Acute blockage of forearm supination due to flap tear of the triangular fibrocartilage disc: A case report.

RATIONALE: Acute blockage of forearm supination has been reported in several studies. It is caused by loose bodies in the wrist joint, extensor carpi ulnaris tendon interposition, and distal radioulnar joint (DRUJ) injuries, including forearm bone fractures. Some studies have reported cases of DRUJ injuries caused by triangular fibrocartilage complex (TFCC) tears.We report a case of acute blockage of forearm supination after minor trauma and suggest a possible TFCC tear when a patient complains of forearm supination blocking. In addition, we present a comparison between our case and other reports on etiology, magnetic resonance imaging (MRI) findings, and arthroscopic findings, and show the specific characteristics of our case. PATIENTS CONCERNS: A 22-year-old male presented with left wrist pain as the chief complaint. He was injured 2 months prior to pushing his left hand on the floor during exercise. Physical examination showed a relative limitation of range of motion (ROM) in the left wrist of about 10° in flexion and about 15° in extension compared with the right side. The patient also complained of supination limitation and volar side wrist pain during supination. The patient showed tenderness in the axial compression test. DIAGNOSES: Plain radiographs showing no abnormalities. MRI showed a TFCC tear in the central portion. A torn flap of the TFCC was interposed on the volar side of the DRUJ. INTERVENTIONS: Arthroscopic surgery of the left wrist joint was performed. Arthroscopic examination revealed a tear in the TFCC on the radial side. A torn flap was interposed on the volar side of the DRUJ. We removed the flap from the DRUJ using an arthroscopic grasper and partially resected it. OUTCOMES: Intraoperative tests showed no locking and the forearm was well supinated. Two months after the surgery, the patient had no pain and showed full forearm supination. LESSONS: DRUJ blocking due to a TFCC tear should be suspected when acute blockage of forearm supination occurs after minor trauma. MRI is helpful for diagnosis; however, we suggest that the diagnosis should be confirmed through arthroscopy. Symptoms can be resolved by surgical treatment using arthroscopy.

Wrist Arthroscopy-Assisted Reduction for Distal Radius Fracture and its Associated Injuries: Clinical Observation of Triangular Fibrocartilage Complex Injuries.

BACKGROUND: To compare the clinical effects between wrist arthroscopy-assisted open reduction plus internal fixation, using the triangular fibrocartilage complex (TFCC) as an example, and simple open reduction plus internal fixation in the treatment of distal radius fractures (DRFs). The study aims to assess the efficacy of arthroscopic-assisted open reduction and internal fixation in treating distal radius fractures. METHODS: The study utilized a retrospective cohort research approach, involving 60 patients treated at Binzhou Medical University Hospital between August 2021 and October 2022. These patients met the specified criteria and underwent two distinct surgical procedures for DRFs. Prior to surgery, thorough communication was established with the patients to elucidate the advantages, risks, and associated costs of wrist arthroscopy, and informed consent was obtained. Subsequent to the surgeries, postoperative follow-up was conducted to evaluate the variances between the two treatment modalities. Postoperative analysis and assessment encompassed the patients' Visual Analogue Scale (VAS) scores, Cooney wrist scores, grip strength of the affected limb (in comparison with the healthy side), wrist range of motion, and the frequency of intraoperative fluoroscopy usage. RESULTS: No surgical complications were observed among all patients. They were followed up for an average duration of (12.1 ± 1.3) months postoperatively, during which all fractures healed successfully. Within the treatment group, arthroscopy detected 14 cases of TFCC tears during the operation, all of which were repaired under a microscope. Conversely, physical examination identified three cases of TFCC injury in the control group, which were treated via incision and suture. At the 3-month postoperative mark, the treatment group exhibited significantly superior comprehensive scores for wrist pain, grip strength, and wrist range of motion compared to the control group (p < 0.05). Cooney's comprehensive wrist joint scoring yielded the following results: treatment group - excellent in 21 cases, good in five cases, and moderate in four cases; control group - excellent in 16 cases, good in nine cases, and moderate in five cases. CONCLUSION: Wrist arthroscopy-assisted surgery facilitates precise reduction of the articular surface and alleviation of intraarticular congestion. Moreover, it enables evaluation and repair of concurrent intra-articular injuries such as TFCC tears and other tissue injuries, thereby reducing the likelihood of chronic wrist pain. Consequently, this technique should be deemed valuable in clinical practice owing to its outstanding clinical efficacy.

Triangular fibrocartilage complex injury: outcomes of operative and non-operative management.

OBJECTIVE: The prevalence TFCC injuries has increased over time. However, there remains a lack of understanding of its natural history. Along with the paucity of evidence on treatment options, there is lack of consensus on how best to manage them. This is a retrospective study with subgroup cohort analysis, examining variables and management options associated with patient-reported disability and pain. METHODS: Patients from a metropolitan health network who have been referred for Magnetic Resonance Imaging (MRI) of the wrist between 2010 and 2019 and identified to have TFCC injury, were followed up to determine patient-reported outcomes. Disability of arm shoulder and hand scores (DASH) and visual assessment pain scale (VAS) were used to measure disability and pain respectively. An 'excellent' DASH and VAS scores were defined as ≤10 and ≤2, respectively. RESULTS: One hundred and twenty-four patients met the inclusion criteria and consented to participate in this study. There were 53 patients with excellent DASH score, 95 excellent VAS score and 51 excellent outcomes at mean follow-up of 75.5 months (Range: 5-402.8 months). Concomitant pathology and surgical management were less likely to have excellent DASH and VAS scores, while traumatic aetiology and smoking were less likely to have excellent VAS score. Age was not predictive of excellent DASH or VAS score. CONCLUSIONS: Surgical management of TFCC injuries were associated with worse outcomes than if they were left alone. Smoking cessation is a patient-modifiable risk factor that may help improve outcomes.

Comparing the Outcomes of Suture Anchor Repair and Rein-Type Capsular Suture for Triangular Fibrocartilage Complex Foveal Tears With a Minimum 2-Year Follow-Up.

PURPOSE: Recent biomechanical studies have highlighted the importance of foveal reinsertion when repairing triangular fibrocartilage complex (TFCC) injury with foveal tears. However, clinical studies comparing different repair techniques are scarce. We compared the clinical outcomes of suture anchor repair and rein-type capsular suture in patients with TFCC palmer 1B foveal tears with a minimum of 2-year follow-up. METHODS: This was a single-surgeon, single-center, retrospective, comparative study. We included patients who underwent TFCC repair surgery due to a foveal tear from December 2013 to October 2018 with a minimum follow-up of 24 months. Postoperative Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) score, Modified Mayo Wrist Score, visual analogue scale for pain, wrist range of motion, and grip strength were compared. We also measured the maximal ulnar head displacement with dynamic ultrasound to quantify distal radioulnar joint stability. RESULTS: In total, 103 patients were in the suture anchor group (group A) and 84 patients in the rein-type capsular suture group (group B). The mean follow-up time exceeded three years for both groups. There was a minimal difference regarding QuickDASH score, visual analogue scale for pain, and grip strength ratio between the two groups. The rein-type group had significantly better Modified Mayo Wrist Score. The suture anchor group showed better distal radioulnar joint stability with dynamic ultrasound, but was more limited in ulnar deviation. However, these differences are most likely clinically insignificant. CONCLUSIONS: Both suture anchor repair and rein-type capsular suture yielded satisfactory results for TFCC 1B foveal tear in a minimum of 2-year follow-up. The functional scores were similar, and no major complications or recurrent instability were noted in either group. TYPE OF STUDY/LEVEL OF EVIDENCE: Retrospective Therapeutic Comparative Investigation IV.

Complications after arthroscopic triangular fibrocartilage complex (TFCC) surgery.

Wrist arthroscopy is a valuable and widely utilized tool in the treatment of triangular fibrocartilage complex (TFCC) injuries. These procedures include synovectomy alone, peri-capsular or transosseous repair, and arthroscopic-assisted reconstruction, and each are associated with specific complications. This review describes the types of complications and their rates in different types of arthroscopic TFCC surgery reported in the literature and in our centre. Across the spectrum of arthroscopic TFCC surgery, complication rates and the learning curve increase with surgical complexity. Relevant anatomy, prevention and management of complications including nerve injury and irritation, extensor tendon injury and tendinitis, fracture, stiffness, and persistence of symptoms or instability are discussed. Vigilance to anatomical details and careful dissection can help to reduce complications that may result in disturbing pain and functional loss.

An All-Arthroscopic Technique of Repairing Foveal Tears of the Triangular Fibrocartilage Complex Using a Bone Anchor-Repair Made Simple.

Traumatic foveal tears of the triangular fibrocartilage complex lead to ulnar-sided wrist pain and instability, resulting in painful motion and loss of grip strength with a severe impact on the overall function of the upper limb. Surgical repair is nothing new and has traversed through the realm of open repair to arthroscopic assisted to all arthroscopic repair techniques over the many decades, with arthroscopic repairs showing better visualization, lesser trauma, and equally favorable patient outcomes. Techniques had varied from using trans osseous tunnels to bone anchors, with or without the usage of special jigs. Here, we describe a simple and fast 3 portal arthroscopic technique of repairing the torn foveal insertion of the triangular fibrocartilage complex using a bone anchor inserted under arthroscopic and fluoroscopic guidance into the fovea. Both the dorsal and volar limbs of the triangular fibrocartilage complex are repaired arthroscopically, resulting in a strong anatomic repair resulting in a stable and pain-free wrist.

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

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

Combined repair of scapholunate ligament (SL) and triangular fibrocartilage complex (TFCC) lesions in chronic trauma of the wrist: surgical treatment of 14 patients.

PURPOSE: Injuries of the scapholunate ligament (SL) and of the triangular fibrocartilage complex (TFCC) represent the main ligament injuries of the traumatic wrist. A double injury of the SL and TFCC ligaments is quite common in the trauma setting, and clinical examination is fundamental. MRI allows to detection of a TFCC and SL ligament injury, but wrist arthroscopy is still the gold standard for diagnosis. We present the clinical results of the combined reconstruction of chronic scapholunate ligament and TFCC injury. MATERIALS AND METHODS: Fourteen patients were treated at our hospital with a combined scapholunate ligament and TFCC complex repair. All patients were surgically treated by the same senior author, after a diagnostic arthroscopy that revealed a lesion of both structures. A comparison between the pre-operative and post-operative pain and function was carried out using VAS, Disability of Arm, Shoulder and Hand score (DASH) and Patient-Related Wrist/Hand Evaluation score (PRWHE). Wrist range of motion and strength were also compared following surgery. RESULTS: All patients had a mean follow-up of 54 months. A statistically significant improvement was observed both with the reduction in pain (VAS from 8.9 to 5) and with the improvement of functionality scores (DASH from 63 to 40 and PRWHE from 70 to 57) and with the increase in ROM and strength. In only one patient (7%), because of pain and instability, a supplement operation was needed (Sauve-Kapandji procedure) 3 months after the initial surgery. CONCLUSIONS: The simultaneous repair of the SL and TFCC complex has shown a good success rate in both decreasing pain and regaining functionality.

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

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

Reliability and Validity Analysis of the Distal Radioulnar Joint Ballottement Test.

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

Peripheral tear of the triangular fibrocartilage complex: diagnostic accuracy of magnetic resonance imaging and diagnostic performance of the primary and secondary signs.

OBJECTIVE: This study is to assess the diagnostic performance of magnetic resonance imaging (MRI) findings for type 1B triangular fibrocartilage complex (TFCC) tear of the wrist. MATERIALS AND METHODS: This study retrospectively enrolled 78 patients to examine the diagnostic performance of preoperative MRI examinations in patients with type 1B TFCC tears. Thirty-nine participants had confirmed type 1B TFCC tear. The control group included 39 patients who were randomly selected from 1157 patients who underwent MRI for wrist pain. Both groups underwent a review of 19 MRI findings by two independent radiologists, and the correlation between each diagnostic finding and type 1B TFCC tear was assessed using the chi-squared test. The 19 MRI findings comprised eight primary signs of abnormalities in the distal or proximal lamina, in conjunction with 11 secondary signs suggestive of abnormalities in the surrounding structures. RESULTS: The TFCC tear group demonstrated a significantly higher incidence of two primary MRI signs, i.e., fiber discontinuity and signal alteration in the distal lamina, as observed by both readers (R1, 74.4% vs. 38.5%, p = 0.003, and 87.2% vs. 43.6%, p < 0.001; R2, 74.4% vs. 35.9%, p = 0.001, and 87.2% vs. 53.8%, p < 0.003, respectively). Reader 2 identified a higher prevalence of two additional primary MRI signs: fiber discontinuity and signal alteration in the proximal lamina (all p < 0.05). None of the 11 secondary MRI signs demonstrated statistically significant associations with type 1B TFCC. CONCLUSION: MRI manifestations of fiber discontinuity and signal alteration in the distal lamina may provide predictive markers for type 1B TFCC wrist tear.

A new arthroscopic repair technique for triangular fibrocartilage complex using an intracapsular suture: an outside-in transfer all-inside repair.

BACKGROUND: Arthroscopic repair is a promising, minimally invasive surgical technique for patients with Palmer type 1B peripheral triangular fibrocartilage complex (TFCC) tears. Although several arthroscopic techniques are effective for repairing Palmer type 1B TFCC tears, some shortcomings remain. So, we report an arthroscopic repair technique for the treatment of Palmer type 1B Atzei class 1 TFCC tears using an intracapsular suture: an outside-in transfer all-inside repair. METHODS: A retrospective analysis of 38 Palmer type 1B TFCC injury patients admitted to our hospital were randomly divided into 2 groups. The group A was sutured from the outside to the inside, with a total of 21 cases; the group B was sutured with the new arthroscopic repair technique, with a total of 17 cases. Observe and compare the VAS scores and modified Mayo wrist function scores of all patients before 3, and 6 months after the operation and evaluate the incidence of thread knots in patients with different treatment methods. The methodology was performed an arthroscopic intracapsular suture using an outside-in transfer, all-inside repair technique, which is a modified method of the outside-in and all-inside technique using the needle of a 10-mL sterile syringe, for Palmer type 1B TFCC tears. A No. 2 polydioxanone suture was threaded through the needle and entered the wrist joint. Next, the needle was withdrawn carefully along the suture to the proximal tear ulnar surface of the TFCC and penetrated the TFCC, exiting the articular cavity surface of the ulnar side of the torn TFCC. Finally, arthroscopic knotting was performed. RESULTS: This new treatment was as effective as the previously arthroscopic techniques and had the advantages of no additional incision and decreased risk of operation-related complications. The incidence of thread knots in the group A (28.57%) was significantly higher than that in the group B (0%), and the difference was statistically significant (P = 0.024). There was no significant difference in VAS score and modified Mayo wrist function scores between the two groups (P > 0.05). CONCLUSIONS: The outside-in transfer, the all-inside repair technique is suitable for Palmer type 1B Atzei class 1 TFCC tears. We recommend this technique as a useful alternative to the conventional methods of repairing Palmer type 1B TFCC tears.

Conservative management of a suspected triangular fibrocartilage complex injury utilizing strength training exercises: A case report.

OBJECTIVE: The purpose of this case report is to describe the conservative chiropractic management of a patient with a suspected triangular fibrocartilage complex (TFCC) injury. CLINICAL PRESENTATION: A 36-year-old Brazilian Jiu-Jitsu black belt athlete sought care for left-sided diffuse ulnar pain (numeric pain scale 5/10) with a notable bump over the ulna and weakness when grappling. A working diagnosis of suspected TFCC injury was made. INTERVENTION AND OUTCOME: The patient was treated with forearm and grip strength exercises to rehabilitate the pain and strength loss. Following 6 visits and a home exercise program for 8 weeks, his numeric pain scale decreased to 0/10. CONCLUSION: In this case, it is evident that Triangular fibrocartilage complex injury was successfully treated conservatively without the need for surgical intervention or passive care modalities.

Morphology of the Radial Attachment of the Radioulnar Ligament and Surrounding Landmarks.

PURPOSE: The triangular fibrocartilage complex (TFCC) is composed of dorsal and palmar radioulnar ligaments (RULs). A common injury pattern of the RUL is the avulsion of the ulnar insertion, which can be treated by arthroscopic or open repair. Although the general method of TFCC reconstruction is a tendon graft with a bone tunnel, detailed information regarding the radial attachment of the RUL is unclear. This study aimed to clarify the morphology of the radial attachments of the palmar radioulnar ligament (PRUL), dorsal radioulnar ligament (DRUL), and short radiolunate ligament (SRL) using three-dimensional imaging. METHODS: A total of 29 upper limbs (16 formalin-fixed and 13 embalmed by Thiel's embalming method) of Japanese cadavers were used. After gross observation, we marked the attachments of the PRUL, DRUL, and SRL using 0.7-mm diameter pins. We created three-dimensional images of the radius, outlining the PRUL, DRUL, and SRL attachments. The software application calculated the centers of the PRUL and DRUL attachments. RESULTS: The PRUL attachment was horizontally shaped. The center of the PRUL was 1.5 mm proximal and 5.8 mm radial to the tip of the palmar pyramid formed by the palmar cortex and the radioulnar and radiocarpal joint surfaces. The DRUL attachment was vertically shaped. The center of the DRUL was 2.0 mm proximal and 1.7 mm radial from the tip of the dorsal pyramid formed by the dorsal cortex and the radioulnar and radiocarpal joint surfaces. The length of the SRL was 9.2 mm. The SRL and PRUL were strongly conjoined. CONCLUSIONS: The anatomical center on the RUL attachment of the radius can be determined from osseous landmarks. CLINICAL RELEVANCE: The findings of this study contribute to the understanding of RUL attachment to the distal radius and may assist surgeons in performing anatomical reconstruction of TFCC.

Current rehabilitation recommendations following primary triangular fibrocartilage complex foveal repair surgery: A survey of Australian hand therapists.

BACKGROUND: Following injury to the Triangular Fibrocartilage Complex (TFCC), foveal repair surgery may be indicated to restore joint stability and function. Protection of the repaired ligament is a clinical consideration during post-surgical rehabilitation, although no "gold standard" rehabilitation protocol currently exists. PURPOSE: To describe the professional opinions of Accredited Hand Therapists (AHT) regarding post-operative rehabilitation recommendations following TFCC foveal repair surgery. STUDY DESIGN: Cross-sectional descriptive study. METHODS: All Australian AHTs were invited to complete a quantitative, online, 10-item survey between December 2019 and March 2020. The survey included questions regarding clinical recommendations for wrist and forearm immobilization, range of motion and exercise methods, and timeframes. AHT characteristics and experience of patients sustaining a TFCC re-rupture were also collected. Categorical and nominal survey responses were reported descriptively and effects of AHT characteristics on survey responses were assessed using Pearson Chi2, with significance set to <0.05. RESULTS: Survey responses were received from 135 AHTs or approximately 37% of the available population at the time of completion (March 2020). Recommendations for post-surgery immobilization ranged from "not required" to 8 weeks, 6 weeks representing the most common answer. Wrist and forearm range of motion commencement time ranged from "immediately" to "later than 8 weeks," with 6 weeks also the most common answer. When asked whether post-surgery rupture had been experienced in their respective patient groups, 15 therapists (11%) indicated "Yes." The most recommended thermoplastic orthosis was a Sugartong orthosis (41%) followed by a Muenster orthosis (30%), both of which immobilizes the wrist and forearm. CONCLUSIONS: Rehabilitation varied widely between AHTs. Further prospective research is recommended to explore whether patient-related or rehabilitation factors influence outcomes following TFCC repair.

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.

Advances in the Repair of Palmer type IB TFCC Injuries With Wrist Arthroscopy.

The triangular fibrocartilage complex (TFCC) is essential for maintaining wrist stability. Injury-caused pain is the primary cause of ulnar wrist pain. The TFCC injury refractory to conservative treatment requires further surgical treatment, and because Palmer type IB tears belong to peripheral injuries due to their proximity to the blood supply area, arthroscopic suture repair has become the preferred surgical method for TFCC injury repair, exhibiting strong healing ability. This study reviewed the anatomy of TFCC, injury classification, and advances in arthroscopic suturing for treating Palmer type IB.

Arthrex Mini Tightrope Fixation for Chronic Distal Radioulnar Joint Instability.

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

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

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

An All-arthroscopic Technique of Repair of Substance Tears of the Triangular Fibrocartilage Complex in Symptomatic Patients.

Substance tears of the triangular fibrocartilage complex (TFCC) can occur secondary to trauma of the wrist. On the dorsal periphery, they are considered Palmer 1B tears or Atzei class 1 tears. If along the radial side, they can manifest as a tear of the central disc, classified as a Palmar class 1A tear. If it involves the ligaments, it is stated as a pre-1D tear as per the new classification system by Luchetti and colleagues. Multiple excellent repair techniques exist in the current literature for dorsal peripheral tears and even for those in the substance of the TFCC, whereas there are successful evolving techniques of repair of avulsed tears and those involving the substance of the ligaments on the radial side adjacent to the sigmoid notch. Here, we describe our technique of repairing substance tears of the TFCC arthroscopically without the need for any specialized equipment apart from the basic arthroscopy set. The technique was conducted in a patient with a transverse substance tear on the radial side of the triangular fibrocartilage involving the central disc with complete resolution of symptoms. It is a simple technique, which can be used to repair class 1B peripheral tears and pre-1D tears in the substance of the TFCC.