Anatomic derangement at the distal radialulnar joint (DRUJ) can result in pain and functional limitations of the wrist. The Sauvé-Kapandji (S-K) procedure is advocated in patients with high demand wrists to relieve pain and restore forearm rotation.6,12,15,17,20,36,39,40 The theoretical advantage of this technique is that it maintains the structural anatomy by preserving the ulnocarpal ligaments, the triangular fibrocartilage, and the ulnar head.9,19,21,32,43 This bony buttress provides additional mechanical support and prevents ulnar translation or dislocation of the wrist in patients with radiocarpal instability.47
Radioulnar convergence, or radioulnar impingement syndrome, which first was described after the Darrach procedure, is also a potential complication following the S-K procedure.1,26 Pain and clicking caused by instability of the ulnar stump has been reported with an incidence of 13% to 39%.14,30,31,36,45 Radiographic evaluation has also documented radioulnar convergence with scalloping of the distal radius corresponding to the site of impingement.1,24,31
There are many soft tissue solutions for stabilization of the ulnar stump at the time of the initial S-K procedure. Tenodesis of the proximal ulna with a slip of the extensor carpi ulnaris (ECU),25,29 the flexor carpi ulnaris (FCU),23 or a combination of both.5 Despite initial stability, these soft tissue procedures have a tendency to deteriorate with time (Table 1).33
In order to control instability of the ulnar stump following a failed S-K procedure, we propose the placement of a spherical ulnar head prosthesis while preserving the radioulnar fusion mass. The prosthesis restores the bony architecture and ulnar column of the forearm.18 The head of the prosthesis seats into a spherical socket reamed in the fused distal ulna and the stem is inserted into the proximal ulnar stump (Fig 1).
In an attempt to avoid radioulnar convergence and reduce pain, we asked whether insertion of an ulnar head prosthesis would restore instability of the ulnar stump.
MATERIALS AND METHODS
We retrospectively reviewed 10 consecutive patients (six women and four men) treated between January 1999 and July 2004 with a spherical ulnar head prosthesis for symptomatic radioulnar convergence after a S-K procedure. Except for one patient with DRUJ arthrosis in a dysplastic wrist, all S-K procedures were done for posttraumatic derangements of the DRUJ. Nine of 10 patients had multiple surgeries either before or after the S-K procedure. Every patient who presented with painful radioulnar convergence and unstable distal ulnar stump was included in the study. All patients had abnormal motion of the ulnar stump with forearm rotation and with transverse compression of the forearm. On stress-loaded anteroposterior (AP) views, every patient had complete radioulnar convergence; all ulnar stumps had full contact with the radius. No patient could work at his or her previous occupation. The mean age at surgery was 43 years (range, 29-63 years). The mean time from the initial surgery to the ulnar head replacement was 2.1 years (range 0.8-4 years). The mean follow-up period was 2.6 years (range, 8-74 months) (Table 2). All clinical and radiographic measures used in this project were performed by the senior author (DLF).
Radioulnar impingement was evaluated clinically and radio-graphically. Preoperative and postoperative clinical evaluation included wrist and forearm range of motion and grip strength. Measurements of wrist and forearm range of motion were recorded with a hand-held goniometer. Grip strength was quantified with a standard dynamometer in the affected and unaffected hands. (Jamar, Asimov Engineering Co, Santa Monica, CA).11 Instability of the ulnar stump was evaluated by forced supination of the wrist and with transverse compression of the radius and ulna. Instability was graded on the following scale: (-) = no motion of the ulna, (+) = mild painful click only when lifting heavy objects; (++) = moderately painful click during forearm rotation or lifting lighter objects; (+++) = substantial visual instability of the ulnar stump, painful click in every activity of daily living. Pain was graded by the Fernandez wrist score11 with (-) = none; (+) = mild pain was present only at the extremes of the active range of motion of the wrist and the patient was neither physically nor psychologically disturbed by the pain; (++) = moderate pain occurred during heavy manual labor and caused the patient to be disturbed physically or psychologically, or both; (+++) = severe pain occurred during daily activities and even at rest.
Radiographic evaluation was performed preoperatively and postoperatively. Preoperative radiographs included anteroposterior (AP), lateral, and stress-loaded (1.250 kg) AP view (Fig 2 A-B). These radiographs were used to measure the gap between the tip of ulnar stump and the fused head (S-K gap) to determine the necessary resection level and to template the correct ulnar head size. Radiographs of the contralateral forearm and wrist were also obtained for preoperative planning. Postoperative radiographs (AP and lateral wrist views) were taken at each postoperative visit (2 weeks, 6 weeks, 4 months, and yearly thereafter). Radiographs were evaluated for new bone formation and implant loosening. Loosening was judged by implant migration and the presence of a radiolucent line around the component. Measurements taken from these radiographs with a ruler (in tenths of 1 mm) included sclerotic rim around the ulnar head and bony resorption between the prosthetic neck and distal ulna.
Working ability was recorded preoperatively and 3 months postoperatively as the number of hours worked per week and expressed as a percentage of a full 40-hour work week. No patient was able to work preoperatively. Postoperatively, all patients were asked if they would have the procedure done again.
In all patients a modular noncemented Herbert ulnar head prosthesis (Martin, Tuttlingen, Germany) consisting of a spherical cobalt-chromium (Co-Cr) head and a porous-coated titanium stem was used. Three head sizes (mini = 13 mm, small = 15 mm, and medium = 18 mm), three stem diameters (small, medium, and large) and three neck lengths (standard = 2 mm, standard+ = 4 mm, and revision = 17 mm) are available. The length of the stem is 5 cm (standard and standard+) and 5.68 cm in revision stems. Type and sizes of the prosthesis used in our series were chosen based on preoperative measurements.
The incision was made through the previous scar but was extended proximally or distally if necessary. The distal incision was curved radially over the ulnar head to avoid the dorsal sensory branch of the ulnar nerve. The approach was made between the fifth and sixth dorsal extensor compartments (between the extensor carpi ulnaris and the extensor digiti quinti muscles). An ulnarly based flap of deep scar tissue was fashioned and preserved to cover the implant at the end of the procedure. The distal end of the ulnar stump was opened with an awl. A partial release of the interosseous membrane was done to facilitate the dorsal displacement of the ulnar shaft. A trial stem was placed along the ulnar shaft to determine the approximate ulnar resection level. The measured resection was done with a small oscillating saw. The medullary canal was prepared thereafter with the appropriate rasps for the planned stem. All previous hardware was removed from the radioulnar fusion mass. Spherical reamers (Martin, Tuttlingen, Germany) then were used to prepare a socket in the ulnar head. Under fluoroscopic guidance the depth and coverage of the trial head were checked. Ideally, the socket should enclose ⅔ of the prosthetic head in its proximal-distal dimension. Reduction of the prosthesis was done with longitudinal traction on the hand and countertraction applied to a flexed elbow. In patients with osteopenic bone or a forearm contracture, we recommend an incomplete radial osteotomy proximal to the arthrodesis to facilitate reduction (Fig 3A). An osteotomy was done in the final three patients in our series. This prevents fracture of the ulnar head during the reduction of the prosthesis. The ulnar aspect of the distal radius was exposed just proximal to the fused ulnar head. Two Hohmann retractors were placed to protect the soft tissues during the osteotomy. The osteotomy was done with an oscillating saw in a slightly proximal to distal direction, aiming at the flare of the radial metaphysis. Care was taken not to disrupt the thin radial cortex, so that it could be used as a fulcrum to hinge open the osteotomy. The trial stem then was inserted and the osteotomy was opened with a spreader clamp, allowing seating of the trial head without damaging the thin dorsal wall of the socket (Fig 3B). The spreader clamp was released, the osteotomy was closed, and the fused ulnar head was reduced on top of the prosthetic head (Fig 3C). The stability of the prosthesis was tested in full pronation and supination. The trial components were removed using the spreader clamp to distract the fused ulnar head distally and the definitive stem and head then were inserted. Stability was rechecked and if no corrections were necessary the osteotomy was closed with an AO 2.7-mm small fragment T-plate applied to the dorsoulnar aspect of the radius. If a soft tissue flap was available, it was used to cover the neck of the prosthesis by suturing it transosseously to the volar-ulnar side of the fused ulnar head. The tendon sheath of the extensor carpi ulnaris was approximated with fine sutures to the sheath of the extensor digiti quinti, providing additional coverage of the prosthesis. The wound was closed over a suction drain that was maintained for 24 hours.
A sugar tong above-elbow splint was worn for 2 weeks postoperatively to control forearm rotation. After suture removal, patients started active forearm rotation and wrist motion but wore a removable wrist brace for protection for an additional 3 weeks. At 5 to 6 weeks, patients returned to their daily and working activities gradually. Working ability was recorded 3 months postoperatively.
Postoperatively, the distal ulna was stable in all patients and in all patients the preoperative painful clicking during pronation and supination or lifting activities had disappeared. Transverse forearm compression caused no motion of the ulna (Table 3).
Pain improved in all patients. While preoperatively seven patients had severe pain and three had moderate pain, postoperatively six patients were pain free and four had residual mild pain at the extremes of the active range of motion of the wrist and forearm.
Range of motion improved in seven patients, worsened in two, and remained the same in one. Two patients lost 10° and 15° degrees of forearm rotation, respectively. Grip strength, as a percentage of the uninjured hand, improved on average from 27% to 55% (range, 36-82%).
Nine of the 10 patients returned to their previous occupations and they had an average working capacity of approximately 30 hours per week. The only patient who did not return to his original work was a farmer who was receiving worker's compensation for his initial accident (open forearm fracture) (Table 3). Overall, insertion of the spherical prosthesis prevented radioulnar convergence, improved forearm stability, and reduced pain in all patients at late follow-up.
The prosthesis was stable radiographically in all patients. Radiographic findings at latest follow-up showed a concentric sclerosis around the prosthetic head with an average joint space (resorption between the fused head and prosthetic head) of 1.3 mm (range, 1.0-2.3 mm). This bone resorption was noted to occur in the first 6 to 8 weeks after surgery, and as soon as the sclerosis line appeared, no further increase in the width of the new joint space was observed (Fig 4). Bony resorption also was noted between the neck of the prosthesis and the distal ulna. In our series, resorption in this location averaged 2.5 mm (range, 1.0-8.0 mm) and did not progress after 6 to 8 months postoperatively. All osteotomies were healed at 8 weeks after surgery (Fig 5).
Periprosthetic calcifications were observed radiographically in four patients. Three patients were asymptomatic and did not have limitation of forearm rotation. One patient (Patient 5) had pain and limited motion and had removal of the calcifications at 6 months. The patient subsequently regained full forearm rotation. There were no infections, loosenings, or mechanical failures of the prostheses.
There were two complications that involved fractures at the previous S-K arthrodesis site. The first fracture occurred intraoperatively during reduction of the prosthesis. The ulnar head was stabilized distal to the prosthesis with two 3.5-mm lag screws. This patient lost 15° of forearm rotation at latest followup (25 months) but had no pain, full working capacity, and 36% grip strength compared with the uninjured hand. The second fracture resulted from a fall on the outstretched hand 6 weeks postoperatively. It was treated with screw fixation and a radial osteotomy to improve dorsal coverage of the prosthesis. Both fractures healed uneventfully and the hardware, which caused irritation of the extensor carpi ulnaris tendon sheath, subsequently was removed.
The overall results in this small preliminary series were considered good in six patients and fair in four. Patients with a good result were those with no ulnar convergence, no pain, and a working capacity of 80-100%. A fair result score was given to those patients in which despite having no ulnar convergence had mild residual pain (Patients 4, 7, 8, and 10 in Table 3) and a working capacity lower than 80%. All patients, when questioned, stated that they would have the procedure done again and they were satisfied with the outcome.
The S-K procedure is one surgical option for the treatment of degenerative DRUJ disease. The success of the procedure has been well documented in the literature.17,28,30,31,36,40,45 Patient satisfaction is high because DRUJ pain is relieved, grip strength increases, and forearm rotation is restored with the creation of a proximal pseudarthrosis.11,23 Despite high success rates, the development of radioulnar convergence is a challenging complication of the S-K procedure, which has been described clinically and radiographically.2,3,17,24,26,29-31,45 Although symptoms do not always correlate with radiographic radioulnar convergence26, all patients in our series had pain and clinical and radiographic signs of ulnar stump instability.
The results are encouraging, but the study is limited by the small number of patients and the relatively short-term followup. Additionally, clinical evaluation of preoperative instability is difficult because there is no validated test to rate forearm instability. A final limitation of this study is that all preoperative and postoperative clinical and radio-graphic measurements were done only by the senior author.
Historically, attempts have been made to address the instability with soft tissue reconstructions and bracing.4,5,22,29,41 Neither solution has been successful at alleviating pain and instability.4,13 Procedures such as the creation of a one-bone forearm34 and wide ulnar excision7,48 also have been described, but are considered salvage operations for failed surgery about the distal ulna.27 Alternatively, we propose the insertion of a spherical ulnar head prosthesis in patients with painful instability after a S-K procedure. In this small series of patients, placement of an ulnar head prosthesis was able to restore the ulnar column of the forearm, control radioulnar convergence, and eliminate the subjective and objective symptoms of instability. Pain also was reduced in all patients.
Swanson first introduced the concept of ulnar head replacement arthroplasty to restore DRUJ anatomy in 1966. In his study, he described silicone rubber capping of the distal ulna combined with ligament reconstruction to achieve painless stability after failed Darrach resections.44 Despite initial early success, long-term results were unfavorable, with marked silicone synovitis and implant failure.35,42
Using the same hypothesis, Herbert developed the first contemporary ulnar head prosthesis in 1995. This implant was designed to be used in patients with painful instability after partial or total excision of the ulnar head. It was designed to simulate ulnar head geometry and act as a mechanical spacer while the primary soft tissue stabilization procedure was allowed to heal. At 27-month follow-up, stability and marked symptomatic improvement was achieved in 22 of 23 patients. There were no radiographic signs of load failure or implant loosening.46 In this study, forearm stability was achieved with a combination of an ulnar head prosthesis and suitable soft tissue repair. Authors of biomechanical studies combining an ulnar head replacement with a soft tissue construction have supported these early clinical results.16,37,38
The use of an ulnar head prosthesis after a failed S-K procedure only has been reported once in the literature. In this retrospective study of three patients, the fused ulnar head was removed and a Herbert prosthesis was used. The longest follow-up was 22 months, but the early preliminary results showed clinical stability and pain relief.8
We present a new technique to solve the issue of instability after a S-K procedure. Our series is unique because the radioulnar fusion mass is maintained. Stability of the prosthesis is guaranteed by the spherical bony containment of the ulnar head in the reamed socket; therefore, additional soft tissue stabilization is not necessary. We think this is a distinct advantage because most patients have had multiple previous surgeries, and adequate soft tissue for stabilization often is lacking. There are technical challenges to maintaining the radioulnar fusion mass. The dorsal edge of the fused head can be damaged while reaming the ulnar medullary canal. Additionally, fractures can occur in the osteopenic fusion mass while repetitive trial reductions are done. After intraoperatively fracturing the radioulnar fusion mass in the sixth patient of our series, we modified the technique to include an incomplete radial osteotomy to facilitate atraumatic reduction of the prosthesis.
The success of any arthroplasty is determined by its survivorship analysis. The followup time in this study is inadequate for such an evaluation, but initial radiographic parameters did not show any signs of loosening of the prosthesis. Stress shielding, similar to what occurs to the femoral shaft in noncemented total hip arthroplasty, was noted between the neck of the prosthesis and distal ulna, but did not progress.46 A rim of concentric sclerosis developed around the ulnar head, but also was stable. Because the radius migrates proximally and distally during pronation and supination of the forearm, we postulate that this bone resorption occurs because of this physiologic telescoping or pistoning of the distal ulna.10 We believe the bony socket created in the radioulnar fusion mass remodels with time and contributes to the stability of the prosthesis.
Radioulnar convergence is a painful complication after the S-K procedure. This study presents a series of 10 patients in whom pain was decreased and ulnar stability was achieved by retaining the distal radioulnar fusion mass and seating an ulnar head prosthesis within this bone stock. Because of the small number of patients and the relatively short-term followup, only time will determine whether this surgical technique will work as a long-term solution.
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