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The Outcome of Total Distal Radioulnar Joint Arthroplasty in Madelung Deformity
Roongsak Limthongthang, MD1; Ryan M. Zimmerman, MD2; Luis Scheker3; Douglas P. Hanel, MD4; Richard A. Berger, MD, PhD5; Jesse B. Jupiter, MD6
1Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; 2Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard University, Boston, MA; 3Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY; 4Hand and Wrist Services, Harborview Medical Center, University of Washington, Seattle, WA; 5Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN; 6Hand and Upper Extremity Services, Massachusetts General Hospital, Boston, MA

Introduction: Madelung deformity comprises the volar-ulnar-tilt deformity of radius, and positive ulnar variance, resulting in subsidence of the lunate in between the ulnar and radius. Patients may represent with pain, limited motion of radiocarpal joint and distal radioulnar joint (DRUJ). The treatments include corrective osteotomy, radiocarpal fusion, ligament reconstruction and resection arthroplasty of the DRUJ. However, with the young-active characteristics of these patients, many of them developed symptomatic radioulnar impingement, which often refractory to treatment. The total DRUJ replacement is increasingly used for challenging DRUJ problems. The study aims to report the outcome after prosthesis replacement in these uncommon situations.

Methods: We retrospectively reviewed all patients with the Madelung deformity who had the total DRUJ replacement between January 2005 and December 2012. A total of 8 patients underwent the procedures; 3 had bilateral replacements. Wilcoxon signed-rank tests were used to compare preoperative and postoperative visual analog pain score (VAS), range of motion, grip strength, Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH), and Patient-Rated Wrist Evaluation (PRWE).

Results: The mean age at procedure was 33 years. The mean duration after the replacement was 61 months. A total of 11 joint replacements had been done. Average VAS significantly decreased from 8.9 preoperatively to 1.3 postoperatively. Average range of motion was not significantly. Average DASH improved from 68 to 5. Average PRWE improved from 74 to 4. Average patient satisfaction scale was 8.2. Complications occurred in 4 wrists (36%): 1 case of extensor carpi ulnaris tenosynovitis, 2 of ectopic bone at the distal ulna, and 1 prosthesis-carpal impingement.

Discussion and Conclusion: The result of the total DRUJ replacement demonstrated a significant improvement in pain score. The functional scores showed improvement but the available data had not enough power. Given the young age group of the Madelung deformity patients, these mid-term results may not reassure them as a life-long procedure. However, in a salvage situation that patient has failed multiple previous DRUJ surgeries, other non-prosthesis salvage surgery, such as one-bone forearm, will result in substantial disability. The prosthesis replacement may help patients returning to their activities with the improvements in pain and functionality. The complications including extensor carpi ulnaris tenosynovitis, ectopic bone, and carpal impingement, have resolved after subsequent procedures. Until now, there's no prosthesis revision due to the component loosening however, longer follow-up is required to assess possible long-term degenerative consequences.

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