Intact Triangular Fibrocartilage Complex Research Articles

Reverse Wafer Procedure

Abstract Purpose This study aimed to present the results of an alternative technique for treating ulnar impaction syndrome, the “reverse wafer procedure,” and assess the mid-term clinical outcomes of patients treated with this technique. Methods A retrospective evaluation was conducted on 14 patients who underwent the reverse wafer procedure for ulnar impaction syndrome between 2013 and 2020. The inclusion criteria for the study were persistent ulnar-sided wrist pain, even after a minimum of 3 months of nonoperative treatment, the presence of a chondral lesion on the lunate, and an intact triangular fibrocartilage complex (TFCC) based on arthroscopic evaluation. Postoperative clinical and subjective functional outcomes were assessed using measures such as wrist range of motion (ROM), grip strength, the Turkish version of the quick disabilities of the arm, shoulder, and hand questionnaire (Quick DASH), and pain levels measured on a visual analog scale (VAS) and were compared with preoperative values. Patient satisfaction was also evaluated postoperatively. Results The mean follow-up period was 42.2 months (range: 24–68 months). Postoperatively, none of the patients experienced any restriction in ROM. Grip measurements significantly increased after the surgery (p = 0.003). Preoperatively, the patients had a grip strength of 41.14 kg (range 28–48 kg), which improved to 44 kg (range 30–52 kg) postoperatively. Postoperative VAS values and QDASH scores significantly decreased compared with the preoperative values (p < 0.001, p = 0.001). The mean VAS score decreased from 6.1 (range 4–8) preoperatively to 0.9 (range 0–5) postoperatively. The mean Quick DASH score decreased from 49.44 (range 25–68.3) preoperatively to 10.13 (range 3.3–36) postoperatively. When asked about their satisfaction with the operation, 13 out of 14 patients reported being highly satisfied with the results. Conclusions The reverse wafer procedure presents an alternative treatment option for ulnar impaction syndrome in cases where the TFCC is intact. The mid-term results of this described technique are promising. However, further comparative studies with longer follow-ups are necessary to support these findings. Level of Evidence IV Therapeutic.

Arthroscopic Wafer Procedure for Ulnar Impaction Syndrome in an Intact Triangular Fibrocartilage Complex

AbstractUlnocarpal impaction or ulnar abutment symptom occurs secondary to abnormal load bearing on the ulnar side of the wrist leading to pain symptoms and degeneration of the structures of the ulnocarpal joint.The two classical surgical methods used to address this problem are ulnar shortening osteotomy and the wafer procedure, which can either be open or arthroscopic. With the advent of arthroscopy, with surgeon harboring arthroscopy skills, arthroscopic wafer resection has been intensely popularized which requires a central perforation of the triangular fibrocartilage to approach the ulna dome through the ulnocarpal joint.So, what happens in symptomatic patients with ulnocarpal abutment with an intact triangular fibrocartilage complex who have failed conservative management. Do we perform an open procedure or do we create a perforation in the central disc of the triangular fibrocartilage complex to expose the ulnar dome? Or do we just do an ulnar shortening osteotomy?Here, we describe our arthroscopic technique of conducting arthroscopy in the narrow confines of the space below the triangular fibrocartilage complex above the ulnar dome to carry out an arthroscopic wafer procedure in a triangular fibrocartilage complex with no central perforation. The procedure can produce results similar to those of the classical arthroscopic wafer procedure described explicitly in the literature.

MRI-Related Risk Factors for Distal Radioulnar Joint Instability.

Instability of the dorsal radioulnar ligament (DRUL) is caused by multiple factors from bony and soft tissue structures. Studies of DRUJ instability based on MRI have rarely been reported. This study aims to investigate related instability factors in the distal radioulnar joint (DRUJ) after trauma based on MRI imaging. The MRI imaging was performed on 121 post-traumatic patients with or without DRUJ instability from April 2021 to April 2022. All patients demonstrated pain or attenuated wrist ligamentous tissue quality with physical examination. The interesting variables, including age, sex, the distal radioulnar transverse shape, the triangular fibrocartilage complex (TFCC), DRUL, the volar radioulnar ligament (VRUL), distal interosseus membrane (DIOM), the extensor carpi ulnaris (ECU), and pronator quadratus (PQ), were analyzed using univariable and multivariable logistic regression model. The different variables were compared in radar plots and bar chart. An average age of 121 patients was 42.16 ± 16.07 years. The 50.4% DRUJ instability existed in all patients and the distal oblique bundle (DOB) presented in 20.7% of patients. The TFCC (p=0.03), present DIOM (p=0.001), and PQ (p=0.006) were identified to be significant in final multivariable logistic model. The percentage of patients with ligament injuries were general higher in DRUJ instability group. The patients with absent DIOM had a higher rate in DRUJ instability, TFCC, and ECU injury. There was higher stability in shape of C-type, intact TFCC, and present DIOM. DRUJ instability is closely associated with TFCC, DIOM, and PQ. It could provide a potential for early detection of potential instability risk and taking necessary preventive measures.

Radioulnar joint reconstruction: a novel surgical technique and biomechanical assessment for chronic instability

PurposeThis study aims to describe and biomechanically evaluate a novel technique using a strip of the flexor carpi ulnaris tendon for distal radioulnar joint reconstruction.MethodsSurgical technique was thoroughly detailed, and a cadaveric biomechanical test was conducted to evaluate sagittal plane stability. Pronosupination range of motion was measured before and after the procedure. Dorsal and volar translation resistances were checked in three situations: with the uninjured triangular fibrocartilage complex, after its complete resection and after the surgical procedure.ResultsFor distal radioulnar joint translation, higher values were found both in dorsal and volar translation in situations with an injured triangular fibrocartilage complex, with means equal to 25.4 mm (SD: 9.4 mm) and 26.1 mm (SD: 8.0 mm), respectively. For intact triangular fibrocartilage complex, both dorsal and volar translations averages were 3.4 mm (SD: 0.9 mm) and 4.5 mm (SD: 1.8 mm), respectively. Finally, when evaluating dorsal and volar translations after surgical reconstruction, means were 6.3 mm (SD: 1.3 mm) and 6.8 mm (SD: 0.9 mm), respectively. Regarding supination and pronation range of motion, which ranged from 57.9 to 63.4o, there were no differences in mean and median measures, when the cadavers with intact and reconstructed triangular fibrocartilage complex were compared (p > 0.05).ConclusionPromising mechanical evaluations encourage us to hypothesize that the technique effectively reconstructs the dorsal and volar radioulnar ligaments, preserving pronosupination and maintaining the physiological characteristics of the wrist joint. Clinical comparative studies are still necessary to fully validate this procedure.Level of evidenceTherapeutic - Level V.

Outcomes of surgically treated distal radius fractures associated with triangular fibrocartilage complex injury

Study DesignProspective cohort. IntroductionClinical studies that evaluate the correlation between associated lesions of the triangular fibrocartilage complex (TFCC) and outcome of distal radius fractures expressed with the patient-rated disability are missing. The purpose of this study was to evaluate the outcomes of distal radius fractures associated with or without an injury of the TFCC. MethodsPatients undergoing operative treatment for distal radius fracture were prospectively enrolled (n = 70). TFCC was examined by wrist arthroscopy and injuries classified according to Palmer. Comparative analyses were performed on 45 patients with TFCC injury (injured group) and 25 patients with intact TFCC (intact group). The outcome measures included the Patient-Rated Wrist Evaluation (PRWE) and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaires, 3 and 12 months after injury. ResultsTFCC was injured in 45 patients (64%). In patients with intact TFCC, mean total PRWE score was 27 (3 months) and 16 (12 months), compared to patients with TFCC injury with 40 (at 3 months) and 24 (at 12 months). Mean DASH scores were 26 and 13 at 3 and 12 months for the intact group and 39 and 27 for the injured group. PRWE and DASH results showed significant difference at 3 and 12 months when compared with Mann–Whitney test. DiscussionPRWE and DASH scores evaluation showed that patients with associated TFCC injury had greater pain and disability at 3 and 12 months after injury. ConclusionsDisability outcomes were worse in patients with distal radius fracture, where TFCC was injured. TFCC injuries are an important cofactor affecting the outcome of distal radius fractures.

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

Distal radius fractures are associated with ahigh incidence of triangular fibrocartilage complex (TFCC) tears. This study aims to evaluate the status of TFCC after the healing of distal radius fractures, and its clinical significance. Wrist arthroscopies were performed on 43 distal radius fractures, with an average age of 54years old. Twenty-six complete tears and 15 partial healed tears were noted. Five out of eight patients with intact TFCC tears had neither signs nor symptoms, while eight patients with TFCC tears had no complaint. While no association was found between ulnar wrist pain and TFCC tears, there was association between DRUJ instability and TFCC tears and fovea tears. The function outcome did not differ with respect to the integrity of TFCC. A large majority of TFCC tears remained unhealed after the union of distal radius fractures. However, not all patients with tear were symptomatic.

Outcomes of surgically treated distal radial fractures with associated triangular fibrocartilage complex injury

Study DesignProspective cohort. IntroductionClinical studies that evaluate the correlation between associated lesions of the triangular fibrocartilage complex (TFCC) and outcome of distal radial fractures expressed with the patient-rated disability are missing. Purpose of the StudyTo evaluate the outcomes of distal radius fractures associated with or without an injury of the TFCC. MethodsPatients undergoing operative treatment for distal radial fracture were prospectively enrolled (n = 70). The TFCC was examined by wrist arthroscopy, and injuries were classified according to Palmer. Comparative analyses were performed on data from 45 patients with TFCC injury (the injured group) and 25 patients with an intact TFCC (the intact group). The outcome measures included The Patient-Rated Wrist Evaluation (PRWE) and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaires, 3 and 12 months after injury. ResultsThe TFCC was injured in 45 patients (64%). In patients with an intact TFCC, the mean total PRWE score was 27 (at 3 months) and 16 (at 12 months), whereas in patients with TFCC injury, it was 40 (at 3 months) and 24 (at 12 months). Mean DASH scores were 26 and 13 for the intact group and 39 and 27 for the injured group at 3 and 12 months, respectively. PRWE and DASH results showed significant difference at 3 and 12 months when compared using the Mann-Whitney test. ConclusionsDisability outcomes were worse in patients with distal radial fracture where TFCC was injured. TFCC injuries are an important cofactor affecting the outcome of distal radial fractures.

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

Certain distal ulna fractures may contribute to distal radioulnar joint (DRUJ) instability. We hypothesized that residual distal ulna translation could affect DRUJ stability by slackening the distal interosseous membrane (DIOM). We aimed to test this hypothesis in a cadaver model. We created an ulnar translated distal ulna fracture model in 6 cadavers. Dorsal and palmar displacements of the ulna relative to the radius were measured and DRUJ instability was staged under the following conditions: (1) 0-, 2-, and 4-mm ulnar translation of the distal ulna with an intact triangular fibrocartilage complex (TFCC) and DIOM; (2) 0-, 2-, and 4-mm translations with TFCC divided and an intact DIOM; and (3) a 0-mm translation with TFCC and DIOM divided. With an intact TFCC, dorsal and palmar displacements were not increased with any amount of distal ulna translation. After TFCC division with 0-mm translation, dorsal displacement increased significantly with DRUJ dislocation, whereas palmar displacement increased to a lesser extent with DRUJ subluxation. Palmar displacement gradually increased as the translation increased, and with 4-mm translation the ulnar head displaced to a perched position off the sigmoid notch. With TFCC and DIOM division, displacements increased markedly with DRUJ dislocation both dorsally and palmarly. Dorsal dislocation occurred when the TFCC was divided regardless of the amount of distal ulna translation. Palmar subluxation occurred when the TFCC alone was divided. Palmar displacement to a perched position occurred because of slackening of the DIOM as a result of translation of the distal ulna. Bidirectional DRUJ instability with dorsal dislocation and palmar displacement to a perched position occurred when the TFCC was divided and the distal ulna was ulnarly translated. Bidirectional DRUJ instability might occur when distal ulna translation deformity is associated with TFCC injury because the DIOM loses its function as a secondary stabilizer.

Do Ligamentous Tears Heal After Anatomically Reduced Distal Radius Fracture?

Objectives: Distal radius fracture was associated with a high incidence of ligamentous injury, including triangular fibrocartilage complex (TFCC) tear, scapholunate ligament (SL) tear, and lunotriquetral (LT) tear. This study aims to evaluate the status of these ligaments after the healing of distal radius fractures with plate fixation. Materials and Methods: Patients who were elected for the removal of plate after the healing of their distal radius were recruited for the study from August 2014 to January 2016. Concomitant wrist arthroscopy was performed to assess the status of the TFCC, SL, and LT. Results: In total, 34 patients with an average age of 53 years with healed distal radius fractures were recruited for the study. Twelve patients had extra-articular distal radius fractures; 15 patients had preoperative symptoms, including ulnar wrist pain; and 24 were noted to have distal radial ulnar joint (DRUJ) instability on examinations. The findings of wrist arthroscopies revealed 25 complete TFCC tears and 9 incomplete tears, showing signs of healing. Four patients had combined TFCC tears. All patients with symptoms and signs had TFCC tears, while the 9 patients with intact TFCC tear had neither symptoms nor signs. Sixty-seven percent of the patients had TFCC tears arisen from the sigmoid notch, and 29% had fovea tears. There was no correlation between ulnar wrist pain and the location of the TFCC tears, and there was no correlation between TFCC tear and the presence of ulnar styloid fractures. There were 26 SL tears and 15 LT tears. One patient with LT tear suffered from volar intercalated segment instability (VISI). None of the patients with SL and LT tears suffered from clinical signs and symptoms. No significant correlation was found between the SL and LT tears and the TFCC tears. Conclusion: A high incidence of TFCC, SL, and LT tears was noted after the union of anatomically reduced distal radius fractures. While TFCC tears may give rise to clinical signs and symptoms in terms of DRUJ instability, patients with SL and LT tears are relatively asymptomatic.

Effect of Electrothermal Treatment on Nerve Tissue Within the Triangular Fibrocartilage Complex, Scapholunate, and Lunotriquetral Interosseous Ligaments

To evaluate the effect of thermal treatment on neural tissue in the triangular fibrocartilage complex (TFCC), scapholunate interosseous ligament (SLIL), and lunotriquetral interosseous ligament (LTIL). The intact TFCC, SLIL, and LTIL were harvested from cadaveric specimens and treated with a radiofrequency probe as would be performed intraoperatively. Slides were stained using a triple-stain technique for neurotrophin receptor p75, pan-neuronal marker protein gene product 9.5 (PGP 9.5), and 4',6-diamidino-2-phenylindole for neural identification. Five TFCC, 5 SLIL, and 4 LTIL specimens were imaged with fluorescence microscopy. Imaging software was used to measure fluorescence signals and compare thermally treated areas with adjacent untreated areas. A paired t test was used to compare treated versus untreated areas. P < .05 was considered significant. For the TFCC, a mean of 94.9% ± 2.7% of PGP 9.5-positive neural tissue was ablated within a mean area of 11.7 ± 2.5mm(2)(P= .02). For the SLIL treated from the radiocarpal surface, 97.4% ± 1.0% was ablated to a mean depth of 2.4 ± 0.3mm from the surface and a mean horizontal spread of 3.4 ± 0.5mm(P= .01). For the LTIL, 96.0% ± 1.5% was ablated to a mean depth of 1.7 ± 0.7mm and a mean horizontal spread of 2.6 ± 1.0mm(P= .02). Differences in the presence of neural tissue between treated areas and adjacent untreated areas were statistically significant for all specimens. Our study confirms elimination of neuronal markers after thermal treatment of the TFCC, SLIL, and LTIL in cadaveric specimens. This effect penetrates below the surface to innervated collagen tissue that is left structurally intact after treatment. Electrothermal treatment as commonly performed to treat symptomatic SLIL, LTIL, and TFCC tears eliminates neuronal tissue in treated areas and may function to relieve pain through a denervation effect.

Effect of Volarly Angulated Distal Radius Fractures on Forearm Rotation and Distal Radioulnar Joint Kinematics

To examine the effect of volar angulation deformities of the distal radius with and without triangular fibrocartilage complex (TFCC) rupture on forearm range of motion and the kinematics of the ulnar head at the distal radioulnar joint (DRUJ) during simulated active forearm rotation. Volar angulation deformities of the distal radius with 10° and 20° angulation from the native orientation were created in 8 cadaveric specimens using an adjustable apparatus. Active supination and pronation were performed using a forearm motion simulator. Pronation and supination range of motion was quantified with each deformity. In addition, changes in the dorsovolar position of the ulnar head relative to the radius were calculated after simulating each distal radial deformity. Testing was performed with the TFCC intact and sectioned. Volar angulation deformities of 20° decreased the supination range with preservation of pronation. There was no effect of TFCC status on the range of forearm rotation. With the TFCC intact, volar angulation deformities translated the ulna slightly dorsally in pronation and volarly in supination. After sectioning the TFCC, volar angulation deformities of 10° and 20° translated the ulna dorsally throughout forearm rotation. Volar angulation deformities reduce supination range and alter the DRUJ kinematics. The increased tension in the intact TFCC caused by volar angulation deformities likely prevented the expected dorsovolar displacement at the DRUJ and restricted supination. Dividing the TFCC released the constraining effect on the DRUJ and allowed the ulna to translate dorsally. However, supination remained limited, presumably because of impediment from the dorsally subluxated ulna. This study demonstrated the importance of correcting volar angulation deformities of the distal radius to less than 20° in order to maintain normal range of forearm rotation and to less than 10° to maintain normal DRUJ kinematics when the TFCC is ruptured.

The effects of dorsally angulated distal radius fractures on distal radioulnar joint stability: a biomechanical study

Relationship between dorsal tilt of the distal radius and distal radioulnar joint stability was examined. Stiffness in dorsopalmar displacement of the radius (distal radioulnar joint stiffness) was recorded at 10° intervals until 30° of dorsal angulation from 10° of palmar tilt. Tests were repeated after partial sectioning of the radioulnar ligament, then after complete sectioning of the radioulnar ligament. All data were compared with control (intact triangular fibrocartilage complex, 10° of palmar tilt). The distal radioulnar joint stiffness in dorsal translation decreased significantly with dorsal tilt 10° and 20° in pronation. Partial sectioning of the radioulnar ligament indicated a decrease of the distal radioulnar joint stiffness in the dorsal translation at neutral tilt to 20° of dorsal tilt in the neutral position and in pronation. Distal radioulnar joint stiffness decreased significantly in both dorsal and palmar translations in all forearm positions at 10° and 20° of dorsal tilt. From these findings, the dorsal angulation of the radius should be corrected to less than 10° of dorsal tilt.

Reconstructive Procedure for Unstable Radial-Sided Triangular Fibrocartilage Complex Avulsions

Radial-sided avulsions of the triangular fibrocartilage complex (TFCC) (Palmer 1D) with distal radioulnar joint (DRUJ) instability remain a challenging pathology to treat. We tested an intra-articular reconstruction that addresses unstable radial-sided TFCC avulsions. Ten preserved, dissected, cadaveric forearm specimens with intact TFCC and without ulnar-positive variance had biomechanical testing using a hydraulic testing device. The measurement of total displacement of the ulna relative to the radius was performed with an applied load ranging from 20 N in a volar direction to 20 N in a dorsal direction. Specimens were tested sequentially with intact TFCC, with surgically induced Palmer 1D lesions, and after reconstruction of the TFCC. All tests were performed at neutral, maximal pronation, and maximal supination. The mean total displacements of the DRUJ of the specimens at neutral rotation were as follows: 4.1 +/- 0.4 mm for the intact specimens compared with 11.8 +/- 0.8 mm after creation of the tear and 3.9 +/- 0.7 mm for the reconstructed specimens. In maximal pronation the mean total displacements were as follows: 2.4 +/- 0.3 mm intact versus 4.9 +/- 0.7 mm for torn and 2.1 +/- 0.3 mm after reconstruction. In maximal supination the mean total displacements were as follows: 1.4 +/- 0.2 mm intact versus 5.7 +/- 1.3 mm for torn and 1.0 +/- 0.1 mm after reconstruction. All specimens obtained the preoperative pronation and supination motion after the reconstruction. Current procedures are unable to restore DRUJ stability without a significant limitation of pronation and supination. This intra-articular reconstruction of radial-sided TFCC avulsions succeeded in restoring baseline stability to the DRUJ without interfering with pronation/supination.

遠位どう尺関節における尺骨掌側脱臼の２例

Two cases of fresh traumatic anterior dislocation of the ulna at the distal radioulnar joint (DRUJ) are reported: one is an isolated dislocation and the other with the styloid process fracture of the ulna. In the latter arthrography of the wrist revealed the triangular fibrocartilage complex (TFCC) remained intact.Computerized tomography through DRUJ is helpful for the diagnosis of the dislocation. Closed reduction under general anaesthesia failed in both of them. At operation the intact TFCC prevented the dislocated ulna from reduction.