Retinacular Sling Reconstruction for Extensor Carpi Ulnaris Tendon Subluxation Has Lasting Results

Retinacular sling reconstruction is an option for patients with extensor carpi ulnaris (ECU) tendon subluxation when conservative treatment is unsuccessful. Some experts advocate for deepening the ECU groove during the procedure, but this concept remains controversial.

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Svenna Verhiel, MD, research fellow, Jesse B. Jupiter, MD, orthopaedic surgeon in the Hand and Arm Center of the Department of Orthopaedics at Massachusetts General Hospital, and colleagues recently reported good long-term outcomes of patients who received a radially-based sling of the extensor retinaculum without groove deepening. Their paper appears in Techniques in Hand & Upper Extremity Surgery.

Patients and Procedures

Six male and nine female patients, median age 39, underwent retinacular sling reconstruction a median of 5.9 weeks after a trial of nonoperative treatment. The surgery was performed according to the technique described by Drs. Ruchelsman and Vitale in The Journal of Hand Surgery.

Eight of the 15 patients in this cohort underwent concomitant procedures:

• Synovectomy of the ECU (four patients)
• Repair of the triangular fibrocartilage complex (TFCC) (one patient)
• Debridement of the TFCC (one patient)
• Excision of a wrist ganglion (one patient)
• Neurolysis of three sensory branches of the dorsal ulnar nerve (one patient, who previously had a primary subsheath repair)

Complications

No ECU tendon ruptures occurred. The following complications occurred for patients:

• Two patients developed ECU tendinitis five and nine months postoperatively, respectively. Both patients were injected with dexamethasone and lidocaine, which resolved symptoms in one patient. The other had continued wrist pain
• After playing tennis three months postoperatively, one patient experienced ulnar-side wrist pain, which completely resolved after casting for three weeks
• One patient had ongoing pain during rotation. Magnetic resonance imaging showed thickening around the extensor tendon but no pathology, and the patient did not undergo any further treatment

Three patients underwent reoperation. Details are as follows:

• One experienced irritation from a permanent stitch used in the reconstruction and asked for it to be removed
• One had continued ulnar-side wrist pain and underwent arthroscopic TFCC debridement nine months after the initial surgery
• One underwent three subsequent surgeries: (a) at five months after initial surgery, neurolysis of two sensory branches of the dorsal ulnar nerve and ECU tenolysis that maintained the integrity of the reconstruction; (b) at 15 months, ulnar-shortening osteotomy for ulna impaction; and (c) at 24 months, repeat neurolysis with release of the ECU tendon sheath. At the latest follow-up, the patient still reported stiffness and pain with activity

Patient-reported Outcomes

Ten patients completed questionnaires on telephone follow-up with a median of 8.4 years after the primary procedure. On the PROMIS (Performance of Patient-Reported Outcomes Measurement Information System) scale for upper-extremity physical function, the median score was 56. Other median scores were 0.5/5 for pain and 9.5/10 for satisfaction.

Four patients reported persistent symptoms at rest or during forceful forearm rotation. One patient experienced mild limitation of daily activities and four experienced limitations in sports-related activity.

Surgical Learnings

Retinacular sling reconstruction allows for concomitant treatment of intrinsic ECU pathologies, unlike strategies that leave the ECU sheath intact. Wrist arthroscopy can be performed before ECU stabilization to rule out or diagnose and treat other causes of ulnar-sided wrist pain, such as TFCC lesions.

Carefully identify and protect any crossing sensory branches of the dorsal ulnar nerve. Injury to the branches can cause postoperative pain and paresthesia.

Confirm smooth gliding of the ECU tendon without any signs of subluxation upon wrist flexion and extension. A repair that is too tight can cause a stenosing tenosynovitis.

Why Not Deepen the Groove?

The researchers share the concern of other surgeons that overaggressive deepening of the ECU groove can weaken the bone and cause rim fractures. Furthermore, if the groove is deepened and the ulnar border is not re-established, the tendon may actually have a higher risk of subluxation. That would lead to more tendon damage than if the groove were shallower and had a smoother transition at its border.

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