Gary R. Kuzma

New Tuohy needle technique for triangular fibrocartilage complex repair: Preliminary studies

The treatment of injuries to the triangular fibrocartilage complex (TFCC) has evolved from closed casting through open excision to arthroscopic repair. The authors present the preliminary results of arthroscopic repair of peripheral (Palmer type IB) TFCC tears using a Tuohy needle. Results in 17 patients treated with this technique were obtained retrospectively through chart review and telephone interview. Average age of the patients was 33 years (range, 16 to 54 years). Conservative treatment averaged 9 months (range, 2 to 26 months). The repairs were performed with one or two horizontal mattress sutures of 2-0 polydioxanone. Follow-up ranged from 4 to 13 months (average, 8 months). Sixteen patients were satisfied or very satisfied with the result; 1 was not satisfied. No complications occurred. We believe this Tuohy needle technique is practical and cost-effective for the arthroscopic management of peripheral TFCC tears.

Closed traumatic rupture of finger flexor pulleys

Nine patients are described with closed traumatic rupture of the digital flexor pulley system. All presented with significant flexion contractures of the proximal interphalangeal joint and bow-stringing of the flexor tendons. In seven patients, the pathology was verified at surgery and pulley reconstruction provided a good result. The diagnoses in the other patients, treated conservatively, were verified by tenogram and magnetic resonance imaging.

Anatomic investigation of the role of the lumbrical muscles in carpal tunnel syndrome

This study investigates whether the proximal origins of the lumbrical muscles contribute significantly to the etiology of carpal tunnel syndrome. We explored the carpal canals of 128 hands in patients undergoing carpal tunnel release for carpal tunnel syndrome. The origins of the lumbrical muscles were examined at the time of surgery and their relation to the transverse carpal ligament was recorded in all cases. Also, 40 cadaveric hands were dissected to determine the lumbrical muscle origins. In the hands of patients with idiopathic carpal tunnel syndrome, the lumbrical muscle origins were located significantly more proximal in the canal than were the muscles in the cadaveric hands. Younger patients whose jobs required repetitive hand motions had large lumbrical muscles and origins that were more proximal than the lumbricals found in the hands of fresh cadavers.

Dorsal wrist ligament insertions stabilize the scapholunate interval: cadaver study.

This study examined sequential arthroscopic sectioning of volar, interosseous, and dorsal ligaments about the scapholunate complex in cadaver wrists. We attempted to clarify the contributions of the dorsal ligamentous complex to scapholunate instability and carpal collapse. We found that after sequential sectioning of volar ligaments and the scapholunate interosseous ligament, no scapholunate diastasis or excessive scaphoid flexion occurred. After dividing the dorsal intercarpal ligament, scapholunate instability occurred without carpal collapse. With sectioning of the dorsal radiocarpal ligament from the lunate, a dorsal intercalated scapholunate instability deformity ensued. This information may be of value in comprehending the pathogenesis of scapholunate instability and carpal collapse and in devising the rationales for conservative measures and surgical intervention.

Reconstruction of Essex-Lopresti Injury of the Forearm: Technical Note

Longitudinal instability of the forearm resulting from an Essex-Lopresti injury is a surgical challenge, and no technique has yet met universal success. A new technique is presented here consisting of reconstruction of the radial head, leveling of the distal radioulnar joint, reconstruction of the central band of the interosseous membrane by using a pronator teres rerouting technique, and finally repair of the triangular fibrocartilage complex. It is hoped that by addressing all of the contributing longitudinal stabilizing structures, the longitudinal instability of the forearm will be controlled. The technique is challenging and requires much surgical experience.

Arthroscopic Management of Volar Lunate Facet Fractures of the Distal Radius

The clinical outcome of an intraarticular distal radius fracture is generally thought to be associated with the following factors: amount of radial deformity, joint congruity, and associated soft-tissue injuries. The proposed technique to manage this fracture pattern that involves a displaced volar lunate facet fragment uses wrist arthroscopy and pinning. Distraction of the fracture before arthroscopy is accomplished either by external fixation or by the arthroscopy tower. A freer elevator is introduced dorsally to disimpact the fragments, and next, a nerve hook is used to reduce the volar lunate facet, which is subsequently pinned to the radial styloid. The remaining fragments are reduced with interfragmentary pin fixation, and this anatomical articular construct is fixed to the radial metaphysis. The advantages of this technique are: (a) accurate assessment of articular congruency by direct visualization, (b) identification and repair of associated lesions, and (c) minimal soft tissue disruption. Potential disadvantages of external fixation supplemented by interfragmentary pins may be that it does not provide for rigid stable fixation, and therefore, does not allow for early motion compared to open reduction and internal fixation. Furthermore, it is technically challenging, and is therefore suggested as an alternative for the aforementioned fracture pattern.

Debridement of Central TFCC Tears

The radiocarpal and midcarpal components of the wrist joint are capable of significant freedom of movement and act as a universal joint. The forearm architecture and distal radial ulnar joint (DRUJ) allow rotation through 180 degrees of pronation and supination to further enhance the arm’s ability to position the hand in a vast array of functional positions. The triangular fibrocartilage complex (TFCC) extends the articular surface of the concave distal radius over the convex head of the distal ulna. The motion of each component of this multifaceted joint is extremely complex. Movements involve rotation, translation with shifting axis of movement, and changing points of load transmission. Further, because no muscle is attached to the carpal bones, they are loaded by the geometry of the distal radius and ulna. Stability is provided instead by the intrinsic and extrinsic ligaments, and motion is generated by the carpal bones being pushed or pulled into position. Wrist arthroscopy has made a significant contribution to the diagnosis and treatment of injury to the wrist. With minimal incision and no disruption to the major ligaments of the wrist, the arthroscope provides an unparalleled view of the interior of the wrist joint. Injury of the TFCC can affect the function of both radiocarpal and distal radial ulnar joints. Arthroscopy is especially useful in both the diagnosis and treatment of injury to the TFCC.