CHAPTER 35 Hemi-resection Interposition Arthroplasty

In the setting of advanced articular involvement of the distal radioulnar joint (DRUJ), a salvage or ablative procedure is recommended. Ablative procedures of the distal ulna include the hemi-resection interposition technique (HIT) arthroplasty,¹ the Sauvé-Kapandji procedure,² the matched resection,³ and the Darrach procedure.⁴ The author has no personal experience with the matched resection procedure, but it is conceptually similar to the HIT procedure. Implant arthroplasty of the DRUJ is yet another alternative, and favorable early results have been reported using the implant developed by van Schoohoven and colleagues in the setting of a failed salvage procedure.⁵

The HIT procedure was developed by William H. Bowers in 1981 as an integral part of managing the rheumatoid ulnar wrist. The principle of the procedure is to maintain a strong soft tissue connection of the ulna to the carpus and radius while removing the damaged joint surface. Although originally designed primarily for the rheumatoid wrist, the HIT procedure has also been used successfully in the nonrheumatoid wrist and, in particular, as a reconstructive option in the setting of distal radial malunion.^6–8 It has also been successfully employed in patients affected by symptomatic, primary osteoarthritis of the DRUJ.

Ablative procedures are championed by others, especially in the setting of a relatively young patient with a distal radial malunion in conjunction with a nonsalvageable DRUJ. The Sauvé-Kapandji procedure was first reported by Louis Sauvé and Mehmed Kapandji in 1936 and combines a DRUJ arthrodesis along with a surgical pseudarthrosis between the proximal ulna and ulnar head. The principle of the procedure is to maintain a radioulnar joint surface, thus providing a more physiological pattern of force transmission from the hand to the forearm. Instability of the proximal stump remains problematic at times, similar to the Darrach procedure.

Caveats

The success of the HIT procedure depends on an intact or reconstructable triangular fibrocartilaginous complex (TFCC). The procedure cannot succeed if the TFCC is not a functional structure. This is often the case in advanced rheumatoid arthritis, and the HIT procedure is not recommended in this setting. In such a patient, a Darrach resection or a Sauvé-Kapandji procedure is recommended. In the absence of inflammatory disease, the TFCC is typically intact or reconstructable. In the setting of a markedly malunited distal radius, a peripheral tear is often present but the overall integrity of the ligament typically remains intact.

Conceptually, the HIT procedure preserves the ulnocarpal ligament complex, thus maintaining some stability while simultaneously addressing the problematic DRUJ by removing the involved distal ulnar articular surface. Thus, the resection involves resection of the ulnar articular head while the shaft/styloid relationship is left intact. The ideal nonrheumatoid candidate presents with a painful distal radioulnar joint with or without a distal radius malunion. The procedure is rarely indicated in the acute setting. The TFCC can be partially deficient, but it must be able to be repaired. It is best if the TFCC is intact; and if it is neither intact nor can be repaired, the procedure offers no advantages over a Darrach procedure. The HIT procedure may also be successfully utilized in the setting of a partially treated distal radius fracture associated with a fracture of the ulnar styloid with associated dislocation of the distal ulna (Fig. 35-1).

FIGURE 35-1 Preoperative posteroanterior (A) and lateral (B) radiographs of a partially treated distal radius fracture with ulnar styloid fracture and distal ulna dislocation. C, After ORIF of the distal ulna using a tension band technique and DRUJ temporary stabilization with two K-wires. D, Despite restoration of reasonable forearm rotation, pain and crepitus persisted, requiring an HIT procedure.

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