Treatment Outcomes in Patients Undergoing Surgical Treatment for Arthritis of the Distal Radioulnar Joint

Abstract

Objective Surgical treatment options for distal radioulnar joint (DRUJ) arthritis include distal ulnar resection (DUR), DRUJ arthrodesis, and ulnar head replacement. Ulnar convergence leading to persistent pain and clicking is a relatively common complication of complete DUR and DRUJ arthrodesis with distal ulnar segment resection (DRUJA). This led to the development of the distal ulna hemiresection (DUHR) and distal ulnar stump stabilization techniques to reduce the risk of this complication. Patients may experience incomplete relief of pain and limited range of motion (ROM) with these procedures. We hypothesized that there would be no differences in outcomes between the treatment groups, but patients undergoing DUHR, tendon interposition, or distal ulnar stump stabilization would be at lower risk of complications. Methods Records were retrospectively reviewed for 121 patients undergoing DRUJ procedures between 2000 and 2018 at a single institution to collect patient demographics, surgical details, preoperative diagnosis, and outcomes including complications, revision procedures, ROM, pain, and swelling. Patients were grouped for analysis by procedure type: DUR (Darrach procedure), DUHR (Bowers procedure), and DRUJA (Sauve–Kapandji procedure). Continuous variables were compared using an analysis of variance test and categorical variables using the Freeman–Halton extension of the Fisher's exact test. A multivariate logistic regression analysis was performed to identify significant predictors of outcomes. Results Seventy-three patients underwent a DUR procedure, while 33 patients underwent a DUHR procedure and 11 underwent a DRUJA procedure. Mean follow-up was 70.6 months. Patients undergoing DRUJA were significantly younger than those undergoing DUR or DUHR procedure (42.4 vs. 60.0 vs. 62.1, p < 0.001). No significant differences between groups were demonstrated in measured outcomes. Posttraumatic arthritis was the most common preoperative diagnosis (43.4%). Persistent pain was the most common negative outcome (25.6%) followed by limited ROM (19.7%). Five patients (4.3%) suffered postoperative complications, most common being rupture of extensor tendons. Five patients (4.3%) underwent revision procedures. Body mass index (BMI) was a significant predictor of persistent pain (odds ratio = 1.09, p = 0.031). Conclusion The results of our study suggest that outcomes are equivalent between the three distinct treatment groups. Despite the potential benefits, hemiresection, tendon interposition, and distal stump stabilization had no significant effect on outcomes in this study. More than a quarter (25.6%) of patients undergoing DRUJ procedures experience persistent pain postoperatively, while one-fifth (19.7%) experienced limited ROM. Patients with higher BMI are at a significantly greater risk of experiencing persistent postoperative pain. Level of Evidence This is a Level III, retrospective comparative study.

Sauvé-Kapandji and Darrach Salvage Procedure Rates and Perioperative Parameters for Distal Radioulnar Joint Arthritis and Instability

“…Four previous retrospective cohort analyses of Darrach versus S-K procedures similarly report Darrach treatment groups to be an average of 5 to 18 years older than S-K treatment groups. 9,11,14,15 As expected, there exist a greater proportion of men who undergo the S-K procedure compared with the Darrach procedure. This is likely due to physician and patient preference for the S-K procedure because it is regarded as the preferred procedure for active patients or those whose occupation is physical in nature due to its preservation of force transmission and improvement in grip strength.…”

“…5,9-15 The literature for Darrach and S-K procedures is inconsistent in methodology, and studies often differ considerably regarding sample size, cause of DRUJ arthritis, and measures of postoperative outcomes. 5,9-15…”

“…5,8,10 Several studies directly comparing the Darrach and S-K procedures regarding postoperative outcomes have been conducted, and most studies have found nonsignificant differences in overall complication rates between the 2 procedures. 5,[9][10][11][12][13][14][15] Reporting of complication rates for both procedures varies considerably from study to study, and complication rates can be relatively high, ranging from 0% to 60%. 5,[9][10][11][12][13][14][15] Common complications include painful/prominent hardware (specific to S-K), heterotopic ossification, symptoms related to irritation of the dorsal sensory branch of the ulnar nerve, continued DRUJ pain, and ulnar stump instability (commonly seen in Darrach patients).…”

“…5,[9][10][11][12][13][14][15] Reporting of complication rates for both procedures varies considerably from study to study, and complication rates can be relatively high, ranging from 0% to 60%. 5,[9][10][11][12][13][14][15] Common complications include painful/prominent hardware (specific to S-K), heterotopic ossification, symptoms related to irritation of the dorsal sensory branch of the ulnar nerve, continued DRUJ pain, and ulnar stump instability (commonly seen in Darrach patients). 5,[9][10][11][12][13][14][15] The literature for Darrach and S-K procedures is inconsistent in methodology, and studies often differ considerably regarding sample size, cause of DRUJ arthritis, and measures of postoperative outcomes.…”

Distal Radio-Ulnar Joint Reconstruction after failed Darrach operation using free autogenous second toe Metatarso-phalangeal joint transfer. Development of the technique and a long-term (over 25 year) follow-up

“…Historically, that problem has been treated using a short or a modified resection of ulna head (Darrach procedure, Bowers procedure or Sauve-Kapandji procedure). All these resections are leaving some instability and persistent pains are found in over 25% even in recent well studied series [2] . If the shortening is too aggressive, that may easily induce a major iatrogenic instability between distal radius and remaining distal ulna shaft leading to a severe impingement.…”