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

Performance of the Aptis distal radioulnar joint implant: kinematic and geometric analysis

This study reviews the performance of the Aptis distal radioulnar joint arthroplasty by comparing multiple kinematic and geometric measurements in the operated and contralateral healthy forearm to elucidate whether these are altered after arthroplasty. Forearm geometry and motion were captured using 3-D and 4-D computed tomography in 12 patients with unilateral Aptis arthroplasties. After segmentation and registration, the axis of forearm rotation, translation of the radius along the ulna and range of wrist flexion-extension were measured, and the Dice coefficient and Hausdorff distance were calculated. The forearm rotation axis in the corrected arm deviated 2.3° from the healthy contralateral rotation axis, radial translation along the ulna decreased by 45% and wrist flexion-extension also decreased significantly. Multiple intra-individual geometric differences were observed. The Aptis distal radioulnar joint arthroplasty considerably alters forearm kinematics, which can have clinical implications.Level of evidence: IV.

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.

The semiconstrained DRUJ prosthesis: blessing or curse?

PURPOSE

There are numerous operative procedures to treat osteoarthritic changes or a significant instability of the distal radioulnar joint (DRUJ). The key problem of most methods is the destabilization of the forearm leading to secondary painful impingement between the radius and ulna, as well as a significant limitation of forearm rotation. The Aptis-Prosthesis designed by Scheker represents a complete substitute for the DRUJ. It is mostly used after the failure of various treatment options to solve the primary problems (arthritis, instability). We have used this type of prosthesis mostly after multiple operative treatments for more than 25 years.

METHODS

In the following retrospective study, we analyzed the data of patients that received an Aptis-prosthesis between 2016 and 2021. We have implanted this prosthesis in 13 cases (11 female, 2 male). Routinely, we document the clinical outcome concerning range of motion (ROM), grip strength, and pain according to numeric rate scaling (NRS) after more than 12 months (month 12-24). In addition, complications, osseous changes, and the rate of loosening of the prosthesis were registered. Furthermore, DASH-Score and patients ' satisfaction were evaluated. Also-as with other implants-follow-up x-rays were performed.

RESULTS

Removal or significant revision of any of the prostheses was not needed. The ROM was 68.1° ± 19.7° for pronation and 72.3° ± 20.9° for supination, grip strength amounted to 27.7 kg ± 11.0 kg equaling 83% of the contralateral side. NRS was 0 at rest and 1.2 (0-2) under weight-bearing. A lysis margin of the radial tap was noted in the radiological examination in 2 patients but without any signs of loosening. The DASH-Score added up to 31.8 ± 13.8 (13-55). All patients were satisfied or very satisfied having this implant.

CONCLUSION

The semiconstrained Aptis-prosthesis is a safe and efficient treatment option after failed DRUJ surgeries. It is striking that of the 20 implanted prostheses no significant revision or explantations were necessary over a period of 25 years.

Distal radioulnar joint instability: Diagnosis and treatment of acute and chronic lesions

Distal radioulnar joint instability is a common clinical condition that can be either acute or chronic. Its management requires extensive knowledge of all the anatomical structures around the wrist area. The clinical examination must identify all damaged structures in order to define a customized reconstruction strategy. The aim of treatment is to prevent the development of chronic instability and/or arthritic lesions, which can only be treated with palliative surgery. Distal radioulnar instability is complex. Its management shares similarities with that of knee instability, with a wide range of conditions ranging from a sprain with isolated ligament tear to complex dislocation in which multiple ligaments are torn. In particular, the triangular fibrocartilage complex, which is a pillar of distal radioulnar joint stability, is not the sole stabilizer of this joint. The treatment strategy is not as simple as just reattaching this ligament to treat all of the acute and chronic clinical signs. The goal of the present study is to describe the various structures and possible lesions in this joint and then how to repair them. The diagnostic and therapeutic difficulties justify treatment at a specialized center.

Kinematic analysis of forearm rotation using four-dimensional computed tomography

This study aimed to quantify forearm kinematics with a focus on the forearm rotation axis. Ten healthy volunteers were included in the study. One three-dimensional computed tomographic scan and two four-dimensional computed tomographic scans were done in all the arms to capture forearm joint motion. After image processing, the rotation axis and the movement of the radius with respect to various axes were quantified. The rotation axis was calculated using finite helical axis analysis and a circle fitting approach. The mean error of the rotation axis found through circle fitting was 0.2 mm (SD 0.1) distally and 0.1 mm (SD 0.1) proximally, indicating an improvement in precision over the finite helical axis approach. The translations of the radius along the ulnar axis and the forearm rotation axis were 2.6 (SD 0.8) and 0.6 mm (SD 0.9), respectively. The rotation of the radius around the radial axis was 7.2°. The techniques presented provide a detailed description of forearm kinematics.

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.

Salvage of Painful Porous Coated Stem Ulnar Head Prosthesis With Semiconstrained Distal Radioulnar Joint Arthroplasty

PURPOSE

To determine the functional outcome and complications after conversion from a painful and unstable ulnar head prosthesis to a semiconstrained distal radioulnar joint arthroplasty.

METHODS

We conducted a retrospective review of 11 ulnar head prostheses in 10 patients with porous coated stems that were revised to semiconstrained prostheses. The median age of the patients was 47 years. The median number of wrist surgeries prior to conversion was 4 (range, 1-9). The median time from the ulnar head implant to the revision surgery was 47 months. Pre- and postoperative pain levels were recorded. Mayo Wrist Scores were calculated. Grip strength, range of motion, and complications and reoperations were recorded.

RESULTS

All patients reported moderate or severe pain before surgery, whereas 3 patients reported moderate pain after surgery. The Mayo Wrist Score improved considerably from a median of 50 before surgery to 65 after surgery. The grip strength and forearm pronation-supination showed no change following surgery. The median wrist flexion-extension range improved considerably. Follow-up was a median of 64 (range, 15-132) months after revision surgery. Removal of the ulnar head implant was described as difficult by the surgeons, except in 1 case where the implant was loose. Resection of bone from the distal ulna was often necessary. One patient needed a reoperation requiring prosthesis removal for aseptic loosening of the stem 5 years after revision. There were 2 nondisplaced periprosthetic fractures successfully treated with cast immobilization and 2 additional minor complications, 1 postoperative stitch abscess, and 1 extensor carpi ulnaris tendinitis.

CONCLUSIONS

Conversion from an ulnar head implant to a semiconstrained prosthesis provided improved pain scores and function with a low reoperation rate in this patient series. Removal of an ulnar head prosthesis can be technically challenging, but it can be performed leaving enough bone stock for immediate implantation of a semiconstrained implant.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

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.

Fixação suspensiva percutânea de luxação crônica da articulação radioulnar distal (ARUD) usando um dispositivo de endobutton de laço ajustável: Relato de caso

Luxação crônica da articulação radioulnar distal (ARUD) foi tratada historicamente com osteotomias complexas e procedimentos reconstrutivos, geralmente resultando em rigidez intratável e perda de função. É desejável usar uma técnica de fixação que não apenas restaure a biomecânica do punho, mas também seja esteticamente atraente para o indivíduo. Apresentamos uma nova técnica de redução e fixação de uma ARUD deslocada cronicamente em um homem de 26 anos, usando uma abordagem minimamente invasiva, com restauração bem-sucedida da função da ARUD e sem complicações pós-operatórias.

Validity and Responsiveness of Forearm Strength Measurements in the Evaluation of Distal Radioulnar Joint Implant Arthroplasty

PURPOSE

To assess the responsiveness of forearm strength tests and to correlate the change to grip strength and a patient-reported outcome measure used for evaluation of distal radioulnar joint (DRUJ) implant arthroplasty.

METHODS

We performed a retrospective review of 18 patients treated with Herbert (n = 12) and Scheker (n = 6) DRUJ implants. Patients who had undergone the various measurements of arm and grip strength both before surgery and after a minimum follow-up of 1 year were included. Our primary aim was to compare the responsiveness of grip strength with our new methods for measuring forearm torque and lifting strength. The secondary aim was to correlate observed changes in strength measurements to change in a patient-reported outcome measure with use of the patient-reported wrist evaluation (PRWE). Measurements of grip strength, forearm torque, and lifting strength were performed with the Jamar dynamometer and the Kern and Baseline instruments. Preoperative values were compared with 1-year values.

RESULTS

Standardized response mean and effect size values were higher for forearm torque than for grip strength. Change in forearm torque and lifting strength had a moderate to strong correlation with change in PRWE. The correlation between grip strength and PRWE was weak.

CONCLUSIONS

Forearm torque measurements were better than grip strength in detecting changes after DRUJ arthroplasty. It also had a stronger correlation to patient-reported outcome, measured with the PRWE.

CLINICAL RELEVANCE

Forearm torque testing may add further information to the evaluation of DRUJ disorders and their treatments. These tests can provide quantifiable data on the patient's ability to perform various tasks requiring physical strength.

Total Distal Radioulnar Joint Arthroplasty for Paget's Disease of Bone

Background  Distal radioulnar joint (DRUJ) and ulnocarpal pathology, such as ulnocarpal impaction, are relatively common causes of ulnar-sided wrist pain. We herein report a rare case of ulnocarpal impaction and DRUJ arthropathy due to Paget's disease of bone (PDB) in the ulna. Case Description  A 65-year-old, right-hand-dominant male was diagnosed with right-sided ulnocarpal impaction secondary to PDB. While diagnosing the cause of this patient's ulnar wrist pain was relatively straightforward, the management of his pain and symptoms was less so. After a thorough discussion with the patient regarding medical versus surgical management, and after presenting all available surgical options, he opted for a total distal radioulnar joint arthroplasty (TDRUJA). At 3-year follow-up, his wrist is pain-free, has excellent functionality, near-normal motion, and he is highly satisfied. Literature Review  Currently, there are no specific recommendations for surgical management of PDB in the ulna, causing ulnocarpal impaction. While resection of the pathologically enlarged ulnar head (Darrach procedure) and the Suavé-Kapandji (SK) procedure are standard surgical treatment options, a major known disadvantage of these procedures is painful ulnar impingement syndrome. TDRUJA, a relatively new treatment option, provides good long-term outcomes with high patient satisfaction and protects from ulnar impingement. Clinical Relevance  Since recommendations are lacking for surgical management of PDB, we propose that the TDRUJA be considered as an effective surgical option for the management of PDB causing ulnocarpal impaction. Furthermore, this can reduce the incidence of ulnar impingement, especially for patients who have pathologically enlarged ulnas that are prone to impingement.

Salvage Operation for a Failed Total Wrist Prosthesis and Darrach Procedure by Total Wrist Revision and Distal Radioulnar Joint Arthroplasty

An unstable distal ulnar stump after Darrach resection, alongside pathology of the radiocarpal joint, is difficult to manage without fusion of at least one joint. Currently, no standard 2-in-1 arthroplasty is available. We report the case of a 72-year-old woman with loosening of the radial stem of a Universal 2 total wrist prosthesis combined with radioulnar impingement after a Darrach procedure. Because of poor radial bone stock, the standard fixation technique of a semi-constrained distal radioulnar joint prosthesis (Aptis) was not possible. We present a technique to fix the semi-constrained distal radioulnar joint prosthesis as well as a total wrist prosthesis by a custom 3-dimensional printed flange prosthesis to the ulnar border of the radius. Three years after surgery, the patient remained pain-free, with 60° flexion, 75° extension, 80° pronation, and 80° supination.

Ulnar head replacement and sigmoid notch resurfacing arthroplasty with minimum 12-month follow-up

Our study aimed to report the short-term outcomes of patients who underwent partial ulnar head replacement and distal radial ulnar joint interposition arthroplasty. From 2012 to 2016, nine patients underwent this procedure with mean follow-up of 27 months (range 12-55). Seven of the nine patients had previously undergone surgical intervention on the ipsilateral wrist. The procedure resulted in substantial improvements in pain and function. Mayo Wrist Score improved from 37 preoperatively to 73 postoperatively, and six patients achieved a good or excellent outcome. Visual analogue pain scores decreased from 7 preoperatively to 1 postoperatively. Grip improved from 20 kg preoperatively to 30 kg postoperatively. There was no significant change in wrist range of motion. Two patients underwent revision surgery to improve wrist motion. We conclude that over short-term follow-up the procedure provides a feasible option for distal radial ulnar joint arthritis. 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.

[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.

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.

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.

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.

Management of a Complex, Multioperated Intra-Articular Distal Radius Fracture

Background Intra-articular distal radius fractures can have many complications, including radiocarpal osteoarthritis and distal radioulnar joint (DRUJ) dysfunction leading to pain and restricted wrist function. Case Description We describe the case of a 38-year-old patient who sustained a left distal radius intra-articular fracture, which was treated with volar plating. She developed pain from the radiocarpal joint as a result of intra-articular malunion and was listed for total wrist fusion. On the day of surgery this was converted to a Darrach procedure for minor DRUJ symptoms. This resulted in pain from the DRUJ as a result of instability, in addition to persisting radiocarpal arthritis pain. Due to her subsequent poor wrist function, she presented to the authors and underwent DRUJ arthroplasty with a proximally placed Scheker prosthesis to deal with her DRUJ symptoms and, later, a KinematX radiocarpal hemiarthroplasty for her radiocarpal symptoms. She remains happy with her outcome at 36-month follow-up. Literature Review The complications of the Darrach procedure include painful radioulnar convergence and wrist instability. The Scheker prosthesis allows restoration of stability of the DRUJ with good outcomes and 100% 5-year survival in one series. Sparing the midcarpal joint, the KinematX hemiarthroplasty allows preservation of the dart thrower's motion arc, which is key in many complex wrist movements and functions. Clinical Relevance This case highlights the negative consequences of distal ulna resection and shows both the Scheker and KinematX prostheses as viable, effective means to restore function to young, active patients with posttraumatic radiocarpal arthritis and/or instability.

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.