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A Modified Darrach Procedure for Treatment of the Painful Distal Radioulnar Joint

Sotereanos, Dean; Leit, Michael

Clinical Orthopaedics and Related Research: April 1996 - Volume 325 - Issue - p 140-147
Upper Extremity

Controversy exists regarding the best treatment for pain and instability of the distal radioulnar joint. Until recently, the Darrach distal ulnar resection had been the standard procedure for this disorder. The Bowers hemiresection interposition arthroplasty, however, and the Watson matched distal ulna resection have been developed to preserve the styloid attachment of the triangular fibrocartilage complex. This article presents a retrospective chart review of a consecutive series of patients who had painful distal radioulnar joints which were treated with a modified Darrach procedure. This procedure was performed to alleviate the problems of impingement and styloid carpal abutment during grip, and provide stabilization. Fifteen patients (16 wrists) were seen during followup for an average of 37 months after resection arthroplasty of the distal ulna was performed; 6 procedures were revisions. The results were uniformly good with marked alleviation of pain in all but 1 patient. Patients experienced consistent improvement toward pain-free pronation/supination and increased grip strength.

From University Orthopaedics Inc., 3471 Fifth Avenue, Suite 1010, Pittsburgh, PA.

Reprint requests to Dean G. Sotereanos, MD, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA 15213.

Received: May 3, 1994.

Revised: June 2, 1995; September 8, 1995.

Accepted: October 11, 1995.

In 1912, Darrach suggested that resection of the distal ulna was indicated for any derangement of the distal radioulnar joint that resulted in either limitation of forearm rotation or pain, or both.5 However, criticism of the Darrach method included the view that less support for the triangular fibrocartilage complex occurred with this procedure, along with unstable rotation of the radiocarpal unit around the ulnar axis, ulnar radial impingement, and proximal instability.2,8-10,14,15 Dingman6 reported that the amount of bone resection of the distal ulna was the major factor that determined successful outcome. He suggested that only the ulna adjacent to the sigmoid notch of the radius be removed and that the ulna styloid be left in situ. Additionally, Bieber et al believed that a dynamic decrease in interosseous space resulted in significant contact forces between the ulnar stump and radius. They subsequently showed that the interosseous space narrows, leading to radioulnar impingement following Darrach resection.1

The Bowers hemiresection interposition arthroplasty was created as a result of what Dingman6 described as the “best Darrach procedure.”3,7,13,20 The hemiresection interposition arthroplasty resects the ulnar articular head while maintaining the shaft styloid relationship. An autogenous interposition graft is employed to prevent radioulnar impingement. Bowers cautioned not to use the procedure in patients who have positive ulnar variance unless the ulna is shortened as part of the procedure.3 Furthermore, Watson et al19,20 reshaped the distal ulna over a 5- to 6-cm length to match the radius and prevent any soft tissue interposition. In their original description, the ulnar styloid was preserved. Subsequently, the procedure was altered to resect the ulnar styloid and shape the remaining ulna to match the contour of the radius while positioned through full supination and pronation. They noted that the distal ulna should be resected at the level of the radial articular surface.

Concerns with both the hemiresection interposition arthroplasty and the matched distal ulna resection include persistent radioulnar impingement and abutment from a prominent styloid process, particularly with patients with ulnar positive variance.4,19 A functionally adequate or reconstructible triangular fibrocartilage complex must be present before hemiresection arthroplasty can be performed, thus hemiresection arthroplasty has no advantage over the Darrach procedure or its modifications in such patients.4 Treatment of stylocarpal impingement involves either shortening the ulnar styloid or doing a more proximal osteotomy with plating.4 The results of matched distal ulna resection were better in patients who had isolated problems of the distal radioulnar joint, a preserved radiocarpal joint, and no other wrist instability.19 Therefore, the use of matched distal ulna resection is limited in patients who have distal radioulnar joint and other complex problems. In addition, the hemiresection interposition arthroplasty and the matched distal ulna resection do not adequately affect dorsal subluxation of the ulnar stump. Several authors have advocated reconstruction procedures that use either a portion of flexor carpi ulnaris or the extensor carpi ulnaris tendon to stabilize the distal ulna.11,12,16-18,21

This article presents retrospective chart review of a consecutive series of patients who had distal radioulnar joint pain that was treated with a modified Darrach procedure, including extensor carpi ulnaris stabilization. This procedure treated ulnar abutment, radioulnar joint pain and impingement, and dorsal subluxation of the ulna with a single operation. The purpose of this study was to evaluate the patients who underwent this procedure with respect to functional outcome including strength, range of motion, and pain relief.

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A retrospective chart review of a consecutive series of 15 patients (16 wrists) who underwent the modified Darrach procedure for distal radioulnar joint pain from August 1990 to October 1992 was performed at the authors' institution. The patient data were abstracted from the hospital records and office notes. The inclusion criteria for this review was having undergone a modified Darrach procedure with an extensor carpi ulnaris stabilization and a followup of at least 2 years. Patients who had undergone other distal ulnar resection arthroplasty procedures were excluded from the study. Indication for surgery was pain with ulnocarpal abutment or forearm rotation. All patients were examined by the same orthopaedic surgeon. The parameters evaluated included pre- and postoperative pain on a subjective rating scale of 0 to 10 points, forearm pronation/supination, wrist flexion/extension, and grip strength.

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The patient was placed in the supine position on the operating table with the affected extremity fully pronated on a hand-table extension. The operation was performed after the patient had been given either general or regional anesthesia. Under tourniquet control, a vertical incision was made dorsally from the ulnar head and extended 4 cm proximally. Care was taken to protect the dorsal cutaneous branch of the ulnar nerve. This approach provided excellent exposure of the distal ulna.

The extensor retinaculum was opened through the fifth and sixth compartments; the extensor carpi ulnaris tendon was then located (Fig 1A). Subperiosteal flaps, including the radioulnar joint capsule, were sharply elevated with a scalpel in a longitudinal fashion from the distal ulna (Fig 1B). The triangular fibrocartilage complex was sharply elevated away from the ulnar styloid and then debrided. The flaps were protected until final closure.

The ulna was shortened with a transverse osteotomy by the same amount of the proximal extent of the sigmoid notch of the radius-usually 1 cm (Fig 1C). The radial border of the shortened ulna was then obliquely osteotomized and the sharp edges were smoothed with a small rasp. Harvesting the extensor carpi ulnaris was the next priority.

The radial ½ of the extensor carpi ulnaris tendon was carefully prepared with minimal handling. The tendon was split longitudinally with a number 15 blade scalpel, beginning the incision approximately 5 cm proximal to the resected end of the distal ulna and then continuing it distally to the base of the fifth metacarpal base. The ulnar tendon slip remained intact distally at the base of the fifth metacarpal base and was wrapped in a moist gauze pad while the distal ulna was further prepared.

An assistant stabilized the distal ulna and a 1/8-inch bicortical drill hole, directed dorsal to volar, was made in the distal ulna (Fig 1D). The tendon slip was passed from volar to dorsal and pulled taut with the wrist ulnarly deviated. The radial tendon slip then was sutured to itself, using a 2-0 nonabsorbable suture, while the ulna was held volar (Figs 1E-F). The forearm was pronated and supinated while the surgeon palpated between the bones to ensure that a smooth arc of motion was possible without impingement.

The closure was performed meticulously with careful handling of the skin. The subperiosteal flaps and capsule were snugly imbricated over the distal ulna stump using an absorbable suture. The skin then was closed with a 4-0 nylon vertical mattress suture technique. The wrist was placed in neutral pronation/supination and flexion/extension in a well-padded, long, arm splint.

The patient usually was discharged from the hospital the same day the procedure was performed and was seen in followup 7 to 10 days later. During followup, the splint was removed, the wound was inspected, and the sutures were removed. A well-padded, long, arm cast was applied with the wrist in neutral pronation/supination and flexion/extension, to be worn for an additional 4 weeks. Six weeks after the procedure, the plaster was removed and the patient began a rehabilitation program, initially experiencing active and active-assisted range of motion progressing to strengthening, and then functional activities.

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The operation was performed on 16 wrists in 15 patients with an average patient age of 37.5 ± 23 years (range, 15 to 77 years). The average followup was 37 ± 7.3 months (range, 28 to 47 months), and all patients were examined by the author (DGS). Six cases were revised Bowers, wafer, ulnar shortening, or Darrach procedures. Three procedures were performed to treat rheumatoid arthritis, 2 for chronic distal ulna dislocations after forearm trauma, 1 for Madelungs' deformity (Patient 7, Table 1, Fig 2), and 1 for severe degenerative joint disease with ulnar translocation of the carpus (Patient 8, Table 1, Fig 3), The remaining 3 patients required resection for distal radioulnar arthrosis after distal radius fracture. Seven of 15 patients were receiving workman's compensation preoperatively.

The results of the modified Darrach procedure were uniformly good with marked alleviation of pain in all but 1 patient. At most recent followup, the average postoperative patient pain rating on a scale of 0 to 10 points was 1; this was an improvement over the average preoperative patient pain rating of 7. Overall improvement was noted in postoperative range of motion in forearm pronation / supination with an average increase of 53 ° ± 35 °. Wrist flexion/extension improved 25 ° ± 39 °, excluding the 2 patients who had wrist fusions. In addition, grip strength in the affected wrist improved an overall 29 ± 16 pounds. When used as a revision procedure, this modification of Darrach's original technique, including extensor carpii ulnaris stabilization and radial oblique osteotomy of the ulnar stump, performed well for patients who had persistent ulnocarpal abutment and/or radioulnar impingement.

Five patients had pain ratings of 2 or less points after the procedure and experienced occasional pain related to heavy use of the involved extremity. Both patients treated for instability felt an occasional click with pronation/supination. Ten patients were completely asymptomatic at the most recent followup. No further revision surgery was required in any patient for ulnocarpal abutment or radioulnar impingement following the modified Darrach procedure in this series.

The 1 poor result was Patient 4 (Table 1). This patient had undergone 3 previous procedures including an arthroscopic wafer procedure, an open wafer procedure, and a hemiresection interposition arthroplasty. The patient experienced pain with ulnar deviation and dorsiflexion of the wrist. Diagnosis was stylocarpal abutment. After surgery, the patient no longer felt pain with ulnar deviation of the wrist; however, a neuropathy of the dorsal sensory branch of the ulnar nerve seemed to develop and was verified by nerve conduction studies. The authors attributed this patient's neuropathy (not the distal ulna resection) as the cause for persistent pain. The patient was receiving worker's compensation before the procedure and did not return to work afterward. Of the remaining 6 patients receiving worker's compensation at the time of surgery, 5 have returned to gainful employment at their previous occupations.

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The distal radioulnar joint is a complex articulation deriving stability from both bony and ligamentous structures. Once it is damaged, it is difficult to restore the original anatomy and function. Distal ulnar resections including the Darrach, Bowers, and Watson procedures are all attempts to provide pain-free distal radioulnar function. Although largely successful, each procedure has its inherent pitfalls and complications.

The distal ulnar resection technique described in this article attempted to treat both radioulnar impingement and stylocarpal abutment with decreased morbidity. This modified Darrach procedure incorporates features from other distal radioulnar joint salvage procedures previously reported, including resection of the distal ulna and styloid, and oblique radial osteotomy to decrease impingement. Unlike Goldner and Hayes,9 who used a dynamic extensor carpi ulnaris tenodesis with the tendon slip based at the musculotendinous junction, the authors used a static tenodesis with the tendon slip attached at the base of the fifth metacarpal. This extensor carpi ulnaris stabilization is similar to that described by Rowland,17 and prevents instability by augmenting a minimal subperiosteal distal ulnar resection and capsular repair.

Distal ulnar Darrach resection has the inherent problem of decreased support for the triangular fibrocartilage complex. Using these modifications, despite lack of support for the triangular fibrocartilage complex, there were no instances of ulnar translocation of the carpus or instability. Two patients in this series were treated primarily for instability. In these patients, pain was markedly relieved, although the patients did experience occasional clicking with pronation and supination. Hence, the procedure also can be used to treat instability; however, this usage is limited to few patients.

Other authors have reported results of distal ulnar resection and extensor carpi ulnaris stabilization.11,12,16,17,21 These procedures have been performed primarily in patients with rheumatoid arthritis. O'Donovan and Ruby, for example, treated 27 wrists in 23 patients by performing distal ulnar resection and extensor carpi ulnaris stabilization.16 In addition, Melone and Taras reported on 50 wrists in 41 persons who had rheumatoid disease.12 Forty-three wrists showed improvement in pain and pain-free arc of radioulnar rotation; however, overall wrist motion remained largely unchanged. The radial oblique osteotomy that the authors performed at the time of distal ulnar resection may have improved forearm pronation/ supination and prevented impingement.

Watson and Gabuzda reported results from a series of 32 patients who had mechanical or posttraumatic problems of the distal radioulnar joint, excluding patients with rheumatoid arthritis.19 They reported that 24 of 32 patients had mild or no pain, with little difference experienced between the affected and unaffected sides while in pronation and supination. They purport that the mostly cancellous distal ulna becomes adherent to the ulnar sling mechanism, preventing distal ulnar waggle. In addition, Watson and Gabuzda's procedure presupposes an intact preoperative triangular fibrocartilage complex for stabilization, which is often damaged in the patient with rheumatoid arthritis.

Increasing awareness exists that an osteotomized ulna is prone to instability. According to Melone and Taras, the purpose of the extensor carpi ulnaris tenodesis is to provide a restraint for dorsal subluxation, an ulnar and dorsal buttress to counteract ulnar translocation and volar subluxation, and a sling for the extensor carpi ulnaris tendon.12 Rowland concurs that the extensor carpi ulnaris tenodesis is necessary to offset the destabilizing influence of chronic rheumatoid disease.17

The modified Darrach procedure attempts to combine excellent aspects of other well-known distal ulnar procedures into 1 relatively simple and quick operation. These modifications, including distal ulnar resection combined with extensor carpi ulnaris stabilization and a radial oblique osteotomy, have a role in both primary treatment and revision procedures for refractory distal radioulnar joint pain.

Fig 1A-F

Fig 1A-F

Fig 2A-B

Fig 2A-B

Fig 3A-B

Fig 3A-B

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