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Resection of the distal ulna in rheumatoid arthritis.

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Resection of the Distal Ulna in Rheumatoid Arthritis
By ANDREA
CRA~CHIOLO,
111, M.D., AND LEONARD
MARMOR,M.D.
Forty-two wrists in patients with rheumatoid arthritis were subjected to distal
ulna resection, and follow-up examinations were made. Failure of conservative
medical therapy, subluxation or dislocation of the distal ulna with pain or limited motion, persistent synovitis, and tendon involvement are the primary indi-
cations for surgery. These painful, deformed joints experienced an increased
range of motion and improved strength
and function postoperatively. There was
no recurrence of pain or synovitis, and
tendon rupture has not occurred. No operative or postoperative complications
occurred.
D
25 YEARS, the entire
concept of surgical care of patients
with rheumatoid arthritis has changed. NO
longer is complete quiescence of the disease
a necessary prerequisite; acutely inflamed
joints are treated surgically to relieve pain,
preserve function, and arrest the disease
process ( Smith-Petersonet al.I3 and Laws).
Surgical procedures performed on joints include synovectomy, arthoplasty, arthrodesis,
and osteotomy.
The wrist is a key point for muscle balance of the hand, and along with the distal
radioulnar joint is frequently involved in
rheumatoid patients. Of those affected, 95
per cent have bilateral inv~lvement.~
An
active proliferative synovitis in the wrist
involves both the radiocarpal and radioulnar joints, producing swelling with ligamentous laxity and resultant dorsal-ulnar
subluxation or dislocation of the distal ulna.
This produces pain and limits motion by
mechanically blocking supination. The adjacent tendons may be involved by synovial
infiltration and the deformed dislocated
ulnar head. Rupture of the extensor tendons
is almost a certainty if this condition develops and remains untreated or is resistant to treatment for any length of time.293,6
The combination of wrist weakness and
pain, especially during rotation, a dorsally
dislocated ulnar head, and rupture of long
extensor tendons has been called the “caput
ulnae syndrome” by Backdahl in his extensive review of this conditi0n.l
Resection of the distal ulna was reported
by E. M. Moore in 1880l1 and popularized
by Darrach in 1912.4It is commonly performed in an attempt to relieve symptoms
and improve wrist function in derangement
of the distal radioulnar joint secondary to
t r a ~ m a . ~ * ~The
. ~ Jprocedure
*
has been reported in rheumatoid patients as part of
the technic of wrist f u ~ i o n . ~ *Flatt
J ~ J ~described resection of the distal ulna in rheumatoid wrist surgery.GClayton reported distal ulna resection in 41 cases of patients
operated upon for extensor tendon rupture.3
From the Department of Surgery and Orthopedics, School of Medicine, University of California
at Los Angeles, Los Angeles, California.
Presentcd in part at the Interim Meeting of the
American Rheumatism Association, Atlanta, Georgia, December 6-7, 1968.
ANDREA.
CRACCHIOLO,
111, M.D.: Assistant Professor of Surgery and Orthopedics, Assistant
Research Rheumatologist, Giannini Foundation
Fellow, School of Medicine, University of Cali-
fornia at Los Angcles, Los Angeles, California.
LEONARD
MARMOR,M.D.: Associate Professor of
Surgery and Orthopedics, School of Medicine,
University of California at Los Angeles, Los
Angeles, California.
Reprint requests should be addressed to Dr.
Cracchiolo at the Division of Orthopedic Surgey,
School of Medicine, The Center for the Health
Sciences, University of California at Los Angeles,
Los Angeles, California 90024.
URING THE PAST
Ammms
AND
RHEUMATISM,VOL.12, No. 4 (AUGUST1969)
415
416
ANDREA CRACCHIOLO, III, AND LEONARD MARMOR
Fig. 1.-Case 11: preoperative x-rays showing widening of the distal radioulnar joint
with dorsal ulnar dislocation of the distal ulna. Note the lack of support of the ulna for
the carpal bones.
CLINICAL
MATERIAL
Thirty-four patients (31 women, 3 men)
with classical or definite rheumatoid arthritis underwent resection of the distal ulna.
Twenty-six patients had unilateral resections
( 15 right, 11 left), and 8 had bilateral procedures. The mean duration of their arthritis was 15 years (range 3-37 years), with
mean wrist involvement of 13 years (range
3-33 years ) . Their mean age was 45 years
(range 20-82 years). They were motivated,
cooperative patients who came to the clinic
with severe wrist pain and deformity as
their chief complaint. Wrist function was
weak, and motion was frequently impaired.
Some patients were unable to do such simple things as turning a door handle or performing personal tasks. All wrists had a
dorsally subluxated or dislocated ulnar head
which appeared enlarged and irregular.
Pain was common on palpation of the ulnar
head, and all wrists were swollen. The
range of motion was limited, especially
supination, which was frequently completely absent.
One of the earliest radiographic signs in
rheumatoid arthritis is soft tissue swelling
around the distal ulna. Erosive changes in
the ulnar styloid and ulnar head are seen
as the disease progresses. Later cases show
widening of the distal radioulnar joint. Finally, dorsal and ulnar dislocation results,
with the ulna presenting a mechanical block
to the radius rotating about it (Figs. 1, 2,
4A). All wrists in this series were classified
as stage I11 according to the ARA classifications.
Injection of 1 to 2 cc. of a 1 per cent
local anesthetic solution at the ulnar styloid
relieved symptoms in most of the wrists
RESECl'ION OF DLSTAL ULNA IN RA
417
Fig. 2 . 4 a s e 8: 55-year-old woman showing x-ray evidence of dorsally dislocated
ulna blocking supination.
when this was used as a diagnostic test. vading synovium. The resected bone end is
This is especially useful in evaluating pa- smoothed with a rasp (Figs. 3,4A,and 4B ) .
tients preoperatively if the ulnar head is The triangular fibrocartilage is almost alonly subluxated. Where this is the case, the ways completely destroyed, and its rempain and loss of motion are due to a florid nants should be removed. The periosteal
sleeve is repaired to prevent dorsal dissynovitis.
Therefore the indications used for resec- placement of the ulna. Only one patient here
tion of the distal ulna are: (1)subluxation exhibited a small amount of new bone foror dislocation of the distal ulna with pain mation within the sleeve. This consisted of
or limited motion, ( 2 ) persistent synovitis a pointed tip developing at the resected
about the distal ulna, and (3) extensor end which in no way interfered with the
tendon involvement together with (1) or excellent postoperative result. If it is not
totally destroyed, the ulnar collateral liga(2).
ment can be sutured to the periosteum or
OPERATIVE
TECHNIC
deep fascia. Excessive resection of the distal
Under tourniquet control, a standard ulna, including all of the pronator quadbayonet incision approximately 2 inches ratus attachment, tends to produce a delong is made longitudinally over the distal formity, as the remaining end of the ulna
ulna. Care is taken to preserve the super- protrudes beneath the skin of the distal
ficial cutaneous branch of the ulnar nerve forearm. The wound is closed in layers, and
and the extensor carpi ulnaris tendon. The a light pressure dressing is applied. Pronaperiosteum is carefully stripped from the tion and supination are vigorously encourdistal ulna. Drill holes outline the transverse aged on the first postoperative day and
osteotomy site ?4 to % inch from the distal should be intensified as postoperative pain,
end of the ulnar styloid. After resection, which is minimal, diminishes.
wrist exposure is excellent and as much
RESULTS
diseased synovium as possible is removed
A total of 42 wrists underwent this profrom the radioulnar and wrist joints with a
cedure
and were followed from 12 to 43
rongeur. If necessary, the extensor tendons
months
(mean, 22 months); 3 other pacan and should be cleaned free of all in-
418
ANDREA CRACCHIOLO, 111, AND LEONARD MARMOR
Fig. 3.-Case 3: ulnar head resected and end smoothed with a rasp. Motion is started
as early as possible.
419
RESECTION OF DISTAL ULNA I N FU
Fig. 4.-Case No. 6: (A) Preoperative anteroposterior view of right and left wrist.
Note the severe arthritic changes, and the ulnar drift of the carpal bones present before resection. (B) Postoperative 3% year follow-up anteroposterior and oblique views,
left wrist. The carpal bones are stable and unchanged from their preoperative position.
tients were lost to follow-up. Eighteen
wrists were followed for over 24 months.
There was no evidence of recurrence of
wrist swelling (Fig. 5 ) , and no extensor
tendons were ruptured postoperatively.
Pain was completely relieved in all but 2
patients, and these complained of only
minor occasional discomfort which did not
interfere with their activities. Twenty-seven
wrists had a 30 to 50 per cent improvement
of wrist strength, as determined by grip
strength and subjective assessment. The
remaining 15 patients had unchanged good
wrist strength a t follow-up. They considered the operated side functionally superior
to the unoperated side, unless, of course,
the unoperated side was not involved. Be-
cause most of the patients were female,
they were better able to perform household tasks, such as cleaning and cooking.
Postoperatively, 28 wrists had full pronation and supination as compared to 18
wrists prior to surgery (Table 1).Only nine
wrists had 20 degrees or more of dorsiilexion
and palmar flexion preoperatively, whereas
18 wrists had 20 degrees or more postoperatively, along with full pronation and
supination. More than twice as many wrists
had optimal range of wrist motion after the
operation. After resection of the distal ulna,
only four wrists had 45 degree supination;
all others had full supination. This should
be compared with the seven wrists with
0 degree supination and another seven with
420
ANDREA CRACCHIOLO, 111, AND LEONARD MARMOR
Fig. 5.-Case No. 3: (A) 82-year-old woman at 24 months after resection of ulnar
head only. Note the swelling of the unoperated right wrist. (B) Postoperative views; compare operated and unoperated side.
421
RESEC'IION OF DISTAL ULNA IN RA
Table 1 . D - e - and Postoperative Range of Motion in 34 Wrists, Degrees
Pronation
Supination
Dorsiflexion
Palmar flexion
Preoperative
Postoperative
90
90
90
90
45
20
45
5
4
11
7
10
20
90
90
90
45
9
1
90
0
7
0
0
90
1
7
0
2
34
34
<45
<45
<20
Total
less than 45 degree supination preoperatively.
On the basis of these data, 33 wrists were
graded I by the ARA Therapeutic Criteria.
Eight wrists were grade 11, one grade 111,
and none grade IV. Using the ARA Functional Classification, 31 wrists could be
placed in class I, 11in class 11, and none in
class I11 or IV. Although cosmesis was never
a primary indication for this procedure, all
patients were pleased by the appearance of
their wrists.
DISCUSSION
All patients came to operation with advanced destruction of the distal radioulnar
joint. In those patients with advanced destruction of both the radioulnar and radiocarpal joints, wrist fusion had been considered. Radiographic evidence of radiocarpal stability, however, as well as clinical
evaluation, using injections of local anesthetics along with the criteria mentioned
previously, allowed the proper patient selection for distal ulnar resection. No wrist
to date has required subsequent arthrodesis. If this ever becomes necessary, however, previous removal of the distal ulna in
no way interferes with wrist fusion at a
later date. The most significant finding postoperatively is the relief of symptoms and
improved function despite the severe destruction which had occurred.
Prior to surgery, pain, the most disabling
symptom, is localized generally to the wrist
and specifically to the dislocated ulnar
<20
4
head. Postoperatively, this is relieved and
the deformity is diminished, both of which
permit an increased range of motion with
improved strength and return of function.
Subjectively and clinically, all patients
were improved and none were made worse
by the procedure.
Pronation and supination are functions
of the proximal and distal radioulnar joints.
In our cases elbow dysfunction was not a
complaint. All ranges of motion were increased or maintained, and no patient lost
motion even when preoperative range of
motion was normal (Table 1). The improvement in wrist supination was of great
functional benefit to those patients who had
no preoperative supination.
At follow-up, no patient felt that the
operated wrist was in any way inferior to
the nonoperated (Fig. 5A and 5B) , even
when it was the nondominant arm. Thus
the procedure in no way limits postoperative function.
Factors such as age, sex, which wrist was
involved, drug therapy, the clinical course,
and radiographic appearance were of no
significance in terms of the results obtained.
The amount of ulna to be resected is
best determined after adequate exposure is
achieved. In general, the least amount that
allows correction of the deformity and return of motion (especially supination)
should be resected. It is not necessary to
preserve the ulnar styloid. Migration of the
carpal bones into the space produced by
resecting the ulnar head did not occur to
422
ANDREA CRACCHIOLO, III, AND LEONARD MARMOR
any significant degree in our patients (Fig.
and 4B). When the distal ulna is dislocated it gives no support to the carpals
4A
and supination (Fig. 4B). If unstable or
symptomatic, these wrists may require arthrodesis. The surgical scar in our patients
gave no problem as it is always placed on
the ulnar side.
None of the patients required a second
procedure. There were no postoperative
complications. Healing was prompt, and
(Figs. 1 and 2), which normally articulate
only with the distal radius. With significant
wrist involvement in rheumatoid patients,
the carpals usually shift toward the ulnar
side of the distal radius (Figs. 1 and 4A).
Their further shift and ulnar dislocation is
those patients taking corticosteroids preundoubtedly a feature of continuing disease
sented no problems.
in the joint. Some wrists develop a fibrous
Patients with early involvement of the
ankylosis between the carpal bones and the
distal radius which may involve the distal distal radioulnar joint should first have
ulna (Fig. 4A). In these cases, the carpals good conservative management. This should
will not migrate and resection of the distal include splinting, heat, local injections, and
ulna may well restore or improve pronation proper systemic medications.
SUMMARIOIN INTERLINGUA
Quaranta-duo carpos de patientes con arthritis rheumatoide esseva subjicite a distal
resection ulnar sequite de repetite examines catamnestic. Le nonsuccesso de un therapia
conservatori, subluxation o dislocation del ulna distal con dolores o limitation del
mobilitate, persistente synovitis, e affection de tendines es le indicationes primari pro
chirurgia. Tal dolorose e deformate articulationes attingeva post le operation un augmentate mobilitate e un meliorate fortia e functionamento. Esseva notate nulle recurrentia de dolor o de synovitis, e nulle ruptura de tendine ha occurrite. Le serie includeva
nulle caso de complicationes operatori o postoperatori.
REFERENCES
1. Backdahl, M.:The caput ulnae syndrome in
rheumatoid arthritis. Acta Rheum. Scand., 1963,
Supplement 5.
2. Boyers, J. H.:Bunnell's Surgery of the Hand.
Philadelphia, J. B. Lippinmtt Co., 1964.
3. Clayton, M. L.: Surgical treatment at the
wrist in rheumatoid arthritis. J. Bone Joint Surg.
47A:741, 1965.
4. Darrach, W.:Anterior disIocation of the head
of the ulna. Ann. Surg. 56:802,1912.
5. Dingman, R. C. V.: Resection of the distal
end of the ulna. J. Bone Joint Surg. 34A:893,1952.
6. Flatt, A. E.: The Care of the Rheumatoid
Hand. St. Louis, C. V. Mosby Co.,1963.
7. Henderson, E. D., and Lipscomb, P. R.:
Surgical treatment of rheumatoid hand. J.A.M.A.
175:431, 1961.
8. Law, W. A.: Surgical treatment of rheumatoid diseases. J. Bone Joint Surg. 34B:215, 1952.
9. Metal, A. S.: The problem of the distal radioulnar joint. J. Bone Joint Surg. 44A:1263, 1962.
10. Milch, R. A.: Surgery of Arthritis. Baltimore,
Williams & Wilkins Co., 1964.
11. Moore, E. M.: Three cases illustrating luxation of the ulna in connection with Colles' fracture. Med. Rec. 17:305,1880.
12. Patrick, J.: A study of supination and pronation with special reference to the treatment of
forearm fractures. J. Bone Joint Surg. 28:737,1946.
13. Smith-Petersen, M. N., Aufranc, O., and
Larson, C. B.: Useful surgical pracedures for
rheumatoid arthritis involving joints of the upper
extremity. Arch. Surg. 46:764,1943.
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