Arthroscopic Foveal Repair of the Triangular Fibrocartilage Complex Improved the Clinical Outcomes in Patients With Persistent Symptomatic Distal Radio-Ulnar Joint Instability After Plate Fixation of Distal Radius Fractures: Minimum 2-Year Follow-Up

Manual reduction and splint fixation for distal radius fracture with dislocation: a case report

Introduction

Distal radius fractures (DRF) are one of the most common fractures, accounting for approximately 20% of all fractures. DRF is frequently associated with distal radioulnar joint (DRUJ) dislocation, which may be initially overlooked due to subtle symptoms and imaging findings. This can lead to misdiagnosis and suboptimal treatment.

Patient concerns

An elderly female patient presented with a distal radius fracture. Early clinical and imaging evaluations failed to identify a co-existing DRUJ dislocation.

Diagnosis

The DRUJ dislocation was subsequently diagnosed after careful assessment, highlighting the need for a thorough examination in cases of DRF.

Interventions

The DRUJ dislocation was managed with manual reduction followed by splint fixation. The patient was closely monitored throughout the treatment process.

Outcomes

Following the intervention, the patient demonstrated significant functional recovery, with improvement in wrist mobility and reduction in pain.

Conclusion

This case underscores the importance of early detection of DRUJ dislocation in patients with DRF to avoid misdiagnosis and prevent long-term wrist dysfunction. Timely and appropriate intervention can lead to substantial recovery.

Generalized Joint Laxity Increases the Risk of Recurrence of Distal Radioulnar Joint Instability after Arthroscopic Foveal Repair of the Triangular Fibrocartilage Complex

PURPOSE

To compare the clinical results of the arthroscopic foveal repair of the triangular fibrocartilage complex (TFCC) for distal radioulnar joint (DRUJ) instability in patients with or without generalized joint laxity.

METHODS

Patients who underwent arthroscopic transosseous foveal TFCC repair of Palmer 1B foveal TFCC tears (Atzei classification class II or III) from January 2018 to October 2021 were identified. Patients treated for symptomatic DRUJ instability for more than 3 months, and with at least 2 years of follow-up, were included. Patients were categorized into two groups based on the Beighton and Horan criteria: those with generalized joint laxity (group L) and those without (group N). Clinical outcomes were measured by the Disabilities of the Arm, Shoulder, and Hand (DASH) score, modified Mayo wrist score (MMWS), wrist range of motion (ROM), grip strength, sports/recreation activity level, recurrent DRUJ instability, and achievement of minimal clinically important differences (MCID).

RESULTS

One-hundred-and-twenty patients (Group L, 51 patients; Group N, 69 patients) were included. Both groups showed significant improvements in preoperative DASH and MMWS at the final follow-up. Overall, 103 patients (85.8%) achieved MCID, with 82.4% in Group L and 88.4% in Group N, and no significant differences between the two groups (P = .347). At the final follow-up, ROM and sports/recreation activity levels were similar between the groups. Significantly, the rates of postoperative DRUJ instability recurrence were 17.7% in group L (9/51) and 5.8% in group N (4/69) (P=0.039). Beighton scores were an independent risk factor for recurrent DRUJ instability in the multivariable analysis (P=0.024; odds ratio=1.62).

CONCLUSIONS

Clinical outcomes after arthroscopic TFCC foveal repair in patients with generalized joint laxity are comparable to those without, with 82.4% achieving MCID. Generalized joint laxity impacts DRUJ instability recurrence over a minimum 2-year follow-up period.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Surgical intervention for distal radial fractures with concurrent ulnar styloid fractures may be beneficial for the elderly patients: a retrospective study

BACKGROUND

Distal radius fractures are highly prevalent among older adults. Ulnar styloid fractures frequently accompany distal radius fractures, raising concerns about treatment outcomes due to the risk of distal radioulnar joint (DRUJ) instability. This study investigated the necessity of surgical intervention (open reduction internal fixation; ORIF) for distal radius fractures in very old patients with coexisting ulnar styloid fractures.

MATERIALS AND METHODS

A retrospective analysis of 96 patients aged ≥ 80 years with AO classification 23-A2 to 23-B3 distal radius fractures with concomitant ulnar styloid fracture between 2019 and 2022 was performed. Patients were excluded if they were aged < 80 years, had a preinjury Barthel index of < 90, or had high-energy multiple trauma. The primary outcome was the Disabilities of the Arm, Shoulder, and Hand (DASH) score assessed at 3, 6, and 12 months. We compared the DASH score and their trajectories between the ORIF and conservative treatment groups.

RESULTS

ORIF group demonstrated significantly better DASH functional scores (25.31 ± 4.71) at the 12-month follow-up compared with the conservative group (34.42 ± 8.03; p < 0.001). Treatment choice was identified as a significant predictor of DASH scores at 12 months, with ORIF significantly improved patient's wrist function and demonstrated a β coefficient of - 9.11 (95% confidence interval: -11.95 to - 6.27, p < 0.001). The other factors investigated, namely age, lowest T-score, and medical history of diabetes mellitus, hypertension, coronary artery disease, cerebrovascular accidents, cancer, and dementia, did not exhibit a significant association with the 12-month DASH scores in the adjusted model (p > 0.05).

CONCLUSIONS

Our findings suggest that very old patients with distal radius fracture accompanied by ulnar styloid fractures may benefit from ORIF to achieve optimal long-term functional recovery.

Distal Radioulnar Joint Instability

SUMMARY

The distal radioulnar joint (DRUJ) is vital to the stability and function of the wrist and forearm. The osseous morphology is variable and provides little stability. A complex of confluent soft tissues is the primary stabilizer; however, the contribution of each component has yet to be elucidated. It has become increasingly clear that the anatomic fixation of distal radius fractures restores DRUJ stability, obviating the need for additional DRUJ stabilization. This review will describe the anatomy and biomechanics of the DRUJ and discuss injury patterns, treatments, and clinical results.

Clinical Outcomes and Failure Rate of Triangular Fibrocartilage Complex Foveal Repair Were Comparable between Arthroscopic and Open Techniques

Background: This study compared clinical outcomes between arthroscopic and open repair of triangular fibrocartilage complex (TFCC) foveal tears in chronic distal radioulnar joint (DRUJ) instability patients. Methods: A total of 79 patients who had gone through foveal repair of TFCC using arthroscopic technique (n = 35) or open technique (n = 44) between 2016 and 2020 were retrospectively analyzed. The visual analog scale (VAS) score for pain, active range of motion (ROM), grip strength, Mayo Modified Wrist Score (MMWS), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score, and Patient-Rated Wrist Evaluation (PRWE) score at 2-4-6-12-24 months postoperatively were compared between two groups. Results: Two years after the operation, clinical parameters (VAS, MMWS, DASH, and PRWE), grip strength, and ROM showed significant advancement in the two groups in comparison to their values measured preoperatively (p < 0.001). Nonetheless, we could not identify any statistically significant differences in the above clinical factors between the two groups. The arthroscopic group showed a better flexion-extension arc at 2 months and supination-pronation arc at 2 and 4 months than the open group (p < 0.001). There were no significant differences between the two groups at 2 years postoperatively. Ten patients (12.6%) had recurrent instability (three in the arthroscopic group and seven in the open group, p = 0.499). Similarly, both groups showed no significant difference in the return to work period. Conclusions: Arthroscopic foveal repair of TFCC provided similarly favorable outcomes and early recovery of pain and ROM compared to open repair.

Effectiveness of suture anchor and transosseous suture technique in arthroscopic foveal repair of the triangular fibrocartilage complex: a systematic review

BACKGROUND

Currently, there were two major surgical methods for arthroscopic triangular fibrocartilage complex (TFCC) foveal repair: suture anchor (SA) and transosseous suture (TOS). The purpose of this systematic review is to examine the relevant outcome improvement and safety of SA and TOS technique.

METHODS

Literature review of electronic databases for studies investigating the effects of SA and TOS in patients undergoing arthroscopic TFCC foveal repair was performed. We compared the pre-operative and postoperative functional outcomes, clinical outcomes [pain, range of motion (ROM) and grip strength], and complications of two methods. Minimal clinically important difference (MCID) was used to determine clinically meaningful improvement.

RESULTS

There were 1263 distinct studies identified, with 26 (904 patients) meeting the inclusion criteria. The mean age of participants ranged from 21.4 to 41 years, and the mean follow-up time ranged from 6 to 106 months. Both SA and TOS groups reported significant improvement in the modified mayo wrist score, the disabilities of the arm, shoulder, and hand (DASH) score, quick DASH score, patient-reported wrist evaluation (PRWE) score, and the visual analog scale (VAS) score. According to MCID, all the studies from both groups reporting DASH, quick DASH, PRWE and VAS score achieved clinically meaningful improvement. (MCID: 10 for DASH, 14 for quick DASH, 14 for PRWE and 1.6-18 for VAS). The ROM changes in both groups varied from improvement to deterioration. Grip strength improved in both SA and TOS group. Most complications were self-limited. The reoperation rates in SA and TOS ranged from 0 to 20% and 0 to 27.3%, respectively.

CONCLUSIONS

Both SA and TOS technique for arthroscopic TFCC foveal repair could achieve improvement in postoperative functional outcomes, pain, and grip strength with low reoperation rate. However, the ROM improvement was still inconclusive.

LEVEL OF EVIDENCE IV

Systematic review of level III and IV studies.

Editorial Commentary: Artificial Intelligence for the Wrist: Moving to the Forefront of Diagnostic Imaging for Triangular Fibrocartilage Complex Injury

Accurate diagnosis of the etiology of ulnar-sided wrist pain and injury to the triangular fibrocartilage complex, particularly Palmar 1B tears, can prove to be challenging. Multiple peer-reviewed studies have demonstrated that accurate diagnosis and treatment of tears of the triangular fibrocartilage complex through nonoperative and operative means, including arthroscopy, can result in improved patient outcomes and function. One of the keys to successful treatment, however, is accurate diagnosis. While our current imaging modalities help to provide additional data for the assessment of this pathology, magnetic resonance imaging and computed tomography scans have limitations. Thus, employing the power of artificial intelligence and deep learning to ultrasound assessment of this injury is appealing. Efficient integration of this technology into daily practice has potential to bolster diagnostics not only in large medical centers but also in underserved areas with limited access to magnetic resonance imaging and computed tomography.

Editorial Commentary: Symptomatic Distal Radioulnar Joint Instability After Distal Radius Fracture Fixation: Improved Outcomes With Arthroscopic Management Are Still Possible After a Trial of Nonoperative Treatment

The literature to guide clinical-decision making for the treatment of symptomatic distal radioulnar joint instability in the setting of distal radius fracture is mixed, with some advocating for surgical treatment at the time of fracture fixation and others reporting acceptable clinical outcomes with conservative management. Given this, it can be challenging to determine which treatment strategy to employ for each individual patient. For injuries that are the result of high-energy trauma or when there is persistent instability lasting 6 months or longer after fracture fixation, surgical intervention may be needed. However, a period of conservative treatment does not appear to result in poorer outcomes.