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Salvage Procedures for the Distal End of the Ulna: There Is No Magic

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Salvage Procedures for the Distal End of the Ulna: There Is No Magic PINNACLE SERIES William B. Kleinman, MD on Salvage Procedures for the Distal End of the Ulna: There Is No Magic Abstract as the “quick fix” for painful arthritis or instability at the Resection of the distal end of the ulna is not a DRUJ.5-8 But the implications of surgical resection of the benign procedure; nor is it a panacean surgical distal ulna are considerable. treatment of disorders at the distal radioulnar and First and foremost is for us to appreciate that we are ulnocarpal joints. bipedal human beings. Most of our upper extremity activi- Over the past 96 years, since Darrach first ties of daily living are performed while standing or sitting, described his classic procedure, many authors with our hinged elbows flexed, and our hand–forearm have warned surgeons of the consequences of units positioned as in Figure 1. The humerus is adducted, the Darrach resection. For salvag- the elbow is flexed, and the forearm is ing the persistently painful distal in neutral (“zero”)9 radioulnar rotation. forearm after Darrach resection, The forearm parallels the ground, with researchers have recommended “For salvaging the alignment of the hand–forearm unit a spectrum of possible surgical perpendicular to the force of gravity options. Each has its advantages persistently painful acting on the hand and its contents. The and disadvantages; none substi- distal forearm after ginglymus elbow ulnotrochlear joint tutes completely for the painless, does not participate in forearm rota- load-bearing capacity of a healthy Darrach resection, tion. The rotating radius–carpus–hand distal radioulnar joint. Resection of unit rests on top of the ulna, with the the seat of the distal ulna eliminates researchers have fulcrum for load transfer at the DRUJ the fulcrum of the ulna through recommended being the intra-articular seat of the dis- which load is transferred from the tal head of the ulna. In equilibrium, the hand to the forearm. a spectrum of moments (length [L] × force [F]) distal At this time, there is still and proximal to the DRUJ fulcrum no surgical “magic” available possible surgical must be equal (≡). The length of the to the reconstructive surgeon for options. ” forearm multiplied by the restraining salvaging normal use of the upper forces that proximally hold the radial limb after failed Darrach resection. head at the elbow (eg, the annular liga- ment) must equal (≡) the load carried or almost a century, functionally incapacitating dis- by the hand, multiplied by the distance of the handheld orders at the distal end of the ulna have been treated load from the DRUJ fulcrum (F×L ≡ F'×L'). The total load with simple resection of the ulna head,1 a surgical borne by the seat of the ulna at the sigmoid notch of the Fprocedure described by Darrach in 1912 for a single radius (the DRUJ joint reaction force) equals the sum of case of chronic volar dislocation of the distal radioulnar the moments distal and proximal to the DRUJ. The joint joint (DRUJ).2-4 The Darrach resection has certainly stood reaction force can easily reach 6 to 8 times body weight the test of time; it is used commonly and internationally when sufficient weight is supported by the hand!1,10,11 My focus in this article is on why these elementary Dr. Kleinman is Senior Attending Surgeon at The Indiana Hand principles of physics must be remembered when con- Center, and Clinical Professor of Orthopedic Surgery, Indiana sidering traditional Darrach resection for our patients University School of Medicine, Indianapolis, IN. with painful injury or disease at the DRUJ. Address correspondence to: William B. Kleinman, MD, The Indiana Hand Center, 8501 Harcourt Rd, Indianapolis, IN The Basic Darrach Philosophy 46260 (tel, 317-471-4336; fax, 317-872-1578). The basic Darrach philosophy has certainly stood the Am J Orthop. 2009;38(4):172-180. Copyright, Quadrant test of time since 1912 (Figure 2). Resecting the entire HealthCom Inc. 2009. All rights reserved. head of the distal ulna accomplishes decompression 172 The American Journal of Orthopedics® W. B. Kleinman Figure 1. Ulna seat (yellow arrow at distal radioulnar joint) is Figure 3. Radiograph of dis- Figure 4. Zero-rotation radio- fulcrum for load transfer from hand through forearm. In equi- tal forearm shows overzeal- graph shows radioulnar (R-U) librium, moment distal to fulcrum (force [F] × length [L]) must ously performed Darrach impingement 6 weeks after equal (≡) moment proximal to fulcrum (F'×L'). resection. The osteotomy Darrach resection. Lateral should remove the ulna border of osteotomized ulna head at a level that effec- impinges mechanically against tively clears the sigmoid, medial border of radius, poten- and not much more. In this tially causing painful crepitus, example, the ulna is 1 cm clicking, or locking of forearm too short. rotation. impingement (grinding contact) between the resected distal ulna and the medial border of the radius, result- ing in pain and the potential for decreased strength. In a landmark 1973 article, Rana and Taylor19 reported that 25% of their long-term follow-up patients complained of distal ulna clicking against the radius during forearm rotation, each with resection of more than 3.5 cm of dis- tal ulna. Hartz and Beckenbaugh20 reported that 30.6% Figure 2. Schematic of classic Darrach resection shows com- plete removal of ulna head, including seat (at distal radioulnar of their higher demand, posttrauma Darrach resections joint) and pole (distal, at triangular fibrocartilage complex). suffered from mechanical symptoms of impingement Copyright 2009, Indiana Hand Center. during forearm rotation at long-term follow-up (Figure 4). It seems, from my experience and from many com- of a painful ulnocarpal joint; elimination of a painful pelling reports in the orthopedic/hand literature, that DRUJ; restoration (or maintenance) of forearm rota- a cavalier attitude toward simple surgical elimination tion limited by DRUJ pathology; and improvement in of the DRUJ fulcrum (Figures 1, 2) might represent a strength by pain reduction. The technique as originally fundamental lack of appreciation of DRUJ mechanics. described involves careful subperiosteal dissection, Might the Darrach resection alone be an oversimplified leaving the triangular fibrocartilage complex (TFCC) approach to a rather complex mechanical problem? intact. A sufficient length of distal ulna should be Reported complications of Darrach resection include dorso- resected for the remaining proximal stump to clear the palmar forearm instability; distal radius–carpus–hand sublux- sigmoid notch of the radius, but no more. A secure, ation off the resected distal ulna stump (distal ulna winging); multilayer dorsal closure should be performed. The mechanical symptoms of clicking, catching, and locking; pain procedure seems straightforward (Figure 3) and should and weakness from bone-on-bone contact (impingement); and lead to consistently positive results. progressive medial carpal translation (progressive attenuation Unfortunately, the experience that has been report- of the long radiolunate ligament secondary to absence of ulna- ed over more than 60 years demonstrates less than sided support for the carpus). A surgeon might ask: Is some- excellent patient outcomes through use of the simple thing inherently wrong with the Darrach procedure? Does it Darrach resection.12-18 These reports of suboptimal out- make biomechanical sense? Why have so many complications comes consistently emphasize the postoperative poten- been reported? It is evident that simple surgical removal of the tial for instability (“winging”) of the distal ulna stump ulna seat (the DRUJ fulcrum) by Darrach resection (Figures (ie, volar drift of the radius–carpus–hand off the non- 2, 3) leaves the 2 forearm bones mechanically unsupported rotating postresection ulna), loss of ulna-sided carpal distally, unstable, and subject to any or all of the potential support, TFCC disruption, and postresection mechanical complications just listed. April 2009 173 Salvage Procedures for the Distal End of the Ulna Figure 5. This figure from Bowers’s original article on the Figure 7. “Matched distal ulna resec- Figure 8. Impingement hemiresection interposition technique shows the portion of tion,” in this drawing from Watson’s between radius and the ulna head to be removed for the procedure to be effective. original publication, provides per- ulna can occur after Medial portion of distal ulna is left untouched, preserving integ- fectly paralleling surfaces between “matched” resection. rity of triangular fibrocartilage complex to minimize winging. medial radius and lateral ulna after Will contouring the This figure was published in J Hand Surg Am, Vol. 10, Bowers resection of seat and pole of distal border of the ulna WH, Distal radioulnar joint arthroplasty: the hemiresection-inter- ulna. This figure was published in to perfectly match position technique, 169-178. Copyright Elsevier 1985.21 J Hand Surg Am, Vol. 11, Watson the medial border HK, Ryu J, Burgess R, Matched of the radius ensure distal ulnar resection, 812-817. absence of pain and Copyright Elsevier 1986.31 absence of mechani- cal signs of crepitus, clicking, and catch- ing? load transfer from distal radius to distal ulna in the absence of a diarthrodial DRUJ, Bowers advocated placing rolled- up palmaris longus tendon graft as an interposition buffer between the sigmoid notch and the hemiresected distal ulna (Figure 6). The advantages of the HIT procedure over the Figure 6. According to Bowers, the rolled-up palmaris lon- Darrach resection are that HIT is designed to recreate a ful- gus tendon is an effective shock absorber for load transfer crum for load transfer through a soft-tissue shock absorber between radius and ulna at the distal radioulnar joint in the between the 2 forearm bones; reduces the propensity for low-demand, rheumatoid hand. Bowers suggested that ulna winging by protecting the TFCC; and enhances radio- mechanical impingement could be prevented with use of the ulnar stability by anchoring the dorsal DRUJ capsule to the technique shown in this drawing from his original work.
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