Hemiarthroplasty of the distal ulna with an eccentric prosthesis

Replacement arthroplasty of the ulnar head is indicated primarily for stiffness and pain as a consequence of rheumatoid, degenerative, and posttraumatic arthritis of the distal radioulnar joint. It is also successfully used in the setting of previous failed excisional arthroplasty of the distal ulna. A distal ulnar hemiarthroplasty, which anatomically recreates the native ulnar head by employing an eccentric design, is discussed. The surgical technique includes a dorsal approach and careful repair of the soft tissue stabilizers.     

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.     

Open repair of the ulnar disruption of the triangular fibrocartilage complex with double three-dimensional mattress suturing technique

Open repair technique of the ulnar disruption of the triangular fibrocartilage complex is described. This technique is indicated for a fresh or a relatively fresh (less than 1 year after the initial injury) ulnar foveal detachment tear, horizontal tear, and proximal slit tear of the triangular fibrocartilage complex, all of which are accompanied by severe dorsal, palmar, or multidirectional instability of the distal radioulnar joint. A chronic tear greater than 1 year from initial injury and a fresh triangular fibrocartilage complex tear without distal radioulnar joint instability, such as central slit tear, are excluded from our indications. A dorsal C-shaped skin incision, a longitudinal incision of the radial edge of the extensor carpi ulnaris subsheath and the dorsal distal radioulnar joint capsule, exposes the distal radioulnar joint. A small, 5-mm longitudinal incision at the origin of the radioulnar ligament exposes its fovea detachment and/or the proximal slit tear of the triangular fibrocartilage complex. The disrupted radioulnar ligament is sutured in a pullout fashion to the ulna with a 3-dimensional double mattress technique through 2 bone tunnels that is precisely made at the central portion of the fovea with 1.2-mm K-wire. An additional horizontal mattress suture is used for closure of the small incision made at the radioulnar ligament, then the extensor carpi ulnaris is repaired. This open-repair technique is complex and requires precise technical skills; however, early results have been more rewarding than the conservative treatment.     

Ulnar wrist pain after Colles' fracture: 109 fractures followed for 4 years

109 patients with unilateral Colles' fracture, treated with closed reduction and cast immobilization, were re-examined after 4 (1-9) years. At follow-up, 40 patients had persistent ulnar wrist pain. The most important factor for predicting ulnar pain was final dorsal angulation of the radius. Initial and final radial shortening, fracture of the distal radioulnar joint, ulnar styloid fracture, or instability of the distal ulna were not correlated to ulnar wrist pain. We suggest that ulnar wrist pain following Colles' fracture is caused by incongruity of the distal radioulnar joint.     

The distal radioulnar joint complex in rheumatoid arthritis: an overview

Rheumatoid arthritis frequently involves the distal radioulnar joint region and is progressive. Early recognition of involvement is paramount to offering patients appropriate and timely treatment. Early operative intervention should be considered preventative. Synovectomy, hemiresection interposition technique, matched distal ulna resection and distal radioulnar fusion with creation of a pseudarthrosis through the distal ulnar shaft have been advocated for patients with early involvement. Distal ulnar resection remains the most commonly used procedure for advanced disease. No soft tissue reconstructive procedure to stabilize the ulnar stump offers distinct advantages. They should be considered modifiers and augmentations to distal ulna resection. Judicious resection of the ulnar head minimizes instability of the ulnar stump. The use of an ulnar cap is not recommended for routine use.     

The distal radioulnar joint in relation to the whole forearm.

The functional anatomy of the distal radioulnar joint was studied in relation to the whole forearm, using three fresh-frozen, above-elbow amputation specimens. The specimens demonstrate how the proximal and distal radioulnar joints together form a bicondylar joint of special character. The proximal "condyle," the radial head, rotates axially, whereas the distal "condyle," the ulnar head, is fixed with respect to rotation. The ordinary articulation of a bicondylar joint (pure axial rotation) is thereby changed into pronation-supination. Axial rotation is preserved proximally, while distally the radius swings around the ulnar head. The mobile radius is distally attached to the stable ulnar head by the dorsal and volar radioulnar ligaments, the dorsal ligament being tight for stabilization in supination and the volar ligament being tight in pronation. The ulnar head also serves as a keystone, carrying the load of the radius. Removal of the ulnar head allows the radius to "fall in" towards the ulna, with narrowing of the interosseous space.     

Biomechanical analysis of two ulnar head prostheses

The biomechanical effectiveness of 2 ulnar head prostheses was evaluated in 5 fresh-frozen cadaver arms. By using electromagnetic sensors, the amount of forearm rotation, diastasis, and dorsal/palmar subluxation of the radius at the level of the sigmoid notch was measured with the forearm in neutral rotation, pronation, and supination with and without dorsal/palmar loading. Testing was done in the intact specimens and after insertion of 2 types of ulnar head prostheses. Dynamic forearm rotation was also achieved by applying loads in the line of action of the appropriate pronator or supinator muscles to obtain a centroidal path of the radius relative to the ulna. Overall after ulnar head replacement forearm rotation lessened in pronation, diastasis decreased in most forearm positions, and subluxation increased in supination compared with the intact specimen. Despite these changes, both prostheses maintained near-normal biomechanics of the distal radioulnar joint when compared with the irregular behavior occurring after distal ulna resection. Therefore these prostheses are suggested for restoration of distal radioulnar joint function.     

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.     

The "wafer" procedure. Partial distal ulnar resection.

A technique of partial resection of the distal ulna ("wafer" procedure) for the treatment of patients with symptomatic tears of the triangular fibrocartilage complex or mild ulnar impaction syndrome or both is described. The distal 2-4 mm of the distal ulna is resected while preserving the distal radioulnar joint and the styloid process of the ulna and the ligaments attached to it. The triangular fibrocartilage can be debrided, repaired, or partially excised. The wafer procedure has several advantages and avoids some of the potential complications of other treatment methods.     

Bilateral traumatic dislocation of the distal radioulnar joint, ulna dorsal: case report and review of the literature

Bilateral dislocation of the distal radioulnar joint seems not to have been reported in the literature. This is a report of a 22-year-old man successfully treated with closed reduction and immobilization in long arm casts. Limited forearm rotation and wrist pain after a twisting injury are typical findings. In ulna dorsal dislocation the patient's forearm is locked in pronation. In ulna volar dislocation the wrist appears narrow and the forearm is locked in supination. The mechanism of injury for dorsal dislocations is hyperpronation; for volar dislocations it is hypersupination. Dislocation of the distal radioulnar joint injures the triangular disk and/or fractures the ulnar styloid. Suspicion is important in making the diagnosis. Fifty per cent of unilateral cases reported in the literature were missed initially or were diagnosed late. The acute case is easily treated by closed reduction under local anesthesia and immobilization in a long arm cast. Treatment of the chronic dislocation includes various soft tissue reconstructions or resection of the distal ulna depending on the degree of arthrosis.     

尺侧腕伸肌腱固定治疗桡尺远侧关节背侧半脱位的疗效

目的 介绍一种韧带再造的新方法治疗桡尺远侧关节背侧半脱位的疗效。方法 对3例患者,取尺侧腕伸肌腱的桡侧半腱条,自尺骨背侧骨孔突出,由桡骨掌侧骨孔穿入,再从桡骨骨侧骨孔穿出后拉紧,固定于尺骨上。结果 3例患者均取得了满意效果,术前的疼痛症状消失,关节半脱位已矫正,前臂旋转功能改善。结论 用尺侧腕伸肌腱固定治疗玩关节炎改变的桡尺远侧关节背侧半脱位简便有效。     

The blood supply of the human distal radioulnar joint and the microvasculature of its articular disk.

The arterial blood supply of the distal radioulnar joint was investigated in 35 upper extremities taken from 22 fresh cadavers (11 newborns and 11 adults using the India ink injection and tissue-clearing techniques according to Spalteholz). Microvasculature of the articular disk of the distal radioulnar joint was also performed in 35 articular disks taken from 22 fresh human cadavers, 11 newborn and 11 adults using the same technique. It was found that the general blood supply to the joint is received mainly from the palmar and dorsal branches of the anterior interosseous artery. These branches, after dividing at the proximal border of the pronator quadratus, arborize in a fanlike fashion around the joint and their small ramifications penetrate and vascularize the capsule and the articular disk from the palmar, dorsal, and medial sides. The terminal branches of the anterior interosseous artery reinforced by the posterior interosseous artery and a small branch of the ulnar artery give the direct peridiscal vessels to the palmar, medial, and dorsal margins of the articular disk, which arborize and anastomose with one another and form the terminal capillary networks that end at the peripheral segments of the disk in a series of terminal capillary loops, leaving the inner segments devoid of blood vessels. The posterior interosseous artery anastomoses at the distal part of the forearm with one of the terminal rami of the dorsal branch of the anterior interosseous artery and, in that way, contribute to the vascularization of the dorsal capsule of the distal radioulnar joint. The ulnar artery gives off a small branch that anastomoses with one of the terminal ramifications of the palmar branch of the anterior interosseous artery and contributes to the formation of a small arterial arch on the anteromedial side of the distal ulna, supplying the anteromedial capsule and the basistyloid area of the ulna. Both ulnar and radial arteries contribute to the vascularity of the joint through the collateral network of the palmar and dorsal carpal arches. In the articular disk, the major central portion of the disk is avascular and only its peripheral, palmar, medial, and dorsal margins are vascularized. The proportion of vascularized zone to avascular zone depends on the age of the subject and, in newborns, is approximately 33%. In adults, only 25% of the peripheral segments are vascularized.(ABSTRACT TRUNCATED AT 400 WORDS)     

The effect of the wafer procedure on pressure in the distal radioulnar joint

PURPOSE: To investigate the effect of the wafer procedure on pressure within the distal radioulnar joint. METHODS: The effect of increasing transverse distal ulnar head resection with preservation of the ulnar styloid was evaluated in 4 fresh frozen cadaver arms. Specimens were tested in neutral rotation. A standard transaxial load was applied from the radius to the ulna and the distal radioulnar joint intra-articular pressure was evaluated. RESULTS: Increasing amounts of distal ulnar resection led to a linear increase in pressure in the distal radioulnar articulation. CONCLUSION: The wafer procedure leads to an increase in pressure in the distal radioulnar joint that may lead to the early onset of osteoarthritis.     

Matched distal ulnar resection

Painful disorders of the distal radioulnar joint severely limit the work capability of the hand. Until recently, the standard treatment for this problem has been transverse resection of the distal ulna, as originally proposed by Darrach. A technique for a "matched" resection arthroplasty of the distal ulna, leaving the ulnar shaft--styloid axis along with the triangular fibrocartilage complex and the distal ulnar ligamentous attachments intact, has been used since 1967. This procedure resects the distal ulna in a long, smooth, convex curve, matching the opposing surface of the concave radial metaphysis in three dimensions. Forty-four wrists were followed for an average of 6.5 years and showed that the procedure is reliable and relieves pain while retaining a more normal ulnocarpal, radioulnar, and radiocarpal alignment, with painless pronation averaging 80.5 degrees and supination of 88.5 degrees.     

The load-bearing characteristics of the forearm: pattern of axial and bending force transmitted through ulna and radius

A biomechanical study was performed on 12 cadaveric arms to define the normal profiles of force transmission through the ulna and radius and demonstrate the effect on these of simulated injury of the distal radioulnar joint (DRUJ). Strain gauges were used to measure the axial and bending forces transmitted through each bone. Axial force transmitted through the ulna is, broadly, reciprocal to that seen in the radius, with the greatest force seen in supination. In all 12 arms, axial loading of the hand created an anterior bending force (to create a posterior convexity) in the distal radius. Axial loading of the hand created an anterior bending force in the distal ulna for half the specimens and a posterior bending force in the remaining half. Division and division with reconstruction of either the volar or the dorsal distal radioulnar ligament (DRUL) had no significant effect on force transmission through the ulna and radius, while excision of the ulnar head significantly disrupted the profiles of the axial and bending forces.     

Extensor tendon rupture associated with osteoarthritis of the distal radioulnar joint

Non-rheumatoid osteoarthritis of the distal radioulnar joint can cause extensor tendon rupture. We analysed the radiographic morphology of the distal radioulnar joint to identify the risk factors for this complication. Forty-one wrist X-rays of 37 patients with extensor tendon rupture caused by distal radioulnar joint osteoarthritis were evaluated retrospectively for the severity of osteoarthritis by the Kellgren/Lawrence scoring system. Measurements were obtained from posteroanterior views. All but one wrist had severe osteoarthritic changes exceeding grade 3. The radiographic features that were different from those of the contralateral wrists included deepening and widening of the sigmoid notch, radial shift of the ulnar head and dorsal inclination of the sigmoid notch. There was no significant association between tendon rupture and the morphology of the ulnar head or ulnar variance. The scallop sign, dorsal inclination of the sigmoid notch and radial shift of the ulnar head are radiological risk factors for extensor tendon ruptures.     

Comminuted Monteggia fracture-dislocation--a technique for restoration of ulnar length: case reports

A technique to aid the reconstruction of the ulna in case of comminuted Monteggia fracture-dislocation is presented. This involves reducing the proximal radioulnar joint and temporarily transfixing the radial head to the ulna by 1 or 2 Kirschner (K) wires to establish the ulnar length. Once ulnar length has been defined, reconstruction of the comminuted ulna fracture is simplified. The radioulnar K-wires are then removed and the radioulnohumeral joint is tested for stability. This technique has been used in 6 cases of type-1 Monteggia fracture-dislocation with no subsequent malunion of the ulnar fracture or redislocation' of the radial head. After an average of 13 months follow-up, all patients had nearly full range of motion of the elbow joint.     

Rekonstruktion des distalen Radioulnargelenks mit der Herbert-Ulnakopfprothese

Objective

To provide painfree forearm rotation in patients with degenerative changes of the distal radioulnar joint (DRUJ). The primary goal is to stabilize the DRUJ in patients with an unstable stump of the distal ulna following resection arthroplasty with the secondary effect of restoring painfree forearm rotation.

Indications

Instability of the distal ulna following various types of resection arthroplasties. Primary or secondary osteoarthritis of the DRUJ. Replacement of an ulnar head destroyed by tumor or trauma.

Contraindications

Longitudinal instability of the forearm (e.g., following an Essex?CLopresti-type of injury, resection of the radial head). Inadequate soft tissue with severe ulnocarpal ligamentous insufficiency. Radial deformity (must be corrected before replacement of the ulnar head).

Surgical technique

In cases of osteoarthritis of the DRUJ, dorsal exposure of the distal radioulnar joint to the depth of the 5th extensor compartment. Raising of an ulnar-based capsuloretinacular flap by sharp dissection off the ulnar neck proximally and off the dorsal part of the triangular fibrocartilage complex (TFCC) distally. Osteotomy of the distal ulna corresponding to the preoperatively planned size of the prosthesis and removal of the ulnar head, while preserving the attachment of the TFCC within the capsuloretinacular flap. Reaming of the ulnar medullary canal. Insertion of a trial prosthesis. The trial prosthesis has to fit accurately into the shaft with a fluoroscopically documented ulna minus situation of minus 1?C2?mm at the wrist joint level. After implanting the definite stem and ulnar head of the Herbert ulnar head prothesis (Martin Medizintechnik?, Tuttlingen, Germany), the capsuloretinacular flap is reattached to the dorsal rim of the sigmoid notch through drilling holes and under advanced tension. In patients with an unstable distal ulnar stump, the operative procedure is technically more demanding as it is more difficult to raise a sufficient capsuloretinacular flap and due to the loss of the ulnar head as an anatomic landmark.

Postoperative management

Long arm cast with 70° elbow flexion, 40° forearm supination, and 20° wrist extension for 2?weeks. Subsequently forearm rotation is limited at 40° in a removable ulnar gutter splint. Six weeks postoperatively unlimited active range of motion is allowed and normal activities are gradually commenced. Return to maximum stress 12?weeks postoperatively.

Results

Patient satisfaction is high due to an increased forearm rotation, stronger grip force, and remarkable pain relief. In most patients with an unstable distal ulnar stump following resection arthroplasty of the DRUJ, stability can be restored.     

Wafer distal ulna resection for triangular fibrocartilage tears and/or ulna impaction syndrome.

Partial resection of the distal ulna (wafer resection) has been used to treat patients with symptomatic tears of the triangular fibrocartilage complex or mild ulna impaction syndrome. In this procedure, the distal 2 to 4 mm of the distal ulnar head is resected while preserving the ulnar styloid process and the ligaments attached to it. The triangular fibrocartilage is debrided, repaired, or partially excised as necessary. The procedure is contraindicated if there is more than 4 mm of positive ulnar variance. Thirteen wafer resections of the distal ulna were performed in 12 patients. All had good to excellent results after a minimum follow-up of 1 year. Wafer resection has specific advantages and avoids many of the potential complications of distal ulna recession and ulnar head resection for patients with the conditions described. The procedure is not indicated if instability or degenerative arthritis of the distal radioulnar joint is present or if there is carpal instability.