Pulley Reconstruction for Symptomatic Instability of the Tendons of the First Extensor Compartment Following de Quervain's Release

Abstract

Surgical management of de Quervain's tenosynovitis is based on decompression of the first extensor compartment. A simple release of the first compartment can cause instability of the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons in zone seven of the extensors. The WHAT test (wrist hyperflexion and abduction of the thumb) is very effective in diagnosing this instability. In this retrospective monocentric study, we analyzed a case series of 10 patients all of whom underwent a reconstruction of the first extensor compartment using a retinacular graft because of symptomatic instability after decompression surgery. The reconstruction was a modified technique of the sixth compartment. Functional outcome and characteristics of the newly reconstructed pulley were examined by physical examination with the aid of ultrasound and internationally validated questionnaires. Four patients had a good-to-excellent functional outcome, all of those had a maximum of two surgical procedures performed on the first extensor compartment. Six patients presented poor functional outcome. In four of them, more than two surgical procedures were performed. Minor residual instability was noted in six cases, found in both the groups. The reconstruction procedures on the first compartment seemed to be satisfactory in treating instability of the EPB and APL tendons after primary surgical release for de Quervain's disease. Level IV, observational study without controls.

Surgical Treatment Outcome of de Quervain’s Disease: A Systematic Review and Meta-analysis

“…In the study by Kumar, 18 one patient had a neuroma excision reoperation because of a painful neuroma. In the study by Renson et al, 32 one patient required reoperation because of fibrosing stenosis, another patient because of synovitis, and one patient because of recurrent instability of the EPB and the APL, resulting in a (sub)luxation of these tendons.…”

“…In addition, also other techniques were used in the included articles, such as a Z-plasty of the retinaculum 19 (Fig. 8 ) and a pulley reconstruction of the first compartment 32 (Fig. 9 ).…”

“…Some studies excluded patients with carpometacarpal osteoarthritis and bilateral DQ disease, 14,17,19,23 whereas others included these patients. [21][22][23][24]27,28,32,33 Besides this, prior conservative treatment was also not always reported. 27,31,32 Only the study by Bakhach et al 24 reported the number of corticosteroid injections before surgery for each subject.…”

The ultrasound-guided percutaneous release technique for De Quervain's disease using an acupotomy

“…A study reported cutting on the surface of the tendon sheath, a 90°rotation of the needle to orient the bevel perpendicular to the fibres being cut to release an intertendinous septum was required (10). Although there has not been reported whether release an intertendinous septum in dQD patients can achieve better results, the fulllength release in the first extensor tendon compartment is not needed because it will cause tendon subluxation (26,27). We demonstrated that releasing the tendon sheath between the bone ridges can depressurize the tendons.…”

Management of de Quervain Tenosynovitis

“…While considered a rare complication, tendon dislocation following open release can result in poor outcomes and often requires surgery when symptomatic. The direction of dislocation is usually volar; however, dorsal dislocation also has been described 46,47 . Some authors have suggested that as long as open release is performed on the FDC’s dorsoulnar aspect and only minimal extensor retinaculum is excised, then volar instability is not a problem (Table V).…”