Current concepts and new trends in management of isolated triangular fibrocartilage complex injuries.

The triangular fibrocartilaginous complex is made of multiple components, of which the palmar and dorsal radioulnar ligaments play an important role in distal radioulnar joint stability. The ulnar wrist ligaments may be injured during forearm and wrist trauma. There are several aspects of triangular fibrocartilaginous complex management that are still open to debate. The aim of the present study was to review the current concepts and discuss emerging trends to better elucidate and treat this important ligament complex.Level of evidence: V.

A New Arthroscopic Classification of Triangular Fibrocartilage Complex Disorders.

Introduction The use of wrist arthroscopy has become a prerequisite for diagnosis and treatment of triangular fibrocartilage complex (TFCC) disorders. Since Palmer's landmark paper, many new arthroscopic descriptions of TFCC tears have been published but there is no currently available updated comprehensive arthroscopic classification of TFCC lesions. Purpose We recently described the arthroscopic anatomy of the TFCC as viewed from a 3-4 portal. Our purpose was to propose a new TFCC disorders classification based on this new arthroscopic TFCC description. Methods We included all currently described TFCC disorders to the best of our knowledge into our arthroscopic, functional, and vascular anatomical concept. We also included patient's specific ulnar variance and distal radial ulnar joint coronal inclination as baseline treatment-oriented parameters. The fresh or chronic, reparable or nonreparable nature of some types of TFCC tears were considered as separate parameters. Results The proposed classification includes disc "D" (degenerative or traumatic), reins "R" (traumatic), and wall "W" (traumatic) lesions. Combined lesions of those three parts of the TFCC may be easily identified. This new classification should facilitate future analysis of isolated or combined TFCC disorders whether they are degenerative and/or traumatic. Discussion The authors present a new three-dimensional-three-part arthroscopic updated description of TFCC disorders with relevance to etiology and treatment principles.

Interdisciplinary consensus statements on imaging of DRUJ instability and TFCC injuries.

OBJECTIVES: The purpose of this agreement was to establish evidence-based consensus statements on imaging of distal radioulnar joint (DRUJ) instability and triangular fibrocartilage complex (TFCC) injuries by an expert group using the Delphi technique. METHODS: Nineteen hand surgeons developed a preliminary list of questions on DRUJ instability and TFCC injuries. Radiologists created statements based on the literature and the authors' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panelists consisted of twenty-seven musculoskeletal radiologists. The panelists scored their degree of agreement to each statement on an 11-item numeric scale. Scores of "0," "5," and "10" reflected complete disagreement, indeterminate agreement, and complete agreement, respectively. Group consensus was defined as a score of "8" or higher for 80% or more of the panelists. RESULTS: Three of fourteen statements achieved group consensus in the first Delphi round and ten statements achieved group consensus in the second Delphi round. The third and final Delphi round was limited to the one question that did not achieve group consensus in the previous rounds. CONCLUSIONS: Delphi-based agreements suggest that CT with static axial slices in neutral rotation, pronation, and supination is the most useful and accurate imaging technique for the work-up of DRUJ instability. MRI is the most valuable technique in the diagnosis of TFCC lesions. The main indication for MR arthrography and CT arthrography are Palmer 1B foveal lesions of the TFCC. CLINICAL RELEVANCE STATEMENT: MRI is the method of choice for assessing TFCC lesions, with higher accuracy for central than peripheral abnormalities. The main indication for MR arthrography is the evaluation of TFCC foveal insertion lesions and peripheral non-Palmer injuries. KEY POINTS: • Conventional radiography should be the initial imaging technique in the assessment of DRUJ instability. CT with static axial slices in neutral rotation, pronation, and supination is the most accurate method for evaluating DRUJ instability. • MRI is the most useful technique in diagnosing soft-tissue injuries causing DRUJ instability, especially TFCC lesions. • The main indications for MR arthrography and CT arthrography are foveal lesions of the TFCC.

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

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.

Arthroscopic Assisted Treatment of Combined Trapezium and Bennett Fracture-Dislocation.

Trapezium fractures are unusual; however, they represent the third most frequent fracture of the carpal bones. As they usually follow a high-energy trauma, they are associated with distal radius, Bennett, or Rolando fractures in 80% of cases. Traditional treatment options include, closed reduction and percutaneous pinning, or open reduction and internal fixation. To minimize the additional surgical trauma, an arthroscopic technique has been developed for safe, minimally invasive management of complex injuries of the first carpo-metacarpal joint. Intra-articular dislocated fracture fragments are reduced under direct visualization and fixed through small incisions. Limiting additional surgical damage on the carpo-metacarpal joint ligaments, capsule, and other soft tissues around the fracture preserves the blood supply to fracture fragments and also the proprioceptive system, which is key for the dynamic stability of such a hypermobile joint. This report confirms that the procedure is feasible, and a complete functional recovery can be expected with reduced postoperative rehabilitation.

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

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.

Preservation of terminal branches of the palmar cutaneous branch of the median nerve in open carpal tunnel release.

PURPOSE: Post-operative pain in the palm and scar area is the most common complication after carpal tunnel release and injury to the terminal branches of the palmar cutaneous nerve is generally considered one of the causes for this complication. The Authors performed an intraoperative study preserving the terminal branches of the palmar cutaneous branch of the median nerve and verifying the frequency, location and direction of the branches that cross an interthenar incision. METHOD AND MATERIAL: Eighty-five consecutive patients (57 F - 28 M, mean age 66 y) underwent carpal tunnel release between February and June 2021. The cutaneous branches crossing the incision were identified and preserved by careful dissection. Subsequently they were counted and classified by their direction and distance from the proximal border of the transverse carpal ligament. RESULTS: Sensory branches were found in 40 % of cases (34/85) and their origin was observed at an average of 1.05 cm (0-1.8 cm) distal from the proximal border of the carpal tunnel. A total of 44 branches were observed of which 23 branches crossed the incision with a transverse course and 21 with an oblique, generally proximal-distal radio-ulnar course. The subcutaneous layer overlying the distal third of the transverse carpal ligament was found to be devoid of sensory branches, therefore it can be considered a relatively safe area. CONCLUSION: Isolation and protection of palmar sensory branches is important for improving carpal tunnel release results. This goal can be more easily achieved by locating the skin incision on the distal third of the transverse carpal ligament, where the sensory branches have a lower frequency, possibly associated with a second proximal incision (biportal technique) to better visualize the proximal portion of the ligament and antebrachial fascia.

Revolutions in arthroscopic wrist surgeries.

Recent technical and technological developments in wrist arthroscopic surgery allow for advanced treatments of difficult wrist disorders. In this review, world leaders of wrist arthroscopy describe bone graft for scaphoid nonunion, transosseous repair for triangular fibrocartilage fovea avulsion, palmaris longus reconstruction of the triangular fibrocartilage, and arthroscopic reconstruction of the scapholunate and lunotriquetral ligaments.

Arthroscopic Assisted Treatment of Thumb Metacarpal Base Articular Fractures.

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.

Interdisciplinary consensus statements on imaging of scapholunate joint instability.

OBJECTIVES: The purpose of this agreement was to establish evidence-based consensus statements on imaging of scapholunate joint (SLJ) instability by an expert group using the Delphi technique. METHODS: Nineteen hand surgeons developed a preliminary list of questions on SLJ instability. Radiologists created statements based on the literature and the authors' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panellists consisted of twenty-seven musculoskeletal radiologists. The panellists scored their degree of agreement to each statement on an eleven-item numeric scale. Scores of '0', '5' and '10' reflected complete disagreement, indeterminate agreement and complete agreement, respectively. Group consensus was defined as a score of '8' or higher for 80% or more of the panellists. RESULTS: Ten of fifteen statements achieved group consensus in the second Delphi round. The remaining five statements achieved group consensus in the third Delphi round. It was agreed that dorsopalmar and lateral radiographs should be acquired as routine imaging work-up in patients with suspected SLJ instability. Radiographic stress views and dynamic fluoroscopy allow accurate diagnosis of dynamic SLJ instability. MR arthrography and CT arthrography are accurate for detecting scapholunate interosseous ligament tears and articular cartilage defects. Ultrasonography and MRI can delineate most extrinsic carpal ligaments, although validated scientific evidence on accurate differentiation between partially or completely torn or incompetent ligaments is not available. CONCLUSIONS: Delphi-based agreements suggest that standardized radiographs, radiographic stress views, dynamic fluoroscopy, MR arthrography and CT arthrography are the most useful and accurate imaging techniques for the work-up of SLJ instability. KEY POINTS: • Dorsopalmar and lateral wrist radiographs remain the basic imaging modality for routine imaging work-up in patients with suspected scapholunate joint instability. • Radiographic stress views and dynamic fluoroscopy of the wrist allow accurate diagnosis of dynamic scapholunate joint instability. • Wrist MR arthrography and CT arthrography are accurate for determination of scapholunate interosseous ligament tears and cartilage defects.

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

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 < .001) for distal tears and 78.85% and 100.00% (P < .001) and 58.33% and 100.00% (P < .001) for complete or isolated proximal tears, respectively. Specificity for the trampoline and hook tests was 67.27% and 96.36% (P < .001) respectively. 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.

Arthroscopic Distal Scaphoid Resection for Scapho-Trapezium-Trapezoid Arthritis.

Background: The purpose of this study was to describe the technique of arthroscopic resection of the scaphoid head and evaluate both the clinical and radiographic results of scapho-trapezium-trapezoid osteoarthritis cases. Methods: Seventeen cases (13 men and 4 women) with a mean age of 57 years (24-74 years) were operated on from 2002 to 2015. Inclusion criteria were nontraumatic radial-sided wrist pain without improvement after 4 months of conservative treatment and positive radiographic images demonstrating the presence of osteoarthritis. All cases were evaluated preoperatively and postoperatively using visual analog scale, wrist range of motion (ROM), grip strength, and patient's work status (Mayo Wrist Score). Disabilities of the Arm, Shoulder, and Hand (DASH) and Patient-Rated Wrist/Hand Evaluation (PRWHE) questionnaires were also administered. The technique consisted of performing a 3- to 4-mm round-shaped scaphoid head resection via arthroscopy while preserving the scaphotrapezial and scaphocapitate ligament insertions. Results: At an average follow-up of 24 months, all the patients were satisfied. The results showed statistically significant improvement in pain at rest (P = .001), under maximal load (P = .0001), and in Mayo Wrist Score (MWS) (P = .0001). Wrist ROM, grip strength, DASH, and PRWHE showed an improvement without reaching statistical significance. The mean preoperative radiolunate (RL) X-ray measurement angle was 17° (-10° to 35°). The postoperative mean value was 25° (0°-45°). In the preoperative radiographic evaluation, 11 cases exceeded the "critical" 15° RL angle. At follow-up, the RL angle increased in 10 cases and remained unchanged in 7 cases. None of these cases became symptomatic. Transitory neurapraxia of the dorsal superficial branch of the radial nerve was observed in 1 case. Damage of the dorsal branch of the radial artery was immediately fixed. Conclusions: Arthroscopic resection of the distal portion of the scaphoid due to scapho-trapezium-trapezoid osteoarthritis demonstrated an effective and safe technique with less complications than open surgery.

Prevention of symptomatic neuroma in traumatic digital amputation: A RAND/UCLA appropriateness method consensus study.

INTRODUCTION: The appearance of a symptomatic neuroma following finger amputation is a devastating consequence for patient's quality of life. It could be cause of chronic neuropathic pain. The prevention of neuroma formation is a challenging effort for hand surgeons. The biological mechanisms leading to neuroma formation are mostly unknown and different preventing procedures have been tried without certain results. In this paper, a panel of Italian hand surgeons have been asked to express appropriateness about potentially preventive techniques of neuroma formation following the RAND/UCLA appropriateness protocol. METHODS: A literature review was preliminarily performed identifying the most employed methods to reduce the pathologic nerve scar. Afterwards, the selected panelists were asked to score the appropriateness of each procedure in a double scenario: in case of a sharp amputation or in a tear injury. The appropriateness was evaluated according to RAND/UCLA protocol. RESULTS: Nine Italian hand surgeons were included in the panel. Of them 5 were orthopaedic surgeons, 4 plastic surgeons. The identified appropriate procedures were: revision amputation should be done in operating room, the neurovascular bundles should be identified and is mandatory to treat surrounding soft tissues. Only in case of clean-cut amputation, it is appropriate to perform a proximal extension of the dissection, to use diathermocoagulation and coverage with local flaps. Procedures such as shortening in tension of the nerve stump, bone shortening, implantation of the nerve end in the soft tissue, treatment in the emergency room and, in both scenarios, certain results are evaluated as uncertain. DISCUSSION: In order to prevent the formation of a distal stump neuroma few methods were judged appropriate. It is mandatory to identify the neurovascular bundles and treat also the surrounding tissues, but no certain results could be obtained with local flap, bone shortening and other ancillary surgical acts. Moreover, it is not possible to guarantee the non arising of neuroma in any cases, also when every procedure has been temped. CONLUSIONS: The prevention of distal neuroma is actually a challenge, without a well known strategy due to the variability of response of nervous tissue to injury.

Dry Wrist Arthroscopy for Radial-Sided Wrist Disorders.

The development of wrist arthroscopy has been useful in diagnosis, prognosis, and treatment of both ligament and osseous injuries. As the treatment indications and techniques become more refined, this article explores the role of dry arthroscopy to treat radial-sided disorders of the wrist.

Dart-Splint: An innovative orthosis that can be integrated into a scapho-lunate and palmar midcarpal instability re-education protocol.

The Authors describe a novel hinged orthosis that permits selective midcarpal mobilization along the plane of the dart throwing motion. This orthotic device can be used to assist rehabilitation protocols aimed to limit radiocarpal joint mobility and scapho-lunate ligament overload and to accelerate wrist functional recovery after ligamentous injuries around the proximal carpal row. - VictoriaW. Priganc, PhD, OTR, CHT, CLT, Practice Forum Editor.

Arthroscopic foveal repair of the triangular fibrocartilage complex.

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

Current role of open reconstruction of the scapholunate ligament.

This paper is a review of the various surgical techniques used in repair or reconstruction of the scapholunate ligament according to the clinical stages and anatomic-pathologic findings. Arthroscopy permits a direct evaluation of the scapholunate injury and the status of the articular surfaces. Specific indications for each type of scapholunate ligament tear are proposed, from the different types of dorsal capsulodesis to bone-ligament-bone techniques and tenodesis procedures. The authors' preferred techniques and literature review of the expected outcomes are presented.

Foveal TFCC tear classification and treatment.

During the last two decades, increased knowledge of functional anatomy and pathophysiology of the triangular fibrocartilage complex (TFCC) have contributed to a change in surgeons' perspective toward it. The earlier concept of the TFCC as the "hammock" structure of the ulnar carpus has updated to the "iceberg" concept, whereby the much larger "submerged" part represents the foveal insertions of the TFCC and functions as the stabilizer of the distal radioulnar joint and the ulnar carpus, thus lending it greater functional importance. This article presents an algorithm of the treatment of traumatic peripheral TFCC tear based on clinical, radiological, and arthroscopic findings.

Finger fractures imaging: accuracy of cone-beam computed tomography and multislice computed tomography.

OBJECTIVE: To compare the diagnostic accuracy and radiation exposure of cone beam computed tomography (CBCT) and multislice computed tomography (MSCT) in the evaluation of finger fractures. MATERIALS AND METHODS: In a 3-year period, 57 consecutive patients with post-traumatic fractures of the metacarpal-phalangeal (MCP), proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints with involvement of the articular surface were studied by means of CBCT and MSCT. Student's t test was used to compare CBCT and MSCT accuracy in evaluating the percentage of joint surface involvement and in detecting bone fragments. The average tissue-absorbed doses of CBCT and MSCT were also compared. A value of p < 0.05 was considered statistically significant. Inter-observer agreement was calculated. RESULTS: In all cases, CBCT allowed the percentage of articular involvement to be correctly depicted compared with MSCT, showing 100% sensitivity and specificity (p < 0.001). A total of 103 bone fragments were depicted on MSCT (mean 3.8 per patient, range 1-23). CBCT indicated 92 out of 103 fragments (89.3%) compared with MSCT (mean diameter of missed fragments 0.9 mm, range 0.6-1.3 mm), with no statistically significant difference between CBCT and MSCT (p < 0.025). Multislice CT radiation exposure was significantly higher than that of CBCT (0.18 mSv vs 0.06 mSv, p < 0.0025). Inter-observer agreement was good (overall κ = 0.89-0.96). CONCLUSIONS: Cone beam CT may be considered a valuable imaging tool in the preoperative assessment of finger fractures, when MSCT is not available.

Arthroscopically assisted Sauvé-Kapandji procedure: an advanced technique for distal radioulnar joint arthritis.

Osteoarthritis of distal radioulnar joint (DRUJ) leads to chronic wrist pain, weakness of grip strength, and limitation of motion, all of which affect the quality of life of the patient. Over the years, several procedures have been used for the treatment of this condition; however, this condition still remains a therapeutic challenge for the hand surgeons. Many procedures such as Darrach procedure, Bower procedure, Sauvé-Kapandji procedure, and ulnar head replacement have been used. Despite many advances in wrist arthroscopy, arthroscopy has not been used for the treatment of arthritis of the DRUJ. We describe a novel technique of arthroscopically assisted Sauvé-Kapandji procedure for the arthritis of the DRUJ. The advantages of this technique are its less invasive nature, preservation of the extensor retinaculum, more anatomical position of the DRUJ, faster rehabilitation, and a better cosmesis.