Three operations for distal radioulnar joint dysfunction — match the procedure to the patient. The operation is dictated by demand, age and pathology, not by surgeon preference.
- DARRACH: distal ulna resection of 1.5–2cm — for the elderly, low-demand or rheumatoid patient. Contraindicated in young active patients. Complications include ulnar translation of the carpus, convergence syndrome and instability.
- SAUVÉ-KAPANDJI: DRUJ arthrodesis plus a proximal pseudarthrosis — for the young active patient and rheumatoid patients where ulnar carpal support must be preserved; better long-term function than Darrach.
- ULNAR SHORTENING OSTEOTOMY: 2–4mm oblique diaphyseal shortening for ulnar impaction syndrome (positive ulnar variance, degenerative TFCC tears, ulnocarpal abutment).
- TFCC has five components: central articular disc, dorsal radioulnar ligament, volar radioulnar ligament, meniscus homologue and ECU subsheath. The deep foveal fibres of the radioulnar ligaments are the primary stabiliser of the DRUJ.
- Patient selection is THE exam question. Young and active means Sauvé-Kapandji or an ulnar shortening osteotomy; elderly and low demand means a Darrach is acceptable. Never offer a Darrach to a young active patient — convergence syndrome occurs in 20–30 percent of them.
When & Why
Indication. Surgery is offered for symptomatic distal radioulnar joint (DRUJ) dysfunction that has failed conservative management (activity modification, splinting, physiotherapy and an intra-articular corticosteroid injection) — namely DRUJ arthritis, DRUJ instability, or ulnar impaction syndrome. The single most important decision is which of the three operations fits the patient, because each addresses a different problem and carries a different risk profile. Assess the patient first. Confirm the diagnosis clinically and radiographically. Examine for the piano-key sign — depress the dorsally prominent ulnar head; in DRUJ instability it springs back up like a piano key when released, always compared with the contralateral side (some laxity is physiological, so a firm endpoint on the normal side is the reference). CT of both wrists in pronation, neutral and supination is the gold standard for DRUJ instability. Measure ulnar variance on a standard PA radiograph taken in neutral rotation (shoulder abducted 90 degrees, elbow flexed 90 degrees, forearm neutral, beam perpendicular to the wrist): positive variance (ulna longer) drives ulnar impaction; negative variance (radius longer) is associated with Kienböck's disease; grip and pronation create dynamic positive variance, so a static film may underestimate impaction. The one decision that matters. Every DRUJ procedure fits one of three boxes:
Elderly, low-demand patient with symptomatic DRUJ arthritis, rheumatoid arthritis with DRUJ involvement, post-traumatic DRUJ arthritis in a low-demand patient, or salvage of a failed prior procedure. Resect 1.5–2cm of the distal ulna. Avoid in the young, active or high-grip-demand patient.
Young active patient with DRUJ arthritis or instability, rheumatoid arthritis where ulnar carpal support must be preserved, ulnar impaction combined with DRUJ arthritis, or salvage of a failed Darrach with convergence. Fuses the DRUJ and creates a proximal pseudarthrosis so forearm rotation is preserved.
Ulnar impaction syndrome (ulnocarpal abutment) — positive ulnar variance (typically greater than +2mm) with a degenerative central TFCC tear (Palmer class II) and lunotriquetral ligament tears secondary to impaction. Oblique diaphyseal osteotomy shortening the ulna 2–4mm, aiming for zero to slightly negative variance.
When NOT to operate, or to choose differently. Distinguish the pathologies, because the wrong operation destroys function: - Do not perform a Darrach in the young or active patient — convergence syndrome (painful ulnar stump instability, 20–30 percent in active patients), loss of grip strength of 20–40 percent, and ulnar carpal translation are all unacceptably common. Contraindications also include ligamentous laxity, an isolated TFCC tear without bony pathology (too destructive), and ulnar variance abnormality without DRUJ arthritis (a shortening osteotomy is preferable).
- Sauvé-Kapandji is relatively contraindicated in severe osteoporosis (pseudarthrosis fixation is unreliable), active infection, and the very elderly with very low demands (a Darrach is simpler).
- For mild ulnar impaction (positive variance less than roughly 2–4mm) consider the wafer procedure — arthroscopic resection of the distal 2–3mm of the ulnar head through the central TFCC defect. It is less invasive and avoids osteotomy hardware, but allows only limited shortening and is contraindicated when positive variance exceeds 4mm or there is DRUJ instability or arthritis. Consent specifically for residual instability or convergence (after Darrach), ulnar carpal translation (worse in rheumatoid disease and ligamentous laxity), stiffness or loss of forearm rotation, dorsal sensory branch of ulnar nerve injury (numbness or a painful neuroma), hardware prominence requiring later plate removal (ulnar shortening osteotomy, around 30 percent), and the small risk of non-union of a fusion (Sauvé-Kapandji) or osteotomy. Setup. Supine, arm on a hand table, upper-arm tourniquet. For the dorsal DRUJ approach (Darrach, Sauvé-Kapandji) the forearm is pronated; for an ulnar shortening osteotomy the arm is positioned to expose the medial distal forearm. Loupe magnification protects the dorsal sensory branch of the ulnar nerve, which is the structure most often injured.
The Operation
The goal depends on the procedure: a Darrach removes the arthritic distal ulna while stabilising the stump; a Sauvé-Kapandji fuses the DRUJ to abolish arthritis pain and creates a proximal pseudarthrosis to retain rotation; an ulnar shortening osteotomy unloads the ulnocarpal joint to relieve impaction. The dominant exposure is the dorsal approach to the DRUJ, shared by the Darrach and Sauvé-Kapandji, and laid out in full as the first steps of the sequence below. The ulnar shortening osteotomy uses a separate medial approach to the ulnar shaft, described when we reach it.
Operative sequence
- Supine, hand table, upper-arm tourniquet.
- For the dorsal DRUJ approach, pronate the forearm. Mark the distal ulna, the ulnar styloid and the line of the 5th (EDM) and 6th (ECU) extensor compartments.
- A longitudinal dorsal incision over the distal ulna, between the 5th (EDM) and 6th (ECU) compartments, 4–5cm and centred over the distal ulna.
- In the subcutaneous plane, identify and protect the dorsal sensory branch of the ulnar nerve — it runs subcutaneously over the dorsal ulna, crossing ECU about 6–8cm proximal to the ulnar styloid, and is the structure most often injured.
- Open the extensor retinaculum between the 5th (EDM) and 6th (ECU) compartments to reach the DRUJ capsule.
- Preserve the ECU in its subsheath — the subsheath forms the floor of the 6th compartment and is a DRUJ stabiliser; it must be repaired at closure.
- Elevate the periosteum/capsule over the distal ulna and DRUJ. The volar ulnar artery and nerve (radial to the pisiform) and the dorsal cutaneous branch are the structures at risk; the deep dissection works down to the ulnar head and sigmoid notch.
- Through the exposed distal ulna, plan a resection of 1.5–2cm of the distal ulna, preserving periosteum for later soft-tissue closure.
- Make the saw cut perpendicular to the ulnar shaft with an oscillating saw and retractors protecting the soft tissues.
- Smooth all sharp bony edges with a rongeur and rasp — rough edges cause convergence and impingement.
- Avoid over-resection (more than 2cm increases instability and convergence) and under-resection (persistent impingement). Send the specimen for histology if the appearance is unusual.
- Stabilise the proximal ulnar stump to reduce convergence — an ECU tenodesis (reroute ECU to act as a dynamic restraint) or pronator quadratus advancement over the stump.
- Repair the ECU subsheath and retinaculum, and repair periosteum over the stump to create a fibrous cap.
- Layered closure; a sugar-tong or below-elbow splint holds the wrist while the soft tissues heal.
- Through the same dorsal exposure, strip the articular cartilage from both the sigmoid notch and the ulnar head using an osteotome and burr.
- Appose the decorticated surfaces with the ulnar head reduced into the sigmoid notch in neutral forearm rotation.
- Fix the DRUJ arthrodesis with two 3.5mm or 4.0mm cannulated screws (K-wires only if the bone is too poor to hold screws). Confirm position with intra-operative fluoroscopy.
- Resect a 1–1.5cm segment of the ulnar shaft, 1–2cm proximal to the fusion site — remove the segment entirely; this gap is what allows forearm rotation.
- Smooth the edges of the remaining proximal and distal stumps.
- Interpose soft tissue (fascia, pronator quadratus or local soft tissue) in the pseudarthrosis gap — this prevents bony bridging, which would eliminate all forearm rotation.
- Repair the ECU subsheath and close the retinaculum. Splint in neutral rotation.
- This procedure does NOT use the dorsal DRUJ exposure. Make a medial forearm incision over the mid-to-distal ulnar shaft (4–5cm), 4–6cm proximal to the DRUJ.
- Protect the dorsal sensory branch of the ulnar nerve at the proximal end of the incision.
- Subperiosteal exposure of the ulnar diaphysis.
- Confirm the planned shortening from pre-operative ulnar variance (for example, +3mm variance aiming for −1mm means a 4mm shortening).
- Perform an oblique osteotomy of the ulnar diaphysis with an oscillating saw or a dedicated shortening jig; resect the measured 2–4mm segment and cut the distal bone to match the oblique angle.
- Apply a dedicated ulnar shortening plate (6- or 8-hole dynamic compression plate) with a minimum of three screws proximal and three screws distal to the osteotomy; add a lag screw across the oblique cut if the design permits.
- Confirm 2–4mm shortening and the new ulnar variance on intra-operative fluoroscopy, then stress the DRUJ — stability should be improved.
- Layered closure for all three procedures; release the tourniquet and confirm perfusion and (where relevant) DRUJ stability.
- Immobilise per procedure: Darrach — sugar-tong/below-elbow splint; Sauvé-Kapandji — above-elbow cast in neutral rotation; ulnar shortening osteotomy — below-elbow cast.
After a Darrach the proximal ulnar stump loses the sigmoid-notch constraint and approximates the radius under axial load and rotation, producing a painful click, clunk or giving way and a weak grip. It occurs in 20–30 percent of active patients, which is why a Darrach must not be offered to a young or high-demand patient. Resect no more than 2cm, stabilise the stump with an ECU tenodesis or pronator quadratus advancement at the index operation, and repair the ECU subsheath. Established convergence is rarely solved conservatively — salvage is soft-tissue stabilisation, a Bowers hemiresection, a Sauvé-Kapandji conversion, or a constrained DRUJ prosthesis.
A Darrach removes the ulnar buttress, allowing the carpus to translate ulnarly over time (5–15 percent, worse in rheumatoid disease and ligamentous laxity). The Sauvé-Kapandji fuses the ulnar head in its anatomical position, preserving ulnar carpal support while the proximal pseudarthrosis carries forearm rotation. For a working-age rheumatoid patient this is the decisive advantage.
In a Sauvé-Kapandji, if the proximal pseudarthrosis heals with bone, the patient now has both a fused DRUJ and a united ulnar shaft — and all forearm rotation is permanently lost. Prevent it with an adequate resection (1–1.5cm) and soft-tissue interposition in the gap at the primary operation.
Aftercare & Complications
Rehabilitation Forearm rotation is the most critical functional movement to restore after every DRUJ procedure. Begin active-assisted pronation and supination, progressing to resisted; commence grip strengthening once a fusion is confirmed (Sauvé-Kapandji) or the osteotomy is uniting (ulnar shortening osteotomy). Plan an early return to activities of daily living with a protective splint, and full return at 3–4 months.
- Immobilisation
- Sugar-tong or below-elbow splint for 2–3 weeks
- Return to light duties
- 4–6 weeks
- Return to heavy work
- 8–12 weeks
- Hardware / follow-up
- Wound at 2 weeks, ROM at 6 weeks, function at 3 months; no routine hardware
- Immobilisation
- Above-elbow cast in neutral rotation for 4–6 weeks
- Return to light duties
- 6–8 weeks
- Return to heavy work
- 4–6 months (once fusion is confirmed)
- Hardware / follow-up
- X-ray at 6 weeks, 12 weeks and 6 months; hardware removed only if loose or symptomatic
- Immobilisation
- Below-elbow fibreglass cast for 6 weeks
- Return to light duties
- 6–8 weeks
- Return to heavy work
- 3–4 months (once osteotomy unites)
- Hardware / follow-up
- X-ray at 6 weeks, 12 weeks and 6 months; plate removal in roughly 30 percent at 12+ months for prominence
Complications
- Incidence
- 20–30% in active patients
- Mechanism
- Ulnar stump approximates the radius under axial load and rotation after loss of DRUJ constraint; painful clicking and catching
- Management
- Soft-tissue stabilisation (ECU tenodesis, FCU sling); Bowers hemiresection; DRUJ prosthesis (Aptis); Sauvé-Kapandji conversion
- Incidence
- 5–15%
- Mechanism
- Loss of the ulnar buttress allows the carpus to translate ulnarly; progressive in rheumatoid disease
- Management
- Early — splinting and physiotherapy; late or severe — radiocarpal stabilisation or partial wrist fusion
- Incidence
- 5–10%
- Mechanism
- Dorsal sensory branch of the ulnar nerve at risk during the skin incision or dorsal dissection
- Management
- Neuropraxia — observe 6–12 weeks; neuroma — desensitisation, gabapentin; refractory — neuroma excision
- Incidence
- 5–10%
- Mechanism
- Fibrous cap over the stump becomes painful, or incomplete resection leaves a spike
- Management
- Steroid injection; revision shortening and smoothing of any spikes if persistent
- Incidence
- Significant in active patients
- Mechanism
- Loss of ulnar column stability reduces grip strength by 20–40 percent in active patients
- Management
- Physiotherapy and grip strengthening; consider Sauvé-Kapandji pre-emptively in the young patient
- Incidence
- 10–20%
- Mechanism
- An unstabilised pseudarthrosis allows painful proximal stump impingement on the radius
- Management
- Stabilisation — ECU sling, FCU tenodesis or interosseous membrane plasty around the pseudarthrosis
- Incidence
- 5–10%
- Mechanism
- Inadequate decortication, poor fixation, osteoporosis or infection
- Management
- Revision fixation with bone graft; electrical stimulation as an adjunct
- Incidence
- Rare but catastrophic
- Mechanism
- The pseudarthrosis heals with bone — the patient now has a fused DRUJ and a united ulna, and loses all forearm rotation
- Management
- Revision resection of the bony bridge with fresh soft-tissue interposition; prevent at the primary operation with adequate resection and interposition
- Incidence
- 10–15%
- Mechanism
- Inadequate pseudarthrosis gap, scarring or instability limits rotation
- Management
- Physiotherapy and rotation exercises; if the gap is too small, revise to widen the pseudarthrosis
- Incidence
- 2–5%
- Mechanism
- Insufficient compression, poor bone contact, smoking or diabetes
- Management
- Revision fixation with bone grafting; electrical stimulation
- Incidence
- 20–30%
- Mechanism
- Subcutaneous plate over the dorsal ulna is prominent and painful with pressure
- Management
- Hardware removal once the osteotomy is fully healed (minimum 12 months) — common and expected; counsel the patient pre-operatively
- Incidence
- Rare
- Mechanism
- Too much shortening over-tightens the TFCC and causes ulnar-sided pain
- Management
- Usually asymptomatic if mild; ulnar lengthening is rarely needed
- Incidence
- 10–15%
- Mechanism
- The osteotomy heals but the TFCC tear is not addressed — ongoing instability or central disc tear
- Management
- Arthroscopic TFCC debridement or repair if still symptomatic at 6 months
- Indication
- Elderly, RA, low demand
- Pain relief
- Good–excellent 80–90%
- ROM
- Well preserved in the low-demand patient
- Grip strength
- Reduced 20–40% in active patients
- Long-term issues
- Convergence syndrome 20–30%; ulnar carpal translation 5–15%
- Indication
- Young active, RA, failed Darrach
- Pain relief
- Good–excellent 85–90%
- ROM
- Forearm rotation preserved or improved
- Grip strength
- Better preserved than Darrach
- Long-term issues
- Pseudarthrosis instability 10–20%; non-union 5–10%
- Indication
- Ulnar impaction (positive variance)
- Pain relief
- Good–excellent in most series
- ROM
- Maintained
- Grip strength
- Maintained or improved
- Long-term issues
- Hardware removal common (~30%); non-union ~4% (Owens 2018); residual TFCC symptoms 10–15%
- Indication
- Mild ulnar impaction (less than ~2–4mm)
- Pain relief
- Good 75–85%
- ROM
- Maintained
- Grip strength
- Maintained
- Long-term issues
- Only limited shortening possible (2–3mm); not for severe impaction or DRUJ pathology
Viva & Exam Focus
DRUJDRUJ — the five components of the TFCC
DARRACHDARRACH-vs-SK — procedure selection
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A 35-year-old primary school teacher presents with 18 months of right wrist pain, worst on the ulnar side. X-ray shows positive ulnar variance of 3mm. MRI confirms a central TFCC disc tear. She has no arthritis. She has failed 6 months of conservative management including splinting and physiotherapy. What procedure do you recommend and describe the key steps?”
“A 55-year-old retired man presents 2 years after a Darrach procedure performed elsewhere. He complains of a painful click and giving way in his right wrist during forearm rotation, and his grip is very weak. On examination you note medial forearm pain and a palpable clunk when loading the wrist in pronation. What complication has occurred and how do you manage it?”
“A 42-year-old nurse with rheumatoid arthritis has progressive DRUJ instability and pain. She has Larsen grade 3 RA changes at the wrist. Her piano key sign is markedly positive. She is still working full time and requires good hand function. What DRUJ procedure do you recommend and why?”
Procedure selection (critical)
- DARRACH: elderly, low demand, RA (simple), poor bone — resect 1.5–2cm distal ulna
- SAUVÉ-KAPANDJI: young or active, RA (preserve carpal support), failed Darrach — DRUJ arthrodesis plus proximal pseudarthrosis
- ULNAR SHORTENING: ulnar impaction syndrome (positive variance plus TFCC degeneration) — diaphyseal osteotomy 2–4mm
- NEVER Darrach in the young active patient — convergence syndrome 20–30 percent, grip weakness, ulnar carpal translation
- WAFER procedure: arthroscopic 2–3mm distal ulna resection — a less invasive alternative for mild impaction only
TFCC anatomy (5 components)
- 1. Central articular disc (fibrocartilage) — weight-bearing, transmits about 20 percent of axial load via the ulna
- 2. Dorsal radioulnar ligament — foveal attachment, taut in pronation
- 3. Volar radioulnar ligament — foveal attachment, taut in supination
- 4. Meniscus homologue — fibrous tissue, ulnar border, cushioning
- 5. ECU subsheath — floor of the 6th compartment, DRUJ stabiliser
- Foveal attachment of the deep radioulnar ligaments is critical for DRUJ stability — a class IB tear is repairable
Palmer TFCC classification
- Class I (traumatic): IA central (avascular, not repaired); IB peripheral ulnar (vascular, repaired); IC distal; ID radial
- Class II (degenerative): IIA wear, IIB plus chondromalacia, IIC plus perforation, IID plus LT tear, IIE plus DRUJ arthritis
- Ulnar impaction equals class IIC–D degenerative (positive variance, central disc perforation, LT tear)
- IB peripheral tears are the only traumatic tears amenable to primary repair
Darrach technique
- Dorsal approach between the 5th (EDM) and 6th (ECU) compartments
- Protect the dorsal sensory branch of the ulnar nerve (subcutaneous, dorsal ulna)
- Resect 1.5–2cm of distal ulna — NO more (increases instability)
- Soft-tissue stump stabilisation: ECU tenodesis or pronator quadratus advancement
- Repair the ECU subsheath and retinaculum
Sauvé-Kapandji technique
- Step 1: decorticate the DRUJ articular surfaces (sigmoid notch plus ulnar head), fix in neutral rotation with 2 cannulated screws
- Step 2: resect a 1–1.5cm ulnar shaft segment 1–2cm proximal to the fusion — the pseudarthrosis
- Step 3: interpose soft tissue in the pseudarthrosis gap — CRITICAL to prevent bony bridging
- Above-elbow cast in neutral rotation for 4–6 weeks
- If the pseudarthrosis bridges with bone, all forearm rotation is lost (catastrophic)
Ulnar shortening osteotomy technique
- Oblique osteotomy of the ulnar diaphysis 4–6cm proximal to the DRUJ
- Shortening: 2–4mm (aim zero to slightly negative variance) — confirm on intra-operative fluoroscopy
- Fix with a dedicated ulnar shortening plate: minimum 3 screws each side
- Below-elbow cast for 6 weeks until union
- Hardware removal: roughly 30 percent require plate removal at 12+ months for subcutaneous prominence
Key complications
- Darrach: convergence syndrome (20–30 percent in active patients) — stump approximates radius under load; ECU tenodesis or SK conversion
- Darrach: ulnar carpal translation (5–15 percent) — carpus drifts ulnar; worse in RA and laxity
- SK: bony bridging of the pseudarthrosis (rare but catastrophic) — lose all rotation; prevent with soft-tissue interposition
- SK: pseudarthrosis instability or pain (10–20 percent) — ECU sling stabilisation
- USO: hardware irritation (~30 percent) — plate removal at 12+ months; non-union 2–5 percent
Exam tips & key statements
- ALWAYS ask patient age and activity before choosing a DRUJ procedure — young means SK; elderly may accept Darrach
- Ulnar variance measurement: PA view, shoulder abducted 90 degrees, elbow 90 degrees, neutral rotation, beam perpendicular
- Piano key sign equals DRUJ instability (positive — ulnar head springs back up after dorsal compression)
- References: Darrach 1913; Sauvé-Kapandji 1936; Palmer 1989 (PMID 2666492 — TFCC classification); Minami 2005 (PMID 16568521 — SK/HIT superior grip and return-to-work versus Darrach); Owens 2018 (PMID 30342784 — USO non-union ~4%)
Background & Evidence
What the DRUJ is, and why these procedures exist. The distal radioulnar joint is the pivot on which the forearm rotates, and it transmits load between the radius and ulna (about 80 percent through the radius, 20 percent through the ulna via the TFCC). When the joint is destroyed by arthritis, destabilised by trauma or rheumatoid synovitis, or overloaded by positive ulnar variance, three operations address three different failures — resection (Darrach), fusion-with-pseudarthrosis (Sauvé-Kapandji), and unloading by shortening (ulnar shortening osteotomy). Choosing the wrong one converts a salvageable wrist into a dysfunctional one. Surgical anatomy of the DRUJ. The osseous components are the sigmoid notch of the radius (concave), the ulnar head (convex), the ulnar fovea (a sulcus at the base of the ulnar styloid where the deep radioulnar ligament fibres insert — critical for stability), and the ulnar styloid (non-articular; insertion of the superficial radioulnar ligaments and ECU subsheath). The neurovascular structures at risk are the dorsal sensory branch of the ulnar nerve (subcutaneous, dorsal ulna, 6–8cm proximal to the styloid) and the volar ulnar artery and nerve (radial to the pisiform). The ECU runs in the 6th compartment; its subsheath forms the floor of that tunnel and must be repaired after DRUJ surgery. The extensor retinaculum is opened between the 5th and 6th compartments for dorsal DRUJ access.
- Attachments / detail
- Sigmoid notch of the radius to the ulnar styloid base; radial attachment is strong/periosteal
- Function
- Weight-bearing; transmits about 20 percent of axial load via the ulna. Central perforations are normal with age
- Attachments / detail
- Deep fibres to the fovea; superficial fibres to the ulnar styloid tip
- Function
- Primary stabiliser; taut in pronation, restrains dorsal translation of the ulnar head
- Attachments / detail
- Deep fibres to the fovea; superficial fibres to the ulnar styloid tip
- Function
- Primary stabiliser; taut in supination, restrains volar translation of the ulnar head
- Attachments / detail
- Fibrous tissue on the ulnar border of the TFCC
- Function
- Cushions the ulnar head against the proximal carpal row; fills the ulnocarpal space
- Attachments / detail
- Floor of the 6th extensor compartment, confluent with the ulnar capsule
- Function
- DRUJ stabiliser; repaired as part of a peripheral TFCC repair
- Subtype
- IA
- Feature
- Central perforation
- Repairable?
- No — avascular
- Subtype
- IB
- Feature
- Peripheral ulnar (avulsion) tear at the fovea
- Repairable?
- Yes — vascular
- Subtype
- IC
- Feature
- Distal (ulnocarpal) detachment
- Repairable?
- Yes
- Subtype
- ID
- Feature
- Radial avulsion (with the sigmoid notch)
- Repairable?
- Yes (if repairable)
- Subtype
- IIA
- Feature
- TFCC wear
- Repairable?
- N/A — unload the joint
- Subtype
- IIB
- Feature
- Wear plus chondromalacia of the lunate or ulna
- Repairable?
- N/A
- Subtype
- IIC
- Feature
- Plus TFCC perforation
- Repairable?
- N/A
- Subtype
- IID
- Feature
- Plus lunotriquetral ligament tear
- Repairable?
- N/A
- Subtype
- IIE
- Feature
- Plus DRUJ arthritis
- Repairable?
- N/A — consider DRUJ procedure
Key evidence. The two foundational procedures are the original descriptions by Darrach (1913) of distal ulna excision for deformity after a Colles' fracture, and by Sauvé and Kapandji (1936) of combined DRUJ arthrodesis with a proximal pseudarthrosis. Palmer (1989, PMID 2666492) provided the definitive TFCC classification — traumatic (class I) versus degenerative (class II) — still used universally. Feldon, Terrono and Belsky (1992, PMID 1629557) described the wafer resection (distal 2–4mm of the ulnar head), contraindicated when positive variance exceeds 4mm. Minami et al (2005, PMID 16568521) directly compared Darrach, Sauvé-Kapandji and hemiresection-interposition in 61 wrists at a mean 10-year follow-up and found grip strength and return-to-work after Sauvé-Kapandji and hemiresection statistically superior to Darrach, which had the most complications — the evidence base for preferring Sauvé-Kapandji in the working-age patient. Owens et al (2018, PMID 30342784) systematically reviewed 37 studies and 1,423 ulnar-shortening osteotomies and reported an overall non-union rate of only 4.0 percent, with no significant difference between transverse and oblique cuts — establishing the reliability of the osteotomy and directing the transverse-versus-oblique choice toward factors other than union risk (the oblique cut allows lag-screw compression and rotational stability).
References
- Darrach W. Partial excision of the lower shaft of the ulna for deformity following Colles' fracture. Ann Surg 1913;57(5):764–5. [Original description of distal ulna resection for DRUJ dysfunction] 2. Sauvé L, Kapandji M. Nouvelle technique de traitement chirurgical des luxations récidivantes isolées de l'extrémité inférieure du cubitus. J Chir (Paris) 1936;47:589–94. [Original description of DRUJ arthrodesis with proximal pseudarthrosis creation] 3. Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg Am 1989;14(4):594–606. PMID: 2666492. doi:10.1016/0363-5023(89)90174-3. [Definitive classification of TFCC injuries — Palmer class I (traumatic) and class II (degenerative), used universally] 4. Feldon P, Terrono AL, Belsky MR. Wafer distal ulna resection for triangular fibrocartilage tears and/or ulna impaction syndrome. J Hand Surg Am 1992;17(4):731–7. PMID: 1629557. doi:10.1016/0363-5023(92)90325-j. [Original wafer procedure series; distal 2–4mm resection, contraindicated if positive variance greater than 4mm] 5. Minami A, Iwasaki N, Ishikawa J, Suenaga N, Yasuda K, Kato H. Treatments of osteoarthritis of the distal radioulnar joint: long-term results of three procedures. Hand Surg 2005;10(2-3):243–8. PMID: 16568521. doi:10.1142/S0218810405002942. [Darrach versus Sauvé-Kapandji versus hemiresection, 61 wrists, mean 10-year follow-up; SK/HIT superior grip and return-to-work versus Darrach, which had the most complications] 6. Minami A, Iwasaki N, Ishikawa J, Suenaga N, Kato H. Stabilization of the proximal ulnar stump in the Sauvé-Kapandji procedure by using the extensor carpi ulnaris tendon: long-term follow-up studies. J Hand Surg Am 2006;31(3):440–4. PMID: 16516739. doi:10.1016/j.jhsa.2005.11.012. [ECU half-slip stabilisation of the proximal stump to address post-SK radioulnar convergence] 7. Owens J, Compton J, Day M, Glass N, Lawler E. Nonunion rates among ulnar-shortening osteotomy for ulnar impaction syndrome: a systematic review. J Hand Surg Am 2018;44(7):612.e1–612.e12. PMID: 30342784. doi:10.1016/j.jhsa.2018.08.018. [37 studies, 1,423 patients; overall USO non-union 4.0 percent, no difference transverse versus oblique] 8. Adams BD, Berger RA. An anatomic reconstruction of the distal radioulnar ligaments for posttraumatic distal radioulnar joint instability. J Hand Surg Am 2002;27(2):243–51. PMID: 11901383. doi:10.1053/jhsu.2002.31731. [Anatomical reconstruction of the radioulnar ligaments restored stability in 12 of 14 patients with an irreparable TFCC and intact articular surfaces] 9. Scheker LR, Babb BA, Killion PE. Distal ulnar prosthetic replacement. Orthop Clin North Am 2001;32(2):365–76. PMID: 11331548. doi:10.1016/s0030-5898(05)70256-x. [DRUJ/distal ulna prostheses as salvage for failed resection and convergence syndrome]
Treatments of osteoarthritis of the distal radioulnar joint: long-term results of three procedures
- 61 wrists (20 Darrach, 25 Sauvé-Kapandji, 16 hemiresection-interposition) followed 5–14 years (mean 10 years)
- Improvement in grip strength and return to original job after Sauvé-Kapandji and hemiresection were statistically superior to Darrach
- Darrach had the highest number of post-operative complications of the three procedures
- Procedure choice guided by TFCC status and degree of positive ulnar variance
Nonunion rates among ulnar-shortening osteotomy for ulnar impaction syndrome: a systematic review
- 37 studies, 1,423 patients undergoing ulnar-shortening osteotomy for ulnar impaction syndrome
- Overall non-union rate 4.0 percent (transverse 4.16 percent versus oblique 3.86 percent, not significant)
- Overall delayed-union rate 5.7 percent
- No difference in non-union between transverse and oblique osteotomy cuts
Wafer distal ulna resection for triangular fibrocartilage tears and/or ulna impaction syndrome
- Distal 2–4mm of the ulnar head resected while preserving the ulnar styloid and its ligaments
- 13 wafer resections in 12 patients — all good to excellent at minimum 1-year follow-up
- Contraindicated if positive ulnar variance greater than 4mm
- Not indicated where DRUJ instability or arthritis is present
Triangular fibrocartilage complex lesions: a classification
- Classifies TFCC lesions into traumatic (class I) and degenerative (class II)
- Class I subdivided by location: IA central, IB peripheral or ulnar avulsion, IC distal (ulnocarpal), ID radial avulsion
- Class II is the degenerative spectrum of ulnar impaction (IIA–IIE), progressing to lunotriquetral tear and DRUJ arthritis
- Remains the universal reference classification for TFCC pathology
Distal ulnar prosthetic replacement
- Reviews distal ulna and DRUJ prostheses including a total joint replacement designed by the authors
- Prosthetic replacement restores ulnar-head support for both forearm rotation and grip and lifting
- Provides a salvage option after failed resection arthroplasty (for example convergence syndrome)
- A stable, functioning DRUJ is essential for grip and lifting, not only rotation