Acta Orthop. Belg., 2007, 73, 451-457 ORIGINAL STUDY Correction of chronic lunotriquetral instability using extensor retinacular split : A retrospective study of 26 patients Ilkka ANTTI-POIKA, Jukka HYRKÄS, Liisa M VIRKKI, Daisuke OGINO, Yrjö T KONTTINEN From the Orto-Lääkärit Medical Center, Helsinki, Finland, Helsinki University Central Hospital, Helsinki, Finland, the ORTON Orthopaedic Hospital of the Invalid Foundation, Helsinki, Finland, and the COXA Hospital for the Joint Replacement, Tampere, Finland Arthroscopy offers a welcome and reliable supple- INTRODUCTION ment to the current tool set for the diagnosis of lunotriquetral (LT) instability. This study reports the Lunotriquetral (LT) instability may occur as an findings of LT-lesions during arthroscopy and the isolated ligamentous injury of the LT-joint (7) or, clinical results obtained after using dorsal stabilisa- probably in most cases, together with some other tion in its surgical management using extensor reti- injuries of the ulnar side of the wrist. It causes rest nacular split. LT-instability of grade I-III was diag- pain and mostly activity-induced pain in grip nosed in 26 patients. Imaging results were normal, activities, and leads to giving away sensations. The Reagan’s ballottement and Watson tests were posi- diagnosis of lunotriquetral instability is based part- tive in 47% and 79%, respectively. After arthroscop- ly on the patient history and the injury mechanism, ic diagnosis, the procedure was immediately contin- ued with an open repair utilising an 8-10 mm wide and radial-based extensor retinacular split for dorsal capsular reinforcement. At 39 months (range : 14 to ■ Ilkka Antti-Poika, MD, PhD, Senior Hand Surgeon. 84) follow-up, 64% had no or only occasional mild ■ Jukka Hyrkäs, MD, Senior Hand Surgeon. pain and 36% had pain with overuse or lifting. Orto-Lääkärit Medical Center, Helsinki, Finland. Overall scoring encompassing pain, patient satisfac- ■ Daisuke Ogino, PhD, Post doctoral Fellow. tion, range of motion and grip strength, was excellent Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland. in 24% and good in 64%. Only three patients had ■ Liisa M Virkki, MSc, PhD Student. fair results, one after a further injury leading to dis- Department of Medicine, Helsinki University Central tal radio-ulnar joint (DRUJ) instability, and two with Hospital, Helsinki, Finland and ORTON Orthopaedic Hospital concurrent DRUJ-stabilisation. One further patient of the Invalid Foundation, Helsinki, Finland. required a secondary procedure. Arthroscopy seems ■ Yrjö T Konttinen, MD, PhD, Professor. to allow accurate diagnosis of LT-instability and can Department of Medicine, Helsinki University Central be continued in the same session using a straight- Hospital, Helsinki, Finland, ORTON Orthopaedic Hospital of the Invalid Foundation, Helsinki, Finland and COXA Hospital forward reconstruction procedure providing satis- for the Joint Replacement, Tampere, Finland. factory results. Correspondence : Ilkka Antti-Poika, Orto-Lääkärit Medical Keywords : wrist ; lunotriquetral instability ; extensor Center, Yrjönkatu 36 A, 00100 Helsinki, Finland. E-mail : [email protected]. retinacular split. © 2007, Acta Orthopædica Belgica. No benefits or funds were received in support of this study Acta Orthopædica Belgica, Vol. 73 - 4 - 2007 452 I. ANTTI-POIKA, J. HYRKÄS, L. M. VIRKKI, D. OGINO, Y. T. KONTTINEN which are often difficult to recall, and proper diag- lunotriquetral instability, two were lost to follow-up, and nosis and treatment are therefore delayed (9). the outcomes were evaluated for 26 patients. During the past 20 years, the cornerstones of the The mean age of the patients at the time of the oper- correct diagnosis of LT instability have been pain ation was 35 years (range : 14 to 54). Sixty two percent and tenderness over the LT-joint and a positive (n = 16) of the patients were women. The occupations of the patients were as follows : lunotriquetral ballottement test (7). Radiographs may show slight narrowing and cystic changes on Office, sales, management 10 (38%) both sides of the LT-joint, computerised tomogra- Student 5 (19%) phy can further depict the bony structures of the Healthcare, childcare, education 4 (15%) LT-joint, but more recently MRI and especially Industrial 2 (8%) arthroscopy of the radiocarpal and midcarpal joint Transportation 2 (8%) Agricultural 1 (4%) have revolutionised the diagnostics (2). Sports, physical education 1 (4%) Magnetic resonance imaging provides informa- Unknown 1 (4%) tion on the status of the extrinsic and intrinsic ligaments and joint capsule, but it does not allow The injury mechanisms were a fall on the hand in testing of the instability of the LT-joint. Therefore, 10 patients (38%), trauma without falling in 11 patients (42%), no acute trauma in 3 patients (12%) and a seque- arthroscopy offers a welcome and most reliable lae of radial fracture in 2 patients (8%). Of those who supplement to the current diagnostic tool set. fell, six did so when walking or performing some other During normal arthroscopic examination the LT- daily activity, such as walking in stairs, and three when joint is viewed on both radiocarpal and midcarpal performing sports or some equivalent physical activity sides, which allows exact visualisation of the (cycling, rollerblading and football). One further patient location and type of the damage. After arthroscopy fell two meters from a ladder. Of the traumas not involv- has confirmed the diagnosis of lunotriquetral ing a fall, five were related with sports (volleyball, ice instability, specific site-directed treatment can be hockey, floor hockey, tennis and acrobatics), three provided during the same anaesthesia by convert- involved other activities (usage of tools in two and lift- ing the diagnostic arthroscopy to an operative ing injury in one) and three were twisting injuries with- procedure. This is very relevant as the diagnosis by out detailed history. The traumas by falling or without itself is not the goal but is only a means for plan- falling involved twisting, hyperextension or supination injuries of the wrists. In addition, two traumas with a fall ning an injury-type specific treatment. We used this involved a radius fracture. option and developed a new operative modification The right wrist was injured in 14 of the patients for stabilisation of lunotriquetral instability. This is (54%) and the left in 12 (46%). Twelve patients injured particularly important because many of these their dominant hand, and twelve injured their non-dom- patients are young and physically active and, there- inant hand. For two patients the information of handed- fore, incapacitated in their hobbies, mostly sports. ness was missing. The mean time from injury to opera- This study reports the findings of lunotriquetral tion was 19 months (range : 1 to 120). lesions during arthroscopy and the clinical results obtained after dorsal stabilisation using extensor Clinical tests retinacular split. Clinical tests Preoperative lunotriquetral ballottement test results PATIENTS AND METHODS were available for 17 patients, of which 8 (47%) had a positive and 9 (53%) a negative result. Of the 19 patients Patient demographics and injury mechanisms with available information on the preoperative Watson test, 15 (79%) had a positive result and 4 (21%) had a The first author performed 28 lunotriquetral stabilisa- negative result. All those fifteen patients (58%), who tion operations on consecutive patients from 1998 to were tested using midcarpal provocation test, had a neg- 2003 using the technique described below. Of the ative test result ; 11 (42%) patients had not been tested 28 patients who had undergone stabilisation surgery for using this test. Acta Orthopædica Belgica, Vol. 73 - 4 - 2007 CORRECTION OF CHRONIC LUNOTRIQUETRAL INSTABILITY 453 Arthroscopy Wrist arthroscopy was performed using five routine portals of which three had a radiocarpal location and two a midcarpal location. Finger traction was usually applied to the second and fourth fingers using 3-6 kgf, depend- ing on the weight of the patient. Counter-traction was T applied to the upper arm. L Arthroscopy was performed in operation room facili- ERS ties under general anaesthesia and using a tourniquet. If lunotriquetral instability was diagnosed in arthroscopy, ER the operation described below was performed in an open manner with the patient’s arm lying on the table and without counter-traction. Lunotriquetral stabilisation A dorsal operative approach was used. A lazy S- or Z- type skin incision was performed depending on the arthroscopic portals used. The extensor retinaculum was Fig. 1. — Lunotriquetral stabilisation using a dorsal operative exposed and depending on its width and strength, an 8- approach. Extensor retinaculum is exposed and depending 10 mm wide and radial-based strip was harvested distal- on its used width and strength, an 8-10 mm wide and radial- ly from the extensor retinaculum (fig 1). The dorsal sur- based split (ERS)is harvested distally from the extensor faces of both lunatum and triquetrum were exposed by retinaculum (ER). dividing the capsule obliquely. A fixing anchor (Mitek mini anchor, DePuy Mitek Inc., Norwood, MA, or Arthrex Small Bone FasTak titanium anchor, Arthrex Inc., Naples, FL) was inserted into both bones (fig 2). With the wrist in a neutral position in flexion-extension, ERS the strip was turned over the lunotriquetral joint and fixed to the anchor threads with proper tension.