review article arthritis of the distal radioulnar joint...

Arthritis of the Distal RadioulnarJoint: From Darrach to Total JointArthroplasty

Abstract

The distal radioulnar joint (DRUJ) is a complex structure thatcontributes to full, painless forearm rotation and weight bearing.Stability requires adequate bony architecture and robust soft-tissuesupport. Arthritis of the DRUJ between the sigmoid notch of thedistal radius and the ulnar head can be caused by traumatic,inflammatory, congenital, and degenerative processes. Initialmanagement of symptomatic DRUJ arthritis is nonsurgical. Surgeryis reserved for patients with refractory pain. Although outcomestypically are positive following excision of the distal ulna, seriouspotential postoperative complications include instability andpotentially painful impingement of the residual distal ulnar stump.Procedures used to manage the unstable residual ulna includesoft-tissue stabilization techniques and DRUJ implant arthroplasty.

The distal radioulnar joint (DRUJ)is a complex structure that contrib-

utes to full, painless forearm motionand weight bearing. It is a common gen-erator of ulnar-sided wrist pain. Thereis a relatively shallow groove for bonyarticulation. Thus, stability is main-tained by a complex network of liga-mentous and musculotendinous sup-ports.

Types of DRUJ pathology include in-stability, incongruity, and arthrosis.Symptomatic arthrosis of the DRUJhas the potential to cause disability ofboth the wrist and the forearm; histor-ically, it has been managed with distalulna resection following failed nonsur-gical management. Although outcomesare typically favorable, unstable resid-ual distal ulnar stump is a challengingcomplication of DRUJ resection ar-throplasty. Soft-tissue stabilization pro-cedures and DRUJ implant arthroplas-ties have been developed to manageresidual ulnar instability.

Anatomy

The bony architecture of the DRUJconsists of the articulation betweenthe sigmoid notch of the distal radiusand the ulnar head. This relationshipis notable for its significant asymme-try. Anatomic studies have demon-strated that the sigmoid notch has a4- to 7-mm greater radius of curva-ture than the ulnar head; thus, mo-tion through the DRUJ consists ofboth rotational and gliding compo-nents1 (Figure 1). Only 20% ofDRUJ constraint is provided by thearticulation of the ulnar head in thesigmoid notch; most DRUJ stabilitycomes from soft-tissue support, in-cluding the triangular fibrocartilagecomplex (TFCC).2

The TFCC is a complex structureconsisting of the dorsal and volar ra-dioulnar ligaments, dorsal and volarulnocarpal ligaments, articular disk,meniscus homolog, and extensor

Ryan M. Zimmerman, MD

Jaehon M. Kim, MD

Jesse B. Jupiter, MD

From the Department ofOrthopaedic Surgery, MassachusettsGeneral Hospital, Boston, MA.

Dr. Jupiter or an immediate familymember serves as a paid consultantto or is an employee of and hasstock or stock options held in OHKMedical Devices; serves as anunpaid consultant to Synthes andEidosmed; has received research orinstitutional support from the AOFoundation; and serves as a boardmember, owner, officer, orcommittee member of the AmericanAcademy of Orthopaedic Surgeonsand the American Shoulder andElbow Surgeons. Neither of thefollowing authors nor any immediatefamily member has receivedanything of value from or has stockor stock options held in acommercial company or institutionrelated directly or indirectly to thesubject of this article:Dr. Zimmerman and Dr. Kim.

J Am Acad Orthop Surg 2012;20:623-632

http://dx.doi.org/10.5435/JAAOS-20-10-623

Copyright 2012 by the AmericanAcademy of Orthopaedic Surgeons.

Review Article

October 2012, Vol 20, No 10 623

carpi ulnaris (ECU) tendon sheath.The TFCC originates on the medialborder of the distal radius adjacentto the sigmoid notch and inserts ontothe base of the ulnar styloid, bothvolarly and dorsally3 (Figure 2). Ana-tomic studies have confirmed impor-tant contributions to DRUJ stabilityfrom the dorsal and volar radioulnarligaments, pronator quadratus mus-cle, and interosseous membrane.4,5

Recent work has shown that the tri-angular fibrocartilage and the radio-ulnar ligaments can maintain normalDRUJ kinematics in the absence ofother soft-tissue stabilizers.6 Con-versely, DRUJ kinematics were alsopreserved in an anatomic model—de-spite loss of triangular fibrocartilageand radioulnar ligament—whenother soft-tissue stabilizers, such asthe interosseous membrane, werepreserved. This surprising findingsuggests that DRUJ stability may bemore diffusely distributed than previ-ously thought.6 Although certain bio-mechanical aspects of DRUJ stability

remain controversial, multiple inves-tigators have shown that contactpressures and differential tighteningof the distal radioulnar ligamentsduring forearm rotation contributesubstantially to stability.7

The DRUJ is important in weightbearing and maintaining radioulnardistance during forearm rotation.The concept of ulnar variance, whichis the relative length relationship ofthe distal ends of the radius andulna, is helpful in understandingforce transmission through theDRUJ. Some investigators have pro-posed that the ulnar-neutral wristtransmits 20% of force to the distalulna through the ulnocarpal joint.8

Recent work has shown that that

number may be as high as 33%.9

However, even more important arethe changes in load transmission andDRUJ dynamics that occur withchanges in ulnar length.

Nygaard et al9 showed that in-creasing the length of the ulna rela-tive to the radius (from ulnar-neutralto ulnar-positive) by 1 mm may in-crease ulnocarpal loading by morethan half, whereas ulnar shortening(from ulnar-neutral to ulnar-nega-tive) routes more force through theradiocarpal joint.9 Ulnar shorteningmay increase peak pressure in theDRUJ while simultaneously stabiliz-ing it by increasing TFCC ten-sion.10,11 Longitudinal gliding occursat the DRUJ throughout forearm ro-

Axial cross-section of the distalradioulnar joint in a cadaverspecimen. The sigmoid notch(asterisk) is much flatter and has alarger radius of curvature than theulnar head (U). This geometryprovides limited osseous stability tothe joint. R = radius. (Adapted withpermission from Cooney WP III,Berger RA: Distal radioulnar jointimplant arthroplasty. Journal of theAmerican Society for Surgery ofthe Hand 2005;5[4]:217-231.)

Figure 1

Illustration of ulnar wrist anatomy. The triangular fibrocartilage complexconsists of the dorsal and volar radioulnar ligaments, dorsal and volarulnocarpal ligaments, articular disk, meniscus homolog, and extensor carpiulnaris (ECU) tendon sheath. The meniscus homolog is not shown.(Reproduced from Shin AY, Deitch MA, Sachar K, Boyer MI: Ulnar-sided wristpain: Diagnosis and treatment. Instr Course Lect 2005;54:115-128. Bypermission of Mayo Foundation for Medical Education and Research. Allrights reserved.)

Figure 2

Arthritis of the Distal Radioulnar Joint: From Darrach to Total Joint Arthroplasty

624 Journal of the American Academy of Orthopaedic Surgeons

tation, resulting in dynamic ulnarvariance of relative positivity in pro-nation and relative negativity in supi-nation. The ulnar head also func-tions to maintain radioulnar distanceduring forearm rotation. With exci-sion of the ulnar head or discontinu-ity of the distal ulna, such as occursfollowing resection arthroplasty, thatrelationship is lost and radioulnarconvergence can occur. The multiplefunctions and complex biomechanicsof the DRUJ contribute to the chal-lenges inherent in its reconstruction.

DRUJ Pathology

DRUJ pathology takes numerousforms. We focus here on arthritis at

the articulation of the sigmoid notchand the distal ulna. Other pathologicstates affecting the joint include in-stability, ulnocarpal impaction, andTFCC injury. Pathology of the DRUJat the sigmoid notch can arise fromtraumatic, inflammatory, congenital,and degenerative etiologies.

The sequelae of distal radius frac-ture are common causes of posttrau-matic DRUJ dysfunction, although itcan occur following a variety of frac-tures. Distal radius fractures thatpropagate into the sigmoid notch canresult in joint asymmetry and predis-pose to arthrosis. Radial deformity,including fracture malunion, canlead to DRUJ dysfunction secondaryto altered biomechanics. The amountof tolerable deformity is controver-sial, but residual dorsal angulation of>20° to 30° has been associated withpathologic wrist biomechanics12 (Fig-ure 3). Children can experiencemalunion and fracture propagationinto the sigmoid notch, but growtharrest following physeal fracture hasbeen reported to occur in approxi-mately 4% of fractures involving thedistal radius and up to 50% of thosein the distal ulna.13 The resulting de-formity and altered DRUJ biome-chanics can predispose to dysfunc-tion and degeneration.

Inflammatory conditions also af-fect the DRUJ. Rheumatoid arthritisis the most common inflammatorydisorder of the joint, and pathologyat this site may be its first clinicalmanifestation.14 Congenital sourcesof pathology are less common butare nonetheless significant and re-quire prompt diagnosis to preventongoing insult. Madelung deformity,which is an idiopathic arrest of theulnovolar portion of the distal radialepiphysis, is a common congenitalcause of DRUJ dysfunction. Defor-mity occurs around the tether as lon-gitudinal growth continues throughremaining functional epiphyses, re-sulting in angular deformity and al-

tered DRUJ biomechanics. Neopla-sia, such as osteochondroma, canalso impair wrist dynamics, even ifnot located immediately within theDRUJ.15

Instability and ulnar impactionsyndrome should be considered inthe context of any arthritic DRUJ.These diagnoses often coexist, andall modes of pathology must be ap-preciated to guide comprehensivemanagement. DRUJ instability refersto failure of the bony and soft-tissuecomponents to maintain properalignment and support during fullrange of motion (ROM) and weightbearing. May et al16 found that 11%of distal radius fractures were ac-companied by DRUJ instability andreported that risk factors includefracture at the base of the ulnar sty-loid and significant ulnar styloidfracture displacement. Ulnar impac-tion syndrome refers to chroniccompressive overloading through theulnocarpal joint, often from ulnar-positive variance, leading to degener-ative bony changes and TFCC tears.3

Physical Examination

Physical examination of the DRUJbegins with inspection. Salient obser-vations include skin changes such aserythema or edema, prior surgicalscars, deformity, and asymmetrycompared with the contralaterallimb. Particular attention should bepaid to the appearance of the distalulnae because asymmetric promi-nence may exist in the setting of dis-tal radius malunion. Palpation fol-lows inspection, with emphasis onthe distal ulnar diaphysis and styloid.Palpation of the ulnar styloid in pro-nation has been proposed,17 but wehave found a tender styloid to besymptomatic regardless of wrist posi-tion. ROM testing and provocativemaneuvers follow.

Pronation and supination are espe-

Lateral radiograph demonstratingmalunion of a distal radius fracturewith residual volar displacementand distal radioulnar jointsubluxation. (Reproduced withpermission from Shea K,Fernandez DL, Jupiter JB, Martin CJr: Corrective osteotomy formalunited, volarly displacedfractures of the distal end of theradius. J Bone Joint Surg Am1997;79[12]:1816-1826.)

Figure 3

Ryan M. Zimmerman, MD, et al

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cially informative and must be com-pared with that of the contralateralwrist. Crepitus and decreased orpainful rotation, especially in thecontext of instability, should raisesuspicion for DRUJ pathology. Insta-bility can be assessed by grasping thedistal ulna and exerting dorsal andvolar stresses, assessing for pain ormovement of the ulna relative to theradius. This maneuver, known as the“shucking” test, should be repeatedin supination, neutral positioning,and pronation. Both wrists should becompared because findings can varybased on an individual’s baseline lig-amentous laxity. Radioulnar im-pingement typically presents withcrepitus and pain during forearm ro-tation, which can be elicited by pro-nating and supinating the wrist whilecompressing the ulna against the ra-dius. Specific tests can be done toevaluate specific components of theDRUJ. Repetitive pronation and su-pination in ulnar deviation can re-veal ECU subluxation. The presstest, in which the patient uses her orhis arms to rise from a chair, axiallyloads the wrist in ulnar deviationand is painful in persons with aTFCC tear.17-19

Imaging

Imaging begins with standard APand lateral radiographs of the wrist.Bilateral imaging is often helpful. Forexample, bilateral positive ulnarvariance is normal in some persons,but unilateral positive ulnar varianceis more concerning for pathology.Forearm rotation must be consistentbetween radiographs and within 10°of neutral, as greater rotation canhamper evaluation of the DRUJ.Plain radiographs should be assessedfor ulnar variance, signs of fracturemalunion and malalignment, and de-generative changes in the carpus.Particular attention should be paid

to the articulation between the sig-moid notch and ulnar head. Differ-ences in overlap may indicate sub-luxation. Significant asymmetry anddegenerative changes can be notedon plain radiographs.

CT is helpful in assessing for bonyincongruity within the sigmoid notchand should be considered when thereis concern for fracture extension intothe DRUJ. Dynamic CT can be con-sidered for patients with clinicalsigns of instability. MRI, specificallya 3T dedicated wrist coil, is optimalfor assessing the relevant soft tis-sues.20 Although several systems havebeen proposed for radiographic eval-uation of subluxation, no system ex-ists for DRUJ arthritis.

Nonsurgical Management

Nonsurgical measures should beconsidered before proceeding to sur-gical intervention. An initial trialof activity modification, gentle phys-ical therapy, nonsteroidal anti-inflammatory drugs, and immobili-zation should be offered. A trial ofnonsurgical treatment is especiallyimportant for patients who presentwith chronic, ill-defined symptomsand normal imaging. We are un-aware of any high-level study thatexamines the outcomes of nonsurgi-cal modalities for DRUJ arthritis.

Surgical Management

Resection ArthroplastyResection arthroplasty remains oneof the main surgical techniques tomanage symptomatic DRUJ arthro-sis. DRUJ kinematics are consistentlyaltered following distal ulna resec-tion,21 and patients should be coun-seled that although surgery can im-prove their symptoms, it may beunrealistic to expect entirely normalpostoperative function. The type of

resection arthroplasty should be tai-lored to the demands and degree ofpathology of each individual patient.

Darrach ProcedureFirst described in the 19th centuryand later popularized by Darrach,22

distal ulnar resection was originallyindicated for the management ofchronic DRUJ instability. The indica-tions have been broadened and re-fined over the years. The Darrachprocedure remains the preferred op-tion for relatively low-demand pa-tients with DRUJ arthrosis and anonreconstructible joint.

The Darrach procedure involveslimited distal ulna resection with me-ticulous preservation of supportingsoft-tissue structures, with the goalof balancing symptomatic relief viathe resection while maximizing post-operative stability. The distal ulna isexcised subperiosteally just proximalto the sigmoid notch (Figure 4). TheTFCC, periosteum, and ECU tendonsheath are preserved when possible.Some authors recommend maintain-ing the ulnar styloid in situ to opti-mize postoperative TFCC function.The extensor retinaculum can beused to reinforce the dorsal soft-tissue layer and provide a sling tomaintain the ECU on the dorsalwrist.23 Bone resection should beminimal, with just enough to clearthe sigmoid notch, thereby preserv-ing the interosseous membrane tooptimize residual stump stability.23

Hemiresection ProceduresHemiresection techniques provide lo-calized resection of only the articularregion of the distal ulna while pre-serving soft-tissue stabilizers, espe-cially the TFCC insertion onto theulnar styloid. Hemiresection is ap-propriate only in the setting of an in-tact TFCC.

In the classic technique, the articu-lar portion of the ulnar head and itsimmediate subchondral bone is ex-



cised, with the remainder left in situand the attachments of the TFCCpreserved to optimize stability.24,25 Acommon variation is the hemiresec-tion interposition technique (HIT).With this method, the resection com-ponent is unchanged, and the inter-position involves the insertion of softtissue into the resection cavity in anattempt to prevent convergence ofthe radius and ulna.26 Another modi-fication is matched distal ulna resec-tion, in which the distal ulna is re-sected in a convex fashion tooptimize congruency within the sig-moid notch during forearm rotation(Figure 5). The ulnar styloid is usu-ally removed with this technique, butthe continuity of the TFCC is other-wise maintained.24,25

Sauvé-Kapandji ProcedureThe Sauvé-Kapandji procedure com-bines DRUJ fusion with distal ulnaresection just proximal to the sig-moid notch and creation of a proxi-mal ulnar pseudarthrosis (Figure 6).Maintaining the ulnar head preservesthe ulnar column and carpal articula-tion, thereby preventing ulnar trans-lation of the carpus and providinga better postoperative appearancecompared with the Darrach proce-dure.27 The Sauvé-Kapandji proce-dure is thought to be more appropri-ate for young, active patients with anonreconstructible DRUJ. However,there is limited high-level evidencecomparing outcomes or critically as-sessing the appropriate procedure(ie, Sauvé-Kapandji, Darrach) foreach patient population.28

Soft-tissue preservation and mini-mal bone resection are key to suc-

cess. Through a dorsal or ulnar ap-proach, 10 to 15 mm of ulnar neck isresected. Cancellous bone at the ar-ticular surface of the distal radiusand ulna is exposed for fusion. Fixa-tion is achieved with two Kirschnerwires or 3.5-mm cancellous screws incompression, with purchase in threecortices. The ulnar head is securedinto the sigmoid notch in neutral po-sition and variance, and the pronatorquadratus fascia is interposed in theosteotomy site to prevent reossifica-tion.27 A strip of flexor carpi ulnaris(FCU) can be tenodesed through adrill hole in the ulnar stump for ad-ditional stability.29 Insufficient bonestock and tenuous fixation are riskfactors for nonunion and fixationfailure. Fujita et al30 described amodified technique to improve sta-bility and union that uses a 30-mmdistal ulnar segment that is rotated

Illustration of components of theDarrach procedure. The distal ulnais resected just proximal to theradioulnar joint. The osteotomy isslanted 30° to 40° obliquely(dashed line). Although it isimportant to clear the sigmoidnotch, minimal bone resection isfavored to preserve ulnar stumpstability. ECU = extensor carpiulnaris tendon, R = radius,U = ulna. (Adapted with permissionfrom Nolan WB III, Eaton RG: ADarrach procedure for distal ulnarpathology derangements. ClinOrthop Relat Res 1992;[275]:85-89.)

Figure 4

Illustration of matched distal ulna resection, which involves tapering theresection in a smooth, curved fashion to optimize congruence with the distalradius during forearm rotation (inset). The overall resection can be 5 cm inlength and typically requires resection of the ulnar styloid. (Adapted withpermission from Watson HK, Gabuzda GM: Matched distal ulna resection forposttraumatic disorders of the distal radioulnar joint. J Hand Surg Am1992;17[4]:724-730.)

Figure 5


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90° and inserted into a 10-mm holecreated in the sigmoid notch of theradius.

Outcomes of ResectionArthroplastyDistal ulnar resection typically pro-vides improved pain, grip strength,and motion in 80% to 90% of pa-tients.23,27,31,32 Although some patientscan return to heavy labor, caution isadvised when performing distal ulnaresection on higher-demand per-sons.31 Long-term follow-up data onyoung patients and high-demand pa-tients are limited. Although out-comes are often favorable, complica-tions include pain, residual ulnarstump instability, reossification atthe Sauvé-Kapandji resection site, ul-nar translation of the carpus, andpainful abutment of the ulnar stumpon the radius. Encroachment of thedistal ulna on the radius is known asradioulnar convergence, and im-

pingement is the symptomatic clini-cal entity24,31 (Figure 7).

There is evidence that residual ul-nar instability is prevalent. Biome-chanically, DRUJ kinematics are con-sistently abnormal after distal ulnarresection, and radiographic signs ofradioulnar impingement have beennoted in up to 74% of cases.21 In arecent series of 105 patients treatedwith the Sauvé-Kapandji procedure,97% experienced pain relief and74% had radiographic evidence ofradioulnar convergence.33 In a differ-ent study, 50% of patients reportedsubjective instability after undergo-ing the Sauvé-Kapandji procedure.34

Although symptomatic improvementis typically achieved following HIT,DRUJ kinematics remain abnor-mal.30,35 Favorable long-term resultsafter HIT have been noted in pa-tients with rheumatoid arthritis.36

Watson and Gabuzda24 noted good

to excellent results in 24 of 32 pa-tients who underwent matched re-section, with outcome proportionalto preoperative morbidity. Minamiet al37 reported long-term retrospec-tive follow-up for 61 patients withDRUJ arthritis who were treatedwith the Darrach procedure, Sauvé-Kapandji procedure, or HIT. Postop-erative pain improved in all groups,more so in the Sauvé-Kapandji andHIT subsets than in the Darrachgroup, although the difference didnot reach statistical significance. Dis-tal ulnar instability was frequent af-ter all procedures: 60%, 50%, and20% of patients reported clinical in-stability following the Darrach pro-cedure, Sauvé-Kapandji procedure,and HIT, respectively.

The persistently symptomatic, un-stable residual ulnar stump (ie, failedulnar resection) is problematic, withpersistently poor outcomes despitemultiple attempted stabilization pro-

Illustrations of the Sauvé-Kapandji procedure. A, Lateral view demonstratingfusion of the distal ulna to the radius at the sigmoid notch using screws.Approximately 1 cm is resected proximally and interposed with the pronatorquadratus muscle. The flexor carpi ulnaris or extensor carpi ulnaris tendoncan be used to further stabilize the ulnar stump. B, Dorsal viewdemonstrating the final appearance following the procedure. (Adapted withpermission from Slater RR, Szabo RM: The Sauvé-Kapandji procedure. TechHand Up Extrem Surg 1998;2:148-157.)

Figure 6

AP plain radiograph demonstratingradioulnar impingement followingdistal ulna resection and extensorcarpi ulnaris–flexor carpi ulnaristenodesis. (Reproduced withpermission from Scheker LR:Implant arthroplasty for the distalradioulnar joint. J Hand Surg Am2008;33[9]:1639-1644.)

Figure 7



cedures.38 An important unansweredquestion is which patients go on todevelop instability following resec-tion arthroplasty. Minimal data ex-ist, but it makes empirical sense thatexcessive resection of soft-tissue sta-bilizers or inferior preoperative soft-tissue support could be risk factors.Thus, we advocate meticulous soft-tissue handling during any distalulna resection.

Soft-tissue Stabilization ofthe Unstable Ulnar StumpNumerous soft-tissue stabilizationprocedures have been developed tocontrol the unstable residual ulnarstump.39,40 ECU and FCU tenodesishas shown success. In this procedure,a proximally based ECU slip and adistally based FCU slip are used as aweave to control the unstable distalulna.39 In a study by Breen and Jupi-ter,39 all eight patients treated withthis technique obtained stable ulnaepostoperatively. Tenodesis tech-niques using tendon allografts havealso been described.40 A more re-cently described technique involvesreinforcing Achilles tendon allograftin the interosseous space of theDRUJ with two slips of brachioradi-alis tendon passed through the distalradius and then wrapped volarly anddorsally around the recalcitrant ulnastump (Figure 8). Initial outcomesare favorable, but long-term out-come data are lacking.40,41

Implant ArthroplastyDRUJ implant arthroplasties have re-cently been developed to offer addi-tional salvage options. Devices rangefrom partial ulnar head replacementsto self-constrained systems that re-place the entirety of the DRUJ.

Partial Ulnar HeadHemiarthroplastyPartial ulnar head hemiarthroplastyis the least intrusive implant arthro-plasty option. Several partial ulnar

head replacements are available.These implants can take variousforms (eg, pyrocarbon spacers) andare intended for cases of isolatedDRUJ arthritis without instability.This type of implant can be consid-ered after failed HIT but is contrain-dicated following a Darrach proce-dure because the entirety of the ulnarhead has already been excised. Thefocal pathologic site is resected, andthe partial ulnar head replacement isinserted without disrupting the soft-tissue attachments, thus minimallyaltering joint biomechanics42 (Figure9). Early results in three patientstreated with partial ulna head re-placement showed average pronationof 65° and average supination of

70°, as well as uniform 4-kg (8.8-lb)lifting ability throughout forearmrotation. Pain was improved, andno significant complications werenoted.42

Total Ulnar Head ArthroplastyTotal ulnar head arthroplasty in-volves complete replacement of thedistal ulnar head with a stemmed im-plant (Figure 10). Initial designs wereplagued by material failure, butnewer implants with more moderncomponents (eg, ceramic head af-fixed to a titanium intramedullarystem) have yielded favorable resultswithout evidence of material compli-cations.43 Unlike partial ulnar headhemiarthroplasty, which is intendedfor the setting of arthritis in an oth-erwise stable joint, total ulnar headreplacement is indicated for painfulinstability after failed distal ulnar re-section, isolated instability, and, oc-

AP (A) and axial (B) illustrations ofsoft-tissue stabilization of anunstable distal ulnar stump.Achilles tendon allograft in theinterosseous space is furtherstabilized using two slips of adivided brachioradialis tendonpassed through the distal radiusand wrapped volarly and dorsallyaround the distal ulna. (Adaptedwith permission from Allende C:Allograft tendon interposition andbrachioradialis tendon stabilityaugmentation in revision surgeryfor failed Darrach distal ulnaresections. Tech Hand Up ExtremSurg 2010;14[4]:237-240.)

Figure 8

Dorsal photograph demonstratingpartial ulnar head replacementusing the Eclypse implant (Tornier,Cedex, France). (Reproduced withpermission from Garcia-Elias M:Eclypse: Partial ulnar headreplacement for the isolated distalradio-ulnar joint arthrosis. TechHand Up Extrem Surg 2007;11[1]:121-128.)

Figure 9


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casionally, acute trauma.43-45 Biome-chanics are more altered with totalulnar head arthroplasty than withhemiarthroplasty because the soft-tissue components of the DRUJ can-not be anatomically preserved. Somedevices attempt to maximize jointstability via attachment of the TFCCor capsule through holes in the im-plant. Notably, total ulnar head ar-throplasty requires some contribu-tion from native tissues for stabilitybecause the implant has no intrinsicmechanism to stabilize the DRUJ.

At a mean follow-up of 54.3months, Yen Shipley et al44 reporteda 1.68-point improvement in visualanalog pain score and good modi-fied Mayo wrist scores, regardlesswhether the procedure was per-formed in a primary or revision set-

ting. Three of 22 wrists requiredrevision, 2 because of persistentsymptomatic instability and 1 be-cause of implant breakage followinga fall. Mayo scores were good in twoand excellent in one of the patientswho required revision. Two otherwrists demonstrated asymptomaticinstability.

Total DRUJ ArthroplastyTotal DRUJ implant arthroplasty isindicated in the setting of incompe-tent native soft tissues and offers asalvage option for the multiply oper-ated failed distal ulnar resection (Fig-ure 11). Several total DRUJ replace-ments exist, but to our knowledge,only two are available in the UnitedStates.46-48 Although there are indi-vidual differences, total DRUJ re-placements are differentiated fromall other designs because the entirety

of the DRUJ, including its stabilizingmechanisms, is replaced by the im-plant, obviating the need for nativesoft-tissue support. This is an in-triguing idea, especially given thecommon clinical finding of incompe-tent and nonreconstructible nativesoft tissues in the salvage setting.Some early total DRUJ implantswere problematic because of implantloosening, specifically along the in-tramedullary ulna stem; however,this problem has not been noted con-sistently with more recent designsand in more recent studies.47-49 Re-cent work has documented pre-served postoperative grip and pinchstrength as well as ROM, in additionto reduced pain and improved Dis-abilities of the Arm, Shoulder, andHand and subjective questionnairescores in patients undergoing totalDRUJ replacement.46-49

Scheker48 reported on 49 patientswho underwent total DRUJ arthro-plasty. At a minimum 2-year follow-up, average postoperative gripstrength was 63.4% of the contralat-eral side, lifting ability increasedfrom 1.2 to 5.3 kg (2.6 to 11.6 lb),and the visual analog pain score fellfrom 3.8 to 1.3. At final follow-up,mean pronation was 79° and meansupination was 72°. Six complica-tions were noted: two superficial in-fections, two episodes of ECU teno-synovitis, one case of ectopic boneformation at the distal ulna, and oneinstance of transient bone resorp-tion.

Most total DRUJ arthroplastieshave been performed secondary tofailed resection arthroplasty. How-ever, some surgeons have used it tomanage congenital conditions, spe-cifically in the setting of Madelungdeformity.50

Other Salvage OptionsSeveral alternatives exist for manag-ing complex and refractory DRUJ

AP radiograph demonstrating totalulnar head replacement using theHerbert Ulnar Head Prosthesis(KLS Martin Group, Tuttlingen,Germany). (Reproduced withpermission from Herbert TJ, vanSchoonhoven J: Ulnar headreplacement. Tech Hand UpExtrem Surg 2007;11[1]:98-108.)

Figure 10

AP radiograph demonstrating totaldistal radioulnar joint (DRUJ)replacement using the Aptis DRUJprosthesis (Aptis Medical,Glenview, KY).

Figure 11



pathology. Wolfe et al51 performedwide excision of the distal ulna (ie,25% to 50%) to manage failed re-section arthroplasty. Outcomes werepositive in 83% of patients, includ-ing preserved strength, which is sur-prising given the load-bearing role ofthe DRUJ.

Perhaps the ultimate alternative forforearm instability is radioulnarsynostosis (RUS), or creation of aone-bone forearm (OBF). First de-scribed by Hey Groves52 in 1921,RUS is done in an attempt to trans-form a painful, unstable forearm intoa painless, stable one by eliminatingforearm rotation. In a small series,patients who underwent posttrau-matic OBF creation had decreasedpain and preserved strength.53 How-ever, results were more varied forRUS performed for nontraumaticconditions; multiple prior procedureswere identified as one risk factor fora poor outcome after creation of anOBF.54

Authors’ PreferredTreatment Algorithm

At our institution, management be-gins with a thorough history andphysical examination. Particular at-tention is paid to provocative physi-cal examination maneuvers, includ-ing the shuck and press tests toassess for instability and arthrosis ofthe DRUJ.

Meticulous care is required to pre-serve soft-tissue stabilizers duringany procedure involving the DRUJ.Currently, we reserve the Darrachprocedure for elderly, low-demandpatients because outcomes foryounger, active patients appear to usto be less favorable. Initial surgicalmanagement typically consists of ei-ther a Sauvé-Kapandji procedure orHIT for young patients, based onwhether the TFCC is ruptured or in-tact, respectively. For management of

distal ulnar stump instability, we pre-fer ECU-FCU tenodesis with con-comitant repair of amenable soft tis-sues or capsulorrhaphy. We prefertotal DRUJ arthroplasty for recalci-trant instability and for patients whopresent with multiple prior proce-dures and incompetent soft tissues.We have had favorable postoperativeoutcomes with this technique.

Summary

Our understanding of the DRUJ hasadvanced significantly in recentyears. The DRUJ is critical in bothforearm rotation and weight bearing,and its stability relies on soft-tissuesupport. The biomechanics of thisstructure are complex, and recon-struction is challenging. DRUJ pa-thology is a common cause of ulnar-sided wrist pain and is often notedfollowing distal radius fracture. Re-section arthroplasty remains a main-stay for managing symptomaticDRUJ arthrosis, although instabilityof the residual ulnar stump is a prob-lematic complication. Multiple pro-cedures exist to manage failed resec-tion arthroplasty, including novelDRUJ implant arthroplasties. Initialresults with these devices have beenfavorable, but further research isneeded to assess long-term outcomes.

References

Evidence-based Medicine: Levels ofevidence are described in the table ofcontents. In this article, references12, 28, and 37 are level III studies.References 13, 16, 22-27, 30-36, 38-40, 42-51, 53, and 54 are level IVstudies.

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