Masterclass: Extra-articular Reconstruction for DRUJ and Ulnocarpal Instability

Alright team, gather 'round. Today, we're tackling a challenging yet incredibly rewarding area of wrist surgery: the extra-articular reconstructive techniques for the distal radioulnar joint (DRUJ) and ulnocarpal joint. We're talking about restoring stability and function to a complex region often plagued by chronic pain and disability.

The wrist, particularly its ulnar side, is a marvel of biomechanical engineering. The intrinsic stability of the DRUJ and ulnocarpal articulation relies heavily on the integrity of the triangular fibrocartilage complex, or TFCC, which acts as the primary stabilizer. When this complex fails, either traumatically or degeneratively, patients suffer from pain, weakness, and functional limitations. Our goal today is to meticulously reconstruct this stability using two distinct, yet equally effective, approaches: the Modified Herbert reconstruction and the Hui-Linscheid procedure.

Let's scrub in and dive deep.

Comprehensive Surgical Anatomy: Navigating the Ulnar Wrist

Before we make any incision, we must have an absolute mastery of the anatomy. The ulnar side of the wrist is a densely packed region with critical neurovascular structures and intricate tendinous and ligamentous relationships.

The Triangular Fibrocartilage Complex (TFCC)

The TFCC is the cornerstone of stability for the DRUJ and ulnocarpal joint. It's not just a single structure, but a collection of soft tissues:
* Triangular Fibrocartilage Proper: Originates from the medial aspect of the distal radius and inserts into the base of the ulnar styloid. This provides a continuous gliding surface.
* Dorsal and Palmar Radioulnar Ligaments (DRUL, PRUL): These are the primary stabilizers of the DRUJ, often referred to as the marginal ligaments. They are crucial for maintaining congruity through pronosupination.
* Ulnocarpal Ligaments: Specifically, the ulnolunate and ulnotriquetral ligaments, which suspend the ulnar carpus from the ulnar head.
* Extensor Carpi Ulnaris (ECU) Subsheath Fibers: These fibers blend with the TFCC and contribute to dynamic stability.

Surgical Warning: Understand that the ulnar carpus does not directly articulate with the distal ulna. It's suspended by the TFCC. This suspension mechanism is key to its load-transferring and cushioning functions.

FIG 1 • The soft tissue structures encompassing the triangular fibrocartilage complex of the wrist stabilizing the radial-ulnar-carpal unit. The triangular fibrocartilage proper originates from the radius medially and attaches to the base of the ulnar styloid. Fibers originating from the subsheath of the extensor carpi ulnaris dorsally cross paths with fibers originating from the ulnocarpal ligaments volarly and blend with the triangular fibrocartilage proper.

The Extensor Retinaculum

This thick fibrous band is critical for both procedures we'll discuss.
* Attachments: It attaches medially to the pisiform and triquetrum, and laterally to the lateral margin of the radius. Its orientation is radial-proximal to ulnar-distal.
* Continuity: It's continuous with the palmar carpal ligament and has connecting fibers with the flexor retinaculum proximal to the pisiform.
* Compartments: Deep to the retinaculum lie the six extensor compartments, each housing specific tendons. For the Modified Herbert, we're particularly interested in the fourth (extensor digitorum communis, extensor indicis) and fifth (extensor digiti quinti, EDQ) compartments, and the ECU in the sixth.

Surgical Warning: The dorsal cutaneous branch of the ulnar nerve often crosses the surgical field dorsally, particularly near the ulnar styloid. Meticulous dissection and careful retraction are paramount to avoid iatrogenic nerve injury, which can lead to debilitating neuropathic pain.

FIG 2 • Extensor retinaculum ( light blue ), flexor retinaculum ( shaded red ), and palmar carpal ligament ( dark blue ). The extensor retinaculum inserts in the pisiform and triquetrum bones ( 1 ) medially and connects with the lateral margin of the radius laterally ( 2 ), causing its orientation to be radial-proximal to ulnardistal. The extensor and flexor retinaculum connects proximal to the pisiform ( 3 ). The extensor retinaculum is continuous with the palmar carpal ligament, which is superficial to and proximal to the flexor retinaculum.

Relevant Osteology

• Distal Radius: The sigmoid notch articulates with the ulnar head.
• Distal Ulna: The ulnar head, styloid process, and fovea are key landmarks for TFCC attachment and ligamentous reconstructions.
• Carpus: Pisiform, triquetrum, lunate, and capitate are relevant for ulnocarpal stability and graft attachment points.

Pathogenesis and Clinical Presentation

Patients typically present with ulnar-sided wrist pain, often with clicking, especially during forearm pronation-supination. This can be acute, from a fall on an outstretched hand (FOOSH), or chronic, due to repetitive loading or degenerative changes (e.g., rheumatoid arthritis).

Physical Examination Pearls

• Visual Inspection: Look for swelling, subtle ulnar-sided supination deformity.
• Palpation: Tenderness localized to the ulnar carpus, between the ulnar styloid and triquetrum, or over the DRUJ.
• Range of Motion: Assess active and passive pronation-supination, flexion-extension, radial-ulnar deviation. Note any weakness or pain with these movements.
• Provocative Maneuvers:
  • Piano Key Test: A positive test (dorsal displacement of the ulnar head that reduces with pressure but springs back) indicates a complete peripheral tear of the TFCC and/or dorsal radioulnar ligament tear.
  • Supination Test (Diagnostic Maneuver): Stabilize the DRUJ firmly. Stress the wrist in supination and volar translation. Pain reproduction or a "clunk" indicates ulnocarpal instability. Compare to the contralateral side.
  • Watson (Scaphoid Shift) Test & Shuck Test (Lunotriquetral): These should typically be negative in isolated ulnocarpal instability, helping rule out concomitant carpal instability.
  • Wrist Pivot Shift Test (Lichtman): Helps rule out midcarpal instability.

Imaging and Diagnostic Studies

• Radiographs: Standard PA and lateral views are often poor for ligamentous instability but rule out fractures and carpal instability (e.g., DISI/VISI). On a pure lateral view, dorsal positioning of the ulna relative to the radius suggests DRUJ instability.
• CT Scan: Excellent for visualizing joint congruity, fractures, and DRUJ subluxation/dislocation.
• MRI / MR Arthrography: While standard MRI can show TFCC anatomy, MR arthrography (especially with contrast injected into the DRUJ) has higher sensitivity (85%) and specificity (76%) for peripheral TFCC tears, comparable to arthroscopy.
• Live Fluoroscopy with Supination Test: This is invaluable. It allows dynamic visualization of ulnocarpal instability. Observe the triquetrum's changing appearance (decreased length in supination) and the pisiform's relationship to the triquetrum.

FIG 3 • The still photographs shown have been captured from a fluoroscopy video of a wrist with ulnocarpal instability during the supination test. A. Top of the examination cycle with the wrist in neutral position. B. Bottom of the examination cycle. In both images, the black line represents the distance between proximal edges of pisiform and triquetrum. The red line indicates the length of the triquetrum. The shorter length of the red and black lines in B compared with A demonstrates the ulnocarpal instability present during dynamic testing.
* Wrist Arthroscopy: The gold standard for diagnosing TFCC and interosseous ligament injuries, allowing direct visualization and treatment of concomitant lesions or synovitis. We often perform this immediately prior to open reconstruction.

Preoperative Planning and Patient Positioning

Our primary indication for surgery is persistent, painful ulnocarpal instability with diminished grip or pronosupination strength, unresponsive to at least 4-6 weeks of conservative treatment (splinting, NSAIDs, PT). High-demand athletes may warrant earlier surgical consideration.

Preoperative Planning

1. Review All Imaging: Meticulously examine radiographs, CT, MRI, and arthroscopy reports to identify the exact pathology, extent of tears, and any concomitant wrist issues.
2. Templating: For the Hui-Linscheid, consider the required graft length and potential drill hole trajectory.
3. Anesthesia Consultation: General anesthesia with regional block (e.g., supraclavicular or axillary block) for postoperative pain control is preferred.
4. Tourniquet Time: Plan for adequate tourniquet time, typically 60-90 minutes for these procedures.

Patient Positioning

1. Operating Table: Standard operating table with a specialized hand table extension.
2. Patient Position: Supine.
3. Affected Arm: The affected arm is placed on an arm board, with the elbow flexed at approximately 45 degrees. The forearm is positioned in pronation. This pronated position facilitates optimal exposure of the dorsal wrist and helps in reducing the DRUJ.
4. Tourniquet: A pneumatic tourniquet is applied high on the upper arm.
5. Sterile Prep: The entire arm, from the tourniquet down to the fingertips, is prepped and draped in a sterile manner. Ensure adequate exposure of the dorsal aspect of the wrist joint.
6. Fluoroscopy Setup: The C-arm should be readily available and draped sterilely. It should be positioned to allow for immediate AP and lateral views of the DRUJ and ulnocarpal joint, particularly for dynamic assessment during reduction maneuvers.

Intraoperative Execution: The Masterclass

Alright, fellows, let's get started. We'll begin with the Modified Herbert Reconstruction, then move to the Hui-Linscheid.

I. Modified Herbert Reconstruction: Ligamentotaxic Constraint

The Modified Herbert reconstruction aims to stabilize the DRUJ and ulnocarpal joint by creating an ulnar-based flap of the extensor retinaculum, which is then advanced in a distal-ulnar to radial-proximal direction. This effectively creates a sling, providing ligamentotaxic constraint.

A. Incision and Initial Dissection

1. Skin Incision: "Scalpel, please. A #15 blade." We'll make a precise longitudinal incision, approximately 4-5 cm in length, centered directly over the palpable fifth extensor compartment at the level of the wrist joint. This typically lies just ulnar to the extensor digiti minimi tendon.
   

   
   
   

TECH FIG 1A • Longitudinal incision over the fifth extensor compartment at the level of the wrist.

> **Surgical Warning:** As we deepen this incision through the skin and subcutaneous tissue, be mindful of the dorsal cutaneous branch of the ulnar nerve. It often crosses the field obliquely. Use fine blunt dissection with Metzenbaum scissors to identify and carefully retract any nerve branches. Hemostasis is key here; bipolar cautery, please, to maintain a clear field.

1. Exposing the Extensor Retinaculum: "Gelpi retractors, let's get some exposure." We'll carefully expose the extensor retinaculum. You'll see the distinct fibrous bands. Identify the compartments. The fifth compartment houses the extensor digiti quinti (EDQ) and the sixth compartment, further ulnar, contains the extensor carpi ulnaris (ECU).

2. Incising the Extensor Retinaculum: "Now, we need to create our flap. I'll use a #15 blade, carefully, to incise the extensor retinaculum longitudinally." This incision is made between the fourth and fifth extensor compartments.
   

   
   
   

TECH FIG 1B • Incise the extensor retinaculum between the fourth and fifth compartments.

> **Surgical Warning:** This step is critical. Do *not* enter the fourth compartment, as this could compromise the tendons within (EDC, EIP). The goal is to create an ulnar-based flap, so our incision is along the radial border of the fifth compartment. We want to preserve the integrity of the other compartments.

B. Raising the Retinacular Flap and EDQ Transposition

1. Elevating the Ulnar-Based Flap: "We'll now meticulously raise an ulnarly based flap from the distal two-thirds of the retinaculum." Use a small periosteal elevator or a Freer elevator to carefully lift the retinaculum off the underlying extensor tendons. We're aiming to create a robust flap that will serve as our reconstructive material. Keep it thick and well-vascularized.
   

   
   
   

TECH FIG 1C • Raise an ulnar-based flap. Prepare the extensor digiti quinti to be transposed dorsal to the extensor retinaculum.

1. Preparing the Extensor Digiti Quinti (EDQ): "Now, let's identify the EDQ tendon. We need to prepare it for transposition." The EDQ lies within the fifth compartment. We'll carefully dissect around its tendon, freeing it from its subsheath, so it can be relocated dorsally to the planned retinaculum flap. This prevents its impingement once the flap is imbricated.

C. DRUJ Reduction and Flap Fixation

1. Reducing the DRUJ: "This is a key moment. We need to reduce the DRUJ. Assistant, please hold the wrist in neutral position. I will apply a firm, steady downward force on the distal ulna." Simultaneously, apply a slight radial translation to bring the ulnar head back into its anatomical position within the sigmoid notch of the radius. You should feel a distinct reduction, and the joint should feel stable in this position. Confirm with fluoroscopy if needed.

2. Translating and Suturing the Retinacular Flap: "Maintaining that reduction, we'll now translate our retinacular flap proximally and radially." The flap is advanced in a distal-ulnar to radial-proximal direction. "I'll use 2-0 PDS absorbable sutures on a tapered needle for this." We'll secure the leading edge of this flap directly to the periosteum of the ulnar border of the distal radius. Place multiple interrupted sutures, ensuring firm, broad contact between the flap and the periosteum. The tension should be sufficient to maintain the DRUJ reduction and provide a taut sling.
   

   
   
   

TECH FIG 1D • The retinacular flap is sutured to the periosteum of the ulnar border on the distal radius.

> **Surgical Warning:** Ensure your sutures are placed securely into the periosteum and not just superficial soft tissue. Inadequate purchase will lead to early failure of the reconstruction. Avoid overtightening, which can restrict pronosupination.

D. Imbrication and EDQ Relocation

1. Oblique Imbrication of the Retinaculum: "Now, for the final shaping of our sling. We will carefully imbricate the remaining extensor retinaculum." This imbrication is performed obliquely, at a 30 to 40-degree angle, continuing the distal-ulnar to radial-proximal direction. This creates a strong, reinforcing layer over our initial flap. Use non-absorbable sutures (e.g., 2-0 Ethibond) for this layer for long-term stability.
   

   
   
   

TECH FIG 1E • Imbricate the extensor retinaculum obliquely in a distal-ulnar to radial-proximal direction. The extensor digiti quinti should remain dorsally of the imbricated extensor retinaculum flap.

1. Relocating the EDQ: "Finally, remember our EDQ tendon? We will now relocate it dorsally, over the top of this newly imbricated extensor retinaculum flap." This prevents any impingement of the tendon and ensures its smooth gliding function. Check for free movement of the EDQ.

   Surgical Pearl: At this stage, perform a dynamic check. Gently pronate and supinate the forearm. The DRUJ should feel stable, and there should be no excessive laxity or impingement. The goal is stability without undue restriction of motion.

II. Hui-Linscheid Reconstruction: Ulnocarpal Ligament Augmentation

The Hui-Linscheid procedure focuses on augmenting the ulnocarpal ligament function, often combined with imbrication of an attenuated dorsal radioulnar ligament. It utilizes a tendon graft passed through the ulnar head.

A. Incision and Dissection

1. Skin Incision: "For the Hui-Linscheid, we'll make a standard dorsal longitudinal incision." This incision typically begins at the level of the fifth extensor compartment, extending distally towards the carpus and proximally to expose the ulnar head.
   

   
   
   

TECH FIG 2A • A longitudinal incision is made over the dorsal ulnar aspect of the wrist.

> **Surgical Warning:** Again, meticulous care to protect the dorsal cutaneous branch of the ulnar nerve is paramount. Use careful blunt dissection.

1. Exposing the Ulnar Head and Carpus: "We'll elevate skin flaps to expose the ulnar head, the ulnocarpal articulation, and the extensor carpi ulnaris (ECU) tendon sheath." The interval between the fourth and fifth extensor compartments is often used, or the fifth and sixth, depending on the specific approach.

2. Identifying the Flexor Carpi Ulnaris (FCU): "Now, we need to locate our graft source. We'll make a separate, small longitudinal incision, approximately 2-3 cm, over the distal forearm, directly overlying the flexor carpi ulnaris (FCU) tendon." This tendon is easily palpable on the ulnar side of the forearm, just proximal to the pisiform.
   

   
   
   

TECH FIG 2B • A separate incision is made over the flexor carpi ulnaris tendon.

B. Tendon Graft Harvest

1. Harvesting the FCU Tendon Graft: "We'll carefully open the FCU tendon sheath. Now, using a tendon stripper, or by careful sharp dissection, we'll harvest a strip of the FCU tendon." We need a graft approximately 10-12 cm in length, leaving its distal attachment intact to the pisiform. The proximal end is then detached.
   

   
   
   

TECH FIG 2C • The flexor carpi ulnaris tendon is harvested.

> **Surgical Pearl:** Ensure the harvested tendon strip is of adequate diameter and length. If the FCU is too small or damaged, alternative grafts like palmaris longus or plantaris may be considered, but FCU is preferred due to its anatomical proximity and strength.

C. Creating the Ulnar Head Tunnel

1. Identifying Drill Site: "Back to the dorsal wrist. We need to create a bone tunnel through the ulnar head." Identify the ulnar head. The drill entry point is typically on the dorsal aspect of the ulnar head, just distal to the articular cartilage.
   

   
   
   

TECH FIG 2D • A tunnel is drilled in the ulnar head.

1. Drilling the Tunnel: "I'll take a 2.5 mm drill bit, please." Drill a unicortical tunnel through the ulnar head, aiming towards the fovea, or slightly volar and distal to exit on the ulnar styloid or fovea region. The exact trajectory is crucial to mimic the ulnocarpal ligament's course.
   

   
   
   

TECH FIG 2E • The tendon graft is passed through the ulnar head.

> **Surgical Warning:** Drill under constant fluoroscopic guidance to confirm trajectory and prevent iatrogenic fracture of the ulnar head or damage to the articular surface. Ensure the tunnel is smooth and free of sharp edges that could fray the graft. Use a Kirschner wire to create the pilot hole, then over-drill if necessary.

D. Graft Passage and Fixation

1. Passing the Graft: "Now, we'll pass our harvested FCU tendon graft through this tunnel." Use a tendon passer or a curved hemostat to carefully pull the proximal end of the FCU graft through the ulnar head tunnel from dorsal to volar.
   

   
   
   

TECH FIG 2F • The tendon graft is looped back to its insertion on the pisiform.

1. Looping and Securing the Graft: "Once the graft emerges volarly, we'll loop it back proximally to its original insertion point on the pisiform." The graft should be tensioned to provide appropriate ulnocarpal stability.
   

   
   
   

TECH FIG 2G • The tendon graft is secured to the pisiform with a nonabsorbable suture.

> **Surgical Pearl:** Tensioning is critical. With the wrist in a neutral position, apply gentle traction to the graft. The DRUJ should feel stable, and the ulnocarpal articulation should be reduced. Avoid excessive tension, which can lead to stiffness or pain.

1. Fixation to Pisiform: "We'll secure the graft by suturing it firmly to the periosteum and remaining FCU stump at the pisiform insertion using a strong, non-absorbable suture, like 2-0 Ethibond." Multiple sutures are typically used to create a robust repair. The graft can also be woven through the remaining FCU tendon for additional strength.

E. Optional DRUL Imbrication

If there is demonstrable laxity of the dorsal radioulnar ligament, an optional imbrication can be performed. This involves plicating the attenuated dorsal capsule and ligament with sutures to tighten the DRUJ.

III. Final Checks and Wound Closure (Both Procedures)

1. Dynamic Assessment: "Before we close, let's perform a final dynamic assessment." Gently pronate and supinate the forearm, flex and extend the wrist. The DRUJ and ulnocarpal joint should feel stable throughout the range of motion, without excessive laxity or impingement. Confirm with fluoroscopy if indicated.
2. Hemostasis: "Ensure meticulous hemostasis. We want a dry field to minimize hematoma formation."
3. Irrigation: "Copious irrigation with sterile saline, please."
4. Wound Closure:
   • Deep Layers: Close the subcutaneous tissue with absorbable sutures (e.g., 3-0 Vicryl).
   • Skin: Close the skin with non-absorbable sutures or staples (e.g., 4-0 Nylon or skin staples).
   • Dressings: Apply sterile dressings, followed by a well-padded sugar tong splint or a long arm cast, immobilizing the wrist in neutral to slight extension and the forearm in neutral rotation.

Pearls and Pitfalls

Pearls

• Anatomical Precision: True mastery lies in understanding the 3D relationships of structures. Reviewing anatomical models or cadaveric dissection pre-op is invaluable.
• Dynamic Assessment: Use fluoroscopy and manual stress tests intraoperatively to confirm reduction and stability before closing.
• Tensioning: Achieving the "just right" tension for the reconstruction is an art. Too loose, it fails; too tight, it restricts motion.
• Graft Preparation: Handle tendon grafts gently to preserve their integrity and viability.

Pitfalls and Salvage Strategies

• **Nerve Injury (D

Additional Intraoperative Imaging & Surgical Steps

REFERENCES

• A warm, moist wrap can be used around the wrist to provide additional stretching of the wrist before activities. Ice and nonsteroidal anti-inflammatory agents can be used to provide relief after each session.

• Adams BD. Partial excision of the triangular fibrocartilage complex articular disk: a biomechanical study. J Hand Surg Am 1993;18A: 334–340.

• Cooney WP. Evaluation of wrist pain by arthrogram, arthroscopy, and arthrotomy. J Hand Surg Am 1993;18A:815–822.

• Dy CJ, Ouellette EA, Malik A, et al. Mechanical Testing of Distal Radioulnar Instability Repair: Ligament Reconstruction vs. Capsulorrhaphy. Proceedings of the Annual Meeting of the American Academy of Orthopaedic Surgeons, Feb. 16, 2007.

• Glowacki KA, Shin AY. Stabilization of the unstable distal ulna: the Linscheid-Hui procedure. Tech Hand Upper Extr Surg 1993;4: 229–236.

• Harrison RJ, Ouellette EA, Latta LL, et al. The Biomechanics of Diagnosing and Treating Peripheral TFCC Instability. Proceedings of the Annual Meeting of the American Society for Surgery of the Hand, Sept. 9, 2004.

• Hui FC, Linscheid RL. Ulnotriquetral augmentation tenodesis: a reconstructive procedure for dorsal subluxation of the distal radioulnar joint. J Hand Surg Am 1982;7A:230–236.

• Kapindji AI, Martin-Bouyer Y, Verdeille S. Etude du carpe au scanner a trois dimensions sous contraintes de prono-supination (Threedimensional CT study of the carpus under pronation-supination constraint). Ann Chir Main 1991;10:36–47.

• Levinsohn EM, Rosen DI, Palmer AK. Wrist arthrography: value of the three-compartment injection method. Radiology 1991;179:231–239.

• Lichtman DM, Bruckner JD, Culp RW, et al. Palmar midcarpal instability: results of surgical reconstruction. J Hand Surg Am 1993; 18A:307–315.

• Ouellette EA. Distal Radioulnar Joint and Ulnocarpal Instability. Proceedings of the International Wrist Investigators Workshop, American Society for Surgery of the Hand. Washington, DC, Sept. 6, 2006.

• Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg Am 1989;14A:594–606.

• Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist: anatomy and function. J Hand Surg Am 1981;6A:153–162.

• Ritt MJ, Stuart PR, Berglund LJ, et al. Rotational stability of the carpus relative to the forearm. J Hand Surg Am 2000;20A:305–311.

• Ruegger C, Schmidt MR, Pfirrmann CW, et al. Peripheral tear of the triangular fibrocartilage: depiction with MR arthrography of the distal radioulnar joint. AJR Am J Roentgenol 2007;188:187–192.

• Schmidt HM, Lahl J. Studies on the tendinous compartments of the extensor muscles on the back of the human hand and their tendon sheaths. Gegenbaurs Morphol Jahrb 1988;134:155–173.

• Schuind F, An KN, Berglund L, et al. The distal radioulnar ligaments: a biomechanical study. J Hand Surg Am 1991;16A:110.

• Weiss AP, Akelman E, Lambiase R. Comparison of the findings of triple-injection cinearthrography of the wrist with those of arthroscopy. J Bone Joint Surg Am 1996;78A:348–356.

• Wiesner L, Rumehart C, Pham E, et al. Experimentally induced ulnocarpal instability: a study on 13 cadaver wrists. J Hand Surg Br 1996; 21B:24–29.

• Zancolli EA, Elbio PC. Atlas of Surgical Anatomy of the Hand. Churchill Livingstone, 1991.

• Examples of exercises:

• Pronation and supination: Stretching can be achieved by holding a hammer or frying pan as a weight during the motions.

• Wrist flexion and extension: Stretching can be achieved using bucket exercises. The patient places his or her arm on a table with the wrist hanging off the edge while holding an empty bucket. The bucket is filled with water until the point of discomfort. The patient holds the bucket for 2 to 3 minutes and repeats the exercise twice daily in flexion and extension.

• If the patient’s preoperative activities included sports such as golf and tennis, these activities should be gradually incorporated into the strengthening program.

• A Silastic sheet can be applied to aid scar remodeling. Scar massage may be started after the first 6 weeks.

OUTCOMES
- Modified Herbert reconstruction

• A recent long-term follow-up study, ranging from 1 month to 13 years, of 39 wrists showed that 85% of the wrists remained stable at the ulnocarpal joint (in preparation for publication).

• Hui-Linscheid reconstruction

• Successful short-term clinical outcomes have been reported in a small patient series by Hui and Linscheid, with patients reporting satisfactory and excellent outcomes. 6

• Mild limitations in pronation may be expected.

COMPLICATIONS
- The sling repair can loosen if aggressive strengthening occurs too quickly.

• If imbrication of the extensor retinaculum is not performed in an oblique direction, the ulnocarpal effect of the sling is lost, and a supination deformity of the wrist may occur or recur.

• Pain and dysesthesias at dorsal branch of ulnar nerve: Care must be taken when placing sutures for imbrication of the extensor retinaculum to avoid injury to surrounding tissues or nerve structures.

• EDQ tendinitis usually resolves 6 months after the operation.

• Damage to the ulnar nerve during the surgical procedure is concerning because of its anatomic location. The nerve is immediately exposed after the opening incision and is vulnerable

• Additionally, the nerve will be passing directly over an area of soft tissue closure and may be affected by the surrounding scar tissue.

• A protective covering (such as those used for recurrent nerve entrapments) to protect the dorsal ulnar nerve may minimize damage to the nerve.