The triangular fibrocartilage complex (TFCC) and its proximal component, the radioulnar ligaments, constitute the primary intrinsic stabilizer of the distal radioulnar joint (DRUJ).
TFCC injuries are frequently associated (in up to 78% of cases) with distal radius fractures, although the vast majority heals without long-term sequalae.
Chronic lesions of the proximal component of the TFCC can cause pain and DRUJ instability.
The volar and dorsal radioulnar ligaments have an important stabilizing effect in forearm rotation, with an isometric point of insertion in the fovea.
Symptomatic nonrepairable or chronic TFCC tears can be treated by ligament reconstruction if the articular cartilage is in good condition.
Wrist arthroscopy is the most reliable method for diagnosis and decision making in this type of injury, and also enables treatment by ligament reconstruction.
A 35-year-old male patient with a history of left distal radius fracture 7 years previously, which was treated using external fixation ( Figs. 1 and 2 ).
As fracture sequelae, he presented chronic scapholunate instability and DRUJ instability.
The scapholunate instability was successfully treated by arthroscopic ligamentoplasty but an attempt to repair the TFCC failed. Nonrepairable TFCC tissue and the absence of arthritis at the DRUJ level and ulnar side of the wrist were previously confirmed. What is the most effective treatment to restore DRUJ instability, and what is the role for arthroscopic assistance?
Importance of the Problem
Peripheral tears of the triangular fibrocartilage complex (TFCC) can cause pain and distal radioulnar joint (DRUJ) instability. There are several techniques for the repair or reconstruction of these lesions, which vary depending on the location, healing capacity, and tissue viability.
TFCC injuries are frequently associated (in up to 78% of cases) with distal radius fractures. The volar and dorsal radioulnar ligaments form the proximal component of the TFCC. Lesions of this component can cause pain and DRUJ instability, with functional and mobility limitations.
In chronic nonrepairable TFCC tears with clinical DRUJ instability in which the articular cartilage is in good condition, ligament reconstruction with tendon graft is the treatment of choice, either by open or arthroscopy-assisted surgery. It is also the preferred treatment in cases of previous failed repair surgeries in patients with clinical DRUJ instability.
Atzei and Luchetti published a new classification of Palmer class 1-B injuries, in which they differentiated these types of nonrepairable tears of the proximal component with DRUJ instability, designating them as class 4 ( Table 1 ).
Numerous procedures have been described to restore the stability of the DRUJ through nonanatomic reconstructions, and include extra-articular ulnocarpal plasty, direct radioulnar fixation plasty to the joint and dynamic muscle transfers using the pronator quadratus muscle. The role of the distal oblique bundle in DRUJ stability has also been studied recently, but is present in only 40% of cases. These techniques are less effective compared to anatomic reconstruction of the DRUJ ligaments using a tendon graft.
The growth and refinement of arthroscopy has led to a considerable qualitative leap in the diagnosis and treatment of wrist injuries, and many classic surgical techniques have been converted to arthroscopic procedures, including those aimed at restoring stability in the DRUJ. The main advantages of arthroscopy over open procedures are better intraarticular visualization and reduced morbidity.
In order to correctly indicate TFCC reconstruction with tendon graft, it is important to be able to diagnose a nonrepairable injury to the proximal component of the TFCC, ensure that the articular surfaces are in good condition, and confirm the correct functioning of the interosseous membrane (to rule out Essex-Lopresti injury). Wrist arthroscopy is the gold standard for accurate diagnosis and guidance, and very often for the application of the appropriate treatment in a given case.
“What is the most effective ligament reconstruction for management of chronic DRUJ instability associated with a (healed) distal radius fracture?”
Anatomic DRUJ ligament reconstruction using a tendon graft is an effective method for restoring DRUJ stability. The ideal candidate is a patient with clinically significant chronic DRUJ instability, nonrepairable TFCC and healthy articular cartilage. Evidence will need to establish whether there is an advantageous role for arthroscopic and minimally invasive techniques to potentially reduce soft tissue morbidity including periarticular scarring and fibrosis.
Finding the Evidence
A systematic review was carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. On March 2, 2020, a search was conducted on the PubMed and Cochrane databases with the terms “DRUJ instability” or “chronic distal radioulnar joint instability” ( Fig. 3 ). Abstracts and subsequently full-text articles were analyzed by two senior orthopedic surgery and traumatology specialists. Relevant articles from the bibliography of the selected articles were included. Articles that were not available in English or Spanish were excluded.
Quality of the Evidence
Clinical case series: 14
Fourteen level IV studies with case series (of 5–95 patients) of chronic DRUJ instability treated using some type of graft to restore stability were identified ( Table 1 ). The older studies employed different types of open reconstruction techniques, while more recent ones included case series of patients treated with open reconstruction procedures and others using arthroscopy-assisted reconstruction.
In 1983, Mansat et al. described an anatomic ligamentoplasty using a palmaris longus tendon graft reconstructing the distal volar and dorsal radioulnar ligaments. In 1994, Scheker presented a series of 15 patients treated by open distal radioulnar ligamentoplasty with a palmaris longus tendon graft, reconstructing only the dorsal distal radioulnar ligament; pain was eliminated in 80% of the patients, with an increase in grip strength and no loss of mobility compared to before the surgery. In 2000, Adams modified the more anatomic open reconstruction technique by Mansat, in which he reconstructed the distal volar and dorsal radioulnar ligaments using a palmaris longus graft, publishing his results in 2002. His modification of the original technique became the gold standard for treatment. In addition to the initial study, four more series have been published using this method, most of which modify it in some way. The five series of results using the Adams modification (9, 14, 16, 74 and 95 patients) showed good outcomes in 86%–100% of patients, with recovery of wrist stability (78%–100%), disappearance of pain or mild pain only (76%–89%) and improved grip strength in the functional evaluations. Meyer et al. presented a further modification of the Adams technique in which they created a second tunnel in the ulna, allowing the graft to be tied over a bone bridge, giving more resistant fixation and possibly allowing shorter and less strict immobilization; the authors describe results similar to those reported with the Adams technique. Three other techniques have been published using pronator quadratus interposition (volar stabilization), the dorsal capsule and extensor retinaculum (dorsal stabilization) and palmaris longus tendon graft but located more proximal to the diaphysis (extra-articular ligament reconstruction). Although the authors reported good results, and the procedures have the advantage of being technically simpler, the reconstruction is less anatomic and they are less frequently used.
Three patient series have also been published in which wrist arthroscopy was performed to confirm the diagnosis prior to open reconstruction surgery. Pürisa et al. performed diagnostic arthroscopy and then extra-articular ligament reconstruction. Shih et al. performed a diagnostic arthroscopy and, once the diagnosis was confirmed, open reconstruction 1 week later, with tunnels similar to those used in the Adams technique but with extensor carpi ulnaris tendon graft. The results reported were worse, with the drawback of performing the surgery in two stages. Henry carried out wrist arthroscopy to confirm the diagnosis and, in the same procedure, performed the reconstruction using a palmaris longus graft. He made two tunnels in the radius in an attempt to replicate the insertion of the distal radioulnar ligaments in the sigmoid notch, suturing the graft over the bone bridge of the radius; outcomes were good, with joint stability in all patients in the series, improved grip strength, and no loss of motion with respect to the preoperative scores in the functional tests.
A further step has been taken more recently, and two series have been published with arthroscopy-assisted open surgery reconstruction techniques. These allow more accurate localization of the exit point of the ulnar tunnel in the fovea, as well as smaller (and therefore more cosmetic) incisions and less injury to soft tissues. Mak et al. (part of this series previously published by Tse et al. ) performed a procedure similar to the Adams technique, adding a second tunnel in the ulna to fix the graft over a bone bridge. Luchetti and Atzei presented their case series, where they created the same tunnels as in the Adams technique, fixing the graft on the ulna with a bio-tenodesis screw. The authors reported results comparable to the Adams open technique in terms of stability, grip strength, and functional scores, showing an improvement in postoperative mobility, as well as a cosmetic advantage ( Table 2 ).
|Authors||Year||N||Kind of Surgery||Graft||Tunnels and Fixation||Stability (% Patients)||Grip Strength (% of Contralateral)||ROM (°)||Pain||Functional Scores||Complications. Satisfaction|
|Scheker et al.||1994||15||OS||PL or plantaris or EDC||3 in R; 3 in C. |
Fix. 2 sutures over bone bridge (R, U).
|80||F 61; E 62; RD 24; UD 31; P 82; S 80||86% none, |
14% minor discomfort
|1 Postblock brachial plexus neuritis |
1 Mild reflex sympathetic dystrophy
1 Recurrence of instability
|Adams and Berger||2000||14||OS||PL||PA in R; Ob in U. Fix. around U neck.||86||85||P72; S70||64% none, 36% mild pain||2 Recurrence of instability |
2 Paraesthesia (healed)
|Teoh and Yam||2005||9||OS||PL||PA in R; Ob in U. Fix. around U neck.||78||86||P-S (in % of contralateral): 92%||66% mild pain||MMWS 87||1 Paraesthesia (healed) |
|Shih and Lee||2005||37||DA + OS (1 week after)||ECU||PA in R; Ob in U.||65–90||None patients pain in daily activity||MMWS: 29.7% excellent |
|3 Superficial wound infections|
|Seo et al.||2009||16||OS||PL||PA in R; Ob in U. Fix. around U neck.||75||F 70.9; E 72.8; RD 13.4; UD 30.3; P 76.3; S 82.5||PRWE (pain): 9.1/50||MMWS 92.8 |
|3 Laxity |
|Pürisa et al.||2011||5||DA + OS||PL||PA in R diaphysis. Fix. around U diaphysis||100||F 42; E 45; P 49; S 47||VAS 1.88||DASH 6.81|
|Henry||2012||25||DA + OS||PL||2 in sigmoid notch in R. Ob in U. Suture over bone bridge (R).||100||79||F 61; E 62; P 71; S 74||DASH 7|
|Lee et al.||2016||21||OS||PQ||3–4 in U. Suture over bone bridges.||100||91||F 72; E 69; P 77; S 82||DASH 12.5 |
|Luchetti and Atzei||2017||11||AAS||PL||PA in R; Ob in U. Interference screw in U.||91||96||F 60; E 67; P 80; S 81||VAS (rest) 2 |
VAS (stress) 4
|MWS 82 |
|1 Fracture ulnar styloid (healed) |
3 Ulnar paraesthesia (healed)
1 Graft rupture
1 Instability recurrence
|El-Haj et al.||2017||17||OS||ER + DC||Fix. Anchor suture in R.||100||P-S “full”||VAS 2.21||DASH 13.39||None|
|Meyer et al.||2017||48||OS||PL or FCU or LTE||PA in R; 2 Ob in U. Fix. Suture over bone bridge (U).||91||80.3||F 67.1; E 70.1; RD 19.6; UD 32.9; P 67.9; S 66.1||VAS 1.3||2 Subluxation persisted |
2 Recurrent instability
|Mak and Ho||2017||28||AAS||PL||PA in R, Ob in U + PA in U. Suture over bone bridge (U).||71.6||In % of contralateral: |
P + S: 91.1%
E + F: 83.7%
RD + UD: 83.5%
|VAS 3||MWS 79||35.7%: |
4 graft rupture
3 nerve injuries (healed)
3 discomfort over scar
1 breakage KW
|Kootstra et al.||2018||22 a||OS||PL or toe extensor or plantaris||PA in R; Ob in U. Fix. around U neck.||100||89.7||F 67; E 71.8; UD 30.9; RD 17.7; P 73; S 71.4||DASH 13.1 |
|4% Recurrent instability|
|Gillis et al.||2019||95||OS||PL or plantaris or TS or gracilis or semitendinosus||PA in R; Ob in U. Fix. around U neck or fix. anchors or Fix. interference screw||90.8||77.4||F 52.1; E 58.6; RD 19.8; UD 28.6; P 71.3;S 62.7||27.5% none, 48.4% mild pain||MMWS 68.9||31.6%: neuroapraxia, neuroma, recurrent instability, generative disease |
Satisfaction: VAS 8.1. 86.3%