D concept of surgical care of patients

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1 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- URING THE PAST 25 YEARS, the entire D 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-Peterson et 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 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, ANDREA. CRACCHIOLO, 111, M.D.: Assistant Professor of Surgery and Orthopedics, Assistant Research Rheumatologist, Giannini Foundation Fellow, School of Medicine, University of Cali- 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. 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 It is commonly performed in an attempt to relieve symptoms and improve wrist function in derangement of the distal radioulnar joint secondary to tra~ma.~*~.~j* The procedure has been reported in rheumatoid patients as part of the technic of wrist fu~ion.~*j~j~ Flatt described resection of the distal ulna in rheumatoid wrist surgery.g Clayton reported distal ulna resection in 41 cases of patients operated upon for extensor tendon rupture.3 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 024. Ammms AND RHEUMATISM, VOL. 12, No. 4 (AUGUST 1969) 415

2 416 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 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

3 RESECl'ION OF DLSTAL ULNA IN RA 417 Fig. 2.4ase 8: 55-year-old woman showing x-ray evidence of dorsally dislocated ulna blocking supination. when this was used as a diagnostic test. This is especially useful in evaluating patients preoperatively if the ulnar head is only subluxated. Where this is the case, the pain and loss of motion are due to a florid synovitis. Therefore the indications used for resection of the distal ulna are: (1) subluxation or dislocation of the distal ulna with pain or limited motion, (2) persistent synovitis about the distal ulna, and (3) extensor tendon involvement together with (1) or (2). OPERATIVE TECHNIC Under tourniquet control, a standard bayonet incision approximately 2 inches long is made longitudinally over the distal ulna. Care is taken to preserve the superficial cutaneous branch of the ulnar nerve and the extensor carpi ulnaris tendon. The periosteum is carefully stripped from the distal ulna. Drill holes outline the transverse osteotomy site?4 to % inch from the distal end of the ulnar styloid. After resection, wrist exposure is excellent and as much diseased synovium as possible is removed from the radioulnar and wrist joints with a rongeur. If necessary, the extensor tendons can and should be cleaned free of all in- vading synovium. The resected bone end is smoothed with a rasp (Figs. 3,4A, and 4B ). The triangular fibrocartilage is almost always completely destroyed, and its remnants should be removed. The periosteal sleeve is repaired to prevent dorsal displacement of the ulna. Only one patient here exhibited a small amount of new bone formation within the sleeve. This consisted of a pointed tip developing at the resected end which in no way interfered with the excellent postoperative result. If it is not totally destroyed, the ulnar collateral ligament can be sutured to the periosteum or deep fascia. Excessive resection of the distal ulna, including all of the pronator quadratus attachment, tends to produce a deformity, as the remaining end of the ulna protrudes beneath the skin of the distal forearm. The wound is closed in layers, and a light pressure dressing is applied. Pronation and supination are vigorously encouraged on the first postoperative day and should be intensified as postoperative pain, which is minimal, diminishes. RESULTS A total of 42 wrists underwent this procedure and were followed from 12 to 43 months (mean, 22 months); 3 other pa-

4 418 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.

5 RESECTION OF DISTAL ULNA IN FU 419 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 at 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

6 420 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.

7 RESEC'IION OF DISTAL ULNA IN RA 421 Table 1.D-e- and Postoperative Range of Motion in 34 Wrists, Degrees Pronation Supination Dorsiflexion Palmar flexion Preoperative Postoperative 0 <45 Total <45 <20 < 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, 11 in 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 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

8 422 ANDREA CRACCHIOLO, III, AND LEONARD MARMOR any significant degree in our patients (Fig. 4A and 4B). When the distal ulna is dislocated it gives no support to the carpals (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 undoubtedly a feature of continuing disease in the joint. Some wrists develop a fibrous ankylosis between the carpal bones and the distal radius which may involve the distal ulna (Fig. 4A). In these cases, the carpals will not migrate and resection of the distal ulna may well restore or improve pronation 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 those patients taking corticosteroids presented no problems. Patients with early involvement of the distal radioulnar joint should first have good conservative management. This should include splinting, heat, local injections, and proper systemic medications. SUMMARIO IN 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. 1. Backdahl, M.: The caput ulnae syndrome in rheumatoid arthritis. Acta Rheum. Scand., 1963, Supplement Boyers, J. H.: Bunnell's Surgery of the Hand. Philadelphia, J. B. Lippinmtt Co., Clayton, M. L.: Surgical treatment at the wrist in rheumatoid arthritis. J. Bone Joint Surg. 47A:741, Darrach, W.: Anterior disiocation of the head of the ulna. Ann. Surg. 56:802, Dingman, R. C. V.: Resection of the distal end of the ulna. J. Bone Joint Surg. 34A:893, Flatt, A. E.: The Care of the Rheumatoid Hand. St. Louis, C. V. Mosby Co., Henderson, E. D., and Lipscomb, P. R.: Surgical treatment of rheumatoid hand. J.A.M.A. 175:431, REFERENCES 8. Law, W. A.: Surgical treatment of rheumatoid diseases. J. Bone Joint Surg. 34B:215, Metal, A. S.: The problem of the distal radioulnar joint. J. Bone Joint Surg. 44A:1263, Milch, R. A.: Surgery of Arthritis. Baltimore, Williams & Wilkins Co., Moore, E. M.: Three cases illustrating luxation of the ulna in connection with Colles' fracture. Med. Rec. 17:305, Patrick, J.: A study of supination and pronation with special reference to the treatment of forearm fractures. J. Bone Joint Surg. 28:737, 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.