Constrained Implant Arthroplasty for Distal Radioulnar

From the *Department of Orthopedic Surgery, Mayo Clinic, Rocheste

Received for publication October 24, 2017; accepted in revised form

No benefits in any form have been received or will be received relatto the subject of this article.

Presented at the 72nd Annual Meeting of the American Society foSeptember, 2017, San Francisco, CA.

614.e1 r � 2019 ASSH r Published by Elsevier, I

SCIENTIFIC ARTICLE

Constrained Implant Arthroplasty for Distal

Radioulnar Joint Arthrosis: Evaluation and

Management of Soft Tissue Complications
Brent R. DeGeorge, Jr, MD, PhD,* Richard A. Berger, MD,* Alexander Y. Shin, MD*
Purpose Distal radioulnar joint (DRUJ) prostheses designed as semiconstrained devices aimingto replace the function of the ulnar head, sigmoid notch of the radius, and triangularfibrocartilagecomplex have demonstrated the capacity to restore the functional status of the DRUJ. However,soft tissue complications including tendons, nerves, and wounds, although documented, havenot been the primary focus of prior reports. This study investigated short- to medium-term softtissue complications after DRUJ semiconstrained implant arthroplasty.

Methods We performed a retrospective review of patients undergoing semiconstrained DRUJimplant arthroplasty with clinical and radiological follow-up greater than 1 year. Data werereviewed with a focus on soft tissue complications after arthroplasty.

Results Fifty DRUJ implant arthroplasties were performed over 10 years in 49 patients. Patients’average age was 47.8 years. Average duration of follow-up was 35.8� 3.7 months. A total of 46patients underwent multiple operations before DRUJ arthroplasty. Postoperative pronosupinationrange of motion, grip strength, and visual analog scale pain scores were significantly improvedafter DRUJ arthroplasty. Wound-healing problems occurred in 11 arthroplasties; however, allwounds subsequently healed without operative intervention. Wound-related complications weresignificantly increased in patients with a history of rheumatoid arthritis or immunosuppression.Eighteen operations were required to address complications in 8 patients. Extensor tendinopathywas themost common indication for reoperation; 5 tenosynovectomy procedures were required in4 wrists. A prominent screw requiring removal was identified in 3 cases of tenosynovitis. Peri-prosthetic fractures were identified in 3 wrists; 2 of these required reoperation for open treatment.Removal of hardwarewas required in 2 patients; these patients required 9 subsequent reoperations.

Conclusions Distal radioulnar joint arthrosis is a major problem and patients commonlyundergo multiple reconstructive surgeries before DRUJ implant arthroplasty. No instances ofwound-related complications or tendinopathy occurred in patients without previous surgeries,and wound-related complications occurred at a higher frequency with a history of rheumatoidarthritis or immunosuppression. (J Hand Surg Am. 2019;44(7):614.e1-e9. Copyright � 2019by the American Society for Surgery of the Hand. All rights reserved.)

Type of study/level of evidence Prognostic IV.Key words Aptis, arthroplasty, distal radioulnar joint.

r, MN.

September 4, 2018.

ed directly or indirectly

r Surgery of the Hand,

Corresponding author: Alexander Y. Shin, MD, Department of Orthopedic Surgery, MayoClinic, 200 First Street Southwest, Rochester, MN 55905; e-mail: [email protected].

0363-5023/19/4407-0016$36.00/0https://doi.org/10.1016/j.jhsa.2018.09.003

nc. All rights reserved.

mailto:[email protected]

https://doi.org/10.1016/j.jhsa.2018.09.003

FT TISSUE COMPLICATIONS 614.e2

T HE DISTAL RADIOULNAR JOINT (DRUJ) consists ofthe articulation between the ulnar head andthe sigmoid notch of the distal radius and

represents the distal half of the bicondylar forearmjoint.1 Pronosupination of the forearm at the DRUJconfers the ability to position the hand in spacewithout detriment to prehensile function and has animportant role in weight bearing.2 Normal DRUJanatomical relationships are required to maintainstrength, stability, and full motion of the forearm.Procedures to address pain, instability, and arthrosisresulting from degenerative, inflammatory, orposttraumatic arthritis of the DRUJ have beentraditionally managed with resection of the ulnarhead, which alters normal biomechanics of theDRUJ and may result in instability of the proximalulnar stump with pain, radioulnar convergence, andloss of forearm rotation.3 To address these issues,many ulnar head implants have been designed tostabilize the distal ulna mechanically; however,these hemiarthroplasty-based approaches requireintact ligamentous stability of the DRUJ.4 TheAptis DRUJ prosthesis (Aptis Medical, Glenview,KY), a bipolar, semiconstrained, modular implant,was designed to replace the functions of the ulnarhead and sigmoid notch of the distal radius as wellas the ligamentous support of the triangular fibro-cartilage complex (Fig. 1).5,6

Functional outcomes of total DRUJ reconstruc-tion with a DRUJ semiconstrained endoprosthesishave been well-described with improvement ofpronosupination range of motion (ROM), gripstrength, and pain.5e10 Although reports by Schekerand others demonstrated that total semiconstrainedDRUJ arthroplasty is a successful reconstructiveoption, case reports were described of multiplechallenging postoperative complications, includingwound-healing problems, tendinitis and tendinop-athy, periprosthetic bone resorption and fracture,and implant-related complications.11 Few if any re-ports focused on describing the incidence andmanagement of these complications.12 To this end,we undertook a retrospective review of a singleinstitutional experience with DRUJ arthroplasty us-ing a semiconstrained DRUJ endoprosthesis toevaluate the incidence of complications of DRUJarthroplasty. In particular, we sought to characterizethe types of complications that occur and the sub-sequent unplanned or revision operations that wererequired, and to evaluate differences in complicationand revision incidences based on specific patientdemographic factors, surgical history, and intra-operative factors.

DRUJ ARTHROPLASTY SO

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MATERIALS AND METHODSAfter we obtained approval from the institutionalreview board, we performed a retrospective review ofpatients who underwent DRUJ semiconstrainedimplant arthroplasty (Aptis Medical) between 2005and 2015 at a single institution. All operative pro-cedures were performed by 1 of the 2 senior authors(R.A.B. or A.Y.S.). The inclusion criteria was ahistory of DRUJ arthrosis requiring DRUJ semicon-strained implant arthroplasty with more than 1 year ofclinical and radiographic follow-up. Patient de-mographic data were collected, including age, sex,handedness, affected laterality, body mass index,smoking status, and the presence of comorbidities,including diabetes, rheumatoid arthritis, history ofactive immunosuppressive medication use,EhlerseDanlos syndrome, previous distal radiusfracture, and history of tobacco abuse. Disease-specific history was collected, including duration ofsymptoms, number and type of operations, indicationfor operations, and the presence of wrist incisions orscars. Functional assessment was recorded, includingwrist flexion, extension, radial deviation, ulnar devia-tion, pronation, and supination, grip strength, andvisual analog scale pain scores. Operative details werereviewed, including anesthesia type, tourniquet time,total operative time, and concomitant procedures.Complications were recorded following the indexDRUJ arthroplasty procedure and classified as wound-related complications (wound separation, necrosis,dehiscence, hematoma, or seroma), infection-relatedcomplications (superficial surgical site infection,deep surgical site infection, or the need for oral orintravenous antibiotics), soft tissue and nervecomplications (paresthesias, tendinopathy, or chronicpain), implant-related complications (hardwaremalposition or periprosthetic fracture), and majorcomplications (defined as any complication requiringsubsequent operation or hardware removal). Time tocomplication was recorded for implant removal, peri-prosthetic fracture, or tendinopathy.

Operative technique

Preoperative antibiotic prophylaxis using a first-generation cephalosporin (cefazolin), or vancomycinin allergic patients, was administered to all patientswithin 1 hour before the surgical incision. Implanta-tion of the endoprosthesis was performed as previ-ously described.5 For primary implant arthroplasty,the operative approach was performed through adorsal incision centered on the DRUJ and angleddistally toward the third metacarpal. For patients with

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FIGURE 1: Representative radiographs of the Aptis DRUJ semiconstrained endoprosthesis. A, B, Posteroanterior and lateral wristradiographs before DRUJ arthroplasty. C, D Posteroanterior and lateral wrist radiographs after removal of previous hardware, excision ofulnar head, and DRUJ semiconstrained arthroplasty.

614.e3 DRUJ ARTHROPLASTY SOFT TISSUE COMPLICATIONS

J Hand Surg Am. r Vol. 44, July 2019

TABLE 1. Patient and Operative Characteristics

Variables Outcomes

Demographics

Patients, n 49

Wrists, n 50

Age (mean years � SEM) 47.8 � 1.9

Male (%) 34.0

Hand dominance (% right) 92.0

Laterality (% right) 52.0

Duration of symptoms (mean y � SEM) 7.1 � 1.1

Comorbidities

Diabetes (%) 2.0

Rheumatoid arthritis (%) 14.0

Immunosuppression (%) 18.0

Smoking (%) 16.0

Body mass index (mean � SEM) 30.7 � 0.9

Body mass index >30 (%) 46.0

Previous surgery (%) 92.0

Previous surgeries, n (mean � SEM) 2.8 � 0.3

SEM, standard error of the mean.Continuous variables are presented as means � SEM; categorical

variables are presented as incidence (%).

DRUJ ARTHROPLASTY SOFT TISSUE COMPLICATIONS 614.e4

previous dorsal wrist incisions, those incisions wereextended proximally and distally to allow for previ-ous hardware removal and endoprosthesis placement;if sufficient time had passed (more than 2 years), aseparate incision was used instead. All procedureswere performed under regional anesthesia with tour-niquet control. After the operative procedure, patientswere placed in a well-padded sugar tong orthosis for10 to 14 days. Surgical sites were evaluated forwound-related issues at 2 weeks for suture removal.The patients were placed in a Muenster cast for 4weeks followed by supervised occupational therapyfor progressive ROM and strengthening. The authorsadhere to the manufacturer’s recommendationsregarding a 20-lb maximum weight restriction for theoperative extremity.

Descriptive statistics were used to summarize data,including percentages and counts for categorical andordinal data and means and standard error forcontinuous data. Differences between preoperativeand postoperative groups were compared with thechi-square test (or Fisher exact test) for categoricalvariables and Student t test for continuous variables.Because of the limited number of wound-relatedcomplications in the series, our ability to performmultiple regression analysis was restricted. Toascertain the relative effect of comorbidities onwound-related complications, each comorbidity,disease-specific factor, and intraoperative factor wasassessed in a separate mode for univariate analysiswith wound-related complications as the dependentvariable. P < .05 was considered statisticallysignificant.

RESULTSFifty DRUJ implant arthroplasties were performed in49 patients. Four patients were excluded owing toinadequate duration of clinical follow-up. Averagepatient age was 47.8 years (Table 1). Average dura-tion of symptoms was 7.1 � 1.1 years. Forty-sixwrists had a history of multiple operations beforeDRUJ implant arthroplasty, including ulnar headresection (52.0%), triangular fibrocartilage complexrepair (34.0%), prosthetic ulnar head replacement(28.0%), wrist arthrodesis (18%), wrist arthroscopy(18.4%), and other procedures (54.0%) includingdistal ulnar tenodesis, proximal row carpectomy,DRUJ release, anteroposterior interosseous neu-rectomy, and revision procedures for hardwaremalposition. Arthroplasties were performed forchronic pain and instability, posttraumatic arthrosis,and DRUJ deformity in 38, 28, and 10 wrists,

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respectively. No patient had a prior infection in thewrist or active infection elsewhere. Average tourni-quet time was 94.6 � 2.4 minutes and concomitantprocedures were performed in 38.0% of arthro-plasties, most commonly to remove previous hard-ware. Average duration of follow-up was 35.8 � 3.7months (Table 1).

Postoperative pronosupination ROM (P < .05),grip strength (P < .05), and visual analog scale painscores (P < .05) were significantly improvedcompared with preoperative values after DRUJarthroplasty (Table 2). The overall complication ratewas 44.0% with complications noted in 22 of 50arthroplasties. Major complications were identified in8 of 50 wrists (16.0%) and minor ones in 20 of 50wrists (40.0%). Eighteen operations were required toaddress complications in 8 patients (Table 3).

Soft tissue and nerve-related complications weremost common. Paresthesias were noted after 9arthroplasties, with dorsal ulnar sensory branchneuritis most reported. All nerve-related symptomsresolved within 3 months without operative inter-vention. Extensor tendinopathy was reported in 5arthroplasties; there were 2 cases of first dorsalcompartment tenosynovitis and the remainder ofwrists experienced second, fourth, or sixth dorsal

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TABLE 3. Postoperative complications

Variables Outcomes

Wound-healing complications

Any wound-related complication 11 (22.0%)

Peri-incisional necrosis 9 (18.0%)

Wound separation 2 (4.0%)

Abscess 1 (2.0%)

Hematoma 0

Seroma 0

Soft tissue complications

Paresthesias 9 (18.0%)

Tendinopathy 5 (10.0%)

Symptomatic scar 1 (2.0%)

Hardware complications

Symptomatic hardware 5 (10.0%)

Periprosthetic fracture 3 (6.0%)

Hardware removal 2 (4.0%)

Reoperations

Patients 8

Number of reoperations 18

Tenosynovectomy 2

Tenosynovectomy and soft tissueinterposition

3

Fat grafting 1

Open treatment of periprosthetic fracture 2

Removal of device 2

Removal of prominent screw 3

Other 5

Continuous variables are presented as means � SEM; categoricalvariables are presented as incidence (%).

TABLE 2. Functional Assessment of DRUJArthroplasty

Variables Outcomes

Preoperative function

Flexion 45.2 � 3.6

Extension 47.8 � 3.5

Pronation 57.2 � 3.9

Supination 64.9 � 3.6

Grip, kg 14.5 � 1.4

Visual analog scale pain score 7.1 � 0.4

Postoperative function

Flexion 49.9 � 3.2

Extension 51.6 � 3.3

Pronation 73.4 � 2.4*

Supination 69.0 � 2.7*

Grip, kg 18.3 � 2.5*

Visual analog scale pain score 1.5 � 0.4*

Continuous variables are presented as means � SEM; categoricalvariables are presented as incidence (%).*P < .05 versus preoperative function.


compartment symptoms. Extensor tendinopathy wasattributed to a prominent screw after 3 arthroplasties;these prominent screws were removed and replaced.Five tenosynovectomy procedures were performed in4 patients with a mean time of 368 � 61 days toreturn to the operating room for an extensor tendin-opathy. Tenosynovectomy was performed with softtissue interposition in 3 cases using a tensor fascialata allograft; no soft tissue interposition was per-formed in the remaining 2 cases (Fig. 2). No tendonruptures were noted during the study period.

Wound-healing problems occurred after 10arthroplasty procedures ranging from peri-incisionalnecrosis to wound separation (Fig. 3). All woundssubsequently healed within 6 weeks without requiringoperative debridement or soft tissue coverage pro-cedures. Subgroup analysis demonstrated that wound-related complications were significantly increased inpatients with a history of rheumatoid arthritis orimmunosuppression (P< .05). No other demographicfactors, comorbidities, disease-specific factors, orintraoperative factors were associated with a change inthe relative risk of wound-healing complications.

Periprosthetic fracture was noted in 3 wrists; themean time to occurrence of fracture was reported at71.7 � 30.1 days. Of the 3 periprosthetic fractures, 2required open reduction internal fixation and 1 wasmanaged nonsurgically with cast immobilization.One of the wrists managed with open treatment

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subsequently developed a periprosthetic infectionrequiring explantation; the remaining fractures healed.

Removal of the implant for periprosthetic infectionwas performed in 2 wrists; one implant was removedat 245 days and the second at 734 days. Overall, 96%of implants either did not meet criteria for or requireremoval during the study period. The 2 arthroplastiesthat underwent removal of the prosthesis respectivelyrequired 3 and 6 subsequent operations. These 2 pa-tients did not have a history of smoking, rheumatoidarthritis, EhlerseDanlos syndrome, or diabetes;however, both had a body mass index greater than 30.One patient had sustained a periprosthetic fractureafter a fall and had a subsequent periprostheticinfection necessitating removal of hardware. Thepatient subsequently developed a nonunion requiringa free vascularized fibula flap with persistent distal

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FIGURE 2: Extensor digitorum communis tendinopathy afterDRUJ semiconstrained implant arthroplasty. A Tenosynovec-tomy was performed followed by B soft tissue augmentation withallograft tensor fascia lata, with ultimate resolution of symptoms.


nonunion requiring a free vascularized medialfemoral condyle flap reconstruction. The patientcurrently has a stable reconstruction with a one-boneforearm. The remaining prosthesis removal wasassociated with a periprosthetic infection requiringremoval of the prosthesis and antibiotic bead place-ment followed by subsequent bone grafting and softtissue interposition arthroplasty. Neither patient had arevision insertion of an additional device.

DISCUSSIONNormal anatomic relationships of the DRUJ arerequired for painless stable motion of the forearmjoint. In recent years, the importance of the ulnar headto preserve the stability, load-bearing capacity, andbiomechanics of the DRUJ has been described.1,2,13

Resection arthroplasty procedures including Dar-rach, Bowers, and SauvéeKapandji are commonlyperformed to address DRUJ arthrosis; however, theyhave been associated with the potential for radioulnarimpingement and instability of the ulnar stump,which can ultimately lead to continued pain andweakness.4,14e17 The DRUJ semiconstrained

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endoprostheses were designed to treat DRUJ pain,instability, and arthrosis by recreating normalanatomic relationships of the DRUJ with the pros-thesis consisting of a radial plate, which functions asthe sigmoid notch of the radius, an ulnar stem andball construct, which functions as the ulnar head, anda linking plate cover and screws, which function asthe supporting ligamentous structures.5 The implantis indicated for management of posttraumatic,degenerative, or inflammatory arthritis, or arthritisrelated to congenital deformities, and instability ofthe DRUJ and use of the implant has been demon-strated to restore the functional anatomy of the DRUJwith improvement in pain, grip strength, and prono-supination ROM.6e9 However, a recent systematicreview of the literature12 demonstrated a 28%complication rate, and many challenging complica-tions have been reported with the use of this implant.

Wound-related complications range from minorperi-incisional necrosis to wound separation andthreatened implant exposure and are of great concernto both patients and surgeons. Wound-related com-plications occurred in 22.0% of arthroplasties in thecurrent study (11 of 50); however, all wounds healedwithin 6 weeks with local wound care without oper-ative debridement or additional wound coverageprocedures (Fig. 3). At our institution, peri-incisionalnecrosis or dehiscence is typically managed with 1week of MIST Therapy (Alliqua BioMedical, Inc.,Eden Prairie, MN) consisting of low-frequency,noncontact ultrasound therapy with saline mistfollowed by wet-to-dry dressings or semiocclusivedressings.18 Wet-to-dry or semiocclusive dressingsare continued daily until the wounds have healed.Three patients in the current study underwent DRUJimplant arthroplasty as a primary procedure and noincidences of wound-related complications wereidentified in this subpopulation. The number of prioroperations ranged from 0 to 11. The presence andlocation of previous scars should be documented andconsidered before performing the approach to theDRUJ. The standard approach, which consists of an8-cm longitudinal incision extending proximally fromthe ulnar styloid along the ulna and proceedingdistally from the ulnar styloid 3 cm in line with thethird metacarpal, offers excellent exposure for pri-mary operations. In the more common revisionsetting, patients will typically present with previousmultiple longitudinal or transverse incisions fromprior procedures. These incisions can typically beextended proximally or distally to provide sufficientexposure; however, it is also important to considerthe age and maturity of previous scars as well as local

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FIGURE 3: Wound-related complication after DRUJ semiconstrained implant arthroplasty in a patient with a previous scar that wasincluded in the approach and extended distally, with serial photographs at A 7 days, B 14 days, C 21 days, and D 9 months after theoperation.


angiosomes19 (Fig. 4). Multiple reports on previousscar location and the risk for subsequent wound-healing complications have been described in boththe orthopedic and plastic surgery literature, oftenrecommending against placing parallel incisions andundermining previous scars.20e24 Furthermore, theoptimal age of scar at which point the risk forwound-healing complications is mitigated has notbeen elucidated.11 Previous procedures frequentlydisrupt the dorsal anterior and posterior interosseousangiosomes, and therefore skin flaps are based on theradial and ulnar artery extended angiosomes, whichmay also be disrupted from previous ulnar or radialapproaches. In our series, a history of rheumatoidarthritis or immunosuppression was reported in 14%and 18% of wrists, respectively, and was associatedwith a significant increase in wound-related compli-cations, which is consistent with arthroplasty ofother joints.25 We advocate discussing perioperativemanagement using methotrexate, corticosteroids, anddisease-modifying antirheumatic drugs to outline apreoperative and postoperative plan with the primarytreating rheumatologists for pharmacologic manage-ment.26 The authors’ current practice is to continuedisease-modifying antirheumatic drugs, includingmethotrexate, hydroxychloroquine, or leflunamide,

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whereas biologic agents are held for one dosing cyclebefore surgery and typically resumed 10 to 14 daysafter the operation.

Extensor tendinopathy may occur after DRUJarthroplasty, and in the current series, 5 of 50 wristsexperienced some form of tendon dysfunction withno overt tendon ruptures reported. Tendon dysfunc-tion may be an insidious complication with symp-toms of nonspecific pain, crepitus, and restriction infinger or wrist ROM reported. Five tenosynovectomyprocedures were performed in 4 patients in the cur-rent study with a mean time of 368 � 61 days forreturn to the operating room. Two important factorsto consider regarding the prevention of tendondysfunction with the DRUJ semiconstrained endo-prosthesis are proper positioning of the radial plateand proper length and positioning of the screws. Theradial plate component of the implant should beseated on the ulnar aspect of the radial metaphysis; onlateral view, the volar edge of the plate should bealigned with the volar cortex of the radius. Thispositioning confers the appropriate anatomic rela-tionship with the ulnar stem component and preventsdorsal malposition of the ulna, which can causesynovitis in the fourth through sixth dorsal compart-ments. When securing the radial component of the

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FIGURE 4: Angiosomes of the forearm and relationship to the operative approach for DRUJ semiconstrained implant arthroplasty.Dorsal view (left) and volar view (right). Angiosomes for the radial, ulnar, anterior, and posterior interosseous arteries are shaded red,blue, purple, and green, respectively. Orange dotted line indicates the location of the standard approach to DRUJ arthroplasty. In patientswith multiple previous scars, the anterior and posterior interosseous angiosomes may be compromised.


prosthesis, screw lengths should be measured andconfirmed with fluoroscopy. Prominent screws maybe associated with tendinopathy of the first and sec-ond dorsal compartments. In the current study, 3patients experienced tendon dysfunction attributed toa prominent screw requiring screw removal withresolution of symptoms. Selecting a shorter screwlength based on intraoperative depth measurementsand live-mode fluoroscopy might have preventedthese complications. An additional preventativemeasure relates to the creation of an ulnarly basedextensor retinacular flap from the second to sixthdorsal compartments upon approach to the DRUJ;however, creation of this flap is not always feasible,particularly in a patient with multiple previous op-erations. In these patients, we consider the primaryplacement of a tensor fascia lata or acellular dermalmatrix construct to protect the fourth and fifth dorsalcompartments from interacting with the implant. Tomanage established tendon complications, we typi-cally perform tenosynovectomy in conjunction with

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soft tissue interposition, most commonly with tensorfascia lata allograft (Fig. 2); this resulted in resolutionof tendon dysfunction in all patients in the currentseries.

Patients should be extensively counseled beforesurgery about the potential for complications relatedto wounds, infections, soft tissues, and implants afterDRUJ semiconstrained endoprosthesis arthroplastyand the arduous treatment course that may ensue ifimplant-related complications develop. The 2 patientsin this series who required removal of hardwareexperienced a total of 9 operations subsequent to theendoprosthesis placement. Of these, one ultimatelyrequired DRUJ reconstruction with an interpositionarthroplasty procedure as described by Greenbergand Sotereanos27 and Sotereanos et al28 and the otherrequired creation of a one-bone forearm.29 Infectedimplants can be treated by resection arthroplastyfollowed by salvage procedures or attempted reim-plantation. In the current series, we did not performreimplantation of prosthesis procedures.

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Weaknesses of the current study include its retro-spective nature and 1-year minimum follow-up. Werecognize that a 1-year follow-up may be insufficientto study a prosthesis; however, the focus of the currentwork is on soft tissue complications, which occurredduring the study period. There is also the possibilitythat some patients who did not have complicationsduring the study period might have developed com-plications and sought care elsewhere. Furthermore, nopatient-reported outcomes were analyzed because dataregarding validated outcomes were not available formany of the patients. We acknowledge these potentiallimitations; nevertheless, the main purposes were tocharacterize the incidence and modes of complicationsassociated with this operation and to suggest ourapproach to dealing with these problems.

Treatment of pain, arthrosis, and instability of theDRUJ with a prosthetic arthroplasty recapitulates thecritical relationships of the DRUJ with the potential torestore ROM, improve pain, and provide stabilityduring load bearing. However, the procedure is tech-nically demanding, patients often have a history ofmultiple reconstructive procedures, and wound-related, tendon-related, and implant-related complica-tions are frequent. Therefore, surgeons offering thisreconstructive option must be equipped with the meansto prevent and address these problems when they arise.

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Constrained Implant Arthroplasty for Distal Radioulnar