Hand Surgery, Vol. 10, Nos. 2 & 3 (2005) 169–176 © World Scientific Publishing Company
FUNCTIONAL RESULTS POST-TRIANGULAR FIBROCARTILAGE COMPLEX RECONSTRUCTION WITH EXTENSOR CARPI ULNARIS WITH OR WITHOUT ULNAR SHORTENING IN CHRONIC DISTAL RADIOULNAR JOINT INSTABILITY Jui-Tien Shih and Hung-Maan Lee Department of Orthopaedic Surgery, Armed Forces Taoyuan General Hospital, Taiwan, R.O.C. Received 1 September 2004; Accepted 1 September 2005 ABSTRACT From September 1996 to September 2001, 37 adult patients were diagnosed with chronic triangular fibrocartilage complex (TFCC) tears with distal radioulnar joint (DRUJ) instability in our clinic. They had all received the procedure of TFCC reconstruction with partial extensor carpi ulnaris (ECU) combined with or without ulnar shortening. There were 36 males and one female in the study with a mean age of 22.4 years. The follow-up period ranged from 25 to 48 months with a mean of 36.2 months. All patients received the rehabilitation programme and were re-examined at our outpatient department. The results were graded according to the Mayo Modified Wrist Score. Eleven of the 37 patients rated their wrists “excellent”, 22 rated “good”, and four rated “fair”. Overall, a total of 33 patients (89%) rated satisfactorily and returned to work or sport activities. Therefore, TFCC reconstruction with partial ECU tendon combined with or without ulnar shortening procedure is an effective method for post-traumatic chronic TFCC tears with DRUJ instability suggested by this study. Keywords: Triangular Fibrocartilage Complex Tears; Ligament Reconstruction; Ulnar Shortening.
INTRODUCTION
expected outcomes. However, this treatment is controversial for chronic TFCC tears. The TFCC fulfills three important biomechanical functions.4 First, it enables the forearm to be loaded or stressed. Specifically, loading or stress passes from the forearm to the wrist via the TFCC. Second, the TFCC provides primary stability to the distal radioulnar joint (DRUJ). The TFCC is an important stabiliser of DRUJ when distal radioulnar ligaments become taut. Third, the TFCC stabilises the ulnar carpus via the ulnar carpal ligament complex. If the TFCC is traumatised and disrupted, the wrist may become unstable. Thus, the tears cause the progressive
Tears in the triangular fibrocartilage complex (TFCC) are often observed with ulnar wrist pain and limited wrist function in work or sport. The TFCC allows the carpus to rotate with the radius around the ulna, which is the centre of forearm rotation.1–3 Consequently, the TFCC is subjected to axial loads and shear forces. The TFCC comprises of the central fibrocartilage, the dorsal and palmar distal radioulnar ligaments, and the sheath of the extensor carpi ulnaris (ECU) tendon. The TFCC functions as a unit rather than as separate ligaments. The vascularity of TFCC enables surgeons to repair acute peripheral tears with excellent
Correspondence to: Dr. Jui-Tien Shih, Department of Orthopaedic Surgery, Armed Forces Taoyuan General Hospital, No. 168, Joing-Hsing Road, Long-Tan, Taoyuan, Taiwan, R.O.C. Tel: (+886) 3-489-8976, Fax: (+886) 3-489-8976 (Ext. 168), E-mail:
[email protected]
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instability of DRUJ and subsequent degenerative changes in the TFCC, lunate, ulna and triquetrum, as well as loss of wrist motion and grip strength. Chronic cases, namely tears with degeneration of the TFCC combined with DRUJ instability, are difficult to treat. Consequently, this study presents the results of reconstructing the TFCC with the partial ECU tendon, with or without ulnar shortening.
ulna. Passive ulnar deviation and ulna loading-induced pain. DRUJ stress test and the piano key sign were positive for all patients. Reviews of the patient medical histories established that all patients had been previously treated elsewhere using oral non-steroidal anti-inflammatory drugs (NSAIDs) or herbal medicine. All patients underwent plain films to identify any bone fractures or ulnar variance, and to assess possibly degenerative changes. The true lateral film can possibly determine subluxation of DRUJ. All patients underwent a bilateral wrist CT scan (Fig. 1A) to assess the relationship between distal radius and ulna, and also to check for instability of the DRUJ. Thirty-four of the 37 patients received a triple injection wrist arthrogram. The arthrogram was useful before surgery, since it identifies associated interosseous ligament injuries of the carpus and also any TFCC tears. Three of the 37 patients underwent magnetic resonance imaging (MRI) scans and all three displayed tears. All patients underwent wrist arthrosocpic examination and the lesions of the TFCC tears were identified and classified according to Palmer (Table 1).
MATERIALS AND METHODS From September 1996 to September 2001, 37 adult soldiers, 36 male and one female, with chronic TFCC tears were studied. The ages of the subjects ranged from 19 to 24 years, with a mean of 22.4 years. All patients had experienced traumas, such as an axial loading and hyperextensive injury. The period from the accident to surgery ranged from 14 to 28 months, with a mean of 22.6 months. All patients suffered from ulnar wrist pain, reduced grasp strength and limited ability to perform work or sport. Additionally, all patients experienced tenderness over the ballotable area of the
(A) Fig. 1 (A) CT scan shows dorsal subluxation of the ulna when the wrist is fully pronated. (B) No dorsal subluxation of the ulna was detectable at 20 months post-reconstruction.
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(B) Fig. 1 (Continued )
Table 1 Classification of TFCC Lesions According to Palmer. Traumatic Lesions Class IA: Central rupture Class IB: Ulnar avulsion with/without disruption of the ulnar styloid process Class IC: Distal avulsion Class ID: Radial avulsion with/without osseous lesion of the radius Degenerative Lesions Class IIA: Superficial degenerative lesion Class IIB: Degenerative tear with cartilage lesion of the lunate or the ulna Class IIC: Degenerative disc perforation with cartilage lesion of the lunate or the ulna Class IID: Degenerative disc perforation with cartilage lesion of the lunate or the ulna and lunotriquentral instability Class IIE: Degenerative disc perforation with cartilage lesion of the lunate or the ulna, lunotriquentral instability and ulnocarpal arthrosis
Surgical Procedure The surgery was performed under general or regional anaesthesia. An upper arm tourniquet was applied and the pressure
set to between 200 and 250 mmHg. From the dorsal approach, the skin over the ulnar border region of the forearm was incised longitudinally and a zigzag incision was then made to the distal part. A partial ECU tendon graft, around 3–4 mm in diameter and 12 cm in length, was taken. A tunnel of approximately 3 mm in diameter was created from the ulnar border of the ulna bone to the base of the styloid process. The graft was then passed through the tunnel to the pole of the ulna bone. Moreover, the periosteum of the radius was dissected and elevated. Subsequently, the DRUJ was located and a tunnel on radius near the DRUJ around 3 mm in diameter was created from the dorsal to the palmar region. The palmar opening of the radial tunnel is exposed through a 2.5 cm transverse volar incision just located near the proximal wrist crease. The neurovascular bundle is retracted ulnarly and the flexor tendons radially to expose the whole area of the tunnel’s opening. A suture retriever is passed through the tunnel from dorsal to palmar. One end of the graft is pulled through the tunnel with the suture retriever. The graft was then passed through the tunnel from the dorsal to the palmar region. A stright haemostat is directed from dorsal to palmar over the ulnar head and pushed through the palmar DRUJ capsule. The other end of
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Fig. 2 It demonstrates the TFCC reconstruction with partial ECU tendon.
the graft is grasped and pulled along this tract but taking care not to entrap tendons, nerves or vessels with the graft. Both graft limbs should now lie in the dorsal surgical exposure. Finally, the graft was returned to the pole region of the ulna and passed through the tunnel to the ulnar border of the ulna (Fig. 2). Patients with positive ulnar variance underwent ulnar shortening to neutralise the variance. Meanwhile, patients with zero ulnar variance received 2–3 mm of ulnar shortening, which has been demonstrated to constitute optimal unloading of the ulnar.5–7 From the same incision, a transverse osteotomy was made using a 2.0 mm saw blade, and then a five-hole 3.5 mm dynamic compression plate (Synthes Ltd., Paoli, PA) was used to neutralise and fix the osteotomy (Figs. 3A and 3B).
The DRUJ was fixed with mild supination (10◦ –15◦ ) using a 2.0 mm K-wire and the tendon graft was sutured with 2-0 PDS. The mean operating time ranged from one hour 40 minutes to two hours 30 minutes with a mean time of two hours ten minutes. Patients with negative ulnar variance did not undergo ulnar shortening. All wrists that had undergone TFCC reconstruction were immobilised for four weeks with a 2.0 mm K-wire. Thereafter, a rehabilitation programme that included wrist motion and the occupational therapy was initiated. All operations were performed by a single surgeon and the patients were assessed and followed up at the outpatient department. Mayo Modified Wrist Score (Table 2), including pain,
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(A)
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(B)
Fig. 3 Plain films 14 months post-surgery show union of the ulnar bone; lateral film displayed no subluxation.
work status, range of motion and grip strength, was used to assess wrist function. Moreover, a dynamometer of the injured and the contralateral sides of the wrist was used to measured grip strength. The results can thus be reported as percentages of the contralateral data, for normalisation.
RESULTS No patient X-ray films revealed degenerative changes. Ulnar variances were 2.4 ± 0.5 mm. Most patients had dorsal subluxation of the ulna, as shown in the true lateral X-ray. Moreover, 31 patients had positive or zero ulnar variance, and these patients all underwent ulnar shortening. Six patients had negative ulnar variance, and received TFCC reconstruction only. Thirty-four patients had received the wrist arthrogram before surgery. Thirty patients displayed positive arthrographic results. Moreover, four patients presented negative results in their arthrogram but had Palmer type I lesions verified by arthroscopy. None of arthrograms revealed carpal interosseous ligament tears, a finding which was verified by arthroscopy.
In this series, all patients received wrist CT scans to assess subluxation or dislocation of the DRUJ. According to the criteria of Mino et al.,8 the ulnar head of a normal DRUJ lies between two traced lines that define the dorsal and palmar borders of the radius (Fig. 3A). All transverse computed tomographic scans revealed subluxation of DRUJ. Wrist CT scan was repeated again for all patients 12 to 24 months post-surgery. Notably, all ulnar heads lay between the two tracing lines, according to the criteria of Mino et al. (Fig. 3B). Three patients underwent wrist MRI scans and all had a torn TFCC, as confirmed by wrist arthroscopy. All 37 patients received wrist arthroscopy that found TFCC tears with mild degenerative changes (Palmer type IIA or B). Nineteen of the 37 patients had Palmer type IB and 11 had Palmer type IC tears (Fig. 4) and seven patients had Palmer type ID tears (Fig. 5). The tears and inflammatory synovium were debrided using a small joint power shaver. None of the patients suffered interosseous ligament lesions. The function of the injured wrist was evaluated before surgery. Most patients had moderate ulnar wrist pain, could not work or tolerate military training and moreover had decreased grip strength (40% to
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Table 2 Mayo Modified Wrist Score. Pain
Point
No pain Mild occasional Moderate Severe
25 20 15 0
Work Status Regular job Restricted job Able to work but unemployed Unable to work due to pain
25 20 15 0
Range of Motion > 120◦ 100◦ to 119◦ 90◦ to 99◦ 60◦ to 89◦ 30◦ to 59◦ 0◦ to 29◦
25 20 15 10 5 0
Grip Strength (% of Normal) 90 to 100 75 to 89 50 to 74 25 to 49 0 to 24
25 15 10 5 0
Fig. 4 Wrist arthroscopic examination demonstrated huge TFCC tears and mild degenerative change in a 21-year-old male patient with Palmer type IB lesion.
35% of the uninjured hand). Their Mayo Modified Wrist Scores ranged from 30 to 55. After the operations, all 37 patients were followed at the OPD, for between 25 and 48 months, with a mean of 36.2 months. None of the patients displayed continued wrist pain in daily activity. Grip strength improved to around 65% to 90% of the opposite hand. Eleven of the 37 patients (29.7%) achieved “excellent” results; 22 of the 37 (59.5%) had “good” results and four of the 37 (10.8%) had “fair” results. Three patients experienced superficial wound infections. These patients were all treated with antibiotics and then discharged in a stable condition.
DISCUSSION Restoration of stability and a full and painless range of motion are the goals of treatment for chronic post-traumatic unstable DRUJ. When surgical management is indicated and the TFCC is not reparable, preserving the distal ulna and reconstructing both radioulnar ligaments provides the best possibility for achieving these goals. In 1991, Hermansdorfer and Kleinman9
Fig. 5 Wrist arthroscopic examination demonstrated massive TFCC tears and ulna chondromalacia in a 23-year-old male patient with Palmer type IC lesion.
first reported a series of treatments of chronic tears in the TFCC. Eight of 11 patients returned to painless normal activity. Treating patients with chronic TFCC tears and DRUJ instability is difficult. Several TFCC reconstruction procedures have been suggested to
Functional Results Post-TFCC Reconstruction
stabilise the DRUJ.5,10,11 Unfortunately, most of these methods merely tighten the joint and reduce the capacity of the DRUJ to pronate and supinate. Hui and Linscheid12 were the first to describe the anatomic reconstruction for dorsal subluxation of the DRUJ. This study also used anatomic TFCC reconstruction with partial ECU tendon. This procedure not only stabilises the DRUJ but also maintains pronation and supination. This method can significantly improve wrist function and ability to work and participate in military training. In 1985, Darrow et al.6 reported the results of ulnar shortening in patients with ulnar wrist pain due to instability of DRUJ, chronic TFCC tears and Madelung’s deformity. Their study reported good or excellent results in 77% of cases. Biomechanical studies have demonstrated that shortening the ulna by just 2.0 mm significantly reduced the force transmitted to the ulna from the carpus.13,14 In this study, most patients underwent ulnar shortening following TFCC reconstruction, due to a positive or zero variance. Ulnar shortening can reduce TFCC loading, preventing further degeneration. Moreover, ulnar shortening can also tighten the TFCC and thus increase the stability of the DRUJ and ulnocarpal joint. Wrist arthrography has been shown to be a reliable method of diagnosing 20 (83%) patients. Wrist arthrography helped to identify the TFCC tears and their associated interosseous ligament tears, greatly facilitating surgical planning. Three patients in the current sample received MRI scans that revealed TFCC tears. One study demonstrated MRI to be as much as 95% accurate in detecting TFCC tears.15 MRI is highly sensitive in diagnosing TFCC tears. In our clinic, MRI scans produced positive results in certain patients while arthroscopy yielded negative findings. The present study has demonstrated that the non-invasive technique is not sufficiently reliable for routine use, mirroring the findings of other studies.16–18 Arthroscopy appears to be the most accurate method of diagnosing TFCC tears. Many studies19,20 have obtained satisfactory results after the immediate repair of acute TFCC tears. For chronic cases, shortterm studies have demonstrated good results for partial TFCC excision, but some long-term studies have reported a failure rate of over 30% when TFCC excision is performed without ulnar shortening.21,22 In 1991, Osterman and Terrill23 reported that the debridement of the redundant cartilage remnant was highly successful, with an overall improvement rate ranging from 75% to 85%. Meanwhile, ulnar surgery was a potion for the remaining 15% to 25% of patients who still expressed symptoms. This study
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demonstrated that the debridement of the degenerative TFCC and inflammatory synovium under an arthroscope can successfully alleviate symptoms. Four patients in this study had fair scores after TFCC reconstruction. Although the symptoms of these patients were improved, they still reported mild pain during work or sport, and slight limitation of wrist supination. Possible causes of this condition were the adhesion of the graft and degenerative changes in the wrist joint. The grip strength of these patients improved to at least 65% of that of the opposite hand. Additionally, wrist scores were better than those before surgery. Three patients in this study experienced superficial wound infections and were treated with antibiotics. These three patients showed good results two years later. TFCC reconstruction with the partial ECU tendon with or without ulnar shortening is an effective procedure. This procedure establishes a potentially satisfactory head-notch relationship, restores the integrity and stability of the TFCC, maintains the supination and pronation motions of the DRUJ, and reduces the force transmitted to the ulna, reducing patient symptoms and improving wrist functions and thus enabling patients to tolerate work, sport and military training. The procedure also achieves anatomic reconstruction of both radioulnar ligaments when dissection is efficient. This procedure does not violate the ECU sheath and surrounding tissues, thus preserving ulnocarpal stability. Consequently, TFCC reconstruction with partial ECU tendon combined with or without ulnar shortening is an effective method for treating irreparable TFCC tears with chronic post-traumatic DRUJ instability.
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15. Faupel L, Kunze K, Rehm K, Indikation and ergebruisse Du Verkurzungsosteotome der ulna, Unfallchirurgie 10:250–253, 1984. 16. Miller RJ, Totterman SM, Triangular fibrocartilage in asymptomatic subjects: investigation of abnormal MR signal intensity, Radiology 196:22–23, 1995. 17. Omarini LP, Garcia J, Magnetic resonance imaging of lesions of the triangular carpal ligament, Schweiz Med Wochenschr 125:854–859, 1995. 18. Pederzini L, Luchetti R, Soragni O, Evaluation of the triangular fibrocartilage complex tears by arthroscopy, arthrography and magnetic resonance imaging, Arthroscopy 8:191–197, 1992. 19. Salvatore JC, Felix HS, William B, Arthroscopic repair of peripheral avulsions of the triangular fibrocartilage complex of the wrist: a multicenter study, Arthroscopy 13:78–84, 1997. 20. Thomas ET, Mary G, Nicholas V, Arthroscopic repair of the triangular fibrocartilage complex, Arthroscopy 12:588–597, 1996. 21. Palmer AK, Werner FW, Glisson RR, Murphy DJ, Partial excision of the triangular fibrocartilage complex, J Hand Surg 13A:391–394, 1988. 22. Menon J, Wood VE, Schoene HR, Isolated tears of the triangular fibrocartilage of the wrist: results of partial excision, J Hand Surg 9: 527–530, 1984. 23. Osterman AL, Terrill RG, Arthroscopic treatment of TFCC lesion, Hand Clin 7:277–281, 1991.
