Long term results of matched hemiresection interposition arthroplasty for DRUJ arthritis in rheumatoid patients

Sauvé-Kapandji and Darrach Salvage Procedure Rates and Perioperative Parameters for Distal Radioulnar Joint Arthritis and Instability

BACKGROUND

Distal radioulnar joint (DRUJ) instability and arthritis are often painful and functionally limiting pathologies. Two common salvage procedures for DRUJ dysfunction are the Darrach and Sauvé-Kapandji (S-K) procedures. This study aims to provide an analysis of national Darrach and S-K procedure utilization rates and patient demographics.

METHODS

A national ambulatory surgery database, the 2018 Nationwide Ambulatory Surgery Sample, was filtered for Darrach and S-K procedure encounters. Data related to patient demographics and medical history, indications for DRUJ salvage, and concurrent hand/wrist procedures were collected.

RESULTS

Database analysis revealed 1044 Darrach and 223 S-K procedure encounters. Patients undergoing Darrach procedures were older (60 vs 57, P = .002) and more likely to be women (66.1% vs 54.6%, P < .05). Patients aged <35 years underwent S-K procedures at greater rates compared with Darrach (13.9% vs 8.6%, P < .05). Primary osteoarthritis proved to be the most common indication for DRUJ salvage (64.8%) compared with rheumatoid arthritis (23.2%) and post-traumatic osteoarthritis (12.0%). Darrach and S-K procedures were accompanied by a secondary procedure at rates of 64% and 41%, respectively. The most common secondary procedures were tendon transfer, implant removal, neuroplasty, nerve resections, and wrist arthroscopy.

CONCLUSIONS

Patient age and sex are associated with DRUJ salvage procedure selection. Sauvé-Kapandji procedures are used in higher rates in male and younger patient populations. Furthermore, primary osteoarthritis and rheumatoid arthritis are the main underlying pathologies for Darrach and S-K procedures.

Hemiresection Interposition Arthroplasty of the Distal Radioulnar Joint: A Long-term Outcome Study

Background: The aim of this study was to assess factors associated with long-term patient-reported functional, pain, and satisfaction scores in patients who underwent (Bowers) hemiresection interposition technique (HIT) arthroplasty of the distal radioulnar joint (DRUJ). The secondary aims were to determine the complication and reoperation rates. Methods: A retrospective study with long-term follow-up of patients undergoing HIT arthroplasty was performed. Demographic, disease, and treatment characteristics were collected for the 66 included patients. Thirty-one patients completed all surveys, which were the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), our custom-made HIT arthroplasty questionnaire, Numeric Rating Scale (NRS) for pain, and NRS for satisfaction. The mean interval between surgery and follow-up by means of questionnaires was 8.6 ± 3.4 years. Results: The mean QuickDASH score was 31.0 ± 20.2. The mean score of the HIT arthroplasty questionnaire was 2 ± 2. The median NRS for pain was 1 (interquartile range [IQR], 0-3), and the median NRS for satisfaction was 9 (IQR, 8-10). The complication rate and reoperation rate were 14% and 8%, respectively. Conclusion: Overall, patients expressed satisfaction with HIT arthroplasty, despite a mean QuickDASH score of 31.0. In our cohort, patients with inflammatory arthritis had higher satisfaction and lower pain scores. Patients who had prior trauma, prior surgery, or DRUJ subluxation are generally less satisfied. Men, older patients, and posttraumatic patients had higher long-term pain scores; however, posterior interosseous nerve neurectomy is associated with improved pain scores. Our findings support the use of HIT arthroplasty in patients with inflammatory arthritis.

Modification of matched distal ulnar resection for distal radio-ulnar joint arthropathy: Analysis of distal instability and radio-ulnar convergence

BACKGROUND

In palliative surgery on the distal radio-ulnar joint (DRUJ), ulnar head resection and the Sauvé-Kapandji procedure are often followed by instability and radio-ulnar convergence. The objective of this study was to evaluate the stability of the DRUJ after modified matched distal ulnar resection performed alone or with partial or complete wrist arthrodesis.

HYPOTHESIS

A modification of matched distal ulnar resection, consisting in reconstruction of the sixth compartment and dorsalisation of the extensor carpi ulnaris, minimises these complications, regardless of the cause and associated procedures.

PATIENTS AND METHODS

A single-centre retrospective study was conducted in 46 patients (50 wrists) who underwent modified matched distal ulnar resection. The 50 wrists fell into three groups: total wrist arthrodesis according to Millender, n=21 (TWA group); radius to proximal row arthrodesis, n=17 (RPRA group); and isolated matched distal ulnar resection, n=12 (IMDUR group). Seventy per cent of patients had rheumatoid arthritis. Each patient underwent a clinical and radiographic assessment, with an analysis of radio-ulnar convergence, DRUJ stability, and ulno-carpal impingement, as well as of ulnar translation of the carpus in the IMDUR group.

RESULTS

After the mean follow-up of 8.2±5.4 years, 62% of patients were pain-free, with a mean VAS pain score of 1.3±2.1, and 90% of patients said they would have the procedure again. Clinical and radiographic instability due to excessively proximal resection was noted in 2 (4%) wrists, of which 1 required repeat surgery. Ulno-carpal impingement due to excessively distal resection occurred in 2 (4%) wrists. No significant ulnar translation of the carpus was noted in the IMDUR group (DiBenedetto: 0.011±1.9). Range of motion was similar in the three groups (mean pronation=77±17°; and mean supination=79±8°) (p>0.05). Mean grip strength was 85±35% compared to the other side.

DISCUSSION

Our modification of matched distal ulnar resection minimises the complications specific of other ulnar head resection techniques or of the Sauvé-Kapandji procedure, namely, radio-ulnar convergence and DRUJ instability.

LEVEL OF PROOF

IV; retrospective comparative study.

Solutions for the Unstable and Arthritic Distal Radioulnar Joint

An unstable and osteoarthritic distal radioulnar joint presents with considerable functional impairment, pain, and weakness in gripping manipulation of objects. A wide variety of surgical alternatives have been described to address these concerns. Resection arthroplasties include different types of distal ulna resection and soft tissue procedures; good overall results have been described for these types of procedures, although they have shown limitations in achieving and maintaining pain relief and stability, especially in more active patients. Since the late 1980s, partial and total joint arthroplasties have emerged as good alternatives for treatment in young and more active patients.

Treatment Outcomes in Patients Undergoing Surgical Treatment for Arthritis of the Distal Radioulnar Joint

Objective  Surgical treatment options for distal radioulnar joint (DRUJ) arthritis include distal ulnar resection (DUR), DRUJ arthrodesis, and ulnar head replacement. Ulnar convergence leading to persistent pain and clicking is a relatively common complication of complete DUR and DRUJ arthrodesis with distal ulnar segment resection (DRUJA). This led to the development of the distal ulna hemiresection (DUHR) and distal ulnar stump stabilization techniques to reduce the risk of this complication. Patients may experience incomplete relief of pain and limited range of motion (ROM) with these procedures. We hypothesized that there would be no differences in outcomes between the treatment groups, but patients undergoing DUHR, tendon interposition, or distal ulnar stump stabilization would be at lower risk of complications. Methods  Records were retrospectively reviewed for 121 patients undergoing DRUJ procedures between 2000 and 2018 at a single institution to collect patient demographics, surgical details, preoperative diagnosis, and outcomes including complications, revision procedures, ROM, pain, and swelling. Patients were grouped for analysis by procedure type: DUR (Darrach procedure), DUHR (Bowers procedure), and DRUJA (Sauve-Kapandji procedure). Continuous variables were compared using an analysis of variance test and categorical variables using the Freeman-Halton extension of the Fisher's exact test. A multivariate logistic regression analysis was performed to identify significant predictors of outcomes. Results  Seventy-three patients underwent a DUR procedure, while 33 patients underwent a DUHR procedure and 11 underwent a DRUJA procedure. Mean follow-up was 70.6 months. Patients undergoing DRUJA were significantly younger than those undergoing DUR or DUHR procedure (42.4 vs. 60.0 vs. 62.1, p  < 0.001). No significant differences between groups were demonstrated in measured outcomes. Posttraumatic arthritis was the most common preoperative diagnosis (43.4%). Persistent pain was the most common negative outcome (25.6%) followed by limited ROM (19.7%). Five patients (4.3%) suffered postoperative complications, most common being rupture of extensor tendons. Five patients (4.3%) underwent revision procedures. Body mass index (BMI) was a significant predictor of persistent pain (odds ratio = 1.09, p  = 0.031). Conclusion  The results of our study suggest that outcomes are equivalent between the three distinct treatment groups. Despite the potential benefits, hemiresection, tendon interposition, and distal stump stabilization had no significant effect on outcomes in this study. More than a quarter (25.6%) of patients undergoing DRUJ procedures experience persistent pain postoperatively, while one-fifth (19.7%) experienced limited ROM. Patients with higher BMI are at a significantly greater risk of experiencing persistent postoperative pain. Level of Evidence  This is a Level III, retrospective comparative study.

Distal Radioulnar Joint Instability

Distal radioulnar joint (DRUJ) instability is a common clinical condition but a frequently missed diagnosis. Both surgical and nonsurgical treatments are possible for chronic cases of DRUJ instability. Nonsurgical treatment can be considered as the primary therapy in less active patients, while surgery should be considered to recover bone and ligament injuries if nonsurgical treatment fails to restore forearm stability and function. The appropriate choice of treatment depends on the individual patient and specific derangement of the DRUJ.

Management of complications of wrist arthroplasty and wrist fusion

The human wrist joint is unique from functional and anatomic standpoints. Numerous articulations exist within the wrist that allow for many options for partial wrist fusion and arthroplasty. In cases of pancarpal disease, fusion or arthroplasty of the entire wrist joint can be performed. Because of the high functional demand of the wrist, many of these surgical options can fail, leading to devastating complications. This article addresses the types of fusions and arthroplasties available for the wrist and discusses the potential complications associated with each. Methods to prevent these complications are presented and those to treat them once they have occurred are discussed.

Disorders of the distal radioulnar joint

The distal radioulnar joint is responsible for stable forearm rotation. Injury to this joint can occur following a variety of mechanisms, including wrist fractures, ligamentous damage, or degenerative wear. Accurate diagnosis requires a clear understanding of the anatomy and mechanics of the ulnar aspect of the wrist. Injuries can be divided into three major categories for diagnostic purposes, and these include pain without joint instability, pain with joint instability, and joint arthritis. New advancements in imaging and surgical technique can allow for earlier detection of injuries, potentially preserving joint function. In this article, the authors review the pertinent anatomy, biomechanics, and major abnormality involving the distal radioulnar joint.

Long-term results of simple hemiresection arthroplasty in the rheumatoid distal radio-ulnar joint

We retrospectively studied the radiological and clinical results of a simple hemiresection arthroplasty, a modification of previous oblique distal ulnar resections, in 62 patients with rheumatoid arthritis (68 wrists) over a mean follow-up of 103 (range 60-173) months. Fourteen wrists (20%) became fused at the radiocarpal joint and 28 wrists fused (41%) at the midcarpal joints during follow-up. Severe ulnar translocation of the carpus was observed in two wrists (3%), radio-ulnar convergence in five wrists (7%), as well as a significant decrease of carpal height ratio, without any radiological findings of stylocarpal impingement. Improvements in forearm pronation and supination, and reduction in pain were maintained at the last follow-up. Grip strength was not significantly improved. The Jebsen-Taylor hand function test showed improvements in writing, card turning, and simulated feeding. Fifty-two patients (58 wrists, 85%) were satisfied with the results at the last follow-up. Simple hemiresection arthroplasty showed good long-term results with few complications.