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Distal Radio-Ulna Joint Replacement
An area often forgotten about is the distal radio-ulna joint. Tradionally the distal ulna was excised (Darrach’s Procedure) if troublesome, either from arthritis at the DRUJ or from abutment into the lunate. Later modified by Bowers, with a hemiresection or arthrodesed with a Sauve-Kapanje procedure.
Opinions between orthopaedic consultants will differ about the best choice of procedure, but this is because there is not necessary one CORRECT procedure. Darrach’s procedures nowadays, should be reserved for low demand individuals as the risk of ulna impingement (where the ulna stump rubs against the shaft of the radius) and instability is high. A Bower’s procedure is an option, but often cannot address the whole pathology. A Sauve-Kapanje procedure, although still taught as the treatment of choice for higher demand individuals, still has problems with ulna impingement.
However arthroplasty is an option. Currently there are a number of different implants in use. The Herbert distal ulna replacement has been available for a number of years and is involves the replacement of the distal ulna, it requires excising a large piece of the distal ulna and there is the risk of instability. At present it is often used for revision cases. A newer and more versatile implant is the Ascension® First Choice® DRUJ System. This is either a partial or modular distal ulna. It allows the ulna styloid to remain untouched therefore preserving stability.
The principle indications for replacement are:
- Joint incongruity post distal radius fracture
- Painful instability following previous surgery eg. Darrach’s, Bower’s and Sauve-Kapandji procedures
Are these implants the answer?
Not yet the long-term results are unpublished, but they do work. Even if a hemiarthoplasty of the distal ulna fails and implant requires to be removed, the patient is only left with the equivalent of a Bower’s type procedure. It is for this reason that I believe they are advances in treating patients with DRUJ pathology.