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Distal Oblique Bundle Reconstruction and Distal Radioulnar Joint Instability
Abstract
Background This study created an anatomic reconstruction of the distal oblique bundle (DOB) of the interosseous membrane to determine its effect on distal radioulnar joint (DRUJ) instability and compare this technique with distal radioulnar ligament (DRUL) reconstruction.
Questions/Purposes We hypothesized that this reconstruction would provide equivalent stability to DRUL reconstruction and that combining the two techniques would enhance stability.
Methods Six cadaveric upper limbs were affixed to a custom frame. The volar/dorsal translation of the radius relative to the ulna was measured in 60° pronation, neutral, and 60° supination. Translation was sequentially measured with the DRUJ intact, with sectioned DRULs and triangular fibrocartilaginous complex (TFCC), and with sectioned DOBs. Reconstructions were performed on the DRULs, on the DOB tensioned in both neutral and supination, and employing both techniques.
Results The DOB reconstruction, tensioned both in the neutral position and in 60° supination, was more stable than the partial and complete instability in 6/6 specimens in pronation and the neutral position and in 5/6 specimens in supination. The DOB reconstruction and the DOB reconstruction tensioned in supination were more stable than the DRUL reconstruction in 4/6 patients. Combining the two techniques did not further reduce translation.
Conclusions The DOB reconstruction is capable of improving stability in the unstable DRUJ.
... Έτσι, οι Riggenbach και συν. [259,260] [259,260] είτε η τεχνική με χρήση συστήματος τύπου κομβίου-ράμματος [263]. ...
... Έτσι, οι Riggenbach και συν. [259,260] [259,260] είτε η τεχνική με χρήση συστήματος τύπου κομβίου-ράμματος [263]. ...
... Συμπερασματικά, η ανακατασκευή της DOB αποδείχθηκε ότι σταθεροποιεί επαρκώς την DRUJ. Επιπλέον, παρατηρήθηκε πως η κατασκευή-ανασκευή DOB οδηγούσε στον ίδιο βαθμό σταθερότητας με τα δείγματα όπου φυσιολογικά εντοπίζεται η δομή[238,259,263], εκτός από μία μελέτη, στην οποία η σταθερότητα μετά την ανακατασκευή ήταν μειωμένη κατά τον υπτιασμό[231]. Δεν παρατηρήθηκε σημαντική διαφορά μεταξύ της DOB και της Adams τεχνικής στις τέσσερις μελέτες. ...
The distal oblique bundle is part of the distal interosseous membrane of the forearm and is treated as a recognized distinct structure since 2009 when it was first reported as DOB. The name was given by Noda et al. in their article «Interosseous membrane of the forearm: an anatomical study of ligament attachment locations», published in March 2009, in «Journal of Hand Surgery (Am.)». The exact definition was the following: «The DOB originated from approximately the distal one sixth area of the ulnar shaft, approximately coinciding with the proximal border of the pronator quadrates muscle, and ran distally toward the distal radioulnar joint. The fibers blended into the capsular tissue of the distal radioulnar joint and eventually the DOB inserted to the inferior rim of the sigmoid notch of the radius. Furthermore, some fibers extended more distally along the anterior and posterior ridges of the sigmoid notch, so the DOB seemed to display continuity with the dorsal and palmar radioulnar ligaments of the triangular fibrocartilage complex».
Until recently, DOB was not recognized as a separate structure. It is not observed in the entire population, but as recent studies indicate, it plays an important role in the stability of the distal radioulnar joint, when present. The issue has not been analyzed by a large number of writers and its study has been under development for less than fifteen years. However, interest in the subject grows between surgeons who deal with surgical anatomy of the wrist. It is considered very likely to give key responses and solutions to the complex biomechanic of instability problems of the distal radioulnar joint, where in many cases conventional rehabilitation techniques are not sufficient.
Our review will attempt to gather all the knowledge that exists until today on the surgical anatomy of the area by analyzing and decoding the very long bibliography. On the other hand, due to the relatively recent recognition of the DOB structure, the bibliography on the specific subject is relatively limited. For this reason, beyond the review of the literature, we will try to add a little bit of knowledge around the bibliography on the structure and we will attempt to further direct the research that will improve the techniques of restoring the instability of the distal radioulnar joint by analyzing the gaps that exist in current literature, but also trying and completing some of them.
It is our strong belief that distal oblique bundle is worth investigating in full, since it seems to have an important role as an isometric stabilizer of the distal radioulnar joint when present.
... Both tendon [17][18][19] and suture-button graft [20] techniques have previously been evaluated biomechanically. These previous studies [17][18][19][20] assessed the volar/dorsal and/or total translation of the distal radius in relation to the ulna. ...
... Both tendon [17][18][19] and suture-button graft [20] techniques have previously been evaluated biomechanically. These previous studies [17][18][19][20] assessed the volar/dorsal and/or total translation of the distal radius in relation to the ulna. Additionally, the isolated DOB reconstruction had been evaluated [20] or compared to the Adams and Berger technique [17][18][19]. ...
... These previous studies [17][18][19][20] assessed the volar/dorsal and/or total translation of the distal radius in relation to the ulna. Additionally, the isolated DOB reconstruction had been evaluated [20] or compared to the Adams and Berger technique [17][18][19]. Therefore, the literature lacks studies assessing the stability along the physiological rotation axis of the forearm and comparison between tendon graft and suture-button systems. ...
Chronic instability of the distal radioulnar joint (DRUJ) presents a highly disabling condition. Several surgical techniques have been reported for its treatment. These involve reconstruction of the distal oblique bundle (DOB) of the interosseous membrane (IOM) of the forearm. The aim of this study was to examine whether surgical reconstruction of the DOB is necessary to restore DRUJ stability following trauma with DOB disruption and to compare two restoration techniques utilizing a tendon or suture-button graft.
Stability in supination and pronation was assessed by means of maximum torque and force in twenty forearms. Test cycles were performed with the DOB/IOM in an intact condition, with the DOB or distal IOM transected, and following surgical reconstruction of the DOB with either tendon graft or suture-button system.
In pronation, the relative change in maximum axial force was significantly lower in samples with a transected DOB in comparison to samples without a preexisting DOB. No statistically significant differences were observed between forearms including DOB reconstruction and specimens in the intact and transected state. Neither were there statistically significant differences concerning the two surgical techniques.
From a biomechanical perspective, surgical DOB reconstruction is hence not indicated in cases of isolated DOB rupture.
... All sample measurements were conducted in the same manner and the same analogue vernier calliper. We also decided to include early results of three cases of DOB reconstruction with the "Riggenbach" technique to associate anatomical findings with clinical implementation [15,16]. ...
... A radial aperture was drilled slightly proximally to the sigmoid notch and along the dorsal aspect of the radius. A minimum bone bridge of 3-5 mm, both in the radius and the ulna, was intentionally preserved to ensure stability and integration of the graft with the host bone [15,16]. The graft was threaded through the holes and a Pulvertaft weave was created between the two ends. ...
... The graft was threaded through the holes and a Pulvertaft weave was created between the two ends. The suturing was performed with the hand in 60 o of supination while tension was set during the first pass [15,16]. ...
Background and objective
The distal oblique bundle (DOB) is nowadays recognized as the thickest component of the distal interosseous membrane (DIOM). It is neither thought to be a clear-cut ligament, and nor does it follow the typical configuration of the rest of the DIOM. It is not always present and some studies have raised disputes about its prevalence and a few anatomical features. In this study, we aimed to provide data on the prevalence and anatomical features of the DOB, which are of great importance at this early stage of research into the topic. Our findings have been correlated with current knowledge and are expected to contribute to clinical implementation.
Materials and methods
Twenty-eight fresh-frozen forearms were utilized for measurements. Specifically, mean length, width, distance from the middle of the bundle’s insertion to the ulna to the tip of the styloid process of the ulna, as well as the distance from the midpoint of its insertion to the radius to the tip of the radiuses’ styloid process were calculated. The prevalence was described with a cutoff thickness point of 0.5 mm. Early results based on three cases of DOB reconstruction with the “Riggenbach” technique due to distal radioulnar joint (DRUJ) instability were documented.
Results
Eleven DOBs were reported out of the 28 specimens, suggesting a prevalence of 39.3%. The mean thickness was 0.88 mm (range: 0.6-1.3 mm), the mean width was 5.22 mm (range: 2.2-8.4 mm), and the mean length was 25.68 mm (range: 22.7-29.2 mm). Proximally, the mean distance from the bundle’s ulnar insertion to the tip of the styloid process of the ulna was 51.02 mm (range: 45.5-55.6 mm) while distally, the mean distance from the bundle’s insertion to the radius to the tip of the styloid process of the radius was 34.5 mm (range: 31.3-37.7 mm). After a follow-up of at least six months, improvement was evident in all measured areas in the three patients who underwent surgery. Additionally, they reported satisfaction and accomplishment of their preoperative goals.
Conclusions
Discrepancies in measurements in some anatomic features between studies are probably due to variations in specimen types, measurement methods, and sites. Efforts must continue to be made on a more extensive scale and in a more standardized manner for more factual results and conclusions. "Reconstruction-recreation" or "original construction-creation" procedures yield promising results in a fast, simple, and less invasive manner than traditional methods of DRUJ stabilization.
... In the study by De Vries et al. (2017), DOB incidence was not mentioned. Riggenbach et al. (2013) examined 6 fresh-frozen specimens and reported a DOB incidence of 50%. Measures of length and thickness were not given in the publication, but an ulnar insertion 46 mm (41-52 mm) proximal to the ulnar articular surface and a radial insertion 9 mm (7-12 mm) proximal to the sigmoid notch of the radius was reported. ...
... Three of the four included studies (Riggenbach et al., 2013;Delbast et al., 2020;Low et al., 2020) Low et al. (2020) and Riggenbach et al. (2013), suture button fixation was chosen as the favored method of DOB reconstruction, while tendon-to-tendon suturing was the technique used in the study by Delbast et al. (2020) The exact loading conditions for biomechanical testing were only reported in two articles (Delbast et al., 2020;Low et al., 2020) exerting up to 20 N. This is summarized in Table 1. ...
... Three of the four included studies (Riggenbach et al., 2013;Delbast et al., 2020;Low et al., 2020) Low et al. (2020) and Riggenbach et al. (2013), suture button fixation was chosen as the favored method of DOB reconstruction, while tendon-to-tendon suturing was the technique used in the study by Delbast et al. (2020) The exact loading conditions for biomechanical testing were only reported in two articles (Delbast et al., 2020;Low et al., 2020) exerting up to 20 N. This is summarized in Table 1. ...
Introduction:
The aim of this review was to summarize the available evidence for biomechanical stability following surgical DOB reconstruction, and to determine whether distal radioulnar joint (DRUJ) stability with a reconstructed DOB was similar to the native intact condition or that after the Adams procedure.
Material and methods:
A systematic literature search according to the PRISMA guidelines was performed using the databases PubMed and Embase. The following search algorithm was used: ("DOB" OR "Distal Oblique Bundle") AND "Reconstruction". Biomechanical or human cadaveric studies that measured stability of the DRUJ after reconstruction of the DOB were included.
Results:
Four articles were included in the final analysis. DOB incidence was reported to be between 50% and 70%. Two studies observed no differences between the intact situation and the reconstructed DOB, respectively the Adams procedure. A further author group found no signs of major instability after the Adams reconstruction or after DOB reconstruction, except for decreased stability during supination in the DOB sample. In another study, similar results could be shown for the Adams and DOB reconstruction groups; however, the DOB sample showed decreased dorsal translation of the radius during forearm supination.
Conclusion:
In conclusion, DOB reconstruction was proven to stabilize the DRUJ adequately. Moreover, the reconstructed DOB showed the same stability as the native DOB, except for one study, in which stability following reconstruction was reduced during supination. No significant difference between the DOB and the Adams reconstruction could be observed.
... Despite these advances, tendon graft harvesting and invasive procedures remain a challenge, prompting interest in alternative methods [14,15]. In 2017, a biomechanical study introduced DOB reconstruction using a minimally invasive suture button construct for DRUJ instability [16]. ...
... As a result, DOB reconstruction has garnered increasing attention, particularly in cases of chronic DRUJ instability. Recent biomechanical and clinical studies have underscored the importance of DOB reconstruction in enhancing DRUJ stability [13,14,16,17,26,27]. Similarly, a recent systematic review has demonstrated that DOB reconstruction significantly enhances DRUJ stability, with improvements nearly equivalent to natural stability [28]. ...
Background
Distal radioulnar joint (DRUJ) instability is a common post-traumatic complication, often leading to chronic pain and dysfunction. Current reconstructive techniques, such as the single suture button construct, offer suboptimal stabilization in certain motions. This study aimed to evaluate whether a double suture button construct provides greater stability than the single construct in a cadaver model of DRUJ instability. We hypothesized that the double suture button construct would more effectively minimize dorsal translation of the radius relative to the ulna.
Methods
We used nine freshly frozen human cadaver upper extremities, destabilized the DRUJ, and then reconstructed the joint using three different suture button constructs: single transverse, double (transverse + oblique), and single oblique. The specimens were secured in a custom-designed testing apparatus to measure dorsal translation of the radius. The study proceeded in five stages: stable DRUJ, unstable DRUJ, and reconstruction using a single transverse, double (transverse + oblique), and single oblique suture button construct. Dorsal translation was measured at neutral, 45° pronation, and 45° supination. Statistical comparisons of mean values were conducted for each stage.
Results
Reconstruction with the transverse, transverse plus oblique, and oblique suture button constructs resulted in statistically significant reductions in dorsal translation compared to the unstable DRUJ (p < 0.001 for all). The double-suture button construct significantly minimized dorsal translation in all positions, restoring stability comparable to a stable DRUJ: neutral (p = 1.000), pronation (p = 0.963), and supination (p = 1.000). In contrast, single constructs failed to fully restore stability in pronation and supination.
Conclusion
The double suture button construct provides significantly greater stabilization of the DRUJ compared to the single construct. These findings suggest that the double construct could be a more effective option for treating DRUJ instability, particularly in restoring normal joint function during various motions. Further research is warranted to confirm these results in clinical settings.
... These previous studies 17-20 assessed the volar/dorsal and/or total translation of the distal radius in relation to the ulna. Additionally, the isolated DOB reconstruction had been evaluated 20 or compared to the Adams and Berger technique [17][18][19] . Therefore, the literature lacks studies assessing the stability along the physiological rotation axis of the forearm and comparison between tendon graft and suture-button systems. ...
... Concerning biomechanical trials involving DOB reconstruction, previous studies mainly assessed the dorsal/volar translation of the distal portion of the radius with reference to the ulnar head. Riggenbach and colleagues 19 found that in pronation, complete DOB repairs were significantly more stable when compared to the partial and incomplete states. Reconstructions did further not differ significantly from the intact DRUJ. ...
Chronic instability of the distal radioulnar joint (DRUJ) presents a highly disabling condition. Several surgical techniques have been reported for its treatment. These involve reconstruction of the distal oblique bundle (DOB) of the interosseous membrane (IOM) of the forearm. The aim of this study was to examine whether surgical reconstruction of the DOB is necessary to restore DRUJ stability following trauma with DOB disruption and to compare two restoration techniques utilizing a tendon or suture-button graft. Stability in supination and pronation was assessed by means of maximum torque and force in twenty forearms. Test cycles were performed with the DOB/IOM in an intact condition, with the DOB or distal IOM transected, and following surgical reconstruction of the DOB with either tendon graft or suture-button system. In pronation, the relative change in maximum axial force was significantly lower in samples with a transected DOB in comparison to samples without a preexisting DOB. No statistically significant differences were observed between forearms including DOB reconstruction and specimens in the intact and transected state. Neither were there statistically significant differences concerning the two surgical techniques. From a biomechanical perspective, surgical DOB reconstruction is hence not indicated in cases of isolated DOB rupture.
... It has been previously described in the literature that indirect radioulnar linkage through an ulnocarpal sling or a tenodesis for DRUJ instability enables stabilization of the joint with good clinical outcomes, although prior applications of these techniques were focused on the treatment of chronic DRUJ instability [22][23][24] by reconstruction of the distal oblique bundle (DOB) [25][26][27] . One of these techniques is based upon dynamic stabilization of DRUJ (similarly to our technique), but instead uses a suture-button construct placed percutaneously in the direction of the DOB membrane [27] . ...
... It has been previously reported [22][23][24][25][26][27] that indirect radioulnar linkage techniques may restore stability at the expense of restricting forearm rotation. With our technique, fastening the suture too tightly could also lead to reduced mobility in the wrist. ...
Introduction
: Instability of the distal radioulnar joint (DRUJ) commonly results from traumatic disruption of the distal radioulnar ligaments of the triangular fibrocartilage complex (TFCC). Treatment of this rupture typically requires immobilization of the wrist and elbow for a period of 6 to 8 weeks. This study evaluated the hypothesis that treatment of DRUJ instability with dynamic stabilization would allow early mobilization of both the radiocarpal and distal radioulnar joints by the first postoperative week without compromising restoration of TFCC integrity.
Materials and Methods
: Between September 2017 and January 2019, a retrospective study was conducted on 22 patients presenting with DRUJ instability confirmed by intraoperative Ballottement testing. Once instability was confirmed, dynamic surgical stabilization was performed, followed by one week of short cast immobilization. Arthrographic computed tomography (CT) of each patients’ affected wrist was performed 4 months later to evaluate TFCC integrity. The recovery of patients was monitored at 1, 3, 6, and 12 months after surgery using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, Ballottement test, and evaluation of radioulnar join range of motion (ROM), pain, and complications.
Results
: All patients were followed postoperatively for a mean of 13.5 months. After 1 month, all patients exhibited satisfactory range of motion and DRUJ stability. By 3 months, Ballottement tests were negative in 21 of 22 patients, with instability persisting in only 1 patient. At 4 months, CT arthrography contrast leakage (indicative of a TFCC tear) was observed in 5 of 20 patients. Upon reexamination a mean of 10.5 months later, the TFCC tears of these patients had healed in 2 cases (with foveal tears), while no difference in contrast leakage was observed for the other 3 cases (with horizontal or central tears). Revision surgery for implant related complications was performed in 2 cases.
Conclusion
: Acute DRUJ instability treated with dynamic stabilization led to satisfactory clinical outcomes in terms of range of motion, pain relief and joint stability, allowing DRUJ movement from the first postoperative week. This technique represents a simple, reproducible and minimally invasive procedure with a low rate of implant related complications.
... However, modern studies have focused on the beneficial effects of restoring the DOB in cases of chronic DRUJ instability, using both suture buttons and tendon grafts [23][24][25][26][27] . Among these techniques, it is worth to remember DOB reconstruction procedures by using the brachioradialis tendon, while keeping its distal insertion onto the radial styloid [28][29][30] . The advantages of these techniques are the use of a forearm tendon, whose removal does not affect upper limb function, and the ease to properly tense the graft during the bone tunnel passage, thanks to the preservation of the brachioradialis insertion 31,32 . ...
Volar distal radioulnar joint (DRUJ) dislocation is a very rare condition, and up to 50% of cases are misdiagnosed at the emergency room, because of subtle clinical findings and inadequate evaluation of radiographs in emergency settings. Treatment options vary from closed reduction with immobilization in a pronated position, to open reduction and repair of DRUJ stabilizers in case of locked irreducible or chronic dislocation, as well as in case of unstable DRUJ after an attempt at closed reduction. Among surgical procedures, the Aita-Mantovani technique of distal oblique bundle repair with a brachioradialis tendon strip can fully restore the multiplanar stability of the distal radio-ulnar joint. We present a case of an inveterate volar DRUJ dislocation, where the ulnar head was stuck out of the sigmoid notch, which was managed with open reduction and distal oblique bundle restoration according to the Aita-Mantovani technique.
... Their findings showed that all reconstructive procedures failed to restore natural joint stability. 30 Moore et al 31 suggested that a radial shortening of up to 5 mm does not require disruption of the DRUJ; however, a radial shortening of more than 10 mm requires disruption of the IOM in addition to disruption of the TFCC. In our study, in group 3, all stabilizing structures had been released, and different loads were applied. ...
Purpose
The purpose of this study was to measure distal radioulnar joint (DRUJ) dislocation and radioulnar displacement associated with sequential sectioning of the different bands of the interosseous membrane and triangular fibrocartilage complex in the simulation of a Galeazzi fracture dislocation.
Methods
Twelve fresh-frozen cadaver forearms were dissected. We examined the anatomy and function of the forearm interosseous membrane. Each forearm was then mounted onto a biomechanical wrist and forearm device. In the control group, radial osteotomy was performed and the degree of DRUJ displacement with progressive loads was measured. In addition to radial osteotomy, in group 1, the central band (CB) was sectioned; in group 2, the CB, distal membranous portion of the interosseous membrane, and distal oblique bundle were sectioned; and in group 3, the CB, distal membranous portion of the interosseous membrane, distal oblique bundle, and triangular fibrocartilage complex were sectioned.
Results
The radioulnar displacement (mm) at 25 N, 50 N, and 75 N was recorded. In group 1, applying progressive loads resulted in an average DRUJ displacement of 4.3, 5.9, and 7.9 mm, respectively. In group 2, the displacement was 5.2, 5.7, and 6.9 mm, respectively. In group 3, the displacement was 6.2, 8.1, and 9.9 mm, respectively. Our study showed a correlation between increase in the load applied to the same injury and the degree of displacement (P = .001). In group 3, the degree of DRUJ displacement was statistically increased compared to the other groups (P = .04).
Conclusions
Migration of the radius under loads implies disruption of both the CB and triangular fibrocartilage complex. The distal oblique bundle by itself does not seem to have a relevant role in radioulnar displacement at the DRUJ.
Clinical relevance
This study provides insights into the interosseous membrane and stability of the DRUJ, which can contribute to a better understanding of Galeazzi fracture-dislocations.
... Se dividen en técnicas anatómicas, en las cuales se intenta reconstruir los ligamentos radioulnares volar y dorsal con injerto de tendón, y técnicas no anatómicas, entre las cuales está la técnica de reconstrucción de la banda distal oblicua de la membrana interósea. 15,[33][34][35][36][37][38] La técnica descrita por Adams 33 consiste en reconstruir las porciones volar y dorsal del ligamento radioulnar con un injerto autólogo de tendón (palmaris longus), a través de un túnel en el borde ulnar del radio y, posteriormente, un túnel a nivel de la fóvea, en la ulna distal. Esta técnica ha demostrado buenos y excelentes resultados a mediano y largo plazos, logrando una tasa de éxito global de hasta un 86% a 5 años, con un 90,8% de pacientes que mantienen estabilidad de la ARUD, 75,9% de ellos con dolor leve o sin dolor residual. ...
Resumen
Las lesiones crónicas del complejo fibrocartílago triangular (CFCT) son una entidad que no ha sido descrita previamente como tal y no existe consenso en su manejo. La temporalidad de la lesión y su potencial de reparación son aspectos fundamentales a la hora de indicar un tratamiento. Proponemos un esquema de enfrentamiento a lesiones traumáticas crónicas del CFCT y describimos una técnica novedosa de reconstrucción con injerto de brachioradialis con asistencia artroscópica. Mostramos los resultados y el seguimiento de dos pacientes intervenidos con esta técnica.
... [23] A cadaveric study showed that DOB reconstruction by extensor indicis proprius tendon grafting could improve the stability of the DRUJ. [24] Another cadaveric study utilized a suture-button construct, placing it approximately in the direction of the DOB; therefore, DRUJ instability decreased considerably. [15] The suture-button construct merely requires two small incisions in the distal forearm and bone tunnel drilling in the radius and ulna, aligned with the DOB. ...
The stability of distal radioulnar joints is afforded by bony radioulnar articulation and peripheral soft-tissue stabilizers. The primary soft-tissue stabilizers are structures that surround the distal radioulnar joint and are collectively referred to as the triangular fibrocartilaginous complex. Among the stabilizers, the volar and dorsal radioulnar ligaments contribute the most to the stability of distal radioulnar joints. For acute traumatic distal radioulnar joint instability accompanied by purely ligamentous injury, traditional surgical treatments involve the repair or reconstruction of the distal radioulnar ligament; however, these intra-articular procedures are highly invasive and difficult. The extra-articular reconstruction of the secondary stabilizer such as the distal oblique bundle of the interosseous membrane has attracted significant attention in recent years; however, most studies have only conducted cadaveric or laboratory modelbased investigations. In this article, we present three patients who suffered from acute dorsal wrist pain after a trauma event. Radiographic and physical examinations revealed distal radioulnar joint instability. All patients were treated with minimally invasive suture-button suspension augmentation in the direction of distal oblique bundle of the interosseous membrane. The instability was resolved after the surgical procedure, but two patients developed ulnar wrist pain and one patient underwent implant removal. All patients have been continually followed at our outpatient department and exhibited stable wrists, despite mild limitation in the range of motion after the procedure. In conclusion, acute traumatic distal radioulnar joint instability may be sufficiently treated with suture-button suspension for augmentation of the distal oblique bundle; however, some obstacles impede the in vivo adoption of this treatment.
... A number of techniques for stabilizing the DRUJ have been described; Adams et al. [10], described anatomical reconstruction of the radioulnar ligament using palmaris tendon graft, Riggenbach et al. [11] repaired the DOB with an extensor indicis proprius tendon graft, Stein et al. [12] present a modified Adams approach using a tendon transplant with polyester suture, Brink et al. [13] inserted a palmaris longus tendon graft at the site of the DOB between the radius and ulna. ...
Introduction
and importance.
A distal radioulnar joint (DRUJ) dislocation is an uncommon occurrence. If not managed properly could result in severe functional impairment.
Case Presentation.
We report a case of a 45-year-old lady who was injured 6 months ago. She suffered a volar dislocation of the DRUJ and an ulnar head fracture. The DRUJ was stable after open reduction and reconstruction using suture-button technique.
Clinical Discussion.
Application of the first suture-button still result in positive ballottement with subluxation of ulnar head. Additional of second suture-button improved the stability and restored DRUJ motion.
Conclusion
The double suture-button technique restored the DRUJ's stability and produced a good functional outcome.
... With devices only applicable for ex-vivo use the bidirectional DRUJ translation in pronated forarms was repored to range from 2.9-12.4 mm [19,24,28]. ...
Purpose
Symptomatic instability of the distal radioulnar joint (DRUJ) caused by lesion of the Triangular Fibrocartilage Complex (TFCC) can be treated with a number of surgical techniques. Clinical examination of DRUJ translation is subjective and limited by inter-observer variability.
The aim of this study was to compare the stabilizing effect on DRUJ translation with two different surgical methods using the Piano-key test and a new precise low-dose, non-invasive radiostereometric imaging method (AutoRSA).
Methods
In a randomized experimental study we evaluated the DRUJ translation in ten human cadaver arms (8 males, mean age 78 years) after cutting the proximal and distal TFCC insertions, and after open surgical TFCC reinsertion ( n = 5) or TFCC reconstruction using a palmaris longus tendon graft ad modum Adams ( n = 5).
The cadaver arms were mounted in a custom-made fixture for a standardized Piano-key test. Radiostereometric images were recorded and AutoRSA software was used for image analyses. Standardised anatomical axes and coordinate systems of the forearm computer tomography bone models were applied to estimate DRUJ translation after TFCC lesions and after surgical repair.
Results
The DRUJ translation after cutting the proximal and distal TFCC insertions was 2.48 mm (95% CI 1.61; 3.36). Foveal TFCC reinsertion reduced DRUJ translation by 1.78 mm (95% CI 0.82; 2.74, p = 0.007), while TFCC reconstruction reduced DRUJ translation by 1.01 mm (95% CI -1.58; 3.60, p = 0.17).
Conclusion
In conclusion, foveal TFCC reinsertion significantly decreased DRUJ translation while the stabilizing effect of Adams TFCC reconstruction was heterogeneous. This supports the clinical recommendation of TFCC reinsertion in patients suffering from symptomatic DRUJ instability due to acute fovea TFCC lesions.
... 5 Several DOB reconstruction techniques have been described recently. In 2013, Riggenbach et al. 6 performed an anatomical study in cadavers comparing the reconstruction of distal radioulnar ligaments and DOB reconstruction. The Adams technique was used for the reconstruction of the radioulnar ligaments, whereas the DOB was replaced with a palmaris longus or an extensor carpi radialis brevis (ECRB) hemitendon graft; both techniques achieved similar functional outcomes; in addition, DOB reconstruction had no better functional outcome when associated with a supplementary Adams technique. ...
The main stabilizing element of the distal radioulnar joint (DRUJ) is the triangular fibrocartilage complex (TFCC). Secondary stabilizers include the distal oblique band (DOB), which is inconsistently found. When TFCC repair has failed or cannot be performed, DOB reconstruction is a therapeutic option. Even though distal radioulnar ligamentoplasty remains the technique of choice, recent papers show similar outcomes from both methods. We present two cases of successful DOB repair with the extensor carpi radialis longus (ECRL) hemitendon.
... After recognizing the importance of the DOB, wrist surgeons developed techniques to rebuild it. Riggenbach et al. 21,22 used a typical dorsal approach through the fifth compartment of the wrist, and recreated the bundle using a tendon graft that passed through holes at the ulna and radius at the site of the DOM. Brink and Hannemann 23 devised a minimally invasive percutaneous technique that used a tendon graft passing through drilled holes in the ulna and radius obliquely at the insertions of the DOB, secured with a Bio-Tenodesis Screw System. ...
The distal oblique bundle is a recognized distinct structure of the distal interosseous membrane of the forearm since 2009, when Noda et al. named it. Our mini-review will attempt to summarize knowledge gathered during the past few years and give guidelines towards possible questions that rise when reading studies about this topic. It is our strong belief that distal oblique bundle is worth investigating in full, since it seems to have an important role as a stabilizer of the distal radioulnar joint when present. Due to the efforts of a small number of surgeons and authors, the groundwork for understanding its purpose has been laid, but more research needs to be done.
... The authors presented their approach as a reconstruction technique of DOB, but this seems not to be accurate since the course of the brachioradialis tendon graft is exactly opposite to the normal course of the DOB. The course that the authors describe is more likely to represent the course of the "tract" of the interosseous membrane described by Gabl et al. 2 In our opinion, the reconstruction technique that simulates the DOB in the best way is the one described by Riggenbach et al. 3 The DOB is a structure of the distal interosseous membrane that seems to be an important isometric stabilizer for the DRUJ, according to Moritomo et al. 4 Its anatomical and clinical significance is still under evaluation, so accurate and careful descriptions are of immense importance. ...
... All these measurements are important and seem to have a huge impact on surgical reconstruction procedures that have timidly appeared in international literature [17][18][19][20]. These procedures seem to be a less invasive promising alternative for the stabilization of the DRUJ. ...
The distal oblique bundle of the forearm is a structure that has been under vigorous investigation for the past decade. It is part of the distal interosseous membrane (DIOM) and seems to have an important stabilizing effect in the distal radioulnar joint. In this essay, we have tried to summarize the anatomical characteristics of the structure. We have also compared and contrasted this to our own experience with eight freshly frozen forearms. It is our strong belief that the distal oblique bundle (DOB) may play a keystone role in future stabilization techniques of the distal radioulnar joint, and its anatomy characteristics need to be fully investigated.
... Recently, a number of procedures have been described for stabilization of the DRUJ. Riggenbach et al. reconstructed the DOB using an extensor indicis proprius tendon graft and compared this procedure to the Adams technique (Riggenbach et al., 2013). They achieved comparable stability when the DOB was reconstructed, compared with reconstruction of the DRUJ. ...
This study describes a minimally invasive procedure for stabilization of the distal radioulnar joint, using a suture-button construct placed percutaneously in the direction of the distal oblique bundle in the distal interosseous membrane. In five cadaveric specimens, placement of the suture-button suspension system reduced dorsal displacement of the radius in an unstable distal radioulnar joint to baseline values, both in neutral position and in pronation and supination. These results indicate the possibility of minimally invasive treatment for distal radioulnar joint instability.
... Clinically, Riggenbach et al performed a biomechanical study of a novel technique for DOB reconstruction. 19,20 They restored DRUJ stability in cadaver specimens using a tendon graft to recreate the DOB. This technique has been used clinically, with good early results reported (Dell [Gainesville, Florida], personal oral communication, March 28, 2016). ...
Background:
Injuries of the interosseous membrane (IOM) of the forearm are frequently unrecognized, difficult to treat, and can result in a devastating sequelae for the wrist and elbow.
Purpose:
The purpose of this review article is to evaluate the dignosis, biomechanics, clinical results, and propose a treatment approach to this rare complex entity.
Methods:
The biomechanical and clinical literature is reviewed. A treatment approach is described based on the known biomechanics and clinical experience of the senior author (T. W. W.).
Results:
Multiple different reconstructive methods have been proposed for the treatment of both acute and chronic IOM injuries. The results of the published series are reviewed. IOM injuries can have reasonable outcomes particularly if diagnosed and treated early.
Conclusion:
There are multiple methods for treating patients with IOM injuries. Physicians should be highly suspicious about this injury when a patient presents with a highly displaced radial head fracture associated with wrist pain. Treatment with reconstruction of the cerebral band of the IOM with radial head replacement (do not overstuff) and temporary uploading the construct with K-wires from the ulna to the radius will give the most predictable results.
... 7 Riggenbach's study on cadavers showed that a DOB reconstruction can restore stability to the DRUJ, using a technique as sound as that described by Adams. 10,11 Further, the ultrasound study by Okada et al showed that the absence of a DOB was correlated with more clinical complaints of instability in a small group of patients. 8 It therefore seems to make sense to use the DOB to promote stability in the DRUJ. ...
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.
Purpose Management of acute distal radioulnar joint (DRUJ) instability is complex and controversial. Common treatment options include prolonged immobilization, stabilization with wires, and acute triangular fibrocartilage complex repair. However, none of these permits an early range of motion. The purpose of this study is to investigate the feasibility of a suture-based stabilization (SBS) technique for acute DRUJ instability to permit early active motion.
Methods A biomechanical study utilizing eight cadaveric arms was performed. All specimens were tested in the intact state prior to the creation of bidirectional DRUJ instability. For the SBS group, 2-mm suture tapes with suture button fixation were utilized to recreate the respective contributions of distal oblique bundle and volar and dorsal radioulnar ligaments to DRUJ stability. All specimens were cyclically loaded with a simulated ballottement stress of 20N in forearm positions of neutral, 60 degrees of pronation and 60 degrees of supination. Range of motion and total translation were measured and then compared between the two groups.
Results The average range of motion in the intact and SBS specimens was 174 and 175 degrees, respectively. There were no significant differences in displacement between the intact and SBS group in neutral and in supination. However, the SBS group had less translation than the intact group in pronation.
Conclusions For acute DRUJ instability, the described SBS technique provides similar stability to the native intact DRUJ without compromising the range of motion in a cadaveric model. Future comparative studies are warranted prior to translation into the clinical arena.
Clinical Relevance This is a biomechanical study investigating a treatment technique for acute DRUJ instability that would allow an early range of motion.
Background Triangular fibrocartilage complex (TFCC) injury often results in distal radioulnar joint (DRUJ) instability. However, not all patients with a ruptured TFCC have an unstable DRUJ as in these patients a distal oblique bundle (DOB) may be present. We assumed that augmentation of the DOB leads to a more stable situation following reinsertion of the TFCC. We present the clinical results of a new surgical technique using the TightRope system as a DOB augmentation.
Description of Technique All cases were treated under regional anesthesia with the TightRope implant for which a tunnel was drilled from the distal ulna through the radius along the path of the DOB. The TightRope was passed through the tunnel and secured with buttons on either side. X-rays were made during surgery to confirm correct positioning.
Methods A retrospective study was performed analyzing 21 cases treated with a TightRope augmentation of the DOB. The primary outcome was measured using the patient-rated wrist evaluation (PRWE) score at least 12 months after surgery.
Results Postoperatively, the DRUJ was stable in all patients. The median PRWE score was 16 for the injured side compared to zero for the uninjured side (p-value: < 0.001). The median pronation and supination were not statistically significant when we compared the injured side to the uninjured side. The median grip strength was 31 kg for the injured side compared to 38 kg for the uninjured side (p-value: 0.015). There were two minor postoperative complications (10%).
Conclusion This technique is capable of restoring DRUJ stability with a short immobilization period resulting in good patient-related outcomes and a low complication rate.
Background Treatment algorithm for disruption of the triangular fibrocartilage complex (TFCC) from the ulnar fovea includes direct TFCC repair, tendon reconstruction of the radioulnar ligaments, or a salvage procedure in cases with painful distal radioulnar joint (DRUJ) degeneration.
Case Description We describe our surgical technique for reconstruction of the distal oblique bundle (DOB), to attain DRUJ stability in a young man, after failed attempts of direct TFCC reinsertion and radioulnar ligament reconstruction with the Adams procedure.
Literature Review Reconstruction of the central band of the interosseous membrane is well recognized for Essex-Lopresti injuries that demonstrate longitudinal forearm instability. The role for reconstruction/reinforcement of the DOB to restore DRUJ stability after TFCC injury has not gained the same recognition and needs further clarification.
Clinical Relevance DOB reconstruction technique described is extra-articular and technically straightforward. We believe that the procedure could be considered for patients with an irreparable TFCC injury as a part of the treatment algorithm for younger patients, who otherwise would face a more extensive salvage procedure.
Although the eponym for forearm longitudinal instability is known as Essex-Lopresti, Dr. Peter-Essex-Lopresti was not the first person who reported the injury. It was first described by Brockman in 1931 and again 15 years later by Curr and Coe. Essex-Lopresti correctly identified the injury to the interosseous membrane. He believed maintaining radial length prevented proximal migration. Seventy years later, his treatment tenets remain the standard in the setting of acute injuries. Chronic injuries, however, are more complicated in both timing and presentation. In chronic cases, the interosseous membrane is compromised with no healing potential. Therefore chronic cases with injury to all three components of forearm stability need to be treated.
This study aimed to compare the contact area, mean pressure, and peak pressure of the radiocapitellar joint (RCJ) in the upper limb after transradial amputation with those of the normal upper limb during elbow flexion and forearm rotation. Testing was performed using ten fresh-frozen upper limbs, and the transradial amputation was performed 5 cm proximal to the radial styloid process. The specimens were connected to a custom-designed apparatus for testing. A pressure sensor was inserted into the RCJ. The biomechanical indices of the RCJ were measured during elbow flexion and forearm rotation in all specimens. There was no significant difference in the contact area between the normal and transradial amputated upper limbs. However, in the upper limbs after transradial amputation, the mean pressure was higher than that in the normal upper limbs at all positions of elbow flexion and forearm rotation. The peak pressure was significantly higher in the upper limbs after transradial amputation than in the normal upper limbs, and was especially increased during pronation at 45° of elbow flexion. In conclusion, these results could cause cartilage erosion in the RCJ of transradial amputees. Thus, methods to reduce the pressure of the RCJ should be considered when a myoelectric prosthesis is developed.
Background
Cadaveric studies suggest that a thick part of the distal interosseous membrane (DIOM), known as the distal oblique bundle (DOB), contributes to the distal radioulnar joint (DRUJ)’s stability. We hypothesized that the DIOM thickness, measured via magnetic resonance imaging (MRI), has a clinically significant association with DRUJ stability.
Methods
We retrospectively reviewed patients from February 2018 and April 2019 who underwent wrist MRI examination with physical examination for DRUJ stability. We evaluated the correlation between their MRI findings (i.e., triangular fibrocartilage complex [TFCC] tears and presence of the DOB) and DRUJ instability.
Results
Out of 85 patients with an average age of 42 years, 45 (53%) had foveal TFCC tears and 29 (34%) had a DOB, and 38 patients (45%) had clinical DRUJ instability. Patients with DRUJ instability had a significantly higher incidence of foveal TFCC tears (30/38, vs 15/47, p < 0.001) and absent DOB (36/38 vs. 20/47, p < 0.001). Among 45 patients with foveal TFCC tears, only 1 out of 13 patients with a DOB had DRUJ instability, whereas 29 out of 32 patients without a DOB had DRUJ instability (p < 0.001). The odds ratio for DRUJ instability was 11.7 (95% CI 2.9–47.5, p = 0.001) for foveal TFCC tear and 54.2 (95% CI 8.2–358.2, p < 0.001) for the absent DOB.
Conclusions
Clinical DRUJ instability was less common when the DOB is present in patients with foveal TFCC tears, supporting the DOB's role as a secondary DRUJ stabilizer.
Purpose
A complete ulnar head replacement may be indicated in cases of distal radial ulnar joint (DRUJ) dysfunction to address bony pathology in lieu of using a constrained total DRUJ prosthesis. Complete ulnar head implants are simple, but they may be unstable if soft tissue tension is not adequately restored. We hypothesized that incorporating an increased offset in the complete ulnar head replacement would lead to increased tension on the distal oblique interosseous ligament, increased contact force at the DRUJ, and improved joint stability.
Methods
Using a specially designed jig, we measured instability by comparing displacement under load (stiffness) of the DRUJ in 10 cadaveric specimens under 4 different conditions: (1) intact, (2) native head after excision of the triangular fibrocartilage complex, (3) replacement of the ulnar head with a standard offset ulnar head, and (4) replacement of the ulnar head with an increased offset ulnar head. No soft tissue repair was done. We measured anteroposterior displacement under load with maximum translation of 10 mm or maximum loads of 50 N. We tested all specimens with the forearm positioned in neutral, supination, and pronation.
Results
Excising the triangular fibrocartilage complex decreased the average stiffness of the DRUJ to 46% of the intact state, creating a simulated state of DRUJ instability. Replacing the ulnar head with the standard offset head increased average stiffness to 54% of the intact state. Increasing the ulnar head offset with the simulated total ulnar head replacement increased average stiffness to 77% of the intact state.
Conclusions
An increased offset ulnar head replacement improves DRUJ stability compared with a standard anatomic offset ulnar head replacement.
Clinical relevance
Understanding DRUJ morphology and offset is important in the treatment of DRUJ arthritis and instability.
Résumé
Introduction
L’importance des ligaments radio-ulnaires distaux (RUD) dans la stabilité de l’articulation RUD est reconnue et la ligamentoplastie à ce niveau est une solution thérapeutique admise. Cependant, une autre structure anatomique semble pouvoir stabiliser significativement l’articulation : la bandelette distale oblique (DOB), renfort distal de la membrane interosseuse (MIO). La littérature récente s’est intéressée à des méthodes de reconstruction de cette DOB qu’il convient de comparer à la reconstruction des ligaments RUD.
Matériel et méthode
Douze membres supérieurs ont été étudiés. Dans un premier temps, une analyse anatomique descriptive a été réalisée pour déterminer la prévalence et les caractéristiques de cette DOB (insertions, épaisseur et communication avec les ligaments radio-ulnaires distaux). Dans un second temps, une analyse biomécanique a eu lieu en position neutre, supination et pronation du poignet. La translation du radius distal était d’abord étudiée sur un poignet « sain » puis après création d’une instabilité bidirectionnelle. Enfin, les mêmes tests étaient réalisés après reconstruction des ligaments RUD, selon la technique d’Adams–Berger, et de la DOB, selon la technique de Riggenbach, de façon alternative.
Résultats
La DOB était présente dans 50 % des cas et bilatérale. Sa reconstruction permettait de stabiliser le poignet de façon comparable à la technique d’Adams et Berger en position neutre et pronation (8 % d’instabilité majeure résiduelle). La stabilité semblait plus précaire en supination (25 % d’instabilité majeure). Elle contrôlait davantage la translation radiale postérieure qu’antérieure (3 % contre 14 % d’instabilité majeure).
Discussion et conclusion
La reconstruction de la bandelette distale oblique semble représenter une option thérapeutique fiable et peu invasive (ligamentoplastie extra-articulaire) dans les instabilités RUD. La position du poignet et la direction de la translation radiale semblent toutefois modifier l’efficacité de la stabilisation.
Niveau de preuve
IV ; étude cadavérique.
Introduction
The distal radioulnar (DRU) ligaments play a key role in stabilizing the DRU joint. Ligament reconstruction in this area is an accepted treatment. However, another structure may also be a significant DRUJ stabilizer–the distal oblique bundle (DOB) of the interosseous membrane (IOM). Recent studies have described DOB reconstruction methods, which should be compared to DRU ligament reconstruction.
Methods
Twelve upper limbs were used. First, a descriptive anatomy study was done to determine the prevalence and features of the DOB (insertions, thickness, and relationship with DRU ligaments). Second, biomechanical testing was done with the wrist in neutral position, supination, and pronation. Distal radius translation was evaluated first on an intact wrist then evaluated again after creating bidirectional instability. Lastly, the same tests were repeated after DRU reconstruction using the Adams-Berger technique and DOB reconstruction using the Riggenbach technique.
Results
The DOB was present in 50% of specimens and was bilateral. Reconstructing the DOB stabilized the wrist to the same degree as the Adams-Berger technique in neutral and pronation (8% residual major instability). Stability was harder to achieve in supination (25% major instability). It was better at controlling posterior radial translation than anterior translation (3% versus 14% major instability).
Conclusion
DOB reconstruction appears to be a reliable and less invasive treatment option for DRUJ instability since it is extra-articular. However, the wrist's position and the direction of radial translation seem to alter the stabilization's effectiveness.
Level of evidence
IV; Cadaver study.
Purpose:
Distal oblique bundle (DOB) reconstruction for distal radioulnar joint (DRUJ) instability is an alternative to the Adams 2-incision distal radioulnar ligament reconstruction. The DOB reconstruction offers a single incision and is a technically less demanding procedure requiring a shorter tendon autograft. The DOB and Adams reconstruction may provide similar stability. This study sought to compare the biomechanical stability of the 2 DRUJ reconstructions. We hypothesized that DOB reconstruction would result in equivalent DRUJ translation, cyclic loading to failure, and maximal load to failure compared with the Adams reconstruction.
Methods:
Ten fresh-frozen cadaver arms underwent DOB or Adams reconstructions. Volar, dorsal, and total translation of the radius relative to the ulna at the DRUJ were measured before and after each reconstruction. Translation was measured with a 20-N force in neutral position and 60° in pronation and supination. Measurements were obtained using a custom jig and electromagnetic motion-tracking system sensors. Total cycles and maximal load to failure of each reconstruction were measured and recorded using an electromechanical testing machine.
Results:
There was a DOB incidence of 70%. Distal radioulnar joint translation, total cycles, and failure load were similar for the 2 reconstructions. On average, the DOB reconstruction had less dorsal translation than did the Adams in supination. Translation in the DOB reconstruction was similar to that of native DRUJs. In supination, on average, the Adams reconstruction had greater total, volar, and dorsal translation compared with native DRUJs.
Conclusions:
In terms of translation, cyclical loading, and maximal load to failure, the DOB reconstruction for DRUJ instability is similar to the Adams reconstruction.
Clinical relevance:
This pilot study supports the DOB reconstruction as a possible alternative to the Adams reconstruction for DRUJ instability. The DOB reconstruction may theoretically reduce patient morbidity because it requires only one incision and a shorter tendon graft. However, further clinical and cadaveric studies are required to determine biomechanical equivalence and impact on patient morbidity.
A study was undertaken to examine the presence of the distal oblique bundle of the forearm in a large sample in order to describe its true prevalence. The study sample consisted of 200 cadaveric forearms. Fifteen were excluded due to defects in the distal interosseous membrane. In the remaining 185 specimens, the distal interosseous membrane was examined following removal of soft tissue, to determine whether a distal oblique bundle was present and whether there were connecting fibres to the distal radio-ulnar joint. The distal oblique bundle was observed in 53 specimens (29%). In 45 of these forearms (85%), one or more connecting fibres to the distal radio-ulnar joint were identified. The presence of a distal oblique bundle in 29% is less frequent than that reported in previous literature. The presence of the distal oblique bundle should be noted and may be of importance in the management of disorders of the distal radio-ulnar joint.
described the anatomy of the triangular fibrocartilage complex (TFCC) in 1981 (Fig. 1) and performed biomechanical studies on cadaver specimens demonstrating the importance of the TFCC for distal radioulnar joint (DRUJ) stability. The TFCC consists of the articular disc (triangular fibrocartilage proper), the ulnar collateral ligament (UCL), the ulnocarpal ligament complex (ulnolunate, ulnocapitate, ulnotriquetral), the dorsal and palmar radioulnar ligaments (RUL), and the extensor carpi ulnaris (ECU) tendon sheath. The superficial and deep radioulnar ligaments are the primary soft tissue stabilizers of the DRUJ with the deep fibers (also referred to as the ligamentum subcruentum) inserting into the fovea and the superficial fibers onto the ulnar styloid. New Developments Rotation of the forearm through the proximal radioulnar joint and DRUJ is complex. New data in a 3-dimensional in vivo forearm kinematic study demonstrate the forearm axis of rotation is dynamic, and varies throughout the arc of rotation at both the proximal radioulnar joint and DRUJ. 2 Proximally, the radial head translated from the anterior rim of the radial notch to the posterior rim when moving from pronation to supination. Distally, the axis varied over a small range over the distal ulna. Therefore, pronation and supination of the forearm consists of rolling and gliding in addition to translation. The variability of forearm rotation axis between subjects is likely related to differences in osteology and ligamentous laxity. Kataoka et al 3 classified the distal ulna into 2 types based on shape: a concave-type and a flat-type fovea (Fig. 2). Ulnar variance is typically increased in the flat type, and ulnar variance is associated with an increased distance between the anatomic axis and the pronosupi-nation axis. The clinical significance of ulnar head shape remains unknown. DRUJ stability is greatest in wrist extension and in radial deviation. 4 However, after sectioning of the ulnocar-pal ligaments (ulnolunate, ulnocapitate, ulnotriquetral), the stabilizing effect of wrist extension and radial deviation disappears, and there are no longer differences in any wrist position. 4 The ulnocarpal ligaments may contribute to stability of the DRUJ with the wrist in an extended position via tightening of the palmar RUL. Kataoka et al 5 showed the stabilizing effect of ulno-carpal ligament reconstruction after complete TFCC sectioning in cadaveric studies. Kataoka et al used an exclusively volar approach to suture palmaris longus graft to the remnant ulnocarpal ligament complex and passed the graft through a bone tunnel in the fovea. Biomechan-ical testing demonstrated improved DRUJ stability in all positions. Iida et al 6 demonstrated the dynamic effect of the ECU tendon and its subsheath on DRUJ stability after radioul-nar ligament sectioning. In both the neutral and supinated positions, the ECU tendon provides considerable added stability to the DRUJ when loaded with force and thus, caution is advised against using the ECU as autograft for DRUJ or wrist reconstructions.
The distal radioulnar ligament reconstruction is a technique that may be used for distal radioulnar joint instability without arthritis and failed nonsurgical management; clinical results demonstrate resolved or improved stability. Recent literature has focused on the distal oblique bundle of the interosseous membrane and its contributions to stability. This article describes a technically simple surgical technique to reconstruct the distal oblique bundle and restore distal radioulnar joint stability. © 2015 American Society for Surgery of the Hand All rights reserved.
Currently, up to 25% of patients with spinal cord injuries may experience neurologic deterioration during the initial management of their injuries. Therefore, more effective procedures need to be established for the transportation and care of these to reduce the risk of secondary neurologic damage. Here, we present more acceptable methods to minimize motion in the unstable spine during the management of patients with traumatic spine injuries.
This review summarizes more than a decade of research aimed at evaluating different methods of caring for patients with spine trauma.
The most commonly utilized technique to transport spinal cord injured patients, the log rolling maneuver, produced more motion than placing a patient on a spine board, removing a spine board, performing continuous lateral therapy, and positioning a patient prone for surgery. Alternative maneuvers that produced less motion included the straddle lift and slide, 6 + lift and slide, scoop stretcher, mechanical kinetic therapy, mechanical transfers, and the use of the operating table to rotate the patient to the prone position for surgical stabilization.
The log roll maneuver should be removed from the trauma response guidelines for patients with suspected spine injuries, as it creates significantly more motion in the unstable spine than the readily available alternatives. The only exception is the patient who is found prone, in which case the patient should then be log rolled directly on to the spine board utilizing a push technique.
The distal interosseous membrane (DIOM) of the forearm acts as a secondary stabilizer of the distal radioulnar joint (DRUJ) when the dorsal and palmar radioulnar ligaments of the triangular fibrocartilage complex are cut. Recent anatomical studies revealed that thickness of the DIOM varies widely among specimens and the distal oblique bundle (DOB) exists within the DIOM in 40% of specimens. The DOB originates from the distal one-sixth of the ulnar shaft and runs distally to insert on the inferior rim of the sigmoid notch of the radius. The mean thickness of the DIOM without a DOB was 0.4 mm, which was significantly thinner than 1.2 mm with a DOB. Biomechanical studies have shown that the DOB is an isometric stabilizer of the forearm during pronosupination. The presence of a DOB was shown to have a significant impact on DRUJ stability. Innate DRUJ laxity in the neutral forearm position was greater in the group without a DOB than in the group with a DOB. Ulnar shortening with the osteotomy performed proximal to the attachment of the DIOM had a more favorable effect on stability of the DRUJ compared with the effect of distal osteotomy, especially in the presence of a DOB. The longitudinal resistance to ulnar shortening was significantly greater in proximal shortening than in distal shortening. It also suggested that the DIOM is of great importance in the management of concomitant ulnar-side injuries in distal radius fracture.
The importance of the stabilizing effect of the distal interosseous membrane on the distal radioulnar joint, especially in patients with a distal oblique bundle, has been described. The purpose of this study was to evaluate the stability of the distal radioulnar joint after an ulnar shortening osteotomy and to quantify longitudinal resistance to ulnar shortening when the osteotomy was proximal or distal to the ulnar attachment of the distal interosseous membrane. These relationships were characterized for forearms with or without a distal oblique bundle.
Ten fresh-frozen cadavers were used. A transverse osteotomy and ulnar shortening was performed proximal (proximal shortening) and distal (distal shortening) to the ulnar attachment of the distal interosseous membrane. Distal radioulnar joint laxity was evaluated as the volar and dorsal displacements of the radius relative to the fixed ulna with 20 N of applied force. Testing was performed under controlled 1-mm increments of ulnar shortening up to 4 mm, with the forearm in neutral alignment, 60° of pronation, and 60° of supination. Resistance to ulnar shortening was quantified as the slope of the load-displacement curve obtained by displacing the distal ulnar segment proximally.
In proximal shortening, significantly greater stability of the distal radioulnar joint was obtained with even 1 mm of shortening compared with the control, whereas distal shortening demonstrated significant improvement in stability of the distal radioulnar joint only after shortening of ≥4 mm in all rotational positions. Significantly greater stability of the distal radioulnar joint was achieved with proximal shortening than with distal shortening and in specimens with a distal oblique bundle than in those without a distal oblique bundle. The longitudinal resistance to ulnar shortening was significantly greater in proximal shortening than in distal shortening. The stiffness in proximal shortening was not affected by the presence of a distal oblique bundle in the distal interosseous membrane.
Ulnar shortening with the osteotomy carried out proximal to the attachment of the distal interosseous membrane had a more favorable effect on stability of the distal radioulnar joint compared with distal osteotomy, especially in the presence of a distal oblique bundle.
The distal interosseous membrane (DIOM) is a secondary stabilizer of the distal radioulnar joint (DRUJ) and has a considerably variable morphology. The purpose of this study was to investigate whether innate DRUJ stability is influenced by the anatomic variation of the DIOM.
Ten fresh-frozen cadaver upper extremities were used in this study. The humerus and the ulna were affixed rigidly to a custom-made apparatus, with the elbow in 90° of flexion. Testing was performed by translating the radius in volar and dorsal directions relative to the ulna, with a 20-N applied force in neutral forearm alignment, 60° pronation, and 60° supination. Total translation of the radius was measured as DRUJ laxity. After the experiment, we investigated anatomic variation of the DIOM, especially regarding the existence of the distal oblique bundle (DOB), which is a notably thick fiber within the DIOM. We compared the DRUJ stability between the groups with and without the DOB.
The DOB was found in 4 of 10 specimens. The group with a DOB demonstrated a significantly greater DRUJ stability in the neutral position than the group without a DOB. In pronated and supinated forearm positions, no significant difference in DRUJ stability was obtained between the groups with and without a DOB.
Innate DRUJ stability in the neutral forearm position was greater in the group with a DOB than in those without a DOB.
This study suggests that considerable variation exists in DRUJ laxity and that it partially depends on anatomical variations of the DIOM.
An earlier anatomic study described five ligamentous components in the interosseous membrane of the forearm (central band, accessory band, distal oblique bundle, proximal oblique cord, and dorsal oblique accessory cord) and provided their precise location of attachment. In the present study, we investigated in vivo length changes of these five ligaments during forearm rotation to understand the function of each ligament.
We acquired computed tomographies of nine forearms from seven healthy volunteers for 3 rotation positions: maximum pronation, neutral position, and maximum supination. We created 3-dimensional models of the radius, ulna, and the 5 ligaments by combining osseous images and anatomic data of ligament attachment. We calculated 3-dimensional ligament lengths between attachments during forearm rotation using a markerless bone registration technique. We also examined relationships between the axis of forearm rotation and each ligament.
The distal 3 ligaments (central band, accessory band, and distal oblique bundle) had little change in length during forearm rotation, with their ulnar attachments located almost on the axis of forearm rotation. The 2 proximal ligaments (proximal oblique cord and dorsal oblique accessory cord) changed substantially in length, with their attachments out of the course of the axis.
The distal 3 ligaments of the interosseous membrane are essentially isometric stabilizers of the forearm. The distal oblique bundle in the distal membranous portion may stabilize the distal radioulnar joint in 40% of human subjects who have this ligament.
The interosseous membrane (IOM) of the forearm is a stout ligamentous complex that reportedly comprises several ligamentous components. The purpose of this cadaveric study was to define all IOM ligaments and to clarify the precise attachment locations.
Thirty forearms from 15 embalmed cadavers were used. After dissection, all IOM ligaments were identified, and attachments were measured from the tip of the radial styloid or the ulnar head. Attachment locations were represented as a percentage of total bone length from the distal end of the radius or ulna.
The IOM included 5 kinds of ligaments: central band, accessory band, distal oblique bundle, proximal oblique cord, and dorsal oblique accessory cord. The most distal and proximal ends of the radial origin of the central band were 53% and 64% of total radial length from the tip of the radial styloid, whereas those of the ulnar insertion were 29% and 44% of total ulnar length from the ulnar head. The center point of the radial origin and ulnar insertion of the accessory band were 37% and 23%, respectively. The center points of the ulnar origins and radial insertions were 15% and 10% for the distal oblique bundle; 80% and 79% for the proximal oblique cord; and 64% and 62% for the dorsal oblique accessory cord, respectively.
The present study clarified precise attachment locations of all representative IOM ligaments. This information will be useful in planning proper graft placement in ligament reconstruction surgery and for future biomechanics research into the function of the IOM ligaments.
The controversy surrounding the treatment of radial-head fractures is based, we feel, on the failure to separate undisplaced, displaced, comminuted, complicated, and pediatric fractures. Considering only isolated injuries in adults and each type of fracture separately, we have personally re-examined eighty-eight patients treated at the Massachusetts General Hospital from 1950 to 1962.
Our major findings were: (1) early motion may displace otherwise undisplaced fractures; (2) if more than one-third of the radial head is displaced, limitation of motion will probably result; (3) the range of motion depends on the anatomical result; (4) inferior radio-ulnar subluxation does occur, but is of so little significance that it can be ignored as an argument against excision of the radial head when this procedure is indicated.
We would treat undisplaced fractures involving less than one-third of the radial head with active motion as soon as the patient is comfortable. We have had no experience in treating undisplaced fractures involving more than one-third of the radial head by immobilizing the elbow until displacement by active motion is no longer possible, but such a procedure might improve the results.
Displaced fractures involving less than two-thirds of the radial head should, we think, be treated by early active motion, started when the patient is comfortable. Displaced fractures involving more than two-thirds of the radial head should be treated by early total excision, as should all comminutcd fractures.
The dorsal and palmar distal radio-ulnar ligaments (DRUL) play an important role in the stability of the distal radio-ulnar joint (DRUJ). Various authorities, however, hold opposite opinions regarding DRUL motion during DRUJ pronation and supination, thus implying opposite techniques for reconstruction of the unstable DRUJ. With the hypothesis that relative displacement would increase in the dorsal DRUL during pronation and would increase in the palmar DRUL during supination, measurements were made of the relative DRUL displacement with a Hall-effect displacement transducer during DRUJ pronation and supination in six fresh cadaver wrists. The hypothesis was confirmed that the dorsal radio-ulnar ligament undergoes relative displacement during pronation, while the palmar radio-ulnar ligament undergoes relative displacement during supination.
Numerous reconstructive procedures have been described for the treatment of chronic instability of the distal radioulnar joint or instability of the stump of the resected distal ulna. This biomechanical study presents an evaluation of the three basic design types that have been used in reconstruction. The initial static stability provided by the reconstructions was tested and compared with the stability of the intact joint. Our findings show that all reconstructive procedures failed to restore natural joint stability. A radioulnar sling design was the most effective of the three types, whereas tenodesis procedures and ulnar collateral ligament reconstruction were much less effective in providing stability. We conclude that current designs have significant biomechanical shortcomings. On the basis of our observations during testing, we believe that improved designs will require an intra-articular reconstruction that more closely duplicates the biomechanical functions of the triangular fibrocartilage complex.
A biomechanical cadaver study was performed to determine the roles of the stabilizing structures of the distal radioulnar joint during pronation and supination. Subluxation and dislocation of the radius with respect to the ulna were evaluated in seven cadaver forearms placed in supination, pronation, and neutral forearm rotation. The amount of subluxation was measured with all structures intact, and after sectioning in various sequences the dorsal and palmar radioulnar ligaments, the distal portion of the interosseous membrane including the pronator quadratus, and the entire interosseous membrane. After sectioning two of any four structures, the distal radioulnar joint remained stable. When the interosseous membrane was disrupted first, the dorsal radioulnar ligament was found to be more important than the palmar radioulnar ligament in stabilizing the distal radioulnar joint in pronation, and conversely the palmar radioulnar ligament was more important than the dorsal radioulnar ligament in supination. Dislocation, and frequently diastasis, occurred only with sectioning of all four structures. This suggests that all four structures contribute to stability of the distal radioulnar joint.
Fourteen patients with posttraumatic distal radioulnar joint instability were treated with a reconstruction of the distal radioulnar ligaments. The technique is anatomically accurate, is reproducible, and requires less dissection than previously described techniques. Candidates for the procedure had joint instability and an irreparable triangular fibrocartilage complex. Ten patients had bidirectional instability. Two patients had a concurrent corrective osteotomy of the distal radius for a malunion. The procedure restored stability and relieved symptoms in 12 of 14 patients at 1 to 4 years' follow-up evaluation. One patient with a deficient sigmoid notch and one with ulnocarpal ligament injury did not achieve full stability. All patients attained near full pronation and supination. The procedure is an effective treatment for an unstable distal radioulnar joint when its articular surfaces are intact and the other wrist ligaments are functional, and it can be used in combination with a distal radius corrective osteotomy.
Distal radioulnar joint (DRUJ) instability can result in pain and functional disability. Numerous DRUJ reconstructive options have been described with minimal biomechanical analysis. The purpose of this study was to evaluate the ability of 4 well-described DRUJ reconstructions to restore joint kinematics using a dynamic, motion-controlled simulator.
Eleven cadaveric upper extremities had computer-controlled simulated active forearm rotation. Joint kinematics were quantified by using an electromagnetic tracking system. We compared the passive and simulated active kinematics of the intact, unstable, and reconstructed DRUJ (capsular repair, 2 described radioulnar ligament reconstructions, and a radioulnar tethering procedure).
All reconstructions improved significantly the kinematics of the unstable DRUJ. The capsule repair restored simulated active joint kinematics closest to the intact DRUJ.
All 4 reconstructions improved DRUJ stability significantly. The capsule repair most closely matched intact DRUJ kinematics and the radioulnar ligament reconstructions were found to be superior to a radioulnar tethering procedure.
Although forearm injuries are accompanied frequently by rupture to the interosseous membrane (IOM) diagnosis of the extent of IOM injury is difficult. In this study we evaluated distal radioulnar joint (DRUJ) laxity caused by both partial and complete IOM disruption and compared these quantitative measurements with the common clinical manual evaluation of DRUJ laxity and dislocatability.
Human cadaveric forearms (n = 8) were used in this study. Skin, muscles, and tendons were removed. The specimens were mounted on an experimental apparatus that allowed the radius to move freely about the fixed ulna. Tests were performed in neutral rotation, 60 degrees pronation, and 60 degrees supination. Under various conditions of IOM sectioning testing was performed by volary and dorsally translating the radius relative to the ulna in the coronal plane of the radius. Testing was performed both qualitatively as would be performed in the clinic and quantitatively with an instrumented probe.
Our results show that dorsal dislocation of the radius relative to the ulna strongly suggests distal IOM rupture. Disengagement of the radius from the DRUJ indicated injury to the distal and middle IOM. The distal IOM constrained volar and dorsal laxity of the radius at the DRUJ in all forearm rotation positions. The midportion of the IOM constrained laxity except in the volar direction of the pronated forearm. The proximal IOM did not constrain the proximal radius except dorsally for the pronated forearm position.
The IOM, in particular the distal IOM, plays an important role in constraining dorsal dislocation of the radius at the DRUJ.
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