SURGICAL TECHNIQUE

Technique of Tendon Interposition

Arthroplasty for Chronic Volar Dislocation
of the Distal Radioulnar Joint
Lana Kang, MD, MS,* Yatindra Patel, BS†

Volar distal radioulnar joint (DRUJ) dislocations are uncommon wrist injuries. Failed diag-
nosis or treatment can result in irreversible damage to the articulating surfaces and ultimately
lead to chronic degenerative arthritis. When the DRUJ is reducible, and the cartilage is
preserved, ligament reconstruction and ulnar osteotomy are surgical options for residual wrist
instability or pain. When destruction of the native DRUJ has already occurred, surgical
treatment options are salvage procedures. Here we present treatment for a chronic volarly
dislocated DRUJ with open reduction and internal fixation using an alternative joint-
preserving surgical technique with tendon allograft interposition arthroplasty. (J Hand Surg
Am. 2019;-(-):1.e1-e7. Copyright Ó 2019 by the American Society for Surgery of the
Hand. All rights reserved.)
Key words Distal radioulnar joint, volar wrist dislocation, arthritis, chronic.

(DRUJ) dislocations

D
ISTAL RADIOULNAR JOINT
are common injuries and generally occur when
there is disruption of the sigmoid notch, the
triangular fibrocartilage complex (TFCC), and/or the
soft tissue stabilizers of the DRUJ. Specifically, the
dorsal and volar radioulnar components of the TFCC
have been demonstrated to be important stabilizers of
the DRUJ,1e3 and injury to these ligaments is likely to
result in instability or dislocation. The majority of cases
consist of dorsal dislocations in which the ulna is found
dorsal to the radius, and numerous studies outline
surgical techniques for the treatment of dorsal dislo-
cations in the subacute setting.4,5
In contrast, volar dislocation of the DRUJ occurs
less frequently. The literature generally reports volar
From the *Hospital for Special Surgery, New York, NY; and the †Case Western Reserve
University School of Medicine, Cleveland, OH.
Received for publication August 8, 2018; accepted in revised form January 13, 2019.
No benefits in any form have been received or will be received related directly or
indirectly to the subject of this article.
Corresponding author: Yatindra Patel, BS, 100 Collingwood Pl., Monroeville, PA 15146;
e-mail: yatindrahp@gmail.com.
0363-5023/19/---0001$36.00/0
https://doi.org/10.1016/j.jhsa.2019.01.007
dislocations in the context of case reports in which
the dislocation was irreducible without surgery.6,7
Improper diagnosis and insufficient treatment of
volar dislocations have been shown to lead to chronic
DRUJ instability and degenerative arthritis.4,8 Treat-
ment options in the chronic setting depend on the
integrity of the triangular fibrocartilage complex
(TFCC) and the degree of subsequent arthritic
development of the articulating DRUJ surfaces. Sur-
gical methods generally involve either ligament
reconstruction or ulnar osteotomy for residual
instability when the articulating surfaces of the
DRUJ are relatively preserved. Once degenerative
changes are present, salvage procedures are accepted
standard practice.8,9 However, each of these surgical
treatment options has disadvantages related to an
inability to address or overcome the damage to the
native DRUJ.
Here we describe the procedure of an open
reduction and internal fixation of the DRUJ with
tendon interposition arthroplasty using a semite-
ndinosus allograft to treat a chronic volar dislocation
with secondary arthritis. With tendon interposition,
the allograft serves 2 purposes. First, it provides a soft
tissue layer for articulation and diminishes painful

Ó 2019 ASSH r Published by Elsevier, Inc. All rights reserved. r 1.e1

1.e2 CHRONIC VOLAR DRUJ DISLOCATION

FIGURE 1: A Cross-section of the DRUJ depicts volar displacement of the distal ulna with scar tissue formation and B volar exposure of
the initial capsulotomy approach. FCU, flexor carpi ulnaris; FDP, flexor digitorum profundus; FDS, flexor digitorum superficialis, UN,
ulnar nerve.

bone-on-bone contact between the distal radius and

the distal ulna during rotational wrist and forearm
motion. Second, it reconstructs the attenuated portion
of the anatomical soft tissue sling that stabilizes the
dorsal and volar DRUJ and the TFCC. Re-creation of
only the damaged portion of this soft tissue complex
spares drilling through the ulnar fovea because it is
performed with ligament reconstruction.5 Compared
with the Darrach or Sauve-Kapandji procedure, this
procedure preserves the DRUJ while avoiding ulnar
stump instability and related complications. These
salvage procedures may still be undertaken at a later
time point should the allograft lose its effectiveness if
and when the clinical condition worsens.

INDICATIONS
The general indication for tendon interposition
arthroplasty with temporary internal fixation is DRUJ
dislocation, subluxation, or instability with a repa-
rable TFCC. Specific indications for this procedure
include focal loss of the articulating surfaces of the
DRUJ with posttraumatic absence of cartilage.
CONTRAINDICATIONS
Contraindications to this technique include
advanced and diffuse degenerative changes of both
the sigmoid notch and the articulating surface of
the ulnar head. Other contraindications include
chronic dislocation of greater than 12 to 24 months
because the resultant contracture and scarring of the
muscle-tendon unit of the biceps, supinator, and
pronator muscle groups, as well as the interosseous
ligament, may limit passive and active forearm
FIGURE 2: Dorsal approach through the base of the fifth
extensor and adjacent tendon allograft.
rotation and obviate any gains provided by the
procedure.
SURGICAL ANATOMY
In cases of chronic DRUJ dislocation, surface anat-
omy landmarks for marking the necessary skin in-
cisions will be distorted. Intraoperative fluoroscopy
imaging with a fine-gauge needle placed into both
the volar and the dorsal DRUJ can aid in joint
localization. Whereas restoring the TFCC proper and
its foveal and peripheral attachments is the goal in

J Hand Surg Am. r Vol. -, - 2019

 CHRONIC VOLAR DRUJ DISLOCATION 1.e3

FIGURE 3: A Dorsal aspect of wrist with the tendon allograft passed through the DRUJ and B a view of the adjacent distal ulnar head.

cases of chronic DRUJ instability,10 surgical treat-

ment for young patients with a chronic posttraumatic
volar DRUJ dislocation will focus on re-creating a
functional articulating surface of the DRUJ proper
(in addition to reduction of the DRUJ). While doing
so, a parallel surgical goal will be to re-create the
stabilizing hammock structure of the TFCC com-
plex. This is surgically achieved by reducing the
displaced TFCC proper and restoring and enhancing
its attachments to its native and intact adjacent
ligamentous and osseous structures that include the
volar DRUJ capsule, the volar and dorsal radioulnar
ligaments, the ulnar collateral ligaments, and the
medial and dorsal aspects of the ulnar head over
which the TFCC complex and extensor carpi ulnaris
normally lie.

SURGICAL TECHNIQUE
A volar approach to the wrist is performed to access the
dislocated distal ulna. Capsulotomy of the volar DRUJ
exposes osseous bridging and extensive fibrous scar-
ring, both of which are excised (Fig. 1). However, this
will be insufficient to attain full reduction of the
dislocation. A dorsal approach through the base of the
fifth extensor compartment is then performed to access
the dorsal aspect of the DRUJ and remove additional
bridging bone and scar tissue (Fig. 2). This exposure
allows for dissection and access to the displaced pe-
ripheral dorsal ulnar attachments of the TFCC. The
displaced TFCC is then released from the distal ulna,
tagged with Ethibond sutures, and restored to its
anatomical position. It is secured using a suture anchor
placed in the fovea of the distal ulna for the disc ho-
molog and in the dorsal medial distal ulnar for its dorsal
ulnar attachments. After this circumferential release of
FIGURE 4: Volar aspect of wrist with the tendon allograft passed
through the DRUJ and forceps indicating the site of attachment to
the capsule.
the dislocated soft tissue and osseous structures, the
DRUJ is reduced.
Crepitance and frank instability upon extremes of
pronation or supination are expected owing to the
posttraumatic degeneration of the DRUJ. A semite-
ndinosus allograft (or comparably sized tendon
allograft) is prepared for tendon interposition be-
tween the distal radius and the distal ulna. The
allograft is passed through the DRUJ from dorsal to
volar (Fig. 3); a suture passer with a tagged end of
the allograft tendon may assist with this step. One
end of the allograft is sutured with 3-0 Ethibond and

J Hand Surg Am. r Vol. -, - 2019

1.e4 CHRONIC VOLAR DRUJ DISLOCATION

FIGURE 5: A Graphic and B actual depiction of the dorsal wrist after passing the tendon allograft through the DRUJ and the suture and
anchor of the dorsal end to the TFCC. ECU, extensor carpi ulnaris; EDM, extensor digiti minimi; EIP, extensor indicis propius; TA,
tendon allograft.

2-0 Vicryl to the volar capsule, which should be

stout and intact (Fig. 4). The dorsal end of the
allograft is trimmed to the appropriate length and
sutured both to the distal ulna with additional an-
chors and directly to the surface of the TFCC and its
dorsal attachments (Fig. 5). Forearm rotation is
performed to confirm elimination of the crepitance
throughout and at the limits of pronation and supi-
nation (Fig. 6). A 0.062-mm K-wire is then placed
proximal to the DRUJ, directed from the ulna to the
radius, under fluoroscopic guidance to achieve
temporary fixation and stabilization (Fig. 7). The
capsule is repaired with 3-0 Ethibond and 3-0 Vicryl
sutures, and the soft tissue and skin are closed in
FIGURE 6: Cross-section of the DRUJ demonstrates full reduc-
layers in standard fashion. tion of the distal ulna and tendon allograft interposition with
anchoring to the volar capsule and dorsal TFCC. ECU, extensor
carpi ulnaris; EDM, extensor digiti minimi; TA, tendon allograft;
POSTOPERATIVE MANAGEMENT VC, volar joint capsule.
The wrist and forearm should be immobilized in a
sugar-tong orthosis in a pronated-to-neutral position
for approximately 6 weeks. After this period of COMPLICATIONS
immobilization, both the K-wire and the orthosis are Owing to the chronic and irreversible nature of the
removed, and active range of motion with rehabili- injury, potential complications include graft resorp-
tation therapy is initiated. The DRUJ stability and tion and failure, residual pain and stiffness, and
wrist range of motion are clinically and radiograph- progression of the degenerative arthritis such that
ically assessed throughout recovery. additional salvage procedures may be required.

PEARLS AND PITFALLS
Care should be taken while passing the tendon
from dorsal to volar to avoid sharp or blunt injury
to the adjacent tendons and nerves. Additional
care should be taken during the dorsal exposure
to identify branches of the dorsal sensory ulnar
nerve.
CASE ILLUSTRATION
The patient was a 22-year-old right-handed man who
sustained an occupational injury while working at a
resort hotel in the Caribbean islands. While carrying a
boat on the beach, he fell onto his outstretched right
hand with the boat landing onto his supinated fore-
arm. The onset of pain and swelling and an inability
to move his wrist or forearm prompted him to seek

J Hand Surg Am. r Vol. -, - 2019

 CHRONIC VOLAR DRUJ DISLOCATION 1.e5

FIGURE 7: A Posteroanterior and B lateral radiographs demonstrate proximal fixation of the DRUJ with a 0.062-mm K-wire.

FIGURE 8: A Posteroanterior radiograph demonstrates overlap between the distal radius and the distal ulna consistent with a volar
dislocation. B Lateral radiograph demonstrates volar displacement of the distal ulna relative to the distal radius.

immediate evaluation at a local emergency depart-
ment. X-Ray imaging reports stated a fracture of the
distal radius. He initially underwent a period of
immobilization with short-arm casting followed by
orthosis wear. After starting formal therapy 4 to 6
weeks after injury, he experienced moderate relief of
pain and restoration of hand function; however, his
inability to rotate his wrist and forearm remained
unchanged.
Four months later, the patient presented with the
chief complaint of an inability to rotate his wrist or
forearm. He also reported pain, weakness, and difficulty
with use of the hand with unaffected hand sensibility.
Clinical examination revealed a fixed supination

J Hand Surg Am. r Vol. -, - 2019

1.e6 CHRONIC VOLAR DRUJ DISLOCATION

FIGURE 9: AeC Axial and DeF coronal computed tomography images demonstrate secondary focal degenerative changes of the DRUJ
and synostosis bridging the radius and ulna.

position of the wrist with deformity involving an

observable bony prominence of the wrist volarly and
ulnarly and a palpable depression of the distal ulna
dorsally. There was focal tenderness along the ulno-
carpal joint and the dorsal and volar DRUJ. Range of
motion testing revealed intact wrist flexion and exten-
sion and no active or passive forearm or wrist rotation.
Plain radiographs of the wrist and forearm were
obtained (Fig. 8). Posteroanterior films demonstrated
incongruity of the DRUJ with an increased overlap
between the distal radius and the distal ulna consis-
tent with a volar dislocation. A lateral view demon-
strated volar displacement of the ulnar head relative
to the distal radius. Computed tomography imaging
was obtained to assess the posttraumatic changes and
incongruity of the DRUJ and the possible anatomical
pathology of the distal radius that may have
contributed to its unreduced and dislocated position,
FIGURE 10: Seated patient demonstrates postoperative wrist range
of which there was none. Computed tomography
of motion with A full pronation to 90 and B supination to 60 .
imaging demonstrated secondary focal degenerative

J Hand Surg Am. r Vol. -, - 2019

 CHRONIC VOLAR DRUJ DISLOCATION 1.e7

FIGURE 11: A Posteroanterior and B lateral radiographs demonstrate stable reduction and restoration of the DRUJ.

changes of the DRUJ with loose bony fragments and
a focal site of synostosis bridging the radius and ulna 2.
(Fig. 9), consistent with the patient’s resultant me-
chanical block to rotation. After full informed consent
with the risks and benefits explained, the patient 3.
decided to proceed with surgical treatment.
After surgery, the patient underwent 6 weeks of 4.
wrist immobilization. After 3 weeks, the K-wire was
5.
removed, and stable reduction of the DRUJ was
radiographically confirmed. After 6 weeks, orthosis
wear was discontinued, and physical therapy was 6.
begun. At 5 years after surgery, the patient reported
maintained improvement in function, and wrist range 7.
of motion was full pronation to 90 and supination to
60 (Fig. 10). Radiographic imaging indicated
8.
increased bone density with cortical smoothening of
the sigmoid notch and ulnar head (Fig. 11).
9.
REFERENCES
10.
1. Lindau T, Adlercreutz C, Aspenberg P. Peripheral tears of the
triangular fibrocartilage complex cause distal radioulnar joint
instability after distal radial fractures. J Hand Surg Am. 2000;25(3):
464e468.
Schuind F, An KN, Berglund L, et al. The distal radioulnar liga-
ments: a biomechanical study. J Hand Surg Am. 1991;16(6):
1106e1114.
Stuart PR, Berger RA, Linscheid RL, An KN. The dorsopalmar
stability of the distal radioulnar joint. J Hand Surg Am. 2000;25(4):
689e699.
Nicolaidis SC, Hildreth DH, Lichtman DM. Acute injuries of the
distal radioulnar joint. Hand Clin. 2000;16(3):449e459.
Adams BD, Berger RA. An anatomic reconstruction of the distal
radioulnar ligaments for posttraumatic distal radioulnar joint insta-
bility. J Hand Surg Am. 2002;27(2):243e251.
Kikuchi Y, Nakamura T, Horiuchi Y. Irreducible chronic palmar
dislocation of the distal radioulnar joint—a case report. Hand Surg.
2005;10(2e3):319e322.
Garrigues GE, Aldridge JM III. Acute irreducible distal radioulnar
joint dislocation: a case report. J Bone Joint Surg Am. 2007;89(7):
1594e1597.
Mirghasemi AR, Lee DJ, Rahimi N, Rashidinia S, Elfar JC. Distal
radioulnar joint instability. Geriatr Orthop Surg Rehabil. 2015;6(3):
225e229.
Thomas BP, Sreekanth R. Distal radioulnar joint injuries. Indian J
Orthop. 2012;46(5):493e504.
Adams B. Distal radioulnar joint instability. In: Green D,
Hotchkiss R, Pederson W, Wolfe S, eds. Green’s Operative Hand
Surgery. 5th ed. Amsterdam, Netherlands: Elsevier; 2005.

J Hand Surg Am. r Vol. -, - 2019