BONE AND JOINT 15-5 Hand Surgery
2010
IFSSH Reconstruction of Unstable Distal Radioulnar Joint(DRUJ) with Double Breasted Extensor Retinacular Slip Ravi Kumar Gupta, MS, DNB Government Medical College Hospital, Chandigarh, India
A number of surgical procedures have been described in the literature for reconstruction of an unstable DRUJ 1-5. We achieved the stabilization of DRUJ with a new technique with the use of double breasted slip of extensor retinaculum (ER).
cm apart, are drilled on the dorso-ulnar border of radius which are connected with each other with the help of a towel clip to facilitate the easy passage of the curved suture needle. Non absorbable number 1 polyester suture is passed through one hole and taken out from the other hole (Figure 1B). The ER slip is passed under the tendon of extensor carpi ulnaris (ECU). With manual reduction of the DRUJ by volarward pressure on the distal ulna and the forearm in full supination, the site of attachment on the ER slip with the holes on the dorso-ulnar border of the radius is identified and marked. The two free ends of the suture are passed and tied over the raised ER slip at the marked site (Figure 1C). The redundant part of the slip is folded back on itself and sutured to give the double breasted strength to DRUJ (Figure 1 D). Post-operatively, the forearm is immobilized
SURGICAL PROCEDURE Through a dorsal curvilinear incision, approximately 2X3 centimeter rectangular, ulnar based flap of ER is raised from its proximal aspect (Figure 1A). Inflamed synovium, if any, is debrided and the cartilage of DRUJ is inspected. Two unicortical converging 2 mm drill holes, 1.5
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IFSSH 2010
Hand Surgery
A
B
C
D
Fig. 1. A) Raising of the rectangular ER slip; B) Nonabsorbable suture passed through the 2 holes on the dorsoulnar border of radius; C) ER slip having been passed under the tendon of extensor carpi ulnaris and being attached to the dorso-ulnar border of radius; D) Double breasting of ER slip
in full supination for 2 weeks, followed by 2 weeks in mid prone position. Active sports and heavy manual activities are only allowed at 6 months.
assessed by modified Mayo Score. Follow up ranged from 13 months to 96 months (average 38.1 months). The wrist score improved from a preoperative mean of 23.89 (range 10-50) to a final mean of 94.4 (85-100). 12 patients had excellent, 16 good and 2 fair results. One patient had temporary numbness in the distribution of the dorsal branch of the ulnar nerve that improved with time. All the patients returned to their full activities.
CLINICAL RESULTS 30 painful wrists with unstable DRUJ, reconstructed with the above technique were
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Bone and Joint-Ulnar wrist
2. Hermansdorfer JD, Kleinmann WB. Management of chronic peripheral tears of the triangular fibrocartilage complex. J Hand Surg 1991;16A: 3406. 3. Hui FC, Linscheid RL. Ulnotriquetral augmentation tenodesis: a reconstructive procedure for dorsal subluxation of the distal radioulnar joint. J Hand Surg 1982;7:230-6. 4. Tsai, T., and Stilwell, J. H.: Repair of chronic subluxation of the distal radioulnar joint (ulnar dorsal) using flexor carpi ulnaris tendon. J Hand Surg 1984; 9-B: 289-94. 5. Scheker LR, Belliappa PP, Acosta R, German DS. Reconstruction of the dorsal ligament of the triangular fibrocartilage complex. J Hand Surg [Br]. 1994;19:310-8.
SUMMARY Stabilization of DRUJ by our method of using a double breasted extensor retinaculum slip gives satisfactory results and we feel that our procedure is simple and reproducible.
REFERENCES 1. Shih JT, Lee HM. Functional results of posttriangular fibrocartilage complex reconstruction with extensor carpi ulnaris with or without ulnar shortening in chronic distal radioulnar joint instability. Hand Surg. 2005;10:169-76.
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