541749 research-article2014
JHS0010.1177/1753193414541749The Journal of Hand SurgeryStockton et al.
JHS(E)
Review article
Operative treatment of ulnar impaction syndrome: a systematic review D. J. Stockton1, M.-E. Pelletier2 and J. M. Pike3
The Journal of Hand Surgery (European Volume) 2015, Vol. 40E(5) 470–476 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1753193414541749 jhs.sagepub.com
Abstract This article critically and systematically reviews the surgical treatments for ulnar impaction syndrome. Three types of treatments currently exist: arthroscopic wafer procedure, open wafer procedure, and ulna shortening osteotomy. A total of 36 articles were included from searching the electronic databases PubMed MEDLINE, Ovid MEDLINE, and Ovid EMBASE. Studies were evaluated for quality using the Modified Detsky Score. Of these, 14 articles had a Modified Detsky Score of 6/10 or higher. Satisfaction rates were 100% for arthroscopic wafer procedure, 89% for open wafer procedure, and 84% for ulna shortening osteotomy. The percentage of participants reporting an excellent or good outcome was 82% for arthroscopic wafer procedure, 87% for open wafer procedure, and 76% for ulna shortening osteotomy. In conclusion, available evidence shows that arthroscopic wafer procedure and open wafer procedure may be viable alternatives to the more popular ulna shortening osteotomy, but clinical superiority is yet to be established. Future research should focus on prospective cohort methods and should report participant outcomes using validated scoring methods. Keywords Osteotomy, systematic review, ulnar impaction, ulno-carpal abutment, wafer procedure Date received: 21st October 2013; revised: 20th May 2014; accepted: 20th May 2014
Introduction Ulnar impaction syndrome (UIS) is a common cause of ulnar-sided wrist pain. The differential diagnosis of ulnar-sided wrist pain is diverse due to the complex nature of the bony and soft tissue anatomy. The clinical scenario of UIS may include pain that localizes to the region of the ulno-carpal articulation and is exacerbated with a pronated grip and/or ulnar deviation. Decreased joint space between the ulnar-carpal bones and the ulnar head is present, either due to positive ulnar variance (UV) (Darrow et al., 1985) or less commonly, in ulnar-neutral or negative UV wrists with a thickened triangular fibrocartilage complex (TFCC) (Tomaino, 1998). UIS is synonymous with ulno-carpal impaction syndrome and ulno-carpal abutment, but is a distinct entity from ulnar styloid impaction and ulnar impingement syndrome. Ulnar styloid impaction is caused by impaction between the ulnar styloid and the proximal triquetrum; ulnar impingement syndrome is defined by a shortened ulna impinging on the distal radius (Watanabe et al., 2010). UIS may lead to degenerative lesions of the triquetrum, lunate, ulnar head cartilage, or of the TFCC. Concomitantly the triquetrolunate ligaments may be disrupted. Associated factors of ulno-carpal joint space narrowing may include
previous fracture (e.g. of the distal radius), premature physeal arrest of the distal radius, or congenital ulna positive variance. Treatment is initially non-operative. If nonoperative management fails, surgery to decompress the ulno-carpal joint is indicated. Joint decompression may be achieved by either ulna shortening osteotomy (USO) or by wafer procedure. Wafer procedure may be either arthroscopic (AWP) or open (OWP). Various techniques for performing USO have been described. The choice of surgical treatment for refractory UIS is largely based on surgeon preference. Each surgery 1Faculty
of Medicine, University of Toronto, Toronto, Ontario, Canada 2Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada 3Department of Orthopaedic Surgery, St. Paul’s Hospital, Vancouver British Columbia, Canada Corresponding author: J. M. Pike, St. Paul’s Hospital, 590–1144 Burrard St., Vancouver, BC, V6Z 2A5, Canada. Email: [email protected]
471
Stockton et al. has unique risks, though there exists no high-level evidence to inform decision-making. This article critically and systematically reviews the methods used to study the surgical treatments for UIS. Where possible, results of homogeneous studies are pooled and outcomes comparisons are made to clarify the current state of ulno-carpal decompressive procedures and to guide future research.
Materials and methods Inclusion criteria Studies were selected if (1) the population was composed of adult (>18 y) patients having surgery for symptomatic, refractory UIS; (2) the surgical intervention was either ulnar shortening osteotomy, OWP, or AWP; and (3) the study included either a subjective or an objective outcome measure.
Study identification Two authors searched the electronic databases PubMed MEDLINE and Ovid MEDLINE (1946–2013) and Ovid EMBASE (1980–2013) using the following terms and Boolean operators: (ulna OR ulnar OR ulnocarpal) AND (impaction OR abutment) AND (treatment OR outcome OR outcomes OR surgery OR result OR results). A librarian at the Harvard School of Public Health vetted the search strategy. The search was last updated September 2013. The authors independently reviewed the results by first removing duplicates, then applying the inclusion criteria to title review, abstract review, and full-text review. A third author resolved discrepancies. The authors included articles not in English and contacted the appropriate authors for translation, and also reviewed the reference sections of articles.
Assessment of study quality Each study was evaluated for quality, using a Modified Detsky Score (Detsky et al., 1992; Macadam et al., 2009). Each study was scored out of 10 possible points. One point was awarded if the study (1) described the outcome measure, (2) included at least one outcome measure that was quantitative (either pre- and post-operative range of motion and/or grip strength), (3) described the inclusion and exclusion criteria, (4) described the statistical methods, (5) had a follow-up period of at least 1 year, (6) had a sample size that was calculated before the study, (7) was Level 2 evidence or higher, and (8) was published in a journal whose impact factor was 3 or greater. Up to
two points were awarded for appropriate statistical analysis. Studies gaining a score of 6 or greater out of 10 points were rated as high quality. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (Liberati et al., 2009).
Results The search yielded 481 articles. After 287 duplicates were removed, two authors independently reviewed 194 titles. Figure 1 outlines the application of the inclusion criteria to the literature search. A total of 36 articles were included in final analysis, 14 of which were deemed high quality (Table 1). Five retrospective cohort studies (Bernstein et al., 2004; Constantine et al., 2000; Kim and Song, 2011; Sunil et al., 2006; Vandenberghe et al., 2012) either examined outcomes of different treatment options or examined different technological aspects of a particular treatment option. Nunez et al. (2012) performed the only case series study with a prospective design. The Modified Detsky Scores ranged from 1–8/10. The Levels of Evidence were either Therapeutic III or IV. AWP studies had a total of 129 subjects and an average therapeutic shortening of 3.2 mm. Grip strength improved from 63.9% to 84.5% of the uninjured arm. OWP studies had a total of 77 subjects and an average therapeutic shortening of 1.5 mm. Grip strength improved from 62.0% to 95.2% of the uninjured arm. USO studies had a total of 750 subjects and an average therapeutic shortening of 3.7 mm (Figure 2). Grip strength improved from 71.2% to 87.6% of the uninjured arm. There were notable missing data points (Appendix B, available online) and significance between groups was not analysed. Five subjective outcomes measures reported the efficacy of treatment for UIS: the Modified Mayo Wrist Score, the Gartland and Werley Score as modified by Chun and Palmer, the visual analogue score for pain, the disabilities of the arm, shoulder, and hand (DASH) questionnaire, and a simple satisfaction score (i.e. in hindsight would the patient choose to undergo the same treatment for their condition) (Appendix C, available online). For AWP, two studies reported 100% patient satisfaction. For OWP, two studies reported visual analogue pain scores, for an average pre-operative pain score of 8.0/10 and a post-operative score of 2.2/10. Patient satisfaction, reported by three studies, was 89%. For USO, six studies reported outcomes using the Gartland and Werley score as modified by Chun and Palmer. The average pre-operative score was 68.0 and post-operatively it was 91.9. Ten studies reported outcomes using the visual analogue scale for
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The Journal of Hand Surgery (Eur) 40(5)
Figure 1. Study selection process.
pain. Pre-operatively the average was 6.7/10 and postoperatively it was 2.2/10. Ten studies reported DASH scores. Pre-operatively the scores averaged 49.6 and post-operatively they averaged 19.0. Patient satisfaction, reported by seven studies, was 84% for USO. Many of the subjective rating scales employed by UIS studies give a numerical score that is translated to a rating of excellent, good, fair, or poor (Figure 3). Two AWP studies had an average of 81.8% excellent or good outcome. Three OWP studies had an average of 87.1% excellent or good outcome. Fourteen USO studies had an average of 75.7% excellent or good outcome.
Discussion Systematic review of the outcome measures for surgical interventions for UIS reveals a mix of inconsistent
methods. This systematic review synthesizes 36 studies that report on outcomes of UIS surgery, assesses their quality, and discusses the current state of the evidence behind ulno-carpal decompressive surgeries. Factors associated with UIS include: (1) congenital positive UV; (2) radial shortening as a result of malunited distal radial fracture, radial head excision, or premature distal radial physeal closure; and (3) dynamic positive UV resulting from wrist pronation and forceful grip. Some studies reported exclusively on either post-traumatic UIS or idiopathic UIS, and many did not specify. Future studies should include aetiologic factors so as to permit comparative analysis. The Detsky score has been utilized in orthopaedic literature as a method of quality assessment for
473
Stockton et al. Table 1. High quality studies included in review. Study
Treatment
Quality score*
Year
Country
Journal
Design
N
Level of Evidence
Tomaino and Weiser Berstein et al. Tomaino
AWP
6/10
2001
USA
J Hand Surg (Am)
12
IV
AWP vs USO OWP
7/10
2004
USA
Arthroscopy
27
III
6/10
1999
USA
J Hand Surg (Br)
13
IV
OWP
6/10
2001
USA
Am J Orth
26
IV
OWP vs USO USO
7/10
2000
USA
J Hand Surg (Am)
22
III
6/10
2007
Belgium
28
IV
Nunez et al.
USO
6/10
2012
USA
Scand J Plast Reconstr Surg Hand Surg J Hand Surg (Am)
Retrospective case series Retrospective cohort study Retrospective case series Retrospective case series Retrospective cohort study Retrospective case series
6
IV
Baek et al.
USO
6/10
2011
36
IV
Kitzinger et al. Kim and Song Luria et al.
USO
6/10
2007
South Korea Germany
27
IV
USO
7/10
2011
19
III
USO
7/10
54
IV
USO
18
IV
31
IV
53
IV
Tomaino and Shah Constantine et al. Moermans et al.
Cherchel et al. Baek et al. Iwasaki et al.
Clin Orthop Surg Ann Plast Surg
2008
South Korea USA
Clin Orthop Surg J Hand Surg (Am)
7/10
2012
Belgium
Acta Orthop Belg
USO
8/10
2005
USO
8/10
2007
South Korea Japan
J Bone Joint Surg (Am) Clin Orthop Relat Res
Prospective case series Retrospective case series Retrospective case series Retrospective cohort study Retrospective case series Retrospective case series Retrospective case series Retrospective case series
*See Appendix A (available online).
randomized trials (Detsky et al., 1992) and has demonstrated reliability (Bhandari et al., 2002). The score was necessarily modified to permit assessment of lower level evidence such as case series and cohort studies (Macadam et al., 2009). Studies that gave Level IV Evidence ranged in quality from 1–8 out of 10, and studies that gave Level III Evidence ranged in quality from 5–7 out of 10. Accurate reporting of pre- and post-operative ulnar variances is of key importance. Consensus among authors was to achieve a post-operative UV of 0 to −1 mm. The majority of studies measured UV with the wrist in neutral rotation using the method of perpendiculars. Schuurman and Bos (1995) and Boulas and Milek (1990) measured UV with the wrist in neutral rotation using the method of concentric circles. Tomaino and Weiser (2001) and Darlis et al. (2005) measured UV with the pronated grip view. Ten studies did not specify which method was used to determine pre- and post-operative UV. Forearm rotation has significant impact on the position of the
radius relative to the ulna, with important implications for measuring UV radiographically (Quigley et al., 2013). Novel methods that take the dynamic nature of UV into consideration, such as four-phase grip magnetic resonance imaging, may be useful (Oda et al., 2013). Buterbaugh (1992) first reported the AWP technique. Advantages include less surgical pain, less disruption of dorsal radiocarpal and radioulnar capsules, and no requirement for hardware removal or bony union (Nagle and Bernstein, 2002). Disadvantages include the fact that less ulna can be resected compared with alternate procedures. Nagle and Bernstein (2002) suggested that a positive UV >4 mm is a contraindication to AWP. In addition, certain authors (Nagle and Bernstein, 2002) treated an intact TFCC as a contra-indication to performing AWP for UIS. The main complication from AWP is revision to open surgery (Buterbaugh, 1992). The OWP was first described by Feldon et al. (1992). Advantages of OWP include the preservation
474 of the native distal radioulnar joint (DRUJ), the ability to openly address TFCC pathology, and the avoidance of internal fixation (Schuurman and Bos, 1995). Although usually only the sigmoid notch cartilage is preserved, a method has been described that retains
Figure 2. Mean pre- and post-operative ulnar variances with 95% confidence intervals for arthroscopic wafer procedure (AWP), open wafer procedure (OWP), and ulna shortening osteotomy (USO).
The Journal of Hand Surgery (Eur) 40(5) the distal ulnar cartilage (Barry and Macksoud, 2008). Similar to AWP, it has been described that a positive UV >4 mm is a contraindication to OWP for UIS (Feldon et al., 1992), and the main complication is revision to open surgery (Tomaino and Shah, 2001). USO has largely been considered the reference standard in treatment of UIS and a range of operative hardware and techniques exist to achieve ulna shortening. Advantages of USO are that it does not disrupt distal articular structures, any desired length of ulna may be resected (Sachar, 2012), and it tightens the ulno-carpal ligamentous complex (Tatebe et al., 2005). Disadvantages include prolonged immobilization and a more prominent scar. Complications include delayed union or non-union (Iwasaki et al., 2007; Meier and Krimmer, 2002), and removal of symptomatic hardware (Iwasaki et al., 2007; Luria et al., 2008). While most authors view removal of symptomatic hardware as a complication of USO, some do not (Fricker et al., 1996). The methods of evaluating the outcomes of surgical intervention for UIS were a heterogeneous mix of subjective and objectives measures. Objective outcomes measures reported by studies included preand post-operative ulnar variance, range of motion, grip strength, and time to union. Since one of the hallmark symptoms of UIS is pain with forceful grip, we suggest that pre- and post-operative grip strength, expressed as a percentage of the non-injured wrist,
Figure 3. Subjective patient ratings. Asterisk (*) denotes high quality study. Note that Iwasaki et al. (2007) grouped outcomes into ‘excellent or good’ and ‘fair or poor’. For the subjective rating tool used in each study, see Appendix D (available online).
Stockton et al. is a useful outcome measure to include in future studies. Subjective outcomes were reported with much more regularity, though with the same lack of standardization. Few of the outcomes measures employed have proven validity and reliability. For this reason, we suggest that future research employ validated scoring systems. The authors recognize several limitations to this review. Included studies may be subject to selection bias given that both the AWP and OWP are limited in the amount of ulna that can be resected. The Modified Detsky scoring system was utilized to confer some measure of quality to the analysis, and the designation of ≥6/10 being ‘high quality’ was arbitrary. The heterogeneity of methods used in the UIS literature inhibited statistical analysis. The aetiology of UIS in the studies being reviewed was not considered, and in many cases was not reported. In addition, the techniques and devices used to achieve USO varied substantially. These potential confounders and their unknown effects would benefit from future research. In summary, available evidence shows that AWP and OWP may be viable alternatives to the more popular USO, but clinical superiority is yet to be established. Current decisions are guided by surgeon preference and technical limitations of the interventions themselves. We suggest that further research should ideally take into account aetiologic factors, and should include accurate reporting of pre- and post-operative UV using the method of perpendiculars, as well as objective outcome measurements like grip strength and range of motion. Future research should focus on prospective cohort methods, and should also report participant outcomes using validated scoring methods. Conflict of interests None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Supplementary Material The online appendices are available at http://jhs.sagepub. com/supplemental.
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475 syndrome: at least 5-years follow-up. Clin Orthop Surg. 2011, 3: 295–301. Barry JA, Macksoud WS. Cartilage-retaining wafer resection osteotomy of the distal ulna. Clin Orthop Relat Res. 2008, 466: 396–401. Bernstein MA, Nagle DJ, Martinez A, Stogin JM Jr, Wiedrich TA. A comparison of combined arthroscopic triangular fibrocartilage complex debridement and arthroscopic wafer distal ulna resection versus arthroscopic triangular fibrocartilage complex debridement and ulnar shortening osteotomy for ulnocarpal abutment syndrome. Arthroscopy. 2004, 20: 392–401. Bhandari M, Richards RR, Sprague S, Schemitsch EH. The quality of reporting of randomized trials in the Journal of Bone and Joint Surgery from 1988 through 2000. J Bone Joint Surg Am. 2002, 84-A: 388–96. Boulas HJ, Milek MA. Ulnar shortening for tears of the triangular fibrocartilaginous complex. J Hand Surg Am. 1990, 15: 415–20. Buterbaugh GA. Ulnar impaction syndrome: Treatment by arthroscopic removal of the distal ulna. Tech in Orthop. 1992, 7: 66–71. Cherchel A, Vandendungen S, Moermans JP, Ledoux P. Ulna-shortening osteotomy: subjective appreciation and long-term functional outcome. Acta Orthop Belg. 2012, 78: 317–22. Constantine KJ, Tomaino MM, Herndon JH, Sotereanos DG. Comparison of ulnar shortening osteotomy and the wafer resection procedure as treatment for ulnar impaction syndrome. J Hand Surg Am. 2000, 25: 55–60. Darlis NA, Ferraz IC, Kaufmann RW, Sotereanos DG. Stepcut distal ulnar-shortening osteotomy. J Hand Surg Am. 2005, 30: 943–8. Darrow JC Jr, Linscheid RL, Dobyns JH, Mann JM 3rd, Wood MB, Beckenbaugh RD. Distal ulnar recession for disorders of the distal radioulnar joint. J Hand Surg. 1985, 10: 482–91. Detsky AS, Naylor CD, O’Rourke K, McGeer AJ, L’Abbe KA. Incorporating variations in the quality of individual randomized trials into meta-analysis. J Clin Epidemiol. 1992, 45: 255–65. Feldon P, Terrono AL, Belsky MR. The “wafer” procedure. Partial distal ulnar resection. Clin Orthop Relat Res. 1992, 275: 124–9. Fricker R, Pfeiffer KM, Troeger H. Ulnar shortening osteotomy in posttraumatic ulnar impaction syndrome. Arch Orthop Trauma Surg. 1996, 115: 158–61. Iwasaki N, Ishikawa J, Kato H, Minami M, Minami A. Factors affecting results of ulnar shortening for ulnar impaction syndrome. Clin Orthop Relat Res. 2007, 465: 215–9. Kim BS, Song HS. A comparison of ulnar shortening osteotomy alone versus combined arthroscopic triangular fibrocartilage complex debridement and ulnar shortening osteotomy for ulnar impaction syndrome. Clin Orthop Surg. 2011, 3: 184–90. Kitzinger HB, Karle B, Löw S, Krimmer H. Ulnar shortening osteotomy with a premounted sliding-hole plate. Ann Plast Surg. 2007, 58: 636–9.
476 Liberati A, Altman DG, Tetzlaff J et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009, 62: 1–34. Luria S, Lauder AJ, Trumble TE. Comparison of ulnarshortening osteotomy with a new Trimed dynamic compression system versus the Synthes dynamic compression system: clinical study. J Hand Surg Am. 2008, 33: 1493–7. Macadam SA, Bezuhly M, Lefaivre KA. Outcomes measures used to assess results after surgery for cubital tunnel syndrome: a systematic review of the literature. J Hand Surg Am. 2009, 34: 1482–91. Meier R, Krimmer H. Ulnar shortening osteotomy. Orthop Traumatol. 2002, 10: 190–9. Moermans A, Degreef I, De Smet L. Ulnar shortening osteotomy for ulnar ideopathic impaction syndrome. Scand J Plast Reconstr Surg Hand Surg. 2007, 41: 310–4. Nagle DJ, Bernstein MA. Laser-assisted arthroscopic ulnar shortening. Arthroscopy. 2002, 18: 1046–51. Nunez FA Jr, Barnwell J, Li Z, Nunez FA Sr. Metaphyseal ulnar shortening osteotomy for the treatment of ulnocarpal abutment syndrome using distal ulna hook plate: A case series. J Hand Surg Am. 2012, 37: 1574–9. Oda T, Wada T, Iba K, Aoki M, Tamakawa M, Yamashita T. Reconstructed animation from four-phase grip MRI of the wrist with ulnar-sided pain. J Hand Surg Eur. 2013, 38: 746–50. Quigley RJ, Robicheaux GW, Lee TQ. The proximal and distal position of the radius relative to the ulna through a full range of elbow flexion and forearm rotation. J Hand Surg Eur. 2013, 39: 535–40. Sachar K. Ulnar-sided wrist pain: Evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal
The Journal of Hand Surgery (Eur) 40(5) impaction syndrome, and lunotriquetral ligament tears. J Hand Surg Am. 2012, 37: 1489–500. Schuurman AH, Bos KE. The ulno-carpal abutment syndrome. Follow-up of the wafer procedure. J Hand Surg Br. 1995, 20: 171–7. Sunil TM, Wolff TW, Scheker LR, McCabe SJ, Gupta A. A comparative study of ulnar-shortening osteotomy by the freehand technique versus the Rayhack technique. J Hand Surg Am. 2006, 31: 252–7. Tatebe M, Nakamura R, Horii E, Nakao E. Results of ulnar shortening osteotomy for ulnocarpal impaction syndrome in wrists with neutral or negative ulnar variance. J Hand Surg Br. 2005, 30: 129–32. Tomaino MM. Results of the wafer procedure for ulnar impaction syndrome in the ulnar negative and neutral wrist. J Hand Surg Br. 1999, 24: 671–5. Tomaino MM. Ulnar impaction syndrome in the ulnar negative and neutral wrist. Diagnosis and pathoanatomy. J Hand Surg Br. 1998, 23: 754–7. Tomaino MM, Shah M. Treatment of ulnar impaction syndrome with the wafer procedure. Am J Orthop. 2001, 30: 129–33. Tomaino MM, Weiser RW. Combined arthroscopic TFCC debridement and wafer resection of the distal ulna in wrists with triangular fibrocartilage complex tears and positive ulnar variance. J Hand Surg Am. 2001, 26: 1047–52. Vandenberghe L, Degreef I, Didden K, Moermans A, Koorneef P, De Smet L. Ulnar shortening or arthroscopic wafer resection for ulnar impaction syndrome. Acta Orthop Belg. 2012, 78: 323–6. Watanabe A, Souza F, Vezeridis PS, Blazar P, Yoshioka H. Ulnar-sided wrist pain II: Clinical imaging and treatment. Skeletal Radiol. 2010, 39: 837–57.
JHS0010.1177/1753193414541749The Journal of Hand SurgeryStockton et al.
JHS(E)
Review article
Operative treatment of ulnar impaction syndrome: a systematic review D. J. Stockton1, M.-E. Pelletier2 and J. M. Pike3
The Journal of Hand Surgery (European Volume) 2015, Vol. 40E(5) 470–476 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1753193414541749 jhs.sagepub.com
Abstract This article critically and systematically reviews the surgical treatments for ulnar impaction syndrome. Three types of treatments currently exist: arthroscopic wafer procedure, open wafer procedure, and ulna shortening osteotomy. A total of 36 articles were included from searching the electronic databases PubMed MEDLINE, Ovid MEDLINE, and Ovid EMBASE. Studies were evaluated for quality using the Modified Detsky Score. Of these, 14 articles had a Modified Detsky Score of 6/10 or higher. Satisfaction rates were 100% for arthroscopic wafer procedure, 89% for open wafer procedure, and 84% for ulna shortening osteotomy. The percentage of participants reporting an excellent or good outcome was 82% for arthroscopic wafer procedure, 87% for open wafer procedure, and 76% for ulna shortening osteotomy. In conclusion, available evidence shows that arthroscopic wafer procedure and open wafer procedure may be viable alternatives to the more popular ulna shortening osteotomy, but clinical superiority is yet to be established. Future research should focus on prospective cohort methods and should report participant outcomes using validated scoring methods. Keywords Osteotomy, systematic review, ulnar impaction, ulno-carpal abutment, wafer procedure Date received: 21st October 2013; revised: 20th May 2014; accepted: 20th May 2014
Introduction Ulnar impaction syndrome (UIS) is a common cause of ulnar-sided wrist pain. The differential diagnosis of ulnar-sided wrist pain is diverse due to the complex nature of the bony and soft tissue anatomy. The clinical scenario of UIS may include pain that localizes to the region of the ulno-carpal articulation and is exacerbated with a pronated grip and/or ulnar deviation. Decreased joint space between the ulnar-carpal bones and the ulnar head is present, either due to positive ulnar variance (UV) (Darrow et al., 1985) or less commonly, in ulnar-neutral or negative UV wrists with a thickened triangular fibrocartilage complex (TFCC) (Tomaino, 1998). UIS is synonymous with ulno-carpal impaction syndrome and ulno-carpal abutment, but is a distinct entity from ulnar styloid impaction and ulnar impingement syndrome. Ulnar styloid impaction is caused by impaction between the ulnar styloid and the proximal triquetrum; ulnar impingement syndrome is defined by a shortened ulna impinging on the distal radius (Watanabe et al., 2010). UIS may lead to degenerative lesions of the triquetrum, lunate, ulnar head cartilage, or of the TFCC. Concomitantly the triquetrolunate ligaments may be disrupted. Associated factors of ulno-carpal joint space narrowing may include
previous fracture (e.g. of the distal radius), premature physeal arrest of the distal radius, or congenital ulna positive variance. Treatment is initially non-operative. If nonoperative management fails, surgery to decompress the ulno-carpal joint is indicated. Joint decompression may be achieved by either ulna shortening osteotomy (USO) or by wafer procedure. Wafer procedure may be either arthroscopic (AWP) or open (OWP). Various techniques for performing USO have been described. The choice of surgical treatment for refractory UIS is largely based on surgeon preference. Each surgery 1Faculty
of Medicine, University of Toronto, Toronto, Ontario, Canada 2Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada 3Department of Orthopaedic Surgery, St. Paul’s Hospital, Vancouver British Columbia, Canada Corresponding author: J. M. Pike, St. Paul’s Hospital, 590–1144 Burrard St., Vancouver, BC, V6Z 2A5, Canada. Email: [email protected]
471
Stockton et al. has unique risks, though there exists no high-level evidence to inform decision-making. This article critically and systematically reviews the methods used to study the surgical treatments for UIS. Where possible, results of homogeneous studies are pooled and outcomes comparisons are made to clarify the current state of ulno-carpal decompressive procedures and to guide future research.
Materials and methods Inclusion criteria Studies were selected if (1) the population was composed of adult (>18 y) patients having surgery for symptomatic, refractory UIS; (2) the surgical intervention was either ulnar shortening osteotomy, OWP, or AWP; and (3) the study included either a subjective or an objective outcome measure.
Study identification Two authors searched the electronic databases PubMed MEDLINE and Ovid MEDLINE (1946–2013) and Ovid EMBASE (1980–2013) using the following terms and Boolean operators: (ulna OR ulnar OR ulnocarpal) AND (impaction OR abutment) AND (treatment OR outcome OR outcomes OR surgery OR result OR results). A librarian at the Harvard School of Public Health vetted the search strategy. The search was last updated September 2013. The authors independently reviewed the results by first removing duplicates, then applying the inclusion criteria to title review, abstract review, and full-text review. A third author resolved discrepancies. The authors included articles not in English and contacted the appropriate authors for translation, and also reviewed the reference sections of articles.
Assessment of study quality Each study was evaluated for quality, using a Modified Detsky Score (Detsky et al., 1992; Macadam et al., 2009). Each study was scored out of 10 possible points. One point was awarded if the study (1) described the outcome measure, (2) included at least one outcome measure that was quantitative (either pre- and post-operative range of motion and/or grip strength), (3) described the inclusion and exclusion criteria, (4) described the statistical methods, (5) had a follow-up period of at least 1 year, (6) had a sample size that was calculated before the study, (7) was Level 2 evidence or higher, and (8) was published in a journal whose impact factor was 3 or greater. Up to
two points were awarded for appropriate statistical analysis. Studies gaining a score of 6 or greater out of 10 points were rated as high quality. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (Liberati et al., 2009).
Results The search yielded 481 articles. After 287 duplicates were removed, two authors independently reviewed 194 titles. Figure 1 outlines the application of the inclusion criteria to the literature search. A total of 36 articles were included in final analysis, 14 of which were deemed high quality (Table 1). Five retrospective cohort studies (Bernstein et al., 2004; Constantine et al., 2000; Kim and Song, 2011; Sunil et al., 2006; Vandenberghe et al., 2012) either examined outcomes of different treatment options or examined different technological aspects of a particular treatment option. Nunez et al. (2012) performed the only case series study with a prospective design. The Modified Detsky Scores ranged from 1–8/10. The Levels of Evidence were either Therapeutic III or IV. AWP studies had a total of 129 subjects and an average therapeutic shortening of 3.2 mm. Grip strength improved from 63.9% to 84.5% of the uninjured arm. OWP studies had a total of 77 subjects and an average therapeutic shortening of 1.5 mm. Grip strength improved from 62.0% to 95.2% of the uninjured arm. USO studies had a total of 750 subjects and an average therapeutic shortening of 3.7 mm (Figure 2). Grip strength improved from 71.2% to 87.6% of the uninjured arm. There were notable missing data points (Appendix B, available online) and significance between groups was not analysed. Five subjective outcomes measures reported the efficacy of treatment for UIS: the Modified Mayo Wrist Score, the Gartland and Werley Score as modified by Chun and Palmer, the visual analogue score for pain, the disabilities of the arm, shoulder, and hand (DASH) questionnaire, and a simple satisfaction score (i.e. in hindsight would the patient choose to undergo the same treatment for their condition) (Appendix C, available online). For AWP, two studies reported 100% patient satisfaction. For OWP, two studies reported visual analogue pain scores, for an average pre-operative pain score of 8.0/10 and a post-operative score of 2.2/10. Patient satisfaction, reported by three studies, was 89%. For USO, six studies reported outcomes using the Gartland and Werley score as modified by Chun and Palmer. The average pre-operative score was 68.0 and post-operatively it was 91.9. Ten studies reported outcomes using the visual analogue scale for
472
The Journal of Hand Surgery (Eur) 40(5)
Figure 1. Study selection process.
pain. Pre-operatively the average was 6.7/10 and postoperatively it was 2.2/10. Ten studies reported DASH scores. Pre-operatively the scores averaged 49.6 and post-operatively they averaged 19.0. Patient satisfaction, reported by seven studies, was 84% for USO. Many of the subjective rating scales employed by UIS studies give a numerical score that is translated to a rating of excellent, good, fair, or poor (Figure 3). Two AWP studies had an average of 81.8% excellent or good outcome. Three OWP studies had an average of 87.1% excellent or good outcome. Fourteen USO studies had an average of 75.7% excellent or good outcome.
Discussion Systematic review of the outcome measures for surgical interventions for UIS reveals a mix of inconsistent
methods. This systematic review synthesizes 36 studies that report on outcomes of UIS surgery, assesses their quality, and discusses the current state of the evidence behind ulno-carpal decompressive surgeries. Factors associated with UIS include: (1) congenital positive UV; (2) radial shortening as a result of malunited distal radial fracture, radial head excision, or premature distal radial physeal closure; and (3) dynamic positive UV resulting from wrist pronation and forceful grip. Some studies reported exclusively on either post-traumatic UIS or idiopathic UIS, and many did not specify. Future studies should include aetiologic factors so as to permit comparative analysis. The Detsky score has been utilized in orthopaedic literature as a method of quality assessment for
473
Stockton et al. Table 1. High quality studies included in review. Study
Treatment
Quality score*
Year
Country
Journal
Design
N
Level of Evidence
Tomaino and Weiser Berstein et al. Tomaino
AWP
6/10
2001
USA
J Hand Surg (Am)
12
IV
AWP vs USO OWP
7/10
2004
USA
Arthroscopy
27
III
6/10
1999
USA
J Hand Surg (Br)
13
IV
OWP
6/10
2001
USA
Am J Orth
26
IV
OWP vs USO USO
7/10
2000
USA
J Hand Surg (Am)
22
III
6/10
2007
Belgium
28
IV
Nunez et al.
USO
6/10
2012
USA
Scand J Plast Reconstr Surg Hand Surg J Hand Surg (Am)
Retrospective case series Retrospective cohort study Retrospective case series Retrospective case series Retrospective cohort study Retrospective case series
6
IV
Baek et al.
USO
6/10
2011
36
IV
Kitzinger et al. Kim and Song Luria et al.
USO
6/10
2007
South Korea Germany
27
IV
USO
7/10
2011
19
III
USO
7/10
54
IV
USO
18
IV
31
IV
53
IV
Tomaino and Shah Constantine et al. Moermans et al.
Cherchel et al. Baek et al. Iwasaki et al.
Clin Orthop Surg Ann Plast Surg
2008
South Korea USA
Clin Orthop Surg J Hand Surg (Am)
7/10
2012
Belgium
Acta Orthop Belg
USO
8/10
2005
USO
8/10
2007
South Korea Japan
J Bone Joint Surg (Am) Clin Orthop Relat Res
Prospective case series Retrospective case series Retrospective case series Retrospective cohort study Retrospective case series Retrospective case series Retrospective case series Retrospective case series
*See Appendix A (available online).
randomized trials (Detsky et al., 1992) and has demonstrated reliability (Bhandari et al., 2002). The score was necessarily modified to permit assessment of lower level evidence such as case series and cohort studies (Macadam et al., 2009). Studies that gave Level IV Evidence ranged in quality from 1–8 out of 10, and studies that gave Level III Evidence ranged in quality from 5–7 out of 10. Accurate reporting of pre- and post-operative ulnar variances is of key importance. Consensus among authors was to achieve a post-operative UV of 0 to −1 mm. The majority of studies measured UV with the wrist in neutral rotation using the method of perpendiculars. Schuurman and Bos (1995) and Boulas and Milek (1990) measured UV with the wrist in neutral rotation using the method of concentric circles. Tomaino and Weiser (2001) and Darlis et al. (2005) measured UV with the pronated grip view. Ten studies did not specify which method was used to determine pre- and post-operative UV. Forearm rotation has significant impact on the position of the
radius relative to the ulna, with important implications for measuring UV radiographically (Quigley et al., 2013). Novel methods that take the dynamic nature of UV into consideration, such as four-phase grip magnetic resonance imaging, may be useful (Oda et al., 2013). Buterbaugh (1992) first reported the AWP technique. Advantages include less surgical pain, less disruption of dorsal radiocarpal and radioulnar capsules, and no requirement for hardware removal or bony union (Nagle and Bernstein, 2002). Disadvantages include the fact that less ulna can be resected compared with alternate procedures. Nagle and Bernstein (2002) suggested that a positive UV >4 mm is a contraindication to AWP. In addition, certain authors (Nagle and Bernstein, 2002) treated an intact TFCC as a contra-indication to performing AWP for UIS. The main complication from AWP is revision to open surgery (Buterbaugh, 1992). The OWP was first described by Feldon et al. (1992). Advantages of OWP include the preservation
474 of the native distal radioulnar joint (DRUJ), the ability to openly address TFCC pathology, and the avoidance of internal fixation (Schuurman and Bos, 1995). Although usually only the sigmoid notch cartilage is preserved, a method has been described that retains
Figure 2. Mean pre- and post-operative ulnar variances with 95% confidence intervals for arthroscopic wafer procedure (AWP), open wafer procedure (OWP), and ulna shortening osteotomy (USO).
The Journal of Hand Surgery (Eur) 40(5) the distal ulnar cartilage (Barry and Macksoud, 2008). Similar to AWP, it has been described that a positive UV >4 mm is a contraindication to OWP for UIS (Feldon et al., 1992), and the main complication is revision to open surgery (Tomaino and Shah, 2001). USO has largely been considered the reference standard in treatment of UIS and a range of operative hardware and techniques exist to achieve ulna shortening. Advantages of USO are that it does not disrupt distal articular structures, any desired length of ulna may be resected (Sachar, 2012), and it tightens the ulno-carpal ligamentous complex (Tatebe et al., 2005). Disadvantages include prolonged immobilization and a more prominent scar. Complications include delayed union or non-union (Iwasaki et al., 2007; Meier and Krimmer, 2002), and removal of symptomatic hardware (Iwasaki et al., 2007; Luria et al., 2008). While most authors view removal of symptomatic hardware as a complication of USO, some do not (Fricker et al., 1996). The methods of evaluating the outcomes of surgical intervention for UIS were a heterogeneous mix of subjective and objectives measures. Objective outcomes measures reported by studies included preand post-operative ulnar variance, range of motion, grip strength, and time to union. Since one of the hallmark symptoms of UIS is pain with forceful grip, we suggest that pre- and post-operative grip strength, expressed as a percentage of the non-injured wrist,
Figure 3. Subjective patient ratings. Asterisk (*) denotes high quality study. Note that Iwasaki et al. (2007) grouped outcomes into ‘excellent or good’ and ‘fair or poor’. For the subjective rating tool used in each study, see Appendix D (available online).
Stockton et al. is a useful outcome measure to include in future studies. Subjective outcomes were reported with much more regularity, though with the same lack of standardization. Few of the outcomes measures employed have proven validity and reliability. For this reason, we suggest that future research employ validated scoring systems. The authors recognize several limitations to this review. Included studies may be subject to selection bias given that both the AWP and OWP are limited in the amount of ulna that can be resected. The Modified Detsky scoring system was utilized to confer some measure of quality to the analysis, and the designation of ≥6/10 being ‘high quality’ was arbitrary. The heterogeneity of methods used in the UIS literature inhibited statistical analysis. The aetiology of UIS in the studies being reviewed was not considered, and in many cases was not reported. In addition, the techniques and devices used to achieve USO varied substantially. These potential confounders and their unknown effects would benefit from future research. In summary, available evidence shows that AWP and OWP may be viable alternatives to the more popular USO, but clinical superiority is yet to be established. Current decisions are guided by surgeon preference and technical limitations of the interventions themselves. We suggest that further research should ideally take into account aetiologic factors, and should include accurate reporting of pre- and post-operative UV using the method of perpendiculars, as well as objective outcome measurements like grip strength and range of motion. Future research should focus on prospective cohort methods, and should also report participant outcomes using validated scoring methods. Conflict of interests None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Supplementary Material The online appendices are available at http://jhs.sagepub. com/supplemental.
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