Comments on: Dorsal Capsuloplasty for Dorsal Instability of the Distal Ulna (J Wrist Surg 2013;2(2):168–175)

It was with great interest that we read the article by Kouwenhoven et al[1] “Dorsal Capsuloplasty for Dorsal Instability of the Distal Ulna.” In this article, the authors describe a simple surgical technique to address the dorsal instability of the DRUJ. This technique, as a first-line treatment, does not block more invasive surgical options in case of persistent instability, which is an advantageous characteristic. We entirely agree with the authors' diagnostic algorithm. Clinical examination is the crucial step regarding DRUJ instability.[2] [3] Which clinical test is considered the most important one by the authors? We agree with the authors that wrist arthroscopy is still the gold standard for assessing chronic ulnar wrist pain. The MRI still lacks sufficient sensitivity and specifity to diagnose TFCC lesions reliably.[4] The described needle test for TFCC lesions seems to be very useful, especially when the hook test is difficult to apply. We perform a push-off needle test with a different insertion.[5] Is it not likely to endanger the deep fibers of the TFCC while inserting the needle according to the way described?

To conclude, we congratulate the authors on their thoughtful and simple technique. We apply a different technique that uses the floor of the fifth extensor compartment with similarly good functional results ([Fig. 1]).[6] [7] We do not reattach the deep fibers of the TFCC regarding chronic instabilities, because we do not believe in a sufficient healing after several months. It would be interesting to know in which case the authors would not consider reattachment of the deep fibers. Further, did the authors identify different functional outcome measurements according to the time interval between onset of symptoms and surgery?

Fig. 1 (a) Completed double mattress suture before tightening (with the friendly permission of Springer Science and Business Media).[6] (b) Suture technique which facilitates the floor of the fifth extensor compartment (with the friendly permission of Springer Science and Business Media).[6]

• References

• 1 Kouwenhoven STP, de Jong T, Koch AR. Dorsal capsuloplasty for dorsal instability of the distal ulna. J Wrist Surg 2013; 2 (2) 168-175
• 2 Spies CK, Müller LP, Oppermann J, Hahn P, Unglaub F. Instability of the Distal Radioulnar Joint - an Overview of Clinical and Radiological Procedures Regarding their Efficacies. Handchir Mikrochir Plast Chir 2014; ; In press
• 3 Hahn P, Wolf MB, Unglaub F. Bilateral test for potential subluxation of the DRUJ. Arch Orthop Trauma Surg 2013; 133 (10) 1459-1461
• 4 Hahn P, Häusler A, Bruckner T, Unglaub F. Quality rating of MRI regarding TFCC lesions in the clinical practice. Handchir Mikrochir Plast Chir 2012; 44 (5) 310-313
• 5 Unglaub F, Mueller LP, Oppermann J, Hahn P, Spies CK. Letter to editor: a push off needle test to assess triangular fibrocartilage integrity. J Hand Surg Am. 2014;
• 6 Manz S, Wolf MB, Leclère FM, Hahn P, Bruckner T, Unglaub F. Capsular imbrication for posttraumatic instability of the distal radioulnar joint. J Hand Surg Am 2011; 36 (7) 1170-1175
• 7 Unglaub F, Manz S, Bruckner T, Leclère FM, Hahn P, Wolf MB. Dorsal capsular imbrication for dorsal instability of the distal radioulnar joint. Oper Orthop Traumatol 2013; 25 (6) 609-614