DEFINITION

The distal ulna resection attributed to Dr. William Darrach was described by Severinus in 1644, Rognetta in 1834, and Dupuytren in 1839.13 Malgaine in 1855 and Moore in 1880 also described distal ulna

resections.9 Dr. William Darrach described the distal ulna resection that bears his name in 1912 and 1913 for the treatment of a posttraumatic volar distal radioulnar joint (DRUJ) dislocation. This operation continues to have a place for the treatment of a variety of afflictions of the DRUJ.

In an effort to preserve some of the critical stabilizing soft tissue elements of the distal ulna, alternative treatments to complete ablation of the distal ulna have been developed.

Bowers2 published his results of the hemiresection interposition technique (HIT). This procedure differs from the Darrach in that the weight-bearing seat and pole are resected, preserving the styloid and soft tissue elements of the triangular fibrocartilage (TFC).

Watson and Gabuzda24 and Watson et al25 advocated the matched resection procedure.

The essential element is matching the profile of the resected distal ulna to the medial side of the radius.

 

 

ANATOMY

 

The DRUJ is formed by the articulation between the sigmoid notch and the head of the ulna (FIG 1A,B). The sigmoid notch is the articular cartilage surface on the medial aspect of the distal radius. This concave surface matches the corresponding convex surface or “seat” of the distal ulna. The arc of curvature of the sigmoid notch ranges between 47 and 80 degrees, with an average radius of 12 to 18 mm.

 

 

 

FIG 1 • Diagrammatic representations of the bony anatomy (A) and relationship of the radius and ulna at the DRUJ (B). C. Soft tissue elements of the DRUJ, including the deep (ligamentum subcruentum) and superficial peripheral attachments of the TFC.

 

 

The articulation is constrained loosely, allowing both forearm rotation through a 150-degree arc and proximal and distal migration as well as dorsal and palmar translation of the ulna relative to the radius during forearm rotation. The articular cartilage-covered “cap” of the distal ulna can be divided into two functional regions. The

seat of the ulna is the concave portion that articulates with the sigmoid notch. The arc of curvature ranges between 90 and 135 degrees, with an average radius of 8 to 13 mm. This region is covered by articular cartilage around 270 degrees of its surface. This is the region that supports the compressive loads of the distal radius during most activities of daily living and can be considered the fulcrum for load support.

 

The pole is the distal portion of the ulna that lies deep to the cartilaginous TFC. This region supports the centrum of the TFC as compressive loads pass from the ulnar carpus to the bony elements of the forearm. The medial distal portion of the ulna projects as the ulnar styloid. The base of the styloid contains the critical attachment of the deep layer of the TFC, the ligamentum subcruentum (FIG 1C).

 

 

Distal to this, and in a more peripheral location, is the attachment of the superficial layer of the TFC. The dorsal and volar portions of the TFC are thickened, forming the limbi of the TFC, the volar and dorsal radioulnar ligaments. These ligaments play critical roles in stabilizing the DRUJ.

 

PATHOGENESIS

 

Conditions that cause DRUJ degenerative change or altered DRUJ mechanics can lead to pain and DRUJ dysfunction. Most commonly, distal ulna resection is performed in

 

P.1008

patients with inflammatory arthropathy, usually rheumatoid arthritis. Frequently, treatment of the DRUJ is performed in conjunction with other bone or soft tissue reconstructions.

 

DRUJ instability secondary to trauma or attritional changes of the supporting soft tissue elements can lead to degenerative change of this articulation.

 

Malunions of the distal radius can negatively affect the sigmoid notch by alterations in angulation or length and can disrupt DRUJ kinematics.

 

A less common cause of DRUJ arthritis is primary osteoarthritis, which may also lead to osteophytes and loose bodies.

 

Developmental conditions, such as Madelung deformity, can alter DRUJ joint mechanics. Painful forearm rotation and degenerative changes as well as ulnar impaction can develop.

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

Patients with DRUJ problems present with pain and limited forearm rotation.

 

 

In isolated DRUJ arthrosis, the patients usually localize their pain at the DRUJ articulation.

 

In patients with concomitant associated pathology of the soft tissue elements and DRUJ stabilizers, the ulnar-sided pain is more diffuse.

 

Pain occurs with activities that require forearm rotation, such as turning doorknobs, turning keys in locks, starting a car, and opening jars. Lifting activities with the arm away from the body are difficult because the DRUJ is loaded in this position.

 

Limited forearm motion may be secondary to an arthritic DRUJ; however, other conditions (eg, capsular contracture) must be considered.

 

Prominence and deformity of the distal ulna is common in patients with inflammatory changes and in patients with distal radius fracture malunions.

 

Inspection is usually unremarkable in patients with isolated DRUJ osteoarthritis. In contrast, DRUJ deformity and

prominence is common in patients with rheumatoid arthritis.19 Fullness due to synovial proliferation may be visible and secondary attritional changes of surrounding soft tissue elements, such as extensor tendon rupture,

can lead to abnormal hand posture.

 

Radius malunions with shortening and angulation produce visible prominence of the distal ulna (FIG 2).

 

Tenderness with pressure on the dorsal aspect of the DRUJ is frequently elicited. In patients with associated impaction or TFC pathology, tenderness may be more diffuse. Palpable crepitance with rotation is often present. Compressing the distal ulna into the sigmoid notch while rotating the forearm elicits painful crepitation and is suggestive of arthrosis.

 

Pain on the ulnocarpal stress test is indicative of TFC pathology.

 

Pain on application of pressure in the interval between the ulnar styloid and flexor carpi ulnaris tendon is indicative of TFC or capsuloligamentous pathology (foveal sign).22

 

Piano key maneuver: Visible dorsal winging or instability of the distal ulna is noted. If the ulna is dorsally prominent, the examiner can manually reduce the ulna into the sigmoid notch. The ulna spontaneously dorsally subluxates when pressure is removed. Winging is associated with loss of structural support of the DRUJ.

 

Grip strength is frequently limited secondary to painful compressive loading of the DRUJ.

 

 

 

FIG 2 • Loss of the soft tissue support with or without associated degenerative change or malunion of the radius with resultant sigmoid notch incongruity leads to dorsal prominence and winging of the ulna relative to the radius.

A. Dorsal prominence of the ulna relative to the radius is seen in a patient with a radius malunion. B. Radiograph of a wrist of a patient with rheumatoid arthritis shows the volar translation and secondary changes in the carpus that are associated with dorsal ulna prominence.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Plain radiographs are usually sufficient to supplement physical examination findings. It is essential to obtain a neutral forearm rotation posteroanterior (PA) and lateral views (FIG 3A) to accurately assess ulnar variance, styloid morphology, inclination of the sigmoid notch, and position of the ulnar styloid. These factors are important in selecting the appropriate surgical management for disorders of the distal ulna.

 

 

 

FIG 3 • A. The zero rotation view is taken with the patient's shoulder abducted at 90 degrees, the elbow flexed 90 degrees, and the wrist pronated in the PA position. The ulnar styloid is seen in full profile in this view. This view is the standard radiographic view used to determine ulnar variance. B. Although not part of the routine imaging evaluation for the TFC, MRI can confirm the diagnosis for related conditions. This MRI in a patient with an ulnar positive wrist shows a discrete intense lesion at the ulnar base of the lunate consistent with ulnar impaction.

 

 

P.1009

 

Thin-section computed tomography (CT) scanning can provide useful additional information about DRUJ articular surfaces and subluxation.

 

Magnetic resonance imaging (MRI) evaluation is rarely necessary to diagnose arthritic disorders of the DRUJ but can be useful when detailed information about the radioulnar ligaments or surrounding bony ligaments of the TFC is necessary (FIG 3B).

 

DIFFERENTIAL DIAGNOSIS

DRUJ arthritis Inflammatory Osteoarthritis

Traumatic

Iatrogenic (eg, altered joint mechanics after ulnar shortening) DRUJ instability

TFC tears

 

Ulnar impaction

Lunotriquetral ligament tears or instability Extensor carpi ulnaris tendinitis

Extensor carpi ulnaris instability Pisotriquetral disorders

Nerve entrapment (canal of Guyon)

Nerve injury (eg, neuromas of dorsal ulnar sensory nerve) Madelung deformity with DRUJ dysfunction

 

 

NONOPERATIVE MANAGEMENT

 

Patients with mild symptoms and minimal functional impairment may be managed with oral anti-inflammatories, intra-articular injections, or splinting.

 

Splinting must include the elbow to eliminate forearm rotation.

 

SURGICAL MANAGEMENT

 

 

Maintaining the distal ulna has gained recent popularity as resection can be associated with considerable postoperative complications and functional disability. Meticulous attention to preoperative, intraoperative, and postoperative detail is essential for a successful result.

 

Adjunctive Procedures

After complete or partial resection of the distal ulna, convergence between the radius and ulna can

develop.14 Loss of the weight-bearing fulcrum of the ulna seat can yield convergence with grip or loaded lifting with the arm extended and the forearm in neutral rotation (FIG 4).

Adjunctive procedures incorporate some type of tendon transfer or interpositional material to stabilize the resected ulnar stump (FIG 5). The pronator quadratus, extensor carpi ulnaris, and flexor carpi ulnaris tendons have been used alone and in combination.

In addition to tendon transfer, some authors have recommended suturing the ulnar capsule to the dorsal

ulnar stump to help stabilize the remaining ulna.21 Kleinman and Greenberg11 advocated use of a dynamic pronator quadratus interosseous transfer in conjunction with an extensor carpi ulnaris distal tenodesis for

failed distal ulna resections. More recently, allograft soft tissue interposition has been advocated12 as well as distal ulna implant arthroplasty.27

Most adjunctive procedures have been described for treatment of a failed symptomatic Darrach procedure; however, they can be incorporated during the initial surgery. Symptomatic convergence tends to develop in a relatively younger, higher demand patient. If distal ulna resection is necessary in this patient population, use of an adjunctive procedure is recommended.

 

FIG 4 • Impingement of the resected distal ulna against the medial wall of the radius is common after distal ulna resection. It can be demonstrated radiographically even in patients who may be asymptomatic after distal ulna resection. Convergence is demonstrated with a weighted PA radiograph. A. Radiograph of a patient who has undergone Darrach resection shows a wide separation between the ulna and radius without external load. B. Significant convergence is noted on a weighted, loaded view.

 

 

 

Preoperative Planning

 

The ideal candidate for a Darrach resection is a patient with a relatively low-demand upper extremity that does not require the load-bearing DRUJ.

 

Coexisting pathology is frequently present in patients with distal ulna dysfunction, especially in patients with inflammatory arthropathy.19 Assessing for associated tenosynovitis and tendon ruptures is necessary.

 

The status of the radiocarpal joint is critical. Patients with loss of radial-sided carpal support due to tenosynovitis often have ulnar translation. In advanced cases, the carpus may abut the distal ulna and isolated Darrach resection without carpal stabilization is contraindicated to avoid exacerbating ulnar translation.

 

 

 

FIG 5 • After resection of the distal ulna, the pronator quadratus muscle has been transferred dorsally through the interosseous space, providing a dynamic interpositional material to help mitigate impingement and dorsal translation of the ulna relative to the radius.

 

 

P.1010

 

If a limited resection of the distal ulna is considered, one must evaluate the length of the ulna, ulnar variance, and position of the styloid. If stylocarpal abutment exists, it will persist after limited resection. Therefore, consideration needs to be given to a joint leveling procedure or styloid recession in conjunction with limited resection.

 

 

Alternatively, a complete distal ulna resection that addresses the ulna head as well as the styloid or a Sauvé-Kapandji DRUJ arthrodesis may be considered.

 

Positioning

 

The patient is positioned supine. The operative arm is extended with the shoulder abducted at 90 degrees. The arm is supported on a standard table used for upper extremity surgery.

 

A tourniquet is used.

 

The motion of the elbow and shoulder should be noted before surgery. Limited passive motion can create awkward arm positioning.

 

Approach

 

The incision used for distal ulna resection is based on whether the resection is performed alone or in conjunction with other procedures (FIG 6).

 

The recommended approach for distal ulna resections is dorsal, deep to the fifth extensor compartment.

 

 

 

FIG 6 • Options for incisions when approaching the DRUJ and TFC. The longitudinal incision is frequently used in patients undergoing complex reconstructions involving the DRUJ and radiocarpal or midcarpal joint. This incision is also recommended in patients requiring extensor tendon reconstruction in conjunction with treatment of the DRUJ. The chevron incision, with its distal limb paralleling the dorsal sensory branch of the ulnar nerve, is recommended for isolated arthroplasty of the DRUJ.

 

 

A medial approach between the extensor carpi ulnaris and flexor carpi ulnaris tendons is not recommended. This approach has greater potential for disrupting the linea jugata, with resultant potential extensor carpi ulnaris destabilization.

 

 

TECHNIQUES

• Complete Distal Ulna Resection: The Darrach Procedure

Incision and Dissection

Frequently, Darrach resection is performed in conjunction with other procedures, especially in patients with inflammatory arthropathies. In this situation, the surgical incision is usually dorsal midline longitudinal, which enables all aspects of the wrist reconstruction (wrist fusion, arthroplasty, tenosynovectomy, tendon transfer, etc.) to be completed via a single approach.

If the Darrach procedure is to be performed independently, a single oblique or chevron dorsal approach is made (see FIG 6) overlying the fifth dorsal compartment.

During the dissection to the retinacular layer, take care to avoid injury to the transverse retinacular branch and dorsal sensory branch of the ulnar nerve that pass from the medial forearm to the dorsal hand between the ulnar styloid and pisiform (TECH FIG 1A).

Keep the oblique incision or distal limb of the chevron approach parallel to this nerve to minimize this complication.

Frequently, dorsal capsular reinforcement is necessary after distal ulna resection. This is especially true in patients with inflammatory arthropathies and multiple extensor tendon ruptures.

When performed in conjunction with other procedures, raise opposing extensor retinacular flaps so that

one of the flaps can be used to reinforce the dorsal capsule and create a stabilizing extensor carpi ulnaris sling during closure (TECH FIG 1B,C).

 

When performed as an isolated procedure, raise a retinacular flap from the margin of the fourth dorsal compartment (TECH FIG 1D).

Capsulotomy and Osteotomy

 

Perform a longitudinal capsulotomy deep to the fifth dorsal compartment (TECH FIG 2A). This capsular approach starts proximal to the dorsal radioulnar ligament and proceeds in a proximal direction.

 

Extend the capsular release parallel and just proximal to the dorsal radioulnar ligament to facilitate exposure. Take

 

P.1011

care during the deep periosteal dissection to elevate and maintain as thick a periosteal sleeve as possible.

 

 

 

 

TECH FIG 1 • A. The dorsal sensory branch of the ulnar nerve, held in the retractor, passes from volar to dorsal just distal to the head of the ulna. It is vulnerable in all approaches to the DRUJ and TFC and should be protected. (continued)

 

 

TECH FIG 1 • (continued) B,C. Opposing retinacular flaps are raised to provide wide exposure and access to all extensor compartments. This approach is frequently necessary in patients with concomitant extensor tendon dysfunction. One of the flaps can then be used to reinforce the capsule deep to the extensors at the termination of the procedure. D. The fifth compartment is opened, exposing the EDQP tendon. An ulnarly based retinacular flap is raised, preserving the wall of the fourth dorsal compartment for later repair. All figures in the technique section are oriented as follows: fingers to the left and elbow to the right.

 

 

Osteotomize the distal ulna using a power oscillating saw just proximal to the sigmoid notch (TECH FIG 2B). Enough ulna is sacrificed to completely decompress the DRUJ. Keep resection to 2 cm or less.

 

 

 

TECH FIG 2 • A. A longitudinal capsulotomy exposes the distal ulna (arrow) and allows access to the distal metaphysis, depending on the reconstruction being performed. B. The distal ulna has been osteotomized just proximal to the sigmoid notch. The resection should be less than 2 cm and should clear all abnormal bony elements that may affect rotation from within the sigmoid notch.

 

 

Intraoperative fluoroscopic guidance is frequently helpful to assist with the location of the osteotomy.

 

Once the distal pole and seat are resected, there is no advantage to preserving the ulnar styloid, and the entire styloid should be removed with the distal ulna.

 

 

P.1012

 

 

 

TECH FIG 3 • A. Closure is performed (arrow), leaving the EDQP superficial to the retinaculum. B. In another example, both retinacular flaps have been closed deep to the EDQP but superficial to the other extensors. If capsular reinforcement is necessary, the distal flap can be closed deep to the extensors. The ulnar portion of the proximal radially based flap is used to reinforce the sixth dorsal compartment.

Wound Closure

 

Meticulous attention to closure is imperative.

 

Perform a secure multilayered closure. Perform separate closure of the periosteal and capsular layers with nonabsorbable sutures.

 

Suture the retinacular flaps for capsular reinforcement.

 

Transpose the extensor digiti quinti proprius (EDQP) tendon dorsal to the extensor retinaculum. This does not create any functional disability (TECH FIG 3).

 

Routine skin closure follows.

• Distal Ulna Hemiresection Interposition Technique

   

  The surgical approach for the HIT procedure as developed by Bowers is identical to the Darrach resection. The difference lies in the treatment of the bone and soft tissue interposition after bone resection.

   

  Instead of resecting the distal ulna at the proximal margin of the sigmoid notch, the osteotomy removes the seat and pole of the ulnar head (TECH FIG 4A,B). The entire shaft and the styloid are left intact.

   

  After resection, the forearm is rotated through a full arc. This ensures that prominent osteophytes or bone that may interfere with forearm rotation have been removed.

   

  The resected shaft should be round in cross-section and should taper distally. The resection is lateral to the insertion of the deep portion of the TFC, so the integrity of both the deep and superficial components of the TFC is maintained. If the TFC is incompetent or cannot be made functionally competent by reconstruction, then there are no advantages over the Darrach complete distal ulna resection.

   

   

   

  TECH FIG 4 • A. The level of osteotomy for the HIT procedure is marked before osteotomy. B. This osteotomy eliminates the entire ulnar head but leaves the attachments of the TFC intact. (continued)

   

   

  P.1013

   

   

   

  TECH FIG 4 • (continued) C. After osteotomy and removal of the ulnar head, the space is filled with a free tendon graft that provides bulky tissue and mitigates impingement of the resected ulna against the medial wall of the distal radius.

   

  Convergence of the radius and ulna develops after ulnar head resection. To mitigate this, the ulnarly based capsular flap raised during the approach is interposed between the radius and resected ulna. Interposition bulk may be increased by using a free tendon graft (TECH FIG 4C).

  Modification

   

   

  In an effort to avoid an interpositional tendon graft, Adams1 advocates a modification of the HIT procedure.

   

  In this technique, an ulnar-based retinacular flap is raised from the radial margin of the extensor carpi ulnaris sheath.

   

  Only 3 to 7 mm of bone is resected, and the ulna is tapered distally in a dowel shape. The fovea is not violated, thereby preserving all TFC attachments.

   

  The retinacular flap is then interposed and sutured to the volar DRUJ capsule. As in other procedures, attention is paid to avoid stylocarpal impingement.

• Matched Distal Ulna Resection

 

In this modification, developed by Watson, the distal ulna is resected in a long, sloping convex curve that matches the opposing concave radius (TECH FIG 5).

 

The surgical approach is identical to the approaches listed for prior procedures. Although Watson advocated a transverse incision just proximal to the DRUJ, I prefer a more utilitarian longitudinal or chevron incision as previously described.

 

The entire 270-degree arc of the ulna is addressed. Similar to the HIT procedure, great care is taken after bone resection to ensure full, unimpeded forearm rotation. Any osteophytes or prominent bone that may interfere with rotation must be removed.

 

 

 

TECH FIG 5 • The matched resection osteotomy is more proximal than the Bowers osteotomy (A) and is resected in a long, sloping curve matching the opposite concave surface of the radius through a complete 270-degree arc (B).

 

 

This technique differs from the HIT procedure because the ulna is reshaped over a longer distance and no interposition material is used. Although this technique is advocated to preserve the ulnar sling, by necessity, the resection sacrifices both the deep and superficial insertions of the TFC. Any resultant stability of the residual stump of the ulna is generated only by soft tissue scarring.

 

 

P.1014

 

PEARLS AND PITFALLS

 

	Indications ▪ Consider distal ulna resection as a final salvage procedure. Consider alternative procedures that will preserve the loadbearing fulcrum of the DRUJ. Distal ulna resections are tolerated in a relatively older, lower demand patient.     Associated ▪ Diagnose and treat associated bone and soft tissue pathology. Consider the conditions effects of distal resection on the radiocarpal joint.     Approach ▪ Meticulous attention to soft tissue handling and avoiding injury to cutaneous nerves is essential. Raise retinacular and capsular flaps carefully so they can be used for stabilization or interposition if necessary. Avoid destabilizing the extensor carpi ulnaris. If the extensor carpi ulnaris sheath is violated and stability needs to be restored, reconstruct the sheath using retinacular flaps.     Bone ▪ Decompress the entire length of the sigmoid notch when performing a Darrach resection resection. Avoid removing the insertions of the TFC during the HIT procedure. Ensure that full forearm rotation is possible after bone resection. Similarly, after partial distal ulna resection, eliminate any remaining osteophytes or bony prominences to ensure full range of motion. Assess for postresection stylocarpal impingement and correct length if impingement is present.     Convergence ▪ Consider additional procedures that may stabilize or prevent symptomatic and convergence and impingement, especially in the younger, more active, higher instability demand patient.     Aftercare ▪ Maintain neutral forearm rotation with a long-arm or Munster-type splint for the first 3 postoperative weeks. Allow gentle forearm rotation until 6 weeks postoperatively. Full activity is allowed at 3 months postoperatively.

 

 

POSTOPERATIVE CARE

 

Postoperatively, the extremity is maintained in a long-arm bulky dressing with the elbow at 90 degrees and the forearm supinated for 3 weeks. At 3 weeks postoperatively, long-arm splintage between exercises and at night begins and persists until 6 to 8 weeks postoperatively. Strengthening without splint immobilization can begin at that time.

 

OUTCOMES

In general, distal ulna resections are associated with relief of pain and restoration of function. Elderly patients with lower demands on the upper extremities tend to have more favorable results than younger, active, higher demand patients.

Good results regarding relief of pain and recovery of function can be expected in 60% to 95% of patients

with rheumatoid arthritis.4 Early clinical reports on the Darrach resection demonstrated marked improvement in pain and range of motion in greater than 80% of patients; however, other series do not present such optimistic clinical results. Two reviews describe improved functional results in patients undergoing distal ulna resections; however, caution is advised regarding patient selection and potential

 

postoperative complications.18,30

 

Leslie et al13 in 1990 and Melone and Taras15 in 1991 demonstrated 85% and 86% favorable results,

respectively. Fraser et al's6 1999 study supported the use of the Darrach resection in patients with rheumatoid arthritis, finding 85% good to excellent results in 23 patients with rheumatoid arthritis versus only 36% satisfactory results in 27 patients with posttraumatic arthritis.

 

Despite significant attrition within their patient cohort, Grawe et al9 demonstrated satisfactory functional, subjective, and objective long-term (13-year average follow-up) results in a group of patients that had Darrach resections in conjunction with wrist trauma. Interestingly, half of the patients demonstrated dynamic radioulnar convergence.

 

Yoneda and Watanabe28 used the Darrach distal ulna resection as primary treatment for a comminuted distal ulna fracture in conjunction with distal radius fractures. This study evaluated 23 patients older than 70 years old. They concluded that a primary Darrach resection in this clinical situation was an effective treatment alternative. Reduction of pain and improvement in forearm rotation after trauma was also

demonstrated by De Witte et al,5 even though some patients in this cohort still had pain after the procedure.

 

George et al7 demonstrated satisfactory results in 21 patients treated with Darrach resections compared to a group who underwent Sauvé-Kapandji resection. They concluded that results were comparable and unpredictable. Despite reported complications, authors have advocated the use of the Darrach resection for patients with rheumatoid arthritis, emphasizing attention to correct technique as a critical factor in the

procedure's success.10,16

 

Compiled results using the HIT procedure for a variety of afflictions indicate that 76% of patients are pain-free and 24% report mild pain.3,8,17,29

 

Minami et al16 demonstrated better clinical outcomes using the HIT or Sauvé-Kapandji procedure than the Darrach procedure in 61 patients with osteoarthritis. This study supports the use of the Darrach procedure

for the lower demand, elderly patient. Van Schoonhoven and Lanz23 advocate use of partial resection of the ulnar head in cases of instability or radial malunion associated with arthrosis. These authors feel that maintaining the remaining contact of the TFC adds a biomechanical advantage to prevent secondary problems after resection.

 

Two publications on the matched resection report good to excellent results in 24 of 32 patients with posttraumatic or mechanical disorders of the DRUJ24 and no or mild pain in 44 patients, most with rheumatoid arthritis.25 Weinzweig and Watson26 report excellent results in their entire series of 97 wrists

over 21 years. Pain was improved in 14 of 15 patients with rheumatoid arthritis in Srikanth et al's20 clinical study.

 

 

P.1015

 

COMPLICATIONS

Persistent pain

Distal ulnar stump instability (coronal, sagittal) Radioulnar impingement

Loss of forearm rotation

 

Ulnar translation due to loss of ulnar support in rheumatoid arthritis Extensor tendon rupture

Soft tissue irritation Cutaneous nerve injury Stylocarpal impingement

Complex regional pain syndrome

Extensor carpi ulnaris tendinitis or instability

 

 

REFERENCES

1. Adams BD. Distal radioulnar joint instability. In: Green DP, Hotchkiss RN, Pederson WC, et al, eds. Green's Operative Hand Surgery, ed 5. Philadelphia: Churchill Livingstone, 2005:605-644.

    

    

2. Bowers WH. Distal radioulnar joint arthroplasty: the hemiresection-interposition technique. J Hand Surg Am 1985;10(2):169-178.

    

    

3. Bowers WH, Zelouf DS. Treatment of chronic disorders of the distal radioulnar joint. In: Lichtman DM, Alexander AH, eds. The Wrist and Its Disorders, ed 2. Philadelphia: WB Saunders, 1997:429-441.

    

    

4. De Smet L. The distal radioulnar joint in rheumatoid arthritis. Acta Orthop Belg 2006;72:381-386.

    

    

5. De Witte PB, Wijffels M, Jupiter JB, et al. The Darrach procedure for post-traumatic reconstruction. Acta Orthop Belg 2009;75: 316-322.

    

    

6. Fraser KE, Diao E, Peimer CA, et al. Comparative results of resection of the distal ulna in rheumatoid arthritis and post-traumatic conditions. J Hand Surg Br 1999;24(6):667-670.

    

    

7. George MS, Kiefhaber TR, Stern PJ. The Sauvé-Kapandji procedure and the Darrach procedure for distal radioulnar joint dysfunction after Colles' fracture. J Hand Surg Br 2004;29(6):608-613.

    

    

8. Glowacki KA. Hemiresection arthroplasty of the distal radioulnar joint. Hand Clin 2005;21:591-601.

    

    

9. Grawe B, Heincelman C, Stern P. Functional results of the Darrach Procedure: a long-term outcome study. J Hand Surg Am 2012;37(12): 2475-2480.

    

    

10. Greenberg JA. Resection of the distal ulna: the Darrach procedure. Hand Clin 2000;5:19-30.

     

     

11. Greenberg JA, Kleinman WB. Salvage of the failed Darrach procedure. In: Gelberman RH, ed. Master Techniques in Orthopaedic Surgery: The Wrist, ed 2. Philadelphia: Lippincott Williams & Wilkins, 2002:331-337.

     

     

12. Greenberg JA, Sotereanos D. Achilles allograft interposition for failed Darrach distal ulna resections. Tech Hand Upper Extrem Surg 2008;12:121-125.

     

     

13. Leslie BM, Carlson G, Ruby LK. Results of extensor carpi ulnaris tenodesis in the rheumatoid wrist undergoing a distal ulnar excision. J Hand Surg Am 1990;15(4):547-551.

     

     

14. McKee MD, Richards RR. Dynamic radio-ulnar convergence after the Darrach procedure. J Bone Joint Surg Br 1996;78(3):413-418.

     

     

15. Melone CP Jr, Taras JS. Distal ulna resection, extensor carpi ulnaris tenodesis, and dorsal synovectomy for the rheumatoid wrist. Hand Clin 1991;7:335-343.

     

     

16. Minami A, Iwasaki N, Ishikawsa J, et al. Treatments of osteoarthritis of the distal radioulnar joint: long-term results of three procedures. Hand Surg 2005;10:243-248.

     

     

17. Minami A, Kaneda K, Itoga H. Hemiresection-interposition arthroplasty of the distal radioulnar joint associated with repair of triangular fibrocartilage complex lesions. J Hand Surg Am 1991;16(6):1120-1125.

     

     

18. Murray PM. Current concepts in the treatment of rheumatoid arthritis of the distal radioulnar joint. Hand Clin 2011;27:49-55.

     

     

19. Papp SR, Athwal GS, Pichora DR. The rheumatoid wrist. J Am Acad Orthop Surg 2006;14:65-77.

     

     

20. Srikanth KN, Shahane SA, Stilwell JH. Modified matched ulnar resection for arthrosis of distal radioulnar joint in rheumatoid arthritis. Hand Surg 2006;11:15-19.

     

     

21. Syed AA, Lam WL, Agarwal M, et al. Stabilization of the ulna stump after Darrach's procedure at the wrist. Int Orthop 2003;27:235-239.

     

     

22. Tay SC, Tomita K, Berger RA. The “ulna fovea sign” for defining ulna wrist pain: an analysis of sensitivity and specificity. J Hand Surg Am 2007;32(4):438-444.

     

     

23. Van Schoonhoven J, Lanz U. Salvage operations and their differential indications for the distal radioulnar joint [in German]. Orthopade 2004;33:704-714.

     

     

24. Watson HK, Gabuzda GM. Matched distal ulna resection for posttraumatic disorders of the distal radioulnar joint. J Hand Surg Am 1992;17(4):724-730.

     

     

25. Watson HK, Ryu JY, Burgess RC. Matched distal ulnar resection. J Hand Surg Am 1986;11(6):812-817.

     

     

26. Weinzweig J, Watson HK. Matched ulnar resection arthroplasty. In: Gelberman RH, ed. Master Techniques in Orthopaedic Surgery: The Wrist, ed 2. Philadelphia: Lippincott Williams & Wilkins, 2002: 355-361.

     

     

27. 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;32(2):177-189.

     

     

28. Yoneda H, Watanabe K. Primary excision of the ulnar head for fractures of the distal ulna associated with fractures of the distal radius in severe osteoporotic patients. J Hand Surg Eur Vol 2014;39(3):293-299.

     

     

29. Zelouf DS, Bowers WH, Osterman AL. Distal radioulnar joint reconstruction: hemiresection-interposition technique and Sauvé-Kapandji. In: Katzman B, Feldon P, eds. Rheumatoid Arthritis of the Wrist (Atlas of the Hand Clinics). Philadelphia: WB Saunders, 2005:319-325.

     

     

30. Zimmerman RM, Kim JM, Jupiter JB. Arthritis of the distal radioulnar joint: from Darrach to total joint arthroplasty. J Am Acad Orthop Surg 2012;20:623-632.