Ulnar lengthening for forearm deformities in hereditary multiple exostoses: a systematic review and meta-analysis (2015–2025)

Abstract Background Hereditary multiple exostoses (HME) is an autosomal dominant skeletal disorder frequently associated with progressive forearm deformities, including ulnar shortening, radial bowing, and radial head dislocation. Ulnar lengthening using distraction osteogenesis has become the principal surgical strategy; however, outcomes, techniques, and complication profiles vary across studies. This systematic review and meta-analysis synthesize contemporary evidence on radiographic correction, functional outcomes, and complications following ulnar lengthening for HME-related forearm deformities. Methods A systematic search of SciSpace, PubMed, and Google Scholar was performed to identify studies published between January 2015 and December 2025 evaluating ulnar lengthening in patients with HME. Observational studies reporting radiographic, functional, or complication outcomes were included. Data were extracted on patient characteristics, surgical techniques, radiographic parameters, functional outcomes, and complications. Study quality was assessed using the Newcastle–Ottawa Scale. Random-effects meta-analyses were conducted, with heterogeneity assessed using the I 2 statistic. Results Thirty observational studies comprising 350 patients and 380 forearms were included, with a mean follow-up of 38.6 months. The pooled mean ulnar lengthening achieved was 33.8 mm (95% CI: 28.4–39.2; I 2 = 68%). Significant improvements were observed in radial articular angle (mean difference − 6.3°, 95% CI: − 8.7 to − 3.9; I 2 = 52%) and ulnar variance (mean difference − 15.4 mm, 95% CI: − 18.2 to − 12.6; I 2 = 58%). Radial head reduction was achieved in 76% of affected forearms. Functional outcomes improved significantly, with DASH scores decreasing by a pooled mean of 12.7 points ( p < 0.001). The overall complication rate was 18.1%, with most complications being minor and manageable. Conclusions Ulnar lengthening via distraction osteogenesis provides effective radiographic correction and meaningful functional improvement in patients with HME-related forearm deformities, with acceptable complication rates. Monolateral external fixation is the most commonly employed technique and yields reliable outcomes. Despite encouraging results, the evidence base is limited to observational studies with heterogeneous reporting, underscoring the need for prospective studies with standardized outcome measures and longer follow-up.