Arthroscopic transosseous foveal footprint repair of the triangular fibrocartilage complex

Foveal disruption of the triangular fibrocartilage complex contributes to the instability of distal radioulnar joint. We have developed an arthroscopic transosseous foveal footprint repair technique, which maximizes the contact between the disrupted triangular fibrocartilage complex and its foveal footprint for better healing by using four sutures in a divergent configuration through a 1.6-mm bone tunnel. Twelve patients with triangular fibrocartilage complex foveal injuries who had undergone this repair technique were reviewed with a mean follow-up of 53 months. All patients achieved significant improvement in the modified Mayo wrist score and the Disabilities of the Arm, Shoulder and Hand score. All patients had stable distal radioulnar joints with comparable ranges of motion and grip strengths between the operated and contralateral wrists. There was no significant difference in functional score in those who were treated more than 6 months after injury. Level of evidence: IV

Motion Analysis of Triangular Fibrocartilage Complex by Using Ultrasonography Images: Preliminary Analysis

The triangular fibrocartilage complex (TFCC) is a significant stabilizer of the distal radioulnar joint. Diagnosing TFCC injury is currently difficult, but ultrasonography (US) has emerged as a low-cost, minimally invasive diagnostic tool. We aimed to quantitatively analyze TFCC by performing motion analysis by using US. Twelve healthy volunteers, comprising 24 wrists (control group), and 15 patients with TFCC Palmer type 1B injuries (injury group) participated. The US transducer was positioned between the ulnar styloid process and triquetrum and was tilted ulnarly 30° from the vertical line. The wrist was then actively moved from 10° of radial deviation to 20° of ulnar deviation in a 60-rounds-per-minute rhythm that was paced by a metronome. The articular disc displacement velocity magnitude was analyzed by using particle image velocimetry fluid measurement software. The mean area of the articular discs was larger on ulnar deviation in the control group. The mean articular disc area on radial deviation was larger in the injury group. The average articular disc velocity magnitude for the injury group was significantly higher than that for the control group. The results suggest that patients with TFCC injury lose articular disc cushioning and static stability, and subsequent abnormal motion can be analyzed by using US.

Reconstruction of the Distal Oblique Bundle for DRUJ Instability

Background Treatment algorithm for disruption of the triangular fibrocartilage complex (TFCC) from the ulnar fovea includes direct TFCC repair, tendon reconstruction of the radioulnar ligaments, or a salvage procedure in cases with painful distal radioulnar joint (DRUJ) degeneration. Case Description We describe our surgical technique for reconstruction of the distal oblique bundle (DOB), to attain DRUJ stability in a young man, after failed attempts of direct TFCC reinsertion and radioulnar ligament reconstruction with the Adams procedure. Literature Review Reconstruction of the central band of the interosseous membrane is well recognized for Essex-Lopresti injuries that demonstrate longitudinal forearm instability. The role for reconstruction/reinforcement of the DOB to restore DRUJ stability after TFCC injury has not gained the same recognition and needs further clarification. Clinical Relevance DOB reconstruction technique described is extra-articular and technically straightforward. We believe that the procedure could be considered for patients with an irreparable TFCC injury as a part of the treatment algorithm for younger patients, who otherwise would face a more extensive salvage procedure.

3T MRI of wrist ligaments and TFCC using true plane oblique 3d T2 Dual Echo Steady State (DESS) – a study of diagnostic accuracy

Objectives: This study was designed to assess the accuracy of unenhanced 3T MRI supplemented with dedicated true plane reformats of 3d T2DESS, in assessing tears of scapholunate, lunotriquetral ligaments and triangular fibrocartilage complex, using arthroscopy as gold standard. Methods: In a retrospective cohort review, patients who underwent wrist arthroscopy and MRI over 2 years (n=46) were identified. Dedicated axial and coronal reformats were obtained from 3d T2 DESS sequence for assessing intrinsic ligaments and TFCC. At arthroscopy tears were classified using Geissler’s classification and compared to MRI findings. Results: The sensitivity of unenhanced 3T MRI in detecting scapholunate ligament tears was 87% and specificity was 90% and negative predictive value of 93%. The lunate triquetral ligament was assessed with a high specificity (97%) and negative predictive value (93%), sensitivity was 63%. Triangular fibrocartilage (TFCC) tears were assessed with a sensitivity of 100%. The overall diagnostic accuracy of unenhanced 3T MRI of wrist in detecting ligament tears was 91%. Conclusion: 3T wrist MRI with dedicated reformats from 3d T2 DESS have a high diagnostic accuracy in assessing acute intrinsic ligament and TFCC injuries. High strength 3T MRI with good technical quality isotropic 3d T2 DESS is critical for accurate wrist ligament assessment. Negative predictive values of 3T MRI of 95% can lead to reduced need for diagnostic arthroscopy of the wrist. Advances in knowledge: This study assesses the diagnostic performance of unenhanced 3T MRI with 3dT2 DESS in assessing traumatic wrist ligament tears. The accuracy of T2 DESS in wrist imaging has not been previously reported.