Effect of dorsal capsular imbrication on intraoperative DRUJ instability following arthroscopic TFCC repair surgery.

BACKGROUND: To assess the clinical outcomes and identify the ideal indication for implementing dorsal distal radioulnar joint (DRUJ) capsular imbrication after triangular fibrocartilage complex (TFCC) repair in cases of DRUJ instability. METHODS: We conducted a retrospective study on patients who underwent arthroscopic TFCC repair between 2016 and 2021. Inclusion criteria comprised a symptomatic ulna fovea sign for over 6 months and dorsal DRUJ subluxation on magnetic resonance imaging. A total of 225 patients were divided into two groups: Group 1 (135 cases) with a negative ballottement test after "Cross-form TFCC repair" (CR) and Group 2 (90 cases) with a positive ballottement test after "Cross-form TFCC repair" and augmented DRUJ stability through dorsal DRUJ capsular imbrication (CR + DCI). Pain visual analog scale score (VAS), grip strength, modified Mayo Wrist Score (MMWS), wrist range of motion (ROM), and patient-reported outcomes (PROMs) were assessed for a minimum of 3 years postoperatively. RESULTS: Both groups showed significant improvements in pain VAS score, grip strength, wrist ROM, MMWS, and PROMs between the preoperative and postoperative periods (all P < 0.05). Recurrent DRUJ instability occurred in 3.7% and 1.1% of patients in the "CR" and "CR + DCI" groups, respectively, with a significant difference. Despite the "CR + DCI" group initially exhibiting inferior ROM compared with the "CR" group, subsequently, no significant difference was noted between them. CONCLUSIONS: Dorsal DRUJ capsular imbrication effectively reduces postoperative DRUJ instability rates, enhances grip strength, and maintains wrist ROM in patients with a positive intra-operative ballottement test after arthroscopic TFCC repair.

Ligamentoplasty using the ulnotriquetral ligament with wafer procedure for chronic triangular fibrocartilage complex foveal tear: Short-tem outcome.

BACKGROUND: We developed a new ligamentoplasty technique using the ulnotriquetral ligament (UTL) via a palmar approach for cases with dorsal instability of the ulna due to a foveal tear of the triangular fibrocartilage complex (TFCC). The study aimed to evaluate the clinical outcomes of this procedure. METHODS: We retrospectively analyzed 19 cases with foveal tears of TFCC who underwent the ligamentoplasty using UTL. We harvested the UTL from the triquetrum as a pedicle graft, avoiding damage of the connection between the base of the UTL and palmar radioulnar ligament (PRUL) as possible. The graft was flipped proximally and pulled out through the bone tunnel from the ulnar fovea to the ulnar neck, then fixed to the fovea using a tenodesis screw. The function of the TFCC can be reproduced by pulling out the UTL along with the PRUL through the ulnar fovea and re-establishing the PRUL tension. Clinical results were evaluated at least 12 months following surgery. The preoperative and postoperative wrist pain level on a neumerical rating scale (NRS), the radioulnar joint (DRUJ) ballottement test, the range of motion, the grip strength, and the Patient-rated wrist evaluation (PRWE) scores were evaluated. RESULTS: In all cases, the DRUJ ballottement test became negative at the final follow up compared with the normal side on manual examination. The pain levels significantly decreased as reflected by a decrease in NRS from 6.8 to 2.5 at final follow up (p < 0.01). The range of pronation/supination motion was improved from 149° to 157°. The mean PRWE score significantly decreased from 52.1 to 22.8 (p < 0.01). The postoperative pain level on the NRS scale of the three patients poorly improved. One case of the three with the 3 mm positive ulnar variance needed additional ulnar shaft shortening using a plate seven months after the primary procedure. CONCLUSIONS: The ligamentoplasty using UTL efficiently restored the ulnar palmar stability in all 19 cases and significantly decreased the wrist pain and the PRWE scores. STUDY DESIGN: Clinical, retrospective study.

Distal Radioulnar Joint: Normal Anatomy, Imaging of Common Disorders, and Injury Classification.

The distal radioulnar joint (DRUJ) is the distal articulation between the radius and ulna, acting as a major weight-bearing joint at the wrist and distributing forces across the forearm bones. The articulating surfaces are the radial sigmoid notch and ulnar head, while the ulnar fovea serves as a critical attachment site for multiple capsuloligamentous structures. The DRUJ is an inherently unstable joint, relying heavily on intrinsic and extrinsic soft-tissue stabilizers. The triangular fibrocartilage complex (TFCC) is the chief stabilizer, composed of the central disk, distal radioulnar ligaments, ulnocarpal ligaments, extensor carpi ulnaris tendon subsheath, and ulnomeniscal homologue. TFCC lesions are traditionally classified into traumatic or degenerative on the basis of the Palmer classification. The novel Atzei classification is promising, correlating clinical, radiologic, and arthroscopic findings while providing a therapeutic algorithm. The interosseous membrane and pronator quadratus are extrinsic stabilizers that offer a minor contribution to the joint's stability in conjunction with the joints of the wrist and elbow. Traumatic and overuse or degenerative disorders are the most common causes of DRUJ dysfunction, although inflammatory and developmental abnormalities also occur. Radiography and CT are used to evaluate the integrity of the osseous constituents and joint alignment. US is a useful screening tool for synovitis in the setting of TFCC tears and offers dynamic capabilities for detecting tendon instability. MRI allows simultaneous osseous and soft-tissue evaluation and is not operator dependent. Arthrographic CT or MRI provides a more detailed assessment of the TFCC, which aids in treatment and surgical decision making. The authors review the pertinent anatomy and imaging considerations and illustrate common disorders affecting the DRUJ. Online supplemental material is available for this article. © RSNA, 2022.

Treatment of type II symptomatic ulnar styloid nonunions with reinsertion of the triangular fibrocartilage complex.

PURPOSE: The purpose of this retrospective study was to introduce an alternative technique for the treatment of type II symptomatic ulnar styloid nonunion by the reinsertion of the triangular fibrocartilage complex and the ulnar collateral ligament. METHODS: Between March 2009 and May 2017, 45 patients (34 males and 11 females) suffering from the nonunion of type II ulnar styloid fractures all underwent the subperiosteal resection of the avulsed fragments and the reinsertion of the TFCC and ulnar collateral ligament. Outcome assessments included the ranges of motion of the wrist, grip strength, pain, and Mayo wrist score. The preoperative and postoperative parameters were compared. A P-value less than 0.05 was considered to be statistically significant. RESULT: The mean follow-up period was 21.66 ± 7.93 months (range, 12 to 26 months). At the final follow-up, the mean preoperative flexion and extension were 79.32 ± 4.52° and 74.40 ± 4.36° respectively. The mean preoperative pain score, grip strength, and Mayo wrist score were 32.48 ± 4.00; 23.88 ± 8.38 kg, and 77.72 ± 8.31 respectively. The mean postoperative flexion and extension of the wrist were 80.56 ± 6.32° and 75.43 ± 3.12° respectively. The mean postoperative pain score, grip strength, and Mayo wrist score were 12.41 ± 3.27, 26.31 ± 8.30 kg, and 90.71 ± 7.97 respectively. There were significant differences in pain, grip strength, and Mayo wrist score (P < 0.05), but no significant differences concerning the range of motion of the wrist. CONCLUSION: In the treatment of the nonunion of type II ulnar styloid fractures, the resection of the avulsed fragments followed by the reinsertion of the TFCC and the ulnar collateral ligament with an anchor was a reliable alternative technique, bringing the satisfactory function of the wrist.

Ulnar positive variance associated with TFCC foveal tear.

OBJECTIVE: The ulnar positive variance (UPV) can be observed on simple radiography due to a triangular fibrocartilage complex (TFCC) foveal tear. This study investigated to identify how much radiographic UPV occurs due to a TFCC foveal tear, which may be misdiagnosed as an ulnar impaction syndrome (UIS). MATERIALS AND METHODS: One hundred forty patients who underwent arthroscopic transosseus TFCC foveal repair from March 2013 to March 2019 in our institution were enrolled in this study. Ulnar variances were measured in preoperative, postoperative 6 weeks, 1-year follow-up wrist posteroanterior (PA) radiograph, and power grip PA radiograph of the affected wrist and were compared with those of the same patient's unaffected wrist. RESULTS: In the neutral wrist PA radiograph, ulnar variance increased by 0.56 mm (p < 0.001) after TFCC foveal tear compared to the unaffected side. In the power grip view, ulnar variance also increased by 0.39 mm (p < 0.001) in the affected wrist. The preoperative ulnar positive variance was reduced after an arthroscopic transosseous TFCC foveal repair from 0.56 to 0 mm (p < 0.001). No significant statistical difference was observed between an Atzei class 2 and 3 TFCC tear (0.56 mm vs. 0.41 mm, p = 0.263). CONCLUSION: This study revealed that TFCC foveal tear induces 0.56 mm of radiologic UPV, which was successfully corrected after arthroscopic transosseous TFCC foveal repair. Therefore, UPV associated with TFCC foveal tear should not be misdiagnosed as an UIS. Also, when ulnar shortening osteotomy is planned in case of UIS combined with TFCC foveal tear, the amount of UPV induced by TFCC foveal tear should be considered to prevent over-shortening.

Dry Wrist Arthroscopy: Technique and Rationale.

Wrist arthroscopy has been established as a useful, minimally invasive tool for diagnosing and treating many different wrist conditions. The standard portals are located on the dorsum of the hand and wrist and are named for their relation to the extensor compartments. They include the radiocarpal and midcarpal portals. The radiocarpal portals are 3-4, 4-5, 6R, 6U, and 1-2. The midcarpal portals are STT (scaphotrapeziotrapezoidal), MCR (midcarpal radial), and MCU (midcarpal ulnar). Traditionally, wrist arthroscopy is performed with constant inflow of saline solution for joint insufflation and visualization. Dry wrist arthroscopy (DWA) is a technique that allows for arthroscopic exploration and instrumentation without infusing any fluid into the joints. Some advantages of DWA include lack of fluid extravasation, less obstruction by floating synovial villi, decreased risk of compartment syndrome, and the ability to perform concomitant open procedures more easily than with a wet technique. Additionally, the risk of fluid displacing carefully laid bone graft is much less without constant flow. DWA can be used in the assessment and management of triangular fibrocartilage complex (TFCC) and scapholunate interosseous ligament tears and other ligamentous injuries. DWA can also be used in fracture fixation to assist with reduction and restoration of articular surfaces. Moreover, it is used in more chronic settings to diagnose scaphoid nonunions. DWA does have its disadvantages such as generation of heat through the use of burrs and shavers and clogging of these instruments during debridement of tissue. DWA is a technique that can be used to manage multiple orthopaedic conditions including soft-tissue and osseous injuries. With a minimal learning curve for surgeons who already perform wrist arthroscopy, DWA can be a useful addition to their practice.

Clinical Outcomes of Arthroscopic One-Tunnel Triangular Fibrocartilage Complex Transosseous Suture Repair Are Not Diminished in Cases of Ulnar Styloid Process Fracture Nonunion.

PURPOSE: To determine whether clinical outcomes of arthroscopic one-tunnel wrist triangular fibrocartilage complex (TFCC) transosseous suture repair are not diminished in cases of ulnar styloid process fracture nonunion (USPFN). METHODS: Patients who underwent arthroscopic 1-tunnel transosseous suture repair of Palmer 1B foveal TFCC tear (with/without superficial fiber tear; Atzei class 2 or 3 TFCC tear) from 2015 to 2020 were retrospectively reviewed. Group I was the TFCC foveal tear repair group with USPFN. Group II was the TFCC foveal tear repair group without USPFN. In group I, no additional treatment for USPFN was made. Functional preoperative and postoperative outcomes were compared by Modified Mayo Wrist Score (MMWS); Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) score; grip strength; pain visual analog scale (VAS); and distal radioulnar joint (DRUJ) stability. Wrist posteroanterior, lateral, and both oblique views of the wrist were used to assess the ulnar styloid process before and after operation. RESULTS: This study consisted of 66 patients: group I (n = 22) and group II (n = 44). No differences were found between the 2 groups preoperatively in MMWS, Quick-DASH, grip strength, and VAS (MMWS: P = .94, Quick-DASH: P = .23, grip strength: P = .69, VAS: P = .45). No differences were found between the 2 groups with respect to outcome measures postoperatively in MMWS, Quick-DASH, grip strength, and VAS (MMWS: P = .59, Quick DASH: P = .82, grip strength: P = .15, VAS: P = .84). All of the enrolled patients achieved restored function with negative ballottement test and maintained DRUJ stability on follow-up. Of the 22 USPFN cases in group I, 11 (50%) showed spontaneous union after transosseous TFCC foveal repair without any additional USPFN treatment. The proportion of patients achieving a minimal clinically important difference for the Quick-DASH was similar between the 2 groups. CONCLUSIONS: Although this current study has insufficient statistical power, the available data suggest that patients with TFCC foveal tear combined with USPFNs treated with arthroscopic transosseous repair surgery could experience similar functional improvement compared with those with TFCC foveal tear without USPFNs. The presence of USPFN accompanied by Palmer 1B type TFCC foveal tear may not affect the clinical results, including MMWS, Quick-DASH, grip strength, VAS, and DRUJ stability of patients who undergo arthroscopic 1-tunnel transosseous suture repair. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Return to Activity After Arthroscopically Assisted Triangular Fibrocartilage Complex Repair: A Systematic Review.

OBJECTIVE: To evaluate patients' ability to return to preinjury activity level after arthroscopically assisted triangular fibrocartilage complex (TFCC) repair. DATA SOURCES: The PubMed electronic library was systematically searched from inception to August 2021 for any eligible articles using a combination of the phrases "TFCC," "return to sport," "return to work," and "athlete." RESULTS: Studies that evaluated patients who had undergone arthroscopic repair of isolated TFCC injury and reported objective or patient-reported outcome measures were included. Fifteen studies representing 478 patients fulfilled the inclusion criteria. An average of 84% of patients were able to fully return to their previous work or sport activities. Most studies reported that range of motion (ROM) and grip strength (GS) both returned to >90% of the contralateral side, and every study that evaluated pain levels found a significant reduction in pain postoperatively. Mayo Modified Wrist Score was reported as excellent or good in 83% of patients, and the average Disabilities of the Arm, Shoulder, and Hand score was 13.8 postoperatively. CONCLUSION: Patients were able to return to their previous work or sport activities at a high rate after TFCC repair, even those participating in more strenuous activities. Measurable functional outcomes of ROM and GS were also reliably restored to near preinjury levels. Patient-reported outcomes of pain and disability were similarly improved after TFCC repair. Current literature has established the long-term success of TFCC repair but is lacking in evaluation of the time points at which patients can expect functional status to be restored.

Do triangular fibrocartilage complex foveal injuries affect the clinical outcome of ulnar shortening osteotomy for ulnar impaction syndrome?

BACKGROUND: Ulnar shortening osteotomy (USO), as its name implies, is used to shorten the ulna. It subsequently tightens the triangular fibrocartilage complex (TFCC) and ulnar wrist. TFCC foveal insertion is a primary stabilizer of the distal radioulnar joint. It is unclear whether USO is effective in TFCC foveal injuries. The purpose of this study was to review the clinical outcomes of ulnar shortening osteotomies with and without TFCC foveal injuries. METHODS: We retrospectively reviewed patients with ulnar wrist pain treated with USO and wrist arthroscopy including the distal radioulnar joint (DRUJ). Sixty-five patients were included in this study. An algorithm was used to guide surgical decision-making. After arthroscopic confirmation of ulnar impaction syndrome, we performed USO with a locking compression plate (mean length of shortening, 2.7 mm; range, 1-7.5 mm). The flattened TFCC disc due to ulnar shortening was confirmed arthroscopically. If the DRUJ was unstable after USO, we repaired the TFCC foveal insertion. RESULTS: There were 32 post-traumatic and 33 idiopathic cases. We detected TFCC disc injuries in 34 wrists and TFCC foveal injuries in 33 wrists; both types were found in 15 wrists. TFCC foveal injuries were not significantly correlated with patient age, history of trauma, or clinical outcome. Most patients showed good clinical outcomes; 31 of 65 patients had preoperative DRUJ instability, with a significant number having foveal but not disc injuries. CONCLUSION: USO achieved reasonable outcomes, even in patients with TFCC foveal injuries. In cases demonstrating ulnar impaction, USO should be prioritized over TFCC repair.

Relevant landmarks to navigate the suture locations for the arthroscopic triangular fibrocartilage complex foveal reattachment.

INTRODUCTION: Key step of arthroscopic triangular fibrocartilage complex (TFCC) foveal reattachment is to suture dorsal and palmar deep components of radioulnar ligaments (RULs) to the fovea of ulnar head to ensure distal radioulnar joint stability. However, the deep components are covered and cannot be identified arthroscopically from standard radiocarpal joint view. Suturing sites described in previous studies have not been proved gasping of the deep components. The purpose of this study was to investigate our TFCC suture locations using relevant landmarks on securing the RULs' deep components for arthroscopic TFCC foveal reattachment. MATERIALS AND METHODS: Wrist arthroscopy and horizontal mattress suture was performed in 20 fresh-frozen cadaver wrists. Based on close proximity of the ulnocarpal ligaments to the palmar RUL and fovea, palmar suture location was designated at the junction between ulnolunate, ulnotriquetral ligaments and palmar border of TFCC disc, whereas dorsal suture location was at dorsal border of TFCC disc, opposite the palmar location, at same distance between prestyloid recess and palmar location. The radiocarpal and ulnocarpal joint was subsequently opened to evaluate grasping of RULs' deep components and evaluate the relevant landmarks. RESULTS: Thirty-nine of 40 (97%) RULs' deep components were successfully grasped by the sutures. With 0.98-0.99 interobserver agreement for the measurements, mean distance between sigmoid notch to suture and suture to ulnar capsule were 5.6 ± 1.1 and 4.0 ± 0.9 mm, respectively. Whereas, the dissecting point of deep component from the superficial component of the RULs was detected immediately radial to the midpoint between the sigmoid notch and the ulnar capsule (4.5 ± 0.9 mm from sigmoid notch). CONCLUSIONS: We determined the relevant anatomical landmarks to navigate the TFCC suture locations, which reliably secure the deep components of the radioulnar ligaments for the arthroscopic TFCC foveal reattachment.

Distal radius fracture with concomitant ulnar styloid fracture: does distal radioulnar joint stability depend on the location of the ulnar styloid fracture?

INTRODUCTION: Studies are conflicting regarding the relationship between ulnar styloid fracture (USF) location and distal radioulnar joint (DRUJ) instability in patients with distal radius fracture (DRF) and concomitant USF. The objective of this study was to determine the association of USF location with TFCC foveal tear and factors associated with DRUJ instability in patients with both DRF and USF. MATERIALS AND METHODS: Fifty-four patients with both DRF and USF who had wrist MRI examination before surgery were analyzed. USF location (tip or base) and TFCC foveal insertion status (intact, partial tear, or complete tear or avulsion with fractured fragment) were evaluated. DRUJ stability was assessed intra-operatively after fixation of the radius. Factors potentially associated with DRUJ instability, such as age, gender, USF location, USF fragment gap, radioulnar distance, radial shortening, and TFCC foveal tear, were analyzed. RESULTS: Among 54 patients, 37 (69%) and 17 (31%) had USF at the base and the tip, respectively. In patients with base fractures, TFCC foveal insertion was found to be disrupted in 89% (33/37) patients (complete tear in 11 and partial tear in 22) but intact in 11% (4/37). On the contrary, in patients with tip fractures, the insertion was found to be disrupted in 88% (15/17) patients (complete tear in 2 and partial tear in 13) but intact in 12% (2/17). After fixation of the radius, total 52% (28/54) patients showed DRUJ instability. Especially, DRUJ instability was found in 57% (21/37) of ulna styloid process base fracture patients and 41% (7/17) of ulna styloid process tip fracture patients. In univariate analysis, complete tear of TFCC foveal insertion and wider USF fragment distance were associated with DRUJ instability. CONCLUSIONS: Tears of TFCC foveal insertion are common in patients with DRF and concomitant ulnar styloid base fractures. Based on the findings of this study, tear of TFCC foveal insertion seems to be also common in patients with DRF and concomitant ulnar styloid tip fractures. And also, DRUJ instability seems to be associated with a TFCC foveal tear independent of USF location.

Wrist and forearm range of motion commencement time following primary triangular fibrocartilage complex foveal repair surgery: A scoping review.

STUDY DESIGN: Scoping review. BACKGROUND: Rehabilitation guidelines following triangular fibrocartilage complex (TFCC) foveal repair surgery have been inconsistently reported in the published literature, with no consensus regarding wrist or forearm range of motion (ROM) commencement time. PURPOSE OF THE STUDY: To scope the available literature to identify the extent and strength of the evidence supporting the clinical guidelines for wrist and forearm ROM commencement time following primary TFCC foveal repair surgery. METHODS: A systematic search produced 26 studies (3 retrospective cohort studies, 1 prospective cohort study, 1 retrospective comparative study, and 21 retrospective case series) that described specific rehabilitation protocols following TFCC foveal repair surgery. RESULTS: No supporting evidence was identified regarding rehabilitation protocol recommendations across all the included studies. Postsurgery wrist ROM commencement ranged from 2 to 8 weeks; forearm ROM commencement ranged from 2 to 12 weeks. ROM commencement times did not appear to systematically influence the rate of adverse events, although adverse events were poorly reported. CONCLUSIONS: TFCC rehabilitation protocols were poorly reported and varied widely between the included studies. Additional research is recommended to comprehensively evaluate the association between wrist and/or forearm ROM and the rate of adverse events for this complex and multifaceted condition.

Arthroscopic foveal repair with suture anchors for traumatic tears of the triangular fibrocartilage complex.

BACKGROUND: Foveal tears of the traumatic triangular fibrocartilage complex (TFCC) are the most commonly neglected high-energy injuries of the wrist joint, and the patients with such tears often experience unrecovered ulnar-sided wrist pain and poor wrist function. This study investigated the functional outcomes of patients who underwent arthroscopic repair of foveal TFCC tears with suture anchors and adjuvant platelet-rich plasma (PRP) injections after the surgery. METHODS: From September 2014 to August 2018, 156 men and 45 women with diagnoses of foveal TFCC tears without wrist fractures underwent arthroscopic repair by using the outside-in method with 1.3-mm suture anchors and subsequent PRP injection. After surgery, splinting was applied for 6 weeks, and the patients underwent rehabilitation, re-examination, and follow-up at our clinic. The patients' wrist functional scores and grip strength data were retrospectively collected. RESULTS: The mean follow-up period was 32.6 months, and the mean age was 26.7 years. The mean modified Mayo wrist score improved from 48.5 ± 2.6 to 82.4 ± 2.5, whereas the mean Disabilities of the Arm, Shoulder and Hand (DASH) score decreased from 39.2 ± 6.7 to 10.6 ± 7.5. Overall, the wrist functions of 186 (92.5%) of the patients were satisfactory according to their modified Mayo wrist scores, and the patients with satisfactory scores returned to sports or work activities. These patients retained normal ranges of motion, and their average grip strength in the affected hand was restored to at least 85% of that of the other hand. CONCLUSIONS: According to the postoperative 25-36 months surgical results of our study, arthroscopic repair with adjuvant PRP injections is a satisfactory method of repairing early foveal tears of the TFCC and can enhance wrist function by relieving pain and increasing tolerance for work or sports.

Functional Outcomes Are Similar After Arthroscopic Capsular Repair of Triangular Fibrocartilage Complex Tears Between Outside-In Technique and All-Inside Technique Using Pre-Tied Suture Device.

PURPOSE: To compare outcomes of arthroscopic triangular fibrocartilage complex capsular repair at 2-year follow-up between outside-in and all-inside techniques. METHODS: In total, 58 consecutive patients (wrists) with a Palmer 1B triangular fibrocartilage complex tear without symptomatic distal radioulnar joint instability underwent arthroscopic suture repair from 2011 to 2019 including 31 patients via the outside-in technique (group A) and 27 via the all-inside technique using a pre-tied needle device (group B). Two-year follow-up included visual analog scale (VAS) pain score, motion range, grip strength, Mayo Modified Wrist Score (MMWS), the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, and complication rate. Correlation between functional result and patient satisfaction was analyzed. RESULTS: Score changes in VAS, wrist flexion-tension, supination-pronation, grip strength, MMWS, and QuickDASH at 2-year follow-up were not significantly different between group A (3.4 ± 0.8, 18.4 ± 17.5, 12.9 ± 13.3, 30.7 ± 11.2, 26.6 ± 7.9 and 19.4 ± 9.9 and group B (3.4 ± 1.0, 18.5 ± 18.3, 15.6 ± 13.7, 30.8 ± 11.4, 28.1 ± 8.6, and 7.6 ± 7.2) with P values of .400, .489, .223, .486, .240, and .223 respectively. Surgical time averaged 105 minutes (78 to 136) in group A and 94 minutes (61-126) in group B with significant difference (P = .012). Patient satisfaction averaged 1.1 (0-3.5) in group A and 1.0 (range 0-3.0) in group B. Satisfaction score was more strongly correlated with QuickDASH (coefficients: 0.863 in group A and 0.918 in group B) than with MMWS (-0.693 in group A and -0.465), grip strength (-0.619 in group A and -0.417 in group B) and VAS score (0.607 in group A and 0.222 in group B). CONCLUSIONS: Both techniques achieved comparable outcomes with shorter surgical time in all-inside repair using pre-tied needle device. Patient satisfaction was strongly correlated with QuickDASH score. LEVEL OF EVIDENCE: Level III, retrospective therapeutic comparative investigation.

Ultrasound With Artificial Intelligence Models Predicted Palmer 1B Triangular Fibrocartilage Complex Injuries.

PURPOSE: To calculate the diagnostic accuracy from the confusion matrix using deep learning (DL) on ultrasound (US) images of Palmer 1B triangular fibrocartilage complex (TFCC) injury. METHODS: Twenty-nine wrists of 15 healthy volunteers (11 men; mean age, 34.9 years ± 9.7) (control group) and 20 wrists of 17 patients (11 men; mean age 41.0 years ± 12.2) with TFCC injury (Palmer type IB) (injury group) were included in the study. The diagnosis of Palmer 1B TFCC injury was made using magnetic resonance imaging, computed tomography arthrography, and intraoperative arthroscopic findings. In total, 2,000 images were provided to each group, 80% of which were randomly selected by AI and used as training data; the remaining data were used as test data. Transfer learning was conducted using a pretrained 3 separate models (GoogLeNet, ResNet50, ResNet101). Model evaluation was performed using a confusion matrix. The area under a receiver operating characteristic curve was also calculated. The occlusion sensitivity was used to visualize the important features. RESULTS: For the prediction of TFCC injury by the DL model, the best score of accuracy was 0.85 in GoogLeNet, a recall was 1.0 in ResNet50 and ResNet101, and a specificity was 0.78 in GoogLeNet. In predicting the TFCC injury for the test data, the best score of the AUC was 0.97 on ResNet101. Visualization of important features showed that AI predicted the presence of injury by focusing on the morphology of the articular disc. CONCLUSIONS: US images using the DL model predicted Palmer 1B TFCC injury with high accuracy, with the best scores of 0.85 for accuracy on GoogLeNet, 1.00 for sensitivity on ResNet50 and ResNet101, and 0.78 for specificity on GoogLeNet. The use of DL for US imaging of Palmer 1B TFCC injury predicted the injury as well as magnetic resonance imaging and computed tomography arthrography LEVEL OF EVIDENCE: IV; retrospective case series study.

Midterm Results of Arthroscopy-Assisted "Tent Form" Triangular Fibrocartilage Complex Repair With Dorsal Distal Radioulnar Joint Capsule Imbrication for Posttraumatic Chronic Distal Radioulnar Joint Instability.

PURPOSE: To evaluate the outcomes of "tent form" triangular fibrocartilage complex (TFCC) repair combined with dorsal distal radioulnar joint (DRUJ) capsule imbrication for posttraumatic chronic DRUJ instability. METHODS: All patients treated with arthroscopic "tent form" TFCC repair and DRUJ capsule imbrication from 2016 to 2019 were retrospectively reviewed. The inclusion criteria were symptomatic chronic DRUJ instability for >6 months and dorsal DRUJ subluxation on magnetic resonance imaging. The Disabilities of the Arm, Shoulder, and Hand score, Patient-Rated Wrist Evaluation, grip strength, Modified Mayo Wrist Score, range of motion, and distal radioulnar joint stability were assessed for a minimum of 2 years postoperatively. RESULTS: Thirty-eight patients were included in the final analysis. The average follow-up duration was 35.6 months (range, 24-48 months). The 24-month postoperative grip strengths and 3-dimensional motions of wrist were not significantly different from that of the nonoperated wrist. Compared with their preoperative status, Disabilities of the Arm, Shoulder, and Hand score, Patient-Rated Wrist Evaluation, and Modified Mayo Wrist Score indicated the significant improvement with P values of .001, .001, and .002, respectively. CONCLUSIONS: In chronic DRUJ instability with a loosening dorsal capsule, "tent form" TFCC transcapsular repair combined with DRUJ capsule imbrication restored the integrity of TFCC and dorsal DRUJ capsule and achieved a promising outcome. We recommend this procedure as an option of treatment for patients with posttraumatic chronic DRUJ instability. LEVEL OF EVIDENCE: IV, case series.

Arthroscopic-Assisted Foveal Reattachment of Triangular Fibrocartilage Complex Tears With Distal Radioulnar Joint Instability: A Comparison of Suture Anchors and Transosseous Sutures.

PURPOSE: To compare the clinical outcomes of arthroscopically-assisted suture anchor repair and transosseous sutures for repair of foveal triangular fibrocartilage complex tears in patients with distal radioulnar joint (DRUJ) instability. METHODS: Sixty patients with triangular fibrocartilage complex foveal detachment associated with DRUJ instability were prospectively recruited and randomized into 2 equal groups-the anchor repair group and the transosseous repair group. The primary outcome was DRUJ function after 2 years, which was assessed by the DRUJ evaluating system. The secondary outcomes were grip strength, visual analog scale for pain, Mayo Modified Wrist ScorePatient-Rated Wrist Evaluation score, and the Disabilities of the Arm, Shoulder, and Hand score. RESULTS: There were no significant differences between the groups for any of the outcome measures. Good-to-excellent outcomes (according to the DRUJ evaluation system) were achieved in 27 (90%) patients in the anchor repair group and 26 (86.7%) patients in the transosseous repair group. Fewer complications were observed in the anchor repair group. CONCLUSIONS: Both techniques yielded good and comparable outcomes with a lesser incidence of early complications in the anchor repair group. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Anatomical Study of the Innervation of Triangular Fibrocartilage Complex and Distal Radioulnar and Radiocarpal Joints: Implications for Denervation.

PURPOSE: Open and percutaneous denervation is an emerging technique for joint pain. This study investigated the course and distribution of the articular branches innervating the triangular fibrocartilage complex (TFCC), distal radioulnar joint (DRUJ), and radiocarpal joint (RCJ) relative to bony and soft tissue landmarks to guide wrist denervation procedures. METHODS: Fourteen formalin-embalmed specimens were serially dissected to expose the origin, course, and distribution of articular branches innervating the TFCC, DRUJ, and RCJ. Bony and soft tissue landmarks to localize each articular branch were documented and visualized on a 3-dimensional reconstruction of the bones of the distal forearm and hand. RESULTS: The TFCC was innervated by articular branches from the posterior interosseus nerve (10 of 14 specimens), dorsal cutaneous branch of the ulnar nerve (14 of 14 specimens), palmar cutaneous branch of the ulnar nerve (12 of 14 specimens), and medial antebrachial cutaneous nerve (9 of 14 specimens). The DRUJ was innervated by the posterior interosseus nerve (9 of 14 specimens) and anterior interosseus nerve (14 of 14 specimens). The RCJ was innervated by the posterior interosseus nerve (14 of 14 specimens), superficial branch of the radial nerve (5 of 14 specimens), lateral antebrachial cutaneous nerve (14 of 14 specimens), and palmar cutaneous branch of the median nerve (10 of 14 specimens). CONCLUSIONS: Multiple nerves were found to innervate the TFCC, DRUJ, and RCJ. The relationship of anatomical landmarks to specific articular branches supplying the TFCC, DRUJ, and RCJ can inform selective denervation procedures based on the structural origin of pain. CLINICAL RELEVANCE: The detailed documentation of the spatial relationship of the nerve supply to the wrist provides clinicians with the anatomical basis to optimize current, and develop new denervation protocols to manage chronic wrist pain.

Traumatic Osteonecrosis of the Distal Ulna.

A 46-year-old male was referred to our clinic for persistent ulnar-sided wrist pain 9 weeks after sustaining a traumatic injury while playing volleyball. The patient unsuccessfully underwent nonoperative management for a suspected injury to the triangular fibrocartilage complex. After magnetic resonance imaging revealed a lesion of the distal ulna, he was treated with diagnostic wrist arthroscopy and Bowers hemiresection. The diagnosis of osteonecrosis was confirmed through histology. While traumatic osteonecrosis of the carpal bones has been described, no previous literature was found on traumatic osteonecrosis of the distal ulna. Treatment with diagnostic wrist arthroscopy and Bowers hemiresection resulted in an excellent outcome at 12 months after surgery.

Revisional triangular fibrocartilage complex (TFCC) repair using arthroscopic one-tunnel transosseous suture: preliminary results.

PURPOSE: The purpose of this study was to report the clinical outcome of revision arthroscopic triangular fibrocartilage complex (TFCC) foveal repair using a one-tunnel transosseous suture technique after failed primary TFCC repair. METHODS: Consecutive patients treated with arthroscopic TFCC foveal repair using the uniform one-tunnel transosseous suture technique after failed TFCC repair from 2014 to 2018 were retrospectively reviewed. The clinical outcome was evaluated using the Modified Mayo Wrist Score (MMWS) and the Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) score. The Visual Analog Scale (VAS) for pain, stability of the distal radioulnar joint (DRUJ), grip strength, and active range of motion (ROM) of the wrist joint also were assessed. RESULTS: This study cohort consisted of eight patients, and their mean time to revision after initial surgery was 15.1 months. Previous surgeries were performed using an arthroscopy-assisted mini-open TFCC repair in six cases, an arthroscopic all-inside repair in one case, and an arthroscopic transosseous suture technique in the remaining case. After revisional TFCC foveal repair, all patients demonstrated improved pain and a stable DRUJ. Participants showed improvement in grip strength and mean active wrist ROM. There was improvement in MMWS (from 58.6 to 87.5) and Quick-DASH score (from 46.9 to 12.2) during the mean follow-up of 15.6 months (range: 8-36 months). CONCLUSION: Based on the results of this study, remaining ulnar TFCC remnants may be appropriate for sufficient stable repair using an arthroscopic one-tunnel transosseous suture technique after failed primary repair. However, only a small number of patients was examined. A larger number has to be investigated to confirm the promising preliminary results. LEVEL OF EVIDENCE: Level IV, therapeutic case series.