Olimpionique Athlete - DRUJ Case
Dear all,
« 54 Y old female ex-olimpionique heptathlon athlete
- severe DRUJ Pain with consecutive loss of function in every day life
- no pain radiocarpal
- Ex/Flex free, Prono-Supination ROM good, but painful
Treatment Options:
- Constrained Shaker Prosthesis
- Bowers w. Interposition (not ideal)
- Kapandji-Sauve »
JUSTIN HASENECKER
Germany
Why not a simple partial DRUJ replacement like an Eclypse (Garcia-Elias) ?
CHRISTIAN DUMONTIER (France)
Dear colleague the case is very interesting, the only data detectable at the resonance is a lytic area on the epiphysis of the ulna and therefore I would advise you to do an arthroscopy using the distal DRUJ portal under the TFCC.
Good Luck and Best Regards
PROF.FERDINANDO DA RIN DE LORENZO (Italy)
Thanks for so far! Let me add some Considerations:
- We have a severe osteoarthritic lesion in the notch as well, it is only the ulna head.
- The DRUJ joint ist stable.
- Painfull cracking DRUJ while Prono-Supination
In my opinion only ulna head prosthesis or partial prosthesis like KLS or Eclypse does not work sufficient due to the Notch Issue. A plain denervation might be of some help, but the DRUJ ist severely osteoarthritic.
Scoping might be of some help as well.
The Options available I have listed before are quite radical, I wanted to know if there is a less invasive Procedure, a simple resurfacing would be nice to have like an Individual Patient Specific Custom Made FULL DRUJ Replacement.
Maybe you hove some provoking ideas?
DR. MED. JUSTIN HASENECKER, FEBHS (Germany)
Dear friend
In this case with a stable DRUJ and (it seems) a not so bad TFCC, the best option for me is the Eclipse hemi ulnar head prosthesis (White Tornier)
Easy to place, excellent result
PROF. CHRISTOPHE MATHOULIN (France)
Dear Justin,
Thanks for the interesting case.
I would prefer sliding radial osteotomie of the radius to decompress druj as described by Hermann Krimmer.
Our personal results with this technique are good in treatment of painful impingement.
Good luck
FRAUKE DENEKEN (Germany)
Dear Justin
How can you be so sure of DRUJ arthritis?!?
The MRI shows only a signal hyper intensity at the very top of the dome of the ulnar head: the sigmoid notch is OK
still there is very little synovial fluid within the DRUJ
X-rays show no spurs
It may be simple an osteochondral bruise (bone edema) from ulno-carpal impaction
Before beheading another innocent ulna, I would have a CT scan and then make an arthroscopic assessment
Just my 2 cents
Ciao
ANDREA ATZEI (Spain)
Try it with the radial decompression osteotomy
it don t burn bridges Hermann it s described in a publication.
H KRIMMER (Germany)
Arthroscopic resection Arthroplasty has worked well for me and burns no bridges.
TYSON COBB (United States)
Thank you all for your perspectives on the case, my concern is, that due to the painful severe crepitus while prono-supinating and the affected Notch a ulna-head only procedure won’t suffice.
i think the approach of Hermann as Frauke recommended as well might be a solution, thus I find it personally quite radical.
She is a high demand lady, she won’t accept anything, but excellent range of motion and being free of pain.
I am not willing to demand more than one operative procedure. So a staged trial and error approach from less to more invasive is not an option.
Thank you so much.
Best,
DR. MED. JUSTIN HASENECKER, FEBHS (Germany)
Agree with CT
TYSON COBB (United States)
Goodnight. I suggest to perform a distal radioulnar arthroscopy and evaluating it. I suggest making microperforations in the sigmoid fossa and/or ulna head o(subcondral) and or if necessary, coating the articular surface with a chondrocytic matrix.
a big hug.
MARCIO AITA (Brazil)
Dear Justin,
I totally agree with Andrea.
I think the pain may come from dynamic ulnar impaction.
And I think ECU subluxation is another problem for this patient.
I would recommend arthroscopic evaluation for TFCC and ulnar impaction and reserve aggressive procedures for later.
Just my personal opinion.
JOO-YUP LEE, MD, PHD. (South Korea)
Hi everybody,
The first thing I would do is inject the Druj with 1 cc of lidocaine, if the pain disappears I would inject 1 cc of triamcinolone, sometimes with that it improves enough and also allows to confirm with certainty that the pain comes from that joint and not from another place.
Best regards
GABRIEL CLEMBOSKY (Argentina)
Dear Justin
All opinions are very good, I think that this pain on pronosupination is in the first part due to a phenomenon of instability in the DRUJ and in the X-ray we can see sclerosis of the triquetrum. I think it may have an instability and dynamic impactation that has injured the TFCC and also damages the midcarpal joint. Please do not forget the sensory and motor influence of the ulnar nerve, which can also cause pain in the area
Wrist arthroscopy would be my next step
and there make my decision of what to do according to everything raised
Best regards
RENE ANDRES JORQUERA AGUILERA (Chile)
Good morning,
In addition to what everybody said, could some of the pain be from the HALT? You can notice the type II lunate and already some changes on that articular surface...
I would at first considerar and arthroscopic approach and probably ressection of the distal hamate. Also evaluation of the DRUJ.
Att,
JOAO MUSSI (Brazil)
