THE INTEROSSEOUS MEMBRANE.

CAN WE REPAIR OR REPLACE IT ?

Pr Christian Dumontier, MD, PhD

Pr Marc Soubeyrand, MD, PhD
Presentation and some references can be seen on www.diuchirurgiemain.org
Some pictures belong to the authors that are quoted in the references
IMPORTANT MESSAGE TO NOTICE

An isolated torn interosseous

membrane has no clinical
consequence +++

An intact or repaired IOM is not

sufficient for a functional forearm
without the integrity of the PRUJ
AND DRUJ

In the treatment of a longitudinal

instability, the other lockers should
be either intact or repaired
 TO REPAIR IT ?

Be able to make an early

diagnosis
In a series of 106 referred Essex-Lopresti
injuries, the complete diagnosis was made
only 38% of the time (Osterman)

It can heal with proper

treatment and immobilisation
 EARLY DIAGNOSIS
First, think of it: Woman, 19 yrs old, violent fall or her left
forearm

Monteggia + TFCC lesion = Essex-Lopresti

 IMAGING TECHNIQUES
MRI has proven very sensitive and
specific IN CADAVERS
PPV : 100% (TP / TP + FP)

NPV : 89% (TN / FN + TN)

Sensibility: 87,5 % (TP / TP + FN)

Specificity: 100 % (FP / FP + TN)

Limited availability, may be

artefacted by metallic devices

Fester EW, Murray PM, Sanders TG, et al. The efficacy of magnetic resonance imaging and ultrasound in detecting
disruptions of the forearm interosseous membrane: a cadaver study. J Hand Surg Am 2002;27(3):41824.
 IMAGING TECHNIQUES
Longitudinal view

Sonography has almost the same

sensitivity/specificity than MRI and
can (even) be done during surgery
if needed

Dynamic sonography is easy to

perform

transversal view

Soubeyrand M et al. The muscular hernia sign: an original ultrasonographic sign to detect lesions of the forearms
interosseous membrane. Surg Radiol Anat 2006;28(3):3728.
 Intact membrane

Ruptured IOM with the Hernia sign

 PER-OPERATIVE TESTING
Some maneuvers have been
described

Mehlhoff: stress X-rays under

anesthesiae

Radius pull test (Smith 2002) :

proximal migration of the
radius > 3 mm is associated
with IOM disruption (Se 83%,
Sp 83%); > 6 mm IOM +
TFCC
Smith AM, et al. Radius pull test: predictor of longitudinal forearm instability. J Bone Joint Surg Am 2002;84-A(11):19706.
 RADIUS JOYSTICK TEST

In full-pronation, once the

radial head is removed, you
cannot laterally translate
the radial head if the IOM
is intact

PPV 90%, NPV 100%

Validated if > 5,5 mm in

supination-extension
Soubeyrand M, et al. The intra-operative radius joystick test to
diagnose complete disruption of the interosseous membrane. J Bone
Joint Surg Br 2011;93(10):138994.
Kachooei AR, Rivlin M, Shojaie B. van Dijk CN, Mudgal C.
Intraoperative Technique for Evaluation of the Interosseous Ligament
of the Forearm. J Hand Surg Am. 2015;40(12):2372-2376.
 WE PROBABLE CAN MAKE AN EARLY
DIAGNOSIS: CAN THE IOM REALLY HEAL ?
Few reports and no clinical evidence: healing of the IOM may occur, which
seems to be at least somewhat supported by the finding that early recognition and treatment has a far better
outcome than treatment in the delayed setting

12 patients with radial head ORIF, pinning of the DRUJ, and

immobilization. At 59 months FU, functional results were
satisfactory (Mayo wrist score 88.4, MEPS 86.7, DASH20.5)

As deformities seen in Essex-Lopresti appear progressively,

there may be some lesions of the IOM that may aggravate if
not treated adequately (but may heal if treated properly)
Grassmann JP, Hakimi M, Gehrmann SV, et al. The treatment of the acute Essex-Lopresti injury. Bone Joint J 2014;96-B(10): 13851391
 No healing with aggravation
at 8 months even after
treatment of PRUJ and
DRUJ

Gong HS, Chung MS, Oh JH, Lee YH, Kim SH, Baek GH. Failure of the Interosseous Membrane to Heal With Immobilization, Pinning of the
Distal Radioulnar Joint, and Bipolar Radial Head Replacement in a Case of Essex-Lopresti Injury: Case Report. J Hand Surg 2010;35A:976980
 CAN IT REALLY HEAL ?
Failla, in fresh injury, describes a widening of the
edges (like in ACL lesions) and a muscular
interposition (like in Steners lesion)

In 10 acute cases of central band disruptions,

Osterman found 80% midligament disruptions and
20% ulnar avulsions. Once torn, the leaves of
the tear did not lie in apposition in any forearm
position and were separated both by forearm bone
displacement and muscle interposition

central third of the IOM was seen to be thick

enough to be grasped with forceps, approximated,
and suitable for suturing

No healing after direct sutures or unable to sustain

the loads (Failla)
Failla JM, Jacobson J, van Holsbeeck M. Ultrasound Diagnosis and Surgical Pathology of the Torn Interosseous Membrane in Forearm Fractures/
Dislocations. J Hand Surg 1999;24A:257266.
Osterman AL, Warhold L, Culp RW, Bednar JM. Presented at the American Society for Surgery of the Hand 52nd Annual Meeting, 1997
 TO REPLACE IT ?

Which part to replace ?

With which material ?

How tense should it be ?

In which position ?

?
 remodelling in some instances but erosion in others. removed from the frame and reversed. The pneumatic
be a better long-term solution for higher
Therefore a total prosthetic distal radioulnar joint may demand pa-deviceof the frame.
moves on twoTwo steel high
rods tension
parallel tobraided
the longsteel
axiswi
be atients,
betterbut good results
long-term willfor
solution only be achieved
higher demandby correctof thetached
pa- frame. to Twothehighpneumatic device pass
tension braided steel along the
wires at-
understanding
tients, but good results of joint biomechanics
will only be achieved and by reproduction
correct tachedparallel
to the to the steel device
pneumatic rods and passover pulleys
along at the
the frame

WHICH PART ? THE CENTRAL BAND

in the design
understanding of prosthetic
of joint components.
biomechanics and reproduction end
parallel to ofthethe frame.
steel rodsWeights
and over attached
pulleys toat these wires
the other
The aim
in the design of this study
of prosthetic was to investigate the eect ofend ofathe
components. compressive
frame. Weights axial attached
load to to be these
applied
wiresto allow
the fo
changing
The aim of the
this orientation
study was toofinvestigate
the distalthe radioulnar from the axial
eect of jointa compressive handloadacross
to the wrist. to the forearm
be applied
on the force in the joint and the strain
changing the orientation of the distal radioulnar joint in the interosseous A FlexiForce"
from the hand across the wrist. A101 transducer (Tekscan, B
membrane,
on the force in theand to repeat
joint and thethese
strainmeasurements
in the interosseous USA) was inserted
at dierent A FlexiForce" into the(Tekscan,
A101 transducer distal radioulnar
Boston,
loadings across the wrist and with
membrane, and to repeat these measurements at dierent change in forearm USA) was inserted into the distal radioulnar the
through the sacciform recess to measure jointfo
rotation.
loadings acrossThisthe work will with
wrist and lead change
to improvement
in forearmin thethrough thethe joint. The transducer
sacciform recess to was calibrated
measure by conn
the force in
design of a total distal radioulnar
rotation. This work will lead to improvement in the joint replacement. to a digital multimeter (Model T110B,
the joint. The transducer was calibrated by connecting Beckman
design of a total distal radioulnar joint replacement. trial Ltd,
to a digital Fullerton,
multimeter (ModelCalifornia, USA) toIndus-
T110B, Beckman measu
resistance.
trial Ltd, A flat
Fullerton, plastic disc
California, USA) wastocut with dime
measure the
2. Methods resistance. A flat plastic
just covering disc was
the sensing areacut withtransducer.
of the dimensionsW

Ligamentous structure, 2,18 2. Methods

Three
Three cadaveric upper limbs were dissected to liga-were balanced
mentscadaveric
and boneupper from limbs were dissected
the proximal third oftothe
just covering

forearmto 1100
liga-
to 1100 on
grams,
tional
the sensing
were balanced
grams,
areapuck
on the
the puck
and tothe
and thelogarithm
to inverse
of the
load
to transducer.
load
load was of found
Weights
load the transducer
thewas
transducer
found to from
to be propor-
the resistance.
be0p

mm thickness mentsto and

to the
the bone
forearm
forearm
carpus.

rotation
from
carpus.rotation
A the
A custom
and
proximal
custom

axial
third ofallowed
apparatus
andapparatus
axial loading
loading across
the forearm
allowedacross
measured
the
measuredtional to A
the wrist A 3lington,
wrist lington,
inverse
3 mmlogarithm
mm microminature
Vermont,
Vermont, USA)
USA) was
of the resistance.
microminature
DVRT"
sutured
DVRT" (Microstrain
(Microstrain,
was sutured
to the central
Bur-
to the centra
band
(Department of Clinical Engineering, Withington Hos- of the interosseous membrane on the dorsal surfa
(Department of Clinical Engineering, Withington
pital, Manchester, UK). The specimens were securely at- Hos- of the interosseous
parallel to themembrane
fibres (Fig. on2).
theThedorsal
DVRTsurface
wasandcon
pital,tached
Manchester, UK). The specimens were securely
to the frame at 90! of elbow flexion by a 5 mm at- parallel to the fibres (Fig. 2). The DVRT
to a PC via the Microstrain motherboard. The was connected
Rigidity:13,1 +/- 3,0 N/mm tached to the frame at 90! of elbow flexion
diameter threaded bolt into the olecranon of the ulna
diameter
by a 5 mm to a PC via the
strain Microstrain
software allowedmotherboard.
a continuousThe Micro-of
reading
and athreaded
pneumatic boltdevice
into the olecranon
to !grip" of the ulna (Fig.strain displacement
the metacarpals software allowed shown a continuous readingversus
as a displacement of linear
time
and 1).a pneumatic device to !grip" the metacarpals
A transverse 2 mm k-wire passed across the ulna, (Fig. displacement shown as a displacement
on the PC. The DVRT was calibrated by the ma versus time graph
1). A transverse 2 mm k-wire passed across the ulna, on the PC. The DVRT was calibrated by the manufac-
perpendicular to the olecranon bolt, and rested on two turer and the readings were in millimetres. The
Elastic modulus: 608,1 +/- 160,2 mPa perpendicular to the olecranon bolt, and rested on two
further 5mm bolts attached to the frame to prevent rota-
further 5mm bolts attached to the frame to prevent rota-
turer and the readings were in millimetres. The strain
was calculated as the change in length over the o
was calculated as the change in length over the original
tion of the ulna. length of the DVRT at the start of a set of readi
tion of the ulna. length of the DVRT at the start of a set of readings.

Elasticity: 9,0 +/- 2,0 %

The most important

mechanically (strength
identical to the ACL)

Poitevin LA (2001) Anatomy and biomechanics of the interosseous

Fig. 1. Specimen
Fig.
rotating
mounted
1. Specimen
devicedevice
rotating
membrane:
on frame.
mounted
and gripped
on frame.
aroundaround
and gripped
its
Hand Hand
metacarpals.
importance
passed passed
metacarpals.
throughthrough
in the longitudinal
slot onslot onFig. 2. Fig.
membrane.
DVRT
stability
sutured sutured
2. DVRT
membrane.
of the
to the central
forearm.
to the band
centralof band
Hand
the interosseous
of the inte

Clin 17:97110
 THE CENTRAL BAND
Insertion site is larger on
the volar aspect of the
radius and dorsal aspect of
the ulna

However, it seems to have

little mechanical
consequences

The CB does not wrap

around the radius.
Pereira BP. Biomechanics of forearm stabilisers [dissertation]. Singapore: National University of Singapore; 2013.
Farr LD, Werner FW, McGrattan ML, Zwerling SR, Harley BJ. Anatomy and Biomechanics of the Forearm Interosseous Membrane. J Hand Surg
Am. 2015;40(6):1145-1151.
 WITH WHAT TO REPAIR THE IOM ?

Palmaris longus tendon is

inadequate both clinically
(Hotchkiss) and
biomechanically (Skahen)

Hotchkiss RN. Injuries to the interosseous ligament of the forearm. Hand Clin 1994;10:391398.
Skahen JR 3rd, Palmer AK, Werner FW, Fortino MD. Reconstruction of the interosseous membrane of the forearm in cadavers. J Hand Surg
1997;22A:986 994.
 WITH WHAT TO REPAIR THE IOM ?

Flexor carpi radialis tendon

(single bundle) is less
effective than a double
bundle FCR reconstruction

Only reported in cadavers

Skahen JR 3rd, Palmer AK, Werner FW, Fortino MD. Reconstruction of the interosseous membrane of the
forearm in cadavers. J Hand Surg 1997;22A:986 994.
Pfaeffle HJ, Stabile KJ, Li ZM, Tomaino MM. Reconstruction of the interosseous ligament restores normal
forearm compressive load transfer in cadavers. J Hand Surg Am. 2005;30(2):319-325.
 WITH WHAT TO REPAIR THE IOM ?
The pronator teres tendon
is detached proximally, its
distal attachment left intact
whereas the proximal part
is rotated (this is
approximately the level at
which the IOL originates
on the radius

it is technically
challenging and requires
much surgical
experience however
no case is reported

Chloros GD, Wiesler ER, Stabile KJ, Papadonikolakis A, Ruch DS, Kuzma GR.. Reconstruction of Essex-
Lopresti Injury of the Forearm: Technical note. J Hand Surg 2008;33A:124130
 WITH WHAT TO REPAIR THE IOM ?
A bone-tendon-
graft (patellar
ligament) is the
most frequently
reported
technique used

The only one

used in clinical
series

Ruch DS, Change DS, Koman LA. Reconstruction of longitudinal stability of the forearm after disruption of interosseous ligament and radial
head excision (Essex-Lopresti lesion). J South Orthop Assoc 1999;8:4752.
Marcotte AL, Osterman AL. Longitudinal radioulnar dissociation: identification and treatment of acute and chronic injuries. Hand Clin
2007;23:195-208
 IOM RECONSTRUCTION USING A BONE-
TENDON-BONE GRAFT

16 pts, ulna levelling and bone-ligament-bone (auto then allografts)

reconstruction

The graft should be tensioned in neutral to 20 degrees of supination.

78 months FU

15 pts improved (grip strength 58 to 86%), 10 (70%) RTW

Preoperatively, four patients had a normal arc of forearm motion (three

postoperatively), seven had 120 to 140 degrees (six postoperatively), four had
100 to 120 degrees (four postoperatively), and one had less than 120 degrees
(three postoperatively). Overall, patients were very satisfied with the procedure

Adams JE, Culp RW, Osterman AL. Interosseous membrane repair for the Essex-Lopresti injury. J Hand Surg Am. 2010;35:129-136.
 SYNTHETIC MATERIAL
One acute case treated with the Tightrope with good results (Brin)

Adams and Osterman (as others) have replaced the BTBG by a mini
TightRope in 10 chronic cases.

Nine of 10 patients reported subjective satisfaction.

Three patients required additional surgery (one persistent ulnar

impingement; one radial midshaft fracture 5 weeks after reconstruction; one
dorsal subluxation of the ulna at the DRUJ with very limited supination).

Sabo MT, Watts AC. Reconstructing the interosseous membrane: a technique using synthetic graft and endobuttons. Tech Hand Up
Extrem Surg. 2012;16(4):187-193.
Brin YS, Palmanovich E, Bivas A, Sagiv P. Treating acute Essex-Lopresti injury with the tightrope device: a case study. Tech Hand Up
Extrem Surg 2014;18:51-5
Gaspar MP, Kane PM, Pflug EM, Jacoby SM, Osterman AL, Culp RW, Interosseous membrane reconstruction with a suture-button
construct for treatment of chronic forearm instability. J Shoulder Elbow Surg (2016) 25, 14911500
 TECHNICAL TIPS TO REMEMBER

Positioning of the graft (30% of ulna length, 60% of radius length)

During forearm rotation the length of tendinous portion does

not change (Nakamura)

Orientation of the graft

Tension of the graft

Ulna shortening/leveling
Nakamura T, Yabe Y, Horiuchi Y. In vivo MR studies of dynamic changes in the interosseous membrane of the forearm during rotation. J
Hand Surg Br 1999; 24(2):245-248.
Posterior view
length of insertion is 3 cm on both bones

1,1 to 2,6 cm

2,7-3,5 cm

7,7 cm 57%

25
13,2 cm 32%
Anterior view
POSITIONING OF THE GRAFT ?

The graft should be placed dorsal to

the native IOM to prevent vascular and
nerve injuries
 ORIENTATION OF THE GRAFT ?
Regarding the normal 22 angle
relative to the ulna,

More longitudinally oriented

graft has little effect on CB
length.

More transversely oriented graft

shows a trend to be shorter in
supination than in neutral by 1.6
mm

Forster RI, Sharkey NA, Szabo RM. Forearm Interosseous Ligament Isometry. J Hand Surg 1999;24A:538545.
Farr LD, Werner FW, McGrattan ML, Zwerling SR, Harley BJ. Anatomy and Biomechanics of the Forearm Interosseous Membrane. J Hand
Surg Am. 2015;40(6):1145-1151.
 TENSION OF THE GRAFT
CB length is greater in neutral

To maximally tension a graft,

it should be tightened in
supination (and during early
rehabilitation, the forearm
should be kept in supination
and active forearm rotation
minimized)

Skahen JR 3rd, Palmer AK, Werner FW, Fortino MD. Reconstruction of the interosseous membrane of the forearm in cadavers. J Hand Surg
1997;22A:986 994.
Farr LD, Werner FW, McGrattan ML, Zwerling SR, Harley BJ. Anatomy and Biomechanics of the Forearm Interosseous Membrane. J Hand
Surg Am. 2015;40(6):1145-1151.
ULNA SHORTENING / LEVELLING
Most techniques include a
shortening of the ulna at
the level of the insertion of
the graft (to unload the
radius and avoid creating a
stress riser if it was placed
more proximal)
WE CHOOSE A DIFFERENT APPROACH
If the graft is not perfectly positioned, we
believe it cannot sustain the loads as it does
not fit with the axis of forearm rotation (from
the centre of the radial head and the base of
the styloid ulnar process at the insertion of
the TFCC)
THE TECHNIQUE SOUBEYRAND DESCRIBED

Long transplant (semi-

tendinosus or synthetic
material)

Along the mechanical axis

of the forearm

Placed dorsally to the native

IOM

Soubeyrand M, Oberlin C, Dumontier C, et al. Ligamentoplasty of the forearm interosseous membrane using the semitendinosus tendon:
anatomical and surgical procedure. Surg Radio Anat. 2006;28:300-307.
 IOM Reconstruction

40 years old, professional moto-cross

Radial head stabilisation DRUJ stabilisation

 OUR MAIN PROBLEM

We were able to stabilise

the longitudinal instability
with this technique

The PRUJ was not a

problem

Many patients were still

unstable at the DRUJ
 CONCLUSION
We should be able to make an early diagnosis of IOM
disruption

We cannot repair the IOM but can replace it in acute

or chronic injuries along with the treatment of the
other lockers

Two technical options are available: either the

reconstruction of the central band using a bone-
tendon-bone graft (or a substitute) OR reconstruction
of the axis of rotation
THANK YOU FOR YOUR ATTENTION