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Salvage of the failed Darrach procedure
Salvage of the Failed Darrach Procedure William B. Kleinman, MD, Jeffrey A. Greenberg, MD, Indianapolis, IN Six patients (5 post-traumatic, 1 rheumatoid) underwent a three-component reconstruction for correction of dorsal instability and radioulnar impingement following failure of a Darrach resection of the entire distal end of the ulna. The technique was devised to prevent simultaneous coronal and sagittal instability. The procedure used longitudinal intramedullary tenodesis of the extensor carpi ulnaris tendon, dorsal transfer of the pronator quadratus through the interosseous space, and temporary percutaneous pinning to maintain corrected distal radioulnar relationship. The were evaluated for 11 to 39 months (average, 20 months) following reconstruction. The preoperative wrist extension-flexion arc was preserved following surgery; there was a minimal loss of radial and ulnar deviation. The arc of forearm rotation increased 24 ~ to a range equal to 95% of the rotational arc of the opposite, unoperated wrist. Postoperative grip strength improved to an average value of 65 lb., two and one Inalf times the preoperative value, representing 80% of the value for the opposite extremity. Four patients were able to return to their previous employment. All patients achieved pain-free forearm rotation and relief of their preoperative complaints of painful mechanical popping, clicking, and catching. (J Hand Surg 1995;20A:951-958.)
A variety of operative procedures have been designed for management of distal radioulnar joint arthritisY Most have evolved as alternatives to resection of the entire distal end of the ulna, described by Darrach 9-H and Darrach and Dwighf 2 in the early 1900s, with emphasis on preservation of stabilizing soft tissue elements. Several publications have recently pointed out the inadequacies of Darrach's procedure2.7.13 18; however, when indications are appropriately applied and meticulous attention is paid to surgical technique, the Darrach procedure has been shown to be a reasonably effective procedure. ~5,19-2' More recent popular procedures have focused on the
From the Indiana Hand Center and the Indiana UniversitySchoolof Medicine, Indianapolis,IN. Receivedfor publicationFeb. 7, 1994;acceptedin revisedformApril 28, 1995. No benefitsin any formhave been receivedor will be receivedfrom a commercialpatty related directlyor indirectlyto tbe subject of this article. Reprint requests: William B. Kleinman, MD, 8501 HarcourtRoad, Indianapolis, IN 46260.
effectiveness of partial resection of the distal ulna for treatment of arthritic disorders of the distal radioulnar joint.~,3.5-~ The failed, symptomatic Darrach resection poses a difficult reconstructive surgical dilemma. In addition to resultant wrist pain and compromised hand function, secondary occupational and psychosocial hardship may develop. 13'22There have been many soft tissue reconstructive procedures designed to overcome instability and impingement following resection of the distal ulna, but use of these procedures may be difficult. If a Dan'ach resection of the distal ulna must be performed and fails, failure may be due to excessive bony resection, insufficient soft tissue structures to tether the ulna, minimizing its translational moment, postsurgical scarring, or absence of usable bone and soft tissue. A variety of soft tissue and bony procedures have been described in recent years, each directed at management of this failure. 16'~7'23-28 This article critically analyzes the results of a reconstructive salvage technique we have used for patients suffering with persistent painful instability after Darrach resection. The procedure consists of The Journal of Hand Surgery 951
952
Kleinman and Greenberg / Salvage of Failed Darrach Procedure
three components, each essential to the success of the operation.
Materials and Methods Six patients, three men and three women, with painful post-Darrach instability requiring surgical management were identified. Patient records were reviewed, and each individual was personally interviewed and examined at the end of the follow-up period. X-ray films before and after the stabilization procedure were reviewed and compared with preDarrach and immediate post-Darrach studies. Five of the patients had undergone initial Darrach resection for post-traumatic arthritis and one for rheumatoid arthritis (Table 1). Four of the five trauma cases were work-related. The average age at follow-up examination was 45 years (range, 20-65 years). The average postsalvage follow-up period was 20 months (range, 11-39 months). Follow-up examinations emphasized both subjective and objective parameters. Symptomatic complaints such as weakness, pain, and changes in work status justified our emphasis on subjective evaluation. The subjective evaluations related to activities of daily living, ranges of motion, and pain. Patients were asked to fill out visual analog scales, rating their responses on a scale of 0 to 10 regarding their preand postoperative ability to perform activities of daily living, changes in forearm range of motion, and pre- and postoperative differences in pain perception. The questionnaires were completed by the patients prior to objective evaluation. Objective data, including pre- and postoperative wrist/forearm range of motion, grip strengths (Jamar dynamometer, position #2, Jamar, Clifton, NJ), and stability of the distal radioulnar relationship, quantified the improvements
in functional capability following surgical salvage. Pre- and postoperative static x-ray films in the "zero position" were evaluated with emphasis on long-term maintenance of the distal radioulnar interosseous space. Stress views were not routinely obtained.
Surgical Technique A curvilinear dorsoulnar approach is made at the wrist level, extending proximally along the distal diaphysis of the ulna. Care is taken to avoid injury to the dorsal branches of the ulnar nerve. 29The ulna is approached through the interval between the extensor carpi ulnaris (ECU) and the flexor carpi ulnaris, isolating the distal end of the previous Darrach resection. If ragged or irregular, the end of the ulna should be appropriately contoured with an oscillating saw or rongeur (Fig. 1A). The pronator quadrams (PQ) is dissected free of its palmar-medial insertion on the ulna and mobilized radially to allow its subsequent transfer from a palmar to dorsal direction through the interosseous space to the dorsal, medial aspect of the ulna (Fig. 1B). The PQ is mobilized, along with its ulnar border tendon of insertion, to preserve tissue for later secure bony fixation. A sidecutting power burr is then used to ream the medullary canal for later intramedullary passage of the ECU tendon. The harvested portion remains distally attached and is dissected free to the level of the sixth dorsal compartment fibroosseous canal. An exit hole for the tendon is prepared 1.5 cm proximal to the end of the ulna (Fig. 1C). The distally based 50% portion of the ECU is then passed through the cortical drill hole in preparation for later longitudinal tenodesis (Fig. 1D). With the elbow flexed at 90 ~ (fingers toward the ceiling, forearm maintained in neutral rotation), two
Table 1. Changes in Wrist Range of Motion Patient 1 2 3 4 5 6
Etiology Trauma Trauma Trauma Trauma Rheumatoid arthritis Trauma
Associated Procedures None None None None Proximal row arthrodesis Carpal tunnel release,wrist arthrodesis
*Measurement not available.
Extension~Flexion(degrees) Preoperative
Pronation/Supination(degrees)
Grip Strength (lb.)
Postoperative Preoperative Postoperative Preoperative Postoperative
40/55 70/70 50/40 30/60 10/35
35/65 55/80 55/45 35/70 5/45
80/80 90/90 70/65 55/65 75/85
55/90 90/90 85/90 90/80 85/90
* 18 10 35 35
80 40 106 45 50
10/0
0/0
45/70
60/80
25
67
The Journal of Hand Surgery / Vol. 20A No. 6 November 1995 953
Figure 1. (A) The dorsoulnar aspect of the left wrist of a 65-year-old man 10 months following initial Darrach resection, with resultant dorsal instability and impingement. The ragged end of the distal ulna is clearly seen, and half of the extensor carpi ulnaris (ECU) has been harvested in preparation for distal ulnar tenodesis (arrows). (B) The pronator quadratus (white arrows), held by hemostats, is mobilized free from its palmar-medial insertion on the ulna, in preparation for interosseous transfer to the dorsomedial aspect of the ulna. (C) A drill hole is prepared approximately 1.5 cm proximal to the distal end of the ulna, through which the 50% harvested ECU (*) will be passed in preparation for longitudinal tenodesis. (D) The 50% of the ECU prepared for longitudinal tenodesis of the distal ulna (DU). The free end will be reflected distally and anchored to itself under appropriate tension, prior to pronator quadratus transposition.
divergent 0.062-inch Kirschner wires are passed percutaneously through the ulnar border of the ulna into the radius, using a lamina spreader to maintain the desired interosseous separation. Divergence of the Kirschner wires prevents postoperative migration of the radius and ulna, and placement proximal to the proximal margin of the PQ allows subsequent PQ transfer. Once securely fixed, the PQ is brought dorsally between the two forearm bones and anchored to the medial periosteum of the ulna. With the hand-forearm unit supported in 10 ~ ulnar deviation, the ECU is tensioned to support the corrected radioulnar space (Fig. 2).
Aftercare consists of a plaster-reinforced longarm, bulky compression dressing for 2 weeks, followed by a long-arm cylinder cast for 4 weeks; Kirschner wires are removed at the end of the sixth postoperative week. At this time therapy begins, consisting of active, active-assisted, and passive wrist, forearm, and elbow range-of-motion exercises; interval splinting can be used as necessary for comfort.
Results Objective Data
Postoperative changes in arcs of wrist range of motion were variable (Table 1). There was an average
954
Kleinman and Greenberg / Salvage of Failed Darrach Procedure
mrtment
i
"' / /~. /i,. . . . ~1 --~.-/_ ..,~ ~ ~ ~ / . :
Pr~176 ~ Quadratusf
N
Retards Dorsal Translation ("Winging")
Figure 2. Diagrammatic representation of all three components of the salvage reconstruction for instability of the distal ulna following failed Darrach resection. The ECU longitudinal tenodesis retards radioulnar impingement, while the pronator quadratus transfer retards dorsal translation. Temporary percutaneous pinning of the distal radioulnar joint allows complete soft tissue healing; by 6 weeks, stability can be maintained independently of the hardware.
loss of 3 ~ of extension but a gain of 8 ~ of flexion, with overall preservation of wrist range of motion. The preoperative total arc of forearm rotation was maintained or improved in five of six patients. There was an average increase of 24 ~ of rotation; this averaged 95% of the total pronation and supination arc of the contralateral limb. Grip strength improved in all patients from an average preoperative value of 25 lb. to a postoperative value of 65 lb., approximately 80% of that for the opposite extremity (Table 1). Comparison of pre- and postoperative x-ray films taken in the zero-rotation position revealed maintenance of an improved radioulnar separation. There were slight variations in the length of the revised resected ulna and in the relationship of the resected ulna to the shaft of the radius, which prevented statistical comparison of measurements made on preand postoperative x-ray films. Postoperative measurements, however, revealed the average separation for the group to be 8 mm compared with an average preoperative x-ray film radioulnar separation of 5 mm (Fig. 3).
In addition to range-of-motion and strength measurements, patients were studied for residual elements of dorsal ulnar prominence manifested by dorsal translational instability, impingement, and/or painful range of motion; the presence of a "piano key" sign (ulnar instability noted with resisted forearm pronation) was also noted. Although all patients had a modest residual positive postsalvage piano key sign, none had pain with either active or passive forearm or wrist range of motion. In the series, there was no crepitus or grinding; the forearm compression test (compression of the distal ulna against the distal radius in neutral position) was also negative in all patients.
Subjective Data Visual analog scales were used to evaluate patients' responses to subjective questioning, in order to not affect their answers by preprinted digital values. Before surgery, each patient complained of painful "locking," "clicking," and/or a "catching" sen-
The Journal of Hand Surgery / Vo[. 20A No. 6 November 1995
955
Figure 3. (A) Preoperative x-ray film demonstrating radioulnar impingement, irregularity of the distal ulnar stump, and medial scalloping of the distal radius (arrows). (B) Postoperative x-ray film following salvage of the failed Darrach resection shows maintenance of an improved radioulnar separation, resolution of the scalloped border of the distal radius, and a less irregular contour of the resected distal ulna.
sation. All patients claimed postoperative improvement both in their ability to perform activities of daily living and in their ability to rotate their affected limbs through a full arc of forearm rotation. Preoperative pain levels were substantially reduced by surgery. Prior to surgery, five of the six patients reported pain at rest. Of these five patients, one reported no pain at postoperative follow-up examination, two reported pain with light activities, and two experienced pain only with heavy use of their affected extremity. One patient who reported preoperative pain only with light activity complained of pain only with heavy activity following reconstruction. While patients' subjective responses with respect to general postoperative satisfaction were variable, all stated that they would have the salvage procedure performed again. Three of the six patients returned to full gainful employment at their previous level of activity (one
fireman, one toolmaker, one computer analyst). One patient was unable to continue as a factory assemblyline worker due to the inability to perform heavy lifting and became a counter hostess. One with an active workmen's compensation claim remains unable to work because of an unrelated ipsilateral elbow problem requiring additional surgery, and one patient employed as a systems analyst retired to take over full-time care of an ill relative.
Discussion The Darrach procedure, first performed in 1911 at the Roosevelt Hospital in New York City, 9'1~ maintains its place in the hand surgeon's armamentarium as a surgical option for disorders of the distal radioulnar joint. Although first applied by Darrach for a case of chronic traumatic palmar dislocation of the distal ulna, today's applications include post-traumatic dis-
95;6 Kleinman and Greenberg / Salvage of Failed Darrach Procedure
tal radioulnar arthritis, instability, extensor tendon rupture (caput ulnae syndrome), ulnar impingement, disorders of the triangular fibrocartilage complex, and osteoarthritis or rheumatoid arthritis. Many procedures have been designed as alternatives to Darrach's distal ulna resection, 1,~-8largely because of the potential for associated complications such as pain, weakness, attritional tendon ruptures, mechanical impingement, and distal ulnar instability. Despite numerous papers advocating alternative procedures, distal ulna resection maintains its place as a viable option for distal radioulnar arthritis. Tulipan et al.21in 1.991 defended the Darrach resection, emphasizing careful preoperative indications, meticulous technique, and appropriate aftercare as essentials for surgical success. Bieber et al. TM were able to identify only 20 of 288 patients with Darrach resections who did not have a satisfactory surgical result. Following distal ulna resection, all the mechanical restraints preventing radioulnar impingement have been eliminated. Because of loss of bony contact at the distal radioulnar joint, impingement of the radius and ulna can now occur, with progressive narrowing of the interosseous space. In addition, a variety of muscular forces may accentuate distal radioulnar impingement. The PQ is a muscle that normally stabilizes the distal radioulnar joint in the unaltered state; it can become a strong deforming force, exaggerating distal radioulnar impingement, in the absence of an intact ulna seat. Also contributing to potential impingement are the muscles of the first dorsal compartment (abductor pollicis longus, extensor poliicis brevis), which originate along the ulnar border of the interosseous membrane, crossing from medial to lateral across the interosseous space as they converge on the thumb. Their combined contractile force contributes to distal radioulnar impingement in the absence of distal bony contact. Finally, loss of stability of the triangular fibrocartilage complex and the associated ulnocarpal soft tissue stabilizers of the triangular fibrocartilage allows accentuated translation of the distal ulna with forearm rotation. TM Despite critical attention to technical details, instability after Darrach resection may develop. ~,15-1s,22'24,28 Symptoms include painful mechanical "popping," "catching" sensations, or "clicking"; severe ulnar impingement may be identified by erosive changes at the medial cortical margin of the distal radius, seen on x-ray film 13 (Fig. 3A). Painful instability and its associated secondary weakness become difficult management problems.
There is a paucity of literature regarding salvage of the failed Darrach procedure; comparison among the many small series of clinical cases and our own series is difficult. Each clinical series advocates a different approach to the painful, unstable distal ulnar stump following Darrach resection. Goldner and Hayes ~5 described treatment of 50 patients for post-Darrach instability with a partial ECU tenodesis, without giving detailed results. Incorporation of a tenodesis with a distal ulna resection was reported by Tsai et al. 28 who used 50% ECU, and Hui and Linscheid, 3~ who incorporated 50% of the flexor carpi ulnaris as an ulnotriquetral ligament augmentation. Neither group applied this technique to salvage of the failed Darrach resection. Breen and Jupiter 24 combined a distally based flexor carpi ulnaris tenodesis and a proximally based ECU tenodesis to tether the unstable distal ulna, but in only three of their eight patients was the procedure used for a symptomatic failed Darrach resection. Two of the five patients in Tsai and Stilwell's report 27 of the use of partial flexor carpi ulnaris tenodesis had good results when the procedure was applied to salvage of the failed Darrach. Noble and Arafa's 16 one patient had good pain relief and returned to work following stabilization of the previously resected distal ulnar stump with the palmaris longus. Johnson 26 reported 15 patients who did well following advancement for painful instability (not through the interosseous space) and suggested that this technique could be applied to the unstable ulna following Darrach resection. Finally, Blatt's palmar capsulodesis 23 has been used at the time of distal ulna resection, but not for independent salvage after failure of a Darrach procedure. In 1973, Swanson 3~ reported his results using silicone rubber "capping" of the distal ulna plus ligament reconstruction to achieve painless stability following failed Darrach resection. Unfortunately, implant failure and silicone synovitis at long-term follow-up examination currently make this salvage technique unacceptable. Watson and Brown ~7 addressed post-Darrach instability and impingement by reestablishing ulna length by step-cut osteotomy. They recommended advancement of the lengthened distal ulna into the medial portion of the triangular fibrocartilage complex. Procedures that address instability by recreating a radioulnar tether are difficult to apply following failure of a distal ulna resection, 2,~4for success, these techniques rely on an intact distal radioulnar joint, which is absent following a Darrach resection.
The Journal of Hand Surgery / Vol. 20A No. 6 November 1995
Comparison among approaches is difficult owing to small patient numbers and the variety of preoperative conditions and treatments leading to both Darrach resection and Darrach salvage. The goal in treatment o f a failed Darrach is to correct (1) coronal and sagittal instability caused b y loss of bony contact at the distal radioulnar joint; (2) loss of the soft tissue-stabilizing elements of the triangular fibrocartilage; and (3) associated soft tissue complex and muscular forces that exaggerate lateral migration of the resected ulna against the medial cortex of the radius. While each previously reported clinical series advocates a technique that tethers the ulna in some fashion, our procedure seems to be the only one that addresses coronal instability (ECU tenodesis) and sagittal instability (PQ transfer) separately (Fig. 2). Our approach to problematic instability and impingement after Darrach resection was developed by analyzing the individual component parts of the problem; the r e c o m m e n d e d surgical procedure addresses each facet of the instability problem separately. 1. The PQ origin is detached from the palmar-medial ulna and transferred through the interosseous space to the dorsomedial aspect of the ulna. This substantial modification of Johnson's technique 26serves multiple purposes: first, a strong deforming force is eliminated by PQ tenotomy; second, a secure, palmar-oriented, dynamic tenodesis is provided by transferring the origin of the PQ from palmar-medial to dorsomedial, through the interosseous space, thereby reducing the tendency toward dorsal subluxation of the distal ulnar stump. This transfer also changes the "angle of attack" of the PQ tethering the ulna palmarly and retarding the propensity for dorsal ulnar instability, or "winging." Finally, the transferred muscle-tendon unit serves as interpositional material, further helping to prevent impingement of the resected distal ulna against the medial border of the radius. 2. Longitudinal ECU tenodesis to a point just proximal to the fibroosseous canal of the sixth dorsal compartment gives additional support to the unstable distal ulnar stump and retards its tendency to translate medially. Only half of the ECU is used; its fibroosseous canal and the linea jugata are left intact. Longitudinal tenodesis can therefore be made to the remaining intact partial tendon of the ECU, just proximal to the unviolated semirigid fibrous tissue of the sixth dorsal compartment. 3. The appropriate relationship between the distal radius and ulna is maintained securely by two divergent, percutaneously placed 0.062 Kirschner wires until soft tissue healing has occurred. Stability can then be maintained independently of the hardware.
957
References 1. Bilos ZJ, Chamberland D. Distal ulnar head shortening for treatment of triangular fibrocartilage complex tears with ulna positive variance. J Hand Surg 1991; 16A:115-9. 2. Bowers WH. Surgical procedures for the distal radioulnar joint. In: Lichtman D, ed. The wrist and its disorders. Philadelphia: WB Saunders, 1988:232-43. 3. Bowers WH. Distal radioulnar joint arthroplasty: the hemiresection-interposition technique. J Hand Surg 1985;10A: 169-78. 4. Darrow JC, Linscheid RL, Dobyns JH et al. Distal ulnar recession for disorders of the distal radioulnar joint. J Hand Surg 1985;10:482-91. 5. Dibenedetto MR, Lubbers LM, Coleman CR. Long-term results of the minimal resection Darrach procedure. J Hand Surg 1991;16A:445-50. 6. Feldon P, Terrono AL, Belsky MR. The "wafer" procedure. Clin Orthop 1992;275:124-9. 7. Watson HK, Ryu J, Burgess RC. Matched distal ulnar resection. J Hand Surg 1986:11A:812-7. 8. Watson HK, Gabuzda GM. Matched distal ulna resection for posttraumatic disorders of the distal radioulnar joint. J Hand Surg 1992;17A:724-30. 9. Darrach W. Anterior dislocation of the head of the ulna. Ann Surg 1912;56:802-3. 10. Darrach W. Habitual forward dislocation of the head of ulna. Ann Surg 1913;57:928-30. 11. Darrach W. Partial excision of lower shaft of ulna for deformity following Colles' fracture. Aim Surg 1913;57:764-5. 12. Darrach W, Dwight K. Derangements of the inferior radioulnar articular. Med Rec 1915 ;87:708. 13. Bell MJ, Hill RJ, McMurtry RY. Ulnar impingement syndrome. J Bone Joint Surg 1985;67B:126-9. 14. Dell PC. Distal radioulnar joint dysfunction. Hand Clin 1987;3:563-82. 15. Hartz CR, Beckenbaugh RD. Long-term results of resection of the distal ulna for post-traumatic conditions. J Trauma 1979;19:219-26. 16. Noble J, Arafa M. Stabilization of distal ulna after excessive Darrach's procedure. J Hand Surg 1983;15:70-2. 17. Watson HK, Brown RE. Ulnar impingement syndrome after Darrach procedure: treatment by advancement lengthening osteotomy of the ulna. J Hand Surg 1989;14A:302-6. 18. Bieber EJ, Linscheid RL, Dobyns JH, Beckenbaugh RD. Failed distal ulna resections. J Hand Surg 1988;13A: 193-200. 19. Dingman PVC. Resection of the distal end of the ulna (Darrach operation). J Bone Joint Surg 1952;34A: 893-900. 20. Rana NA, Taylor AR. Excision of the distal end of the ulna in rheumatoid arthritis. J Bone Joint Surg 1973;55B:96-105. 21. Tulipan DJ, Eaton RG, Eberhart RE. The Darrach procedure defended: technique redefined and long-term followup. J Hand Surg 1991;16A:438-44. 22. Field J, Majkowski RJ, Leslie IJ. Poor results of Darrach's procedure after wrist injuries. J Bone Joint Surg 1993;75B:53-7.
958
Kleinman and Greenberg / Salvage of Failed Darrach Procedure
23. Blatt G. Capsulodesis in reconstructive hand surgery. Hand Clin 1987;3:81-102. 24. Breen TF, Jupiter JB. Extensor carpi ulnaris and flexor carpi ulnaris tenodesis of the unstable distal ulna. J Hand Surg 1989;14A:612-7. 25. Goldner JL, Hayes MG. Stabilization of the remaining ulna using one-half of the extensor carpi ulnaris tendon after resection of the distal ulna. Orthop Trans 1979;3:330-1. 26. Johnson RK. Muscle-tendon transfer for stabilization of the distal radioulnar joint. J Hand Surg 1985;10A:437. 27. Tsai TM, Stilwell JH. Repair of chronic subluxation of the distal radioulnar joint (ulnar dorsal) using flexor carpi ulnaris tendon. J Hand Surg 1984;9B:289-94.
28. Tsai TM, Shimizu H, Adkins E A modified extensor carpi ulnaris tenodesis with the Darrach procedure. J Hand Surg 1993;18A:697-702. 29. Lourie GM, King J, Kleinman WB. The transverse radioulnar branch from the dorsal sensory ulnar nerve: its clinical and anatomical significance further defined. J Hand Surg 1994;19A:241-5. 30. Hui FC, Linscheid RL. Ulnotriquetral augmentation tenodesis: a reconstructive procedure for dorsal subluxation of the distal radioulnar joint. J Hand Surg 1982:7: 230-6. 31. Swanson AB. Flexible implant arthroplasty in the hand and extremities. St. Louis: CV Mosby, 1973;275.
A variety of operative procedures have been designed for management of distal radioulnar joint arthritisY Most have evolved as alternatives to resection of the entire distal end of the ulna, described by Darrach 9-H and Darrach and Dwighf 2 in the early 1900s, with emphasis on preservation of stabilizing soft tissue elements. Several publications have recently pointed out the inadequacies of Darrach's procedure2.7.13 18; however, when indications are appropriately applied and meticulous attention is paid to surgical technique, the Darrach procedure has been shown to be a reasonably effective procedure. ~5,19-2' More recent popular procedures have focused on the
From the Indiana Hand Center and the Indiana UniversitySchoolof Medicine, Indianapolis,IN. Receivedfor publicationFeb. 7, 1994;acceptedin revisedformApril 28, 1995. No benefitsin any formhave been receivedor will be receivedfrom a commercialpatty related directlyor indirectlyto tbe subject of this article. Reprint requests: William B. Kleinman, MD, 8501 HarcourtRoad, Indianapolis, IN 46260.
effectiveness of partial resection of the distal ulna for treatment of arthritic disorders of the distal radioulnar joint.~,3.5-~ The failed, symptomatic Darrach resection poses a difficult reconstructive surgical dilemma. In addition to resultant wrist pain and compromised hand function, secondary occupational and psychosocial hardship may develop. 13'22There have been many soft tissue reconstructive procedures designed to overcome instability and impingement following resection of the distal ulna, but use of these procedures may be difficult. If a Dan'ach resection of the distal ulna must be performed and fails, failure may be due to excessive bony resection, insufficient soft tissue structures to tether the ulna, minimizing its translational moment, postsurgical scarring, or absence of usable bone and soft tissue. A variety of soft tissue and bony procedures have been described in recent years, each directed at management of this failure. 16'~7'23-28 This article critically analyzes the results of a reconstructive salvage technique we have used for patients suffering with persistent painful instability after Darrach resection. The procedure consists of The Journal of Hand Surgery 951
952
Kleinman and Greenberg / Salvage of Failed Darrach Procedure
three components, each essential to the success of the operation.
Materials and Methods Six patients, three men and three women, with painful post-Darrach instability requiring surgical management were identified. Patient records were reviewed, and each individual was personally interviewed and examined at the end of the follow-up period. X-ray films before and after the stabilization procedure were reviewed and compared with preDarrach and immediate post-Darrach studies. Five of the patients had undergone initial Darrach resection for post-traumatic arthritis and one for rheumatoid arthritis (Table 1). Four of the five trauma cases were work-related. The average age at follow-up examination was 45 years (range, 20-65 years). The average postsalvage follow-up period was 20 months (range, 11-39 months). Follow-up examinations emphasized both subjective and objective parameters. Symptomatic complaints such as weakness, pain, and changes in work status justified our emphasis on subjective evaluation. The subjective evaluations related to activities of daily living, ranges of motion, and pain. Patients were asked to fill out visual analog scales, rating their responses on a scale of 0 to 10 regarding their preand postoperative ability to perform activities of daily living, changes in forearm range of motion, and pre- and postoperative differences in pain perception. The questionnaires were completed by the patients prior to objective evaluation. Objective data, including pre- and postoperative wrist/forearm range of motion, grip strengths (Jamar dynamometer, position #2, Jamar, Clifton, NJ), and stability of the distal radioulnar relationship, quantified the improvements
in functional capability following surgical salvage. Pre- and postoperative static x-ray films in the "zero position" were evaluated with emphasis on long-term maintenance of the distal radioulnar interosseous space. Stress views were not routinely obtained.
Surgical Technique A curvilinear dorsoulnar approach is made at the wrist level, extending proximally along the distal diaphysis of the ulna. Care is taken to avoid injury to the dorsal branches of the ulnar nerve. 29The ulna is approached through the interval between the extensor carpi ulnaris (ECU) and the flexor carpi ulnaris, isolating the distal end of the previous Darrach resection. If ragged or irregular, the end of the ulna should be appropriately contoured with an oscillating saw or rongeur (Fig. 1A). The pronator quadrams (PQ) is dissected free of its palmar-medial insertion on the ulna and mobilized radially to allow its subsequent transfer from a palmar to dorsal direction through the interosseous space to the dorsal, medial aspect of the ulna (Fig. 1B). The PQ is mobilized, along with its ulnar border tendon of insertion, to preserve tissue for later secure bony fixation. A sidecutting power burr is then used to ream the medullary canal for later intramedullary passage of the ECU tendon. The harvested portion remains distally attached and is dissected free to the level of the sixth dorsal compartment fibroosseous canal. An exit hole for the tendon is prepared 1.5 cm proximal to the end of the ulna (Fig. 1C). The distally based 50% portion of the ECU is then passed through the cortical drill hole in preparation for later longitudinal tenodesis (Fig. 1D). With the elbow flexed at 90 ~ (fingers toward the ceiling, forearm maintained in neutral rotation), two
Table 1. Changes in Wrist Range of Motion Patient 1 2 3 4 5 6
Etiology Trauma Trauma Trauma Trauma Rheumatoid arthritis Trauma
Associated Procedures None None None None Proximal row arthrodesis Carpal tunnel release,wrist arthrodesis
*Measurement not available.
Extension~Flexion(degrees) Preoperative
Pronation/Supination(degrees)
Grip Strength (lb.)
Postoperative Preoperative Postoperative Preoperative Postoperative
40/55 70/70 50/40 30/60 10/35
35/65 55/80 55/45 35/70 5/45
80/80 90/90 70/65 55/65 75/85
55/90 90/90 85/90 90/80 85/90
* 18 10 35 35
80 40 106 45 50
10/0
0/0
45/70
60/80
25
67
The Journal of Hand Surgery / Vol. 20A No. 6 November 1995 953
Figure 1. (A) The dorsoulnar aspect of the left wrist of a 65-year-old man 10 months following initial Darrach resection, with resultant dorsal instability and impingement. The ragged end of the distal ulna is clearly seen, and half of the extensor carpi ulnaris (ECU) has been harvested in preparation for distal ulnar tenodesis (arrows). (B) The pronator quadratus (white arrows), held by hemostats, is mobilized free from its palmar-medial insertion on the ulna, in preparation for interosseous transfer to the dorsomedial aspect of the ulna. (C) A drill hole is prepared approximately 1.5 cm proximal to the distal end of the ulna, through which the 50% harvested ECU (*) will be passed in preparation for longitudinal tenodesis. (D) The 50% of the ECU prepared for longitudinal tenodesis of the distal ulna (DU). The free end will be reflected distally and anchored to itself under appropriate tension, prior to pronator quadratus transposition.
divergent 0.062-inch Kirschner wires are passed percutaneously through the ulnar border of the ulna into the radius, using a lamina spreader to maintain the desired interosseous separation. Divergence of the Kirschner wires prevents postoperative migration of the radius and ulna, and placement proximal to the proximal margin of the PQ allows subsequent PQ transfer. Once securely fixed, the PQ is brought dorsally between the two forearm bones and anchored to the medial periosteum of the ulna. With the hand-forearm unit supported in 10 ~ ulnar deviation, the ECU is tensioned to support the corrected radioulnar space (Fig. 2).
Aftercare consists of a plaster-reinforced longarm, bulky compression dressing for 2 weeks, followed by a long-arm cylinder cast for 4 weeks; Kirschner wires are removed at the end of the sixth postoperative week. At this time therapy begins, consisting of active, active-assisted, and passive wrist, forearm, and elbow range-of-motion exercises; interval splinting can be used as necessary for comfort.
Results Objective Data
Postoperative changes in arcs of wrist range of motion were variable (Table 1). There was an average
954
Kleinman and Greenberg / Salvage of Failed Darrach Procedure
mrtment
i
"' / /~. /i,. . . . ~1 --~.-/_ ..,~ ~ ~ ~ / . :
Pr~176 ~ Quadratusf
N
Retards Dorsal Translation ("Winging")
Figure 2. Diagrammatic representation of all three components of the salvage reconstruction for instability of the distal ulna following failed Darrach resection. The ECU longitudinal tenodesis retards radioulnar impingement, while the pronator quadratus transfer retards dorsal translation. Temporary percutaneous pinning of the distal radioulnar joint allows complete soft tissue healing; by 6 weeks, stability can be maintained independently of the hardware.
loss of 3 ~ of extension but a gain of 8 ~ of flexion, with overall preservation of wrist range of motion. The preoperative total arc of forearm rotation was maintained or improved in five of six patients. There was an average increase of 24 ~ of rotation; this averaged 95% of the total pronation and supination arc of the contralateral limb. Grip strength improved in all patients from an average preoperative value of 25 lb. to a postoperative value of 65 lb., approximately 80% of that for the opposite extremity (Table 1). Comparison of pre- and postoperative x-ray films taken in the zero-rotation position revealed maintenance of an improved radioulnar separation. There were slight variations in the length of the revised resected ulna and in the relationship of the resected ulna to the shaft of the radius, which prevented statistical comparison of measurements made on preand postoperative x-ray films. Postoperative measurements, however, revealed the average separation for the group to be 8 mm compared with an average preoperative x-ray film radioulnar separation of 5 mm (Fig. 3).
In addition to range-of-motion and strength measurements, patients were studied for residual elements of dorsal ulnar prominence manifested by dorsal translational instability, impingement, and/or painful range of motion; the presence of a "piano key" sign (ulnar instability noted with resisted forearm pronation) was also noted. Although all patients had a modest residual positive postsalvage piano key sign, none had pain with either active or passive forearm or wrist range of motion. In the series, there was no crepitus or grinding; the forearm compression test (compression of the distal ulna against the distal radius in neutral position) was also negative in all patients.
Subjective Data Visual analog scales were used to evaluate patients' responses to subjective questioning, in order to not affect their answers by preprinted digital values. Before surgery, each patient complained of painful "locking," "clicking," and/or a "catching" sen-
The Journal of Hand Surgery / Vo[. 20A No. 6 November 1995
955
Figure 3. (A) Preoperative x-ray film demonstrating radioulnar impingement, irregularity of the distal ulnar stump, and medial scalloping of the distal radius (arrows). (B) Postoperative x-ray film following salvage of the failed Darrach resection shows maintenance of an improved radioulnar separation, resolution of the scalloped border of the distal radius, and a less irregular contour of the resected distal ulna.
sation. All patients claimed postoperative improvement both in their ability to perform activities of daily living and in their ability to rotate their affected limbs through a full arc of forearm rotation. Preoperative pain levels were substantially reduced by surgery. Prior to surgery, five of the six patients reported pain at rest. Of these five patients, one reported no pain at postoperative follow-up examination, two reported pain with light activities, and two experienced pain only with heavy use of their affected extremity. One patient who reported preoperative pain only with light activity complained of pain only with heavy activity following reconstruction. While patients' subjective responses with respect to general postoperative satisfaction were variable, all stated that they would have the salvage procedure performed again. Three of the six patients returned to full gainful employment at their previous level of activity (one
fireman, one toolmaker, one computer analyst). One patient was unable to continue as a factory assemblyline worker due to the inability to perform heavy lifting and became a counter hostess. One with an active workmen's compensation claim remains unable to work because of an unrelated ipsilateral elbow problem requiring additional surgery, and one patient employed as a systems analyst retired to take over full-time care of an ill relative.
Discussion The Darrach procedure, first performed in 1911 at the Roosevelt Hospital in New York City, 9'1~ maintains its place in the hand surgeon's armamentarium as a surgical option for disorders of the distal radioulnar joint. Although first applied by Darrach for a case of chronic traumatic palmar dislocation of the distal ulna, today's applications include post-traumatic dis-
95;6 Kleinman and Greenberg / Salvage of Failed Darrach Procedure
tal radioulnar arthritis, instability, extensor tendon rupture (caput ulnae syndrome), ulnar impingement, disorders of the triangular fibrocartilage complex, and osteoarthritis or rheumatoid arthritis. Many procedures have been designed as alternatives to Darrach's distal ulna resection, 1,~-8largely because of the potential for associated complications such as pain, weakness, attritional tendon ruptures, mechanical impingement, and distal ulnar instability. Despite numerous papers advocating alternative procedures, distal ulna resection maintains its place as a viable option for distal radioulnar arthritis. Tulipan et al.21in 1.991 defended the Darrach resection, emphasizing careful preoperative indications, meticulous technique, and appropriate aftercare as essentials for surgical success. Bieber et al. TM were able to identify only 20 of 288 patients with Darrach resections who did not have a satisfactory surgical result. Following distal ulna resection, all the mechanical restraints preventing radioulnar impingement have been eliminated. Because of loss of bony contact at the distal radioulnar joint, impingement of the radius and ulna can now occur, with progressive narrowing of the interosseous space. In addition, a variety of muscular forces may accentuate distal radioulnar impingement. The PQ is a muscle that normally stabilizes the distal radioulnar joint in the unaltered state; it can become a strong deforming force, exaggerating distal radioulnar impingement, in the absence of an intact ulna seat. Also contributing to potential impingement are the muscles of the first dorsal compartment (abductor pollicis longus, extensor poliicis brevis), which originate along the ulnar border of the interosseous membrane, crossing from medial to lateral across the interosseous space as they converge on the thumb. Their combined contractile force contributes to distal radioulnar impingement in the absence of distal bony contact. Finally, loss of stability of the triangular fibrocartilage complex and the associated ulnocarpal soft tissue stabilizers of the triangular fibrocartilage allows accentuated translation of the distal ulna with forearm rotation. TM Despite critical attention to technical details, instability after Darrach resection may develop. ~,15-1s,22'24,28 Symptoms include painful mechanical "popping," "catching" sensations, or "clicking"; severe ulnar impingement may be identified by erosive changes at the medial cortical margin of the distal radius, seen on x-ray film 13 (Fig. 3A). Painful instability and its associated secondary weakness become difficult management problems.
There is a paucity of literature regarding salvage of the failed Darrach procedure; comparison among the many small series of clinical cases and our own series is difficult. Each clinical series advocates a different approach to the painful, unstable distal ulnar stump following Darrach resection. Goldner and Hayes ~5 described treatment of 50 patients for post-Darrach instability with a partial ECU tenodesis, without giving detailed results. Incorporation of a tenodesis with a distal ulna resection was reported by Tsai et al. 28 who used 50% ECU, and Hui and Linscheid, 3~ who incorporated 50% of the flexor carpi ulnaris as an ulnotriquetral ligament augmentation. Neither group applied this technique to salvage of the failed Darrach resection. Breen and Jupiter 24 combined a distally based flexor carpi ulnaris tenodesis and a proximally based ECU tenodesis to tether the unstable distal ulna, but in only three of their eight patients was the procedure used for a symptomatic failed Darrach resection. Two of the five patients in Tsai and Stilwell's report 27 of the use of partial flexor carpi ulnaris tenodesis had good results when the procedure was applied to salvage of the failed Darrach. Noble and Arafa's 16 one patient had good pain relief and returned to work following stabilization of the previously resected distal ulnar stump with the palmaris longus. Johnson 26 reported 15 patients who did well following advancement for painful instability (not through the interosseous space) and suggested that this technique could be applied to the unstable ulna following Darrach resection. Finally, Blatt's palmar capsulodesis 23 has been used at the time of distal ulna resection, but not for independent salvage after failure of a Darrach procedure. In 1973, Swanson 3~ reported his results using silicone rubber "capping" of the distal ulna plus ligament reconstruction to achieve painless stability following failed Darrach resection. Unfortunately, implant failure and silicone synovitis at long-term follow-up examination currently make this salvage technique unacceptable. Watson and Brown ~7 addressed post-Darrach instability and impingement by reestablishing ulna length by step-cut osteotomy. They recommended advancement of the lengthened distal ulna into the medial portion of the triangular fibrocartilage complex. Procedures that address instability by recreating a radioulnar tether are difficult to apply following failure of a distal ulna resection, 2,~4for success, these techniques rely on an intact distal radioulnar joint, which is absent following a Darrach resection.
The Journal of Hand Surgery / Vol. 20A No. 6 November 1995
Comparison among approaches is difficult owing to small patient numbers and the variety of preoperative conditions and treatments leading to both Darrach resection and Darrach salvage. The goal in treatment o f a failed Darrach is to correct (1) coronal and sagittal instability caused b y loss of bony contact at the distal radioulnar joint; (2) loss of the soft tissue-stabilizing elements of the triangular fibrocartilage; and (3) associated soft tissue complex and muscular forces that exaggerate lateral migration of the resected ulna against the medial cortex of the radius. While each previously reported clinical series advocates a technique that tethers the ulna in some fashion, our procedure seems to be the only one that addresses coronal instability (ECU tenodesis) and sagittal instability (PQ transfer) separately (Fig. 2). Our approach to problematic instability and impingement after Darrach resection was developed by analyzing the individual component parts of the problem; the r e c o m m e n d e d surgical procedure addresses each facet of the instability problem separately. 1. The PQ origin is detached from the palmar-medial ulna and transferred through the interosseous space to the dorsomedial aspect of the ulna. This substantial modification of Johnson's technique 26serves multiple purposes: first, a strong deforming force is eliminated by PQ tenotomy; second, a secure, palmar-oriented, dynamic tenodesis is provided by transferring the origin of the PQ from palmar-medial to dorsomedial, through the interosseous space, thereby reducing the tendency toward dorsal subluxation of the distal ulnar stump. This transfer also changes the "angle of attack" of the PQ tethering the ulna palmarly and retarding the propensity for dorsal ulnar instability, or "winging." Finally, the transferred muscle-tendon unit serves as interpositional material, further helping to prevent impingement of the resected distal ulna against the medial border of the radius. 2. Longitudinal ECU tenodesis to a point just proximal to the fibroosseous canal of the sixth dorsal compartment gives additional support to the unstable distal ulnar stump and retards its tendency to translate medially. Only half of the ECU is used; its fibroosseous canal and the linea jugata are left intact. Longitudinal tenodesis can therefore be made to the remaining intact partial tendon of the ECU, just proximal to the unviolated semirigid fibrous tissue of the sixth dorsal compartment. 3. The appropriate relationship between the distal radius and ulna is maintained securely by two divergent, percutaneously placed 0.062 Kirschner wires until soft tissue healing has occurred. Stability can then be maintained independently of the hardware.
957
References 1. Bilos ZJ, Chamberland D. Distal ulnar head shortening for treatment of triangular fibrocartilage complex tears with ulna positive variance. J Hand Surg 1991; 16A:115-9. 2. Bowers WH. Surgical procedures for the distal radioulnar joint. In: Lichtman D, ed. The wrist and its disorders. Philadelphia: WB Saunders, 1988:232-43. 3. Bowers WH. Distal radioulnar joint arthroplasty: the hemiresection-interposition technique. J Hand Surg 1985;10A: 169-78. 4. Darrow JC, Linscheid RL, Dobyns JH et al. Distal ulnar recession for disorders of the distal radioulnar joint. J Hand Surg 1985;10:482-91. 5. Dibenedetto MR, Lubbers LM, Coleman CR. Long-term results of the minimal resection Darrach procedure. J Hand Surg 1991;16A:445-50. 6. Feldon P, Terrono AL, Belsky MR. The "wafer" procedure. Clin Orthop 1992;275:124-9. 7. Watson HK, Ryu J, Burgess RC. Matched distal ulnar resection. J Hand Surg 1986:11A:812-7. 8. Watson HK, Gabuzda GM. Matched distal ulna resection for posttraumatic disorders of the distal radioulnar joint. J Hand Surg 1992;17A:724-30. 9. Darrach W. Anterior dislocation of the head of the ulna. Ann Surg 1912;56:802-3. 10. Darrach W. Habitual forward dislocation of the head of ulna. Ann Surg 1913;57:928-30. 11. Darrach W. Partial excision of lower shaft of ulna for deformity following Colles' fracture. Aim Surg 1913;57:764-5. 12. Darrach W, Dwight K. Derangements of the inferior radioulnar articular. Med Rec 1915 ;87:708. 13. Bell MJ, Hill RJ, McMurtry RY. Ulnar impingement syndrome. J Bone Joint Surg 1985;67B:126-9. 14. Dell PC. Distal radioulnar joint dysfunction. Hand Clin 1987;3:563-82. 15. Hartz CR, Beckenbaugh RD. Long-term results of resection of the distal ulna for post-traumatic conditions. J Trauma 1979;19:219-26. 16. Noble J, Arafa M. Stabilization of distal ulna after excessive Darrach's procedure. J Hand Surg 1983;15:70-2. 17. Watson HK, Brown RE. Ulnar impingement syndrome after Darrach procedure: treatment by advancement lengthening osteotomy of the ulna. J Hand Surg 1989;14A:302-6. 18. Bieber EJ, Linscheid RL, Dobyns JH, Beckenbaugh RD. Failed distal ulna resections. J Hand Surg 1988;13A: 193-200. 19. Dingman PVC. Resection of the distal end of the ulna (Darrach operation). J Bone Joint Surg 1952;34A: 893-900. 20. Rana NA, Taylor AR. Excision of the distal end of the ulna in rheumatoid arthritis. J Bone Joint Surg 1973;55B:96-105. 21. Tulipan DJ, Eaton RG, Eberhart RE. The Darrach procedure defended: technique redefined and long-term followup. J Hand Surg 1991;16A:438-44. 22. Field J, Majkowski RJ, Leslie IJ. Poor results of Darrach's procedure after wrist injuries. J Bone Joint Surg 1993;75B:53-7.
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23. Blatt G. Capsulodesis in reconstructive hand surgery. Hand Clin 1987;3:81-102. 24. Breen TF, Jupiter JB. Extensor carpi ulnaris and flexor carpi ulnaris tenodesis of the unstable distal ulna. J Hand Surg 1989;14A:612-7. 25. Goldner JL, Hayes MG. Stabilization of the remaining ulna using one-half of the extensor carpi ulnaris tendon after resection of the distal ulna. Orthop Trans 1979;3:330-1. 26. Johnson RK. Muscle-tendon transfer for stabilization of the distal radioulnar joint. J Hand Surg 1985;10A:437. 27. Tsai TM, Stilwell JH. Repair of chronic subluxation of the distal radioulnar joint (ulnar dorsal) using flexor carpi ulnaris tendon. J Hand Surg 1984;9B:289-94.
28. Tsai TM, Shimizu H, Adkins E A modified extensor carpi ulnaris tenodesis with the Darrach procedure. J Hand Surg 1993;18A:697-702. 29. Lourie GM, King J, Kleinman WB. The transverse radioulnar branch from the dorsal sensory ulnar nerve: its clinical and anatomical significance further defined. J Hand Surg 1994;19A:241-5. 30. Hui FC, Linscheid RL. Ulnotriquetral augmentation tenodesis: a reconstructive procedure for dorsal subluxation of the distal radioulnar joint. J Hand Surg 1982:7: 230-6. 31. Swanson AB. Flexible implant arthroplasty in the hand and extremities. St. Louis: CV Mosby, 1973;275.