Posttraumatic DRUJ Arthritis

Key Points

Salvage procedures of distal radioulnar joint (DRUJ) arthritis after distal radius fractures (DRFs) can be divided in resection arthroplasties and implant arthroplasties.
Corrective osteotomy, ulnar shortening, ligament—reinsertion or reconstruction should be considered before reconstruction of the joint.
Specific indications for the different reconstructive procedures after DRFs have not been established, and the scientific evidence for any treatment is weak.
Decision on what operative treatment to choose for DRUJ osteoarthritis is primarily based on factors related to; patient demands, especially on loading of the forearm, DRUJ morphology, and stability provided by constraining soft tissues.

Panel 1: Case Scenario

A 64-year-old female with osteoporosis presents at your clinic. She has retired since a few years after knee arthroplasties, but is still living an active lifestyle, including a wish to continue playing golf.

A year earlier she was treated at a nearby hospital with external fixation and pinning for a distal radius fracture (DRF) ( Fig. 1 ). Upon initial consultation, she complains of ulnar-sided wrist pain while lifting or moving her arm.

$Fig. 1, (A) Initial fracture, (B) primary treatment, (C and D) presentation at 1 year.$

Her grip strength is reduced by 50%, compared to the uninjured side, but range of motion is less affected, with a pronosupination of 130 degrees ( Table 1 ).

Table 1

Recordings of PROMs and physical measures before and after surgery

	VAS S	VAS R	VAS A	DASH	PRWE	ROM S°	ROM P°	Grip (kg)	Lift N (kg)	Lift S (kg)	Lift P (kg)	Torque S (N m)	Torque P (N m)
Preop.		55	75	25	71	60	70	20	5.6	6.2	5.8	3.9	3.9
Latest	96	17	40	24	31	70	80	30	10.1	10	8.7	3.9	3
Contral.						70	85	40	10.6	12.5	8.9	4.2	3.9

Preop. , preoperative recordings. Latest , latest follow-up measurements. Contral ., recordings from the unaffected side. VAS , visual analogue scale; VAS S , satisfaction; VAS R , VAS pain at rest; VAS A , VAS pain during activity; ROM S , range of motion-supination; VAS P , pronation; Grip , grip strength; Lift N , lifting strength in neutral forearm position; Lift S , lifting strength in fully supinated position; LIFT P , lifting strength in pronated position. Torque S , torque in supinated direction. Torque P , torque in pronating direction.

She experiences pain on palpation and compression of the DRUJ as well as on resisted forearm rotation. There is a minor instability on the shear test of the DRUJ in fully pronated position. Radiographs reveal ulnocarpal impaction, because of radial shortening, and a 10 degree dorsal tilt compared to the uninjured wrist ( Fig. 1 C and D).

What treatment will you suggest to this patient?

Importance of the Problem

Involvement of the sigmoid notch of the distal radio ulnar joint (DRUJ) is known to be as high as 80% in intraarticular distal radius fractures (DRF). How many of these injuries that actually progresses to symptomatic OA and disability is not known, however data from Cooney et al. in the 70s show a prevalence of DRUJ osteoarthritis in Colles’ fractures of 5%. Diagnostic modalities and treatment techniques has changed considerably since then, and the frequency of DRUJ involvement in DRF may also be underestimated, as it has been shown that displacement of the sigmoid notch of intraarticular fractures is often missed with plain radiographs. Nevertheless, it seems like involvement of the sigmoid notch with DRF does not necessarily lead to development of OA, and a poor result. Vitale et al. hypothesize that the DRUJ may be a more tolerant joint for articular injury and malalignment than the radiocarpal joint.

Not only involvement of the sigmoid notch, but also direct injury to the joint surfaces, will cause joint degeneration. It is likely that associated ligament injuries, or a combination of ligamentous injuries and fracture later on will lead to OA. Therefore, depending on how the OA developed different treatment modalities need to be considered when the joint is reconstructed.

Patients that are affected by DRUJ arthritis may suffer from substantial physical morbidity with; disabling ulnar-sided wrist pain, decreased ability to load the wrist in all static positions, as well as during forearm rotation. Conservative treatment with pronosupination locking splints may offer some relief, but is a poor option as restriction of forearm movements is not well tolerated. Selective denervation of the DRUJ is rarely performed and current literature is sparse for this treatment. Other surgical treatments for disabling DRUJ arthritis range from simple low-cost resection arthroplasties to complex and expensive implant arthroplasties. The paucity of data—not only on the prevalence of symptomatic DRUJ OA following DRF—is even more striking when it comes to comparing treatment modalities.

Main Question

What is the optimal surgical treatment for a patient with a painful osteoarthritic DRUJ after a DRF?

Current Opinion

To sort out what treatment option is best for the individual patient, some critical factors need to be addressed. Most importantly, the patient's functional demands and expectations, specifically regarding the ability to bear load, needs to be assessed. This is often, but not necessarily, related to the patient's age. Previous multiple surgeries will usually affect the outcome in a negative way, why they need to be taken into consideration. DRUJ characteristics, the localization of the OA, any remaining malalignment, and signs of ligamentous injuries are other key elements that need to be identified.

If a bony deformity remains, it should usually be treated first. Not only does a corrected malalignment reduce symptoms and potentially prevent further deterioration of the DRUJ, but also enable a better starting point for later salvage procedures if needed. Corrective osteotomy of the radius is usually first considered, but an ulnar shortening might be sufficient in certain cases, such as when there is a positive ulnar variance and a suitable type of joint geometry.

Second to addressing malunion is determining if there is a concomitant ligamentous injury that can be fixed, or needs to be accounted for when the treatment strategy is decided upon. In general, surgery to repair or reconstruct ligaments can be done simultaneously to a corrective osteotomy, but many times it is better left to a later point when the outcome of the osteotomy can be evaluated.

If the primary procedures to correct for malunion or joint instability fail, or in case of a remaining severe DRUJ arthritis, salvage procedures are to be considered.

For many decades, the only surgical intervention that could be offered for an arthritic DRUJ was some kind of resection arthroplasty. Functionally, the main drawback of resection arthroplasties is the loss of solid support to the loaded hand and wrist which will affect the ability to grip and lift. As the ulnar head is removed also the separation of the distal radius and ulna is lost, sometimes causing painful dynamic impingement of the bones. Only solid DRUJ prostheses have the possibility to solve this problem, as the distal ulnar buttress is restored. This treatment option became available in the late 90s, primarily as salvage procedures for failed resection arthroplasties. Biomechanical studies which show superior properties compared to resection arthroplasties and with favorable clinical results, that seems to last, has made the joint replacements gain approval with increased popularity. In most institutions though, resection arthroplasty, with or without soft tissue stabilization of the ulnar stump remains as standard treatment of care for the osteoarthritic DRUJ.

Surgical Treatment Options

Denervation

When doing our literature search, we have not found any reports on outcomes of selective denervation of the DRUJ, although the anatomical prerequisites are described.

DRUJ Resection Arthroplasties

Darrach's Procedure

The easiest way to remove an arthritic DRUJ surface is through simple complete ulnar head resection, popularized as the Darrach procedure. There is a great disparity in the published long-term results after Darrach's procedure, and the majority of the literature is on patients with rheumatoid arthritis. Most studies recognize the risk for mechanical impingement, and a loss of grip strength up to 50%, and several studies have shown that only about 50% of posttraumatic patients are satisfied with the results of the procedure, especially in slightly younger age groups ( Fig. 2 ).

Fig. 2, Schematic sketches of the different resection arthroplasties.

Some recent reports show reasonably good pain relief in the long term, but data on outcome after treatment secondary to DRF is scarce.

A magnitude of technical modifications of the procedure has been described, including, whether or not the styloid should be spared, if there should be an extraperiosteal or intraperiosteal resection or whether or not the distal ulna should be stabilized or not.

Partial Ulnar Head Resection/Hemiresection Interposition Technique (Bowers Procedure or HIT)

The technique is designed to preserve ulnocarpal ligamentous structures, and thereby theoretically provide a more stable distal ulnar end. Although there is some evidence supporting this assumption, based primarily on in vitro studies (see below—“ Complications to Resection Arthroplasties ” section), clinical follow-up show marginally better stabilizing effects of the ulnar head compared to unsupported S-K and Darrach´s procedures. The main benefit compared to Darrach's procedure is the increase in grip strength, and ability to return to work.

There is no consensus on what capsular interposition flap should be used for optimal results. A modified approach to the initial procedure has been advocated by Bain et al., where a more robust, single ulnar compound capsular flap is used. The ECU is mobilized within its sheath to a more dorsal position, possibly acting as a dynamic stabilizer to the distal ulna.

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here