So, leading on the top of that pyramid, then, with pain and arthritis, I'd like to invite Dr. Adams to come up and talk to us about the management of DRUJ arthritis. Thank you. My task, in many ways, is easy. That's how to think about it and make the diagnosis. And then once the diagnosis is made, which I don't think a lot of times is terribly difficult with DRUJ arthritis, then it becomes a difficult, perhaps difficult, choice to make in terms of your options of care. And my task here is to present some of those options, and then, of course, you're going to have to make the decision based on your patient's needs. I'm going to assume a fairly high level of sophistication in the crowd and hit what I think are the pearls and pitfalls of the different treatment options that I think are available. And I doubt I can cover all of them, but I'll do my best to cover some of the main ones that we would all consider in this room. I do need to disclose that I am a consultant to Integra Life Sciences, and I will be presenting some cases with almond head implants. We have a lot of choices for DRUJ arthritis, and I actually think they're all viable choices. And I use all of these. Every day, I consider these in my distal radial ulnar joint arthritis patients, and I try to match what I think is the appropriate procedure to that patient. And I think it is necessary to have this entire armamentarium available to you for many reasons, whether it be because they're elderly or because of the cost that one may be over another. As we all know, implants can be expensive. And then, of course, there are physical demand requirements. Perhaps the easiest one, but not necessarily thought of by many in the audience, is a simple ulnar shortening osteotomy to realign the DRUJ. And there's been a couple centers that have shown this, and it makes good sense. We certainly do it in all kinds of other joints, particularly the knee, but also the ankle, and to some degree, the hip, where we rearrange, if you will, the loading axis of the joint. And in this case, we know there's some ulnar impaction, but there's also some degeneration of the DRUJ from being out of alignment. And simply by shortening the ulna, we relieve both problems. So consider that. Many times, you'll need an MRI scan to assess the degree of degeneration, if this is appropriate. Another one that's been talked about, which I do occasionally in the younger patient, is simply to debride the joint. We know this is relatively ineffective long-term in most joints, but in non-weight-bearing joints, it tends to be a bit more helpful, although even in the shoulder, it's been shown to not be successful long-term. But consider it in the DRUJ, especially in the post-traumatic group, where there may be some proximal osteophytes, the most common area. But also be ready to do something different, because it's not uncommon where you'll think the osteophytes are limited to one area, but you get in there, and just like this particular specimen, there's a lot more degeneration. We all know about the DERA procedure. Well, how can we make it work better? I think it's still considered an appropriate operation in the elderly and the rheumatoid patient, and perhaps it's not particularly appropriate for the more higher-demand patients. But we do need to try to stabilize it. We do need to try to also prevent radiolar impingement of the stum. And there's been lots in the last few years to try to limit those potential complications, if you will, or the drawbacks of those, and one of those is to use an allograft for interposition, which Dean Soterianos has talked a lot about, and I think we can do that. And we also have these tenodesis procedures that can help stabilize the joint. So by all means, consider that. These are two of the more common ones that are done, but there are many others, as you know, from the textbooks. I think it's rare in a non-rheumatoid that I would consider doing a DERA without doing some sort of stabilization. Remember, regrowth of the distal ulna is not a bad thing. It actually can help stabilize the DRUJ, and so don't panic if you see that. In some older studies, they said it actually is more stable. And then lastly, know what the potential complications are, especially in somebody with a high radial inclination. They can have ulnar translocation, and perhaps it may be indicated to do a radial lunate fusion, particularly in the rheumatoid patient. And then also, you do need to counsel the patient that their risk of decreased grip strength and radial ulnar impingement is fairly high. The next option we have, which has been one of my favorites over the years, goes by different names. Certainly, one of them that we all know is the HIT procedure that Bowers described, hemiresection interposition arthroplasty. It was originally said that it's best if the radial ulnar ligaments are functional. I don't think this is always necessary. I think it can be simplified. I'll show you in a minute. I do think you need to worry about ulnocarpal impingement. In other words, or particularly, stylocarpal impingement that needs to be addressed at the same time. And again, some sort of allograft interposition. So here's such a case where there's ulnar positive variants, a lot of DRUJ arthritis. So as Dr. Garcia-Lias was talking about, we need to worry about all the different things that are going on here, and also Dr. Berger. So this is one method, I think, to do that, to resect it. And again, it's important to stabilize the distal ulna as well as to provide some sort of interposition material. I prefer a dorsal capsular interposition taken with the retinaculum and turning that down over the ulna and resecting as little ulna rather than more ulna, because I think you actually maintain better space across the DRUJ and less stylocarpal impingement. And of course, shorten the ulna if you need to. So what are the pitfalls? Well, it's not usually recommended in the RA patient. I think in the younger RA patient, it is possible to consider this. In fact, it's my procedure of choice, despite what's written in the literature. Again, avoid the stylocarpal impingement. Note that it could still lead to radial ulnar impingement and stump instability. Now one of the most popular procedures worldwide is the Savi Kaponji procedure, or SK procedure. It has a wide range of patients, including RA patients. In this case, President Bob Szabo said that this is the most supported procedure of the DRUJ of any that are in the literature. So in other words, it's evidence-based. It certainly reduces the risk of ulnar translocation and improves joint loading. So it has a lot of positive benefits to it. I think there are some technical aspects to it. Make sure you resect the periosteum so you do not get regrowth across the gap. Avoid narrowing that radial ulnar distance to prevent stylocarpal impingement. And then stabilize this particular fusion that you're trying to obtain, which isn't always easy to do. I prefer two screws. I think the pitfalls are it does require a relatively good ulnar head. It can be technically challenging. I mentioned regrowth. And ulnar stump instability remains one of our biggest problems, as shown potentially in this patient. More recently, and there's many variations of this, this is by one of our Japanese colleagues showing that you can turn the ulnar head and its neck on its side and create more of a support for the carpus, particularly at those with ulnar translocation in the rheumatoid patient. And it gives you more ulnar head to work with. And it's certainly technically easier to perform, especially if you embed it in the radius. So consider that as an option. Also stabilize the stump. I prefer to use Diego, I'm sorry, Diego Fernandez's method. I think it's quite helpful and it does work. And I would encourage you to read that write-up that he has. It's been around for quite some time. Here's another method that he's used to salvage a failed SK, where he puts an implant underneath the previous fusions. It's something to think about if it didn't work for you, and he's described a variation recently on how to prevent the complications in that procedure. Another one that's commonly talked about, Dean Soterianos again has promoted this. I think there's several variations of it. And that's basically to put a large interposition of soft tissue there. He describes how to do this well. I think it's an excellent procedure. He uses allograft and it can salvage some pretty substantial problems. It does provide also some stability to the joint. Some people would consider this now a primary procedure, but it started off as a salvage. And here's such a patient that he provided to me. You can see the amount of impingement and across the radial ulnar stump, and an eight-year follow-up, again, maintaining that distance. So not the most kinematically elegant procedure, but certainly one that clinically seems to work well. And here's the follow-up of that patient. Silicon implant arthroplasty dates back to 1973. It tended to work quite well for about five years, and then they usually broke. They didn't always become painful if they did, but silicon synovitis was a bit of a problem. And then the concept went dormant for a while, but it came back, I think, pretty strongly. And as we talked about a few times in this conference before, I think there are places for DRUJ implant arthroplasty. Certainly in many laboratories across the world, the obvious in some way is proven, and that is if you take out the ulnar head, DRUJ doesn't work very well, but if you put one back in, it works pretty well. So the ulnar head is a good thing. There are multiple designs out there. I think they all offer something, and they should be thought about. I think very ahead of time, not just choose something as a reflex, as a joint, and they each have their place. I don't have time to go into all the details of each of these, but basically, there's complete ulnar head replacement, an unconstrained total joint, a constrained total joint, and a partial ulnar head. The most common indication, as far as I know, one on the orthopedic board that's accepted is to salvage a distal, or sorry, a dera resection. And the implants can come, as you all know, from a simple ulnar head or with a collar, and those people have more resection. There is a complete joint replacement that could provide better pain relief because there's not metal against bone, and perhaps improve stability of the joint. There's the constrained version, which also would obviously treat radial ulnar impingement, provide maybe better strength and relieve pain. And then the partial ulnar head, which the concept is to preserve the soft tissue stability across the joint, which we've heard a few times now how important that is for the overall function of the DREJ. So what are the indications? I think they've broadened substantially as we've all gained more information and longer follow-up with these implants. My range of use includes all of these on the slide here, from a failed resection all the way down to traumatic injuries and those where the ulnar head is not reconstructed. And I think it's becoming more common to consider as a primary treatment for osteoarthritis. Be very careful, particularly when performing a complete ulnar head replacement with a flat sigmoid notch. This could lead to substantial instability and pain in that patient, and it becomes even harder to treat. So those kind of patients are usually contraindicated for me. I think CT scan will help you. Here's a classic case where there's a nice C-shaped sigmoid notch, very arthritic. To me, this is a candidate from an anatomic point of view for a joint replacement. On the other hand, you see here an MR scan showing arthritic changes and substantial instability. So you need to be ready, as we've heard in the previous talks, for some sort of stabilization or other bony procedure. Because just putting in an implant doesn't mean it's going to go back into the notch. It may well be right where this current ulnar head is, and they might not like you even as much as they did before. So my approach to this is to try to preserve as much of the soft tissue as you can in the multiple operated. I prefer to go in from the ulnar side, because I think you can stabilize the joint better with a nice capsular closure. But in a virgin DRUJ, I think it's better to go in dorsally to preserve the ulnar carpal ligaments. You can preserve the ECU sheath even dorsally, and it allows you then, again, for a nice stable resolve. And here, simply to tell you, if you perform the procedure, you do not need a broad exposure, but it does need to be anatomically aligned with the natural anatomy. In such a case, perform for a primary DRUJ arthritis, as I showed you earlier. Again, the primary indication, probably in the United States anyway, is to salvage a DERA procedure. The results have been quite good. I don't have time to go into all of those. But you can also salvage partial resections, like in this one with a hemiresection that was now eight years, and presented with recurrent instability. A failed wafer resection, I showed this case earlier in a symposium. Again, considering it in a higher demand patient, to maintain their natural kinematics and their good strength. Occasionally, it's indicated, although in the Swedish study, that it works quite well in the rheumatoid. I tend not to use it so much in the rheumatoid. Here you see I combined it with a radial lunate fusion in order to treat all the problems that were present, as Mark mentioned earlier. There are a lot of pitfalls with DRUJ implants. Again, to highlight a few, remember, if you're doing a total overhead, you're relying on all the secondary restraints of the DRUJ, not the primary ones. So again, it's important that the joint is aligned before you get started. And here's a case where I did not find that happen. You can see the dorsal instability that became symptomatic. So I had to go back and do a reconstruction. In these two cases, showing a CAPIT ulna syndrome and active synovitis, contraindications in my opinion, but others would try to tackle these and say that it's still a valid option. But I would say be careful with this group because the risks are much higher. In my personal series to close up with, the things that I found were both good and bad about ulnar head implants. In this group that we had, and you can see the range of follow-ups of 10 years, we used various different implants. Most of them had previous surgeries, which is not uncommon with most of the series using ulnar head implants. But most of these were either primary arthritis, osteoarthritis, or post-traumatic, and very few rheumatoids. Here's an important slide. I think that when I follow up these patients, it's important. I think Dr. Berger found the same thing in his series, is a lot of these patients have residual pain, and you need to counsel them before you get started. It's not a complete pain-relieving operation, it's a pain-improvement operation in maintaining their function. But with respect to the function, in most cases, they were restored to good motion in their DRUJ, in other words, form rotation, and maintain their wrist flexion extension. We're certainly worried about the resorption that can occur around the ulnar neck. I think it's because we do detach a lot of the soft tissues, and the less we can do, probably the better they do, so partial ulnar head replacement may be somewhat advantageous. And then, of course, we're all worried about the sigmoid notch erosion that can occur, metal on bone, perhaps better with pyrocarbon. I would think it would be. Not available yet in the United States. But in most series, the erosion stabilizes by two years, again, as we talked about earlier in the main session. So, I think the complications are low, as in my series, one revised for instability, one removed for pain and instability, fortunately no infections, but again, not a complete pain-relieving operation. So, in conclusion, I think you need to consider all of these operations in your patients, and then match them to the right patient in terms of demand, age, perhaps finances, quickness of rehabilitation, talk to them about what the expectations are in detail. But I think, overall, we have a very low revision rate if we follow certain algorithms, as we heard today. Thank you.

DRUJ arthritis

management options

ulnar shortening osteotomy

DERA procedure

Hit procedure