Distal Metaphyseal Shortening Osteotomy of the Ulna
01 October 2019 (online)
There are several treatment options for ulnocarpal abutment syndrome or symptomatic positive ulnar variance wrist, such as conventional ulnar shortening with plate or arthroscopic or open Wafer's procedure. Ulnar shortening procedure can stabilize the distal radioulnar joint (DRUJ) simultaneously with decompressing the ulnocarpal joint, resulting in an excellent clinical result; however, this procedure also has disadvantages: increase of pressure in the DRUJ indicating subsequent DRUJ osteoarthritic changes, nonunion of the shortening site because of the plate fixation failure, and refracture after removal of the plate. Arthroscopic Wafer's procedure simply resects the triangular fibrocartilage complex (TFCC) and recesses the ulnar head for decompression of the ulnocarpal joint, while this has not a stabilizing effect on the DRUJ. In 2007, Slade and Gillon described metaphyseal shortening osteotomy on the ulna neck with fixation of the single or double Acutrak screw(s) from the ulnar head to the ulnar shaft. Metaphyseal osteotomy has an advantage of earlier union of the osteotomy site, while this includes the slight radial translocation of the fovea insertion of the radioulnar ligament (RUL) that may result in destabilization effect of the DRUJ and longer shortening cannot be possible with this procedure. People may believe that this article is the first description of the metaphyseal shortening osteotomy of the ulna.
Almost 14 years before when Slade published his procedure, Kitano et al described his technique of metaphyseal osteotomy of the ulna with Herbert's screw fixation, inserting at the fovea of the ulna. This procedure had a risk to damage the fovea insertion of the RUL, so I remember that I did argue about this risk to Dr. Kitano in a meeting at the Japanese Society for Surgery of the Hand in 1993. Later, Yoshida et al modified Kitano's technique with fixation of the metaphyseal ulna with a Herbert's screw from the head of the ulna to the ulnar shaft. This could avoid any violence into the fovea area, still including a risk to destabilize the DRUJ when the RUL was partially injured at the fovea. However, when the TFCC is intact, the metaphyseal ulnar shortening procedure may obtain excellent and good clinical results.
This issue features the Special Review Article on “Distal ulnar metaphyseal wedge osteotomy for ulnar abutment syndrome” authored by Kubo, Moritomo, Arimitsu, Nishimoto, and Yoshida with their clinical results of 43 patients who underwent their distal metaphyseal osteotomy of the ulna. I am proud of their first article on metaphyseal ulnar shortening procedure in English language. Various other original techniques or research have been written in languages other than English, but have remained unnoticed because of the language. The Journal of Wrist Surgery will try to pick such manuscripts and introduce them to readers under the section of “Special Review Article.”
Interesting wrist papers such as proximal scaphoid biomechanics, problems on median nerve with distal radius fracture, anatomy of the first extensor compartment, ulnar shortening for ulnocarpal abutment syndrome, all arthroscopic TFCC repair, scaphoid proximal nonunion treatment, interesting case reports, and systematic review of cast fixation for distal radius fracture are also included in this issue. Do not miss it!
- 1 Slade III JF, Gillon TJ. Osteochondral shortening osteotomy for the treatment of ulnar impaction syndrome: a new technique. Tech Hand Up Extrem Surg 2007; 11 (01) 74-82
- 2 Kitano K, Yoshida T, Uemura K, Tada K, Kawai H. Distal ulnar wedge osteotomy for ulnocarpal abutment syndrome (a preliminary report). (Article in Japanese). J Jpn Soc Surg Hand 1993; 10: 20-23
- 3 Yoshida T, Moritomo H, Tada K. Closed wedge osteotomy of distal ulnar metaphysis for ulnocarpal abutment syndrome. (Article in Japanese). J Jpn Soc Surg Hand 1998; 15: 198-201