Review 295
Arthroscopy of the Distal Radioulnar Joint
Authors
T. Nakamura1, N. Matsumura2, T. Iwamoto2, K. Sato2, Y. Toyama2
Affiliations
1
Department of Orthopaedic Surgery, Clinical Research Center, International University of Health and Welfare, Sanno Hospital, Tokyo, Japan 2 Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan
Key words ▶ arthroscopy ● ▶ distal radioulnar joint ● ▶ DRUJ ● ▶ triangular fibrocartilage ● complex ▶ TFCC ● ▶ radioulnar ligaments ● ▶ instability ●
Abstract
Zusammenfassung
Wrist arthroscopy is now widely indicated for diagnosis and treatment of acute or chronic wrist pain, especially for triangular fibrocartilage complex (TFCC) lesions, as a gold standard. In most cases radiocarpal and midcarpal arthroscopy was performed, while DRUJ arthroscopy has been rarely performed because of its difficulties. Recent anatomic and biomechanical studies demonstrated that the radioulnar ligament (RUL), which is the proximal component of the TFCC facing to the DRUJ, is the primary stabilizer of the distal radioulnar joint (DRUJ). Rupture of the radioulnar ligament (RUL) at the fovea area, where it is the main attaching portion to the ulna and is the isometric point during forearm rotation as the rotation axis passes, is responsible for DRUJ instability. Although physical examination and imaging diagnosis may indicate a foveal detachment of the TFCC, DRUJ arthroscopy is potential for visualizing the RUL at the fovea. Role of DRUJ arthroscopy should be more important not only for diagnosis of rupture of the RUL but also for decision making of treatment option for RUL tear. DRUJ arthroscopy also demonstrates the joint surface of both the sigmoid notch and ulnar head, and the proximal surface of the TFCC.
Die Handgelenksarthroskopie wird heute vielerorts zur Diagnostik und Therapie akuter und chronischer Handgelenksschmerzen verwendet, wobei sie bei der Abklärung von Läsionen des dreieckförmigen Faserknorpels (TFCC) als Goldstandard gilt. Meistens erfolgt eine Arthroskopie des Radio- und Mediokarpalgelenkes, wohingegen das distale Radioulnargelenk (DRUG) aufgrund technischer Schwierigkeiten bisher selten gespiegelt wurde. Jüngere anatomische und biomechanische Studien haben gezeigt, dass die radioulnaren Zügelbänder (RUL) als proximaler, dem DRUG zugewandter Teil des TFCC der Hauptstabilisator des DRUG sind. Abrisse der RUL an ihrem Ansatz in der Fovea ulnaris, wo ihr Hauptverankerungsstelle an der Ulna und zugleich der isometrische Punkt bei der Unterarmrotation lokalisiert ist, führen zur Instabilität im DRUG. Während klinische Untersuchung und Bildgebung lediglich einen Abriss des TFCC in der Fovea vermuten lassen, kann man mit einer Arthroskopie des DRUG die RUL in der Fovea direkt einsehen. Die Bedeutung der DRUGArthroskopie liegt nicht allein in dem Umstand, dass man die RUL unter Sicht beurteilen kann, sondern vielmehr darin, dass sich abhängig vom Befund ein differenziertes therapeutisches Vorgehen ergibt. Darüber hinaus ist es möglich bei der DRUG-Arthroskopie die Gelenkfläche der Sigmoidnotch als auch des Ulnakopfes und die Unterfläche des TFCC einzusehen.
Introduction
in late 1980s, including arthroscopy for the DRUJ by Whipple et al. [1]. Radiocarpal arthroscopy was then widely indicated for the diagnosis and treatment to the soft tissue injuries in the wrist, especially injury onto the triangular fibrocartilage complex (TFCC). Dry radiocarpal arthroscopy was recently introduced for arthroscopic treatment of intra-articular distal radius fracture [2]. Because of its technical difficulties, arthros-
Schlüsselwörter ▶ Arthroskopie ● ▶ distales Radioulnargelenk ● ▶ DRUG ● ▶ triangulärer fibrokartilag● inärer Komplex ▶ TFCC ● ▶ radioulnare Bäder ● ▶ Instabilität ● received accepted
26.06.2014 17.07.2014
Bibliography DOI http://dx.doi.org/ 10.1055/s-0034-1387706 Handchir Mikrochir Plast Chir 2014; 46: 295–299 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0722-1819 Correspondence Toshiyasu Nakamura, MD, PhD Department of Orthopaedic Surgery Clinical Research Center International University of Health and Welfare Sanno Hospital 8-10-16 Akasaka Minato-ku Tokyo 107-0052 Japan Tel.: + 81/3/3401 3151 Fax: + 81/3/3401 3151 [email protected]
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The wrist is a complex joint, consisting of the midcarpal, radiocarpal and distal radioulnar joints. This joint achieves multiple directional motion, flexion-extension, radial and ulnar deviation, and pronation-supination. Arthroscopic evaluation for the wrist, providing information on bony and soft tissue lesions, was introduced
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Arthroskopie des distalen Radioulnargelenkes
copy for the DRUJ was described only for the diagnosis of intraarticular lesions between the sigmoid notch of the radius and ulnar head [3, 4], as opposed to most of the structures in the radiocarpal and midcarpal joints which could be observed with radiocarpal or midcarpal arthroscopy in the 1990s [5, 6]. Based on the recent advances of anatomic and biomechanical knowledge [7, 8], the TFCC is the primary stabilizer of the distal radioulnar joint (DRUJ). Rupture of the radioulnar ligament (RUL) at the ulnar fovea can induce DRUJ instability. When the triangular fibrocartilage (TFC) was not torn, radiocarpal arthroscopy never visualized the fovea lesion, unless perforation on the TFC would be created artificially [7]. Since a 1.9 mm 30 ° oblique view scope, which is a quite smaller diameter arthroscope compared with standard 2.7 mm diameter scope, was developed, there were several studies on DRUJ arthroscopy, where better visualization of the DRUJ [9–12]. In the literature, DRUJ arthroscopy was still only used for diagnosis of the foveal attachment of the RUL [9] or debridement of the synovial tissue proliferation through palmar DRUJ portal [12]. Nakamura recently used a DRUJ arthroscope to treat a proximal lesion of the TFCC, such as an avulsion of the RUL at the fovea [13, 14].
Anatomy of the DRUJ
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The DRUJ consists of the sigmoid notch of the radius, ulnar head, TFCC and dorsal and palmar joint capsules. The TFCC consists of triangular fibrocartilage (TFC), ulnolunate ligament (UL), ulnotriquetral ligament (UT) and radioulnar ligament (RUL), the sheath floor of the extensor carpi ulnaris (ECU) tendon, and meniscus homologue [7, 8, 15]. The TFCC stabilizes the DRUJ and ulnocarpal joint, distributes load between ulna and ulnar carpus, and allows smooth rotation of the forearm [8, 15]. Histological examinations have revealed that the TFCC divides the ▶ Fig. 1). The fovea of the radiocarpal and DRU joints [16, 17] (● ulna is the largest attaching area of the RUL on the ulna, thus an RUL tear at the fovea can result in DRUJ instability readily [18].
Fig. 1 This histological section demonstrates that the triangular fibrocartilage (TFC) and radioulnar ligament (RUL) lie between the radiocarpal joint (RCJ) and distal radioulnar joint (DRUJ), thus the TFCC divides the RCJ and DRUJ. If there is no tear on the TFC, the RCJ arthroscopy never visualizes the fovea lesion.
Fig. 2 Illustration of the 3 dorsal DRUJ portals, distal, proximal and ulnar.
Foveal Injury of the RUL
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Palmer [19] classified TFCC tears into traumatic (Class 1) and degenerative (Class 2) tears. Traumatic TFCC tears were also subclassified as central tears (1A), ulnar tears (1B), distal tears (1C), and radial tears (1D) based upon the clinical patterns seen through radiocarpal arthroscopy [19]. Palmer 1B tears are defined with peripheral ulnar tears of the TFCC which may be associated with an ulnar styloid fracture, because the TFCC had been considered to attach only to the ulnar styloid in late 1980s and early 1990s. As the TFCC is anchored to the DRUJ via the RUL which attaches to the ulnar fovea and base of the ulnar styloid, a hyperrotation force or dislocation force applied to the RUL from the ulnar head, such as in a fall, may disrupt the RUL not only from the ulnar styloid but also from the fovea [7, 20]. A foveal detachment of the TFCC is clearly evident in clinical practice [13, 21]. Atzei recently sub-classified the Palmer 1B tear into a distal component, a proximal component or both (complete) [22, 23]. An isolated foveal detachment is equivalent to a proximal component tear.
TFCC
sigmoid notch
fovea
ulnar portal
ulnar head distal portal proximal portal
DRUJ Arthroscopy
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Portals There are numbers for portals of the radiocarpal joint, such as 1-2, 3-4, 4-5, 6R and 6U [5], while only 3 dorsal portals, distal, ▶ Fig. 2), and the palmar portal were proximal and ulnar (● described for DRUJ. Abrams et al. [5] described the DRUJ portal at the very proximal end of the joint, which is now known as the
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296 Review
Review 297
Indication for DRUJ arthroscopy An arthroscopic assessment of the DRUJ is indicated in any patient with acute or chronic forms of TFCC injury with moderate to severe DRUJ instability that is suspected by physical examination [12]. Moderate DRUJ instability demonstrates obvious unstable DRUJ in comparison to the contralateral intact DRUJ and there was either at least a dorsal or palmar endpoint with a ballottement testing. Severe DRUJ instability indicates multidirectional instability of the DRUJ without any endpoint from the ligament. DRUJ arthroscopy also is indicated for complete or partial foveal avulsion of the RUL on MRI [24]. Recently high resolution MRI is able to delineate foveal avulsion of the RUL easily [25]. It is also useful in the case of a symptomatic displaced non-union of the ulnar styloid [11] and radial displaced distal radius fracture [26].
mosquito forceps is advanced until it reaches the head of the ▶ Fig. 4b) ulna. The forceps were then used to gradually divide (● and penetrate the upper side of the DRUJ joint capsule and then to enter the joint. The mosquito forceps were next used to guide ▶ Fig. 4). the 1.9-mm scope into the DRUJ (● The DRUJ space including the fovea area can easily be seen in cases of foveal detachment because the DRUJ is loose [13, 24]. It is difficult to visualize the foveal area with DRUJ arthroscopy when the TFCC is completely attached to the ulna without any DRUJ instability, although the joint surface of ulnar head and sigmoid notch of the radius can easily be seen.
Fig. 3 DRUJ arthroscopic view from distal DRUJ portal. Articulation of the sigmoid notch of the radius and ulnar head, the proximal surface of the TFC, seat of the ulnar head, attaching of the RUL to the fovea are seen through this portal. Dorsal and palmar portions of the RUL are demonstrated (arrows).
a
b
Authors preferred technique The authors recommends DRUJ arthroscopy for the diagnosis of moderate to severe DRUJ instability, for evaluating the condition of the foveal origin of the RUL. DRUJ arthroscopy is also useful to refresh the ulnar fovea while arthroscopically repairing a TFCC rupture [13, 14, 24]. We used the DRUJ (distal) portal, which is just 5 mm proximal to the 4-5 or 6R portal, just ulnar to the extensor digiti minimi tendon and just distal to the head of the ulna as the viewing portal ▶ Fig. 2). Saline was used to expand the DRUJ (● ▶ Fig. 4a). Mos(● quito forceps divides the subcutaneous tissue to avoid penetration on the extensor digiti minimi tendon, and then the tip of the
Fig. 4 Introducing the trocar to the DRUJ. a Saline is injected to the DRUJ to expand the joint. b Bent mosquito forceps penetrates the DRUJ capsule to expand the portal. A trocar is introduced between the tips of the mosquito forceps.
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proximal DRUJ portal [9]. Before the 1.9 mm oblique view scope was introduced, the proximal DRUJ portal was the safety portal for inserting a trocar [11]. The proximal DRUJ portal provides better visualization of the joint surface of the sigmoid notch of the radius and ulnar head, and radial area of the proximal surface of the TFC [11], however it is difficult to see the fovea area through the proximal DRUJ portal [24]. A 1.9 mm diameter 30 ° oblique scope is necessary for the distal DRUJ portal [12, 24], even though a standard, 2.7 mm diameter scope can be inserted to the joint [12]. From the distal DRUJ portal, a better visualization can be obtained for the proximal surface of the TFC, distal surface of the ulnar head, RUL and fovea with a more ulnarward view and the joint surface of the sigmoid notch and ulnar head were demonstrated with more a proximal▶ Fig. 3). ward view [24] (● Slutsky described the palmar DRUJ portal combined with the ulnar palmar RCJ portal [11, 12]. The palmar DRUJ portal needed a 2-cm longitudinal incision along the ulnar edge of the finger flexor tendons at the proximal wrist crease, which is the same incision as for the palmar ulnar portal for the radiocarpal joint, avoiding damage on the ulnar nerve and vessels [11]. This portal was used for visualization of the palmar portion of the RUL and debridement of the synovial tissue with an arthroscopic view from the distal DRUJ portal. Motion of the shaver is in a counter direction from the scope view – there must be a learning curve. Nakamura et al. described an ulnar DRUJ portal for the probe checking the condition of the RUL and for debridement of the fovea through the arthroscopic transosseous repair [24]. This portal is not for visualization of the DRUJ constitutions. Atzei also reported a direct fovea portal which is just palmar to the ulnar styloid in the forearm in a supinated position for an arthroscope-assisted fovea repair of the TFCC [22]. This portal is also not for the scope.
298 Review Clinical results Since 2000, we have performed DRUJ arthroscopy in 196 wrists of 194 cases. All cases indicated moderate to severe DRUJ instability. DRUJ surfaces including ulnar head and sigmoid notch of the radius could be observed in all 196 joints. Origins of the RUL at the fovea could be observed in 170 wrists, while no visualization at the fovea was obtained in 26 wrists due to severe proliferation of the synovial at the fovea. Conditions of the RUL were ▶ Fig. 5a), depicting an empty (i) complete foveal detachment (● RUL, vacant ligament tissue surrounded by synovial tissue and ▶ Fig. 5b) in 58, (ii) partial avulsion either on fragile scarring (● ▶ Fig. 5c) (in 35) or palmar portion (in 9) of the RUL, the dorsal (● which indicates moderate DRUJ instability that has either a pal▶ Fig. 5d) in mar or dorsal endpoint, (iii) relaxation of the RUL (● b
d
e
Algorithm for treatment of RUL tears at the fovea Treatment of RUL tears was decided according to the findings of ▶ Fig. 6). Before decision RUL on DRUJ arthroscopy in our series (● making, synovial proliferation at the fovea should be debrided as much as possible. When the history of trauma is considered to be acute or sub-acute (less than 6 months after the initial injury) and avulsed ligament fibers can be seen through the DRUJ arthroscopy, we prefer to arthroscopically repair the RUL with a transosseous technique [13]. When we see complete disruption or vacant ligament tissue surrounded by synovial tissue and c
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a
32, (iv) fibrillation on the RUL surface in 20, (v) normal RUL ▶ Fig. 5e) in 16 (may be related to the horizontal type tear of (● the TFCC).
Fig. 5 DRUJ arthroscopic findings of the RUL: a complete foveal detachment, b vacant ligament tissue surrounded by synovial tissue, c partial avulsion on the dorsal portion of the RUL, d relaxation of the RUL, e normal RUL.
Fig. 6 Algorithm for treatment of the RUL depending on the DRUJ arthroscopic findings.
DRUJ Arthroscopy findings on the RUL tear
Simple detachment of the RUL with ligament tissue
Partial avulsion of the RUL
Arthroscopic transosseous repair
Open repair
Vacant RUL
Reconstruction with ECU halfslip
Relaxed RUL Intact RUL with degeneration or with horizontal tear
Ulnar shortening
Fibrillation on the RUL
Debridement
Nakamura T et al. Arthroscopy of the Distal … Handchir Mikrochir Plast Chir 2014; 46: 295–299
Review 299
Conclusion
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DRUJ arthroscopy now provides useful information on the condition of the attachment of the RUL to the fovea, the proximal surface of the TFC, the ulnar head and the sigmoid notch of the radius, even though DRUJ arthroscopy is still technically difficult. When the patient indicates moderate to severe DRUJ instability, DRUJ arthroscopy is essential for decision making as to the treatment option for the RUL injury. Toshiyasu Nakamura Date of birth: October 20, 1963 Birth Place: Shizuoka, Japan Education: 3/31/1988 School of Medicine, Keio University, Tokyo, Japan 3/31/1994 Graduate School of Medicine, Keio University, Tokyo, Japan (Orthopaedic Surgery) PhD degree: (Thesis) Functional anatomy of the triangular fibrocartilage complex. Professional position: 5/1/1988 Resident, Keio University Hospital, Tokyo, Japan 4/1/1994 Chief Resident, Keio University Hospital, Tokyo, Japan 8/1/1995 Instructor, Fujita Health University School of Medicine (Second Orthopaedic Surgery, Bunbuntane Houtokukai Hospital), Nagoya, Japan 5/1/1996 Assistant Professor, Fujita Health University School of Medicine (Second Orthopaedic Surgery, Bunbuntane Houtokukai Hospital), Nogoya, Japan 7/1/1998 Research Fellow, Orthopaedic Biomechanics Laboratory, Mayo Clinic/Mayo Foundation, Rochester, MN 10/1/1999 Research Fellow, Hand Center of Western New York, Department of Orthopaedic Surgery, State University of New York at Buffalo, Buffalo, NY 11/1/2000 Instructor, Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan 9/1/2005 Assistant Professor (Intra-School), Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan 7/1/2006 Assistant Professor (tenure track), Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan 7/1/2014 Professor, Clinical Research Center, International University of Health and Welfare, Department of Orthopaedic Surgery, Sanno Hospital, Tokyo, Japan
Conflict of interest: None References 1 Whipple TL, Marotta JJ, Powel JH III. Techniques of wrist arthroscopy. Arthroscopy 1986; 2: 244–252 2 del Pinal F, Garcia-Bernal FJ, Pisani D et al. Dry arthroscopy of the wrist: surgical technique. J Hand Surg 2007; 32A: 119–123 3 Leibovic SJ, Bowers WH. Arthroscopy of the distal radioulnar joint. Orthop Clin North Am 1995; 26: 755–757 4 Whipple TL. Arthroscopy of the distal radioulnar joint. Indications, portals and anatomy. Hand Clin 1994; 10: 589–592 5 Abrams RA, Petersen M, Botte MJ. Arthroscopic portals of the wrist: an anatomic study. J Hand Surg 1994; 19A: 940–944 6 Berger RA. Arthroscopic anatomy of the wrist and distal radioulnar joint. Hand Clin 1999; 15: 393–413 7 Nakamura T. Anatomy and biomechanics of the distal radioulnar joint. In: Del Pinal F, Mathoulin C, Nakamura T (eds.). Arthroscopic management of ulnar pain. Springer; Heidelberg: 2012; 15–23 8 Nakamura T, Yabe Y, Horiuchi Y. Functional anatomy of the triangular fibrocartilage complex. J Hand Surg 1996; 21B: 581–586 9 Yamamoto M, Koh S, Tatebe M et al. Arthroscopic visualization of the distal radioulnar joint. Hand Surg 2008; 13: 133–138 10 Yamamoto M, Koh S, Tatebe M et al. Importance of distal radioulnar joint arthroscopy for evaluating the triangular fibrocartilage complex. J Orthop Sci 2010; 15: 210–215 11 Slutsky DJ. Distal radioulnar joint arthroscopy and the volar ulnar portal. Tech Hand Upper Extrem Surg 2007; 11: 1–7 12 Slutsky DJ. Arthroscopic evaluation of the foveal attachment of the triangular fibrocartilage. Hand Clin 2011; 27: 255–261 13 Nakamura T, Sato K, Okazaki M et al. Repair of foveal detachment of the triangular fibrocartilage complex: Open and arthroscopic transosseous techniques. Hand Clin 2011; 27: 281–290 14 Nakamura T. DRUJ instability: arthroscopic repair of the detached TFCC to the fovea of the ulna. In: Del Pinal F, Mathoulin C, Nakamura T (eds.). Arthroscopic management of ulnar pain. Springer; Heidelberg: 137–145, 2012 15 Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist – anatomy and function. J Hand Surg 1981; 6: 153–162 16 Nakamura T, Yabe Y. Histological anatomy of the triangular fibrocartilage complex of the human wrist. Ann Anat 2000; 182: 567–572 17 Nakamura T, Yabe Y, Horiuchi Y. Origins and insertions of the triangular fibrocartilage complex – a histological study. J Hand Surg 2001; 26B: 446–454 18 Haugstvedt JR, Berger RA, Nakamura T et al. Relative contributions of the ulnar attachment of the triangular fibrocartilage complex to the dynamic instability of the distal radioulnar joint. J Hand Surg 2006; 26A: 445–451 19 Palmer AK. The triangular fibrocartilage complex lesions: a classification. J Hand Surg 1989; 14A: 594–606 20 Nakamura T, Makita A. The proximal ligamentous component of the triangular fibrocartilage complex: functional anatomy and three-dimensional changes in length of the radioulnar ligament during pronation and supination. J Hand Surg 2000; 25B: 479–486 21 Nakamura T, Nakao Y, Ikegami H et al. Open repair of the ulnar disruption of the triangular fibrocartilage complex with double 3D-mattress suture technique. Tech Up Extrem Surg 2004; 8: 116–123 22 Atzei A, Rizzo A, Luchetti R et al. Arthroscopic foveal repair of triangular fibrocartilage complex peripheral lesion with distal radioulnar joint instability. Tech Hand Upper Extrem Surg 2008; 12: 226–235 23 Atzei A. New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability. J Hand Surg 2009; 34E: 582–591 24 Nakamura T. Causes and Management of Acute and Chronic Distal Radioulnar Joint Instability. In: Slutsky D (eds.). Upper extremity surgery: A palette of procedures. McGraw Hill; in press 25 Tanaka T, Yoshioka H, Ueno T et al. Comparison between high-resolution MRI with a microscopy coil and arthroscopy in triangular fibrocartilage complex injury. J Hand Surg 2006; 31A: 1308–1314 26 Nakamura T, Iwamoto T, Matsumura N et al. Radiographic and arthroscopic assessment of DRUJ instability due to foveal avulsion of the radioulnar ligament in distal radius fracture. J Wrist Surg 2014; 3: 12–17
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fragile scarring in chronic cases (more than 6 months after the initial injury), we open the DRUJ through the 6th compartment [21, 24] and check the integrity of the RUL with forceps. When the remnant RUL can be attached to the original site at the fovea, we prefer open repair [13, 21]. If not, we perform reconstruction of the TFCC using an ECU half-slip tendon to reattach the remnant TFCC to the center of the fovea [24]. Partial detachment of the RUL can be repaired arthroscopically or in an open fashion. When DRUJ arthroscopy reveals the relaxed RUL or even an intact RUL with horizontal tears of the TFC or other degenerative conditions, an ulnar shortening procedure is performed. When DRUJ arthroscopic findings are simply fibrillation on the RUL surface, debridement of the RUL surface was done.
Arthroscopy of the Distal Radioulnar Joint
Authors
T. Nakamura1, N. Matsumura2, T. Iwamoto2, K. Sato2, Y. Toyama2
Affiliations
1
Department of Orthopaedic Surgery, Clinical Research Center, International University of Health and Welfare, Sanno Hospital, Tokyo, Japan 2 Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan
Key words ▶ arthroscopy ● ▶ distal radioulnar joint ● ▶ DRUJ ● ▶ triangular fibrocartilage ● complex ▶ TFCC ● ▶ radioulnar ligaments ● ▶ instability ●
Abstract
Zusammenfassung
Wrist arthroscopy is now widely indicated for diagnosis and treatment of acute or chronic wrist pain, especially for triangular fibrocartilage complex (TFCC) lesions, as a gold standard. In most cases radiocarpal and midcarpal arthroscopy was performed, while DRUJ arthroscopy has been rarely performed because of its difficulties. Recent anatomic and biomechanical studies demonstrated that the radioulnar ligament (RUL), which is the proximal component of the TFCC facing to the DRUJ, is the primary stabilizer of the distal radioulnar joint (DRUJ). Rupture of the radioulnar ligament (RUL) at the fovea area, where it is the main attaching portion to the ulna and is the isometric point during forearm rotation as the rotation axis passes, is responsible for DRUJ instability. Although physical examination and imaging diagnosis may indicate a foveal detachment of the TFCC, DRUJ arthroscopy is potential for visualizing the RUL at the fovea. Role of DRUJ arthroscopy should be more important not only for diagnosis of rupture of the RUL but also for decision making of treatment option for RUL tear. DRUJ arthroscopy also demonstrates the joint surface of both the sigmoid notch and ulnar head, and the proximal surface of the TFCC.
Die Handgelenksarthroskopie wird heute vielerorts zur Diagnostik und Therapie akuter und chronischer Handgelenksschmerzen verwendet, wobei sie bei der Abklärung von Läsionen des dreieckförmigen Faserknorpels (TFCC) als Goldstandard gilt. Meistens erfolgt eine Arthroskopie des Radio- und Mediokarpalgelenkes, wohingegen das distale Radioulnargelenk (DRUG) aufgrund technischer Schwierigkeiten bisher selten gespiegelt wurde. Jüngere anatomische und biomechanische Studien haben gezeigt, dass die radioulnaren Zügelbänder (RUL) als proximaler, dem DRUG zugewandter Teil des TFCC der Hauptstabilisator des DRUG sind. Abrisse der RUL an ihrem Ansatz in der Fovea ulnaris, wo ihr Hauptverankerungsstelle an der Ulna und zugleich der isometrische Punkt bei der Unterarmrotation lokalisiert ist, führen zur Instabilität im DRUG. Während klinische Untersuchung und Bildgebung lediglich einen Abriss des TFCC in der Fovea vermuten lassen, kann man mit einer Arthroskopie des DRUG die RUL in der Fovea direkt einsehen. Die Bedeutung der DRUGArthroskopie liegt nicht allein in dem Umstand, dass man die RUL unter Sicht beurteilen kann, sondern vielmehr darin, dass sich abhängig vom Befund ein differenziertes therapeutisches Vorgehen ergibt. Darüber hinaus ist es möglich bei der DRUG-Arthroskopie die Gelenkfläche der Sigmoidnotch als auch des Ulnakopfes und die Unterfläche des TFCC einzusehen.
Introduction
in late 1980s, including arthroscopy for the DRUJ by Whipple et al. [1]. Radiocarpal arthroscopy was then widely indicated for the diagnosis and treatment to the soft tissue injuries in the wrist, especially injury onto the triangular fibrocartilage complex (TFCC). Dry radiocarpal arthroscopy was recently introduced for arthroscopic treatment of intra-articular distal radius fracture [2]. Because of its technical difficulties, arthros-
Schlüsselwörter ▶ Arthroskopie ● ▶ distales Radioulnargelenk ● ▶ DRUG ● ▶ triangulärer fibrokartilag● inärer Komplex ▶ TFCC ● ▶ radioulnare Bäder ● ▶ Instabilität ● received accepted
26.06.2014 17.07.2014
Bibliography DOI http://dx.doi.org/ 10.1055/s-0034-1387706 Handchir Mikrochir Plast Chir 2014; 46: 295–299 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0722-1819 Correspondence Toshiyasu Nakamura, MD, PhD Department of Orthopaedic Surgery Clinical Research Center International University of Health and Welfare Sanno Hospital 8-10-16 Akasaka Minato-ku Tokyo 107-0052 Japan Tel.: + 81/3/3401 3151 Fax: + 81/3/3401 3151 [email protected]
▼
▼
▼
The wrist is a complex joint, consisting of the midcarpal, radiocarpal and distal radioulnar joints. This joint achieves multiple directional motion, flexion-extension, radial and ulnar deviation, and pronation-supination. Arthroscopic evaluation for the wrist, providing information on bony and soft tissue lesions, was introduced
Nakamura T et al. Arthroscopy of the Distal … Handchir Mikrochir Plast Chir 2014; 46: 295–299
Downloaded by: University of British Columbia. Copyrighted material.
Arthroskopie des distalen Radioulnargelenkes
copy for the DRUJ was described only for the diagnosis of intraarticular lesions between the sigmoid notch of the radius and ulnar head [3, 4], as opposed to most of the structures in the radiocarpal and midcarpal joints which could be observed with radiocarpal or midcarpal arthroscopy in the 1990s [5, 6]. Based on the recent advances of anatomic and biomechanical knowledge [7, 8], the TFCC is the primary stabilizer of the distal radioulnar joint (DRUJ). Rupture of the radioulnar ligament (RUL) at the ulnar fovea can induce DRUJ instability. When the triangular fibrocartilage (TFC) was not torn, radiocarpal arthroscopy never visualized the fovea lesion, unless perforation on the TFC would be created artificially [7]. Since a 1.9 mm 30 ° oblique view scope, which is a quite smaller diameter arthroscope compared with standard 2.7 mm diameter scope, was developed, there were several studies on DRUJ arthroscopy, where better visualization of the DRUJ [9–12]. In the literature, DRUJ arthroscopy was still only used for diagnosis of the foveal attachment of the RUL [9] or debridement of the synovial tissue proliferation through palmar DRUJ portal [12]. Nakamura recently used a DRUJ arthroscope to treat a proximal lesion of the TFCC, such as an avulsion of the RUL at the fovea [13, 14].
Anatomy of the DRUJ
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The DRUJ consists of the sigmoid notch of the radius, ulnar head, TFCC and dorsal and palmar joint capsules. The TFCC consists of triangular fibrocartilage (TFC), ulnolunate ligament (UL), ulnotriquetral ligament (UT) and radioulnar ligament (RUL), the sheath floor of the extensor carpi ulnaris (ECU) tendon, and meniscus homologue [7, 8, 15]. The TFCC stabilizes the DRUJ and ulnocarpal joint, distributes load between ulna and ulnar carpus, and allows smooth rotation of the forearm [8, 15]. Histological examinations have revealed that the TFCC divides the ▶ Fig. 1). The fovea of the radiocarpal and DRU joints [16, 17] (● ulna is the largest attaching area of the RUL on the ulna, thus an RUL tear at the fovea can result in DRUJ instability readily [18].
Fig. 1 This histological section demonstrates that the triangular fibrocartilage (TFC) and radioulnar ligament (RUL) lie between the radiocarpal joint (RCJ) and distal radioulnar joint (DRUJ), thus the TFCC divides the RCJ and DRUJ. If there is no tear on the TFC, the RCJ arthroscopy never visualizes the fovea lesion.
Fig. 2 Illustration of the 3 dorsal DRUJ portals, distal, proximal and ulnar.
Foveal Injury of the RUL
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Palmer [19] classified TFCC tears into traumatic (Class 1) and degenerative (Class 2) tears. Traumatic TFCC tears were also subclassified as central tears (1A), ulnar tears (1B), distal tears (1C), and radial tears (1D) based upon the clinical patterns seen through radiocarpal arthroscopy [19]. Palmer 1B tears are defined with peripheral ulnar tears of the TFCC which may be associated with an ulnar styloid fracture, because the TFCC had been considered to attach only to the ulnar styloid in late 1980s and early 1990s. As the TFCC is anchored to the DRUJ via the RUL which attaches to the ulnar fovea and base of the ulnar styloid, a hyperrotation force or dislocation force applied to the RUL from the ulnar head, such as in a fall, may disrupt the RUL not only from the ulnar styloid but also from the fovea [7, 20]. A foveal detachment of the TFCC is clearly evident in clinical practice [13, 21]. Atzei recently sub-classified the Palmer 1B tear into a distal component, a proximal component or both (complete) [22, 23]. An isolated foveal detachment is equivalent to a proximal component tear.
TFCC
sigmoid notch
fovea
ulnar portal
ulnar head distal portal proximal portal
DRUJ Arthroscopy
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Portals There are numbers for portals of the radiocarpal joint, such as 1-2, 3-4, 4-5, 6R and 6U [5], while only 3 dorsal portals, distal, ▶ Fig. 2), and the palmar portal were proximal and ulnar (● described for DRUJ. Abrams et al. [5] described the DRUJ portal at the very proximal end of the joint, which is now known as the
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296 Review
Review 297
Indication for DRUJ arthroscopy An arthroscopic assessment of the DRUJ is indicated in any patient with acute or chronic forms of TFCC injury with moderate to severe DRUJ instability that is suspected by physical examination [12]. Moderate DRUJ instability demonstrates obvious unstable DRUJ in comparison to the contralateral intact DRUJ and there was either at least a dorsal or palmar endpoint with a ballottement testing. Severe DRUJ instability indicates multidirectional instability of the DRUJ without any endpoint from the ligament. DRUJ arthroscopy also is indicated for complete or partial foveal avulsion of the RUL on MRI [24]. Recently high resolution MRI is able to delineate foveal avulsion of the RUL easily [25]. It is also useful in the case of a symptomatic displaced non-union of the ulnar styloid [11] and radial displaced distal radius fracture [26].
mosquito forceps is advanced until it reaches the head of the ▶ Fig. 4b) ulna. The forceps were then used to gradually divide (● and penetrate the upper side of the DRUJ joint capsule and then to enter the joint. The mosquito forceps were next used to guide ▶ Fig. 4). the 1.9-mm scope into the DRUJ (● The DRUJ space including the fovea area can easily be seen in cases of foveal detachment because the DRUJ is loose [13, 24]. It is difficult to visualize the foveal area with DRUJ arthroscopy when the TFCC is completely attached to the ulna without any DRUJ instability, although the joint surface of ulnar head and sigmoid notch of the radius can easily be seen.
Fig. 3 DRUJ arthroscopic view from distal DRUJ portal. Articulation of the sigmoid notch of the radius and ulnar head, the proximal surface of the TFC, seat of the ulnar head, attaching of the RUL to the fovea are seen through this portal. Dorsal and palmar portions of the RUL are demonstrated (arrows).
a
b
Authors preferred technique The authors recommends DRUJ arthroscopy for the diagnosis of moderate to severe DRUJ instability, for evaluating the condition of the foveal origin of the RUL. DRUJ arthroscopy is also useful to refresh the ulnar fovea while arthroscopically repairing a TFCC rupture [13, 14, 24]. We used the DRUJ (distal) portal, which is just 5 mm proximal to the 4-5 or 6R portal, just ulnar to the extensor digiti minimi tendon and just distal to the head of the ulna as the viewing portal ▶ Fig. 2). Saline was used to expand the DRUJ (● ▶ Fig. 4a). Mos(● quito forceps divides the subcutaneous tissue to avoid penetration on the extensor digiti minimi tendon, and then the tip of the
Fig. 4 Introducing the trocar to the DRUJ. a Saline is injected to the DRUJ to expand the joint. b Bent mosquito forceps penetrates the DRUJ capsule to expand the portal. A trocar is introduced between the tips of the mosquito forceps.
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proximal DRUJ portal [9]. Before the 1.9 mm oblique view scope was introduced, the proximal DRUJ portal was the safety portal for inserting a trocar [11]. The proximal DRUJ portal provides better visualization of the joint surface of the sigmoid notch of the radius and ulnar head, and radial area of the proximal surface of the TFC [11], however it is difficult to see the fovea area through the proximal DRUJ portal [24]. A 1.9 mm diameter 30 ° oblique scope is necessary for the distal DRUJ portal [12, 24], even though a standard, 2.7 mm diameter scope can be inserted to the joint [12]. From the distal DRUJ portal, a better visualization can be obtained for the proximal surface of the TFC, distal surface of the ulnar head, RUL and fovea with a more ulnarward view and the joint surface of the sigmoid notch and ulnar head were demonstrated with more a proximal▶ Fig. 3). ward view [24] (● Slutsky described the palmar DRUJ portal combined with the ulnar palmar RCJ portal [11, 12]. The palmar DRUJ portal needed a 2-cm longitudinal incision along the ulnar edge of the finger flexor tendons at the proximal wrist crease, which is the same incision as for the palmar ulnar portal for the radiocarpal joint, avoiding damage on the ulnar nerve and vessels [11]. This portal was used for visualization of the palmar portion of the RUL and debridement of the synovial tissue with an arthroscopic view from the distal DRUJ portal. Motion of the shaver is in a counter direction from the scope view – there must be a learning curve. Nakamura et al. described an ulnar DRUJ portal for the probe checking the condition of the RUL and for debridement of the fovea through the arthroscopic transosseous repair [24]. This portal is not for visualization of the DRUJ constitutions. Atzei also reported a direct fovea portal which is just palmar to the ulnar styloid in the forearm in a supinated position for an arthroscope-assisted fovea repair of the TFCC [22]. This portal is also not for the scope.
298 Review Clinical results Since 2000, we have performed DRUJ arthroscopy in 196 wrists of 194 cases. All cases indicated moderate to severe DRUJ instability. DRUJ surfaces including ulnar head and sigmoid notch of the radius could be observed in all 196 joints. Origins of the RUL at the fovea could be observed in 170 wrists, while no visualization at the fovea was obtained in 26 wrists due to severe proliferation of the synovial at the fovea. Conditions of the RUL were ▶ Fig. 5a), depicting an empty (i) complete foveal detachment (● RUL, vacant ligament tissue surrounded by synovial tissue and ▶ Fig. 5b) in 58, (ii) partial avulsion either on fragile scarring (● ▶ Fig. 5c) (in 35) or palmar portion (in 9) of the RUL, the dorsal (● which indicates moderate DRUJ instability that has either a pal▶ Fig. 5d) in mar or dorsal endpoint, (iii) relaxation of the RUL (● b
d
e
Algorithm for treatment of RUL tears at the fovea Treatment of RUL tears was decided according to the findings of ▶ Fig. 6). Before decision RUL on DRUJ arthroscopy in our series (● making, synovial proliferation at the fovea should be debrided as much as possible. When the history of trauma is considered to be acute or sub-acute (less than 6 months after the initial injury) and avulsed ligament fibers can be seen through the DRUJ arthroscopy, we prefer to arthroscopically repair the RUL with a transosseous technique [13]. When we see complete disruption or vacant ligament tissue surrounded by synovial tissue and c
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a
32, (iv) fibrillation on the RUL surface in 20, (v) normal RUL ▶ Fig. 5e) in 16 (may be related to the horizontal type tear of (● the TFCC).
Fig. 5 DRUJ arthroscopic findings of the RUL: a complete foveal detachment, b vacant ligament tissue surrounded by synovial tissue, c partial avulsion on the dorsal portion of the RUL, d relaxation of the RUL, e normal RUL.
Fig. 6 Algorithm for treatment of the RUL depending on the DRUJ arthroscopic findings.
DRUJ Arthroscopy findings on the RUL tear
Simple detachment of the RUL with ligament tissue
Partial avulsion of the RUL
Arthroscopic transosseous repair
Open repair
Vacant RUL
Reconstruction with ECU halfslip
Relaxed RUL Intact RUL with degeneration or with horizontal tear
Ulnar shortening
Fibrillation on the RUL
Debridement
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Conclusion
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DRUJ arthroscopy now provides useful information on the condition of the attachment of the RUL to the fovea, the proximal surface of the TFC, the ulnar head and the sigmoid notch of the radius, even though DRUJ arthroscopy is still technically difficult. When the patient indicates moderate to severe DRUJ instability, DRUJ arthroscopy is essential for decision making as to the treatment option for the RUL injury. Toshiyasu Nakamura Date of birth: October 20, 1963 Birth Place: Shizuoka, Japan Education: 3/31/1988 School of Medicine, Keio University, Tokyo, Japan 3/31/1994 Graduate School of Medicine, Keio University, Tokyo, Japan (Orthopaedic Surgery) PhD degree: (Thesis) Functional anatomy of the triangular fibrocartilage complex. Professional position: 5/1/1988 Resident, Keio University Hospital, Tokyo, Japan 4/1/1994 Chief Resident, Keio University Hospital, Tokyo, Japan 8/1/1995 Instructor, Fujita Health University School of Medicine (Second Orthopaedic Surgery, Bunbuntane Houtokukai Hospital), Nagoya, Japan 5/1/1996 Assistant Professor, Fujita Health University School of Medicine (Second Orthopaedic Surgery, Bunbuntane Houtokukai Hospital), Nogoya, Japan 7/1/1998 Research Fellow, Orthopaedic Biomechanics Laboratory, Mayo Clinic/Mayo Foundation, Rochester, MN 10/1/1999 Research Fellow, Hand Center of Western New York, Department of Orthopaedic Surgery, State University of New York at Buffalo, Buffalo, NY 11/1/2000 Instructor, Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan 9/1/2005 Assistant Professor (Intra-School), Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan 7/1/2006 Assistant Professor (tenure track), Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan 7/1/2014 Professor, Clinical Research Center, International University of Health and Welfare, Department of Orthopaedic Surgery, Sanno Hospital, Tokyo, Japan
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fragile scarring in chronic cases (more than 6 months after the initial injury), we open the DRUJ through the 6th compartment [21, 24] and check the integrity of the RUL with forceps. When the remnant RUL can be attached to the original site at the fovea, we prefer open repair [13, 21]. If not, we perform reconstruction of the TFCC using an ECU half-slip tendon to reattach the remnant TFCC to the center of the fovea [24]. Partial detachment of the RUL can be repaired arthroscopically or in an open fashion. When DRUJ arthroscopy reveals the relaxed RUL or even an intact RUL with horizontal tears of the TFC or other degenerative conditions, an ulnar shortening procedure is performed. When DRUJ arthroscopic findings are simply fibrillation on the RUL surface, debridement of the RUL surface was done.
