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Heifner JJ, Bain GI, Mercer DM, Orbay JL. Addressing the Central Band in Acute and Chronic Essex-Lopresti Injury: A Case Report and Technique Description. JBJS Case Connect 2024; 14:01709767-202406000-00041. [PMID: 38820195 PMCID: PMC11139232 DOI: 10.2106/jbjs.cc.24.00059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
CASE A 34-year-old man was acutely treated with radial head arthroplasty and central band repair following Essex-Lopresti injury. A 38-year-old man presented with chronic longitudinal instability following failed radial head arthroplasty, which was performed for failed fixation. Treatment with revision radial head arthroplasty and central band reconstruction restored longitudinal stability. CONCLUSION We have a low threshold to repair the central band in acute Essex-Lopresti injury with sufficient evidence of disruption. Nearly all chronic cases require central band reconstruction to restore longitudinal stability. We do not temporarily pin the DRUJ, and distal ulnar shortening is rarely indicated.
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Affiliation(s)
| | - Gregory I. Bain
- Flinder Medical Centre, Adelaide, South Australia, Australia
| | - Deana M. Mercer
- Department of Orthopedics, University of New Mexico, Albuquerque, New Mexico
| | - Jorge L. Orbay
- Department of Orthopaedic Surgery, Larkin Hospital, Miami, Florida
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Heifner JJ, Lacau GE, Orbay JL. Revision management of a 17-year-old patient initially treated with radial head excision following terrible triad injury with associated Essex Lopresti. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:106-112. [PMID: 38323199 PMCID: PMC10840582 DOI: 10.1016/j.xrrt.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
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Wittig US, Prager W, Sarahrudi K, Gkourlias G, Thomas N, Hammer N, Hohenberger GM. Does surgical reconstruction of the distal oblique bundle (DOB) provide similar stability as the intact bundle or Adams procedure? A systematic review. Ann Anat 2023; 250:152130. [PMID: 37467811 DOI: 10.1016/j.aanat.2023.152130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/21/2023] [Accepted: 06/28/2023] [Indexed: 07/21/2023]
Abstract
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.
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Affiliation(s)
- Ulrike Susanne Wittig
- Department of Trauma Surgery, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria; Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria.
| | - Walter Prager
- Department of Trauma, LKH Feldbach-Fürstenfeld, Feldbach, Austria
| | - Kambiz Sarahrudi
- Department of Trauma Surgery, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - Georgios Gkourlias
- Department of Trauma Surgery, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - Norbert Thomas
- Department of Trauma Surgery, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - Niels Hammer
- Division of Macroscopic and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria; Department of Trauma, Orthopedic and Plastic Surgery, University Hospital of Leipzig, Leipzig, Germany; Fraunhofer Institute for Machine Tools and Forming Technology (Fraunhofer IWU), Division of Medical Technology, Dresden, Germany
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Sheth M, Mitchell S, Bell B, Wu C. Essex-Lopresti Lesions and Longitudinal Radioulnar Instability: A Narrative Review. JBJS Rev 2022; 10:01874474-202203000-00006. [PMID: 35263316 DOI: 10.2106/jbjs.rvw.21.00212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» An Essex-Lopresti injury (ELI) is classically described as a radial head fracture with a concomitant interosseous ligament complex (IOC) injury. However, multiple injury patterns may be present, and an interosseous membrane (IOM) injury should be evaluated for in any axial load injury through the forearm. ELI may result in longitudinal radioulnar instability (LRUI). » Diagnosis of an IOC injury can be difficult. Evaluation begins with standard wrist and elbow radiographs and is supplemented with radiographs and intraoperative maneuvers to assess for proximal radial migration. Magnetic resonance imaging and ultrasonography may be useful in the acute setting, although indications and the clinical importance of the findings remain unclear. » Surgical management of an acute ELI is focused on restoration of radial length and temporary distal radioulnar joint (DRUJ) stabilization. Radial head excision in the acute setting should be approached with caution because proximal migration may not be present acutely but may develop over time. The indication for acute IOM repair and reconstruction remains unclear. » Surgical management of a chronic ELI is focused on restoration of radial length, wrist leveling, and treatment of degenerative changes (either at the radiocapitellar joint or the DRUJ). Reconstruction of the central band can restore forearm load transfer and produce favorable functional outcomes, but its indications continue to be debated.
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Affiliation(s)
- Mihir Sheth
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas
| | - Scott Mitchell
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas
| | - Bryce Bell
- Department of Orthopedic Surgery, Texas Children's Hospital, Houston, Texas
| | - Chia Wu
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas
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Abstract
This article reviews the anatomy and mechanics of pronation and supination (axial rotation) of the forearm through the distal radioulnar joint (DRUJ), and the proximal radioulnar joint (PRUJ). Injuries to the bones and/or ligaments of the forearm, wrist, or elbow can result in instability, pain, and limited rotation. Acute dislocations of the DRUJ commonly occur along with a fracture to the distal radius, radial metadiaphysis, or radial head. These injuries are all caused by high-energy trauma. Outcomes are predicated on anatomic reduction and restoration of stability to the DRUJ and PRUJ with or without ligamentous repair or reconstruction.
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Affiliation(s)
- Louis H Poppler
- Department of Plastic & Reconstructive Surgery, St. Luke's Health System, Boise, ID, USA
| | - Steven L Moran
- Department of Plastic & Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA; Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.
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Wang J. The serious full-length forearm injury - a case report and literature review. BMC Musculoskelet Disord 2020; 21:381. [PMID: 32539757 PMCID: PMC7296690 DOI: 10.1186/s12891-020-03394-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 06/02/2020] [Indexed: 11/26/2022] Open
Abstract
Background Among upper limb injuries, carpal bone fractures and dislocation, Essex-Lopresti injury, and the terrible triad injury of the elbow are serious and relatively rare injuries. These injuries require surgical intervention. The surgical method is difficult, and the treatment effect is poor. These injuries have not been described in the same limb in the literature. Case presentation A 21-year-old male patient fell from a height in our institution and sustained multiple injuries, including carpal bone fracture-dislocation, Essex-Lopresti injury, and the terrible triad injury of the elbow of his right upper limb. After 2 surgeries and rehabilitation, he returned to work. We reviewed available reviews and related literature on serious upper-limb damage. Conclusions Full-length forearm injury is very rarely encountered, and the management of such fractures is difficult. Radial head replacement with a metal prosthesis, reconstructed the IOM with Tightrope, and fixed the DRUJ with a K-wire pin is appropriate treatment.
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Affiliation(s)
- Jun Wang
- Department of orthopedic, Xiaoshan 1st People's Hospital, Hangzhou, 311200, China. .,Department of orthopedic, Xiaoshan 1st People's Hospital, No. 199 Shixin Road, Hangzhou, 311201, Zhejiang Province, China.
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Masouros PT, Apergis EP, Mavrogenis AF, Babis GC, Artemi DK, Nikolaou VS. Reconstruction of the forearm interosseous membrane: a biomechanical study of three different techniques. J Hand Surg Eur Vol 2020; 45:360-368. [PMID: 31399010 DOI: 10.1177/1753193419866382] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Reconstruction of the interosseous membrane has the potential to re-establish a normal loading pattern through the forearm and enhance stability after an Essex-Lopresti lesion. The aim of our study was to assess the capacity of three different techniques, which all use a regionally harvested autograft, to restore longitudinal stability. Simulation of the Essex-Lopresti lesion was done by excising the radial head and sectioning the interosseous membrane in seven cadaveric specimens. Each technique was used in each specimen consecutively, using the pronator teres, the brachioradialis and the flexor carpi radialis tendons, respectively. The specimens were submitted to mechanical testing by applying proximally migratory forces to the radius and radioulnar displacement was assessed fluroscopically at wrist level. The pronator teres tendon achieved the greatest reduction (94% correction with respect to the intact interosseous membrane/radial head out state, followed by brachioradialis (92%) and flexor carpi radialis (85%). However, no statistically significant differences in displacement data or strength were detected between the techniques.
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Affiliation(s)
| | | | - Andreas F Mavrogenis
- 1st Department of Orthopaedics, National and Kapodistrian University of Athens, Athens, Greece
| | - George C Babis
- 2nd Department of Orthopaedics, National and Kapodistrian University of Athens, Athens, Greece
| | - Dendi K Artemi
- Department of Anesthesiology, Children Hospital "Agia Sofia", Athens, Greece
| | - Vasileios S Nikolaou
- 2nd Department of Orthopaedics, National and Kapodistrian University of Athens, Athens, Greece
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Rein S, Esplugas M, Garcia-Elias M, Magin TM, Randau TM, Siemers F, Philipps HM. Immunofluorescence analysis of sensory nerve endings in the interosseous membrane of the forearm. J Anat 2019; 236:906-915. [PMID: 31863467 DOI: 10.1111/joa.13138] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 11/20/2019] [Indexed: 12/22/2022] Open
Abstract
The human interosseous membrane (IOM) is a fundamental stabilizer during forearm rotation. To investigate the dynamic aspects of forearm stability, we analyzed sensory nerve endings in the IOM. The distal oblique bundle (DOB), the distal accessory band (DAB), the central band (CB), the proximal accessory band (PAB), the dorsal oblique accessory cord (DOAC) and the proximal oblique cord (POC) were dissected from 11 human cadaver forearms. Sensory nerve endings were analyzed at two levels per specimen as total cell amount/mm2 after immunofluorescence staining with low-affinity neurotrophin receptor p75, protein gene product 9.5, S-100 protein and 4',6-diamidino-2-phenylindole on an Apotome microscope, according to Freeman and Wyke's classification. Sensory nerve endings were significantly more commonly found to be equally distributed throughout the structures, rather than being epifascicular, interstitial, or close to the insertion into bone (P ≤ 0.001, respectively). Free nerve endings were the predominant mechanoreceptor in all six structures, with highest density in the DOB, followed by the POC (P ≤ 0.0001, respectively). The DOB had the highest density of Pacini corpuscles. The DOAC and CB had the lowest amounts of sensory innervation. The high density of sensory corpuscles in the DOB, PAB and POC indicate that proprioceptive control of the compressive and directional muscular forces acting on the distal and proximal radioulnar joints is monitored by the DOB, PAB and POC, respectively, due to their closed proximity to both joints, whereas the central parts of the IOM act as structures of passive restraint.
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Affiliation(s)
- Susanne Rein
- Department of Plastic and Hand Surgery, Burn Unit, Hospital Sankt Georg, Martin-Luther-University Halle-Wittenberg, Leipzig, Germany
| | | | | | - Thomas M Magin
- Division of Cell and Developmental Biology, Institute of Biology, University of Leipzig, Leipzig, Germany
| | - Thomas M Randau
- Department of Orthopaedic and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Frank Siemers
- Department of Plastic and Hand Surgery, Burn Unit, Trauma Center Bergmannstrost, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Hubertus M Philipps
- Department of Plastic and Hand Surgery, Burn Unit, Hospital Sankt Georg, Martin-Luther-University Halle-Wittenberg, Leipzig, Germany
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Hackl M, Leschinger T, Rausch V, Wegmann K, Müller LP. Therapieoptionen bei schmerzhaften Folgezuständen nach Radiuskopffraktur. ARTHROSKOPIE 2019. [DOI: 10.1007/s00142-019-0289-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Masouros PT, Apergis EP, Babis GC, Pernientakis SS, Igoumenou VG, Mavrogenis AF, Nikolaou VS. Essex-Lopresti injuries: an update. EFORT Open Rev 2019; 4:143-150. [PMID: 31057951 PMCID: PMC6491950 DOI: 10.1302/2058-5241.4.180072] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Reconstruction of the central band of the interosseous membrane is an emerging procedure implemented in the treatment of longitudinal radioulnar dissociation (LRUD), usually in its chronic setting, after Essex-Lopresti injuries of the forearm. There are no sufficient clinical data to support reconstruction of the central band of the interosseous membrane in acute LRUD injuries. Clinical and cadaveric studies comparing autografts (palmaris longus, flexor carpi radialis and bone-patellar-bone), allografts (Achilles tendon) and synthetic ligaments have not shown superiority of one technique versus another; however, they have shown special concerns with respect to the use of synthetic grafts. Latrogenic fracture, decrease of rotational range of movement, iatrogenic nerve injury (superficial radial and median nerve), donor site morbidity with autografts and recurrent instability are the complications reported in literature after interosseous membrane reconstruction.
Cite this article: EFORT Open Rev 2019;4:143-150. DOI: 10.1302/2058-5241.4.180072
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Affiliation(s)
| | | | - George C Babis
- Second Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | | | - Vasilios G Igoumenou
- First Department of Orthopaedics, National and Kapodistrian University of Athens, Athens, Greece
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasileios S Nikolaou
- Second Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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Oppermann J, Burkhart KJ, Löw S, Müller LP. [The proximal radioulnar joint in consideration of the distal radioulnar joint]. DER ORTHOPADE 2018; 47:663-669. [PMID: 29947876 DOI: 10.1007/s00132-018-3590-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The movement of the forearm follows a complex interplay of three main components: the proximal and distal radioulnar joint and the interosseous membrane. Injuries to one or even all components have a huge impact on the integrity of this system. The Essex-Lopresti lesion presented a high challenge in clinical diagnostics as well as therapy. Reconstructions of the length and stability are essential for a satisfactory postoperative outcome. If a reconstruction of the radial head by osteosynthesis is not possible, a radial head prosthesis should be implanted in the case of longitudinal instability - avoiding overlapping and/or oversizing. The reconstruction of the interosseous membrane should be considered, as well as the assessment of the distal radioulnar joint and/or the triangular fibrocartilage complex. Various reconstruction options are available in this regard.
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Affiliation(s)
- J Oppermann
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universität zu Köln, Kerpener Straße 62, 50937, Köln, Deutschland.
- Cologne Center for Musculoskeletal Biomechanics, Medical Faculty, University of Cologne, Köln, Deutschland.
| | | | - S Löw
- Praxis für Handchirurgie und Unfallchirurgie, Bad Mergentheim, Deutschland
| | - L P Müller
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universität zu Köln, Kerpener Straße 62, 50937, Köln, Deutschland
- Cologne Center for Musculoskeletal Biomechanics, Medical Faculty, University of Cologne, Köln, Deutschland
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Abstract
Essex-Lopresti Lesions are rare injuries that are often missed in the acute setting. Delayed intervention may lead to chronic wrist and elbow pain and overall poor outcomes. The literature currently supports treatments that involve shortening of the ulna to reduce the relative degree of ulnar impaction, followed by attempted reduction of the distal radioulnar joint. Although such techniques may help to temporarily reduce wrist pain secondary to ulnar impaction, they do not address the proximal migration of the radius and ipsilateral radial head dislocation at the elbow. Subsequent procedures are often needed to replace or resect the radial head. We present a novel approach to chronic Essex-Lopresti lesions resulting in anatomic restoration of forearm length with return of elbow and wrist flexion/extension as well as improved forearm pronation/supination.
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An uncommon variant of the Essex-Lopresti injury. Skeletal Radiol 2018; 47:397-400. [PMID: 28971244 DOI: 10.1007/s00256-017-2782-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 09/11/2017] [Accepted: 09/19/2017] [Indexed: 02/02/2023]
Abstract
The Essex-Lopresti injury is an extremely rare condition combining radial head or neck fracture, distal radio-ulnar joint dislocation and rupture of the interosseous membrane. However, there are rare or unusual varieties or associated injuries. We report a case of a 46-year-old woman with a posterior dislocation of the radio-humeral joint, a radial shaft fracture, and a distal radio-ulnar joint dislocation. She underwent open reduction and internal fixation of the radial shaft fracture followed by an immobilization by a long elbow splint in supination for 6 weeks. At 18 months of follow-up, she was asymptomatic and she had a full range of elbow and wrist motion and had resumed thoroughly her previous job. The Essex-Lopresti injury results from a complex injury to the forearm axis with resultant longitudinal instability, which can be challenging to treat. There are some variations that can lead to a missed diagnosis resulting in persistent pain and instability of the wrist. The best outcomes are reached with early diagnosis and prompt management.
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Gaspar MP, Kearns KA, Culp RW, Osterman AL, Kane PM. Single- versus double-bundle suture button reconstruction of the forearm interosseous membrane for the chronic Essex-Lopresti lesion. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 28:409-413. [PMID: 28986647 DOI: 10.1007/s00590-017-2051-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 10/03/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE Reconstruction of the ruptured interosseous membrane (IOM) is critical to restore forearm stability for the chronic Essex-Lopresti injury. Positive outcomes have been reported following IOM reconstruction with a single-bundle suture button (Mini-Tightrope) construct, although recent work suggests that double-bundle Mini-TightRope® IOM reconstruction is biomechanically superior. The purpose of this study was to determine whether double-bundle Mini-TightRope® reconstruction of the forearm IOM results in superior clinical outcomes to the single-bundle technique. METHODS Five patients with chronic Essex-Lopresti injuries treated with double-bundle Mini-TightRope® IOM reconstruction were matched to five patients treated with single-bundle Mini-TightRope® reconstruction. Improvement in clinical examination measures and patient-reported outcomes was compared between the groups. RESULTS Results were good to excellent in all 10 patients. At final follow-up, forearm rotation was significantly better in the single-bundle group, while maintenance of ulnar variance was better in the double-bundle group. No significant differences were noted between the two groups for any other numerical outcomes, and no complications occurred. CONCLUSION These findings suggest that while IOM reconstruction with a double-bundle Mini-TightRope® construct results in greater resistance to proximal migration of the radius in the intermediate term, there is a modest concomitant loss of forearm rotation when compared to single-bundle reconstruction. LEVEL OF EVIDENCE Therapeutic Level IV.
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Affiliation(s)
- Michael P Gaspar
- Philadelphia Hand to Shoulder Center, Department of Orthopedic Surgery, Thomas Jefferson University, The Franklin, Suite G114, 834 Chestnut Street, Philadelphia, PA, 19107, USA. .,Darden School of Business, University of Virginia, Charlottesville, VA, 22903, USA.
| | - Kenneth A Kearns
- Philadelphia Hand to Shoulder Center, Department of Orthopedic Surgery, Thomas Jefferson University, The Franklin, Suite G114, 834 Chestnut Street, Philadelphia, PA, 19107, USA
| | - Randall W Culp
- Philadelphia Hand to Shoulder Center, Department of Orthopedic Surgery, Thomas Jefferson University, The Franklin, Suite G114, 834 Chestnut Street, Philadelphia, PA, 19107, USA
| | - A Lee Osterman
- Philadelphia Hand to Shoulder Center, Department of Orthopedic Surgery, Thomas Jefferson University, The Franklin, Suite G114, 834 Chestnut Street, Philadelphia, PA, 19107, USA
| | - Patrick M Kane
- Philadelphia Hand to Shoulder Center, Department of Orthopedic Surgery, Thomas Jefferson University, The Franklin, Suite G114, 834 Chestnut Street, Philadelphia, PA, 19107, USA
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