A simple button-to-button fixation for chronic distal radio-ulnar junction disruption: a case report and literature review

Abstract

Introduction and importance:

The stability of the wrist joint is essential. A simple button-to-button (BtB) fixation technique may provide long-term stability after a chronic distal radio-ulnar joint (DRUJ) disruption and result in a good functional outcome.

Case presentation:

A 32-year-old female was admitted to the clinic right after having difficulties with wrist rotation movement for 6 months before admission. There was a history of traffic accidents before this complaint. She fell to the ground with her arm holding her body in a wrist rotation position. A tenderness was found during physical examination, specifically on her left wrist joint. Further, a piano key sign was positive. Magnetic Resonance Imaging revealed DRUJ disruption. The patient was diagnosed with chronic DRUJ disruption.

Clinical discussion:

We implement a simple, minimally invasive surgical approach with a novel kit of BtB fixation to stabilize wrist function. The length of surgery was measured and showed a short duration of 10 minutes. The Visual Analog Scale (VAS), Euroqol 5-Dimension (EQ5D) score, and Disability of Arm, Shoulder, and Hand (DASH) were determined and showed a good patient-reported outcome. The cost of treatment was estimated, resulting in an Average Cost-Effectiveness Ratio of $2692/QALY.

Conclusion:

The minimally invasive approach with the BtB procedure is a simple and cost-effective approach for treating a chronic DRUJ disruption in selected patients. VAS, EQ5D, and DASH scores pointed out a good functional outcome.

Introduction

Distal radio-ulnar joint (DRUJ) instability can occur following trauma or fractures of the upper extremity, accounting for 10–19% of distal ulnar and radius fractures. It happens independently and often goes unnoticed, primarily secondary to other injuries^[1,2^]. Diagnosing a DRUJ injury requires careful attention, especially in recent wrist injuries with new symptoms like restricted pronation or supination maneuvers. The diagnosis is made based on clinical evaluation and advanced radiology examination, like Magnetic Resonance Imaging (MRI)^[1,2^].

HIGHLIGHTS

• A female patient sustained a chronic DRUJ disruption after a traffic accident.

• A simple BtB fixation for chronic DRUJ disruption is an easy technique to perform, while preserving soft-tissue integrity and providing stability with a good functional outcome.

• VAS, EQ5D score, and DASH show a favorable score

Several surgical approaches for the management of DRUJ have been reported in the literature, such as direct repair, internal fixation, or reconstruction[3]. Appropriate treatment is crucial to prevent long-term complications. A simple surgical option aiming to restore wrist function with better functional outcomes and cost-effectiveness was needed. The simple button-to-button (BtB) fixation with a minimally invasive surgical approach was hypothesized to suit this condition. This report pictured this surgical technique with a novel kit of BtB and described the treatment outcomes measured by the Visual Analog Scale (VAS), Euroqol 5-Dimension (EQ5D), and Disability of Arm, Shoulder, and Hand (DASH) score. Our report was made based on the SCARE Guideline 2025[4].

Case presentation

A 32-year-old woman presented to the clinic right after having difficulties with wrist rotation movement for 6 months before admission. There was a history of traffic accidents before this complaint, where she fell to the ground with her arm holding her body in a wrist rotation position. She was working as a laundry attendant for 3 years with right-hand dominance; there was no prior history of trauma or any medical condition affecting the wrist. There was no family history of similar complaints. The patient had no history of hospitalization, prolonged use of medication, never consumed cigarettes, and the patient did not report any other complaint regarding the traffic accident.

Hemodynamic stats showed blood pressure 127/82 mmHg, heart rate 86 bpm, respiration rate 19 times per minute, and without sign of fever. The Body Mass Index of the patient revealed a normal weight. The physical examination revealed tenderness at the wrist joint. Active left wrist motion caused pain and resistance in supination and pronation. Another test, the piano key sign, was positive. Wrist X-ray and MRI were obtained to establish a precise diagnosis of DRUJ injury. Radiographs showed intact bone without discontinuity, with slight dorsal migration of the ulnar head. MRI revealed soft tissue DRUJ disruption (Fig. 1). After further examination, the patient was diagnosed with chronic DRUJ disruption. Differential diagnosis includes either triangular fibrocartilage complex (TFCC), an undisplaced fracture of the distal part of the ulnar bone, and extensor carpi ulnaris tendon subluxation.

Figure 1.

Wrist X-ray AP view (a), wrist X-ray lateral view (b), wrist MRI axial view (c), and wrist MRI AP view (d).

The focus of this case is to restore stability in the left wrist. In this condition, a simple and effective surgical intervention is needed to ensure a good healing process. Therefore, the BtB procedure with a minimally invasive approach should be applied. This surgery was performed by an orthopedic surgeon at our local hospital. The estimated time was around 15–30 minutes, depending on the patient’s condition. This procedure was performed in a general hospital by an orthopedic specialist without assistance from another specialist.

The procedure was performed with the patient in the supine position under general anesthesia. Preoperative prophylactic medications included cefazolin 2 g/IV. A minimal incision of about 0.5 cm was performed at the ulnar side, about 2 cm below the ulnar head. While maintaining the wrist sinistra lying in the supination position, the distal portion of the radio-ulnar segment was drilled by a drill bit with a size 3.0 mm diameter, starting from the ulnar to the radius bone. The BtB kit (ArthroTEC, MJ Surgical) then passes through the hole with C-arm guidance to ensure the radio-ulnar position. After the button reached the outside part of the radial bone, the deploy button on the button kit was pressed to release the tightrope. The other button was pushed to the surface of the ulnar bone, and the rope was pulled to tighten both bones. The procedure was continued with further saline irrigation, and we closed the wound with a simple suture. The procedure was performed in 10 minutes without any difficulties; no early or acute complication after surgery was found (Fig. 2).

Figure 2.

Incision procedure on wrist sinistra (a), distal portion of the radio-ulnar segment was drilled (b), a surgical field of BtB passing through the hole (c), a 3D procedure of BtB (d), a tight rope was placed and tightened on the ulnar surface (e), and fluoroscopy BtB post-surgery (f).

After surgery, a posterior wrist splint was applied in a full supination position. At the 2-week follow-up, physical examination revealed limited wrist rotation and elbow flexion, with a DASH score of 70 and VAS scores reduced to 2–3. Motor and sensory function remained intact. The physiotherapist advised the patient to avoid lifting heavy objects during rehabilitation. The EQ5D score was 0.61, indicating slight difficulty with usual activities such as cooking, without anxiety or depression. At home, the patient consistently practiced the prescribed rehabilitation exercises, including pronation and supination training. At the 3-week follow-up, the wrist splint was removed, and the patient demonstrated improvement in Range of Motion (ROM). The patient was able to perform 10° of pronation and supination during home exercises. Functional outcomes improved, with a DASH score of 40, VAS scores of 1–2, and better motor performance without pain while lifting a 2-lb object. The EQ5D score increased to 0.72, reflecting improved ability in dressing, washing, and other daily activities.

At 2 months, the patient demonstrated continued progress. Wrist pronation and supination, elbow flexion and extension, and other functional movements were implemented during exercise at home. This was supported by the DASH score result, which was 11.7, the VAS score was 0, and the EQ5D of 0.96. The patient exhibited stable sensorimotor function. The post-surgery recovery trajectory indicated promising outcomes, with substantial functional and pain improvement observed during follow-ups.

Three months after surgery, the patient was advised by the physiotherapist to do elbow and wrist joint pronation and supination of 0–90° during exercise at home. There were no complaints, no specific pain, and could achieve better ROM. The patient showed regular activity without any wrist restriction 6 months after surgery. There was no complication recorded during this procedure, as long as the follow-up interval is maintained. This favorable outcome was attributed to the patient’s strong adherence to the rehabilitation program and consistent compliance with the prescribed rehabilitation protocol. In this phase, the patient revealed a better functional outcome with a DASH score of 1.7, the VAS score was 0, and the EQ5D of 1.

Total hospital cost following BtB surgery was $1050, and the incremental utility was 0.39 QALY, resulting in an Average Cost-Effectiveness Ratio (ACER) was $2692/QALY.

Informed consent for documentation or photographic content was obtained from the patient. The patient felt satisfied following the surgery, and the recovery process shows promising results with good functional outcomes. We present a table (Table 1) that describes the patient’s treatment progress from baseline up to 6 months post-surgery.

Table 1.

Timeline table.

Date	Main event	Outcome/findings
23th October 2024	Fell to the ground with her arm holding her body in a wrist rotation position
23th October 2024	Transferred to primary health care	Initial treatment provided (symptomatic management for pain relief)
4th April 2025	Persistent symptoms; difficulty performing daily activities and work	Transferred to the orthopedic clinic for further examination
11th April 2025	Further examination in the orthopedic clinic	Physical examination, laboratory tests, wrist X-ray, and MRI
12th April 2025	Diagnosed with DRUJ disruption	Planned for BtB procedure
14th April 2025	BtB procedure	A posterior wrist splint was applied in a full supination position
28th April 2025	2 weeks post-surgery	Limited wrist rotation and elbow flexion, DASH score 70, VAS scores 2–3, motor and sensory systems showed good function, and EQ5D score 0.61
5th May 2025	3 weeks post-surgery	Wrist splint was removed, improvement in ROM, DASH score 40, VAS scores 1–2, motor function improved, EQ5D score 0.72
9th June 2025	2 months post-surgery	Wrist pronation and supination, elbow flexion and extension, and other functional movements showed significant improvement, DASH score 11.7, VAS score 0, EQ5D score 0.96, and stable sensorimotor function
7th July 2025	3 months post-surgery	Full ROM of the elbow and wrist joints, with pronation and supination of 0–90°
29th September 2025	6 months post-surgery	Regular activity without any wrist restriction, DASH score 1.7, VAS score 0, and EQ5D score 1

Discussion

Appropriate treatment is mandatory following DRUJ disruption. In selected cases, a chronic case of DRUJ disruption could be treated appropriately by the simple BtB fixation with a minimally invasive surgical approach, as shown in this study.

Vries et al reported the use of minimally invasive suture-button techniques oriented along the distal oblique bundle to restore radio-ulnar stability in cadaveric models. The hole was made by a bone drill 2–3 mm in the distal interosseous membrane portion. The procedure showed a good outcome in wrist stability[5]. Next, Kaul et al implement a minimally invasive procedure using an adjustable loop endo-button to restore DRUJ disruption. The technique involved suspensory fixation at the distal interosseous membrane, aligned with the distal oblique bundle[6]. Based on our report, a BtB was located in the transverse direction, about 2 cm below the ulnar head. This procedure was performed with a minimally invasive approach and also showed good functional outcomes. The transverse direction was performed more easily than the oblique direction, which has the risk of migration of the initial tunneling site. However, both directions resulted in a comparatively good outcome. It can improve ROM and overall wrist stability[7]. The novelty of our surgical approach was that the BtB kit set was a novel implant; the method is emerging, easy to perform with shorter duration, cost-effective, and resulting in good outcomes both in functionality and cosmetically. We did not find any complications during the post-surgery phase, such as paresthesia or numbness. Three-month evaluations pointed out good grip strength, improving the movement of the wrist joint with 90° of dorsiflexion, 90° of supination, and 90° of pronation while performing hand and wrist maneuvers.

Despite BtB, several modalities exist that could be an option, such as Kirschner wires (K-wires), suture anchors, or conservative treatment with splints. Disruption of the DRUJ is a complex injury that often requires surgical intervention to restore joint stability and function. While K-wire fixation is a minimally invasive and cost-effective option, it carries potential drawbacks, such as the risk of joint stiffness and the need for hardware removal. Moreover, when compared with more extensive surgical techniques, K-wire fixation may offer limited joint stability and suboptimal functional recovery. This underscores the need for individualized treatment strategies in managing DRUJ injuries. Surgeons must carefully consider factors like injury severity, patient comorbidities, and the risk of complications when choosing the most appropriate technique[8].

In minimally invasive orthopedic procedures, beside the button kit, the suture anchors are frequently applied in the upper extremity, particularly for reattachment of soft tissues such as tendons and ligaments. These devices typically comprise a sleeve or tape integrated with ultrahigh molecular-weight polyethylene sutures, which confer superior strength and durability. While the benefits of suture anchors are significant, their use is associated with three primary considerations for efficacy: maximizing pullout strength, minimizing acute iatrogenic damage, and reducing long-term pro-arthritic potential. Suture anchors perform better in areas with higher bone mineral density. However, the risk of anchor pullout is increased in patients with low bone quality, such as those older or with osteoporosis[9]. In our case, despite the advantages of minimal invasiveness and widespread use in attaching soft tissues, suture anchors were not selected. This decision was made due to the suture anchor usually used in combination with a tendon allograft in a reconstruction procedure. This was not the case in this study.

For situations in which TFCC repair is unachievable, tendon allograft procedures utilizing palmaris longus, the extensor carpi radialis longus, or the extensor carpi radialis brevis (ECRB) tendons provide a feasible method to restore DRUJ stabilization. The Adam and Berger technique is often used with this allograft utilization, with good functional results. This approach targets distal radio-ulnar ligament reconstruction through grafting with palmaris longus or ECRB tendons. However, this tendon allograft procedure is typically more invasive, despite the fact that it has the benefit of maintaining soft tissue integrity and lowering the possibility of implant discomfort. The BtB approach offers the advantage of fewer difficulties associated with soft tissue dissection because it is minimally invasive[7].

In this study, DRUJ reconstruction was performed using a single suture-button construct. While recent evidence suggests that double suture-button constructs – incorporating both transverse and oblique orientations – more effectively limit dorsal translation and provide superior stability compared with a single construct, a single suture-button reconstruction still achieves satisfactory stability and favorable clinical outcomes[7]. This BtB procedure is also shown to be cost-effective, with the total direct hospital cost being $1050 in our institution, resulting in the ACER of $2692/QALY. This value is lower compared to some other procedures, such as immediate arthroscopic debridement of the TFCC or conservative treatment by immobilization for 6 weeks (total costs of $2936 and $739, respectively)[10].

A VAS is valuable for assessing pain improvement and functional outcomes following surgical intervention for DRUJ instability. By providing a simple yet effective method for quantifying pain levels, the VAS allows patients and clinicians to objectively follow post-surgery progress[11]. The DASH score is also commonly used for patients with DRUJ instability following surgical treatment. It comprises 30 items that evaluate the motoric and sensory function of the arm, shoulder, and hand. DASH can be measured using scores of 0–100, starting with zero as normal function and 100 as complete dysfunction[12]. On the other hand, EQ-5D assesses mobility, self-care, daily activities, pain, and mental health aspects, including anxiety and depression[13]. In our report, VAS, DASH, and EQ5D scores were used to evaluate the outcome, and good functional outcomes were revealed.

There were some limitations in this study. First, we only report one case with short-duration follow-up during the BtB procedure. More patients with longer follow-up are needed to clarify the advantage of this procedure. Second, this study reported a single case without a control group or reference to pre-existing surgical methods. Further study with a control group design is needed to compare the BtB technique with others comprehensively.

Conclusion

In a selected patient with a chronic case of DRUJ disruption, a minimally invasive surgical approach with BtB fixation points has yielded promising results with a prompt recovery process. This procedure is simple and cost-effective.

Ethical approval

Our institution did not require ethical approval for this case report.

Consent

The patient obtained written informed consent to publish this case report containing the picture. A copy of the consent form is available for review by the Editor-in-Chief upon request.

Sources of funding

This case report received no specific funding from public, commercial, or non-profit organizations.

Author contributions

All authors contributed to creating all parts of this case.

Conflicts of interest disclosure

The authors declare that they have no conflicts of interest.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Romy Deviandri.

Provenance and peer review

Not commissioned.

Data availability statement

Not applicable.

Acknowledgements

We would like to thank all colleagues of Surgery Department in Arifin Achmad Hospital for their support in this study.