Reconstruction Of Distal Radioulnar Joint Research Articles

Biomechanical Comparison of Distal Radioulnar Joint Reconstruction Graft Preparation Techniques.

Background Graft preparation techniques for the Adams-Berger distal radioulnar joint (DRUJ) reconstruction vary among surgeons with insufficient evidence to support any specific technique. Questions/Purposes We compared survival with cyclic loading, absolute elongation, elongation rate, and modes of failure of four graft preparation techniques. Methods Fifteen porcine extensor tendons were divided into three equal groups: tendon only; tendon augmented along its full length with nonlocking 2-0 FiberLoop suture spaced at 6 mm intervals; and tendon with suture at 12 mm intervals. Suture only was also tested. Samples were woven through custom radius- and ulna-simulating jigs mounted on a mechanical testing machine. Samples underwent a staircase cyclic loading protocol and were then inspected visually for the mode of failure. Survival with cyclic loading, absolute elongation, and elongation rate was compared. Results Average survival with cyclic loading of suture-augmented tendon was significantly higher than tendon only. All tendon groups had significantly higher survival compared with suture only. Absolute elongation was subject to variability due to initial nonlinear elongation behavior of samples. The elongation rate was significantly lower with suture compared with all tendon groups. Modes of failure included rupture of the tendon and/or suture at the simulated graft-bone interface and elongation of the entire construct without rupture. Conclusions In this biomechanical study, augmentation of porcine tendons with suture spaced at either 6 or 12 mm for DRUJ reconstruction significantly increased survival to a staircase cyclic loading protocol Clinical Relevance For the Adams-Berger reconstruction, tendon grafts augmented along their entire length by nonabsorbable braided suture are biomechanically superior to tendon alone.

Clinical and functional outcomes of reconstruction following en bloc resection for the Campanacci grade III distal ulnar giant cell tumors

Background: Wide resection of the tumor is essential for the treatment of Campanacci grade III giant cell tumor of the distal ulna but radioulnar convergence and dorsal displacement of the ulnar stump are known complications. Various reconstructive options to reduce these complications have been described in the literature. Methods: Seven patients with Campanacci grade III giant cell tumor distal end of the ulna were treated at our institute by extra-periosteal wide local excision of the tumor followed by reconstruction of the distal radioulnar joint by fixation of tricortical iliac crest graft to the distal end radius using two cancellous screws and extensor carpi ulnaris (ECU) tenodesis for stabilizing the residual ulnar stump. All patients were followed up for an average period of 3.5 years (32–48 months) at regular intervals. Functional outcome and complications if any, were recorded at every follow-up. Results: At final follow-up, the mean range of motion of wrist with 42.1° ± 5.9° of flexion, 72.9° ± 6.4° of extension, 82.1° ± 8.1° of supination and 85.0° ± 5.8° of pronation was achieved. The mean visual analog scale score at the final follow-up was 0.9 ± 0.9. The mean modified Mayo wrist score was 71.4 ± 6.4 with a mean modified Musculoskeletal Tumor Society score of 25.9 ± 0.8 and a mean Disability of Arm, Shoulder, and Hand score of 17.9 ± 1.6 at the final follow-up. The average time for the radiological union of iliac crest graft with the distal end radius was 13.3 weeks. None of the patient reported any complication or recurrence. Conclusion: The reconstruction of distal radioulnar joint by fixation of tricortical iliac crest graft with distal end radius and stabilization of ulnar stump by extensor capi ulnaris tenodesis after the wide resection of distal ulna giant cell tumor is recommended for good to excellent functional outcomes.

Biomechanical Comparison of Modified Adams-Berger and DX technique in DRUJ Reconstruction.

Background Adams-Berger ligamentoplasty is a widely accepted reconstruction for unrepairable triangular fibrocartilage complex (TFCC) injuries with instability. Failure of the reconstruction and recurrent instability is still a clinical problem. Internal brace augmentation of tendon grafts is gaining more popularity, but use in the distal radioulnar joint (DRUJ) is not yet published. Questions/Purposes The purpose of this study was to compare a novel anatomical DRUJ reconstruction with a modified Adams-Berger reconstruction to answer which technique stabilize better the DRUJ and which has enough stabilizing effect to allow early mobilization. Methods Nine matched pairs of cadaveric upper extremities were used. The dorsopalmar translations in the DRUJ that occurred with 50 N load were measured before and after detachment of the TFCC from the ulna and after ligament reconstruction with either modified Adams-Berger procedure or DX Swivelock technique. Internal brace augmented palmaris longus tendon grafts were used in all reconstruction. Results In the Adams-Berger group, the injured and the reconstructed displacements were significantly higher than the native, while in the DX group both the native and the reconstructed displacements were significantly lower than the injured. The mean (standard deviation) change of translations was 0.46 (1.94) mm after Adams-Berger and 2.51 (1.31) mm after DX reconstruction, implying significant better stabilizing effect of the latter. Conclusions DX Swivelock reconstruction showed better time zero stabilizing effect compared with Adams-Berger procedure, regaining almost normal stability of the DRUJ.

Distal Radio-Ulnar Joint Reconstruction after failed Darrach operation using free autogenous second toe Metatarso-phalangeal joint transfer. Development of the technique and a long-term (over 25 year) follow-up

During the development of microvascular surgery in 1980-95 many new methods to overcome different traumatic disorders were studied. Previously unsolved problems could be treated using free tissue transfer. Typical problems in wrist surgery were the painful complications from ulna head resection. No sound or acceptable artificial protheses for ulna head were available. Author did study the possibilities of reversal of resected ulna head using an autogenous microvascular joint transfer. First it was done using cadaver models and evaluating the possibilities of a toe MTP-II joint in replacing the distal radio-ulnar joint. Then same principle was used in three clinical cases. All patients had suffered a poor result after ulna head resection or Darrach procedure. First two cases had complications but third case from year 1994 resulted in a good outcome. This paper introduces the development of a surgical technique for the replacement of the resected ulna head. Also, it will describe the excellent long-term result achieved in the last case with 26-year follow-up. Although today many sophisticated prosthetic replacement techniques have become developed for this purpose, this kind of autogenous reconstruction might have a place in treating similar problems in young posttraumatic patients. Also it demonstrates the potential benefit of microsurgery in a difficult wrist problem.

Extensor Retinaculum Reconstruction of the Distal Radioulnar Joint in Adolescents.

This study characterizes the outcomes and complications of surgical reconstruction of distal radioulnar joint (DRUJ) instability using the extensor retinaculum (Herbert sling). Our hypothesis was that extensor retinaculum reconstruction is a reliable method of DRUJ stabilization in adolescents. This was a retrospective study of pediatric patients treated surgically using the Herbert sling for DRUJ instability at a single institution. We identified 22 subjects who underwent surgery at an average of 16.2 years of age (range, 12-18 years). Medical records and available imaging were reviewed for all subjects, and patients were contacted to participate in the prospective completion of the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. Preoperative symptoms were more commonly pain (95%) than feelings of DRUJ instability (45%), although 100% had instability on physical examination. Eight (36%) patients demonstrated limited supination preoperatively. Twenty-one subjects (95%) noted prior injury to that wrist, 15 of which were distal radius fractures. Surgery consisted of stabilization of the DRUJ using extensor retinaculum, in concert with other procedures to address all potential causes of wrist pain. Postoperatively, DRUJ stability was maintained in 21 of 22 subjects. Of the 12 patients who provided functional outcome scores, median QuickDASH score was 7.6 (range, 0-45). Distal radioulnar joint instability in adolescents is often preceded by fracture of the distal radius. Surgeons must maintain a high level of suspicion to appropriately diagnose DRUJ instability, which is often not an isolated pathoanatomical problem. The Herbert sling technique using extensor retinaculum can successfully confer DRUJ stability in this population.

Long-term Outcome of Surgical Reconstruction of the Interosseous Membrane after Chronic Essex-Lopresti Injury

An Essex-Lopresti injury (ELI) is a rare lesion that describes an interosseous membrane (IOM) disruption associated with dislocation of the distal radio-ulnar joint (DRUJ) and radial head fracture. They are rare and have a tendency to be underdiagnosed in the ER, so it is not uncommon to see chronic cases. As part of the treatment options different IOM reconstructions have been proposed along with associated procedures to the radial head and DRUJ. One of the most effective treatment strategies has been the use of a bone-tendonbone (BTB) patellar graft for IOM reconstruction with promising outcomes. We present a case of 46-yearold man who suffered an Essex-Lopresti injury with a radial head fracture and associated posterolateral elbow instability that was managed initially non-operatively. After failure for continued pain and instability if the elbow and forearm, we treated the patient with a radial head arthroplasty, ligament reconstruction of the posterolateral complex, and DRUJ ligament reconstruction with extensor hallucis tendon without a formal IOM. This operation was successful initially, but continued forearm instability contributed to failure of the RHA and DRUJ reconstruction. A second operation was performed resecting the loosened radial head arthroplasty, performing an ulnar shortening osteotomy, and an IOM reconstruction with BTB allograft. After eight years of follow-up the patient is very satisfied with the procedure and rates his elbow as almost normal. ELI are rare and represent a severe injury of the forearm with axial and transverse instability, leading to severe symptoms and instability of the forearm. Initial diagnosis is challenging, and acute treatment yields better results than chronic cases. IOM reconstruction seems to be necessary in the setting of chronic reconstructions, along with other procedures to balance the forearm. We review different IOM grafting options and associated procedures for the treatment of these challenging injuries.

Physeal sparing distal radio-ulnar joint ligament reconstruction in children.

Distal radio-ulnar joint (DRUJ) injuries are under-reported in the paediatric population. No single study has discussed methods of DRUJ reconstruction in immature patients with chronic instability. We present a physeal sparing ligamentoplasty for chronic DRUJ instability and describe the outcomes in two patients. Two consecutive children with chronic DRUJ instability were treated using physeal sparing ligamentoplasy. After the failure of triangular fibrocartilage complex repair, reconstruction was done using palmaris longus tendon graft that was tunnelled through the distal radius epiphysis and wrapped subperiosteally around the ulnar neck. Graft was tied in a neutral forearm position. DRUJ stability was achieved in both patients. Grip strength averaged 90% of the healthy side. Prono-supination range of motion (ROM) averaged 88 and 86%, respectively, of the healthy side, without intraoperative nor postoperative complications. Our novel technique was effective in the regain of DRUJ stability with minor effect on the prono-supination ROM. Further studies are planned to experiment the biomechanical effectiveness of our technique. Level of evidence: Therapeutic IV.

Role of the Interosseous Membrane in Preventing Distal Radioulnar Gapping.

Background Damage to the interosseous membrane (IOM) can alter load transmission between the radius and ulna and decrease their axial stability. Less is known about the effect of IOM sectioning on the transverse stability between the radius and ulna. Purpose The purpose of this study was to quantify the radioulnar gapping at the distal radioulnar joint (DRUJ) during forearm rotation when the IOM was experimentally sectioned while maintaining the integrity of the distal radioulnar ligaments. Methods In 12 fresh-frozen cadaver forearms tested in a combined wrist-forearm simulator, the increase in gap between the radius and ulna, at the level of the DRUJ, was determined during cyclic forearm rotation following IOM sectioning. Results IOM sectioning caused a significant increase in dorsal gapping at the DRUJ by 2.1 mm in supination and 0.6 mm in pronation. It also caused an increase in palmar gapping by 1.3 mm in supination and 0.5 mm in pronation. Conclusion This experiment has shown that the IOM has an important role in stabilizing the DRUJ, especially in supination, and that IOM sectioning caused greater loads on the palmar and dorsal radioulnar ligaments. Since DRUJ instability is primarily treated by fixing the laxity at the dorsal radioulnar ligament (DRUL) and palmar radioulnar ligament (PRUL), untreated IOM damage could permit additional injury and instability to the radioulnar ligaments or their reconstruction. Clinical Relevance Reconstruction of a torn IOM should be considered in the presence of persistent DRUJ instability following DRUJ reconstruction.

Sauvé-Kapandji法に加え橈骨頭切除術を施行後に生じたradioulnar impingementに対し遊離血管柄付き腓骨を用いて遠位橈尺関節再建術を施行した1例

Sauvé-Kapandji法に加え橈骨頭切除術を施行後に生じたradioulnar impingementに対し遊離血管柄付き腓骨を用いて遠位橈尺関節再建術を施行した1例

A Newer Technique of Distal Ulna Reconstruction Using Proximal Fibula and TFCC Reconstruction Using Palmaris Longus Tendon following Wide Resection of Giant Cell Tumour of Distal Ulna

Giant cell tumour of the bone (GCT) is a rare locally aggressive primary bone tumour with an incidence of 3% to 5% of all primary bone tumours. The most common location for this tumour is the long bone metaepiphysis especially of the distal femur, proximal tibia, distal radius, and the proximal humerus. Involvement of distal ulna is rare accounting for 0.45% to 3.2%. Considering local aggressive nature and high recurrence, wide resection is the treatment recommended. Instability of ulnar stump and ulnar translation of the carpals are known complications following resection of distal ulna. To overcome these problems, we attempted a newer technique of distal ulna reconstruction using proximal fibula and TFCC reconstruction using palmaris longus tendon following wide resection of giant cell tumour of distal ulna in a 44-year-old male. This technique of distal radioulnar joint reconstruction has excellent functional results with no evidence of recurrence after one-year followup.