Phẫu thuật cắt bỏ một phần và ghép mô khớp quay-trụ xa (DRUJ) Thông tin

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Topic scope: post-operative rehabilitation after hemiresection-interposition arthroplasty (HIT) of the distal radioulnar joint (DRUJ) — the Bowers procedure — for painful DRUJ arthritis (degenerative, post-traumatic, or inflammatory). The arthritic portion of the ulnar head is partially resected and a soft-tissue spacer is interposed, preserving the TFCC, ulnar styloid and ulnar soft-tissue attachments so the distal ulna remains supported. This is a joint-reshaping arthroplasty, not a repair or reconstruction: the rehab is therefore an early-rotation pathway built around a short protected settling phase, then prioritised restoration of forearm pronation/supination, then graded loading — not months of construct protection.

Defining principle of the rehab here: the operation exists to restore pain-free forearm rotation, and nothing is sutured under tension that must heal protected for months. The deliberate restraint is a brief splinted phase (commonly an above-elbow / Muenster-type splint limiting forearm rotation for ~2-3 weeks in the isolated case) to let the soft-tissue interposition and capsule settle. After that, early active pronation/supination is the explicit priority — rotation is the function the operation restores. The single load to respect throughout is rotational/axial loading of the distal ulna, which provokes the characteristic failure mode: painful ulnar-stump instability and radioulnar convergence. The main branch point that lengthens the protected phase is a concurrent procedure (TFCC repair, distal radius osteotomy, extensor reconstruction).

A. PROCEDURE OUTCOMES (hemiresection-interposition arthroplasty)

The Bowers HIT is a long-established, generally reliable salvage for the arthritic DRUJ. The evidence base is level IV (retrospective cohorts and case series, no randomised trials), but it is consistent across decades: most patients gain durable pain relief and improved, stable forearm rotation, with the principal residual concern being ulnar-stump instability / radioulnar convergence under load.

• The original Bowers series established the procedure and its rationale. Bowers' 1985 description (38 patients, mean ~2.5 yr) reported stable, painless rotation in the great majority — in rheumatoid patients ~85% achieved stable painless rotation (pronation ~84°, supination ~77°), and degenerative/post-traumatic patients achieved painless rotation averaging ~80° in each direction. The technique was explicitly designed to preserve the functional ulnocarpal ligament complex [Bowers, J Hand Surg Am 1985]. Level IV (foundational case series).
• Long-term outcomes are durable but with a defined complication rate. A long-term cohort (66 patients, mean follow-up 8.6 years) reported low residual pain (median NRS 1/10), an overall complication rate of ~14% and reoperation ~8%; reported complications included stylocarpal impingement, ulnar subluxation, exostoses and tendon rupture. Inflammatory-arthritis patients had lower pain than post-traumatic patients (median 0 vs 5). The same series found PIN neurectomy associated with improved pain scores [HIT long-term outcome study, Hand (N Y) 2019]. Level IV (cohort).
• Forearm rotation, grip and pain all improve measurably. A capsuloretinacular HIT series (21 wrists, mean ~2 yr 10 mo) reported significant gains: pronation 56.8°→83.0°, supination 60.0°→82.0°, grip 66.0%→87.4% of the contralateral side, VAS pain 62→23 mm, DASH 37.7→25.0, PRWE 48.1→24.4, with no post-operative DRUJ instability reported in that series [HIT capsuloretinacular series, J Wrist Surg 2023]. Level IV (cohort).
• HIT sits within a family of DRUJ salvage options (Darrach distal ulna resection, Sauvé-Kapandji arthrodesis-pseudarthrosis, matched/hemiresection variants, and ulnar-head implant arthroplasty), each with its own instability/convergence profile; HIT's selling point is preservation of the ulnar support structures to reduce stump instability versus a formal Darrach [Bowers 1985; Glowacki, Hand Clin 2005; Chidgey, JAAOS 1995; Rekant, Hand Clin 2012; Murray, Hand Clin 2011]. Mechanistic / narrative-review.

B. REHABILITATION / THERAPY EVIDENCE

There is no trial-level evidence for any specific rehabilitation regimen after DRUJ HIT. Protocols are surgeon- and technique-derived expert consensus, reported as the post-operative methods of the outcome series and operative-technique articles above. The consensus is consistent on its key features.

• A brief protected settling phase, not prolonged immobilisation. In the isolated hemiresection (no distal radius osteotomy, no TFCC repair), a long-arm plaster splint for ~10 days followed by a removable Muenster splint for a further 2-3 weeks is typical; cohort series report an upper-arm cast ~3 weeks then a forearm cast 1-2 weeks. Where a distal radius osteotomy or TFCC repair is added, immobilisation is longer (e.g. a long-arm cast in ~45° supination for ~4 weeks) [Pillukat & van Schoonhoven, Oper Orthop Traumatol 2009; HIT capsuloretinacular series, J Wrist Surg 2023]. Weak / expert consensus.
• Early forearm rotation is the explicit priority once protection ends. The whole point of the operation is rotation, so active pronation/supination is pursued early and frequently. Some protocols further limit end-range rotation by splint for ~4 more weeks after the cast comes off before unrestricted motion and load [Pillukat & van Schoonhoven 2009]. Weak / expert consensus.
• Loading is added last, watching for the characteristic failure mode. Range and load are returned to normal after the rotation-limited window; the specific thing to watch is painful ulnar-stump instability and radioulnar convergence under axial/rotational load, which is the biomechanically demonstrated weak point of distal-ulna procedures [Sauerbier et al., J Hand Surg Br 2002; Douglas et al., J Hand Surg Am 2014; Barret et al., Orthop Traumatol Surg Res 2020]. Mechanistic (biomechanical) + consensus.
• Finger, thumb, elbow and shoulder motion from day one is standard to prevent stiffness, as in any forearm/wrist immobilisation pathway. Consensus.

Recovery trajectory (expected, evidence-anchored)

(Phase windows mirror the precautions and phase tables in the patient protocol; they are typical expert-consensus guides, not trial-derived deadlines, and lengthen with concurrent procedures.)

C. KEY CONTROVERSIES / EVIDENCE QUALITY

1. HIT vs Darrach. The Darrach (complete distal ulna resection) is simpler but sacrifices the ulnar support structures and is more prone to painful proximal ulnar-stump instability and radioulnar convergence, especially in younger, higher-demand or post-traumatic patients. HIT preserves the TFCC/styloid/attachments to mitigate this — but biomechanical work shows HIT also converges under load, just to a different degree, so convergence is a spectrum, not a HIT-vs-Darrach binary [Sauerbier et al., J Hand Surg Br 2002; Douglas et al., J Hand Surg Am 2014]. Darrach remains reasonable in low-demand/elderly patients. *Moderate (biomechanical
2. cohort).*
3. HIT vs Sauvé-Kapandji. Sauvé-Kapandji fuses the DRUJ and creates a controlled proximal pseudarthrosis, preserving the ulnar head/buttress for the carpus; it is often favoured where ulnar translation of the carpus is a concern (e.g. rheumatoid), but it too can develop painful proximal-stump instability. Long-term Sauvé-Kapandji and modified-Sauvé-Kapandji series report durable function with that caveat [Reissner et al., J Hand Surg Eur 2021; Zimmermann et al., Arch Orthop Trauma Surg 2003]. Choice is patient- and pathology-specific, not evidence-mandated. Moderate.
4. HIT vs ulnar-head (implant) replacement. Implant ulnar-head arthroplasty is an alternative — particularly for failed resection/instability salvage — restoring a load-bearing buttress, but it adds implant-specific complications. Long-term implant series report good outcomes; it is increasingly used to rescue a painful, unstable stump after resection-type procedures [Kakar et al., J Hand Surg Am 2010; Adams, Hand Clin 2010; Watts et al., Hand Clin 2010; Rekant, Hand Clin 2012]. Moderate.
5. The rehab regimen itself is consensus, not trial-derived. No RCT compares immobilisation length, rotation timing or loading progression after HIT. The "brief protection → early rotation → graded load" structure is inferred from technique articles and the methods of level-IV outcome series. Exact phase timings are typical, not deadlines, and shift with concurrent procedures. Weak / expert consensus.
6. Patient selection drives results. Inflammatory-arthritis patients report lower residual pain than post-traumatic patients in long-term follow-up; adjunct PIN neurectomy is associated with better pain scores. Both point to outcome being substantially a selection/technique matter, not a rehab one [HIT long-term cohort, Hand 2019]. Moderate (within level-IV data).

D. EVIDENCE STRENGTH FLAGS (summary)

• STRONG (RCT / SR): none. There are no randomised trials of DRUJ HIT or of its rehabilitation.
• MODERATE: the biomechanical basis of radioulnar convergence / ulnar-stump instability under load across distal-ulna procedures (cadaveric studies); the comparative trade-offs among HIT / Darrach / Sauvé-Kapandji / ulnar-head replacement (consistent cohort + mechanistic data).
• LEVEL IV (cohort / case series — the outcome evidence): pain relief, grip recovery (~85-90% contralateral), pronation/supination gains (toward ~80° each), ~14% complication and ~8% reoperation rates, durability to ~8-9 years. Consistent but uncontrolled and surgeon-reported.
• WEAK / EXPERT CONSENSUS (the rehab regimen): the specific brief-protection → early-rotation → graded-load programme, the Muenster/above-elbow splint choice, the ~2-3 week protected window, and all exact phase timings — derived from technique articles and the methods sections of level-IV series, lengthened by concurrent procedures. No comparative rehab evidence exists.

CITATIONS

RAG corpus (180,000+ Orthopaedic articles)

• Glowacki KA. Hemiresection arthroplasty of the distal radioulnar joint. Hand Clin. 2005. DOI: 10.1016/j.hcl.2005.08.002
• Sauerbier M, Fujita M, Hahn ME, et al. The dynamic radioulnar convergence of the Darrach procedure and the ulnar head hemiresection interposition arthroplasty: a biomechanical study. J Hand Surg Br. 2002. DOI: 10.1054/jhsb.2002.0763
• Douglas KC, Parks BG, Tsai MA, et al. The biomechanical stability of salvage procedures for distal radioulnar joint arthritis. J Hand Surg Am. 2014. DOI: 10.1016/j.jhsa.2014.03.028
• Barret H, Lazerges C, Chammas P, et al. Modification of matched distal ulnar resection for distal radio-ulnar joint arthropathy: analysis of distal instability and radio-ulnar convergence. Orthop Traumatol Surg Res. 2020. DOI: 10.1016/j.otsr.2020.07.008
• Chidgey LK. The distal radioulnar joint: problems and solutions. J Am Acad Orthop Surg. 1995. DOI: 10.5435/00124635-199503000-00005
• Murray PM. Current concepts in the treatment of rheumatoid arthritis of the distal radioulnar joint. Hand Clin. 2011. DOI: 10.1016/j.hcl.2010.10.002
• Lee SK, Hausman MR. Management of the distal radioulnar joint in rheumatoid arthritis. Hand Clin. 2005. DOI: 10.1016/j.hcl.2005.08.009
• Ozer K. Management of complications of distal radioulnar joint. Hand Clin. 2015. DOI: 10.1016/j.hcl.2014.12.003
• Zimmerman RM, Jupiter JB. Instability of the distal radioulnar joint. J Hand Surg Eur Vol. 2014. DOI: 10.1177/1753193414527052
• Rekant M. Distal ulna arthroplasties. Hand Clin. 2012. DOI: 10.1016/j.hcl.2012.08.016
• Watts AC, Hayton MJ, Stanley JK. Salvage of failed distal radioulnar joint reconstruction. Hand Clin. 2010. DOI: 10.1016/j.hcl.2010.05.004
• Kakar S, Swann R, Perry K, et al. Distal radioulnar joint implant arthroplasty: a long-term outcome analysis. J Hand Surg Am. 2010. DOI: 10.1016/j.jhsa.2010.05.010
• Adams BD. Complications of wrist arthroplasty. Hand Clin. 2010. DOI: 10.1016/j.hcl.2010.01.006
• Reissner L, Schweizer A, Unterfrauner I, et al. Long-term results of the Sauvé-Kapandji procedure. J Hand Surg Eur Vol. 2021. DOI: 10.1177/17531934211004459
• Zimmermann R, Gschwentner M, Arora R, et al. Treatment of distal radioulnar joint disorders with a modified Sauvé-Kapandji procedure: long-term outcome with special attention to the DASH questionnaire. Arch Orthop Trauma Surg. 2003. DOI: 10.1007/s00402-003-0529-5
• Nypaver C, Bozentka DJ. Distal radius fracture and the distal radioulnar joint. Hand Clin. 2021. DOI: 10.1016/j.hcl.2021.02.011
• Pillukat T, van Schoonhoven J. Die Hemiresektions-Interpositionsarthroplastik des distalen Radioulnargelenks nach Bowers [The hemiresection-interposition arthroplasty of the distal radioulnar joint]. Oper Orthop Traumatol. 2009. DOI: 10.1007/s00064-009-1913-2

DRUJ hemiresection literature (URLs)

• Bowers WH. Distal radioulnar joint arthroplasty: the hemiresection-interposition technique. J Hand Surg Am. 1985;10(2):169-178. https://www.jhandsurg.org/article/S0363-5023(85)80100-3/abstract (PMID: 3980927)
• Hemiresection interposition arthroplasty of the distal radioulnar joint: a long-term outcome study. Hand (N Y). 2019. DOI: 10.1177/1558944719873430. https://pmc.ncbi.nlm.nih.gov/articles/PMC8461192/
• Hemiresection capsuloretinacular interposition arthroplasty for distal radioulnar joint osteoarthritis. J Wrist Surg. 2023. DOI: 10.1055/s-0043-1771341. https://pmc.ncbi.nlm.nih.gov/articles/PMC11606672/
• Mid- to long-term functional results after Bowers' hemiresection interposition arthroplasty of the distal radio-ulnar joint. PubMed. https://pubmed.ncbi.nlm.nih.gov/35238965/
• Pillukat T, van Schoonhoven J. The hemiresection-interposition arthroplasty of the distal radioulnar joint (operative technique). Oper Orthop Traumatol. 2009. https://link.springer.com/article/10.1007/s00064-009-1913-2 (PMID: 20058126)
• Ulnar head hemiresection with interposition and extensor reconstruction — surgical technique. OrthOracle. https://www.orthoracle.com/library/ulnar-head-hemiresection-with-interposition-and-extensor-reconstruction/