Currently there are a number of different implants in use. The Herbert distal ulna replacement has been available for a number of years and is involves the replacement of the distal ulna. A newer and more versatile implant is the Ascension® First Choice® DRUJ System. This is either a partial or modular distal ulna.
The principle indications for replacement are:
Joint incongruity post distal radius fracture
OA
Painful instability following previous surgery eg. Darrach’s, Bower’s and Sauve-Kapandji procedures
Post op regime:
Sugar tong POP in theatre with DRUJ at 20 degrees supination
One post op dose of antibiotics
Operative details will dictate the exact nature of post-operative management, but implant stability, extent of soft tissue reconstruction, intra-operative complications, pre-operative range of movement and individual patient characteristics dictate the length of the initial period of immobilisation in a Sugar Tong Splint / above elbow POP to control forearm rotation.
Post-operative Management Guidelines
Where stiffness is likely:
Sugar Tong POP is applied in theatre and converted to a sugar tong splint as comfort and oedema dictate
Mobilisation of the DRUJ commences at 2 weeks.
Active and passive exercises
Support the joint in a splint, for comfort, between exercises and to protect against forced rotation.
Where instability is likely:
A Sugar Tong POP to control forearm rotation is applied in theatre and converted to a Sugar Tong splint as comfort and oedema dictate.
A clinical and radiological assessment is carried out at 5-6- weeks.
If x-ray satisfactory and implant stable rotation block splinting can be discarded and unrestricted mobilisation commenced. If necessary, for comfort, or concerns related to heavy activity, a removable below elbow splint should be provided.
If instability is still likely to occur controlled mobilisation, within the limits of stability, is commenced and a sugar tong (or substantial below elbow splint) retained for between exercise and at night. This is discarded when stability is achieved.
When movement potential has been maximised strengthening exercises are encouraged.
Return to work at 12 weeks.
Heavy manual occupations and stucatto movements should be discouraged to protect the implant from loosening and/or dislocation
Links:
Evidence:
Herbert,T.J., Herbert Ulnar Head Prosthesis, Martin Manufacturers Literature
Herbert,T.J., Van Schoonhoven,J., Ulnar Head Prosthesis: a new solution for the problems at the distal radioulnar joint. In: Hand Arthroplasties. Eds.,Simmen, Allieu, Ll uch, Stanley. Pub.Martin Dunitz. 2000
De Smet,L., Peeters,T. Salvage of Failed Sauve-Kapandji Procedure With an Ulnar Head Prosthesis: Report of Three Cases. Journal of Hand Surgery, British and European Volume 28B. p271-272
Stanley, J.K., Causes of stiffness of the distal radioulnar joint. In: Joint Stiffness of the Upper Limb, Eds.Copeland,Gschwend,Landi,Saffar. Pub.Martin Dunitz.1997.
Saffar,P., Treatment of stiffness of the distal radioulnar joint. In: Joint Stiffness of the Upper Limb, Eds.Copeland,Gschwend,Landi,Saffar. Pub.Martin Dunitz.1997.
Gwilliam,L., Rehabilitation of the distal radioulnar joint. In: Joint Stiffness of the Upper Limb, Eds.Copeland,Gschwend,Landi,Saffar. Pub.Martin Dunitz.1997.