Radially Based Extensor Retinacular Sling Reconstruction in Extensor Carpi Ulnaris Subsheath Injuries
Michael Andrew Mastroianni, MS1, Matthew Leibman, MD2, Mark Belsky, MD3, Mark A. Vitale, MD, MPH4 and David Ruchelsman, MD3, (1)Tufts University School of Medicine, Boston, MA, (2)Hand Surgery PC, Newton-Wellesley Hospital/Tufts University School of Medicine, Newton, MA, (3)Hand Surgery PC, Newton Wellesley Hospital, Newton, MA, (4)ONS Foundation for Clinical Research and Education, Greenwich, CT
Background: Extensor carpi ulnaris (ECU) subsheath injuries result in ulnar-sided wrist pain. Subsheath rupture and tendon instability often present concurrently with intrinsic ECU pathology and ulnocarpal compartment injuries, and reconstruction of the ECU subsheath insufficiency is often performed together with wrist arthroscopy to address concomitant pathology. There is a lack of surgical outcome data despite the variety of described ECU subsheath reconstructive techniques.
Methods: We retrospectively reviewed our single-center experience of 35 patients who prospectively underwent radially based extensor retinacular sling ECU subsheath reconstruction by three senior hand surgeons from April, 2010 to April, 2021. Independent variables addressed were age, sex, mechanism of injury, time to presentation/surgery, pre-operative imaging, presence of ECU snapping, concurrent wrist injuries, and sport played. Dependent variables addressed were range of motion and return to sport. Statistical analysis was conducted via a two-tailed paired t-test.
Results: Median age at time of surgery was 41 years (range, 18-63 years) and 48.6% of patients were female. 22 patients (62.9%) had surgeries on their dominant wrist. Median time between symptom onset and surgery was 186.5 days (range, 4-835 days). 11 patients (31.4%) were collegiate-level or professional athletes. 9 patients (25.7%) had frank ECU snapping on pre-operative exam and 11 patients (31.4%) had apprehension with provocation. All 35 patients received a pre-operative MRI. 29 patients also underwent wrist arthroscopy (82.6%). 18 patients (51.4%) had intrinsic ECU tendinopathy, 20 patients (57.1%) had ECU tenosynovitis, 3 patients had EDQ tenosynovitis (8.6%), 20 patients (57.1.%) had TFCC pathology, 24 patients (68.6%) had ulnocarpal synovitis, and 2 patients (5.7%) had lunotriquetral interosseous ligament tears. Mean preoperative flexion-extension arc was 122.9 +/- 19.4o and mean postoperative flexion-extension arc was 130.6 +/- 16.4o (p-value = 0.02). Mean preoperative pronosupination arc was 152.8 +/- 9.4o and mean postoperative pronosupination arc was 157.8 +/- 7.3o (p-value = 0.01). Mean time to unrestricted return to sports was 89.8 +/- 25.9 days for the athletes in this study. There were no major complications, and at latest follow-up (mean of 5.4 months +/- 3.3 months) only one patient required secondary surgery for recurrence of a TFCC tear 7 months post-operatively, although their ECU remained stable.
Conclusions: Radially based extensor retinacular sling ECU subsheath reconstruction resulted in significant functional improvement in our cohort. We also described the prevalence of concurrent wrist injuries with ECU subsheath insufficiency and demonstrated how our approach allows for simultaneous treatment of these pathologies with minimal post-operative complications.
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