Unstable DRUJ

7/30/2019 Unstable DRUJ

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Saturday, October 9, 2010General Scientific Session

Room: Auditorium, Hynes CC2:45 - 3:30 PM

65th Annual Meeting of the American Society for Surgery of the HandEmbracing Excellence: Making a Difference

Symposium 12

The Unstable DRUJ

Co-Moderators:Richard A. Berger, MDScott W. Wolfe, MD

Faculty:David S. Ruch, MD

J effrey A. Greenberg, MDBrian D. Adams, MDDean G. Sotereanos, MD


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Anatomy, Diagnosis andAnatomy, Diagnosis andPathomechanics of DRUJPathomechanics of DRUJ

InstabilityInstability

Richard A. Berger, MD, PhDRichard A. Berger, MD, PhD

Symposium 12Symposium 12

ASSH Boston 2010ASSH Boston 2010

Why do we care about the DRUJ?Why do we care about the DRUJ?

Serves as a connection between theServes as a connection between theforearm and the wristforearm and the wrist


Torque TransmissionTorque Transmission


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Positioning the handPositioning the hand


Weight/load bearingWeight/load bearing


Differentiates primatesDifferentiates primates

Well, maybe!!!


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AnatomyAnatomy

Andreas Vesaliu s 1514-1564

Distal Radioulnar JointDistal Radioulnar Joint

sigmoid

notch


sigmoid

notch


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styloid


fovea


seat


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ECUgroove


AnatomyAnatomy


AnatomyAnatomy


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Radius of curvatureRadius of curvature

ulnar head


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TTriangularriangular FFibroibroCCartilageartilage CComplexomplex

TTriangularriangular FFibroibroCCartilageartilage CComplexomplex

radius

lunate

TFCC

RadioUlnar LigamentsRadioUlnar Ligaments

dorsal radioulnar ligament

fovea

styloid

radius

lunate

palmar

radioulnar

ligament


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Ulnar HeadUlnar Head

styloid

TFCC

head

fovea

radius

coronal section, fetal wrist

ECU subsheathECU subsheath

DRUJ capsuleDRUJ capsule

radius

ulna


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Ulnocarpal LigamentsUlnocarpal Ligaments

Ulnar styloid

Ulnar headprocess

radius


DRU

PRU

UC ligamentsUC ligaments

ulnar head TFC

ulnocarpal

ligaments


Ulnolunate (UL)

Ulnotri uetral UT

Ulnocapitate (UC)


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Functional AnatomyFunctional Anatomy

forearm joint forearm joint

bicondylar jointbicondylar joint

PRUJ DRUJPRUJ DRUJ

Carl J. Hagert

forearm joint forearm joint

annular ligamentannular ligament TFCCTFCC

IOMIOM


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KinematicsKinematics

Axes of Rotat ionAxes of Rotat ion


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Stabili ty AnalysesStabili ty Analyses

Role of Ulnar headRole of Ulnar head

Common FailureCommon Failure

Loss of articular contact constraintLoss of articular contact constraint

30% of join t const raintStuart et al. JHS 2000


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Loss of cam effectLoss of cam effect

of ulnar headof ulnar head








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ResultsResults

Dynamic si mulator:

- actively loads tendons

- simultaneousl

measures torque,

displacement, tendon

excursion and resultant

tendon load

Sauerbier et al., 2001

Acta Ort hop, J HS(Am), JHS(Br-E)

ResultsResults

ResultsResults


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intact

resectionre lacement

To

r

u

e

pro sup

A Functional Algori thm forA Functional Algori thm forUlnarUlnar--sided Wrist Painsided Wrist Pain

Disclaimer:Disclaimer:

-- not intended as a research toolnot intended as a research tool

-- used as a tool to guideused as a tool to guidediagnostic and therapeuticdiagnostic and therapeuticdecisionsdecisions

DRUJ: Soft Tissue InjuryDRUJ: Soft Tissue Injury

Injury to:Injury to:

triangular disctriangular discdistal radioulnar l igamentsdistal radioulnar l igaments

distal radioulnar joint capsuledistal radioulnar joint capsuleulnar extrinsic t endon mechanismsulnar extrinsic t endon mechanisms


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DRUJ: Articular Surface InjuryDRUJ: Articular Surface Injury

Injury to:Injury to:

ulnar headulnar headsigmoid notchsigmoid notchpisiformpisiform

DRUJ InjuryDRUJ Injury

Etiology:Etiology:

traumatrauma torsion and axial loadtorsion and axial load developmental variancedevelopmental variance inflammatory arthropathyinflammatory arthropathy


Spectrum o f InjurySpectrum o f Injury

soft tissue disruption of TFCCsoft tissue disruption of TFCC

fracture of radius, ulna, or carpalfracture of radius, ulna, or carpaloneoneextension of perilunate dislocationextension of perilunate dislocation


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ClassificationClassification

A

B

C

D


painpain


painpain

oror


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painpainoror

oror

pain with arthrosispain with arthrosis


pain alone:pain alone:

central TFC tearcentral TFC tear




split of UL/UT ligaments split of UL/UT ligaments


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central TFC tearcentral TFC tear split of UL/UT ligaments split of UL/UT ligaments

capsular stretchcapsular stretch




split of UL/UT ligaments split of UL/UT ligaments

capsular stretchcapsular stretch

tear of LTI ligament tear of LTI ligament




split of UL/UT ligaments split of UL/UT ligamentscapsular stretchcapsular stretch

tear of LTI ligament tear of LTI ligament

synovitissynovitis


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pain with instabilitypain with instability

tear/avulsion of DRU/PRU ligamentstear/avulsion of DRU/PRU ligaments(ulnar or radial)(ulnar or radial)




ransverse ear o gamen sransverse ear o gamen s





tear of joint capsuletear of joint capsule


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tear of joint capsuletear of joint capsule

ECU subsheath tearECU subsheath tear



LT dissociationLT dissociation



ulnar impaction syndromeulnar impaction syndrome


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ulnar impaction syndromeulnar impaction syndromepisotriquetral DJDpisotriquetral DJD



ulnar impaction syndromeulnar impaction syndrome

pisotriquetral DJDpisotriquetral DJD

Overview of ClassificationOverview of Classification

PainPain stablestable

normal imagingnormal imaging

conservative vs. debridement surgeryconservative vs. debridement surgery


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Pain wi th InstabilityPain wi th Instability unstableunstable

abnormal provocative imagingabnormal provocative imaging

stabilization surgerystabilization surgery





Pain wi th InstabilityPain wi th Instability unstableunstable

abnormal provocative imagingabnormal provocative imaging

stabilization surgerystabilization surgery

Pain with ArthrosisPain with Arthrosis pain with loadingpain with loading

abnormal plain filmsabnormal plain films

conservative vs. resection/arthroplasty surgeryconservative vs. resection/arthroplasty surgery

Thank You!Thank You!


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Destabilizing Tears of the TFCC

Brian D. Adams, M.D.

Professor of Orthopedic Surgery

University of Iowa

Types of Destabilizing TFCC Injuriesi) TFCC tear (radioulnar ligaments) from ulna

(a)No fractures(b)Fleck fracture from fovea of ulnar head(c) Basilar ulnar styloid fracture (displaced or mobile nonunion)

ii) TFCC tear (radioulnar ligaments) from radius(a)No fractures(b)Avulsion fracture of rim(s) of sigmoid notch

Techniques for Ulnar Styloid Fracture Fixation

Percutaneous pinning

Avoid dorsal cutaneous branch of ulnar nerve

Causes irritation, requires immobilization, and removal

May split fragment

Tension band wire/suture

May be used with or without pinning

Wire causes hardware irritation, suture more acceptable

May not produce bony union

Screw fixation

May be technically difficult

May split fragment

A screw head causes hardware irritation, headless screws can be retained

Bone anchorsRequires appropriate fracture/fragment configuration

Avoids hardware irritation

May not produce bony union

_________________________

TFCC Repair

Arthroscopic techniques

May be done outside-in or inside-out Does not create an anatomic repair of TFCC/radioulnar ligaments May not reliably restore DRUJ stability, in my opinion they are not indicated for established

DRUJ instability

Open repair Dorsal exposure is optimum for visualization TFCC/distal radioulnar ligaments should be anatomically repaired to fovea thru bone tunnels Placing suture over dorsal ulnar neck reduces risk of knot irritation that can be problematic if

tied over subcutaneous border of ulna

Radioulnar pinning is optional My preferred technique is described below

_________________________


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My preferred technique for TFCC Repair

A dorsal surgical approach to the DRUJ is made identical to that described below for distal

radioulnar ligament reconstruction. In addition, an L-shaped ulnocarpal capsulotomy is created. One limb

of the capusulotomy is made along the radial margin of the ECU sheath and the other just distal and

parallel to the dorsal radioulnar ligament, extending to the radial edge of the lunate fossa. Care is taken

not to cut the dorsal radioulnar ligament. Distal-radial retraction of this flap exposes the articular surfacesof the lunate and triquetrum and the distal surface of the TFCC. The integrity of the TFCC and its

potential for repair are determined. If it is attenuated and can not be repaired to the fovea of the ulnar

head or its substance is inadequate to provide joint stability, then proceed to reconstruct the radioulnar

ligaments. Debride granulation tissue from the fovea but retain the TFCC. However, a central tear in the

disk can be debrided to smooth margins. The ECU sheath should not be opened or dissected during the

procedure to preserve its important stabilizing function for the ulnocarpal joint. If an ulnar styloid

nonunion is present and not indicated for skeletal repair, the styloid fragment is excised subperiosteally

as described below in distal radioulnar ligament reconstruction.

The TFCC is reattached to the fovea with transosseous sutures. Using a 0.062 Kirschner wire, 2

holes are created in the distal ulna that extend from the dorsal aspect of the ulnar neck to the fovea. Two

horizontal mattress sutures of 2-0 absorbable monofilament (3-0 fiberwire suture may also be considered)

are passed from distal to proximal through the ulnar periphery of the TFCC. The sutures are then passed

through the bone holes. The sutures are tied over the ulnar neck with the joint reduced and the forearm in

neutral rotation. The dorsal DRUJ capsule is closed. If the capsule is attenuated, it can be reinforced with

the previously opened extensor retinaculum, leaving this portion of the extensor digiti minimi

subcutaneous.

An ulnar shortening osteotomy through the ulnar shaft using standard techniques described in the

literature should be performed at the same operating setting if the patient is ulnar positive variance or in

some cases also with ulnar neutral variance in order to unload the ulnocarpal joint and thus reduce the

loads on the repair and the central disk.

A long arm splint is applied with the forearm rotated 20 towards the most stable joint position,

eg, in supination for dorsal instability. The splint is converted to a long arm cast at 2 weeks followed by a

short arm cast at 4 weeks, which is worn for an additional 2 weeks. A removable splint is then used for 4weeks while motion is regained. Strengthening and resumption of activities is typically delayed until pain

is minimal and motion recovered. The results of TFCC repair are generally very good. DRUJ stability is

achieved and motion and strength are recovered is most cases.

My preferred technique for DRUJ Ligament Reconstruction

A 4 cm incision is made between the 5th and 6th extensor compartments, extending proximally

from the level of the ulnar styloid. The 5th compartment is opened, except for its distal portion, and the

extensor digiti minimi tendon is retracted radially. An L-shaped flap is created in the DRUJ capsule,

with one limb made along the dorsal rim of the sigmoid notch and the other just proximal and parallel to

the dorsal radioulnar ligament. Care is taken not to cut the dorsal radioulnar ligament. Proximal-ulnar

retraction of this flap exposes the articular surfaces of the distal radioulnar joint and the proximal surfaceof the TFCC. The integrity of the TFCC and its potential for repair are determined. If it is attenuated and

can not be repaired to the fovea of the ulnar head or its substance is inadequate to provide joint stability,

then proceed to reconstruct the radioulnar ligaments. Debride granulation tissue from the fovea but

retain the functioning remnants of the TFCC, especially any remaining portion of the palmar radioulnar

ligament and the attached ulnocarpal ligaments. However, a central tear in the disk can be debrided to

smooth margins. The ECU sheath should not be opened or dissected from the ulnar groove during the

procedure, as preserving the sheath will maintain its important stabilizing function for the ulnocarpal

joint. If an ulnar styloid nonunion is present, resect the styloid by subperiosteal sharp dissection volar to


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the ECU sheath. To bring the styloid into view, extend the skin incision distally and retract the skin

ulnarly while protecting the dorsal cutaneous branch of the ulnar nerve. Alternatively, the fragment can

be excised through the previous ulnocarpal capsulotomy, but the ECU sheath should not be excessively

mobilized.


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A palmaris longus tendon graft or a different graft of similar length and size is harvested and a

suture is placed in each end to make it easier to pass through bone tunnels and tissue. I now often use a

strip of the FCU harvested through the same incision used for passing the graft (see below). Prepare the

site for the tunnel in the radius by elevating the periosteum from the dorsal margin of the sigmoid notch.

Under fluoroscopic control, a guide wire for a 2-3 mm cannulated drill bit is driven through the radius a

few millimeters proximal to the lunate fossa and radial to the articular surface of the sigmoid notch. Wire

placement is chosen so that a tunnel large enough for the graft ( 4-6 mm diameter ) can be created

without disrupting the subchondral bone of the radiocarpal joint or the sigmoid notch. True PA and

lateral fluoroscopic views are necessary to confirm accurate placement. Do not plunge through the volar

cortex during wire insertion to avoid injuring volar structures. A 2-3 mm cannulated drill bit is used to

create a pilot tunnel. Using standard drill bits, the tunnel is progressively enlarged to accommodate the

tendon graft.

If the sigmoid notch is incompetent due to the natural shape of the sigmoid notch or from trauma,

then a sigmoid notch osteoplasty is indicated. The incompetency typically involves the volar rim. The

surgical method that I prefer is a modification of the method described by Wallwork and Bain. The

technique is described below. A slightly longer volar incision is helpful when also performing an

osteoplasty.

If a corrective osteotomy for a distal radial malunion is planned in conjunction with radioulnarligament reconstruction, it is easier but not mandatory to create the radial tunnel before performing the

osteotomy. However, the tunnel must be created parallel to the malaligned lunate fossa to avoid

penetrating the articular surface. In addition, graft insertion and tensioning should not be done until the

bony correction is completed.

An obliquely directed tunnel is created in the distal ulna between the fovea and the ulnar neck.

To expose the fovea, flex the wrist while retracting the ECU sheath ulnarly and the TFC remnants

distally. Apply the same cannulated drilling technique used for the radius to ensure accurate placement

of the tunnel. The guide wire is inserted through the fovea and directed to exit the ulnar neck just volar

to the ECU. Retracting the incision ulnarly exposes the wires exit site from the ulnar neck. Apply the

cannulated drill bit over the leading end of the guide wire and drill a pilot tunnel from the ulnar neck to

the fovea. Drilling in this in a retrograde direction will reduce the risk of fracturing the ulnar neck and

injuring the carpus. Carefully enlarge the tunnel with standard drill bits to allow passage of both limbs ofthe graft.

An alternative and perhaps easier technique especially in a wrist with reduced flexion is to create

the ulnar tunnel by first making a hole in the outer cortex on the subcutaneous border of the ulna just

volar to the ECU tendon using a standard 3.5 mm drill bit aimed perpendicular to the cortex. The guide is

inserted through this hole and drilled to exit the fovea under direct vision. The 3.5 mm cannulated drill

bit is used to make the pilot tunnel. The tunnel is enlarged with standard drill bits as needed.

The volar opening of the radial tunnel is exposed through a 3 cm longitudinal volar incision

extending proximally from the proximal wrist crease and located between the ulnar neurovascular bundle

and the finger flexor tendons. Retract the neurovascular bundle ulnarly and the finger flexors radially to

expose the tunnels opening. Inserting a blunt probe through the tunnel from the dorsum will help

identify the site. Using a suture passer, the graft is passed through the tunnel, leaving its volar limb about

3 cm longer. A straight hemostat is passed from dorsal to volar over the ulnar head and under (proximal)to any remnant of the TFC. Penetrate the volar DRUJ capsule and open the hemostat slightly to increase

the size of the capsular rent. Grasp the volar limb of the graft with the hemostat and pull it through the

capsule and into the dorsal surgical exposure.

Using a suture passer, both limbs of the graft are passed through the tunnel in the distal ulna from

the fovea to the ulnar neck. Ensure the limbs were directed proximal to any TFC remnants prior to

entering the fovea. At the ulnar neck, a curved hemostat is passed under the ECU in an ulnar direction.

The dorsal limb is grasped and pulled back through this track. Using a ligature passer, the volar limb is


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passed volarly around the ulnar neck with care not to injure or entrap the ulnar neurovascular bundle.

Both limbs should now lie near the dorsal-radial aspect of the ulnar neck. With the forearm in neutral

rotation, pull the limbs taut while compressing the DRUJ and make the first throw of a surgeons knot

with the two limbs. Pull the limbs extremely taut against the ulnar neck and secure the graft tension with

3-0 nonabsorbable sutures. An additional half-hitch can be made to further strengthen the fixation.

Alternative methods are used to tension and secure the graft when it is too short to tie around the

ulnar neck.. One alternative is to make an additional hole in the ulna neck and weave one limb throughthis hole and tie it to the other limb over the small bone bridge between the holes. Another alternative is

to use the floor of the ECU sheath. In this method, the ECU sheath is opened at the level of the ulnar

neck but not over the ulnar head. One limb of the graft is passed subperiosteally at the ulnar neck under

the ECU sheath floor, which is typically substantial, and then passed back over the sheath but beneath the

ECU tendon. It is then tied to the other graft limb.

Close the dorsal DRUJ capsule and the extensor retinaculum in separate layers with 3-0 sutures,

leaving the EDQ tendon subcutaneous over the DRUJ. The more distal, intact retinaculum will provide

sufficient guidance for the EDQ and prevent bowstringing. Pinning the ulna to the radius is the

surgeons discretion. Residual instability, obesity and patient compliance are among the factors that

influence this decision. If pinning is done, the pin should be placed at least 2 cm proximal to the ulnar

tunnel to reduce the risk of ulnar fracture and large enough to resist breaking. To be prepared to extract a

broken pin, one technique is to leave the leading end of the pin prominent within the subcutaneous

tissues on the radial aspect of the distal forearm. The pin should be temporarily advanced through the

skin to cut its point off and then backed up. If irritation of the superficial radial nerve develops, the pin

can be backed up further postoperatively.

Immobilize the extremity in a long-arm cast with the forearm in neutral rotation for 3 weeks. A

sugar-tong splint is discouraged because it may not control forearm rotation sufficiently. A well-molded

short arm cast is applied for an additional 3 weeks that allows some motion about the neutral forearm

position. A well-molded, ulnar-gutter wrist splint is used for an additional 3 weeks to prevent the

extremes of forearm rotation and wrist deviation. Exercises are performed during this time, including

active wrist motion, gentle hand and forearm strengthening and active but not passive forearm rotation.

Supination and pronation are typically regained gradually over 4 to 6 months and thus passive motion is

not necessary and may be detrimental. Near full activity is usually permitted after 4 months if gripstrength and wrist motion are almost recovered, however heavy lifting and impact loading are

discouraged for another 2 months.


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7

My preferred technique forOsteoplasty for Deficiency of the Sigmoid Notch

Modification of the technique described by Wallwork NA, Bain GI

In patients with a history of a fracture involving the sigmoid notch or a naturally shallow notch

on plain radiographs, a preoperative CT is recommended to evaluate the rims of the notch and the shape

of the ulnar head. A sigmoid notch osteoplasty can be considered as an isolated procedure or tocomplement a ligament reconstruction. The osteoplasty increases the prominence of a rim to create a

better bony buttress. Because the osteotomies are proximal to the radioulnar ligament, ligament tension is

increased which also improves joint stability. In the procedure described by Wallwork and Bain, parallel

osteotomies are made, with one just proximal to the lunate fossa and the other at the proximal margin of

the sigmoid notch. A third osteotomy is made in the longitudinal plane 5 mm from the articular surface of

the notch and between the first two cuts. An osteotome is carefully advanced and with each increment it

is levered in an ulnar direction to produce a thin, slightly curved osteocartilaginous flap (figure below).

The wedge-shaped defect is filled with a bone graft harvested from the distal radius. Wallwork and Bain

describe fixing the construct with Kirschner wires. When a osteoplasty is used in conjunction with a

ligament reconstruction, graft stability can be gained without Kirschner wires. Since the radial tunnel for

the ligament reconstruction lies radial to the osteotomy, the ligament graft passes directly over the bone

graft and the oseteochondral flap which provides good fixation of the construct. For additional fixation,

sutures can be placed through the soft tissues overlying the osteoplasty just proximal and distal to the

ligament graft. The reported results of the procedure are very limited but the concept appears sound.

Wallwork and Bain had a good result when used as the sole procedure to treat palmar instability in a

patient with a flat sigmoid notch.Our experience has been limited to use only in conjunction with a

ligament reconstruction when the notch is naturally flat or has been damage by trauma.

1. Adams B. Anatomic reconstruction of the distal radioulnar ligaments for DRUJ instability. TechHand Upper Extrem Surg 2000;4:154-160.

2. Adams BD, Berger RA. An Anatomic Reconstruction of the Distal Radioulnar Ligaments forPosttraumatic Distal Radioulnar Joint Instability. J Hand Surg 2002; 27A:243-251.

3. Bowers WH. The distal radioulnar joint. p. 1014. In Green DP, Hotchkiss RN, and Peterson WC(eds): Greens Operative Hand Surgery, 4th Ed. Churchill Livingstone, New York, 1999.

4. Kuzma GR. Stabilization with a tendon graft. pp. 307-308 In Kasden M, Amdio PC, Bowers WH(eds.): Technical Tips for Hand Surgery. Hanley & Belfus, Philadelphia, 1994.

5. Leung PC, Hung LK: An effective method of reconstructing posttraumatic dorsal dislocated distalradioulnar joints. J Hand Surg 1990; 15A: 925-28.

6. Sanders RA, Hawkins B. Reconstruction of the distal radioulnar joint for chronic volar dislocation.Orthopedics 1989; 12(11): 1473-76.

7. Sanders WE, Johnston-Jones K. Posttraumatic radioulnar instability: Treatment by anatomicreconstruction of the volar and dorsal radioulnar ligaments. Presented at the 50th Annual Meeting of

the American Society for Surgery of the Hand, San Francisco, September 1995.

8. Scheker LR, Belliappa PP, Acosta R, German DS. Reconstruction of the dorsal ligament of thetriangular fibrocartilage complex. J Hand Surg 1994; 19B: 310-8.9. Wallwork NA, Bain GI: Sigmoid notch osteoplasty for chronic volar instability of the distal

radioulnar joint: a case report. J Hand Surg. 26A(3):454-9, 2001.


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The Unstable Distal Radioulnar Joint ASSH Annual Meeting, Boston October 9, 2010

NOTES

Chronic DRUJ Instability/DJD: Bony Procedures

Scott W. Wolfe, MD

Professor of Orthopedic Surgery

Chief, Hand and Upper Extremity Surgery

Hospital for Special SurgeryNew York

[email protected]

I. General considerations

A. Definitiona. Abnormal radio-ulnar kinematics during mechanical loadb. Fixed or dynamic subluxation of radio-ulnar joint

B. Etiologya. Unrecognized DRUJ ligament injury

i. TFCC disruption(1)ii. Ulnar basi-styloid fracture/nonunion(2)

iii. Distal radioulnar dislocationiv. Galeazzi fracture-dislocationv. Essex-Lopresti injury

vi. Iatrogenic; aggressive capsular release(3;4)b. Radial malunion(5;6)c. Ulnar malunion

C. Anatomic components of DRUJ stabilitya. Articular congruency and alignmentb. Radio-ulnar contact pressure(7;8)c. TFCC(9)d. Distal radio-ulnar ligaments(10;11)e. Interosseous membrane(12)

D. Diagnosisa. Clinical examinationb. Radiographsc. Advanced imaging

i. Computed tomography(13;14)ii. Magnetic resonance imaging

E. Considerations for treatmenta. Direction of instability

i. Dorsalii. Palmariii. Multidirectional

b. Sigmoid notch shape (15)c. Chronicity (acute, subacute, chronic)


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NOTES

d. Bony alignment (determines sigmoid notch alignment)(16)e. Articular cartilage qualityf. Capsular contracture(4;17)g. Integrity of interosseous membrane(18)

F. Surgical options: Chronic DRUJ instability(19)a.

Bony proceduresi. Ulnar styloid fixation(20) for basi-styloid nonunions with instability

ii. Osteotomy for radial/ulnar malunion(21)1. Generally realigns sigmoid notch and restores stability2. If sigmoid notch articular cartilage intact, and

a. Stability restored by osteotomy no further treatmentb. If unstable, TFCC repair or reconstruction

3. +/- ulnar shortening osteotomy for ulnar positive variance4. If sigmoid notch arthritic, choices include:

a. Darrachb. Sauve-Kapandjic.

DRUJ arthroplastyb. Ablative procedures

i. Resection arthroplasty1. Darrach, HIT, matched arthroplasty(22-24)

a. Sedentary individuals, advanced DRUJ arthritisb. Technique

i. Minimal resectionii. no more than 1cm proximal to sigmoid notch

iii. Careful capsular closureiv. Immobilize in supination 2 wks

c. Contraindicationsi. limited role as primary treatment for radial malunion

ii. Correct malunion to restore radio-ulnar alignmentiii. Preoperative instability may lead to postoperative instability

d. Few options if resection fails(25-29)2. Wide excision of the ulna(30;31)

a. Consider for failed Darrachb. Intact IOM central band criticalc. One bone forearm is only recourse should this fail

ii. Sauve-Kapandji arthrodesis(32)1. May have a role in younger arthritic patient with higher loads2. Improved support for ulnar carpus3. Minimal resection (< 1cm)4. Soft tissue interposition to limit heterotopic bone5. Primary tenodesis to stabilize ulnar stump(33)

a. Pronatorb. FCU: hemi tendon, based distally and woven through stumpc. +/- ECU


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NOTES

6. Failure: limited success with conversion to DRUJ arthroplasty(34)iii. Role of joint arthroplasty

1. Not ideal for dorso-volar instability2. Excellent outcomes for failed Darrach with convergence(35;36)

II. Case-based approach to treatmentA. 36 y.o. female EMT with painful DRUJ instability for two years, multiple surgeriesB. 45 y.o. office manager with fixed dislocation following capsular releaseC. 62 y.o. retired female with RA and tendon rupturesD. 45 y.o. nurse with multiply operated distal ulna and instability

REFERENCES

(1) Kihara H, Short WH, Werner FW, Fortino MD,

Palmer AK. The stabilizing mechanism of the

distal radioulnar joint during pronation andsupination. J Hand Surg [Am] 1995

Nov;20(6):930-6.

(2) Hauck RM, Skahen J, III, Palmer AK.

Classification and treatment of ulnar styloid

nonunion. J Hand Surg [Am] 1996

May;21(3):418-22.

(3) Kleinman WB, Graham TJ. The distal radioulnar

joint capsule: clinical anatomy and role in

posttraumatic limitation of forearm rotation. J

Hand Surg [Am] 1998 Jul;23(4):588-99.

(4) af Ekenstam FW. Capsulotomy of the distal radio

ulnar joint. Scand J Plast Reconstr Surg Hand

Surg 1988;22(2):169-71.

(5) Fernandez DL. Correction of post-traumatic wrist

deformity in adults by osteotomy, bone-grafting,

and internal fixation. J Bone Joint Surg [Am]

1982;64(8):1164-78.

(6) Geissler WB, Fernandez DL, Lamey DM. Distal

radioulnar joint injuries associated with fractures

of the distal radius. Clin Orthop 1996

Jun;(327):135-46.

(7) Hagert CG. The distal radioulnar joint in relation

to the whole forearm. Clin Orthop Relat Res 1992

Feb;(275):56-64.

(8) Hagert CG. The distal radioulnar joint. Hand Clin

1987 Feb;3(1):41-50.

(9) Palmer AK. Triangular fibrocartilage complex

lesions: a classification. J Hand Surg [Am] 1989Jul;14(4):594-606.

(10) af EF, Hagert CG. Anatomical studies on the

geometry and stability of the distal radio ulnar

joint. Scand J Plast Reconstr Surg 1985;19(1):17-

25.

(11) Schuind F, An KN, Berglund L, Rey R, Cooney

WP, III, Linscheid RL, et al. The distal radioulnar

ligaments: a biomechanical study. J Hand Surg

[Am] 1991 Nov;16(6):1106-14.

(12) Kihara H, Short WH, Werner FW, Fortino MD,Palmer AK. The stabilizing mechanism of the

distal radioulnar joint during pronation and

supination. J Hand Surg [Am] 1995

Nov;20(6):930-6.

(13) Mino DE, Palmer AK, Levinsohn EM.

Radiography and computerized tomography in the

diagnosis of incongruity of the distal radio-ulnar

joint. A prospective study. J Bone Joint Surg Am

1985 Feb;67(2):247-52.

(14) Mino DE, Palmer AK, Levinsohn EM. The role of

radiography and computerized tomography in the

diagnosis of subluxation and dislocation of the

distal radioulnar joint. J Hand Surg [Am] 1983

Jan;8(1):23-31.

(15) Tham SK, Bain GI. Sigmoid notch osseous

reconstruction. Tech Hand Up Extrem Surg 2007


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NOTES

Mar;11(1):93-7.

(16) Adams BD. Effects of radial deformity on distal

radioulnar joint mechanics. J Hand Surg [Am]

1993 May;18(3):492-8.

(17) Kleinman WB, Graham TJ. The distal radioulnarjoint capsule: clinical anatomy and role in

posttraumatic limitation of forearm rotation. J

Hand Surg [Am] 1998 Jul;23(4):588-99.

(18) Kihara H, Short WH, Werner FW, Fortino MD,

Palmer AK. The stabilizing mechanism of the

distal radioulnar joint during pronation and

supination. J Hand Surg [Am] 1995

Nov;20(6):930-6.

(19) Murray PM, Adams JE, Lam J, Osterman AL,

Wolfe S. Disorders of the distal radioulnar joint.

Instr Course Lect 2010;59:295-311.

(20) Hauck RM, Skahen J, III, Palmer AK.

Classification and treatment of ulnar styloid

nonunion. J Hand Surg [Am] 1996

May;21(3):418-22.

(21) af EF, Hagert CG, Engkvist O, Tornvall AH,

Wilbrand H. Corrective osteotomy of malunited

fractures of the distal end of the radius. Scand J

Plast Reconstr Surg 1985;19(2):175-87.

(22) Bowers WH. Distal radioulnar joint arthroplasty:

the hemiresection-interposition technique. J Hand

Surg [Am] 1985 Mar;10(2):169-78.

(23) Watson HK, Gabuzda GM. Matched distal ulna

resection for posttraumatic disorders of the distal

radioulnar joint. J Hand Surg [Am] 1992

Jul;17(4):724-30.

(24) Tulipan DJ, Eaton RG, Eberhart RE. The Darrach

procedure defended: technique redefined and

long-term follow-up. J Hand Surg [Am] 1991

May;16(3):438-44.

(25) Gonzalez del PJ, Fernandez DL. Salvage

procedure for failed Bowers' hemiresectioninterposition technique in the distal radioulnar

joint. J Hand Surg [Br ] 1998 Dec;23(6):749-53.

(26) Breen TF, Jupiter J. Tenodesis of the chronically

unstable distal ulna. Hand Clin 1991

May;7(2):355-63.

(27) Breen TF, Jupiter JB. Extensor carpi ulnaris and

flexor carpi ulnaris tenodesis of the unstable distal

ulna. J Hand Surg [Am] 1989 Jul;14(4):612-7.

(28) Kleinman WB, Greenberg JA. Salvage of thefailed Darrach procedure. J Hand Surg [Am] 1995

Nov;20(6):951-8.

(29) Bieber EJ, Linscheid RL, Dobyns JH,

Beckenbaugh RD. Failed distal ulna resections. J

Hand Surg [Am] 1988 Mar;13(2):193-200.

(30) Greenberg JA, Yanagida H, Werner FW, Short

WH. Wide excision of the distal ulna:

biomechanical testing of a salvage procedure. J

Hand Surg [Am] 2003 Jan;28(1):105-10.

(31) Wolfe SW, Mih AD, Hotchkiss RN, Culp RW,

Keifhaber TR, Nagle DJ. Wide excision of the

distal ulna: a multicenter case study. J Hand Surg

[Am] 1998 Mar;23(2):222-8.

(32) Schroven I, De Smet L, Zachee B, Steenwerckx

A, Fabry G. Radial osteotomy and Sauve-

Kapandji procedure for deformities of the distal

radius. Acta Orthop Belg 1995;61(1):1-5.

(33) Lamey DM, Fernandez DL. Results of the

modified Sauve-Kapandji procedure in the

treatment of chronic posttraumatic derangement

of the distal radioulnar joint. J Bone Joint Surg

Am 1998 Dec;80(12):1758-69.

(34) Rotsaert P, Cermak K, Vancabeke M. Case report:

revision of failed Sauve-Kapandji procedure with

an ulnar head prosthesis. Chir Main 2008

Feb;27(1):47-9.

(35) Willis AA, Berger RA, Cooney WP, III.

Arthroplasty of the distal radioulnar joint using a

new ulnar head endoprosthesis: preliminary

report. J Hand Surg Am 2007 Feb;32(2):177-89.

(36) van SJ, Fernandez DL, Bowers WH, Herbert TJ.

Salvage of failed resection arthroplasties of thedistal radioulnar joint using a new ulnar head

prosthesis. J Hand Surg Am 2000 May;25(3):438-

46.


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Salvaging the failed DRUJ Dean G. Sotereanos, MDAaron I. Venouziou, MD

ASSH, 2010 Annual Meeting

Salvaging the failed DRUJ

Dean G. Sotereanos

Professor, Vice-Chairman,Drexel University

College of Medicine

Department of OrthopaedicsAllegheny General Hospital

Pittsburgh, PA

DARRACH PROCEDURE

Dr. William Darrach 1912

- Excision of the distal 1 cm of the ulna

Gold standard (for many decades)

Indications

osteoarthritis- DRUJ arthritis rheumatoid

post-traumatic

DARRACH PROCEDURE

Modifications- Bower Hemi-resection interposition

- Watson Matched distal ulna resection

- Feldon Wafer procedure

Failure rate 7 48 %

- despite modifications

Dingman 1952, Hartz 1979, Nobel 1983, Bieber 1988, Buck-Gramcko 1990,

Field 1993, McKee 1996, Kleinman1996, Hove 1999


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DARRACH PROCEDURE

Distal ulna excision loss of ulnar support

of the carpus

Radio-ulnar convergence

Impingement

Loss of linkage between radius & ulna

FAILED DARRACH PROCEDURE

PATHOPHYSIOLOGY

Bell et al, JBJS Br 1985

Ulnar Impingement Syndrome

1. loss of

ulnar buttress2. pull of

pronator

quadratus

3. pull of

interosseous

membrane

4. pull of EPB

and APL


PATHOPHYSIOLOGY

Instability / Impingement


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Instability / Impingement


Clinical features

- Instability

- Impingement

- Grip weakness

- Attritional tendon ruptures

- Pain


Difficult

reconstructive

dilemma !


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Salvage Techniques

Further shortening

ECU/FCU stabilization

Silicon capping

PQ advancement

Volar capsulodesis

Metallic prosthesis


Results

No technique has demonstrated clinical superiority

Some techniques are technically demanding with

irreproducible results (tendon weaves)

Implant technique challenging and revisions

difficult


OUR PREFERRED TECHNIQUE

Allograft / Mechanical interposition

Prevents radioulnar impingement


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OPERATIVE TECHNIQUE

Incision: previous surgical incisions areincorporated into the approach

resected distal ulna

OPERATIVE TECHNIQUE

Subperiosteal exposure of distal ulna

4 6 cm proximal to distal stump

Exposure of

medial cortex of radius

OPERATIVE TECHNIQUE

3 - 4 suture anchors into medial cortex of radius- proximal to sigmoid notch

- at site of impingement


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OPERATIVE TECHNIQUE

3 - 4 drill holes in distal ulna

Create 3 4 cm length for fixation of allograft

to medial radial cortex

Create a large buffer between two bones

Placement of allograft:

Achilles tendon

OPERATIVE TECHNIQUE

Allograft attached to:

- Medial cortex of radius using suture anchors

- Ulna with sutures passed through drill holes

OPERATIVE TECHNIQUE

Allograft sutured together as an anchovycreation ofpillow-shaped spacer


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OPERATIVE TECHNIQUE

Size of the allograft: Important !

OPERATIVE TECHNIQUE

Size of the allograft:

- determined by pronating /supinating forearm

- pressure applied to theulnar side of the ulna

to assess for crepitus

- increase allograft size ifcrepitus palpated

OPERATIVE TECHNIQUE

Final allograft placement

Significant padding between radius & ulna

Prevents any palpable crepitus

during forearm rotation under compression


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OPERATIVE TECHNIQUE

POST-OP CARE

Long-arm splint x 10 d

(in neutral position)

Cast day 10 6 wks

Physical therapy > 6 wks

- AAROM / AROM

- strengthening (as tolerated)

MATERIALS and METHODS

17 patients

Age (mean): 47 yrs

range: 39 68 yrs

Time after index procedure

average: 15 mo

range: 9 26 mo

Follow-up (mean): 34 mo


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Indication for revision surgery:

- incapacitating pain over the distal ulnar stump

- aggravated by - active grip

- pronation /supination

- compression of distal ulna

against radius


Radiographs: pre- and post-op

Pain: VAS Visual Analog Scale

Grip strength: dynamometer

Range of motion

Palpable crepitus

Subjective assessment

RESULTS

6 Patients: Excellent

10 Patients: Good

1 Patient: Poor Failure- 1st pt (inadequate amount of allograft)


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RESULTS

Improvement:

Pain: VAS

mean : -6

Grip strength: mean : +74%

Range of motion:

- Pronation / Supination: mean: +30o / +42o

Crepitus: 1 patient only

No infection

RESULTS

Case

47 y-o female, severe pain after failed Bowers

Pre-op


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Achilles Allograft Interposition for Failed Bowers

4ys Post-op

painfree

Case

Post-op (4 yrs)

Case

Post-op (4 yrs)

Case


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CONCLUSIONS

ALLOGRAFT Mechanical interposition

Size is important

Obtain as much as necessary

Prevents crepitus / impingement

CONCERNS

Reaction to allograft

- swelling progressively decreased

Cost

Availability

Need for long term follow-up

- early results very promising

Documents

Unstable DRUJ