Excision of the distal ulna in rheumatoid arthritis

E X C I S I O N OF T H E D I S T A L U L N A IN R H E U M A T O I D ARTHRITIS Is t h e price t o o high? J. NANCHAHAL, P. J. SYKES and R. L. WILLIAMS

From the Welsh Centrefor Plastic Surgery, Morriston Hospital, Swansea, Wales Patients with rheumatoid arthritis who underwent excision of the distal ulna were reviewed and the operated wrist was compared with the non-operated side in the 40 patients who had the procedure performed unilaterally. Radiological assessment showed that the radiocapitate measurement of carpal translocation was the most consistent and that excision of the distal ulna was not associated with statistically significant collapse, ulnar translocation or radial rotation of the carpus. 61% of wrists spontaneously developed a radial shelf or limited radiocarpal fusion following excision of the distal ulna, compared to 21% of non-operated wrists. However, there was no statistically significant difference in carpal collapse or ulnar translocation between these two groups.

Journal of Hand Surgery (British and European Volume, 1996) 21B: 2:189-196 Numerous modifications to the basic procedure of distal ulna excision have been proposed, including capsulodesis or tenodesis of the ulnar stump (Breen and Jupiter, 1991; Posner and Ambrose, 1991). These may be associated with a significantly diminished range of movement (Thirupathi et al, 1983), although wrist motion appears to be preserved in other studies (Leslie et al, 1990). Limited wrist arthrodesis (Chamay et al, 1983) has also been suggested to overcome the ulnar translocation associated with resection of the distal ulna alone. Alternative techniques such as hemiresection arthroplasty (Bowers, I985), matched ulnar resection (Watson et al, 1986) and the Sauv6-Kapandji procedure (Taleisnik, 1992) have also been proposed. Hemiresection arthroplasty was developed because it preserves the ulnocarpal ligaments and is only appropriate when the triangular fibrocartilage complex is intact or can be repaired (Bowers, 1985): these form the minority of the cases in our practice. Furthermore, in more severely affected wrists, the ulnar styloid may remain prominent, abrade the extensor tendons and ulnocarpal impingement may not be relieved (Bogoch et al, 1992) unless combined with an ulna shortening procedure. The Sauvd-Kapandji procedure may transfer symptomatic instability to the proximal ulnar stump (Nathan and Schneider, 1991), as evidenced by a clunk on rotation of the forearm in 17% (Taleisnik, 1992) to 60% of patients (Vincent et al, 1993), and may be associated with a decrease in the range of movement (Vincent et al, 1993). Since resection of the distal ulna alone dramatically improves the patients' symptoms, this study was undertaken to determine whether it is associated with greater translocation, collapse or radial rotation of the carpus compared to the non-operated side in the same patients.

The wrist is affected in 95% of patients with rheumatoid arthritis (Rasker et al, 1980) and deteriorates more rapidly than any other joint (Scott et al, 1986; H/imN/iinen et al, 1992). Involvement of the distal radioulnar joint may lead to the caput ulnae syndrome (B/ickdahl, 1963), characterized by synovial proliferation, dorsal displacement of the ulna with pain on attempted reduction, weakness, decline in function and pain. The range of movement, especially rotation, may be diminished and the long digital extensors may rupture. Resection of the distal ulna was popularized by Darrach (1912) and first reported for the treatment of the rheumatoid wrist by Smith-Petersen et al (1943). Over the years this has gained popularity and in Souter's (1979) assessment of procedures useful in treating the "rheumatoid hand," it came second to fusion of the metacarpal joint of the thumb. Many studies have confirmed the improvement in patients' pain, function and range of pronation and supination at the wrist (Cracchiolo and Marmor, 1969; Mooller, 1973; Rana and Taylor, 1973; Ansell et al, 1974; Jackson et al, 1974; Mikic and Helal, 1977; Rasker et al, t980; Newman, 1987; O'Donovan and Ruby, 1989; Brumfield et al, 1990; Leslie et al, 1990; Melone and Taras, 1991; Horlbeck et al, 1992; Ishikawa et al, 1992b). Despite the apparent benefits of resection of the distal ulna, it has been suggested that removal of the ulnar buttress of the wrist accentuates some of the deformities associated with rheumatoid arthritis (Linscheid and Dobyns, 1971). Jackson et al (1974) noted ulnar translocation of the carpus postoperatively in patients with "gross disease" and assumed that this was a direct result of the surgery. In a study comparing the mean ulnar translocation of the carpus in operated and unoperated wrists, Ishikawa et al (1992b) found that translocation increased with time following surgery and they attributed this to loss of bony support provided by the ulna. These authors went on to recommend combination of excision of the distal ulna with tendon transfer (Clayton and Ferlic, 1974) for early disease and limited wrist arthrodesis in later stages.

MATERIALS AND METHODS

The case notes of 111 patients admitted under the care of one consultant in the period 1977 to 1992 who 189

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underwent excision of the distal ulna were retrieved. An attempt was made to contact these patients directly by letter or, failing this, via their general medical practitioners. In the clinic, they were asked for their subjective assessment of pain and function of the wrist as to whether it was better, the same or worse than their preoperative state. It was noted whether a click occurred at the distal ulna on pronation and supination. Posterior-anterior radiographs were obtained of both wrists in neutral, maximal ulnar and maximal radial deviation. These were compared with radiographs taken immediately preoperatively. The severity of the radiological changes in the preoperative radiographs were compared with standard reference films (Larsen et al, 1977). Patient selection for resection of the distal ulna was based on pain and tenderness localized to the distal radioulnar joint with limitation of pronation and supination, despite adequate medical treatment. If the wrist was clinically unstable and there was radiological evidence of gross bony destruction, the patient was offered fusion of the wrist.

Operative procedures A "lazy S" or a straight dorsal skin incision was made, protecting the veins and the sensory branch of the ulnar nerve. The extensor retinaculum was split longitudinally along the sixth dorsal compartment and reflected radially. A synovectomy of the extensor tendons was performed at this stage and the terminal branch of the posterior interosseous nerve resected. The distal ulna was approached subperiosteally, resected just proximal to the distal radioulnar joint and any sharp bone ends rounded. Synovectomy of this joint and of the radiocarpal joint was performed. The capsule was then closed and the extensor carpi ulnaris tendon relocated in its dorsal position using a radially-based sling of the extensor retinaculum. Repair of any ruptured extensor tendons was performed and the majority of the remainder of the retinaculum was sutured deep to the tendons, with a strip placed over the tendons to prevent bowstringing. A corrugated drain was placed down to the resected bone end and the hand, wrist and forearm covered with a well padded dressing. The drain was removed at 48 hours and graduated physiotherapy commenced 4 days postoperatively.

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2. The perpendicular distance, C, between the centre of rotation and a line drawn through the radial styloid (Chamay et al, 1983). 3. The perpendicular distance, D, between the centre of rotation and an extension of the midaxial line of the radius (DiBenedetto et al, 1990). These were expressed as ratios of the length of the third metacarpal to account for differences in film magnification. Carpal translocation was calculated from the difference between the pre- and postoperative ratios. Carpal height was defined as the distance between the base of the third metacarpal and the distal articular surface of the radius in the line of the midaxis of the metacarpal (Youm et al, 1978) (Fig lb). It was expressed as a ratio of the length of the third metacarpal and carpal collapse was calculated by subtracting the postoperative ratio from the preoperative ratio. Radial deviation of the carpus was assessed by measuring the angle formed between the midaxis of the radius and the midaxis of the third metacarpal. In patients with end-stage disease it may be impossible to obtain reliable measurements and there was only one patient of this type in our series (Fig 2). The presence of spontaneous radiocarpal fusion or a radial shelf was noted (Fig 3). RESULTS In total, 104 patients were identified. Seventeen patients had died, 21 were untraceable and nine were either too infirm or refused to attend for follow-up. The total number of patients recalled was 57. Of these, 17 had the procedure performed bilaterally. The age range of the patients was 29-77 years, with a mean of 59 years (Fig 4) and 48 (84%) of the patients were female. The dominant hand was operated on in 31 (78%) of the 40 patients who had the procedure performed unilaterally. The postoperative period ranged from 1 to 17 years, with a mean of 6.4 years (Fig 5). Based on the patients' subjective assessment, pain was absent in 55% of operated wrists and improved in 45%. Function was reported as being better postoperatively by more than 80% of the patients. Clicking on pronation and supination was present in 7% of operated wrists.

Radiological assessment Larsen grading

Radiological measurements Carpal translocation was determined by three methods (Fig la): 1. The carpal-ulnar distance, U, from the centre of rotation of the capitate, situated along its longitudinal axis at a point one quarter of its total length from the proximal end, to the intersection of the perpendicular to the distal projection of the midaxis of the ulna (Youm et al, 1978).

Considering the operated wrists of patients who underwent surgery unilaterally, 12 (36%) were graded as 1 to 2, 20 (61%) as 3 to 4 and one (3%) as grade 5. On the nonoperated side, 13 (40%) were graded as 1 to 2, 19 (57%) as 3 to 4 and one (3%) as 5.

Carpal translocation The most accurate means of measuring carpal translocation was determined by assessing which measurement

DISTAL ULNAR EXCISION

Fig 1

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(a) The ulnar-carpal ( U ) and radiocarpal (C and D) measurements used carpal height used to calculate carpal collapse.

was least dependent on the posture of the wrist. The carpal-ulnar ( U ) and the carpal-radial (C and D) measurements (Fig 1a) were performed on postoperative radiographs taken in neutral, maximum ulnar and maximum radial deviation. The average percentage variation from neutral with the wrist in maximum ulnar and radial deviation was determined. Forty-seven wrists were assessed. The mean percentage variations were 8% for the carpal-ulnar ( U ) , 0.4% for the Chamay (C) and 2.6% for the DiBenedetto (D) ratio. The Chamay radiocapitate measurement is clearly the most consistent and was used in all subsequent analyses. To determine whether excision of the distal ulna led to carpal translocation, the postoperative Chamay ratio was subtracted from the preoperative ratio and the operated hands were compared with the non-operated hands using a paired t-test. Patients who underwent surgery bilaterally were excluded. The difference was not statistically significant (P = 0.31 ). Therefore, excision of the distal ulna did not lead to significant carpal translocation. The results are represented graphically in Figure 6.

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calculate carpal translocation. (b) The measurement of

Spontaneous radiocarpalfusion or radial shelfformation When adequate pre- and postoperative radiographs were available, the development of spontaneous radiocarpal fusion or a radial shelf was assessed (Fig 3). Only patients who underwent surgery unilaterally were considered and those with a shelf or fusion preoperatively were excluded. Of the operated wrists, 17 (61%) developed a shelf or fusion postoperatively compared to 11 where this did not occur. In the non-operated group, the numbers were 5 (20%) and 20, respectively. A Z2test showed that there was a highly significant correlation (P=0.006) between excision of the distal ulna and the spontaneous development of a radial shelf or a limited radiocarpal fusion. In operated wrists, the mean change in the Chamay translocation ratio was compared for those patients who developed a radial shelf or fusion with those where this did not occur. A t-test showed there was no statistically significant difference (P = 0.8). This did not change when only patients with a limited radiocarpal fusion were compared with those where neither a shelf or fusion

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Fig 2

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Radiographs of a patient with end stage (Larsen grade 5) rheumatoid disease, making measurements impracticable.

formed (P=0.89). Thus, the spontaneous development of a radial shelf or a limited radiocarpal fusion did not appear to control carpal translocation following excision of the distal ulna.

Carpal collapse The postoperative carpal height ratio was subtracted from the preoperative ratio and the operated hand compared with the non-operated side using a paired ttest. This was restricted to patients who underwent unilateral excision of the distal ulna. There was no significant difference between the two groups (P=0.52) and thus excision of the distal ulna did not cause statistically significant carpal collapse. The results are represented graphically in Fig 7. In some instances there appeared to be an increase in carpal height postoperatively, and this is represented by the negative values.

Carpal rotation The preoperative radiocarpal angle was subtracted from the postoperative value to determine the change in carpal rotation. Operated and non-operated wrists of

patients who underwent surgery unilaterally were compared using a paired t-test. The difference did not reach statistical significance (P = 0.72), indicating that excision of the distal ulna did not contribute significantly to radial deviation of the carpus in patients with rheumatoid arthritis.

DISCUSSION The majority of patients who attended for follow-up were pain free and had improved function after excision of the distal ulna. These results rely on the patients' recall and are influenced by the status of other joints in the upper limb. Nonetheless, subjective assessment of the rheumatoid patient is important (Leslie et al, 1990) and our findings confirm the results of several previous studies. In our practice, patients tend to present to the surgeon when their disease is in a relatively advanced state. The radiographs of approximately 60% of the individuals in this study were classified as Larsen grade 3 or 4, that is with moderate or severe destructive changes. This is also reflected by the rarity of the occasions when the triangular fibrocartilage complex

DISTAL ULNAR EXCISION

Fig 3

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(a) The development of spontaneous radiolunate fusion following resection of the distal ulna. (b) The spontaneous development of a radial shelf.

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can be reconstructed to enable the hemi-resection arthroplasty procedure (Bowers, 1985) to be carried out. We limited resection of the ulna just proximal to the distal radioulnar joint. Gainor and Schaberg (1985) found a correlation between marked ulnar translocation and excision of more than 2 cm of the distal ulna. Limiting the amount of bone resected may also avoid complications such as tendon rupture (Friedman et al,

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1986) and has the added benefit of preserving the insertion of the pronator quadratus (Clawson and Stern, 1991 ). In his comparison of the results following surgery for non-rheumatoid disorders, Dingman (1952) found that preservation of the periosteum or the styloid process did not influence the results, although resection of the minimum amount of bone correlated with a good result. It has been suggested that clicking can also be avoided by excising less than 2 cm of the distal ulna (Rana and

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Graphical representation of carpal translocation of patients who underwent surgery unilaterally. Positive values represent ulnar translocation and negative values radial translocation. There was no statistically significant difference between the operated and non-operated wrists of each patient.

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Graphical representation of carpal collapse in patients who underwent surgery unilaterally. There was no statistical difference between the operated and non-operated wrists of each patient.

Taylor, 1973). Previous reports suggest that approximately a third of patients develop clicking postoperatively (Mooller, 1973; Rana and Taylor, 1973). The comparatively small number (7%) of wrists in our study which developed a click postoperatively may have been due to the limited resection and also to the careful relocation of the extensor carpi ulnaris tendon dorsally, as suggested by Spinner and Kaplan (1970). In our experience, clicking also tends to diminish with time postoperatively and our relatively long mean follow-up time of 6.4 years may have contributed to the low incidence. After resection of its distal end, the shaft of the ulna deviates radially (Chamay et al, 1983; Gainor and Schaberg 1985; Linscheid and Dobyns, 1985; Newman, 1987). Therefore, measurement of the ulnar-carpal distance (Youm et al, 1978) is no longer a reliable index of carpal translocation. The radiocapitate measurements (Chamay et al, 1983; DiBenedetto et al, 1990) overcome these problems. Our results indicate that the method described by Chamay et al (1983) is the least dependent

on position of the wrist. This technique had a specificity of 100%, an accuracy of 87% and an extremely high interobserver correlation compared to other techniques for measurement of carpal translocation (Pirela-Cruz et al, 1993). Observer differences were eliminated in the present study as all the measurements were performed by one of the authors. The relatively low sensitivity of the technique (27%) quoted by Pirela-Cruz et al (1993) did not affect our study as all the calculations were based on subtracting the postoperative from the preoperative ratio and comparing the operated and nonoperated wrists. It has been suggested that the measurement described by Chamay is not accurate as it is not directly related to the length of the third metacarpal (Bouman et al, 1994). In our study this would not affect the results as the operated and unoperated wrists of each patient were compared in a paired fashion. The alternative measurement proposed by these authors relies on the length of the distal articular surface of the radius, which may be altered in rheumatoid arthritis when there is erosion of the ulnar border of the radius. We have used a widely accepted method of expressing carpal height as a ratio of the length of the third metacarpal. Bouman et al (1994) suggested that the height of the capitate may be preferable as the denominator but this is not constant and is likely to alter with the severity of the carpal collapse. Our results indicate that excision of the distal ulna does not lead to statistically significant carpal collapse when comparing wrists of each patient undergoing surgery on one side only. Ishikawa et al (1992b) reported similar findings as a result of their unpaired analyses. Although there is a consensus amongst many authors that resection of the distal ulna improves the patient's symptoms, there is a growing body of opinion that the procedure leads to progressive ulnar translocation of the carpus. This was suggested by Linscheid and Dobyns (1971) and reiterated by Jackson et al (1974) and Goncalves (1974). However, Rasker et al (1980) found that ulnar translocation was not commoner in operated compared to non-operated wrists, although no objective measurements were obtained. Ishikawa et al (1992b) used the radiocapitate measurement described by DiBenedetto et al (1990) to show that 2 years after excision of the distal ulna, there was statistically significant translocation of the carpus in an ulnar direction compared to unoperated wrists. However, the surgically treated and untreated wrists of each patient were not compared in a paired fashion and their results may have been influenced by differences in disease patterns between patients. A recent study (Van Gemert and Spauwen, 1994) comparing the mean ulnar translocation of operated and unoperated wrists in the same patients concluded that the rheumatoid process contributed more to ulnar translocation than resection of the distal ulna. Although the two groups were matched in terms of the severity of the Larsen grading, again a paired statistical analysis was not done. We retained the pairing of the

DISTAL U L N A R EXCISION

wrists of each individual during statistical analysis and our results show that excision of the distal ulna is not associated with ulnar carpal translocation. Although comparison of the operated and non-operated wrists in the same individual would at first appear unjustified as the majority of the operations were on the dominant hand, this may at least to some extent reflect functional impairment rather than accelerated progress of the disease on the dominant side. H~im~,lfiinen et al (1992) found that an equal number of left and right wrists had radiological changes about 10 years after onset of the disease. Our data showed that an equal number of operated and non-operated wrists fell into early (Larsen grades 1-2) and late (3-4) categories, with approximately two-thirds falling into the latter group. Black et al (1977) suggested that it is the destructive process at the ulnar border of the radius rather than resection of the distal ulna which leads to carpal translocation. The absence of radiolunate contact in preoperative radiographs predicted the group of patients who required subsequent surgery and this may be an important prognostic factor, a view shared by Melone and Taras (1991). In our practice this group with marked radiocarpal instability would be treated by total wrist arthrodesis. In the present series, 20% of non-operated wrists developed a radial shelf or spontaneous limited radiocarpal fusion, compared to 61% following excision of the distal ulna. Spontaneous radiolunate arthrodesis has been reported to occur in about 13% of non-operated rheumatoid wrists (Chamay et al, 1983), whilst others quote fgures of 24% (Melone and Taras, 1991 ). Chamay et al (1983) suggested that this limited carpal translocation and carpal collapse after resection of the distal ulna and recommended that the procedure be carried out surgically if there is radiocarpal instability. These findings were confirmed by Linscheid and Dobyns (1985), although neither study compared matched unoperated control wrists. A recent longer-term (1-15 years) follow-up, with a mean of 4.8 years, by Della Santa and Chamay (1995) compared operated and non-operated wrists of the same patients, albeit not in a paired fashion. The progression of carpal collapse was the same in the two groups and ulnar translocation was found to be greater in the wrists treated by excision of the ulnar head and surgical radiotunate fusion. Moreover, radiolunate arthrodesis may lead to a decrease in the range of motion (Linscheid and Dobyns, 1985), particularly flexion and extension, of 30% (Chamay et al, 1983) to 70% (Ishikawa et al, 1992a). Limited wrist arthrodesis may also be associated with undue stress (Linscheid and Dobyns, 1985) and continued degeneration (Stanley and Boot, 1989) at adjacent intercarpal joints. Our results suggest that carpal translocation was not significantly affected by the development of spontaneous radiocarpal fusion or a radial shelf. The pattern of degeneration at the wrist in rheumatoid arthritis can be classified as ankylosis, osteoarthritis and disintegration (Simmen and Huber, 1992). The concept

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of limited radiocarpal fusion is based on the results seen in the ankylosis subgroup, and may not be applicable to the other two categories. The differences seen between the first two types and the disintegration group (Simmen and Huber, 1992) means that it is vital to limit comparison of operated and non-operated wrists to the same individual. The present study is one of the few to do this. Simmen and Huber (1992) found that the initial accelerated carpal translocation and collapse seen on the operated "~rists of the disintegration pattern became equal to that of the non-operated wrists on prolonged follow-up. This indicates that the rheumatoid process is the primary factor in both these deformities. Our results suggest that excision of the distal ulna makes little contribution in the long-term and emphasizes the need for adequate follow-up when assessing these patients. Della Santa and Chamay (1995) suggest that resection of the distal ulna and radiolunate fusion should be used in patients with the osteoarthritis pattern and radiological changes ranging from marginal erosions and wrist deviation to midcarpal ankylosis and major radiocarpal instability. They recommend total wrist arthrodesis or arthroplasty for patients with the ankylosis or destructive patterns at these stages and for more advanced stages of the osteoarthritis type. It is accepted that fusion of the wrist in rheumatoid arthritis leads to a pain-free situation. However, a fixed position compromises function, particularly if performed bilaterally and function of other joints of the upper limb is already diminished (Linscheid and Dobyns, 1971; Taleisnik, 1989). The procedure should be reserved for completely unstable wrists with osseous destruction (Straub and Ranawat, 1969). Ulnar translation of the carpus down the inclined surface of the radius is said to be caused by loss of the ulnar buttress, leading to radial rotation of the carpus and the zigzag deformity (Linscheid and Dobyns, 1971 ). A radial inclination angle greater than 22° was found to be associated with radial carpal rotation and ulnar carpal translocation (DiBenedetto et al, 1991 ). We found no statistically significant increase in radial deviation of the carpus in operated wrists compared to the nonoperated side. The lack of statistically significant radial rotation, collapse and ulnar translocation of the carpus in our patients undergoing resection of the distal ulna compared to the non-operated side suggests that the ulnar buttress is not the primary structure in controlling these deformities. The carpus is suspended from the radius by radiolunotriquetral and radioscaphocapitate ligaments arising from palmar-radial corner of the radius and by the radiolunotriquetral ligament arising from the dorsal ulnar corner of the radius (Taleisnik, 1976; 1989). Destruction of these ligaments by the rheumatoid process leads to radial deviation, collapse (Taleisnik, 1979', 1989) and ulnar translocation (Posner and Ambrose, 1991) of the carpus. In our series there was a higher incidence of the spontaneous development of a radial

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shelf or limited radiocarpal fusion in operated wrists, but this was not associated with a decrease in ulnar translocation of the carpus. Acknowledgments We would like to thank John Firrell, PhD, Christine Kleinert Institute, Louisville, Kentucky, for his invaluable help with the statistical analyses. The secretarial assistance of Jo Bailey is gratefully acknowledged. Dr Arnold Williams of the University Hospital of Wales, Cardiff also helped retrieve many radiographs without which the paper would never have been written. Referellces ANSELL B M, ARDEN G P and HARRISON S H (1974). The results of ulna styloidectomy in rheumatoid arthritis. Scandinavian Journal of Rheumatology, 3: 67, BACKDAHL M The caput ulnae syndrome in rheumatoid arthritis. Uppsala, Almqvist and Wiksells, 1963: 27. BLACK R M, BOSWICK J A and WlEDEL J (1977). Dislocation of the wrist in rheumatoid arthritis: the relationship to distal ulna resection. Clinical Orthopaedics and Related Research, 124:184-188. BOGOCH E, WEILER P, McCALDEN R and HASTINGS D Perilunar Deformity in the Rheumatoid Wrist. In: Simmen B R and Hagena F-W (Eds.): The wrist in rheumatoid arthritis, Basel, Karger, 1992: 43-51. BOUMAN H-W, MESSER E and SENNWALD G (1994). Measurement of ulnar translation and carpal height, Journal of Hand Surgery, 19B: 325-329. BOWERS W H (1985). Distal radioulnar joint arthroplasty: the hemiresectioninterposition technique. Journal of Hand Surgery, 10A: 2: 169-178. BREEN T F and JUPITER J ( 199l ). Tenodesis of the chronically unstable distal ulna. Hand Clinics, 7:355 363. BRUMFIELD R, KUSCHNER S H, GELLMAN H, LILES D N and VAN WINCKLE G (1990). Results of dorsal wrist synovectomies in the rheumatoid hand. Journal of Hand Surgery, 15A: 733-735. CHAMAY A, DELLA SANTA D and VILASECA A (1983). L'arthrod6se radio-lunaire: facteur de stabilit6 du poignet rheumatoide. Annales de Chirurgie de la Main, 2: 5-17. CLAWSON M C and STERN P J (1991). The distal radioulnar joint complex in rheumatoid arthritis: an overview. Hand Clinics, 7: 373-381. CLAYTON M L and FERLIC D C (1974). Tendon transfer for radial rotation of the wrist in rheumatoid arthritis. Clinical Orthopaedics and Related Research, 100: 176-185. CRACCHIOLO A and MARMOR L (1969). Resection of the distal ulna in rheumatoid arthritis. Arthritis and Rheumatism, 12:415 422. DARRACH W (1912). Anterior dislocation of the head of the ulna. Annals of Surgery, 56:802 803. DELLA SANTA D and CHAMAY A (1995). Radiological evolution of the rheumatoid wrist after radiolunate arthrodesis. Journal of Hand Surgery, 20B: 146-154. DIBENEDETTO M R, LUBBERS L M and COLEMAN C R (1990). The standardized measurement of ulnar carpal translocation. Journal of Hand Surgery, 15A: 1009-1010. ~IBENEDETTO M R, LUBBERS L M and COLEMAN C R (1991). Relationship between radial inclination angle and ulnar deviation of the fingers. Journal of Hand Surgery, 16A: 36-39. DINGMAN P V C (1952). Resection of the distal end of the ulna (Darrach operation). Journal of Bone and Joint Surgery, 34A: 893-899. FRIEDMAN B, YAFFE B, KAMCHIN M and ENGEL J (1986). Rupture of extensor digitorum communis after distal ulnar styloidectomy. Journal of Hand Surgery, l l A : 818 822. GAINOR B J and SCHABERG J (1985), The rheumatoid wrist after resection of the distal ulna. Journal of Hand Surgery, 10A: 837-844. GON(2ALVES D (1974). Correction of disorders of the distal radioulnar joint by artificial pseudoarthrosis of the ulna. Journal of Bone and Joint Surgery, 56B: 462-464. HAM/~.LA.INEN M, KAMMONEN M, LEHT1MAKI M e t al. In: Simmen, B R and Hagena F W (Eds.): The Wrist in Rheumatoid Arthritis. Basel, Karger, 1992, 1-7. HORLBECK M, DINGES H and THABE H, Midterm Results after Wrist and Tenosynovectomy. In: Simmen B R and Hagena F-W (Eds.): The wrist in rheumatoid arthritis. Basel, Karger, 1992:87 89. ISHIKAWA H, HANYU T, SAITO H and TAKAHASHI H (1992a). Limited arthrodesis for the rheumatoid wrist. Journal of Hand Surgery, 17A: 1103-1109. ISHIKAWA H, HANYU T and TAJJMA T (1992b). Rheumatoid wrists treated with synovectomy of the extensor tendons and the wrist joint combined with a Darrach procedure. Journal of Hand Surgery, 17A: 1109-1117. JACKSON I T, MILWARD T M, LEE P and WEBB J (1974). Ulnar head resection in rheumatoid arthritis. The Hand, 6: 172-180.

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