Article
Combined Total Wrist Arthroplasty with Ulna Head Prosthesis in a Rheumatoid Patient with Gross Distal Radio-Ulnar Joint Instability Using Interosseous Membrane Reconstruction with Brachioradiallis Tendon Graft
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Published: | February 6, 2020 |
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Background: We report a patient with Rheumatoid Arthritis, submitted to Total Wrist Arthroplasty (TWA) and Ulna Head Prosthesis (UHP), addressing a previous gross instability of Distal Radio-ulnar Joint (DRUJ) by ligament reconstruction of the distal part of interosseous membrane using brachioradialis (BR) tendon graft. The surgical technique is described as well the follow-up after 6 years from the surgery showing a good outcome.
Potential benefit of combining TWA with UHP is a more balanced load distribution on the wrist, compared to Darrach. The technique of BR tendon reconstruction of IOM for DRUJ instability was largely used by the authors with reliable results, on post traumatic injuries.
Case Description: The patient was a 38-year-old woman presented with wrist degenerative deformity by RA in his right, dominant wrist. Wrist radiographs and CT scan demonstrates signs of advanced arthritis, affecting radio-carpal, midcarpal and DRUJ, with dorsal dislocation of the ulnar Head. The patient was directed by other hand surgeons to undergo total wrist arthrodesis associated with the Darrach procedure, an indication not accepted by her. Twenty-four months later, the patient complained of persistent wrist pain and radiographs signs worsened.
On pre operative physical examination, there was a painful limited mobility on the wrist. Wrist flexion was limited to 30°; extension was limited to 10°. Pronation was 70º and supination 45º. The patient's Disabilities of the Arm, Shoulder and Hand (DASH) score of was 54, and the visual analog scale (VAS) pain score was 7. Grip strength was 38% of that achieved by the wrist on the unaffected side.
Since the patient expectation was a functional motion on her dominant wrist, we decided for entire Wrist Replacement using a TWA technique with Radio-carpal prosthesis and ulna head replacement adressing the DRUJ instability by reconstruction of the distal part of interosseous membrane using BR tendon.
Results and Conclusions: On follow-up 6 years after surgery, the patient exhibited good wrist, forearm, and elbow range of motion, with 70° flexion, 60° extension, 20° radial deviation, 30° ulnar deviation, 85° pronation, and 90° supination. The patient had normal movement of all digits, a DASH score of 5, VAS of 0, and grip strength of 92% the unaffected wrist. Wrist radiographs shown articular congruency of DRUJ and radio carpal joint and good bone attachment to the implants.