Distal Radioulnar Joint Instability Research Articles

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

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

Extensor carpi ulnaris longitudinal tear: An overlooked etiology of ulnar-sided wrist pain

The common etiologies of ulnar-sided wrist pain include fracture, triangular fibrocartilage complex injury, ulnocarpal impaction, extensor carpi ulnaris tenosynovitis, and distal radioulnar joint instability. Early and precise diagnosis is the cornerstone for management and early recovery from the disease. A dual-modality approach with X-ray and ultrasound wrist can be used as an efficient and cost-effective screening procedure for ulnar-sided wrist pain in a busy tertiary care setting or where magnetic resonance imaging is not available. We report a case of a 36-year-old male with chronic ulnar-sided wrist pain.

Headless screw fixation of unstable ulnar styloid base fractures after distal radial fractures fixation

Ulnar styloid fractures occur frequently concomitant with distal radial fractures. Although unstable distal radial fractures are mostly surgically treated, ulnar styloid fractures are often ignored. Unstable fractures at the base of the ulnar styloid may lead to persistent ulnar pain, due to distal radioulnar joint instability or ulnar styloid non-union.We retrospectively analyzed a single-surgeon cohort series of surgically treated distal radial fractures on how these concomitant ulnar styloid fractures were regarded: indications for surgery and surgical technique with headless screw fixation.119 surgically treated distal radial fractures were assessed. 51 (42.8%) of the surgically treated distal radial fractures had a distal ulnar fracture, and more specifically 23 (19.3%) had a base fracture of the ulnar styloid. 9 (7.6%) of the wrists had a base fracture of the ulnar styloid which was considered after distal radial fracture fixation as persistently unstable, during distal radioulnar joint ballottement translation test. This fracture subtype was immediately treated with headless screw fixation, resulting in all cases in bony union, with a mean active pronation of 85°, a mean active supination of 80° and a clinical stable distal radioulnar joint, with minimal ulnar pain after 6 weeks (mean Visual Analogue Scale 1). After at least 12 months, persistent pain did not occur and mean QuickDASH was 2.5.According to this single-surgeon cohort series, headless screw fixation provides a reliable treatment for unstable base fractures of the ulnar styloid after distal radial fixation.

Dynamic Computed Tomography of the Distal Radioulnar Joint Versus Magnetic Resonance Imaging in Detecting Foveal Tears of the Triangular Fibrocartilage Complex.

Diagnosis of foveal triangular fibrocartilage complex (TFCC) tears remains difficult. The purpose of this study was to evaluate whether dynamic computed tomography (CT) of the distal radioulnar joint (DRUJ) has a higher sensitivity in detecting foveal tears of the TFCC when compared with magnetic resonance imaging (MRI). A database query identified all patients above the age of 18 years with suspected foveal TFCC injuries who underwent bilateral dynamic CT imaging of the DRUJ, static 3T MRI, and subsequent wrist arthroscopy. All patients had evidence of foveal tenderness on clinical examination. The imaging results were validated with wrist arthroscopy. Twelve patients with a mean age of 31 years (range, 18-53 years) were identified. Eight patients were diagnosed with a complete foveal detachment of the TFCC on wrist arthroscopy. Of the 8 patients with a foveal tear on DRUJ arthroscopy, only 3 had a preoperative physical examination suggestive of DRUJ instability. Magnetic resonance imaging identified foveal injuries in 4 of these 8 patients (sensitivity, 50%), and 3 of these were identified as only partial tears. Dynamic CT identified instability of DRUJ in 6 of 8 patients (sensitivity, 75%). Seven of 8 patients had imaging findings suggestive of a foveal tear when including either MRI or CT imaging (sensitivity, 88%). Of the 4 patients with an intact foveal attachment on arthroscopy, 3 (specificity, 75%) had a stable DRUJ on CT and all 4 (specificity, 100%) had an intact foveal attachment on MRI. Sixty-two percent of patients with foveal tears on arthroscopy have a stable DRUJ on clinical examination. When combining MRI and dynamic CT imaging of the DRUJ, the sensitivity of detecting a foveal TFCC tear approaches 88% compared with a gold standard of wrist arthroscopy.

Suture-Based Distal Radioulnar Joint Stabilization: A Biomechanical Evaluation in a Cadaveric Model

Abstract Purpose Management of acute distal radioulnar joint (DRUJ) instability is complex and controversial. Common treatment options include prolonged immobilization, stabilization with wires, and acute triangular fibrocartilage complex repair. However, none of these permits an early range of motion. The purpose of this study is to investigate the feasibility of a suture-based stabilization (SBS) technique for acute DRUJ instability to permit early active motion. Methods A biomechanical study utilizing eight cadaveric arms was performed. All specimens were tested in the intact state prior to the creation of bidirectional DRUJ instability. For the SBS group, 2-mm suture tapes with suture button fixation were utilized to recreate the respective contributions of distal oblique bundle and volar and dorsal radioulnar ligaments to DRUJ stability. All specimens were cyclically loaded with a simulated ballottement stress of 20N in forearm positions of neutral, 60 degrees of pronation and 60 degrees of supination. Range of motion and total translation were measured and then compared between the two groups. Results The average range of motion in the intact and SBS specimens was 174 and 175 degrees, respectively. There were no significant differences in displacement between the intact and SBS group in neutral and in supination. However, the SBS group had less translation than the intact group in pronation. Conclusions For acute DRUJ instability, the described SBS technique provides similar stability to the native intact DRUJ without compromising the range of motion in a cadaveric model. Future comparative studies are warranted prior to translation into the clinical arena. Clinical Relevance This is a biomechanical study investigating a treatment technique for acute DRUJ instability that would allow an early range of motion.

Arthroscopic Treatment of Traumatic Isolated Volar Dislocation of the Distal Radioulnar Joint: Case Report and Management Proposal

Abstract Background Traumatic isolated dislocation of the distal radioulnar joint (DRUJ) has always been an injury recognized for its rarity, misdiagnosis, and possibility of inability to be reduced at emergency care. As a result, little has been discussed so far about the guidelines and routines for its treatment.It is known that some degree of injury to the triangular fibrocartilage (TFC) is required for a DRUJ to be dislocated. However, there is no evidence to prove that this injury will cause any degree of DRUJ instability following reduction. Methods We show a case of a patient with traumatic isolated volar dislocation of the DRUJ in which, after failure in the attempt to reduce it in the emergency room, surgical treatment was performed using an arthroscopic method. Results Computed tomography and magnetic resonance imaging axial sections showed the impaction of the distal ulna, with its groove to the extensor carpi ulnaris tendon blocked in the anterior labrum of the sigmoid notch of the radius. Arthroscopy before reduction showed that the distal portion of the TFC was intact, with damage to the foveal insertion (Palmer Type 1B, Atzei Class 3). After joint reduction, a loop-shaped repair of the TFC foveal lesion was performed through the central disc and attached to the distal ulna footprint. The patient presented good progression, with quick recovery, and no serious complications or the need for a second surery. Conclusion We indicate the use of arthroscopy in patients with irreducible isolated volar dislocation, with subacute or chronic presentation, who have to be managed in the operating room. It is a useful method for diagnosing and repairing the TFC injury. This will prevent possible complications and provide faster recovery, mainly reducing the time of immobilization.

Diagnostic value of MRI in traumatic triangular fibrocartilage complex injuries: a retrospective study

BackgroundTriangular fibrocartilage complex (TFCC) injuries commonly manifest as ulnar-sided wrist pain and can be associated with distal radioulnar joint (DRUJ) instability and subsequent wrist functional decline. This study aimed to assess the diagnostic value of MRI compared to wrist arthroscopy in identifying traumatic TFCC injuries and to determine the distribution of different TFCC injury subtypes in a normal clinical setting.MethodsThe data of 193 patients who underwent both preoperative wrist MRI and wrist arthroscopy were retrospectively reviewed. The analysis focused on the proportion of subtypes and the diagnostic value of MRI in traumatic TFCC injuries, utilizing Palmer’s and Atzei’s classification with wrist arthroscopy considered as the gold standard.ResultsThe most prevalent subtype of TFCC injuries were peripheral injuries (Palmer 1B, 67.9%), followed by combined injuries (Palmer 1 A + 1B, 14%; Palmer 1B + 1D, 8.3%). Compared with wrist arthroscopy, the diagnostic sensitivity, specificity, negative predictive value (NPV), and Kappa value of MRI was as follows: traumatic TFCC tears 0.99 (95% CI: 0.97-1), 0.90 (0.78-0.96), 0.97 (0.87-1), and 0.93; styloid lamina tears 0.93 (0.88-0.96), 0.53 (0.30-0.75), 0.47 (0.26-0.69), and 0.44; and foveal lamina tears 0.85 (0.74-0.92), 0.38 (0.29-0.49), 0.79 (0.65-0.89), and 0.21.ConclusionsThe diagnostic value of MRI in traumatic TFCC injuries has been confirmed to be almost perfect using Palmer’s classification. In more detailed classification of TFCC injuries, such as pc-TFCC tears classified by Atzei’s classification, the diagnostic accuracy of MRI remains lower compared to wrist arthroscopy. Radiological associated injuries may offer additional diagnostic value in cases with diagnostic uncertainty.

The Distal Oblique Bundle in the Distal Forearm: From Anatomical Features to Clinical Implementation.

Background and objective The distal oblique bundle (DOB) is nowadays recognized as thethickest component of the distal interosseous membrane (DIOM). It is neither thought to be a clear-cut ligament, and nor does it follow the typical configuration of the rest of the DIOM. It is not always present and some studies have raised disputes about its prevalence and a few anatomical features. In this study, we aimed to provide data on the prevalence and anatomical features of the DOB, which are of great importance at this early stage of research into the topic. Our findings have been correlated with current knowledge and are expected to contribute to clinical implementation. Materials and methods Twenty-eightfresh-frozen forearms were utilized for measurements. Specifically, mean length, width, distance from the middle of the bundle's insertion to the ulna to the tip of the styloid process of the ulna, as well as the distance from the midpoint of its insertion to the radius to the tip of the radiuses' styloid process were calculated. The prevalence was described with a cutoff thickness point of 0.5 mm. Early results based on three cases of DOB reconstruction with the "Riggenbach" technique due to distal radioulnar joint (DRUJ) instability were documented. Results Eleven DOBs were reported out of the 28 specimens, suggesting a prevalence of 39.3%. The mean thickness was 0.88 mm (range: 0.6-1.3 mm), the mean width was 5.22 mm (range: 2.2-8.4 mm), and the mean length was 25.68 mm (range: 22.7-29.2 mm). Proximally, the mean distance from the bundle's ulnar insertion to the tip of the styloid process of the ulna was 51.02 mm (range: 45.5-55.6 mm) while distally, the mean distance from the bundle's insertion to the radius to the tip of the styloid process of the radius was 34.5 mm (range: 31.3-37.7 mm). After a follow-up of at least six months, improvement was evident in all measured areas in the three patients who underwent surgery. Additionally, they reported satisfaction and accomplishment of their preoperative goals. Conclusions Discrepancies in measurements in some anatomic features between studies are probably due to variations in specimen types, measurement methods, and sites. Efforts must continue to be made on a more extensive scale and in a more standardized manner for more factual results and conclusions. "Reconstruction-recreation" or "original construction-creation" procedures yield promising results in a fast, simple, and less invasive manner than traditional methods of DRUJ stabilization.

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

Chronic distal radioulnar joint (DRUJ) instability is a challenging problem of hand surgery practice. The complex motion and function of DRUJ make surgeons give special consideration to pathologies of this joint. DRUJ instability can occur in isolation or associated with dislocations, fractures and malunions of radius and ulna, and ligamentous injuries.1 Untreated DRUJ instability leads to alterations in wrist and forearm kinematics, which can result in loss of function and disability secondary to decreased grip strength, ulnar-sided wrist pain and degenerative changes.2 In case of mild instability in lower-demand patients, nonsurgical management including functional bracing, exercise program could be appropriate in the first-line treatment of chronic DRUJ instability. However, when there is gross DRUJ instability, pain, weakness, and failed nonsurgical management, surgical options should be considered. The common goals of the surgery are to increase stability and decrease pain while preserving wrist and forearm motions. Proper bony alignment is a prerequisite for the stability of the DRUJ. Corrective osteotomy should be performed in case of a malunion accompanying DRUJ instability. However, soft tissue reconstruction is indicated in DRUJ instability with an irreparable triangular fibrocartilage complex (TFCC) when there is no bony malalignment or instability persists following bony correction.3 Several reconstruction techniques have been defined to re-create DRUJ stability. Soft tissue reconstruction procedures can be divided as extra-articular and intra-articular. Extra-articular procedures do not attempt to reconstruct the normal anatomy; however, these techniques create a tether directly between the ulna and radius or indirectly tether the joint using a tenodesis. On the other hand, intra-articular procedures attempt to mimic the normal anatomy by reconstructing the radioulnar ligaments. These intra-articular techniques are usually more complex and technically demanding than the extra-articular techniques. Nakamura described a new technique in patients with chronic DRUJ instability.4 The technique combines both ligament reconstruction and tenodesis using a distally pedicled half-slip of the extensor carpi ulnaris (ECU) tendon graft. In the surgical technique, the graft is first passed through the TFCC remnants, and then through the bone tunnel made from the center of the fovea to the ulnar neck proximally. The ECU half-slip is then anchored to the ulnar fovea with an interference screw.4 The advantages of this technique are reconstruction of the foveal bundle of TFCC by an extra-anatomical way and stabilization of ECU in its groove. However, as the purpose is to reattach the TFCC to the fovea, this technique cannot be performed in cases when there is severe damage to the total structure of the TFCC. Moreover, making bone tunnel can be complicated with fracture or bone tunnel expansion in time which result in recurrent DRUJ instability. We herein would like to present a new technique in the treatment of chronic DRUJ instability using hemi-ECU tendon graft without making a bone tunnel. ANATOMY The bony architecture of the DRUJ leads the joint inherently unstable. Shallower dimension and greater radius of curvature of the sigmoid notch compared with the ulna head result in both rotational and translational motion. This causes natural laxity of the joint. There are 4 types of sigmoid notch morphologies: flat type (42%), C type (30%), S type (14%), and ski slope (14%). Each of these variations of sigmoid notch have variable contribution rates on the stability of DRUJ. A cadaveric study demonstrated that only 20% of DRUJ stability was provided by bony constraints.5 This study shows that the stability of DRUJ is predominantly provided by surrounding soft tissue. Soft tissue stabilizers of DRUJ can be divided into two; dynamic and static. The ECU tendon and the pronator quadratus form the dynamic stabilizers. They act as agonists/antagonists and stabilize the joint during pronation-supination when they are under tension. The static stabilizers of DRUJ are composed of interosseous membrane, ulnocarpal ligaments, joint capsule, and TFCC. The primary static stabilizers of the DRUJ are palmar and dorsal radioulnar ligaments which is a part of TFCC. Recent studies have focused attention on the distal oblique band, the thickened distal portion of the interosseous membrane. This bundle is present in 40% of the cases, and the presence of this bundle results in a significantly more stable DRUJ even TFCC is torn. When the role of soft tissue stabilizers in the stability of DRUJ was examined, the palmar radioulnar ligament was found to provide the greatest restraint to dorsal translocation of the ulna and both interosseous membrane and dorsal-palmar radioulnar ligaments provide restraint to palmar translocation.5 The importance of each soft tissue stabilizer to DRUJ stability was demonstrated by an in vitro kinematic study. Gofton et al found that sectioning all soft tissues altered the DRUJ kinematics.6 However, normal DRUJ motion was observed when the radioulnar ligaments and TFCC were intact. Moreover, near-normal kinematics were observed after sectioning the radioulnar ligaments and preserving the remaining soft tissue constraints. INDICATIONS/CONTRAINDICATIONS The surgical indication for the present technique is chronic, symptomatic, gross DRUJ instability with TFCC foveal detachment. Furthermore, the articular cartilage of DRUJ should be in good condition and, sigmoid notch and ulnar styloid should be competent. The present technique is suitable for wrists with positive, neutral or negative ulnar variance unless there is a bony malalignment. Major symptoms of the patients are pain, mainly during pronation and supination, clicking, weakness, and loss of forearm rotation. Laxity should be assessed with the elbow against a table in forearm neutral, pronation, and supination, and then compared with the uninjured side. The anteroposterior drawer test or stress test is performed by locking the radius and rocking the ulna from the volar to the dorsal (Video 1, Supplemental Digital Content 1, https://links.lww.com/TIO/A59). A positive piano-key test shows DRUJ instability. The technique is contraindicated in case of advanced DRUJ arthrosis, ulnar styloid nonunion, or chronic DRUJ instability with ulnar styloid atrophy. Moreover, any bony malalignment and sigmoid notch incongruity should be addressed before performing this reconstruction procedure. SURGICAL TECHNIQUE The patient is positioned in the supine position under general or regional anesthesia. An upper arm tourniquet is applied. An approximately 8 cm, longitudinal, dorsal skin incision is made over the ECU tendon, starting from the tip of the ulnar styloid continued proximally. The dorsal sensory branch of the ulnar nerve is identified and preserved. ECU tendon sheath is incised, and distally based, ulnar-half ECU tendon graft is harvested (Fig. 1A, B). Next, a soft tissue tunnel is made with a right angle mosquito just beneath the TFCC and around the ulnar styloid (Fig. 2). The tendon graft is taken with mosquito forceps through this soft tissue tunnel and turned around the ulnar styloid (Fig. 3A). The tendon graft is then sutured to itself with pulvertaft weave technique under appropriate tension in neutral rotation (Fig. 3B). The tension and stability of DRUJ is checked with anteroposterior drawer test. Forearm rotation is checked for any limitations.FIGURE 1: A, Half of the ECU tendon is incised distally. B, Distally based partial ECU tendon graft is harvested. ECU indicates extensor carpi ulnaris.FIGURE 2: Soft tissue tunnel is made with a right angle mosquito just beneath the TFCC and around the ulnar styloid. TFCC indicates triangular fibrocartilage complex.FIGURE 3: A, The tendon graft is turned around the ulnar styloid. B, The tendon graft is sutured to itself with the pulvertaft weave technique.The patient is immobilized in a long-arm cast for 3 weeks in neutral rotation. The cast is then removed, and rehabilitation is initiated under the supervision of a hand therapist in the 3rd week (Video 2, Supplemental Digital Content 2, https://links.lww.com/TIO/A60). EXPECTED OUTCOMES The present study demonstrates a new technique using a distally based ECU tendon slip for the stabilization of DRUJ. Stabilization of DRUJ is provided through the stabilization of the distal ulna. In this technique, the ECU tendon acts as a static stabilizer besides its dynamic stabilizer effect. The ECU tendon slip is turned around the ulnar styloid and sutured back onto itself, which provides direct stability on the distal ulna in gross DRUJ instability with complete disruption of soft tissue stabilizers of DRUJ. Moreover, this technique also indirectly increases the stabilization of the DRUJ by tensioning the superficial portion of the radioulnar ligaments and the remaining soft tissue stabilizers in cases with incomplete disruption of soft tissue stabilizers. The major advantages of this technique over others are straightforward technical application and a shorter operation time without a need for a bone tunnel. Thus, this technique avoids the complications related to bone tunnels, such as fracture, expansion of the tunnel, and loosening. This is especially important in osteoporotic patients. Furthermore, there is no need for any implant fixation which avoids implant-related complications. COMPLICATIONS The dorsal sensory branch of the ulnar nerve may be injured during exposure. Rupture of the tendon graft may occur if the graft is not harvested in sufficient thickness. The half thickness of the ECU tendon is appropriate to perform this technique. Infection and recurrent instability could be other possible complications of this procedure.

Predictive factors of distal radioulnar joint instability after surgical treatment of distal radius fractures.

Distal radioulnar joint (DRUJ) instability is a common postoperative complication of distal radius fractures, seriously impacting patients' quality of life. This study investigated its possible influencing factors to determine prognosis and to guide treatment better. We retrospectively included a series of patients with distal radius fractures that underwent volar locking plate fixation. Basic patient information and imaging parameters were collected. The incidence of DRUJ instability during follow-up was recorded, and factors associated with DRUJ instability were determined using univariate analysis and multifactorial logistic regression analysis. A total of 159 patients were enrolled in this study. At 6 months of follow-up, 54 patients (34.0%) had DRUJ instability, and multivariate analysis showed coronal plane displacement (OR, 1.665; 95% CI, 1.091-2.541), fracture classification (OR, 0.679; 95% CI, 0.468-0.984) and DRUJ interval (OR, 1.960; 95% CI, 1.276-3.010) were associated with DRUJ instability after volar locking plate. DRUJ interval, coronal plane displacement, and fracture classification are associated with DRUJ instability during follow-up. Therefore, preoperative risk communication and intraoperative attention to recovering relevant imaging parameters are necessary for these patients.

Arthrex Mini Tightrope Fixation for Chronic Distal Radioulnar Joint Instability.

Chronic distal radioulnar joint (DRUJ) instability is a complex clinical condition that is difficult to treat. Currently, there is no gold standard treatment. We present a novel technique using Arthrex Mini Tightrope for DRUJ stabilization. In this case series, a 1.6 mm K-wire was passed transversely through the distal ulna and radius. The Mini Tightrope was inserted into the end of the K-wire and pulled through the bone tunnels. Appropriate tension was achieved to stabilize the joint according to individual laxity comparable to the contralateral side. Five patients (3 males and 2 females) comprised this pilot series, with a mean age of 27.1 years. All sustained a traumatic injury at an average of 12.4 months before surgery (range: 5 to 32 mo). In addition, 3 patients had central triangular fibrocartilage complex tears treated with arthroscopy at the time of Mini Tightrope placement. While one patient was lost to follow-up after 7 weeks postoperative due to incarceration, 4 patients demonstrated coronal and sagittal stability in the context of DRUJ motion and a satisfactory range of motion. The mean time for the return to work for the two patients who were laborers or normal activity postoperatively was 5.2 weeks (range: 1 to 16.4 wk). Unrestricted activity was generally allowed 8 weeks postoperatively but varied by patient. The same 4 patients underwent hardware removal at an average of 31 weeks (range: 15 to 44 wk). Although this is only a pilot series, this suggests that temporary Mini Tightrope stabilization of the DRUJ may be a viable solution while upholding the benefits of minimally invasive surgery.

Reliability and Validity Analysis of the Distal Radioulnar Joint Ballottement Test

Triangular fibrocartilage complex injuries can cause distal radioulnar joint (DRUJ) instability, which can be evaluated clinically with the DRUJ ballottement test. However, the reliability and validity of the test are unclear. This study aimed to analyze the reliability and validity of the test using a tracking device on healthy participants and patients with triangular fibrocartilage complex injuries. In this cross-sectional study, three orthopedic hand surgeons performed the DRUJ ballottement test using a technique of holding the carpal bones to the radius on 25 healthy participants (50 hands; 10 men and 15 women; mean age, 33 years; range, 20-51 years) and eight patients with triangular fibrocartilage complex injuries (16 hands; six men and two women; mean age, 43 years; range, 27-59 years). We used a three-dimensional electromagnetic tracking device to quantify the movement of the DRUJ and verify the reliability and validity of the test. The intrarater and interrater intraclass correlation coefficients for DRUJ movement were 0.77 and 0.61, respectively, and the kappa coefficient for grading of DRUJ instability was 0.79. The correlation coefficient between DRUJ movement measured using the tracking device and instability judged clinically was 0.77. A comparison of healthy participants and the patients showed significantly greater DRUJ movement in the patients. The test showed substantial intrarater and interrater reliability for assessing DRUJ movement and instability. The significant positive correlation between DRUJ movement and instability indicates the concurrent validity of the test. Moreover, the test showed discriminative validity in identifying mild or moderate DRUJ instability. The DRUJ ballottement test using the holding technique has a relatively high diagnostic accuracy and can be used to assess DRUJ instability.

Morphometry of sigmoid notch: A novel method of shape assessment for clinical practice

PurposeUsing a novel technique, we assess and describe the distal radioulnar joint (DRUJ) anatomy with reference to sigmoid notch shapes. The purpose of this study was to develop a non-invasive, fast, reliable and reproducible technique for analysing the shapes of sigmoid notch on CT scans. Methods40 cadaveric wrist specimens exposing the sigmoid notch and 100 normal adult wrist CT scans with end on axial sections showing the sigmoid notch outline were obtained. The shape of the sigmoid notch was assessed on both using the geometric construction method. ResultsOf the 40 cadaveric specimens, 42 % were C-shaped, 33 % were flat,17 % were Ski sloped, and 8 % were S-shaped.Of the 100 wrist CT scans, 48 % were C-shaped sigmoid notch, 17 % were flat, 15 % were ski-sloped, and 20 % were S-shaped shapes. ConclusionsOur sample population had a higher prevalence of C-shaped sigmoids in both cadaveric and CT-based studies. It is considered the most stable shape because of its increased depth. The DRUJ morphology in our sample population can be inferred to have a stable configuration. Clinical relevanceThe relationships and measurements demonstrated in this study can be a guide when considering ligament reconstruction for DRUJ instability, managing complex fractures involving the DRUJ and in decision-making for notchplasty, osteotomy and arthroplasty of DRUJ.

Comparative Analysis of Treatment Outcomes: Modified Ulnar Gutter Slab vs. Sugar Tong Slab for Distal Radioulnar Joint Instability Following Triangular Fibrocartilage Complex Repair.

The standard treatment for distal radioulnar joint (DRUJ) instability involves repairing the triangular fibrocartilage complex (TFCC) and immobilizing the joint with a sugar tong slab, but this can cause elbow stiffness. To address this, a modified ulnar gutter slab was designed to enhance elbow mobility during immobilization. A prospective randomized controlled trial was conducted on 23 DRUJ instability patients who underwent arthroscopic TFCC repair. Two post-operative splinting techniques were compared: the modified ulnar gutter slab and the sugar tong slab. The assessment included the Disabilities of Arm, Shoulder, and Hand (DASH) score; elbow, forearm, and wrist range of motion (ROM); post-operative DRUJ stability; and complications. DASH scores at 4 and 6 weeks were not significantly different. However, the modified ulnar gutter slab improved elbow extension range of motion at 4 weeks (extension lag: 20.0 vs. 6.5 in the sugar tong group) (p = 0.011). Post-operative DRUJ stability was comparable between the two groups. Notably, one patient in the sugar tong slab group experienced complex regional pain syndrome (CRPS). The modified ulnar gutter slab offers a post-operative alternative after TFCC repair. It effectively immobilizes forearm and wrist motion while enhancing elbow mobility, potentially reducing post-operative elbow stiffness.

Aptis Distal Radioulnar Joint Arthroplasty: A Multicenter Evaluation of Functional Outcomes, Complications, and Patient Satisfaction

Abstract Background The Aptis distal radioulnar joint (DRUJ) implant has been commonly used to replace the DRUJ and restore wrist function in patients with a severely destroyed DRUJ. Objective Promising results have been described in the literature. However, the clinical results in a multicenter setting are sparse and variable. This study evaluates the short- to midterm clinical results of 53 patients with a (mean) follow-up of 51 months. Patients and Methods Fifty-three patients (59 implants) treated between 2011 and 2020 in three different institutions were retrospectively identified in a prospectively collected database. The main indication for Aptis DRUJ arthroplasty was a destroyed DRUJ and gross distal radioulnar instability and isolated DRUJ osteoarthritis. Functional outcome, complications, and patient satisfaction were evaluated. Patients completed the Patient-Rated Wrist Evaluation (PRWE) questionnaire and an additional questionnaire about patient satisfaction and return to hobby/work. Results Implant survival was 92%, the surgical follow-up showed many complications (64,4%), and revision surgery was needed frequently (40.7%). In 13 cases, the follow-up was longer than 5 years. Three reimplantations had to be performed and two implants were permanently explanted. In spite of this all, wrist and forearm motion as well as pain reduction was adequate and patient satisfaction was reasonable (72.2%). Conclusion The Aptis DRUJ arthroplasty is a viable option that can provide adequate wrist and forearm function after secure patient selection and surgical placement of the implant in the wrist with a good bone stock of the radius. The complication rate was found to be high, yet patient satisfaction was reasonable. In the case of secondary surgery, additional surgery seems to be needed. For primary surgery, the implant seems to be successful without complications. Different complications have been described, but further analysis is warranted to find the causes of complications and to objectify the performance of the Aptis DRUJ implant. Level of Evidence IV.

An alternative treatment for degenerative triangular fibrocartilage complex injuries with distal radioulnar joint instability: first experience with 48 patients.

Treatment of ulnar impaction syndrome combined with distal radioulnar joint instability due to irreparable degenerative triangular fibrocartilage complex injuries can be complex. We describe the outcomes of a novel technique for restoring distal radioulnar stability due to ulnar impaction syndrome using a distally based extensor carpi ulnaris tendon strip combined with ulnar shortening osteotomy in 48 patients. Patients were assessed using standardized outcome measurements. The patient-rated wrist/hand evaluation total score improved from 66 (SD 15) at intake to 40 (SD 25) at 3 months, and 28 (SD 23) at 12 months postoperatively (p < 0.001). Wrist extension and flexion improved significantly at 12 months from 53° (SD 11) to 65° (SD 8) (p < 0.001) and from 45° (SD 10) to 56° (SD 12) (p = 0.01), respectively. Adding a distally based longitudinal extensor carpi ulnaris strip to ulnar shortening osteotomy for restoring distal radioulnar joint stability seems to be an effective treatment in patients with irreparable degenerative triangular fibrocartilage complex injuries due to ulnar impaction syndrome. Level of evidence: IV.

Weight-bearing test of traumatic triangular fibrocartilage complex lesion with unstable radioulnar joint

BackgroundUlnar-sided wrist pain might be caused by a lesion of the triangular fibrocartilage complex (TFCC). Patients with TFCC lesion may show an instability of the distal radioulnar joint (DRUJ). Before arthroscopic assessment, conservative therapy using a brace or splint may result in alleviation of symptoms. The results of our previous study showed that patients with a traumatic TFCC lesion and instability of the DRUJ had the smallest weight-bearing capacity and had the largest increase in application of the wrist brace (WristWidget). PurposeIn this prospective study, we wanted to test if the weight-bearing capacity with and without the wrist brace can be used as a diagnostic tool to differentiate between patients with traumatic TFCC lesion and instability of the DRUJ. We tested if patients with traumatic TFCC lesion and instability of the DRUJ (1) have a lower weight-bearing capacity and (2) show a higher increase of weight-bearing capacity after application of a wrist brace compared to all other types of injury. Study DesignThis was a prospective cohort study. MethodsForty-eight patients presented to an outpatient clinic with suspected TFCC lesion. We measured the dynamic weight-bearing capacity of both hands with and without the wrist brace (WristWidget) by letting the patients lean on an analog scale with extended arm and wrist. The stability of the DRUJ was assessed by clinical examination by a hand surgeon preoperatively and intraoperatively. Forty-five patients received an arthroscopy and were included in the analysis. During arthroscopy, the surgeon determined if there was a traumatic TFCC lesion and DRUJ instability. Patients with a traumatic lesion of the TFCC and DRUJ instability were compared to all other cases. We used the t-test for normally distributed values, Mann-Whitney U test for nonnormally distributed values, and the Chi-square test for categorical variables, respectively Fisher’s exact if the expected cell count was less than five. ResultsPatients with a traumatic TFCC lesion and DRUJ instability had a higher weight-bearing capacity (22.8 kg) than all other cases (13.8 kg; p < 0.01). This is in contrast to our previous study, in which patients with a traumatic lesion of the TFCC had the tendency to show lower values of weight-bearing capacity than those with a degenerative lesion. While the wrist brace was worn, the relative gain was not significantly lower in patients with traumatic TFCC lesions and DRUJ instability compared to all other cases (21% vs 54%, p = 0.16). All included cases showed the same absolute increase of about 4 kg in weight-bearing capacity with the wrist brace (p = 0.93) ConclusionsThe weight-bearing test cannot be used to identify patients with traumatic TFCC lesion and DRUJ instability among those with suspected TFCC lesion. The results of our previous study could be confirmed that the weight-bearing capacity on the injured side was higher with brace than without.

Four-dimensional computed tomography detects dynamic three-dimensional pathologies of the wrist in patients with calcium pyrophosphate deposition disease.

Crystal deposits in ligaments of the wrist are typical findings in patients with calcium pyrophosphate deposition (CPPD) disease. CPPD crystals trigger inflammation and ultimately result in ligament tears with scapholunate (SL) advanced collapse (SLAC). This study aimed to investigate carpal instabilities in patients with CPPD using four-dimensional computed tomography (4D-CT) of the wrist. This IRB-approved prospective feasibility study investigated patients with CPPD of the hand. All patients underwent a static 3D-CT and two dynamic 4D-CT in ulnar- and radial abduction and in supination and pronation movements to analyze instabilities of the SL region and of the distal radioulnar joint (DRUJ). Two independent readers scored the images for the presence of SL ligament and triangular fibrocartilage complex (TFCC) calcifications. Furthermore, the readers assessed the dynamic images for SL and DRUJ instabilities. Descriptive analyses were performed. Inter-rater reliability was assessed using Cohen's kappa (κ). Nine patients were included. SL ligament calcifications and instabilities were found in all patients. Of these, dynamic SL instability was detected in 77.8% of the patients, while 22.2% had a SLAC wrist. TFCC calcifications were found in 87.5% of the patients. Four patients had DRUJ instability (50%). No patient showed DRUJ instability without the presence of TFCC calcifications. Agreement between readers for calcifications was excellent (κ = 1) and almost perfect (κ = 0.89) for instabilities. This study provides the first evidence of relevant dynamic carpal instability in CPPD patients using advanced imaging techniques with 4D-CT, offering unique insights into wrist biomechanics.

The Hook Test Is Not Pathognomonic for Foveal Detachment of the Triangular Fibrocartilage.

Background  The integrity of the foveal insertion of the triangular fibrocartilage complex (TFCC) is currently assessed by inference using the hook test. Using dry arthroscopic techniques, the primary author observed that many patients with painful distal radioulnar joint (DRUJ) instability and a positive hook test had an intact foveal insertion. This study was performed to determine whether a positive hook test is a reliable index of a tear of the foveal insertion. Technique  The hook test is performed using a probe to elevate the TFCC off the ulna head toward the articular surface of the lunate. In this study, the hook test was considered positive if the TFCC could be elevated to bridge more than 80% of the space between the TFCC and the articular surface of the lunate. Patients and Methods  A retrospective study was performed using the medical records and arthroscopic videos of 113 patients who had clinical signs of DRUJ instability and underwent arthroscopic surgery performed by the primary author in 2020. It was documented whether the hook test was positive or negative, whether the foveal insertion was intact, abnormal or absent, and whether there were peripheral (dorsal or volar) tears of the TFCC. Sensitivity and specificity were calculated using arthroscopic findings as the reference standard. Results  The sensitivity of the hook test was found to be 100%, and the specificity was 7.0%. The positive predictive value for foveal pathology was found to be 12.3% and the negative predictive value 100%. The diagnostic accuracy of the hook test in determining the presence of foveal tears was found to be 17.7%. The diagnostic accuracy of the hook test in determining the presence of a TFCC abnormality was 99.1%. Conclusions  A positive hook test is indicative of a tear of the TFCC, but it is not anatomically specific for a tear of the foveal insertion. To reliably assess the foveal insertion, it must be visualized and probed using dry arthroscopic techniques.

A structured non-operative treatment program for traumatic triangular fibrocartilage complex tear: A quasi-experimental study

ObjectivesTriangular fibrocartilage complex (TFCC) injury is a common cause of ulnar-sided wrist pain. However, treatment protocols vary across clinical settings and a standardized treatment protocol is needed to improve quality of care.We devised a rehabilitation regime which comprised both orthoses and exercises. We hypothesized that the program can effectively reduce pain and improve functional performance. Materials and methodsThirty-two subjects participated in the 5-phase rehabilitation program. Progress was monitored every 3 weeks. Outcome measures comprised numeric pain rating scale (NPRS), activities of daily living (ADL) pain score, wrist range of motion (ROM), ADL performance score, patient-rated wrist evaluation (PRWE), power grip and distal radioulnar joint (DRUJ) instability grade. ResultsNPRS decreased from 5.3/10 to 0.5/10 while the ADL pain score improved from 10/20 to 19.1/20. ROM in flexion/extension and supination/pronation improved by 35%. Functional performance on ADL performance score and PRWE improved from 21/40 to 38/40 and 49.5/100 to 14.6/100, respectively. Power grip increased by 59.5%, and DRUJ stability improved. DiscussionThe combination of orthoses and progressive strengthening and proprioception training was effective in re-establishing DRUJ stability, and improving wrist strength and functional performance. ConclusionsThis study provided insight for the development of a rehabilitation protocol for patients with TFCC injury.