Name:
Tendon Sheath Reconstruction for Extensor Carpi Ulnaris Instability
Description:
Tendon Sheath Reconstruction for Extensor Carpi Ulnaris Instability
Thumbnail URL:
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Duration:
T00H09M45S
Embed URL:
https://stream.cadmore.media/player/6d7e0917-f02b-43b2-a2d9-7246852ab08c
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/6d7e0917-f02b-43b2-a2d9-7246852ab08c/v-005179.mp4?sv=2019-02-02&sr=c&sig=4reFCO2u6aZkA7gtZbRQ9%2BfJqrJZZCj9LnElmTE%2BDV4%3D&st=2024-11-23T11%3A44%3A38Z&se=2024-11-23T13%3A49%3A38Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
SONU JAIN: Hi, I'm Sonu Jain at Ohio State University and I'm going to talk about reconstructing an unstable ECU tendon sheath for chronic instability. Andrew Rust and Austin Roebke both assisted with this video. We have no disclosures. Indications for surgery include symptomatic ECU tendon subluxation with supination in the non acute setting.
SONU JAIN: It also includes failure of conservative management, which includes Munster splinting and even long arm casting with the wrist slightly extended and in radial deviation. Contraindications to this procedure include prior surgical procedures that have led to the violation of the extensor retinaculum. For this particular method of reconstruction, also, if the patient is medically unable to have surgery, there is an alternative surgical option using a retinacular sling for the chronically unstable ECU tendon.
SONU JAIN: Incisions are made over the distal ulna and dissections carried down to the subcutaneous tissue until we encounter the extensor retinaculum and we identify and protect any branches of the dorsal ulnar cutaneous nerve. And you can see here there's a branch transversing our plane, and we are going to isolate it and protect it, period. You can see the extensor retinaculum and we want to preserve the distal most portion of this.
SONU JAIN: I try to preserve about an 8 to 10 millimeter section of this distally and use the proximal portion of this extensor retinaculum for the reconstruction of the ECU tendon sheath period. I did paste a vessiloop around the ulnar sensory nerve to keep it in visualization and to protect it. So I'm making my incision transversely, leaving that distal cuff of retinaculum and I'm going to take this down as ulnarly as I can over it to its insertion on the carpus and over the ECU tendon and elevate this proximally and making sure I completely release that as far as I can to get as much width of this and then also release it radially over the ECU tendon toward the fifth extensor compartment.
SONU JAIN: So I try to keep this flap intact and as thick as I can and try not to undercut it. And then I elevate this over the fifth compartment here and then eventually over the fourth compartment, and I do this over to the third compartment and depending upon the length of what I need and include that if need be.
SONU JAIN: So here you can see I have a pretty adequate length of retinacular flap for reconstruction and I'm going to now release the ECU tendon sheath, which I want to make sure that there is no synovitis and I want to make sure if there is, I do an appropriate synovectomy and also check the floor of the compartment to make sure there's no spurs or osteophytes that I need to address.
SONU JAIN: I'm identifying my points for fixation with suture anchors, and looking at where the ECU tendon will be with this. So the two proximal points are what I will use here, and I'm drilling my holes for my suture anchors. In this case, I used a soft anchor for both of these,
SONU JAIN: and I'm just drilling this back and forth. So that way the soft anchor pops in without resistance. And I like these for this, and it goes in quite smoothly and I don't need a mini c-arm for this. And so I put one of these in and then make sure it's stout and then I'll put my second one in as well, and then I will plan on mobilizing my extensor retinaculum over the ECU tendon and I'll begin to suture this retinaculum that's transposed proximally, ulnarly with my suture anchors.
SONU JAIN: So I'll suture these in place and tighten the retinaculum over the ECU tendon, but I will also try to make sure that once I tighten these, that the ECU tendon is not overly tight by the retinaculum and such that I can fit a freer elevator in this space, period.
SONU JAIN: And I did that for my initial anchor and now I'm going to put my second set of anchor needles and tie this down and I'll cut these sutures after they're knotted. And what I'd like to do is throw additional support sutures at this transpose site of the retinaculum to make sure that this repair is quite stout.
SONU JAIN: And so I'm putting an extra suture here, and I'll put a few more as well after this. I am also making sure that this freer elevator still maintains the space and the tendon sheath. So once I'm happy with this, I'm taking the risk to a range of motion and making sure that this ECU tendon is not subluxating and I'm putting one more stitch again to really get some extra support ulnarly.
SONU JAIN: I also put a mattress suture just in between the sixth and fifth compartment to help stabilize this ECU tendon on the radial aspect, also maintaining that space within the newly reconstructed sheath. Here I'm putting one extra one as well for extra support.
SONU JAIN: Then I take the wrist through a final range of motion and I'm happy with this, making sure that the tendon is not subluxating with pronation and supination. Here, we're closing the wound. Post-operative care includes placing the patient in a long arm plaster splint in neutral, keeping the elbow flexed 90 degrees, and then when they come back to the office in about 10 to 14 days, I switch them to a Munster splint, keeping the wrist in neutral,
SONU JAIN: and they see our therapist at that time to start initial range of motion under therapy guidance, including gentle, pronation, supination and advancing them weekly. With this and at six weeks post op they can work on full range of motion. Three months, this patient had full range of motion with no subluxation or pain of the ECU tendon with pronosupination.
SONU JAIN: Here you can see her range of motion in pronation and supination. One pearl for this type of injury is to be aware of if they have concomitant TFCC injuries. Pitfalls of this operation are that you could potentially have limited range of motion afterwards. These studies show that outcomes from this operation are quite good and that patients have great range of motion grip strength and are usually satisfied with this.
SONU JAIN: But also there's those who are treated with a retinacular sling who also have quite good outcomes as well. Thanks.
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