The distal radioulnar joint in rheumatoid arthritis

Rheumatoid arthritis commonly affects the distal radioulnar joint (DRUJ). This can result in pain, instability, or tendon rupture. The goals of surgical reconstruction of the DRUJ are to relieve pain, stabilize the joint, and prevent tendon rupture. We review many of the previously described procedures and report our experience with distal ulna excision and soft tissue reconstruction with a distally based slip of extensor carpi ulnaris tendon.     

The distal radioulnar joint in rheumatoid arthritis

Rheumatoid arthritis (RA) involves the wrist in up to 80% of cases; up to 95% of patients have signs of wrist arthritis after 12 years of disease. The distal radioulnar joint (DRUJ) is involved in 31% to 75% of these patients and is often the first compartment of the wrist involved. The inflammatory sequence of events leads to the "caput ulnae syndrome" described by Backdahl in 1963. Extensor tendon ruptures are frequently associated. The presence of the "scallop" sign on radiographs is an alerting sign for tendon attrition. The gold standard in treatment remains resection of the distal ulnar head, known as Darrach's procedure. The most frequent complication is instability of the proximal ulnar stump. In order to restore stability or to prevent instability, several stabilisation techniques have been reported with free tendon grafts, the extensor carpi ulnaris, the flexor carpi ulnaris, the joint capsule and the pronator quadratus muscle. There is no evidence that stabilisation of the proximal ulnar stump during the initial operation gives better results. Another drawback of ulnar head resection is the progression of ulnar translation of the carpus. There are however several surveys showing that this ulnar translocation is the consequence of the disease rather than the result of the Darrach procedure. Several features such as an increased radial slope (> 23 degrees) and/or destruction of the ulnar corner of the distal radial epiphysis have been mentioned as predictive elements for further ulnar slide of the carpus. The Sauvé Kapandji procedure is in these cases a useful alternative choice. Another advantage of this technique is that it provides a larger surface so that other (radial) procedures can be more easily combined (Chamay partial radiocarpal fusion, wrist prosthesis).     

Reossification and fusion across the acromioclavicular joint after arthroscopic acromioplasty and distal clavicle resection

Arthroscopic acromioplasty and distal clavicle resection has now become an accepted method of treatment for acromioclavicular (AC) joint arthritis. Complications following arthroscopic acromioplasty are relatively uncommon and include instrument breakage, hematoma, traction neuropathy, infection, acromial fracture, reflex sympathetic dystrophy, and recurrence of symptoms. Although heterotopic ossification within the soft tissues has also been reported, complete reossification of the resected clavicle has not. We report a case of reossification of the clavicle and fusion across the AC joint following arthroscopic acromioplasty and distal clavicle resection.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 9 (November-December), 2001: E36     

The distal radioulnar joint complex in rheumatoid arthritis: an overview

Rheumatoid arthritis frequently involves the distal radioulnar joint region and is progressive. Early recognition of involvement is paramount to offering patients appropriate and timely treatment. Early operative intervention should be considered preventative. Synovectomy, hemiresection interposition technique, matched distal ulna resection and distal radioulnar fusion with creation of a pseudarthrosis through the distal ulnar shaft have been advocated for patients with early involvement. Distal ulnar resection remains the most commonly used procedure for advanced disease. No soft tissue reconstructive procedure to stabilize the ulnar stump offers distinct advantages. They should be considered modifiers and augmentations to distal ulna resection. Judicious resection of the ulnar head minimizes instability of the ulnar stump. The use of an ulnar cap is not recommended for routine use.     

Acromioclavicular stability: a biomechanical comparison of acromioplasty to acromioplasty with coplaning of the distal clavicle

Purpose: The purpose of the study was to compare the laxity of the acromioclavicular (AC) joint in the superior, posterior, and anterior planes after isolated acromioplasty and after acromioplasty with inferior clavicular coplaning. Type of Study: In vitro (cadaveric) analysis. Methods: Eight fresh-frozen cadaveric shoulders were evaluated using a hydraulic actuator. While the scapula was stabilized, a 30-N force was applied to the distal clavicle perpendicular to the AC joint in the superoinferior plane and parallel to the joint in the anteroposterior plane. Laxity of the AC joint in the superior, anterior, and posterior directions was evaluated via load-displacement analysis after acromioplasty and after acromioplasty with coplaning. Results: Coplaning the distal clavicle increased superior AC laxity by 53% compared with acromioplasty alone (P = .012). With regard to anteroposterior laxity, coplaning increased anterior translation by 19% (P = .047) and increased posterior translation by 16% (P = .237). Bony impingement was seen to limit posterior translation in 3 specimens. Conclusions: Acromioplasty with coplaning increases AC laxity significantly in the superior and anterior directions as compared with acromioplasty alone. A trend toward increased posterior translation was found; posterior bony impingement may limit posterior laxity.     

Management of the distal radioulnar joint in rheumatoid arthritis

The DRUJ frequently is involved in RA and can be a source of major disability. Nonoperative treatment consists of adequate hand/occupational therapy, judicious splinting, and pharmacologic management. If unacceptable pain and dysfunction persists or if there is tendon rupture, surgery is indicated. Surgical treatment ranges from debridement and soft tissue balancing if the joint is preserved to osseous procedures ranging from Darrach resection, Sauve-Kapandji procedure, hemiresection, to distal ulna replacement. Tendon ruptures usually require tendon transfers.If an osseous procedure is required, the authors prefer the Sauve-Kapandji procedure in the younger, active adult. Darrach distal ulna resection is recommended for the older, sedentary patient. For either procedure, if there is evidence of pre-existing radiocarpal instability, partial or total wrist arthrodesis or arthroplasty should bea concomitant procedure.     

类风湿性关节性患者肩关节病变的相关危险因素探讨

目的探讨类风湿性关节炎(rheumatoid athritis,RA)患者肩关节病变的发生情况与相关危险因素。方法选择2016年6月至2017年5月收治的38例RA患者合并肩关节病变的临床资料作为试验组,同期收治38例无肩关节病变的RA患者资料作为对照组,对两组常规调查资料、B超检查结果与实验室检测指标进行比较。结果试验组经超声检查显示51侧肩关节发生病变,包括骨质侵蚀10侧、肌腱炎7侧、关节积液11侧、滑膜增生13侧、肩袖病变10侧。与对照组相比,试验组的抗环瓜氨酸肽抗体(anti cyclic citrullinated peptide,ACCP)、C-反应蛋白(C-reactive protein,CRP)、红细胞沉降率(erythrocyte sedimentation rate,ESR)水平均显著提高(P0.05)。单因素条件Logistic回归分析,RA患者肩关节病变的发生与中重度体力劳动、肩部过度运动、炎症、外伤史、类风湿因子、ACCP、CRP、ESR等因素相关。进一步多因素分析显示,RA患者肩关节病变的相关危险因素包括中重度体力劳动、肩部过度运动、炎症、外伤史以及RF-Ig A、RF-Ig M、ACCP、CRP、ESR水平升高等。结论了解RA患者肩关节病变的相关危险因素,对早期防治肩关节病变,避免病变加重具有重要意义。     

The influence of distal clavicle resection and rotator cuff repair on the effectiveness of anterior acromioplasty

Anterior acromioplasty, described by Neer in 1972, is generally accepted as the procedure of choice for symptomatic subacromial impingement. Subsequent authors have written little about the prolonged length of postoperative rehabilitation, residual strength deficits, and the effect of the addition of a distal clavicle resection and/or rotator cuff repair. The authors reviewed 50 patients with late Neer Stage II and Stage III impingement lesions who were treated with anterior acromioplasty. In addition to the acromioplasty, 13 shoulders had a distal clavicle resection, nine had a rotator cuff repair, and ten had a distal clavicle resection and rotator cuff repair. The average patient age was 53 years (range, 36-70 years), and the average duration of symptoms was 43 months. Overall, 92% of the patients were graded as good or excellent on the basis of pain relief, strength, range of motion, and ability to resume full activity. Prolonged rehabilitation was noted in all groups, averaging 8.5 months; however, patients with a distal clavicle resection and rotator cuff repair required a 25% longer rehabilitation before full activity was obtained. A residual strength deficit was also noted in 70% of the patients requiring cuff repairs versus 50% in the patients with intact cuffs. Pain relief was equally obtained in all groups.     

The acromioclavicular joint in rheumatoid arthritis

The acromioclavicular (AC) joint was clinically and roentgenographically examined in 49 rheumatic patients with painful shoulders. Clinically, the AC joint was tender and painful in about one-third of the shoulders. Roentgenographically, AC changes were encountered in 85% of the shoulders. The AC joint destruction was frequently associated with the glenohumeral joint disease. There was a time-dependent progression of subchondral bone erosion, tapering, and osteolysis of the acromial end of the clavicle corresponding to the duration and/or severity of the rheumatoid disease.     

Current concepts in the treatment of rheumatoid arthritis of the distal radioulnar joint

Rheumatoid arthritis (RA) may progressively affect all articulations of the wrist. Involvement of the distal radioulnar joint (DRUJ) is common and may be the first clinical signs of symptoms of RA. When the DRUJ is affected by RA, upper extremity function can be affected. Effective surgical management includes the Darrach procedure, the Suave-Kapandji procedure, the hemiresection interposition arthroplasty procedure and extensor tenosynovectomy. The long-term effectiveness of DRUJ arthroplasty is currently unknown.     

The unstable radiocarpal joint in rheumatoid arthritis

The inflammation of the wrist occurs very early in Rheumatoid arthritis. In cases of wrist deviation the biomechanics of the hole hand are affected. Carpal collapse will severely influence the range of motion (ROM) of the fingers. Operative techniques of how to maintain hand function are discussed. There are different procedures available - partial arthrodesis, arthrodesis and arthroplasty.     

Osteolysis of the distal clavicle: an important consideration in chronic shoulder pain

Post-traumatic osteolysis of the distal clavicle must be considered as a differential diagnosis in all cases of progressive shoulder pain with insidious onset. While its mechanisms is still not fully understood, its incidence of recognition is rapidly increasing in clinical practice. Two case reports with substantially different etiology are documented. Osteolysis is a largely self-limiting disease that responds very well to chiropractic care.     

Functional outcome following extensor synovectomy and excision of the distal ulna in patients with rheumatoid arthritis

We prospectively measured hand and wrist function in rheumatoid patients undergoing excision of the distal ulna. Range of motion, visual analogue pain scores and grip strength were measured in 22 wrists, and the Jebsen hand function test was administered to seven patients, preoperatively and at 3 and 12 months. At 1 year there were improvements in forearm pronation (P=0.04), supination (P=0.03) and wrist extension (P=0.02), but a reduction in flexion (P=0.009). Active radial deviation was reduced and ulnar deviation increased. There was a significant improvement in grip strength (P=0.05) and reduction in wrist pain (P=<0.0001). At 1 year the Jebsen hand function test showed improvements in simulated feeding, stacking checkers, and lifting large empty cans. Excision of the distal ulna in rheumatoid patients results in an improvement in some aspects of hand function.     

The role of the distal radioulnar ligaments, interosseous membrane, and joint capsule in distal radioulnar joint stability

The individual contribution of the distal radioulnar ligaments to dorsal and palmar translational stability during forearm rotation remains controversial. Furthermore, the role of the distal radioulnar joint capsule as a restraint and contributor to stability has not been investigated. A biomechanical study was performed in 11 fresh cadaver specimens to simultaneously measure dorsal and palmar radioulnar ligament tension. Joint rotation and radial translation were measured after sequential excision of the disk, interosseous membrane, joint capsule, and radioulnar ligaments. Results confirmed that the dorsal ligament tightens during pronation while the palmar ligament becomes progressively lax; the converse occurred during supination. Translational stability remained intact at all positions throughout the sectioning sequence until one of the radioulnar ligaments was sectioned. The most significant increases in translation occurred after sectioning the dorsal radioulnar ligament in pronation and after sectioning the palmar radioulnar ligament in supination. Forearm rotation increased significantly after excising either hemicapsule.     

The results of shoulder arthroplasty in patients with rheumatoid arthritis

We have performed a clinical and radiological analysis of 105 shoulder arthroplasties in patients with rheumatoid arthritis. The clinical results showed improvements in the Constant-Murley and Association of Shoulder and Elbow Surgeons score of 21 and 35, respectively. Both were statistically significant (p < 0.001). This improvement was maintained over a period of 8.8 years. There was no statistically significant difference in the scores after hemiarthroplasty and those after total arthroplasty. The presence of an intact rotator cuff was associated with improved function in both groups. In spite of the use of an uncemented humeral stem, no implant was radiologically loose or at risk. There was lucency in a single zone in 14 implants. One glenoid component was at risk and 16 had lucency in a single zone. There was, however, a significant difference in the amount of lucency which was associated with pegged and keeled glenoid components (p = 0.005). In the group with hemiarthroplasty, two or more years after surgery there was superior migration of the humeral component by more than 5 mm in 18 shoulders (28%) and medial migration by more than 2 mm in eight (16%). Both superior and medial migration had an effect on the outcome. Revision was undertaken in four patients for persistent pain relating to medial migration. With revision taken as the endpoint for survival after eight years, 92% were found to be still in situ.     

Modified matched ulnar resection for arthrosis of distal radioulnar joint in rheumatoid arthritis.

The pain of distal radioulnar arthrosis in rheumatoid patients is often due to disease largely confined to the radioulnar rather than the ulnocarpal articulation. This is a retrospective study of 14 patients (14 wrists) who underwent selective shaving of the radial articulation of the ulnar head leaving the ulnocarpal articulation intact. The ulnar head is reduced to the circumference of its shaft and a dorsal retinacular flap is interposed between it and the distal radius. Average age of the patients and follow-up were 63.5 years and 31 months, respectively. All patients had rheumatoid arthritis. Pain improved in 14 out of 15 wrists. Overall results were 67% good to excellent and 33% fair based on the modified Mayo's wrist score. This novel procedure for DRUJ arthrosis produces predictable pain relief in low demand rheumatoid patient.