Arthroscopic Assisted Distal Radial Ulnar Joint Reconstruction Using a Modified Anatomic Ligament Reconstruction

Extensor Carpi Ulnaris “Turn Around” Ligamentoplasty For Distal Radioulnar Joint Instability

Biomechanical analysis of simultaneous distal and proximal radio-ulnar joint instability

BackgroundTears in the triangular fibrocartilage complex (TFCC) often manifest as ulnar wrist pain and limited wrist function. In chronic cases, the treatment of large tears with irreparable TFCC degeneration combined with distal radioulnar joint (DRUJ) instability is difficult. In the current report, we describe the outcomes of a minimally invasive technique for TFCC reconstruction using the free palmaris longus (PL) tendon via arthroscopy.MethodsWe examined the cases of 67 adult patients [54 men and 13 women; age range, 19–34 years (mean age, 26.4 years)] treated for chronic and irreparable TFCC tears from 2001 to 2019. We used the arthroscopic TFCC reconstruction method with the free PL tendon for all chronic and irreparable TFCC injuries with DRUJ instability in our clinic. Thereafter, the patients underwent the rehabilitation program, which included wrist motion and occupational therapy. The mean time period from the event causing the tear to the operation was 22.6 months.ResultsThe function results of these patients significantly improved, and the ulnar wrist pain significantly decreased at postoperative follow-up. Of the 67 patients, 38 rated their wrists as “excellent,” 26 as “good,” and 3 as “fair.” None of the patients developed wound infections or complications.ConclusionsThe results of this study suggest that arthroscopic TFCC reconstruction using the free PL tendon is an effective method for treating chronic and irreparable TFCC tears with DRUJ instability.

Background: Distal Radius Fractures (DRF) are common fractures with variety of complications if treated inadequately. Among them, Distal Radio-Ulnar Joint (DRUJ) instability is one of the common residual disabilities leading to chronic and persistent subluxation or dislocation of the DRUJ which causes arthritis, pain and limitation of the hand functions. Aims and Objectives: This study aims to identify the factors either clinical of radiographic, indicative of DRUJ instability patients in acute DRF which may help the orthopedic surgeons to correctly diagnose and allow proper treatment.Materials and Methods: All patients from Aug 1, 2016-July 31, 2017 with acute DRF who were treated at Manipal Teaching Hospital were examined and evaluated for DRUJ instability. The demographic, clinical and radiological parameters of all the patients were analyzed and compared with those with stable DRUJ. Preoperatively all the fractures were classified using AO classification. Based on the classification, the association of fracture comminution, and intra-articular involvement with DRUJ instability, as well as its relation to the osteoporotic age was analyzed. Associated ulna styloid fracture and sigmoid notch involvement if present was noted with its size and displacement.Results: Out of 74 wrists, there were 30 males and 44 females, with a mean age of 44 (range 18-79). Most of the females (72%, n=32/44) sustained low energy trauma, while most of the males (77%, n=23/30) sustained high energy trauma. Irrespective of the sex, it was noted that DRUJ instability was significantly higher in males (p<0.0001) and in the non-osteoporotic age group (p=0.05). In our study 72.72% of DRF was associated with unstable DRUJ in patients with high energy trauma. AO types A3/B3/C3 (81.25%, n=26/32) was associated with more DRUJ instability compared to less comminuted fractures as AO type A2/B2/C2 (56%, n=14/25) or A1/B1/C1 (29.41%, n=5/17) (p<0.001). AO type C (43.24%, n=32) were associated with more DRUJ instability as compared to AO type B (25.67%, n=19) or AO type A (31.08%, n=23) (p=0.009). Ulnar styloid fractures was noted in 37.83% (28/74) of DRF and 35 (47.29%) patients had involvement of the sigmoid notch out of which 7 (20%) was displaced > 2mm and 28 (80%) was undisplaced.Conclusion: Factors associated with DRUJ instability in DRF were young male patients, high energy trauma, displaced ulnar styloid base fractures, sigmoid notch involvement, AO type C.Asian Journal of Medical Sciences Vol.9(5) 2018 62-66

Reliability and Validity Analysis of the Distal Radioulnar Joint Ballottement Test

Purpose: The purpose of this study was to make an assessment of distal radioulnar joint (DRUJ) instability after the treatment of intra-articular fractures of the distal radius using computed tomography (CT) including contralateral normal wrist. Materials and Methods: Twenty-seven intra-articular fractures of the distal radius in twenty-seven patients who had had the surgical treatment were evaluated at follow-up of mean 17.9 months (range, 10-36 months). The DRUJ was assessed with clinical examination, plain radiography, and bilateral CT. CT scans were obtained in pronation, neutral, and supination. The radioulnar ratio and the subluxation ratio which was modified radioulnar line method were used to measure DRUJ instability. Results: Eight patients were diagnosed as DRUJ instability based on CT assessment. Nine patients were considered to have DRUJ instability in clinical examination, but 4 patients of them were confirmed to have DRUJ instability based on CT measurements. Nonunions of ulnar styloid or malunions of the distal radius were not found to have statistical correlation with DRUJ instability (p>0.05). Conclusion: In patient with suspicious DRUJ instability following distal radius fractures, we recommend computed tomography scans of both the injured and uninjured wrists in pronation, neutral, and supination position for objective assessment.

Distal radioulnar joint (DRUJ) instability following distal radius fracture (DRF) is an increasingly recognised entity, particularly with recent advances in the management of DRF. This review aims to provide a comprehensive appraisal of DRUJ anatomy, methods of assessing instability and current treatment strategies. Both non-operative and operative modalities are considered. In the acute setting, surgical management primarily involves open reduction and internal fixation (ORIF) of the distal radius, which can restore DRUJ stability through correction of translation and distraction of the distal fragment. Management of concomitant injuries, such as ulnar styloid fractures and triangular fibrocartilage complex (TFCC) tears, are also addressed, particularly in cases where instability persists following DRF fixation. In the chronic setting, DRUJ instability is categorised according to underlying pathology: bony abnormalities (including distal radius malunion and ulnar styloid nonunion) and soft-tissue insufficiency (notably TFCC tears). Finally, attention is drawn to associated conditions - such as DRUJ subluxation and stiffness - which may complicate management or remain underrecognised in clinical practice. Level of Evidence: Level V (Therapeutic).

Background: Forearm peak pronation and supination torque measurements are reduced up to 30% in patients with triangular fibrocartilage complex (TFCC) 1B injuries with concomitant distal radioulnar joint (DRUJ) instability. The aim of our study was to evaluate whether patients with TFCC 1B injuries, with concomitant DRUJ instability, improve in forearm peak pronation and supination torque following TFCC reinsertion surgery where postoperative DRUJ stability was achieved. Methods: We report a retrospective case series with short-term follow-up (20 months) of the postoperative forearm peak torque in pronation and supination in 11 patients (9 women/2 men, average age at surgery 32 years) operated on by TFCC reinsertion. Two of the initial 13 patients were later on reoperated due to recurring DRUJ instability and were therefore excluded in this follow-up study. Nine were treated by arthroscopic TFCC reinsertion and 2 by open technique. The forearm peak pronation and supination torque were measured pre- and postoperatively and compared with the uninjured side. Results: On average, a 16% improvement of the forearm peak torque was achieved in the injured wrist, as well as clinically assessed DRUJ stability. Functional postoperative improvement was noted in all patients, with reduced pain, good satisfaction, and acceptance of the surgery and the final result. Conclusion: We conclude that patients with TFCC injuries and DRUJ instability gain improved forearm peak pronation and supination torque after reinsertion. We also conclude that forearm peak pronation and supination torque is a valuable tool in the preoperative diagnostics of TFCC injuries with DRUJ instability as well as in the postoperative follow-up.

There is a lack of methods to objectively evaluate improvement in distal radioulnar joint (DRUJ) instability through treatment. We used ultrasonography to assess DRUJ instability and calculated the minimal detectable change (MDC) in healthy individuals. MDC was used to evaluate post-treatment changes in a patient with triangular fibrocartilage complex (TFCC) injury. DRUJ instability was evaluated using force-monitor ultrasonography in eight healthy male participants to determine MDC and in a man in his 60s who underwent surgery and rehabilitation for TFCC injury (Palmer classification: type 2C). In the patient, DRUJ instability was measured pre-operatively, 3months postoperatively, and 1year post-operatively. Self-reported hand and upper limb functional ability were also recorded. The transducer of the force-monitor ultrasonographic system was used to apply cyclic compressions to the wrists automatically and measure DRUJ displacements. The amount of displacement was calculated using the distance between the radius and ulna before and during cyclic compression to the wrists. The applied pressure was measured as the force to the wrist, and the displacement-to-force ratio was calculated. The 95% confidence MDC95 for radioulnar displacement, displacement force, and displacement-to-force ratio were 0.27-0.31mm, 0.30-0.59N, and 0.12-0.15mm/N, respectively. The patient's post-operative decrease in displacement exceeded the MDC95. DRUJ stability, pain, and use of the affected hand in daily life improved. Force-monitor ultrasonography can quantitatively evaluate post-treatment improvement in DRUJ stability over time. MDC for DRUJ instability can assess recovery after treatment or rehabilitation and determine changes resulting from interventions.

Impact of Distal Ulnar Fracture Malunion on Distal Radioulnar Joint Instability: A Biomechanical Study of the Distal Interosseous Membrane Using a Cadaver Model

BackgroundWrist injury affects wheelchair basketball players’ performance; however, the relationship between distal radioulnar joint (DRUJ) instability and hand functions is unclear. This cross-sectional pilot study investigated DRUJ instability in elite female wheelchair basketball athletes using force-monitor ultrasonography.MethodsNine elite female wheelchair basketball athletes (18 wrists) were included in the study. A triangular fibrocartilage complex (TFCC) injury was confirmed using magnetic resonance imaging (MRI). Hand functions were evaluated based on the range of motion (ROM) of wrist palmar flexion, dorsiflexion, radial deviation, and ulnar deviation; grip strength; arm circumference; forearm circumference; and DRUJ instability or pain using the ballottement test. The Mann–Whitney U test was used to compare parameters between the TFCC-injured and intact wrists. Radioulnar displacement was measured using force-monitor ultrasonography and pressure data, and the displacement-to-force ratio was used as an indicator of DRUJ instability. The correlation between the DRUJ displacement-to-force ratio and each hand function assessment was evaluated using Pearson correlation coefficient for the TFCC-injured and intact wrists. A generalized linear mixed model (GLMM) was used to estimate the relationship between hand functions and DRUJ instability.ResultsTFCC injuries in seven wrists were confirmed using MRI findings (38.9%). The ulnar deviation ROM values of the TFCC-injured wrist (n = 7) and intact (n = 11) groups were 38.6 ± 8.0° and 48.6 ± 7.8°, respectively. The ulnar deviation ROM was significantly smaller in the TFCC-injured wrists (p = 0.02, r = − 0.54). In the TFCC-injured wrists, no correlation was observed between the displacement-to-force ratio and the hand function assessment. In contrast, the displacement-to-force ratio negatively correlated with grip strength, arm circumference, and forearm circumference in the intact wrists (Pearson correlation coefficient r = − 0.78, − 0.61, and − 0.74, respectively). The GLMM showed that the displacement-to-force ratio significantly affected grip strength, arm circumference, and forearm circumference in the intact group.ConclusionsIn intact wrists, correlations were observed between hand functions such as upper arm/forearm strength and DRUJ stability evaluated using ultrasound. Maintaining and strengthening grip strength, forearm circumference, and arm circumference are associated with DRUJ stability and may be related to TFCC injury prevention in wheelchair basketball athletes.Trial registration: The protocol was registered with the UMIN Clinical Trials Registry (UMIN000043343) [Date of first registration: 16/02/2021].

Background Foveal disruption of the triangular fibrocartilage complex (TFCC) is associated with distal radioulnar joint (DRUJ) instability. TFCC fixation onto the fovea is the suitable treatment, which is not achieved by conventional arthroscopic techniques. We describe an all-inside arthroscopic technique that uses a suture anchor through distal DRUJ arthroscopy for foveal repair of the TFCC. Materials and Methods Forty-eight patients with TFCC foveal tear and DRUJ instability were selected according to the Atzei-European Wrist Arthroscopy Society (EWAS) algorithm of treatment. Retrospective evaluation included pain, DRUJ instability, range of motion (ROM), grip strength, Modified Mayo Wrist Score (MMWS), and the Disabilities of the Arm, Shoulder, and Hand (DASH) Score. Description of Technique DRUJ arthroscopy was performed to débride the TFCC and the foveal area. Under arthroscopic guidance, a suture anchor was inserted via the distal foveal portal to repair the TFCC onto the fovea. Sutures were tied on the radiocarpal surface of the TFCC. Postoperative immobilization of forearm rotation was maintained for 4 weeks. Heavy tasks were allowed after 3 months. Results After a mean follow-up of 33 months, pain improved significantly but remained moderate in four patients, severe in one. DRUJ instability resolved in 44 patients. Wrist ROM increased. Grip strength, MMWS, and DASH score improved significantly. Excellent and good MMWS equaled 83.3%. Forty-one patients (85.5%) resumed previous work and sport activities. As a postoperative complication, five patients experienced neuroapraxia of the dorsal sensory branch of the ulnar nerve (DSBUN) with full spontaneous recovery. Conclusions With appropriate indications and patient selection, arthroscopic foveal repair of the TFCC may restore DRUJ stability and provide satisfactory results without significant complications.

To the Editor: It was with great interest that we read Farr et al.’s article [1] BClinical experience with arthroscopically-assisted repair of peripheral triangular fibrocartilage complex tears in adolescents— technique and results.^. In this article, the authors examined adolescents who suffered from triangular fibrocartilage complex (TFCC) 1B tears among other pathologies postoperatively after TFCC refixation to the capsule. TFCC tears and concomitant distal radioulnar joint (DRUJ) instability are often neglected entities among young patients [2]. Therefore, the study is of relevance and the postoperative results are very encouraging. Nevertheless, in our opinion, several issues ought to be pointed out. Since you examined the DRUJ postoperatively, did you assess the latter prior to surgery? In this context, we often regard the assessment of the DRUJ as a real challenge [3, 4]. What test do you apply or prefer for detecting DRUJ instability? It would be interesting to know if patients suffered from DRUJ instability prior to surgery. In cases of DRUJ instability, it may be of relevance if the results of these patients were assessed separately. Moreover, did the authors find significant differences of sturdiness for the refixation technique applied, since degenerative changes are not to be expected concerning these young patients? We would like to know if the authors regard transosseous refixation as an option for young patients with DRUJ instability? Furthermore, the authors stated that all patients were examined using MRI prior to surgery. We would like to stress that MRI findings should be interpreted very cautiously regarding TFCC lesions, and we agree with the authors that wrist arthroscopy is not only the reference standard for treatment of many wrist pathologies but also for diagnosing [5]. In summary, the study shows clearly that wrist arthroscopy and additional treatment can be performed successfully for young patients.

Functional results of arthroscopic triangular fibrocartilage complex reconstruction in chronic distal radioulnar joint instability

Objective To investigate the causes of instability of distal radioulnar joint caused by displacement in distal radius fracture, and to analyze the importance of radial displacement in distal radius fracture to wrist stability. Methods There were 60 patients with distal radius fracture, 22 males and 38 females, aged from 26 to 67 years, with an average age of 41 years. There were 29 cases with ulnar styloid process fracture and 31 cases without ulnar styloid process fracture. According to the degree of displacement, they were divided into three groups: 13 cases with displacement less than 2 mm, 20 cases with displacement more than 2 mm and less than 4 mm, and 27 cases with displacement more than 4 mm. All the patients were treated with open reduction and plate internal fixation of distal radius fracture. The stability of distal radioulnar joint was examined after plate fixation. Fifteen patients with unstable distal radioulnar joint examined by intraoperative physical examination (associated with ulnar styloid process fracture) were divided into two groups. In one group, the styloid process of ulna was fixed with steel wire, while in the other group the styloid process of ulna was not fixed. The effect of radial displacement on ulnar styloid process after distal radius fracture and the effect of ulnar styloid process fracture on the stability of distal radioulnar joint were analyzed. The degree of radial displacement of distal radius fracture and the effect of ulnar styloid process fracture on the stability of distal radioulnar joint were evaluated according to the postoperative follow-up of palmar inclination angle, ulnar deviation angle and wrist function score. Results The injury of TFCC when radial displacement of distal radius fracture was greater than 4 mm was the main cause of instability of distal radioulnar joint and affecting wrist function. There was statistically significant difference in the incidence of distal radioulnar joint instability whether distal radial fractures accompanied by ulnar styloid process fractures or not. There was significant difference between radial displacement greater than 4 mm and ulnar styloid process fracture. Conclusion The radial displacement of distal radius fracture has great influence on the stability of distal radioulnar joint. There are more patients with ulnar styloid process fracture in the instability of distal radioulnar joint. The ulnar styloid process fracture suggests a higher risk of TFCC injury. The good reduction of ulnar styloid process plays an important role in the stability of distal radioulnar joint. Key words: Radius; Fractures,bone; Distal radioulnar joint; Triangular fibrocartilage complex; Ulnar styloid process