SURGICAL TECHNIQUE

The Original Anatomic Reconstruction of

Palmar and Dorsal Radioulnar Ligaments
for Distal Radioulnar Joint Instability
Bernard F. Hearon, MD,*† Lisa M. Frantz, MD, MPAS,* Harry A. Morris, MD*†

Thirty years ago, the first anatomic reconstruction of the palmar and dorsal radioulnar liga-
ments for chronic distal radioulnar joint (DRUJ) instability was proposed by Sanders. In this
surgical technique, the midpoint of a free tendon autograft is firmly secured in a bony tunnel
at the ulnar fovea. The 2 graft limbs anchored at the fovea traverse the DRUJ and are securely
woven into the periarticular soft tissues radially, reproducing the ligamentous anatomy while
not overconstraining the joint. This report documents the original anatomic DRUJ recon-
struction technique described by Sanders and our procedure modifications. (J Hand Surg Am.
2020;-(-):-e-. Copyright Ó 2020 by the American Society for Surgery of the Hand. All
rights reserved.)
Key words Anatomic distal radioulnar joint reconstruction, distal radioulnar joint instability,
surgical technique, triangular fibrocartilage complex disruption, ulnar-sided wrist pain.

E
ARLY SOFT TISSUE RECONSTRUCTIONS for chronic
distal radioulnar joint (DRUJ) instability were
nonanatomic procedures. These included sling
techniques in which the distal radius and ulna were
encircled by tendon or fascia lata autograft, stabili-
zation of the distal ulna by tenodesis methods, and
ulnocarpal ligament reconstruction with tendon
autograft. Biomechanical cadaver studies demon-
strated that these nonanatomic reconstructions do not
restore baseline DRUJ stability.1
In 1990, Sanders proposed an anatomic recon-
struction of the palmar and dorsal radioulnar liga-
ments using a 2-limb tendon autograft. The center of
the graft was anchored at the ulnar fovea and the
From the *Department of Orthopaedic Surgery, University of Kansas School of Medicine;
and the †Advanced Orthopaedic Associates, PA, Wichita, KS.
Received for publication March 3, 2020; accepted in revised form August 3, 2020.
No benefits in any form have been received or will be received related directly or
indirectly to the subject of this article.
Corresponding author: Bernard F. Hearon, MD, Department of Orthopaedic Surgery,
University of Kansas School of Medicine, 929 N. Saint Francis, Wichita, KS 67214; e-mail:
bhearon@cox.net.
0363-5023/20/---0001$36.00/0
https://doi.org/10.1016/j.jhsa.2020.08.001
limbs were anchored radially to the palmar wrist joint
capsule and the dorsal retinaculum to reproduce the
ligamentous anatomy and provide elastic end points
to restraint. Therefore, the procedure is different from
the more recent Adams-Berger technique2 in which
the stabilizing tendon graft spanning the DRUJ is
anchored to both the ulna and the radius.
Although Sanders reported favorable short-term
clinical results,3 his method of DRUJ stabilization
was never published. The procedure described in this
report includes several minor modifications to the
original technique of Sanders, but is consistent with
principles he espoused for DRUJ reconstruction. This
surgical method represents an important evolutionary
step in the history of surgical treatment for DRUJ
instability.
INDICATIONS
Anatomic reconstruction of the palmar and dorsal
radioulnar ligaments is indicated for subacute or
chronic DRUJ instability associated with irreparable
triangular fibrocartilage complex (TFCC) tears. In our
experience, many chronic TFCC disruptions have
poor healing potential and are not amenable to ulnar
foveal reattachment. When such injuries result in

Ó 2020 ASSH r Published by Elsevier, Inc. All rights reserved. r 1

2 ORIGINAL ANATOMIC DRUJ RECONSTRUCTION

FIGURE 1: Dorsal approach to the distal ulna. Left wrist, proximal to the right, distal to the left. A Curvilinear dorsal skin incision
measures 5 to 6 cm with the longitudinal component along the ulnar aspect of the distal ulna and the transverse component at the level of
the ulnocarpal and radiocarpal joints. B After a radially based flap of skin and subcutaneous tissue is raised and secured with suture, an
ulnarly-based flap of dorsal retinaculum is raised over the distal ulna exposing the DRUJ capsule. Note the ulnarly reflected retinaculum
is held with forceps. C The DRUJ capsule is incised longitudinally, stripped from the ulnar neck proximally, and retracted radially and
ulnarly (see forceps) exposing the distal ulna. D With the wrist hyperpalmar-flexed, a power drill is used to create a 3.5-mm bony tunnel
from the ulnar fovea to the ulnar neck proximal to the articular cartilage.

longstanding severe DRUJ instability, we prefer
anatomic reconstruction of the marginal stabilizing
portions of the TFCC with tendon autograft to ach-
ieve consistently favorable outcomes.
Indications for the Sanders DRUJ reconstruction
also include failed nonsurgical treatment for acute
DRUJ instability, persistent wrist pain and instability
after TFCC repair, and failed arthroscopic treatment
for subacute or chronic DRUJ instability. Cases of
failed TFCC reconstruction owing to wrist reinjury and
primary graft rupture may be revised using a second
tendon autograft or allograft tendon. The Sanders
technique is also well-suited for DRUJ instability
following an anatomically united distal radius fracture
in which retained hardware impedes radial tunnel
placement required by the Adams-Berger technique.2
CONTRAINDICATIONS
Contraindications to reconstruction include inflam-
matory arthropathy, posttraumatic arthrosis, and
osteoarthrosis. Mild osteoarthrosis discovered at
surgery does not prohibit surgical stabilization,
which may proceed at the surgeon’s discretion.
Posttraumatic DRUJ incongruity secondary to
fracture malunion requires corrective osteotomy of
the bony deformity to restore DRUJ alignment
prior to soft tissue reconstruction, as either staged
or concurrent procedures. Whereas patients with
generalized ligamentous laxity4 are considered
suitable candidates for reconstruction, those with
severely hyperelastic collagen, as in Ehlers-Danlos
or Marfan syndromes, are relatively contra-
indicated for this surgical technique.
SURGICAL ANATOMY
Pronosupination of the forearm occurs about a lon-
gitudinal axis of rotation extending from the radial
head proximally through the ulnar fovea at the base
of ulnar styloid distally. The distal radioulnar bony
articulation between the seat of the ulnar head and the
sigmoid notch of the distal radius accounts for just
20% of DRUJ stability,5 owing to disparity between

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 ORIGINAL ANATOMIC DRUJ RECONSTRUCTION
FIGURE 2: Palmar approach for tendon graft harvest and inser-
tion into the ulnar tunnel using the original technique of Sanders.
Left wrist, proximal to the right, distal to the left. A Longitudinal
palmar incision, proximal to the wrist flexion crease and ulnar to
the median nerve, measures 4 to 5 cm. Palmaris longus or one-
half of the flexor carpi radialis is harvested using a tendon
stripper or other standard technique (not shown). B Folded tendon
graft is advanced through the bony tunnel with a suture passer so
that the looped end is distal. C Tails of the graft are passed
through the tendon loop. Then the tails are tightly cinched and
secured at the fovea with 2-0 nonabsorbable braided sutures
placed in horizontal mattress fashion (not shown).
the radii of curvature of the articular surfaces and
variations in concavity of the sigmoid notch. Thus,
the supporting soft tissue structures adjacent to the
J Hand Surg Am.
3
joint provide about 80% of DRUJ stability. Biome-
chanical studies have shown that the key intrinsic
DRUJ stabilizers are the palmar and dorsal radioulnar
ligaments of the TFCC.6
Each ligament consists of superficial and deep
fibers that attach to the palmar and dorsal aspects
of the distal radius at the sigmoid notch. The more
crucial deep fibers of both ligaments attach to the
ulnar fovea, whereas the superficial fibers insert
onto the ulnar styloid base. Importantly, with
forearm pronation, the deep fibers of the palmar
radioulnar ligament tighten and act as a checkrein
to dorsal displacement of the ulna with respect to
the radius. Conversely, with forearm supination,
deep fibers of the dorsal radioulnar ligament are
taut and act as a checkrein to palmar displacement.
The well-established functional anatomy of the
TFCC marginal ligaments7,8 is the predicate for
the Sanders anatomic distal radioulnar ligament
reconstruction.
PREOPERATIVE CONSIDERATIONS
The clinical diagnosis of DRUJ instability is based on
a positive dorsopalmar stress test as described by
Kleinman.8 When provocative stress applied to the
distal ulna results in significant translation of the ulna
with respect to the radius with no firm end point to
displacement and the maneuver reproduces the pa-
tient’s wrist pain, symptomatic DRUJ instability is
confirmed. Such physical findings are absent on ex-
amination of the opposite wrist. The symptomatic
side should also be assessed for the presence of pal-
maris longus, which may be used as tendon graft for
the reconstruction.
Before surgery is contemplated, other causes of
ulnar-sided wrist pain must be excluded.
Although not mandatory, wrist arthrogram or
high-resolution wrist magnetic resonance imaging
may be helpful to document TFCC pathoanatomy
and to rule out other sources of wrist pain. If
DRUJ instability has occurred after distal radius
or ulna fracture, preoperative wrist computed to-
mography scan should be obtained to confirm that
fractures are well healed, to rule out bony mal-
union, and to assess DRUJ congruity and sigmoid
notch anatomy.
Surgical reconstruction is done with the patient
under general anesthesia, with pneumatic tourni-
quet control, and using loupe magnification. After
induction of anesthesia, the dorsopalmar stress
test should be done to determine the direction and
severity of DRUJ laxity. Often examination under
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4 ORIGINAL ANATOMIC DRUJ RECONSTRUCTION

FIGURE 3: Modified technique for graft insertion into the ulnar tunnel. Left wrist, proximal to the right, distal to the left. A A loop
suture passer is advanced through the bony tunnel and graft is passed through the loop. B The passer is withdrawn from the tunnel
leaving a single strand of tendon graft in the tunnel. C Two graft limbs of equal length are created by using the Pulvertaft weave
technique and securing the tendon graft at the fovea with 2-0 nonabsorbable braided sutures placed in horizontal mattress fashion.

anesthesia provides a more reliable assessment of to confirm that TFCC disruption from the foveal
DRUJ instability than in the clinic. The surgeon attachment is irreparable before proceeding with
should also consider performing wrist arthroscopy reconstruction.

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 ORIGINAL ANATOMIC DRUJ RECONSTRUCTION 5

FIGURE 4: Passing the graft tail and anchoring into the palmar wrist capsule. Left wrist is shown in all photographs. A Distal is to the
top, dorsal to the right. Graft tail is grasped with a tendon passer and advanced through the wrist capsule from dorsal to palmar at the
ulnar border of the distal radius. BeD Proximal is to the left, distal to the right. B Graft tail passed through the wrist capsule for palmar
radioulnar ligament reconstruction. C Graft tail being woven through the palmar wrist capsule radial to the DRUJ. D Graft tail tightened
after being woven through the palmar capsule, then secured with 3-0 nonabsorbable braided figure-of-eight sutures.

SURGICAL TECHNIQUE throughout the procedure. The dorsal capsule is

The dorsal approach to the distal ulna is made
through a 5- to 6-cm L-shaped incision that begins
over the distal ulna and curves radially at the ulno-
carpal joint (Fig. 1A). A radially based flap of skin
and subcutaneous tissue is raised, taking care to
identify and protect the dorsal sensory branch of the
ulnar nerve. The extensor retinaculum is exposed as
far radial as the Lister tubercle by undermining the
flap or extending the transverse component of the
incision.
While preserving the underlying DRUJ capsule, an
ulnarly-based flap of dorsal retinaculum is raised
between the fifth and the sixth dorsal compartments
and is reflected ulnarly (Fig. 1B). Alternatively, as
originally described by Sanders, the fifth dorsal
compartment may be opened to mobilize the extensor
digiti minimi, which must then be protected
divided longitudinally and stripped from the ulnar
neck proximally (Fig. 1C). If present, small osteo-
phytes along the ulnar seat and TFCC flap tears are
debrided. With the wrist hyperpalmar-flexed to
expose the ulnar dome, a 2-mm drill bit with
accompanying drill guide is used to create a 2-cm
long bony tunnel from the ulnar fovea to the ulnar
neck (Fig 1D). The tunnel is progressively widened
to 3.5 mm with sequentially larger drill bits, taking
care to avoid violating the bony bridge dorsally.
Attention is directed to the palmar aspect of
the distal forearm where a 4- to 5-cm longitu-
dinal incision is made ulnar to the median nerve
over the digital flexors (Fig. 2A). The palmaris
longus or one-half of the flexor carpi radialis is
harvested with a tendon stripper or other stan-
dard technique to ensure maximum graft length.

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6 ORIGINAL ANATOMIC DRUJ RECONSTRUCTION
FIGURE 5: Passing and anchoring the dorsal graft tail and wound
closure. Left wrist, proximal to the right, distal to the left. A
Dorsal graft tail is passed beneath the tendons of the fourth and
fifth dorsal compartments. Graft is then woven into the dorsal
wrist capsule and retinaculum between the third and the fourth
dorsal compartments (not shown). B Palmar incision and ancil-
lary incisions made to harvest the tendon graft are closed with 4-
0 absorbable subcutaneous sutures. C Dorsal wound is closed in
layers with 4-0 absorbable sutures for the DRUJ capsule, 3-
0 nonabsorbable braided sutures for the dorsal retinaculum, fol-
lowed by 4-0 absorbable subcutaneous sutures.
Returning to the dorsal wound, the folded
tendon graft is advanced through the ulnar
tunnel with a suture passer so that the looped
end is distal (Fig. 2B). The tails of the graft
exiting the tunnel proximally are passed through
the tendon loop (Fig. 2C) and are cinched
tightly. The tendon loop and incarcerated tendon
tails are thereby positioned at the ulnar fovea
where the construct is secured with 2-0 nonab-
sorbable braided suture.
J Hand Surg Am.
To preserve graft length, our modified technique
may be used to anchor the tendon graft to the ulna. A
suture passer is advanced through the bony tunnel
and the graft is passed through the loop (Fig. 3A).
The passer is withdrawn leaving a single graft strand
in the tunnel (Fig. 3B). Two graft limbs of equal
length are created by using a Pulvertaft weave tech-
nique (Fig. 3C) and securing the woven tendon graft
at the fovea with 2-0 nonabsorbable braided suture.
Because only 1 graft strand is within the bony tunnel,
about 2 cm of graft length are conserved by our
technique modification.
Typically, the more robust graft limb is then used to
reconstruct the palmar radioulnar ligament. With the
forearm upright in neutral rotation and with full exposure
of the capsule from the palmar incision, a small-gauge K-
wire is advanced by hand from the dorsal incision
through the palmar wrist capsule at the ulnar border of
the lunate fossa. When the K-wire penetrates the capsule
and is visualized palmarly, a No. 69 Beaver blade is used
to cut down along the K-wire creating a focal capsu-
lotomy. A tendon passer, advanced from palmar to
dorsal through the capsular defect, is used to grasp the
selected graft limb (Fig. 4A) that is pulled through the
palmar wrist capsule into the palmar incision (Fig. 4B).
The forearm is repositioned on the hand table and fully
supinated. At the radiocarpal joint level and radial to the
DRUJ, short parallel incisions extending partially
through the palmar wrist capsule are made (Fig. 4C). The
graft limb is advanced through this small capsular win-
dow, put under tension (Fig. 4D), and secured with 3-
0 nonabsorbable braided suture, completing the palmar
radioulnar ligament reconstruction.
With the forearm pronated, an extracapsular path
for the dorsal graft limb is created with a Kelly clamp
beneath the tendons of the fourth and fifth dorsal
compartments. A tendon passer, positioned from
radial to ulnar along this pathway (Fig. 5A), is used to
advance the graft limb beneath the digital extensors
exiting at the radiocarpal level between the third and
the fourth dorsal compartments. In this tendon-free
zone, the graft is woven into the wrist capsule and/
or dorsal retinaculum and secured with 3-0 nonab-
sorbable braided suture, completing the dorsal radi-
oulnar ligament reconstruction. During this phase of
the procedure, care is taken to prevent injury to
branches of the superficial radial nerve and to avoid
incarcerating tendons of the third, fourth, or fifth
dorsal compartments. A schematic diagram of the
final reconstruction is shown in Figure 6.
Stability of the reconstructed DRUJ is assessed by
the dorsopalmar stress test. If residual laxity is noted,
the direction of laxity is determined by examination
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 ORIGINAL ANATOMIC DRUJ RECONSTRUCTION
FIGURE 6: Schematic drawing of the distal radioulnar ligament
reconstruction. Center of the tendon graft is anchored at the ulnar
fovea (FA, foveal attachment). One graft limb is passed through
and woven into the palmar wrist capsule (PA, palmar attachment)
near the lunate fossa (LF). The second graft limb is passed
beneath the digital extensors and woven into the dorsal wrist
capsule and retinaculum (DA, dorsal attachment) distal to the
Lister tubercle (LT). Modified with permission from Frantz et al.9
and tension in the appropriate graft limb is readjusted
accordingly. If laxity is appreciated with dorsal-
directed stress applied to the distal ulna when the
forearm is pronated, then the palmar graft limb ten-
sion is increased. Conversely, if laxity is found on
palmar-directed stress with the forearm supinated,
then the dorsal graft limb is tightened.
The pneumatic tourniquet is deflated and hemo-
stasis achieved. After wound irrigation, the palmar
wrist incision and any ancillary incisions made to
harvest the tendon graft are closed with 4-0 absorb-
able subcutaneous suture (Fig. 5B). The dorsal
wound is closed anatomically in layers using 4-
0 absorbable sutures for the DRUJ capsule, 3-
0 nonabsorbable braided suture for the retinaculum,
followed by 4-0 absorbable subcutaneous sutures
(Fig. 5C). The extremity is immobilized in a non-
removable single sugar-tong plaster orthosis with the
wrist slightly ulnarly deviated, the forearm in neutral
rotation, and the fingers free.
POSTOPERATIVE CARE
Patients continue postoperative immobilization of the
wrist and elbow for 6 weeks with single sugar-tong
orthosis changes at 2-week intervals. Alternatively,
Sanders recommended a long-arm cast or Meunster
J Hand Surg Am.
7
cast be used for immobilization. Six weeks after
surgery, a removable short-arm orthosis is applied for
2 to 4 weeks. The patient begins doctor-directed,
gradually progressive, active wrist dorsiflexion and
palmar flexion, while limiting active pronosupination.
No passive wrist range of motion or formal hand
therapy is prescribed to minimize the likelihood of
stretching or rupturing the graft reconstruction.
Heavy lifting and sports activity are discouraged for 6
months after surgery.
COMPLICATIONS
Our observation has been that the Sanders recon-
struction will improve wrist pain and stability, but
may result in minimal loss of terminal wrist palmar
flexion or forearm supination. The most common
complications are continued ulnar-sided wrist pain
and/or persistent DRUJ instability. Mild residual
DRUJ instability without wrist pain is considered an
acceptable outcome. Painful, limited pronosupination
without instability warrants consideration of alterna-
tive diagnoses, such as DRUJ arthrosis. Persistent
pain and failure of the procedure to restore DRUJ
stability may be attributed to patient-related factors
like collagen hyperelasticity, surgical errors including
improper graft placement or tensioning, insufficient
immobilization, or aggressive wrist motion or
stretching leading to graft rupture. Transient dyses-
thesia involving the superficial radial nerve, dorsal
sensory ulnar nerve, or median nerve may also occur.
DISCUSSION
We believe that the Sanders DRUJ reconstruction is
functionally equivalent to the Adams-Berger tech-
nique,2 because both methods are intended to repli-
cate the crucial deep fibers of palmar and dorsal
radioulnar ligaments to restore DRUJ stability. In
both techniques, there is firm bony attachment of the
tendon graft at the ulnar fovea. Also, graft loading
across the DRUJ is similarly directed toward the
sigmoid notch attachment points of the native radio-
ulnar ligaments in both methods. This is true despite
the fact that the graft is anchored through a bony
tunnel in the distal radius for the Adams-Berger
technique,2 whereas the graft limbs are firmly
anchored separately into adjacent soft tissues in the
Sanders technique. Palmar and dorsal graft limbs are
required in both reconstructions to balance stabilizing
forces across the DRUJ throughout pronosupination.
Sanders advocated radial-side graft-to-capsule
attachment to avoid overconstraining the DRUJ at the
extremes of pronosupination. Although none of the
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8 ORIGINAL ANATOMIC DRUJ RECONSTRUCTION
14 patients in the Adams and Berger series10 had
limited wrist motion, Kootstra et al11 found limited
pronosupination in a cohort of 22 Adams-Berger re-
constructions at 5-year mean follow-up. In our
experience, a patient treated with the Adams-Berger
technique developed postoperative wrist stiffness
requiring palmar DRUJ capsulotomy. These data,
although limited, suggest that concerns about pre-
disposing patients to DRUJ stiffness by anchoring the
tendon graft to both radius and ulna may be well
founded.
Comparison of the 2 techniques also indicates that
a longer tendon graft is required for the Adams-
Berger procedure, because the graft must be passed
around the ulnar neck before it is placed under ten-
sion and secured. When the available tendon graft
length is less than 15 cm, the Sanders technique of
DRUJ reconstruction with our Pulvertaft weave
modification for anchoring the graft at the ulnar fovea
may be preferred to conserve graft length. Modern
fixation implants may now be used to secure tendon
graft to the ulnar fovea, not only conserving graft
length but also shortening surgical time.
Special considerations are required for patients
with DRUJ instability after distal radius fractures. In
these cases, preoperative evaluation should include
wrist computed tomography scan to rule out DRUJ
incongruity or malalignment resulting from fracture
malunion. When found, corrective osteotomy of the
malunion as a staged procedure before DRUJ stabi-
lization is preferred because the bony correction
alone may improve DRUJ stability and render radi-
oulnar ligament reconstruction unnecessary. The
J Hand Surg Am.
Sanders reconstruction may also be preferred when
retained hardware from prior distal radius fracture
fixation prohibits the creation of the radial tunnel
required in the Adams-Berger technique.
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