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RU Joint: Hemi-resection Arthroplasty

- See: RU joint  

- Discussion:
    - involves resection of ulnar articular head, leaving shaft and styloid relationship intact;
    - in cases of distal radial malunion, a Bower's hemiarthroplasty may be indicated to restore passive pronation and supination of the forearm;
    - this procedure should be considered before performing Darrah procedure;
    - surgical indications:
           - main indication is pain due to derangement of the DRUJ;
           - indicated for rheumatoid patients in early stages of the disease;
           - requires that TFCC is intact or reconstructible;
                 - w/o intact or reconstructable TFCC, there is no advantage over Darrah procedure;
                 - in RA TFCC will frequently be damaged, and one should instead consider modified Darrah procedure with a radiolunate arthrodesis;
                 - another alternative is a Sauve-Kapandji procedure;

    - relative contraindications:
           - TFCC injury (which may be manifested by base of ulnar styloid non union);

- Technique:
    - supratendinous portion of the extensor retinaculum is divided over the 5th extensor compartment;
           - 5th compartment is divided and the EDQ is retrated;
    - dorsal radioulnar joint capsule and the overlying adherent extensor retinaculum are divided 1 mm from their their radial attachment to the sigmoid notch;
           - do not attempt to separate the retinaculum and the capsule;
    - take care not to remove the ECU from the retinacular flap;
    - osteotomy:
           - radial aspect of distal ulna is resected obliquely and is shaped to match the contour of the distal radius;
           - ensure that there is no ulnar impingement is thru out range of rotation of the forearm;
                  - flouroscopy is useful to judge impingement;
    - interposition:
           - gap left by resected ulna is filled by tendon interposition;
                  - interpositional anchovy of tendon is placed in cavity to limit contact of radial & ulnar shafts which may migrate to each other after this procedure;
           - alternatively, ulnar based retinacular flap is undermined from the adjacent ulna and tendons, so that it can be mobilized and then used as an interposition graft;
                  - this interposition also helps to transfer the ECU to a more dorsal position, so that it acts as a dynamic stabilizer;
    - procedure should leave ulnar ligament complex unmolested;
           - since distal ulna has not been totally resected wrist does not lose its ulnar support;

- Complications:
    - stylocarpal impaction:
          - in some cases this must be managed with ulnar shortening;
    - carpus may migrate in ulnar direction if ulnar ligaments are removed;
    - w/ ulnar translocation:
          - requires strengthening ulnar wrist extension:
          - perform transfer of ECRB to ulnar side of wrist;
          - this helps to stabilize ECU in dorsal rather than volar position

Distal Radioulnar Joint Arthroplasty: the Hemiresection Interposition Technique.

Radial osteotomy and Bowers arthroplasty for malunited fractures of the distal end of the radius.

Matched hemiresection interposition arthroplasty of the distal radioulnar joint.

(see ulnocarpal impingement)