Related Analysis Of Wrist Arthroscopy In Treatment Of TFCC Injury With Ulnar Impaction

Objective: Injury of the triangular fibrocartilage complex(TFCC)is the most common cause of ulnar-sided wrist pain,TFCC injury is commonly associated with ulnar impaction.TFCC interacts with ulnocarpal joint,how to repair the injuries of triangular fibrocartilage complex(TFCC)remains controversial.The purposes of the study are as follows:(1)Aim to provide basic anatomical information for the rational clinical diagnosis and treatment of TFCC injury,we study the anatomical structure of TFCC and its manifestations of wrist arthroscopy portals.(2)To overall evaluate the clinical outcome of the TFCC injury with ulnar impaction following wrist arthroscopic assisted ulnar shortening osteotomy(3)To compare different approaches of ulnar shortening osteotomy for patients with ulnar impaction and TFCC injury,and to compared the results of patients treated for ulnar impaction with TFCC injury using an ulnar shortening osteotomy(USO)alone with those treated with wrist arthroscopic assisted USO.Methods: This study was composed of three parts:(1)Firstly,the anatomical structure and adjacent relationship of TFCC were dissected and observed in 7 formalin-preserved cadaveric specimens of the upper forearm,and the conventional portals of wrist arthroscopy for repairing TFCC injury were labeled,so as to lay an anatomical foundation for surgical practice.Secondly,23 patients with TFCC injury were diagnosed and treated by wrist arthroscopy routine portals,and their manifestations of anatomical structures under wrist arthroscopy portals were analyzed.(2)The medical records of 20 inpatients who were arthroscopically diagnosed as the TFCC injury with ulnar impaction and underwent combined wrist arthroscopy and ulnar shortening osteotomy(USO)from Mar 2016 to Dec 2020 were analyzed,and the patients were regularly followed-up after surgery.Daily self-care ability was assessed by Quick-Disabilities of the Arm,Shoulder,and Hand(Quick-DASH)scores;Patient-Rated Wrist Evaluation(PRWE)scores.Pain scale was evaluated with visual analogue scale(VAS),grip strength and wrist range of motion,and postoperative satisfaction were assessed,and overall outcomes were evaluated by modified Mayo wrist scoring system.(3)MEDLINE(Ovid),Pub Med,EMBASE,Cochrane Library,and FMRS databases were systematically searched(expanded to July 8,2019)for articles comparing the effectiveness of DUSO and MUSO for UIS.Participants’ demographics,complication rates,secondary procedure rate,postoperative DASH score outcome,wrist pain on a visual analog scale,and grip strength improvement were assessed.In addition,the correlation of grip strength improvement and the length of ulnar shortening osteotomy were analyzed.The patients’ outcomes were discontinuous,so the odds ratio(OR),risk ratio(RR),and 95% confidence intervals(CI)were calculated,and the final analysis was carried out by the Rev Man 5.3 software.Results:(1)TFCC locates at the ulnocarpal joint,between the ulnar head and the ulnar carpal bone.It is composed of distal radioulnar volar and dorsal ligaments,triangular fibrocartilage and its homologous collateral,ulnotriquetral ligament,ulnolunate ligament,ulnar collateral ligament and part of the tendon sheath structure of the extensor carpi ulnaris.The TFCC extends from the central triangular fibrocartilage disc(TFC)to the periphery,and extends to the volar and dorsal side to form the volar and dorsal distal radioulnar ligaments.The radial side of TFCC attaches to the ulnar margin of the lunar fossa on the articular surface of the distal radius,and the transition to the ulnar side was divided into shallow and deep layers.The superficial ulnar part is attached to the styloid process of the ulna,part of the transitional lunotriquetral ligament and the articular ligament of the base part of the fifth metacarpal bone.The ulnar deep structure is attached to the anterior fovea of the ulnar styloid base.By conventional portal wrist arthroscopy,TFCC was observed and located between the ulnar head and the ulnar carpal bone,and was suspended between the distal radioulnar joint(DRUJ)and the ulnocarpal joint under a certain tension.The TFC is a double concave disk structure with thick edge and thin center.TFCC rise from the ulnar side of the lunate fossa at the distal radius,the transition to the ulnar side was divided into shallow and deep layers.The shallow structure attaches to the ulnar styloid process and the distal of the ulnar carpal joint.The deep fibrous structure attaches to the anterior fovea at the base of the ulnar styloid process,and the TFC extend to volar and dorsal side to contribute the volar and dorsal distal radioulnar ligaments.23 cases of disk triangular fibrocartilage(TFC)in patients with perforation of 13 cases,TFCC attachment avulsion 15 cases,TFC perforation + TFCC attachment avulsion in 8 cases,combined with ulnar impaction 18 cases,which underwent the wrist arthroscopy assisted ulnar shortening osteotomy + TFCC debridement attachment reconstruction in 8 cases,underwent wrist arthroscopy debridement + TFCC attachment reconstruction in 15 cases,underwent wrist arthroscopy assisted ulnar shortening osteotomy 16 cases.(2)8 male patients and 12 female patients,with mean ages of 34.8±10.2 years at time of surgery were included.Postoperative mean follow-up was 21.4 months.There were no major complications during and follow-up.Modified MAYO wrist score(preoperatively: 68.5±9.3;postoperatively: 85.3±14.8,p< 0.05),Quick-DASH Score(preoperatively: 40.4±22.3;postoperatively: 16.7±16.8,p<0.05),PRWE score(preoperatively:38.3±20.9;postoperatively: 19.3±18.1,p<0.05),VAS(preoperatively: 4.9 ± 2.8;postoperatively: 2.7 ± 2.4,p< 0.05),grip strength(preoperatively: 23.5±8.7 Kg;postoperatively: 30.2±10.4Kg,p< 0.05)improved significantly.Wrist flexion(preoperatively:63.5±11.1°;postoperatively:68.9±14.1°,p< 0.05);wrist extension(preoperatively: 50.3±12.0°;postoperatively:62.8±11.4°,p< 0.05);wrist radial deviation(preoperatively:15.3±4.6°;postoperatively:18.3±6.8°,p<0.05);wrist supination(preoperatively:87.3±6.4°;postoperatively:90.3±9.0°,p< 0.05)improved significantly.The differences in wrist ulnar deviation and pronation between preoperative and postoperative were not significantly significant.Postoperative satisfaction: 95%(19/20).(3)According to inclusion criteria,six studies with 83 patients who underwent MUSO(experimental group)and 112 patients who underwent DUSO(control group)were included.The secondary procedure rate was significantly higher after DUSO than after MUSO.Patients who underwent MUSO showed slightly better pain relief than patients who underwent DUSO.The postoperative DASH score of MUSO was slightly lower than that of DUSO,but the differences in postoperative DASH score and VAS score between groups were not statistically significant.The differences in the complication rates and grip strength improvement between groups were not statistically significant.Conclusions :(1)TFCC connects with the complex ulnocarpal structure and is the key structure to stabilize the distal radioulnar joint.Patients with ulnar impaction may be more commonly associated with TFCC injury.(2)Clinical follow-up observation showed that: wrist arthroscopic assisted ulnar shortening osteotomy maybe an effectiveness treatment for patients of the TFCC injury with ulnar impaction.Wrist arthroscopic assisted ulnar shortening osteotomy can significantly improve patient quality of life with pain relief,improving the wrist function and range of motion.It is a treatment of patient high satisfaction.(3)DUSO and MUSO provide similar effectiveness for UIS.With a lower secondary procedure rate,slightly lower postoperative DASH score,and slightly more pain relief,MUSO may be a viable alternative to the more popular DUSO.MUSO might be more advisable for UIS patients with low bone mineral density,smoking status,and opioid utilization.Wrist arthroscopic assisted ulnar shortening osteotomy is suitable for patients of TFCC injury with ulnar impaction.