Clinical case : Patient of 30 years, young female, with severe pain in the Druj.  

[clinical case 1 - Christophe Mathoulin - EWAS 2015]

thank you to give me your opinion, Patient of 30 years, young female, with severe pain in the Druj.
Congenital Madelung disease,
isolated osteoarthritis Druj,
almost normal  range of motion,
Decreasing of strength.

What do you think?  what proposals ? thank you

Christophe Mathoulin (France)
 

Note: ULNAR SHORTENING FOR THE TREATMENT OF EARLYPOST-TRAUMATIC OSTEOARTHRITIS AT THE DISTALRADIOULNAR JOINTL. R. SCHEKER and A. SEVERO From the Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, Kentucky, USAThis prospective study describes the outcome of ulnar shortening performed on 32 wrists with earlyosteoarthritis of the distal radiounlar joint (DRUJ) in an attempt to change the contact areabetween the ulnar head and the radial sigmoid notch. By changing the contact area, we attempted torelieve pain, while maintaining the function of the DRUJ. The mean age of the patients was 34years, and the mean follow-up was three years and two months. The wrists were graded by thepatients' self-assessment of satisfaction and by a clinical wrist rating that assessed pain, functionalstatus, range of motion, and grip strength. In terms of self-assessment, 16/32 patients were verysatisÆed, with complete pain relief. Of the 32 patients, 26 said that they would have surgery again ifcircumstances were similar. The postoperative wrist ratings were 7/32 excellent, 11/32 good, 9/32fair, 5/32 poor. The most frequent postoperative complaint was plate irritation.Journal of Hand Surgery (British and European Volume, 2001) 26B: 1: 41±44

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2015 Medical discussion:

I see an incongruent DRUJ. I would do a Sauve Kapandji procedure with proximal stump stabilization.
Dr Christian Perrotto (France)

I don’t think that it is a Madelung deformity.
I guess I would prefer Kapanji-Sauvé-procedure. It is a young patient. If I doesn’t work you still have the option of an ulnar head prosthesis.
Best regards
Dr.med. Martin Richter (Germany)

Hi Christophe
It is not a Madelung deformity but definitely a malformation of the DRUJ. I have performed ulnar shortening on a couple of these with this special configuration of the DRUJ and early OA with very good result. 2mm of shortening is enough. I think the reason for the success is the deloading of the DRUJ which in this case is a combination of ulnar minus variance and Tolat type II joint with impaction between ulnar head and proximal lip of sigmoid notch.
I will try to find pictures of my cases tomorrow. Meanwhile I have attached Scheker's paper on early OA and ulnar shortening.
Best wishes
Dr Peter Jørgsholm (Denmark)

Higher is the stump, more difficult is the stabilization so why not choose a "simple" Darrach procedure ? Dr Bernard Cadot, (France)

This is no Madelung deformity. The painful. discongruent DRU can best treated by an arthrodesis( Sauvé-Kapandji) in the end an DRU prosthesis
Dr Peter Houpt (The Netherlands)

Dear Christophe,
obvious degenerative DRUG due to malformation by severe ulna minus probably mild Madelung.
Of course Kapandji might solve the problem however with the inherent risks of this procedure, for that reason
I would prefer ulnar head prosthesis.
Alternatively a decompressive osteotomy of the radius with wedge osteotomy, decreasing radial inclination, shortening and radial shift would be an alternative.
We have treated 8 patients successful with this procedure, however without severe arthritic changes at the DRUG to improve symptoms
and to prevent arthritic changes and we could observe some remodelling of the DRUG (see attached examples).
My personal decision making: CT of DRUG severe arthritic changes ulnar head prosthesis mild arthritic changes decompressive osteotomy DRUG
Good luck Hermann
Dr Hermann Krimmer PHD (Germany)

hello
in a young patient of 30 Y old, it is very severe to do first a SK procedure
i don't think it is a madelung, maybe a CT scan will be helpfull to have a better idea of the DRUJ
what about the ECU?
i will try, and for a long time, physiotherapy, learn to use her wrist unloading this joint with a better upper limb posture etc...
Dr Erle Weltzer (France)

I agree with Hermann, Prof Diego Fernandez have wrote a paper in JHS of this dysplatic wrist! CT scan could give you additional information for final decision! Good luck!! Dr. Martin F. Caloia (Argentina)

Dear prof Cristhophe, my option to treat the advanced problem of the DRUJ is for a sauve kapandji. the best
Dr Fabio Suarez MD (Colombia)

Dear Christophe,
very intersting case, I completely agree with Hermann Krimmer, CT scan first and then decide between the osteotomy or ulnar head hemiarthroplasty
Good luck and send us the end of the story!
Dr Jane Messina (Italy)

Hi Christophe,
I would happily do a radial osteotomy if there were a significant deformity in the radius. However, this is not the case.
Strictly speaking, there is no failure of growth of the ulno-volar aspect of the radius. Consequently, I would not operate on the radius through an osteotomy.
There is degenerative change already in the DRUJ so this will always be a source of pain in a 30 y.o.
I would not do a Darrach’s in a 30 y.o.
I would consider him for S-K procedure.
Kindest regards,
Dr Dimitri Yanni (UK)