83: Darrach Procedure

Published on 17/04/2015 by admin

Filed under Surgery

Last modified 22/04/2025

Print this page

This article have been viewed 1641 times

Procedure 83 Darrach Procedure

Nathan S. Taylor, Kevin C. Chung

See Video 62: Darrach Procedure

Indications

Older, sedentary patients with posttraumatic distal radioulnar (DRU) joint arthritis, rheumatoid arthritis, and osteoarthritis without preexisting radiocarpal instability.

Destruction of the triangular fibrocartilage complex with caput ulna syndrome and painful pronation and supination of the DRU joint.

The Darrach procedure (distal ulna head excision) is preferred in patients with no ulnar translation of the carpus and low chance of translation in the future.

In the setting of radiocarpal instability, the Darrach procedure can be performed concomitantly with a partial or total wrist fusion.

Examination/Imaging

Clinical Examination

Evaluate active and passive wrist and DRU joint motion and compare with the opposite side. The affected wrist should be taken through full wrist motions of flexion-extension, pronation-supination, and radioulnar deviation with axial loading to assess stability and pain.

Painful crepitus with pronation and supination indicate DRU joint arthritis that can be accentuated with manual compression of the joint.

Dorsal wrist swelling can indicate extensor tendon synovitis. Palpation of the inflamed wrist is painful, and wrist mobility may be limited.

Caput ulna syndrome is diagnosed as dorsal prominence of the ulnar head with accompanying ulnopalmar subluxation and supination of the carpus. The DRU joint will be swollen and painful on palpation. There may be painful limitation of pronation and supination.

ECU subluxation and tendonitis should be distinguished from DRU joint arthritis by noting ECU subluxation with supination and ulnar deviation.

Lunotriquetral (LT) instability from ligamentous tears should be distinguished from DRU joint arthritis by performing the LT shear test. The lunate is stabilized between the examiner’s thumb and index finger, and the triquetrum is sheared against the lunate in a dorsopalmar direction with the examiner’s other hand.

The prominent caput ulna can cause extensor tendon ruptures, primarily at the fourth and fifth extensor compartments.

Imaging

Standard three views of the wrist are useful to assess extent of arthritis and wrist stability. Changes associated with arthritis include osteophytes, joint space narrowing, erosive changes, cystic lesions, and disuse osteopenia (Fig. 83-1).

For differentiation of extensor tendon from joint synovitis, ultrasonography is the diagnostic tool of choice.

Computed tomography and magnetic resonance imaging are typically not necessary in the evaluation of the DRU joint in rheumatoid arthritis.

FIGURE 83-1

Surgical Anatomy

The dorsal sensory branch of the ulnar nerve lies in the subcutaneous tissue of the dorsal ulnar wrist.

In the presence of caput ulna syndrome, the sixth dorsal compartment with the ECU is subluxed palmarly. The fifth dorsal compartment with the extensor digiti minimi (EDM) crosses the ulnar head.

The pronator quadratus originates at the distal radius and inserts on the distal ulna and is an important dynamic stabilizer of the distal ulna. The distal ulna should be excised to the level of the sigmoid notch to preserve the attachments of the pronator quadratus on the distal ulna.

Positioning

The procedure is performed under tourniquet control with the patient in the supine position and the extremity abducted with the hand on a hand table.

Support of the wrist in slight flexion is helpful.

Procedure

Step 1

Use an oscillating saw to resect 20 mm of distal ulna at 45 degrees so that the long end of the oblique cut is along the ulnar border to minimize ulnar impingement against the radius (Fig. 83-4).

FIGURE 83-4

Step 2

Sharply excise the ulnar head from the surrounding soft tissue with a no. 15 blade (Fig. 83-5).

Remove any sharp edges with a rongeur.

Synovitis within the sigmoid notch is removed with a rongeur.

FIGURE 83-5

Step 3

The dorsal wrist capsule is imbricated with 2-0 or 3-0 braided permanent horizontal mattress sutures with the wrist fully supinated, taking care to note that the ulna is not dorsally prominent in this position (Fig. 83-6). If the distal ulna stump is unstable with pronation-supination, an ulna-stabilizing procedure can be performed using a distally based ulnar half ECU tenodesis to correct prominence of the ulnar stump. This is performed as follows:

• Drill a hole in the dorsal cortex of the distal ulna stump using a 3-mm bur.

• The distally based ulnar half of the ECU is woven from inside the ulnar canal and out the hole dorsally and sutured to itself with the ulna stump reduced palmarly and the wrist extended 15 degrees and ulnarly deviated 15 degrees.

• The dorsal wrist capsule is then imbricated as described previously.

The tourniquet is released, and all bleeding points are cauterized.

The skin is closed with 3-0 absorbable monofilament dermal sutures and 4-0 absorbable monofilament running subcuticular suture.

FIGURE 83-6

Postoperative Care and Expected Outcomes

The wrist is immobilized in a sugar tong splint with the forearm fully supinated for 4 weeks, keeping the fingers free for movement.

Gentle active range of motion is begun at 4 weeks. If an ulnar stump–stabilizing procedure has been performed, pronation and supination should be limited until 6 weeks postoperatively.

The patient should be expected to return to full activities as tolerated at 6 to 8 weeks.

De Witte PB, Wijffels M, Jupiter JB, Ring D. The Darrach procedure for post-traumatic reconstruction. Acta Orthop Belg. 2009;75:316-322.

The authors report their experience with the Darrach procedure in 26 patients with a mean age of 53 years to address posttraumatic stiffness, instability, nonunion, and radioulnar length discrepancy. With an average follow-up of 21 months, the authors note an average improvement in total arc of forearm rotation of 87 degrees, from 49 to 136 degrees (P < .001), and pain reduction (P = .04), with only two patients requiring reoperation related to the residual ulna. They conclude that the Darrach procedure significantly improves forearm rotation and reduces pain in patients with posttraumatic problems of the DRU joint with a low complication and reoperation rate. (Level IV evidence)

George MS, Kiefhaber TR, Stern PJ. The Sauve-Kapandji procedure and the Darrach procedure for distal radio-ulnar joint dysfunction after Colles’ fracture. J Hand Surg [Br]. 2004;29:608-613.

The authors retrospectively evaluated the results of 30 Darrach procedures and 18 Sauve-Kapandji procedures for the treatment of distal radioulnar joint derangement following malunion of displaced intraarticular distal radius fractures in patients younger than 50 years. In the Sauve-Kapandji group, 12 patients completed the Disabilities of the Arm, Shoulder, and Hand (DASH) survey at a mean of 4 years postoperatively, and 9 patients were available for follow-up examination at a mean of 2 years postoperatively. In the Darrach group, 21 patients completed the DASH survey at a mean of 6 years postoperatively, and 13 patients were available for follow-up examination at a mean of 4 years postoperatively. There were no significant differences between the two groups with regard to forearm or wrist range of motion, grip strength, Modified Mayo Wrist scores, or DASH scores. All patients in the Sauve-Kapandji group showed radiographic fusion of the DRU joint, and one patient was revised to a Darrach procedure for a painful click with complete resolution of symptoms. Six patients in the Darrach group showed evidence of significant regrowth of the ulnar stump, and one patient showed significant ulnar carpal translation. The authors conclude that both procedures yield comparable and unpredictable results following Colles fracture in patients younger than 50 years. The Sauve-Kapandji procedure is better in younger patients because it maintains the ulnocarpal buttress, preserves the triangular fibrocartilage complex and ulnocarpal ligaments, provides a more physiologic pattern of force transmission from the hand to the forearm, and maintains the extensor carpi ulnaris tendon in its compartment. (Level III evidence)

Minami A, Iwasaki N, Ishikawa J, et al. Treatments of osteoarthritis of the distal radioulnar joint: long-term results of three procedures. Hand Surg. 2005;10:243-248.

The authors retrospectively evaluated 61 wrists in 61 patients with an average age of 59.8 years with osteoarthritis of the distal radioulnar joint treated by three consecutive procedures (20 Darrach, 25 Sauve-Kapandji, and 16 hemiresection-interposition arthroplasty procedures). Postoperative pain, range of motion, grip strength, return to work status, and radiographic results were evaluated over an average follow-up of 10 years (range 5 to 14 years). The authors found that pain relief was superior with the Sauve-Kapandji and hemiresection-interposition arthroplasty procedures compared with the Darrach procedure, although this was not statistically significant. Both the Sauve-Kapandji and hemiresection-interposition arthroplasty procedures had statistically significant improvements in wrist flexion and extension, grip strength, and return to original work status compared with the Darrach procedure. All procedures showed statistically significant improvements in forearm supination and pronation. The authors conclude that the Darrach procedure is better indicated for severe osteoarthritic changes of the distal radioulnar joint in elderly patients; the Sauve-Kapandji procedure is indicated when the triangular fibrocartilage complex cannot be reconstructed or with positive ulnar variance greater than 5 mm even with intact triangular fibrocartilage complex; and the hemiresection-interposition arthroplasty procedure is indicated when the triangular fibrocartilage complex is intact or could be reconstructed. (Level III evidence)

Related

Operative Techniques Hand and Wrist Surgery