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CHAPTER The Interosseous Ligament

53
and the Essex-Lopresti Injury
A. Lee Osterman, MD, and Anthony L. Marcotte, DO

INTRODUCTION FIGURE 53-1        Force distribution across the forearm. A, Normal
The Essex-Lopresti injury or longitudinal radioulnar dissociation force transmission across radius and ulna at the wrist
(LRUD) results from a triad of injuries to the interosseous mem- and elbow. The interosseous ligament (IOL) and distal radioulnar joint
(DRUJ) distribute some of the radial load to the ulna, which is evident
brane (IOM) combined with injuries to the radial head and distal from the change in distribution of force at the wrist and elbow.  
radioulnar joint (DRUJ). A patient’s optimum recovery from this B, When the interosseous ligament complex (ILC) and DRUJ are
unforgiving injury depends on a high index of suspicion, accurate disrupted, there is no transfer of load between the radius and ulna.
diagnosis, and timely treatment. Despite the appropriate man- These two bones act independently of each other when force is ap-
agement of some LRUD injuries, however, failed outcomes arise, plied. C, When the radiocapitellar relationship is lost, as with a radial
and patients often present with chronic injuries.1 The ultimate head resection or fracture of the neck or head, the ulna transmits the
salvage option has classically been creation of a one-bone fore- entire load to the elbow. The ILC and DRUJ become crucial in load
arm.2–4 This chapter, in particular, presents the reconstruction of transfer and likely experience stress, eventually stretching over time.
the interosseous ligament (IOL) using a bone–patellar ligament– D, With injury to the IOL and DRUJ, the radius is longitudinally un-
bone (BLB) graft, which is a novel surgical option that stabilizes stable and dissociated from the ulna, allowing the radius to migrate
proximally and resulting in an Essex-Lopresti injury. In treating the
the forearm, increases function, and decreases pain to the forearm chronic IOL injury, recreating the mechanics shown in A is anticipat-
and wrist in patients with chronic LRUD.1 ed. If there is capitellar arthritis or other reasons to avoid radial head
arthroplasty, then resection may be warranted with bone–patellar
BASIC SCIENCE ligament–bone reconstruction, similar to that in B.

The radial head behaves as the primary restraint to proximal migra-
tion of the radius and is responsible for transferring the majority 80%
of the load at the wrist.5 In fact, Palmer and Werner6 demon- 43%
strated that approximately 80% of force at the wrist is endured 20% 57%
by the radius compared with 20% by the ulna. Load transferred
to the capitellum by the radius, however, is not equal to the 80% A
seen at the wrist; rather, only 43% of force is transmitted through
the radiocapitellar joint and 57% at the ulnohumeral articula-
tion.7 This change in force transmission between the radius and
ulna is chiefly attributed to the IOM and the DRUJ.5
Hence, an intact IOM and DRUJ are the primary soft tissues
responsible for load transference from the radius to the ulna. If
these soft tissues are jeopardized, however, the radius and ulna
behave independently, and load across the distal radius is equal to B
the proximal radius and the load transferred at the distal ulna is
equal to the proximal ulna.5 In addition, when the radiocapitel-
lar relationship is compromised, as in a proximal radius fracture 80%
or radial head resection, the IOM and DRUJ are responsible for
transferring the entire radial load to the ulna (Fig. 53-1A–D). The
20% 100%
IOL and DRUJ experience increased stress when the radiocapi-
tellar relationship is disrupted. As a result, 1 to 3 mm of proximal C
migration may be exhibited years after a radial head resection,
which is usually asymptomatic.8–12
Aside from serving as the secondary restraints to proximal mi-
gration of the radius, the IOM and DRUJ also provide stiffness
to the forearm. Hotchkiss and colleagues13 illustrated that when

*To my wife, Elissa, and our children, Meredith, Alexis, and Zoe. D
†To my wife, Sandra, and our children, Michael, Mia, and Peyton.
552 Part IX  Ligament Instability/Tears

FIGURE 53-2        Components of the interosseous ligament FIGURE 53-4        Mechanism of injury. Patients usually sustain an
complex (ILC). The central band (CB), also called the Essex-Lopresti injury from a violent fall onto an out-
interosseous ligament, is the most crucial component of the ILC. AB, stretched hand that causes an injury to the radial head, interosseous
accessory bands; PB, proximal band. ligament, and distal radioulnar joint.

AB CB PB

FIGURE 53-3        Details of the central band. The central band, or
interosseous ligament, inserts approximately at one
third of the length of the ulna from the styloid and angles acutely at
21 degrees toward the radius.

21o

the radial head is removed, approximately 71% of longitudinal
stiffness of the forearm is attributed to the IOL and 8% to the tri-
angular fibrocartilage complex (TFCC). Injury to the IOM and
DRUJ creates dissociation between the radius and ulna along the
longitudinal plane of the forearm, thereby resulting in the Essex-
Lopresti injury. TFCC may transpire. Thus, all these structures must be consid-
The IOM is the most critical of the secondary restraints.13,14 ered during the evaluation and treatment of Essex-Lopresti injury
It consists of three main bands of tissue: the central band (CB), (Fig. 53-5).
the proximal band (PB), and the accessory bands (AB) that span
between the interosseous crests of the radius and ulna (Fig. 53-2). Acute Injury
This tissue histologically and mechanically resembles a ligament and In an acute injury, the basic tenets of treatment are to reestablish the
is more appropriately termed the interosseous ligament complex radiocapitellar articulation, repair the TFCC, and immobilize the
(ILC).15,16 These bands have a high collagen content and little elas- forearm, allowing the IOL to heal. An acute injury is usually recog-
tin, similar to other ligaments, particularly the patellar ligament.15 nized within 4 weeks. Unfortunately, patients often present as refer-
The strongest and most important component of the ILC is rals for chronic injuries or with failed initial management after radial
the central band, which is also called the interosseous ligament. It head excision, which is typically more than 1 month after injury.
originates on the radius at an average of 7.7 cm from the head Open reduction and internal fixation (ORIF) of the radial
of the radius, angles 21 degrees from the axis of the radius, and head fracture is performed through a standard Kocher incision
inserts on the ulna approximately 13.7 cm from the tip of the when three or fewer fragments are present.17–20 After exposure,
olecranon, which is approximately one third of the length of the a push-pull test is performed. Bone grafting may be necessary to
ulna from the tip of the styloid (Fig. 53-3). It is trapezoidal in fill bone defects. When the radial head is unsalvageable, a radial
shape and is an average of 40 mm long and 1 to 2 mm thick. head arthroplasty is performed with particular attention that the
The proximal band and accessory bands are less substantial in radius and ulna are level at the wrist and that overstuffing of the
size, and their role in forearm stability is relatively minor.16 The prosthesis is avoided. Yet arthroplasty may behave as a temporary
proximal band, also called the oblique ligament, is inconsistently internal splint, and the IOL may not heal and create excess force
present and courses perpendicular and proximal to the IOL. The transmission to the capitellum.1 As a result, it is recommended
accessory bands vary in number from 1 to 5 and course parallel that patients with LRUD be forewarned that arthritis and pain at
and distal to the IOL15,16 (see Fig. 53-2). the elbow may develop.
The prosthesis should lie even with the lateral edge of the
coronoid process on an anteroposterior view of the elbow.21
RATIONALE FOR TREATMENT
In the acute injury, joint leveling at the wrist can commonly
The Essex-Lopresti injury is a continuum that begins with a radial be ­ accomplished with proper radial head open reduction and
head fracture from a violent axial load (Fig. 53-4). With contin- ­internal fixation or arthroplasty without an ulnar-shortening os-
ued axial loading, the IOL tears and injury to the DRUJ and teotomy. A radial head excision should never be performed alone
CHAPTER 53  The Interosseous Ligament and the Essex-Lopresti Injury 553

FIGURE 53-5        Treatment algorithm for the Essex-Lopresti injury. Essential components of diagnosis include anteroposterior (AP) and  
lateral x-ray views of the wrist, elbow, and forearm with grip views of the wrist. Ultrasound (US) and magnetic resonance imag-
ing (MRI) are typically unnecessary for chronic injuries but can be made use of in acute cases, particularly when suture repair of the ligament is
considered. BLB, bone–patellar ligament–bone; DRUJ, distal radioulnar joint; IOL, interosseous ligament; LRUD, longitudinal radioulnar dissocia-
tion; ORIF, open reduction and internal fixation; RC, radiocapitellar; USO, ulnar-shortening osteotomy.

Radial head fracture

Assess forearm and wrist for IOL and DRUJ injury
History: mechanism, wrist pain
Physical: pain, swelling, motion
Imaging: AP/lateral/grip x-rays, ± US vs. MRI

No Yes

Treat radial head fracture
1. Monitor closely for DRUJ LRUD Acute (<4 weeks)
instability, wrist pain
2. Consider US or MRI in
comminuted fractures Chronic (>4 weeks) 1. Reestablish RC articulation
where excision is an option a. ORIF
3. Radius pull test for excision or b. Radial head arthroplasty
replacement 2. Secure DRUJ in supination
Pain, instability
–If positive, treat for LRUD for 4–8 weeks
a. Cast (if stable)
No Yes
b. K wires
c. 3.5-mm screws
Observe 1. USO ± wrist arthroscopy 3. Acute repair or
for carpal lesions
reconstruction of IOL?
2. Reconstruct IOL with
BLB graft
3. Radial head excision ±
replacement

with an Essex-Lopresti injury.13,18,20,22–26 Also, silicone implants Chronic Injury
are not recommended because of their inability to withstand The primary objectives in the treatment of chronic injuries are
forearm load, risk of synovitis, and high frequency of implant to reestablish the radiocapitellar articulation, level the radius
fracture.13,17,25,27–29 and ulna at the wrist, and reconstruct the IOL. If radiocapitellar
The wrist is then examined for stability. In a true Essex-Lopresti arthritis exists, then radial head resection or implant removal is
injury, the DRUJ is unstable and warrants immobilization to al- warranted as long as the IOL is reconstructed. However, patients
low the IOL to heal. Wrist arthroscopy is ­ generally performed with chronic injuries often present after a radial head resection
with an arthroscopic or open TFCC repair. We then immobi- with an initially missed injury to the IOL.1 An ulnar-shortening
lize the forearm with a cast or hardware—either two 0.062-inch osteotomy is performed to level the ulna but should not be
Kirschner wires or two 3.5-mm fully ­ threaded cortical screws performed without IOL reconstruction, since the radius will
placed proximal to the DRUJ with the arm in supination (Fig. ­continue to migrate until it impinges on the capitellum. The
53-6A and B). These are removed after 8 weeks. The uncertainty details of reconstruction of the IOL are described in the text that
that the ligament actually heals with enough integrity to main- follows.
tain its original function emphasizes the necessity to reestablish Other procedures may be necessary for coexisting pathology.
the primary restraint to proximal migration of the radius with We have concomitantly performed radial head excision,1 removal
appropriate treatment of the radial head injury. of radial head prosthesis,2 wrist arthroscopy,3 DRUJ resection,1
Suture repair of the IOL has been described for acute inju- Sauvé-Kapandji procedure,1 and carpal tunnel release1 in our
ries.30 Tears of the IOL appear to occur in the midsubstance of ­series of 16 patients.1
the tendon; however, there are some reports of injury to the ulnar
insertion.30–32 An MRI or ultrasound of the forearm is recom-
mended to locate the site of injury if this procedure is going to
INDICATIONS FOR REPAIR
be attempted. The IOL can be approached through a dorsal inci-
sion between extensor digitorum communis and extensor digiti The ideal candidate for reconstruction of the IOL of the forearm
minimi quinti. Midsubstance repair can be done with a 2-0 non- using a BLB graft is the patient with a chronic Essex-Lopresti
absorbable braided polyethylene suture. Suture anchors or drill injury, a radial head resection, wrist pain from proximal migra-
holes can be used to repair tears from the ulna. Another option tion of the radius documented by appropriate radiographs, and no
we have used in the acute setting is a pronator teres transfer as arthritis at the DRUJ or capitellum. Occasionally, other pathol-
described by Kuzma and colleagues.33,34 ogy is evident, and concomitant procedures may be necessary.
554 Part IX  Ligament Instability/Tears

FIGURE 53-6        A and B, Examples of temporary pinning and screw fixation of the distal radioulnar joint. Hardware is removed after 8 weeks.

A B

CONTRAINDICATIONS FIGURE 53-7        Dorsal prominence of the ulna in an interosseous
ligament and distal radioulnar joint injury.
Smoking is a relative contraindication to performing an ulnar-
shortening osteotomy because of the risk of delayed union and
nonunion.35

PREOPERATIVE PLANNING
Making the diagnosis of an Essex-Lopresti injury is essential.
These patients have a history of a violent axial load that causes
a radial head fracture. Thus, all radial head fractures should be
examined for injuries to the IOL and DRUJ. They may also pre­
sent with wrist and forearm pain, although these are not always
present. A thorough examination of the upper extremity should
be performed with examination of the opposite side for compari-
son. Range of motion, grip strength, and stability of the DRUJ
should be noted. Patients typically have a dorsal prominence of
the ulnar head and reproducible pain with pronation and power
grip (Fig. 53-7).
True posteroanterior and lateral x-ray views of the wrist and i­nformation, since some studies report that most IOL injuries
elbow are mandatory. With the posteroanterior view of the wrist, were undetectable on standard posteroanterior x-rays of the
ulnar variance can be determined. Contralateral wrist films may wrist.25 To obtain grip views, both wrists should be in prona-
be helpful, and when there is a difference of more than 2 mm, tion while gripping 20 kg on a dynamometer36 (Fig. 53-8). The
the ILC is likely injured.10,11 If there is a positive ulnar variance x-ray beam is directed 15 degrees proximally and centered over the
of more than 2.5 mm, the normal wrist mechanics change, and DRUJ. Another useful radiographic examination is the radioul-
the ulna transmits more load to the forearm.6 Positive variance nar instability stress test (RIST). This is performed by comparing
may also result in ulnocarpal abutment. When 3 mm or more the change in ulnar variance at the wrist with an axial distraction
of ulnar variance are present, patients are likely to have wrist and compression along the radius. The senior author (ALO) has
pain.25 Both IOL and TFCC are likely injured with 7 mm ulnar analyzed this examination in cadaver models with serial section-
variance.14 ing of the radial head, ILC, and TFCC and in subjects with an
In addition, grip views of both wrists aid in the detection uninjured forearm. Unpublished data from the study suggest that
of dynamic radial shortening that may not be present on stan- an ulnar variance greater than 3.0 mm is concerning for disrup-
dard posteroanterior films. These radiographs provide valuable tion of the central band of the IOM and that values greater than
CHAPTER 53  The Interosseous Ligament and the Essex-Lopresti Injury 555

and confirmed intraoperatively. The plate is then secured distally
FIGURE 53-8        Grip views showing positive ulnar variance. and compressed through the proximal holes (Fig. 53-9A–D).
Many plates are available for performing the ulnar-shortening
osteotomy, but usually an LCDC plate is sufficient. The TriMed
USO plate (TriMed Ortho, Valencia, CA) and the Rayhack Gen-
eration II USO plate (Wright Medical Technology, Arlington,
TN) are other options that perform adequately. If more than 5
mm of shortening are anticipated, then a compression jig can
be advantageous for attaining bone apposition and compression.
Placement of the plate may be dorsal, ulnar, or volar; however,
anticipation for graft placement distal to the osteotomy site must
be taken into consideration. Typically, the best fit is ulnar for the
plate and dorsal for the graft.
Step 2: Preparation of the Graft
A BLB (bone–patellar ligament–bone) allograft is obtained from
a local bone bank and is used for reconstruction. Acquiring a
5.0 mm indicate complete ligamentous instability of the forearm. spare graft is advisable. Autograft BLB is not recommended as a
A normal RIST value averages 1.25 mm.37 result of knee pain complications associated with weather changes,
Recently, MRI and ultrasound have likewise been used to im- which were experienced by four patients in our original series of 16
age the forearm to diagnose IOL injury and determine the loca- patients. Although it may take longer to incorporate radiographi-
tion of the tear.25,38,39 These modalities each have their attributes, cally, we have experienced that the bone allograft provides the same
and we find them helpful in diagnosis and treatment. They can be stability to the forearm as an autograft. If extra bone is present at
considered, especially when primary repair of the ligament will be each end of the harvest, the majority of the cancellous bone should
performed in the acute setting. be removed from the graft. The cortical portion is trimmed to
Intraoperatively, a radius pull test can also be performed.40 Af- approximately 10 mm wide and 20 mm long but can be trimmed
ter the radial head is removed, a bone tenaculum is used to apply further once fitted and secured with screws (Fig. 53-10A and B).
a 20-pound axial load to the radius. Imaging is used to evaluate
ulnar variance at the wrist with and without the applied axial Step 3: Reconstruction of the Interosseous Ligament
load. A 3-mm change is associated with IOL disruption, and if a The main objective to the fixation of the BLB graft is to secure it
variance of 6 mm or more is noted, both the IOL and the TFCC near the IOL origin and insertion. The IOL inserts an average of
are likely injured.40 3.2 cm from the ulnar styloid and angles acutely at an average of
21 degrees toward its insertion on the radius.13,15,41
A plane is developed at an acute angle with a periosteal eleva-
SURGICAL TECHNIQUE tor between the wrist extensors and the ILC. A second incision is
The patient is positioned supine on the operating table with then made over the radius using the trajectory of the elevator as a
an arm board. An upper-arm pneumatic tourniquet is used for guide. The interval between the extensor carpi radialis brevis and
hemostasis. The arm is sterilely prepared and draped, and a time- the brachioradialis is developed to reveal the radius. The graft can
out is performed to confirm the proper surgical site. also be placed over the dorsum of the forearm with one end at
the insertion site to estimate the second incision. The insertion of
The following equipment is used for surgery: the pronator teres is a good landmark to identify, since this is ap-
Hand pan proximately the level at which the IOL originates on the radius.
Small fragment set (or plate of choice for USO) The graft is passed through the tunnel and then fixed to the
forearm, starting distally. The best fit is generally distal to the os-
Oscillating saw teotomy site on the dorsal cortex. The ligament fibers should be
Burr oriented in the direction of the native IOL to avoid buckling. The
Compression jig dorsal cortex, in the shape of the graft, is removed with a burr.
After predrilling with a 2.5-mm drill bit, the graft is secured with
Patellar ligament allograft a 3.5-mm self-tapping cortical screw (Fig. 53-11A–F).
The forearm is then placed in neutral to 20 degrees of supina-
Step 1: Ulnar-Shortening Osteotomy tion. The tendency to fit the cortex of the graft parallel with the
An incision is made along the subcutaneous border of the ulna shaft should be avoided, since buckling of the patellar ligament can
starting 1 cm from the styloid and extending proximally for 8 to occur (Fig. 53-12). Preferably, it is more important for the fibers of
10 cm. The dissection is continued between the extensor carpi the graft to parallel the native ligament. The graft should be angled
ulnaris and flexor carpi ulnaris to expose the ulna, leaving the acutely, approximately 21 degrees. Tension is pulled on the graft, the
periosteum undisturbed. A six-hole low-contact dynamic com- area on the dorsal radius is marked, and a trough is created with a
pression (LCDC) plate is placed in the ulnar border and centered burr to expose cancellous bone. The graft is then placed in the trough
at the anticipated site for the osteotomy approximately 6 cm from in the cancellous area and should lie flush with the dorsal cortex
the ulnar styloid. The distal screws are predrilled and measured. of the native bone. The forearm is placed in neutral to 20 degrees
An oblique osteotomy is performed, and enough bone is resected of supination, and tension is pulled on the graft at approximately
to allow for a negative ulnar variance of 2 mm at the wrist. The 21 degrees. It is held in place with a bone clamp to allow for screw
amount of resection is determined from the preoperative x-rays fixation. One or two cortical screws can be used to secure the graft.
556 Part IX  Ligament Instability/Tears

FIGURE 53-9        Ulnar-shortening osteotomy. A, An 8- to 10-mm incision is made 1 cm proximal to the ulnar styloid along the
­subcutaneous border of the ulna. Dissection between the extensor carpi ulnaris (ECU) and the flexor carpi ulnaris (FCU) leads
to the ulna. The periosteum is left intact. The dotted line represents the planned site for the osteotomy. B, A six-hole low-contact dynamic
compression plate is centered on the ulna and held with a bone clamp. Two distal holes are predrilled with a 2.5-mm drill bit and measured.
C, The plate is then removed to perform the osteotomy. The amount of resection is based on preoperative radiographs with a goal to achieve
2 mm of negative ulnar variance. D, The distal screws are placed to secure the plate to the bone. The proximal ulna is then placed in the “axilla”
of the construct and held there with a bone clamp. If ulnar variance is +4 mm or more, a compression jig is used. The proximal holes are drilled
­eccentrically to allow compression at the osteotomy site.

Ulna ECU Wrist X-ray

5mm

3mm

5mm
FCU resection

A C

Bone clamp

Place screws to
allow for compression

Screws

Power drill
B D

FIGURE 53-10        Examples of bone–patellar ligament–bone elbow, wrist, and finger active range of motion/passive range of
allograft. Each bony end of the graft is trimmed motion. X-rays are obtained at 2, 6, 12, 24, and 52 weeks post-
to roughly 10 mm wide by 25 mm long with the oscillating saw and
rongeur. Most of the cancellous bone is removed with a rongeur so
operatively, then yearly.
that only a thin layer remains. After the graft is properly tensioned
and secured on both ends, then excess prominent bone is removed COMPLICATIONS
with the rongeur to fit so there is no overhang.
The complications encountered in over 91⁄2 years’ follow-up with
this procedure are relatively minor. Four patients in our original
series complained of knee aches, mainly as a result of weather
change. Bone allografts were implemented thereafter. Tran-
sient posterior interosseous nerve palsy was recognized in one
patient. Two patients experienced extensor tendon adhesions that
responded to therapy. Three patients had delayed unions of the
ulna, which healed after 6 months with the use of a bone stim-
ulator. Two patients who were a smokers required repeat open
reduction and internal fixation of the ulna with bone grafting
for ulnar nonunions. As noted earlier, smoking with its effect
on bone healing is a relative contraindication to performing an
ulnar-shortening osteotomy.

RESULTS
Results are available from a prospective series of 16 patients,
who, since 1992, have been treated with autograft BLB recon-
struction. All these patients presented with chronic injuries after
POSTOPERATIVE MANAGEMENT failed initial management of an average of 10 months after radial
Patients are maintained in a volar splint until follow-up in 10 head excision (range 2 months to 12 years), with 75% presenting
to 14 days, when sutures are removed and a short-arm cast is less than 2 years from the initial injury. The patients included
applied. Elbow, wrist, and finger motion are encouraged imme- 11 males and 5 females, with an average age of 35 years (range 26
diately. Therapy is commenced at 10 to 14 days after surgery for to 49). Initial diagnoses included radial head fracture,7 Monteggia
CHAPTER 53  The Interosseous Ligament and the Essex-Lopresti Injury 557

FIGURE 53-11        Reconstruction of the interosseous ligament (IOL). A, Most of the cancellous bone is removed from the graft with a
­rongeur so that only a thin layer remains. B, A tunnel is created beneath the extensors proximally toward the radius at an
acute angle with an elevator. An incision is made proximally over the radius, and dissection is carried out in between the brachioradialis (BR)
and the extensor carpi radialis brevis (ECRB). C, After exposing the radius, the anticipated site for securing the graft is marked using the graft as
a template. D, The dorsal cortex is removed with a burr from the ulna and radius. E, The graft is then secured to the ulna with a 3.5-mm screw
with the fibers oriented parallel with the IOL. A bone clamp is used to hold the graft to the radius with the forearm in neutral to slight supina-
tion. The graft is then secured with one or two screws. F, Excess bone is removed with a rongeur or burr so there is no overhang. The cortex of
the graft should be flush with the dorsal cortex of the native bone.

10mm
Thin
25mm
cancellous
layer
Cancellous D
bone
Cortical Cortical bone
bone
A

Plate Ulna

E

Radius Second
ECRB incision
BR
B

Top view
21° of ulna

Side view
C F of ulna

fracture,3 radial head fracture with posterior dislocation,2 radial and four patients had knee pain with weather changes. Grip
head fracture with distal radius fracture,1 Essex-Lopresti injury,2 strength improved an average of 59% to 86% of the unaffected
and unconfirmed initial diagnosis.1 Three patients had a primary limb. Over 70% (10 of 14) returned to their pre-injury work
radial head excision, 5 had a Silastic radial head implant, and 12 duties, and three patients returned with modified duties. Initial
had secondary radial head excision. All Silastic prostheses resulted postoperative ulnar variance was ���������������������
–��������������������
2 mm (range –4 to ��������
+1 mm).
in failure. The average preoperative positive ulnar variance was On ­ follow-up, the average variance was –1.5 mm (range –�����������
3 to
3 mm (range 2 to 5 mm). Four patients also had lunate impac- +1 mm). Preoperatively, four patients had a normal arc of forearm
tion, another two had DRUJ arthritis, and five had mild arthritis motion (three postoperatively), seven had 120 to 140 ­degrees (six
at the elbow. postoperatively), four had 100 to 120 degrees (four postopera-
All patients received an ulnar-shortening osteotomy with an tively), and one had less than 120 degrees (three post­operatively).
autograft BLB reconstruction. Concomitant surgeries include Overall, patients were very satisfied with the procedure.
radial head excision,1 removal of radial head prosthesis,2 wrist Although autograft BLB reconstructions produce satisfac-
arthroscopy,3 DRUJ resection,1 Sauvé-Kapandji procedure,1 and tory results, our preliminary studies using allograft BLB recon-
carpal tunnel release.1 structions in 40 patients generated similar functional outcomes,
Outcomes after an average of 91⁄2 years revealed that no however, with the absence of complications related to knee pain.
­patient was subjectively worse and no patient needed secondary These early findings suggest that allograft BLB reconstructions
surgery to stabilize the forearm. Wrist pain improved in 94% of for chronic Essex-Lopresti injuries are preferred and result in
patients (15 of 16), and no patient experienced radiocapitellar high satisfaction for patients with this seemingly unforgiving
impingement. Two patients had progression of elbow arthritis, injury.
558 Part IX  Ligament Instability/Tears

16. Skahen JR III, Palmer AK, Werner FW, Fortino MD: The interosse-
FIGURE 53-12        Improperly tensioned graft. Note buckling of ous membrane of the forearm: anatomy and function. J Hand Surg [Am]
the ligament (arrow). The tendency to fit the cortex 1997;22(6):981–985.
of the graft parallel with the shaft should be avoided, since buckling 17. Boulas HJ, Morrey BF: Biomechanical evaluation of the elbow following
of the patellar ligament can occur. To prevent this, the graft should be radial head fracture: comparison of open reduction and internal fixation vs.
oriented so that the tendon fibers parallel the interosseous ligament. excision, Silastic replacement, and non-operative management. Chir Main
This leaves overhung bone from the graft that can be trimmed to 1998;17(4):314–320.
fit, once secured (as seen in the distal portion of this graft). Equally 18. Geel CW, Palmer AK, Ruedi T, Leutenegger AF: Internal fixation of proxi-
important, the graft should be tensioned in neutral to 20 degrees of mal radial head fractures. J Orthop Trauma 1990;4(3):270–274.
19. Hotchkiss RN: Displaced fractures of the radial head: internal fixation or
supination.
excision? J Am Acad Orthop Surg 1997;5(1):1–10.
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tures of the radial head. J Bone Joint Surg [Am] 2002;84(10):1811–1815.
21. Doornberg JN, Linzel DS, Zurakowski D, Ring D: Reference points for
­radial head prosthesis size. J Hand Surg [Am] 2006;31(1):53–57.
22. Essex-Lopresti P: Fractures of the radial head with distal radio-ulnar disloca-
tion: report of two cases. J Bone Joint Surg [Br] 1951;33(2):244–247.
23. Edwards G, JS Jupiter JB: Radial head fractures with acute distal radioulnar
dislocation: Essex-Lopresti revisited. Clin Orthop 1988;234:61–69.
24. Skahen JR III, Palmer AK, Werner FW, Fortino MD: Reconstruction of
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