A study of functional outcomes following implantation of a total distal radioulnar joint prosthesis

Aptis Distal Radioulnar Joint Arthroplasty: A Multicenter Evaluation of Functional Outcomes, Complications, and Patient Satisfaction

Background  The Aptis distal radioulnar joint (DRUJ) implant has been commonly used to replace the DRUJ and restore wrist function in patients with a severely destroyed DRUJ. Objective  Promising results have been described in the literature. However, the clinical results in a multicenter setting are sparse and variable. This study evaluates the short- to midterm clinical results of 53 patients with a (mean) follow-up of 51 months. Patients and Methods  Fifty-three patients (59 implants) treated between 2011 and 2020 in three different institutions were retrospectively identified in a prospectively collected database. The main indication for Aptis DRUJ arthroplasty was a destroyed DRUJ and gross distal radioulnar instability and isolated DRUJ osteoarthritis. Functional outcome, complications, and patient satisfaction were evaluated. Patients completed the Patient-Rated Wrist Evaluation (PRWE) questionnaire and an additional questionnaire about patient satisfaction and return to hobby/work. Results  Implant survival was 92%, the surgical follow-up showed many complications (64,4%), and revision surgery was needed frequently (40.7%). In 13 cases, the follow-up was longer than 5 years. Three reimplantations had to be performed and two implants were permanently explanted. In spite of this all, wrist and forearm motion as well as pain reduction was adequate and patient satisfaction was reasonable (72.2%). Conclusion  The Aptis DRUJ arthroplasty is a viable option that can provide adequate wrist and forearm function after secure patient selection and surgical placement of the implant in the wrist with a good bone stock of the radius. The complication rate was found to be high, yet patient satisfaction was reasonable. In the case of secondary surgery, additional surgery seems to be needed. For primary surgery, the implant seems to be successful without complications. Different complications have been described, but further analysis is warranted to find the causes of complications and to objectify the performance of the Aptis DRUJ implant. Level of Evidence  IV.

Early Results in Total Replacement of the Distal Radioulnar Joint

BACKGROUND

Pathology of the distal radioulnar joint (DRUJ) including instability and arthritis presents a challenge for hand and upper extremity surgeons. Surgical options include a Darrach procedure and similar resections, soft tissue interposition arthroplasty, and a one-bone forearm. In 2005, a prosthesis for DRUJ arthroplasty was approved for use in the United States. The authors hypothesize that DRUJ arthroplasty will lead to improved pain and range of motion (ROM) with a moderate, but manageable, complication rate.

METHODS

A retrospective review of 46 patients who underwent DRUJ arthroplasty by a single private group of hand surgeons was performed. Demographics, complications, postoperative visual analog scale (VAS), and postoperative ROM were obtained and analyzed.

RESULTS

The patients were followed up for a mean of 60 weeks. The implant was used both as primary surgical treatment for DRUJ pathology and as salvage for previous failed procedures. Twenty-two percent of patients experienced complications: 15% required revision surgery. No patients were converted to another type of implant, including those who underwent revision surgery. Prominent hardware was the most common indication requiring revision. Patients achieved an improvement in supination of 17° and extension of 5°. They additionally achieved a decrease in average VAS score from 7.1 to 2.3.

CONCLUSIONS

Distal radioulnar joint arthroplasty reduces pain and improves ROM in patients with DRUJ pathology with a 22% complication rate. This cohort demonstrates improved pain, modest improvement in ROM, but a 22% complication rate for this implant. Further long-term studies are encouraged.

Long-term results of the AptisTM total distal radioulnar joint prosthesis after previous failed surgical procedures

We present a prospective study with the results of ten Aptis total distal radioulnar joint replacements in patients who had one to five previous operations. The mean postoperative follow-up was 9.7 years (range 3-14.7). The mean postoperative range of motion of the wrist improved by 9° for extension, 15° for flexion, 10° for pronation and 14° for supination, achieving values equivalent to 88%, 78%, 97% and 88% of those of the non-operated hand. There were minimal changes in radial and ulnar deviations. Grip strength improved by 7 kg, pain decreased by 8 points, QuickDASH and Mayo wrist scores improved by 51 and 53 points, respectively. Two implants had radiolucency less than 1 mm. Serum titanium ion levels were slightly elevated in two patients. Three prostheses required revision surgery for heterotopic ossification, a prominent radial screw and a periprosthetic fracture. No prostheses were removed. Six patients returned to their former professional activities and four patients adapted their jobs.Level of evidence: IV.

Replacement of the distal radio-ulnar joint with a semi-constrained Scheker DRUJ prosthesis

OBJECTIVE

To describe the indications, operative technique, and long-term outcomes of patients treated with the Scheker (Aptis) distal radio-ulnar joint (DRUJ) prosthesis.

INDICATIONS

The Scheker prosthesis is intended to replace the DRUJ in patients with rheumatoid, degenerative, or posttraumatic arthritis of the sigmoid notch and/or ulnar head, or in cases of gross instability of the DRUJ. Moreover, a Scheker prosthesis can be used to treat failed salvage procedures, such as the Sauvé-Kapandji procedure, ulnar head resection, and ulnar head arthroplasty.

CONTRAINDICATIONS

Severe osteoporosis, active infection, immature skeleton, less than 14 cm of the proximal ulna remaining.

SURGICAL TECHNIQUE

In supine position with the forearm in full pronation, an ulnar S‑shaped incision is made. The ulnar head is resected and the proximal part is brought to the palmar side to enable visualization of the sigmoid notch. Following preparation of the sigmoid notch and the proximal ulnar part of the radius, a radial plate is attached. When the position is verified with fluoroscopy, screw holes are drilled together with a separate hole for the radial peg. A metal stem is inserted in the ulnar shaft. A polymer ball is then slid on to a polished peg on top of the ulnar stem. This polymer ball is seated in the socket of the radial plate and fixed with a small metal cap. Radiographic images are made for confirmation of correct positioning and full pro- and supination is tested, after which the wound is closed.

POSTOPERATIVE MANAGEMENT

After 48 h of pressure bandages, patients are instructed to start with full range of motion and weight-bearing exercises under the guidance of a hand therapist. Weight-bearing is constrained to 10 kg.

RESULTS

We retrospectively assessed 50 Scheker prostheses in 48 patients treated between 2016 and 2021. The median age was 56 years (IQR: 50-65) and 30 (60%) were female. Median follow-up was 29 months (IQR: 12-48). The primary outcome was the PRWE score. The median PRWE score at the final follow-up was 23 (IQR: 4-52) for the operated side versus a median PRWE score of 5 (IQR: 0-25) for the non-operated side (p < 0.005). Six patients had a complication. Three patients developed extensor carpi ulnaris tendinitis with one patient requiring additional surgery. One patient developed a neuroma of the distal branch of the ulnar nerve that was surgically removed. One synovectomy was performed because of synovitis and one endoscopic ulnar release was performed because of hyperesthesia of the ulnar area. None of the prostheses had to be removed.

Technique for insertion of a Scheker prosthesis for failed Sauve-Kapandji with a well fixed ulnar stem: A case report

INTRODUCTION

The Scheker prosthesis is a distal radioulnar joint (DRUJ) arthroplasty used as a salvage option for many DRUJ pathologies.

PRESENTATION OF CASE

We report the case of a patient who underwent insertion of a Scheker prosthesis for continued pain and limited motion at the wrist in the setting of a failed Sauve-Kapandji with a well fixed ulnar stem and DRUJ pseudo-arthrosis.

DISCUSSION

This report aims to provide a technique for ulnar stem removal without compromising the bone needed for the Scheker prosthesis and for describing the location of a DRUJ osteotomy without compromising radio-lunate stability.

CONCLUSION

The Scheker prosthesis is able to be safely inserted for DRUJ salvage after removal of a well fixed ulnar stem if careful removal prevents destruction of the ulna, as described here.

Retrospective and Prospective Outcomes of Distal Radioulnar Joint Prosthesis Arthroplasty at a Single Center

Purpose

Distal radioulnar joint (DRUJ) arthritis can cause painful and limited motion of the forearm leading to decreased function. When conservative treatment options are exhausted, surgical treatments are the next step. The purpose of this study was to retrospectively and prospectively evaluate outcomes of Scheker DRUJ total arthroplasty at a single center and add to the limited data on this procedure.

Methods

In a retrospective and prospective cohort of 12 patients, 13 DRUJ prosthetics implanted from 2014 to 2021 were evaluated from a single center. The primary outcome was patient satisfaction with the procedure, including comparisons of preoperative and postoperative visual analog scale, Disabilities of the Arm, Shoulder, and Hand, and willingness to repeat the procedure. Secondary outcomes included range of motion, subjective grip strength, need for hardware revision, subsequent procedures, and postoperative complaints.

Results

Out of 12 patients that were at least 1-year after surgery from DRUJ arthroplasty, 1 was deceased at the time of final survey and 1 underwent bilateral DRUJ arthroplasty. Seven of 12 available patients were surveyed over the phone. On average, patient range of motion after surgery was 76° in each direction for pronation and supination. There was a clinically significant improvement in the Disabilities of the Arm, Shoulder, and Hand score and a statistically significant improvement in visual analog scale pain rating. Seventy-five percent of patients surveyed were satisfied with their outcomes and would undergo the surgery again. Only one patient required additional surgery, and there were no instances of hardware failure at an average follow-up of 40 months.

Conclusions

Our study has shown positive outcomes with decrease in pain, improvement in function via Disabilities of the Arm, Shoulder, and Hand evaluation, and subjective patient satisfaction, with a 100% prosthesis survival rate. The DRUJ arthroplasty prosthesis is a viable alternative to other DRUJ salvage procedures.

Type of study/level of evidence

Therapeutic Level III.

Twenty-Year Experience With Primary Distal Radioulnar Joint Arthroplasty From a Single Institution

PURPOSE

The use of implant arthroplasty in the distal radioulnar joint is increasing. Two main types of implants are commonly used, ulnar head prosthesis (UHP) and hemi or semi-constrained total distal radioulnar joint arthroplasty. The literature consists mainly of small patient series. The purpose of this study was to examine our long-term outcomes of distal radioulnar joint arthroplasty.

METHODS

Patient data were collected in a patient registry from 2000 to 2019. The follow-up included radiographic examination, physical examination, Mayo Wrist Scores, pain level, range of motion, and grip strength. Reoperations were recorded. The implants were a semi-constrained prosthesis and a metallic UHP. The mean age at surgery was 50 years. Patient demographics were similar, but the semi-constrained group had a higher preoperative percentage of instability (85 vs 52 percent). The median follow-up time was 30 months for the semi-constrained implants group and 102 months for the UHP group.

RESULTS

A total of 53 primary semi-constrained total joint arthroplasties and 102 UHPs were included. The grip strength and Mayo Wrist Score improved for both the implant groups. Pain reduced in 76% of the patients. Supination improved for the semi-constrained total joint arthroplasty group. Lifting capacity was better in the semi-constrained total joint arthroplasty patients. The unadjusted reoperation rate was 23% for the semi-constrained implants group and 34% for the UHP group. Twenty-two implants were bilateral; these had comparable results to unilateral implants. Kaplan-Meier survival curves demonstrated 94% survival rate for the semi-constrained implants group and 87% survival for the UHP group after 5 years. The risk factors associated with reoperation for the combined implant group included younger age at surgery, previous wrist surgery, ulnar shortening, and wrist fusion.

CONCLUSIONS

Distal radioulnar joint arthroplasty improved functional outcomes in both the implant groups, but reoperations were frequent. The semi-constrained implants group had better lifting capacity. The bilateral implants had comparable outcomes to the unilateral implants.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The distal radio ulnar joint: a journey of discovery and invention of the Aptis prosthesis

This article describes the journey the authors took in discovering a new distal radioulnar joint prosthesis. The beginning deals with the problems we can potentially create for patients when we blindly follow the literature without any critical thinking. By challenging the established thinking on the function of the forearm, a new way of looking at the distal radioulnar joint emerged. Through trial, error and a moment of desperation, a new solution was found that allow us to relive pain and improve function for our patients with distal radioulnar joint pathologies.

Outcomes following Distal Radioulnar Joint Arthroplasty in the Setting of Total or Partial Wrist Fusion

Purpose  To evaluate the functional outcome and complications following primary ulnar head or total distal radial ulnar joint (DRUJ) arthroplasty in patients who have a partial or total wrist fusion. Methods  We conducted a retrospective review of 33 primary DRUJ implants in 31 patients who had a partial or total wrist fusion. Follow-up time averaged 67 months. There were 11 partial and 22 total wrist fusions with 22 ulnar head prosthesis and 11 total DRUJ implants. The mean age of the patients was 49 years. Eighty-one percent had previous surgeries with an average number of 4.6 previous wrist procedures. Pre- and postoperative pain levels were recorded. Mayo Wrist Scores were calculated. Grip strength, range of motion (ROM), and post-operative complications were noted. Results  The pain scores improved in 67% of the patients. The Mayo Wrist Score improved significantly from a mean of 39 preoperatively to 51 postoperatively. The grip strength and pro-supination remained stable. The wrist ROM also remained stable in the patients with partial wrist fusions. During the follow-up period, 10 (30%) of the DRUJ implants were explanted, with a trend toward higher explantation rates in total wrist fusions with one in the partial fusion group and nine in the total wrist fusion group. Four of the explantations happened in the first postoperative year. Nineteen (61%) of the patients required a second surgery for a DRUJ implant-related complication; this rate was similar between the partial and total fusion groups. Conclusions  DRUJ replacement resulted in improved pain scores and Mayo wrist scores in the majority of patients; however, the combination of primary DRUJ arthroplasty and total wrist fusion was associated with high complication rates. Surgeons should be aware of the high complication rate seen with DRUJ arthroplasty when combined with total wrist fusion.

Finite element analysis of intraosseous distal radioulnar joint prosthesis

BACKGROUND

Joint replacement is one of the options to retrieve the interosseous distal radioulnar joint (DRUJ) function. DRUJ prosthesis has recently been introduced clinically to treat DRUJ instability. This article analyzes the biomechanical behavior of the prosthesis during different loadings by the finite element method.

METHODS

CT images of a healthy 33 years old man were used to construct the three-dimensional geometry of the forearm bone. Then two models, a healthy foreman (Model A) and a damaged model with an inserted interosseous prosthesis (Model B), were constructed to analyze and compare the foreman's biomechanical behavior under different loading conditions using the finite element method. Both models were examined during pronation and supination with 500, 1000, 2000, and 5000 N.mm values. Also, both models were subjected to volar and dorsal loads with values of 10, 30, and 50 N and traction force with 100, 150, and 200 N.

RESULTS

Maximum and minimum principal stresses were evaluated for bones in all conditions, and von Mises stress was considered for the prosthesis and fixing screws. In supination, the maximum stress in Model A is significantly higher than the Model B. However, the maximum principal stress of both models is similar during volar and dorsal loading. In Model A, the maximum principal stress in traction is much smaller than in Model B. The absolute value of minimum principal stress in pronation and supination in Model B is higher than in Model A. The prostheses and screws are subjected to higher stresses during pronation than supination. Also, the amount of stress created in prostheses and screws during volar and dorsal loading is almost equal. In traction loading, screws are subjected to significantly high stresses.

CONCLUSION

Our study indicates that the interosseous DRUJ prosthesis can perform the foreman's normal daily activities. This prosthesis provides the ability similar to a normal hand.

LEVEL OF EVIDENCE

IV.

Clinical and radiological results of distal radioulnar joint arthroplasty with the Aptis prosthesis

We report the results of the treatment of disorders of the distal radioulnar joint with the semi-constrained Aptis prosthesis. Nineteen patients were assessed at a mean follow-up of 7 years. All patients had been operated on previously at the wrist, forearm or elbow. The Disabilities of Arm, Shoulder and Hand score had a mean value of 40, the Patient-Rated Wrist Evaluation score had a mean of 49 and the visual analogue scale for pain had a mean of 3.9. The mean ranges of pronation, supination, wrist flexion and wrist extension were 78°, 76°, 60° and 51°, respectively. The mean grip strength was 23 kg. Complications were noted in ten patients. Eighteen patients would undergo the operation again. The 10-year cumulative survival rate was 84%. The Aptis prosthesis may be a solution to treat patients in whom previous surgery at the distal radioulnar joint has failed.Level of evidence: IV.

Two-Year Clinical and Radiographic Evaluation of Scheker Prosthesis (Aptis) Distal Radioulnar Joint Arthroplasty

PURPOSE

To evaluate the clinical and radiographic outcomes of patients who underwent semiconstrained distal radioulnar joint arthroplasty.

METHODS

A retrospective analysis was performed on a series of patients who underwent distal radioulnar joint arthroplasty with more than a 23-month follow up. The quantitative outcome variables included the visual analog scale for pain; Disability of the Arm, Shoulder, and Hand (DASH) score; Patient-Rated Wrist Evaluation (PRWE); and Mayo wrist score. The range of motion, grip strength, torque, and lifting capacity were measured at final follow up and compared with that of the nonsurgical extremity. Complications related to the prosthesis were assessed.

RESULTS

Twenty-one patients (mean age 57 years) were assessed at an average 41-month follow up (23-73 months). Fifteen underwent prior hand, wrist, or elbow procedures. Four patients required 5 reoperations. The postoperative median visual analog scale pain score was 0.6 at rest and 2.1 with activity. The median postoperative DASH score was 26.7, PRWE 41, and Mayo wrist score was 65. Upon comparing the supination torque of the operative and intact sides, the operative side was found to average 87% of the intact side on a work simulator and 77% on the simulator's D-ring. Eight of 20 patients had lysis around the collar of the ulnar component (40%), as detected using radiography. Three of 21 (14%) radial plates were malpositioned, with 2 resulting in a fracture. The overall complication rate was 29%.

CONCLUSIONS

Distal radioulnar joint arthroplasty using the Scheker prosthesis demonstrated good patient pain scores and the restoration of supination strength. The collar lysis resulted in weaker supination and grip strength. Still, the patients experienced mild levels of pain and moderate disability. A moderate complication rate persisted, as reported by other authors. Accurate radial component placement is important.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.

Radical Resection of a Recurrent Giant Cell Tumor of the Distal Ulna and Immediate Reconstruction With a Distal Radio-Ulnar Joint Implant Arthroplasty

Background: Giant cell tumors (GCTs) of the distal ulna are rare. Despite being benign, they can be locally aggressive and may recur following conventional treatment by curettage and bone grafting. Salvage reconstructive options after failed conventional treatment include Darrach resection, Suave-Kapandji procedure, hemi-arthroplasty, or total joint arthroplasty. Methods: We discuss reconstruction options for the distal radio-ulnar joint following tumor resection, and present the outcomes of a constrained distal radio-ulnar prosthesis in a 29-year-old male following resection of a distal ulna GCT. Results: Reconstruction of the distal radio-ulnar joint by a constrained prothesis yielded excellent functional outcomes following resection of a GCT of the distal ulna. Conclusions: This case demonstrates that successful oncologic and functional outcomes can be achieved by radical resection of a recurrent GCT of the distal ulna and reconstruction with a constrained total joint arthroplasty.

Long-term results after semiconstrained distal radioulnar joint arthroplasty: A focus on complications

Arthroplasty of the distal radioulnar joint (DRUJ) using a semiconstrained DRUJ implant yields good outcomes according to the literature. The aim of this study was to investigate the subjective, clinical and radiographic outcomes with a special focus on complications in nine patients with a mean follow-up of 6years and to compare them with our previously published 3-year follow-up results. No subjective or objective changes were seen between the 3-year and the 6-year follow-up. In the previous study, one implant loosening and two irritations of the superficial branch of the radial nerve occurred. We saw three complications that needed surgery in addition to the three complications already found 3years after surgery. One patient with a large ulna had loosening of the cemented ulnar stem and therefore the prosthesis was explanted. One patient had an allergic reaction to the metal alloy of the prosthesis, which also led to removal. One patient had an ulnar impaction syndrome caused by too-distal placement of the implant that needed revision. Prior studies reported low complication rates. In our study, six complications occurred in four out of nine patients, requiring reoperation including two revisions and two implant removals. A precise surgical technique is mandatory to avoid the otherwise frequent complications and potential implant failures. LEVEL OF EVIDENCE: IV.

Distal Radioulnar Joint Replacement in the Scarred Wrist

Background  Radiocarpal or midcarpal arthritis can occur simultaneously with arthritis of the distal radioulnar joint (DRUJ), leading to functional impairment of the wrist. Treatment often involves wrist arthroplasty or arthrodesis, either with simultaneous or secondary procedures, addressing the DRUJ. Successful treatment of solitary DRUJ arthritis with DRUJ replacement has been reported. However, outcomes in patients with multiple prior wrist surgeries are lacking. Surgery in these wrists is challenging because surgical scarring and advanced bone deformities make implant positioning more difficult. Therefore, the aim of this study was to evaluate the outcomes in patients that underwent total wrist arthrodesis and DRUJ replacement after multiple prior wrist surgeries. Methods  We prospectively enrolled patients that underwent total wrist arthrodesis and replacement of the DRUJ, either simultaneously or during separate procedures from 1999 to 2012. We included 14 patients with a median age of 43 years (interquartile range [IQR]: 35-47). As objective outcomes range of motion, weight-bearing ability, grip strength, was measured. For the subjective outcomes, we used an analogue pain score and the disabilities of the arm shoulder and hand (DASH) scores. Results  At a median follow-up of 5.6 years (IQR: 3.2-7.1). The average DRUJ range of motion and weight lifting ability significantly improved. As for the subjective evaluations, postoperative pain scores improved significantly, as did the DASH scores. Four of the patients had a postoperative complication, including infection and heterotopic ossification, of which two required reoperations. Additionally, 5 patients developed pisotriquetral arthritis requiring, pisiform excision, triquetrum excision, or the combination of both. Conclusion  Distal radioulnar joint replacement with a semiconstrained prosthesis was an effective method to restore the function of the wrist and forearm. As the surgical anatomy and soft tissue envelope were compromised in these patients, additional surgical exposure is necessary, adding to the complexity in these patients. No radiographic loosening Level of Evidence  This is a therapeutic level IV study.

Complications of Semiconstrained Distal Radioulnar Joint Arthroplasty

PURPOSE

The Aptis total distal radioulnar joint (DRUJ) prosthesis is a semiconstrained implant designed for treatment of DRUJ arthritis and instability. The purpose of this study was to analyze short-term complications of this device.

METHODS

We performed a retrospective chart review of patients undergoing semiconstrained DRUJ arthroplasty from 2007 to 2015 at a single institution. Records were analyzed for complications and the need for subsequent surgical procedures.

RESULTS

Two senior hand surgeons at one institution performed 52 semiconstrained DRUJ arthroplasties over 8 years. Nineteen complications necessitating operative management occurred in 15 patients (29%). A total of 26 procedures were undertaken to address these complications. Complications included 4 periprosthetic fractures, 3 infections, 2 instances of aseptic loosening, 2 implant component failures, 1 instance of screw loosening, 3 neuromas requiring neurectomy, 2 instances of finger stiffness necessitating extensor tenolysis, and 2 cases of heterotopic ossification at the DRUJ. Three of the 52 implants were revised (6%) and 2 were explanted (4%); 3 of these (6%) were caused by deep infection.

CONCLUSIONS

There is limited literature on outcomes of the semiconstrained DRUJ prosthesis. Prior studies reported low complication rates, with 0% to 5% revisions. In the current clinical series, 29% of patients required further surgery for complications, the most common reasons for which were periprosthetic fracture and infection.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

[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.

Salvage of Failed Achilles Tendon Interposition Arthroplasty for DRUJ Instability After Ulnar Head Resection With Aptis Prosthesis

BACKGROUND

Historically, failed conservative treatment for irreparably damaged distal radioulnar joints (DRUJs) is treated via distal ulnar resection or DRUJ fusion; complications include disabling painful convergence of the radius and ulnar stump during lifting Various treatments for radioulnar impingement include distal radioulnar Achilles tendon allograft interpositional arthroplasty. This technique does not adequately prevent radioulnar impingement and we explore an alternative treatment.

METHODS

We report 7 adult patients who failed Achilles tendon interposition, subsequently treated with Aptis total DRUJ prostheses (mean follow-up, 26 months; range, 7-40).

RESULTS

Revision to Aptis prosthesis produced clinically stable DRUJ, improved grip strength and painless lifting capabilities, high patient satisfaction, and no major complications. All returned to daily activities and even recreational sports.

CONCLUSIONS

Tendon lacks biomechanical features key to the shock-absorbing function of cartilage-features it cannot deliver when used to prevent radioulnar convergence. We report Aptis DRUJ prosthesis as an alternative to the tendon allograft technique.

Ulnar head replacement and sigmoid notch resurfacing arthroplasty with a lateral meniscal allograft: 'calamari procedure'

We report the outcomes of ulnar head replacement with concomitant resurfacing of the sigmoid notch with a lateral meniscal allograft that attempted to recreate the palmar and dorsal radioulnar ligaments in four patients. Patients' ranges of motion, grip strength, postoperative complications and radiographs were assessed. The mean follow-up was 20 (range 12-28) months. There was an increase in postoperative range of motion with an average increase in grip strength of 43% to the unaffected extremity. All patients experienced marked reduction in their postoperative pain. No patients reported symptoms of implant instability. Distal ulna implant arthroplasty with a lateral meniscal allograft gives favourable short-term outcomes.

LEVEL OF EVIDENCE

IV.

Classification of ulnar triangular fibrocartilage complex tears. A treatment algorithm for Palmer type IB tears

The classical definition of 'Palmer Type IB' triangular fibrocartilage complex tear, includes a spectrum of clinical conditions. This review highlights the clinical and arthroscopic criteria that enable us to categorize five classes on a treatment-oriented classification system of triangular fibrocartilage complex peripheral tears. Class 1 lesions represent isolated tears of the distal triangular fibrocartilage complex without distal radio-ulnar joint instability and are amenable to arthroscopic suture. Class 2 tears include rupture of both the distal triangular fibrocartilage complex and proximal attachments of the triangular fibrocartilage complex to the fovea. Class 3 tears constitute isolated ruptures of the proximal attachment of the triangular fibrocartilage complex to the fovea; they are not visible at radio-carpal arthroscopy. Both Class 2 and Class 3 tears are diagnosed with a positive hook test and are typically associated with distal radio-ulnar joint instability. If required, treatment is through reattachment of the distal radio-ulnar ligament insertions to the fovea. Class 4 lesions are irreparable tears due to the size of the defect or to poor tissue quality and, if required, treatment is through distal radio-ulnar ligament reconstruction with tendon graft. Class 5 tears are associated with distal radio-ulnar joint arthritis and can only be treated with salvage procedures. This subdivision of type IB triangular fibrocartilage complex tear provides more insights in the pathomechanics and treatment strategies.

LEVEL OF EVIDENCE

II.

The ulnar side of the wrist: Clinically relevant anatomy and biomechanics

BACKGROUND

In the hectic environment of a hand therapy clinic, the opportunity to carefully consider the relationships among pathology, pathomechanics, surgical repair techniques, tissue healing, postoperative management, and rehabilitation program development and progression is limited. Clinicians often default to seeking a protocol, a recipe to follow.

OBJECTIVES

Using the ulnar side of the wrist as an example, relevant anatomy and biomechanics are directly related to several commonly seen pathologies, including fractures, ligament injuries, and instability.

CONCLUSION

Armed with knowledge of anatomy, biomechanics, and surgical procedures, the need for a protocol disappears. Each patient can be individually managed according to his or her unique set of variables and responses to injury, repair, healing, and recovery of function.

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.

Midterm Results of Semiconstrained Distal Radioulnar Joint Arthroplasty and Analysis of Complications

Range of motion and stability are important outcome parameters to assess function of the distal radioulnar joint (DRUJ), in particular pronation, supination, and weight-lifting capacity. The DRUJ semiconstrained implant developed by Scheker et al is intended to reproduce all the functions of the triangular fibrocartilage complex and the DRUJ. The aim of the study was to investigate the subjective, clinical, and radiographic results in 10 patients after primary implantation of the semiconstrained DRUJ arthroplasty following DRUJ derangement and painful instability, with an average follow-up of 3 years with a special focus on the complications. Standardized preoperative and postoperative evaluation included assessment of pain by a visual analog scale, radiographic examination, range of motion measurements, lifting capacity, and grip strength. The patient-perceived function was investigated using clinical score charts. Compared with the preoperative status, range of motion showed little change, while grip strength, lifting capacity, pain score, and patient-perceived functions improved significantly. One patient developed an ulna stem loosening, while two patients had to be reoperated because of an irritation of the extensor tendons and the superficial radial nerve at the first dorsal compartment of the wrist. In this study, arthroplasty of the DRUJ using the semiconstrained DRUJ arthroplasty was found to result in satisfactory outcome. Level of evidence: Level IV.

Osseous Anatomy of the Distal Radioulnar Joint: An Assessment Using 3-Dimensional Modeling and Clinical Implications

PURPOSE

Using a novel technique, we assess and describe the distal radioulnar joint (DRUJ) anatomy. The purpose of this study was to provide the anatomic dimensions of the DRUJ and to evaluate contralateral symmetry.

METHODS

Computed tomography images of 100 cadaveric forearms were obtained. Three-dimensional models of the radius and ulna were generated and evaluated using 3-dimensional modeling software. Measurements of the radius of curvature of the sigmoid notch (SN) and ulnar head (UH), as well as the length of the SN and volar and dorsal lips were performed in the axial and coronal sequences. In addition, mid-coronal angular measurements were made of the SN and UH to quantify the obliquity of the DRUJ. All coronal measurements were performed with the forearm set to neutral rotation.

RESULTS

The average ulnar variance was -0.9 ± 1.8 mm. The radius of curvature of the UH (8.2 ± 1.3 mm) was markedly smaller than that of the SN (18.2 ± 8.5 mm). The length of the SN in coronal sequences increased from volar to dorsal by 65%. The mid-coronal angle (DRUJ obliquity) of the SN and UH measured 6.0 ± 9.9° and 18.0 ± 9.9°, respectively. A direct inverse correlation was demonstrated in the obliquity of the DRUJ and ulnar variance. All anatomic measurements were similar when comparing bilateral specimens.

CONCLUSIONS

The SN length tends to increase in size from volar to dorsal. Bilateral specimens from the same individual demonstrate similarities and can be cautiously used for comparison.

CLINICAL RELEVANCE

The relationships and measurements demonstrated in this study can be a guide when considering reconstructive procedures or dealing with complex fractures involving the DRUJ.

Anatomic Relationships of the Distal and Proximal Radioulnar Joints Articulating Surface Areas and of the Radius and Ulna Bone Volumes - Implications for Biomechanical Studies of the Distal and Proximal Radioulnar Joints and Forearm Bones

Background

Previous work from this laboratory has evidenced the biomechanical role of forearm osseoligamentous structures in load transfer of applied forces. It has shown that forces transmitted across the distal radioulnar joint (DRUJ) and proximal radioulnar joint (PRUJ) are similar, though not identical, under axial loading conditions. The purpose of the study was to assess the articulating surface areas of the radioulnar joints and the volumes of the forearm bones addressing the hypothesis that there may be anatomic adaptations that reflect the biomechanical function of the integrated forearm unit.

Methods

The articulating surface areas of PRUJ and DRUJ were assessed using a laser scanner in 24 cadaver forearms. The articulating joint surfaces were additionally delineated from standardized photographs assessed by three observers. The surface areas of matched pairs of joints were compared on the null hypothesis that these were the same within a given forearm specimen. An additional 44 pairs of matched forearm bone volumes were measured using water displacement technique and again compared through statistical analysis (paired sample t-test and Bland–Altman analysis).

Results

The findings of this study are that the articulating surface areas of the DRUJ and PRUJ as well as the bone volumes are significantly different and, yet, strongly correlated. The paired sample t-test showed a significant difference between the surface areas of the DRUJ and PRUJ (p < 0.05). The PRUJ articulating surface area was marginally larger than the DRUJ with a PRUJ:DRUJ ratio of 1.02. Paired sample t-test showed a significant difference between the two bone volumes (p < 0.01) with a radius to ulna bone volume ratio of 0.81. When the olecranon was disregarded, radius volume was on average of 4% greater than ulna volume.

Conclusion

This study demonstrates and defines the anatomical relationships between the two forearm bones and their articulating joints when matched for specimen. The data obtained are consistent with the theory of integrated forearm function generated from published biomechanical studies.

The "Four-Leaf Clover" Treatment Algorithm: A Practical Approach to Manage Disorders of the Distal Radioulnar Joint

Most symptomatic distal radioulnar joint (DRUJ) conditions result from derangements to several structures that may include the length, shape, and/or orientation of the articulating surfaces; the cartilage of the DRUJ and/or ulnocarpal joint; the DRUJ and/or ulnocarpal joint ligaments; and the extensor carpi ulnaris and/or pronator quadratus muscle. Once a complete diagnosis is made, often only one of these components is addressed, which results in suboptimal clinical outcomes. In this article, we present a treatment algorithm (the Four-Leaf Clover algorithm) to guide treatment of DRUJ pathology. The Four-Leaf Clover principle is a guiding algorithm, not a document forcing the surgeon to adopt one particular treatment. Its purpose is to provide treating physicians with a checklist that helps ensure that they do not miss any of the different components that need to be addressed for a complete treatment. Using the treatment algorithm, we should achieve satisfactory resolution of patients' symptoms after addressing the particular components in a stepwise approach.

Short- to mid-term results of ulna head replacement as both a primary and revision implant

We present the results of short- to medium-term follow-up of 10 patients following ulna head replacement. The mean age of patients was 63.2 years (range 48-81 years), with the mean duration of follow-up being 48 months (12-88 months). The indications for the procedure were primary osteoarthritis (n = 3), post-traumatic osteoarthritis (n = 4), failed Darrach's procedure (n = 2) and rheumatoid arthritis (n = 1). Two patients required revision (20%), one for gross aseptic loosening of the stem and another for an initially oversized head. At final follow-up, the satisfactory rate was 90%. The mean VAS score was 2.4 (range 0-8). The average DASH score was 37 (range 0-72.5). Our study suggests that ulna head replacement can give satisfactory forearm function; however, concerns exist regarding bone resorption and tapering around the prosthesis, which may affect the long-term performance of the prosthesis.

LEVEL OF EVIDENCE

IV.

Functional Outcomes of the Aptis-Scheker Distal Radioulnar Joint Replacement in Patients Under 40 Years Old

PURPOSE

To study the functional results after Aptis-Scheker distal radioulnar joint (DRUJ) replacement in young patients.

METHODS

We performed a retrospective study selecting all patients under age 40 years, with a clinical and radiological follow-up longer than 2 years, who underwent DRUJ replacement. Patients' charts were reviewed and age at surgery, profession, hobbies, comorbidities, diagnosis, previous procedures, and complications were recorded. Preoperative and postoperative Disabilities of Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation scores, visual analog scale score, grip strength, lifting capacity, and wrist range of motion were recorded. Functional results and characteristics of the patients were correlated with linear regression. A Kaplan-Meier curve was plotted.

RESULTS

We performed 46 arthroplasties. Average patient age was 32 years. Forty-one arthroplasties were performed for pain and 5 for pain and instability. Average follow-up was 61 months. Thirty-seven patients underwent multiple procedures before DRUJ replacement (1.7 ± 1.2 procedures). Extensor carpi ulnaris release with implant coverage using a local adipofascial flap (5) or dermal-fat graft (4) was the most common procedure performed after implantation of the prosthesis. Thirty surgeries were undertaken to address complications after DRUJ replacement in 15 wrists. A total of 36 procedures not related to DRUJ replacement were performed in 15 wrists after the arthroplasty. Grip, lifting, Disabilities of Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation scores, visual analog scale score, and supination showed statistically significant improvement after surgery. Functional results were comparable in patients who received the implant with either a standard or extended stem. Patient age and number of the previous procedures did not correlate with functional results. The 5-year survival of the implant was 96%.

CONCLUSIONS

In this group of young patients, the implant improved the functional status of the extremity. The most frequent complication was extensor carpi ulnaris tendonitis, which was addressed by interposition of an adipofascial flap.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Total joint arthroplasty of the distal radioulnar joint for rheumatoid arthritis

PURPOSE

To evaluate the clinical and radiological results of primary total distal radioulnar joint (DRUJ) replacement as well as reconstruction following ulnar head excision in patients with rheumatoid arthritis (RA).

METHODS

Seventeen patients with RA underwent 19 total DRUJ replacement between 2005 and 2011. Mean age at the time of the surgery was 57 years. Mean follow-up was 39 months (range, 12-79 mo). Pain level was evaluated using a visual analog scale (VAS). Pronation and supination were recorded before and after surgery. A patient satisfaction survey was used, as well as postoperative Disabilities of the Arm, Shoulder, and Hand (DASH) and Patient-Related Wrist Evaluation (PRWE) scores. Ulnar translocation of the carpus was assessed radiographically, and the presence or absence of radiolucent zones around the implant were recorded.

RESULTS

The preoperative average VAS score for the 19 joints was 7.3. Pain decreased after surgery to 2.2. Pronation improved from 56° before surgery to 78° afterward, a 39% improvement. Supination improved from 57° before surgery to 71° afterward, a 27% improvement. Final scores were 24 for the DASH and 24 for the PRWE. Fifteen patients reported substantial pain relief. All patients were satisfied with their surgical result.

CONCLUSIONS

The results of this study suggest that total replacement of the DRUJ is of benefit to the patient with RA. Pronation was significantly increased and supination was increased but did not approach significance. Improvement in VAS score suggests that pain was decreased.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Instability of the distal radioulnar joint

The distal radioulnar joint is a complex structure necessary for forearm motion and force transmission across the wrist. Anatomic and biomechanical advances have revealed broad contributions to distal radioulnar joint stability and refined our understanding of the forces acting across it. Instability often co-occurs with other modes of pathology, such as arthrosis or malunion; and appropriate diagnosis and treatment require a comprehensive understanding of all contributing factors. Distal radioulnar joint instability can be broadly categorized as primary, post-traumatic or post-surgical. Treatment strategies include percutaneous, arthroscopic, soft-tissue, osteotomy and arthroplasty techniques. The purpose of this article is to review distal radioulnar joint instability and its management.

Linked distal radioulnar joint arthroplasty: an analysis of the APTIS prosthesis

Painful radioulnar convergence following resection of the distal ulna can produce substantial disability and prove a challenging surgical problem, particularly in the revision setting. The purpose of this study was to evaluate the outcome of a series of patients with chronic distal radioulnar joint instability or multiple prior procedures treated with linked distal radioulnar joint arthroplasty with the APTIS prosthesis. A series of ten patients were identified with a mean follow up of 4.0 years. At final follow-up nine of ten implants survived free from revision or removal, with patients experiencing good pain relief and functional outcomes, with reasonable overall satisfaction in all seven patients who returned the questionnaires. Despite the medium-term follow-up and small number of patients, our results suggest the linked distal radioulnar joint arthroplasty may be a viable option for treating painful radioulnar convergence following multiple failed procedures at the distal radioulnar joint.

One-bone forearm procedure for Hajdu-Cheney syndrome: a case report

One-bone forearm surgery is generally regarded as one of the last available salvage procedures that could be used to treat patients with longitudinal forearm instability secondary to a congenital, oncologic, or a post-traumatic etiology. We performed this procedure on a 23-year-old patient with longitudinal forearm instability secondary to Hajdu-Cheney syndrome, which is a rare genetic disorder characterized by generalized ligamentous laxity, skeletal dysplasia, acro-osteolysis, and generalized osteoporosis. The patient developed shoulder pain secondary to overuse 28 months following treatment, and was managed conservatively. Eight years after surgery, the patient had not undergone any additional procedures, had no pain, reported a Quick Disabilities of the Arm Shoulder and Hand score of 21, and was completely satisfied with treatment. Although OBF procedure is a radical first-line salvage option, in unique circumstances and appropriate patient selection, it may provide acceptable, durable, and predictable results.

Indications and early to mid-term results of ulnar head replacement

INTRODUCTION

The aim of this study was to explore the indications and show the early to mid-term results of ulnar head replacement for the treatment of pathological conditions of the distal radioulnar joint.

METHODS

Our study group comprised 52 patients with a mean age of 64 years who had 56 ulnar head replacements. Seven were implanted to salvage an unstable deletive procedure; the rest were for primary treatment of osteoarthritis, rheumatoid arthritis and trauma. Concomitant procedures along with the ulnar head replacement included wrist arthrodesis, joint replacement and tendon transfers.

RESULTS

The follow-up duration ranged from 1 year to 11 years (mean: 60 months, median: 60 months). In almost all of the patients, pain improved with a median visual analogue scale score of 2 (mean: 2.2, range: 0-8) and a median DASH (Disabilities of the Arm, Shoulder and Hand) score of 12.5 (mean: 17.9, range: 0-56). Of the 52 patients, 47 reported they would have the same procedure again.

CONCLUSIONS

Ulnar head replacement appears to be a reliable and effective procedure solving several pathological problems of the distal radioulnar joint. We present a large patient group with a short to medium-term follow-up duration.

Objective outcomes following semi-constrained total distal radioulnar joint arthroplasty

A dysfunctional distal radioulnar joint (DRUJ) can significantly compromise an individual's forearm rotation, grip, and weight bearing at the hand and wrist. This retrospective study reports surgeon- and therapist-collected objective wrist function and subjective pain scores of 10 patients who received the Scheker total DRUJ prosthesis. A review of these patients' medical records was performed to collect preoperative measurements of wrist range of motion (ROM), grip strength, and pain scores (0-10 scale). The degree of pronation, supination, flexion, extension, radial deviation, and ulnar deviation were the outcome measures used to evaluate wrist ROM. Postoperative measurements were collected at a follow up of 5 ± 1.1 years in our clinic (minimum follow-up of 2yrs). Mean final wrist flexion and extension were 32.1 ± 22.8° and 44.8 ± 13.9°, respectively. Mean final supination and pronation were 72.5 ± 14.4° and 69.5 ± 14.6°, respectively. Average grip strength was 54.9 ± 23.7 lbs. The mean pain score was 3.6 ± 3.1. Although there were no statistically significant changes in any of these outcome measures, the Scheker prosthesis improved wrist ROM (with the exception of wrist flexion) and decreased pain. Grip strength decreased by less than 1 lb but was still higher than the postoperative grip strength measurements in the literature for this prosthesis. Because of the self-stabilizing nature of this prosthesis and the satisfactory functional outcomes from this study and other studies, the Scheker prosthesis is still a viable option for DRUJ pathology that is refractory to nonimplant arthroplasties. This is a therapeutic level IV study.

Functional anatomy of the distal radioulnar joint in health and disease

The distal radioulnar joint (DRUJ) is critical to the function of the forearm as a mechanical unit. This paper is concerned with the concepts and observations that have changed understanding of the function of the DRUJ, notably with respect to the biomechanics of this joint. The DRUJ has been shown to be important in acting to distribute load and removal of the ulna head leads to the biomechanical equivalent of a one-bone forearm. The soft tissues with topographical relations to the distal forearm and DRUJ have also been investigated in our experimental series with findings including the description of a clinical disorder termed subluxation-related ulna neuropathy syndrome.

Constrained implant arthroplasty as a secondary procedure at the distal radioulnar joint: early outcomes

PURPOSE

To evaluate the clinical and radiological outcomes for the Scheker total joint endoprosthesis when used for previously failed surgeries of the distal radioulnar joint (DRUJ).

METHODS

Eight patients with DRUJ derangement with painful instability and 1 patient with DRUJ synostosis received a Scheker DRUJ total joint endoprosthesis between 2006 and 2010. All patients had at least 1 procedure previously performed on the distal ulna (mean, 3.6 procedures). The follow-up time was on average 3.7 years (range, 2-5 y). Standardized preoperative and postoperative assessments included radiographic examination, evaluation of pain by a visual analog scale, and measurements of range of motion and grip strength. We evaluated patient-perceived function with the Disabilities of the Arm, Shoulder, and Hand questionnaire.

RESULTS

There was significant improvement in pain and Disabilities of the Arm, Shoulder, and Hand scores. Grip strength was improved but not significantly. Range of motion was not impaired. We encountered no major complications. Radiographic evaluation showed bone resorption at the distal ulna for most patients and at the tip of a screw in 1 patient, but we found no evidence of implant loosening.

CONCLUSIONS

Our short-term results in a limited patient series show that in selected cases, the Scheker total joint endoprosthesis is a safe and efficient treatment option for previously failed surgeries of the DRUJ.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Complications following one-bone forearm surgery for posttraumatic forearm and distal radioulnar joint instability

PURPOSE

To present the outcomes after one-bone forearm (OBF) surgery for chronic posttraumatic forearm and distal radioulnar joint instability.

METHODS

We conducted a retrospective chart review to study patients who underwent OBF surgery because of a traumatic etiology. We collected patient demographics, surgical technique, preoperative and postoperative range of motion, final grip strength, and complications from the medical records. Patients were asked to complete the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire, a 0- to 10-point pain scale, and a 0- to 10-point treatment satisfaction scale.

RESULTS

There were 5 male and 5 female patients, with a mean age of 32 years at the time of OBF surgery (range, 17-44 y). The mean number of procedures before OBF surgery was 3.6 (range, 2-7); 4 patients had undergone a Darrach procedure and 3 patients had undergone a Sauvé-Kapandji procedure. The median clinical follow-up duration was 6 years (range, 1-17 y). Wrist and elbow range of motion did not change remarkably before and after surgery. Of 8 primary OBF surgeries, 3 resulted in nonunion. Of 10 patients, 4 experienced painful impingement of the remaining proximal radius on adjacent bone and soft tissue and required a total of 7 procedures after OBF surgery. The median follow-up duration for patient-rated outcomes was 10 years (range, 5-21 y; n = 7). The median Quick Disabilities of the Arm, Shoulder, and Hand questionnaire score was 77, the median pain score was 7, and the median satisfaction score was 7.

CONCLUSIONS

In our experience, complications after OBF surgery are common. Although wrist and elbow range of motion were spared, pain persisted and functional outcomes were poor. One-bone forearm surgery is our last resort for a chronically painful and unstable forearm.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Rehabilitation following thumb CMC, radiocarpal, and DRUJ arthroplasty

Hand therapy is essential after arthroplasty around the wrist. This article includes therapy guidelines and goals after surgical reconstruction of the thumb carpometacarpal joint, radiocarpal joint, and distal radioulnar joint. Typical concerns and treatment options are addressed. Tables and figures are included to guide the hand therapist in the process of returning this patient population to pain-free function.

Distal radioulnar joint constrained arthroplasty

This article presents the use of a constrained total distal radioulnar joint replacement with its indications, contraindications, pearls, and pitfalls. The distal radioulnar joint is a complex articulation that carries weight while allowing vector changes without interfering with its function. The total distal radioulnar joint is a solution to those cases with absence of the sigmoid notch, poor soft tissue, or too much ulnar bone resected. The ability of patients to return to regular activities is documented, with a 5-year follow-up.

[Treatment of distal radioulnar joint osteoarthritis]

The distal radioulnar joint (DRUJ) plays a key role in stable forearm rotation. The main stabilizer of the DRUJ is the triangular fibrocartilaginous complex (TFCC). If the integrity of the DRUJ is disturbed, commonly after distal radius fractures, osteoarthritis may develop. For the surgical treatment of osteoarthritis, different techniques are available and in most cases salvage procedures (Darrach, Bowers and Sauvé-Kapandji operations) are performed which generally promise reasonable results but include the potential risk of radioulnar instability which can lead to pain and weakness. Soft tissue stabilizing techniques have only limited success rates. In an attempt to mechanically stabilize the distal forearm following ulnar head resection various endoprostheses have been developed to replace the ulnar head. The prostheses can be used for the secondary treatment of failed ulnar head resection but can also achieve good results in the primary treatment of osteoarthritis of the DRUJ.

Distal ulna arthroplasties

The distal radioulnar joint (DRUJ) is the distal link between the radius and the ulna, and forms a pivot for forearm pronation and supination. As well as being susceptible to idiopathic arthritis, any injury or deformity of the DRUJ involving the radius or ulna can alter the function of this joint. Treatment options for irreparable destruction of this joint have ranged from fusion of the DRUJ joint to a variety of excision techniques with soft-tissue reconstructions, and are ever evolving. Understanding the distal ulnar anatomy is key to success.

Functional and radiographic outcomes following distal ulna implant arthroplasty

PURPOSE

To determine the outcome of ulnar head endoprostheses in the treatment of distal radioulnar joint instability, arthrosis, or both.

METHODS

We conducted a retrospective review of 47 patients to analyze the outcome of a single ulnar head replacement over a 10-year period. All patients reported pain or instability at the distal radioulnar joint. Standardized assessments included a patient-rated pain score, forearm range of motion, grip strength, and Mayo wrist score. We examined preoperative and postoperative radiographs for final implant position, loosening, and osteolysis.

RESULTS

We observed 47 patients for a median of 56 months (minimum, 16 mo). There was a statistically significant decrease in pain scores from 4.6 to 2.2 and improvement in the mean Mayo wrist score from 14 to 69 points after surgery. There was no significant improvement in forearm rotation and wrist function. Kaplan-Meier analysis demonstrated 83% survival at 6 years. A total of 14 patients (30%) required additional surgical procedures after primary arthroplasty. Risk factors for failure included history of previous surgery, use of an extended collar, lucency greater than 2 mm around the implant stem, and pedestal formation at the tip of the implant.

CONCLUSIONS

Distal ulna implant arthroplasty reduces pain and improves function in patients with distal radioulnar joint instability, arthrosis, or both.

SALVAGE OF A FAILED SAUVÉ-KAPANDJI PROCEDURE USING A TOTAL DISTAL RADIO-ULNAR JOINT REPLACEMENT

This is the first report in the literature of a patient treated with a DRUJ replacement after Sauvé-Kapandji procedure failed due to pain and instability. The DRUJ replacement is an unconstrained, biomechanically more advantageous implant which can confer stability in cases where soft tissues are inadequate. We describe the treatment and outcome of persistent ulnar instability with a distal radio-ulnar joint replacement following failed salvage procedures for a malunion of a distal radius fracture.

Imaging assessment of the postoperative arthritic wrist

Wrist arthritis is a common disease entity that can result in severe pain, swelling, and decreased wrist motion, leading to the impairment of daily activities and vocational functions. Nonsurgical treatment for wrist arthritis can improve function and provide pain relief in some cases. With disease progression, however, conservative therapy may become ineffective, and surgical treatment may be required. The three main surgical options for wrist arthritis are arthrodesis, carpectomy, and arthroplasty. Because of the high prevalence of wrist arthritis, radiologists will commonly encounter images that were obtained in patients who have undergone one or more of these surgical options. All three options are common in contemporary orthopedic practice and have evolved in recent years, making it imperative that radiologists understand current procedures and stay abreast of advances in techniques and hardware. In addition, familiarity with both normal and abnormal postoperative imaging findings can aid in the assessment of complications and early failure.

Distal radioulnar joint prosthesis for the treatment of giant cell tumor of the distal ulna: a case report and literature review

Giant cell tumor (GCT) of the distal end of the ulna is an uncommon site for primary bone tumors. When it occurs, en-bloc resection of the distal part of the ulna with or without reconstruction stabilization of the ulnar stump is the recommended treatment. We present a case of a 56-year-old man with a GCT of the distal ulna treated successfully with an en-bloc resection of the distal ulna with reconstruction using radioulnar joint prosthesis. Although the experience with this type of treatment is limited, implantation of a metallic prosthesis to replace the distal part of the ulna can also be considered as a salvage procedure for the treatment of this difficult pathology.

Foveal TFCC tear classification and treatment

During the last two decades, increased knowledge of functional anatomy and pathophysiology of the triangular fibrocartilage complex (TFCC) have contributed to a change in surgeons' perspective toward it. The earlier concept of the TFCC as the "hammock" structure of the ulnar carpus has updated to the "iceberg" concept, whereby the much larger "submerged" part represents the foveal insertions of the TFCC and functions as the stabilizer of the distal radioulnar joint and the ulnar carpus, thus lending it greater functional importance. This article presents an algorithm of the treatment of traumatic peripheral TFCC tear based on clinical, radiological, and arthroscopic findings.

Current concepts in the treatment of rheumatoid arthritis of the distal radioulnar joint

Rheumatoid arthritis (RA) may progressively affect all articulations of the wrist. Involvement of the distal radioulnar joint (DRUJ) is common and may be the first clinical signs of symptoms of RA. When the DRUJ is affected by RA, upper extremity function can be affected. Effective surgical management includes the Darrach procedure, the Suave-Kapandji procedure, the hemiresection interposition arthroplasty procedure and extensor tenosynovectomy. The long-term effectiveness of DRUJ arthroplasty is currently unknown.