Between 1986 and 1994, eighteen patients who had posttraumatic derangement of the distal radioulnar joint were managed with a Sauvé-Kapandji procedure with tenodesis of the flexor carpi ulnaris performed by the senior one of us (D. L. F.) (Table I). There were fourteen men and four women. The mean age was thirty-four years (range, nineteen to fifty-four years), and the mean duration of follow-up was four years and two months (range, two years to eight years and four months). The mean duration between the initial injury and the index operation was one year (range, five months to one year and nine months) (Table I). A course of nonoperative treatment that included the administration of nonsteroidal anti-inflammatory medications, application of a splint, and physical therapy had failed for all patients. Eleven patients had previously performed strenuous manual labor.
Patients were considered to be candidates for a Sauvé-Kapandji procedure if they had pain that was localized to the distal radioulnar joint, decreased rotation of the forearm, and radiographic evidence of either degenerative changes or instability, subluxation, or dislocation of the distal radioulnar joint. Pain in the radioulnar joint that was elicited by ballottement of the head of the ulna was differentiated from pain in the radiocarpal or ulnocarpal joint by its location. When there was destruction of the sigmoid notch and part of the lunate fossa of the radius (another indication for this procedure), the intact ulnar head was used for osseous support of the ulnar side of the carpus and for arthrodesis of the distal radioulnar joint. Only young patients who placed high demands on the forearm and wrist were considered candidates for this procedure. Patients who were elderly or had low functional demands were managed with other procedures such as a Darrach resection or a hemiresection and interposition arthroplasty.
The initial injury was an intra-articular fracture of the distal part of the radius in eight patients, an extra-articular fracture of the distal aspect of the radius in five, an extensively comminuted intra-articular fracture of the distal third of the radius in one, a Galeazzi fracture in one, a fracture-dislocation of the radius and a fracture of the scaphoid in one, an intra-articular fracture of the distal part of the radius associated with an Essex-Lopresti type of radioulnar dissociation in one, and an intra-articular fracture of the radius with a fracture-dislocation of the elbow in one. One comminuted fracture was open, and all of the other fractures were closed. The fractures were initially treated with internal or external fixation, and additional operative procedures were performed as needed before the index procedure (Table I).
Pain was rated as mild if it occurred at the extremes of the active range of motion and did not bother the patient or interfere with the activities of work or daily living, moderate if it occurred during strenuous manual labor or caused some alteration in work activities but did not interfere with the activities of daily living, and severe if it occurred during the activities of daily living or at rest. Preoperatively, all patients had limited rotation of the forearm and had pain in the region of the distal radioulnar joint that was elicited by rotation of the forearm. The pain was rated as severe in thirteen patients and as moderate in five. In addition, nine patients also had pain at the radiocarpal level that was elicited by flexion and extension of the wrist; it was rated as mild in seven patients and as moderate in two.
Preoperatively, the patients had markedly reduced rotation of the forearm, measured at the level of the hand, with a mean supination of 16 degrees (range, 0 to 75 degrees) and a mean pronation of 42 degrees (range, 0 to 80 degrees). Supination was limited to 15 degrees or less in fifteen patients. The motion of the wrist was also decreased. Flexion averaged 43 degrees (range, 25 to 65 degrees); extension, 38 degrees (range, 15 to 60 degrees); radial deviation, 10 degrees (range, 0 to 25 degrees); and ulnar deviation, 14 degrees (range, 0 to 35 degrees). The mean range of motion on the unaffected side was 86 degrees of supination and pronation, 68 degrees of flexion, 69 degrees of extension, 18 degrees of radial deviation, and 30 degrees of ulnar deviation. Two patients (Cases 14 and 17) also had multidirectional instability of the distal part of the ulna. The mean grip strength, measured with a Jamar dynamometer (Therapeutic Equipment, Clifton, New Jersey), was sixteen kilograms-force (range, two to thirty-eight kilograms-force) compared with forty-five kilograms-force (range, twenty to sixty-five kilograms-force) on the unaffected side.
Degenerative changes were graded, according to the criteria described by Knirk and Jupiter14, as mild if there was slight narrowing of the joint space, moderate if there was marked narrowing of the joint space and formation of osteophytes, and severe if there was complete loss of the joint space and formation of osteophytes and subchondral bone cysts. Preoperative posteroanterior and lateral radiographs showed degenerative changes in the distal radioulnar joint in twelve patients. The changes were severe in three patients, moderate in eight, and mild in one. Radiographs also revealed dorsal subluxation or dislocation of the distal part of the ulna in nine patients and volar subluxation in one patient. Subluxation was diagnosed when true lateral radiographs showed overlap of the scaphoid tuberosity and the pisiform. Of note, all nine patients who had radiographic evidence of dorsal subluxation had supination limited to 15 degrees or less. Ten patients had a nonunion of the ulnar styloid process: nine nonunions were at the base, and one was at the tip. The mean preoperative ulnar variance was +2.1 millimeters (range, -2.0 to +8.0 millimeters). Preoperative computed tomographic scans were not made routinely.
We believe that a dorsal tilt of more than 15 degrees (more than 25 degrees from normal alignment on the lateral radiograph) is unacceptable and that a dorsal tilt between 0 and 15 degrees should be corrected if the patient has pain with longitudinal loading of the wrist when gripping objects and during flexion-extension movements. A radial inclination of less than 10 degrees on the anteroposterior radiograph should be corrected. One patient (Case 16) who had an unacceptable dorsal tilt of the distal part of the radius and carpal malalignment reported pain in the radiocarpal joint during flexion and extension of the wrist. An osteotomy of the distal part of the radius was performed at the time of the index operation.
Operative Technique
A longitudinal skin incision was made over the subcutaneous border of the ulna between the flexor carpi ulnaris and extensor carpi ulnaris tendons, starting five to six centimeters proximal to the prominence of the ulnar head and ending at the level of the pisiform. The dorsal sensory branch of the ulnar nerve, which crosses the space between the tip of the ulnar styloid process and the pisiform, was carefully identified and protected. The sixth dorsal compartment of the wrist was dissected subperiosteally and retracted toward the radius.
The pretendinous retinaculum was exposed and incised, and the distal aspect of the ulna was exposed subperiosteally. A ten-millimeter segment of the distal end of the ulna was marked for resection, leaving room for the placement of two screws distally. If there was positive ulnar variance, a correspondingly longer segment of the ulna was removed so that, when the ulnar head was recessed to neutral ulnar variance, the resulting gap would measure ten millimeters. An oscillating saw was used to divide the ulna at the proximal end of the segment to be removed, and the distal fragment was levered out. The dorsal aspect of the capsule of the distal radioulnar joint was incised, and cartilage from the articular surfaces of the sigmoid notch and the ulnar head was denuded down to cancellous bone. The distal osteotomy then was completed, periosteum in the region of the gap was meticulously resected, and the region was thoroughly irrigated to remove bone debris. These measures were performed to prevent the formation of ectopic bone in the gap that was created after resection of the segment of the ulna.
Cancellous bone graft, obtained from the resected segment, was packed into the area of the arthrodesis. The ulnar head was temporarily fixed to the sigmoid notch of the distal part of the radius with a single Kirschner wire. Image intensification was used to ensure fixation in a position of neutral ulnar variance. Both cortices of the ulnar neck and the near cortex of the radius were predrilled, and a 2.7-millimeter cortical-bone screw was inserted. The lag-screw technique should not be used for this screw in order to avoid tilting the head of the ulna, which must remain parallel to the long axis of the ulnar shaft. The Kirschner wire was removed and was replaced with a 3.5-millimeter cortical-bone screw inserted in the same fashion as a lag screw to compress the site of the arthrodesis (Fig. 1-A). In the first eleven patients in this series we used two 4.0-millimeter cancellous-bone screws, and in the next seven patients we used a 3.5-millimeter cortical-bone screw as a lag screw as well as a 2.7-millimeter cortical-bone screw. We believed that the latter combination allowed use of a smaller head-neck segment, which made it possible to resect the bone more distally. As a result, the ulnar stump was more stable because the tenodesis of the flexor carpi ulnaris was shorter and there was less disruption of the interosseous membrane. In one patient (Case 11), in whom a previous hemiresection and interposition arthroplasty had failed, the portion of the ulna that was resected was used to maintain the normal width of the wrist and was employed, in lieu of the distal end of the ulna, for the arthrodesis to the radius.
Through the volar aspect of the incision, a distally based slip of flexor carpi ulnaris tendon (measuring approximately one-half of the width of the tendon) attached to the pisiform was isolated over a distance of eight to ten centimeters. A 4.0 to 4.5-millimeter drill-hole was placed on the volar cortex, one centimeter proximal to the end of the osteotomized surface of the proximal ulnar segment. This was facilitated by inserting the drill-bit obliquely through the medullary cavity in a dorsal-to-volar direction. The slip of flexor carpi ulnaris tendon then was passed deep to the flexor carpi ulnaris muscle through the distal end of the ulnar stump, was looped back on itself, and was secured with nonabsorbable suture (Fig. 1-B). The tendon was sutured under moderate tension, keeping the forearm in neutral rotation and the wrist in neutral flexion-extension and neutral radioulnar deviation. Excessive tightening of the tendon with the wrist in ulnar deviation or flexion may limit postoperative radial deviation and extension. The pronator quadratus muscle, having already been freed from the distal part of the ulna, was pulled into the gap in the ulna and sutured to the volar aspect of the tendon sheath of the extensor carpi ulnaris. During closure of the wound, the sixth dorsal compartment was reattached within the groove on the ulnar head.
Postoperative Management
The patient was allowed to perform gentle forearm-rotation exercises in a volar below-the-elbow splint immediately after the operation. Two weeks postoperatively, the sutures were removed, the patient was fitted with a removable orthosis for the wrist, and physical therapy was begun with active forearm-rotation exercises. Flexion and extension exercises of the wrist were started at six weeks. The wrist splint was removed when there was radiographic evidence of fusion.
The latest evaluation was based on both subjective and objective criteria, including residual pain, the active range of motion of the wrist, active rotation of the forearm, grip strength, tenderness over the resected segment, stability of the ulnar stump, the results of a sensory examination, and the ability of the patient to work. The patient was specifically asked if he or she had pain over the ulnar stump or a sensation of movement or instability of the stump. Passive anteroposterior stability of the stump was evaluated with the forearm and hand in a relaxed position and then with the patient making a tight fist. The distal part of the radius and the radial side of the wrist were stabilized by the examiner. Motion of the stump was palpated as the patient alternately contracted and relaxed the forearm muscles. The ulnar stump was considered to be mildly unstable if it had excessive passive motion when the forearm muscles were relaxed but not when they were contracted, moderately unstable if it had excessive passive motion when the forearm muscles were contracted, and severely unstable if it had visible or palpable motion that caused discomfort when the forearm muscles were contracted.
The range of motion and the grip strength were compared with those on the contralateral side as well as with the preoperative values. Sensory evaluation included light-touch and pinprick sensibility tests as well as a two-point discrimination test of the median, ulnar, and radial nerves. Particular attention was given to alterations of sensibility and to the presence of a neuroma of the dorsal sensory branch of the ulnar nerve. The ability to work was evaluated on the basis of whether or not the patient had returned to his or her original occupation and was able to work full-time (100 percent) or part-time (25, 50, or 75 percent of the normal working time).
For the combined assessment of the results at the time of the latest follow-up, the wrist-scoring system of the Mayo Clinic (modified to include rotation of the forearm7) was used, with residual pain, functional status, range of motion, and grip strength given a maximum of 25 points each (Table II). A score of 90 to 100 points indicates an excellent result; 80 to 89 points, a good result; 65 to 79 points, a fair result; and less than 65 points, a poor result.
Radiographs made in the early postoperative period and at the time of the latest follow-up were evaluated for evidence of union at the site of the arthrodesis, ulnar variance, ossification at the site of the resection, resorption of bone in the ulnar stump, and progressive degenerative changes in the radiocarpal joint.
At the most recent follow-up examination, fifteen patients had no pain in the region of the distal radioulnar joint and three patients had mild pain with rotation of the forearm. Preoperatively, eight of the eleven patients who had radiographic degenerative changes in the radiocarpal joint had pain with flexion and extension of the wrist. Postoperatively, seven of those eleven patients had pain with flexion and extension of the wrist. One patient (Case 13) had severe pain secondary to progressive degenerative osteoarthrosis of the radiocarpal joint, and he eventually had an arthrodesis of the wrist.
Sixteen patients had no subjective or objective findings of instability of the ulnar stump. One patient (Case 13) who had a stable stump had moderate pain that appeared to be related to ossification in the resected area. Excision of scar tissue and bone decreased the pain, but mild instability of the ulnar stump subsequently developed. We believe that the reoperation may have compromised the tenodesis of the flexor carpi ulnaris. One patient (Case 17) who had had multidirectional instability of the distal radioulnar joint before the operation had moderate pain and volar instability of the ulnar stump immediately after the index operation. He was managed with a tenodesis of the extensor carpi ulnaris as described by Breen and Jupiter8. At the latest follow-up examination, the patient had no pain and the stump was stable. Three other patients (Cases 3, 4, and 11) had mild tenderness at the tip of the stump, but they had good rotation of the forearm and no radiographic evidence of impingement between the ulnar stump and the radius.
Analysis of grip strength demonstrated a mean increase from sixteen kilograms-force (range, two to thirty-eight kilograms-force) preoperatively to thirty-five kilograms-force (range, ten to fifty-eight kilograms-force) at the latest follow-up examination. The grip strength had increased from 36 percent to 73 percent of that on the unaffected side. The nine patients with involvement of the dominant side had a mean grip strength of 79 percent (range, 27 to 140 percent) of that on the nondominant side at the time of the latest evaluation. The mean supination had improved from 16 degrees (range, 0 to 75 degrees) preoperatively to 76 degrees (range, 40 to 90 degrees) at the time of follow-up. The mean pronation had improved from 42 degrees (range, 0 to 80 degrees) preoperatively to 81 degrees (range, 60 to 90 degrees) at the time of follow-up. The preoperative motion of the wrist had averaged 43 degrees (range, 25 to 65 degrees) of flexion, 38 degrees (range, 15 to 60 degrees) of extension, 10 degrees (range, 0 to 25 degrees) of radial deviation, and 14 degrees (range, 0 to 35 degrees) of ulnar deviation. These values remained substantially unchanged at the time of the latest evaluation.
The site of the arthrodesis healed in all patients. Despite the extraperiosteal resection, three patients (Cases 2, 5, and 8) had slight ossification at the site of the resection, but it did not cause pain or limitation of rotation. One patient (Case 13) had extensive ossification that needed excision. Five patients had resorption at the distal end of the ulnar stump, which was rated as mild in three and as moderate in two. The mean postoperative ulnar variance was +0.1 millimeter (range, -2.0 to +2.0 millimeters).
Complications
Six patients had a total of eight complications, which included a neuroma of the dorsal sensory branch of the ulnar nerve (three patients), hypoesthesia without a neuroma (two), extensive ossification at the site of the gap (one), carpal tunnel syndrome (one), and volar instability of the ulnar stump (one) (Table IV).
Eleven patients had an additional operation, which included removal of the hardware only (six patients), removal of the hardware and neurolysis (two), neurolysis and tenodesis of the extensor carpi ulnaris (one), removal of the hardware and carpal tunnel release (one), and removal of the hardware with excision of ossification and arthrodesis of the wrist (one) (Table IV). The primary indication for removal of the hardware was pain when the ulnar side of the wrist came into contact with any hard surface. The heads of the screws rest on the ulnar border of the distal part of the ulna, where there is little soft-tissue covering. The heads of the screws cannot be countersunk because the cortical bone in the ulnar head is very thin. The hardware was removed at a mean of eight months (range, five to twelve months).
At the latest follow-up examination, seventeen patients had returned to their original occupation. Fourteen patients worked at 100 percent of the preinjury capacity; two, at 75 percent; and one, at 50 percent. Although one patient (Case 13) eventually had a successful arthrodesis of the wrist for the treatment of radiocarpal osteoarthrosis, he did not return to his preoperative occupation of construction work. The overall functional result was excellent for six patients, good for seven, fair for four, and poor for one (Table II).
Illustrative Case Report
CASE 2. A twenty-one-year-old man had open reduction and internal fixation of an intra-articular fracture of the distal part of the radius and subsequent removal of the hardware. Eleven months after the injury, he had severe pain, marked limitation of rotation of the forearm (5 degrees of pronation and 10 degrees of supination), and grip strength that was 36 percent of that on the nondominant side. The radiographs and computed tomographic scans showed severe degenerative changes in the distal radioulnar joint and loss of bone in the lunate fossa (Fig. 2-A).
Radiographs made six years and five months after the index operation showed a solid fusion between the distal aspect of the radius and the ulnar head, mild ossification in the area of the resection, and resorption of the end of the ulnar stump (Figs. 2-B and 2-C). The patient had no residual pain on the ulnar side of the wrist or over the ulnar stump, and grip strength had improved to 87 percent of that on the normal side. He had 85 degrees of pronation and 90 degrees of supination (Fig. 2-D) as well as 55 degrees of extension, 60 degrees of flexion, 40 degrees of ulnar deviation, and 10 degrees of radial deviation (Fig. 2-E).
The numerous operative procedures, such as the Darrach resection of the distal part of the ulna, the hemiresection and interposition arthroplasty described by Bowers, the matched resection of the distal aspect of the ulna described by Watson et al., silicone replacement of the ulnar head, the Sauvé-Kapandji procedure, and arthrodesis4-6,9,24,27, that are used to treat chronic instability, subluxation, dislocation, and degenerative osteoarthrosis of the distal radioulnar joint attest to the difficult nature of these problems.
A chronically unstable distal radioulnar joint without degenerative changes can be treated with several different procedures depending on the abnormalities. These procedures include repair of a nonunion of the ulnar styloid process, repair of the triangular fibrocartilage complex, reconstruction of the radioulnar ligaments, tenodesis of the ulna to the carpus, and a variety of radioulnar sling procedures6,12,15,25. Leung and Hung15 reported good results with use of a distally based graft of the palmaris longus tendon to reconstruct the radioulnar ligaments. Bowers6 reviewed the results of eight radioulnar sling procedures for soft-tissue reconstruction that were described in twelve reports and noted that, as a group, these procedures either failed to restore stability or limited the rotation of the forearm even if stability was restored. All eight patients in the study by Hui and Linscheid12 and all five in the report by Tsai and Stilwell25 had a good result after tenodesis of the distal part of the ulna to the carpus with use of a distally based graft of the flexor carpi ulnaris tendon. The procedure, as described by Tsai and Stilwell, has also been used for the treatment of instability of the ulnar stump after a Darrach type of resection.
A radial osteotomy may restore normal alignment and function of the distal radioulnar joint when the subluxation or dislocation is associated with radial shortening or malunion. If the subluxation is longitudinal, as in ulnocarpal impaction syndrome, an ulnar shortening procedure alone may restore alignment and stability to the distal radioulnar joint5,10. However, in patients who have a malunited fracture of the distal part of the radius, with dorsal or volar subluxation or dislocation of the distal radioulnar joint, the radioulnar ligaments are often ruptured or secondarily elongated10 and additional soft-tissue procedures may be necessary to restore stability of the distal radioulnar joint after restoration of alignment of the distal part of the radius. Patients who have a malunited fracture of the distal aspect of the radius with volar or dorsal translation have limited pronation and supination of the forearm because of functional shortening of the distal radioulnar ligaments.
Arthrodesis of the distal radioulnar joint with creation of an ulnar pseudarthrosis proximal to the arthrodesis was at one time mistakenly referred to as the Lauenstein procedure but, in fact, was first described, in 1936, by Sauvé and Kapandji23. Several investigators have reported good results with the Sauvé-Kapandji procedure in patients who had a painful subluxated or dislocated distal radioulnar joint with or without a history of rheumatoid arthritis13,17,19,20,22,24,26. However, as Bowers6 pointed out, the Sauvé-Kapandji procedure shares with the Darrach procedure the undesirable feature of a potentially unstable ulnar stump. Taleisnik24 reviewed the results of the Sauvé-Kapandji procedure in twenty-three patients who had posttraumatic derangement of the distal radioulnar joint. He noted that nine patients had some degree of pain related to the ulnar stump and two patients needed a repeat operation because of instability of the ulnar stump. Furthermore, patients who had preoperative instability, dorsal subluxation, or dislocation of the ulna were more likely to have postoperative problems with instability of the ulnar stump. Taleisnik suggested that the Sauvé-Kapandji procedure "is probably contraindicated when treating the unstable or frankly subluxed or dislocated distal radioulnar joint, ulna dorsal, a therapeutic problem for which there is no reliable solution."
Sanders et al.22, in a study of nine patients who had had the Sauvé-Kapandji procedure for the treatment of posttraumatic arthritis of the distal radioulnar joint, reported that two patients had painful instability of the ulnar stump. Nakamura et al.20, in a review of the results of the procedure in fifteen patients, reported that four patients had painful instability of the ulna. Narrowing of the interosseous space, which was seen on radiographs of fourteen of the fifteen patients, was believed to be related to ulnar instability in the radioulnar plane. However, the clinical relevance of this type of instability was unclear. Kapandji13 recommended that a short fragment of the distal part of the ulna and a small ulnar gap be used to reduce problems of instability of the ulnar stump, although his series of seven patients was too small to support this claim. Minami et al.19, in a study of fifteen patients, found that the site of the resection did not alter the results; two of their patients had persistent pain in the ulnar stump.
The relative importance of the various soft-tissue and osseous constraints that maintain the stability of the distal radioulnar joint remains controversial, although most authors have agreed that the dorsal and volar radioulnar ligaments at the periphery of the triangular fibrocartilage complex provide the primary constraints to the distal radioulnar joint6,16. After the Sauvé-Kapandji procedure alone, the remaining structures that stabilize the ulnar shaft are the interosseous membrane, which provides some static stabilization, as well as the extensor carpi ulnaris and flexor carpi ulnaris tendons and a portion of the pronator quadratus, which provide dynamic stabilization. We believe that tenodesis of the flexor carpi ulnaris provides static stabilization by tethering the ulnar stump to the carpus.
Breen and Jupiter8 reported that a combined tenodesis of the flexor carpi ulnaris and the extensor carpi ulnaris is a reliable procedure for stabilizing a painful, unstable ulnar stump after resection of the distal part of the ulna. To our knowledge, the senior one of us10 was the first to describe the technique of tenodesis of the flexor carpi ulnaris after the Sauvé-Kapandji procedure to help to prevent instability of the ulnar stump, although no results were included at that time. In the present study, none of the patients had postoperative dorsal instability of the ulnar stump. One patient who had had multidirectional instability of the ulna preoperatively needed a tenodesis of the extensor carpi ulnaris to correct volar instability that had developed in the immediate postoperative period.
We believe that release of the pronator quadratus from the ulna and its reattachment to the extensor carpi ulnaris sheath in the area of the resection is an important part of the index operation. The muscle probably helps to prevent ossification and acts as a soft-tissue spacer, preventing impingement between the radius and the ulna during rotation of the forearm. Release of the pronator quadratus muscle from the ulna theoretically prevents it from actively contracting and narrowing the radioulnar space. However, its release from the ulna probably has a destabilizing effect on the ulnar stump in a dorsal-volar direction.
The etiology of the bone resorption at the distal end of the ulnar stump that was observed in five of our patients is not entirely clear and, to our knowledge, has not been previously reported in association with the Sauvé-Kapandji procedure. We believe that it probably represents pressure resorption due to the stabilizing effect of the tenodesis of the flexor carpi ulnaris. A similar phenomenon was observed by Leung and Hung15, who looped the palmaris longus tendon through the ulna and the radius to stabilize distal radioulnar joints that had dorsal instability.
Despite careful operative technique, a painful neuroma of the dorsal sensory branch of the ulnar nerve developed in three of our patients and hypoesthesia without a neuroma developed in two other patients. In order to obtain the distally based slip of flexor carpi ulnaris tendon, the incision that we used extends farther distally than the incision used in standard Sauvé-Kapandji procedures, and this places the nerve and its branches at greater risk. On the basis of our findings, we believe that the use of two incisions to perform the index operation should be considered.
The hardware was removed from ten of the eighteen patients in our study. Four patients had removal of the hardware in conjunction with other secondary procedures, but six patients had it removed because of tenderness over the heads of the screws when the wrist was placed in neutral rotation on a table. Countersinking of the heads of the screws to avoid this complication is not recommended because the distal part of the ulna has a very thin cortex.
It is important to distinguish ulnocarpal pain from radioulnar pain. Patients who have ulnocarpal impaction syndrome without tenderness or degenerative changes at the radioulnar joint can be managed with ulnar shortening or recession. We strongly recommend against performing the index operation to obtain ulnar recession if a stable, pain-free distal radioulnar articulation can be maintained with a less extensive procedure.
Our results support the conclusion reached by other investigators11,13,22,24 that the Sauvé-Kapandji procedure is an excellent salvage operation for the treatment of posttraumatic derangement of the distal radioulnar joint as it can reliably restore rotation of the forearm and grip strength while relieving pain and maintaining a functional range of motion of the wrist. On the basis of the results of the present study, specific indications include massive destruction of the sigmoid notch, associated loss of bone in the lunate fossa, fixed subluxation or dislocation of the ulnar head, blocked rotation of the forearm, and failure of a partial resection of the distal part of the ulna. The addition of a tenodesis of the flexor carpi ulnaris to the carpus reduces the risk of instability of the ulnar stump. We recommend this procedure only for young or active patients, including those who perform strenuous manual labor.