Osteotomy of the ulnar head for ulnar impingement syndrome

Surgical Principles Decompression of the ulnar compartment of the wrist is achieved by increasing the distance between ulnar head and the proximal row of the carpus. It decreases the pressure on the articular disk and on articular cartilage. — A segment of the ulnar head will be removed through 2 parallel, oblique osteotomies. After exact apposition of the fragments, stabilization is obtained using the lag screw principle. This results in an ulnar shortening and a decompression (Figure 1). The congruency of the distal radio-ulnar joint is barely affected by this procedure.     

Outcome Following Acute Primary Distal Ulna Resection for Comminuted Distal Ulna Fractures at the Time of Operative Fixation of Unstable Fractures of the Distal Radius

Optimal acute management of the highly comminuted distal ulna head/neck fracture sustained in conjunction with an unstable distal radius fracture requiring operative fixation is not well established. The purpose of the present study was to determine the clinical, radiographic, and functional outcomes following acute primary distal ulna resection for comminuted distal ulna fractures performed in conjunction with the operative fixation of unstable distal radius fractures. Between 2000 and 2007, 11 consecutive patients, mean age 62 years (range, 30–75) were treated for concomitant closed, comminuted, unstable fractures of the distal radius and ulna metaphysis. All 11 patients underwent distal ulna resection through a separate dorsal ulnar incision with ECU tenodesis following surgical fixation of the distal radius fracture. According to the Q modifier of the Comprehensive Classification of Fractures, there were six comminuted fractures of the ulnar neck (Q3) and five fractures of the head/neck (Q5). Operative fixation of the distal radius fracture included volar plate fixation in four patients and spanning external fixation with supplemental percutaneous Kirschner wires in seven patients. At a mean of 42 months (range, 18–61 months) postoperatively, clinical, radiographic, and wrist-specific functional outcome with the modified Gartland and Werley wrist score were evaluated. At latest follow-up, mean wrist range of motion measured 53° flexion (range, 35–60°), 52° extension (range, 30–60°), 81° pronation (range, 75–85°), and 77° supination (range, 70–85°). Mean grip strength measured 90% of the contralateral, uninjured extremity (range, 50–133%). No patient had distal ulna instability. Final radiographic assessment demonstrated restoration of distal radius articular alignment. According to the system of Gartland and Werley as modified by Sarmiento, there were seven excellent and four good results. No patient has required a secondary surgical procedure. Acute primary distal ulna resection yields satisfactory clinical, radiographic, and functional results in appropriately selected patients and represents a reliable alternative to open reduction and internal fixation when anatomic restoration of the distal ulna/sigmoid notch cannot be achieved. Primary distal ulna resection with distal radius fracture fixation may help avoid secondary procedures related to distal ulna fixation or symptomatic post-traumatic distal radioulnar joint arthrosis.     

单边外固定架治疗合并下尺桡关节脱位的桡骨远端粉碎性骨折

目的：介绍一种手法复位欠佳的桡骨远端粉碎性骨折合并下尺桡关节脱位的治疗方法。方法：用Bastiani外固定架撑开固定,手法复位。结果：复位满意,愈合佳,术后腕关节功能恢复好。结论：应用Bastiani外固定架治疗手术复位欠佳的桡骨远端粉碎性骨折合并下尺桡关节脱位,具有较好疗效。     

改良Kapandji手术在治疗尺桡骨远端陈旧性骨折中的应用

目的：观察应用改良Kapandji手术治疗尺桡骨远端陈旧性骨折的治疗效果。方法：自1996年9月～2001年9月共收治尺桡骨远端陈旧性骨折15例。采用改良Kapandji手术方法以矫正骨折畸形、改良前臂旋转功能。根据术后前臂旋转活动范围、截骨区旋转痛、冲击痛以及手腕部功能和负重情况有无改善等评价其临床效果。结果：13例患者获良好功能恢复，优良率为86．6％。无感染、骨不连等发生。结论：改良Kapandji手术是治疗尺桡骨远端陈旧性骨折伴有前臂旋转痛和功能受限的疗效好、后遗症少的手术方法。     

Reconstruction of the DRUJ in a young adult after resection of a large exostosis of the distal radius

The prevalence of known solitary exostosis is around 1–2 % in the general population. Treatment of an exostosis may consist of resection with or without further treatment for deformity. The distal radioulnar joint (DRUJ) acts as the link between radius and ulna at the wrist and is important in the transmission of load. Its anatomic integrity should be respected in surgical procedures or ulnar-sided wrist pain because of instability, limitation of forearm rotation and potential development of grip weakness may develop. We present a case of reconstruction of the DRUJ with distraction lengthening of the ulna after resection of a large exostosis of the distal radius that had resulted in a malformed and dysplastic ulna. This treatment in a young patient resulted in a stable, functional and congruent distal radioulnar joint.     

桡尺远侧关节稳定性重建手术的生物力学评价

目的比较稳定桡尺远侧关节及尺骨头切除术后残端的几种常用术式的效果,为临床选择术式提供科学依据.方法采用8侧青年男性上肢标本,从生物力学的角度对重建桡尺远侧关节(DRUJ)和尺骨头切除术(RDU)后尺骨残端稳定性的几种术式进行生物力学评价.结果Fulkerson-Watson和Boyes-Bunnell手术对失稳的DRUJ在中立位及旋前位仅有部分稳定作用,在旋后位有显著的稳定作用(P＜0.05);Bunnell和Breen-Jupiter手术仅在旋后位对尺骨切除术后尺骨残端有显著稳定作用(P＜0.05).结论受试的几种术式均不能使DRUJ的稳定性恢复至正常水平.     

Distal radioulnar joint prosthesis for the treatment of giant cell tumor of the distal ulna: a case report and literature review

Giant cell tumor (GCT) of the distal end of the ulna is an uncommon site for primary bone tumors. When it occurs, en-bloc resection of the distal part of the ulna with or without reconstruction stabilization of the ulnar stump is the recommended treatment. We present a case of a 56-year-old man with a GCT of the distal ulna treated successfully with an en-bloc resection of the distal ulna with reconstruction using radioulnar joint prosthesis. Although the experience with this type of treatment is limited, implantation of a metallic prosthesis to replace the distal part of the ulna can also be considered as a salvage procedure for the treatment of this difficult pathology.     

急性桡尺远侧关节脱位的诊治分析

目的:探讨急性桡尺远侧关节脱位的临床特点和治疗方法。方法:桡尺远侧关节脱位患者23例,其中男13例,女10例;年龄28~56岁,平均41岁。Galeazzi骨折18例,单纯桡尺远侧关节脱位5例。尺骨头向掌侧脱位13例,向背侧脱位10例。急性桡尺远侧关节脱位行手法复位,应用克氏针和(或)空心拉力螺钉固定。结果:23例术后随访6~32个月,平均22个月。18例腕痛消失,5例有轻微疼痛及不适。腕关节掌屈(53°±5°),为健侧的(81.5%±5.0%);背伸(51°±8°),为健侧的(83.6%±7.0%);桡偏(13°±4°),为健侧的(76.5%±5.0%);尺偏(27°±6°),为健侧的(77.1%±8.0%);前臂旋前(78°±6°),为健侧的(88.6%±8.0%);旋后(80°±7°),为健侧的(88.8%±7.0%);握力和捏力分别达健侧的(87.5%±6.0%)和(92.0%±7.0%)。20例恢复了原工作,3例改为轻工作。结论:桡尺远侧关节脱位常合并其他损伤,应用空心拉力螺钉或克氏针是治疗急性远侧桡尺关节脱位有效方法之一。     

Tendon Graft—Ulna Fixation in Distal Radio-Ulnar Joint Stabilisation; Biomechanical Comparison of Three Graft-Bone Fixation Methods

A common distal radio-ulnar joint (DRUJ) stabilisation procedure uses a tendon graft running from the lip of the radial sigmoid notch to the ulnar fovea and through a bony tunnel to the ulnar shaft, before being wrapped round the distal ulna and sutured to itself. Such graft fixation can be challenging and requires a considerable tendon length. The graft length could be reduced by fixing the graft to the ulna using a bone anchor or interference screw. The aim of this study was to compare the strength of three distal ulna graft fixation methods (tendon wrapping and suturing, bone anchor and interference screw). Four human cadaveric ulnae were used. A tendon strip was run through a tunnel in the distal ulna and secured by: (1) wrapping round the shaft and suturing it to itself, (2) a bone anchor and (3) an interference screw in the bone tunnel. Load to failure was determined using a custom-made apparatus and an Instron machine. Maximum failure load was highest for the bone anchor fixation (99.3 ± 23.7 N) followed by the suturing (96.2 ± 12.1 N), and the interference screw fixation (46.9 ± 5.6 N). There was no significant difference between the tendon suturing and bone anchor methods, but the tendon suturing was statistically significantly higher compared to the interference screw (P = 0.028). In performing anatomical stabilisation of the DRUJ fixation of the tendon graft to the distal ulna with a bone anchor provides the most secure fixation. This may make the stabilisation technique less demanding and require a smaller tendon graft.     

Repair of chronic subluxation of the distal radioulnar joint (ulnar dorsal) using flexor carpi ulnaris tendon

Chronic dislocation of the distal radio-ulnar joint is usually treated conservatively or by resection of the ulnar head (the Darrach procedure). Recently there has emerged a trend towards reconstructive stabilization procedures, based on modifications of old methods. This article describes a stabilization procedure for correction of chronic subluxation of the distal radio-ulnar joint (ulnar-dorsal) using the flexor carpi ulnaris tendon. A series of five patients is presented together with a historical review of the development of reconstructive approaches in this area.     

Dorsal dislocation of the distal end of the ulna in a judo player.

A 32-year-old policeman injured his left wrist while engaged in judo training. A distal radio-ulnar dislocation, ulna dorsal, was reduced under general anesthesia, but, as the distal radio-ulnar joint was unstable, a Liebolt's ligamentous reconstruction procedure and a partial excision of the triangular fibrocartilage complex were carried out. The patient could resume his job eight weeks after the operation, and light training after a further six months. The need for proper physical examination and accurate radiographic positioning is stressed.     

The Essex-Lopresti lesion

The Essex-Lopresti lesion represents a severe injury of the forearm unit. In the 1940s, it’s pathology and consequences have already been mentioned by several authors. Over the course of time, the pathophysiology of the lesion was displayed in more detail. Therefore, an intensive analysis of the involved anatomic structures was done. The interosseous membrane was shown to play a major role in stabilising the forearm unit, in the situation of a fractured radial head, which is the primary stabiliser of the longitudinal forearm stability. Moreover, biomechanical analyses showed a relevant attribution of the distal radio-ulnar joint to the forearm stability. If, in the case of a full-blown Essex-Lopresti lesion, the radial head, the interosseous membrane and the distal radio-ulnar joint are injured, proximalisation of the radius will take place and will come along with secondary symptoms at the elbow joint and the wrist. According to actual studies, the lesion seems to occur more often than realised up to now. Thus, to avoid missing the complex injury, subtle clinical diagnosis combined with adequate imaging has to be undertaken. If the lesion is confirmed, several operative treatment options are available, yet not proofed to be sufficient.     

Non-articular malunions of the distal radius: evaluation and techniques of correction

Malunion remains the most common complication following fracture of the distal radius. Deformities can be observed in all three planes with displacement in dorsal or palmar tilt, translation, shortening and axial rotation. Preoperative evaluation requires a comparative analysis with clinical, radiological and scanographic assessment. The functional consequences affect the radiocarpal and distal radio-ulnar joints and the carpus. Biomechanical aspects include changes in pressure forces on the distal radius and ulna, and displacement of the centers of rotation. If present, associated lesions should be evaluated. The degree of clinical acceptance depends on each patient, but generally functional outcome is closely correlated with the anatomic result. Limits of radiological acceptance should be defined at 20 degrees dorsal tilt, 5 degrees radial inclination, and a - 4 mm distal radio-ulnar index. Corrective osteotomy is performed on the radius, with or without a complementary ulnar procedure. Closing wedge and re-orientation osteotomies are no longer used. Opening wedge osteotomy with or without lengthening is preferred, generally with an access on the same side as the sagittal tilt. The osteotomy should be performed just above the distal radio-ulnar joint. A temporary external fixator provides the best way to check peroperative corrections. Bone grafts may be harvested from the radius or the iliac crest. Pins and cast are sufficient to immobilize the dorsal tilt corrections. In case of volar tilt, an internal plate fixation is best. Depending on the status of the distal radio-ulnar joint, a conservative (shortening osteotomy, wafer procedure) or non-conservative (Darrach-Moore, Kapandji-Sauvé.) procedure should be performed on the ulna. If needed, associated lesions of the carpus must be treated. Surgical correction is mainly indicated in case of a functionally unacceptable deformation, but should be discussed if the radiographical limits have been overrun. The goal of such corrective procedures is to recover anatomical restitution.     

Rettungsoperationen und deren Differenzialindikation am distalen Radioulnargelenk

The most common cause of an arthritically damaged distal radioulnar joint is a malunion of a distal radius fracture. Therapeutically, ulnar head resection, hemiresection-interposition-technique, Kapandji-Sauvé procedure and implantation of an ulnar head prosthesis have been described. None of these procedures is able to restore the complete function of the joint. Therefore, anatomical reconstruction of the joint in acute or secondary correction osteotomy for malunited fractures of the distal radius should be performed to avoid the development of the arthrosis. Numerous clinical studies have demonstrated a similar reduction of the clinical symptoms for all procedures. Therefore, classification of the different procedures has to consider the number of complications. Biomechanically, partial resection of the distal ulna will destabilize the distal radioulnar context and clinically may lead to painful radioulnar and/or dorsopalmar instability of the distal ulnar stump. Biomechanically and clinically, this complication, next to secondary extensor tendon ruptures, has to be expected far more often following complete resection of the ulnar head than in the alternative procedures. We do not see any remaining indication for complete resection of the ulnar head. Clinical results and the occurrence of painful instability of the distal ulnar stump have been reported almost identically for the hemiresection-interposition technique and the Kapandji Sauvé procedure. Therefore, both procedures appear to be equally suitable for the treatment of painful arthrosis of the distal radioulnar joint. In patients with a preexisting instability of the distal radioulnar joint, or a major deformity of the radius or the ulna, we prefer to perform the hemiresection-interposition-technique. In these conditions we consider the remaining contact of the triangular fibrocartilage complex with the distal end of the ulna a biomechanical advantage to reduce the risk of secondary instability. Biomechanically as well as clinically, replacement of the ulnar head using a prosthesis has been shown to either avoid or solve the problem of instability. We therefore consider ulnar head replacement the treatment of choice in secondary painful instability following resection procedures at the distal end of the ulna. Primary ulnar head replacement should be considered in special indications until long-term follow-up results are available.     

Extensor tendon rupture due to osteoarthritis of the distal radio-ulnar joint.

Five cases of closed rupture of the finger extensor tendon due to osteoarthritis of the distal radioulnar joint were studied. Difficulty in extension began at the little finger and extended to the ring and long fingers. Pain and swelling in the dorsal aspect of the wrist preceded the tendon rupture. Osteoarthritic changes at the distal radio-ulnar joint were more severe than those at the radio-carpal and intercarpal joints. The distal end of the ulna showed the plus variant, as well as dorsal dislocation or subluxation. All patients underwent a tendon graft or tendon transfer, with excision of the distal ulna. The tendon rupture was thought to be caused mainly by friction between the displaced distal end of the ulna and osteophytes of the distal radio-ulnar joint.     

Treatment of distal radioulnar joint disorders with a modified Sauvé-Kapandji procedure: long-term outcome with special attention to the DASH Questionnaire

Introduction An intact distal radioulnar joint (DRUJ) is essential for normal functioning of the upper limb. Osteoarthritis of the DRUJ often leads to ulnar wrist pain, limitation of forearm rotation and reduced grip strength, all of which limit activities of daily living. Once the joint is damaged, salvage procedures are recommended.Materials and methods Between 1986 and 1996 a modified Sauvé-Kapandji procedure was performed in 117 patients with painfully limited forearm rotation and osteoarthritis of the distal radioulnar joint (DRUJ). Of the 117 patients, 73 women and 32 men, whose ages at operation ranged from 22 to 74 years (average 58 years), were retrospectively reviewed clinically and radiologically 8 years (range 5–12 years) after the operation. The DASH questionnaire was used with 53 patients, 43 patients were accepted for the study, and 10 were excluded.Results Forearm rotation improved in all patients, ulnar wrist pain was reduced in 97% of the patients, and 9% had mild pain at the proximal ulnar stump. Grip strength improved from a preoperative mean of 38% to a postoperative mean of 55% compared with the contralateral side. The mean DASH score was 28 points (range 0–53 points). In all cases the arthrodesis fused within 8 weeks. The radiographs showed approximation between the proximal ulna stump and the radius compared with the preoperative situation in 74% of the patients.Conclusion Our clinical and radiological findings suggest that the Sauvé-Kapandji procedure is indicated in symptomatic, non-reconstructable disorders of the DRUJ. The DASH questionnaire provides a general view of the functional outcome after the Sauvé-Kapandji procedure. The DASH questionnaire is very helpful in evaluating the effect of the Sauvé-Kapandji procedure on the entire upper limb.     

History and evolution of the sauvé-kapandji procedure

Arthrodesis of the distal radioulnar joint combined with the creation of a pseudarthrosis of the distal ulna is frequently referred to as the Sauvé-Kapandji procedure. This eponym is based on the 1936 report by Sauvé and Kapandji, which is believed to be the first report of this innovative technique. There has been some controversy regarding the origin of this procedure, with similar techniques described by Berry in 1930 and Steindler in 1932. This article examines the evolution of the Sauvé-Kapandji procedure and sheds light on the lives of James Allan Berry, Arthur Steindler, Louis de Gonzague Sauvé, and Mehmed Kapandji.     

The Sauvé-Kapandji procedure.

In 1936, Sauvé and Kapandji described a procedure that included an arthrodesis across the distal radioulnar joint and created a pseudarthrosis of the ulna, proximal to the fusion, to restore pronation and supination. The author has used this technique because preservation of the head of the ulna minimizes the potential for some of the complications that can follow its excision. Retention of the head of the ulna would secure a more normal transmission of loads across the wrist, maintain full support to the carpal condyle and to the extensor carpi ulnaris tendon, and preserve the normal contour and appearance of the wrist. This paper presents the author's experience using this procedure in 37 wrists with rheumatoid arthritis, osteoarthrosis and posttraumatic changes of the distal radioulnar joint, and chondromalacia of the head of the ulna. This is a satisfactory operation, although not infallible. It is probably contraindicated when treating the unstable or frankly subluxed or dislocated distal radioulnar joint, ulna dorsal, a therapeutic problem for which there is no reliable solution. Indications for the Sauvé-Kapandji technique are discussed in relation to other operations frequently used for the distal radioulnar joint.     

Resection arthroplast of the distal ulna

Controversy exists regarding the best treatment for pain and instability of the distal radioulnar joint. Until recently the Darrach distal ulna resection had been the standard procedure. The Bowers hemiresection interposition arthroplasty and the Watson matched distal ulna resection were developed to preserve the styloid attachment of the triangular fibrocartilage complex. The authors present a technique for the treatment of patients with painful distal radioulnar joints. The treatment is aimed at alleviating the problems of impingement and styloid carpal abutment during grip as well as providing stabilization. The goal is improved pain-free pronation or supination, flexion or extension, and increase in grip strength.     

Ulnar impingement syndrome

We report the ulnar impingement syndrome, which is caused by a shortened ulna impinging on the distal radius and causing a painful, disabling pseudarthrosis. Of the 11 cases reported, 10 were due to excision of the distal ulna after injury to the wrist; the other was a result of a growth arrest after a fracture of the distal ulna in a child. The symptoms are a painful, clicking wrist and a weak grip; clinical examination reveals a narrow wrist with pain on compression of the radius and ulna and on forced supination. Radiographs in the majority of cases show scalloping of the distal radius corresponding to the site of impingement. The mechanism by which ulnar impingement occurs after radio-ulnar convergence is illustrated. The plan of management for the young patient with traumatic dysfunction of the distal radio-ulnar joint is discussed; excision of the lower end of the ulna is not advised in such patients.