Tight-Rope Augmented Adams Berger Technique for Distal Radioulnar Joint Instability

Detailed Description (Revised) Chronic distal radioulnar joint (DRUJ) instability is a disabling condition that compromises wrist function and quality of life. It typically arises from trauma and may persist despite extended conservative management. The DRUJ comprises complex bony and soft tissue components, with the triangular fibrocartilage complex (TFCC) being critical to stability. When the TFCC is irreparably damaged, surgical reconstruction is often indicated.

The Adams-Berger procedure, an anatomical reconstruction technique, is commonly utilized to restore dorsal and palmar radioulnar ligaments using a tendon graft. While this method has demonstrated clinical efficacy, limitations include residual instability and delayed functional recovery. To address these challenges, a modified surgical technique integrating the TightRope® suture-button system into the Adams-Berger procedure was developed, aiming to enhance biomechanical stability.

This prospective, randomized controlled trial was conducted between January 2015 and January 2020. Thirty-six adult patients with post-traumatic, dynamic DRUJ instability and a minimum of six months of failed conservative management were enrolled. Randomization into two groups was performed using sealed opaque envelopes: Group A received the standard Adams-Berger procedure, while Group B underwent the same procedure with additional TightRope® augmentation.

All surgical procedures were performed by a single orthopedic surgeon. In both groups, the palmaris longus tendon was harvested and used to reconstruct the dorsal and palmar distal radioulnar ligaments. For Group B, an additional 2.7 mm bone tunnel was drilled through the distal radius and ulna, and the TightRope® device was positioned and tensioned with the forearm in a neutral position. Fluoroscopic confirmation of placement was obtained intraoperatively.

Postoperative management included a three-week period of long-arm splinting, followed by passive-assisted motion and progressive strengthening exercises. Functional outcomes, pain, grip strength, range of motion, and DRUJ stability were evaluated at baseline, 3 months, and 6 months postoperatively. Assessment tools included the QuickDASH questionnaire, visual analog scale (VAS) for pain, dynamometric grip strength testing, and clinical examination of pronation-supination arc and joint stability.

Both groups showed significant improvements in functional and pain outcomes. However, Group B (TightRope®-augmented) demonstrated statistically superior results in QuickDASH scores, grip strength, and range of motion. Recurrent instability was observed in two patients in Group A, whereas no recurrence was noted in Group B.

Advantages of the TightRope®-augmented technique include:

Dynamic stabilization without the need for hardware removal

Early initiation of mobilization due to semi-rigid fixation

Decreased risk of recurrent instability

Simplified intraoperative application using fluoroscopic guidance

Study limitations include a relatively short follow-up duration and the necessity for further investigation into optimal

Inclusion criteria

Male patients aged between 18 and 47 years

Clinical diagnosis of chronic post-traumatic distal radioulnar joint (DRUJ) instability

Persistent ulnar-sided wrist pain refractory to at least 6 months of conservative treatment

Intraoperative confirmation of irreparable triangular fibrocartilage complex (TFCC) injury

Intact articular surfaces of the distal radius and ulna

Adequate palmar or dorsal rim of the sigmoid notch confirmed radiologically

Willingness to participate and ability to provide informed consent

Exclusion criteria

Evidence of DRUJ arthritis on imaging

Ulnar impaction syndrome

Extensor carpi ulnaris (ECU) tendon subluxation or tear

Inadequate sigmoid notch morphology (palmar/dorsal rim deficiency)

Age <18 or >47 years

Previous surgery on the affected wrist

Neurological or systemic conditions affecting wrist function

Patients unwilling or unable to comply with follow-up protocol