Unstable DRUJ
Transcript of Unstable DRUJ
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Saturday, October 9, 2010General Scientific Session
Room: Auditorium, Hynes CC2:45 - 3:30 PM
65th Annual Meeting of the American Society for Surgery of the HandEmbracing Excellence: Making a Difference
Symposium 12
The Unstable DRUJ
Co-Moderators:Richard A. Berger, MDScott W. Wolfe, MD
Faculty:David S. Ruch, MD
J effrey A. Greenberg, MDBrian D. Adams, MDDean G. Sotereanos, MD
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Anatomy, Diagnosis andAnatomy, Diagnosis andPathomechanics of DRUJPathomechanics of DRUJ
InstabilityInstability
Richard A. Berger, MD, PhDRichard A. Berger, MD, PhD
Symposium 12Symposium 12
ASSH Boston 2010ASSH Boston 2010
Why do we care about the DRUJ?Why do we care about the DRUJ?
Serves as a connection between theServes as a connection between theforearm and the wristforearm and the wrist
Why do we care about the DRUJ?Why do we care about the DRUJ?
Torque TransmissionTorque Transmission
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Why do we care about the DRUJ?Why do we care about the DRUJ?
Positioning the handPositioning the hand
Why do we care about the DRUJ?Why do we care about the DRUJ?
Weight/load bearingWeight/load bearing
Why do we care about the DRUJ?Why do we care about the DRUJ?
Differentiates primatesDifferentiates primates
Well, maybe!!!
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AnatomyAnatomy
Andreas Vesaliu s 1514-1564
Distal Radioulnar JointDistal Radioulnar Joint
sigmoid
notch
Distal Radioulnar JointDistal Radioulnar Joint
sigmoid
notch
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Distal Radioulnar JointDistal Radioulnar Joint
styloid
Distal Radioulnar JointDistal Radioulnar Joint
fovea
Distal Radioulnar JointDistal Radioulnar Joint
seat
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Distal Radioulnar JointDistal Radioulnar Joint
ECUgroove
Distal Radioulnar JointDistal Radioulnar Joint
AnatomyAnatomy
Distal Radioulnar JointDistal Radioulnar Joint
AnatomyAnatomy
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Distal Radioulnar JointDistal Radioulnar Joint
Radius of curvatureRadius of curvature
ulnar head
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TTriangularriangular FFibroibroCCartilageartilage CComplexomplex
TTriangularriangular FFibroibroCCartilageartilage CComplexomplex
radius
lunate
TFCC
RadioUlnar LigamentsRadioUlnar Ligaments
dorsal radioulnar ligament
fovea
styloid
radius
lunate
palmar
radioulnar
ligament
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Ulnar HeadUlnar Head
styloid
TFCC
head
fovea
radius
coronal section, fetal wrist
ECU subsheathECU subsheath
DRUJ capsuleDRUJ capsule
radius
ulna
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Ulnocarpal LigamentsUlnocarpal Ligaments
Ulnar styloid
Ulnar headprocess
radius
Ulnocarpal LigamentsUlnocarpal Ligaments
DRU
PRU
UC ligamentsUC ligaments
ulnar head TFC
ulnocarpal
ligaments
Ulnocarpal LigamentsUlnocarpal Ligaments
Ulnolunate (UL)
Ulnotri uetral UT
Ulnocapitate (UC)
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Functional AnatomyFunctional Anatomy
forearm joint forearm joint
bicondylar jointbicondylar joint
PRUJ DRUJPRUJ DRUJ
Carl J. Hagert
forearm joint forearm joint
annular ligamentannular ligament TFCCTFCC
IOMIOM
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KinematicsKinematics
Axes of Rotat ionAxes of Rotat ion
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Stabili ty AnalysesStabili ty Analyses
Role of Ulnar headRole of Ulnar head
Common FailureCommon Failure
Loss of articular contact constraintLoss of articular contact constraint
30% of join t const raintStuart et al. JHS 2000
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Common FailureCommon Failure
Loss of cam effectLoss of cam effect
of ulnar headof ulnar head
Common FailureCommon Failure
Loss of cam effectLoss of cam effect
of ulnar headof ulnar head
Common FailureCommon Failure
Loss of cam effectLoss of cam effect
of ulnar headof ulnar head
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ResultsResults
Dynamic si mulator:
- actively loads tendons
- simultaneousl
measures torque,
displacement, tendon
excursion and resultant
tendon load
Sauerbier et al., 2001
Acta Ort hop, J HS(Am), JHS(Br-E)
ResultsResults
ResultsResults
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intact
resectionre lacement
To
r
u
e
pro sup
A Functional Algori thm forA Functional Algori thm forUlnarUlnar--sided Wrist Painsided Wrist Pain
Disclaimer:Disclaimer:
-- not intended as a research toolnot intended as a research tool
-- used as a tool to guideused as a tool to guidediagnostic and therapeuticdiagnostic and therapeuticdecisionsdecisions
DRUJ: Soft Tissue InjuryDRUJ: Soft Tissue Injury
Injury to:Injury to:
triangular disctriangular discdistal radioulnar l igamentsdistal radioulnar l igaments
distal radioulnar joint capsuledistal radioulnar joint capsuleulnar extrinsic t endon mechanismsulnar extrinsic t endon mechanisms
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DRUJ: Articular Surface InjuryDRUJ: Articular Surface Injury
Injury to:Injury to:
ulnar headulnar headsigmoid notchsigmoid notchpisiformpisiform
DRUJ InjuryDRUJ Injury
Etiology:Etiology:
traumatrauma torsion and axial loadtorsion and axial load developmental variancedevelopmental variance inflammatory arthropathyinflammatory arthropathy
DRUJ InjuryDRUJ Injury
Spectrum o f InjurySpectrum o f Injury
soft tissue disruption of TFCCsoft tissue disruption of TFCC
fracture of radius, ulna, or carpalfracture of radius, ulna, or carpaloneoneextension of perilunate dislocationextension of perilunate dislocation
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ClassificationClassification
A
B
C
D
ClassificationClassification
painpain
ClassificationClassification
painpain
oror
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ClassificationClassification
painpainoror
oror
pain with arthrosispain with arthrosis
DRUJ: Soft Tissue InjuryDRUJ: Soft Tissue Injury
pain alone:pain alone:
central TFC tearcentral TFC tear
DRUJ: Soft Tissue InjuryDRUJ: Soft Tissue Injury
pain alone:pain alone:
central TFC tearcentral TFC tear
split of UL/UT ligaments split of UL/UT ligaments
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DRUJ: Soft Tissue InjuryDRUJ: Soft Tissue Injury
pain alone:pain alone:
central TFC tearcentral TFC tear split of UL/UT ligaments split of UL/UT ligaments
capsular stretchcapsular stretch
DRUJ: Soft Tissue InjuryDRUJ: Soft Tissue Injury
pain alone:pain alone:
central TFC tearcentral TFC tear
split of UL/UT ligaments split of UL/UT ligaments
capsular stretchcapsular stretch
tear of LTI ligament tear of LTI ligament
DRUJ InjuryDRUJ Injury
pain alone:pain alone:
central TFC tearcentral TFC tear
split of UL/UT ligaments split of UL/UT ligamentscapsular stretchcapsular stretch
tear of LTI ligament tear of LTI ligament
synovitissynovitis
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DRUJ InjuryDRUJ Injury
pain with instabilitypain with instability
tear/avulsion of DRU/PRU ligamentstear/avulsion of DRU/PRU ligaments(ulnar or radial)(ulnar or radial)
DRUJ InjuryDRUJ Injury
pain with instabilitypain with instability
tear/avulsion of DRU/PRU ligamentstear/avulsion of DRU/PRU ligaments(ulnar or radial)(ulnar or radial)
ransverse ear o gamen sransverse ear o gamen s
DRUJ InjuryDRUJ Injury
pain with instabilitypain with instability
tear/avulsion of DRU/PRU ligamentstear/avulsion of DRU/PRU ligaments(ulnar or radial)(ulnar or radial)
ransverse ear o gamen sransverse ear o gamen s
tear of joint capsuletear of joint capsule
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DRUJ InjuryDRUJ Injury
pain with instabilitypain with instability
tear/avulsion of DRU/PRU ligamentstear/avulsion of DRU/PRU ligaments(ulnar or radial)(ulnar or radial)
ransverse ear o gamen sransverse ear o gamen s
tear of joint capsuletear of joint capsule
ECU subsheath tearECU subsheath tear
DRUJ InjuryDRUJ Injury
pain with instabilitypain with instability
LT dissociationLT dissociation
DRUJ InjuryDRUJ Injury
pain with arthrosispain with arthrosis
ulnar impaction syndromeulnar impaction syndrome
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DRUJ InjuryDRUJ Injury
pain with arthrosispain with arthrosis
ulnar impaction syndromeulnar impaction syndromepisotriquetral DJDpisotriquetral DJD
DRUJ InjuryDRUJ Injury
pain with arthrosispain with arthrosis
ulnar impaction syndromeulnar impaction syndrome
pisotriquetral DJDpisotriquetral DJD
Overview of ClassificationOverview of Classification
PainPain stablestable
normal imagingnormal imaging
conservative vs. debridement surgeryconservative vs. debridement surgery
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Overview of ClassificationOverview of Classification
PainPain stablestable
normal imagingnormal imaging
conservative vs. debridement surgeryconservative vs. debridement surgery
Pain wi th InstabilityPain wi th Instability unstableunstable
abnormal provocative imagingabnormal provocative imaging
stabilization surgerystabilization surgery
Overview of ClassificationOverview of Classification
PainPain stablestable
normal imagingnormal imaging
conservative vs. debridement surgeryconservative vs. debridement surgery
Pain wi th InstabilityPain wi th Instability unstableunstable
abnormal provocative imagingabnormal provocative imaging
stabilization surgerystabilization surgery
Pain with ArthrosisPain with Arthrosis pain with loadingpain with loading
abnormal plain filmsabnormal plain films
conservative vs. resection/arthroplasty surgeryconservative vs. resection/arthroplasty surgery
Thank You!Thank You!
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Destabilizing Tears of the TFCC
Brian D. Adams, M.D.
Professor of Orthopedic Surgery
University of Iowa
Types of Destabilizing TFCC Injuriesi) TFCC tear (radioulnar ligaments) from ulna
(a)No fractures(b)Fleck fracture from fovea of ulnar head(c) Basilar ulnar styloid fracture (displaced or mobile nonunion)
ii) TFCC tear (radioulnar ligaments) from radius(a)No fractures(b)Avulsion fracture of rim(s) of sigmoid notch
Techniques for Ulnar Styloid Fracture Fixation
Percutaneous pinning
Avoid dorsal cutaneous branch of ulnar nerve
Causes irritation, requires immobilization, and removal
May split fragment
Tension band wire/suture
May be used with or without pinning
Wire causes hardware irritation, suture more acceptable
May not produce bony union
Screw fixation
May be technically difficult
May split fragment
A screw head causes hardware irritation, headless screws can be retained
Bone anchorsRequires appropriate fracture/fragment configuration
Avoids hardware irritation
May not produce bony union
_________________________
TFCC Repair
Arthroscopic techniques
May be done outside-in or inside-out Does not create an anatomic repair of TFCC/radioulnar ligaments May not reliably restore DRUJ stability, in my opinion they are not indicated for established
DRUJ instability
Open repair Dorsal exposure is optimum for visualization TFCC/distal radioulnar ligaments should be anatomically repaired to fovea thru bone tunnels Placing suture over dorsal ulnar neck reduces risk of knot irritation that can be problematic if
tied over subcutaneous border of ulna
Radioulnar pinning is optional My preferred technique is described below
_________________________
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My preferred technique for TFCC Repair
A dorsal surgical approach to the DRUJ is made identical to that described below for distal
radioulnar ligament reconstruction. In addition, an L-shaped ulnocarpal capsulotomy is created. One limb
of the capusulotomy is made along the radial margin of the ECU sheath and the other just distal and
parallel to the dorsal radioulnar ligament, extending to the radial edge of the lunate fossa. Care is taken
not to cut the dorsal radioulnar ligament. Distal-radial retraction of this flap exposes the articular surfacesof the lunate and triquetrum and the distal surface of the TFCC. The integrity of the TFCC and its
potential for repair are determined. If it is attenuated and can not be repaired to the fovea of the ulnar
head or its substance is inadequate to provide joint stability, then proceed to reconstruct the radioulnar
ligaments. Debride granulation tissue from the fovea but retain the TFCC. However, a central tear in the
disk can be debrided to smooth margins. The ECU sheath should not be opened or dissected during the
procedure to preserve its important stabilizing function for the ulnocarpal joint. If an ulnar styloid
nonunion is present and not indicated for skeletal repair, the styloid fragment is excised subperiosteally
as described below in distal radioulnar ligament reconstruction.
The TFCC is reattached to the fovea with transosseous sutures. Using a 0.062 Kirschner wire, 2
holes are created in the distal ulna that extend from the dorsal aspect of the ulnar neck to the fovea. Two
horizontal mattress sutures of 2-0 absorbable monofilament (3-0 fiberwire suture may also be considered)
are passed from distal to proximal through the ulnar periphery of the TFCC. The sutures are then passed
through the bone holes. The sutures are tied over the ulnar neck with the joint reduced and the forearm in
neutral rotation. The dorsal DRUJ capsule is closed. If the capsule is attenuated, it can be reinforced with
the previously opened extensor retinaculum, leaving this portion of the extensor digiti minimi
subcutaneous.
An ulnar shortening osteotomy through the ulnar shaft using standard techniques described in the
literature should be performed at the same operating setting if the patient is ulnar positive variance or in
some cases also with ulnar neutral variance in order to unload the ulnocarpal joint and thus reduce the
loads on the repair and the central disk.
A long arm splint is applied with the forearm rotated 20 towards the most stable joint position,
eg, in supination for dorsal instability. The splint is converted to a long arm cast at 2 weeks followed by a
short arm cast at 4 weeks, which is worn for an additional 2 weeks. A removable splint is then used for 4weeks while motion is regained. Strengthening and resumption of activities is typically delayed until pain
is minimal and motion recovered. The results of TFCC repair are generally very good. DRUJ stability is
achieved and motion and strength are recovered is most cases.
My preferred technique for DRUJ Ligament Reconstruction
A 4 cm incision is made between the 5th and 6th extensor compartments, extending proximally
from the level of the ulnar styloid. The 5th compartment is opened, except for its distal portion, and the
extensor digiti minimi tendon is retracted radially. An L-shaped flap is created in the DRUJ capsule,
with one limb made along the dorsal rim of the sigmoid notch and the other just proximal and parallel to
the dorsal radioulnar ligament. Care is taken not to cut the dorsal radioulnar ligament. Proximal-ulnar
retraction of this flap exposes the articular surfaces of the distal radioulnar joint and the proximal surfaceof the TFCC. The integrity of the TFCC and its potential for repair are determined. If it is attenuated and
can not be repaired to the fovea of the ulnar head or its substance is inadequate to provide joint stability,
then proceed to reconstruct the radioulnar ligaments. Debride granulation tissue from the fovea but
retain the functioning remnants of the TFCC, especially any remaining portion of the palmar radioulnar
ligament and the attached ulnocarpal ligaments. However, a central tear in the disk can be debrided to
smooth margins. The ECU sheath should not be opened or dissected from the ulnar groove during the
procedure, as preserving the sheath will maintain its important stabilizing function for the ulnocarpal
joint. If an ulnar styloid nonunion is present, resect the styloid by subperiosteal sharp dissection volar to
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the ECU sheath. To bring the styloid into view, extend the skin incision distally and retract the skin
ulnarly while protecting the dorsal cutaneous branch of the ulnar nerve. Alternatively, the fragment can
be excised through the previous ulnocarpal capsulotomy, but the ECU sheath should not be excessively
mobilized.
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A palmaris longus tendon graft or a different graft of similar length and size is harvested and a
suture is placed in each end to make it easier to pass through bone tunnels and tissue. I now often use a
strip of the FCU harvested through the same incision used for passing the graft (see below). Prepare the
site for the tunnel in the radius by elevating the periosteum from the dorsal margin of the sigmoid notch.
Under fluoroscopic control, a guide wire for a 2-3 mm cannulated drill bit is driven through the radius a
few millimeters proximal to the lunate fossa and radial to the articular surface of the sigmoid notch. Wire
placement is chosen so that a tunnel large enough for the graft ( 4-6 mm diameter ) can be created
without disrupting the subchondral bone of the radiocarpal joint or the sigmoid notch. True PA and
lateral fluoroscopic views are necessary to confirm accurate placement. Do not plunge through the volar
cortex during wire insertion to avoid injuring volar structures. A 2-3 mm cannulated drill bit is used to
create a pilot tunnel. Using standard drill bits, the tunnel is progressively enlarged to accommodate the
tendon graft.
If the sigmoid notch is incompetent due to the natural shape of the sigmoid notch or from trauma,
then a sigmoid notch osteoplasty is indicated. The incompetency typically involves the volar rim. The
surgical method that I prefer is a modification of the method described by Wallwork and Bain. The
technique is described below. A slightly longer volar incision is helpful when also performing an
osteoplasty.
If a corrective osteotomy for a distal radial malunion is planned in conjunction with radioulnarligament reconstruction, it is easier but not mandatory to create the radial tunnel before performing the
osteotomy. However, the tunnel must be created parallel to the malaligned lunate fossa to avoid
penetrating the articular surface. In addition, graft insertion and tensioning should not be done until the
bony correction is completed.
An obliquely directed tunnel is created in the distal ulna between the fovea and the ulnar neck.
To expose the fovea, flex the wrist while retracting the ECU sheath ulnarly and the TFC remnants
distally. Apply the same cannulated drilling technique used for the radius to ensure accurate placement
of the tunnel. The guide wire is inserted through the fovea and directed to exit the ulnar neck just volar
to the ECU. Retracting the incision ulnarly exposes the wires exit site from the ulnar neck. Apply the
cannulated drill bit over the leading end of the guide wire and drill a pilot tunnel from the ulnar neck to
the fovea. Drilling in this in a retrograde direction will reduce the risk of fracturing the ulnar neck and
injuring the carpus. Carefully enlarge the tunnel with standard drill bits to allow passage of both limbs ofthe graft.
An alternative and perhaps easier technique especially in a wrist with reduced flexion is to create
the ulnar tunnel by first making a hole in the outer cortex on the subcutaneous border of the ulna just
volar to the ECU tendon using a standard 3.5 mm drill bit aimed perpendicular to the cortex. The guide is
inserted through this hole and drilled to exit the fovea under direct vision. The 3.5 mm cannulated drill
bit is used to make the pilot tunnel. The tunnel is enlarged with standard drill bits as needed.
The volar opening of the radial tunnel is exposed through a 3 cm longitudinal volar incision
extending proximally from the proximal wrist crease and located between the ulnar neurovascular bundle
and the finger flexor tendons. Retract the neurovascular bundle ulnarly and the finger flexors radially to
expose the tunnels opening. Inserting a blunt probe through the tunnel from the dorsum will help
identify the site. Using a suture passer, the graft is passed through the tunnel, leaving its volar limb about
3 cm longer. A straight hemostat is passed from dorsal to volar over the ulnar head and under (proximal)to any remnant of the TFC. Penetrate the volar DRUJ capsule and open the hemostat slightly to increase
the size of the capsular rent. Grasp the volar limb of the graft with the hemostat and pull it through the
capsule and into the dorsal surgical exposure.
Using a suture passer, both limbs of the graft are passed through the tunnel in the distal ulna from
the fovea to the ulnar neck. Ensure the limbs were directed proximal to any TFC remnants prior to
entering the fovea. At the ulnar neck, a curved hemostat is passed under the ECU in an ulnar direction.
The dorsal limb is grasped and pulled back through this track. Using a ligature passer, the volar limb is
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passed volarly around the ulnar neck with care not to injure or entrap the ulnar neurovascular bundle.
Both limbs should now lie near the dorsal-radial aspect of the ulnar neck. With the forearm in neutral
rotation, pull the limbs taut while compressing the DRUJ and make the first throw of a surgeons knot
with the two limbs. Pull the limbs extremely taut against the ulnar neck and secure the graft tension with
3-0 nonabsorbable sutures. An additional half-hitch can be made to further strengthen the fixation.
Alternative methods are used to tension and secure the graft when it is too short to tie around the
ulnar neck.. One alternative is to make an additional hole in the ulna neck and weave one limb throughthis hole and tie it to the other limb over the small bone bridge between the holes. Another alternative is
to use the floor of the ECU sheath. In this method, the ECU sheath is opened at the level of the ulnar
neck but not over the ulnar head. One limb of the graft is passed subperiosteally at the ulnar neck under
the ECU sheath floor, which is typically substantial, and then passed back over the sheath but beneath the
ECU tendon. It is then tied to the other graft limb.
Close the dorsal DRUJ capsule and the extensor retinaculum in separate layers with 3-0 sutures,
leaving the EDQ tendon subcutaneous over the DRUJ. The more distal, intact retinaculum will provide
sufficient guidance for the EDQ and prevent bowstringing. Pinning the ulna to the radius is the
surgeons discretion. Residual instability, obesity and patient compliance are among the factors that
influence this decision. If pinning is done, the pin should be placed at least 2 cm proximal to the ulnar
tunnel to reduce the risk of ulnar fracture and large enough to resist breaking. To be prepared to extract a
broken pin, one technique is to leave the leading end of the pin prominent within the subcutaneous
tissues on the radial aspect of the distal forearm. The pin should be temporarily advanced through the
skin to cut its point off and then backed up. If irritation of the superficial radial nerve develops, the pin
can be backed up further postoperatively.
Immobilize the extremity in a long-arm cast with the forearm in neutral rotation for 3 weeks. A
sugar-tong splint is discouraged because it may not control forearm rotation sufficiently. A well-molded
short arm cast is applied for an additional 3 weeks that allows some motion about the neutral forearm
position. A well-molded, ulnar-gutter wrist splint is used for an additional 3 weeks to prevent the
extremes of forearm rotation and wrist deviation. Exercises are performed during this time, including
active wrist motion, gentle hand and forearm strengthening and active but not passive forearm rotation.
Supination and pronation are typically regained gradually over 4 to 6 months and thus passive motion is
not necessary and may be detrimental. Near full activity is usually permitted after 4 months if gripstrength and wrist motion are almost recovered, however heavy lifting and impact loading are
discouraged for another 2 months.
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7
My preferred technique forOsteoplasty for Deficiency of the Sigmoid Notch
Modification of the technique described by Wallwork NA, Bain GI
In patients with a history of a fracture involving the sigmoid notch or a naturally shallow notch
on plain radiographs, a preoperative CT is recommended to evaluate the rims of the notch and the shape
of the ulnar head. A sigmoid notch osteoplasty can be considered as an isolated procedure or tocomplement a ligament reconstruction. The osteoplasty increases the prominence of a rim to create a
better bony buttress. Because the osteotomies are proximal to the radioulnar ligament, ligament tension is
increased which also improves joint stability. In the procedure described by Wallwork and Bain, parallel
osteotomies are made, with one just proximal to the lunate fossa and the other at the proximal margin of
the sigmoid notch. A third osteotomy is made in the longitudinal plane 5 mm from the articular surface of
the notch and between the first two cuts. An osteotome is carefully advanced and with each increment it
is levered in an ulnar direction to produce a thin, slightly curved osteocartilaginous flap (figure below).
The wedge-shaped defect is filled with a bone graft harvested from the distal radius. Wallwork and Bain
describe fixing the construct with Kirschner wires. When a osteoplasty is used in conjunction with a
ligament reconstruction, graft stability can be gained without Kirschner wires. Since the radial tunnel for
the ligament reconstruction lies radial to the osteotomy, the ligament graft passes directly over the bone
graft and the oseteochondral flap which provides good fixation of the construct. For additional fixation,
sutures can be placed through the soft tissues overlying the osteoplasty just proximal and distal to the
ligament graft. The reported results of the procedure are very limited but the concept appears sound.
Wallwork and Bain had a good result when used as the sole procedure to treat palmar instability in a
patient with a flat sigmoid notch.Our experience has been limited to use only in conjunction with a
ligament reconstruction when the notch is naturally flat or has been damage by trauma.
1. Adams B. Anatomic reconstruction of the distal radioulnar ligaments for DRUJ instability. TechHand Upper Extrem Surg 2000;4:154-160.
2. Adams BD, Berger RA. An Anatomic Reconstruction of the Distal Radioulnar Ligaments forPosttraumatic Distal Radioulnar Joint Instability. J Hand Surg 2002; 27A:243-251.
3. Bowers WH. The distal radioulnar joint. p. 1014. In Green DP, Hotchkiss RN, and Peterson WC(eds): Greens Operative Hand Surgery, 4th Ed. Churchill Livingstone, New York, 1999.
4. Kuzma GR. Stabilization with a tendon graft. pp. 307-308 In Kasden M, Amdio PC, Bowers WH(eds.): Technical Tips for Hand Surgery. Hanley & Belfus, Philadelphia, 1994.
5. Leung PC, Hung LK: An effective method of reconstructing posttraumatic dorsal dislocated distalradioulnar joints. J Hand Surg 1990; 15A: 925-28.
6. Sanders RA, Hawkins B. Reconstruction of the distal radioulnar joint for chronic volar dislocation.Orthopedics 1989; 12(11): 1473-76.
7. Sanders WE, Johnston-Jones K. Posttraumatic radioulnar instability: Treatment by anatomicreconstruction of the volar and dorsal radioulnar ligaments. Presented at the 50th Annual Meeting of
the American Society for Surgery of the Hand, San Francisco, September 1995.
8. Scheker LR, Belliappa PP, Acosta R, German DS. Reconstruction of the dorsal ligament of thetriangular fibrocartilage complex. J Hand Surg 1994; 19B: 310-8.9. Wallwork NA, Bain GI: Sigmoid notch osteoplasty for chronic volar instability of the distal
radioulnar joint: a case report. J Hand Surg. 26A(3):454-9, 2001.
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Chronic DRUJ Instability/DJD: Bony Procedures
Scott W. Wolfe, MD
Professor of Orthopedic Surgery
Chief, Hand and Upper Extremity Surgery
Hospital for Special SurgeryNew York
I. General considerations
A. Definitiona. Abnormal radio-ulnar kinematics during mechanical loadb. Fixed or dynamic subluxation of radio-ulnar joint
B. Etiologya. Unrecognized DRUJ ligament injury
i. TFCC disruption(1)ii. Ulnar basi-styloid fracture/nonunion(2)
iii. Distal radioulnar dislocationiv. Galeazzi fracture-dislocationv. Essex-Lopresti injury
vi. Iatrogenic; aggressive capsular release(3;4)b. Radial malunion(5;6)c. Ulnar malunion
C. Anatomic components of DRUJ stabilitya. Articular congruency and alignmentb. Radio-ulnar contact pressure(7;8)c. TFCC(9)d. Distal radio-ulnar ligaments(10;11)e. Interosseous membrane(12)
D. Diagnosisa. Clinical examinationb. Radiographsc. Advanced imaging
i. Computed tomography(13;14)ii. Magnetic resonance imaging
E. Considerations for treatmenta. Direction of instability
i. Dorsalii. Palmariii. Multidirectional
b. Sigmoid notch shape (15)c. Chronicity (acute, subacute, chronic)
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d. Bony alignment (determines sigmoid notch alignment)(16)e. Articular cartilage qualityf. Capsular contracture(4;17)g. Integrity of interosseous membrane(18)
F. Surgical options: Chronic DRUJ instability(19)a.
Bony proceduresi. Ulnar styloid fixation(20) for basi-styloid nonunions with instability
ii. Osteotomy for radial/ulnar malunion(21)1. Generally realigns sigmoid notch and restores stability2. If sigmoid notch articular cartilage intact, and
a. Stability restored by osteotomy no further treatmentb. If unstable, TFCC repair or reconstruction
3. +/- ulnar shortening osteotomy for ulnar positive variance4. If sigmoid notch arthritic, choices include:
a. Darrachb. Sauve-Kapandjic.
DRUJ arthroplastyb. Ablative procedures
i. Resection arthroplasty1. Darrach, HIT, matched arthroplasty(22-24)
a. Sedentary individuals, advanced DRUJ arthritisb. Technique
i. Minimal resectionii. no more than 1cm proximal to sigmoid notch
iii. Careful capsular closureiv. Immobilize in supination 2 wks
c. Contraindicationsi. limited role as primary treatment for radial malunion
ii. Correct malunion to restore radio-ulnar alignmentiii. Preoperative instability may lead to postoperative instability
d. Few options if resection fails(25-29)2. Wide excision of the ulna(30;31)
a. Consider for failed Darrachb. Intact IOM central band criticalc. One bone forearm is only recourse should this fail
ii. Sauve-Kapandji arthrodesis(32)1. May have a role in younger arthritic patient with higher loads2. Improved support for ulnar carpus3. Minimal resection (< 1cm)4. Soft tissue interposition to limit heterotopic bone5. Primary tenodesis to stabilize ulnar stump(33)
a. Pronatorb. FCU: hemi tendon, based distally and woven through stumpc. +/- ECU
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NOTES
6. Failure: limited success with conversion to DRUJ arthroplasty(34)iii. Role of joint arthroplasty
1. Not ideal for dorso-volar instability2. Excellent outcomes for failed Darrach with convergence(35;36)
II. Case-based approach to treatmentA. 36 y.o. female EMT with painful DRUJ instability for two years, multiple surgeriesB. 45 y.o. office manager with fixed dislocation following capsular releaseC. 62 y.o. retired female with RA and tendon rupturesD. 45 y.o. nurse with multiply operated distal ulna and instability
REFERENCES
(1) Kihara H, Short WH, Werner FW, Fortino MD,
Palmer AK. The stabilizing mechanism of the
distal radioulnar joint during pronation andsupination. J Hand Surg [Am] 1995
Nov;20(6):930-6.
(2) Hauck RM, Skahen J, III, Palmer AK.
Classification and treatment of ulnar styloid
nonunion. J Hand Surg [Am] 1996
May;21(3):418-22.
(3) Kleinman WB, Graham TJ. The distal radioulnar
joint capsule: clinical anatomy and role in
posttraumatic limitation of forearm rotation. J
Hand Surg [Am] 1998 Jul;23(4):588-99.
(4) af Ekenstam FW. Capsulotomy of the distal radio
ulnar joint. Scand J Plast Reconstr Surg Hand
Surg 1988;22(2):169-71.
(5) Fernandez DL. Correction of post-traumatic wrist
deformity in adults by osteotomy, bone-grafting,
and internal fixation. J Bone Joint Surg [Am]
1982;64(8):1164-78.
(6) Geissler WB, Fernandez DL, Lamey DM. Distal
radioulnar joint injuries associated with fractures
of the distal radius. Clin Orthop 1996
Jun;(327):135-46.
(7) Hagert CG. The distal radioulnar joint in relation
to the whole forearm. Clin Orthop Relat Res 1992
Feb;(275):56-64.
(8) Hagert CG. The distal radioulnar joint. Hand Clin
1987 Feb;3(1):41-50.
(9) Palmer AK. Triangular fibrocartilage complex
lesions: a classification. J Hand Surg [Am] 1989Jul;14(4):594-606.
(10) af EF, Hagert CG. Anatomical studies on the
geometry and stability of the distal radio ulnar
joint. Scand J Plast Reconstr Surg 1985;19(1):17-
25.
(11) Schuind F, An KN, Berglund L, Rey R, Cooney
WP, III, Linscheid RL, et al. The distal radioulnar
ligaments: a biomechanical study. J Hand Surg
[Am] 1991 Nov;16(6):1106-14.
(12) Kihara H, Short WH, Werner FW, Fortino MD,Palmer AK. The stabilizing mechanism of the
distal radioulnar joint during pronation and
supination. J Hand Surg [Am] 1995
Nov;20(6):930-6.
(13) Mino DE, Palmer AK, Levinsohn EM.
Radiography and computerized tomography in the
diagnosis of incongruity of the distal radio-ulnar
joint. A prospective study. J Bone Joint Surg Am
1985 Feb;67(2):247-52.
(14) Mino DE, Palmer AK, Levinsohn EM. The role of
radiography and computerized tomography in the
diagnosis of subluxation and dislocation of the
distal radioulnar joint. J Hand Surg [Am] 1983
Jan;8(1):23-31.
(15) Tham SK, Bain GI. Sigmoid notch osseous
reconstruction. Tech Hand Up Extrem Surg 2007
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NOTES
Mar;11(1):93-7.
(16) Adams BD. Effects of radial deformity on distal
radioulnar joint mechanics. J Hand Surg [Am]
1993 May;18(3):492-8.
(17) Kleinman WB, Graham TJ. The distal radioulnarjoint capsule: clinical anatomy and role in
posttraumatic limitation of forearm rotation. J
Hand Surg [Am] 1998 Jul;23(4):588-99.
(18) Kihara H, Short WH, Werner FW, Fortino MD,
Palmer AK. The stabilizing mechanism of the
distal radioulnar joint during pronation and
supination. J Hand Surg [Am] 1995
Nov;20(6):930-6.
(19) Murray PM, Adams JE, Lam J, Osterman AL,
Wolfe S. Disorders of the distal radioulnar joint.
Instr Course Lect 2010;59:295-311.
(20) Hauck RM, Skahen J, III, Palmer AK.
Classification and treatment of ulnar styloid
nonunion. J Hand Surg [Am] 1996
May;21(3):418-22.
(21) af EF, Hagert CG, Engkvist O, Tornvall AH,
Wilbrand H. Corrective osteotomy of malunited
fractures of the distal end of the radius. Scand J
Plast Reconstr Surg 1985;19(2):175-87.
(22) Bowers WH. Distal radioulnar joint arthroplasty:
the hemiresection-interposition technique. J Hand
Surg [Am] 1985 Mar;10(2):169-78.
(23) Watson HK, Gabuzda GM. Matched distal ulna
resection for posttraumatic disorders of the distal
radioulnar joint. J Hand Surg [Am] 1992
Jul;17(4):724-30.
(24) Tulipan DJ, Eaton RG, Eberhart RE. The Darrach
procedure defended: technique redefined and
long-term follow-up. J Hand Surg [Am] 1991
May;16(3):438-44.
(25) Gonzalez del PJ, Fernandez DL. Salvage
procedure for failed Bowers' hemiresectioninterposition technique in the distal radioulnar
joint. J Hand Surg [Br ] 1998 Dec;23(6):749-53.
(26) Breen TF, Jupiter J. Tenodesis of the chronically
unstable distal ulna. Hand Clin 1991
May;7(2):355-63.
(27) Breen TF, Jupiter JB. Extensor carpi ulnaris and
flexor carpi ulnaris tenodesis of the unstable distal
ulna. J Hand Surg [Am] 1989 Jul;14(4):612-7.
(28) Kleinman WB, Greenberg JA. Salvage of thefailed Darrach procedure. J Hand Surg [Am] 1995
Nov;20(6):951-8.
(29) Bieber EJ, Linscheid RL, Dobyns JH,
Beckenbaugh RD. Failed distal ulna resections. J
Hand Surg [Am] 1988 Mar;13(2):193-200.
(30) Greenberg JA, Yanagida H, Werner FW, Short
WH. Wide excision of the distal ulna:
biomechanical testing of a salvage procedure. J
Hand Surg [Am] 2003 Jan;28(1):105-10.
(31) Wolfe SW, Mih AD, Hotchkiss RN, Culp RW,
Keifhaber TR, Nagle DJ. Wide excision of the
distal ulna: a multicenter case study. J Hand Surg
[Am] 1998 Mar;23(2):222-8.
(32) Schroven I, De Smet L, Zachee B, Steenwerckx
A, Fabry G. Radial osteotomy and Sauve-
Kapandji procedure for deformities of the distal
radius. Acta Orthop Belg 1995;61(1):1-5.
(33) Lamey DM, Fernandez DL. Results of the
modified Sauve-Kapandji procedure in the
treatment of chronic posttraumatic derangement
of the distal radioulnar joint. J Bone Joint Surg
Am 1998 Dec;80(12):1758-69.
(34) Rotsaert P, Cermak K, Vancabeke M. Case report:
revision of failed Sauve-Kapandji procedure with
an ulnar head prosthesis. Chir Main 2008
Feb;27(1):47-9.
(35) 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 Feb;32(2):177-89.
(36) van SJ, Fernandez DL, Bowers WH, Herbert TJ.
Salvage of failed resection arthroplasties of thedistal radioulnar joint using a new ulnar head
prosthesis. J Hand Surg Am 2000 May;25(3):438-
46.
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Salvaging the failed DRUJ
Dean G. Sotereanos
Professor, Vice-Chairman,Drexel University
College of Medicine
Department of OrthopaedicsAllegheny General Hospital
Pittsburgh, PA
DARRACH PROCEDURE
Dr. William Darrach 1912
- Excision of the distal 1 cm of the ulna
Gold standard (for many decades)
Indications
osteoarthritis- DRUJ arthritis rheumatoid
post-traumatic
DARRACH PROCEDURE
Modifications- Bower Hemi-resection interposition
- Watson Matched distal ulna resection
- Feldon Wafer procedure
Failure rate 7 48 %
- despite modifications
Dingman 1952, Hartz 1979, Nobel 1983, Bieber 1988, Buck-Gramcko 1990,
Field 1993, McKee 1996, Kleinman1996, Hove 1999
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DARRACH PROCEDURE
Distal ulna excision loss of ulnar support
of the carpus
Radio-ulnar convergence
Impingement
Loss of linkage between radius & ulna
FAILED DARRACH PROCEDURE
PATHOPHYSIOLOGY
Bell et al, JBJS Br 1985
Ulnar Impingement Syndrome
1. loss of
ulnar buttress2. pull of
pronator
quadratus
3. pull of
interosseous
membrane
4. pull of EPB
and APL
FAILED DARRACH PROCEDURE
PATHOPHYSIOLOGY
Instability / Impingement
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FAILED DARRACH PROCEDURE
Instability / Impingement
FAILED DARRACH PROCEDURE
Clinical features
- Instability
- Impingement
- Grip weakness
- Attritional tendon ruptures
- Pain
FAILED DARRACH PROCEDURE
Difficult
reconstructive
dilemma !
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Salvage Techniques
Further shortening
ECU/FCU stabilization
Silicon capping
PQ advancement
Volar capsulodesis
Metallic prosthesis
FAILED DARRACH PROCEDURE
Results
No technique has demonstrated clinical superiority
Some techniques are technically demanding with
irreproducible results (tendon weaves)
Implant technique challenging and revisions
difficult
FAILED DARRACH PROCEDURE
OUR PREFERRED TECHNIQUE
Allograft / Mechanical interposition
Prevents radioulnar impingement
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OPERATIVE TECHNIQUE
Incision: previous surgical incisions areincorporated into the approach
resected distal ulna
OPERATIVE TECHNIQUE
Subperiosteal exposure of distal ulna
4 6 cm proximal to distal stump
Exposure of
medial cortex of radius
OPERATIVE TECHNIQUE
3 - 4 suture anchors into medial cortex of radius- proximal to sigmoid notch
- at site of impingement
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OPERATIVE TECHNIQUE
3 - 4 drill holes in distal ulna
Create 3 4 cm length for fixation of allograft
to medial radial cortex
Create a large buffer between two bones
Placement of allograft:
Achilles tendon
OPERATIVE TECHNIQUE
Allograft attached to:
- Medial cortex of radius using suture anchors
- Ulna with sutures passed through drill holes
OPERATIVE TECHNIQUE
Allograft sutured together as an anchovycreation ofpillow-shaped spacer
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OPERATIVE TECHNIQUE
Size of the allograft: Important !
OPERATIVE TECHNIQUE
Size of the allograft:
- determined by pronating /supinating forearm
- pressure applied to theulnar side of the ulna
to assess for crepitus
- increase allograft size ifcrepitus palpated
OPERATIVE TECHNIQUE
Final allograft placement
Significant padding between radius & ulna
Prevents any palpable crepitus
during forearm rotation under compression
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OPERATIVE TECHNIQUE
POST-OP CARE
Long-arm splint x 10 d
(in neutral position)
Cast day 10 6 wks
Physical therapy > 6 wks
- AAROM / AROM
- strengthening (as tolerated)
MATERIALS and METHODS
17 patients
Age (mean): 47 yrs
range: 39 68 yrs
Time after index procedure
average: 15 mo
range: 9 26 mo
Follow-up (mean): 34 mo
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MATERIALS and METHODS
Indication for revision surgery:
- incapacitating pain over the distal ulnar stump
- aggravated by - active grip
- pronation /supination
- compression of distal ulna
against radius
MATERIALS and METHODS
Radiographs: pre- and post-op
Pain: VAS Visual Analog Scale
Grip strength: dynamometer
Range of motion
Palpable crepitus
Subjective assessment
RESULTS
6 Patients: Excellent
10 Patients: Good
1 Patient: Poor Failure- 1st pt (inadequate amount of allograft)
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RESULTS
Improvement:
Pain: VAS
mean : -6
Grip strength: mean : +74%
Range of motion:
- Pronation / Supination: mean: +30o / +42o
Crepitus: 1 patient only
No infection
RESULTS
Case
47 y-o female, severe pain after failed Bowers
Pre-op
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Achilles Allograft Interposition for Failed Bowers
4ys Post-op
painfree
Case
Post-op (4 yrs)
Case
Post-op (4 yrs)
Case
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Salvaging the failed DRUJ Dean G. Sotereanos, MDAaron I. Venouziou, MD
CONCLUSIONS
ALLOGRAFT Mechanical interposition
Size is important
Obtain as much as necessary
Prevents crepitus / impingement
CONCERNS
Reaction to allograft
- swelling progressively decreased
Cost
Availability
Need for long term follow-up
- early results very promising