Ulnar Shortening—Avoid This Barbaric Procedure
POSTED ON 5/26/2016 IN Hand and Wrist BY Christopher Centeno
I have a rule when seeing patients. If they describe a past surgical procedure to me and I involuntarily say, "They did what to you?" that procedure is a candidate for my top 10 dumb surgeries list. One of those procedures that has always been right up there is ulnar shortening. Your wrist hurts? It must be because your ulna bone is too long, so let's just lop a piece out of that—you won't miss it! Thankfully, the medical research on the complications of this procedure is now catching up to my gut-check response.
What Is Ulnar Shortening?
The procedure is actually called an ulnar shortening osteotomy. The belief is that the pinky side of the wrist (called the ulnar side) gets arthritis and accumulated damage because people are born with an ulna bone that's too long. Hence surgeons go in and cut out a piece of the ulna bone to shorten it and hopefully take pressure off that side of the wrist. The tissue on the ulnar side that surgeons are most concerned with is the TFCC, so let's learn more about that structure.
What Is the TFCC?
If there is one part of the body that's responsible for our modern civilization and everything that separates us from the animal kingdom (other than our brain), it would be the triangular fibrocartilage complex (TFCC). This is a complex of ligaments and a meniscus-like spacer on the ulnar side of the hand that allows you to use your opposable thumbs. Given that thumbs that allow you to grasp and manipulate things require a big brain to run, the TFCC is the reason we learned how to make simple tools and eventually rocket ships. When patients have TFCC damage, the ulnar side of the wrist hurts, and this gets worse with activity. There can also be swelling in the area. Finally, progressive wrist arthritis ensues, leading to pain and deformity.
For What Diagnosis Is Ulnar Shortening Surgery Performed?
This surgery is used to treat "ulnar impaction syndrome." This simply means that there's too much pressure on that side of the wrist due to a long ulna bone. This diagnosis is actually made by measuring angles on the wrist X-ray or MRI. There's just one little problem with the diagnosis: it's what I call a "squiggle of the wiggle and angle of the dangle" diagnosis. Radiologists love to measure lengths and angles, because what else are you going to do sitting in a darkroom all day staring at a computer screen? They're famous for observational studies that try to tie some angle measured on a picture of a patient with a musculoskeletal disease (like wrist arthritis). The problem is that this type of snapshot-in-time study can't ever get to causality (e.g., the abnormal angle caused the arthritis). So the angle they've measured and the presence of the disease may well have little to do with one another. The research studies that are written about these angles often drive surgical care—like adding gasoline to the surgical fire. It's not long after one of these papers is published that orthopedic surgeons begin to figure out new and invasive ways to change the measured angle back to "normal." That would be good if the new measured angle had anything to do with why the problem began, but it frequently turns out that it doesn't, so a whole new world of unnecessary surgeries is born that are hard to later eliminate.
What Are the Complications?
This is where the big problems begin with ulnar shortening. The surgical research of the last few years has finally begun to realize all on its own that this is a dumb surgery. Let me explain. As discussed, the surgeon is removing a piece of the ulna to try and reduce pressure on the wrist, but regrettably research using computer models has shown that if you change the relationship between the radius and ulnar bones, you actually put more negative forces on the wrist! Who knew? This has been bolstered by other studies reporting the occurrence of more arthritis due to alternations in wrist pressure caused by the surgery. Complications are also huge, with several studies reporting that about half of all operated patients report irritation of the surrounding tissues by the plates that are used to heal the bone. Another recent study showed even worse outcomes, including delayed healing of the bone (13% of patients), nonhealing of the bone (8%), severe chronic nerve pain due to the surgery (7%), the need for revision surgery (13%), and the need to remove the hardware due to pain (45%)! Bottom line, this surgery is a complications fest!
Is There Any Research Showing Ulnar Shortening Works?
Given all the serious complications of the procedure, you would think that this would be balanced by loads of research showing that the procedure was very effective in ending wrist pain. Regrettably, you would be wrong. We have no high-level research that shows this procedure is effective!
What Are the Alternatives?
If you have TFCC problems or wrist pain, we've used minimally invasive injections of orthobiologics, like platelets and stem cells, for years to help these tissues heal. In addition, in our experience, the wrist commonly hurts due to bad biomechanics that are usually centered in a neck problem. Here irritated neck nerves give bad signals to the forearm muscles, and all of this places too much pressure on the wrist. Alternatively, an old injury to the wrist ligaments causes instability, and this results in excessive motion of the wrist bones leading to wear-and-tear arthritis. In either case, fixing the bad movement patterns or precisely injecting your own platelets or stem cells into the TFCC, arthritic wrist joints, ligaments, or neck usually reduces pain and increases function without invasive surgery. The upshot? Ulnar shortening is thankfully being exposed in the medical research as a dumb idea. This is consistent with the many patients I've seen through the years who have had this surgery and regretted making that decision. So stay away from surgeons who want to rearrange your anatomy—it's probably just fine how it is!
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