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

Association between radioulnar impingement and salvage surgical procedures of the distal radioulnar joint: influence of confounding variables

We conducted an ambispective cohort study to assess the association between symptomatic radioulnar impingement syndrome (SRUIS) and distal radioulnar joint (DRUJ) salvage surgery to examine the influence of confounders on the final effect. The outcome variable was the incidence of SRUIS and the exposure variable was the surgical procedure. Seventy-two patients with median age of 48 years (IQR 25-78) were examined using bivariate and logistic regression multivariate analyses, and confounders were analysed in 15 multivariate models. Overall, SRUIS occurred in 21 patients (29%). Bivariate analysis showed a significant association between SRUIS and type of surgical procedure, observed in 71% after Sauvé-Kapandji, 50% after Bowers and 15% after Darrach procedure. When adjusted for age, aetiology and previous surgery, the significant association disappeared. Confounding is an important factor when accounting for SRUIS after DRUJ salvage surgery. The risk of SRUIS did not depend on the procedure, but rather on patient's age, aetiology and previous surgery.Level of evidence: II.

Reconstruction of the distal radioulnar joint with rib perichondrium - midterm follow-up

Background

Reconstruction of an osteoarthritic distal radioulnar joint (DRUJ) in patients with high physical demands and a long lifetime expectancy is challenging. A variety of methods like implant surgery and salvage procedures as partial or total ulnar head resection and the Sauve-Kapandji procedure are reasonable options in the elderly patient but not in young individuals since it often compromises manual power and stability and may cause impingement problems. Reconstruction of the DRUJ with rib perichondrium is a new treatment option with promising short-term outcome. The aim the present study was to investigate if the outcome is consistent over time.

Methods

Four female patients with a mean age of 40.5 years suffered severe unilateral osteoarthritis in the DRUJ. They underwent reconstruction of the joint with rib perichondrium transplants. Preoperatively, mean pain under manual load was 8.5 (range 7–10) and 4.2 (range 2–5) at rest, using the visual analogue scale (VAS). Range of motion (ROM) in forearm rotation was on average 118° and grip strength was 86% in comparison to the contralateral hand. The outcome was assessed at a clinical follow-up in 2016, measuring ROM, grip-strength, pain at rest and under manual load and DASH-score. Radiological examination was performed. An additional follow-up by letter was performed in 2021 using a patient-reported-outcome survey (PROS). The patients were asked to grade the ROM and grip-strength as changed or unchanged in comparison to the clinical follow-up in 2016.

Results

At clinical follow-up at a mean of 3.1 years (range 1–5) after surgery, pain level had decreased to VAS 1.5 (0–5) under load and all patients were pain free at rest. Forearm rotation was on average 156° (range 100–180) and grip strength was 97% of the unoperated hand. The mean DASH-score was 14.4 (0–45). An additional follow-up by letter was conducted at a mean of 7.5 years (5.5–9.5) after surgery. ROM and grip strength were reported as unchanged by all patients in relation to the previous clinical follow-up. No additional surgery or complications were reported.

Conclusion

Reconstruction of the osteoarthritic DRU-joint with rib perichondrium transplantation can provide good clinical outcome with perseverance over time.

Level of evidence

IV.

[Mid- to long-term functional results after Bowers' hemiresection interposition arthroplasty of the distal radio-ulnar joint]

BACKGROUND

Bowers' hemiresection interposition arthroplasty of the distal radio-ulnar joint has been performed for decades, mainly for the treatment of osteoarthritis of the distal radio-ulnar joint. However, long-term test results are sparse.

OBJECTIVE

Evaluation of a homogeneous patient population following a mid- to long-term postoperative follow-up interval after hemiresection interposition arthroplasty.

PATIENTS AND METHODS

Twenty-five patients were evaluated 77.2 (±34.6) months after surgical therapy with regard to range of motion, grip strength and pain level. The subjective and objective scores DASH (Disabilities of Arm, Shoulder, and Hand) and MMWS (modified Mayo Wrist Score) were collected.

RESULTS

Wrist mobility is not worse than 10.4° in relation to all directions of wrist movement compared with the healthy opposite side. Coarse grip strength is reduced by an average of 5.8 kg compared with the opposite side. The pain level decreased on average from 8.2 preoperatively to 1.8 postoperatively. Postoperatively, 22 patients (88 %) had a stable distal radio-ulnar joint. At the time of follow-up DASH averaged 26.7 (±21.4) and the MMWS averaged 78 (±15.7).

DISCUSSION

Hemiresection interposition arthroplasty is a reliable and safe surgical technique with good subjective and functional outcomes in the mid- to long-term.

Poor results after pyrocarbon interpositional shoulder arthroplasty

BACKGROUND

This study aimed to describe the clinical outcomes and complications of 10 cases of pyrocarbon interposition shoulder arthroplasty (PISA).

METHODS

The clinical and radiographic records of 10 patients who underwent PISA using the InSpyre shoulder prosthesis (Tornier-Wright) between July 2012 and March 2017 were reviewed. The mean age at surgery was 55 years. Surgical indications included patients aged <60 years with Walch type B glenoid glenohumeral osteoarthritis (n = 7), avascular necrosis (AVN) of the humeral head (n = 1), or secondary severe glenohumeral osteoarthritis with axillary nerve dysfunction (n = 2). Outcomes of interest were postoperative complications and need for revision surgery, preoperative and postoperative patient-reported outcomes (Constant score [CS] and Subjective Shoulder Value [SSV]), and range of motion. The radiographic characteristics of the implants were evaluated.

RESULTS

Among the 10 patients, 5 underwent revision to reverse shoulder arthroplasty during the study period owing to poor clinical outcomes based on the CS and SSV. All 5 revised patients had Walch type B glenoid morphology at the time of the index procedure. The mean time to revision surgery in this subset of patients was 60 months. The remaining 5 patients who did not undergo any revision procedure had significant improvement in mean CS and SSV from 30-65 points and 32%-87%, respectively, but at a shorter duration of follow-up of 35 months.

CONCLUSION

High clinical failure rate and poor results at mean 5-year follow-up were found in younger PISA patients with baseline Walch B glenohumeral osteoarthritis. We would caution against use of PISA in this challenging patient population. PISA yielded more favorable short-term outcomes in patients with humeral-sided deformity or severe secondary glenohumeral osteoarthritis with axillary nerve dysfunction; however, longevity of the implant in this population remains unclear.

Extensor Tendon Rupture After Distal Radioulnar Joint Surgery: A Case Series

Symptomatic arthritis of the distal radioulnar joint (DRUJ) is often treated nonoperatively but with persistent symptoms may be treated surgically with partial or complete distal ulna resection. In many of these cases, ulna resection in combination with tendon reconstruction can successfully restore hand function. We identified three patients who underwent the Darrach procedure to treat DRUJ arthritis that developed attritional ruptures due to sharp prominent bone edges or dorsal capsule disruption. In addition to our recent three patients, an additional three isolated case reports, and two cases in a 29-patient series reported post-operative extensor tendon rupture as a complication after a Darrach procedure more than 30 years ago. While extensor tendon rupture is rarely reported in recent literature as a complication of distal ulna excision, surgeons may be able to minimize the risk of this complication intra-operatively by ensuring the resected distal ulnar stump is smooth, free of bony prominences, any capsular deficiencies are reconstructed, and that extensor tendons are able to glide freely.

Solutions for the Unstable and Arthritic Distal Radioulnar Joint

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