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Outcomes of Ulnar Shortening Osteotomy with an Intramedullary Bone Graft for Idiopathic Ulnar Impaction Syndrome Kyung Wook Kim, MD, Ji Hyeung Kim, MD * , Hyung Ryul Lim, MD † ,# , Kee Jeong Bae, MD ‡ , Yo Han Lee, MD ‡ , Young Kwang Shin, MD, Goo Hyun Baek, MD § Department of Orthopaedic Surgery, Dankook University Hospital, Dankook University College of Medicine, Cheonan, * Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, † Department of Preventive Medicine, Dankook University College of Medicine, Cheonan, ‡ Department of Orthopedic Surgery, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, § Department of Hand Surgery, Yeson Orthopaedic Hospital, Bucheon, Korea Background: Although several techniques for the treatment of ulnar impaction syndrome (UIS) have been introduced, there have still been reports on various complications such as delayed union, nonunion, refracture, wrist pain, plate irritation, and chronic re- gional pain syndrome. This study aimed to compare the differences in radiological and clinical outcomes of patients in which intra- medullary bone grafting was performed in addition to plate stabilization with those without additional bone grafting during ulnar shortening osteotomies (USOs). Methods: Between November 2014 and June 2021, 53 wrists of 50 patients with idiopathic UIS were retrospectively reviewed. Patients were divided into 2 groups according to whether intramedullary bone grafting was performed. Among the 53 wrists, USO with an intramedullary bone graft was performed in 21 wrists and USO without an intramedullary bone graft was performed in 32 wrists. Demographic data and factors potentially associated with bone union time were analyzed. Results: There was no significant difference between the 2 groups when comparing postoperative radioulnar distance, postopera- tive ulnar variance, amount of ulnar shortening, and postoperative Disabilities of the Arm, Shoulder and Hand score. Compared to the without-intramedullary bone graft group, bone union time of the osteotomy site was significantly shortened, from 8.8 ± 3.0 weeks to 6.7 ± 1.3 weeks in the with-intramedullary bone graft group. Moreover, there were no cases of nonunion or plate-induced symptoms. Both in univariable and multivariable analyses, intramedullary bone grafting was associated with shorter bone union time. Conclusions: USO with an intramedullary bone graft for idiopathic UIS has favorable radiological and clinical outcomes. The ad- vantage of this technique is the significant shortening of bone union time. Keywords: Ulnar impaction syndrome, Ulnar shortening osteotomy, Intramedullary bone graft, Bone union Original Article Clinics in Orthopedic Surgery 2024;16:313-321 • https://doi.org/10.4055/cios23266 Copyright © 2024 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Clinics in Orthopedic Surgery • pISSN 2005-291X eISSN 2005-4408 Received August 24, 2023; Revised October 19, 2023; Accepted October 24, 2023 Correspondence to: Goo Hyun Baek, MD Department of Hand Surgery, Yeson Orthopaedic Hospital, 206 Bucheon-ro, Bucheon 14555, Korea Tel: +82-32-674-8275, Fax: +82-32-674-8276, E-mail: ghbaek@snu.ac.kr #Current affiliation: Department of Preventive Medicine and Public Health, Ajou University School of Medicine, Suwon, Korea
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314 Kim et al. Ulnar Shortening Osteotomy with Intramedullary Bone Graft for Ulnar Impaction Syndrome Clinics in Orthopedic Surgery • Vol. 16, No. 2, 2024 • www.ecios.org Ulnar impaction syndrome (UIS), which can lead to symptoms such as ulnar-side wrist pain, limitation of wrist motion, and diminished grip strength, is known to result from excessive pressure of the ulnar head against the triangular fibrocartilage complex (TFCC) and the carpal bones on the ulnar side of the wrist. 1) The etiology of this syndrome is categorized as idiopathic or secondary, such as traumatic conditions including malunion of the distal radius fracture, radial premature physeal arrest (Madelung syndrome), excision of the radial head, or Essex-Lopresti fracture-dislocation. 2-4) Since Milch 5) described the ulnar shortening oste- otomy (USO), it has been widely used to decompress the ulnocarpal articulation by restoring zero or negative ulnar variance. Moreover, this extra-articular procedure has the advantage of preserving the distal radioulnar joint (DRUJ) and surrounding structures over other intra-articular sur- gical methods, such as distal ulnar recession or the wafer procedure. 6,7) Since then, various surgical methods for the treatment of UIS have been introduced with the goal of restoring ulnar variance and reducing complications and have shown generally satisfactory outcomes. 8,9) However, despite these procedures, some studies have reported vari- ous complications, such as delayed union or nonunion, refracture, wrist pain, plate irritation, and chronic regional pain syndrome (CRPS). 10,11) We hypothesized that grafting the osteotomized ulnar bone fragment, which was extracted during the USO, to the osteotomy site could decrease and improve such complications, especially those related to bone union. Hence, this study aimed to compare the differences in radiological and clinical outcomes depending on whether bone grafting was performed during USO or not. METHODS Patient Selection This study’s design was approved by the Institutional Review Board of the Seoul National University College of Medicine/Seoul National University Hospital (No. H-2004-121-1118), which waived the need for informed consent, owing to its retrospective nature. Among the pa- tients who had a history of ulnar-side wrist pain that wors- ened by pronation and ulnar deviation and presented with positive physical examination, static or dynamic positive ulnar variance with wrist pronation, and forceful grip on plain radiographs, 65 wrists with idiopathic UIS that un- derwent the USO between November 2014 and June 2021 were included. Twelve wrists that had a history of con- genital disease, trauma, surgery, inflammatory disease of the upper extremity, or less than 1 year of follow-up were excluded. Finally, 53 wrists of 50 consecutive patients with idiopathic UIS were enrolled. Patients were divided into 2 groups according to whether intramedullary bone graft- ing was performed: (1) without-intramedullary bone graft and (2) with-intramedullary bone graft. The former group comprised 32 wrists on which USO was performed with- out intramedullary bone graft by a single surgeon (JHK). While the latter group consisted of 21 wrists on which a single surgeon (GHB) performed USO with intramedul- lary bone graft. Both surgeons were fellowship-trained in hand surgery and had a minimum 15 years of clinical ex- perience in the hand practice. There were 17 men (32.1%) and 36 women (67.9%), with a mean age of 46.8 years (range, 22–83 years). Surgical Techniques In all patients, nonoperative treatments, such as immo- bilization, nonsteroidal anti-inflammatory drug medica- tion, and life-style modification were attempted for over 3 months. An incision of approximately 8 cm was placed on the lateral aspect of the forearm, beginning 4 cm proxi- mal to the tip of the ulnar styloid. While protecting the dorsal sensory branch of the ulnar nerve, the ulna was approached between the flexor carpi ulnaris (FCU) and extensor carpi ulnaris. After FCU retraction, the plate was placed on the volar side of the ulna and subsequently cov- ered back with the FCU to reduce irritation. A transverse osteotomy was performed and a bone fragment was re- sected according to the preoperatively determined amount to restore the ulnar variance between –1 and 0 mm. Before compressing the osteotomy site using a low-profile dy- namic compression plate (Arix; Jeil Medical), half of the osteotomized fragment was inserted into the medullary canal. After compression of the osteotomy site, the re- maining screws were secured. The other half of the resect- ed fragment was morselized and locally grafted around the osteotomy site (Fig. 1). During the entire procedure, the periosteum was preserved as much as possible. Postopera- tively, a long-arm splint was applied for the first 2 weeks, followed by a removable long-arm splint for another 4 to 6 weeks. Assessment of Outcomes Demographic features such as age, sex, follow-up duration, diabetes mellitus, smoking, and radiological or clinical variables were compared between the 2 groups. Radiologi- cal variables were compared pre- and postoperatively. The anteroposterior plain radiographs of the wrist were taken with the shoulder at 90° of abduction, the elbow at 90° of
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315 Kim et al. Ulnar Shortening Osteotomy with Intramedullary Bone Graft for Ulnar Impaction Syndrome Clinics in Orthopedic Surgery • Vol. 16, No. 2, 2024 • www.ecios.org flexion, and the forearm in a neutral position. To quantify the dorsal subluxation of DRUJ, radioulnar distance was measured in the true lateral position of the wrist with a pi- soscaphoid distance of less than 3 mm. 12) Moreover, ulnar variance was analyzed by measuring the distance between a line drawn perpendicular to the longitudinal axis of the radius on its distal ulnar side and the horizontal line at the end of the distal ulna. 3) The amount of ulnar shortening, signs of preoperative radiographic carpal chondromala- cia, postoperative arthritic change in the DRUJ, and bone union were also evaluated. Radiological as well as clinical variables, such as pre- and postoperative Disabilities of the Arm, Shoulder and Hand (DASH) score, were measured. The union of the osteotomy site was radiographi- cally determined and clinically confirmed. Radiographic assessments were performed immediately, 1 week after surgery, and then every 2 weeks until bone union was veri- fied. Bone union was defined as the radiographic presence of confluent bony bridging on either side of the osteotomy site. In addition, nonunion was defined when 3 of 4 corti- ces of the osteotomy site had not shown continuity over 6 months or had not shown any radiographic change for 3 consecutive months and were accompanied by clinical fea- tures of nonunion. 13) The radiographic features were mea- sured by 2 independent orthopedic surgeons who were blinded to the demographic data (KWK and KJB). Post- operative radiological complications such as nonunion or refracture and clinical complications such as plate related symptoms, infection, or CRPS were also evaluated. Statistical Analysis Changes in variables were compared according to whether intramedullary bone grafting was performed. Categori- cal variables were compared using the chi-square test and continuous variables were compared using an indepen- dent t -test. Factors potentially associated with bone union time, such as intramedullary bone graft, age, sex, diabetes mellitus, smoking, radioulnar distance, ulnar variance, and amount of ulnar shortening, were analyzed. Univari- able and multivariable analyses were performed using a linear regression model to identify the factors associated with bone union time. In the multivariable linear regres- sion model, intramedullary bone graft (yes/no), sex (men/ women), and age were selected as predictor variables us- ing the stepwise Akaike Information Criterion regression method. Statistical power was calculated using the statisti- cal software R version 4.0.1 (R Foundation for Statistical Computing). A B C D Fig. 1. Schematic diagram of the ulnar shortening osteotomy with an intramedullary bone graft. From the proximal side, the second oblong compression hole and the third sliding hole are for the cortical screws. The remaining holes are combination holes, and both cortical and locking screws can be used, depending on the purpose. (A) After predrilling the proximal and distal holes along the marked line to verify the alignment and to prevent malrotation, the ulnar bone was cut by a transverse osteotomy to the length that had been preoperatively measured. (B) Through the predrilled distal screw holes, the plate was secured to the bone by screws. After the osteotomized fragment, which had been cut in half, was grafted in the medullary canal, the proximal oblong compression and sliding holes were temporarily secured. (C) The osteotomy site was compressed by securing the oblong compression hole. (D) After tightening the screw in the sliding hole, the rest of the screws were tightened in sequence. Additionally, the remaining half of the resected bone was morselized and placed at the osteotomy site as a graft.
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316 Kim et al. Ulnar Shortening Osteotomy with Intramedullary Bone Graft for Ulnar Impaction Syndrome Clinics in Orthopedic Surgery • Vol. 16, No. 2, 2024 • www.ecios.org RESULTS The average follow-up duration was 37.1 months (range, 14–78 months). Among the all cases, 1 case of diabetes and 6 cases of smoking history were confirmed. The aver- age preoperative radioulnar distance was 2.7 ± 1.3 mm and 2.9 ± 1.5 mm in the without- and with intramedullary bone graft groups, respectively. Meanwhile, the postopera- Table 1. Demographics of the Groups without and with Intramedullary Bone Grafts Variable Overall Without-intramedullary bone graft p-value* With intramedullary bone graft p-value* p-value † No. of patients 53 32 21 - Age (yr) 46.8 ± 13.4 46.5 ± 13.8 46.2 ± 13.1 0.951 Sex 0.551 Male 17 9 8 Female 36 23 13 Follow-up duration (mo) 37.1 ± 20.0 33.0 ± 17.2 43.3 ± 22.7 0.671 Diabetes mellitus 0.604 – 52 31 21 + 1 1 0 Smoking 0.671 – 47 29 18 + 6 3 3 Radioulnar distance (mm) < 0.001 < 0.001 Preoperative 2.8 ± 1.4 2.7 ± 1.3 2.9 ± 1.5 0.610 Postoperative 1.1 ± 1.0 1.1 ± 1.0 1.0 ± 1.1 0.635 Ulnar variance (mm) < 0.001 < 0.001 Preoperative 3.5 ± 1.1 3.3 ± 1.0 3.7 ± 1.3 0.209 Postoperative –0.1 ± 0.6 –0.1 ± 0.6 0.1 ± 0.7 0.251 Amount of ulnar shortening (mm) 3.4 ± 1.1 3.3 ± 0.8 3.5 ± 1.0 0.320 DASH score < 0.001 < 0.001 Preoperative 45.5 ± 10.3 44.0 ± 9.5 47.7 ± 11.2 0.195 Postoperative 15.8 ± 5.0 15.8 ± 5.8 15.8 ± 3.7 0.981 Preoperative radiographic carpal chondromalacia 0.738 – 47 28 19 + 6 4 2 Postoperative arthritic change 0.415 – 46 29 17 + 7 3 4 Values are presented as mean ± standard deviation. DASH: Disabilities of the Arm, Shoulder and Hand. *Comparison of preoperative to postoperative values in each group. † Comparison of the 2 groups.
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317 Kim et al. Ulnar Shortening Osteotomy with Intramedullary Bone Graft for Ulnar Impaction Syndrome Clinics in Orthopedic Surgery • Vol. 16, No. 2, 2024 • www.ecios.org tive radioulnar distance was 1.1 ± 1.0 mm and 1.0 ± 1.1 mm in the without- and with-intramedullary bone graft group, respectively. The average of preoperative ulnar vari- ance was 3.3 ± 1.0 mm and 3.7 ± 1.3 mm, and postopera- tive ulnar variance was –0.1 ± 0.6 mm and 0.1 ± 0.7 mm, respectively, in without- and with-intramedullary bone graft group. Additionally, the average amount of ulnar shortening was 3.4 ± 1.1 mm. The average preoperative DASH score of the without- and with-intramedullary bone graft groups was 44.0 ± 9.5 and 47.7 ± 11.2, respec- tively; at the final follow-up, and the score significantly improved to 15.8 ± 5.8 and 15.8 ± 3.7, respectively. How- ever, in terms of the postoperative DASH score, there was no significant difference between the 2 groups. Six of the 53 wrists showed cystic changes in the carpal bones preop- eratively: 4 wrists had changes in the lunate, 1 in the lunate and ulna, and 1 in the lunate, ulna, and triquetrum bones. These cystic changes began to disappear at least 1 year after USO and had vanished at the last follow-up. More- over, 7 of the 53 wrists showed degenerative changes in the DRUJ postoperatively (Table 1). However, no other clinical symptoms were noted. Union of the osteotomy site was achieved in all pa- tients at a mean of 8.0 ± 2.7 weeks (range, 4–19 weeks). Table 2. Linear Regression Analyses for Factors Associated with Bone Union Time Variable Univariable linear regression Multivariable linear regression β SE p-value β SE p-value Intramedullary bone graft – Ref Ref + –2.2 0.7 0.003* –2.3 0.7 0.001* Age (yr) 0.1 0.0 0.089 0.0 0.0 0.121 Sex Male Ref Ref Female –1.1 0.8 0.148 –1.2 0.7 0.091 Smoking – Ref + 0.3 1.2 0.816 Radioulnar distance (preoperative) (mm) 0.3 0.6 0.654 Radioulnar distance (postoperative) (mm) –0.1 0.3 0.756 Ulnar variance (preoperative) (mm) –0.1 0.4 0.828 Ulnar variance (postoperative) (mm) 0.0 0.3 0.988 Amount of ulnar shortening (mm) –0.0 0.4 0.987 β : correlation coefficient, SE: standard error, Ref: reference. *Indicates significant value. Without intramedullary bonegraft 10 8 6 4 2 Bone union time (wk) Ulnar shortening osteotomy 8.8 3.0 6.7 1.3 0 *** With intramedullary bonegraft Fig. 2. Comparison of the mean value (and standard deviation) for bone union time between the without or with intramedullary bone grafts. The bone union time was significantly shortened from 8.8 ± 3.0 to 6.7 ± 1.3 weeks in the with-intramedullary bone graft group (*** p < 0.001).
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318 Kim et al. Ulnar Shortening Osteotomy with Intramedullary Bone Graft for Ulnar Impaction Syndrome Clinics in Orthopedic Surgery • Vol. 16, No. 2, 2024 • www.ecios.org When comparing the bone union time according to whether the intramedullary bone grafting was used, the time significantly decreased from 8.8 ± 3.0 weeks to 6.7 ± 1.3 weeks in the with-intramedullary bone graft group ( p < 0.001) (Fig. 2). Additionally, there were no cases of non- union. However, there were 3 cases in which bone union had taken more than 3 months in the without-intramed- ullary bone graft group. Regarding clinical manifestations, there were no cases of plate-induced symptoms, infection, neurologic deficits, or CRPS. Prior to the linear regression analyses, the distribu- tion between the 2 groups was compared based on the median value of overall bone union time (7.1 weeks) to find the factors related to bone union time. As a result, the proportion of intramedullary bone grafting was higher in the group with low bone union time ( p = 0.033) (Supple- mentary Table 1). In the univariable analysis, intramedullary bone grafting was significantly associated with bone union time. Moreover, in the multivariable regression analysis, which was adjusted for other covariates (age and sex), in- tramedullary bone grafting showed a significant association with bone union time (β = –2.3, p = 0.001) (Table 2). The intraclass correlation coefficient for bone union was 0.92 for intraobserver reliability and 0.81 for interobserver reliability. DISCUSSION Although several novel techniques and devices have been introduced for the treatment of UIS over the past de- cades, 8,9) a previous systematic review 11) reported that the average rates of delayed union and nonunion of osteotomy sites after USO were 5.7% and 4.0%, respectively. In gen- eral, bone grafting in USO has been performed when a nonunion has occurred, rather than in primary surgery. 14) Furthermore, in cases where bone grafting is required, bone is usually harvested from the iliac bone, but this can lead to various donor-site complications such as pain, nerve injury, hemorrhage, or infection, delaying return to daily activities. 15) However, by using the bone fragment that would normally be discarded, rather than performing any invasive or additional procedures, our surgical method is useful in that not only are there no cases of nonunion, but the bone union time is significantly reduced. Moreover, from the perspective of bone healing, endosteal bone healing has not received sufficient atten- tion, unlike periosteal bone healing. 16) However, Schwartz and Boyan 17) mentioned the importance of cellular re- sponses during endosteal bone healing in animal mod- els. In addition, McKinley 18) focused on the responses of endosteal bone healing that differ from healing responses in the surrounding periosteum, soft tissue, and between the cortical ends. Hence, in this study, we considered the combination of osteogenic, osteoinductive, and osteocon- ductive properties of autologous bone grafts 19) and also the fact that the mid-distal of the ulna contains less than 10% cancellous bone. 20) Therefore, in addition to adequate saline irrigation to reduce thermal damage 21) and maximal preservation of the periosteum during USO, intramedul- lary bone grafting was applied to promote bone healing Fig. 3. Postoperative plain radiographs of a 57-year-old man with ulnar impaction syndrome. At the last follow-up, the osteotomized fragment that was cut in half and grafted in the medullary canal was still well- settled (asterisk). Solid bone union was achieved and there were no complications. Table 3. Comparison of Outcomes with Previous USO Studies Study Case (n) Follow-up duration (mo) Union time (wk) Delayed union Nonunion Plate-induced symptom Darrow et al. (1985) 6) 36 25 13 8 1 2 Wehbe et al. (1995) 22) 24 32 9.7 3 0 24 Clark et al. (2012) 23) 93 6 7 0 0 5 Ahsan et al. (2013) 14) 30 8 10 Not documented 2 4 Iniesta et al. (2020) 24) 20 16 11 Not documented 1 3 USO: ulnar shortening osteotomies.
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319 Kim et al. Ulnar Shortening Osteotomy with Intramedullary Bone Graft for Ulnar Impaction Syndrome Clinics in Orthopedic Surgery • Vol. 16, No. 2, 2024 • www.ecios.org and reduce complications. As a result, not only were there no delayed union or nonunion cases, but bone union time was significantly shortened. Although many studies have reported satisfactory results for USO, the bone union time and complications related to USO in this study are superior to those of previous studies (Table 3). 6,14,22-24) It is suspected that autologous bone grafting in the medullary canal and around the osteotomy site could promote bone union. At the final follow-up period, the osteotomized fragment that had been cut in half and grafted in the med- ullary canal was confirmed to be well-settled (Fig. 3). Diabetes mellitus and smoking are known signifi- cant risk factors for delayed union or nonunion in USO. 25) However, in this study, the influence of these factors was limited. Although diabetes mellitus and smoking were considered, statistical significance could not be drawn due to their low prevalence in the sample. In particular, due to the extremely low prevalence of diabetes mellitus in the sample, we could not adjust for it in our linear regression models. However, regardless of the presence or absence of these factors, delayed union or nonunion did not occur. This study has some limitations. First, it was limited by the relatively small sample size and its retrospective nature. Although statistical significance was obtained, a more robust result could have been achieved if a prospec- tive randomized study design with a larger number of samples had been conducted. Second, this study is an ob- servational study, which means that potential confounding variables could not be fully excluded since the surgical ap- proach was not randomly assigned. However, the inclusion and exclusion criteria were strictly applied to ensure that the preoperative characteristics of the subjects were com- parable. Additionally, it was confirmed that the baseline characteristics were not statistically significantly different between the without- and with-intramedullary bone graft groups (Supplementary Table 1). Using a multivariable regression model, possible confounders that might affect the association of graft intervention with bone union time were adjusted. Third, as different surgical methods were performed by 2 different surgeons, bias could have oc- curred. However, not only was there no preference about the patients’ allocation, but the surgeries were performed by 2 experienced surgeons (experience levels IV and V 26) ) in the hand practice and were followed by the same peri- operative protocol at the same institution. Fourth, only a transverse cut osteotomy for the USO was performed. Although it has been hypothesized that oblique osteotomy could provide a large surface area for bone healing, 4) there was no statistically significant difference in the rate of bone healing time, nonunion, or functionality between trans- verse and oblique cut osteotomy. 12,14) Fifth, bone grafting was performed using bone material that was extracted from the osteotomy site of each patient. Because the thick- ness of the removed bone fragment at the osteotomy site was different for each patient, the amount of bone frag- ments used for bone graft was not the same. Finally, we did not proceed with further examinations or additional surgeries for TFCC. Previous studies have reported that TFCC tears are associated with UIS. 27,28) However, recent arthroscopic and radiologic studies have reported on the effectiveness of USO alone for TFCC tears in UIS. 29,30) In particular, Nishiwaki et al. 31) reported that USO leads to a suspension effect on the TFCC, resulting in the stabiliza- tion of the DRUJ. Furthermore, excellent clinical outcomes were observed in our study regardless of TFCC repair. USO with an intramedullary bone graft for idio- pathic UIS, which provides the effects of an autologous bone graft, significantly shortens the bone union time compared to USO without an intramedullary bone graft. Particularly, it is significant that such remarkable results were obtained without any additional devices or invasive procedures. Hence, this technique, which aims to promote bone healing, can be an alternative treatment option for UIS. CONFLICT OF INTEREST No potential conflict of interest relevant to this article was reported. ACKNOWLEDGEMENTS This research was supported by the Bio&Medical Tech- nology Development Program of the National Research Foundation (NRF) funded by the Korean government (MSIT) (RS-2023-00220408). We would like to thank the Medical Statistics Sup- port Team, Dankook University College of Medicine. ORCID Kyung Wook Kim https://orcid.org/0000-0003-3879-0768 Ji Hyeung Kim https://orcid.org/0000-0002-3182-5035 Hyung Ryul Lim https://orcid.org/0000-0002-3371-0557 Kee Jeong Bae https://orcid.org/0000-0002-6254-7373 Yo Han Lee https://orcid.org/0000-0002-2078-3167 Young Kwang Shin https://orcid.org/0009-0009-6026-4933 Goo Hyun Baek https://orcid.org/0000-0002-9126-7194
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320 Kim et al. Ulnar Shortening Osteotomy with Intramedullary Bone Graft for Ulnar Impaction Syndrome Clinics in Orthopedic Surgery • Vol. 16, No. 2, 2024 • www.ecios.org SUPPLEMENTARY MATERIAL Supplementary material is available in the electronic version of this paper at the CiOS website, www.ecios.org REFERENCES 1. Palmer AK, Werner FW. Biomechanics of the distal radioul- nar joint. Clin Orthop Relat Res. 1984;(187):26-35. 2. Baek GH, Chung MS, Lee YH, Gong HS, Lee S, Kim HH. Ulnar shortening osteotomy in idiopathic ulnar impaction syndrome. J Bone Joint Surg Am. 2005;87(12):2649-54. 3. Coleman DA, Blair WF, Shurr D. Resection of the radial head for fracture of the radial head: long-term follow-up of seventeen cases. J Bone Joint Surg Am. 1987;69(3):385-92. 4. Loh YC, Van Den Abbeele K, Stanley JK, Trail IA. The re- sults of ulnar shortening for ulnar impaction syndrome. J Hand Surg Br. 1999;24(3):316-20. 5. Milch H. Cuff resection of the ulna for malunited Colles’ fracture. J Bone Joint Surg. 1941;23(2):311-3. 6. Darrow JC Jr, Linscheid RL, Dobyns JH, Mann JM 3rd, Wood MB, Beckenbaugh RD. Distal ulnar recession for dis- orders of the distal radioulnar joint. J Hand Surg Am. 1985; 10(4):482-91. 7. Feldon P, Terrono AL, Belsky MR. The “wafer” proce- dure: partial distal ulnar resection. Clin Orthop Relat Res. 1992;(275):124-9. 8. Papatheodorou LK, Baratz ME, Bougioukli S, Ruby T, Weiser RW, Sotereanos DG. Long-term outcome of step-cut ulnar shortening osteotomy for ulnar impaction syndrome. J Bone Joint Surg Am. 2016;98(21):1814-20. 9. Low S, Rau M, Van Schoonhoven J, Kitzinger H, Krimmer H. Standardised operation technique for ulna-shortening with a new sliding-hole plate. Handchir Mikrochir Plast Chir. 2003;35(3):181-5. 10. Chan SK, Singh T, Pinder R, Tan S, Craigen MA. Ulnar shortening osteotomy: are complications under reported? J Hand Microsurg. 2015;7(2):276-82. 11. Owens J, Compton J, Day M, Glass N, Lawler E. Nonunion rates among ulnar-shortening osteotomy for ulnar impac- tion syndrome: a systematic review. J Hand Surg Am. 2019; 44(7):612. 12. Nakamura R, Horii E, Imaeda T, Tsunoda K, Nakao E. Distal radioulnar joint subluxation and dislocation diagnosed by standard roentgenography. Skeletal Radiol. 1995;24(2):91-4. 13. Hernigou J, Schuind F. Smoking as a predictor of negative outcome in diaphyseal fracture healing. Int Orthop. 2013; 37(5):883-7. 14. Ahsan ZS, Song Y, Yao J. Outcomes of ulnar shortening os- teotomy fixed with a dynamic compression system. J Hand Surg Am. 2013;38(8):1520-3. 15. Kurz LT, Garfin SR, Booth RE Jr. Harvesting autogenous iliac bone grafts: a review of complications and techniques. Spine (Phila Pa 1976). 1989;14(12):1324-31. 16. Aoki J, Yamamoto I, Hino M, et al. Reactive endosteal bone formation. Skeletal Radiol. 1987;16(7):545-51. 17. Schwartz Z, Boyan BD. Underlying mechanisms at the bone-biomaterial interface. J Cell Biochem. 1994;56(3):340- 7. 18. McKinley T. Principles of fracture healing. Surgery (Oxford). 2003;21(9):209-12. 19. Giannoudis PV, Dinopoulos H, Tsiridis E. Bone substitutes: an update. Injury. 2005;36 Suppl 3:S20-7. 20. Schlenker RA, VonSeggen WW. The distribution of cortical and trabecular bone mass along the lengths of the radius and ulna and the implications for in vivo bone mass mea- surements. Calcif Tissue Res. 1976;20(1):41-52. 21. Firoozbakhsh K, Moneim MS, Mikola E, Haltom S. Heat generation during ulnar osteotomy with microsagittal saw blades. Iowa Orthop J. 2003;23:46-50. 22. Wehbe MA, Cautilli DA. Ulnar shortening using the AO small distractor. J Hand Surg Am. 1995;20(6):959-64. 23. Clark SM, Geissler WB. Results of ulnar shortening oste- otomy with a new plate compression system. Hand (N Y). 2012;7(3):281-5. 24. Iniesta A, Bonev B, Curvale C, Legre R, Gay A. Outcomes of ulnar shortening osteotomy using a new compression plate. Hand Surg Rehabil. 2020;39(1):19-22. 25. Gaspar MP, Kane PM, Zohn RC, Buckley T, Jacoby SM, Shin EK. Variables prognostic for delayed union and nonunion following ulnar shortening fixed with a dedicated osteotomy plate. J Hand Surg Am. 2016;41(2):237-43. 26. Tang JB. Re: Levels of experience of surgeons in clinical studies. J Hand Surg Eur Vol. 2009;34(1):137-8. 27. Boulas HJ, Milek MA. Ulnar shortening for tears of the tri- angular fibrocartilaginous complex. J Hand Surg Am. 1990;
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321 Kim et al. Ulnar Shortening Osteotomy with Intramedullary Bone Graft for Ulnar Impaction Syndrome Clinics in Orthopedic Surgery • Vol. 16, No. 2, 2024 • www.ecios.org 15(3):415-20. 28. Tatebe M, Horii E, Nakao E, et al. Repair of the triangular fibrocartilage complex after ulnar-shortening osteotomy: second-look arthroscopy. J Hand Surg Am. 2007;32(4):445- 9. 29. Kim BS, Song HS. A comparison of ulnar shortening os- teotomy alone versus combined arthroscopic triangular fibrocartilage complex debridement and ulnar shortening osteotomy for ulnar impaction syndrome. Clin Orthop Surg. 2011;3(3):184-90. 30. Tatebe M, Shinohara T, Okui N, Yamamoto M, Hirata H, Imaeda T. Clinical, radiographic, and arthroscopic out- comes after ulnar shortening osteotomy: a long-term follow- up study. J Hand Surg Am. 2012;37(12):2468-74. 31. Nishiwaki M, Nakamura T, Nakao Y, Nagura T, Toyama Y. Ulnar shortening effect on distal radioulnar joint stability: a biomechanical study. J Hand Surg Am. 2005;30(4):719-26. |