Wrist traumatology in the 2020s

The triangular fibrocartilage complex (TFCC) is the most important stabilizer of the distal radioulnar joint (DRUJ). Its injury is the main cause for ulnar sided pain after wrist trauma. In recent years, advancements of wrist arthroscopy improved the diagnostics and treatment of the TFCC tears. The purpose of this article is to describe a variant of radial tears (1D according to Palmer), in which the radio-ulnar ligaments were ruptured in the midsubstance just before (Pre) their insertion on the sigmoid notch and illustrate the arthroscopic surgical technique used for its treatment. We name this variant of the Palmer 1D lesion, the pre-1D TFCC lesion. 

http://www.arthroscopytechniques.org/article/S2212628722001086/pdf

The Pre-1D Lesion of the TFCC—A New Variant of the Palmer 1D Class

To investigate the longitudinal trend of symptomatic distal radioulnar joint (DRUJ) instability after plate fixation for distal radius fractures (DRFs), determine which factors are associated with persistent symptomatic DRUJ instability, and evaluate the postoperative outcomes of arthroscopic foveal repair of the triangular fibrocartilage complex (TFCC) in patients with persistent symptomatic DRUJ instability after plate fixation for DRF.All consecutive patients who underwent plate fixation for DRF between January 2014 and December 2017 and were followed up for a minimum of 1 year were included in this retrospective study. DRUJ instability was evaluated by subjective ulnar wrist pain and physical examination that included foveal sign and ballottement testing every 2 months after surgery. In patients with persistent symptomatic DRUJ instability lasting >6 months, arthroscopic transosseous foveal repair was performed with consent. Clinical outcomes were evaluated at a minimum of 2 years after surgery. The Generalized Estimating Equation model was used to analyze the incidence rate trend of symptomatic DRUJ instability.Overall, 204 patients were included. The incidence of symptomatic DRUJ instability decreased gradually with time after fixation for DRF until 6 months and was maintained thereafter. Thirty-four of 204 patients (16.6%) had persistent symptomatic DRUJ instability. In multivariable analysis, only high-energy injury was an independent risk factor for persistent symptomatic DRUJ instability (P = .003; odds ratio = 3.599). Seventeen patients underwent arthroscopic foveal repair. The mean follow-up period thereafter was 28.6 months. All clinical outcomes improved significantly compared with preoperative values, and no patient had residual DRUJ instability.In patients who had persistent symptomatic DRUJ instability for >6 months after plate fixation for DRFs, arthroscopic foveal repair of the TFCC is considered as a treatment option. Arthroscopic foveal repair of the TFCC to stabilize the DRUJ provided satisfactory clinical and functional outcomes and decreased ulnar-side pain.Level IV, retrospective case series. 

Arthroscopic Foveal Repair of the Triangular Fibrocartilage Complex Improved the Clinical Outcomes in Patients With Persistent Symptomatic Distal Radio-Ulnar Joint Instability After Plate Fixation of Distal Radius Fractures: Minimum 2-Year Follow-Up

Wrist arthroscopy: indications, portal anatomy and therapeutic advances

Radial-sided tears of the triangular fibrocartilage, though uncommon, can still be a reason for ulnar-sided wrist pain, and, at times, instability of the distal radioulnar joint. Historically, it has been believed that because of the paucity of vascularity along the radial edge of the triangular fibrocartilage complex (TFCC), any form of repair will not lead to healing, thus stating it to be an exercise in futility. Current literature deftly argues against this previously prevailing concept and supports the need of repair in case of symptomatic radial-sided TFCC tears. In our study, we describe an all-arthroscopic technique of repairing radial-sided tears using a bone anchor which can be a fast and simple procedure in the hands of an orthopaedic or hand surgeon trained in arthroscopy. This technique also circumvents the risk of injuring the superficial radial nerve and other radial-sided structures which are stated complications of the current arthroscopic repairs.

Symptomatic Radial-Sided Tears of the Triangular Fibrocartilage Complex: An All-Arthroscopic Repair Using Bone Anchors

Purpose To evaluate the accuracy of the trampoline and hook tests, used in the arthroscopic assessment of triangular fibrocartilage complex (TFCC) tears compared with arthroscopic direct visualization of the radiocarpal joint (RCJ) and of the distal radial ulnar joint (DRUJ). Methods In total, 135 patients (97 male, 38 female, mean age 43.5 years) were divided into 2 groups: (1) 80 patients with chronic ulnar-sided wrist pain and positive fovea sign and (2) 55 patients with other complaints. TFCC was assessed by RCJ and DRUJ arthroscopy and by the trampoline and hook tests to detect rupture of distal and proximal components of the TFCC. Accuracy, specificity, sensitivity, and likelihood ratio of the 2 diagnostic methods were measured and compared, using RCJ and DRUJ arthroscopy as reference. Results The trampoline and the hook tests showed an overall accuracy of 70.37% and 86.67%, respectively. The accuracy of the trampoline test was similar for distal (69%), proximal (66%), and complete (73%) TFCC tears. The hook test was more accurate when evaluating proximal (97%) and complete (98%) tears, rather than distal lesions (75%). Sensitivity for the trampoline and hook tests was 75.00% and 0.00% (P Conclusions The trampoline and hook tests can assure accurate diagnosis of peripheral TFCC tear. The hook test shows greater specificity and sensitivity to recognize foveal TFCC tears. Values of positive likelihood ratio suggest a greater probability to detect foveal laceration of peripheral TFCC for the hook test than for the trampoline test. These findings suggest that DRUJ arthroscopy is not necessary to confirm foveal incompetence of the TFCC, if the hook test is positive. Level of Evidence Level II, retrospective diagnostic trial.

The Hook Test Is More Accurate Than the Trampoline Test to Detect Foveal Tears of the Triangular Fibrocartilage Complex of the Wrist.

Fracture of the base of the thumb metacarpal (M1) is a common finding in hand trauma. Closed reduction and K-wire fixation and open reduction–internal fixation are traditional treatments of choice. The arthroscopic assisted technique has been introduced to improve intra-articular fragment reduction and to preserve fragment vascularization and capsular and ligamentous integrity along with joint stability. Indications for arthroscopic assistance are all types of intra-articular fractures or pending malunions involving the base of M1 and/or the trapezium. The aim of this article is to describe the surgical technique used in managing articular fractures of the base of M1, with arthroscopic assistance. Our experience with this technique confirms the advantages of a minimally invasive method that provides articular reduction under direct vision, with limited soft-tissue damage, and allows early rehabilitation (from day 1 after surgery). This technique is extremely valuable for high-demand patients such as manual workers or athletes. The relative disadvantage of the technique is its technical difficulty, which requires experience with small-joint arthroscopy.

Arthroscopic Assisted Treatment of Thumb Metacarpal Base Articular Fractures.

Arthroscopic treatment in traumatic lesion of the wrist

Background In recent years, new arthroscopic techniques have been introduced to address the irreparable tears of the triangular fibrocartilage complex (TFCC) (Palmer type 1B, Atzei class 4) by replicating the standard Adams–Berger procedure. These techniques, however, show the same limitations of the open procedure in relation to the anatomically defective location of the radial origins of the radioulnar ligaments (RUL) and the risk of neurovascular and/or tendon injury. Aiming to improve the quality of reconstruction and reduce surgical morbidity, a novel arthroscopic technique was developed, with the advantages of reproducing the anatomical origins of the RUL ligaments and providing all-inside tendon graft (TG) deployment and fixation. Description of Technique The Allinside anatomic arthroscopic (3A) technique is indicated for TG reconstruction of irreparable TFCC tears in the absence of distal radioulnar joint (DRUJ) arthritis. Standard wrist arthroscopy portals are used. A small incision in the radial metaphyseal area and arthroscopic control are required to set a Wrist Drill Guide and create two converging tunnels, whose openings are at the radial anatomical origins of the RUL. An ulnar tunnel is drilled at the fovea from inside-out via the 6U portal. A 3-mm tendon strip, from the palmaris longus or extensor carpi radialis brevis, is woven through the tunnels and then secured into the ulnar tunnel with an interference screw. Postoperative immobilization with restricted forearm rotation is discontinued at 5 weeks, and then postoperative rehabilitation is started. Patients and Methods The 3A technique was applied on 5 patients (2 females and 3 males), with an average age 42 years. DRUJ stability, range of motion (ROM), pain (0–10 visual analogue scale [VAS]), grip strength, modified Mayo wrist score (MMWS), and patient satisfaction were used for evaluation before surgery and at follow-up. Results No intraoperative or early complications were registered. At a mean follow-up of 26 months, DRUJ was stable in all patients, which recovered 99% ROM. Pain VAS decreased from 7 to 0.6. Grip strength increased from 38 to 48.8 Kgs. There were 4 excellent results and 1 good result on MMWS. All patient showed high satisfaction. Conclusions Although the 3A technique requires dedicated instrumentation and arthroscopic expertise, it takes advantage of improved intra-articular vision and minimized surgical trauma to reduce the risk of complications and obtain promising functional results.

Allinside Anatomic Arthroscopic (3A) Reconstruction of Irreparable TFCC Tear

The triangular fibrocartilage complex (TFCC) is the major stabilizer of the distal radioulnar joint. TFCC disorders may have traumatic or degenerative etiology. TFCC is most often lacerated at its ulnar periphery. According to the magnitude and direction of the traumatic force, the TFCC may rupture in a variable manner, and the ulnar styloid may also fracture, producing different subtypes of type 1B tears. Treatment options are variable, depending on the tear’s features. Atzei introduced in 2011 a novel treatment-oriented classification subdividing 1B-type lesions into five different classes according to the finding of special radiocarpal arthroscopic tests and distal radioulnar joint arthroscopy. In this chapter, the all-inside arthroscopic repair technique for Atzei class 2 and 3 TFCC foveal lesions is described.

Lucian Lior Marcovici

Papers

The Hook Test Is More Accurate Than the Trampoline Test to Detect Foveal Tears of the Triangular Fibrocartilage Complex of the Wrist.

Arthroscopic Assisted Treatment of Thumb Metacarpal Base Articular Fractures.

Arthroscopic treatment in traumatic lesion of the wrist

Allinside Anatomic Arthroscopic (3A) Reconstruction of Irreparable TFCC Tear

Ulnocarpal Arthroscopy and Distal Radioulnar Arthroscopy