- Discussion:
- a wafer of upto 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 Matthew M. Tomaino 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
Matthew M. Tomaino, MD Journal of Hand Surg. November 2001 Volume 26 Number 6
- 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;
The "wafer" procedure. Partial distal ulnar resection.
Wafer distal ulna resection for triangular fibrocartilage tears and/or ulna impaction syndrome.
Distal Ulnar Recession for Disorders of the Distal Radioulnar Joint.
Darrow JC, Linschied RL, Dobyns JH, Mann JM, Wood MB, Beckenbaugh RD.
J. Hand Surg. 1985; 10A: 482-491.
Matched distal ulnar resection.
Watson HK, Ryu J, Burgess RC.
J. Hand Surg. 1986; 11-A 812-817.
The effect of the wafer procedure on pressure in the distal radioulnar joint.
