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Abstract
The distal radioulnar joint (DRUJ) is a complex structure that enables sufficient, painless forearm rotation and provides weight-bearing capabilities of the upper extremity. Arthritis of DRUJ is multifactorial; the most common causes are trauma, congenital anomalies, as well as degenerative and inflammatory diseases. Congenital etiologies, as well as degenerative and inflammatory causes of arthritis are more common in women. Conventionally, initial management of symptomatic DRUJ arthritis is nonsurgical; surgery is generally reserved for patients with refractory pain. Moreover, advanced arthritis arising from trauma can be prevented by early interventions in the form of corrective osteotomy for malunited distal radius and distal ulna fractures, repair/reconstruction of the triangular fibrocartilage complex, and ulnar shortening osteotomy. Although the outcomes are typically positive following excision of the distal ulna in definitive arthritis, postoperative complications, such as instability and impingement of the residual distal ulna stump, can be serious. Procedures managing unstable residual ulna include soft tissue stabilization techniques and DRUJ implant arthroplasty.
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Figure 2
The interosseous membrane is composed of 5 ligaments: - Central band (key portion to be reconstructed in case of injury) - Accessory band - Distal oblique bundle - Proximal oblique cord - Dorsal oblique accessory cord. In distal area, the distal 3 ligaments (central band, accessory band, and distal oblique band) had little change in length during forearm rotation, with their ulnar attachments located almost on the axis of forearm rotation.
Figure 3
Stability of distal radioulnar joint, originated from the longitudinal resistance to ulnar shortening was significantly greater in proximal shortening.
Figure 4
(A) A 37-year-old man with history of right side radius fractures treated conservatively, suffered from intermittent ulnar-side wrist pain. Also, distal radioulnar joint (DRUJ) instability was definitive in physical examinations. (B) Lateral simple radiographs showed malunited distal radial metaphysis of dorsal tilt about 10°. (C, D) After corrective osteotomy, DRUJ instability was resolved without soft tissue procedures.
Figure 5
Initial radiologic findings of destructive lesion in rheumatoid arthritis were occasionally found in distal radioulnar joint.
Figure 6
Just ulnar shortening osteotomy without soft tissue procedure, improved the instability of distal radioulnar joint in both clinical and radiographic evaluations.
Figure 7
Measurement methods for assessing distal radial ulnar joint instability on axial computed tomography images. (A) Radioulnar lines (Mino method). (B) Congruency method. (C) Epicenter method. (D) Radioulnar ratio method. SD: standard deviation. Redrawn by Cha and Shin from each reports.
Figure 8
Hemiresection interposition arthroplasty (HIT). (A) In the modifications by Bowers, a single and wide dorsal flap of extensor retinaculum-dorsal capsule interposed after resection of the articular area of ulna. Reproduced from the article of Bowers (J Hand Surg Am. 1985;10:169-78).22) (B, C) Degenerative lesions in distal radioulnar joint were treated by HIT. (D) Matched distal ulna resection. The ulna was tapered in a smooth, curved fashion to optimize the congruency with the sigmoid notch during supination/pronation. Reproduced from the article of Watson and Gabuzda (J Hand 23)
Figure 10
Modified Sauvé-Kapandji procedure. Reproduced from the article of Fujita et al. (J Bone Joint Surg Am. 2005;87:134-9).24)
Figure 11
Tenodesis for stabilization of resected distal ulna using strips of flexor carpi ulnaris and extensor carpi ulnaris tendons as described by Breen and Jupiter. Reproduced from the article of Breen and Jupiter (J Hand Surg Am. 1989;14:612-7).31)
Figure 12
Ascension (Austin, TX, USA) partial ulnar head replacement prosthesis for resurfacing only the articular area of distal ulna (images courtesy of Ascension).
Figure 13
Eclypse (Bioprofile, Tornier, France) pryocarbon resurfacing ulnar head replacement prosthesis (images courtesy of Eclypse, cited from the article of Garcia-Elias [Tech Hand Up Extrem Surg. 2007;11:121-8]41) with original copyright holder's permission).
Figure 15
Ulnar head prosthesis composed by ceramic head/porous coated titanium stem collared and standard uHead ulnar head arthroplasty. Cited from the article of van Schoonhoven et al. (J Hand Surg Am. 2000;25:438-46)42) with original copyright holder's permission.
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