Unstable DRUJ

Saturday, October 9, 2010 General Scientific Session Room: Auditorium, Hynes CC 2:45 - 3:30 PM
Symposium 12
The Unstable DRUJ
Co-Moderators: Richard A. Berger, MD Scott W. Wolfe, MD Faculty: David S. Ruch, MD Jeffrey A. Greenberg, MD Brian D. Adams, MD Dean G. Sotereanos, MD
65th Annual Meeting of the American Society for Surgery of the Hand
Embracing Excellence: Making a Difference
Anatomy, Diagnosis and Pathomechanics of DRUJ Instability
Richard A. Berger, MD, PhD Symposium 12 ASSH Boston 2010
Why do we care about the DRUJ?

Serves as a connection between the forearm and the wrist

Torque Transmission

Positioning the hand

Weight/load bearing

Differentiates primates
Well, maybe!!!
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Anatomy
Andreas Vesalius 1514-1564
Distal Radioulnar Joint
sigmoid g notch
sigmoid notch
styloid
fovea
seat
ECU groove
Anatomy sigmoid notch
Anatomy ulnar head
Radius of curvature ulnar head < sigmoid notch
Radius of curvature ulnar head < sigmoid notch = translation
Radius of curvature ulnar head < sigmoid notch = translation and rotation
,
Triangular FibroC ibroCartilage Complex
Triangular Fibro ibroC Cartilage Complex
radius
TFCC
lunate
RadioUlnar Ligaments
dorsal radioulnar ligament fovea styloid
radius palmar radioulnar ligament
lunate
Ulnar Head
TFCC styloid radius head fovea
coronal section, fetal wrist
ECU subsheath
DRUJ capsule
radius ulna
Ulnocarpal Ligaments
Ulnar styloid process Ulnar head radius
DRU ulnar head PRU UC ligaments TFC ulnocarpal ligaments
Ulnolunate (UL) Ulnotriquetral U ot quet a (UT) (U ) Ulnocapitate (UC)
Functional Anatomy
forearm joint
bicondylar joint PRUJ DRUJ
Carl J. Hagert
forearm joint
annular ligament TFCC IOM
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Kinematics
Axes of Rotation
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Stability Analyses
Role of Ulnar head
Common Failure
Loss of articular contact constraint
30% of joint constraint

Stuart et al. JHS 2000
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Common Failure
Loss of cam effect of ulnar head
Common Failure
Common Failure
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Results
Dynamic simulator: - actively loads tendons - simultaneously measures torque, displacement, tendon excursion and resultant tendon load
Sauerbier et al., 2001 Acta Orthop, JHS(Am), JHS(Br-E)
Results
Results
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T intact o r q replacement u e
resection
pro
sup
A Functional Algorithm for UlnarUlnar -sided Wrist Pain
Disclaimer: - not intended as a research tool - used as a tool to guide diagnostic and therapeutic decisions
DRUJ: Soft Tissue Injury
Injury to: triangular disc distal radioulnar ligaments ulnocarpal ligaments distal radioulnar joint capsule ulnar extrinsic tendon mechanisms
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DRUJ: Articular Surface Injury
Injury to: ulnar head sigmoid notch triquetrum/lunate pisiform
DRUJ Injury
Etiology: trauma torsion and axial load developmental variance inflammatory arthropathy
DRUJ Injury
Spectrum of Injury soft tissue disruption of TFCC fracture of radius, ulna, or carpal bone bone extension of perilunate dislocation
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Classification
A B C D
Classification
pain
Classification
pain or pain with instability
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Classification
pain or pain with instability or pain with arthrosis
pain alone: central TFC tear
pain alone:
central TFC tear split of UL/UT ligaments
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pain alone: central TFC tear split of UL/UT ligaments capsular stretch
pain alone: central TFC tear split of UL/UT ligaments capsular stretch tear of LTI ligament
DRUJ Injury
pain alone: central TFC tear split of UL/UT ligaments capsular stretch tear of LTI ligament synovitis
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DRUJ Injury
pain with instability

tear/avulsion of DRU/PRU ligaments (ulnar or radial)
DRUJ Injury
pain with instability tear/avulsion of DRU/PRU ligaments (ulnar or radial) t transverse tear t of f UT/UL ligaments li t
DRUJ Injury
pain with instability tear/avulsion of DRU/PRU ligaments (ulnar or radial) t transverse tear t of f UT/UL ligaments li t tear of joint capsule
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DRUJ Injury
pain with instability tear/avulsion of DRU/PRU ligaments (ulnar or radial) t transverse tear t of f UT/UL ligaments li t tear of joint capsule ECU subsheath tear
DRUJ Injury
pain with instability
LT dissociation
DRUJ Injury
pain with arthrosis ulnar impaction syndrome
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DRUJ Injury
pain with arthrosis ulnar impaction syndrome pisotriquetral DJD
DRUJ Injury
pain with arthrosis ulnar impaction syndrome pisotriquetral DJD DRUJ proper
Overview of Classification
Pain
stable normal imaging conservative vs. debridement surgery
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Pain
Pain with Instability

unstable abnormal provocative imaging stabilization surgery
Pain
Pain with Instability

unstable abnormal provocative imaging stabilization surgery
Pain with Arthrosis

pain with loading abnormal plain films conservative vs. resection/arthroplasty surgery
Thank You!
23
TFCC Repair and Reconstruction: Surgical Options

David S Ruch, MD
Chief Section of Hand Surgery Duke University Medical Center Durham, North Carolina
Classification:TFCC Traumatic
Palmar JHS
Central (1A) Peripheral (1B)
Distal(1C)
Mooney JHS
Radial(1D)
Usually in conjunction with fracture
Dilemma: Management of the peripheral tear What is torn? Is the DRUJ unstable? Can 2 sutures to capsule or bone maintain DRUJ stability?
What is the role of ligament reconstruction? What is the role of shortening?
Arthroscopy is gold standard for diagnosis

But Arthroscopy does not permit visualization of the two components of the DRUJ ligaments
If the ligaments are intact what is torn?
Role of Arthroscopy
Arthroscopic assessment of stability Can arthroscopy document instability? Key Point the pathophysiology is a separation of the disc from the capsule and ecu
Arthroscopically repairable tears typically present with: typical foveal pain

Worse with extension and supination Interferes with certain activities Painful click but does not result in gross instability Arthroscopic repair may be treatment of choice
Arthroscopic Repair: Peripheral Tear Arthroscopic Repair:Results

Trumble et al JHS 1997 2-3 2.0 PDS sutures
ROM=90% Grip strength=85% 21/24 pain relief 89% good/ excellent Limited studies post-op without evidence of repeat
tear
Management of Complete Tears

Acute Traumatic Complete Avulsions seen frequently with
Galliazzi fracture dislocations and distal radius fractures
In distal radius fractures reduction and stablization in
supination offers comparable outcomes to repair if anatomic reduction obtained

Ruch et al Arthroscopy Ruch et JHS
Technique of Repair Biomechanical Stability: Arthroscopic v. Open
Repair
12 matched wrists Open release of TFCC from styloid Repair with three 2-0 PDS Group1 repair to ECU sheath /capsule Group2 repair to bone
Biomechanical Stability: Arthroscopic v. Open
Repair
Translation-LVDT measured in pronation supination to
.1mm No statistical difference between groups in pronation/ supination or neutral
Biomechanical Stability: Arthroscopic v. Open
Repair
Failure occurred at the articular disc / suture interface not
at the bone or ECU sheath attachment
Who needs reconstruction ?

Arthroscopic TFCC repairs (Palmer IB) have a success
rate of 85-90% B ut
15-10% failure in relieving symptoms
Trumble T et al J Hand Surg 1997 Cooney WP J Hand Surg 1994 Ruch DS Arthroscopy 2003
Factors Associated with worse outcome following TFCC repair

Ruch et al Arthroscopy
35 patients treated for a peripheral TFCC tear
arthroscopically Pain localized to the fovea, painful rotation, tenderness over dorsal TFCC Mean follow-up 29 months (6-82) Age 3412 yrs DASH score primary variable
At least six months conservative treatment
Results
Poor outcome: age (>50, DASH >20) loss of grip strength loss supination (p=0.009) zero or negative ulnar variance (DASH 45) Positive u. variance (DASH 1712) p=0.004
Who is not an ideal candidate for repair?

Chronic tear in patient over 50 Ulnar positive variance on stress view that is different than
the contralateral uninjured wrist
Consideration of Ulnar Shortening

Ulnar shortening will stabilize the tfcc by increasing tension
on the deep fibers of the druj ligaments

Nishiwaki et al JHS 2005
Shortening results in healing of the tfcc in upto 50% of
c as es
Tatebe et al JHS 2007
Complications
Non union Transverse osteotomy Delayed union Prominent hardware Place palmarly Refracture through osteotomy site after plate removal
Conclusions Imaging currently inconsistent Repair affords excellent results for separation of the articular disc from the ecu subsheath
Gross instability may require alternative treatment
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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 Injuries i) 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 anchors Requires 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 surfaces of 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 4 weeks 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 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 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 radioulnar ligament 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 of the 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 through this 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 grip strength and wrist motion are almost recovered, however heavy lifting and impact loading are discouraged for another 2 months.
My preferred technique for Osteoplasty 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 to complement 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. Tech Hand Upper Extrem Surg 2000;4:154-160. 2. Adams BD, Berger RA. An Anatomic Reconstruction of the Distal Radioulnar Ligaments for Posttraumatic 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 distal radioulnar 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 anatomic reconstruction 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 the triangular 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.
The Unstable Distal Radioulnar Joint
ASSH Annual Meeting, Boston October 9, 2010
Chronic DRUJ Instability/DJD: Bony Procedures Scott W. Wolfe, MD Professor of Orthopedic Surgery Chief, Hand and Upper Extremity Surgery Hospital for Special Surgery New York wolfes@hss.edu
I. General considerations A. Definition a. Abnormal radio-ulnar kinematics during mechanical load b. Fixed or dynamic subluxation of radio-ulnar joint B. Etiology a. Unrecognized DRUJ ligament injury i. TFCC disruption(1) ii. Ulnar basi-styloid fracture/nonunion(2) iii. Distal radioulnar dislocation iv. Galeazzi fracture-dislocation v. Essex-Lopresti injury vi. Iatrogenic; aggressive capsular release(3;4) b. Radial malunion(5;6) c. Ulnar malunion C. Anatomic components of DRUJ stability a. Articular congruency and alignment b. Radio-ulnar contact pressure(7;8) c. TFCC(9) d. Distal radio-ulnar ligaments(10;11) e. Interosseous membrane(12) D. Diagnosis a. Clinical examination b. Radiographs c. Advanced imaging i. Computed tomography(13;14) ii. Magnetic resonance imaging E. Considerations for treatment a. Direction of instability i. Dorsal ii. Palmar iii. Multidirectional b. Sigmoid notch shape (15) c. Chronicity (acute, subacute, chronic)
NOTES
d. Bony alignment (determines sigmoid notch alignment)(16) e. Articular cartilage quality f. Capsular contracture(4;17) g. Integrity of interosseous membrane(18) F. Surgical options: Chronic DRUJ instability(19) a. Bony procedures i. Ulnar styloid fixation(20) for basi-styloid nonunions with instability ii. Osteotomy for radial/ulnar malunion(21) 1. Generally realigns sigmoid notch and restores stability 2. If sigmoid notch articular cartilage intact, and a. Stability restored by osteotomy no further treatment b. If unstable, TFCC repair or reconstruction 3. +/- ulnar shortening osteotomy for ulnar positive variance 4. If sigmoid notch arthritic, choices include: a. Darrach b. Sauve-Kapandji c. DRUJ arthroplasty b. Ablative procedures i. Resection arthroplasty 1. Darrach, HIT, matched arthroplasty(22-24) a. Sedentary individuals, advanced DRUJ arthritis b. Technique i. Minimal resection ii. no more than 1cm proximal to sigmoid notch iii. Careful capsular closure iv. Immobilize in supination 2 wks c. Contraindications i. limited role as primary treatment for radial malunion ii. Correct malunion to restore radio-ulnar alignment iii. 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 Darrach b. Intact IOM central band critical c. 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 loads 2. Improved support for ulnar carpus 3. Minimal resection (< 1cm) 4. Soft tissue interposition to limit heterotopic bone 5. Primary tenodesis to stabilize ulnar stump(33) a. Pronator b. FCU: hemi tendon, based distally and woven through stump c. +/- ECU
NOTES
6. Failure: limited success with conversion to DRUJ arthroplasty(34) iii. Role of joint arthroplasty 1. Not ideal for dorso-volar instability 2. Excellent outcomes for failed Darrach with convergence(35;36) II. Case-based approach to treatment A. 36 y.o. female EMT with painful DRUJ instability for two years, multiple surgeries B. 45 y.o. office manager with fixed dislocation following capsular release C. 62 y.o. retired female with RA and tendon ruptures D. 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 and supination. 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] 1989 Jul;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):1725. (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
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 radioulnar joint 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' hemiresection interposition 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 the failed 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 SauveKapandji 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 the distal radioulnar joint using a new ulnar head prosthesis. J Hand Surg Am 2000 May;25(3):43846.
NOTES
Salvaging the failed DRUJ
Dean G. Sotereanos, MD Aaron I. Venouziou, MD

Dean G. Sotereanos
Professor, Vice-Chairman, Drexel University College of Medicine Department of Orthopaedics Allegheny 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 - DRUJ arthritis osteoarthritis rheumatoid post-traumatic
DARRACH PROCEDURE
Modifications - Bower Hemi-resection interposition - Watson Matched distal ulna resection - Feldon Wafer procedure Failure rate
- despite modifications
Dingman 1952, Hartz 1979, Nobel 1983, Bieber 1988, Buck-Gramcko 1990, Field 1993, McKee 1996, Kleinman 1996, Hove 1999
7 48 %
ASSH, 2010 Annual Meeting
DARRACH PROCEDURE
Distal ulna excision
loss of ulnar support of the carpus
Loss of linkage between radius & ulna Radio-ulnar convergence Impingement
FAILED DARRACH PROCEDURE PATHOPHYSIOLOGY

Ulnar Impingement Syndrome 1. loss of ulnar buttress 2. pull of pronator quadratus
4. pull of EPB and APL

Bell et al, JBJS Br 1985
3. pull of interosseous membrane
FAILED DARRACH PROCEDURE PATHOPHYSIOLOGY

Instability / Impingement
FAILED DARRACH PROCEDURE

Instability / Impingement
Clinical features - Instability - Impingement - Grip weakness - Attritional tendon ruptures - Pain
Difficult reconstructive dilemma !

Salvage Techniques
Further shortening ECU/FCU stabilization Silicon capping PQ advancement Volar capsulodesis Metallic prosthesis

Results
No technique has demonstrated clinical superiority Some techniques are technically demanding with
irreproducible results (tendon weaves)

Implant technique challenging and revisions
difficult
OUR PREFERRED TECHNIQUE

Allograft / Mechanical interposition Prevents radioulnar impingement
OPERATIVE TECHNIQUE
Incision: previous surgical incisions are incorporated 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
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 anchovy creation of pillow-shaped spacer
OPERATIVE TECHNIQUE
Size of the allograft: Important !
OPERATIVE TECHNIQUE
Size of the allograft: - determined by pronating / supinating forearm - pressure applied to the ulnar side of the ulna to assess for crepitus - increase allograft size if crepitus palpated
OPERATIVE TECHNIQUE
Final allograft placement
Significant padding between radius & ulna Prevents any palpable crepitus during forearm rotation under compression
OPERATIVE TECHNIQUE
POST-OP CARE
Long-arm splint
(in neutral position)
x 10 d
Cast Physical therapy

- AAROM / AROM - strengthening (as tolerated)
day 10 6 wks > 6 wks
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
Indication for revision surgery: - incapacitating pain over the distal ulnar stump - aggravated by - active grip - pronation /supination - compression of distal ulna against radius

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)
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
Case
Achilles Allograft Interposition for Failed Bowers
4ys Post-op painfree
Case
Post-op (4 yrs)
Case
Post-op (4 yrs)
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

Unstable DRUJ

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Saturday, October 9, 2010 General Scientific Session Room: Auditorium, Hynes CC 2:45 - 3:30 PM

Anatomy, Diagnosis and Pathomechanics of DRUJ Instability

Richard A. Berger, MD, PhD Symposium 12 ASSH Boston 2010

Why do we care about the DRUJ?

Why do we care about the DRUJ?

Why do we care about the DRUJ?

Why do we care about the DRUJ?

Why do we care about the DRUJ?

Andreas Vesalius 1514-1564

Distal Radioulnar Joint

Distal Radioulnar Joint

Distal Radioulnar Joint

Distal Radioulnar Joint

Distal Radioulnar Joint

Distal Radioulnar Joint

Distal Radioulnar Joint

Anatomy sigmoid notch

Distal Radioulnar Joint

Anatomy ulnar head

Distal Radioulnar Joint

Radius of curvature ulnar head < sigmoid notch

Distal Radioulnar Joint

Radius of curvature ulnar head < sigmoid notch = translation

Distal Radioulnar Joint

Triangular FibroC ibroCartilage Complex

Triangular Fibro ibroC Cartilage Complex

dorsal radioulnar ligament fovea styloid

radius palmar radioulnar ligament

TFCC styloid radius head fovea

coronal section, fetal wrist

Ulnar styloid process Ulnar head radius

DRU ulnar head PRU UC ligaments TFC ulnocarpal ligaments

Ulnolunate (UL) Ulnotriquetral U ot quet a (UT) (U ) Ulnocapitate (UC)

bicondylar joint PRUJ DRUJ

annular ligament TFCC IOM

Role of Ulnar head

Loss of articular contact constraint

30% of joint constraint

Loss of cam effect of ulnar head

Loss of cam effect of ulnar head

Loss of cam effect of ulnar head

A Functional Algorithm for UlnarUlnar -sided Wrist Pain

DRUJ: Soft Tissue Injury

DRUJ: Articular Surface Injury

Injury to: ulnar head sigmoid notch triquetrum/lunate pisiform

pain or pain with instability

pain or pain with instability or pain with arthrosis

DRUJ: Soft Tissue Injury

pain alone: central TFC tear

DRUJ: Soft Tissue Injury

DRUJ: Soft Tissue Injury

DRUJ: Soft Tissue Injury

pain with instability

pain with instability

pain with arthrosis ulnar impaction syndrome

pain with arthrosis ulnar impaction syndrome pisotriquetral DJD

Pain with Instability

Pain with Instability

Pain with Arthrosis

TFCC Repair and Reconstruction: Surgical Options

Central (1A) Peripheral (1B)

Arthroscopy is gold standard for diagnosis

If the ligaments are intact what is torn?

Arthroscopically repairable tears typically present with: typical foveal pain