Ulnar head replacement and related biomechanics

Clinical outcome and survival rate of the Herbert ulnar head prosthesis for reconstruction of the distal radioulnar joint depending on co-morbidity and different indications

INTRODUCTION

Ulnar head prostheses have been developed to restore the integrity of the DRUJ and relieve pain. This study aims to evaluate the long-term outcome of the clinical and radiographic results as well as the survival rate of the Herbert ulnar head prosthesis (UHP) depending on co-morbidity and different indications.

MATERIALS AND METHODS

The Herbert ulnar head prosthesis was implanted in 62 patients. In the majority of the patients, the indication was given due to pain during forearm rotation. This was on account of painful instability of the distal ulna following Bowers (59.7%) or Kapandji procedure (16.1%), Darrach procedure (8.1%) or painful post-traumatic (12.9%) or primary osteoarthritis (3.2%). Of the 62 patients, 34 were men and 28 women. The mean age at the time of operation was 49 years (range 18-84 years). A clinical and radiographic evaluation was performed including pain scale, range of motion, grip strength and the DASH and modified Mayo wrist scores.

RESULTS

The average follow-up was 84.5 months (range 8-206 months), and statistically significant reduction of pain was observed (p < 0.05). The range of motion of pro- and supination improved slightly, but not significantly, whereas the DASH score improved significantly from 56 to 43 (p < 0.05). Patients without an arthrodesis achieved better results in the DASH and in the modified Mayo wrist score. In 39 cases, a small amount of bone resorption was seen at the collar of the prosthesis in the follow-up radiographs. A revision surgery was necessary in 14 patients. The Kaplan-Meier survival rate after 15 years was 90.3%.

CONCLUSION

The long-term results of the UHP are encouraging regardless of different indications with a survival rate of more than 90% 7 years following surgery, high patient satisfaction and good clinical and radiographic results.

LEVEL OF EVIDENCE

IV.

3D analysis of the distal ulna with regard to the design of a new ulnar head prosthesis

STUDY DESIGN

A retrospective, single center, data analysis.

OBJECTIVE

Persistent pain and instability are common complications after distal ulnar head arthroplasty. One main reason may be the insufficient representation of the anatomical structures with the prosthesis. Some anatomical structures are neglected such as the ulnar head offset and the ulnar torsion which consequently influences the wrist biomechanics.

METHODS

CT scans of the ulnae of forty healthy and asymptomatic patients were analyzed in a three-dimensional surface calculation program. In the best fit principle, cylinders were fitted into the medullary canal of the distal ulna and the ulnar head to determine their size. The distance between the central axes of the two cylinders was measured, which corresponds to the ulnar offset, and also their rotational orientation was measured, which corresponds to the ulnar torsion.

RESULTS

The mean medullary canal diameter was 5.8 mm (±0.8), and the ulnar head diameter was 15.8 mm (±1.5). The distance between the two cylinder axes was 3.89 mm (±0.78). The orientation of this offset was at an average of 8.63° (±15.28) of supination, reaching from 23° pronation to 32° supination.

CONCLUSION

With these findings, a novel ulnar head prosthesis should have different available stem and head sizes but also have an existing but variable offset between these two elements. A preoperative three-dimensional analysis is due to the high variation of offset orientation highly recommended. These findings might help to better represent the patients natural wrist anatomy in the case of an ulnar head arthroplasty.

LEVEL OF EVIDENCE

III.

Clinical, radiological and patient-rated outcome comparison between total and partial ulnar head implants

This study aimed to analyse the clinical and radiological outcomes after ulnar head replacement and to compare partial and total ulnar head implants. Twenty-two patients with 23 implants were available with a mean follow-up time of 7 years (range 1.3 to 17) after distal radioulnar joint arthroplasty. At the final follow-up, patients had a low level of pain at rest and during effort, a median Disabilities of the Arm, Shoulder, and Hand (DASH) score of 12 and Patient-Rated Wrist Evaluation score of 12 with partial ulnar head implants, and scores of 20 and 22 in total ulnar head implants, respectively. While the range of motion in patients with partial ulnar head implants was slightly reduced in comparison with the preoperative condition and to the patients with total ulnar head implants, there was a tendency to a higher grip strength and rotational torque. Both types of prosthesis showed sigmoid notch resorptions and resorptions around the neck. We conclude that the results after partial ulnar head replacement do not significantly differ from the total ulnar head implants in many aspects.Level of evidence: III.

Distal Radioulnar Joint Osteoarthritis: An Update on Treatment Options

The distal radioulnar joint (DRUJ), the articulation between the sigmoid notch of the radius and the distal ulna, plays a pivotal role in stability and load bearing and allows for pronation and supination of the forearm. Osteoarthritis (OA) of the DRUJ commonly occurs due to distal radius trauma but may also be the result of conditions such as joint instability, septic arthritis, or primary OA. It is initially managed with conservative therapy, but surgery is often considered when nonoperative methods fail. The surgical approaches available to treat this pathology have grown over the years. The procedures have generally favorable outcomes, each with their own unique complications and considerations. This paper comprises a review of the outcomes and complications for the different procedures commonly used to surgically treat DRUJ OA.

Distal Radioulnar oint Prosthesis

The distal radioulnar joint (DRUJ) prostheses have been available for many years and despite their superior outcomes compared to conventional DRUJ reconstructions in both short and long-term follow-ups, they have not become as popular as common hip and knee prostheses. In the current review article, at the first step, we discussed the applied anatomy and biomechanics of the DRUJ, and secondly, we classified DRUJ prostheses according to available literature, and reviewed different types of prostheses with their outcomes. Finally we proposed simple guidelines to help the surgeon to choose the appropriate DRUJ prosthesis.

Females Are Not Proportionally Smaller Males: Relationships Between Radius Anthropometrics and Their Sex Differences

Background: Distal radius fracture reduction by internal fixation is most commonly achieved using volar locking plates (VLPs). Many standard VLP designs make little point contact with radius anatomy, and most postsurgical complications following fixation are attributed to poor implant fit. Sex differences may require consideration in implant design, as females more commonly require VLP removal. Therefore, the purpose of this research was to determine whether the relationships between measures of radius shape are proportional between the sexes. Methods: Three-dimensional radius bone geometries were created from 40 male and 34 female (mean age = 72.04 years) forearm computed tomographic scans in Mimics (Materialise NV, Leuven, Belgium). Eleven measures of radius shape were collected from each scan. Principal components analysis was performed on these measures to determine which shape variables account for the greatest differences in radius shape among individuals and between the sexes. Results: Principal component scores representing isometric radius size separated the sexes. Six anthropometric measures significantly correlated with isometric radius size for all specimens, whereas 3 and 1 measures significantly correlated with isometric radius size in males and females, respectively. Conclusions: Anthropometrics of male and female radii vary by different proportions. Using anthropometrics from both sexes to create a single implant system may not result in optimal patient fit for either sex.

Ulnar Head or Total Distal Radioulnar Joint Replacement, Isolated and Combined with Total Wrist Arthroplasty: Midterm Results

Purpose  Various implants have been described for ulnar head replacement (UHR) or for total replacement of the distal radioulnar joint (DRUJ). Many series are small and few reports on mid- or long-term results. This study is primarily aimed to report on the midterm results after ulnar head only and total DRUJ replacement using the uHead in the treatment of painful disorders of the DRUJ. The secondary aim of the study was to eventually assess the combination of UHR and total wrist arthroplasty (TWA). Materials and Methods  We included 20 consecutive patients in whom an UHR with the uHead was performed at our institution between February 2005 and March 2017. There were 6 men and 14 women with mean age of 59 years (range: 36-80 years). The mean follow-up time was 5 years (range: 2-15 years). Data were recorded prospectively before operation and at follow-up examinations and entered in a registry. The patients were followed-up at 3 and 6 weeks and 3, 6, and 12 months postoperatively and thereafter annually. In five cases, the uHead was implanted simultaneously with a Remotion TWA. In four cases, a Remotion TWA had been implanted previously. Kaplan-Meier survival analysis was used to estimate the cumulative probability of remaining free of revision. A nonparametric Wilcoxon's signed-rank test was used for comparing data not normally distributed (qDASH [quick disabilities of the hand, shoulder, and arm] scores), and the paired parametric Student's t -test was used for normally distributed data (pain and visual analogue scale [VAS] scores, range of motion, and grip strength). Significance was set at a p -value of less than 0.05. Results  Pain, grip strength, and the function improved significantly. Pain after surgery decreased with 50 points on the VAS score scale of 100, from 66 (mean), preoperatively (range: 16-97) to 16 (mean; range: 0-51), postoperatively, while grip strength nearly doubled from 12 KgF (mean; range: 4-22), before to 21 KgF (mean; range: 6-36), after the surgery. Patients function measured with qDASH scores improved from 56 (mean; range: 36-75), preoperatively to 19 (mean; range: 4-47), postoperatively. Wrist extension, flexion, and ulnar and radial deviation did not change to a clinically or statistically significant extend, neither did supination nor pronation improved after surgery. While three UHRs were revised early because of pain problems and/or unsatisfactory forearm rotation in two cases and infection in one, 17 had an uncomplicated postoperative course and these patients were satisfied with the results of the surgery at all the follow-ups. Due to limited number of cases, the calculation of significance in comparing combined cases with UHR only cases was abandoned. Conclusion  Ulnar head arthroplasty (uHead) showed significant improvement in pain, grip strength, and the function of the patients with a painful disability of the DRUJ, without impairment on mobility on the midterm follow-up. The overall implant survival over the time and the complication rate was acceptable.

Unipolar ulnar head replacement for treatment of post-Darrach procedure instability

The aim of this study was to assess distal radioulnar joint stability after unipolar ulnar head replacement for post-Darrach instability. All the patients who underwent ulnar head replacement between1999 and 2015 for post-Darrach procedure instability at our clinic were reviewed. Seven Hebert-type and two uHead (SBI/Stryker) prostheses were implanted. None of the implants were cemented. We assessed stability, pain, range of motion and strength pre- and postoperatively. The changes in the radiographic appearance between immediate postoperative and the last follow-up were determined. All patients (8 patients and 9 joint replacements) had a stable distal ulnar stump at the mean follow-up of 69 months. No complications occurred and no revisions were needed. Pain on a visual analog scale (VAS) was 0 at rest and 6 during maximum effort at the last follow-up; it was 1.5 at rest and 8.5 during effort preoperatively. Wrist flexion and extension, supination and grip strength were unchanged. Pronation increased from 45° to 70°. An area of bone resorption proximal to the ulnar head implant was found in 5 cases but no secondary displacement of the implant or increased pain was reported. Ulnar head replacement stabilizes the ulnar stump. The implant acts as a spacer to place the soft tissues under tension. Distal ulnar stump instability after the Darrach procedure can be solved by a unipolar ulnar head replacement procedure.

[Endoprostheses of the distal radioulnar joint]

BACKGROUND

A stable distal radioulnar joint (DRUJ) is mandatory for the rotation and load transmission in the forearm and wrist. Salvage procedures such as the Darrach operation, Bowers arthroplasty, and the Kapandji-Sauvé procedure include the potential risk of dynamic radioulnar instability and impingement, despite stabilizing techniques addressing the soft tissues.

PROSTHESES

In an attempt to stabilize the distal forearm mechanically following ulnar head resection, various endoprostheses have been developed to replace the ulnar head. These prostheses can be used for secondary treatment of persistent complaints and unsatisfactory results after ulnar head resection, but also in the primary treatment of osteoarthritis of the DRUJ. Based on promising results concerning improvement in pain, range of motion, and grip strength, with proper indications ulnar head prostheses should be considered as a valuable treatment option for osteoarthritis of the DRUJ.

Distal radio-ulnar implant arthroplasty: a systematic review

The use of implant arthroplasty in the hand and wrist is increasing, often with little evidence of outcomes in the literature. We therefore undertook a systematic review of the outcomes of distal radio-ulnar joint arthroplasties following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Papers were assessed for outcomes, implant survival and methodological quality. Fourteen papers assessed ulna head replacements. The implant survival rate was 93% at a mean follow-up of 45 months. One paper assessed a partial ulna head replacement. Fourteen papers assessed total distal radio-ulnar joint replacements; all but two used the Aptis prosthesis. These implants had a survival rate of 97% at a mean of 56 months. Complications rates were 28% in both groups, and many were major. Although these data are impressive, worldwide there are many more implants placed and not followed up. All studies were level IV and V studies with low Coleman scores. This systematic review demonstrates that implant arthroplasty for the distal radio-ulnar joint has produced acceptable results in small numbers of patients. Whilst these short term outcomes are encouraging, the indications should be carefully considered and there should be proper consideration of the potential for later failure.

LEVEL OF EVIDENCE

III.

Distal radioulnar joint arthroplasty with implants: a systematic review

A severely painful, dysfunctional, or destroyed distal radio-ulnar joint (DRUJ) can be reconstructed by fusion, interposition of soft tissue, or by arthroplasty using prostheses.

The objective of this study was to review the literature on implants and evaluate their effectiveness in terms of pain relief, range of motion and longevity.

A search was carried out using protocols and well-defined criteria in PubMed, the Cochrane Library and by screening reference lists. The review was conducted according to PRISMA guidelines.

Of the 27 publications reporting on nine different implants, we excluded reports with less than five cases and silastic replacements of the ulna head. Eighteen publications describing a total of five implants were selected for analysis. Nine of the publications were useful for the evaluation of implant longevity. Despite methodological shortcomings in many of the source documents, a summary estimate was possible.

It seems that DRUJ implants have good potential to improve function through pain reduction; an improvement was observed in 17 series, although it was significant in only seven series.

Instability is not uncommon with ulna head-only implants, but they cause fewer clinical problems and re-interventions than might be expected.

The risk of deep infection is small with the available implants.

Overall implant survival in papers with at least five years’ follow-up is 95%, with a slightly better longevity of 98% for the constrained implants.

Periprosthetic osteolysis/radiolucency is frequently reported. Its causes and consequences are not clarified.

Cite this article: Calcagni M, Giesen T. Distal radioulnar joint arthroplasty with implants: a systematic review. EFORT Open Rev 2016;1:191-196. DOI: 10.1302/2058-5241.1.160008.

Long-term functional outcome and patient satisfaction after ulnar head resection

BACKGROUND AND AIM

Resection of the ulnar head (Darrach procedure) is still frequently performed in patients suffering from posttraumatic osteoarthritis of the distal radioulnar joint (DRUJ). Ulnar impingement syndrome is sometimes observed with subsequent poor functional outcome. Here, we present a long-term follow-up study after Darrach procedure to evaluate functional results, pain relief, and patient satisfaction.

METHODS

Thirty-seven patients after ulnar head resection who were treated in our clinic between 2006 and 2012 were invited for follow-up investigation. Follow-up included radiologic outcomes, objective measures (active range of motion (AROM) and grip strength), the patients' individual perception of disability (pain, visual analog scale (VAS), the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and patient-rated wrist evaluation score (PRWE)).

RESULTS

A total of 25 patients with 27 operated wrists were available for clinical evaluation and radiologic follow-up. The AROM of the treated wrists averaged 145.7° (89.7% of the contralateral side) for pronation and supination. The average VAS decreased from 6.5 to 2.3 postoperatively. Mean grip strength was 12.4 kg (57.1%). Patients showed satisfying results with an average PRWE of 42 and an average DASH of 25.5. Radiographic radioulnar convergence did not correlate with clinical symptoms. Overall, patient satisfaction was high and 22 patients (88%) would choose to undergo the operation again.

CONCLUSIONS

In patients with posttraumatic and chronic DRUJ osteoarthritis, the Darrach procedure leads to satisfactory long-term results especially concerning mobility and sustainable pain relief. Symptomatic ulnar impingement and persistent pain of the ulnar stump are rare sequelae of this procedure.

Intermediate term evaluation of the Eclypse distal radio-ulnar prosthesis for rheumatoid arthritis. A report of five cases

HYPOTHESIS

Early medical management of rheumatoid arthritis with biotherapy has changed the traditional musculoskeletal damage from this disease. When the distal radio-ulnar joint (DRUJ) is involved, classic procedures may be inappropriate. We chose a hemi-arthroplasty of the DRUJ joint (Eclypse™) in patients with persistent synovitis and chondrolysis with a stable joint. The aim of this study was to assess the intermediate term results of this approach in these specific cases.

MATERIALS AND METHODS

We report a retrospective study of 5 Eclypse arthropasties implanted between March 2005 and March 2011. There were 4 women and 1 man, mean age: 58.4years old (54-62) with RA that had been present for 21.6years (15-33). This hemi-arthroplasty replaced the ulnar head with a pyrocarbon component. Patients were evaluated by an independent observer for pain by VAS, range of motion, grip strength in the neutral position by Jamar dynamometer, pronation and supination strengths with a pronosupinator, DASH score and wrist X-rays.

RESULTS

One patient was lost to follow-up and the 4 others underwent a follow-up evaluation at 64 months (43-90). There were no intra-operative or postoperative complications. The pain score at the final follow-up was 1.5/10 (0-4), pronation was 70° (60-80) and supination was 80° (80-80). Grip strength was 148% compared to the contralateral side (73-200%). Pronation and supination strengths were 1.7kg (1.5-2) and 2.1kg (2-2.5) respectively. The DASH score was 55.9 points (42.6 to 79.3). X-rays did not show any changes in the ulnar notch.

CONCLUSION

This distal radio-ulnar arthroplasty is less invasive and preserves the bone and ligaments. Clinical results are rapid, remain stable over time and are well tolerated. This arthroplasty, which was initially developed for osteoarthritis and traumatic lesions of the DRUJ, is promising for specific cases of rheumatoid arthritis.

Arthroplasty of the distal ulna distal in managing patients with post-traumatic disorders of the distal radioulnar joint: measurement of quality of life

Objective

To measure the quality of life and clinical–functional results from patients diagnosed with osteoarthrosis of the distal radioulnar joint who underwent surgical treatment using the technique of total arthroplasty of the ulna, with a total or partial Ascension^® prosthesis of the distal ulna.

Methods

Ten patients were evaluated after 12 months of follow-up subsequent to total or partial arthroplasty of the distal ulna. All of them presented post-traumatic osteoarthrosis and/or chronic symptomatic instability of the distal radioulnar joint. The study was prospective. Seven patients had previously undergone wrist procedures (two cases with Darrach, three with Sauvé–Kapandji and two with ligament reconstruction of the fibrocartilage complex) and three presented fractures of the distal ulna that evolved with pain, instability and osteoarthrosis of the distal radioulnar joint. The following were assessed: quality of life (DASH scale); percentage degree of palm grip strength (kgf) and pronosupination range of motion in relation to the unaffected side; pain (VAS); return to work; subjective evaluation of radiography; and complications.

Results

The patients presented a mean range of motion of 174.5° (normal side: 180°). Quality of life was analyzed by applying the DASH questionnaire and the mean value found was 5.9. The mean pain score using the VAS was 2.3. The mean degree of palm grip strength (kgf) was 50.7, which represented 90.7% of the strength on the unaffected side. The complication rate was 10%: this patient presented slight dorsal instability of the ulna and persistent pain, and did not return to work. This patient is still being followed up in the outpatient clinic and occupational therapy sector, with little improvement. He does not wish to undergo a new procedure. The mean length of follow-up was 16.8 months, with a minimum of 10 and maximum of 36 months.

Conclusion

This concept is subject to the test of time. Implantation of a prosthesis is a very interesting addition to the surgical arsenal for those who are specialists in hand surgery. Arthroplasty of the distal ulna is a safe and effective method with clinical–functional and quality-of-life improvements for patients and presents a low complication rate.

Distal ulna leiomyosarcoma treated with custom polymethylmethacrylate prosthesis with a 4-year follow-up

BACKGROUND

Intraosseous leiomyosarcoma is a rare neoplasm having an aggressive biologic behavior. The distal end of the ulna is a very uncommon site for this type of primary bone tumor frequently mistaken for benign lesions. En bloc resection of the distal ulna with reconstruction is a valid option as a limb salvage procedure for the treatment of this difficult problem, minimizing local recurrence while preserving hand function.

CASE DESCRIPTION

We present an unusual case of a 63-year-old woman with a primary leiomyosarcoma arising from the distal end of the ulna treated successfully with a wide excision and custom distal ulna, with 4-year follow-up and no recurrence.

LITERATURE REVIEW

Tumors to develop at the distal end of the ulna have been reported as part of large series such as Dahlin and few case reports. According to Cooney, Exner, and Mankin, reconstruction for distal ulnar neoplasms is not necessary to maintain function. However, Noble and Laurentin-Perez disagree because stabilization of the distal ulna following large resection, as in our case, can be a significant problem with associated pain and weakness due to a decreased interosseous space with ulnar stump impingement on the radial metaphysis and ulnar translation of the carpus.

CLINICAL RELEVANCE

Custom methacrylate in situ radioulnar joint prosthesis for reconstruction of a large segment of the distal ulna can be a valid option to reestablish the mechanical continuity of the forearm, reducing pain and improving strength and function.

Outcome Assessment after Aptis Distal Radioulnar Joint (DRUJ) Implant Arthroplasty

BACKGROUND

Conventional treatments after complicated injuries of the distal radioulnar joint (DRUJ) such as Darrach and Kapandji-Sauvé procedures have many drawbacks, which may eventually lead to a painful unstable distal ulna. The development of DRUJ prosthesis has significantly evolved over the past years. In this study, we assessed the outcome results of patients after DRUJ implant arthroplasty using the Aptis (Scheker) prosthesis.

METHODS

We identified 13 patients with 14 prosthesis during the past 10 years. Patients underwent DRUJ arthroplasty due to persistent symptoms of instability, chronic pain, and stiffness. Records and follow-up visits were reviewed to find the final post-operative symptoms, pain, range of motion, and grip strength with a mean follow-up of 12 months (range: 2-25 months). Also, patients were contacted prospectively by phone in order to administer the disabilities of the arm shoulder and hand (DASH), patient rated wrist evaluation (PRWE), and visual analogue scale (VAS), and to interview regarding satisfaction and progress in daily activities. Eleven patients out of 13 could be reached with a median follow-up time of 60 months (range: 2 to 102 months).

RESULTS

No patient required removal of the prosthesis. Only two patients underwent secondary surgeries in which both required debridement of the screw tip over the radius. The median DASH score, PRWE score, VAS, and satisfaction were 1.3, 2.5, 0, and 10, respectively. The mean range of flexion, extension, supination, and pronation was 62, 54, 51, and 64, respectively.

CONCLUSIONS

Distal radioulnar joint injuries are disabling and patients usually undergo one or more salvage surgeries prior to receiving an arthroplasty. The Scheker prosthesis has shown satisfactory results with 100% survival rate in all reports. The constrained design of this prosthesis gives enough stability to prevent painful subluxation.