Palmar reconstruction of the triangular fibrocartilage complex for static instability of the distal radioulnar joint

Ligamentoplasty using the ulnotriquetral ligament with wafer procedure for chronic triangular fibrocartilage complex foveal tear: Short-tem outcome

BACKGROUND

We developed a new ligamentoplasty technique using the ulnotriquetral ligament (UTL) via a palmar approach for cases with dorsal instability of the ulna due to a foveal tear of the triangular fibrocartilage complex (TFCC). The study aimed to evaluate the clinical outcomes of this procedure.

METHODS

We retrospectively analyzed 19 cases with foveal tears of TFCC who underwent the ligamentoplasty using UTL. We harvested the UTL from the triquetrum as a pedicle graft, avoiding damage of the connection between the base of the UTL and palmar radioulnar ligament (PRUL) as possible. The graft was flipped proximally and pulled out through the bone tunnel from the ulnar fovea to the ulnar neck, then fixed to the fovea using a tenodesis screw. The function of the TFCC can be reproduced by pulling out the UTL along with the PRUL through the ulnar fovea and re-establishing the PRUL tension. Clinical results were evaluated at least 12 months following surgery. The preoperative and postoperative wrist pain level on a neumerical rating scale (NRS), the radioulnar joint (DRUJ) ballottement test, the range of motion, the grip strength, and the Patient-rated wrist evaluation (PRWE) scores were evaluated.

RESULTS

In all cases, the DRUJ ballottement test became negative at the final follow up compared with the normal side on manual examination. The pain levels significantly decreased as reflected by a decrease in NRS from 6.8 to 2.5 at final follow up (p < 0.01). The range of pronation/supination motion was improved from 149° to 157°. The mean PRWE score significantly decreased from 52.1 to 22.8 (p < 0.01). The postoperative pain level on the NRS scale of the three patients poorly improved. One case of the three with the 3 mm positive ulnar variance needed additional ulnar shaft shortening using a plate seven months after the primary procedure.

CONCLUSIONS

The ligamentoplasty using UTL efficiently restored the ulnar palmar stability in all 19 cases and significantly decreased the wrist pain and the PRWE scores.

STUDY DESIGN

Clinical, retrospective study.

The Combined Procedure of Ulnar Metaphyseal Shortening Osteotomy With Triangular Fibrocartilage Complex Foveal Knotless Repair

Ulnar impaction syndrome (UIS) and triangular fibrocartilage complex (TFCC) tear are common causes of ulnar-sided wrist pain. As a standard surgical treatment, ulnar-shortening osteotomy (USO) and TFCC repair are used respectively. Patient spectrums of UIS accompanied by distal radioulnar joint instability or traumatic TFCC foveal tear with UIS symptoms exist, and both USO and TFCC repair are necessary for treating some of these patients. However, there have been few reports on the procedure for performing these 2 operations concurrently. We introduce a combined procedure to concurrently perform USO and TFCC repair. We performed a USO in the ulnar metaphysis using a locking plate and open TFCC knotless repair using a suture anchor at the ulnar fovea. In this technique, USO is conducted in the metaphysis, which is favorable to union, using a small plate that is easy to handle, and knotless TFCC repair can be performed simultaneously through a single small incision.

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

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.

Tenodesis of the Ulnotriquetrum Ligament to the Fovea for a Triangular Fibrocartilage Complex Tear

We developed a novel procedure to treat a triangular fibrocartilage complex (TFCC) foveal tear, namely tenodesis of the ulnotriquetrum ligament (UTL) to the fovea. We attempted to reestablish the tension of the palmar radioulnar ligament by the procedure specifically in cases with palmar radius instability relative to the ulna. We used a palmar surgical approach to expose the palmar aspect of TFCC in which the ulnocarpal ligament merges with the palmar radioulnar ligament. UTL was distally excised at a 4 mm width from the triquetrum without disrupting its ligamentous connection to the palmar radioulnar ligament proximally. We pulled out the distal UTL through the bone tunnel from the fovea to ulnar neck. The UTL graft was fixed to the fovea with an interference screw. In 13 cases, this procedure effectively decreased ulnar wrist pain, improved distal radioulnar joint instability, and restored wrist motion and grip strength.

Arthroscopic assisted tendon reconstruction for triangular fibrocartilage complex irreparable tears

We report our 11-year experience of performing arthroscopically assisted triangular fibrocartilage complex reconstruction in the treatment of chronic distal radio-ulnar joint instability resulting from irreparable triangular fibrocartilage complex injuries. Eleven patients were treated. Three skin incisions were made in order to create radial and ulna tunnels for passage of the tendon graft, which is used to reconstruct the dorsal and palmar radio-ulnar ligaments, under fluoroscopic and arthroscopic guidance. At a mean follow-up of 68 months all but one had a stable distal radio-ulnar joint. Pain and grip strength, Mayo wrist score, Disability of the Arm Hand and Shoulder and patient-rated wrist and hand evaluation scores improved. The ranges of forearm rotation remained largely unchanged. Complications included an early tendon graft tear, two late-onset graft ruptures, one ulna styloid fracture during surgery and persistent wrist discomfort during forearm rotation requiring tendon graft revision in one case. An arthroscopic assisted approach for triangular fibrocartilage complex reconstruction appears safe and produces comparable results with the open technique.

LEVEL OF EVIDENCE

IV.

Minimally invasive stabilization of the distal radioulnar joint: a cadaveric study

This study describes a minimally invasive procedure for stabilization of the distal radioulnar joint, using a suture-button construct placed percutaneously in the direction of the distal oblique bundle in the distal interosseous membrane. In five cadaveric specimens, placement of the suture-button suspension system reduced dorsal displacement of the radius in an unstable distal radioulnar joint to baseline values, both in neutral position and in pronation and supination. These results indicate the possibility of minimally invasive treatment for distal radioulnar joint instability.

Bidirectional Dislocation of the Distal Radioulnar Joint After Distal Radius Fracture: Case Report

We report a patient with bidirectional dislocation of the distal radioulnar joint after malunited distal radius fracture, in which the ulnar head dislocated dorsally during forearm pronation and palmarly during supination without manual compression of the ulnar head. The patient had chronic ulnar wrist pain and experienced a painful clunk during forearm rotation. The distal radioulnar joint ballottement test was positive in both the dorsal and palmar directions. Her distal radius was malunited with a 20° dorsal angulation and 18° pronation deformity. A corrective osteotomy of the radius with open repair of the triangular fibrocartilage complex foveal avulsion yielded success. At the 7-year follow-up, there was almost a normal range of wrist and forearm motion, 83% grip strength, no arthritis, and a stable distal radioulnar joint.

Open repair of the triangular fibrocartilage complex from palmar aspect

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.