1
|
Atiyya AN, Diab RA, Soliman RA. Styloid Ulna Window Approach for Repair of Avulsed Foveal Attachment of Triangular Fibrocartilage Complex. J Hand Surg Am 2024; 49:800.e1-800.e6. [PMID: 36372596 DOI: 10.1016/j.jhsa.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/14/2022] [Accepted: 10/12/2022] [Indexed: 11/12/2022]
Abstract
PURPOSE To describe a surgical approach for open repair of the triangular fibrocartilage complex foveal avulsion via ulnar styloid osteotomy, and to assess its clinical results. METHODS We reviewed 12 patients with distal radioulnar joint (DRUJ) instability due to isolated foveal avulsion of DRUJ ligaments. Wrist arthroscopy was conducted for all patients to exclude the presence of concomitant tear of the superficial part of the triangular fibrocartilage complex and to corroborate the diagnosis with a positive hook test. Through an ulnar approach between flexor and extensor carpi ulnaris, an ulnar styloid osteotomy was performed under image intensifier control just ulnar to the fovea of the head of the ulna. The avulsed foveal attachment was anchored through transosseous sutures passing from the fovea to the neck of the ulna. The ulnar styloid was fixed by means of screws or tension band wires. Outcome measures included clinical assessment of pain (visual analog scale), grip strength, DRUJ instability, range of motion of the wrist, and modified Mayo wrist score. Radiographic assessment was done to determine union of the ulnar styloid osteotomy, DRUJ subluxation, and any hardware-related problems. RESULTS Outcome measures were evaluated after a mean follow-up of 21 months. Healing of the osteotomy was obtained in all cases by 11 weeks. The DRUJ laxity, visual analog scale, and modified Mayo wrist score improved, while grip strength and range of motion remained unchanged. One patient had prominent hardware necessitating removal after union of the osteotomy. There were no reported cases of injury or neuropraxia of the dorsal cutaneous branch of the ulnar nerve. CONCLUSIONS Open repair of an avulsed foveal attachment of the triangular fibrocartilage complex using an ulnar styloid osteotomy is an alternative to either open or arthroscopic repair approaches. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
Collapse
Affiliation(s)
| | - Ramy Ahmed Diab
- Department of Orthopaedic Surgery, Ain Shams University, Cairo, Egypt.
| | | |
Collapse
|
2
|
Lo IN, Chen KJ, Yin CY, Huang HK, Wang JP, Huang YC. Comparing the Outcomes of Suture Anchor Repair and Rein-Type Capsular Suture for Triangular Fibrocartilage Complex Foveal Tears With a Minimum 2-Year Follow-Up. J Hand Surg Am 2024; 49:321-328. [PMID: 38300191 DOI: 10.1016/j.jhsa.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 12/13/2023] [Accepted: 12/20/2023] [Indexed: 02/02/2024]
Abstract
PURPOSE Recent biomechanical studies have highlighted the importance of foveal reinsertion when repairing triangular fibrocartilage complex (TFCC) injury with foveal tears. However, clinical studies comparing different repair techniques are scarce. We compared the clinical outcomes of suture anchor repair and rein-type capsular suture in patients with TFCC palmer 1B foveal tears with a minimum of 2-year follow-up. METHODS This was a single-surgeon, single-center, retrospective, comparative study. We included patients who underwent TFCC repair surgery due to a foveal tear from December 2013 to October 2018 with a minimum follow-up of 24 months. Postoperative Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) score, Modified Mayo Wrist Score, visual analogue scale for pain, wrist range of motion, and grip strength were compared. We also measured the maximal ulnar head displacement with dynamic ultrasound to quantify distal radioulnar joint stability. RESULTS In total, 103 patients were in the suture anchor group (group A) and 84 patients in the rein-type capsular suture group (group B). The mean follow-up time exceeded three years for both groups. There was a minimal difference regarding QuickDASH score, visual analogue scale for pain, and grip strength ratio between the two groups. The rein-type group had significantly better Modified Mayo Wrist Score. The suture anchor group showed better distal radioulnar joint stability with dynamic ultrasound, but was more limited in ulnar deviation. However, these differences are most likely clinically insignificant. CONCLUSIONS Both suture anchor repair and rein-type capsular suture yielded satisfactory results for TFCC 1B foveal tear in a minimum of 2-year follow-up. The functional scores were similar, and no major complications or recurrent instability were noted in either group. TYPE OF STUDY/LEVEL OF EVIDENCE Retrospective Therapeutic Comparative Investigation IV.
Collapse
Affiliation(s)
- I-Ning Lo
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Kuan-Jung Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Orthopaedics, China Medical University Hsinchu Hospital, Zhubei, Taiwan
| | - Cheng-Yu Yin
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hui-Kuang Huang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Orthopaedics, Chiayi Christian Hospital, Chiayi, Taiwan; Chung Hwa University of Medical Technology, Tainan, Taiwan
| | - Jung-Pan Wang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Chao Huang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| |
Collapse
|
3
|
Nakamura T, Takagi T. Differentiated Approaches to Treat Lesions of the TFCC Based on new arthroscopic Classification. HANDCHIR MIKROCHIR P 2022; 54:389-398. [PMID: 36037815 DOI: 10.1055/a-1872-0109] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
In this article, pathology of the TFCC lesions, image diagnosis and arthroscopic examination were described. According to the radiocarpal arthroscopic findings, TFCC lesions are classified into intra-disc lesions (Class 1), radial lesion (Class 2), peripheral disc lesions which indicate slight to moderate DRUJ instability (Class 3) and degenerative lesion (Class 4). The radioulnar ligament (RUL) lesions that indicate moderate to severe DRUJ instability were classified with staging system with DRUJ arthroscopic findings (Stage 1 to 5). Author's treatment algorism with wrist arthroscopic findings including DRUJ arthroscopy was demonstrated and along with this algorism, various arthroscopic and open techniques to treat TFCC injuries were selected and resulted in success. Precise diagnosis of the TFCC lesions helped to select an adequate treatment for each lesion.Dieser Artikel beschreibt die pathologischen Veränderungen des TFCC sowie deren Befunde in der Bildgebung und Arthroskopie. Am TFCC lassen sich mittels Arthroskopie bei Sicht von radiokarpal zentrale (Typ 1), radiale (Typ 2) sowie periphere Läsionen (Typ 3), die mit einer moderaten Instabilität des distalen Radioulnargelenkes (DRUG) einhergehen, und degenerative Läsionen (Typ 4) unterscheiden. Läsionen der radioulnaren Bänder, die mit einer moderaten bis ausgeprägten Instabilität des DRUG vergesellschaftet sind, werden anhand der Befunde bei der DRUG-Arthroskopie in fünf Stadien eingeteilt. Diesen unterschiedlichen Befunden angepasst wurde ein Behandlungsalgorithmus mit verschiedenen arthroskopischen und offenen Verfahren entwickelt, der sich als erfolgreich erwies. Eine exakte Klassifizierung von TFCC-Läsionen ermöglicht die Wahl des für die jeweilige Läsion adäquaten Therapieverfahrens.
Collapse
Affiliation(s)
- Toshiyasu Nakamura
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Tokyo, Japan.,Department of Orthopaedic Surgery, National Center for Child Health and Development, Setagaya-ku, Japan
| | - Takehilko Takagi
- Department of Orthopaedic Surgery, National Center for Child Health and Development, Setagaya-ku, Japan
| |
Collapse
|
4
|
Afifi A, Abdel-Ati EA, Abdel-Wahed M, Moharram AN. Arthroscopic-Assisted Foveal Reattachment of Triangular Fibrocartilage Complex Tears With Distal Radioulnar Joint Instability: A Comparison of Suture Anchors and Transosseous Sutures. J Hand Surg Am 2022; 47:507-516. [PMID: 35341629 DOI: 10.1016/j.jhsa.2022.01.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 11/30/2021] [Accepted: 01/21/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the clinical outcomes of arthroscopically-assisted suture anchor repair and transosseous sutures for repair of foveal triangular fibrocartilage complex tears in patients with distal radioulnar joint (DRUJ) instability. METHODS Sixty patients with triangular fibrocartilage complex foveal detachment associated with DRUJ instability were prospectively recruited and randomized into 2 equal groups-the anchor repair group and the transosseous repair group. The primary outcome was DRUJ function after 2 years, which was assessed by the DRUJ evaluating system. The secondary outcomes were grip strength, visual analog scale for pain, Mayo Modified Wrist ScorePatient-Rated Wrist Evaluation score, and the Disabilities of the Arm, Shoulder, and Hand score. RESULTS There were no significant differences between the groups for any of the outcome measures. Good-to-excellent outcomes (according to the DRUJ evaluation system) were achieved in 27 (90%) patients in the anchor repair group and 26 (86.7%) patients in the transosseous repair group. Fewer complications were observed in the anchor repair group. CONCLUSIONS Both techniques yielded good and comparable outcomes with a lesser incidence of early complications in the anchor repair group. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.
Collapse
Affiliation(s)
- Ahmed Afifi
- Hand and Microsurgery Unit, Department of Orthopedic Surgery, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Emad A Abdel-Ati
- Hand and Microsurgery Unit, Department of Orthopedic Surgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Abdel-Wahed
- Hand and Microsurgery Unit, Department of Orthopedic Surgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ashraf N Moharram
- Hand and Microsurgery Unit, Department of Orthopedic Surgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| |
Collapse
|
5
|
Yang CY, Chen WJ. Arthroscopic transosseous foveal footprint repair of the triangular fibrocartilage complex. J Hand Surg Eur Vol 2022; 47:486-494. [PMID: 35001678 DOI: 10.1177/17531934211065874] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Foveal disruption of the triangular fibrocartilage complex contributes to the instability of distal radioulnar joint. We have developed an arthroscopic transosseous foveal footprint repair technique, which maximizes the contact between the disrupted triangular fibrocartilage complex and its foveal footprint for better healing by using four sutures in a divergent configuration through a 1.6-mm bone tunnel. Twelve patients with triangular fibrocartilage complex foveal injuries who had undergone this repair technique were reviewed with a mean follow-up of 53 months. All patients achieved significant improvement in the modified Mayo wrist score and the Disabilities of the Arm, Shoulder and Hand score. All patients had stable distal radioulnar joints with comparable ranges of motion and grip strengths between the operated and contralateral wrists. There was no significant difference in functional score in those who were treated more than 6 months after injury.Level of evidence: IV.
Collapse
Affiliation(s)
- Chen-Yuan Yang
- Division of Hand and Reconstructive Microsurgery, Kuang Tien General Hospital, Taichung, Taiwan.,Department of Nursing, Hungkuang University, Taichung, Taiwan
| | - Wei-Jen Chen
- Department of Orthopedics, Show Chwan Memorial Hospital, Changhua, Taiwan.,Department of Orthopedics, Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan
| |
Collapse
|
6
|
Jung HS, Kim SH, Jung CW, Woo SJ, Kim JP, Lee JS. Arthroscopic Transosseous Repair of Foveal Tears of the Triangular Fibrocartilage Complex: A Systematic Review of Clinical Outcomes. Arthroscopy 2021; 37:1641-1650. [PMID: 33359818 DOI: 10.1016/j.arthro.2020.12.209] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 12/09/2020] [Accepted: 12/14/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether arthroscopic transosseous foveal repair of the triangular fibrocartilage complex (TFCC) results in significant and clinically relevant improvement in clinical outcomes including pain and function with low complication and reoperation rates. METHODS We reviewed studies investigating the clinical outcomes of arthroscopic transosseous foveal repair of the TFCC through MEDLINE, Embase, and the Cochrane Library. Studies on TFCC repair performed with an open or capsular technique and combined with other procedures, such as ulnar shortening osteotomy and a wafer procedure, were excluded. Methodologic quality was assessed using the Methodological Index for Non-randomized Studies score. Clinical outcomes were assessed using range of motion, grip strength, and patient-reported outcomes. Clinically relevant improvement was determined using the minimal clinically important difference (MCID). RESULTS A total of 443 unique studies were identified, of which 7 (131 patients) met the inclusion criteria. The mean age ranged from 27 to 37 years, and the mean follow-up period ranged from 23.5 to 31.1 months. The grip strength (as a percentage) increased after foveal repair of the TFCC in all studies (mean difference range, 11.8% to 22.3%). All studies also reported an improvement in the visual analog scale score (mean difference range, -9.8 to -1.88); Modified Mayo Wrist Score (mean difference range, 10.5 to 27); and Disabilities of the Arm, Shoulder and Hand score (mean difference range, -51.8 to -24.48). Considering clinically relevant improvements based on the MCID, 4 of 5 studies reporting the visual analog scale score showed improvements in this score (MCID, 2) and all studies reporting the Disabilities of the Arm, Shoulder and Hand score showed improvements in this score (MCID, 10). Most complications recovered without any treatment, and 3 patients (2.29%) needed a reoperation. CONCLUSIONS Arthroscopic transosseous foveal repair of the TFCC resulted in improvements in grip strength and functional outcomes with low complication and reoperation rates. However, the evidence for which technique produces better clinical outcomes remains limited. LEVEL OF EVIDENCE Level IV, systematic review of Level III and IV studies.
Collapse
Affiliation(s)
- Hyoung-Seok Jung
- Department of Orthopaedic Surgery, Hospital of Chung-Ang University of Medicine, Seoul, Republic of Korea
| | - Seong Hwan Kim
- Department of Orthopaedic Surgery, Hyundae General Hospital, Namyangju-si, Republic of Korea
| | - Chan Woo Jung
- Department of Orthopaedic Surgery, Hospital of Chung-Ang University of Medicine, Seoul, Republic of Korea
| | - Sung Jong Woo
- Department of Orthopaedic Surgery, Guro Narsha Hospital, Seoul, Republic of Korea
| | - Jong Pil Kim
- Department of Orthopaedic Surgery, Dankook University, Cheonan, Republic of Korea
| | - Jae-Sung Lee
- Department of Orthopaedic Surgery, Hospital of Chung-Ang University of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
7
|
Thalhammer G, Haider T, Lauffer M, Tünnerhoff HG. Mid- and Long-Term Outcome After Arthroscopically Assisted Transosseous Triangular Fibrocartilage Complex Refixation-Good to Excellent Results in Spite of Some Loss of Stability of the Distal Radioulnar Joint. Arthroscopy 2021; 37:1458-1466. [PMID: 33561484 DOI: 10.1016/j.arthro.2021.01.056] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 01/16/2021] [Accepted: 01/21/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate mid- and long-term outcomes after arthroscopically-assisted transosseous reattachment of the triangular fibrocartilage complex (TFCC) and to analyze the association of distal radioulnar joint (DRUJ) stability with the clinical outcome. METHODS Patients treated with an arthroscopically-assisted transosseous reattachment of the deep layer of the TFCC between 2000 and 2009 and a minimum follow-up of 12 months at mid-term and 4 years at long-term follow-up were retrospectively reviewed. Mayo Modified Wrist Score (MMWS); Disabilities of the Arm, Shoulder and Hand (DASH) score; pain visual analogue scale (VAS); grip strength and stability of the DRUJ were assessed at 2 follow-up clinical examinations. At the last follow-up, the Patient-Rated Wrist Evaluation score was additionally recorded. RESULTS Thirty patients with a mean age of 29 (±13) years were included. Most of the patients were female (70%, n = 21). The mid-term evaluation took place at a median of 30 months (range, 12-83 months). The assessed scores showed statistically significant clinical improvement (MMWS, P < .001; DASH score P < .001; VAS P < .001). Stability assessment showed a stable DRUJ in 23 (76.7%) patients. At a median of 106 months (range 52-215 months), the long-term clinical assessment was performed. The evaluated scores demonstrated persisting significant improvement (MMWS P < .001; DASH score P < .001; VAS P < .001). Stability assessment showed a stable DRUJ in 19 patients (63.3%). DRUJ instability did not correlate with clinical outcome. No permanent surgery-related complications occurred. CONCLUSION Arthroscopically-assisted transosseous reattachment of the deep fibers of radioulnar ligaments leads to excellent and good clinical results in mid- and long-term follow-up. In 95.5% of the analyzed patients, the measured improvement in the DASH score exceeded the in literature reported minimal clinically important difference of 13.5. Loss of DRUJ stability during follow-up was not associated with deterioration of clinical parameters and patient satisfaction. LEVEL OF EVIDENCE Level IV, retrospective case series.
Collapse
Affiliation(s)
- Gerhild Thalhammer
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria.
| | - Thomas Haider
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria; Department of Orthopedics and Traumatology, Hospital of the St. John of God Brothers Eisenstadt, Eisenstadt, Austria, Marbach, Austria
| | - Martin Lauffer
- Handchirurgische Praxis, Dr.Tünnerhoff/Dr. Lauffer, Marbach, Marbach/Neckar, Germany
| | | |
Collapse
|
8
|
Nakamura T, Moy OJ, Peimer CA. Relationship between Fracture of the Ulnar Styloid Process and DRUJ Instability: A Biomechanical Study. J Wrist Surg 2021; 10:111-115. [PMID: 33815945 PMCID: PMC8012095 DOI: 10.1055/s-0040-1719041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 08/28/2020] [Indexed: 10/23/2022]
Abstract
Background There has been clinical question in the treatment of ulnar styloid fracture with distal radius fracture, surgical fixation of the styloid fragment, or ignorance of the fragment. We examined relationship between size of the ulnar styloid fracture and distal radioulnar joint (DRUJ) stability biomechanically to answer the above clinical question. Methods Changes in the dorsopalmar stiffness of the DRUJ after experimentally simulating in four types of ulnar styloid fractures were examined in cadavers. After tip, middle, base-horizontal, and base-oblique type of styloid fractures were made sequentially, changes in dorsopalmar DRUJ stiffness were measured using the MTS machine in the intact wrist, for each fracture, at 60 degrees pronation, neutral, and 60 degrees supination, respectively. Additional cutting of the radioulnar ligament (RUL) at the fovea was also simulated with the base-horizontal fracture. Results The tip and middle type fractures did not demonstrate significant loss of stiffness compared with the intact. The base-horizontal fracture demonstrated only significant loss of stiffness in the dorsal direction (radius palmar; ulnar dorsal) with forearm in neutral rotation. The base-oblique fracture demonstrated significant loss of dorsopalmar stiffness of the DRUJ. Additional section of the RUL with the base-horizontal fracture induced significant loss of stiffness of the DRUJ compared with the intact. Conclusions Because the RUL originates from the fovea as well as from the base of the ulnar styloid, these results suggest that DRUJ instability closely correlates with how much of the bony fragment includes the originating portions of the RUL. The findings further suggest that larger base-oblique and base-horizontal fragments with resultant DRUJ instability must be reattached, but that even base-horizontal fragment as well as tip and middle ulnar styloid fragment can be ignored when there is no instability.
Collapse
Affiliation(s)
- Toshiyasu Nakamura
- Hand Center of Western New York, State University of New York at Buffalo, Buffalo, New York
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Tokyo, Japan
| | - Owen J. Moy
- Hand Center of Western New York, State University of New York at Buffalo, Buffalo, New York
| | - Clayton A. Peimer
- Hand Center of Western New York, State University of New York at Buffalo, Buffalo, New York
- Department of Orthopaedic Surgery, Marquette General Hospital, Marquette, Michigan
| |
Collapse
|
9
|
Auzias P, Camus EJ, Moungondo F, Van Overstraeten L. Arthroscopic-assisted 6U approach for foveal reattachment of triangular fibrocartilage complex with an anchor: Clinical and radiographic outcomes at 4 years' mean follow-up. HAND SURGERY & REHABILITATION 2020; 39:193-200. [PMID: 32032802 DOI: 10.1016/j.hansur.2020.01.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/10/2019] [Accepted: 01/29/2020] [Indexed: 10/25/2022]
Abstract
The main objective of this study was to evaluate the long-term clinical and radiological outcomes of arthroscopic-assisted foveal repair of proximal triangular fibrocartilage complex (TFCC) tears with an anchor. The secondary objective was to look for ligament damage associated with TFCC tears. Twenty-four patients who underwent foveal repair of the TFCC were evaluated retrospectively: 16 stage 2 and 8 stage 3 in the Atzei-EWAS classification. The TFCC was repaired with an anchor using an expanded 6U approach. Systematic testing of intrinsic and extrinsic ligaments was performed. The assessment criteria were pain on a visual analog scale (VAS), wrist joint range of motion, grip strength and pronation-supination strength, and the QuickDASH and PRWE outcome scores. X-rays were also taken to assess anchor position and to look for distal radioulnar (DRU) joint damage. The average follow-up was 44 months. After the surgical repair, pain was reduced (7.36±1.3 preoperatively vs. 0.69±1.3 postoperatively; P<0.001), the QuickDASH score improved (52.1±16 vs. 21.7±7; P<0.001), the PRWE score improved (83.7±35 vs. 9.3±12; P<0.001) as did strength (35 vs. 43kg; P<0.001). The DRU joint stability was also significantly improved. The time away from work was 2.6 months. During the arthroscopy exploration, 25% of patients had an ulnotriquetral ligament lesion and 8% had an ulnolunar ligament lesion in combination with their TFCC tear. Fifteen anchors were positioned in the anatomical fovea (62%). No DRU joint damage was noted. Six patients had neurapraxia of the dorsal branch of the ulnar nerve, although it recovered spontaneously. One patient still had hypoesthesia of the ulnar side of the fifth finger at 48 months. Arthroscopic-assisted foveal repair of the TFCC yields good results in terms of pain, strength and DRU joint stability. In one-quarter of cases, TFCC foveal tears are associated with lesions of the ulnotriquetral ligament. There is no long-term degeneration of the DRU joint.
Collapse
Affiliation(s)
- P Auzias
- Service d'orthopédie, CHRU de Lille, hôpital Roger Salengro, rue du Professeur Emile-Laine, 59037 Lille cedex, France.
| | - E J Camus
- Polyclinique du Val de Sambre, 162, route de Mons, 59600 Maubeuge, France
| | - F Moungondo
- Hôpital Erasme, ULB, route de Lennik, 1070 Bruxelles, Belgium
| | - L Van Overstraeten
- Hôpital Erasme, ULB, route de Lennik, 1070 Bruxelles, Belgium; Hand and foot surgery unit, 9, rue Pierre-Caille, Tournai, Belgium
| |
Collapse
|
10
|
Dunn J, Polmear M, Daniels C, Shin E, Nesti L. Arthroscopically Assisted Transosseous Triangular Fibrocartilage Complex Foveal Tear Repair in the United States Military. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2019. [DOI: 10.1016/j.jhsg.2019.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
11
|
Honigmann P, Steiger R. Intra-Articular Distal Ulnar Sliding Osteotomy for Ulnar Shortening. JBJS Essent Surg Tech 2019; 9:e7. [PMID: 31086725 DOI: 10.2106/jbjs.st.18.00024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Ulnocarpal impaction is the most common reason to perform ulnar shortening osteotomy. There are 3 osteotomy techniques for ulnar shortening: transverse, step-cut, and oblique cut1-3.First described by Milch4 in 1941, extra-articular diaphyseal oblique or transverse shortening is the most frequently performed type of shortening. However, it is associated with a nonunion rate of up to 10%, and irritation by implants requiring removal occurs in up to 28% of cases5,6. Intra-articular procedures such as the wafer procedure affect the distal ulnar joint surface, which can lead to stiffness of the distal radioulnar joint (DRUJ) due to scar tissue formation and adhesion of the triangular fibrocartilage complex (TFCC)7. Lapner et al.8 described increased pressure in the DRUJ after the wafer procedure, which may lead to an early onset of osteoarthritis. Complication rates between 8% for open wafer procedures and 21% for arthroscopic wafer procedures have been described9.Intra-articular shortening has also been described by Slade and Gillon10 in 2007 and Hammert et al.11 in 2012 and was tested in cadavers by Greenberg et al.12 in 2013. This closing wedge technique preserves the distal joint surface of the ulna and also allows for easy correction of the inclination of the hub joint surface of the ulna.In contrast to the technique of Slade, our described osteotomy is steeper and longer proximally, which allows for fixation with >2 screws13-16. Rapid healing of the metaphyseal bone compared with diaphyseal bone is described, and implant removal is necessary less often14,17,18.With the described procedure, the interosseous membrane remains untouched, especially the distal oblique bundle, which additionally provides stability of the DRUJ in 40% of patients19. Description A dorso-ulnar approach through the fifth extensor sheath is performed. The ulnocarpal joint and the DRUJ are accessed through an arthrotomy distal and proximal to the TFCC. The foveal attachment of the TFCC and the subsheath of the sixth extensor sheath are visualized. The osteotomy is intra-articular oblique from distal ulnar to proximal radial. Sliding the head of the ulna proximally achieves the desired shortening of up to 5 mm, and the head is fixed using 2, 3, or 4 cannulated headless screws. A slight correction of the axis of the ulnar head is also possible. Alternatives An alternative to this procedure is extra-articular osteotomy using a palmar or dorsal ulnar approach. If necessary, additional ulnocarpal procedures can be performed in an open or arthroscopically assisted manner. Rationale The shortening takes place only in the articular part of the distal aspect of the ulna. This procedure can easily be combined with TFCC repair, synovectomy of the DRUJ, or repair or reconstruction of the lunotriquetral ligament if needed. Shortening of up to 5 mm is possible.
Collapse
Affiliation(s)
| | - Regula Steiger
- Hand Surgery, Kantonsspital Baselland, Liestal, Switzerland
| |
Collapse
|
12
|
Pfanner S, Diaz L, Ghargozloo D, Denaro V, Ceruso M. TFCC Lesions in Children and Adolescents: Open Treatment. J Hand Surg Asian Pac Vol 2019; 23:506-514. [PMID: 30428785 DOI: 10.1142/s2424835518500509] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND There has been little discussion regarding the lesion of the TFCC in pediatric and adolescent patients. This study examines 11 cases treated with open technique. METHODS Range of motion (ROM), strength and functional scores (QUICK DASH, PWRE, VAS pain, and NAKAMURA score) were evaluated. RESULTS The mean postoperative flexion-extension arc was 95% of the contralateral side, the radio-ulnar deviation 91% of the contralateral side and the pronation-supination arc 94% of the unaffected side. Grip strength was 85.6% of the uninjured wrist, pinch was 88%. The mean PRWE decreased from 84.4 to 9.85 postoperatively. The mean Q-DASH scored 10.4. The VAS pain under stress decreased from a mean of 6.8 to a mean of 2.27, while at rest it decreased from a mean of 5 to a mean of 0.5. The final clinical results obtained by Nakamura score were 2 excellent, 6 good and 3 fair. CONCLUSIONS This study emphasizes that open surgical TFCC repair is a safe and reliable therapeutic procedure in children and adolescent populations.
Collapse
Affiliation(s)
- Sandra Pfanner
- * Surgery and Reconstructive Microsurgery of the Hand, AUO Careggi, Florence, Italy
| | - Lorenzo Diaz
- † Orthopedics and Traumatology Department, Campus Bio-Medico University of Rome, Rome, Italy
| | - Dariush Ghargozloo
- ‡ Orthopedics and Traumatology Department, ASST Valcamonica, Esine Hospital, Esine (BS), Italy
| | - Vincenzo Denaro
- † Orthopedics and Traumatology Department, Campus Bio-Medico University of Rome, Rome, Italy
| | - Massimo Ceruso
- * Surgery and Reconstructive Microsurgery of the Hand, AUO Careggi, Florence, Italy
| |
Collapse
|
13
|
Abe Y, Fujii K, Fujisawa T. Midterm Results after Open versus Arthroscopic Transosseous Repair for Foveal Tears of the Triangular Fibrocartilage Complex. J Wrist Surg 2018; 7:292-297. [PMID: 30174985 PMCID: PMC6117178 DOI: 10.1055/s-0038-1641720] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 03/06/2018] [Indexed: 10/17/2022]
Abstract
Purpose Various surgical procedures for foveal tears of the triangular fibrocartilage complex (TFCC) have been reported, and the procedures can be grossly divided into open and arthroscopic repair. The surgical results of both procedures were compared. Materials and Methods Twenty-nine patients underwent repair of a TFCC foveal tear. The 13 men and 16 women were in the age range of 14 to 72 years (average age, 30 years). Five patients had a history of distal radius fractures that healed uneventfully with nonoperative treatment. The mean duration of symptoms before surgery was 7.1 months. The procedure for repair consisted of 8 open repairs and 21 arthroscopic repairs. In both procedures, the TFCC was repaired transosseously to the ulna. The mean follow-up period was 34.4 (range, 24-70) months. The patients' pain, range of motion (ROM), grasping power, ulnar head instability, Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), and Mayo modified wrist score (MMWS) were evaluated. The operating time was also compared. Results There were no significant differences between the groups in pain, ROM, grasping power, ulnar head instability, and DASH. The MMWS was excellent in 8 patients in the open repair group, with 18 excellent and 3 good in the arthroscopic repair group. The mean operating time was significantly shorter for arthroscopic repair than for open repair. Conclusion Satisfactory outcomes were achieved for both open and arthroscopic repair techniques in the midterm. If a surgeon becomes familiar with the arthroscopic repair, the arthroscopic technique would be more feasible than the open repair in terms of technical facility and shortening of the operating time. Level of Evidence Level III, therapeutic study.
Collapse
Affiliation(s)
- Yukio Abe
- Department of Orthopaedic Surgery, Saiseikai Shimonoseki General Hospital, Yamaguchi, Japan
| | - Kenzo Fujii
- Department of Orthopaedic Surgery, Saiseikai Shimonoseki General Hospital, Yamaguchi, Japan
| | - Takeyoshi Fujisawa
- Department of Orthopaedic Surgery, Saiseikai Shimonoseki General Hospital, Yamaguchi, Japan
| |
Collapse
|
14
|
Arthroscopic one-tunnel transosseous foveal repair for triangular fibrocartilage complex (TFCC) peripheral tear. Arch Orthop Trauma Surg 2018; 138:131-138. [PMID: 29124362 DOI: 10.1007/s00402-017-2835-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Indexed: 02/09/2023]
Abstract
PURPOSE Arthroscopic repair of a peripheral triangular fibrocartilage complex (TFCC) tear is a promising, minimally invasive surgical technique, especially in patients with symptomatic distal radioulnar joint (DRUJ) instability. The purpose of this study was to evaluate the clinical result of arthroscopic one-tunnel transosseous foveal repair for peripheral TFCC tears. METHODS Sixteen patients who underwent TFCC foveal repair were retrospectively evaluated. The mean follow-up period was 31.1 months. The torn TFCC of all patients was repaired with the arthroscopic one-tunnel transosseous foveal repair technique. Postoperative outcomes were evaluated using the visual analogue scale (VAS) for pain, wrist range of motion, grip strength, Mayo wrist score, Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH) score, and postoperative complications. RESULTS On arthroscopic examination, all 16 patients showed Palmer 1B type peripheral TFCC tears with foveal disruption. Among them, 13 patients had a proximal component TFCC tear (Atzei class 3) and 3 patients had a complete TFCC tear (Atzei class 2). At the final follow-up, the mean range of the pronation-supination arc (P = 0.03) and grip strength (P = 0.001) was significantly increased. Twelve patients had normal stability of the DRUJ and six patients showed mild laxity compared with the contralateral side. The mean VAS for pain perception decreased from 3.7 to 0.8 (P = 0.001). The modified Mayo wrist (P = 0.001) and Quick DASH (P = 0.001) scores showed significant functional improvement. No surgery-related complications occurred. CONCLUSIONS The present study shows that arthroscopic one-tunnel transosseous repair is a good treatment strategy for TFCC foveal tears in terms of reliable pain relief, functional improvement, and re-establishment of DRUJ stability.
Collapse
|
15
|
Nakamura T, Abe K, Nishiwaki M, Iwamoto T, Sato K. Medium- to long-term outcomes of anatomical reconstruction of the radioulnar ligament to the ulnar fovea. J Hand Surg Eur Vol 2017; 42:352-356. [PMID: 27932401 DOI: 10.1177/1753193416679625] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED We examined the medium- to long-term outcome of the original reconstruction technique of the radioulnar ligament using a half-slip of the extensor carpi ulnaris tendon for chronic foveal avulsion of the triangular fibrocartilage complex. We treated 37 wrists in 36 patients with a minimum follow-up of 5 years. Of 36 patients, 12 had more than 10 years follow-up. At final follow-up, 30 patients (31 wrists) reported no pain, five patients (five wrists) reported mild occasional pain and one patient reported severe persistent pain. Two patients had lost 30° of supination. Complete stability of the distal radio-ulnar joint was achieved in 31 wrists, moderate instability was noted in five and severe distal radio-ulnar joint instability remained in one. The size of the bone tunnel was assessed radiologically: in two it had enlarged; in 23 it was unchanged; and in 12 it appeared to have closed over the tendon graft. The overall clinical outcomes were 28 excellent, four good, four fair and one poor. The 12 wrists with more than 10 years follow-up had seven excellent, three good and two fair clinical results. This reattachment technique appears to work and last over the medium- to long-term. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- T Nakamura
- 1 Clinical Research Center, International University of Health and Welfare, Tokyo, Japan
| | - K Abe
- 1 Clinical Research Center, International University of Health and Welfare, Tokyo, Japan
| | - M Nishiwaki
- 2 Department of Orthopaedic Surgery, Keio University, Tokyo, Japan
| | - T Iwamoto
- 2 Department of Orthopaedic Surgery, Keio University, Tokyo, Japan
| | - K Sato
- 2 Department of Orthopaedic Surgery, Keio University, Tokyo, Japan
| |
Collapse
|
16
|
Ma CH, Lin TS, Wu CH, Li DY, Yang SC, Tu YK. Biomechanical Comparison of Open and Arthroscopic Transosseous Repair of Triangular Fibrocartilage Complex Foveal Tears: A Cadaveric Study. Arthroscopy 2017; 33:297-304. [PMID: 28034486 DOI: 10.1016/j.arthro.2016.10.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 10/16/2016] [Accepted: 10/26/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To biomechanically compare the stability between open repair and arthroscopic transosseous repair technique for reattachment of the foveal triangular fibrocartilage complex (TFCC). We also evaluated the feasibility of a new aiming device for the creation of 2 bone tunnels simultaneously during the arthroscopic technique. METHODS Six matched pairs of fresh-frozen forearm cadaver specimens were prepared for testing. Group I specimens were treated by open repair with suture anchor. Group II specimens were treated by arthroscopic transosseous suture with a new aiming device. Before and after disruption of the TFCC fovea and after its repair, dorsal and palmar translation of the ulna was measured in both groups in response to a load (3 kg) applied in the palmar and then in the dorsal direction. The total translation of the ulna was calculated as the sum of the mean dorsal and palmar translations. RESULTS The mean total ulnar translation before and after TFCC disruption, and after TFCC repair was 5.94 ± 2.16 mm, 9.08 ± 2.64 mm, and 6.04 ± 2.18 mm, respectively. The specimens demonstrated a significant increase in the total translation of the ulna after disruption of the ulnar attachment of TFCC (P = .003), whereas a significant decrease was observed after TFCC foveal repair (P = .003). The median percentage of eliminated translation after TFCC repair was 64% and 172%, respectively, in groups I and II (P = .043). CONCLUSIONS The athroscopic transosseous suture technique demonstrated superior repair efficacy to the open repair technique in terms of biomechanical strength. This cadaveric study also demonstrated the feasibility of a new aiming device. CLINICAL RELEVANCE When making decisions about TFCC foveal repair, arthroscopic transosseous suture technique may provide better biomechanical strength than the open repair technique.
Collapse
Affiliation(s)
- Ching-Hou Ma
- Department of Orthopedics, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan
| | - Ting-Sheng Lin
- Department of Biomedical Engineering, I-Shou University, Kaohsiung, Taiwan
| | - Chin-Hsien Wu
- Department of Orthopedics, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan.
| | - Dong-Yi Li
- Department of Biomedical Engineering, I-Shou University, Kaohsiung, Taiwan
| | - Shih-Chieh Yang
- Department of Orthopedics, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan
| | - Yuan-Kun Tu
- Department of Orthopedics, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan
| |
Collapse
|
17
|
Woo SJ, Jegal M, Park MJ. Arthroscopic-assisted repair of triangular fibrocartilage complex foveal avulsion in distal radioulnar joint injury. Indian J Orthop 2016; 50:263-8. [PMID: 27293286 PMCID: PMC4885294 DOI: 10.4103/0019-5413.181790] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Disruption of the triangular fibrocartilage complex (TFCC) foveal insertion can lead to distal radioulnar joint (DRUJ) instability accompanied by ulnar-sided pain, weakness, snapping, and limited forearm rotation. We investigated the clinical outcomes of patients with TFCC foveal tears treated with arthroscopic-assisted repair. MATERIALS AND METHODS Twelve patients underwent foveal repair of avulsed TFCC with the assistance of arthroscopy between 2011 and 2013. These patients were followed up for an average of 19 months (range 14-25 months). The avulsed TFCC were reattached to the fovea using a transosseous pull-out suture or a knotless suture anchor. At the final followup, the range of motion, grip strength and DRUJ stability were measured as objective outcomes. Subjective outcomes were assessed using the Visual Analog Scale (VAS) for pain, patient rated wrist evaluation (PRWE), Disabilities of the Arm, Shoulder and Hand questionnaire (DASH score) and return to work. RESULTS Based on the DRUJ stress test, 5 patients had normal stability and 7 patients showed mild laxity as compared with the contralateral side. Postoperatively, the mean range of pronation supination increased from 141° to 166°, and the mean VAS score for pain decreased from 5.3 to 1.7 significantly. The PRWE and DASH questionnaires also showed significant functional improvement. All patients were able to return to their jobs. However, two patients complained of persistent pain. CONCLUSIONS Arthroscopically assisted repair of TFCC foveal injury can provide significant pain relief, functional improvement and restoration of DRUJ stability.
Collapse
Affiliation(s)
- Sung Jong Woo
- Department of Orthopaedic Surgery, Prime Hospital, Busan, Korea
| | - Midum Jegal
- Department of Orthopaedic Surgery, MS Jaegeon Hospital, Daegu, Korea
| | - Min Jong Park
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea,Address for correspondence: Prof. Min Jong Park, Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-Dong, Gangnam-Gu, Seoul 135-710, Korea. E-mail:
| |
Collapse
|
18
|
Gong HS, Cho HE, Kim J, Kim MB, Lee YH, Baek GH. Surgical treatment of acute distal radioulnar joint instability associated with distal radius fractures. J Hand Surg Eur Vol 2015; 40:783-9. [PMID: 26037650 DOI: 10.1177/1753193415588478] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 04/21/2015] [Indexed: 02/03/2023]
Abstract
This study investigates the question of whether open repair of acute distal radioulnar joint instability at the time of volar plating of distal radius fractures would enable early mobilization of the wrist without the risk of distal radioulnar joint instability. We evaluated 29 patients of mean age 53 years with a distal radius fracture and acute distal radioulnar joint instability who underwent volar plating of the radius combined with surgical repair of the triangular fibrocartilage complex or an ulnar styloid base fracture, followed by active motion exercise of the wrist at 1 week after surgery. At 1 year after treatment, all patients had a stable distal radioulnar joint and grip strength averaged 90% of the normal side. This study demonstrates that surgical repair of the triangular fibrocartilage complex or ulnar styloid fracture followed by early mobilization did not result in distal radioulnar joint instability, and suggests that the surgical treatment of distal radioulnar joint instability may permit early mobilization of the wrist in patients who are considered suitable for rapid rehabilitation after surgery. Type of study: Therapeutic Level IV.
Collapse
Affiliation(s)
- H S Gong
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - H E Cho
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - J Kim
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - M B Kim
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Y H Lee
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - G H Baek
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
19
|
Spies CK, Niehoff A, Unglaub F, Müller LP, Langer MF, Neiss WF, Oppermann J. Biomechanical comparison of transosseous re-fixation of the deep fibres of the distal radioulnar ligaments versus deep and superficial fibres: a cadaver study. INTERNATIONAL ORTHOPAEDICS 2015; 40:315-21. [DOI: 10.1007/s00264-015-2986-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 08/24/2015] [Indexed: 11/28/2022]
|
20
|
Abstract
Background Although foveal tears of the triangular fibrocartilage complex (TFCC) can be surgically reattached to the fovea via a dorsal approach, the foveal lesion is difficult to visualize from the dorsal side because the extensor carpi ulnaris (ECU) sheath floor and the superficial dorsal limb of the radioulnar ligament hinders the view of the fovea. Materials and Methods Twenty-one patients with foveal tears were treated by an open repair method from the palmar aspect. Pain, instability, motion, and grip strength were evaluated after a mean follow-up period of 26 months, and each patient was rated according to the Mayo Modified Wrist Score (MMWS). Description of Technique A 4-cm skin incision is made on the palmar aspect of the ulnar fovea. The ulnar fovea is exposed through a transverse capsulotomy of the distal radioulnar joint. The distal aspect of the TFCC is also exposed between the ECU tendon sheath and the ulnotriquetral ligament. After curettage of the scar tissue in the fovea, the deep palmar and dorsal limbs of the TFCC are sutured back to the fovea using a suture anchor technique. Results Foveal TFCC tears could be repaired via a palmar surgical approach without violating the floor of the ECU tendon sheath and the superficial dorsal limb. Excellent results were achieved in 18 patients, and a good result was achieved in three. Conclusions Our result compared favorably with those reported for dorsal approach. The palmar surgical approach facilitates the inspection and repair of the TFCC foveal tears. Level of Evidence IV.
Collapse
Affiliation(s)
- Hisao Moritomo
- Yukioka Hospital Hand Center, Osaka Yukioka College of Health Science, Osaka, Japan
| |
Collapse
|
21
|
Abstract
Background Foveal disruption of the triangular fibrocartilage complex (TFCC) is associated with distal radioulnar joint (DRUJ) instability. TFCC fixation onto the fovea is the suitable treatment, which is not achieved by conventional arthroscopic techniques. We describe an all-inside arthroscopic technique that uses a suture anchor through distal DRUJ arthroscopy for foveal repair of the TFCC. Materials and Methods Forty-eight patients with TFCC foveal tear and DRUJ instability were selected according to the Atzei-European Wrist Arthroscopy Society (EWAS) algorithm of treatment. Retrospective evaluation included pain, DRUJ instability, range of motion (ROM), grip strength, Modified Mayo Wrist Score (MMWS), and the Disabilities of the Arm, Shoulder, and Hand (DASH) Score. Description of Technique DRUJ arthroscopy was performed to débride the TFCC and the foveal area. Under arthroscopic guidance, a suture anchor was inserted via the distal foveal portal to repair the TFCC onto the fovea. Sutures were tied on the radiocarpal surface of the TFCC. Postoperative immobilization of forearm rotation was maintained for 4 weeks. Heavy tasks were allowed after 3 months. Results After a mean follow-up of 33 months, pain improved significantly but remained moderate in four patients, severe in one. DRUJ instability resolved in 44 patients. Wrist ROM increased. Grip strength, MMWS, and DASH score improved significantly. Excellent and good MMWS equaled 83.3%. Forty-one patients (85.5%) resumed previous work and sport activities. As a postoperative complication, five patients experienced neuroapraxia of the dorsal sensory branch of the ulnar nerve (DSBUN) with full spontaneous recovery. Conclusions With appropriate indications and patient selection, arthroscopic foveal repair of the TFCC may restore DRUJ stability and provide satisfactory results without significant complications.
Collapse
Affiliation(s)
- Andrea Atzei
- Fenice Hand Surgery and Rehabilitation Team, Treviso, Pordenone, Italy
| | | | | |
Collapse
|
22
|
Abstract
Background Since 1998, we treated 25 wrists with foveal detachment of the triangular fibrocartilage complex (TFCC) by our original reattachment technique using a half-slip of the extensor carpi ulnaris (ECU) tendon with a very small titanium interference screw. We examine the clinical outcome of this procedure with a minimum of 2 years follow-up. Patients and Methods There were 25 wrists of 24 patients (16 right, 7 left, 1 bilateral, mean age, 34.8 years) with a minimum follow-up of 2 years (range 2-7 years, average 3.1). There was a neutral ulnar variance in 19 wrists and positive in 6. In the positive-variance wrists, an ulnar shortening was performed to prevent ulnar abutment before the reattachment. The diagnosis of a TFCC injury was done by arthrogram, magnetic resonance imaging (MRI), and distal radioulnar (DRUJ) arthroscopy. The clinical outcome was evaluated using our original DRUJ evaluating system. Technique A distally based ECU half-slip was harvested, introduced into the TFCC, sutured to the remnant of the TFCC, and pulled out through a 2.5-mm bone tunnel at the center of the fovea. The ECU half-slip was subsequently anchored to the ulnar fovea with a small titanium interference screw. Results At the final follow-up, 21 wrists had no pain, 3 wrists indicated mild pain, and 1 wrist severe pain. One patient had a loss of supination by 30 degrees. The DRUJ was stable in 22 wrists, moderately unstable in 2 wrists, and severely unstable in 1 wrist. There were 21 excellent, 2 good, 1 fair, and 1 poor results. Conclusions Anatomic reattachment of the TFCC to the ulnar fovea using an ECU half-slip tendon is a promising procedure. This technique is effective for severe DRUJ instability due to chronic foveal avulsion of the TFCC.
Collapse
Affiliation(s)
- Toshiyasu Nakamura
- Clinical Research Center, International University of Health and Welfare, Department of Orthopaedic Surgery, Sanno Hospital, Tokyo, Japan
| |
Collapse
|
23
|
Minami A. Triangular fibrocartilage complex tears. HAND SURGERY : AN INTERNATIONAL JOURNAL DEVOTED TO HAND AND UPPER LIMB SURGERY AND RELATED RESEARCH : JOURNAL OF THE ASIA-PACIFIC FEDERATION OF SOCIETIES FOR SURGERY OF THE HAND 2015; 20:1-9. [PMID: 25609268 DOI: 10.1142/s0218810415010017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Akio Minami
- Department of Orthopaedic Surgery, Hokkaido Chuo Rosai Hospital Spinal Cord Injury Center, Japan Labor Health and Welfare Organization, Bibai, Hokkaido, Japan
| |
Collapse
|
24
|
Spies CK, Müller LP, Unglaub F, Hahn P, Klum M, Oppermann J. Anatomical transosseous fixation of the deep and superficial fibers of the radioulnar ligaments. Arch Orthop Trauma Surg 2014; 134:1783-8. [PMID: 25380839 DOI: 10.1007/s00402-014-2103-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The triangular fibrocartilage complex is in conjunction with the interosseous membrane the most important stabilizer of the distal radioulnar joint. Lesions of the triangular fibrocartilage complex may cause instability of the distal radioulnar joint with serious consequences. Therefore, the goal is to reconstruct and provide stability to prevent further harm. SURGICAL TECHNIQUE Based on the anatomical configuration of the radioulnar ligaments, we present a technique which addresses both the deep and the superficial fibers of the radioulnar ligaments. This surgical procedure can be performed either openly or arthroscopically assisted. Two osseous 2-mm tunnels starting from the ulnar neck to the foveal surface are created. A nonabsorbable suture is passed through the tunnels and the triangular fibrocartilage using a 20-gauge venipuncture needle in order to attach the deep fibers. Then a third osseous tunnel starting from the lateral base of the styloid process to the medial aspect is created. The suture is passed through this tunnel and through the triangular fibrocartilage and around the styloid process palmarily using the same needle as before in order to anchor the superficial fibers anatomically. After reducing the ulna head the sutures are tightened. CONCLUSION This technique is quite simple and addresses the anatomical configuration of the radioulnar ligaments.
Collapse
Affiliation(s)
- Christian K Spies
- Abteilung für Handchirurgie, Vulpius Klinik, Vulpiusstraße 29, 74906, Bad Rappenau, Germany,
| | | | | | | | | | | |
Collapse
|
25
|
Luchetti R, Atzei A, Cozzolino R, Fairplay T, Badur N. Comparison between open and arthroscopic-assisted foveal triangular fibrocartilage complex repair for post-traumatic distal radio-ulnar joint instability. J Hand Surg Eur Vol 2014; 39:845-55. [PMID: 23962870 DOI: 10.1177/1753193413501977] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The aim of this study was to assess the objective and subjective functional outcomes after foveal reattachment of proximal or complete ulnar-sided triangular fibrocartilage complex lesions by two surgical procedures: an open technique or an arthroscopically assisted repair. The study was done prospectively on 49 wrists affected by post-traumatic distal radio-ulnar joint instability. Twenty-four patients were treated with the open technique (Group 1) and 25 by the arthroscopically assisted technique (Group 2). Magnetic resonance imaging demonstrated a clear foveal detachment of the triangular fibrocartilage complex in 67% of the cases. Arthroscopy showed a positive ulnar-sided detachment of the triangular fibrocartilage complex (positive hook test) in all cases. Distal radio-ulnar joint stability was obtained in all but five patients at a mean follow-up of 6 months. Both groups had improvement of all parameters with significant differences in wrist pain scores, Mayo wrist score, Disability of the Arm, Shoulder and Hand questionnaire and Patient-Rated Wrist/Hand Evaluation questionnaire scores. There were no significant post-operative differences between the two groups in the outcome parameters except for the Disability of the Arm Shoulder and Hand questionnaire score, which was significantly better in Group 2 (p < 0.001).
Collapse
Affiliation(s)
- R Luchetti
- Rimini Hand and Rehabilitation Center, Rimini, Italy
| | - A Atzei
- Fenice Hand Surgery and Rehabilitation Team, Treviso, Pordenone, Italy
| | - R Cozzolino
- Rimini Hand and Rehabilitation Center, Rimini, Italy
| | - T Fairplay
- Studio Fairplay, Hand Rehabilitation Private Center, Bologna, Italy
| | - N Badur
- Department of Hand Surgery and Surgery of Peripheral Nerves, University Hospital Bern, Bern, Switzerland
| |
Collapse
|
26
|
Pirolo JM, Yao J. Current surgical treatment options for triangular fibrocartilage complex tears. CURRENT ORTHOPAEDIC PRACTICE 2014. [DOI: 10.1097/bco.0000000000000148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
27
|
Abstract
Three cases of a block to forearm rotation after a distal radius fracture were presented. The unique feature is that the surgeon should be diligent in seeking and rectifying causes of distal radioulnar joint (DRUJ) instability and rotation loss after fracture treatment.
Collapse
Affiliation(s)
- Daniel Mok
- Upper Limb Unit, Epsom General Hospital, Surrey, United Kingdom
| | | | - Toshiyasu Nakamura
- Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan
| |
Collapse
|
28
|
Arthroscopically assisted repair of triangular fibrocartilage complex foveal tears. J Hand Surg Am 2013; 38:271-7. [PMID: 23351910 DOI: 10.1016/j.jhsa.2012.11.008] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 11/02/2012] [Accepted: 11/02/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE To give a detailed clinical outcome analysis of a consecutive series of patients treated arthroscopically for traumatic triangular fibrocartilage complex (TFCC) foveal tears. METHODS This study was a consecutive case series of 11 patients who underwent arthroscopically assisted repair for traumatic TFCC foveal lesions. The mean age at the time of surgery was 27 years. The mean follow-up was 30 months (range, 20-51 mo). All patients underwent arthroscopy-assisted foveal reattachment of the TFCC by means of a transosseous outside-in technique. The primary outcome measure was a self-administered upper limb disability questionnaire (Hand20 questionnaire) at the final follow-up. The Hand20 scores range from 0 to 100, with high scores indicating severe disability. Secondary outcome measures included pain, grip strength, range of motion, distal radioulnar joint (DRUJ) instability, and the Mayo Modified Wrist Score. We assessed postoperative complications for all patients. RESULTS The mean preoperative Hand20 score was 29; it decreased significantly to 6 at final follow-up. Pain completely resolved in 7 patients, whereas mild pain during activity persisted in 4 patients. Grip strength improved significantly after surgery, from 84% to 98% of the unaffected side. Nine patients had no DRUJ instability and 2 had mild DRUJ instability at final follow-up. The Mayo Modified Wrist Score at final follow-up was 94 points; results were excellent in 7 patients, good in 3, and fair in 1. Skin irritation at the ulnar neck caused by the suture thread was recognized as a postoperative complication in 3 patients. CONCLUSIONS Transosseous arthroscopic repair for traumatic TFCC foveal tear can restore stability to the DRUJ and provide satisfactory subjective and objective results without serious complications after more than 20 months' follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
Collapse
|
29
|
Kikuchi Y, Nakamura T, Horiuchi Y. IRREDUCIBLE CHRONIC PALMAR DISLOCATION OF THE DISTAL RADIOULNAR JOINT – A CASE REPORT. ACTA ACUST UNITED AC 2012; 10:319-22. [PMID: 16568536 DOI: 10.1142/s0218810405002930] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2005] [Accepted: 12/16/2005] [Indexed: 11/18/2022]
Abstract
We report a rare case of irreducible chronic palmar dislocation of the distal radioulnar joint (DRUJ). This case showed that the dislocated ulnar head was impacted to the palmar cortex of the radius probably due to the dynamic force of the pronator quadratus muscle. Re-attachment of the ulnar styloid and partial resection of the ulnar head were necessary to make the reduction of the DRUJ possible. The continuity of the radioulnar ligament to the ulnar head was restored and the stability of DRUJ was maintained after reduction.
Collapse
Affiliation(s)
- Y Kikuchi
- Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan.
| | | | | |
Collapse
|
30
|
Iwasaki N, Nishida K, Motomiya M, Funakoshi T, Minami A. Arthroscopic-assisted repair of avulsed triangular fibrocartilage complex to the fovea of the ulnar head: a 2- to 4-year follow-up study. Arthroscopy 2011; 27:1371-8. [PMID: 21868189 DOI: 10.1016/j.arthro.2011.05.020] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Revised: 05/23/2011] [Accepted: 05/31/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE The objective of this study was to conduct a follow-up evaluation of an arthroscopic reattachment technique using an avulsed deep component of the triangular fibrocartilage complex (dc-TFCC) from the fovea of the distal ulna (ulnar fovea). METHODS A retrospective study was performed on a consecutive cohort of 12 patients who underwent arthroscopic reattachment of the avulsed dc-TFCC into the ulnar fovea over a 24-month period. The mean age was 31 years (range, 20 to 50 years). There were 6 men and 6 women. This technique anchors the avulsed portion of the dc-TFCC to the ulnar fovea by means of a repair suture passed through the created osseous tunnel from the ulnar neck to the foveal surface. Postoperative clinical and functional outcomes were quantitatively evaluated with the Modified Mayo Wrist Score. The Disabilities of the Arm, Shoulder and Hand questionnaire served to assess each patient's subjective outcome. A questionnaire regarding each patient's return to his or her previous job was also completed. Radiographic evaluation was based on computed tomography and magnetic resonance imaging examinations. RESULTS At the mean follow-up of 30 months, all patients had significant reduction of wrist pain. The mean Modified Mayo Wrist Score was 92.5 ± 7.5, and all patients were rated as having excellent or good clinical results. The Disabilities of the Arm, Shoulder and Hand score significantly improved from 59.5 ± 18.5 to 7.7 ± 11.9 postoperatively (P < .0001). Of the 9 working patients, 7 returned to their previous work. Two patients had occasional extensor carpi ulnaris tendinitis after surgery. Magnetic resonance images at 12 weeks postoperatively showed findings indicating attachment of the triangular fibrocartilage complex (TFCC) to the fovea. CONCLUSIONS Arthroscopic reattachment of the avulsed TFCC to the ulnar fovea by the described technique is a valid alternative for treating avulsion of the foveal TFCC insertion.
Collapse
Affiliation(s)
- Norimasa Iwasaki
- Department of Orthopaedic Surgery, Hokkaido University School of Medicine, Sapporo, Japan.
| | | | | | | | | |
Collapse
|
31
|
Abstract
Anatomical and biomechanical studies have highlighted the importance of the deep attachment of the TFCC for maintaining stability of the distal radioulnar joint (DRUJ). The standard arthroscopic assessment of the TFCC does not allow one to definitively determine whether the deep fibers are indeed intact, and establishing the diagnosis of a foveal detachment remains an exacting challenge. DRUJ arthroscopy is useful to assess the foveal fibers in any patient with DRUJ instability and can aid in the surgical decision making.
Collapse
Affiliation(s)
- David J Slutsky
- Los Angeles County Harbor-UCLA Medical Center, 1000 W Carson Street, Torrance, CA 90502, USA.
| |
Collapse
|
32
|
Abstract
During the last two decades, increased knowledge of functional anatomy and pathophysiology of the triangular fibrocartilage complex (TFCC) have contributed to a change in surgeons' perspective toward it. The earlier concept of the TFCC as the "hammock" structure of the ulnar carpus has updated to the "iceberg" concept, whereby the much larger "submerged" part represents the foveal insertions of the TFCC and functions as the stabilizer of the distal radioulnar joint and the ulnar carpus, thus lending it greater functional importance. This article presents an algorithm of the treatment of traumatic peripheral TFCC tear based on clinical, radiological, and arthroscopic findings.
Collapse
|
33
|
Nakamura T, Sato K, Okazaki M, Toyama Y, Ikegami H. Repair of foveal detachment of the triangular fibrocartilage complex: open and arthroscopic transosseous techniques. Hand Clin 2011; 27:281-90. [PMID: 21871351 DOI: 10.1016/j.hcl.2011.05.002] [Citation(s) in RCA: 120] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Because the radioulnar ligament attaches to the ulnar fovea and base of the ulnar styloid, foveal detachment of the triangular fibrocartilage complex (TFCC) induces severe distal radioulnar joint instability. This article describes both an arthroscopic and open repair technique to reattach the TFCC to the fovea. Both techniques reanchor the detached TFCC to the fovea. Both techniques are reliable and promising techniques in the repair of a foveal detachment of the TFCC.
Collapse
Affiliation(s)
- Toshiyasu Nakamura
- Department of Orthopaedic Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
| | | | | | | | | |
Collapse
|
34
|
Moritomo H. Advantages of open repair of a foveal tear of the triangular fibrocartilage complex via a palmar surgical approach. Tech Hand Up Extrem Surg 2009; 13:176-181. [PMID: 19956042 DOI: 10.1097/bth.0b013e3181bd8319] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Foveal tears of the triangular fibrocartilage complex (TFCC) can be repaired via a palmar surgical approach. Unlike the dorsal approach, in this method the floor of the extensor carpi ulnaris tendon subsheath and the dorsal superficial limb of the radioulnar ligament do not hinder the view of the fovea. Patients with a fresh or chronic TFCC foveal tear and a positive ulnar fovea sign with its dorsal styloid insertion remaining intact are candidates for this procedure. During operation, the shoulder is positioned at 90 degrees of abduction, and the elbow is flexed at 90 degrees on an arm board. A 4 cm curved skin incision along the flexor carpi ulnaris tendon is made on the anterior aspect of the ulnar fovea. The ulnar fovea is exposed through a transverse capsulotomy of the distal radioulnar joint. The ulnocarpal joint distal to the TFCC is also exposed between the extensor carpi ulnaris tendon subsheath and the ulnotriquetrum ligament. After curettage of the scar tissues at the fovea, the lifted TFCC is sutured onto the fovea using a suture anchor technique.
Collapse
Affiliation(s)
- Hisao Moritomo
- Department of Orthopaedic Surgery, Osaka University, Suita, Osaka, Japan.
| |
Collapse
|
35
|
Namba J, Fujiwara T, Murase T, Kyo T, Satoh I, Tsuda T. Intra-articular distal ulnar fractures associated with distal radial fractures in older adults: early experience in fixation of the radius and leaving the ulna unfixed. J Hand Surg Eur Vol 2009; 34:592-7. [PMID: 19687083 DOI: 10.1177/1753193409103728] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
There is no clear consensus about the best management of intra-articular distal ulnar fractures associated with distal radial fractures in older adults. We describe a treatment wherein the distal radial fractures were securely fixed with a palmar plate, leaving the associated ulnar fractures unfixed. The wrists of 14 patients with a mean age of 74 years were reviewed at an average of 18 months after surgery. The results were excellent in 11 cases and good in three, according to the modified Gartland and Werley score. All fracture sites displayed union, and there was no instability of the distal radioulnar joint. A widening of the distal radioulnar joint space was present in one wrist. Angular deformity of the distal ulnar metaphysis was seen in five wrists. This treatment could be an alternative to open reduction with internal fixation for intra-articular distal ulnar fractures in older adults.
Collapse
Affiliation(s)
- J Namba
- Department of Orthopaedic Surgery, Minoh City Hospital, Ryokufukai Hospital, Osaka University Graduate School of Medicine, Japan.
| | | | | | | | | | | |
Collapse
|
36
|
Abstract
Advances in radiocarpal and distal radioulnar joint (DRUJ) diagnostic arthroscopy permits a treatment-oriented classification of triangular fibrocartilage complex (TFCC) peripheral tears: 1) repairable distal tears; 2) repairable complete tears; 3) repairable proximal tears; 4) non-repairable tears; and 5) tears associated with DRUJ arthritis. Class 1 tears should be sutured; Class 2 and 3 are associated with DRUJ instability and require TFCC reattachment to the fovea; Class 4 tears need reconstruction using a tendon graft and Class 5 tears require an arthroplasty. Arthroscopic assisted TFCC foveal reattachment is possible through the direct foveal portal, a dedicated DRUJ working portal. Arthroscopic TFCC reconstruction using a tendon graft showed promising results.
Collapse
Affiliation(s)
- A Atzei
- Hand Surgery Unit, Policlinico G. B. Rossi, Verona, Italy.
| |
Collapse
|
37
|
Atzei A, Rizzo A, Luchetti R, Fairplay T. Arthroscopic foveal repair of triangular fibrocartilage complex peripheral lesion with distal radioulnar joint instability. Tech Hand Up Extrem Surg 2008; 12:226-235. [PMID: 19060683 DOI: 10.1097/bth.0b013e3181901b1] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
There is still controversy regarding the value of arthroscopic suture of triangular fibrocartilage complex (TFCC) peripheral tears compared with open transosseous repair because only the latter method restores foveal insertions of TFCC in case of distal radioulnar joint (DRUJ) instability. Five classes of TFCC peripheral tears are recognized in a treatment-oriented algorithm based on arthroscopic findings, and indications to proper treatment are set accordingly. Complete repairable tears (class 2) and proximal repairable tears (class 3) are associated with DRUJ instability and require foveal reattachment of the TFCC. We describe a new arthroscopic technique to repair the foveal attachment of the TFCC with the use of a suture anchor, which is indicated for class 2 and 3 TFCC peripheral tears, instead of an open repair. This technique requires a dedicated working portal to approach the fovea ulnaris. This Direct Foveal portal is used to prepare the ligament and bone and to drill and insert a suture anchor loaded with a pair of sutures. Under arthroscopic vision, a suture is passed through each limb of the ligament and tied using a small knot-pusher. This arthroscopic technique restores original TFCC anatomy and adequate DRUJ stability with less morbidity and potentially accelerated rehabilitation compared with open repair.
Collapse
Affiliation(s)
- Andrea Atzei
- Hand Surgery Unit, Policlinico G.B. Rossi, Verona, Italy.
| | | | | | | |
Collapse
|
38
|
del Piñal F. Dry Arthroscopy of the Wrist: Its Role in the Management of Articular Distal Radius Fractures. Scand J Surg 2008; 97:298-304. [DOI: 10.1177/145749690809700405] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- F. del Piñal
- Unit of Hand-Wrist and Plastic Surgery, Hospital Mutua Montañesa, and Instituto de Cirugía Plástica y de la Mano, Santander, Spain
| |
Collapse
|
39
|
Slutsky DJ, Nagle DJ. Wrist arthroscopy: current concepts. J Hand Surg Am 2008; 33:1228-44. [PMID: 18762125 DOI: 10.1016/j.jhsa.2008.07.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2008] [Revised: 07/22/2008] [Accepted: 07/22/2008] [Indexed: 02/02/2023]
Abstract
Wrist arthroscopy has steadily grown from a mostly diagnostic tool to a valuable adjunctive procedure in the treatment of myriad wrist disorders. The number of conditions that are amenable to arthroscopic treatment continues to grow. A detailed knowledge of the topographical and intracarpal anatomy, however, is essential to minimize complications and maximize the benefits. Although wrist arthroscopy can identify an anatomic abnormality, it cannot be used to differentiate between an asymptomatic degenerative condition versus a pathologic lesion that is the cause of wrist pain. A thorough wrist examination is still integral to any arthroscopic assessment. This article focuses on the methodology behind a normal arthroscopic wrist examination and discusses some of the more standard arthroscopic procedures along with the expected outcomes.
Collapse
|
40
|
Anderson ML, Larson AN, Moran SL, Cooney WP, Amrami KK, Berger RA. Clinical comparison of arthroscopic versus open repair of triangular fibrocartilage complex tears. J Hand Surg Am 2008; 33:675-82. [PMID: 18590850 DOI: 10.1016/j.jhsa.2008.01.020] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2007] [Revised: 01/15/2008] [Accepted: 01/17/2008] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether traumatic triangular fibrocartilage complex (TFCC) tears treated by arthroscopic repair have improved functional outcome scores, range of motion, grip strength, and pain relief compared with those repaired using an open surgical technique. METHODS From 1997 to 2006, 75 patients had repair of traumatic TFCC tears. Thirty-six patients had arthroscopic TFCC repair, and 39 patients had open repair. One patient was lost to follow-up. Evaluation included range of motion, grip strength, preoperative and postoperative Mayo Modified Wrist Score (MMWS), and patient-reported Disabilities of the Arm, Shoulder, and Hand score and visual analog scale score. Data were analyzed using chi-square tests or 2-sample t-tests; significance was set at p < .05. RESULTS Mean follow-up was 43 months +/- 11. Mean MMWS improved 6.5 points +/- 19.9 after surgery. Fifty-seven percent of patients improved at least 1 level in the MMWS pain score. No statistical difference was found between open and arthroscopic repair in the improvement of MMWS or visual analog scale pain scores. There was increased postoperative nerve pain (ulnar nerve branch) in the open group (14 out of 39 patients) compared with the arthroscopic group (8 out of 36 patients), but this was not found to be statistically significant. Reoperation for distal radioulnar joint instability was performed in 17% of patients. No statistical association was observed between surgery type and the rate of reoperation for instability. Female gender was significantly associated with a higher rate of total reoperation. CONCLUSIONS There was no statistical difference in clinical outcomes after open versus arthroscopic TFCC repair. Although not statistically significant, there was an increased rate of postoperative superficial ulnar nerve pain in the open group (14 out of 39 patients) compared with the arthroscopic group (8 out of 36 patients). After TFCC repair, 13 out of 75 patients required reoperation for distal radioulnar joint instability in this sample. A statistically significant association was found between reoperation rate and female gender.
Collapse
|
41
|
Tracy MR, Wiesler ER, Poehling GG. Arthroscopic Management of Triangular Fibrocartilage Tears in the Athlete. OPER TECHN SPORT MED 2006. [DOI: 10.1053/j.otsm.2006.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
|