Partial Ulnar Head Replacement Arthroplasty

by Brian Adams, M.D.

Primary Osteoarthristis with ulnar impaction syndrome

The Distal Radioulnar Joint (DRUJ) is the distal link between the radius and the ulna and a pivot for pronation and supination. Its articulation is incongruent and therefore, the soft tissues play a substantial role in guiding and restraining the joint. Not only is the DRUJ susceptible to arthritis, any injury or deformity involving the radius or ulna can alter the function of the joint. Complete implant replacement of the distal ulna has become a popular and accepted procedure to alleviate pain and restore function to the joint. However, in many cases complete replacement sacrifices normal portions of the distal ulna along with important soft tissue attachments. Consequences of resecting unaffected portions of the distal ulna include a higher risk of distal radioulnar joint instability, implant prominence, soft tissue irritation, and ulnocarpal instability. A partial ulnar head replacement was designed to minimize the resection and to optimize the functional results of implant arthroplasty for the treatment of distal radioulnar arthritis. The Ascension Partial Ulnar Head Replacement implant allows retention of the ulnar neck, ulnar styloid, extensor carpi ulnaris grove, ulnocarpal ligament attachments, extensor carpi ulnaris sheath, and the triangular fibrocartilage complex attachments to the ulnar styloid. Thus, while all articular surfaces of the ulnar head are replaced, the ligaments and other bony anatomy responsible for DRUJ stability are maintained. Because the DRUJ anatomy is preserved, the joint mechanics are not altered. Furthermore, since the procedure is performed through a minimal exposure and immediate implant fixation can be achieved, rapid rehabilitation is possible.
INDICATIONS

Primary Osteoarthritis with ulnar impaction syndrome

48-yr-old female with oligoarticular rheumatoid arthritis

IMAGES COURTESY OF PHILIPPE KOPYLOV, M.D.

54-yr-old female with osteoarthritis

The partial ulnar head replacement implant is well suited for a wide variety of patients with DRUJ arthritis, including those with relatively high activity levels. Patients with osteoarthritis and post-traumatic arthritis are particularly good candidates; however, patients with relatively quiet rheumatoid arthritis can also be considered.
Combined radiocarpal, midcarpal and DRUJ arthritis

Although there is no specific age group requirement, it is not recommended for use in skeletally immature patients. Native ulnar positive or negative variance can be either reproduced or altered toward neutral variance, as is usually recommended for ulnar positive variance to reduce the risk of ulnar impaction syndrome. In cases of modest ulnar positive variance, the tip of the ulnar styloid can also be resected to prevent stylocarpal impingement. However, excessive acquired ulnar positive variance may be a contra-indication for the partial ulnar head replacement implant; these patients are better suited for total head replacement.
CLINICAL ASSESSMENT

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To deliver the ulnar head dorsally for implant preparation, the foveal attachments of the TFCC are incised but its remaining attachments are preserved. The fovea is a depression near the base of the ulnar styloid. To best expose the ulnar head, the wrist is flexed over a large bump with the forearm fully pronated. A curved narrow retractor, such as a baby Hohman, is placed beneath the ulnar head to lift it dorsally. It is not necessary to completely deliver the ulnar head, as only a straight-line view of the fovea is needed for the preparation. If mobilization of the ulnar head is not adequate, the soft tissues attaching to the tip and dorsal aspect of the ulnar styloid are released. In cases with a very difficult ulnar exposure, the ECU sheath is also elevated from the ulna. The ulnar shaft is entered through the fovea with the awl and subsequent reamers, which allows the cutting guide and implant to be aligned with the medullary canal of the ulna. Reaming should progress until cortical contact is obtained but should not be excessive.

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A radiographic study was performed on 10 cadaveric specimens to assess the implants replication of the natural anatomy. Several radiographic parameters were compared between the natural state of the distal ulna and its state after implantation. In addition, the results of the first 10 patients treated by three surgeons were reviewed to assess its clinical efficacy. Plain radiographs demonstrated a good match (within 7%) between the size and shape of the natural ulna and after implant replacement, as well as for ulnar variance, ulnar offset, and ulnar height at the distal radioulnar joint. Distal radioulnar joint stability was maintained by subjective assessment, and there was no loss of forearm rotation. Of the 10 clinical patients, 7 were treated for osteoarthritis and 3 for posttraumatic arthritis. In a retrospective chart review at an average 6 months follow-up, there were no intraoperative or postoperative complications. Pain relief was good in all patients; however, none were completely pain free. Motion was also improved in all, with patients achieving at least 75 of pronation and 65 of supination. Wrist flexion and extension were unaffected. There were no cases of distal radioulnar joint instability. In conclusion, this preliminary report suggests that partial conservative implant replacement of the distal ulna may offer advantages over complete distal ulnar replacement in selected patients.
KEY TECHNICAL FEATURES OF MINIMAL OPERATIVE APPROACH

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10. Careful alignment of the cutting guide using the true subcutaneous border of the ulna, which is defined by the ulnar styloid and olecranon tip, is necessary for proper alignment of the cuts. 11. Radiographic assessment of ulnar variance will ensure a proper level of bony cuts and final implantation. 12. A range of sizes of the head and stem are available to optimize a match with the patients anatomy. 13. The retinaculum and dorsal capsule are closed as a single layer but should not be over-tightened. 14. A sugar tong splint with the forearm in neutral rotation is applied initially and maintained until the first postoperative visit at 10 to 14 days.
REHABILITATION

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A 5 cm dorsal incision is made over the dorsal aspect of the ulnar head and neck. The 5th extensor compartment containing the extensor digiti minimi tendon is opened over the DRUJ but its distal portion is preserved. The retinaculum does not need to be repaired at the conclusion of the procedure. An L-shaped dorsal DRUJ capsulotomy is made with care to preserve the dorsal radioulnar ligament of the TFCC and the extensor carpi ulnaris tendon sheath.

The sugar tong splint is converted to a well-molded short arm cast applied with the forearm in neutral rotation. The cast will allow a short arc of forearm rotation but it will prevent full rotation. The cast is removed at 4 weeks postoperative. A removable wrist splint is applied and used for an additional 3 to 4 weeks while motion exercises are initiated. The splint is removed for active but not passive forearm rotation and wrist motion during this time. At 6-8 weeks postoperative the patient is released from splint wear and activities are advanced gradually as tolerated. However, additional splint wear may be used for more stressful activities.
NMP-WPR-ADM-DRUJ rev 070808