The Unpredictable Palmaris Longus Tendon Variation in Distal Radio-Ulnar Joint Reconstruction: A Technical Consideration for Undersized Graft

Abstract

Background: Distal radioulnar joint (DRUJ) instability results from the disruption of the triangular fibrocartilaginous complex consisting of DRUJ's primary and secondary stabilizers. The gold standard of stabilization procedure remains ligament reconstruction that utilizes tendon grafts to reanimate the volar and dorsal radioulnar ligament (RUL) as the primary stabilizers of the joint. The palmaris longus (PL) tendon, the graft of choice in reconstructive surgery, is commonly used in DRUJ reconstruction. However, it can exhibit anatomic variations from agenesis to the variation in morphology, location, and attachment that is rarely encountered other than in cadaveric studies. Case Presentation: We present a case of a 14-year-old boy with ulnar-sided wrist pain and instability following an injury in a boxing match four months before admission. The clinical and radiological results suggested a DRUJ injury with extensor carpi ulnaris (ECU) tendinitis. A ligament reconstruction using the PL tendon graft was planned. Intraoperatively, the PL was found anomalous with dual distal attachments and a short graft length. Results: We performed Adams ligament reconstruction technique with some modifications to the original design. To overcome the under-sized graft, instead of passing it around the ulnar neck, we added one more bone tunnel on the ulna to enhance the construct stability by a tendon to bone healing. Conclusion:In reconstructive surgeries, surgeons should consider the other sources of grafts as graft variations exist. Otherwise, as in our case, modifications to the standard technique can be made.

Ligament reconstruction with modified suture anchor fixation technique for chronic distal radioulnar joint instability: A case report and literature review

“…The palmaris longus (PL) is the preferred tendon donor for ligament reconstruction. On the other hand, it may display anatomical alterations, such as agenesis and changes in morphology, position, and attachment [ 5 ]. In this case report, we performed a chronic DRUJ reconstruction using the harvesting palmaris longus technique.…”

“…As this is a chronic case and the patient is actively working, it is recommended to do surgery with the DRUJ ligament reconstruction technique [ [3] , [4] , [5] ]. The surgery was performed on September 9th, 2022, after consent.…”

“…Reconstruction of the distal radioulnar ligaments offers the best possibility of restoring normal DRUJ primary constraints and kinematics [ 4 , 5 ]. When reconstructing ligaments using the method described by Adam and Berger in 2002, the palmaris longus is the preferred tendon donor [ 3 , 4 ].…”

Prediction Of Palmaris Longus Tendon Length And Thickness Through Simple Anthropometric Measurements

“…The PLT length was insufficient for their individual specimen in 3 of the 6 remaining specimens (50 %) [11]. Similarly, Hidajat et al had to modify the planned surgical technique in a patient with DRUJ instability due to a short and anomalous PL muscle [10]. Furthermore, Low et al planned a two-stage tendon reconstruction for the 3rd and 4th finger Zone 2 FDS incision and had to postpone the operation when the thickness of the harvested PLT was 2 mm [12].…”

“…Generally speaking, a PLT graft 15 cm in length and 3 mm in thickness is advocated 7 8 9 . Harvesting a tendon with insufficient length and thickness may create problems during surgery 10 . Jang et al dissected 7 fresh-frozen cadavers and measured the graft length required to complete distal radioulnar ligament reconstruction.…”