6-24 months). The median time from surgery to the database query was 61 months (IQR = 43-117 months).
Our final cohort consisted of 38 men (40%) and 56 women (60%; Table 1). Nearly half of the patients (n = 48; 49%) could recall a specific trauma as beginning of their symptoms (Table 2). The osteotomies were exclusively diaphyseal, either transverse or oblique using a freehand technique or a dynamic compression system (Table 2). The posttreatment protocol varied per the surgeon’s discretion.
Table 1.
Demographic Factors Associated With Reoperation After Ulna Shortening Osteotomy.
| Explanatory variable | All (n = 94) | Reoperation |
P value | |
|---|---|---|---|---|
| No (n = 60) | Yes (n = 34) | |||
| Age, y, mean ± SD | 46 ± 13 | 47 ± 13 | 44 ± 13 | .21a |
| Sex, No. (%) | .83b | |||
| Male | 38 (40) | 25 (42) | 13 (38) | |
| Female | 56 (60) | 35 (58) | 21 (62) | |
| Body mass index, kg/m2, mean ± SDc | 27 ± 4.7 | 27 ± 5.0 | 27 ± 4.3 | .81a |
| Alcohol abuse reported in chart, No. (%) | 6 (6.4) | 3 (5.0) | 3 (8.8) | .66b |
| Tobacco abuse reported in chart, No. (%) | 13 (14) | 9 (15) | 4 (12) | .76b |
| Diabetes, No. (%)d | 6 (7.0) | 4 (7.1) | 2 (6.7) | >.99b |
| Occupation, No. (%)d | >.99b | |||
| Heavy manual labor | 5 (5.9) | 3 (5.6) | 2 (6.5) | |
| Other | 80 (94) | 51 (94) | 29 (94) | |
| Workers’ compensation, No. (%)d | 7 (7.6) | 3 (5.1) | 4 (12) | .25b |
Student t test with equal variances.
The Fisher exact test.
Not reported in 13 patients.
Not extractable from all medical charts.
Table 2.
Condition- and Treatment-Related Factors Associated With Reoperation After Ulna Shortening Osteotomy.
| Explanatory variable | All (n = 98) | No (n = 64) | Yes (n = 34) | P value |
|---|---|---|---|---|
| Condition related | ||||
| Dominant side affected, No. (%)a | 46 (52) | 24 (41) | 22 (73) | .007 b |
| Origin, No. (%) | .003 b | |||
| Nontraumatic | 50 (51) | 40 (63) | 10 (29) | |
| Traumatic | 48 (49) | 24 (38) | 24 (71) | |
| Prior surgery to the ipsilateral wrist, No. (%) | 36 (37) | 17 (27) | 19 (56) | .008 b |
| Radiographic signs of triangular fibrocartilage complex tear, No. (%) | 42 (43) | 29 (45) | 13 (38) | .53b |
| Treatment related | ||||
| Prior nonsurgical treatment, No. (%) | 59 (60) | 40 (63) | 19 (56) | .67 |
| Arthroscopy prior to surgery, No. (%) | .91b | |||
| Therapeutic arthroscopy | 26 (27) | 17 (27) | 9 (26) | |
| Diagnostic arthroscopy | 2 (2.0) | 2 (3.1) | 0 (0) | |
| Osteotomy type, No. (%) | >.99b | |||
| Oblique | 77 (79) | 50 (78) | 27 (79) | |
| Transverse | 21 (21) | 14 (22) | 7 (21) | |
| Reduction, mm, mean ± SDc | 4.1 ± 1.8 | 4.3 ± 2.0 | 3.7 ± 1.2 | .12d |
| Plate type, No. (%) | .44b | |||
| TriMed Ulnar Osteotomy Compression Plate | 52 (53) | 35 (55) | 17 (50) | |
| Synthes LC-DCP | 22 (22) | 12 (19) | 10 (29) | |
| Rayhack Ulnar Shortening Plate | 11 (11) | 6 (9.4) | 5 (15) | |
| Synthes LCP | 8 (8.2) | 7 (11) | 1 (2.9) | |
| AcuMed Ulnar Shortening Plate | 5 (5.1) | 4 (6.3) | 1 (2.9) | |
| Plate position, No. (%) | .89b | |||
| Volar | 71 (72) | 47 (73) | 24 (71) | |
| Dorsal | 15 (15) | 10 (16) | 5 (15) | |
| Ulnar | 12 (12) | 7 (11) | 5 (15) | |
| Concomitant wrist procedure, No. (%) | .42b | |||
| None | 52 (53) | 35 (55) | 17 (50) | |
| Arthroscopy | 19 (19) | 14 (22) | 5 (15) | |
| Other procedure | 27 (28) | 15 (23) | 12 (35) | |
Note. LC-DCP = Limited Contact Dynamic Compression Plate.
Not extractable from all medical charts.
The Fisher exact test.
Not reported in 2 patients.
Student t test with equal variances.
Bold text indicates a statistically significant difference with a p-value less than 0.05.
Statistical Analysis
We described discrete data using frequencies and percentages, normally distributed continuous data through means and standard deviations, and nonnormally distributed continuous data through medians and IQRs.
Bivariate analysis was performed using the 2-sided Fisher exact test for dichotomous and categorical variables and an unpaired Student t test for continuous variables.
Factors with a P value of less than .10 in bivariate analysis were entered into a multivariable logistic regression analysis to assess whether they were independently associated with reoperation after USO. A P value of less than .05 was considered statistically significant.
Results
Of the 94 patients, 34 (36%) underwent a reoperation. The median time from the USO to the reoperation was 11 months (IQR = 9.0-17 months) after the USO. Most reoperations were removal of hardware (n = 19, 19%), followed by refixation due to nonunion of osteotomy (n = 6, 6.1%) and other surgeries (n = 9, 9.2%; Table 3). Three patients who underwent removal of hardware also underwent a concurrent procedure because of other complaints besides hardware irritation. Of the patients who underwent “other” surgeries, 8 were performed for persistent pain on the ulnar side of the wrist. Three patients underwent an arthroscopy with synovectomy, 2 patients underwent exploration and neurolysis of the dorsal ulnar sensory nerve branch, 2 patients underwent an arthroscopic TFCC debridement, 2 patients underwent a Darrach procedure, and 1 patient underwent a prosthetic DRUJ arthroplasty (Scheker distal radioulnar joint prosthesis; Aptis Medical, Glenview, Kentucky, USA). Six (6.4%) of the 34 patients required more than 1 reoperation; 3 patients underwent 2 reoperations, 2 underwent 3 reoperations, and 1 underwent 4 reoperations (Supplemental Appendix 1).
Table 3.
Types of Reoperation After Ulna Shortening Osteotomy (n = 34).
| Reoperation procedure | No. (%) |
|---|---|
| Removal of hardware | 16 (16) |
| With concurrent: | |
| Arthroscopy with complete synovectomy, TFCC debridement, and cubital tunnel release | 1 (1.0) |
| Arthroscopy with complete synovectomy and TFCC debridement | 1 (1.0) |
| Diagnostic arthroscopy, neurolysis of dorsal ulnar sensory nerve, and tenosynovectomy of the ECU | 1 (1.0) |
| Refixation due to nonunion of osteotomy | |
| No graft | 3 (3.1) |
| Iliac crest bone graft | 2 (2.0) |
| Local bone graft | 1 (1.0) |
| Other | |
| Arthroscopy with synovectomy | 3 (3.1) |
| Exploration of right ulnar wrist and neurolysis of dorsal ulnar sensory nerve branch | 1 (1.0) |
| DRUJ arthroplasty | 1 (1.0) |
| Removal of broken DRUJ pin | 1 (1.0) |
| Radial head excision and Darrach procedure with ECU tenodesis | 1 (1.0) |
| Darrach procedure with ECU tenodesis | 1 (1.0) |
| Ulnar nerve decompression elbow and screw removal with inability to remove cold welded plate | 1 (1.0) |
Note. TFCC = triangular fibrocartilage complex; DRUJ = distal radioulnar joint; ECU = extensor carpi ulnaris.
In bivariate analysis, surgery on the dominant side (P = .007), perceived traumatic origin (P = .003), and prior surgery to the affected wrist (P = .008) were associated with reoperation (Table 2 and Supplemental Appendix 2). A total of 24 patients who underwent reoperation recalled a traumatic origin. Preoperatively, 8 (33%) of these patients had radiographic evidence of a TFCC tear and 3 (13%) patients had radiographic evidence of traumatic DRUJ arthritis. Multivariable logistic regression analysis revealed that dominant side being affected (odds ratio = 3.9; P = .011) and perceived traumatic origin (odds ratio = 3.4; P = .039) were independently associated with reoperation after USO (Table 4).
Table 4.
Multivariable Analysis—Factors Independently Associated With Reoperation After Ulna Shortening Osteotomy.
| Explanatory variable | Odds ratio | SE | 95% CI |
P value | |
|---|---|---|---|---|---|
| Lower | Upper | ||||
| Dominant side affected (ref. = dominant side not affected) | 3.9 | 2.1 | 1.36 | 11 | .011 |
| Traumatic origin (ref. = nontraumatic) | 3.4 | 2 | 1.1 | 11 | .039 |
| Prior surgery to the wrist (ref. = no prior surgery to the wrist) | 2.5 | 1.4 | 0.82 | 7.4 | .11 |
Note. Area under the receiver operating characteristic curve = 0.78; pseudo R2 = 0.19; P value for Hosmer-Lemeshow test = 0.96. CI = confidence interval.
Bold text indicates a statistically significant difference with a p-value less than 0.05.
Because most of the reoperations were performed for hardware removal or refixation due to nonunion of osteotomy, we performed an additional analysis to identify factors that were associated specifically with these procedures. Bivariate analysis identified younger age (P = .0039) and prior surgery of the affected wrist (P = .015) as factors associated with hardware removal (Tables 5 and 6). More operations for refixation due to nonunion of osteotomy were performed in patients with a transverse osteotomy compared with patients with an oblique osteotomy (P = .018) (Table 7, Supplemental Appendices 3 and 4).
Table 5.
Demographic Factors Associated With Hardware Removal After Ulna Shortening Osteotomy.
| Explanatory variable | All (n = 94) | Hardware removal |
P value | |
|---|---|---|---|---|
| No (n = 75) | Yes (n = 19) | |||
| Age, y, mean ± SD | 46 ± 13 | 48 ± 12 | 38 ± 13 | .0039 a |
| Sex, n (%) | .80b | |||
| Male | 38 (40) | 31 (41) | 7 (37) | |
| Female | 56 (60) | 44 (59) | 12 (63) | |
| Body mass index, kg/m2, mean ± SDc | 27 ± 4.7 | 27 ± 4.7 | 27 ± 4.9 | .90a |
| Alcohol abuse reported in chart, No. (%) | 6 (6.4) | 4 (5.3) | 2 (11) | .60b |
| Tobacco abuse reported in chart, No. (%) | 13 (14) | 11 (15) | 2 (11) | >.99b |
| Diabetes, No. (%)d | 6 (7.0) | 4 (5.7) | 2 (13) | .31b |
| Occupation, No. (%)d | .58b | |||
| Heavy manual labor | 5 (5.9) | 5 (7.3) | 0 (0) | |
| Other | 80 (94) | 64 (93) | 16 (100) | |
| Workers’ compensation, No. (%)d | 7 (7.6) | 6 (8.1) | 1 (5.6) | >.99b |
Student t test with equal variances.
The Fisher exact test.
Not reported in 13 patients.
Not extractable from all medical charts.
Bold text indicates a statistically significant difference with a p-value less than 0.05.
Table 6.
Condition- and Treatment-Related Factors Associated With Hardware Removal After Ulna Shortening Osteotomy.
| Explanatory variable | All (n = 98) | Hardware removal | P value | |
|---|---|---|---|---|
| No (n = 79) | Yes (n = 19) | |||
| Condition related | ||||
| Dominant side affected, No. (%)a | 46 (52) | 36 (49) | 10 (67) | .27b |
| Origin, No. (%) | .075b | |||
| Nontraumatic | 50 (51) | 44 (56) | 6 (32) | |
| Traumatic | 48 (49) | 35 (44) | 13 (68) | |
| Prior surgery to the ipsilateral wrist, No. (%) | 36 (37) | 24 (30) | 12 (63) | .015 b |
| Radiographic signs of triangular fibrocartilage complex tear, No. (%) | 42 (43) | 35 (44) | 7 (37) | .61b |
| Treatment related | ||||
| Prior nonsurgical treatment, No. (%) | 59 (60) | 47 (59) | 12 (63) | >.99b |
| Arthroscopy prior to surgery, No. (%) | .73b | |||
| Therapeutic arthroscopy | 26 (27) | 22 (28) | 4 (21) | |
| Diagnostic arthroscopy | 2 (2.0) | 2 (2.5) | 0 (0) | |
| Osteotomy type, No. (%) | .35b | |||
| Oblique | 77 (79) | 60 (76) | 17 (89) | |
| Transverse | 21 (21) | 19 (24) | 2 (11) | |
| Reduction, mm, mean ± SDc | 4.1 ± 1.8 | 4.3 ± 1.9 | 3.4 ± 1.1 | .067d |
| Plate type, No. (%) | .87b | |||
| TriMed Ulnar Osteotomy Compression Plate | 52 (53) | 43 (54) | 9 (47) | |
| Synthes LC-DCP | 22 (22) | 17 (22) | 5 (26) | |
| Rayhack Ulnar Shortening Plate | 11 (11) | 8 (10) | 3 (16) | |
| Synthes LCP | 8 (8.2) | 7 (8.9) | 1 (5.3) | |
| AcuMed Ulnar Shortening Plate | 5 (5.1) | 4 (5.1) | 1 (5.3) | |
| Plate position, No. (%) | .20b | |||
| Volar | 71 (72) | 60 (76) | 11 (58) | |
| Dorsal | 15 (15) | 10 (13) | 5 (26) | |
| Ulnar | 12 (12) | 9 (11) | 3 (16) | |
| Concomitant wrist procedure, No. (%) | .52b | |||
| None | 52 (53) | 44 (56) | 8 (42) | |
| Arthroscopy | 19 (19) | 15 (19) | 4 (21) | |
| Other procedure | 27 (28) | 20 (25) | 7 (37) | |
Note. LC-DCP = Limited Contact Dynamic Compression Plate.
Not extractable from all medical charts.
The Fisher exact test.
Not reported in 2 patients.
Student t test with equal variances.
Bold text indicates a statistically significant difference with a p-value less than 0.05.
Table 7.
Characteristics of Patients With Refixation Due to Nonunion of Osteotomy.
| Patient | Sex | Age | Comorbidities | Dominant side affected | Origin | Prior surgery | Prior nonsurgical treatment | TFCC tear | Prior arthroscopy | Osteotomy type | Plate type | Plate position | Millimeter reduction | Unplanned reoperation (indication) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | F | 58 | Obese, alcohol and tobacco abuse | Yes | Nontraumatic | No | Splint, NSAID, steroid injection | Yes | Yes, with TFCC debridement | Transverse | 6-hole LC-DCP | Volar | 3.5 | 1. ORIF with 8-hole LC-DCP (nonunion) |
| 2 | F | 41 | None | No | Traumatic | No | None | Yes | Yes, with synovectomy | Transverse | 5-hole LC-DCP | Volar | 3 | 1. ORIF with local bone graft (nonunion) |
| 3 | M | 43 | Obese | Yes | Traumatic | Yes; arthroscopy with TFCC debridement | None | No | No | Oblique | Rayhack USO plate | Ulnar | 2.5 | 1. ORIF with iliac crest bone graft (nonunion) 2. ORIF with iliac crest bone graft (infection nonunion) 3. Removal of hardware (hardware irritation) |
| 4 | F | 55 | None | Yes | Traumatic | No | Splint | No | No | Oblique | TriMed USO plate | Volar | 6 | 1. ORIF with iliac crest bone graft (nonunion) |
| 5 | F | 66 | None | Yes | Traumatic | Yes; arthroscopy with extensive debridement | Splint, NSAID, steroid injection | Yes | Yes, with TFCC debridement | Transverse | 6-hole LC-DCP | Volar | 6 | 1. ORIF with 8-hole LC-DCP (nonunion) 2. Removal of hardware (hardware irritation) 3. Darrach resection and ECU-FCU transfer (DRUJ incongruity) 4. DRUJ arthroplasty (DRUJ incongruity) |
| 6 | F | 47 | None | Yes | Traumatic | No | No | Yes | Yes, with TFCC debridement | Transverse | 6-hole LC-DCP | Volar | 3 | 1. ORIF with 7-hole LC-DCP (nonunion) |
Note. TFCC = triangular fibrocartilage complex; USO = ulna shortening osteotomy; NSAID = nonsteroidal anti-inflammatory drug; ORIF = open reduction internal fixation; DRUJ = distal radioulnar joint; ECU = extensor carpi ulnaris; FCU = flexor carpi ulnaris; LC-DCP = Limited Contact Dynamic Compression Plate.
At the final clinical note at median 13 months (IQR = 6.6-24 months), 21 (22%) of 94 patients reported persistent ulnar-sided wrist pain, regardless of reoperation. The suspected underlying cause for this pain was TFCC pathology in 6 patients, tendon irritation by the plate in 4 patients, extensor carpi ulnaris tendinitis in 1 patient, and unknown in the others. Six patients received either splinting or corticosteroid injection at their last clinical follow-up.
Of the patients who had undergone hardware removal (n = 19), 3 patients still had tenderness at the prior plate location. Four of the 6 patients who had undergone a reoperation for nonunion of the osteotomy had radiographic evidence of osteotomy union at last follow-up; the other 2 had a complex postoperative course with multiple reoperations (Supplemental Appendix 1).
Discussion
In our cohort of 98 ulna shortening osteotomies, we found that nearly 1 in 5 patients underwent reoperation for hardware irritation and 1 in 20 patients underwent reoperation for refixation due to nonunion. Involvement of the dominant limb and prior surgery were associated with reoperation.
There are some limitations to our study. Due to its retrospective nature, erroneous documentation may affect the results. We considered 2 forms of follow-up: time from surgery to last clinical note and time from surgery to database query. Defining follow-up as time from surgery to query assumes that most patients would return to the original surgeon. It is possible that secondary surgeries occurred at a different institution. Based on our experience with referral patterns within our institutions, this is not likely. We found that 4 of our included patients switched care from one institution to another institution within our system. Nonunion of osteotomy was defined by the treating surgeon, and the threshold for reoperation varied. There is no clear consensus among surgeons regarding the definitions of union, delayed union, or nonunion of long-bone fractures, and the ulna is notoriously slow to heal.32-34 Although we found a significant association between transverse osteotomy and reoperation for nonunion, there were a small number of nonunions. This result may not be accurate if there was sampling error, and these 6 nonunion cases do not parallel the actual nonunion population.
These limitations are counterbalanced by the large number of patients accrued during a 13-year time frame across 3 hospitals among 13 surgeons. There was variety of osteotomy types and fixation techniques which make these data more generalizable to usual practice than a single-surgeon case series.
We found an overall reoperation rate of 35%. Other studies quote reoperation rates between 25% and 59%: Gaspar et al found a reoperation rate of 25% among 69 ulnar shortening osteotomies, while Chan et al reported a rate of 48% in 63 patients.6,8,9,13,17,20,22,28-30
Nineteen patients (19% of total) underwent removal of hardware, which is similar to prior research.9,17-21,30,35 Prior studies report conflicting results on the relation between hardware removal and the position and type of plate.9,13-18,23 Some authors have suggested ulnar or volar placement to be superior to dorsal placement because of better coverage by the forearm muscles, whereas others promote dorsal placement.16,18,24 In our study, plate location did not appear to be associated with hardware removal. Significantly more reoperations for removal of hardware were found in patients who had a prior surgery of the affected wrist. Hardware removal is a discretionary surgery, and this finding may reflect a preference of these patients toward surgical intervention to address symptoms.
Six patients (6.1% of total) had a reoperation because of nonunion of osteotomy. Prior studies report inconsistent rates for reoperation for nonunion of osteotomy: ranging from 1.9% to 7.7% in transverse osteotomies6,12,21,24 and from 0% to 18% in oblique osteotomies.8,9,30,12,13,16-18,22,28,29 A greater surface area of contact in oblique osteotomies compared with transverse osteotomies would facilitate bone healing and lead to lower rates of nonunion in the former group.7,12,29,35,36 This is consistent with our finding that more operations for nonunion of osteotomies were performed in patients with a transverse osteotomy compared with oblique osteotomy.
Other studies report that delayed union or nonunion is associated with diabetes, poor bone mineral density, decreased wrist range of motion, and smoking. We did not have evidence for either association or absence of association between nonunion of osteotomy and age, poor nutrition, alcohol consumption, smoking, or diabetes.9,24-28 It is important to recognize that we identified nonunions that underwent reoperation and did not identify all radiographic nonunions. This may explain some of the differences in our findings compared with prior studies. It may be argued that these are clinically important nonunions and not stable, fibrous unions.
We also found that at last follow-up, 1 in 5 patients reported persistent ulnar-sided wrist pain after USO. Prior studies report persistent ulnar-sided wrist pain ranging from 5.2% to 23%.5,8,12,15,18,20,28,29 In a study by Loh et al,19 5 of 22 patients reported no pain relief after the procedure. Ahsan et al13 found persistent ulnar-sided wrist pain in 2 of 38 patients: one case involved pain at the ulnocarpal joint with twisting and the other patient had dorsal ulnar sensory neuropathic pain.
In conclusion, 1 in 3 patients will undergo an reoperation after USO, most often due to hardware irritation. Hardware removal tends to occur in younger patients who had another surgery pre-dating the USO. Reoperation for nonunion occurs in about 1 in 20 patients and has a relationship to osteotomy technique. Persistent ulnar-sided wrist pain occurs in about 1 in 5 patients, regardless of reoperation. Both surgeons and patients should be aware of these rates and incorporate this in the surgical decision making when considering USO.
Supplemental Material
Supplemental material, Appendix_1 for Nonunion and Reoperation After Ulna Shortening Osteotomy by Svenna H. W. L. Verhiel, Sezai Özkan, Kyle R. Eberlin and Neal C. Chen in HAND
Supplemental material, Appendix_2 for Nonunion and Reoperation After Ulna Shortening Osteotomy by Svenna H. W. L. Verhiel, Sezai Özkan, Kyle R. Eberlin and Neal C. Chen in HAND
Supplemental material, Appendix_3 for Nonunion and Reoperation After Ulna Shortening Osteotomy by Svenna H. W. L. Verhiel, Sezai Özkan, Kyle R. Eberlin and Neal C. Chen in HAND
Supplemental material, Appendix_4 for Nonunion and Reoperation After Ulna Shortening Osteotomy by Svenna H. W. L. Verhiel, Sezai Özkan, Kyle R. Eberlin and Neal C. Chen in HAND
Footnotes
Supplemental material is available in the online version of the article.
Ethical Approval: The institutional review board of our institution approved this study under protocol #2017P000694.
Statement of Human and Animal Rights: All procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. Informed consent was obtained from all patients being included in the study.
Statement of Informed Consent: Informed consent was obtained from all individual participants included in the study.
Declaration of Conflict of Interest Statement: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
References
- 1. Palmer AK, Werner FW. Biomechanics of the distal radioulnar joint. Clin Orthop Relat Res. 1984;(187):26-35.http://www.ncbi.nlm.nih.gov/pubmed/6744728. Accessed January 24, 2019. [PubMed]
- 2. Werner FW, Palmer AK, Fortino MD, et al. Force transmission through the distal ulna: effect of ulnar variance, lunate fossa angulation, and radial and palmar tilt of the distal radius. J Hand Surg Am. 1992;17(3):423-428. doi: 10.1016/0363-5023(92)90342-M. [DOI] [PubMed] [Google Scholar]
- 3. Baek GH, Lee HJ, Gong HS, et al. Long-term outcomes of ulnar shortening osteotomy for idiopathic ulnar impaction syndrome: at least 5-years follow-up. Clin Orthop Surg. 2011;3(4):295-301. doi: 10.4055/cios.2011.3.4.295. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Sachar K. Ulnar-sided wrist pain: evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears. J Hand Surg Am. 2012;37(7):1489-1500. doi: 10.1016/j.jhsa.2012.04.036. [DOI] [PubMed] [Google Scholar]
- 5. Darrow JCJ, Linscheid RL, Dobyns JH, et al. Distal ulnar recession for disorders of the distal radioulnar joint. J Hand Surg Am. 1985(4);10:482-491. doi: 10.1016/S0363-5023(85)80069-1. [DOI] [PubMed] [Google Scholar]
- 6. Hulsizer D, Weiss APC, Akelman E. Ulna-shortening osteotomy after failed arthroscopic debridement of the triangular fibrocartilage complex. J Hand Surg Am. 1997;22(4):694-698. doi: 10.1016/S0363-5023(97)80130-X. [DOI] [PubMed] [Google Scholar]
- 7. Rayhack JM, Gasser SI, Latta LL, et al. Precision oblique osteotomy for shortening of the ulna. J Hand Surg Am. 1993;18(5):908-918. doi: 10.1016/0363-5023(93)90065-B. [DOI] [PubMed] [Google Scholar]
- 8. Mizuseki T, Tsuge K, Ikuta Y. Precise ulna-shortening osteotomy with a new device. J Hand Surg Am. 2001;26(5):931-939. doi: 10.1053/jhsu.2001.26201. [DOI] [PubMed] [Google Scholar]
- 9. Chen NC, Wolfe SW. Ulna shortening osteotomy using a compression device. J Hand Surg Am. 2003;28(1):88-93. doi: 10.1053/jhsu.2003.50003. [DOI] [PubMed] [Google Scholar]
- 10. Chennagiri R, Burge P. Pre-osteotomy plate application technique for ulnar shortening. J Hand Surg Am. 2004;29(5):453-457. doi: 10.1016/j.jhsb.2004.04.007. [DOI] [PubMed] [Google Scholar]
- 11. Darlis NA, Ferraz IC, Kaufmann RW, et al. Step-cut distal ulnar-shortening osteotomy. J Hand Surg Am. 2005;30(5):943-948. doi: 10.1016/j.jhsa.2005.05.010. [DOI] [PubMed] [Google Scholar]
- 12. Sunil TM, Wolff TW, Scheker LR, et al. A comparative study of ulnar-shortening osteotomy by the freehand technique versus the Rayhack technique. J Hand Surg Am. 2006;31(2):252-257. doi: 10.1016/j.jhsa.2005.09.017. [DOI] [PubMed] [Google Scholar]
- 13. Ahsan ZS, Song Y, Yao J. Outcomes of ulnar shortening osteotomy fixed with a dynamic compression system. J Hand Surg Am. 2013;38(8):1520-1523. doi: 10.1016/j.jhsa.2013.04.040. [DOI] [PubMed] [Google Scholar]
- 14. Chun S, Palmer AK. The ulnar impaction syndrome: follow-up of ulnar shortening osteotomy. J Hand Surg Am. 1993;18(1):46-53. doi: 10.1016/0363-5023(93)90243-V. [DOI] [PubMed] [Google Scholar]
- 15. Baek GH, Chung MS, Lee YH, et al. Ulnar shortening osteotomy in idiopathic ulnar impaction syndrome: surgical technique. J Bone Joint Surg Am. 2006;88(suppl 1, pt 2):212-220. doi: 10.2106/JBJS.F.00320. [DOI] [PubMed] [Google Scholar]
- 16. Van Sanden S, De Smet L. Ulnar shortening after failed arthroscopic treatment of triangular fibrocartilage complex tears. Chir Main. 2001;20(5):332-336. [DOI] [PubMed] [Google Scholar]
- 17. Pomerance J. Plate removal after ulnar-shortening osteotomy. J Hand Surg Am. 2005;30(5):949-953. doi: 10.1016/j.jhsa.2005.06.005. [DOI] [PubMed] [Google Scholar]
- 18. Das De S, Johnsen PH, Wolfe SW. Soft tissue complications of dorsal versus volar plating for ulnar shortening osteotomy. J Hand Surg Am. 2015;40(5):928-933. doi: 10.1016/j.jhsa.2014.12.042. [DOI] [PubMed] [Google Scholar]
- 19. Loh YC, Van Den Abbeele K, Stanley JK, et al. The results of ulnar shortening for ulnar impaction syndrome. J Hand Surg Br. 1999;24(3):316-320. doi: 10.1054/JHSB.1999.0062. [DOI] [PubMed] [Google Scholar]
- 20. Rajgopal R, Roth J, King G, et al. Outcomes and complications of ulnar shortening osteotomy: an institutional review. Hand. 2014;10(3):535-540. doi: 10.1007/s11552-014-9727-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21. Iwasaki N, Ishikawa J, Kato H, et al. Factors affecting results of ulnar shortening for ulnar impaction syndrome. Clin Orthop Relat Res. 2007;465:215-219. doi: 10.1097/BLO.0b013e31815a9e21. [DOI] [PubMed] [Google Scholar]
- 22. Fulton C, Grewal R, Faber KJ, et al. Outcome analysis of ulnar shortening osteotomy for ulnar impaction syndrome. Can J Plast Surg. 2012;20(1):e1-e5. doi: 10.1177/229255031202000112. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23. Jungwirth-Weinberger A, Borbas P, Schweizer A, et al. Influence of plate size and design upon healing of ulna-shortening osteotomies. J Wrist Surg. 2016;5(4):284-289. doi: 10.1055/s-0036-1582430. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Cha SM, Shin HD, Ahn KJ. Prognostic factors affecting union after ulnar shortening osteotomy in ulnar impaction syndrome: a retrospective case-control study. J Bone Joint Surg Am. 2017;99(8):638-647. doi: 10.2106/JBJS.16.00366. [DOI] [PubMed] [Google Scholar]
- 25. Ding L, He Z, Xiao H, et al. Factors affecting the incidence of aseptic nonunion after surgical fixation of humeral diaphyseal fracture. J Orthop Sci. 2014;19(6):973-977. doi: 10.1007/s00776-014-0640-1. [DOI] [PubMed] [Google Scholar]
- 26. Dodson NB, Ross AJ, Mendicino RW, et al. Factors affecting healing of ankle fractures. J Foot Ankle Surg. 2013;52(1):2-5. doi: 10.1053/j.jfas.2012.10.013. [DOI] [PubMed] [Google Scholar]
- 27. Jiao H, Xiao E, Graves DT. Diabetes and its effect on bone and fracture healing. Curr Osteoporos Rep. 2015;13(5):327-335. doi: 10.1007/s11914-015-0286-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28. Gaspar MP, Kane PM, Zohn RC, et al. Variables prognostic for delayed union and nonunion following ulnar shortening fixed with a dedicated osteotomy plate. J Hand Surg Am. 2016;41(2):237-243.e1-e2. doi: 10.1016/j.jhsa.2015.10.017. [DOI] [PubMed] [Google Scholar]
- 29. Chan SKL, Singh T, Pinder R, et al. Ulnar shortening osteotomy: are complications underreported? J Hand Microsurg. 2015;7(2):276-282. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30. Fufa DT, Carlson MG, Calfee RP, et al. Mid-term results following ulna shortening osteotomy. HSS J. 2014;10(1):13-17. doi: 10.1007/s11420-013-9371-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31. Megerle K, Hellmich S, Germann G, et al. Hardware location and clinical outcome in ulna shortening osteotomy. Plast Reconstr Surg Glob Open. 2015;3(10):e549. doi: 10.1080/02844310310023909. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32. Marsh D. Concepts of fracture union, delayed union, and nonunion. Clin Orthop Relat Res. 1998. October; (suppl 355):S22-S30. [DOI] [PubMed] [Google Scholar]
- 33. Bhandari M, Fong K, Sprague S, et al. Variability in the definition and perceived causes of delayed unions and nonunions. J Bone Joint Surgery Am. 2012(15);94:e109-e111. doi: 10.2106/JBJS.K.01344. [DOI] [PubMed] [Google Scholar]
- 34. Bhandari M, Guyatt GH, Swiontkowski MF, et al. A lack of consensus in the assessment of fracture healing among orthopaedic surgeons. J Orthop Trauma. 2002;16(8):562-566. doi: 10.1097/00005131-200209000-00004. [DOI] [PubMed] [Google Scholar]
- 35. Papatheodorou LK, Baratz ME, Bougioukli S, et al. Long-term outcome of step-cut ulnar shortening osteotomy for ulnar impaction syndrome. J Bone Joint Surg Am. 2016;98(21):1814-1820. doi: 10.2106/JBJS.15.01111. [DOI] [PubMed] [Google Scholar]
- 36. Tatebe M, Nishizuka T, Hirata H, Nakamura R. Ulnar shortening osteotomy for ulnar-sided wrist pain. J Wrist Surg. 2014;3(2):77-84. doi: 10.1055/s-0034-1372516. [DOI] [PMC free article] [PubMed] [Google Scholar]
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Supplementary Materials
Supplemental material, Appendix_1 for Nonunion and Reoperation After Ulna Shortening Osteotomy by Svenna H. W. L. Verhiel, Sezai Özkan, Kyle R. Eberlin and Neal C. Chen in HAND
Supplemental material, Appendix_2 for Nonunion and Reoperation After Ulna Shortening Osteotomy by Svenna H. W. L. Verhiel, Sezai Özkan, Kyle R. Eberlin and Neal C. Chen in HAND
Supplemental material, Appendix_3 for Nonunion and Reoperation After Ulna Shortening Osteotomy by Svenna H. W. L. Verhiel, Sezai Özkan, Kyle R. Eberlin and Neal C. Chen in HAND
Supplemental material, Appendix_4 for Nonunion and Reoperation After Ulna Shortening Osteotomy by Svenna H. W. L. Verhiel, Sezai Özkan, Kyle R. Eberlin and Neal C. Chen in HAND