Anatomic Reconstruction Of The Distal Radio-Ulnar Ligament and Osteotomy For Malunion Distal Radius and Ulna With Distal Radio-Ulnar Joint Instability.

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(1)

ANATOMIC RECONSTRUCTION OF THE DISTAL

RADIO-ULNAR LIGAMENT AND OSTEOTOMY FOR

MALUNION DISTAL RADIUS AND ULNA WITH

DISTAL RADIO-ULNAR JOINT INSTABILITY:

A CASE REPORT

Oleh :

dr. Putu Mega Wiyastha

Pembimbing :

dr. A.A. Gde Yuda Asmara, Sp. OT

PROGRAM PENDIDIKAN DOKTER SPESIALIS I

BAGIAN/SMF ORTHOPAEDI DAN TRAUMATOLOGY

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ANATOMIC RECONSTRUCTION OF THE DISTAL

RADIO-ULNAR LIGAMENT AND OSTEOTOMY FOR MALUNION

DISTAL RADIUS AND ULNA WITH DISTAL RADIO-ULNAR

JOINT INSTABILITY:

A CASE REPORT

Putu Mega Wiyastha*, A.A. Gde Yuda Asmara**,

* Orthopaedic and Traumatology Resident of Udayana University, Sanglah Hospital Denpasar **Teaching Staff of Orthopaedic and Traumatology of Udayana University, Sanglah Hospital Denpasar

Introduction

Stability of the distal radioulnar joint (DRUJ) is provided by bony architecture and by soft tissues such as the triangular fibrocartilage complex (TFCC), the joint capsule, and surrounding muscles. Anatomic reconstruction of the major structures

responsible for joint stability is the most important principle for the treatment of instability of an injured joint with an intact articular surface by using a palmaris longus tendon graft.

Case

Male, 19 year old with DRUJ instability associated with distal radial and ulna malunion. Patient had history of trauma two years ago. On examination there is restricted of the Range Of Motion (ROM) wrist flexion-extension and forearm

supination. The management with corrective osteotomy of the distal radius and ulna

with the radioulnar ligament reconstruction.

Discussion

Restoration of stability and a full painless arc of pronation–supination are the goals of treatment for the posttraumatic unstable DRUJ. The reconstruction procedures

suggested by some authors using the palmaris longus tendon has been shown to be the most reliable and anatomically acceptable surgical technique. We performed distal radioulnar ligament reconstruction after osteotomy distal radius and ulna then fixation using plate and screw.

(3)

ANATOMIC RECONSTRUCTION OF THE DISTAL

RADIO-ULNAR LIGAMENT AND OSTEOTOMY FOR MALUNION

DISTAL RADIUS AND ULNA WITH DISTAL RADIO-ULNAR

JOINT INSTABILITY:

A CASE REPORT

Putu Mega Wiyastha*, A.A. Gde Yuda Asmara**,

* Orthopaedic and Traumatology Resident of Udayana University, Sanglah Hospital Denpasar

**Teaching Staff of Orthopaedic and Traumatology of Udayana University, Sanglah Hospital

Denpasar

Introduction

Stability of the distal radioulnar joint (DRUJ) is provided by bony architecture and by

soft tissues such as the triangular fibrocartilage complex (TFCC), the joint capsule,

and surrounding muscles. Anatomic reconstruction of the major structures

responsible for joint stability is the most important principle for the treatment of

instability of an injured joint with an intact articular surface by using a palmaris

longus tendon graft.1

Many authors have made various attempts to restore DRUJ stability surgically

following trauma. Some have employed indirect methods such as tenodesis using the

flexor carpi ulnaris tendon or the extensor carpi ulnaris tendon. However, these

nonanatomic procedures are not reliable in that the normal stability of the joint is not

restored and the joint motion may be restricted. Anatomic reconstruction of the major

structures responsible for joint stability is the most important principle for the

treatment of instability of an injured joint with an intact articular surface. In this

sense, some authors have tried to achieve anatomic reconstruction of the volar and

(4)

The objective of this study was to analyze clinical outcomes after anatomic

reconstruction of the distal radio-ulnar ligaments in a patient with post-traumatic

chronic instability of the DRUJ.

Case

Male, nineteen years old with DRUJ instability associated with distal radial and ulna

malunion. Patient had history of trauma two years ago and treated in bone setter.

History of fever denied by the patient. Patient was a student. On examination there is

deformity angulations and shortening on the left wrist without tenderness on

palpation. The piano key sign was positive. restricted of the range of motion (ROM)

wrist flexion-extension and forearm supination.

(A) (B)

Figure 1. (A) shows the clinical picture pre operative with deformity angulation and

shortening of the left wrist. (B) shows restricted flexion-extension active ROM of the

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Figure 2. Shows the clinical picture pre operative with restricted supination-pronation

active ROM of the left forearm

First we correct the malunion distal radius with osteotomy and fixation with

locking small T-plate three hole, then we do osteotomy and correction deformity

distal ulna with fixation using locking one third tubular plate six hole. We use

Palmaris longus tendon as a graft for stabilization distal radioulnar joint. The site for

the tunnel in the radius is prepared, we use guidewire for a 2 mm cannulated drill bit

is driven through the radius a few millimeters proximal to the lunate fossa and radial

to the articular surface of the sigmoid notch.

The cannulated drill bit is used to create a pilot tunnel. The tunnel is

progressively enlarged with standard drill bits, if necessary, to accommodate the

tendon graft. Then we use ligament sling for stabilize the distal radio ulnar joint. In this case we didn’t do osteotomy simoid notch. The last we use K-wire 1.4 mm to stabilize the distal radioulnar joint and we plan remove after 3 weeks.

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Figure 3. The clinical picture intra operative when osteotomy the radial bone (A) and

(B) clinical picture of the osteotomy distal ulna, (C) fixation distal radius using distal

radial locking plate

(A) (B) (C)

Figure 4. (A) show the Palmaris longus tendon as a graft for stabilization distal

radioulnar joint, (B) and (C) clinical picture of the radial and ulnar side with Palmaris

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Figure 5. Show the X-ray post operative. We use K-wire about 3 weeks.

Figure 6. The clinical picture 4 weeks after operation, show the deformity was

reduced.

Discussion

The distal radioulnar ligaments are key stabilizers of the distal radioulnar joint

(DRUJ). When these ligaments fail to heal adequately after injury, DRUJ instability

may develop. Reconstruction of the distal radioulnar ligaments offers the best

(8)

Numerous techniques have been described, which can be classified into 3 categories:

(1) a direct radioulnar tether that is extrinsic to the joint, (2) an indirect radioulnar

link through an ulnocarpal sling or a tenodesis, or (3) reconstruction of the distal

radioulnar ligaments.1,3

In patients with radial malunion, a planned osteotomy was performed prior to

distal radioulnar ligament reconstruction to restore normal DRUJ alignment. After

proper internal fixation was applied, an anteroposterior stress test was performed to

determine the necessity of distal radioulnar ligament reconstruction. Because

instability was still observed in all patients, distal radioulnar ligament reconstruction

was performed at the same time. In one patient with radial shaft malunion, distal

radioulnar ligament reconstruction actually preceded osteotomy because the

preoperative angular deformity on the sagittal plane was not definite, but subluxation

during supination was observed requiring additional distal radius osteotomy.1,4

A palmaris longus tendon graft was harvested, and each end of the graft was

connected to a thread to facilitate easy passage through the tunnels. The periosteum

was dissected from the distal and dorsal margin of the sigmoid notch to make an

anteroposterior tunnel in the radius. A guide wire was inserted in parallel with the

articular surface of the sigmoid notch. The proper guide wire position was checked

with a C-arm followed by creation of a 3-4 mm tunnel for the graft without damaging

the subchondral bone of the radiocarpal joint and the sigmoid notch. A 2 cm

transverse incision was made over the volarly protruding guide wire to expose the

volar opening of the tunnel and the volar side of the DRUJ. A 2.0 mm drill hole was

made in the radius, then gradually enlarged with a straight curette to allow for

passage of the tendon graft . To make the ulnar tunnel, the wrist was flexed volarly

and the TFCC was pulled distally to expose the ulnar fovea. With the ulna pulled

dorsally, a tunnel was made through the ulnar fovea at a tilt angle toward the ulnar

side of the ulnar neck in the same way for the radial tunnel. The tendon graft was

passed through the radial tunnel and both of its limbs were brought to the opening in

(9)

hemostat was used to pierce the anterior capsule between the ulnar head and the

TFCC without damaging the ulnar nerves or vessels.1,5

Both limbs were passed through the ulna tunnel to the ulnar side of the ulnar

neck. The limb on the volar side surrounded the ulna and was sutured with the other

limb using 3-0 nonabsorbable sutures. During the suturing procedure, both limbs

were pulled taut with the forearm in neutral position, and care was taken not to

restrict forearm rotation by imposing excessive tension. Motion of the wrist joint and

the DRUJ was checked, and the final status of the reconstructed tendon was assessed

(10)
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Reference

1. 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):243-51.

2. Lawler E, Adams BD. Reconstruction for DRUJ instability. Hand (N Y).

2007;2(3):123-6.

3. Sahoo J. Anatomic reconstruction of the distal radioulnar ligament for distal

radioulnar joint instability: a case report. IJPMR June 2013; Vol 24 (2):

48-50.

4. Kyu Nam Seo, Min Jong Park, Hong Je Kang. Anatomic Reconstruction of

the Distal

5. Radioulnar Ligament for Posttraumatic Distal Radioulnar Joint Instability.

Clinics in Orthopedic Surgery 2009;1:138-145

6. Adams BD. Post-Traumatic (Chronic) Distal Radioulnar Joint Instability.

Figur

Figure 1. (A) shows the clinical picture pre operative with deformity angulation and

Figure 1.

A shows the clinical picture pre operative with deformity angulation and . View in document p.4
Figure 2. Shows the clinical picture pre operative with restricted supination-pronation

Figure 2.

Shows the clinical picture pre operative with restricted supination pronation . View in document p.5
Figure 4. (A) show the Palmaris longus tendon as a graft for stabilization distal

Figure 4.

A show the Palmaris longus tendon as a graft for stabilization distal . View in document p.6
Figure 5. Show the X-ray post operative. We use K-wire about 3 weeks.

Figure 5.

Show the X ray post operative We use K wire about 3 weeks . View in document p.7
Figure 6. The clinical picture 4 weeks after operation, show the deformity was

Figure 6.

The clinical picture 4 weeks after operation show the deformity was . View in document p.7

Referensi

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