the treatment of chronic traumatic sumuxation of the...

Problems of the Distal Radiodlnar Joint 0749-0712/91 $0.00 + .20

The Treatment of Chronic TraumaticSuMuxation of the Distal Ulna by

Hemiresection InterpositionArthroplasty

Joseph E. Imbriglia, MD,* and David Matthews, MD~

Instability of the distal radioulnar joint mayoccur following trauma1" ~s" x~ or may result :frominflammatory arthritis. Chronic instability ofthis joint creates pain, limitation of motion, andweakness. Lidstrom2~ reported persi:~tentpathologic mobility of this joint in 15% 0:~ thepatients he reviewed with fractures of the ra-dius, and other authors have reported similarresults, n Most papers refer to dorsal subluxa-tion of the distal ulna as a condition in whichthe ulna articulates more dorsally in respect tothe sigmoid notch of the radius than in normalpatients. The difficulty with the radiologic di-agnosis of dorsal subluxation distal ulna..hasbeen noted in the literature, a’ 2r The diagnosisis most often established by the patient’s historyand physical examination.2v Palmar subluxationof the distal ulna occurs most frequently fellow-ing displaced or malaligned fractures of theradius, and can often be diagnosed using a truelateral radiograph of the distal radius and ulna.

Multiple operations have been used or sug-gested as options for treating symptoms iin in-stability. Ligamentous reconstruction orosteotomy~,27. z~ have been proposed as solutions

to the problem. Other authors have recom-mended resection arthroplasties,6’ ~’ ~ ulna re-sections,V, 24 and hemiresection arthroplasties.2

There is no consensus in the literature as to the

best treatment for pathologic instability of thedistal ulna.

ANATOMY

Palmer and Werner~s’ ’~ and Gibsont~ believethat the triangular fibrocartilage complex(TFCC) functions as the major stabilizer of thedistal radioulnar joint. The extensor retinacu-lure and surrounding structures are also majorrestraints to both dorsal and palmar subluxa-tion.2O, a4 The fibrocartilage complex arises fromthe ulnar aspect of the radius and inserts at thebase of the ulnar styloid. The dorsal and palmarradioulnar ligaments make up the outer bor-ders. The ulnar collateral ligament lies just deepto the extensor tendon sheath. Mtl-che4 andSpinner and Kaplana4 believe that an intactulnar collateral ligament and an intact ulnarstyloid are critical to the stability of the distalulna. The relative contributions to stability thatthese structures provide continues to be de-fined.

Hagartla has proposed that we think of theradius and ulna as a forearm joint that has aproximal and a distal compartment. The con-cave distal articular surface of the radius mustbe able to freely rotate around the convex stable

*Associate Professor of Orthopedic Surgery, Medical College of Pennsylvania, Philadelphia; Director, Division of HandSurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania

]’Hand Surgeon, Kaiser Permanente, Honolulu, Hawaii

Itand Clinics--Vol. 7, No. 2, May 1991

330 Joseph E. Imbriglia and David Matthews

distal ulna. Any displaced fracture of the fore-arm will naturally affect the tenuous relation-ship between the distal ulna and radius becauseof the relative joint incongruity secondary todisplacement of the fracture.

of dorsal subluxation can be evaluated on thelateral film. To measure the degree of dorsalsubluxation, a CT scan in supination, neutralrotation, and pronation may be obtained. CTscans have helped us diagnose both subluxationand dislocation of the distal ulna.

CLINICAL PRESENTATION

Dorsal Subluxation of the Distal Ulna

Most patients with subluxation of the distalulna have a definite history of trauma. Oftenthere is no fracture but simply a history of asprain of the distal radioulnar joint. In a reviewof 24 patients with dorsal subluxation of thedistal ulna, 12 of the patients had either radiusor ulnar fractures, while the remaining 12 pa-tients had a history of trauma but no radiologicevidence of fracture. 18 The chief complaint inthese patients is pain accompanied by decreasedrotation and weakness of grip. The distal ra-dioulnar joint is tender to palpation, and thereis a visible dorsal prominence of the ulnar headthat is more pronounced in full pronation (Fig.1A and B). Palpation of the ulnar head as theforearm is rotated will cause discomfort, andoften there is an audible snap. As the instabilityworsens, the patient may have a positive "pianokey" sign. The sign is best elicited when thewrist is palmarflexed against a fixed object withthe forearm in pronation.

Anteroposterior and neutral lateral planeradiographs should be obtained in all patients(Fig. 2). Bowers2 recommends that the radiusbe in a neutral rotation for both the posterior,ar~terior, and lateral radiographs. The humerusis abducted 90 degrees, the elbow is flexed 90degrees, and the cassette is placed fiat on asufficiently large foam block to maintain thearm in position. ~ Ulnar variance can be meas-ured on the posteroanterior film and the degree

Palmar Subluxation of the Distal Ulna

As opposed to dorsal subluxation of the distalulna, chronic palmar subluxation of the distalulna is most often due to a malunion of a forearmfracture.3s Palmar instability of the distal ulnaoccurs when the patient supinates. The mal-aligned radius fracture actually spins off thefixed distal ulna as the forearm rotates. Thelateral radiograph of the forearm in supinationwill show the distal ulna to be in a palmarposition relative to the distal radius (Fig. 3Aaud B). On physical examination, there is oftena "clunk" in the distal radioulnar joint as thepatient supinates. Once the subluxation occurs,a very prominent ulnar mass is evident at thedistal palmar side of the forearm. Correctiveosteotomy of the radius can be attempted as atreatment for this condition as long as the distalradioulnar joint surface has not become ar-thritic. Ifposttraumatic arthritis is present, thenan interposition arthroplasty is indicated. At thepresent time, there is no agreement regardingth.6 treatment for either chronic posttraumaticdorsal or pahnar instability of the distal ulna.Hemiresection interposition arthroplasty maybe used as a salvage procedure to relieve pair,and restore function in both dorsal and palmarsubluxation of the distal ulna.

OPERATIVE TECHNIQUE

The operative technique of distal radioulnarjoint hemiresection arthroplasty has been de-

- Figure 1. Posterior (A) and lat-

eral (B) "de,.v:~ .~t" a i~:,.tie~’.t withchronic dorsal sui)~uxation of thedistal ulna.

Hemiresection Interposition Arthroplasty

:l on theof dorsal

neutralned. CT~luxation

Ulna

:he distalhe distal, forearmstal ~ulna~he mal-; off thetes. Thelpination~ pahnar(Fig. 3A~ is oftenat as then occurs,nt at theorreetive9ted as a:he distal.~ome ar-ent, thend. At the’egarding:raumatic:tal ulna.tsty may.eve paind palmar

~dionlnar3een de-

A) and lat-~tient with:ion of the

Figure 2. Radiograph showingdorsal subluxation of the distal ulna.

scribed by Bowers.e The operation proposedcan be used for both dorsal and palmar sublux-ation conditions when the surgeon feels thatneither soft tissue reconstruction nor correctiveosteotomy is indicated. The procedure wouldalso be indicated after failure of either soft tissuereconstruction or corrective osteotomy. A dorsalincision is used to expose the distal radioulnarjoint. The extensor retinaeulum is opened lon-gitudinally over the fourth compartment for adistance of 1 to 1.5 inches. Transverse incisionsare then made in the retinaeulum proximallyand distally .and the retinaeulum is mobilizedas an ulnar-based flap. The fifth and sixth com-partment tendons are retracted, and the dorsalradioulnar joint capsule is raised from its attach-ments to the distal radius (Fig. 4). Again, trans-verse incisions are made proximally and distallyand the capsular flap is left attached to the distalulna. The surgeon is left with two separate,

ulnar-based flaps. Using osteotomes or a powersaw, the medial portion of the distal ulna isreseeted, leaving intact the ulnar border andulnar styloid. Once the bone resection is com-plete, the patient’s forearm is put through apassive range of motion. If there is any boneblock to motion, more bone can be reseeted.The ulnar-based radioulnar capsule flap is usedas interposition material by placing it withinthe joint and securing it with sutures pahnarlyto the pronator quadratus fascia or the perios-tem of the distal radius (Fig. 5). This dorsalcapsule serves as both interposition material toprevent bone-to-bone contact and also providesa cheek-rein to motion of the distal ulna. Ifadditional stabilitv is necessary, a portion of theextensor carpi ulnaris can be detached proxi-mally and woven through the distal ulna. Theulnar-based flap of extensor retinaeulum is thenplaced below the ECU and extensor digiti mTfi-

Figure 3. A and B, Radiographs showing palmar subluxation of the distal ulna secondary to ;: mal~.mi~m of the distalradius.


for’ another 3 to 4 xveeks. Upon removal of thecast, active range of motion and strengtheningexercises are started (Fig. 7).

Retinacular Flap

Ulnar Head

~sular Flap

Figure 4, Two separate, ulna-based flaps are raised toexpose the radioulnar joint. ECU, extensor carpi ulnaris;EDQ, extensor digiti quinti.

imi (Fig. 6), and is secured to the dorsal portionof the radius. This provides additional stabilityto the distal ulna. Patients are placed in long-arm splints or casts for 4 weeks with the forearmin neutral rotation. The long-arm cast is re-moved at 4 weeks and a short-arm cast is applied

Retinacular Flap:apsular Flap

Radius

Ulna

Figure 5, The capsular flap is placed over the bonesurface of the distal ulna and secured to the deep pronator

fascia.

DISCUSSION

One difficulty encountered in comparing theresults of various operations is defining thepathologic condition. Dorsal subluxation of thedistal ulna is most often due to a soft tissuedeiq.cit resulting in subluxation of the distal ulnawhen the patient pronates. The diagnosis ismade by history and physical examination;radiographs occasionally are helpful. Multiplesoft tissue reconstructive procedures have beenrecommended for this condition.

Most of these reports deal with a small num-ber of patients and residual limitation of motionis frequently encountered.

Hui and Linscheid17 collected eight cases ofposttraumatic dorsal subluxation of the distalulna, which they treated with ulna triquetralaugmentation tenodesis. The diagnosis wasbased on clinical examination in these cases.They reported five excellent and three satisfac-tory results regarding pain relief, but notedpostoperative limitation of motion in all cases;in three cases, residual joint laxity was evident.Distal ulna resection has also been recom-mended for symptomatic dorsal instability ofthe distal radioulnar joint. Diminished gripstrength and postoperative instability have beenreported after this procedure. A recent reportsugge, sts that distal ulna resections in youngerpatients may result in a high complication rate.7

Palmar subluxation of the distal ulna is lesscommon than dorsal subluxation. Althoughthere is much material in the literature describ-ing tile treatment of dorsal subluxation of thedistal radioulnar joint, there is very little infor-matio:n regarding the treatment of palmar sub-luxation/dislocation of the distal ulna. This con-dition can often be diagnosed by taking a lateralradiograph of the distal forearm in supination.If one is not sure of the diagnosis on plainlateral radiographs, a CT scan of the distalradioulnar joint may help confirm the diagnosis.Soft tissue reconstruction of the distal radioul-nar joint for palmar subluxation will not besuccessful if a bony malunion is present. Cor-rective, osteotomy may be ind~cat.~:d [}" the distal

removal of the~d strengthening

a comparing theis defining thehluxation of theto a soft tissue)f the distal ulna’he diagnosis isal examination;~lpful. Multiplelures have been1.

th a small num-ration of motion

~ eight eases of~n of the distalulna triquetraldiagnosis was

in these cases.J three satisfac-[ief, but notedon in all eases;ty was evident.

been recom-J instability ofiminished gripfility have been~ recent report~ns in younger~plication rate. 7tal ulna is lession. Althoughrature deserib-[uxation of thecry little infor-of palmar sub-~lna. This con-taking a lateralin supination.

aosis on plainof the distal

~the diagnosis.distal radioul-n will not bepresent. Cor-

ed if the distal

:

Hemiresection Interposition ArthropIastg333

"RetlnacularFlap

"CapsularFlap

joint surfaces are still intact and not arthritic.However, most often these patients present ina chronic phase, and it is our feeling that ff anyarthritis is present, hemireseetion interpositionarthroplasty is indicated.

Hemireseetion arthroplasty is a salvage pro-eedure that can be performed in both dorsaland palmar subluxation of the distal radioulnarjoint. It is indicated ~vhen the surgeon feelsthat soft tissue reconstructive procedures orcorrective osteotomies will not work. The pro-cedure has yielded approximately 80% good toexcellent and 20% fair results in both dorsaland palmar subluxation of the distal ulna.

Figure 6. The extensor retinaculum is transposed belowthe extensor carpi ulnaris and extensor digiti minimi.

Figure 7. A postoperative radiograph showing the com-pleted hemi resection arthroplasty.

REFERENCES

1. Beiber EJ, Linseheid RL, Dobyns JH, BeekenbaughRD: Failed distal ulna resections. J Hand Surg [Am]13:i93-200, 1988

2. Bo~vers WH: Distal radio-ulnar joint arthroplasty: Thehemireseetion-interposition technique. J Hand Surg[Am] 10:169-178, 1985

3. Cotton FJ, Brickley WJ: Luxation of the ulna forwardat the wrist (without fracture). Ann Surg 55:368, 1912

4. Cox FJ: Anterior dislocation of the distal extremitv ofthe ulna. Surgery 12:41-45, 1942

5. Dameron TB: Traumatic dislocation of the distal radio-ulnar joint. Clin Orthop 83:55-63, 1972

6. Darrach W: Anterior dislocation of the head of theulna. Ann Surg 56:802-803, 1912

7. Darrow JC, Linscheid RL, Dobyns JH, et ah Distalulnar recession for disorders of the distal radio-ulnarjoint. J Hand Surg [Am] 10:482-491, 1985

8. Dingman PVC: Resecting of the distal end of the ulna(Darrach operation). J Bone Joint Surg [Aml 34:893-900, 1952

9. Ekenstam F, Engkrist O, Wadin K: Results fromresection of the distal end of the ulna after-fracturesof the lower end of the radius. Scand J Plast ReconstrSurg 16:177-181, 1982

10. Essex-Lopresti p: Fracture of the radial head wit.hdistal radio-ulnar dislocation. J Bone Joint Surg [Br]33:244, 1951

11. Frykman G: Fracture.0f the distal radius includingsequelae-shoulder, hand, finger syndrome, distur-bance in the distal radio-ulnar joint and impairmentof nerve function. Acta Orthop Scand (Suppl)108:1531967 ’

12. Gibsott A: U~eomp~icated dislocation of the inferiorradio-ulnar joint. J Bone Joint Surg 7:180-189, 1925

13. Goncalves D: Correction of disorders of the distal radio-.ulnar joint by artificial pseudarthrosis of the ulna. JBone Joint Surg [Br] 56:462-464, 1974

14. Hagart C: The distal radioulnar joint. Hand Clin 3:41-51, 1987

15. Hamlin C: Traumatic disruption of the distal radio-ulnar joint. A~n J Sports Med 5:93-97, 1977

16. Heiple KG, Freehafer AA, Van’t Hof A: Isolated trau-matic dislocation of the distal end of the ulna ordistal radio-ulna joint. J Bone Joint Surg [Am]4-;:!387-~39k !962


17. Hui FC, Linscheid t/L: Ulnotriquetral augmentationtenodesis. J Hand Surg 7:230, 1982

18. Imbriglia JE, Matthews D: Dorsal subluxation of thedistal ulna--treatment by hemiresection interposi-tion arthroplasty. J Hand Surg (in press)

19. King GJ, McMurtry BY, Ilugbenstein JD, GertzbeinS D: Kinematics of the distal radio-ulnar joint. J HandSurg [Am] 11:798-804, 1986

20. King GJ, McMurtry BY, Rubenstein JD, Ogston NG:Computerized tomography of the distal radio-ulnarjoint: Correlation with ligamentous pathology in acadaveric model. J Hand Surg [Am] 11:711-717,1986

21. Lidstrom A: Fracture of the distal end of the radius: Aclinical and statistical study of the end results. ActaOrthop Scand (Suppl)4i:69-110, 1959

22. Lippman RK: Laxity of radio-ulnar joint followingColles" fracture. Arch Surg 35:772-886, 1937

23. Lowman CL: The use of fascia tara in the repair ofdisahility at the wrist. J Bone Joint Surg 12:400-402,1930

24. Milch H: Cuffresection of the ulna for malunited Collesfracture. J Bone Joint Surg 23:311-313, 1941

25. Minami A, Ogino T, Minami M: Treatment of distalradio-ulnar disorders. J Hand Surg [Am] 12:189-196,1987

26. M/no DE, Palmer AK, Levinson EM: The role ofradiography and computerized tomography in thediagnosis of subluxation and dislocation of the distalradio-ulnar joint. J Hand Surg 8:23-31, 1983

27. Morrissy IlT, Nalebuff EA: Dislocation of the distalradio-ulnar joint: Anatomy and clues to prompt di-agnosis. Clin Orthop 144:154-158, 1979

28. Pahner AK, Werner FW: Biomechanics of the distalradio-ulnar joint. Clin Orthop 187:26-35, 1984

29. Palmer AK, Werner FW: The triangular fibrocartilagecomplex of the wrist anatomy and function. J HandSurg 6:153-162, 1981

30. Ilegan JM, Bickel WH: Fascial sling operation forinstability of the lower radio-ulnar joint. Staff Meet-ings of the Mayo Clinic 2 June 1945, p 200

31. Ilockwood CA, Green DP (eds.): Fractures. Philadel-phia. J,B. Lippincott Co., 1975

32. Rose-Innes AP: Anterior dislocation of the ulna at theinferior radio-ulnar joint: Case reports with a discus-sion of the anatomy of rotation of the forearm. J BoneJoint Surg [Br] 42:515-521, 1960

33. Snook GA, Chrissman OD, Wilson TC, Wiesma IlD:Subluxation of the dista/radio-ulnar joint by hyper-pronation. J Bone Joint Surg [Am] 5t:1315-i323,1969

34. Spinner M, Kaplan EB: Extensor carpi ulnaris: Itsrelationship to stability of the distal radio-ulnar joint.Clin Orthop 68:124-129. 1970

35. Thompson JD, Chenck RC: Supination Dissociation ofthe Distal Radio Ulnar Joint. San Antonio, Texas,ASSH, 1987

36. Trumble T, Glisson RR, Seaber AV, Urbaniak JR:Forearm force transmition after surgical treatment ofdistal radio-ulnar joint disorders. J Hand Surg [Am]12:196-202, I987

37. Wechsler RJ, Wehbe MA, Rifkin MD, et al: Computedto~nography diagnosis of distal radio-ulnar subluxa-tion. Skeletal Radiol 16:1-5, 1987

Address reprint requests to

Joseph E. Imbriglia, MD127 Anderson Street, #201

Pittsburgh, PA 15212

Do not mark this box!Document: 11000230

THE JOURNAL OFMARCH 1985

VOLUME 10A, NUMBER 2

Official journalAMERICAN SOCIETY FOR SURGERY OF THE HAND

HANDSURGERY

AMERICAN VOLUME

ORIGINAL COMMUNICATIONS

Distal radioulnar joint arthroplasty: Thehemiresection-interposition technique

The hemiresection-interposition technique for distal radioulnar joint arthroplasty was developedfrom anatomic studies that indicated the importance of preserving the functional elements of theulnocarpal ligament complex. The technique has been previously described. My experience with38 patients who were followed for an average of 21/2 years shows that the procedure is mostvaluable for patients with rheumatoid arthritis (85% had stable, painless pronation averaging84° and supination of 77°, while 15% had mild pain and pronation ~of 70° and supination of 75°).It is also valuable for patients with degenerative or trauma-induced arthritis (100% had painlessrotation-pronation averaging 80° and supination of 80~). A modified procedure is useful forpatients with ulnocarpal impingement syndrome where the Milch shortening osteotomy may notsucceed because of radioulnar incongruity. (J HAND St:l~G 10A:169-78, 1985.)

William H. Bowers, M.S., M.D., Asheville, N.C.

This article describes a reconstructive ap-

proach to disorders of the distal radioulnar joint andtriangular fibrocartilage complex (TFCC). The proce-dure, which was developed from anatomic studies ofthis joint, came about because past treatment modalitiesseemed too radical or empiric and failed to recognizethe importance of preserving the integrity of the ulno-carpal ligament complex. My anatomic investigations(Fig. 1), along with those of others,~’~ have emphasizedthe importance of the TFCC in stabilizing the ulnar sideof the wrist. TFCC serves several functions: (1) It pro-vides a stable radioulnar connection that allows rotationvia its triangular fibrocartilage component; (2) it pro7vides a stable ulnocarpal connection with its ulnocarpalligament components; (3) the triangular fibrocartilagecomponent transmits forces that are delivered to the

From The Asheville Hand Center, Asheville, N.C.Received for publication March 30, 1984; accepted in revised form

Aug. 7, 1984.Reprint req.uests: William H. Bowers, M.S., M.D., The Asheville

Hand Center, 34 Granby St., Asheville, N.C. 28801.

ulna. from the hand-wrist unit; (4) the combined trian-gular fibrocartilage-ulnocarpaI ligament functions as asling that suspends the ulnar carpus from the radius;and (5) it extends the gliding surface for the proximalcaqgal row across the entire face of the distal end-ofthe forearm bones. This anatomic concept has led treat-merit of the distal radioulnar joint and TFCC dysfunc-tion away from ablative alternatives and toward pres-ervation and reconstruction. The TFCC is destroyed byexcision and is functionally disabled by the Darrachpre.cedure.~-~° In an excellent study of the latter pro-cedure, Dingman~ noted in 1952 that all of the patientswith good or excellent results had very little bone re-moved or that the process of regeneration had been veryactive with little final discrepancy between the lengthsof the radius and the ulna. He also noted that becausethe strength and stability of such wrists were unim-paired, one could reason that physioIogical regenerationwas an asset rather thana detriment to the end result.The anatomically based opinion that preservation ofthese structures is desirable and the clinical observationthat regeneration is an asset led to the development of

THEJOURNAL OF HANDSURGERY 169

170 BowersThe Journal of

HAND SURGERY

Fig. 1, The "heart" of the TFCC. A shows the two major components, the TFCC and the ulnocarpalligaments, while B shows the structures as seen in the human wrist. (Reproduced with permissionof Betty Montgomery from Bowers WH: The distal radioulnar joint. In Greene DP, editor: Operativehand surgery. New York, 1982, ChurchiII-Livings~:one lnc).

the hemiresection-interposition technique (HIT) for dis-tal radioulnar joint arthroplasty.

Technique

Only the ulnar articular cylinder and its subchondralbone (Figs. 2 and 3) are removed, which leaves theshaft and styloid (with its triangular fibrocartilage con-nectlons) in osseous continuity. The important radioul-nar and ulnocarpat connections remain undisturbed(FIE. 1). Therefore, ulnar column instability is avoided.

Several aspects of the technique have been refinedsince my initial description of the procedure.~ Theretinacular flaps were developed to conserve tissue fordorsal stabilization of the extensor carpi ulnaris (ECU)and augmentation of the deficient triangular fibrocar-tilage. If not needed for these purposes, the first (prox-imal) flap is excised, and the second (distal) flap is usedto cover the arthroplasty site. ECU stabilization is done¯ only if the ECU is displaced palmarly or if it is unstablein its ~ompartment. In these instances, the ECU is freedto its insertion on the base of the fifth metacarpal. Thefirst (proximal) retinacular flap is then used to create sling. The technique is similar to that r~commended by

Spinner and Kaplan,~2 but varies in that after it is passedaround the ECU, the flap is sewn to the fourth com-partment wall distal to its point of takeoff. This ensurescreation of a sling rather than a noose (Fig. 4). Inter-position of material in the cavity that is left after ex-cision is necessary because of the tendency of the__radialand ulnar shafts to approximate one another after re-section of the head. This tendency is most obvious withpower grip (Fig. 5) when the ulnar head no longercounters the muscle action pf the pronator quadratusand other forearm muscles. In most cases, the need forinterposition will be satisfied by using the ulnar-basedcapsular flap, as demonstrated in the standard procedure(Fig. 3, B). l In some instances, interposition bulk needsto be increased. If significant positive ulnar variance ispresent or if the styloid is unusually lo/~g, then thestyloid may impinge on the triquetrum after head re-.section, thereby creating postoperative pain (cases 4,23, 30, and 31). The best approach to this problem isprevention. If positive variance is greater than 2 mm,the HIT should be used with ulnar shortening. If var.-iance is less than 2 mm or if the styloid length is theproblem, shortening the ulna is unnecessary if inter-

Vol. 10A, No. 2 ~March 1985 Distal radioulnar joint arthroplas~, 171

Fig. 2. These skeletal specimens show the amount of bone that will be resected.

Fig. 3. The resection has been done (B), and the two optionsfor interposition are shown. Either the dorsal capsule or an"anchovy" made of tendon/muscle is used.

position bulk is increased. This is accomplished byplacing a carefully made ball of tendon and muscleabout the size of the resected dome into the vacant jointcavity (Fig. 3, B) and stabilizing it through palmar anddorsal capsules with a few sturdy sutures. The materialmay be obtained from the palmaris longus (preferred),ECU, or flexor carpi ulnaris (FCU). This added bulkseems to counter shaft approximation sufficient to elim-inate impingement. Augmentation of the triangular fi-brocartilage may be needed in cases where its majorstabilizing portions are impaired. After the ulnar headis removed, the triangular fibrocartilage can be clearlyseen on both its surfaces. Lesions of the triangular fi-brocartilage will be readily apparent. If centrally lo-

Fig. 4. Construction of the ECU sling made from a retinacularflap. The flap is based on the fibrous wall between the fourthand fifth compartments.

cate, d, these perforations or tears are now functionallyinconsequential since resection of the ulnar head hasaccomplished full decompression. Repair is unneces-sary, and the lesion can be cleaned up with minor de-bridement. If the peripheral margins are disrupted orattenuated (as is frequently the case in the more severecases of rheumatoid arthritis), they may be effectivelyrepaired or augmented with the use of either the second


HAND SURGERY

Fig. 5. A, The patient’s hand is relaxed and then forcefully gripped. B, An approximation of theradius and ulna after ulnar head resection is shown. In this case, there was no variance, and nostylocarpal impingement is expected (case 34).

retinacular flap or distally based strips of ECU or FCU.This technique is discussed in my original article. ~ Itshould be emphasized that there is no standard way ofreconstructing this Structure. The surgeon must under-stand the functional goals of reconstruction and be will-ing to vary the technique according to the lesion pre-senting in each individual case.

Technical errors have occurred in three areas. Thefirst is inadequate bone removal. Large osteophytesmust be removed. All of the ulnar head should be re-moved. The remaining shaft should be rounded in crosssectiron and resemble a tapering 1 cm diameter dowel.Before closure, rotation .should be tested and shown tohave no impingement . The radial and ulnar shaftsshould be compressed and rotated and the wrist ulnarlydeviated to test for possible stylocarpal impingement.If present, the ulna should be .shortened or the "an-chovy" added to increase interposition bulk. Second,the shaft may fracture if resection has been too gen-erous. This is not disasterous. The fragments can besutured with a heavy suture, and postoperative splintingis continued for a full 3 weeks to allow adequate heal-ing. Finally, I have observed that before the "sling"technique of dorsal ECU stabilization is used, someearly postoperative discomfort could be attributed todecreased or painful ECU glide, which is thought to becaused by the "noose" effect of the ~lassic Spinnertechnique. ~2

Postoperative care

When triangular fibrocartilage reconstruction has notbeen performed, the forearm is immobilized in a short-arm bulky dressing with dorsopalmar plaster reinforce-ment. Finger motion is encouraged, but forearm rota-tion is neither encouraged nor discouraged. At 2 weeks,the operative dressing is changed to whatever splint isrequired for other procedures that have been performed,and unrestricted forearm rotation is allowed. If trian-gular fibrocartilage augmentation has been performed,a long-arm splint in neutral rotation is used for 3 weeks.Unrestricted rotation is then permitted.

Application

The HIT for distal radioulnar joint arthroplastyshould be considered in the following situations.

Trauma. Unreconstructible fractures of the ulnarhead or those displaced fractures entirely within theulnar head provide a condition where articular incon-gruity of the distal radioulnar joint is likely. HIT mayallow an early return to a functional state.

Ulnoearpal impingement syndrome with poten-tially inadequate surfaces of the distal radioulnarjoint. Such cases are found in malunions of Collesfractures and early radial epiphyseal closures. In theformer, irregularities of the distal radioulnar joint sec-ondary to fractures will be a problem, while in the latter,the joint may be inadequate in size and conformation

Vol. t0A, NO. 2March 1985

Fig. 6. A, "Settled" Colles fracture that shows intact triangular fibrocartilage and ulnolunate-triquetral impingement on the arthrogram. B, The head is resected along with a 3 mm segmentof adjacent shaft to shorten the ulna. The ulnar sl:~aft/styloid axis is stable in this 6-monthfilm.

Distal radioulnar joint arthroplasty 173

to allow a successful Milch osteotomy~4. In this case,it would be reasonable to perform the HIT for arthro-plasty along with ulnar shortening (Fig. 6).

Rheumatoid arthritis. The early stages of this dis-ease provide a major indication for the procedure. TheHIT, together with ulnocarpal synovectomy, has proveda valuable preventive and reconstructive option. Its ma-jor usefulness is during the earliest stages of synovitisthat are "unresponsive to medical management. Whenit is used with triangular fibrocartilage augmentationand anchovy interposition, it provides stable rotationfor later cases that is unobtainable with other proce-dures (Fig. 7).

Arthritis after trauma and osteoarthritis of thedistal radioulnar joint. If the triangular fibrocartilageis adequate or reconstructible, the HIT is the procedureof choice (Figs. 8 and 9).

Chronic painful triangular fibrocartilage tears.Although limited debridement of these tears, perhapscoupled with the Milch shortening osteotomy, is theprocedure of choice, HIT may be considered whenarticulation of the distal radioulnar joint is also in-,adequate.

Ulnar head chondromalacia. Little is known about

this condition. It is often diagnosed only after the headha,,; been removed during a Darrach procedure for apainful clicking wrist. The HIT provides a conserva-tiv,, g approach and is preferred over the Darrach pro-cedure.

Contraindications __

The basis for this procedure is a functionally adequateor reconstructible TFCC. Otherwise, there are no ad-vantages over the Darrach procedure or its modifica-tions. An arthrogram will help)hssess the triangularfibrocartilage and joint surfaces before surgery. In fact,the only instance where the TFCC is unreconstructibleis with severe arthritis. Here, a modified Darrach pro-cedure,68 coupled with radiolunate arthrodesis,13 is agc,od choice. Alternatives might include the Lauensteinor Baldwin procedures. 1

Results

Thirty-eight patients were operated on and followedfor sufficient duration to allow me to come to someconclusions about this procedure (Table 1). Most pa-tients had rheumatoid arthritis (27 patients, or 71% ofthe total). Five patients had ulnocarpal abutment syn-


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Fig. 7. A, In this patient with rheumatoid arthritis, pain in the distal radioulnar joint and a rupturedextensor digiti minimi were treated with HIT (case 121). A painful silicone rubber trapezial implantwas also removed. B, A follow-up x-ray film was taken 4 years later. She was withoutsymptoms.

Fig. 8. A, Painful arthrosis of-the distal radioulnar joint.with osteophyt~ on the ulnar head. B,Two years later, the wrist is asymptomatic with rotation of 80° of pronation and 80° of supination(case 36).

Vol. 10A, No. 2March 1985 Distal radioulnar joint arthroplasty 175

Fig. 9. A, This patient required arthrodesis of the wrist for painful radiocarpal arthrosis. Rotationwas also painful. At operatiom the distal radioulnar joint showed degenerative changes, and HITwas performed. B, Eight months after surgery, he was able to perform heavy manual labor withno pain and 900/90° rotation (case 37).

drome of various etiologies (13% of the total), and sixhad distal radioulnar arthrosis (16%). Excluding thepatient with an 11-year follow-up, the follow-up av-eraged 31 months. Patients with less than a 3-monthfollow-up were not included. Patients with a 3- to 6-month follow-up were included only if I felt that aconclusion could be reached.; Assessment was difficult. Surgery in patients withrheumatoid arthritis was intended to prevent progressivedestabilization of the wrist and reduce the risk of tendonrupture. Surgery in the. ulnocarpal abutment group wasintended to decompress ulnocarpal impingement. Fi-nally, surgery in the arthrosis group was intended toeliminate rotational pain. The goal common to all threegroups was to provide relief of pain and to accomplishthis with a procedure that allowed a stable functionalarc of rotation that was without complications. Thus,pain, arc of rotation, and stability were selected as testsof this procedure.

Pain was determined by asking the patient to rotatehis/her forearm in both the relaxed and grip modes andto report pain as absent, mild, or worse. I then examinedthe patient and recorded my assessment of pain to pal-pation and passive rotation. Next, I measured rotationand questioned the patient about his/her perception ofstability.

Grip strength was considered a parameter, but wasdisregarded as a meaningful way to evaluate this pro-cedure. Excluding my bias that formal grip testing inpatients with rheumatoid arthritis is misleading, themultiplicity of other procedures performed could havecontributed to changes in this test. In fact, most pa-tients who were relieved of pain reported increasedfunctional grip even if it was not reflected in the mea-surement.

Rheumatoid arthritis. In the rheumatoid arthritisgroup (cases 1 through 27), 86% were women. Theages averaged 53.5 years, with the youngest 36 yearsold and the oldest 72 years old.’Most had classic sero-positive rheumatoid arthritis, and all were being treatedby a rheumatologist. As with all of the distal radioulnarjoint procedures in this group, the ECU was stabilizeddorsally, and therefore, it was not listed as a separateprocedure. The HIT was employed as a preventive aswell as therapeutic measure in patientswith mild rheu-matoid arthritis who had painful function of the distalradioulnar joint and synovitis, but only minimal de-structive changes in the osseous skeleton (67.8% of thea~hritic patients in this study). These patients are listedin Table I as having the HIT alone orwith synovectomy.Synovectomy of the distal radioulnar joint was usedwith synovectomy of the ulnocarpal joint in a dual ex-


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Table I. Data on 38 patients on whom HIT was performed

CaseNo. Age(yr)/race/sex Problem(s) Procedure(s)

1 M.O. 67/W/female RA 1,2,32 R.G. 65/W/male RA 1,2,3,43 P.D. 60/B/female Juvenile RA 1,2,3,4

4 B.G. 35/W/female RA5 M.S. 43/W/female RA6 H.M. 72/W/female RA7 M.I. 66/W/female RA8 M.I. 66/W/female RA

9 M.B. 52/W/female RA10 S.G. 54/W/female RA11 B.L. 67/W/female RA12 P.M. 70/W/female RA¯ 13 P.M. 70/W/female RA (ruptured exten-

sors)14 W.L. 59/B/male RA15 S.D. 47/W/female RA16 S.D. 46/W/female RA17 T.B. 52/W/female RA. gout18 J.J. 56/W/female RA19 C.G. 40/W/female RA20 H.L. 6 I/W/female RA21 H.L. 59/W/female RA22 S.R. 40/W/female RA

16 mo 90/90 None36 mo 90/60 None3 mo 40/60 None

1,2 12 mo 60/90 Mild pain1,2 4 mo 70/70 None1,2 17 mo 60/50 None1,2,3 (left) 8 mo 70/70 None1,2,3,7 3 mo 70/60 Mild pain

(right)1,2,3 72 mo 90/90 None1,2,3 133 mo 80/80 None1,2 43 mo 60/40 None1,2 (right) 46 mo 90/90 None1,2,5 (left) 49 mo 90/90 None

1,2 33 mo 60/60 None1,2 (left) 35 mo 80/70 None1 (right) 46 mo 90/40 None1 38 mo 90/90 None1 67 mo 90/90 None1,2 68 mo 90/90 None1,2 60 mo 80/90 None1,2 78 mo 80/80 None1,2 63 mo 90/90 None

23 P.K. 43/F/female RA 1 31 mo 90/90 Mild pain24 J.T. 72/W/female RA 1,2,3,6 3 mo 60/60 Mild pain25 W.C. 52/W/male RA 1,2,3,6 -- 6 mo 90/90 None26 B.C. 36/W/female RA 1 8 mo 90/90 None27 B. McC. 44/W/female RA 1 4 mo 90/90 None

Comments

Total elbow done simulta-neously

Stylocarpal impingement

Radiolunate arthrodesis

Patient had moderate painfor 6 mo


RA, rheumatoid arthritis; TFC, Triangular fibrocartilage. ~Procedures: 1, hemiresection-interposition arthroplasty; 2, wrist synovectomy; 3, triangular fibrocartilage augmentation; 4, total wrist replacement; 5, repairextensors;6, anchovy interposition; 7, wrist arthrodesis; 8, Milch ulnar shortening.

posure over the ulnar aspect of the wrist. Wrists withmore severe destruction (ulnocarpal descent and trian-gular fibrocartilage-ulnocarpal ligament disruption)were approached as a reconstructive operation. In thesepatients, retinacular flaps and distally based portionsof ECU or FCU were used to recreate or augmentthe ulnocarpal ligaments and triangular fibrocartilageaccording to the requirements of each individual case.If the TFCC was not reconstructible, the HIT was aban-doned and modified Darrach procedure6"8 was per-formed, often with a radiolunate fusion. These patients

were not included in this study. Range of rotation inthe 27 patients with arthritis averaged 80° of pronationand 75° of supination with 13 patients achieving and

maintaining 900/90° rotation. No patient complained of

instability. There were no tendon ruptures after surgery.Four patients complained of ~mild pain at follow-up.Two of them had radiographic evidence of stylocarpalimpingement. In retrospect, these two patients shouldhave had an anchovy interposition as a modification tothe basic operative procedure. In the remaining two,the cause of pain could not be determined. None of thefour required treatment.

Ulnocarpal impingement group. HIT should havebeen combined with ulnar shortening or anchovy in-terposition in the six patients (12.8% of the total) withan ulna that was too long and who also had painfululnocarpal impingement and articulation of the distalradioulnar joint considered tooincongruous for simpleulnar shortening. Where this combined procedure was

Vol. 10A, No. 2March 1985 Distal radioulnar joint arthroplasty 177

Table I. cont’d

Case ~

28 L.H.

Agefyr)/race/sex Problem(s) Procedure(s)

63/W/female Settled Colles 1,8

29 G.R. 36/W/female

30 J.F. 36/W/female

31 J.C. 40/W/female

32 T.D. 45/W/male

33 D.W. 39/W/female

34 J.S. 38/W/male

35 M.L. 25/W/female

36 B.V. 42/W/male

37 M.H. 28/W/male38 A.F. 28/W/female

Pb[[ow-up

3 mo 60/60 None

Early radial epiphyseal1,8 24 mo 90/90 Noneclosure with u/no-carpal abutmentsyndrome

Severe ulnar plus sec- 1 6 mo 60/70 Mild painondary to Galeazzifracture

Settled Colles with ul- 1 (8 at sec- 4 mo 90/90 Moderatenocarpal abutment ond pro- pain*syndrome cedure)

Comments

TFC intact at surgery; ulnafractured at surgery;healed uneventfully

TFC good on arthrogramand at surgery


*Stylocarpal impingementlater revised with Milchosteotomy; good result:no pain

Settled Colles with ul- 1,8 12 mo 90/90 Nonenocarpal abutmentand radioulnar ar-throsis

Radial shaft fracture, 1, plate 24 mo 90/90 None Ulnar head fracture: intra-old Colles-radioul- radius articularnar arthrosis

Painful rotation after 1 6 mo 80/80 None TFC good on arthrogramoperation for ra- and at surgerydioulnar instability

Probable old perilunate 1 plus lu- 12 mo 70/70 Mild TFC had central perfora-dislocation, radioul- nate-tri- pain* tion; *pain resolved af-nar pain quetral at- ter pisiform excision

throdesisDistal radioulnar ar- 1 26 mo 80/80 None

throsisPosttraumatic arthrosis 1,7 8 mo 90/90 None Scaphoid nonunionResolved infectious ar- 1,7 42 mo 90/’90 None

throsis

done (four patients), all patients achieved painless stablerotation of 80° of pronati0n and 80° of supination. Inthe two patients on whom HIT was performed withoutulnar shortening or anchovy interposition, stylocarpalimpingement was present on the x-ray films, motionwas 75° in pronation and 50° in supination, and bothpatients had mild pain.on rotation. A second operationwas done for one of these patients (ca~e 31). After theulna was shortened, pain resolved and a 900/90° arc of

motion was achieved.Distal radioulnar joint arthritis. In five patients

(16.2% of the total), the problem was an arthritic distalradioulnar joint. In these cases, HIT alone achievedrelief of pain and excellent motion. Pronation averaged83° and supination 83°, and no instability was reported.One patient with mild pain was later found to have

pisotriquetral arthrosis that was relieved by injectionsinto the joint. The patient underwent excision of thepisiform and her pain resolved.

Complications

In the entire study of 38 patients, six patients hadpain after surgery. One patient’s pain was relieved byexcising the pisiform. In the remaining five patients,pain could be attributed to stylocarpal impingement.One patient with moderate pain had excellent resultsafter her ulna was shortened. Thus, the overall inci-dence of unresolved postoperative pain was 10.5%. Inthese four patients, pain was mild and none requiredtreatment. I believe that this problem of stylocarpalimpingement, which was present in all four patients,can now be anticipated and effectively prevented by


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anchovy interposition or ulnar shortening during theoriginal operation.

Discussion

Aristotle said, "Understanding the principle is morethan one-half the problem solved." The anatomic factthat for ulnocarpal stability to exist, the ulnocarpal com-plex of the triangular fibrocartilage must function (orbe reconstructible) has recently been understood.Dingman’s1~ observation that the best Darrach proce-dure has active osseous regeneration provided furthersupport. It became obvious that the best way to providestability is to never lose it. The continuity of the shaft/styloid/ulnocarpal ligament/carpal connection shouldnot be interrupted. The benefits of the Darrach proce-dure in this context are provided by resection of thehead alone. Technical variations in the procedure de-

veloped later. The advantages are: (1) the procedure easily performed and anatomically Sound; (2) recoveryof motion is rapid and painless; and (3) exposure of theTFCC is excellent and allows many reconstructive op-tions otherwise unavailable.

Follow-up in various applications has been adequateto demonstrate a late problem (stylocarpal impinge-ment) and to resolve it (added interposition bulk).

procedure appears to be sufficiently useful to warrantits addition to the surgical management of the distalradioulnar joint and TFCC dysfunction.

REFERENCES

1. Bowers WH: The distal radioulnar joint. In Green DP,editor: Operative hand surgery. New York, 1982, Chur-chill Livingstone Inc, pp 754-55

2. Lewis O J, Hamshere R J, Bucknill TM: The anatomy ofthe wrist joint. J Anat 106:539-52, 1970

3. Kauer JMG: The articular disc of the hand. Acta Anat93:590-605, 1975

4. Palmer AK, Werner FW: The triangular fibrocartilagecomplex of the wrist--anatomy and function. J HANDSuRG 6:153-62, 1981

5. Taleisnik J: The ligaments of the wrist. J HArqD StJRC;1:110, 1976

6. Blatt G, Ashworth CR: Volar capsule transfer for sta--bilization following resection of the distal end of the ulna.Orthop Trans 3:13-4, 1979

7. Goldner JL, Hayes MG: Stabilization of the remainingulna using one-half of the extensor carpi ulnaris tendonafter resection of the distal ulna. Orthop Trans 3:330-1,1979

8. Kessler I, Hecht O: Present application of the Darrachprocedure. Clin Orthop 72:254-60, 1970

9. Newmeyer WL, Green DP: Rupture of extensor tendonsfollowing resection of the distal ulna. J Bone Joint Surg[Am] 64:178-82, 1982

I0. Mauer I: Reconstruction following post-traumatic de-rangement of the distal radioulnar joint. Bull Hosp Jt Dis22:95-104, 1961

11. Dingman PV: Resection of the distal end of the ulnar(Darrach operation). An end result study of twenty-fourcases. J Bone Joint Surg [Am] 34:893-900, 1952

12. Spinner M, Kaplan EB: Extensor carpi ulnaris. Its re-lationship to the stability of the distal radio-ulnar joint.Clin Orthop 68:124-9, 1970

13. Chamay A, Santa DD, Vilaseca A: Radiolunate arthro-desis factor of stability for the rheumatoid wrist. AnnChit Main 2:5-17, 1983

14. Milch H: So-called dislocation of the lower end of theulna. Ann Surg 116:282-92, 1942

the treatment of chronic traumatic sumuxation of the...

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