Injury to the dorsal sensory branch of the ulnar nerve in the arthroscopic repair of ulnar-sided triangular fibrocartilage tears using an inside-out technique: a cadaver study

A new arthroscopic repair technique for triangular fibrocartilage complex using an intracapsular suture: an outside-in transfer all-inside repair

BACKGROUND

Arthroscopic repair is a promising, minimally invasive surgical technique for patients with Palmer type 1B peripheral triangular fibrocartilage complex (TFCC) tears. Although several arthroscopic techniques are effective for repairing Palmer type 1B TFCC tears, some shortcomings remain. So, we report an arthroscopic repair technique for the treatment of Palmer type 1B Atzei class 1 TFCC tears using an intracapsular suture: an outside-in transfer all-inside repair.

METHODS

A retrospective analysis of 38 Palmer type 1B TFCC injury patients admitted to our hospital were randomly divided into 2 groups. The group A was sutured from the outside to the inside, with a total of 21 cases; the group B was sutured with the new arthroscopic repair technique, with a total of 17 cases. Observe and compare the VAS scores and modified Mayo wrist function scores of all patients before 3, and 6 months after the operation and evaluate the incidence of thread knots in patients with different treatment methods. The methodology was performed an arthroscopic intracapsular suture using an outside-in transfer, all-inside repair technique, which is a modified method of the outside-in and all-inside technique using the needle of a 10-mL sterile syringe, for Palmer type 1B TFCC tears. A No. 2 polydioxanone suture was threaded through the needle and entered the wrist joint. Next, the needle was withdrawn carefully along the suture to the proximal tear ulnar surface of the TFCC and penetrated the TFCC, exiting the articular cavity surface of the ulnar side of the torn TFCC. Finally, arthroscopic knotting was performed.

RESULTS

This new treatment was as effective as the previously arthroscopic techniques and had the advantages of no additional incision and decreased risk of operation-related complications. The incidence of thread knots in the group A (28.57%) was significantly higher than that in the group B (0%), and the difference was statistically significant (P = 0.024). There was no significant difference in VAS score and modified Mayo wrist function scores between the two groups (P > 0.05).

CONCLUSIONS

The outside-in transfer, the all-inside repair technique is suitable for Palmer type 1B Atzei class 1 TFCC tears. We recommend this technique as a useful alternative to the conventional methods of repairing Palmer type 1B TFCC tears.

Arthroscopic Transosseous Repair of Foveal Tears of the Triangular Fibrocartilage Complex: A Systematic Review of Clinical Outcomes

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.

[Anatomical landmarks for peripheral neural blocks of the forearm and the wrist: A cadaveric study]

BACKGROUND

There are no data ensuring a standardized landmark-based-technique for blocking sensitive nerves of the forearm.

PURPOSE

To identify locations were with use of good palpable bony landmarks and lines between them sensitive nerve blocks on the forearm can be done with great success.

MATERIAL AND METHODS

Dissection of the superficial branch of the radial nerve (SBRN), the dorsal branch of the ulnar nerve (DBUN), the lateral, medial and dorsal antebrachial cutaneous nerve (LACN, MACN, and DACN) as well as the palmar branch of the median nerve (PBMN) was performed on five upper limbs of five different Caucasian cadavers. With respect to radius and ulnar styloid, Lister's tubercle, and the medial and lateral epicondyle of the humerus as well as connecting lines between these bony landmarks locations were defined, where the mentioned nerves can be found and blocked.

RESULTS

The six nerves can be safely blocked at the following sites: the SBRN 85 mm proximal to Lister's tubercle on a line drawn between the latter and the medial humeral epicondyle; the LACN 38 mm and the dorsal one 32 mm ulnar from the lateral epicondyle; the MACN 14 mm radial to the medial epicondyle; the DBUN 27 mm proximal to the ulnar styloid in direction to the lateral epicondyle; the PBMN 45 mm proximal to the radial styloid following a line between the latter and the medial epicondyle and 21 mm ulnarwards perpendicular to this line.

CONCLUSION

Using superficial good palpable landmarks at the wrist and elbow as well as connecting lines between them the SBRN, DBUN, PBMN, LACN, MACN, and DACN can easily be located.

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.

Surgical anatomy of the dorsal cutaneous branch of the ulnar nerve and its clinical significance in surgery at the ulnar side of the wrist

The dorsal cutaneous branch of the ulnar nerve can be easily injured during surgery at the ulnar side of the wrist. We sought to identify the surgical anatomy, the pathway around the ulnar styloid process and the safe zone of the dorsal cutaneous branch of the ulnar nerve. In 44 forearm dissections, we found that the dorsal cutaneous branch of the ulnar nerve originated at a median distance of 6.8 cm proximal to the tip of the ulnar styloid. We classified the crossing pattern of the dorsal cutaneous branch of the ulnar nerve at a vertical axis into three types. The most common type featured the dorsal cutaneous branch of the ulnar nerve crossing the vertical axis at a median distance of 10.0 mm distal to the tip of the ulnar styloid. In 14% of specimens, the dorsal cutaneous branch of the ulnar nerve crossed the vertical axis at the level of the tip of the ulnar styloid. By mapping the course of the nerve using a Cartesian coordinate system, it was found that the areas located proximal and palmar to the tip of the ulnar styloid had a very high density of dorsal cutaneous branches of the ulnar nerve. We were unable to establish a safe zone. We recommend identifying the dorsal cutaneous branch of the ulnar nerve in every patient undergoing surgery at the ulnar side of the wrist.

Neurologic complications in common wrist and hand surgical procedures

Nerve dysfunction after upper extremity orthopedic surgery is a recognized complication, and may result from a variety of different causes. Hand and wrist surgery require incisions and retraction that necessarily border on small peripheral nerves, which may be difficult to identify and protect with absolute certainty. This article reviews the rates and ranges of reported nerve dysfunction with respect to common surgical interventions for the distal upper extremity, including wrist arthroplasty, wrist arthrodesis, wrist arthroscopy, distal radius open reduction and internal fixation, carpal tunnel release, and thumb carpometacarpal surgery. A relatively large range of neurologic complications is reported, however many of the studies cited involve relatively small numbers of patients, and only rarely are neurologic complications included as primary outcome measures. Knowledge of these neurologic outcomes should help the surgeon to better counsel patients with regard to perioperative risk, as well as provide insight into workup and management of any adverse neurologic outcomes that may arise.

Complications of Wrist and Hand Arthroscopy

Arthroscopy of the wrist continues to evolve and advance as a valuable clinical technique in hand surgery. This article aims to address safety of wrist arthroscopy and provide an overview of the known iatrogenic complications. Ultimately, the likelihood of associated injuries during wrist arthroscopy is dependent on the surgeon's ability and understanding of the equipment. Case volume and duration of experience directly correlate with mitigating iatrogenic injury and optimizing patient outcomes.

Results of Arthroscopic Repair of Peripheral Triangular Fibrocartilage Complex Tear With Exploration of Dorsal Sensory Branch of Ulnar Nerve

Background:

Ulnar-sided approach in arthroscopic triangular fibrocartilage complex (TFCC) repair may jeopardize treatment success by exposing the dorsal sensory branch of ulnar nerve (DSBUN) in risk of injury. We aim to conduct a follow-up assessment of arthroscopic outside-in TFCC repair and efficacy of sensory nerve exploration.

Methods:

We conducted a retrospective chart review of 58 patients (59 wrists) who received arthroscopic repair of the peripheral attachment of the TFCC. Ulnar-sided skin incision and exploration of DSBUN were performed before arthroscopy setting. Arthroscopic outside-in repair through pullout suture ligation was performed. Functional survey at 6 months and 1 year postoperatively was based on Mayo Modified Wrist Score (MMWS), and compared to the preoperative assessment. A p-value of less than 0.05 was considered significant as calculated using paired t-test.

Results:

Postoperative MMWS averaged 74.32±11.50 at 6 months, and 84.41±9.52 at one year; both showed significant difference as compared to preoperative status. Significant improvement was noted in all 4 individual items except motion retrieval between 6 months and 1 year. Totally, 45 (76%) cases achieved good or excellent results at one year; however, less patients resumed pre-injury activity level when treatment delay was more than 6 months than those treated earlier (41% vs. 57%). Complication included 6 transient paresthesia; 1 anchor migration and 1 distal radioulnar arthrosis. No more nerve complication was found after modification of perineural dissection.

Conclusion:

Arthroscopy is effective in obtaining both correct diagnosis and treatment of peripheral TFCC tear. Modified perineural dissection can minimize sensory nerve complications.

Proximity of the Triangular Fibrocartilage Complex to Key Surrounding Structures and Safety Assessment of an Arthroscopic Repair Technique: A Cadaveric Study

PURPOSE

To quantify the distance of the dorsal ulnar sensory branch, floor of the extensor carpi ulnaris (ECU) subsheath, and ulnar neurovascular bundles from the triangular fibrocartilage complex (TFCC), and secondarily to assess the safety of an all-inside arthroscopic repair of the TFCC with a commonly used meniscal repair device with respect to the aforementioned structures.

METHODS

A custom K-wire with 1-mm gradation was used to determine the distance of at-risk structures from the periphery of the TFCC in 13 above-elbow human cadaver specimens. An all-inside repair of the TFCC at the location of a Palmer 1B tear was then performed using a commonly employed meniscal repair device. The distance from the deployed devices to the structure in closest proximity was then measured using digital calipers.

RESULTS

The mean distance from the deployed device to the nearest structure of concern for iatrogenic injury was 9.4 mm (range, 5-15 mm). The closest structure to iatrogenic injury was usually, but not always, the dorsal ulnar sensory nerve in 9 of 13 wrists (69.2%) at 9.3 mm (range, 5-15 mm); on 3 occasions it was instead the ulnar nerve (23.1%) at 9.5 mm (range, 9-10 mm), and on 1 occasion 6 mm from the flexor digitorum profundus to the little finger (7.7%). Forearm rotation had no significant effect on measured distances (ulnar nerve: P = .98; dorsal sensory: P = .89; ECU: P = .90). The largest influence of forearm rotation was a 0.4-mm difference between pronation and supination with respect to the distance of the TFCC periphery on the ECU subsheath.

CONCLUSIONS

An all-inside arthroscopic TFCC repair using a commonly used meniscal repair device appears safe with respect to nearby neurovascular structures and tendons under typical arthroscopic conditions.

CLINICAL RELEVANCE

An all-inside arthroscopic TFCC repair using a commonly employed meniscal repair device appears safe in terms of proximity to important structures although further clinical investigation is warranted.

Complications of Wrist Arthroscopy: A Multicenter Study Based on 10,107 Arthroscopies

Background Wrist arthroscopy is now a routine procedure, regarded as safe. Complications are reported in the literature as being rare and mostly minor. Purpose The two goals of this study were to evaluate the incidence and nature of complications based on a very large multicenter retrospective study, and to investigate about a potential learning curve. Methods The authors sent a detailed questionnaire to all members of the European Wrist Arthroscopy Society (EWAS), inquiring about the number and types of complications encountered during their practice of wrist arthroscopy, and about their experience with the technique. Results A total of 36 series comprising 10,107 wrist arthroscopies were included in the study. There were 605 complications (5.98% of the cases), of which 5.07% were listed as serious and 0.91% as minor. The most frequent ones were failure to achieve the procedure (1.16%), and nerve lesions (1.17%). Cartilage lesions and complex regional pain syndrome each occurred in 0.50% cases. Other complications (wrist stiffness, loose bodies, hematomas, tendon lacerations) were less frequent. Breaking down of the data according to each surgeon's experience of the technique showed a significant relationship with the rate of complications, the threshold for a lower complication rate being approximately 25 arthroscopies a year and/or greater than 5 years of experience. Conclusion Although the global incidence of complications was in keeping with the literature, the incidence of serious complications was much higher than previously reported. There is a significant learning curve with the technique of wrist arthroscopy, both in terms of volume and experience.

The Anatomical Relationship Between the Dorsal Cutaneous Branch of the Ulnar Nerve and the Ulnar Styloid Process with Variations in Forearm Position

BACKGROUND

There are significant variations in the anatomy of the dorsal cutaneous branch of the ulnar nerve (DCBUN). The DCBUN is at risk for iatrogenic injury during surgeries around the ulnar side of the wrist. The purpose of this study was to demonstrate the relationship between the ulnar styloid process and the DCBUN and to confirm the DCBUN's change in location with different forearm positions.

METHODS

We examined 9 fresh frozen cadaveric limbs to establish the course of this nerve. The DCBUN was dissected and traced around the ulnar border of the wrist. The distance from the tip of the ulnar styloid process to the origin of the DCBUN was measured. The distances from the ulnar styloid process to the DCBUN were measured in supination, pronation, and in a neutral position of the forearm.

RESULTS

The DCBUN originated on average 4.92 cm proximal to the ulnar styloid process. In all cases, the DCBUN crossed the ulnar distal to ulnar styloid process and it moved more closely to the ulnar styloid process with a forearm position change from supination to pronation.

CONCLUSIONS

We recommend making a skin incision on the ulnar side around the styloid process with the forearm in supination or neutral position was another method to avoid injury of DCBUN.

Risk of Injury to the Dorsal Sensory Branch of the Ulnar Nerve With Percutaneous Pinning of Ulnar-Sided Structures

PURPOSE

To assess the risk of injury to the dorsal sensory branch of the ulnar nerve (DSBUN) with percutaneous pinning of commonly stabilized ulnar-sided structures.

METHODS

Eleven fresh-frozen cadaveric upper extremities were assessed. Percutaneous pinning of the fifth metacarpal base and neck, lunotriquetral joint, ulnar styloid, and distal radioulnar joint (DRUJ) with 1.4-mm Kirschner wires was performed under fluoroscopic guidance. Each specimen was then carefully dissected and the distance from each pin to the DSBUN was measured using a digital caliper. Direct injury to the DSBUN and pins found immediately adjacent to the nerve were recorded.

RESULTS

Mean distance from the pin to the DSBUN at the fifth metacarpal neck was 5.0 ± 1.5 mm; fifth metacarpal base, 2.3 ± 2.2 mm; lunotriquetral joint, 1.8 ± 1.6 mm; ulnar styloid, 0.8 ± 1.1 mm; and DRUJ, 3.1 ± 0.9 mm. Two of 11 ulnar styloid pins and 1 of 11 lunotriquetral pin directly penetrated the DSBUN, whereas 4 of 11 ulnar styloid pins, 3 of 11 fifth metacarpal base pins, and 2 of 11 lunotriquetral pins were directly adjacent to the DSBUN. There was an increased overall risk of DSBUN injury (risk of direct injury and risk of adjacent pin) with pinning of the ulnar styloid compared with fifth metacarpal neck and DRUJ pinning.

CONCLUSIONS

The current study demonstrates the risk of iatrogenic injury to the DSBUN with percutaneous pinning of the ulnar styloid, lunotriquetral joint, and fifth metacarpal base.

CLINICAL RELEVANCE

We recommend identifying and protecting the nerve to mitigate the risk of iatrogenic injury when performing ulnar-sided pinning of structures from the ulnar styloid to the fifth metacarpal base.

All-arthroscopic knotless suture anchor repair of triangular fibrocartilage complex fovea tear by the 2-portal technique

After the importance of the deep fiber of the distal radioulnar ligament had been acknowledged, some repair techniques have been introduced. Because the knotless suture anchor does not cause any knot irritation and yields appropriate tension, it is a useful fixation material. All-arthroscopic knotless suture anchor repair of the triangular fibrocartilage complex fovea tear by a 2-portal technique is easier and less vulnerable to ulnar nerve injury than the original Geissler technique. Instead of the suture hook and accessory portal, this technique uses the always-sharp 18-gauge needle and percutaneous route. This change results in the repair of the complex fovea tear having the smallest possible remnant tissue. Repair of triangular fibrocartilage complex fovea tears combined type IB, ID, and IIC tears can reduce the chance of needing to perform distal radioulnar ligament reconstruction.

Anatomical relationships and branching patterns of the dorsal cutaneous branch of the ulnar nerve

PURPOSE

To describe the variable branching patterns of the dorsal cutaneous branch of the ulnar nerve (DCBUN) relative to identifiable anatomical landmarks on the ulnar side of the wrist.

METHODS

We dissected the ulnar nerve in 28 unmatched fresh-frozen cadavers to identify the DCBUN and its branches from its origin to the level of the metacarpophalangeal joints. The number and location of branches of the DCBUN were recorded relative to the distal ulnar articular surface. Relationships to the subcutaneous border of the ulna, the pisotriquetral joint, and the extensor carpi ulnaris tendon were defined in the pronated wrist.

RESULTS

On average, 2 branches of the DCBUN were present at the level of the distal ulnar articular surface (range, 1-4). On average, 2.2 branches were present 2 cm distal to the ulnar articular surface (range, 1-4). At least 1 longitudinal branch crossed dorsal to the extensor carpi ulnaris tendon prior to its insertion at the base of the fifth metacarpal in 23 of 28 specimens (82%). In 27 of 28 specimens (96%), all longitudinal branches of the DCBUN coursed between the dorsal-volar midpoint of the subcutaneous border of the ulna and the pisotriquetral joint. In 20 of 28 specimens (71%), a transverse branch of the DCBUN to the distal radioulnar joint was present.

CONCLUSIONS

During exposure of the dorsal and ulnar areas of the wrist, identification and protection of just a single branch of the DCBUN are unlikely to ensure safe dissection because multiple branches normally are present. The 6U, 6R, and ulnar midcarpal arthroscopy portals may place these branches at risk. In the pronated forearm, the area between the DCBUN and the pisotriquetral joint contained all longitudinal branches of the DCBUN in 96% of specimens.

CLINICAL RELEVANCE

During surgery involving the dorsal and ulnar areas of the wrist, multiple longitudinal branches and a transverse branch of the DCBUN are normally present and must be respected.

Anatomical study of the dorsal cutaneous branch of the ulnar nerve using ultrasound

OBJECTIVES

To determine whether ultrasound allows precise assessment of the course and relations of the dorsal cutaneous branch of the ulnar nerve (DCBUN).

METHODS

This work, initially undertaken in cadavers, was followed by high-resolution ultrasound study in 20 healthy adult volunteers (40 nerves) by two musculoskeletal radiologists in consensus. Location and course of the DCBUN and its relations to adjacent anatomical structures were analysed.

RESULTS

The DCBUN was consistently identified along its entire course by ultrasound. Mean cross-sectional area of the nerve was 1.6 mm(2) (range 1.1-2.2). The level at which the DCBUN branches from the ulnar nerve was located a mean of 57 mm (range 40-80) proximal to the ulnar styloid process and 11 mm (range 7-15) radial to the medial border of the ulna. The DCBUN then crossed the medial border of the ulna a mean of 14 mm (range 6-25) proximal to the ulnar styloid process.

CONCLUSION

The DCBUN is clearly depicted by ultrasound. Precise mapping of its anatomical course could have significant clinical applications, such as preventing injury during surgery of the ulnar side of the wrist or helping in the diagnosis of chronic pain of the ulnar side of the hand.

KEY POINTS

• The dorsal cutaneous branch of the ulnar nerve (DCBUN) is often injured. • The DCBUN originates from the ulnar nerve in the distal third of the forearm. • It can be clearly depicted by ultrasound. • The level at which the DCBUN crosses the ulna is variable. • Precise mapping of its anatomical course could have significant clinical applications.

Complications of wrist arthroscopy

PURPOSE

The purpose of this systematic review was to address the incidence of complications associated with wrist arthroscopy. Given the paucity of information published on this topic, an all-inclusive review of published wrist arthroscopy complications was sought.

METHODS

Two independent reviewers performed a literature search using PubMed, Google Scholar, EBSCO, and Academic Megasearch using the terms "wrist arthroscopy complications," "complications of wrist arthroscopy," "wrist arthroscopy injury," and "wrist arthroscopy." Inclusion criteria were (1) Levels I to V evidence, (2) "complication" defined as an adverse outcome directly related to the operative procedure, and (3) explicit description of operative complications in the study.

RESULTS

Eleven multiple-patient studies addressing complications of wrist arthroscopy from 1994 to 2010 were identified, with 42 complications reported from 895 wrist arthroscopy procedures, a 4.7% complication rate. Four case reports were also found, identifying injury to the dorsal sensory branch of the ulnar nerve, injury to the posterior interosseous nerve, and extensor tendon sheath fistula formation.

CONCLUSIONS

This systematic review suggests that the previously documented rate of wrist arthroscopy complications may be underestimating the true incidence. The report of various complications provides insight to surgeons for improving future surgical techniques.

LEVEL OF EVIDENCE

Level IV, systematic review of Levels I-V studies.

The dorsal cutaneous branch of the ulnar nerve: an anatomical study

There are significant variations in the anatomy of the dorsal cutaneous branch of the ulnar nerve. The dorsal cutaneous branch is at a risk of injury during a therapy for the ulnar side of the wrist. The purpose of this study is to measure the variations of the dorsal cutaneous branch. We studied 30 embalmed cadaver specimens. In its course, two division patterns of the dorsal cutaneous branch were identified, namely proximal and distal types. The proximal type went around the ulna proximal to the ulnar styloid process, and directed toward the ulnodorsal aspect. The distal type went around to the ulnodorsal aspect, distal to the styloid process. The proximal type was found in 21 of 30 cadavers, and the distal type was found in nine of 30 cadavers.

Safety analysis of all-inside arthroscopic repair of peripheral triangular fibrocartilage complex

PURPOSE

The purpose of this study was to determine whether an all-inside peripheral triangular fibrocartilage complex (TFCC) repair using the FasT-Fix device (Smith & Nephew Endoscopy, Andover, MA) is safe by measuring the proximity of the anchors to ulnar-sided anatomic structures.

METHODS

Eleven fresh-frozen cadaveric wrists were thawed and placed in traction. Under direct arthroscopic visualization, an all-inside arthroscopic peripheral TFCC repair was completed by placing a single FasT-Fix device in a vertical mattress fashion. The wrists were then dissected to visualize the 2 anchors. The distance between these anchors and the flexor carpi ulnaris (FCU), extensor carpi ulnaris (ECU), and dorsal branch of the ulnar sensory nerve (DBUN) were measured with digital calipers and recorded.

RESULTS

The peripheral anchor averaged 4.2 mm (range, 0 to 14 mm) from the ECU tendon, 3.8 mm (range, 0 to 9 mm) from the DBUN, and 8.3 mm (range, 1 to 15 mm) from the FCU tendon. The central anchor averaged 9.6 mm (range, 2 to 15 mm) from the ECU tendon, 6.8 mm (range, 1 to 13 mm) from the DBUN, and 7.6 mm (range, 1 to 13 mm) from the FCU tendon.

CONCLUSIONS

This study exposes some safety concerns with the all-inside peripheral TFCC repair using the FasT-Fix device, which was found to reside in close proximity to the ECU, FCU, and DBUN. In multiple wrists the anchors were noted to underlie the anatomic structure that we measured, making it possible to pierce these structures with the needle before deployment of the anchor.

CLINICAL RELEVANCE

Though technically feasible, all-inside arthroscopic repair of the peripheral TFCC risks injury to the ulnar-sided anatomy.

A technique for arthroscopic all-inside suturing in the wrist

A technique for arthroscopic all-inside suturing in the wrist is presented. The procedure allows placement of the knot inside the joint without additional incisions. We have applied it in cases of dorsal, foveal and coronal tears of the triangular fibrocartilage. No special instrument is required apart from a Tuohy needle.

All-arthroscopic triangular fibrocartilage complex repair: safety and biomechanical comparison with a traditional outside-in technique in cadavers

PURPOSE

To compare the biomechanical strength and safety of an all-arthroscopic triangular fibrocartilage (TFCC) repair technique with an outside-in technique in cadavers.

METHODS

Ten matched pairs of fresh-frozen cadaveric wrists were used for this study. The control group TFCC tears were treated with an outside-in technique using 2-0 polydioxane (PDS) sutures. The experimental group was treated with two FasT-Fix suture devices. I measured the location of the implants in relation to the neurovascular structures using a digital caliper. The strength of the repairs was then determined using a tensile testing machine with the load placed across the repair site. I compared results using the Student's t-test.

RESULTS

The most volar FasT-Fix block averaged 1.8 cm from the ulnar neurovascular bundle, whereas the PDS knots averaged 1.9 cm from it. The most dorsal FasT-Fix averaged 17.1 mm from the dorsal branch of the ulnar nerve, whereas the PDS knot was 4.6 mm. The average load to failure for the FasT-Fix repairs was 3.7 N, compared with 2.4 N for the PDS repairs (p < .05). The mode of failure for the FasT-Fix implants was the suture cutting through the TFCC tissue. The mode of failure for the PDS controls varied between the suture cutting through the tissue and the knots untying. One extensor carpi ulnaris tendon was injured by the PDS technique. No tendons were injured with the FasT-Fix technique.

CONCLUSIONS

This all-arthroscopic technique of TFCC repair is faster and stronger than the inside-out technique and is equally safe. Benefits of this repair are decreased operative time, reduced postoperative immobilization, and decreased irritation from prominent suture knots below the skin. For these reasons, it may be desirable to perform this technique to improve patient satisfaction.

Arthroscopic treatment of triangular fibrocartilage wrist injuries in the athlete

BACKGROUND

Triangular fibrocartilage (TFC) injuries are an increasingly recognized cause of ulnar-sided wrist pain and can be particularly disabling in the competitive athlete. Previous studies show that arthroscopic debridement or repair can improve symptoms, but the results of arthroscopic treatment of TFC injuries in high-level athletes have not yet been reported.

HYPOTHESIS

Arthroscopic debridement or repair of wrist TFC injury will allow a high rate of return to full function in the elite athlete.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between 2001 and 2005, 16 competitive athletes (mean age, 23.4 years) with wrist TFC injuries underwent arthroscopic surgery. Repair was performed in unstable tears, and all others underwent debridement alone. Presurgery and post-surgery mini-DASH (Disabilities of the Arm, Shoulder, and Hand) scores were recorded for each athlete through medical record review and clinical evaluation. The mean duration of follow-up was 32.8 months (range, 24-51 months).

RESULTS

The TFC was repaired in 11 (68.8%) and debrided in 5 (31.3%) patients. The tear was ulnar-sided in 12 (75%), radial-sided in 2 (12.5%), combined radial-ulnar in 1, and central-sided in 1 patient. Mean mini-DASH scores improved from 47.3 (range, 25-65.9) to 0 (all patients) (P = .002), and the mean mini-DASH sports module improved from 79.7 (range, 68.8-100) to 1.95 (range, 0-18.8) (P = .002). Return to play averaged 3.3 months (range, 3-7 months). Associated conditions in the 2 patients unable to return to play at 3 months were distal radioulnar joint (DRUJ) instability with ulnar-carpal abutment (n = 1) and extensor carpi ulnaris (ECU) tendinosis (n = 1).

CONCLUSION

Arthroscopic debridement or repair of wrist TFC injury provides predictable pain relief and return to play in competitive athletes. Return to play may be delayed in athletes with concomitant ulnar-sided wrist injuries.

Injury of the dorsal sensory branch of the ulnar nerve as a complication of arthroscopic repair of the triangular fibrocartilage

This report presents a case of direct injury to the dorsal sensory branch of the ulnar nerve caused by arthroscopic repair of the triangular fibrocartilage complex. The dorsal sensory branch of the ulnar nerve was strangulated by one of the three pull-out sutures of the joint capsule, just ulnar to the extensor carpi ulnaris tendon. Pain and dysaesthesia of the ulnar side of the wrist was completely relieved after excision of the injured nerve segment. This complication can be avoided by careful exploration of the dorsal sensory branch of the ulnar nerve prior to suturing or passage of instruments during arthroscopy.

Direct arthrography of the pisotriquetral joint

OBJECTIVE

The purpose of this study was to describe and evaluate a simple and safe procedure for direct arthrography of and steroid injection into the pisotriquetral joint.

CONCLUSION

Direct pisotriquetral arthrography using a medial approach is an effective and easy-to-perform technique for injection of steroids.

Uses and abuses of wrist arthroscopy

PURPOSE OF REVIEW

The use of wrist arthroscopy in the diagnosis and treatment of carpal pathology continues to expand. The purpose of this paper is to summarize recent advances in the utility of this diagnostic, therapeutic, and research tool.

RECENT FINDINGS

The indications for wrist arthroscopy are growing with the description of volar portals for the radiocarpal and scaphotrapezial trapezoid joint. Arthroscopic assistance in the treatment of distal radius and scaphoid fractures is also becoming more feasible. Arthroscopic excision of dorsal carpal ganglions has met with considerable success. In addition, the application of electrothermal collagen shrinkage is an exciting new frontier in arthroscopic wrist procedures.

SUMMARY

Wrist arthroscopy has evolved to be an essential diagnostic and therapeutic tool in the armamentarium of every surgeon treating disorders of the wrist.

Pediatric distal radius fractures and triangular fibrocartilage complex injuries

Management of distal radius fractures is guided by the pattern and location of injury, degree of deformity, and expectations of bony remodeling based on the amount of remaining skeletal growth.Indications for surgical treatment include unstable or irreducible fractures, open fractures, floating elbow injuries, and neurovascular or soft-tissue compromise precluding cast immobilization. Patients and families should be counseled regarding the potential for post-traumatic distal radial growth arrest following physeal fractures. In these cases, epiphysiodeses, ulnar shortening osteotomies, or corrective radial osteotomies may be performed, depending on the pattern of arrest,degree of deformity, and remaining skeletal growth.TFCC tears may be the source of ulnar-sided wrist pain in children and adolescents, though symptoms and physical examination findings maybe subtle. Patients who have persistent pain and functional limitations despite activity modification and therapy are candidates for surgical treatment. Appropriate repair of peripheral TFCC tears with correction of concomitant wrist pathology restores normal wrist anatomy, alleviates pain, and allows for return to functional activities.

Arthroscopic suture repair of peripheral tears of triangular fibrocartilage complex using a volar portal

Surgical repair of a Palmer type IB triangular fibrocartilage complex (TFCC) tear can be difficult using conventional dorsal portals and it may need special repair kits. The authors describe an arthroscopic technique using an additional volar portal that allows quick access and a secure purchase of peripheral TFCC tears as well as a distinct approach to dorsal wrist structures.

[Transverse radioulnar branch of the dorsal ulnar nerve: anatomic description and arthroscopic implications from 45 cadaveric dissections]

PURPOSE OF THE STUDY

We conducted an anatomic study of the transverse branch of the dorsal ulnar nerve to describe its morphology and position in relation to arthroscopic exploration portals.

MATERIAL AND METHODS

Forty-five non-side-matched anatomic specimens of unknown age and gender were preserved in formol. The dorsal branch of the ulnar nerve was identified and dissected proximally to distally in order to reveal the different terminal branches. The morphometric analysis included measurement of the length and diameter of the transverse branch and measurement of wrist width. We also measured the smallest distance between the transverse branch and the ulnar styloid process, and between the branch and usual arthroscopic portals (4-5, 6R, 6U) in the axis of the forearm.

RESULTS

The transverse branch was inconstant. It was found in 12 of the 45 dissection specimens (27%). In two-thirds of the specimens, the branch ran over less than 50% of the wrist width, tangentially to the radiocarpal joint. Mean nerve diameter was 1 mm. It was found 5-6 mm from the ulnar styloid process and was distal to it in 83% of the specimens. The dissections demonstrated two anatomic variants. Type A corresponded to a branch running distally to the ulnar styloid process, parallel to the joint line (10/12 specimens). Type B exhibited a trajectory proximal to the ulnar styloid process, crossing the ulnar head (2/12 specimens). The relations with the arthroscopic portals (4-5, 6R, 6U) showed that the mean distance from the branch to the portal was 3.75 mm for the 4-5 portal (distally in 11/12 specimens), 3.68 mm for the 6R portal (distally in 10/12 specimens), and 4.83 mm for the 6U portal (distally in 7 specimens and proximally in 5).

DISCUSSION

To our knowledge, there has been only one report specifically devoted to this transverse branch. Two other reports simply mention its existence. According to the literature, the transverse branch of the dorsal ulnar nerve occurs in 60-80% of the cases. We found two anatomic variations different than those described in the literature. Based on our findings and data reported previously, we propose a new classification, describing two main types. In Type 1, the transverse branch arises proximally to the ulnar styloid process;type 1A and type IB are described in relation to the direction of the branch. In Type II, the branch arises distally to the ulnar styloid process;type IIA and type IIB again being described in relation to the direction of the branch. On the tangential trajectory over the radiocarpal joint, the morphometric data show a zone of risk described by a rectangle measuring 10 mm wide (6 mm distal and 4 mm proximal to the ulnar styloid process) and covering 50% of the wrist width. The relations with arthroscopic portals describe a zone of risk corresponding to a 5-7 mm radius circle centered on the portals (4-5, 6R, 6U), which includes 83% of the transverse branches.