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Ulnar shortening osteotomy using the RECOS locking plate

    Overview

    Learn the Ulnar shortening osteotomy using the RECOS locking plate surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Ulnar shortening osteotomy using the RECOS locking plate surgical procedure.
    An ulnar shortening osteotomy is a common procedure in wrist surgery and was originally described by Milch in 1941 for the treatment of an ulnar positive variance following a distal radius malunion. Painless load transmission through the wrist is dependent upon the alignment of the radius with the ulna. Studies have shown that a length alteration in the ulna of 2.5mm has dramatic implication on load transmission across the wrist.
    Ulnar impaction syndrome is a process affecting the ulnocarpal joint with some evidence that overloading through the distal ulna is the cause. Ulnar positive variance is known to be a risk factor as it increases loads through the ulnocarpal joint.
    Ulnar impaction syndrome can be congenital, developmental or degenerative, or may occur following trauma. Post traumatic impaction commonly results from a distal radius fracture or less commonly after premature radial epiphyseal closure.
    Although any amount of ulnar shortening may rebalance and improve wrist loading, between 2-3 mm is recommended by most authors. This should result in an 80% reduction in load transmission through the ulno-carpal articulation.
    Currently ulnar shortening is performed for a variety of indications and although these may demand different degrees of shortening, the same techniques and instruments may be used to ensure a high degree of precision and control.
    Recent years have seen a number of manufacturers introduce specialised instrumentation and customised plates. In this section I describe one technique of ulnar shortening using the RECOS (KLS Martin Group, Germany) locking reconstruction system for ulnar shortening.
    This is a pre-contoured titanium plate with drill sleeves and colour coded screws.
    An adjustable jig allows the surgeon to perform a predetermined degree of shortening whilst two sliding holes allow compression across the osteotomy followed by lag screw placement and rigid fixation.
    The RECOS plate requires a very limited number of instruments and it is consequently one of the simpler procedures to follow, in comparison to a number of alternative implants.



    Indications

    INDICATIONS
    Painless load transmission through the wrist is dependent upon the alignment of the radius with the ulna. Studies have shown that a length alteration in the ulna of 2.5mm has dramatic implication on load transmission across the wrist.
    Ulnar impaction syndrome is a degenerative process affecting the ulnocarpal joint with some evidence that overloading through the distal ulna is the cause. Ulnar positive variance is known to be a risk factor as it increases loads through the ulnocarpal joint.
    Primary ulnar impaction syndrome may be congenital, developmental or degenerative.
    Post traumatic impaction is also well recognised and commonly results from a distal radius fracture or less commonly after premature radial epiphyseal closure.
    Although any amount of ulnar shortening may rebalance and improve wrist loading, between 2-3 mm is recommended by most authors. This should result in an 80% reduction in load transmission through the ulno-carpal articulation.
    It is important to exclude other causes of ulnar sided wrist pain such as a triangular fibrocartilage complex (TFCC) tear or distal radioulnar joint (DRUJ) arthritis.
    SYMPTOMS & EXAMINATION
    The patient in this case was a 40 year old woman who presented with longstanding ulnar sided wrist pain. Presenting symptoms were consistent with ulnar impaction syndrome, also known as ulnocarpal abutment. This which was later confirmed on examination and imaging. Symptoms had recently been exacerbated by wrist trauma and failed to settle with non-operative treatment over the course of a year.
    The patient initially presented with ulnar sided wrist pain. This was localisable to the ulnocarpal articulation and exacerbated by ulnar deviation of the wrist. Activities involving ulnar deviation or a pronated grip reproduced ulnar sided pain.
    Clinical examination also revealed localised swelling, tenderness over the volar and dorsal aspects of the ulnar head and triquetrum. Performing a pisiform boost (a volar pressure over the pisiform causing elevation of the ulnar side of the carpus) whilst depressing the head of the ulna exacerbated pain.
    IMAGING
    Standard x-rays of the wrist will demonstrate arthritic change involving the carpus or DRUJ.
    The PA view will also allow measurement of ulnar variance. A pronated grip view is advocated by some surgeons as this may demonstrate a dynamic increase in ulnar variance.
    An MRI scan may add some useful information about the integrity of the TFCC and the condition of the articular cartilages at the radio-carpal joints and the DRUJ.
    ALTERNATIVE OPERATIVE TREATMENT
    The main alternative operative treatment for the patient is a partial distal ulnar resection, also known as the wafer procedure. This involves excision of the distal 2-4mm of the distal dome of the ulnar head. One potential advantage of this procedure is that it may be performed arthroscopically. It also avoids the potential problems of ulnar shortening osteotomy such as hardware irritation, secondary surgery to remove the plate (65%) and non-union (0-11%). However although long term results are satisfactory, there is a long initial recovery time.
    A diagnostic wrist arthroscopy prior to ulnar shortening may be useful. As well as confirming the presence of degenerative change at the ulnocarpal joint, it also excludes other sources of wrist pain such as a TFCC tear or DRUJ degeneration
    NON-OPERATIVE MANAGEMENT
    All patients should undergo a period of non-operative management before proceeding to surgery. Activity modification to avoid exacerbating symptoms through repeated loading, as well as a course of non steroidal anti-inflammatories may be helpful. Wrist splinting may also help offload the ulno-carpal articulation. If these measures fail to resolve symptoms, a corticosteroid injection may be useful.
    The current patient failed to respond to these measures and therefore an ulnar shortening osteotomy was offered.
    CONTRAINDICATIONS
    One must ensure that other causes of ulnar sided wrist pain have been excluded, and the presence of DRUJ arthritis is important. The morphology of the DRUJ must also be taken into consideration although this is not a contraindication. Shortening of 2-3mm have generally been found to be well tolerated by the DRUJ even though cadaveric studies have found that joint loading pressures may be increased. A DRUJ with reverse inclination is especially prone to developing problems after ulnar shortening with point loading at the proximal edge of the notch.

    Setup

    A general or regional anaesthetic technique may be used. Intravenous antibiotics are administered at induction. An upper arm tourniquet is inflated ensuring a bloodless field.
    The patient is positioned supine with the arm abducted on an arm table. Intra-operative fluoroscopy is a useful adjunct to ensure correct metalwork placement and screw length and also enables radiographic confirmation of the amount of shortening.

    Operation – 1

    Ulnar variance, also known as Hulten variance is a radiographic measure of the relative height of the distal articular surfaces of the radius and ulna. Positive ulnar variance is where the ulna articular surface projects more distally than the radius and negative ulna variance is where the radial articular surface projects more distally than the ulna. Neutral variance is where both distal articular surfaces are at exactly the same level.
    Positive ulnar variance is associated with ulnar impaction syndrome.
    Negative ulnar variance is associated with ulnar impingement syndrome and Keinbocks disease.
    Here the pre-operative PA wrist radiograph demonstrates a positive ulnar variance. It also highlights some cystic changes in the lunate.
    The distal radio-ulnar joint appears normal.

    The subcutaneous ulna is palpated and the incision is marked over the volar aspect of the ulna.
    The incision is approximately 8-10cm in length with its distal end at the level of the ulnar neck.

    The skin and fat are incised.

    The facial layer below has been reached. Superficially there are a number of vessels that should be coagulated with a bipolar diathermy.

    The fascia is divided.
    The dorsal cutaneous branch of the ulnar nerve may be seen at this level passing into the dorsal flap and should be protected. Identification may be aided by a perforating vessel that often accompanies the nerve at this level.
    Dissection continues into the plane between flexor carpi ulnaris (FCU) and extensor carpi ulnaris (ECU).

    With FCU and ECU retracted, The fibres of pronator quadratus (A) are identified running perpendicular to the fibres of FCU and wrapping around the ulna, and blending with the periosteum

    The ulnar insertion of pronator quadratus muscle is divided sharply exposing the periosteum beneath.
    Circumferential bone stripping is to be avoided.

    The volar aspect of the ulna is now exposed and self retaining retractors are carefully placed to maintain the exposure. The plate is now positioned on the volar aspect of the ulna.
    Orientation of the plate at this stage is critical and some time should be taken confirming that this is correct. The plate is labelled distal and proximal. The distal extent of the plate is placed as far distal as possible so that it is seated on the ulnar neck.
    If there is doubt about positioning, intraoperative fluoroscopy may be used to confirm correct placement.

    The correct order of screw placement must be observed. The initial screw is always the second most distal screw.
    This first hole is drilled through the blue drill sleeve, using the 2.0mm drill bit. Good assistance ensures that the plate position is carefully maintained whilst drilling this initial hole.
    Once drilled, the sleeve is removed using the screwdriver.

    With the sleeve removed one may now measure the screw length. To ensure correct measurement, the plate should be applied firmly to the bone surface.

    A 2.5mm standard screw is placed.

    The process is repeated for the next hole, marked by the second most proximal drill sleeve.

    With this screw tightened the plate is positioned securely to the bone surface.

    The third hole to be drilled is the distal most hole.
    Again this is drilled using the 2.0mm drill bit, and the drill sleeve removed prior to measurement using the depth gauge.

    A 2.5mm standard screw is now placed in the distal hole.

    In cases where the quality of bone may be poor, 3.0mm screws are available

    The side-specific saw guide is demonstrated here. The amount of shortening desired can be set by turning the screw hole A using the screwdriver on the set.
    The value B represents the exact amount of shortening that will be achieved.

    The saw guide is screwed into the plate using the screw driver and the two blue screws.
    The proximal screw is first screwed loosely into the distal aspect of the central sliding hole.

    The distal screw is secured into the third hole from the distal end of the plate.
    The distal screw is in a round hole and is therefore tightened first.
    The screws are gradually tightened in turn until the guide is completely secure.

    A power saw is used to make the osteotomy through the slots in the guide.
    The manufacturer recommends that the blade have a thickness of 0.65mm, a length of 35-40mm and a width of 15mm.

    The proximal slot is entered.
    Irrigation with cold saline ensure reduces the risk of thermal injury to the bone.
    The volar edge is difficult to reach under the guide and can be left for completion once the guide is removed.

    The saw guide is unscrewed and removed.

    The volar edge of the osteotomy may now be completed. The blade is passed through the proximal and distal aspects of the osteotomy site.
    Once complete, a 3mm disc of corticocancellous bone is removed.
    An osteotome or a Macdonalds elevator may be used to help in its removal.

    The completed osteotomy can be seen as a gap in the distal ulna.
    The next step is to close this gap and add some compression.
    The two proximal standard screws seen here are loosened by approximately half a turn. This will allow some sliding of these screw heads within their sliding holes as compression is applied.

    Compression forceps are now applied to the plate.
    These engage with the proximal screw head and the round hole between the two sliding holes as demonstrated here.
    The forceps come in a right and left version to ensure that they can be tightened without coming into contact with the screwdriver in the next step.

    Operation – 2

    The compression forceps are now gently closed. The osteotomy gap can be seen to close as compression is applied.
    The forceps are screwed tight once the gap has been closed.
    Subsequent tightening on the second sliding hole screw back into position will now hold this position.
    However, in this case I have chosen to augment the compression with a lag screw across the osteotomy site.
    Therefore this screw will only be tightened by half a turn. Final tightening will be reserved until after lag screw placement.

    A 2.0mm drill is used to drill perpendicular to the osteotomy and passes through to the distal cortex.
    A subsequent 2.5mm drill is used to overdrill the near cortex.
    The depth gauge is used to measure the size of the lag screw.

    Lag screw placement should demonstrate some compression across the osteotomy site as long as the proximal sliding holes have not been completely tightened yet.
    Once the lag screw is in its final position, the proximal sliding screws are tightened and the compression forceps are loosened and released.

    There are now two holes remaining in the plate.
    The locking drill guide is used to drill these using a 2.0mm drill bit.
    Blue 2.5mm locking screws are placed into these holes for added stability of the construct.

    After screw placement, fluoroscopy can be used to confirm screw position and correction of variance.
    The wounds are irrigated.
    DRUJ passive rotation and stability are tested.
    If there are concerns about haemostasis, the tourniquet may be released and any bleeding areas attended to.

    A layered closure is performed using 3/0 vicryl and 4/0 monocryl.

    A subcuticular Monocryl suture is used to close the skin.

    Steristrips and a nonadherent dressing are placed.

    A volar plaster slab is placed to support the wrist and wraped in crepe.
    The arm is placed into a Bradford sling for elevation and safety following a regional block.

    Intraoperative fluoroscopy demonstrates a satisfactory degree of shortening with neutral, or perhaps slightly negative ulnar variance.

    The AP view at 3 months, showing the osteotomy with compression screw across it is well united.
    The correction of the Ulnar varience is also very obvious.

    The lateral view also shows a little of the osteotomy has still to heal.

    Post Operative

    The patient is usually discharged home on the day of surgery. A wound check is performed at 2 weeks and any suture knots can be trimmed at this point.
    The wrist is immobilised in the plaster slab for two weeks initially. Following this a removable splint is placed restricting wrist motion for a further four weeks.
    Repeat x-rays are taken at 6 weeks and loading of the wrist is limited until evidence of union across the osteotomy site is seen.
    At this point the patient is allowed to drive. Heavy lifting should be avoided for the first three months.
    In cases of delayed union a further 6 week period of immobilisation is recommended followed by repeat x-rays.

    Recommended Reading

    The results of ulnar shortening osteotomy are widely reported as satisfactory with an overall 88% of patients achieving good or excellent function and pain relief.
    As mentioned above, hardware irritation requiring removal is a common problem. Delayed union is also a concern and non-union is also reported.
    The importance of DRUJ morphology has been looked at by numerous authors. A recent study showed poorer grip strength and DASH scores in patients with oblique DRUJ configurations following ulnar shortening osteotomy, but no degenerative change over the minimum 5 year follow up period.
    Long-Term Outcome of Step-Cut Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome.
    Papatheodorou LK, Baratz ME, Bougioukli S, Ruby T, Weiser RW, Sotereanos DG.
    J Bone Joint Surg Am. 2016 Nov 2;98(21):1814-1820.
    Ulnar Shortening Versus Distal Radius Corrective Osteotomy in the Management of Ulnar Impaction After Distal Radius Malunion.
    Aibinder WR, Izadpanah A, Elhassan BT.
    Hand (N Y). 2018 Mar;13(2):194-201. doi: 10.1177/1558944716685831. Epub 2017 Jan 4.
    Does Distal Radio-ulnar Joint Configuration Affect Postoperative Functional Results after Ulnar Shortening Osteotomy?
    Gilbert F, Jakubietz RG, Meffert RH, Jakubietz MG.
    Plast Reconstr Surg Glob Open. 2018 Apr 13;6(4):e1760. doi: 10.1097/GOX.0000000000001760. eCollection 2018 Apr.
    Ulna-Shortening Osteotomy: Outcome and Repercussion of the Distal Radioulnar Joint Osteoarthritis.
    de Runz A, Pauchard N, Sorin T, Dap F, Dautel G.
    Plast Reconstr Surg. 2016 Jan;137(1):175-84. doi: 10.1097/PRS.0000000000001870.
    Ulnar shortening osteotomy for ulnar-sided wrist pain.
    Tatebe M, Nishizuka T, Hirata H, Nakamura R.
    J Wrist Surg. 2014 May;3(2):77-84. doi: 10.1055/s-0034-1372516.
    Ulnar Impaction Syndrome: Ulnar Shortening vs. Arthroscopic Wafer Procedure.
    Smet LD, Vandenberghe L, Degreef I.
    J Wrist Surg. 2014 May;3(2):98-100. doi: 10.1055/s-0034-1375966.
    Ulnar Shortening Osteotomy: Are Complications Under Reported?
    Chan SK, Singh T, Pinder R, Tan S, Craigen MA.
    J Hand Microsurg. 2015 Dec;7(2):276-82. doi: 10.1007/s12593-015-0201-7. Epub 2015 Sep 23.

    Reference

    • orthoracle.com

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