Distal Oblique Bundle Reinforcement for Treatment of DRUJ Instability

Abstract

Background Chronic, dynamic bidirectional instability in the distal radioulnar joint (DRUJ) is diagnosed clinically, based on the patient's complaints and the finding of abnormal laxity in the vicinity of the distal ulna. In cases where malunion is ruled out or treated and there are no signs of osteoarthritis, stabilization of the DRUJ may offer relief. To this end, several different techniques have been investigated over the past 90 years.

Materials and Methods In this article we outline the procedure for a new technique using a tendon graft to reinforce the distal edge of the interosseous membrane.

Description of Technique A percutaneous technique is used to harvest the palmaris longus tendon and to create a tunnel, just proximal to the sigmoid notch, through the ulna and radius in an oblique direction. By overdrilling the radial cortex, the knotted tendon can be pulled through the radius and ulna and the knot blocked at the second radial cortex, creating a strong connection between the radius and ulna at the site of the distal oblique bundle (DOB). The tendon is fixed in the ulna with a small interference screw in full supination, preventing subluxation of the ulna out of the sigmoid notch during rotation.

Results Fourteen patients were treated with this novel technique between 2011 and October 2013. The QuickDASH score at 25 months postoperatively (range 16–38 months) showed an improvement of 32 points. Similarly, an improvement of 33 points (67–34 months) was found on the PRWHE. Only one recurrence of chronic, dynamic bidirectional instability in the DRUJ was observed.

Conclusion This simple percutaneous tenodesis technique between radius and ulna at the position of the distal edge of the interosseous membrane shows promise in terms of both restoring stability and relieving complaints related to chronic subluxation in the DRUJ.

Keywords

distal radioulnar joint - distal oblique bundle - instability - posttraumatic wrist disorder

• References

• 1 Eliason EL. An operation for recurrent inferior radioulnar dislocation. Ann Surg 1932; 96 (1) 27-35
• 2 Szabo RM. Distal radioulnar joint instability. J Bone Joint Surg Am 2006; 88 (4) 884-894
• 3 Zimmerman RM, Jupiter JB. Instability of the distal radioulnar joint. J Hand Surg Eur Vol 2014; 39 (7) 727-738
• 4 Gofton WT, Gordon KD, Dunning CE, Johnson JA, King GJ. Soft-tissue stabilizers of the distal radioulnar joint: an in vitro kinematic study. J Hand Surg Am 2004; 29 (3) 423-431
• 5 Mohanti RC, Kar N. Study of triangular fibrocartilage of the wrist joint in Colles' fracture. Injury 1980; 11 (4) 321-324
• 6 Richards RS, Bennett JD, Roth JH, Milne Jr K. Arthroscopic diagnosis of intra-articular soft tissue injuries associated with distal radial fractures. J Hand Surg Am 1997; 22 (5) 772-776
• 7 Okada K, Moritomo H, Miyake J , et al. Morphological evaluation of the distal interosseous membrane using ultrasound. Eur J Orthop Surg Traumatol 2014; 24 (7) 1095-1100
• 8 Noda K, Goto A, Murase T, Sugamoto K, Yoshikawa H, Moritomo H. Interosseous membrane of the forearm: an anatomical study of ligament attachment locations. J Hand Surg Am 2009; 34 (3) 415-422
• 9 Green DP , ed. Operative Hand Surgery, 3rd ed. New York, NY: Churchill Livingstone; 1993: 1003
• 10 Riggenbach MD, Conrad BP, Wright TW, Dell PC. Distal oblique bundle reconstruction and distal radioulnar joint instability. J Wrist Surg 2013; 2 (4) 330-336
• 11 Adams BD, Berger RA. An anatomic reconstruction of the distal radioulnar ligaments for posttraumatic distal radioulnar joint instability. J Hand Surg Am 2002; 27 (2) 243-251
• 12 Wijffels M, Brink P, Schipper I. Clinical and non-clinical aspects of distal radioulnar joint instability. Open Orthop J 2012; 6: 204-210