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The evaluation and treatment of the arthritic distal radioulnar joint.

The arthritic distal radioulnar joint (DRUJ) is a difficult problem. Many of the surgical interventions developed for this condition are associated with complications, such as instability and radioulnar convergence. Recently, prosthetic replacement of either the ulnar head or the entire DRUJ has been advocated in order to better restore the kinematics of the joint. A review of the anatomy and biomechanics of the DRUJ and a discussion of the numerous surgical options and their outcomes is provided.

Anatomy

The DRUJ is a diarthrodial articulation between the ulnar head and the sigmoid notch of the distal radius. The morphology of the DRUJ, as described by Tolat and coworkers, has been divided into three coronal and four transverse orientations. In the coronal plane, a type I DRUJ has a vertical orientation; a type II DRUJ has an oblique orientation; and a type III has a reverse oblique orientation. Type I and type II varieties are the most common, accounting for 88%. The DRUJ has been classified into flat face, ski slope, C-type, and S-type morphologies (Fig. 1). (1)

Because of the mismatch in the radius of curvature of the ulnar head and sigmoid notch, the major contribution to the stability of the DRUJ is from the surrounding soft tissues. The bony anatomy has been determined to provide only 20% to 30% of the total constraint. (2) As the forearm reaches the midrange of rotation, 40% to 60% of the ulnar head is maintained within the sigmoid notch; at the extremes of rotation, as little as 10% of the ulnar head is within the sigmoid notch. Importantly for palmar stability, there is an osteocartilagenous lip on the palmar aspect of the sigmoid notch.

The soft tissue stabilizers of the DRUJ can be divided into static and dynamic restraints. The static restraints include components of the triangular fibrocartilage complex (TFCC), specifically the articular disc, the dorsal and volar radioulnar ligaments, and the ulnocarpal ligaments. The joint capsule of the DRUJ and the interosseous membrane (IOM) constitute the remaining static restraints. Dynamic stabilizers of the DRUJ are the pronator quadratus and extensor carpi ulnaris muscles. (3,4) Cadaveric studies examining these stabilizers have emphasized the complex contributions of each to the stability of the DRUJ. The TFCC and radioulnar ligaments have been shown to maintain the normal kinematics of the DRUJ after sectioning of other soft tissue stabilizers. Similarly, the interosseous membrane can allow normal kinematics after sectioning of the TFCC and radioulnar ligaments. (3)

Biomechanics

The longitudinal axis of the forearm passes from the radial head to the foveal sulcus of the ulna at the base of the ulnar styloid. (3) Motion through the DRUJ is composed of rotation and translation or gliding of the radius around a stable ulna. The translation occurs in both the proximal-distal and dorsalpalmar planes. As the forearm rotates into pronation, there is a dynamic increase in ulnar variance, and the ulnar head translates dorsally within the sigmoid notch. Conversely, in supination, the ulna reaches its maximum of ulnar negative variance and palmar translation. (3,5)

There are two forces acting on the ulnar head at the DRUJ: an axial load transmitted through the carpus and TFCC and a transverse load from the distal radius and carpus. With the ulna in neutral variance, approximately 20% of the total axial load passes through the ulnocarpal joint. Palmar and colleagues demonstrated that with a 2.5 mm increase in variance, the axial load seen by the ulnar head increased to 42%, and that with a 2.5 mm decrease in variance, there was a decrease to 4%. (6) The transverse force is generated during lifting activities and is composed of the weight of an object against gravity. (7) The importance of this function of the DRUJ is highlighted by the instability and potential failure following resection arthroplasty.

Etiology

The etiology of an arthritic DRUJ can be divided into three main categories: post-traumatic, inflammatory, or primary osteoarthritis. Post-traumatic degenerative changes can result from the involvement of the sigmoid notch in a distal radius fracture. These changes can also be secondary to malunion of distal radius fractures. Increased dorsal angulation of the distal radius has been shown to significantly increase the loads seen by the distal ulna. (4) The soft tissue stabilizers of the DRUJ can also be injured during a traumatic event. Chronic instability after trauma can lead to altered biomechanics at the DRUJ and destructive changes. May and associates found that 11% of distal radius fractures were associated with DRUJ instability. Risk factors included fracture at the base of the ulnar styloid and significant ulnar styloid fracture displacement. (8)

Rheumatoid arthritis is the most common inflammatory arthritis to involve the DRUJ. There is destruction of the articular surfaces of the ulnar head and sigmoid notch as well as loss of soft tissue stability. If the destructive changes affect the dorsal border of the sigmoid notch, this can result in subluxation of the ulnar head. This process progresses to the development of caput ulnae syndrome in which the carpus subluxates volarly and supinates while the ulnar head displaces dorsally. There is subsequent development of extensor tendon irritation and rupture. (9)

Primary osteoarthritis of the DRUJ is a rare entity. In a radiographic study of 248 wrist radiographs of subjects older than 50 years of age, Hollevoet and colleagues found that the incidence of non-traumatic degenerative changes were related to greater inclination of the ulnar head and the morphology of the DRUJ. Specifically, primary OA was less frequent in patients with a reverse oblique coronal orientation of the DRUJ. There was no association of primary osteoarthritis of the DRUJ with ulnar variance or age. (10)

Evaluation

DRUJ arthritis is one of many possible causes of ulnar sided wrist pain, and when evaluating patients with this complaint, one should question patients regarding a history of prior trauma or inflammatory arthritis. Patients with DRUJ arthritis will complain of pain with grip or resisted forearm rotation. Pain can also occur with ulnar deviation of the wrist. Complaints of instability should also be noted. On physical examination, the wrist is inspected for deformity or prominence of the ulnar head. On palpation, patients may have pain over the diaphysis of the distal ulna. Pain within the ulnar snuffbox is not a reliable predictor of DRUJ arthritis. There may be loss of wrist range of motion with possible crepitation. Range of motion of the wrist should be compared to the contralateral side. Provocative testing of the DRUJ with dorsal and palmar stress, the shuck test, should be performed in neutral, supination, and pronation. Additionally, pain with forearm rotation while loading the joint can help to isolate the DRUJ as a source of pain.

Radiographic evaluation of the DRUJ should include a neutral posteroanterior (PA) view and true lateral view of the wrist. Additional imaging can include ulnar deviation and pronated grip views. Proper positioning is crucial for accurate radiographic assessment of the DRUJ. The neutral PA view is performed with the shoulder abducted to 90[degrees], the elbow flexed to 90[degrees], and the hand flat on the cassette. Ulnar variance and the presence of degenerative changes are assessed on the PA view. On the lateral view, the alignment of the carpus determines whether the positioning is accurate. The distal pole of the scaphoid and the pisiform should overlap the palmar cortex of the capitate. If the pisiform is palmar to the capitate, the wrist is supinated; if the pisiform overlaps the dorsal cortex of the capitate, the wrist is pronated. Improper positioning on the lateral can lead to inaccurate evaluation of the position of the distal ulna at the DRUJ. (9,11)

Additional imaging of the DRUJ typically includes computed tomography (CT) scans and magnetic resonance imaging (MRI). CT scans of the degenerative DRUJ can aid in the evaluation of post-traumatic incongruity and malunion. Bilateral CT scanning in neutral, pronation, and supination can identify instability of the DRUJ. MRI is reserved for assessing the soft tissue structures about the DRUJ. (9,11) The usefulness of these additional imaging studies in the setting of DRUJ arthritis is reserved more for surgical planning than for diagnosis.

Non-Operative Management

Non-operative management is similar to the treatment of other arthritic joints. An initial trial of nonsteroidal antiinflammatory drugs (NSAIDs), activity modification, and corticosteroid injections should be instituted. Immobilization with forearm splints is also an option. The optimal splint for DRUJ pathology is one that would include immobilization of the elbow to prevent rotation, i.e., a Muenster splint. (4) Nonoperative treatment should be exhausted before addressing the pathology surgically.

Resection Arthroplasty

Resection arthroplasties include the Darrach procedure and hemiresection arthroplasty with either the Bowers or Watson technique. These procedures are considered salvage operations because they universally alter the normal kinematics of the DRUJ. (12) In their original descriptions, a subperiosteal resection of the distal ulna was performed with preservation of the ulnar styloid in an effort to limit instability. (13) As performed today, a subperiosteal resection of the entire distal ulna is performed from just proximal to the sigmoid notch. The Darrach procedure has been advocated for low-demand, elderly patients; however, it can also be used in the younger patient if other options are not available. (14,15)

Outcomes of the Darrach procedure have been shown in multiple studies to result in pain relief, restoration of motion, and moderate increases in grip strength. (14-21) However, patient selection is critical. Fraser and associates reviewed the results of the Darrach in 40 patients with 50 resections. Eighty-six percent of the 23 patients with rheumatoid arthritis affecting the DRUJ had complete relief of pain. This was in contrast to the results in patients with post-traumatic etiology. Of patients undergoing the Darrach for post-traumatic pathology, only 36% reported pain relief. (17) More recently, Grawe and coworkers published long-term outcomes of the Darrach performed in patients with post-traumatic pathology. Of the 98 patients identified, only 27 were available for follow-up at a mean of 5 years. As expected, there was relief of pain with improved analog pain scores to 0.1 at rest and 0.6 with activity. There was a significant improvement in forearm rotation with an average pronation of 85[degrees] and supination of 78[degrees]. The mean DASH score was 17. Of the 27 patients, 6 of them required additional procedures: 5 radiocarpal arthrodeses and 1 DRUJ prosthesis. (16)

Instability of the distal ulna following the Darrach is a significant complication of the procedure, resulting in painful radioulnar convergence. Multiple soft tissue stabilization procedures have been described ranging from weaving a slip of extensor carpi ulnaris (ECU) tendon through the distal ulna and interosseous membrane, to creating a sling around the distal ulna with ECU and FCU tendon, to placing an Achilles allograft as a soft tissue interposition between the radius and ulna. (21-24) Although case series reporting on the outcomes of these stabilization procedures have demonstrated improved stability, concerns of instability in high-demand patients remain.

In the 1980s, hemiresection arthroplasty was described by both Bowers and Watson. Despite differences in their techniques, both procedures involve the resection of the carpal and radial joint surfaces of the ulnar head while maintaining the ulnar sling mechanism. (9,25) Bowers, in a later review of the hemiresection technique, outlined its indications in early rheumatoid arthritis and the osteoarthritic DRUJ. One must anticipate possible stylocarpal impingement and address it concurrently if necessary with an ulnar shortening osteotomy or soft tissue interposition between the radius and ulna. Additionally, he underscored the fact that these procedures do not address instability at the DRUJ and will fail without an intact TFCC. (26)

The early outcomes of hemiresection arthroplasty were positive; however, they included a significant proportion of rheumatoid patients. (25) Later studies reported similarly good results in post-traumatic populations. In a study of 32 patients with minimum 2-year follow-up, Watson demonstrated return of normal forearm rotation and good to excellent results in 75% of patients. (27) Similarly, in a series of 12 patients with post-traumatic or primary OA, Minami showed improvements in pain relief, range of motion, and grip strength. Importantly, 11 of the 12 patients were able to return to prior employment. (28)

Sauve-Kapandji Procedure

The Sauve-Kapandji procedure is a combination of creating a pseudarthrosis at the level of the metadyaphysis of the distal ulna with an arthrodesis of the DRUJ while preserving the head of the ulna. Destot in 1908 first discussed motion improvement due to an ulnar pseudarthrosis in a patient with a malunited distal radius fracture. Subsequently, the creation of an intentional pseudarthrosis was described independently by several investigators; however, these investigators did not mention an arthrodesis of the DRUJ. (29) The Sauve-Kapandji preserves the soft tissues and prevents ulnar translocation of the carpus. Current indications for the Sauve-Kapandji procedure include post-traumatic arthritis with or without instability of the DRUJ and inflammatory arthritis. The procedure is contraindicated in patients with insufficient or absent bone stock of distal ulna, active infection, or an unstable interosseous membrane. (30,31) In the setting of interosseous membrane injury, the Sauve-Kapandji procedure can result in instability of the proximal ulnar stump and significantly increase forces transmitted to the capitellum. (32)

The outcomes of the Sauve-Kapandji are similar to those of the Darrach in respect to pain relief and improved range of motion. The Sauve-Kapandji also allows for near normal return of grip strength. (31,33-47) In a study of 15 patients with primary or post-traumatic arthritis of the DRUJ, Minami and coworkers found significant improvement in grip strength to 88% of the contralateral side. (39) DeSmet and colleagues reported 64% of patients with good to excellent results on Mayo wrist score.43 Zimmerman and associates in a review of 115 patients who had undergone the Sauve-Kapandji procedure detailed a mean DASH score of 27. (45)

Like the resection arthroplasties, the Sauve-Kapandji technique can result in instability of the proximal stump, with resultant scalloping of the distal radius shaft. Minami and coworkers reported 80% of patients with instability on postoperative radiographs. After modifying the technique with an ECU tendon weave, instability was resolved, and the functional gains were maintained. (39,44) Other complications of the Sauve-Kapandji procedure include ossification of the bone gap, emphasizing the importance of an extra-periosteal resection.There are few studies that have compared the Dar rach procedure, hemiresection arthroplasty, and the Sauve-Kapandji procedure (Fig. 2). Minami and coworkers looked at 61 patients with either primary or post-traumatic arthritis. At an average of 10-year follow-up, the Sauve-Kapandji and hemiresection arthroplasty showed superior return to work and significantly better grip strength compared to the Darrach. Additionally, although not statistically significant, the Darrach also trended toward inferior pain relief. Improvements in forearm were equal in all three procedures. As would be expected from resection arthroplasty, instability was a problem with all three procedures: 60% for the Darrach, 50% in the Sauve-Kapandji, and 20% in hemiresection. (15)

Prosthetic Replacement

Numerous types of ulnar head replacements have been designed with the intention of restoring the normal biomechanics of the DRUJ. The first ulnar head replacements to be described were by Swanson in the early 1970s. Because of problems with synovitis and failure related to the silicon, these implants were abandoned. (48) Currently, there are partial ulnar head and full ulnar head replacements available (Fig. 3). Biomechanical studies have verified that prosthetic reconstruction of the DRUJ with either partial or full ulnar head replacement can maintain kinematics similar to that of an intact forearm and prevents the instability seen with distal ulna resection. (49,50)

Outcomes of ulnar head replacement have been promising. Van Schoonhoven and colleagues looked at the longterm outcomes of 23 patients treated with the Herbert ulnar head replacement as a salvage procedure. Of the original 23 patients, 16 were available for long-term follow-up an average of over 11 years. All patients had a clinically stable DRUJ. The improvements in analog pain score, satisfaction, grip strength, and forearm rotation that had been seen at short-term follow-up were maintained. While initially there was concern regarding the development of bony resorption around the collar of the ulna, this radiographic finding had stabilized within 6 months of surgery, and at long-term follow-up there was no evidence of loosening. (51) Herzberg and associates found that 90% of implants developed lucency around the collar with stabilization within 1 year. (52) Kakar and coworkers reported similarly encouraging results in a retrospective review of 47 patients. Implant survival was 83% at 6 years. Interestingly, forearm rotation did not significantly improve. (48)

A series of 22 wrists with average follow-up of nearly 5 years found significant pain relief and an average good result on Mayo wrist score. Not surprisingly, those patients who underwent ulnar head arthroplasty as a salvage procedure scored slightly worse on the Mayo wrist score but still within the good range. In the subset of 10 patients who underwent ulnar head replacement as a primary procedure, there were 4 excellent and 6 good results. (53)

A fully constrained DRUJ prosthesis has been designed to allow longitudinal migration of the radius and pronosupination. Additionally, it prevents painful erosion of the sigmoid notch that can be seen following ulnar head arthroplasty. This implant has been advocated not only as a salvage for failed resection arthroplasty and ulnar head replacement but also as a primary procedure. Contraindications include severe osteoporosis, infection, and low-demand debilitated patients. (54) Scheker and colleagues reported on 31 patients followed for a mean of 5.9 years. There was excellent pain relief and significant improvements in forearm rotation and grip strength. Lifting ability, which the investigators defined as weightbearing through the DRUJ, was restored or increased in 29 of 31 patients with a range of 5 to 20 lbs. The mean DASH score was 23. (55) In a smaller series of six patients with average 2.4-year follow-up, Jupiter detailed excellent return of range of motion and improvements in grip and pinch strength. (56)

Summary

The results of prosthetic replacement suggest that they can be used for the primary treatment of arthritis and instability of the DRUJ; however, patient selection remains critical. There is a role for the Darrach procedure in the low-demand, elderly patient. Despite the recent positive long-term outcome study for the Darrach procedure, (16) the theoretical advantages of prosthetic replacement, including restoring normal kinematics, leads one to question the larger role of resection arthroplasty in the management of DRUJ disorders.

Disclosure Statement

None of the authors has a financial or proprietary interest in the subject matter or materials discussed in the manuscript, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.

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Caption: Figure 1 Anatomical variations of the DRUJ in the transverse plane. (Reprinted from Tolat AR, Stanley JK, Trail IA. A cadaveric study of the anatomy and stability of the distal radioulnar joint in the coronal and transverse planes. J Hand Surg Br. 1996 Oct;21(5):587-94. With permission from Elsevier.)

Caption: Figure 2 Surgical treatment options for DRUJ arthritis. (Reprinted from Katolik LI, Trumble T. Distal radioulnar joint dysfunction. J Am Soc Surg Hand. 2005;5(1):8-29. With permission from Elsevier.)

Caption: Figure 3 Ulnar head replacement for failed hemiresection arthroplasty.

Elliot Nacke, M.D., Resident, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York. Nader Paksima, D.O., Clinical Associate Professor, NYU Hospital for Joint Diseases, New York, New York.

Correspondence: Nader Paksima, D.O., 530 First Avenue, New York, New York 10016; nader.paksima@nyumc.org.

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Author:Nacke, Elliot; Paksima, Nader
Publication:Bulletin of the NYU Hospital for Joint Diseases
Article Type:Disease/Disorder overview
Date:Apr 1, 2015
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