- Email: [email protected]
Ultrasound-guided transection of the interosseous membrane of the forearm
G Model
HANSUR-1102; No. of Pages 4 Hand Surgery and Rehabilitation xxx (2020) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Original article
Ultrasound-guided transection of the interosseous membrane of the forearm Section e´choguide´e de la membrane interosseuse ante´brachiale J. Descamps a,*, V. Costil b, T. Apard b a b
Department of orthopedic surgery, E´cole de Chirurgie, Assistance publique–Hoˆpitaux de Paris, 7, rue du Fer-a`-Moulin, 75005 Paris, France Centre de la main e´chochirurgie de Versailles, 7bis, rue de la Porte-de-Buc, 78000 Versailles, France
A R T I C L E I N F O
A B S T R A C T
Article history: Received 11 June 2019 Received in revised form 17 January 2020 Accepted 25 January 2020 Available online xxx
We sought to evaluate the feasibility of ultrasound-guided transection of the interosseous membrane of the forearm. The study involved ten forearms from five fresh cadavers. An ultrasound scanner (ToshibaTM Aplio V1, Toshigi, Japan) with a linear probe (ToshibaTM PLT-805AT 8Mhz) and a 25-cm long Kemis1 knife (NewClip TechnicsTM, Cholet, France), which was specially created for this study, were used. An approach to the distal and proximal radioulnar joint was made before the transection. The induced muscle hernia sign and the radius joystick test were performed to confirm the effectiveness of the ultrasound-guided transection. Complete dissection of the posterior surface of the forearm was done to check for complications and evaluate the quality of the transection. We registered nine complete transections of the interosseous membrane. The muscular hernia sign was present in all the cases performed. The joystick test was positive in eight cases. One forearm had a vascular complication. This ultrasound-guided interosseous membrane transection technique is feasible and effective with limited vascular and nerve risks. A prospective clinical study is required to validate this anatomical work.
C 2020 Published by Elsevier Masson SAS on behalf of SFCM.
Keywords: Interosseous membrane Forearm Ultrasound-guided Ultrasound Chronic Essex-Lopresti injury
R E´ S U M E´
Mots cle´s : Membrane interosseuse Avant-bras E´choguide´ E´chographie Le´sion d’Essex-Lopresti chronique
Notre but e´tait d’e´valuer la faisabilite´ de la section e´choguide´e de la membrane interosseuse ante´brachiale. Le protocole de l’e´tude e´tait base´ sur dix avant-bras de cinq sujets anatomiques frais. Un e´chographe (ToshibaTM Aplio V1, Toshigi, Japon) avec une sonde line´aire (ToshibaTM PLT-805AT 8Mhz) et un couteau Kemis1 de 25 cm de long (NewClip TechnicsTM, Cholet, France) spe´cialement conc¸u pour cette e´tude, ont e´te´ utilise´s. Un abord de l’articulation radio-ulnaire distale et de l’articulation radioulnaire proximale a e´te´ effectue´ avant la section. Le signe de la hernie musculaire et le test du joystick du radius ont e´te´ effectue´s pour ve´rifier l’efficacite´ de la section e´choguide´e. Une dissection comple`te de la face poste´rieure de l’avant-bras a permis de controˆler les complications et la qualite´ de la section. Nous avons constate´ 9 sections comple`tes de la membrane interosseuse. Le signe de la hernie musculaire provoque´e e´tait pre´sent dans tous les cas. Le test du joystick e´tait positif dans 8 cas. Un cas avait une complication vasculaire. Cette technique de section guide´e par e´chographie de la membrane interosseuse est re´alisable et efficace avec des risques vasculaires et nerveux limite´s. Une e´tude clinique prospective est ne´cessaire pour valider ce travail anatomique.
C 2020 Publie ´ par Elsevier Masson SAS au nom de SFCM.
1. Introduction
* Corresponding author. E-mail address: [email protected] (J. Descamps).
Essex-Lopresti injury (ELI) is the combination of a radial head fracture with distal radioulnar joint (DRUJ) instability, and complete rupture of the interosseous membrane (IOM) of the forearm [1]. The ELI mechanism involves indirect longitudinal
https://doi.org/10.1016/j.hansur.2020.01.008 C 2020 Published by Elsevier Masson SAS on behalf of SFCM. 2468-1229/
Please cite this article in press as: Descamps J, et al. Ultrasound-guided transection of the interosseous membrane of the forearm. Hand Surg Rehab (2020), https://doi.org/10.1016/j.hansur.2020.01.008
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HANSUR-1102; No. of Pages 4 J. Descamps et al. / Hand Surgery and Rehabilitation xxx (2020) xxx–xxx
2
compression of the forearm following high-energy trauma. Trousdale et al. stated that ELI is misdiagnosed in the emergency room in 80% of cases [2]. When chronic or acute ELI is suspected, Soubeyrand et al. proposed a dynamic ultrasound test: the induced muscle hernia sign [3]. In the case of chronic lesions, several IOM reconstruction techniques have been described [4–6]. Indeed, in the chronic phase, the IOM does not heal properly and cannot ensure the forearm’s longitudinal and transverse stability. On the other hand, the radius has ascended and is fixed in the upper position; the ulna is therefore too long, with an inverted positive distal radioulnar index. Pain is located on the ulnar side of the wrist and can result from ulnocarpal impingement [6]. The traditional technique for correcting the distal radioulnar index is an ulnar shortening osteotomy [7] like for treating traumatic or a congenital ulnar impaction syndrome [8]. Other authors have proposed ‘‘lowering’’ the radius without osteotomy and restoring the stability of two out of the three blocks of the ‘‘triarticular’’ forearm complex [9]: the proximal joint (PRUJ) and the middle radioulnar joint, i.e. IOM. For this procedure, the authors had to free the triarticular forearm complex by cutting the pathological IOM and then reconstructing it. The purpose of this cadaver study was to evaluate the feasibility of performing minimally invasive transection of the IOM with ultrasound guidance.
2. Materials and methods The study protocol used ten forearms from five fresh cadavers. The forearms did not have any scars and had not been used for other research projects. The protocol was divided into several successive steps. First, an ultrasound scan of the IOM on the posterior surface of the forearm was performed (muscle hernia test [3]); then the DRUJ and PRUJ approaches and a radius joystick test were carried out. Subsequently, ultrasound-guided transection of the IOM was followed by a post-transection muscle hernia test and a joystick test. Finally, the forearm was dissected to check the quality of the transection and look for complications.
Fig. 1. Ultrasound device.
2.1. Materials used An ultrasound scanner (ToshibaTM Aplio V1, Toshigi, Japan) with an 8 Mhz linear probe (ToshibaTM PLT-805AT) was used (Fig. 1). For the transection, a 25-cm long Kemis1 type knife (NewClip TechnicsTM, Cholet, France) was used that was specially created for this study (Fig. 2).
Fig. 2. Kemis1 knife.
2.2. Surgical technique The DRUJ was approached dorsally by incising the extensor retinaculum between the extensor digiti minimi and extensor carpi ulnaris. Complete anterior release of the pronator quadratus and triangular fibrocartilage complex (TFCC) was needed to expose the IOM (Fig. 3). The radial head was accessed by a Kocher approach [10] in the interval between the anconeus and the extensor carpi ulnaris. The approach, which is traditionally used during IOM reconstruction to reconstruct the radial head, allowed us to control the direction of the Kemis1 knife. The cadaver was supine, with the forearm in supination, elbow bent on the chest. Retrograde transection started at the DRUJ level. The knife was placed under visual control and then located using ultrasound on cross-sectional and longitudinal views. The transection was performed from distal to proximal, under ultrasound
Fig. 3. View of the interosseous membrane through the DRUJ approach.
Please cite this article in press as: Descamps J, et al. Ultrasound-guided transection of the interosseous membrane of the forearm. Hand Surg Rehab (2020), https://doi.org/10.1016/j.hansur.2020.01.008
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control using a longitudinal view (Fig. 4) as close as possible to the interosseous edge of the ulna (Video 1). Two tests were performed to check whether the IOM was completely transected: muscle hernia sign over the entire length of the forearm, as well as the radius joystick test (Fig. 5) [3,11]. An incision was made between the DRUJ approach and the PRUJ. Careful inter-muscular dissection (extensor digitorum, extensor digiti minimi, abductor pollicis longus, extensor pollicis longus, extensor pollicis brevis, extensor indicis proprius) was performed to assess the effectiveness of the ultrasound-guided procedure. The anterior and posterior interosseous nerves were identified as well as their respective arteries, and also the deep branch of the radial nerve between both supinator muscle heads [12] (Fig. 6). 3. Results The results for the ten forearms studied are reported in Table 1. No neurological lesions were found. One lesion of the anterior interosseous artery was found; it was attributed to the transection being done too far from the ulna. In two cases, we found that residual fascia of the flexor digitorum profundus was still present on the ulna. This fascia was not intact and did not stop the radius from translating with respect to the ulna. The average procedure time was 21 minutes (12–33 minutes). The muscle hernia test was positive in 100% of cases. In one case, we found a thickening of the uncut IOM, in the central band, probably because of backwards and forwards movement with the knife.
Fig. 4. Progress of the ultrasound-guided transection: cross-sectional view: a: superior part of the knife; b: inferior part of the knife; IOM: interosseous membrane; EDM: extensor digiti minimi.
4. Discussion According to Smith et al., the IOM is one of the main stabilizers of the forearm, along with the radial head and the TFCC [13]. After resection of the radial head, Hotchkiss et al. showed the TFCC was responsible for 8% of the forearm’s stiffness, while the IOM was responsible for 71% of the stiffness and transmits 90% of the forearm’s longitudinal load [14]. Anatomically, the IOM consists of five ligaments: a central band, an accessory band, a distal oblique beam, a proximal oblique cord and the dorsal oblique accessory cord. The central band is the thickest part (2 mm) of the IOM; it is 2.7 cm long and 1.1 cm wide [15]. The diagnosis of IOM rupture can be made on MRI [16,17] but there may be artifacts [18] (sensitivity 87.5% and specificity 100%). To our knowledge, this ultrasound-guided IOM transection technique has never been described in the literature. The benefit of a minimally invasive approach for IOM repair surgery has not been established, but minimally invasive techniques theoretically minimize devascularization of the reconstruction site, reduce the risk of infection and biologically guide the healing process [19]. A direct approach to the IOM over its entire length carries a significant risk vascular and nerve injury [20]. By analogy with transection of the flexor retinaculum, Capa-Grasa et al. compared the ultrasound-guided release technique with the open technique: they showed a benefit of ultrasound guidance on functional scores, with fewer complications [21]. Our study has several limitations. The subjects were all adults, elderly, with atrophied muscles. Unaffected by any surgery, they also had a normal IOM with an intact radial head. We were unable to reproduce the conditions of an injured IOM, but it is not certain that the IOM will heal with a thicker membrane after an ELI [22]. The absence of elbow and pronation-supination stiffness may have facilitated the procedure. The different tests used were clinical tests that have been validated in previous studies, but they remain subjective and not quantifiable. An anterograde, proximaldistal transection could have been feasible but was not carried out due to the supination and spatial crowding of the knife. It would
Fig. 5. Positive joystick test.
Fig. 6. Dissection of high-value structures after interosseous membrane (IOM) transection to look for damage: a: anterior interosseous nerve; b: anterior interosseous artery; c: deep branch of the radial nerve.
also have been possible to use a hook for a retrograde transection. In this case, we would have had to free the anterior and posterior muscular insertions onto the IOM, increasing the detachment spaces and muscle damage. In addition, we did not have Doppler mode available to verify the procedure and further reduce the vascular risk.
Please cite this article in press as: Descamps J, et al. Ultrasound-guided transection of the interosseous membrane of the forearm. Hand Surg Rehab (2020), https://doi.org/10.1016/j.hansur.2020.01.008
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Table 1 Outcomes of the 10 forearms after ultrasound-guided transection of the IOM. Case No.
Complete transection
Muscle hernia test
Joystick test
Nerve injury
Vascular injury
Duration of procedure (min)
Comments
1 2 3 4 5 6 7 8 9 10
No Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
No Yes Yes Yes Yes Yes Yes Yes Yes Yes
No No No No No No No No No No
No Yes No No No No No No No No
33 31 25 22 18 21 17 12 17 14
5 mm thickening of the central IOM band is uncut Anterior interosseous artery injury Transection not close enough to ulna Muscular fascia residue None Square ligament at the elbow uncut Transection of 20% of extensor digiti minimi None Muscular fascia residue None
IOM: interosseous membrane.
5. Conclusion This ultrasound-guided IMO transection technique is feasible and effective with limited vascular and nerve risks. A prospective clinical study is required to validate this anatomical work. Funding The authors received no financial support for the research, authorship or publication of this article. Disclosure of interest
[5] [6]
[7] [8]
[9]
The authors declare that they have no competing interest. [10]
Acknowledgements Marc Soubeyrand (MD, PhD) for his expertise and support in this project and ‘‘E´cole de Chirurgie’’, who allowed us to bring the first ultrasound device into this institute, Djamel TALEB and all the team. Joanne Archambault, PhD (voice of the video). Mathilde Sennhauser (MD) (support and assistance).
Funging The auteur received no financial support for the research, authorship or publication of this article. Appendix A. Supplementary data Supplementary data (video) associated with this article can be found, in the online version, at https://doi.org/10.1016/j.hansur. 2020.01.008. References [1] Essex-Lopresti P. Fractures of the radial head with distal radio-ulnar dislocation; report of two cases. J Bone Joint Surg Br 1951;33:244–7. [2] Trousdale RT, Amadio PC, Cooney WP, Morrey BF. Radio-ulnar dissociation. A review of twenty cases. J Bone Joint Surg Am 1992;74:1486–97. [3] Soubeyrand M, Lafont C, Oberlin C, France W, Maulat I, Degeorges R. The ‘‘muscular hernia sign’’: an original ultrasonographic sign to detect lesions of the forearm’s interosseous membrane. Surg Radiol Anat 2006;28:372–8. [4] Gaspar MP, Kane PM, Pflug EM, Jacoby SM, Osterman AL, Culp RW. Interosseous membrane reconstruction with a suture-button construct for
[11]
[12] [13]
[14]
[15]
[16]
[17] [18] [19]
[20] [21]
[22]
treatment of chronic forearm instability. J Shoulder Elbow Surg 2016;25:1491–500. Marcotte AL, Osterman AL. Longitudinal radioulnar dissociation: identification and treatment of acute and chronic injuries. Hand Clin 2007;23:195–208. Chloros GD, Wiesler ER, Stabile KJ, Papadonikolakis A, Ruch DS, Kuzma GR. Reconstruction of Essex-Lopresti injury of the forearm: technical note. J Hand Surg Am 2008;33:124–30. Darlis NA, Ferraz IC, Kaufmann RW, Sotereanos DG. Step-cut distal ulnar– shortening osteotomy. J Hand Surg Am 2005;30:943–8. Finnigan T, Makaram N, Baumann A, Ramesh K, Mohil R, Srinivasan M. Outcomes of ulnar shortening for ulnar impaction syndrome using the 2.7 mm AO ulna shortening osteotomy system. J Hand Surg Asian Pac 2018;23:82–9. Soubeyrand M, Wassermann V, Hirsch C, Oberlin C, Gagey O, Dumontier C. The middle radioulnar joint and triarticular forearm complex. J Hand Surg Eur 2011;36:447–54. Kocher T. Textbook of operative surgery. London: Adam & Charles Black; 1911. p. 314–9. Soubeyrand M, Ciais G, Wassermann V, Kalouche I, Biau D, Dumontier C, et al. The intra-operative radius joystick test to diagnose complete disruption of the interosseous membrane. J Bone Joint Surg Br 2011;93:1389–94. Tubiana R, McCullough CJ, Masquelet A-C, Herning R, Dorn L. Voies d’abord chirurgicales du membre supe´rieur. Paris: Elsevier Masson; 2004. Smith AM, Urbanosky LR, Castle JA, Rushing JT, Ruch DS. Radius pull test: predictor of longitudinal forearm instability. J Bone Joint Surg Am 2002;84:1970–6. Hotchkiss RN, An KN, Sowa DT, Basta S, Weiland AJ. An anatomic and mechanical study of the interosseous membrane of the forearm: pathomechanics of proximal migration of the radius. J Hand Surg 1989;14:256–61. Noda K, Goto A, Murase T, Sugamoto K, Yoshikawa H, Moritomo H. Interosseous membrane of the forearm: an anatomical study of ligament attachment locations. J Hand Surg 2009;34:415–22. McGinley JC, Roach N, Hopgood BC, Limmer K, Kozin SH. Forearm interosseous membrane trauma: MRI diagnostic criteria and injury patterns. Skeletal Radiol 2006;35:275–81. Starch DW, Dabezies EJ. Magnetic resonance imaging of the interosseous membrane of the forearm. J Bone Joint Surg Am 2001;83:235–8. Soubeyrand M, Lafont C, De Georges R, Dumontier C. Pathologie traumatique de la membrane interosseuse de l’avant-bras. Chir Main 2007;26:255–77. Russell TA. An historical perspective of the development of plate and screw fixation and minimally invasive fracture surgery with a unified biological approach. Tech Orthop 2007;22:186–90. Jin F, Skie M, Ebraheim NA, Lu J. Anatomic basis of dorsoradial approach for radioulnar synostosis. Surg Radiol Anat 1998;20:239–42. Capa-Grasa A, Rojo-Manaute JM, Rodrı´guez FC, Martı´n JV. Ultra minimally invasive sonographically guided carpal tunnel release: an external pilot study. Orthop Traumatol Surg Res 2014;100:287–92. Stevenson JD, Radesh L, Pickard S, Adrian S, Hay SM. Falsely reassuring magnetic resonance imaging appearance of the forearm interosseous membrane following an Essex-Lopresti injury: does it ever completely heal? Shoulder Elbow 2010;2:287–90.
Please cite this article in press as: Descamps J, et al. Ultrasound-guided transection of the interosseous membrane of the forearm. Hand Surg Rehab (2020), https://doi.org/10.1016/j.hansur.2020.01.008
HANSUR-1102; No. of Pages 4 Hand Surgery and Rehabilitation xxx (2020) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Original article
Ultrasound-guided transection of the interosseous membrane of the forearm Section e´choguide´e de la membrane interosseuse ante´brachiale J. Descamps a,*, V. Costil b, T. Apard b a b
Department of orthopedic surgery, E´cole de Chirurgie, Assistance publique–Hoˆpitaux de Paris, 7, rue du Fer-a`-Moulin, 75005 Paris, France Centre de la main e´chochirurgie de Versailles, 7bis, rue de la Porte-de-Buc, 78000 Versailles, France
A R T I C L E I N F O
A B S T R A C T
Article history: Received 11 June 2019 Received in revised form 17 January 2020 Accepted 25 January 2020 Available online xxx
We sought to evaluate the feasibility of ultrasound-guided transection of the interosseous membrane of the forearm. The study involved ten forearms from five fresh cadavers. An ultrasound scanner (ToshibaTM Aplio V1, Toshigi, Japan) with a linear probe (ToshibaTM PLT-805AT 8Mhz) and a 25-cm long Kemis1 knife (NewClip TechnicsTM, Cholet, France), which was specially created for this study, were used. An approach to the distal and proximal radioulnar joint was made before the transection. The induced muscle hernia sign and the radius joystick test were performed to confirm the effectiveness of the ultrasound-guided transection. Complete dissection of the posterior surface of the forearm was done to check for complications and evaluate the quality of the transection. We registered nine complete transections of the interosseous membrane. The muscular hernia sign was present in all the cases performed. The joystick test was positive in eight cases. One forearm had a vascular complication. This ultrasound-guided interosseous membrane transection technique is feasible and effective with limited vascular and nerve risks. A prospective clinical study is required to validate this anatomical work.
C 2020 Published by Elsevier Masson SAS on behalf of SFCM.
Keywords: Interosseous membrane Forearm Ultrasound-guided Ultrasound Chronic Essex-Lopresti injury
R E´ S U M E´
Mots cle´s : Membrane interosseuse Avant-bras E´choguide´ E´chographie Le´sion d’Essex-Lopresti chronique
Notre but e´tait d’e´valuer la faisabilite´ de la section e´choguide´e de la membrane interosseuse ante´brachiale. Le protocole de l’e´tude e´tait base´ sur dix avant-bras de cinq sujets anatomiques frais. Un e´chographe (ToshibaTM Aplio V1, Toshigi, Japon) avec une sonde line´aire (ToshibaTM PLT-805AT 8Mhz) et un couteau Kemis1 de 25 cm de long (NewClip TechnicsTM, Cholet, France) spe´cialement conc¸u pour cette e´tude, ont e´te´ utilise´s. Un abord de l’articulation radio-ulnaire distale et de l’articulation radioulnaire proximale a e´te´ effectue´ avant la section. Le signe de la hernie musculaire et le test du joystick du radius ont e´te´ effectue´s pour ve´rifier l’efficacite´ de la section e´choguide´e. Une dissection comple`te de la face poste´rieure de l’avant-bras a permis de controˆler les complications et la qualite´ de la section. Nous avons constate´ 9 sections comple`tes de la membrane interosseuse. Le signe de la hernie musculaire provoque´e e´tait pre´sent dans tous les cas. Le test du joystick e´tait positif dans 8 cas. Un cas avait une complication vasculaire. Cette technique de section guide´e par e´chographie de la membrane interosseuse est re´alisable et efficace avec des risques vasculaires et nerveux limite´s. Une e´tude clinique prospective est ne´cessaire pour valider ce travail anatomique.
C 2020 Publie ´ par Elsevier Masson SAS au nom de SFCM.
1. Introduction
* Corresponding author. E-mail address: [email protected] (J. Descamps).
Essex-Lopresti injury (ELI) is the combination of a radial head fracture with distal radioulnar joint (DRUJ) instability, and complete rupture of the interosseous membrane (IOM) of the forearm [1]. The ELI mechanism involves indirect longitudinal
https://doi.org/10.1016/j.hansur.2020.01.008 C 2020 Published by Elsevier Masson SAS on behalf of SFCM. 2468-1229/
Please cite this article in press as: Descamps J, et al. Ultrasound-guided transection of the interosseous membrane of the forearm. Hand Surg Rehab (2020), https://doi.org/10.1016/j.hansur.2020.01.008
G Model
HANSUR-1102; No. of Pages 4 J. Descamps et al. / Hand Surgery and Rehabilitation xxx (2020) xxx–xxx
2
compression of the forearm following high-energy trauma. Trousdale et al. stated that ELI is misdiagnosed in the emergency room in 80% of cases [2]. When chronic or acute ELI is suspected, Soubeyrand et al. proposed a dynamic ultrasound test: the induced muscle hernia sign [3]. In the case of chronic lesions, several IOM reconstruction techniques have been described [4–6]. Indeed, in the chronic phase, the IOM does not heal properly and cannot ensure the forearm’s longitudinal and transverse stability. On the other hand, the radius has ascended and is fixed in the upper position; the ulna is therefore too long, with an inverted positive distal radioulnar index. Pain is located on the ulnar side of the wrist and can result from ulnocarpal impingement [6]. The traditional technique for correcting the distal radioulnar index is an ulnar shortening osteotomy [7] like for treating traumatic or a congenital ulnar impaction syndrome [8]. Other authors have proposed ‘‘lowering’’ the radius without osteotomy and restoring the stability of two out of the three blocks of the ‘‘triarticular’’ forearm complex [9]: the proximal joint (PRUJ) and the middle radioulnar joint, i.e. IOM. For this procedure, the authors had to free the triarticular forearm complex by cutting the pathological IOM and then reconstructing it. The purpose of this cadaver study was to evaluate the feasibility of performing minimally invasive transection of the IOM with ultrasound guidance.
2. Materials and methods The study protocol used ten forearms from five fresh cadavers. The forearms did not have any scars and had not been used for other research projects. The protocol was divided into several successive steps. First, an ultrasound scan of the IOM on the posterior surface of the forearm was performed (muscle hernia test [3]); then the DRUJ and PRUJ approaches and a radius joystick test were carried out. Subsequently, ultrasound-guided transection of the IOM was followed by a post-transection muscle hernia test and a joystick test. Finally, the forearm was dissected to check the quality of the transection and look for complications.
Fig. 1. Ultrasound device.
2.1. Materials used An ultrasound scanner (ToshibaTM Aplio V1, Toshigi, Japan) with an 8 Mhz linear probe (ToshibaTM PLT-805AT) was used (Fig. 1). For the transection, a 25-cm long Kemis1 type knife (NewClip TechnicsTM, Cholet, France) was used that was specially created for this study (Fig. 2).
Fig. 2. Kemis1 knife.
2.2. Surgical technique The DRUJ was approached dorsally by incising the extensor retinaculum between the extensor digiti minimi and extensor carpi ulnaris. Complete anterior release of the pronator quadratus and triangular fibrocartilage complex (TFCC) was needed to expose the IOM (Fig. 3). The radial head was accessed by a Kocher approach [10] in the interval between the anconeus and the extensor carpi ulnaris. The approach, which is traditionally used during IOM reconstruction to reconstruct the radial head, allowed us to control the direction of the Kemis1 knife. The cadaver was supine, with the forearm in supination, elbow bent on the chest. Retrograde transection started at the DRUJ level. The knife was placed under visual control and then located using ultrasound on cross-sectional and longitudinal views. The transection was performed from distal to proximal, under ultrasound
Fig. 3. View of the interosseous membrane through the DRUJ approach.
Please cite this article in press as: Descamps J, et al. Ultrasound-guided transection of the interosseous membrane of the forearm. Hand Surg Rehab (2020), https://doi.org/10.1016/j.hansur.2020.01.008
G Model
HANSUR-1102; No. of Pages 4 J. Descamps et al. / Hand Surgery and Rehabilitation xxx (2020) xxx–xxx
3
control using a longitudinal view (Fig. 4) as close as possible to the interosseous edge of the ulna (Video 1). Two tests were performed to check whether the IOM was completely transected: muscle hernia sign over the entire length of the forearm, as well as the radius joystick test (Fig. 5) [3,11]. An incision was made between the DRUJ approach and the PRUJ. Careful inter-muscular dissection (extensor digitorum, extensor digiti minimi, abductor pollicis longus, extensor pollicis longus, extensor pollicis brevis, extensor indicis proprius) was performed to assess the effectiveness of the ultrasound-guided procedure. The anterior and posterior interosseous nerves were identified as well as their respective arteries, and also the deep branch of the radial nerve between both supinator muscle heads [12] (Fig. 6). 3. Results The results for the ten forearms studied are reported in Table 1. No neurological lesions were found. One lesion of the anterior interosseous artery was found; it was attributed to the transection being done too far from the ulna. In two cases, we found that residual fascia of the flexor digitorum profundus was still present on the ulna. This fascia was not intact and did not stop the radius from translating with respect to the ulna. The average procedure time was 21 minutes (12–33 minutes). The muscle hernia test was positive in 100% of cases. In one case, we found a thickening of the uncut IOM, in the central band, probably because of backwards and forwards movement with the knife.
Fig. 4. Progress of the ultrasound-guided transection: cross-sectional view: a: superior part of the knife; b: inferior part of the knife; IOM: interosseous membrane; EDM: extensor digiti minimi.
4. Discussion According to Smith et al., the IOM is one of the main stabilizers of the forearm, along with the radial head and the TFCC [13]. After resection of the radial head, Hotchkiss et al. showed the TFCC was responsible for 8% of the forearm’s stiffness, while the IOM was responsible for 71% of the stiffness and transmits 90% of the forearm’s longitudinal load [14]. Anatomically, the IOM consists of five ligaments: a central band, an accessory band, a distal oblique beam, a proximal oblique cord and the dorsal oblique accessory cord. The central band is the thickest part (2 mm) of the IOM; it is 2.7 cm long and 1.1 cm wide [15]. The diagnosis of IOM rupture can be made on MRI [16,17] but there may be artifacts [18] (sensitivity 87.5% and specificity 100%). To our knowledge, this ultrasound-guided IOM transection technique has never been described in the literature. The benefit of a minimally invasive approach for IOM repair surgery has not been established, but minimally invasive techniques theoretically minimize devascularization of the reconstruction site, reduce the risk of infection and biologically guide the healing process [19]. A direct approach to the IOM over its entire length carries a significant risk vascular and nerve injury [20]. By analogy with transection of the flexor retinaculum, Capa-Grasa et al. compared the ultrasound-guided release technique with the open technique: they showed a benefit of ultrasound guidance on functional scores, with fewer complications [21]. Our study has several limitations. The subjects were all adults, elderly, with atrophied muscles. Unaffected by any surgery, they also had a normal IOM with an intact radial head. We were unable to reproduce the conditions of an injured IOM, but it is not certain that the IOM will heal with a thicker membrane after an ELI [22]. The absence of elbow and pronation-supination stiffness may have facilitated the procedure. The different tests used were clinical tests that have been validated in previous studies, but they remain subjective and not quantifiable. An anterograde, proximaldistal transection could have been feasible but was not carried out due to the supination and spatial crowding of the knife. It would
Fig. 5. Positive joystick test.
Fig. 6. Dissection of high-value structures after interosseous membrane (IOM) transection to look for damage: a: anterior interosseous nerve; b: anterior interosseous artery; c: deep branch of the radial nerve.
also have been possible to use a hook for a retrograde transection. In this case, we would have had to free the anterior and posterior muscular insertions onto the IOM, increasing the detachment spaces and muscle damage. In addition, we did not have Doppler mode available to verify the procedure and further reduce the vascular risk.
Please cite this article in press as: Descamps J, et al. Ultrasound-guided transection of the interosseous membrane of the forearm. Hand Surg Rehab (2020), https://doi.org/10.1016/j.hansur.2020.01.008
G Model
HANSUR-1102; No. of Pages 4 J. Descamps et al. / Hand Surgery and Rehabilitation xxx (2020) xxx–xxx
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Table 1 Outcomes of the 10 forearms after ultrasound-guided transection of the IOM. Case No.
Complete transection
Muscle hernia test
Joystick test
Nerve injury
Vascular injury
Duration of procedure (min)
Comments
1 2 3 4 5 6 7 8 9 10
No Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
No Yes Yes Yes Yes Yes Yes Yes Yes Yes
No No No No No No No No No No
No Yes No No No No No No No No
33 31 25 22 18 21 17 12 17 14
5 mm thickening of the central IOM band is uncut Anterior interosseous artery injury Transection not close enough to ulna Muscular fascia residue None Square ligament at the elbow uncut Transection of 20% of extensor digiti minimi None Muscular fascia residue None
IOM: interosseous membrane.
5. Conclusion This ultrasound-guided IMO transection technique is feasible and effective with limited vascular and nerve risks. A prospective clinical study is required to validate this anatomical work. Funding The authors received no financial support for the research, authorship or publication of this article. Disclosure of interest
[5] [6]
[7] [8]
[9]
The authors declare that they have no competing interest. [10]
Acknowledgements Marc Soubeyrand (MD, PhD) for his expertise and support in this project and ‘‘E´cole de Chirurgie’’, who allowed us to bring the first ultrasound device into this institute, Djamel TALEB and all the team. Joanne Archambault, PhD (voice of the video). Mathilde Sennhauser (MD) (support and assistance).
Funging The auteur received no financial support for the research, authorship or publication of this article. Appendix A. Supplementary data Supplementary data (video) associated with this article can be found, in the online version, at https://doi.org/10.1016/j.hansur. 2020.01.008. References [1] Essex-Lopresti P. Fractures of the radial head with distal radio-ulnar dislocation; report of two cases. J Bone Joint Surg Br 1951;33:244–7. [2] Trousdale RT, Amadio PC, Cooney WP, Morrey BF. Radio-ulnar dissociation. A review of twenty cases. J Bone Joint Surg Am 1992;74:1486–97. [3] Soubeyrand M, Lafont C, Oberlin C, France W, Maulat I, Degeorges R. The ‘‘muscular hernia sign’’: an original ultrasonographic sign to detect lesions of the forearm’s interosseous membrane. Surg Radiol Anat 2006;28:372–8. [4] Gaspar MP, Kane PM, Pflug EM, Jacoby SM, Osterman AL, Culp RW. Interosseous membrane reconstruction with a suture-button construct for
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Please cite this article in press as: Descamps J, et al. Ultrasound-guided transection of the interosseous membrane of the forearm. Hand Surg Rehab (2020), https://doi.org/10.1016/j.hansur.2020.01.008