RU Joint: Wafer Procedure : Wheeless' Textbook of Orthopaedics

- Discussion:
- a wafer of up to 2-4 mm of distal ulnar head is removed, while the styloid process TFCC, and attatched ligaments remain attached;
- the procedure is contra-indicated if more than 4 mm of positive variance;
- may be indicated for symptomatic positive ulnar variance, ulnocarpal impaction syndrome, or symptomatic TFCC tears;
- some authors feel that for this procedure to be successful, the TFCC must be intact;
- in the report by Tomaino MM, et al, the authors adressed patients with painful positive ulnar variance by combining arthroscopic TFCC debridement with arthroscopic wafer resection in such wrists as part of the same surgical procedure;
- 12 patients (7 posttraumatic and 5 degenerative tears were identified);
- preop ulnar variance w/ pronated grip x-ray averaged 2 mm (range: 1 and 4 mm);
- 8 patients experienced complete pain relief and 4 experienced only minimal symptoms;
- ulnocarpal stress test failed to elicit pain in any wrist;
- 9 patients were very satisfied, and 3 were satisfied;
- grip strength improved 8 kg (36%);
- authors recommend this procedure in the treatment of ulnar wrist pain when TFCC tears and positive ulnar variance coexist;
- ref: Combined arthroscopic TFCC debridement and wafer resection of the distal ulna in wrists with triangular fibrocartilage complex tears and positive ulnar variance

- Technique:
- longitudinal incision on the dorsal-ulnar side of the wrist;
- the extensor retinaculum between the EDQ and ECU is incised;
- the sheath of the ECU is left intact, eventhough this will make retraction of the tendon more difficult;
- open the DRUJ capsule w/ a horseshoe shaped flap, leaving the radial side of the capsule intact;
- the TFCC and ulnar styloid are identified;
- the TFCC (and its attachments) is protected, and a small osteotome is used to make a longitudinal cut 2-4 mm in depth along the radial side of the styloid process;
- subsequently a thin oscillating saw is used to remove 2-4 mm from the head of the distal ulna;
- the goal is to create 2 mm of negative ulnar variance;
- ligametous repair and/or TFCC repair (or debridement) can be performed at this time;
- capsular closure should include the peripheral edge of the TFCC, which allows the TFCC to be suspended w/ normal tension;
- post operatively the arm is immobilized in supination for 2 weeks, and then neutral rotation for 2 weeks;
- typically, patients require a full 3 months to recover