Ulnar impaction syndrome is a complex of symptoms resulting from excessive compression of the ulnar head against the triangular fibrocartilage complex (TFCC) and the carpal bones. Some cases are due to apparent trauma, such as radial fractures1. Since the first description by Milch2, ulnar shortening osteotomy (USO) has become a widely accepted procedure for mechanical decompression at the ulnocarpal joint3-5. However, unexpected complications of USO with regard to consolidation at the osteotomy site, such as delayed union or nonunion, have been described6-11. The prevalence of delayed union or nonunion following USO depends on a multitude of patient demographic, medical, and social factors12,13.
Well-known risk factors for delayed union or nonunion include advanced age, poor nutrition, alcohol consumption, smoking, and endocrine medical comorbidities12,14-27. However, most of these factors were investigated clinically under conditions of fracture-healing and were generally accepted as patient-related factors influencing osseous union. Osseous union after USO has some specific characteristics that differ from those of fracture union. USO is not performed immediately following trauma; with the exception of the periosteum of the ulnar diaphysis, which is dissected, anatomical structures are left intact. In the early 2000s, Chen et al.14 showed that smoking adversely affects osseous union after USO. A more recent study suggested that smoking and diabetes should be regarded as significant factors affecting the outcome of elective USO13.
In the present retrospective case-control study, we investigated whether additional prognostic variables, including preoperative clinical, radiographic, demographic, and surgical factors, increased the rate of radiographically evident adverse outcomes with respect to osteotomy-site healing after USO.
Materials and Methods
Our institutional review board approved this study, and all patients provided informed consent before participating. Prospectively collected data were analyzed retrospectively. Of 392 patients who had undergone USO performed by the senior author between March 2008 and March 2014, 331 fulfilled the inclusion and exclusion criteria. Six patients were lost to follow-up, so 325 patients were included in the investigation.
The inclusion criteria were (1) unilateral ulnar-sided wrist pain worsened by forearm pronation and ulnar deviation28, (2) tenderness just distal to the ulnar head, (3) a positive ulnocarpal stress test29, (4) radiographs showing positive ulnar variance with or without cystic changes of the lunate, (5) arthroscopic findings showing degenerative changes of the TFCC (class II according to the Palmer classification30), (6) availability of complete medical records and radiographic data, and (7) a postoperative follow-up period of at least 2 years. Patients were excluded if they had (1) concurrent instabilities of the distal radioulnar joint requiring ligament reconstruction surgery; (2) an acute traumatic TFCC tear; (3) incomplete recovery from wrist trauma within 2 years; (4) bilateral ulnar impaction syndrome; (5) arthritic changes at the distal radioulnar joint; (6) painful arthritic lesions in the elbow, wrist, or finger joints; (7) symptomatic neuropathy, including radiculopathy, confirmed by electromyography or nerve conduction velocity in the ipsilateral upper extremity; or (8) impaction associated with a congenital anomaly, such as a Madelung deformity.
Patients were divided into 2 groups according to whether they had union (group 1) or delayed union or nonunion (group 2) after the USO.
Demographic and Clinical Variables
We evaluated the basic demographic factors, including age, sex, dominant or nondominant wrist, Workers’ Compensation status, smoking (within 4 weeks before the surgery26), diabetes mellitus, and bone mineral density (BMD). BMD was measured using dual x-ray absorptiometry (DXA) with Lunar Prodigy enCORE software (version 8.8; GE Medical Systems) at the last outpatient visit just before the surgery. The lowest T scores of the proximal part of the femur (except for the value for the Ward triangle) and the lumbar spine were averaged and recorded as the BMD.
The clinical variables included in the analysis were the preoperative visual analog scale (VAS) pain score, range of motion of the wrist and forearm, grip strength, and modified Mayo wrist score31 as well as symptom duration and aggravation period and whether there was a history of trauma.
Radiographic and Operative Variables
The radiographic variables included the degree of dorsal subluxation of the ulna at the distal radioulnar joint32, preoperative and postoperative ulnar variance33, morphological type of the distal radioulnar joint according to the system described by Tolat et al.34 (Figs. 1-A, 1-B, and 1-C), gap at the osteotomy site after plate fixation, and new arthritic changes that developed during the 2-year follow-up period.
We also investigated operative variables, including TFCC degeneration (assessed with the Palmer classification30), use of a parallel double-blade saw (Fig. 2), type of plate used for fixation, number of screws, and plate position on the volar or dorsal ulnar surface. Detailed descriptions of these variables are provided in the Appendix.
Surgical Procedure and Postoperative Care
Detailed descriptions are provided in the Appendix.
Evaluation of Osseous Consolidation
Detailed descriptions of these evaluations are provided in the Appendix.
Evaluation of Clinical Outcomes
The VAS pain score, range of motion of the wrist and forearm, grip strength (percentage of that on the contralateral, normal side), and modified Mayo wrist score were evaluated at 2 years postoperatively or, if the patient required revision surgery for nonunion, just before the revision surgery.
The sample size was calculated on the basis of the ratio of union to delayed union or nonunion (5:1) found in a recent study13. Assuming an effective odds ratio (OR) of ≥1.8 between the 2 groups, a minimum of 247 patients was required for proper statistical comparison between the 2 groups (logistic regression analysis with power of 80% and a maximum of 20% of the patients lost to follow-up). In univariate analysis, the Student t test was used for comparison of continuous variables and the chi-square test or Fisher exact test was used for comparison of categorical variables. In multivariate analysis, logistic regression using a forward selection method with the likelihood ratio was performed for factors that were significant in univariate analysis to calculate the OR with its 95% confidence interval (CI). A paired t test was used to compare final clinical outcomes with preoperative values. Finally, receiver operating characteristic curves were used to determine the predictive cutoff values for significant independent variables. The sample size was calculated using the G*Power program (version 188.8.131.52). Data were analyzed using SPSS for Windows software (version 22.0; IBM). In all analyses, p < 0.05 was considered to indicate significance.
Group 1 consisted of 294 patients with union, and group 2 consisted of 31 patients, 23 with delayed union and 8 with nonunion. Four patients underwent revision surgery, including bone-grafting, at a mean of 14 months postoperatively. An overall univariate analysis of basic demographic characteristics (Table I) showed age, smoking, and BMD to differ significantly between the 2 groups (p < 0.001, p < 0.001, and p = 0.025, respectively). Sex, injury on the dominant or nondominant side, Workers’ Compensation status, and diabetes mellitus status were not significantly associated with osseous consolidation. Among the preoperative clinical variables, only flexion-extension and pronation-supination influenced the success of union (p < 0.001 and p < 0.001, respectively). None of the radiographic features, including the degree of ulnar subluxation of the distal radioulnar joint, preoperative or postoperative ulnar variance, morphological shape of the distal radioulnar joint, degree of gapping at the osteotomized area, findings of new arthritic changes, or type of TFCC degeneration, differed significantly between the groups (p > 0.05). With regard to the operative variables, the use of a double-blade saw was a risk factor for delayed union or nonunion (p < 0.05), whereas placement at the volar surface of the ulna was associated with a higher rate of union (p < 0.05).
Multivariate analysis of the several variables that had differed significantly between the 2 groups on univariate analysis demonstrated that smoking (p < 0.001, OR = 12.63, CI = 4.45 to 35.84), BMD (p < 0.001, OR = 0.56, CI = 0.41 to 0.76), the preoperative flexion-extension arc (p < 0.001, OR = 0.87, CI = 0.80 to 0.94), the preoperative pronation-supination arc (p = 0.003, OR = 0.92, CI = 0.87 to 0.97), and the use of a double-blade saw (p = 0.01, OR = 3.51, CI = 1.32 to 9.37) were significantly associated with osseous union (Table II). Finally, receiver operating characteristic curves were created for 3 continuous independent factors—BMD, preoperative flexion-extension, and preoperative pronation-supination—to determine predictive cutoff values for the achievement of satisfactory radiographic results (Figs. 3-A and 3-B; Table III). The rate of union failure was significantly higher in patients with a mean BMD of less than –1.75 (13/96, 14%) than in those with a mean BMD of –1.75 or higher (18/229, 8%) (p = 0.049), patients with a flexion-extension arc of <113° (16/48, 33%) as opposed to ≥113° (15/277, 5%) (p < 0.001), and patients with a pronation-supination arc of <138° (12/35, 34%) rather than ≥138° (19/290, 7%) (p = 0.001).
Postoperative outcomes measured at the time of final follow-up are summarized as a table in the Appendix.
Additional analysis done with the exclusion of the cases involving oblique osteotomy revealed results similar to those in the multivariate analysis, with use of a double-blade saw as a significant additional independent factor (see Appendix).
Many factors influence osseous union after fracture. In addition, studies concerning arthrodesis of the spine or ankle have revealed many factors that influence fusion. Common types of “shortening” osteotomies, such as radial, calcaneal, femoral, or capitate osteotomies, can be performed successfully in cancellous bone (metaphysis), with effective osseous union35-37. However, osseous union after USO should be investigated differently, as the union is in the diaphysis. Patients with delayed union, and especially nonunion, can experience persistent discomfort at the operative site, and some even report pain worse than what they experienced preoperatively with the ulnar impaction. Therefore, we sought to identify the factors associated with adverse results after USO.
The overall rate of adverse radiographic outcomes (delayed union or nonunion) in the present study was about 10%, and the rate of nonunion was 2.5%. A recent study by Gaspar et al.13 showed a similar overall rate of adverse outcomes of 17% and a nonunion rate of 6%. On univariate analysis in the present study, advanced age was negatively associated with normal union. This was also found in previous reports on nonunion after fixation of shaft fractures of long bones15,25,38; however, age was not found to be an independent variable on multivariate logistic regression analysis in the most recent of those studies13. In the present study, advanced age was shown to be a confounding factor, while low BMD was independently associated with delayed union or nonunion. Although BMD measured with DXA scans could not precisely reflect the status of the ulnar diaphysis, Park and Kim39 reported correlations of general BMD with the BMD of other areas of the extremities, indicating that the overall BMD of the area of the USO did not differ markedly from the general BMD. The qualitative and quantitative alterations that occur at the cellular level during osteoporosis explain the progressive deterioration of the healing ability of bone tissue40.
Smoking and diabetes are 2 factors that have been investigated in many previous studies related to fractures or arthrodeses of the spine or ankle16,17,20,22,41. Among several substances present in cigarettes, nicotine was suggested to play a key role in negative bone-healing outcomes seen in several human and animal studies21,23,24. The authors of these previous studies suggested that even short-term cessation of nicotine intake prior to spinal arthrodesis resulted in improved rates of union, with the optimal period of abstinence suggested to be approximately 1 month. Unlike treatment of traumatic conditions, USO can be performed as an elective procedure after cessation of smoking for a sufficient period. Gaspar et al.13 emphasized the necessity of cessation of smoking by discussing the differences in outcome between active and former smokers. Logistic regression analysis indicated that diabetic smokers were at especially significant risk because of the additive effect of these 2 individual risk factors13. Our findings were similar to those of Gaspar et al. in that smoking was a more significant independent factor than any of the other variables previously suggested to be associated with the operative outcome (e.g., plate type, number of screws, and plate position). Because we considered former smokers (as identified on self-reported questionnaires) to be nonsmokers at the time of USO, we could not compare former smokers with nonsmokers.
Wrist range of motion was independently associated with adverse radiographic effects in the present study. To the best of our knowledge, there have been no previous reports of an association between a decreased preoperative range of motion and delayed union or nonunion. Although we cannot yet provide a full explanation, USO seemed to have a tethering effect around the distal radioulnar joint, reducing subluxation of and increasing pressure in the joint, leading to arthritic changes occasionally developing after surgery in the present study. The same postoperative protocol (splinting and range-of-motion exercises) may produce more load at the osteotomy site when the range of motion of the wrist was decreased preoperatively. However, although the differences in the flexion-extension and rotation arcs between the 2 groups were statistically significant, the actual mean values were not markedly different; thus, further investigation is needed. Many of the patients with delayed union showed callus formation at the osteotomy site until final union occurred, despite the good contact achieved by precise sawing and sufficient compression by the plate (Figs. 4-A through 4-E). These findings indicate that micromotion was caused by bending or rotational forces at the osteotomy site after a period of wearing a long arm splint, and micromotion can inhibit primary bone-healing.
In some patients, the degree or magnitude of shortening was not exactly matched with the osteotomized bone. Specifically, patients who underwent a transverse osteotomy sometimes had an “unintended gap” at the osteotomized area, despite compression and plate fixation, if they had a slightly nonparallel osteotomy. Additionally, “unintended overcompression,” overriding the osteotomy plane, was possible in the few patients who underwent oblique osteotomy. Thus, we considered the preoperative and postoperative ulnar variance and the gap, rather than the amount of shortening, as potential risk factors. Actually, there was no difference in our raw data (the degree of shortening) between the groups.
The final independent factor associated with outcome in the present study was the use of a double-blade saw. Firoozbakhsh et al.12 reported that, if generated heat surpasses the threshold temperature of bone tissue, the organic matrix is irreversibly damaged and necrosis of the osseous ends may occur. They found that the temperature rise with a double-blade saw was 14% higher than that with a single-blade saw and the rise with a triple-blade saw was 23% higher than that with a single-blade saw. They reported no significant relationship between temperature rise and the number of cuts (up to 10) made by the same blade. Our results were very similar to those of Firoozbakhsh et al., suggesting that a single-blade saw should be used with sufficient saline solution irrigation. Also, we used the oblique osteotomy plate system for a relatively small patient group, although we performed an additional analysis excluding the oblique osteotomies to explore the possibility of different results. The reason for the infrequent use of oblique osteotomies was related to the preference of the surgeon (H.D.S.), who believed that the recently developed system failed to properly compress the osteotomy site (i.e., it led to unintended overcompression). However, other authors have shown that oblique osteotomy sites heal faster and have a lower nonunion rate than the sites of transverse osteotomies as a result of the 40% increase in osseous surface area and the use of a compressive lag screw42,43. Thus, there may be a difference between osteotomy techniques with respect to the rates of delayed union or nonunion; this should be investigated in future well-designed, prospective randomized studies.
The main strength of the present study was the inclusion of a large number of patients treated by a single surgeon over a period of several years. In addition, cutoff values predicting delayed union or nonunion were determined using receiver operating characteristic curves. However, there are limitations to this study as well. First, 3 operative techniques were used during the study period. In the earlier period, the conventional freehand technique was most prevalent, while the other 2 methods were used in the later period. These procedural differences may have been responsible in part for the differences in the results. Second, the duration of smoking and presence of diabetes as well as the degree of control of diabetes were not investigated in detail. Third, factors associated with nutrition, such as body mass index, were not evaluated. All of these factors may be associated with delayed union or nonunion, and thorough evaluation would be required to assess their effects in studies of this nature. Finally, the retrospective nature of this study could have introduced selection bias; therefore, a randomized comparative study would help to further elucidate the most important factors.
In conclusion, delayed union or nonunion occurred in about 10% of cases after USO. Smoking, low BMD, preoperative decreased wrist motion, and use of a double-blade mini-saw for a transverse osteotomy were revealed as independent variables in the current study. Thus, we suggest that USO may have better results in nonsmokers and in patients with healthy osseous structures without osteoporosis or restricted wrist motion. Also, we recommend the use of a single-blade saw.
Detailed descriptions of the radiographic and operative variables, surgical procedure and postoperative care, and evaluation of osseous consolidation; figures showing the method for quantification of the dorsal subluxation of the wrist described by Nakamura et al.29; and tables showing the outcomes at final follow-up, comparison between groups in univariate analysis with exclusion of patients who underwent oblique osteotomy, and independent variables investigated with multivariate logistic regression analysis with exclusion of patients who underwent oblique osteotomy are available with the online version of this article as a data supplement at jbjs.org (http://links.lww.com/JBJS/C254).
Investigation performed at the Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea
Disclosure: This research was supported by Chungnam National University Hospital Research Fund, 2015. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/C253).
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