Effect of Dorsal Capsular Imbrication on Intraoperative DRUJ Instability following Arthroscopic TFCC Repair Surgery

Effect of Dorsal Capsular Imbrication on Intraoperative DRUJ Instability following Arthroscopic TFCC Repair Surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect of Dorsal Capsular Imbrication on Intraoperative DRUJ Instability following Arthroscopic TFCC Repair Surgery Chen-Wei Yeh, Cheng-En Hsu, Alvin Kai-Xing Lee, Tsung-Yo Ho, Wei-Chih Wang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3919522/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Distal radioulnar joint (DRUJ) stability during unrestricted forearm rotation relies on several factors, including the integrity of the triangular fibrocartilage complex (TFCC), the interosseous membrane, the bony configuration of the sigmoid notch, DRUJ capsule, and the extensor carpi ulnaris tendon with its subsheath. There are currently numerous reported surgical approaches for TFCC repair, however, postoperative DRUJ instability rates are still reported to be around 8 to 12%. As the integrity and strength of the TFCC is crucial for DRUJ stability, it is thus critical to identify if intraoperative dorsal capsular imbrication can further enhance DRUJ stability for improved functional outcomes. Methods A retrospective study was performed on patients who underwent arthroscopic TFCC repair between 2016 and 2021. Inclusion criteria comprised a symptomatic ulna fovea sign for over 6 months and dorsal DRUJ subluxation on magnetic resonance imaging. A total of 225 patients were assessed to be suitable and recruited for our study. 135 patients underwent our arthroscopic “cross-form TFCC repair” without dorsal capsular imbrication (CR) and 90 patients underwent our arthroscopic “cross-form TFCC repair” with dorsal capsular imbrication for augmentation of DRUJ stability (DCI). Pain visual analog scale score (VAS), grip strength, modified Mayo Wrist Score (MMWS), wrist range of motion (ROM), and patient-reported outcomes (PRO) were evaluated, and all patients were follow-up for a minimum of 3 years postoperatively. Results Both groups showed significant improvements in pain VAS score, grip strength, wrist ROM, MMWS, and PRO between the preoperative and postoperative periods (p < 0.05). Significantly lower recurrent DRUJ instability was noted in the DCI group (3.7% vs 1.1%, p < 0.05). Re-operative rates were also noted to be lower in the DCI group (2.2% vs 1.1%). However, the DCI group was found to have inferior ROM as compared to the CR group. Conclusion Dorsal DRUJ capsular imbrication effectively reduces postoperative DRUJ instability and reoperation rates, enhances grip strength, and maintains wrist ROM in patients with a positive intra-operative ballottement test after arthroscopic TFCC repair. distal radioulnar joint stability triangular fibrocartilage complex arthroscopic repair Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Distal radioulnar joint (DRUJ) stability during unrestricted forearm rotation relies on several factors, including the integrity of the triangular fibrocartilage complex (TFCC), the interosseous membrane, the bony configuration of the sigmoid notch, DRUJ capsule, and the extensor carpi ulnaris tendon with its subsheath [ 1 ]. TFCC injury often results from a fall on the outstretched, pronated, and hyperextended wrist, leading to dorsal instability of the DRUJ [ 2 ]. Within the anatomical structure of the TFCC, the fovea ulnaris serves as the convergent point of proximal component TFCC (pc-TFCC) insertion, thereby becoming the most indispensable stabilizer for the ulnocarpal joint and DRUJ [ 3 ]. Based on the ulnar-side TFCC tear in Palmar type Ib, Atzei et al.[ 4 ] classified the treatment-oriented TFCC peripheral tear into five subgroups depending on whether the distal component (dc-TFCC) or the pc-TFCC was involved. Specifically, Atzei class II and III indicate DRUJ instability with complete and pc-TFCC rupture, respectively [ 5 ]. Consequently, the current approach for foveal-involved TFCC tear aims at achieving anatomical TFCC foveal reattachment, which can be accomplished through transosseous sutures [ 6 – 8 ] or suture anchor fixation [ 4 , 9 , 10 ] and has shown satisfactory outcomes. A prior study revealed that even when radiographic findings are negative in patients experiencing post-traumatic wrist pain, 42% of them receive a diagnosis of TFCC injuries [ 3 ]. and neglecting severe TFCC tears often leads to chronic DRUJ instability. According to tissue-engineering theory, the interface of bone-to-ligament may not regenerate after injury, resulting in a high rupture recurrence rate [ 11 ], and direct bone-to-ligament repair in the chronic stage might exhibit decreased healing potential with the disadvantageous repair margin [ 12 ]. Compared with transosseous sutures, transcapsular repair, involving ligament-to-capsular healing, is an alternative method for addressing TFCC fovea tear [ 13 ]. Research has supported the notion that transcapsular repair alone can stabilize the DRUJ while achieving anatomical restoration of the dorsal subluxation of the ulna head [ 13 , 14 ]. However, the integrity of DRUJ surrounding tissues, such as dorsal and volar radioulnar ligaments (DRUL and VRUL) with a superficial and a deep portion attached to the dorsal capsule, needs to be considered after the completion of TFCC repair [ 15 ]. For instance, Liu et al.[ 16 ] reported post-operative DRUJ instability rates of 12.1% with capsular repair and 10.1% with fovea transosseous repair. Consequently, additional procedures to reinforce DRUJ stability may be necessary. The dorsal capsular imbrication (DCI) technique has been proposed and reported to yield positive clinical results in chronic DRUJ dislocation cases [ 17 – 25 ]. However, the use of DCI as a reinforcement procedure in TFCC repair operations for chronic DRUJ instability has not been extensively studied. Therefore, the purposes of this study were (1) to identify the indication of positive ballottement test for implementing dorsal capsular imbrication after arthroscopic TFCC repair and (2) for evaluation of the functional and clinical outcomes of dorsal capsular imbrication as compared to non-dorsal capsular imbrication TFCC repair. Methods Study Population This study adhered to the tenets of the Helsinki Declaration and was approved by the Research Ethics Committee of our hospital. We retrospectively reviewed patients with repairable type IB TFCC injuries who underwent arthroscopic “cross-form” trancapsular repair with or without dorsal DRUJ capsular imbrication from January 2016 to January 2021. A minimum follow-up period of 36 months was mandatory for inclusion. The exclusion criteria encompassed patients with non-repairable TFCC (Atzei IV) ulnar and DRUJ osteoarthritis changes (Atzei V). All procedures were performed by an individual senior hand surgeon (Dr. YCC). Clinical and Image Assessment Pre-operatively, patients were diagnosed via a series of physical examinations, including ulna fovea sign for TFCC rupture, push-off test, and ballottement test for DRUJ laxity [ 18 ]. Wrist X-rays were employed to assess bony structure malalignment, such as ulnar styloid fracture, ulna variance, distal radius fracture or Galeazzi fracture [ 26 ]. Additionally, magnetic resonance imaging (MRI) of the wrist was performed to evaluate the condition of articular cartilage wear, detect foveal TFCC tear, and identify ulna head subluxation [ 27 ]. Arthroscopic Assessment Radiocarpal joint arthroscopy was performed using a 3/4 viewing portal (2.7-mm arthroscopy), a 6R working portal (equipped with a synovial shaver and probe), and a 6U portal (utilized as a fluid outflow portal). The 3/4 viewing portal allows the visualization of the dc-TFCC lesion over the ulnar margin of the TFCC. Through the 6R portal, a probe was used to perform a hook test, and a shaver served as a suction test to evaluate the pc-TFCC condition. Notably, in cases whereby diagnosis assessment with pc-TFCC was controversial, a direct foveal (DF) portal was established to further confirm for the diagnosis. Arthroscopy-assisted “Cross-form” TFCC Capsular Repair With/Without Dorsal DRUJ Capsule Imbrication The detailed procedure for TFCC repair was described as follows: Part 1: “Cross-form” TFCC Transcapsular Repair Using the 3/4 portals, a combination of 2 − 0 ETHIBOND (Johnson & Johnson, Hamburg, Germany) and 2 − 0 prolene (Ethicon Inc., Somerville, NJ, USA) were combined using the inside-out [ 28 ] and outside-in [ 29 ] TFCC capsular repair techniques, and a 21-gauge spinal needle was employed to perform the two horizontal stitches. Before suturing, a 2-cm incision was made over the 6U portal. The dorsal cutaneous branch of the ulnar nerve (DCBUN) and flexor carpi ulnaris (FCU) tendon were identified and retracted. The first horizontal mattress suture involved a 2 − 0 ethibond stitch close to the volar-ulnar margin of the TFCC lesion through the 3/4 portal using an inside-out technique (Fig. 2 A) and subsequently retracted to avoid DCBUN and FCU involvement (Fig. 3 A). The second stitch, a 2 − 0 prolene lasso loop suture, was performed near the dorsal-radial margin of the intact TFCC part through the 6R portal using an outside-in technique. The lasso loop suture carried one end of the 2 − 0 ethibond to form the first horizontal mattress suture (Fig. 2 B). For the second horizontal mattress suture, the puncture site of the third stitch was performed close to the volar-radial margin of the TFCC intact part through the 3/4 portal with an inside-out technique (Fig. 2 C), and the DCBUN should be protected from being punctured or tied in this step (Fig. 3 B). The fourth stitch, a lasso suture, was performed near the dorsal-ulnar margin of the TFCC lesion through the 6R portal using an outside-in technique. The lasso loop suture was then used to carry one end of the third stitch to form the second horizontal mattress suture (Fig. 2 D). This “cross-form” TFCC capsular repair created an extensive contact area in the ligament to capsule suture (Fig. 4 ). After completing two horizontal mattress sutures, the wrist traction tower device was released and firmly tied in the wrist’s full-pronation position (Fig. 2 E). Both sutures were checked to ensure they were tied below the ECU, FCU and DCBUN to avoid neuro-tendon involvement (Fig. 3 C), achieved by reducing the ulnar head from dorsal subluxation into a neutral position using thumb compression by an assistant (Fig. 2 F). Part 2: Intra-operative Ballottement Test We employed the intra-operative ballottement test to assess DRUJ stability after completing the "Cross-form" TFCC transcapsular repair, categorizing it into four grades: (1) Grade 0: Normal stability (Fig. 5 A). In cases where normal stability is detected, the "Cross-form" TFCC transcapsular repair alone is assumed to provide sufficient DRUJ stability. (2) Grades 1–3: If there is laxity greater than grade 0 in the intraoperative ballottement test after tightening the strings following TFCC repair (Fig. 5 B, C, and D), dorsal DRUJ capsular imbrication is performed to stabilize the DRUJ [ 30 ]. Part 3. Dorsal DRUJ Capsular Imbrication A 4-cm curved incision was made along the extensor digiti minimi (EDM) tendon extending proximally to the proximal margin of the DRUJ. Meticulous dissection of subcutaneous tissue was performed, with attention to the dorsal branch of the ulnar nerve. Following the longitudinal incision of the extensor retinaculum, the fourth and fifth extensor compartments were retracted. Subsequently, the dorsal DRUJ capsule was opened and incised longitudinally. In cases of chronic DRUJ instability, the dorsal capsule often exhibited looseness and weakness due to repetitive dorsal stretching by the ulnar head (Fig. 6 A). A rectangular capsule flap, approximately 2 × 2.5 cm 2 and ulnar based, was carefully dissected from the dorsal cortex of radius bone, extending from the radial to ulnar direction, and exposing the radius sigmoid notch and ulnar head (Fig. 6 B). To enhance the healing potential of DRUJ capsule-to-bone connection, the dorsal cortex of distal radius was decorticated using a rongeur. Two 1.4 all-suture bone anchors (JuggerKnot; Zimmer Biomet, Warsaw, IN) were individually placed radially over the upper and lower borders of the distal radius sigmoid notch (Fig. 6 B). Subsequently, with the elbow flexed at 90º and the forearm in a straightened position with full pronation, the assistant digitally pressed the dorsally displaced ulnar head, lowering it back into the sigmoid notch. The operator then imbricated the detached radius- and ulnar-based capsule flap by tightening sutures from the bone anchors (Fig. 6 C). This maneuver stabilized the ulna head in a secured position (Fig. 6 D). The patient was protected with a long-arm cast, with the forearm in a neutral position, for the first 4 weeks postoperatively. After cast removal, passive three-dimensional (3D) wrist motions were initiated with wrist brace protection from 5 to 8 weeks postoperatively. Low-intensity muscle strengthening exercises were introduced from weeks 9–12 postoperatively. Clinical Evaluation The patient’s profile, time interval from injury to surgery, and intra-operative and post-operative complications were documented based on the medical charts. The push-off test and ballottement test were employed to evaluate the ulnar-side pain relief and DRUJ stability, respectively. At postoperative intervals of 3, 6, 9, 12, 24, and 36 months, active motion arcs were measured using a goniometer and grip strength was measured with the Jamar Hydraulic Hand Dynamometer (Jamar Technologies/America, Hatfield, PA). Additionally, patient-reported outcomes, including MMWS, Patient-Rated Wrist Evaluation (PRWE), and Disabilities of the Arm, Shoulder, and Hand (DASH) were used for clinical results. The proportion of patients meeting the minimal clinically important difference (MCID) of the DASH (MCID: 10–13.5) and PRWE scores (MCID: 14–17) allowed for the quantitative recording of the direct feelings of the patients [ 31 ]. Sample Size Calculation In our prior comparative research [ 20 ], the mean ± standard deviation of wrist range of motion (ROM), with respect to pronation and supination, was found to be 161 ± 13.6º, and 156 ± 12.6º in the “dorsal capsular imbrication” group and the “TFCC repair + dorsal capsular imbrication” group, respectively. Based on a statistical power of 80% and a significance level of 5%, we determined that a minimum of 133 cases for group 1 and 90 cases for group 2 were necessary to ascertain whether a true difference in clinical outcomes existed between both groups. Statistical Analysis All data were analyzed using SPSS software (version 20.0; IBM Corp., Armonk, NY). The Shapiro–Wilk test showed that the data were not normally distributed; therefore, nonparametric tests were employed for comparison. Categorical variables were presented as frequency (%). The Chi-squared test was used for nonparametric statistical analysis of categorical information, and the Mann–Whitney U test was employed for nonparametric analysis of continuous variables. To compare outcome measurements between two groups (DASH score, PRWE score, grip strength, and ROM), the Wilcoxon rank sum test was used. Statistical significance was set at p < 0.05. Results From January 2016 to June 2021, a total of 265 patients underwent surgical treatment for post-traumatic chronic DRUJ instability at our hospital. Among them, 40 patients who underwent DRUJ reconstruction were excluded due to 25 patients having Atzei class IV or V TFCC tear, 4 with radioulnar joint arthritis, 7 without adequate follow-up, and 4 with prior wrist surgery. Ultimately, a total of 225 patients were included in our final analysis. Among them, 110 had Atzei class II and 115 had Atzei class III TFCC tears, and all underwent arthroscopy assisted TFCC capsular repair with dorsal DRUJ capsule imbrication (Fig. 1 ). This study comprised 130 (57.8%) men and 95 (42.2%) women, with right-sided DRUJ instability occurring in 142 (63%) and left-sided in 83 (36%) cases. The patients’ ages ranged from 22 to 58 years (mean, 41 years). The duration of symptoms before surgery ranged from 6 to 24 months (mean, 12.7 months; range, 6–24 months). The mean follow-up time was 45 months (range: 36–60 months) (Table 1 ). Table 2 presents the demographic and clinical characteristics of the patients, who were divided into two groups: Group 1, “Cross form” TFCC repair (CR), and Group 2, “Cross form” TFCC repair + DRUJ dorsal capsular imbrication (DCI), with no significant difference in each variable category. Table 1 Patients Demographic and Clinical Characteristics Variable CR a DCI b P value* Number 135 90 Sex Female 55 40 Male 80 50 Hand (R/L) 76/59 66/24 Age 41.5 (25–58) 36.3 (22–55) > 0.05 Symptoms to surgery (months) 12.2 (6–24) 13.5 (6–24) > 0.05 Follow-up (months) 30.9 (24–42) 34.7 (24–40) > 0.05 Atzei classification II 82 40 III 53 50 P value* significance difference under Chi-squared test CR a : Cross-form repair DCI b : Cross-form repair + Dorsal capsular imbrication Table 2 Cross-form repair group: 135 cases (Pre-operative vs. Post-operative 3 years) Variable Pre-operative Post-operative P value* Grip strength a 50% ± 21% 90.1% ± 5% < 0.05 Wrist ROM b Flex-extension 52.3% ± 17% 95.4% ± 5% < 0.05 Supi-pronation 47.3% ± 22% 92.4% ± 2% < 0.05 Radial-ulnar deviation 57% ± 18% 90.5% ± 5% < 0.05 DASH c score 51.6 ± 14.2 9.9 ± 4.2 < 0.05 PRWE d : score 40.7 ± 10.3 10.5 ± 5.7 < 0.05 MMWS e 50% ± 21% 95.1% ± 5% < 0.05 Grip strength a (op/non-op) × 100%; Wrist range of motion b (op/non-op) × 100% DASH c : Disabilities of the Arm, Shoulder, and Hand PRWE d : Patient-Rated Wrist Evaluation MMWS e : Modified Mayo Wrist score P value* significance difference under Mann-Whitney test The preoperative and 36-month postoperative scores for DASH, PRWE, grip strength, MMWS, and wrist ROM (flexion-extension + pronation-supination + radial-ulnar arcs) are shown in Table 2 (Group 1) and Table 3 (Group 2), and all significant differences were identified with p < 0.05. Additionally, patient-reported outcomes scores showed that 95% (214 in 225) of patients achieved the MCID for DASH scores, and 92% (207 in 225) achieved the MCID for PRWE scores. Table 3 Cross-form repair + Dorsal capsular imbrication group: 90 cases (Pre-operative vs. Post-operative 3 years) Variable Pre-operative Post-operative P value* Grip strength a 47% ± 17% 95.1% ± 5% < 0.05 Wrist ROM b Flex-extension 51.3% ± 20% 92.4% ± 3% < 0.05 Supi-pronation 49.2% ± 19% 91.1% ± 3% < 0.05 Radial-ulnar deviation 56% ± 18% 88.2% ± 4% < 0.05 DASH c score 50.1 ± 17.1 10.2 ± 4.2 < 0.05 PRWE d : score 41.7 ± 11.4 9.5 ± 5.1 < 0.05 MMWS e 44% ± 25% 93.7% ± 5% < 0.05 Grip strength a (op/non-op) × 100%; Wrist range of motion b (op/non-op) × 100% DASH c : Disabilities of the Arm, Shoulder, and Hand PRWE d : Patient-Rated Wrist Evaluation MMWS e : Modified Mayo Wrist score P value* significance difference under Mann-Whitney test Comparison of post-operative results between Group 1 and Group 2 are shown in Table 4 and Fig. 7 . Our findings revealed that in the short-term (post-operative 3 months to 1 year), even though the DCI group exhibited better grip strengths than the CR group, they had wrist stiffness (Fig. 7 ). Interestingly, in the mid-term (post-operative 1 year to 3 years), the DCI group continued to demonstrate superior grip strengths compared with the CR group (Table 4 ). However, no significant difference was observed in all directions of wrist ROM between the two groups at the post-operative 3-year follow-up (Table 4 ). Table 4 Cross-form repair group vs. Cross-form repair + Dorsal capsular imbrication group (Post-operative 3 years) Variable CR f DCI g P value* Grip strength a 90.1% ± 5% 95.1% ± 5% 0.05 Supi-pronation 92.4% ± 2% 91.1% ± 3% > 0.05 Radial-ulnar deviation 90.5% ± 5% 88.2% ± 4% > 0.05 DASH c score 9.9 ± 4.2 10.2 ± 4.2 > 0.05 PRWE d : score 10.5 ± 5.7 9.5 ± 5.1 > 0.05 MMWS e 95.1% ± 5% 93.7% ± 5% > 0.05 Complications Reoperation (%) 2.2% 1.1% > 0.05 Recurrent instability (%) 3.7% 1.1% < 0.05 Grip strength a (op/non-op) × 100%; Wrist range of motion b (op/non-op) × 100% DASH c : Disabilities of the Arm, Shoulder, and Hand PRWE d : Patient-Rated Wrist Evaluation MMWS e : Modified Mayo Wrist score CR f : Cross-form repair DCI g : Cross-form repair + Dorsal capsular imbrication P value* significance difference under Mann-Whitney test Post-operative complications included: (1) Recurrent DRUJ instability, which occurred in 3.7% (5/135) and 1.1% (1/90) in Group 1 and Group 2, respectively, with a significant difference between the two groups; and (2) Repeated surgery, the re-operative ratio was noted as 2.2% (3/135) and 1.1% (1/90) in Group 1 and Group 2, respectively, with no significance difference observed. Notably, a total of 95% (214/225) of patients achieved pain relief in the push-off test, 97.3% (219/225) regained DRUJ stability in the ballottement test, and only 1.8% (4/225) required re-operation due to DRUJ osteoarthritis changes after 3 years postoperatively. Moreover, patient-reported outcomes indicated that 91% and 92% of patients achieved the MCID in the DASH and PRWE scores, respectively [ 31 ]. Discussion Our study showed that incorporating augmented DCI in TFCC repair for patients with an intraoperative positive intraoperative ballottement led to satisfactory postoperative clinical and functional results and could be considered as an indication for DCI augmentation. Such an augmentation led to significantly lower reoperation rates with patients having significantly higher grip strength. However, patients undergoing DCI might experience a brief period of decreased wrist ROM. According to the Atzei classification, TFCC fovea tear (class II, III) required foveal TFCC repair [ 4 , 32 ]. The neglected TFCC fovea tear might contribute to chronic DRUJ instability [ 5 ] resulting in decreased grip strength or limited wrist ROM [ 33 ]. Despite the favorable outcomes reported for “transosseous repair [ 6 – 8 ]” “fovea repair with suture anchors [ 4 , 9 , 10 ]”, re-operation rates have been documented in the range of 6.7–30% [ 8 , 34 – 37 ]. Discrepancies in clinical results and reduced efficacy of fovea repair may be attributed to (1) the poor quality or irreparable remnants of TFCC fovea tears that cannot stabilize DRUJ, (2) insufficient coverage area for sutures or knots, increasing the risk of TFCC cut-through during knot tying, and (3) inadequate foveal debridement or improper positioning of bony tunnels, leading to limited bone-to-ligament regeneration capacity. Recent studies comparing DRUJ stability after capsular repair and transosseous repair have produced varying results: Ruch et al. [ 38 ] demonstrated no significant difference, while Johnson et al.[ 39 ] indicated greater stability with transosseous repair. However, the critical factor for successful TFCC repair lies in the healing potential of the contact surface, which is notably poor in ligament-to-bone repair (fovea repair): 1. Ulna fovea has a “band shaped”-like footprint [ 40 ], whereas “suture anchor repair” and “transosseous tunnel repair” only provide a point contact area between the TFCC remnant and the ulna fovea; 2. “ Enthesis” refers to the insertion site of a tendon, ligament or joint capsule into bone [ 41 ]. Fovea repair, “transooseous repair” or “suture anchor repair,” requires the reattachment of TFCC remnant parts into the ulna fovea. Few vessels penetrate the enthesis due to a calcified barrier [ 42 ]. In contrast, capsular repair may be more effective in enhancing the healing potential of the TFCC through ligament-to-capsule repair compared to [ 43 ] ligament-to-bone repair. However, a comprehensive review involving 825 cases across 30 studies revealed post-operative distal radioulnar joint (DRUJ) instability rates of 12.1% for capsular repair and 10.1% for fovea transosseous repair. Regarding re-operation rates, they were 7.9% for capsular repair and 5.5% for fovea transosseous repair [ 16 ]. These results indicate that intraoperative instability of the DRUJ can be a concern in both primary methods of TFCC repair. Therefore, employing an intraoperative DRUJ stability test could be essential for identifying potential postoperative instability and the failure of TFCC repair. Augmentation with DCI can help prevent postoperative DRUJ instability and the need for subsequent reoperation. The intra-operative ballottement test is a simple method for evaluating DRUJ stability after arthroscopic TFCC repair. A positive result suggests that the strength of the repaired TFCC alone may be insufficient to maintain DRUJ stability. DCI can be employed as a supplementary method to enhance DRUJ stability. Using DCI as a sole treatment for patients with DRUJ instability has been successful in restoring DRUJ stability in 97.8% of cases, with 93.6% of patients experiencing pain relief through this approach [ 17 – 25 ]. In a long-term study spanning 10 years, it was observed that DCI effectively restored wrist function to levels comparable to the contralateral hand. DCI can also function as a secondary stabilizer, following a similar bridging concept to that of the internal brace used in anterior talofibular ligament [ 44 ] or knee medial collateral ligament repair [ 45 ]. When combined with the suture tap and bone anchors, it can reinforce ligament strength and prevent injury recurrence during the rehabilitation process [ 44 ]. Similarly, DCI can restore intact DRUJ kinematics and radioulnar ligament reconstructions in chronic DRUJ instability [ 46 ]. In the present study, recurrent DRUJ instability was found to be significantly lower in patients with the augmentation of DCI, compared to 3.7% and 1.1% in CR group 1 and “DCI group 2, with a significant difference. Thus, we believe that DCI could be an effective method for addressing intraoperative DRUJ instability following TFCC capsular repair. In this treatment protocol, we aim to outline the procedures necessary to restore the integrity of TFCC and DRUJ capsules: (1) “TFCC capsular repair” combines the benefits of the inside-out and outside-in techniques, reducing the cut-through rate, purchasing the wide contact area between the ulna fovea and adhering TFCC remnant part with the surrounding tissue to reinforce the DRUJ stability. The crux of transcapsular repair is the ligament-to-soft tissue healing process. Therefore, non-absorbable suture 2 − 0 ethibond was selected to provide reliable tension support. (2) Intraoperative ballottement test could be used to check for integrity of the DRUJ stability, grade 0 indicates that “TFCC transcapsular repair” was sufficient to maintain DRUJ stability, while grade I, II or III suggests that DRUJ laxity or subluxation existed after transcapsular repair, and the subsequent augmentation for DRUJ stability was needed. (3) Dorsal DRUJ capsular imbrication worked by tightening the redundant laxity of dorsal DRUJ capsule, thereby reducing the subluxation of ulna head and reattaching the DRUL to the tightened DRUJ capsule under wrist full-pronation position. Tension of the imbricated capsule can be optimized to stabilize DRUJ with the utilization of two suture anchors over the dorsal cortex of the radius sigmoid notch. Our results indicated a slightly higher rate of postoperative distal radioulnar joint (DRUJ) instability in Group 1, which underwent only TFCC capsular repair, compared to Group 2, which received both TFCC capsular repair and dorsal DRUJ capsular imbrication. This implies that late DRUJ instability may manifest in patients who initially tested negative in the intraoperative ballottement test but only underwent TFCC repair. It also implies that DCI is a reliable procedure to build up the DRUJ stability. A major concern about our methods was that wrist stiffness was found approximately postoperative 6 months in the DCI group. However, wrist ROM were comparable to the CR group after midterm follow-ups. Furthermore, grip strength of DCI was not affected even with decreased wrist ROM. Another issue to consider was that tying knots during the transcapsular repair may lead to transient dorsal ulnar sensory nerve irritation due to intra-operative retraction; however, symptoms were noted to subside within 2 weeks postoperatively. This study has its own limitations. Firstly, it focused solely on surgical outcomes and functional measures, lacking postoperative axial MRI to verify the repositioned DRUJ. Secondly, being a retrospective comparative study with midterm follow-up, a longer-term investigation is needed to validate the observed clinical outcomes. Third, the intraoperative ballottement test employed in this study remains subjective. Future studies should consider standardizing pull strength and translation distance measurements to enhance the accuracy of identifying subtle cases of DRUJ instability following TFCC repair. Finally, we did not include a control group comprising patients with persistent instability after TFCC repair who did not receive additional augmentation treatment to enhance DRUJ stability. However, establishing such a control group presented ethical and clinical challenges, as leaving untreated cases of persistent DRUJ instability were not considered feasible. Conclusions Our findings revealed that in chronic cases of DRUJ instability with ulna fovea tear, “Cross form” TFCC repair may be employed to restore DRUJ stability. Specifically, if the intra-operative ballottement test indicates residual DRUJ instability following TFCC capsular repair, “Dorsal capsular imbrication” can be applied to augment DRUJ stability. This procedural protocol serves as a viable treatment option for patients experiencing chronic DRUJ instability. Declarations Author contributions: Chen-Wei Yeh and Cheng-En Hsu designed the concept. Wei-Chih Wang, Tsung-Yu Ho and Bor-han Wei were the attending doctor and treated the patient. Chen-Wei Yeh and Cheng-En Hsu contributed to literature review and manuscript drafting. Yung- Cheng Chiu revised the manuscript. Informed consent statement: The patient provided consent for the use of his medical documentation and information for the present article. Consent for publication & Availability of data and materials: The authors agreed for the publication and data usage. Conflict-of-interest statement: The authors declared that they have no conflict of interest. The authors did not receive any financial support or fundings for this manuscript. Acknowledgements & Disclosure of interest: The authors declared that they have no competing interests. References Jawed A, Ansari MT, Gupta V. TFCC injuries: How we treat. J Clin Orthop Trauma 2020;11:570-579. Andersson J, Axelsson P. [Wrist ligament injuries--diagnostics]. Lakartidningen 2011;108:2096-2101. Moritomo H, Murase T, Arimitsu S, Oka K, Yoshikawa H, Sugamoto K. Change in the length of the ulnocarpal ligaments during radiocarpal motion: possible impact on triangular fibrocartilage complex foveal tears. J Hand Surg Am 2008;33:1278-1286. Atzei A, Luchetti R. Foveal TFCC tear classification and treatment. Hand Clin 2011;27:263-272. Atzei A. New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability. J Hand Surg Eur Vol 2009;34:582-591. Iwasaki N, Nishida K, Motomiya M, Funakoshi T, Minami A. Arthroscopic-assisted repair of avulsed triangular fibrocartilage complex to the fovea of the ulnar head: a 2- to 4-year follow-up study. Arthroscopy 2011;27:1371-1378. Nakamura T, Sato K, Okazaki M, Toyama Y, Ikegami H. Repair of foveal detachment of the triangular fibrocartilage complex: open and arthroscopic transosseous techniques. Hand Clin 2011;27:281-290. Shinohara T, Tatebe M, Okui N, Yamamoto M, Kurimoto S, Hirata H. Arthroscopically assisted repair of triangular fibrocartilage complex foveal tears. J Hand Surg Am 2013;38:271-277. Geissler WB. Arthroscopic knotless peripheral triangular fibrocartilage repair. J Hand Surg Am 2012;37:350-355. Park Y. All-arthroscopic knotless suture anchor repair of triangular fibrocartilage complex fovea tear by the 2-portal technique. Arthrosc Tech 2014;3:e673-7. Font Tellado S, Balmayor ER, Van Griensven M. Strategies to engineer tendon/ligament-to-bone interface: Biomaterials, cells and growth factors. Adv Drug Deliv Rev 2015;94:126-140. Lee DH, Ng J, Chung JW, Sonn CH, Lee KM, Han SB. Impact of chronicity of injury on the proportion of mesenchymal stromal cells derived from anterior cruciate ligaments. Cytotherapy 2014;16:586-598. Estrella EP, Hung LK, Ho PC, Tse WL. Arthroscopic repair of triangular fibrocartilage complex tears. Arthroscopy 2007;23:729-37, 737.e1. Lo IN, Chen KJ, Huang TF, Huang YC. The rein-type arthroscopic capsular suture for triangular fibrocartilage complex foveal tears: midterm results for 90 patients. J Hand Surg Eur Vol 2021;46:1049-1056. Scheker LR, Belliappa PP, Acosta R, German DS. Reconstruction of the dorsal ligament of the triangular fibrocartilage complex. J Hand Surg Br 1994;19:310-318. Liu EH, Suen K, Tham SK, Ek ET. Surgical Repair of Triangular Fibrocartilage Complex Tears: A Systematic Review. J Wrist Surg 2021;10:70-83. Wong KH, Yip TH, Wu WC. Distal radioulnar joint dorsal instability treated with dorsal capsular reconstruction. Hand Surg 2004;9:55-61. Manz S, Wolf MB, Leclère FM, Hahn P, Bruckner T, Unglaub F. Capsular imbrication for posttraumatic instability of the distal radioulnar joint. J Hand Surg Am 2011;36:1170-1175. Unglaub F, Manz S, Bruckner T, Leclère FM, Hahn P, Wolf MB. [Dorsal capsular imbrication for dorsal instability of the distal radioulnar joint]. Oper Orthop Traumatol 2013;25:609-614. Kouwenhoven ST, de Jong T, Koch AR. Dorsal capsuloplasty for dorsal instability of the distal ulna. J Wrist Surg 2013;2:168-175. Ahrens C, Unglaub F, Bruckner T, et al. Midterm functional outcome after dorsal capsular imbrication for posttraumatic instability of the distal radioulnar joint. Arch Orthop Trauma Surg 2014;134:1633-1639. El-Haj M, Baughman C, Thirkannad SM. A Technique for Treating Dorsal Instability of the Distal Radioulnar Joint. Tech Hand Up Extrem Surg 2017;21:67-70. Neto BC, Neto JHS. Chronic Posttraumatic Instability of the Distal Radioulnar Joint: Foveal Reattachment of the Triangular Fibrocartilage Complex With Dorsal Capsuloplasty and Extensor Retinaculum Imbrications. Hand (N Y) 2022;17:313-318. Unglaub JM, Heyse T, Bruckner T, Langer MF, Spies CK. Long-term functional outcome after dorsal capsular imbrication for post-traumatic dorsal instability of the distal radioulnar joint. Int Orthop 2020;44:2683-2690. Yeh CW, Hsu CE, Ho TY, Wei BH, Wang WC, Chiu YC. Midterm Results of Arthroscopy-Assisted "Tent Form" Triangular Fibrocartilage Complex Repair With Dorsal Distal Radioulnar Joint Capsule Imbrication for Posttraumatic Chronic Distal Radioulnar Joint Instability. Arthroscopy 2022;38:1846-1856. Pechlaner S, Kathrein A, Gabl M, et al. [Distal radius fractures and concomitant lesions. Experimental studies concerning the pathomechanism]. Handchir Mikrochir Plast Chir 2002;34:150-157. Lo IK, MacDermid JC, Bennett JD, Bogoch E, King GJ. The radioulnar ratio: a new method of quantifying distal radioulnar joint subluxation. J Hand Surg Am 2001;26:236-243. de Araujo W, Poehling GG, Kuzma GR. New Tuohy needle technique for triangular fibrocartilage complex repair: preliminary studies. Arthroscopy 1996;12:699-703. Haugstvedt JR, Husby T. Results of repair of peripheral tears in the triangular fibrocartilage complex using an arthroscopic suture technique. Scand J Plast Reconstr Surg Hand Surg 1999;33:439-447. Seo KN, Park MJ, Kang HJ. Anatomic reconstruction of the distal radioulnar ligament for posttraumatic distal radioulnar joint instability. Clin Orthop Surg 2009;1:138-145. Harris JD, Brand JC, Cote MP, Faucett SC, Dhawan A. Research Pearls: The Significance of Statistics and Perils of Pooling. Part 1: Clinical Versus Statistical Significance. Arthroscopy 2017;33:1102-1112. Atzei A, Rizzo A, Luchetti R, Fairplay T. Arthroscopic foveal repair of triangular fibrocartilage complex peripheral lesion with distal radioulnar joint instability. Tech Hand Up Extrem Surg 2008;12:226-235. Adams BD, Lawler E. Chronic instability of the distal radioulnar joint. J Am Acad Orthop Surg 2007;15:571-575. Chou KH, Sarris IK, Sotereanos DG. Suture anchor repair of ulnar-sided triangular fibrocartilage complex tears. J Hand Surg Br 2003;28:546-550. Kim B, Yoon HK, Nho JH, et al. Arthroscopically assisted reconstruction of triangular fibrocartilage complex foveal avulsion in the ulnar variance-positive patient. Arthroscopy 2013;29:1762-1768. Luchetti R, Atzei A. Arthroscopic assisted tendon reconstruction for triangular fibrocartilage complex irreparable tears. J Hand Surg Eur Vol 2017;42:346-351. Dunn J, Polmear M, Daniels C, Shin E, Nesti L. Arthroscopically Assisted Transosseous Triangular Fibrocartilage Complex Foveal Tear Repair in the United States Military . J Hand Surg Glob Online 2019;1:79-84 Ruch DS, Anderson SR, Ritter MR. Biomechanical comparison of transosseous and capsular repair of peripheral triangular fibrocartilage tears. Arthroscopy 2003;19:391-396. Miyachi Y, Danno K, Imamura S. Pemphigoid following chronic cement dermatitis. Contact Dermatitis 1985;13:188. Shin WJ, Kim JP, Yang HM, Lee EY, Go JH, Heo K. Topographical Anatomy of the Distal Ulna Attachment of the Radioulnar Ligament. J Hand Surg Am 2017;42:517-524. Bunker DL, Ilie V, Ilie V, Nicklin S. Tendon to bone healing and its implications for surgery. Muscles Ligaments Tendons J 2014;4:343-350. Doschak MR, Zernicke RF. Structure, function and adaptation of bone-tendon and bone-ligament complexes. J Musculoskelet Neuronal Interact 2005;5:35-40. Chow RM, Engasser WM, Krych AJ, Levy BA. Arthroscopic capsular repair in the treatment of femoroacetabular impingement. Arthrosc Tech 2014;3:e27-30. Yoo JS, Yang EA. Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace. J Orthop Traumatol 2016;17:353-360. Lubowitz JH, MacKay G, Gilmer B. Knee medial collateral ligament and posteromedial corner anatomic repair with internal bracing. Arthrosc Tech 2014;3:e505-8. Gofton WT, Gordon KD, Dunning CE, Johnson JA, King GJ. Comparison of distal radioulnar joint reconstructions using an active joint motion simulator. J Hand Surg Am 2005;30:733-742. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3919522","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":271602741,"identity":"66b7dc3f-e83a-4c96-b5ce-4a7141b5c70a","order_by":0,"name":"Chen-Wei Yeh","email":"","orcid":"","institution":"China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Chen-Wei","middleName":"","lastName":"Yeh","suffix":""},{"id":271602742,"identity":"8bd4e44d-ca7a-4ce9-b809-4b8a27c0be47","order_by":1,"name":"Cheng-En Hsu","email":"","orcid":"","institution":"Tunghai University","correspondingAuthor":false,"prefix":"","firstName":"Cheng-En","middleName":"","lastName":"Hsu","suffix":""},{"id":271602743,"identity":"4de7f388-5811-410b-b283-8c746e36563c","order_by":2,"name":"Alvin Kai-Xing Lee","email":"","orcid":"","institution":"China Medical University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Alvin","middleName":"Kai-Xing","lastName":"Lee","suffix":""},{"id":271602744,"identity":"96d521cd-b494-42de-827d-ac933b1b6a89","order_by":3,"name":"Tsung-Yo Ho","email":"","orcid":"","institution":"China Medical University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tsung-Yo","middleName":"","lastName":"Ho","suffix":""},{"id":271602745,"identity":"90487ce2-7d65-4168-8f4b-2c92aa1bab5d","order_by":4,"name":"Wei-Chih Wang","email":"","orcid":"","institution":"China Medical University Hsinchu Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wei-Chih","middleName":"","lastName":"Wang","suffix":""},{"id":271602746,"identity":"7f0b17fb-5851-48ff-a505-703d69748b55","order_by":5,"name":"Bor-Han Wei","email":"","orcid":"","institution":"Cheng Ching Hospital Chung Kang Branch","correspondingAuthor":false,"prefix":"","firstName":"Bor-Han","middleName":"","lastName":"Wei","suffix":""},{"id":271602747,"identity":"61b653cb-eb14-4669-8830-5acfd0d92361","order_by":6,"name":"Yung-Cheng Chiu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvElEQVRIiWNgGAWjYBACAyCWYGyQYOBnZmA8wMDATIIWyWYGBpK0ABkHiNVizn724I2fOywSNx9nfnDgY5s1A397dwJeLZY9ecmWvWckErcdZjM4OLMtnUHizNkN+B12IMdMmrENpIWH4TBv22EGA4lcAlrOv4Fo2dxMtJYbUFs2MBOv5Y2xZW+bhPEMkF9mnEvnIeyX8zmGN3621cn29x9++OBDmbUcf3svfi0YgIc05aNgFIyCUTAKsAIA6A1IcJvCyAgAAAAASUVORK5CYII=","orcid":"","institution":"China Medical University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Yung-Cheng","middleName":"","lastName":"Chiu","suffix":""}],"badges":[],"createdAt":"2024-02-02 04:14:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3919522/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3919522/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":50927596,"identity":"4dd28780-c69d-483b-bb53-fe1a554b6b7b","added_by":"auto","created_at":"2024-02-09 17:16:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":136002,"visible":true,"origin":"","legend":"\u003cp\u003eTreatment protocol of patients with chronic DRUJ instability\u003c/p\u003e\n\u003cp\u003e**TFCC, triangular fibrocartilage complex; DRUJ, distal radioulnar joint**\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3919522/v1/ae8b962819ede508cf39ae4b.png"},{"id":50927568,"identity":"645fde56-5b9d-4c49-b744-1a1e5c433082","added_by":"auto","created_at":"2024-02-09 17:16:27","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":802078,"visible":true,"origin":"","legend":"\u003cp\u003ePart 1. “Cross-form” TFCC transcapsular repair (Green color: 3/4 portal, inside-out technique) (Blue color: 6R portal, outside-in technique)\u003c/p\u003e\n\u003cp\u003eFirst suture (Red color) (A) 1\u003csup\u003est\u003c/sup\u003e stitch [volar-ulnar]: inside-out technique from the 3/4 portal (B) 2\u003csup\u003end\u003c/sup\u003e stitch [dorsal-radial]: outside-in technique from the 6R portal; 2\u003csup\u003end\u003c/sup\u003e suture (Orange color)\u003c/p\u003e\n\u003cp\u003e(C) 3\u003csup\u003erd\u003c/sup\u003e stitch [volar-radial]: inside-out technique from 3/4 portal\u003c/p\u003e\n\u003cp\u003e(D) 4\u003csup\u003eth\u003c/sup\u003e stitch [dorsal-ulnar]: outside-in technique from 6R portal\u003c/p\u003e\n\u003cp\u003e(E and F) reduction of the ulna head into the radius sigmoid notch with the assistant’s thumb and tying both sutures.\u003c/p\u003e\n\u003cp\u003e**TFCC, triangular fibrocartilage complex **\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3919522/v1/371d72e2aea5b1f4d069d657.png"},{"id":50927598,"identity":"dae0b40d-85a1-4cd6-9f10-e93b824f4176","added_by":"auto","created_at":"2024-02-09 17:16:33","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":601839,"visible":true,"origin":"","legend":"\u003cp\u003eIdentified DCBUN and FCU (Green color: 3/4 portal, inside-out technique) (Blue color: 6R portal, outside-in technique, 1\u003csup\u003est\u003c/sup\u003e suture: Red color, 2\u003csup\u003end\u003c/sup\u003e suture: Orange color)\u003c/p\u003e\n\u003cp\u003e(A) Applied the first stitch after retracting DCBUN \u0026amp; FCU\u003c/p\u003e\n\u003cp\u003e(B) Applied the third stitch after retracting DCBUN \u0026amp; FCU\u003c/p\u003e\n\u003cp\u003e(C) Retracting the ECU and DCBUN and FCU, and tying both sutures below them\u003c/p\u003e\n\u003cp\u003e** DCBUN: dorsal cutaneous branch ulna nerve; ECU: Extensor carpi ulnaris; FCU: Flexor carpi ulnaris **\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-3919522/v1/d7d9d380f05f9161c0f3f516.png"},{"id":50927602,"identity":"308d6f5e-b0c6-43df-ae20-84573f51bee0","added_by":"auto","created_at":"2024-02-09 17:16:40","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1549729,"visible":true,"origin":"","legend":"\u003cp\u003eCreating a maximum area of “Cross-form” TFCC transcapsular repair under arthroscope (Viewing from 3/4 portal)\u003c/p\u003e\n\u003cp\u003e(Green color: 3/4 portal, inside-out technique) (Blue color: 6R portal, outside-in technique, 1\u003csup\u003est\u003c/sup\u003e suture: Red color, 2\u003csup\u003end\u003c/sup\u003e suture: Orange color)\u003c/p\u003e\n\u003cp\u003e**TFCC, triangular fibrocartilage complex **\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-3919522/v1/7b75a7cac651b85276bdd763.png"},{"id":50927569,"identity":"dda5272d-d167-49da-9976-637a769faa59","added_by":"auto","created_at":"2024-02-09 17:16:27","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1112403,"visible":true,"origin":"","legend":"\u003cp\u003ePart II. Intra-operative Ballottement test\u003c/p\u003e\n\u003cp\u003e(A) Grade 1: Normal stability (relative displacement 0%)\u003c/p\u003e\n\u003cp\u003e(B) Grade 2: Increase laxity with firm endpoint response to stress (relative displacement 0–25%)\u003c/p\u003e\n\u003cp\u003e(C) Grade 3: Increase laxity without firm endpoint response to stress (relative displacement 25–50%)\u003c/p\u003e\n\u003cp\u003e(D) Grade 4: Subluxation with passive range of motion (relative displacement \u0026gt;50%)\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-3919522/v1/5b9c193d8ccd23246b7b00a5.png"},{"id":50927599,"identity":"6f67fcb4-9eb8-4fe8-9abb-11de5bd8ab58","added_by":"auto","created_at":"2024-02-09 17:16:37","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":1202176,"visible":true,"origin":"","legend":"\u003cp\u003ePart III. Dorsal capsular imbrication\u003c/p\u003e\n\u003cp\u003e(A) Chronic DRUJ instability s/p part 1. “Cross-form” TFCC transcapsular repair, the dorsal capsule remains loose.\u003c/p\u003e\n\u003cp\u003e(B) Incision of the dorsal capsule into ulnar-based flap and applying two suture anchors over the dorsal cortex near the sigmoid notch.\u003c/p\u003e\n\u003cp\u003e(C) Reduction of ulna head with assistant’s thumb in full forearm pronation.\u003c/p\u003e\n\u003cp\u003e(D) Operator tightened the knots to maintain the DRUJ’s reduction after restoring the normal alignment of the DRUJ.\u003c/p\u003e\n\u003cp\u003e**TFCC, triangular fibrocartilage complex; DRUJ, distal radioulnar joint**\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-3919522/v1/30750bf12e0d03ba62fbf488.png"},{"id":50927603,"identity":"74203647-f141-4899-badb-1915319a1589","added_by":"auto","created_at":"2024-02-09 17:16:44","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":219302,"visible":true,"origin":"","legend":"\u003cp\u003eCR\u003csup\u003ed\u003c/sup\u003e group 1 (blue color) vs. DCI\u003csup\u003ee\u003c/sup\u003e (orange color)\u003c/p\u003e\n\u003cp\u003e(A) Short-term following: post-operative 6 months to 1 year\u003c/p\u003e\n\u003cp\u003e(B) Mid-term following: post-operative 2 to 3 year\u003c/p\u003e\n\u003cp\u003e** Grip strength\u003csup\u003ea\u003c/sup\u003e (op/non-op) × 100%; Wrist range of motion\u003csup\u003eb\u003c/sup\u003e (op/non-op) × 100%; DASH\u003csup\u003ec\u003c/sup\u003e: Disabilities of the Arm, Shoulder, and Hand; PRWE\u003csup\u003ed\u003c/sup\u003e: Patient-Rated Wrist Evaluation sc**\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-3919522/v1/77c0e09fe4980e56d921d517.png"},{"id":56273288,"identity":"c23f7e11-3b47-4559-89c3-b75dc278eb3a","added_by":"auto","created_at":"2024-05-10 18:51:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4678988,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3919522/v1/0e469954-6dae-4368-8047-8e61a26764ae.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of Dorsal Capsular Imbrication on Intraoperative DRUJ Instability following Arthroscopic TFCC Repair Surgery","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDistal radioulnar joint (DRUJ) stability during unrestricted forearm rotation relies on several factors, including the integrity of the triangular fibrocartilage complex (TFCC), the interosseous membrane, the bony configuration of the sigmoid notch, DRUJ capsule, and the extensor carpi ulnaris tendon with its subsheath [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. TFCC injury often results from a fall on the outstretched, pronated, and hyperextended wrist, leading to dorsal instability of the DRUJ [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Within the anatomical structure of the TFCC, the fovea ulnaris serves as the convergent point of proximal component TFCC (pc-TFCC) insertion, thereby becoming the most indispensable stabilizer for the ulnocarpal joint and DRUJ [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Based on the ulnar-side TFCC tear in Palmar type Ib, Atzei et al.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] classified the treatment-oriented TFCC peripheral tear into five subgroups depending on whether the distal component (dc-TFCC) or the pc-TFCC was involved. Specifically, Atzei class II and III indicate DRUJ instability with complete and pc-TFCC rupture, respectively [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Consequently, the current approach for foveal-involved TFCC tear aims at achieving anatomical TFCC foveal reattachment, which can be accomplished through transosseous sutures [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] or suture anchor fixation [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] and has shown satisfactory outcomes.\u003c/p\u003e \u003cp\u003eA prior study revealed that even when radiographic findings are negative in patients experiencing post-traumatic wrist pain, 42% of them receive a diagnosis of TFCC injuries [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. and neglecting severe TFCC tears often leads to chronic DRUJ instability. According to tissue-engineering theory, the interface of bone-to-ligament may not regenerate after injury, resulting in a high rupture recurrence rate [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and direct bone-to-ligament repair in the chronic stage might exhibit decreased healing potential with the disadvantageous repair margin [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Compared with transosseous sutures, transcapsular repair, involving ligament-to-capsular healing, is an alternative method for addressing TFCC fovea tear [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Research has supported the notion that transcapsular repair alone can stabilize the DRUJ while achieving anatomical restoration of the dorsal subluxation of the ulna head [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, the integrity of DRUJ surrounding tissues, such as dorsal and volar radioulnar ligaments (DRUL and VRUL) with a superficial and a deep portion attached to the dorsal capsule, needs to be considered after the completion of TFCC repair [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. For instance, Liu et al.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] reported post-operative DRUJ instability rates of 12.1% with capsular repair and 10.1% with fovea transosseous repair. Consequently, additional procedures to reinforce DRUJ stability may be necessary.\u003c/p\u003e \u003cp\u003eThe dorsal capsular imbrication (DCI) technique has been proposed and reported to yield positive clinical results in chronic DRUJ dislocation cases [\u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21 CR22 CR23 CR24\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. However, the use of DCI as a reinforcement procedure in TFCC repair operations for chronic DRUJ instability has not been extensively studied. Therefore, the purposes of this study were (1) to identify the indication of positive ballottement test for implementing dorsal capsular imbrication after arthroscopic TFCC repair and (2) for evaluation of the functional and clinical outcomes of dorsal capsular imbrication as compared to non-dorsal capsular imbrication TFCC repair.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy Population\u003c/h2\u003e\n \u003cp\u003eThis study adhered to the tenets of the Helsinki Declaration and was approved by the Research Ethics Committee of our hospital. We retrospectively reviewed patients with repairable type IB TFCC injuries who underwent arthroscopic \u0026ldquo;cross-form\u0026rdquo; trancapsular repair with or without dorsal DRUJ capsular imbrication from January 2016 to January 2021. A minimum follow-up period of 36 months was mandatory for inclusion. The exclusion criteria encompassed patients with non-repairable TFCC (Atzei IV) ulnar and DRUJ osteoarthritis changes (Atzei V). All procedures were performed by an individual senior hand surgeon (Dr. YCC).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eClinical and Image Assessment\u003c/h2\u003e\n \u003cp\u003ePre-operatively, patients were diagnosed via a series of physical examinations, including ulna fovea sign for TFCC rupture, push-off test, and ballottement test for DRUJ laxity [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. Wrist X-rays were employed to assess bony structure malalignment, such as ulnar styloid fracture, ulna variance, distal radius fracture or Galeazzi fracture [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. Additionally, magnetic resonance imaging (MRI) of the wrist was performed to evaluate the condition of articular cartilage wear, detect foveal TFCC tear, and identify ulna head subluxation [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eArthroscopic Assessment\u003c/h2\u003e\n \u003cp\u003eRadiocarpal joint arthroscopy was performed using a 3/4 viewing portal (2.7-mm arthroscopy), a 6R working portal (equipped with a synovial shaver and probe), and a 6U portal (utilized as a fluid outflow portal). The 3/4 viewing portal allows the visualization of the dc-TFCC lesion over the ulnar margin of the TFCC. Through the 6R portal, a probe was used to perform a hook test, and a shaver served as a suction test to evaluate the pc-TFCC condition. Notably, in cases whereby diagnosis assessment with pc-TFCC was controversial, a direct foveal (DF) portal was established to further confirm for the diagnosis.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003eArthroscopy-assisted \u0026ldquo;Cross-form\u0026rdquo; TFCC Capsular Repair With/Without Dorsal DRUJ Capsule Imbrication\u003c/h2\u003e\n \u003cp\u003eThe detailed procedure for TFCC repair was described as follows:\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003ePart 1: \u0026ldquo;Cross-form\u0026rdquo; TFCC Transcapsular Repair\u003c/h2\u003e\n \u003cp\u003eUsing the 3/4 portals, a combination of 2\u0026thinsp;\u0026minus;\u0026thinsp;0 ETHIBOND (Johnson \u0026amp; Johnson, Hamburg, Germany) and 2\u0026thinsp;\u0026minus;\u0026thinsp;0 prolene (Ethicon Inc., Somerville, NJ, USA) were combined using the inside-out [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e] and outside-in [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e] TFCC capsular repair techniques, and a 21-gauge spinal needle was employed to perform the two horizontal stitches.\u003c/p\u003e\n \u003cp\u003eBefore suturing, a 2-cm incision was made over the 6U portal. The dorsal cutaneous branch of the ulnar nerve (DCBUN) and flexor carpi ulnaris (FCU) tendon were identified and retracted. The first horizontal mattress suture involved a 2\u0026thinsp;\u0026minus;\u0026thinsp;0 ethibond stitch close to the volar-ulnar margin of the TFCC lesion through the 3/4 portal using an inside-out technique (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eA) and subsequently retracted to avoid DCBUN and FCU involvement (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003eA). The second stitch, a 2\u0026thinsp;\u0026minus;\u0026thinsp;0 prolene lasso loop suture, was performed near the dorsal-radial margin of the intact TFCC part through the 6R portal using an outside-in technique. The lasso loop suture carried one end of the 2\u0026thinsp;\u0026minus;\u0026thinsp;0 ethibond to form the first horizontal mattress suture (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eB). For the second horizontal mattress suture, the puncture site of the third stitch was performed close to the volar-radial margin of the TFCC intact part through the 3/4 portal with an inside-out technique (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eC), and the DCBUN should be protected from being punctured or tied in this step (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003eB). The fourth stitch, a lasso suture, was performed near the dorsal-ulnar margin of the TFCC lesion through the 6R portal using an outside-in technique. The lasso loop suture was then used to carry one end of the third stitch to form the second horizontal mattress suture (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eD). This \u0026ldquo;cross-form\u0026rdquo; TFCC capsular repair created an extensive contact area in the ligament to capsule suture (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eAfter completing two horizontal mattress sutures, the wrist traction tower device was released and firmly tied in the wrist\u0026rsquo;s full-pronation position (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eE). Both sutures were checked to ensure they were tied below the ECU, FCU and DCBUN to avoid neuro-tendon involvement (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003eC), achieved by reducing the ulnar head from dorsal subluxation into a neutral position using thumb compression by an assistant (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eF).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003ePart 2: Intra-operative Ballottement Test\u003c/h2\u003e\n \u003cp\u003eWe employed the intra-operative ballottement test to assess DRUJ stability after completing the \u0026quot;Cross-form\u0026quot; TFCC transcapsular repair, categorizing it into four grades:\u003c/p\u003e\u003cspan\u003e\n \u003cp\u003e(1) Grade 0: Normal stability (Fig. \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003eA). In cases where normal stability is detected, the \u0026quot;Cross-form\u0026quot; TFCC transcapsular repair alone is assumed to provide sufficient DRUJ stability.\u003c/p\u003e\n \u003c/span\u003e \u003cspan\u003e\n \u003cp\u003e(2) Grades 1\u0026ndash;3: If there is laxity greater than grade 0 in the intraoperative ballottement test after tightening the strings following TFCC repair (Fig. \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003eB, C, and D), dorsal DRUJ capsular imbrication is performed to stabilize the DRUJ [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\n \u003c/span\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003ePart 3. Dorsal DRUJ Capsular Imbrication\u003c/h2\u003e\n \u003cp\u003eA 4-cm curved incision was made along the extensor digiti minimi (EDM) tendon extending proximally to the proximal margin of the DRUJ. Meticulous dissection of subcutaneous tissue was performed, with attention to the dorsal branch of the ulnar nerve. Following the longitudinal incision of the extensor retinaculum, the fourth and fifth extensor compartments were retracted. Subsequently, the dorsal DRUJ capsule was opened and incised longitudinally.\u003c/p\u003e\n \u003cp\u003eIn cases of chronic DRUJ instability, the dorsal capsule often exhibited looseness and weakness due to repetitive dorsal stretching by the ulnar head (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003eA). A rectangular capsule flap, approximately 2 \u0026times; 2.5 cm\u003csup\u003e2\u003c/sup\u003e and ulnar based, was carefully dissected from the dorsal cortex of radius bone, extending from the radial to ulnar direction, and exposing the radius sigmoid notch and ulnar head (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003eB). To enhance the healing potential of DRUJ capsule-to-bone connection, the dorsal cortex of distal radius was decorticated using a rongeur. Two 1.4 all-suture bone anchors (JuggerKnot; Zimmer Biomet, Warsaw, IN) were individually placed radially over the upper and lower borders of the distal radius sigmoid notch (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003eB).\u003c/p\u003e\n \u003cp\u003eSubsequently, with the elbow flexed at 90\u0026ordm; and the forearm in a straightened position with full pronation, the assistant digitally pressed the dorsally displaced ulnar head, lowering it back into the sigmoid notch. The operator then imbricated the detached radius- and ulnar-based capsule flap by tightening sutures from the bone anchors (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003eC). This maneuver stabilized the ulna head in a secured position (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003eD).\u003c/p\u003e\n \u003cp\u003eThe patient was protected with a long-arm cast, with the forearm in a neutral position, for the first 4 weeks postoperatively. After cast removal, passive three-dimensional (3D) wrist motions were initiated with wrist brace protection from 5 to 8 weeks postoperatively. Low-intensity muscle strengthening exercises were introduced from weeks 9\u0026ndash;12 postoperatively.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eClinical Evaluation\u003c/h2\u003e\n \u003cp\u003eThe patient\u0026rsquo;s profile, time interval from injury to surgery, and intra-operative and post-operative complications were documented based on the medical charts. The push-off test and ballottement test were employed to evaluate the ulnar-side pain relief and DRUJ stability, respectively. At postoperative intervals of 3, 6, 9, 12, 24, and 36 months, active motion arcs were measured using a goniometer and grip strength was measured with the Jamar Hydraulic Hand Dynamometer (Jamar Technologies/America, Hatfield, PA).\u003c/p\u003e\n \u003cp\u003eAdditionally, patient-reported outcomes, including MMWS, Patient-Rated Wrist Evaluation (PRWE), and Disabilities of the Arm, Shoulder, and Hand (DASH) were used for clinical results. The proportion of patients meeting the minimal clinically important difference (MCID) of the DASH (MCID: 10\u0026ndash;13.5) and PRWE scores (MCID: 14\u0026ndash;17) allowed for the quantitative recording of the direct feelings of the patients [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eSample Size Calculation\u003c/h2\u003e\n \u003cp\u003eIn our prior comparative research [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e], the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation of wrist range of motion (ROM), with respect to pronation and supination, was found to be 161\u0026thinsp;\u0026plusmn;\u0026thinsp;13.6\u0026ordm;, and 156\u0026thinsp;\u0026plusmn;\u0026thinsp;12.6\u0026ordm; in the \u0026ldquo;dorsal capsular imbrication\u0026rdquo; group and the \u0026ldquo;TFCC repair\u0026thinsp;+\u0026thinsp;dorsal capsular imbrication\u0026rdquo; group, respectively. Based on a statistical power of 80% and a significance level of 5%, we determined that a minimum of 133 cases for group 1 and 90 cases for group 2 were necessary to ascertain whether a true difference in clinical outcomes existed between both groups.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eStatistical Analysis\u003c/h2\u003e\n \u003cp\u003eAll data were analyzed using SPSS software (version 20.0; IBM Corp., Armonk, NY). The Shapiro\u0026ndash;Wilk test showed that the data were not normally distributed; therefore, nonparametric tests were employed for comparison. Categorical variables were presented as frequency (%). The Chi-squared test was used for nonparametric statistical analysis of categorical information, and the Mann\u0026ndash;Whitney U test was employed for nonparametric analysis of continuous variables. To compare outcome measurements between two groups (DASH score, PRWE score, grip strength, and ROM), the Wilcoxon rank sum test was used. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFrom January 2016 to June 2021, a total of 265 patients underwent surgical treatment for post-traumatic chronic DRUJ instability at our hospital. Among them, 40 patients who underwent DRUJ reconstruction were excluded due to 25 patients having Atzei class IV or V TFCC tear, 4 with radioulnar joint arthritis, 7 without adequate follow-up, and 4 with prior wrist surgery. Ultimately, a total of 225 patients were included in our final analysis. Among them, 110 had Atzei class II and 115 had Atzei class III TFCC tears, and all underwent arthroscopy assisted TFCC capsular repair with dorsal DRUJ capsule imbrication (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study comprised 130 (57.8%) men and 95 (42.2%) women, with right-sided DRUJ instability occurring in 142 (63%) and left-sided in 83 (36%) cases. The patients\u0026rsquo; ages ranged from 22 to 58 years (mean, 41 years). The duration of symptoms before surgery ranged from 6 to 24 months (mean, 12.7 months; range, 6\u0026ndash;24 months). The mean follow-up time was 45 months (range: 36\u0026ndash;60 months) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the demographic and clinical characteristics of the patients, who were divided into two groups: Group 1, \u0026ldquo;Cross form\u0026rdquo; TFCC repair (CR), and Group 2, \u0026ldquo;Cross form\u0026rdquo; TFCC repair\u0026thinsp;+\u0026thinsp;DRUJ dorsal capsular imbrication (DCI), with no significant difference in each variable category.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatients Demographic and Clinical Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCR\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDCI\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHand (R/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76/59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66/24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.5 (25\u0026ndash;58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.3 (22\u0026ndash;55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptoms to surgery (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.2 (6\u0026ndash;24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.5 (6\u0026ndash;24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.9 (24\u0026ndash;42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.7 (24\u0026ndash;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtzei classification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eP value* significance difference under Chi-squared test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eCR\u003csup\u003ea\u003c/sup\u003e: Cross-form repair\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eDCI\u003csup\u003eb\u003c/sup\u003e: Cross-form repair\u0026thinsp;+\u0026thinsp;Dorsal capsular imbrication\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCross-form repair group: 135 cases (Pre-operative vs. Post-operative 3 years)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-operative\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-operative\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrip strength\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e50% \u0026plusmn; 21%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e90.1% \u0026plusmn; 5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWrist ROM\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlex-extension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e52.3% \u0026plusmn; 17%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e95.4% \u0026plusmn; 5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupi-pronation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e47.3% \u0026plusmn; 22%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e92.4% \u0026plusmn; 2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadial-ulnar deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e57% \u0026plusmn; 18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e90.5% \u0026plusmn; 5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDASH\u003csup\u003ec\u003c/sup\u003e score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e51.6\u0026thinsp;\u0026plusmn;\u0026thinsp;14.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e9.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePRWE\u003csup\u003ed\u003c/sup\u003e: score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e40.7\u0026thinsp;\u0026plusmn;\u0026thinsp;10.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e10.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMMWS\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e50% \u0026plusmn; 21%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e95.1% \u0026plusmn; 5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eGrip strength\u003csup\u003ea\u003c/sup\u003e (op/non-op) \u0026times; 100%;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eWrist range of motion\u003csup\u003eb\u003c/sup\u003e (op/non-op) \u0026times; 100%\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eDASH\u003csup\u003ec\u003c/sup\u003e: Disabilities of the Arm, Shoulder, and Hand\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ePRWE\u003csup\u003ed\u003c/sup\u003e: Patient-Rated Wrist Evaluation\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eMMWS\u003csup\u003ee\u003c/sup\u003e: Modified Mayo Wrist score\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eP value* significance difference under Mann-Whitney test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe preoperative and 36-month postoperative scores for DASH, PRWE, grip strength, MMWS, and wrist ROM (flexion-extension\u0026thinsp;+\u0026thinsp;pronation-supination\u0026thinsp;+\u0026thinsp;radial-ulnar arcs) are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e (Group 1) and Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e (Group 2), and all significant differences were identified with p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Additionally, patient-reported outcomes scores showed that 95% (214 in 225) of patients achieved the MCID for DASH scores, and 92% (207 in 225) achieved the MCID for PRWE scores.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCross-form repair\u0026thinsp;+\u0026thinsp;Dorsal capsular imbrication group: 90 cases (Pre-operative vs. Post-operative 3 years)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-operative\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003ePost-operative\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrip strength\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47% \u0026plusmn; 17%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e95.1% \u0026plusmn; 5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWrist ROM\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlex-extension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.3% \u0026plusmn; 20%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92.4% \u0026plusmn; 3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupi-pronation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49.2% \u0026plusmn; 19%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.1% \u0026plusmn; 3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadial-ulnar deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56% \u0026plusmn; 18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.2% \u0026plusmn; 4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDASH\u003csup\u003ec\u003c/sup\u003e score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50.1\u0026thinsp;\u0026plusmn;\u0026thinsp;17.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePRWE\u003csup\u003ed\u003c/sup\u003e: score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.7\u0026thinsp;\u0026plusmn;\u0026thinsp;11.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMMWS\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44% \u0026plusmn; 25%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93.7% \u0026plusmn; 5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eGrip strength\u003csup\u003ea\u003c/sup\u003e (op/non-op) \u0026times; 100%;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eWrist range of motion\u003csup\u003eb\u003c/sup\u003e (op/non-op) \u0026times; 100%\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eDASH\u003csup\u003ec\u003c/sup\u003e: Disabilities of the Arm, Shoulder, and Hand\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003ePRWE\u003csup\u003ed\u003c/sup\u003e: Patient-Rated Wrist Evaluation\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eMMWS\u003csup\u003ee\u003c/sup\u003e: Modified Mayo Wrist score\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eP value* significance difference under Mann-Whitney test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eComparison of post-operative results between Group 1 and Group 2 are shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e. Our findings revealed that in the short-term (post-operative 3 months to 1 year), even though the DCI group exhibited better grip strengths than the CR group, they had wrist stiffness (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). Interestingly, in the mid-term (post-operative 1 year to 3 years), the DCI group continued to demonstrate superior grip strengths compared with the CR group (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). However, no significant difference was observed in all directions of wrist ROM between the two groups at the post-operative 3-year follow-up (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCross-form repair group vs. Cross-form repair\u0026thinsp;+\u0026thinsp;Dorsal capsular imbrication group (Post-operative 3 years)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCR\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDCI\u003csup\u003eg\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrip strength\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90.1% \u0026plusmn; 5%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.1% \u0026plusmn; 5%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWrist ROM\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlex-extension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95.4% \u0026plusmn; 5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92.4% \u0026plusmn; 3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupi-pronation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92.4% \u0026plusmn; 2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.1% \u0026plusmn; 3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadial-ulnar deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90.5% \u0026plusmn; 5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.2% \u0026plusmn; 4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDASH\u003csup\u003ec\u003c/sup\u003e score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePRWE\u003csup\u003ed\u003c/sup\u003e: score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMMWS\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95.1% \u0026plusmn; 5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93.7% \u0026plusmn; 5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReoperation (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRecurrent instability (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3.7%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1.1%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.05\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eGrip strength\u003csup\u003ea\u003c/sup\u003e (op/non-op) \u0026times; 100%;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eWrist range of motion\u003csup\u003eb\u003c/sup\u003e (op/non-op) \u0026times; 100%\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eDASH\u003csup\u003ec\u003c/sup\u003e: Disabilities of the Arm, Shoulder, and Hand\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ePRWE\u003csup\u003ed\u003c/sup\u003e: Patient-Rated Wrist Evaluation\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eMMWS\u003csup\u003ee\u003c/sup\u003e: Modified Mayo Wrist score\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eCR\u003csup\u003ef\u003c/sup\u003e: Cross-form repair\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eDCI\u003csup\u003eg\u003c/sup\u003e: Cross-form repair\u0026thinsp;+\u0026thinsp;Dorsal capsular imbrication\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eP value* significance difference under Mann-Whitney test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePost-operative complications included: (1) Recurrent DRUJ instability, which occurred in 3.7% (5/135) and 1.1% (1/90) in Group 1 and Group 2, respectively, with a significant difference between the two groups; and (2) Repeated surgery, the re-operative ratio was noted as 2.2% (3/135) and 1.1% (1/90) in Group 1 and Group 2, respectively, with no significance difference observed.\u003c/p\u003e \u003cp\u003eNotably, a total of 95% (214/225) of patients achieved pain relief in the push-off test, 97.3% (219/225) regained DRUJ stability in the ballottement test, and only 1.8% (4/225) required re-operation due to DRUJ osteoarthritis changes after 3 years postoperatively. Moreover, patient-reported outcomes indicated that 91% and 92% of patients achieved the MCID in the DASH and PRWE scores, respectively [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study showed that incorporating augmented DCI in TFCC repair for patients with an intraoperative positive intraoperative ballottement led to satisfactory postoperative clinical and functional results and could be considered as an indication for DCI augmentation. Such an augmentation led to significantly lower reoperation rates with patients having significantly higher grip strength. However, patients undergoing DCI might experience a brief period of decreased wrist ROM. According to the Atzei classification, TFCC fovea tear (class II, III) required foveal TFCC repair [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The neglected TFCC fovea tear might contribute to chronic DRUJ instability [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] resulting in decreased grip strength or limited wrist ROM [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Despite the favorable outcomes reported for \u0026ldquo;transosseous repair [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u0026rdquo; \u0026ldquo;fovea repair with suture anchors [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u0026rdquo;, re-operation rates have been documented in the range of 6.7\u0026ndash;30% [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR35 CR36\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Discrepancies in clinical results and reduced efficacy of fovea repair may be attributed to (1) the poor quality or irreparable remnants of TFCC fovea tears that cannot stabilize DRUJ, (2) insufficient coverage area for sutures or knots, increasing the risk of TFCC cut-through during knot tying, and (3) inadequate foveal debridement or improper positioning of bony tunnels, leading to limited bone-to-ligament regeneration capacity.\u003c/p\u003e \u003cp\u003eRecent studies comparing DRUJ stability after capsular repair and transosseous repair have produced varying results: Ruch et al. [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] demonstrated no significant difference, while Johnson et al.[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] indicated greater stability with transosseous repair. However, the critical factor for successful TFCC repair lies in the healing potential of the contact surface, which is notably poor in ligament-to-bone repair (fovea repair): 1. Ulna fovea has a \u0026ldquo;band shaped\u0026rdquo;-like footprint [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], whereas \u0026ldquo;suture anchor repair\u0026rdquo; and \u0026ldquo;transosseous tunnel repair\u0026rdquo; only provide a point contact area between the TFCC remnant and the ulna fovea; 2. \u0026ldquo; Enthesis\u0026rdquo; refers to the insertion site of a tendon, ligament or joint capsule into bone [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Fovea repair, \u0026ldquo;transooseous repair\u0026rdquo; or \u0026ldquo;suture anchor repair,\u0026rdquo; requires the reattachment of TFCC remnant parts into the ulna fovea. Few vessels penetrate the enthesis due to a calcified barrier [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. In contrast, capsular repair may be more effective in enhancing the healing potential of the TFCC through ligament-to-capsule repair compared to [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] ligament-to-bone repair. However, a comprehensive review involving 825 cases across 30 studies revealed post-operative distal radioulnar joint (DRUJ) instability rates of 12.1% for capsular repair and 10.1% for fovea transosseous repair. Regarding re-operation rates, they were 7.9% for capsular repair and 5.5% for fovea transosseous repair [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These results indicate that intraoperative instability of the DRUJ can be a concern in both primary methods of TFCC repair. Therefore, employing an intraoperative DRUJ stability test could be essential for identifying potential postoperative instability and the failure of TFCC repair. Augmentation with DCI can help prevent postoperative DRUJ instability and the need for subsequent reoperation.\u003c/p\u003e \u003cp\u003eThe intra-operative ballottement test is a simple method for evaluating DRUJ stability after arthroscopic TFCC repair. A positive result suggests that the strength of the repaired TFCC alone may be insufficient to maintain DRUJ stability. DCI can be employed as a supplementary method to enhance DRUJ stability. Using DCI as a sole treatment for patients with DRUJ instability has been successful in restoring DRUJ stability in 97.8% of cases, with 93.6% of patients experiencing pain relief through this approach [\u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21 CR22 CR23 CR24\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In a long-term study spanning 10 years, it was observed that DCI effectively restored wrist function to levels comparable to the contralateral hand. DCI can also function as a secondary stabilizer, following a similar bridging concept to that of the internal brace used in anterior talofibular ligament [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] or knee medial collateral ligament repair [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. When combined with the suture tap and bone anchors, it can reinforce ligament strength and prevent injury recurrence during the rehabilitation process [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Similarly, DCI can restore intact DRUJ kinematics and radioulnar ligament reconstructions in chronic DRUJ instability [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. In the present study, recurrent DRUJ instability was found to be significantly lower in patients with the augmentation of DCI, compared to 3.7% and 1.1% in CR group 1 and \u0026ldquo;DCI group 2, with a significant difference. Thus, we believe that DCI could be an effective method for addressing intraoperative DRUJ instability following TFCC capsular repair.\u003c/p\u003e \u003cp\u003eIn this treatment protocol, we aim to outline the procedures necessary to restore the integrity of TFCC and DRUJ capsules: (1) \u0026ldquo;TFCC capsular repair\u0026rdquo; combines the benefits of the inside-out and outside-in techniques, reducing the cut-through rate, purchasing the wide contact area between the ulna fovea and adhering TFCC remnant part with the surrounding tissue to reinforce the DRUJ stability. The crux of transcapsular repair is the ligament-to-soft tissue healing process. Therefore, non-absorbable suture 2\u0026thinsp;\u0026minus;\u0026thinsp;0 ethibond was selected to provide reliable tension support. (2) Intraoperative ballottement test could be used to check for integrity of the DRUJ stability, grade 0 indicates that \u0026ldquo;TFCC transcapsular repair\u0026rdquo; was sufficient to maintain DRUJ stability, while grade I, II or III suggests that DRUJ laxity or subluxation existed after transcapsular repair, and the subsequent augmentation for DRUJ stability was needed. (3) Dorsal DRUJ capsular imbrication worked by tightening the redundant laxity of dorsal DRUJ capsule, thereby reducing the subluxation of ulna head and reattaching the DRUL to the tightened DRUJ capsule under wrist full-pronation position. Tension of the imbricated capsule can be optimized to stabilize DRUJ with the utilization of two suture anchors over the dorsal cortex of the radius sigmoid notch. Our results indicated a slightly higher rate of postoperative distal radioulnar joint (DRUJ) instability in Group 1, which underwent only TFCC capsular repair, compared to Group 2, which received both TFCC capsular repair and dorsal DRUJ capsular imbrication. This implies that late DRUJ instability may manifest in patients who initially tested negative in the intraoperative ballottement test but only underwent TFCC repair. It also implies that DCI is a reliable procedure to build up the DRUJ stability.\u003c/p\u003e \u003cp\u003eA major concern about our methods was that wrist stiffness was found approximately postoperative 6 months in the DCI group. However, wrist ROM were comparable to the CR group after midterm follow-ups. Furthermore, grip strength of DCI was not affected even with decreased wrist ROM. Another issue to consider was that tying knots during the transcapsular repair may lead to transient dorsal ulnar sensory nerve irritation due to intra-operative retraction; however, symptoms were noted to subside within 2 weeks postoperatively. This study has its own limitations. Firstly, it focused solely on surgical outcomes and functional measures, lacking postoperative axial MRI to verify the repositioned DRUJ. Secondly, being a retrospective comparative study with midterm follow-up, a longer-term investigation is needed to validate the observed clinical outcomes. Third, the intraoperative ballottement test employed in this study remains subjective. Future studies should consider standardizing pull strength and translation distance measurements to enhance the accuracy of identifying subtle cases of DRUJ instability following TFCC repair. Finally, we did not include a control group comprising patients with persistent instability after TFCC repair who did not receive additional augmentation treatment to enhance DRUJ stability. However, establishing such a control group presented ethical and clinical challenges, as leaving untreated cases of persistent DRUJ instability were not considered feasible.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur findings revealed that in chronic cases of DRUJ instability with ulna fovea tear, \u0026ldquo;Cross form\u0026rdquo; TFCC repair may be employed to restore DRUJ stability. Specifically, if the intra-operative ballottement test indicates residual DRUJ instability following TFCC capsular repair, \u0026ldquo;Dorsal capsular imbrication\u0026rdquo; can be applied to augment DRUJ stability. This procedural protocol serves as a viable treatment option for patients experiencing chronic DRUJ instability.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChen-Wei Yeh and Cheng-En Hsu designed the concept. Wei-Chih Wang, Tsung-Yu Ho and Bor-han Wei were the attending doctor and treated the patient. Chen-Wei Yeh and Cheng-En Hsu contributed to literature review and manuscript drafting. Yung- Cheng Chiu revised the manuscript. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient provided consent for the use of his medical documentation and information for the present article.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication \u0026amp; Availability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors agreed for the publication and data usage.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict-of-interest statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared that they have no conflict of interest. The authors did not receive any financial support or fundings for this manuscript.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements \u0026amp; Disclosure of interest:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; The authors declared that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eJawed A, Ansari MT, Gupta V. TFCC injuries: How we treat.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eJ Clin Orthop Trauma\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2020;11:570-579.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAndersson J, Axelsson P. [Wrist ligament injuries--diagnostics]. \u003cem\u003eLakartidningen\u003c/em\u003e 2011;108:2096-2101.\u003c/li\u003e\n \u003cli\u003eMoritomo H, Murase T, Arimitsu S, Oka K, Yoshikawa H, Sugamoto K. Change in the length of the ulnocarpal ligaments during radiocarpal motion: possible impact on triangular fibrocartilage complex foveal tears.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eJ Hand Surg Am\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2008;33:1278-1286.\u003c/li\u003e\n \u003cli\u003eAtzei A, Luchetti R. Foveal TFCC tear classification and treatment.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eHand Clin\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2011;27:263-272.\u003c/li\u003e\n \u003cli\u003eAtzei A. New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eJ Hand Surg Eur Vol\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2009;34:582-591.\u003c/li\u003e\n \u003cli\u003eIwasaki N, Nishida K, Motomiya M, Funakoshi T, Minami A. Arthroscopic-assisted repair of avulsed triangular fibrocartilage complex to the fovea of the ulnar head: a 2- to 4-year follow-up study.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eArthroscopy\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2011;27:1371-1378.\u003c/li\u003e\n \u003cli\u003eNakamura T, Sato K, Okazaki M, Toyama Y, Ikegami H. Repair of foveal detachment of the triangular fibrocartilage complex: open and arthroscopic transosseous techniques.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eHand Clin\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2011;27:281-290.\u003c/li\u003e\n \u003cli\u003eShinohara T, Tatebe M, Okui N, Yamamoto M, Kurimoto S, Hirata H. Arthroscopically assisted repair of triangular fibrocartilage complex foveal tears.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eJ Hand Surg Am\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2013;38:271-277.\u003c/li\u003e\n \u003cli\u003eGeissler WB. Arthroscopic knotless peripheral triangular fibrocartilage repair.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eJ Hand Surg Am\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2012;37:350-355.\u003c/li\u003e\n \u003cli\u003ePark Y. All-arthroscopic knotless suture anchor repair of triangular fibrocartilage complex fovea tear by the 2-portal technique.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eArthrosc Tech\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2014;3:e673-7.\u003c/li\u003e\n \u003cli\u003eFont Tellado S, Balmayor ER, Van Griensven M. Strategies to engineer tendon/ligament-to-bone interface: Biomaterials, cells and growth factors.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eAdv Drug Deliv Rev\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2015;94:126-140.\u003c/li\u003e\n \u003cli\u003eLee DH, Ng J, Chung JW, Sonn CH, Lee KM, Han SB. Impact of chronicity of injury on the proportion of mesenchymal stromal cells derived from anterior cruciate ligaments.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eCytotherapy\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2014;16:586-598.\u003c/li\u003e\n \u003cli\u003eEstrella EP, Hung LK, Ho PC, Tse WL. Arthroscopic repair of triangular fibrocartilage complex tears.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eArthroscopy\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2007;23:729-37, 737.e1.\u003c/li\u003e\n \u003cli\u003eLo IN, Chen KJ, Huang TF, Huang YC. The rein-type arthroscopic capsular suture for triangular fibrocartilage complex foveal tears: midterm results for 90 patients.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eJ Hand Surg Eur Vol\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2021;46:1049-1056.\u003c/li\u003e\n \u003cli\u003eScheker LR, Belliappa PP, Acosta R, German DS. Reconstruction of the dorsal ligament of the triangular fibrocartilage complex.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eJ Hand Surg Br\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e1994;19:310-318.\u003c/li\u003e\n \u003cli\u003eLiu EH, Suen K, Tham SK, Ek ET. Surgical Repair of Triangular Fibrocartilage Complex Tears: A Systematic Review.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eJ Wrist Surg\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2021;10:70-83.\u003c/li\u003e\n \u003cli\u003eWong KH, Yip TH, Wu WC. Distal radioulnar joint dorsal instability treated with dorsal capsular reconstruction.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eHand Surg\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2004;9:55-61.\u003c/li\u003e\n \u003cli\u003eManz S, Wolf MB, Lecl\u0026egrave;re FM, Hahn P, Bruckner T, Unglaub F. Capsular imbrication for posttraumatic instability of the distal radioulnar joint.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eJ Hand Surg Am\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2011;36:1170-1175.\u003c/li\u003e\n \u003cli\u003eUnglaub F, Manz S, Bruckner T, Lecl\u0026egrave;re FM, Hahn P, Wolf MB. [Dorsal capsular imbrication for dorsal instability of the distal radioulnar joint].\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eOper Orthop Traumatol\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2013;25:609-614.\u003c/li\u003e\n \u003cli\u003eKouwenhoven ST, de Jong T, Koch AR. Dorsal capsuloplasty for dorsal instability of the distal ulna.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eJ Wrist Surg\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2013;2:168-175.\u003c/li\u003e\n \u003cli\u003eAhrens C, Unglaub F, Bruckner T, et al. Midterm functional outcome after dorsal capsular imbrication for posttraumatic instability of the distal radioulnar joint.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eArch Orthop Trauma Surg\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2014;134:1633-1639.\u003c/li\u003e\n \u003cli\u003eEl-Haj M, Baughman C, Thirkannad SM. A Technique for Treating Dorsal Instability of the Distal Radioulnar Joint.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eTech Hand Up Extrem Surg\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2017;21:67-70.\u003c/li\u003e\n \u003cli\u003eNeto BC, Neto JHS. Chronic Posttraumatic Instability of the Distal Radioulnar Joint: Foveal Reattachment of the Triangular Fibrocartilage Complex With Dorsal Capsuloplasty and Extensor Retinaculum Imbrications.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eHand (N Y)\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2022;17:313-318.\u003c/li\u003e\n \u003cli\u003eUnglaub JM, Heyse T, Bruckner T, Langer MF, Spies CK. Long-term functional outcome after dorsal capsular imbrication for post-traumatic dorsal instability of the distal radioulnar joint.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eInt Orthop\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2020;44:2683-2690.\u003c/li\u003e\n \u003cli\u003eYeh CW, Hsu CE, Ho TY, Wei BH, Wang WC, Chiu YC. Midterm Results of Arthroscopy-Assisted \u0026quot;Tent Form\u0026quot; Triangular Fibrocartilage Complex Repair With Dorsal Distal Radioulnar Joint Capsule Imbrication for Posttraumatic Chronic Distal Radioulnar Joint Instability.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eArthroscopy\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2022;38:1846-1856.\u003c/li\u003e\n \u003cli\u003ePechlaner S, Kathrein A, Gabl M, et al. [Distal radius fractures and concomitant lesions. Experimental studies concerning the pathomechanism].\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eHandchir Mikrochir Plast Chir\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2002;34:150-157.\u003c/li\u003e\n \u003cli\u003eLo IK, MacDermid JC, Bennett JD, Bogoch E, King GJ. The radioulnar ratio: a new method of quantifying distal radioulnar joint subluxation.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eJ Hand Surg Am\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2001;26:236-243.\u003c/li\u003e\n \u003cli\u003ede Araujo W, Poehling GG, Kuzma GR. New Tuohy needle technique for triangular fibrocartilage complex repair: preliminary studies.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eArthroscopy\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e1996;12:699-703.\u003c/li\u003e\n \u003cli\u003eHaugstvedt JR, Husby T. Results of repair of peripheral tears in the triangular fibrocartilage complex using an arthroscopic suture technique.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eScand J Plast Reconstr Surg Hand Surg\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e1999;33:439-447.\u003c/li\u003e\n \u003cli\u003eSeo KN, Park MJ, Kang HJ. Anatomic reconstruction of the distal radioulnar ligament for posttraumatic distal radioulnar joint instability.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eClin Orthop Surg\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2009;1:138-145.\u003c/li\u003e\n \u003cli\u003eHarris JD, Brand JC, Cote MP, Faucett SC, Dhawan A. Research Pearls: The Significance of Statistics and Perils of Pooling. Part 1: Clinical Versus Statistical Significance.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eArthroscopy\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2017;33:1102-1112.\u003c/li\u003e\n \u003cli\u003eAtzei A, Rizzo A, Luchetti R, Fairplay T. Arthroscopic foveal repair of triangular fibrocartilage complex peripheral lesion with distal radioulnar joint instability.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eTech Hand Up Extrem Surg\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2008;12:226-235.\u003c/li\u003e\n \u003cli\u003eAdams BD, Lawler E. Chronic instability of the distal radioulnar joint.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eJ Am Acad Orthop Surg\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2007;15:571-575.\u003c/li\u003e\n \u003cli\u003eChou KH, Sarris IK, Sotereanos DG. Suture anchor repair of ulnar-sided triangular fibrocartilage complex tears.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eJ Hand Surg Br\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2003;28:546-550.\u003c/li\u003e\n \u003cli\u003eKim B, Yoon HK, Nho JH, et al. Arthroscopically assisted reconstruction of triangular fibrocartilage complex foveal avulsion in the ulnar variance-positive patient.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eArthroscopy\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2013;29:1762-1768.\u003c/li\u003e\n \u003cli\u003eLuchetti R, Atzei A. Arthroscopic assisted tendon reconstruction for triangular fibrocartilage complex irreparable tears.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eJ Hand Surg Eur Vol\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2017;42:346-351.\u003c/li\u003e\n \u003cli\u003eDunn J, Polmear M, Daniels C, Shin E, Nesti L. Arthroscopically Assisted Transosseous Triangular Fibrocartilage Complex Foveal Tear Repair in the United States Military\u003cem\u003e. J Hand Surg Glob\u003c/em\u003e Online 2019;1:79-84\u003c/li\u003e\n \u003cli\u003eRuch DS, Anderson SR, Ritter MR. Biomechanical comparison of transosseous and capsular repair of peripheral triangular fibrocartilage tears.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eArthroscopy\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2003;19:391-396.\u003c/li\u003e\n \u003cli\u003eMiyachi Y, Danno K, Imamura S. Pemphigoid following chronic cement dermatitis.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eContact Dermatitis\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e1985;13:188.\u003c/li\u003e\n \u003cli\u003eShin WJ, Kim JP, Yang HM, Lee EY, Go JH, Heo K. Topographical Anatomy of the Distal Ulna Attachment of the Radioulnar Ligament.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eJ Hand Surg Am\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2017;42:517-524.\u003c/li\u003e\n \u003cli\u003eBunker DL, Ilie V, Ilie V, Nicklin S. Tendon to bone healing and its implications for surgery.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eMuscles Ligaments Tendons J\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2014;4:343-350.\u003c/li\u003e\n \u003cli\u003eDoschak MR, Zernicke RF. Structure, function and adaptation of bone-tendon and bone-ligament complexes.\u003cem\u003e\u0026nbsp;J Musculoskelet Neuronal Interact\u0026nbsp;\u003c/em\u003e2005;5:35-40.\u003c/li\u003e\n \u003cli\u003eChow RM, Engasser WM, Krych AJ, Levy BA. Arthroscopic capsular repair in the treatment of femoroacetabular impingement.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eArthrosc Tech\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2014;3:e27-30.\u003c/li\u003e\n \u003cli\u003eYoo JS, Yang EA. Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eJ Orthop Traumatol\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2016;17:353-360.\u003c/li\u003e\n \u003cli\u003eLubowitz JH, MacKay G, Gilmer B. Knee medial collateral ligament and posteromedial corner anatomic repair with internal bracing.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eArthrosc Tech\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2014;3:e505-8.\u003c/li\u003e\n \u003cli\u003eGofton WT, Gordon KD, Dunning CE, Johnson JA, King GJ. Comparison of distal radioulnar joint reconstructions using an active joint motion simulator.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eJ Hand Surg Am\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2005;30:733-742.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"distal radioulnar joint, stability, triangular fibrocartilage complex, arthroscopic repair","lastPublishedDoi":"10.21203/rs.3.rs-3919522/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3919522/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDistal radioulnar joint (DRUJ) stability during unrestricted forearm rotation relies on several factors, including the integrity of the triangular fibrocartilage complex (TFCC), the interosseous membrane, the bony configuration of the sigmoid notch, DRUJ capsule, and the extensor carpi ulnaris tendon with its subsheath. There are currently numerous reported surgical approaches for TFCC repair, however, postoperative DRUJ instability rates are still reported to be around 8 to 12%. As the integrity and strength of the TFCC is crucial for DRUJ stability, it is thus critical to identify if intraoperative dorsal capsular imbrication can further enhance DRUJ stability for improved functional outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA retrospective study was performed on patients who underwent arthroscopic TFCC repair between 2016 and 2021. Inclusion criteria comprised a symptomatic ulna fovea sign for over 6 months and dorsal DRUJ subluxation on magnetic resonance imaging. A total of 225 patients were assessed to be suitable and recruited for our study. 135 patients underwent our arthroscopic “cross-form TFCC repair” without dorsal capsular imbrication (CR) and 90 patients underwent our arthroscopic “cross-form TFCC repair” with dorsal capsular imbrication for augmentation of DRUJ stability (DCI). Pain visual analog scale score (VAS), grip strength, modified Mayo Wrist Score (MMWS), wrist range of motion (ROM), and patient-reported outcomes (PRO) were evaluated, and all patients were follow-up for a minimum of 3 years postoperatively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoth groups showed significant improvements in pain VAS score, grip strength, wrist ROM, MMWS, and PRO between the preoperative and postoperative periods (p \u0026lt; 0.05). Significantly lower recurrent DRUJ instability was noted in the DCI group (3.7% vs 1.1%, p \u0026lt; 0.05). Re-operative rates were also noted to be lower in the DCI group (2.2% vs 1.1%). However, the DCI group was found to have inferior ROM as compared to the CR group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDorsal DRUJ capsular imbrication effectively reduces postoperative DRUJ instability and reoperation rates, enhances grip strength, and maintains wrist ROM in patients with a positive intra-operative ballottement test after arthroscopic TFCC repair.\u003c/p\u003e","manuscriptTitle":"Effect of Dorsal Capsular Imbrication on Intraoperative DRUJ Instability following Arthroscopic TFCC Repair Surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-09 17:16:13","doi":"10.21203/rs.3.rs-3919522/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"da2a7b7f-ad68-4911-84ce-7ed2d6c16846","owner":[],"postedDate":"February 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-06T11:55:23+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-09 17:16:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3919522","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3919522","identity":"rs-3919522","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}