Arterial anatomy of the triangular fibrocartilage of the wrist and its surgical significance

Arthroscopic wafer procedure versus ulnar shortening osteotomy for ulnar impaction syndrome: a systematic review and meta-analysis

PURPOSE

This study aimed to systematically compare the efficacy and safety of arthroscopic wafer procedure (AWP) versus ulnar shortening osteotomy (USO) for ulnar impaction syndrome (UIS) treatment.

METHODS

All the studies included in this meta-analysis compared the efficacy of AWP to USO for UIS and were acquired through a comprehensive search across multiple databases. The meta-analysis was performed by calculating the effect sizes with the Cochrane Collaboration's RevMan 5.4 software.

RESULTS

A total of 8 articles were included in this analysis, comprising 148 cases in the AWP group and 163 cases in the USO group. The pooled estimates indicated no significant differences in combined Darrow's Criteria or Modified Mayo Wrist Score, Modified Mayo Wrist Score, DASH scores, grip strength, VAS score, and postoperative ulnar variation. On the other hand, the patients in the AWP group exhibited fewer complications (OR = 0.17, 95%CI 0.05-0.54, P = 0.003) and a lower reoperation rate (OR = 0.12, 95%CI 0.05-0.28, P < 0.00001) than those in the USO group.

CONCLUSIONS

The two surgical techniques were both effective in treating UIS but the AWP group showed fewer complications and a lower reoperation rate. Therefore, AWP may present a superior alternative for UIS treatment.

Radial Sided Triangular Fibrocartilage Complex Tears: A Comprehensive Review

When evaluating the available literature on the diagnosis and management of triangular fibrocartilage complex tears (TFCC), ulnar tears comprise the major focus of TFCC literature. Radial-sided (Class 1D) tears are seldom researched or discussed. The purpose of this study was to review the methods for identifying and treating radial-sided TFCC lesions, by examining the anatomy of the TFCC, the pathology of its radial portion, diagnostic techniques, and both surgical and nonoperative treatments. The avascular nature of the radial TFCC may influence its healing potential. Magnetic resonance arthrogram is the gold standard for non-invasively diagnosing a radial-sided tear. Non-operative management should be exhausted prior to surgical intervention, which commonly involves an inside-out repair involving radial trans-osseous sutures. Still, the literature is limited by patient sample size and therefore requires a greater population of class 1-D tears to confirm optimal diagnostic and treatment methods.

An All-arthroscopic Technique of Repair of Substance Tears of the Triangular Fibrocartilage Complex in Symptomatic Patients

Substance tears of the triangular fibrocartilage complex (TFCC) can occur secondary to trauma of the wrist. On the dorsal periphery, they are considered Palmer 1B tears or Atzei class 1 tears. If along the radial side, they can manifest as a tear of the central disc, classified as a Palmar class 1A tear. If it involves the ligaments, it is stated as a pre-1D tear as per the new classification system by Luchetti and colleagues. Multiple excellent repair techniques exist in the current literature for dorsal peripheral tears and even for those in the substance of the TFCC, whereas there are successful evolving techniques of repair of avulsed tears and those involving the substance of the ligaments on the radial side adjacent to the sigmoid notch. Here, we describe our technique of repairing substance tears of the TFCC arthroscopically without the need for any specialized equipment apart from the basic arthroscopy set. The technique was conducted in a patient with a transverse substance tear on the radial side of the triangular fibrocartilage involving the central disc with complete resolution of symptoms. It is a simple technique, which can be used to repair class 1B peripheral tears and pre-1D tears in the substance of the TFCC.

Wrist and Distal Radioulnar Joint Arthroplasty: Maximizing Results in Difficult Conditions

Traditional management of wrist arthritis consists of proximal row carpectomy, partial carpal fusions, or, in the event of pancarpal arthritis, total wrist fusion. Although proximal row carpectomy and partial wrist fusions preserve some motion at the wrist while relieving pain symptoms, the quality of results obtained from these procedures is not predictable or optimal in many instances. Management of hip, knee, ankle, and shoulder joints has evolved from arthrodesis to arthroplasty. The wrist joint is following the same pattern of evolution with the advent of reliable designs.

Advances in wrist arthroscopic surgery in Indonesia

Since the 1990s, new insights in wrist arthroscopy have led to the introduction of numerous treatment methods. Consequently, therapeutic procedures are no longer limited to resection as more specialized repair and functional reconstruction methods, involving tissue replacement and essential structural augmentation, have been shown to be beneficial. This article discusses the most prevalent reasons and uses for wrist arthroscopy, with an emphasis on Indonesia’s most recent and major advances in reconstructive arthroscopic surgery. Joint debridement, synovectomy, ganglionectomy, capsular release, and osteotomies are frequent resection operations. Ligament repair and arthroscopy-aided reduction and fixation for fractures and nonunion are all examples of reconstructive surgery.

The distal radio ulnar joint: a journey of discovery and invention of the Aptis prosthesis

This article describes the journey the authors took in discovering a new distal radioulnar joint prosthesis. The beginning deals with the problems we can potentially create for patients when we blindly follow the literature without any critical thinking. By challenging the established thinking on the function of the forearm, a new way of looking at the distal radioulnar joint emerged. Through trial, error and a moment of desperation, a new solution was found that allow us to relive pain and improve function for our patients with distal radioulnar joint pathologies.

Lesiones traumáticas crónicas del complejo fibrocartílago triangular: ¿Cómo enfrentarlas?

Las lesiones crónicas del complejo fibrocartílago triangular (CFCT) son una entidad que no ha sido descrita previamente como tal y no existe consenso en su manejo. La temporalidad de la lesión y su potencial de reparación son aspectos fundamentales a la hora de indicar un tratamiento. Proponemos un esquema de enfrentamiento a lesiones traumáticas crónicas del CFCT y describimos una técnica novedosa de reconstrucción con injerto de brachioradialis con asistencia artroscópica. Mostramos los resultados y el seguimiento de dos pacientes intervenidos con esta técnica.

Chronic Posttraumatic Instability of the Distal Radioulnar Joint: Foveal Reattachment of the Triangular Fibrocartilage Complex With Dorsal Capsuloplasty and Extensor Retinaculum Imbrications

Background: The purpose of this article is to describe the surgical technique used by the authors and the outcome in the treatment of chronic posttraumatic instability of the distal radioulnar joint (DRUJ). Methods: A retrospective study was conducted analyzing the medical records of 11 patients with chronic posttraumatic instability of the DRUJ, treated by a foveal reattachment of the triangular fibrocartilage complex with dorsal capsular and extensor retinaculum imbrications between 2016 and 2017, with a follow-up evaluation of 1 year. Results: All patients reported pain relief and the absence of instability, returning to normal activities in 3 to 6 months. Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire ranged from 2 to 25, resulting in a mean score of 9.5. Forearm rotation averaged 89° of pronation and 85° of supination. Conclusion: Foveal reattachment of the triangular fibrocartilage complex with dorsal capsular and extensor retinaculum imbrications is an effective surgical procedure for the treatment of DRUJ chronic posttraumatic instability.

Advanced Imaging of Ulnar Wrist Pain

Ulnar-sided wrist pain can be a diagnostic challenge for clinicians and radiologists. The ulnar wrist has complex morphology and is composed of many small bone and soft tissue structures. Within these structures, a wide variety of pathologic conditions can occur. To successfully diagnose and treat these pathologic conditions, clinicians and radiologists must have a strong understanding of the advanced imaging techniques available to them. In this review, the authors present a brief review of the normal ulnar wrist anatomy, discuss the differential diagnosis of ulnar-sided wrist pain, and examine the indications for different advanced imaging modalities.

Triangular Fibrocartilage Complex Repair/Reconstruction

The triangular fibrocartilage complex (TFCC) is an intricate structure that plays an important role in providing distal radioulnar joint stability and load transmission at the ulnar wrist. Understanding this structure is critical for creating treatment plans based on patient history, physical examination, and imaging. Arthroscopic, arthroscopic-assisted, and open surgical treatment options exist for tears meeting distinct surgical criteria that are discussed in this article. Although long-term comparative outcomes studies are limited, long-term retrospective outcome studies of TFCC repair and reconstructive techniques demonstrate improvement in pain, stability, range of motion, and disability.

Triangular Fibrocartilage Complex Injuries in Children and Adolescents

Triangular fibrocartilage complex (TFCC) tears can cause ulnar-sided wrist pain in children and adolescents following acute rotational injury or prior distal radius fracture. Surgical treatment, guided by the Palmer classification, is considered after activity modification and occupational therapy. All concomitant wrist pathologies, such as distal radioulnar joint instability, ulnocarpal impaction, and distal radius malunion, must be recognized and addressed at the time of TFCC debridement or repair. This article reviews recent literature guiding clinical evaluation and surgical treatment of children and adolescents with TFCC injuries. The authors' techniques for arthroscopic-assisted outside-in repair of Palmer 1B and 1D tears are described.

Open and Arthroscopic Triangular Fibrocartilage Complex (TFCC) Repair

Triangular fibrocartilage complex (TFCC) tears, whether acute or chronic, can result in persistent ulnar-sided wrist pain. Although diagnosis and nonsurgical management of TFCC tears is well described, there remains ongoing discussion about the optimal surgical technique, specifically open or arthroscopic. This article reviews the most up-to-date literature regarding TFCC injury including demographics, risk factors for TFCC injury, classification of acute and chronic TFCC tears, history and physical examination, appropriate diagnostic imaging, surgical indications, pertinent surgical anatomy, open and arthroscopic TFCC repair, fixation biomechanics and techniques, postoperative rehabilitation, and clinical outcomes.

Arthroscopic Capsular Repair for Triangular Fibrocartilage Complex Tears

Background  The triangular fibrocartilage complex (TFCC) lesions are frequently implicated as a cause of ulnar wrist pain following impact and loading injuries. The objective of this study was to describe the clinical outcomes following TFCC lesion repair with the arthroscopic outside-in technique. Description of Technique  We inserted a 21-gauge needle with 4-0 nylon loop perpendicular to the injured triangular fibrocartilage (TFC). We held two 4-0 nylon loops with mosquito forceps, drew them once out of the joint through a 4 to 5 portal, and put both sides through each loop. After that, we pulled out the 21-gauge needles and performed outside-in sutures after making a small incision and tying directly over the capsule. Patients and Methods  Twenty-one wrists who underwent arthroscopic capsular repair were included. Arthroscopic findings were evaluated, and we used a distal radioulnar joint (DRUJ) evaluation system to monitor relief of pain, forearm rotation range of motion, and DRUJ stability postoperatively. Results  Simple ulnar avulsion (Palmer 1B, Atzei Class 1) was recognized in ten wrists. A combination of the 1B tear with a horizontal TFC tear was noted in five wrists; and ulnar avulsion extending to the dorsal half of the TFC was identified in six wrists, including complete dorsal avulsion of the TFC from the capsule. There are significantly better results in the cases whose preoperative periods were 15 months or less. Conclusion  The outside-in TFC repair technique produced excellent clinical results for peripheral detachment of the TFC in cases without severe DRUJ instability and with a preoperative period less than 15 months.

Magnetic Resonance Imaging of the Triangular Fibrocartilage Complex

The imaging evaluation and interpretation of the triangular fibrocartilage complex (TFCC) is both challenging and rewarding for the radiologist and surgeon alike. The TFCC comprises a complicated group of fibrocartilaginous and ligamentous structures at the ulnar aspect of the wrist that plays an important role in wrist biomechanics. It is the main stabilizer of the distal radioulnar and ulnocarpal joints and functions to distribute compressive forces at the ulnocarpal joint during axial loading. Derangement of the TFCC is the most common source of ulnar-sided wrist pain. Imaging plays an important role in the diagnosis and management of these lesions. The TFCC can anatomically be divided into proximal and distal parts to emphasize the role that the proximal TFCC has in stabilizing the distal radioulnar joint. Tears can be divided into traumatic and degenerative categories using the Palmer classification. Further subclassification based on the location for traumatic tears and the degree of derangement in degenerative tears guides clinical management. The vascular anatomy is important in determining management options for various lesions. A detailed understanding of the normal anatomy of the TFCC, imaging limitations and pitfalls, the Palmer classification system, and current treatment options is critical to the accurate and clinically useful interpretation of radiologic examinations of the TFCC.

Arthroscopic Suture Repair With Additional Pronator Quadratus Advancement for the Treatment of Acute Triangular Fibrocartilage Complex Tear With Distal Radioulnar Joint Instability

Treatment of acute triangular fibrocartilage complex (TFCC) tear using arthroscopic suture repair has been used as a general treatment method, but it is difficult to obtain perfect results in all cases. We evaluated clinical and radiologic outcomes of the acute TFCC tear with distal radioulnar joint instability using the arthroscopic suture repair with pronator quadratus (PQ) advancement. Altogether, 80 patients (48 male, 32 female; mean ± SD age, 37.3 ± 11.5 years; mean ± SD follow-up, 23.7 ± 11.4 months) were enrolled in the study. Follow-up was at least 12 months (range, 12-38 months). Patients were divided into group 1 with arthroscopic suture repair alone (34 patients; 17 male, 17 female; mean ± SD age, 35.2 ± 10.8 years; mean ± SD follow-up, 28.1 ± 15.1 months) and group 2 with additional PQ advancement (46 patients; 29 male, 17 female; mean ± SD age, 38.9 ± 11.9 years; mean ± SD follow-up, 18.4 ± 6.2 months), and clinical and radiological assessment was performed. We also compared the ulnar translation of the injured wrist with that of the uninjured wrist using the Push Pull gauge.There was no difference in the range of motion and the grip strength between the 2 groups. However, the disabilities of the arm, shoulder, and hand score (P = 0.042) at 6-month follow-up and disabilities of the arm, shoulder, and hand score (P = 0.015) and patient-rated wrist evaluation score (P = 0.012) at 12-month follow-up were improved in group 2, and patients' satisfaction (P = 0.032) was also higher in group 2. The ulnar translation rate was also improved in group 2 at 6-month follow-up (P = 0.015) and 12-month follow-up (P = 0.045).Arthroscopic suture repair with PQ advancement provided more clinical improvement and proper stability; therefore, it will be an acceptable effective treatment option for acute TFCC tear with distal radioulnar joint instability.

A Systematic Review and Analysis of Palmer Type I Triangular Fibrocartilage Complex Injuries: Outcomes of Treatment

Triangular fibrocartilage complex (TFCC) injuries can present incidentally as an asymptomatic lesion or can cause acute and chronic pain. This study compared different treatment approaches for symptomatic Palmer Type 1 TFCC injuries and rates of improvement using a systematic review of the literature. Two hundred thirty-one articles were identified, 43 met criteria and were included. Two of these articles indicated conservative therapy may be adequate. Patients who underwent debridement for any Type 1 Palmer class returned to work at a rate of 92% ( n = 182), but only 44% ( n = 38) were free of pain. For 1B lesions that underwent repair, 68.3% ( n = 226) were able to return to work and 41% ( n = 52) had persistent pain. 1D lesions were treated with both repair and debridement with similar results. Data for Types 1A and 1C were limited as no authors solely addressed these lesions. For 1A lesions, those treated with traditional treatment of debridement still had high rates of being unable to return to work. The literature remains insufficient, making comparison between studies and techniques difficult. For asymptomatic injuries, there is no need for treatment. For patients with recalcitrant symptoms, surgery improves pain, grip strength, and increases return to work and activity. The level of evidence is IV.

Designing a 20 mm incision to protect the dorsal branch of the ulnar nerve during arthroscopic repair of triangular fibrocartilage complex injuries: Cadaver study and preliminary clinical results

The ulnar-sided approach for arthroscopic peripheral triangular fibrocartilage complex (TFCC) repair may be associated with injury to the dorsal branch of the ulnar nerve (DBUN). The goal of this study was to develop a small incision to help minimize DBUN injury. Ten cadaveric upper limbs were used to measure the anatomic parameters of the DBUN. Based on these measured anatomical relationships, a 20 mm longitudinal incision with the ulnar styloid process as the midpoint was designed to explore and protect the DBUN. Three additional cadaveric upper limbs were used to test the feasibility of this method. Then this method was applied in 15 patients with TFCC injury (IB type). In 10 cadavers, the DBUN was located volar to the ulnar styloid process. The mean linear distance between the DBUN and the ulnar styloid process was 8.04 mm (range: 7.02-8.82mm) in the transverse-volar direction and 13.78 mm (range: 11.06-16.02mm) in the longitudinal-distal volar direction. In three additional cadavers, the DBUN was successfully explored and retracted with this incision, creating a safer space for passing sutures and tying knots. This modified method was used successfully in 15 patients, and the DBUN was protected during surgery. There were no complications, and most importantly, no injuries to the DBUN at the 6-month follow-up visit. Therefore, we recommend that a 20 mm longitudinal incision with the ulnar styloid process as the midpoint be made prior to passing sutures during the arthroscopic repair of TFCC tears to avoid injuring the various branches of the DBUN.

Functional and Surgical Anatomy of the Upper Limb: What the Radiologist Needs to Know

The anatomy of the upper limb is complex and allows for exceptional functionality. The movements of the joints of the shoulder, elbow, and wrist represent a complex dynamic interaction of muscles, ligaments, and bony articulations. A solid understanding and of the characteristics and reciprocal actions of the anatomic elements of the joints of the upper limb helps explain the mechanisms and patterns of injury. This article focuses on the anatomy and functionality of the shoulder, elbow, and wrist, with emphasis on the stabilizing mechanisms, to set the foundation for understanding the occurrence of pathologic conditions.

MR arthrography versus conventional MRI and diagnostic arthroscope in patients with chronic wrist pain

Objective

To assess the diagnostic accuracy of direct wrist MR arthrography (MRA) compared to conventional MRI in diagnosis of different pathologic entities causing chronic wrist pain.

Materials and methods

37 consecutive patients 22 males and 15 females, with age range from 16 to 49 years "mean age 28 years" complaining of unexplained chronic wrist pain were prospectively examined by using MRI and MRA with arthroscopic correlation in 25 of them. Findings were divided into 5 main groups of lesions including triangular fibrocartilage complex (TFCC) lesions, ligamentous injuries, osseous lesions, tendon pathology and ganglion.

Results

MRA picked up more ligamentous injuries and triangular fibrocartilage complex (TFCC) lesions that couldn`t be detected on MRI study while both were equal in detection of other types of lesions. TFCC lesions were the most common pathologic findings in both MRI and MRA. Arthroscopic correlation in 25 suspected TFCC lesions (clinically, radiologically or both) revealed that the sensitivity / specificity / accuracy of MRI and MRA were 87.5% / 100% / 96% and 100% / 100% / 100% respectively for central lesions while were 71.4% / 81.3% / 76% and 100% / 90.9% / 96% respectively For peripheral lesions. Extra-capsular lesions, like tenosynovitis and fracture hook of hamate couldn`t be confirmed arthroscopically.

Conclusion

MRA can replace both MRI and diagnostic arthroscopy in detecting causes of chronic wrist pain.

Anatomy and injuries of the pediatric wrist: beyond the basics

Ligamentous injuries of the pediatric wrist, once thought to be relatively uncommon, are increasingly recognized in the context of acute high-energy mechanism trauma and chronic axial loading, including those encountered in both recreational and high-performance competitive sports. Recent advances in MR-based techniques for imaging the pediatric wrist allow for sensitive identification of these often radiographically occult injuries. Detailed knowledge of the intrinsic and supportive extrinsic ligamentous complexes, as well as normal developmental anatomy and congenital variation, are essential to accurately diagnose injuries to these structures. Early identification of ligamentous injury of the pediatric wrist is essential within the conservative treatment culture of modern pediatric orthopedics because treatment of these lesions often necessitates surgery, and outcomes often depend on early and sometimes aggressive intervention. In this article, we review MR arthrogram technique and pediatric wrist anatomy, and correlate appearances on MR and selected ligamentous pathologies of the pediatric wrist.

Arthroscopic Assisted Resection of Triangular Fibrocartilage Complex Lesions: A 19-Year Follow-up

BACKGROUND

This study assesses long-term functional and subjective outcomes following arthroscopic assisted resection of lesions of the triangular fibrocartilage complex (TFCC).

METHODS

Functional and subjective outcomes were assessed based on review of patient charts for patient demographic characteristics, comprehensive clinical evaluation, obtained radiographs, and patient-reported questionnaires.

RESULTS

Fifteen patients, of whom 9 were female, and 10 dominant wrists, were included in this study. Median age was 60 (range, 37-73) years, and median duration of follow-up was 19 (range, 18-21) years. Median Mayo Wrist Score was 85 (range, 45-100). Four patients scored excellent, 7 good, 3 fair, and 1 poor result according to the Modified Mayo Wrist Score. Median Quick Disabilities of the Arm, Shoulder and Arm was 20 (range, 0-45) and Patient-Rated Wrist and Hand Evaluation was 8 (range, 0-61). Patients reported high rate for satisfaction and low rate for pain. All patients presented intact stability of the distal radioulnar joint.

CONCLUSIONS

This study demonstrates persisting satisfactory subjective and functional outcomes for patients following arthroscopic assisted resection for lesions of the TFCC at 19 years of follow-up. Arthroscopically assisted resection of selected TFCC lesions seems to be both a safe and efficient procedure.

MRI findings in bucket-handle tears of the triangular fibrocartilage complex

The triangular fibrocartilage complex (TFCC) is an intricate ligamentous and cartilaginous structure that helps transmit axial load across the wrist, and provide stability to the ulnocarpal and distal radioulnar joints (DRUJ). Because the blood supply to the TFCC varies depending on location, certain types of tears are more amenable to surgical repair than others. Since Palmer proposed his classification system of TFCC tears in 1989, only 1 case of a "bucket-handle" type tear has been reported. In this article, we describe two new cases of bucket-handle tears of the TFCC. In both cases, the torn fragment was displaced into a previously undescribed location (intra-articular DRUJ and prestyloid recess). Because this type of injury pattern has not been previously well characterized in the literature and such cases rarely reported, MRI findings have not been fully described and its implications on clinical management have largely yet to be determined.

The status of triangular fibrocartilage complex after the union of distal radius fractures with internal plate fixation

PURPOSE

Distal radius fractures are associated with a high incidence of triangular fibrocartilage complex (TFCC) tears. This study aims to evaluate the status of TFCC after the healing of distal radius fractures, and its clinical significance.

METHODS

Wrist arthroscopies were performed on 43 distal radius fractures, with an average age of 54 years old.

RESULTS

Twenty-six complete tears and 15 partial healed tears were noted. Five out of eight patients with intact TFCC tears had neither signs nor symptoms, while eight patients with TFCC tears had no complaint. While no association was found between ulnar wrist pain and TFCC tears, there was association between DRUJ instability and TFCC tears and fovea tears. The function outcome did not differ with respect to the integrity of TFCC.

CONCLUSIONS

A large majority of TFCC tears remained unhealed after the union of distal radius fractures. However, not all patients with tear were symptomatic.

Neuromuscular adaptations in shoulder function and dysfunction

Neuromuscular activity, organized in coordinated patterns, forms the basis of task-specific function in sports and exercise. The content and extent of these patterns may be variable, but include elements of activation/inhibition, co-activation, concentric/eccentric activation, proximal-to-distal activation, plyometric activation, and preactivation stiffness. They may be based on inherent neuromuscular architecture, but are commonly affected by positive or negative adaptations to imposed functional demands. Positive neuromuscular adaptations improve the efficiency of performing the task, which can result in less energy expenditure, maximum force delivered to the task, and protection of involved joints from excessive loads/motions, and improve the effectiveness of task performance. They frequently result from specific training in task mechanics and optimal conditioning of the neuromuscular structures involved in the task. Negative neuromuscular maladaptations can affect the efficiency of performing the task, increase energy expenditure and loads, decrease the effectiveness of task performance, and can be associated with clinical presentation of injury symptoms. They can result from overload, injury, and/or limited recovery. This chapter will focus specifically on shoulder joint function to provide examples of positive adaptations and negative maladaptations. It will then provide guidelines for clinical evaluation, treatment of clinical injury, and training/conditioning, based on understanding the neuromuscular activation.

Arthroscopic Management of Triangular Fibrocartilage Complex Peripheral Injury

Patients suffering from ulnar-sided wrist pain after trauma may develop tenderness, clicking, a positive fovea sign, or instability of the distal radioulnar joint. If the pain is persistent, conservative treatment does not help, and the patient agrees to surgery, arthroscopy may reveal a triangular fibrocartilage complex (TFCC) injury with capsular detachment, foveal avulsion, or a combination thereof. Capsular reattachment is possible using an arthroscopic assisted technique. The reattachment can be performed with an inside-out, outside-in, or all-inside technique, providing good to excellent results, which tend to persist over time, in 60% to 90% of cases.

Arthroscopic-Assisted Triangular Fibrocartilage Complex Reconstruction

Injury of the triangular fibrocartilage complex (TFCC) is a common cause of ulnar-sided wrist pain. Volar and dorsal radioulnar ligaments and their foveal insertion are the most important stabilizing components of the TFCC. In irreparable tears, anatomic reconstruction of the TFCC aims to restore normal biomechanics and stability of the distal radioulnar joint. We proposed a novel arthroscopic-assisted technique using a palmaris longus tendon graft. Arthroscopic-assisted TFCC reconstruction is a safe and effective approach with outcomes comparable to conventional open reconstruction and may result in a better range of motion from minimizing soft tissue dissection and subsequent scarring.

Chronologic and Geographic Trends of Triangular Fibrocartilage Complex Repair

This article shows trends in triangular fibrocartilage complex (TFCC) repair since 1990 by geographic area and year. The repair methods presented in the literature were inside-out, outside-in, all-inside, and open repair. The outside-in technique was reported most often for ulnar-side tears, whereas the inside-out technique was reported most frequently for radial-side tears. Recently, a foveal reattachment technique for ulnar-side tears has garnered attention and has been reported with increasing frequency, especially in Asia, because the deepest portion of TFCC, attached to fovea, plays a key role in stabilizing the distal radioulnar joint. Understanding these trends can help clinicians best treat TFCC tears.

MR imaging of the traumatic triangular fibrocartilaginous complex tear

Triangular fibrocartilage complex is a major stabilizer of the distal radioulnar joint (DRUJ). However, triangular fibrocartilage complex (TFCC) tear is difficult to be diagnosed on MRI for its intrinsic small and thin structure with complex anatomy. The purpose of this article is to review the anatomy of TFCC, state of art MRI imaging technique, normal appearance and features of tear on MRI according to the Palmar's classification. Atypical tear and limitations of MRI in diagnosis of TFCC tear are also discussed.

The ulnar side of the wrist: Clinically relevant anatomy and biomechanics

BACKGROUND

In the hectic environment of a hand therapy clinic, the opportunity to carefully consider the relationships among pathology, pathomechanics, surgical repair techniques, tissue healing, postoperative management, and rehabilitation program development and progression is limited. Clinicians often default to seeking a protocol, a recipe to follow.

OBJECTIVES

Using the ulnar side of the wrist as an example, relevant anatomy and biomechanics are directly related to several commonly seen pathologies, including fractures, ligament injuries, and instability.

CONCLUSION

Armed with knowledge of anatomy, biomechanics, and surgical procedures, the need for a protocol disappears. Each patient can be individually managed according to his or her unique set of variables and responses to injury, repair, healing, and recovery of function.

Suture Anchor Repair of Ulnar-Sided Triangular Fibrocartilage Complex Tears

Traditional open repair of traumatic triangular fibrocartilage complex (TFCC) tears requires a relatively extensive exposure, and arthroscopic repair, though conceptually simple, can be technically demanding. We describe a mini-open suture anchor technique that, while minimally invasive, is easier to perform than previously described open or arthroscopic techniques. Results achieved using this technique in eight cases compare favourably with those reported for other techniques.

A long-term (20 years') follow-up after arthroscopically assisted repair of the TFCC

OBJECTIVE

The present study aimed to assess long-term functional outcome for patients after arthroscopic assisted suture for peripheral tears of the triangular fibrocartilage complex (TFCC).

METHODS

Eleven patients, 26 (15-59) years old at time of surgery, 48 (35-78) years old at time of follow-up, were available for this 20-year follow-up. Subjective and objective outcomes, such as range of motion, grip strength, patients' satisfaction, pain, and Mayo Modified Wrist Score, were assessed, as well as asking the question if the patients would have had the surgery done again, knowing the outcome, based on a clinical examination and patient reported questionnaires.

RESULTS

Median Mayo Wrist score was 85 (30-100) and, according to the Modified Mayo Wrist Score, seven patients presented good or excellent results. The patients reported median low 25 (0-66) on pain and median high 90 (1-100) on satisfaction. Ten patients presented with intact stability of the distal radioulnar joint at follow-up. Compared to the level of pain prior to surgery, two patients reported to be free of pain, five patients experienced major pain relief, two patients reported minor pain relief, while two patients reported no difference.

CONCLUSIONS

The findings of the present study support the trend of persisting good results for the majority of patients having undergone arthroscopically assisted repair with an outside-in suture technique for peripheral tears of the TFCC.

Ulnar Shortening Osteotomy: Are Complications Under Reported?

Ulnar shortening osteotomy is an accepted treatment for ulnar impaction syndrome and numerous techniques for have been described in the literature. We present our single surgeon case series over 10 years of oblique ulnar shortening osteotomy using a jig technique. A review of the current literature with reference to the risk of complications is included. All patients undergoing ulnar shortening osteotomy from 2001 to 2011 were identified and case-notes were reviewed retrospectively. Risks of complications included metalwork irritation (51 %), non-union (6.3 %), refracture (1.6 %) and chronic regional pain syndrome (1.6 %). Oblique ulnar osteotomy using a jig technique is reliable and reproducible in shortening the ulna and maintaining alignment, rotation and compression at the osteotomy site. Symptoms improved in the majority of patients. However, the morbidity associated with the procedure may be underestimated as highlighted by our complication rates. Surgeons should counsel patients appropriately when offering ulnar shortening osteotomy.

Update TFCC: histology and pathology, classification, examination and diagnostics

The TFCC is a crucial stabilizer of the DRUJ. Based on its superficial and deep fibers, the TFCC guarantees unrestricted pronation and supination which is essential for performing sophisticated tasks. The ability to perform complex movements is of uppermost importance for hand function. Therefore, a functional intact TFCC is a prerequisite in this context. The articular disc of the TFCC is a fibrocartilaginous extension of the superficial zone of hyaline articular cartilage which arises from the radius. The peripheral 10-40 % of the TFC is vascularized. Degeneration of the articular disc is common with increasing age. Even though the central part of the articular disc is avascular, potential regeneration of lesions could be detected. The Palmer and Atzei classifications of TFCC lesions are complementary. TFCC innervation is based on different nerves. There is a high variability. A diligent clinical examination facilitates specific tests which help to allocate symptoms to the pathology. Therefore, a thorough clinical examination is not dispensable. Wrist arthroscopy remains the "gold standard" for diagnosing TFCC pathologies despite technical progress in imaging modalities. MR arthrography may have the potential to become a real alternative to wrist arthroscopy for diagnosing TFCC pathologies with technical progress in the future.

Arthroscopic knotless anchor repair of triangular fibrocartilage in distal radius fracture

INTRODUCTION AND OBJECTIVE

Lesions of triangular fibrocartilage (TFC) are associated with distal radioulnar joint instability. Arthroscopic treatment of these lesions improves functional outcome of affected patients. The aim of the present work is to evaluate functional and occupational outcome of TCF repair using an arthroscopic knotless anchor device in patients with associated distal radius fracture.

MATERIAL AND METHODS

An observational, descriptive study was carried out between November 2011 and January 2014 including 21 patients with distal radius fracture and Palmer 1B lesions of TCF (Atzei class 2 and 3) that were treated by arthroscopic knotless anchor (PopLok® 2,8mm, ConMed, USA). Mean follow-up was 18 months. Functional (Mayo Wrist Score) and occupational outcome results were analyzed. Mean age of the group was 43.0±8.8 years, with 19% of the patients being female. There was an associated scapholunate lesion in 5 cases.

RESULTS

Functional results reached a mean of 83.4±16.1 points onMayo Wrist Score. Mean sick-leave time was 153.16±48.5 days. Complete occupational reintegration was reached in 89.5% of cases. There were no postoperative complications.

CONCLUSIONS

Arthroscopic knotless anchor repair of 1B TFC tears is a minimally invasive method of treatment that improves tension of fixation, avoiding subsequent loosen, in our experience, with few complications and good functional and occupational results.

Comparison of conventional MRI and MR arthrography in the evaluation wrist ligament tears: A preliminary experience

Aims:

To compare conventional magnetic resonance imaging (MRI) and direct magnetic resonance (MR) arthrography in the evaluation of triangular fibrocartilage complex (TFCC) and intrinsic wrist ligament tears.

Materials and Methods:

T1-weighted, fat suppressed (FS) proton density plus T2-weighted (FS PD/T2), 3D multiple-echo data image combination (MEDIC) sequences and direct MR arthrography were performed in 53 patients with wrist pain. Images were evaluated for the presence and location of TFCC, scapholunate ligament (SLL) and lunatotriquetral ligament (LTL) tears, and imaging findings were compared with operative findings in 16 patients who underwent arthroscopy or open surgery (gold standard).

Results:

Sixteen patients underwent arthroscopy/open surgery: 12 TFCC tears were detected arthroscopically out of which 9 were detected on FS PD/T2 sequence, 10 on MEDIC sequence, and all 12 were detected on MR arthrography. The sensitivities of FS PD/T2, MEDIC sequences, and MR arthrography in the detection of TFCC tears were 75%, 83.3%, and 100%, respectively. Out of the eight arthroscopically confirmed SLL tears, three tears were detected on FS PD/T2 sequence, five on MEDIC sequence, and all eight were visualized on MR arthrography. The sensitivities of FS PD/T2, MEDIC sequences, and MR arthrography in detecting SLL tears were 37.5%, 62.5%, and 100%, respectively. One arthroscopically confirmed LTL tear was diagnosed on FS PD/T2 sequence, three on MEDIC sequence, and all five arthroscopically confirmed LTL tears were detected with MR arthrography. The sensitivities of PD, MEDIC sequences, and MR arthrography in detecting LTL tears were 20%, 40%, and 100%, respectively.

Conclusions:

MR arthrography is the most sensitive and specific imaging modality for the evaluation of wrist ligament tears.

Minimally invasive approaches to ulnar-sided wrist disorders

Ulnar-sided wrist pain is a common cause of pain and disability, which has long been a diagnostic and therapeutic dilemma for hand surgeons. A thorough understanding of the anatomy, clinical examination, and radiographic evaluation is essential to establish a focused differential diagnosis, with the cause of disability often being multifactorial. Arthroscopy is particularly well suited to both directly visualize and treat multiple causes of ulnar-sided wrist pain, including pathology of the TFCC, UIS, LTIL tears, and hamate arthrosis.

Arthroscopic repair of triangular fibrocartilage tears: a biomechanical comparison of a knotless suture anchor and the traditional outside-in repairs

PURPOSE

To compare the biomechanical strength of a knotless suture anchor repair and the traditional outside-in repair of peripheral triangular fibrocartilage complex (TFCC) tears in a cadaveric model.

METHODS

We dissected the distal ulna and TFCC from 6 matched cadaveric wrist pairs and made iatrogenic complete peripheral TFCC tears in each wrist. In 6 wrists, the TFCC tears were repaired using the standard outside-in technique using 2 2-0 polydioxane sutures placed in a vertical mattress fashion. In the other 6 wrists, we repaired the TFCC tears using mini-pushlock suture anchors to the fovea. The strength of the repairs was then determined using a materials testing machine with the load placed across the repair site. We loaded the repairs until a gap of 2 mm formed across the repair site, and then subsequently loaded them to failure. Thus, for each repair we obtained the load at 2-mm gap formation, load to failure, and mode of failure.

RESULTS

At the 2-mm gap formation, the suture anchor repairs were statistically stronger than the outside-in repairs. For load to failure, the suture anchor repairs were also statistically stronger than the outside-in repairs. Failure in both techniques occurred most commonly as suture pull-out from the soft tissues.

CONCLUSIONS

The all-arthroscopic suture anchor TFCC repair was biomechanically stronger than an outside-in repair.

CLINICAL RELEVANCE

The suture anchor technique allows for repair of both the superficial and deep layers of the articular disk directly to bone, restoring the native TFCC anatomy. By being knotless, the suture anchor repair avoids irritation to the surrounding soft tissues by suture knots.

Arthroscopic direct repair for radial tear of the triangular fibrocartilage complex

Although various repair techniques for Palmer type 1B lesions of the triangular fibrocartilage complex (TFCC) have been introduced, arthroscopic repair techniques for Palmer type 1D lesions are still being honed. Until recently, inside-out techniques have commonly been used to repair radial tears of the TFCC. However, that technique has the disadvantages of a requirement for an extra skin incision, pain resulting from prominent subcutaneous suture knot stacks, and peripheral nerve injury. We describe an all-arthroscopic direct-repair technique using a suture hook with 2-0 polydioxanone that is relatively simple and safe and is thus a useful alternative for radial tears of the TFCC.

Various patterns of traumatic triangular fibrocartilage complex tear

We demonstrate various patterns of traumatic triangular fibrocartilage complex (TFCC) tears including some atypical that cannot be categorized under Palmer's classification. TFCC traumatic tears in 173 wrists were examined arthroscopically or macroscopically and divided into disk tears (subdivided into four types: slit tear, flap tear, horizontal tear and tear within the distal radioulnar joint) and peripheral tears (subdivided into six types: ulnocarpal ligament tear, dorsal tear, radial tear, ulnar styloid tear, foveal tear and distal radioulnar ligament tear). Combinations of these types were found in 32 wrists. Wrist arthroscopy revealed various traumatic TFCC tears that do not come under Palmer's classification; therefore establishment of a new classification for traumatic TFCC tears seems to be warranted.

The aging athlete: part 2, "boomeritis" of the upper extremity

OBJECTIVE

The purpose of this review is to describe the upper extremity injuries that frequently accompany aging, the typical clinical presentations, and the differential diagnoses with an emphasis on the injury most likely encountered with each presentation.

CONCLUSION

Expectation of continued participation in exercise and sports activities by the baby boomer population has presented new challenges to the medical field. The concepts behind factors that predispose older athletes to certain pathologic conditions that affect the muscles, tendons, and bones of the upper extremity must be understood.

Another light in the dark: review of a new method for the arthroscopic repair of triangular fibrocartilage complex

The triangular fibrocartilage complex (TFCC) is an anatomically and biomechanically important structure. Repair of radial-sided TFCC tear has previously been challenging. We designed a new method of radial-sided TFCC tear repair and found that it was also applicable for ulnar-sided TFCC tear repair. From October 2006 to December 2010, 10 patients underwent this operation and were reviewed: 9 men and 1 woman, with a mean age of 33.9 years. Average postoperative follow-up was 8 months. We graded results according to the Mayo modified wrist score. We rated 2 of the 10 patients (20%) as "excellent," 3 (30%) as "good," and 5 (50%) as "fair." The 5 patients who were rated as "fair" returned to regular jobs or had restricted employment. Based on this small sample, we recommend that this technique be considered an alternative method for TFCC repair.

Clinical and non-clinical aspects of distal radioulnar joint instability

Untreated distal radioulnar joint (DRUJ) injuries can give rise to long lasting complaints. Although common, diagnosis and treatment of DRUJ injuries remains a challenge. The articulating anatomy of the distal radius and ulna, among others, enables an extensive range of forearm pronosupination movements. Stabilization of this joint is provided by both intrinsic and extrinsic stabilizers and the joint capsule. These structures transmit the load and prevent the DRUJ from luxation during movement. Several clinical tests have been suggested to determine static or dynamic DRUJ stability, but their predictive value is unclear. Radiologic evaluation of DRUJ instability begins with conventional radiographs in anterioposterior and true lateral view. If not conclusive, CT-scan seems to be the best additional modality to evaluate the osseous structures. MRI has proven to be more sensitive and specific for TFCC tears, potentially causing DRUJ instability. DRUJ instability may remain asymptomatic. Symptomatic DRUJ injuries treatment can be conservative or operative. Operative treatment should consist of restoration of osseous and ligamenteous anatomy. If not successful, salvage procedures can be performed to regain stability.

Anatomy and biomechanics of the distal radioulnar joint

The distal radioulnar joint (DRUJ) is a complex articulation allowing significant rotational and translational motion. Stability of the DRUJ depends on bony contact, intrinsic stabilizers of the triangular fibrocartilage complex, and extrinsic stabilizers of the distal forearm. Understanding the anatomy of this articulation is paramount in clinical decision making for the treatment of disorders involving the DRUJ.