Selection of Tendon Grafts for Distal Radioulnar Ligament Reconstruction and Report of a Modified Technique

Abstract

Purpose To investigate the graft length necessary to complete a distal radioulnar ligament reconstruction and assess the suitability of several tendon graft sources. Methods We measured the graft length needed to complete the distal radioulnar ligament reconstruction in 7 fresh-frozen cadaver specimens. The pure tendon lengths of 7 tendon graft sources were measured: palmaris longus, extensor indicis proprius, slips of extensor digiti minimi and abductor pollicis longus, and portions of flexor carpi ulnaris, flexor carpi radialis, and extensor carpi ulnaris. A modified technique which allows for a shorter length of graft is also described, and the suitability of each graft source for this technique was assessed. Results The mean graft length needed to complete the original and modified reconstructions were 138 mm and 89 mm, respectively. The average length of the tendon graft when measured as pure tendon were: palmaris longus (127 mm), slip of extensor digiti minimi (112 mm), extensor indicis proprius (100 mm), partial flexor carpi radialis (87 mm), slip of abductor pollicis longus (69 mm), partial flexor carpi ulnaris (67 mm), and partial extensor carpi ulnaris (67 mm). The palmaris longus was too short for the original technique in the majority of specimens but was sufficient to complete the modified technique in every specimen that had a palmaris longus. Six specimens also had an extensor indicis proprius of suitable length for the modified technique. Discussion The length of donor graft required for the modified reconstruction was significantly less than that needed for the original reconstruction. Three specimens had no donor tendons sufficiently long to complete the original technique if a pure tendon graft were used, whereas the modified technique could be completed in all specimens. Clinical Relevance Many tendon graft sources in the upper extremity are of insufficient length to complete the distal radioulnar ligament reconstruction as described. A modified technique using suture anchors may be a useful alternative in such cases.

Ultrasound determination of presence, length and diameter of the palmaris longus tendon

“…Rather than measure potential available tendon length, including its intramuscular portion, we agree with previous investigators (Ito et al., 2001; Jang et al., 2014; Milone et al., 2017) who chose to measure ‘pure tendon length’, as it is a reproducible method to identify usable tendon. The mean pure tendon length (12.2 SD 3.6 cm) observed in this study is similar to tendon lengths reported by investigators measuring the PL in this manner (average 11.7–13.1 cm) (Ito et al., 2001; Jang et al., 2014; Milone et al., 2017).…”

“…When the PL tendon was present, the tendon length and diameter was determined using the measurement tool on the LOGIQ E9 ultrasound system in the long axis and short axis planes, respectively. Consistent with previously published methodology, tendon length was measured to the musculotendinous junction and tendon diameter was assessed in the midportion of the tendon (Jang et al., 2014; Milone et al., 2017).…”

“…Forearm length was defined as the distance from the medial epicondyle to the distal wrist crease. Consistent with previously described methodology, each wrist was then explored through a transverse wrist incision made 2 cm proximal to the distal wrist flexion crease, and the tendon was divided in the proximal palm at the point of the tendon’s flare into its aponeurosis (Dowdy et al., 1994; Jang et al., 2014; Matloub et al., 1998). The tendon, when present, was harvested with the use of an Acufex Closed Tendon Stripper (Smith & Nephew; Memphis, TN) to simulate a surgical harvest.…”

“…Intramuscular portions of the PL tendon and muscle belly were not included in the measurements. Rather than measure potential available tendon length, including its intramuscular portion, the ‘pure tendon length’ was chosen because it was a reproducible measurement of usable tendon with consistent cross-sectional width (Ito et al., 2001; Jang et al., 2014; Milone et al., 2017). Tendon diameter at the midportion of the tendon was measured by passing the tendon through the circular holes on the body of the stainless steel ruler; these holes increase in diameter along the length of the ruler in approximately 1 mm increments and are used in the operating room to confirm wire and pin diameter.…”

Predicting Tendon Tissue Grafting Source From the Extensors of Long Fingers: A Systematic Review of Cadaveric Studies

“…However, extra tendons from the dorsum of the hand are usually shorter than PL, and extra slips could be thinner, mainly those of the little finger. 7 For instance, Jang et al 20 reported average lengths as follows: PL (127 mm), EDM (112 mm), and extensor indicis proprius (100 mm).…”