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New revision technique for failed Darrach procedures uses Achilles tendon allograft
Surgeons found good results at 34 months follow-up in 17 patients treated with the procedure.
WASHINGTON – Pittsburgh researchers introduced a novel way to treat painful instability following a failed Darrach procedure: using human Achilles tendon allograft.
Dean G. Sotereanos, MD, of Allegheny General Hospital, and colleagues found promising results with this new revision technique that is an alternative to metal arthroplasty for revising failed distal ulna resection.
In 17 patients at an average 34-month follow-up, the researchers found only one patient who did not perform well.
All patients improved on the Visual Analog Scale, grip strength and range of motion tests.
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Images: Sotereanos DG |
“Basically the allograft works as a mechanical interposition between the radius and the ulna,” Sotereanos said. “The operative technique utilizes the same incision that was previously used for the exposure of the distal end of the receptive ulna.”
He presented the new technique at the American Society for Surgery of the Hand annual meeting.
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Researchers found improvement in range of motion and grip strength, as well as improvement on the Visual Analog Scale, in the 17-patient group after they underwent revision with the allograft. | ||
Surgical technique
To perform the procedure, surgeons exposed about 6 cm of the ulna, proximal to the stump, Sotereanos said. Next, they identified the medial cortex of the radius and placed suture anchors in it, proximal to the sigmoid notch where the impingement occurred.
“We placed two or three drill holes in the ulna and attempted to gain fixation of an allograft to the radius and the ulna,” Sotereanos said. “The purpose is to create a large buffer between the two bones with the Achilles tendon allograft.”
He sutured an adequate amount of the allograft into an “anchovy” and attached it to the medial cortex of the radius with suture anchors and then to the ulna using drill holes.
Noting the importance of determining proper allograft size, Sotereanos instructed colleagues to pronate and supinate the forearm, and to apply pressure to the ulnar nerve side of the ulna in an attempt to create an impingement or crepitus. If crepitus is noted, more allograft is necessary, he said.
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“When the final allograft is placed, there is significant padding between the two bones to prevent crepitus,” Sotereanos said.
Postoperatively, the surgeons placed patients in long-arm splints for 10 days, then in a cast for 6 weeks followed by physical therapy.
Results
The 17 patients studied were an average of 47 years of age. Indications for revision surgery included incapacitating pain that increased with wrist use, Sotereanos said.
Surgeons revised these patients at an average of 15 months after the Darrach procedure. They found no infections.
“We showed six excellent results, 10 good results and one patient who did not do well,” Sotereanos said. “He was a workers’ compensation case [and] we felt we used inadequate allograft.”
Sotereanos said that surgeons should place as much allograft as necessary.
“It can create a cosmetic problem for a few months, but over time it seems to shrink, and most of the patients have not complained of any cosmetic deformities,” he said.
For more information:
- Giannoulis FS, Greenberg JA, Sotereanos DG, et al. Failed Darrach procedure: An allograft solution. #23. Presented at the American Society for Surgery of the Hand 61st Annual Meeting. Sept. 7-9, 2006. Washington.
- Dean G. Sotereanos, MD, Allegheny General Hospital, 1307 Federal St., 2nd Fl., Pittsburgh, PA 15212; 412-359-8571; dsoterea@hotmail.com.