腕关节镜掌侧和背侧联合入路的临床应用及效果

目的 介绍一种腕关节镜掌侧入路建立的新方法,报道使用掌侧和背侧联合入路对腕部疾患诊断和治疗的体会.方法 采用"由内向外的交换棒技术"和"由外向内的浅切开深分离"相结合技术建立腕关节镜掌侧入路.自2004年起,通过掌侧和背侧联合入路,进行11例腕部疾患的腕关节镜手术;三角纤维软骨复合体损伤3例(根据Palmer分型,2A型2例,2C型1例),桡骨远端骨折合并韧带损伤5例(根据AO分型,B1型2例,C3型3例),痛风性关节炎3例.男5例,女6例;年龄30～82岁,平均52岁.对所有病例进行随访观察,了解手术的并发症和治疗效果.结果 通过掌侧入路,成功地观察到腕关节的背侧结构,诊断损伤,并能在镜下施行清理和骨折复位手术.所有病例腕关节活动度得以恢复,疼痛有明显缓解,术后腕关节患者自行评估量表(patient-rated wrist evaluation,PRWE)评分为28.6±9.3.术后3～6个月随访显示无手术相关并发症.结论 通过新技术进行腕关节镜掌侧和背侧联合入路手术,安全可行,是腕部疾患诊疗的一种有效方法.     

Volar portals in wrist arthroscopy

Volar portals for wrist arthroscopy have certain advantages over the standard dorsal portals for visualizing dorsal capsular structures as well as the palmar aspects of the carpal ligaments. The volar radial (VR) portal is relatively easy to use and is an ideal portal for evaluation of the dorsal radiocarpal ligament (DRCL) and the palmar aspect of the scapholunate interosseous ligament. The volar midcarpal portal may be considered as an occasional accessory portal for visualizing the palmar aspects of the capitate and hamate in cases of avascular necrosis or osteochondral fractures. The volar ulnar (VU) portal is especially useful for the viewing and debridement of palmar tears of the lunotriquetral ligament. Copyright © 2002 by the American Society for Surgery of the Hand     

Editorial Commentary: Guidelines for Wrist Triangular Fibrocartilage Complex Foveal Tears: A Compass for a Broad Voyage

The ulnar head attachment of triangular fibrocartilage complex is divided into 2 sections: the distal radioulnar ligament consists of superficial and deep bundles on both the palmar and dorsal sides, which attach at the fovea and the base of the ulnar styloid. A tear on the ulnar side of triangular fibrocartilage complex inevitably occurs at these attachments. Both magnetic resonance imaging and distal radioulnar joint (DRUJ) arthroscopy are crucial. DRUJ arthroscopy can clarify the tear location. An ulnar styloid tear can be treated by capsular repair. However, a foveal tear should be reattached to the fovea because this tear could cause gross DRUJ instability. There are several ways to reattach the bundles to the fovea, including single- or double-tunnel or bone anchors, and open versus arthroscopic.     

Arthroscopic Suture Repair of Peripheral Tears of Triangular Fibrocartilage Complex Using a Volar Portal

Surgical repair of a Palmer type IB triangular fibrocartilage complex (TFCC) tear can be difficult using conventional dorsal portals and it may need special repair kits. The authors describe an arthroscopic technique using an additional volar portal that allows quick access and a secure purchase of peripheral TFCC tears as well as a distinct approach to dorsal wrist structures.     

Clinical applications of volar portals in wrist arthroscopy

Volar portals for wrist arthroscopy have certain advantages over the standard dorsal portals for visualizing dorsal capsular structures as well as the palmar aspects of the carpal ligaments. The volar radial portal is relatively easy to use and is an ideal portal for evaluation of the dorsal radiocarpal ligament and the palmar aspect of the scapholunate interosseous ligament. The volar midcarpal portal may be considered as an occasional accessory portal for visualizing the palmar aspects of the capitate and hamate in cases of avascular necrosis or osteochondral fractures. The volar ulnar portal is especially useful for the viewing and debridement of palmar tears of the lunotriquetral ligament.     

The "ulnar fovea sign" for defining ulnar wrist pain: an analysis of sensitivity and specificity

PURPOSE: Eliciting tenderness in the region of the ulnar fovea is a possibly useful clinical test for defining the source of ulnar-sided wrist pain. Until now, no reports of the clinical sensitivity and specificity of this test have been available. Based on anecdotal observations, a hypothesis was developed stating that ulnar fovea tenderness (positive "ulnar fovea sign") is sensitive and specific in detecting two ulnar-sided wrist conditions: foveal disruption of the distal radioulnar ligaments and ulnotriquetral (UT) ligament injuries. METHODS: The clinical records of 272 consecutive patients with wrist arthroscopy performed by the senior author from 1998 through to 2005 were reviewed. Relevant clinical and surgical data were abstracted. The ulnar fovea sign test is executed by pressing the examiner's thumb distally into the interval between the ulnar styloid process and flexor carpi ulnaris tendon, between the volar surface of the ulnar head and the pisiform. A positive ulnar fovea sign is designated when there is exquisite tenderness that the patient claims replicates their pain, with comparisons made with the contralateral side. RESULTS: There were a total of 90 foveal disruptions and 68 UT ligament injuries diagnosed during wrist arthroscopy. The ulnar fovea sign was positive in 156 patients. The sensitivity of the fovea sign in detecting foveal disruptions and/or UT ligament injuries was 95.2%. Its specificity was 86.5%. CONCLUSIONS: The hypothesis stating that the ulnar fovea sign is a useful clinical maneuver to detect foveal disruptions and UT ligament tears is supported. The conditions represent 2 common sources of ulnar-sided wrist pain. The differentiation between the 2 conditions may be made clinically, where UT ligament tears are typically associated with a stable distal radioulnar joint and foveal disruptions are typically associated with an unstable distal radioulnar joint. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.     

Peripheral tears of triangular fibrocartilage complex: results of primary repair

In 16 patients with ulnar wrist pain, we performed primary arthroscopic or open repair of the peripheral rim tears of the triangular fibrocartilage complex (TFCC) (14 ulnar, 4 volar, and 3 radial tears). The wrist function was assessed before and 1 year after the repair using the Mayo-modified wrist score. The average pain score improved from 9.1+/-8.0 to 21.2+/-6.5, the average functional score from 5.0+/-8.1 to 20.6+/-6.3, the average motion score from 4.7+/-2.8 to 15.6+/-7.3, and the average grip point from 4.4+/-3.5 to 15.6+/-7.7, all with significant differences (P<0.01). Ten of the 17 cases had instability of the distal radioulnar joint and five had recurrent instability after repair.     

Current Concepts in Wrist Arthroscopy

The purpose of this article is to review the recent literature on arthroscopic treatment of distal radius fractures (DRFs), triangular fibrocartilage complex injuries, intercarpal ligament injuries, and ganglion cysts, including the use of electrothermal devices. A major advantage of arthroscopy in the treatment of DRFs is the accurate assessment of the status of the articular surfaces and the detection of concomitant injuries. Nonrandomized studies of arthroscopically assisted reduction of DRFs show satisfactory results, but there is only 1 prospective randomized study showing the benefits of arthroscopy compared with open reduction–internal fixation. Wrist arthroscopy plays an important role as part of the treatment for DRFs; however, the treatment for each practitioner and each patient needs to be individualized. Wrist arthroscopy is the gold standard in the diagnosis and treatment of triangular fibrocartilage complex injuries. Type 1A injuries may be successfully treated with debridement, whereas the repair of type 1B, 1C, and 1D injuries gives satisfactory results. For type 2 injuries, the arthroscopic wafer procedure is equally effective as ulnar shortening osteotomy but is associated with fewer complications in the ulnar positive wrist. With interosseous ligament injuries, arthroscopic visualization provides critical diagnostic value. Debridement and pinning in the acute setting of complete ligament tears are promising and proven. In the chronic patient, arthroscopy can guide reconstructive options based on cartilage integrity. The preliminary results of wrist arthroscopy using electrothermal devices are encouraging; however, complications have been reported, and therefore, their use is controversial. In dorsal wrist ganglia, arthroscopy has shown excellent results, a lower rate of recurrence, and no incidence of scapholunate interosseous ligament instability compared with open ganglionectomy. Arthroscopy in the treatment of volar wrist ganglia has yielded encouraging preliminary results; however, further studies are warranted to evaluate the safety and efficacy of arthroscopy.     

Longitudinal split tears of the ulnotriquetral ligament

Unlike tears of the peripheral triangular fibrocartilage or avulsions of the distal radioulnar ligaments, longitudinal split tears of the ulnotriquetral (UT) ligament do not cause any instability to the distal radioulnar joint or the ulnocarpal articulation. It is mainly a pain syndrome that can be incapacitating. However, because the UT ligament arises from the palmar radioulnar ligament of the triangular fibrocartilage complex (TFCC), it is by definition, an injury of the TFCC. The purpose of this article is to describe the cause of chronic ulnar wrist pain arising from a longitudinal split tear of the UT ligament.     

Arthroscopic knotless peripheral triangular fibrocartilage repair

Peripheral tears to the articular disk of the triangular fibrocartilage complex are fairly common. Patients complain of ulnar-sided wrist pain with ulnar deviation and forearmrotation along the prestyloid recess. The peripheral tears of the articular disk are amenable to arthroscopic repair due to its blood supply. All-arthroscopic knotless repair of peripheral ulnar-sided tears of the articular disk has several advantages. This technique allows for repair of the superficial and deep layers of the articular disk directly down to bone. In addition, by being knotless, it avoids irritation to the surrounding soft tissues by suture knots. This article describes arthroscopic repair of peripheral ulnar-sided tears of the articular disk down to bone with a knotless technique.     

Radiocarpal arthroscopy and arthrography in the diagnosis of ulnar wrist pain

The purpose of this prospective study was to compare arthroscopy with arthrography in the diagnosis of ulnar wrist pain. Thirty-seven consecutive patients with ulnar wrist pain but normal routine and stress radiographs had dynamic and static radiocarpal arthrograms (R.G.H.) and arthroscopy (J.H.R.) performed. Sixteen arthrograms demonstrated a leak of contrast into the distal radioulnar joint. Arthroscopy demonstrated a perforation of the triangular fibrocartilage complex in all 16. Seven arthrograms demonstrated a leak of contrast into the midcarpal joint. Arthroscopy demonstrated lunotriquetral instability in two and no abnormality in five. Seventeen arthrograms showed no abnormality. Arthroscopy confirmed no abnormality in nine but also demonstrated seven triangular fibrocartilage perforations and one case of isolated lunate chondromalacia. Arthroscopy findings were confirmed in eight patients who underwent a subsequent arthrotomy. Radiocarpal arthroscopy is superior to arthrography in the diagnosis of chronic ulnar wrist pain.     

Pressure mapping of the radioulnar carpal joint: effects of ulnar lengthening and wrist position

The purpose of this study was to investigate the effects of ulnar lengthening and wrist position on force transmission through the radioulnar carpal joint in a forced dorsiflexed wrist position. Eight cadaveric arms were subjected to a 30 kg compressive load directed down the forearm towards the wrist. A pressure sensor recorded forces across the wrist joint with the triangular fibrocartilage complex intact and excised. The biomechanics of the distal radioulnar joint were altered by changes in ulnar length and wrist position. Pressures at the ulnolunate articulation increased as the ulna was lengthened and were significantly lower when the triangular fibrocartilage complex was excised. An inverse relationship between triangular fibrocartilage complex thickness and ulnar variance was shown. Greater increases in ulnolunate pressure were observed in more positive ulnar variant wrists.     

Management of acute triangular fibrocartilage complex injury of the wrist

Acute trauma to the triangular fibrocartilage complex includes tears of the fibrocartilage articular disk substance and meniscal homolog as well as radioulnar ligament avulsions, with or without an associated fracture. Patient evaluation includes clinical examination, imaging studies, and wrist arthroscopy (diagnostic). The Palmer classification is typically used to define injuries to the triangular fibrocartilage complex. The critical distinction is in differentiating injuries that produce instability of the distal radioulnar joint from those that do not. Also important is the recognition of acute injuries in the context of an ongoing degenerative pattern (ie, Palmer class 2 lesions). Nonsurgical management includes temporary splint immobilization of the wrist and forearm, oral nonsteroidal anti-inflammatory medication, corticosteroid joint injection, and physical therapy. Surgical strategies include débridement, acute repair, and subacute repair. Most surgical procedures can be performed arthroscopically. However, open ligament repair may be needed in the setting of distal radioulnar joint instability.     

Arthroscopic and open repair of the TFCC

Injury to the triangular fibrocartilage complex is the most common cause of ulnar-sided wrist pain. This functionally related complex of anatomic structures can be a source of pain secondary to acute injury or chronic degeneration. Strategies for the treatment of these injuries involve determining the anatomic location of the tear, the presence of associated distal radioulnar joint instability, and the presence of associated degenerative changes. Surgical management with open and arthroscopic techniques have been described, both with successful results.     

Editorial Commentary: In Cases of Concurrent Triangular Fibrocartilage Complex Tears and Ulnar Styloid Process Fracture Nonunions,We May Neither Need to Excise nor Repair the Ulnar Styloid Fracture Nonunion Fragment

The ulnar-sided wrist contains multiple potential pain generators that may present in isolation. Occasionally, however, wrist trauma results in multiple concurrent and overlapping injuries that make diagnosis and treatment of these conditions challenging. Deep/foveal tears of the triangular fibrocartilage complex (TFCC) may occur in the setting of nonunited ulnar styloid process fractures. Treatment of these injuries has historically included open TFCC repair with fixation or excision of the ulnar styloid fracture nonunion fragment; however, recent literature suggests that addressing the ulnar styloid nonunion fragment may not be as important as we think. Recent research shows that we may not need to excise or repair the ulnar styloid fracture nonunion fragment, which in turn may help preserve the complex ligamentous architecture that stabilizes the ulnar-sided wrist. One thing we know for sure is that foveal tears of the deep fibers of the TFCC, with or without ulnar styloid fracture (Palmer 1B, Atzei class 2 or 3), can produce distal radioulnar joint (DRUJ) instability and wrist dysfunction and should be addressed sooner rather than later to prevent long-term consequences, including DRUJ osteoarthritis. Whether you choose to approach the problem arthroscopically or open, the foveal TFCC tear should be repaired to prevent long-term sequalae.     

三角纤维软骨复合体解剖及生物力学研究

目的从解剖完整的腕关节入手,阐明三角纤维软骨复合体各组成部分的解剖特点,评估三角纤维软骨复合体(TFCC)对于维持远侧桡尺关节稳定的重要性。方法对8个新鲜解冻的腕关节和6个经甲醛浸泡的腕关节进行显微解剖。同时对影响远侧桡尺关节稳定性的因素作了初步的评估。前臂中旋位,垂直于尺骨予20N拉力下测量尺骨相对于桡骨的位移,然后先后切断掌背侧桡尺韧带,测量尺骨相对于桡骨的位移变化。结果发现掌背桡尺韧带由三角纤维软骨盘外周增厚而成,止于尺骨茎突基底部,是维持远侧桡尺关节稳定性的主要因素之一,切断掌背侧桡尺韧带会导致远侧桡尺关节明显不稳。结论TFCC由三角纤维软骨盘、掌背侧桡尺韧带、尺骨月骨韧带、尺骨三角骨韧带、尺侧腕伸肌下腱鞘、半月板同源物、尺侧囊组成。掌背桡尺韧带是维持远侧桡尺关节稳定性的主要因素之一,掌背侧桡尺韧带损伤会导致远侧桡尺关节明显不稳。     

Techniques of wrist arthroscopy

Wrist arthroscopy is a promising new technique for the evaluation of wrist pain or dysfunction. Cadaveric wrist specimens were used to devise safe and advantageous entry portals for arthroscopy and to establish respective advantages for each portal. Thirty-five clinical cases were used to correlate the laboratory experience and to refine a reproducible surgical technique. Seven portals are useful: five in the radiocarpal interval, one in the midcarpal area, and one in the distal radioulnar joint space. Detailed wrist anatomy is reviewed in this paper and must be thoroughly understood to interpret arthroscopic views. Blunt subcutaneous dissection protects cutaneous nerve branches at the various portals. Intraoperative photographs illustrate the excellent perspectives achieved using these techniques.     

Techniques of Wrist Arthroscopy

Wrist arthroscopy is a promising new technique for the evaluation of wrist pain or dysfunction. Cadaveric wrist specimens were used to devise safe and advantageous entry portals for arthroscopy and to establish respective advantages for each portal. Thirty-five clinical cases were used to correlate the laboratory experience and to refine a reproducible surgical technique. Seven portals are useful: five in the radiocarpal interval, one in the midcarpal area, and one in the distal radioulnar joint space. Detailed wrist anatomy is reviewed in this paper and must be thoroughly understood to interpret arthroscopic views. Blunt subcutaneous dissection protects cutaneous nerve branches at the various portals. Intraoperative photographs illustrate the excellent perspectives achieved using these techniques.     

TFCC lesions. Diagnosis and therapy

Lesions of the TFCC may have degenerative or post-traumatic causes. Distal radioulnar joint as well as the ulnocarpal joint can be affected. Patients present with ulnar-sided wrist pain especially in forearm rotation. Therapy depends on the degree of lesions and additional pathology. Wrist arthroscopy offers a certain diagnostic tool. In addition, adequate therapy can be realized. After failed arthroscopic therapy, ulnar shortening osteotomy reduces ulnar load significantly.     

Pathomechanisms of ulnar ligament lesions of the wrist in a cadaveric distal radius fracture model

Background and purpose Mechanisms of injury to ulnar-sided ligaments (stabilizing the distal radioulnar joint and the ulna to the carpus) associated with dorsally displaced distal radius fractures are poorly described. We investigated the injury patterns in a human cadaver fracture model.

Methods Fresh frozen human cadaver arms were used. A dorsal open-wedge osteotomy was performed in the distal radius. In 8 specimens, pressure was applied to the palm with the wrist in dorsiflexion and ulnar-sided stabilizing structures subsequently severed. Dorsal angulation was measured on digitized radiographs. In 8 other specimens, the triangular fibrocartilage complex (TFCC) was forced into rupture by axially loading the forearm with the wrist in dorsiflexion. The ulnar side was dissected and injuries were recorded.

Results Intact ulnar soft tissues limited the dorsal angulation of the distal radius fragment to a median of 32^o (16–34). A combination of bending and shearing of the distal radius fragment was needed to create TFCC injuries. Both palmar and dorsal injuries were observed simultaneously in 6 of 8 specimens.

Interpretation A TFCC injury can be expected when dorsal angulation of a distal radius fracture exceeds 32^o. The extensor carpi ulnaris subsheath may be a functionally integral part of the TFCC. Both dorsal and palmar structures can tear simultaneously. These findings may have implications for reconstruction of ulnar sided soft tissue injuries.