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Krastman P, Kraan G, van Kooij YE, Bierma-Zeinstra SMA, Runhaar J. Diagnostic tests recommended for the clinical assessment of patients with wrist complaints, an e-Delphi study. J Hand Ther 2024:S0894-1130(23)00174-6. [PMID: 38360484 DOI: 10.1016/j.jht.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 10/30/2023] [Accepted: 12/08/2023] [Indexed: 02/17/2024]
Abstract
BACKGROUND Evidence-based practice for history-taking and physical examination in the evaluation of wrist complaints is limited. PURPOSE To create a set of recommended diagnostic tests for the clinical assessment of patients with undifferentiated wrist complaints. STUDY DESIGN An e-Delphi study, following the recommendations on conducting and reporting Delphi studies, was performed. METHODS In this e-Delphi study, a national multidisciplinary panel of experts was invited to inventory diagnostic tests, based on several case scenarios, for the probability diagnosis in patients (age ≥18 years) with undifferentiated wrist complaints. Four case scenarios were constructed and presented to the expert panel members, which differed in age of the patient (35 vs 65 years), location (radial vs ulnar), and duration (6 vs 10 weeks) of the complaints. In consecutive rounds, the experts were asked to rate the importance of the inventoried diagnostic tests. Finally, experts were asked to rank recommended diagnostic tests for each case scenario. RESULTS Merging all results, the following diagnostic tests were recommended for all case scenarios: ask whether a trauma has occurred, ask how the complaints can be provoked, ask about the localization of the complaints, assess active ranges of motion, assess the presence of swelling, assess the difference in swelling between the left and right, assess the deformities or changes in position of the wrist, and palpate at the point of greatest pain. CONCLUSIONS This is the first scientific study where experts clinicians recommended diagnostic tests when assessing patients with undifferentiated wrist complaints, varying in age of the patient (35 vs 65 years), location (radial vs ulnar), and duration (6 vs 10 weeks).
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Affiliation(s)
- Patrick Krastman
- Department of General Practice, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Gerald Kraan
- Department of Orthopedic Surgery, Reinier de Graaf Groep, Delft, the Netherlands.
| | - Yara E van Kooij
- Xpert Handtherapie, Xpert Clinics, Zeist, the Netherlands; Department of Rehabilitation Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Sita M A Bierma-Zeinstra
- Department of General Practice, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Orthopedics, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Jos Runhaar
- Department of General Practice, Erasmus University Medical Center, Rotterdam, the Netherlands.
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Chang EY, Bencardino JT, French CN, Fritz J, Hanrahan CJ, Jibri Z, Kassarjian A, Motamedi K, Ringler MD, Strickland CD, Tiegs-Heiden CA, Walker REA. SSR white paper: guidelines for utilization and performance of direct MR arthrography. Skeletal Radiol 2024; 53:209-244. [PMID: 37566148 PMCID: PMC10730654 DOI: 10.1007/s00256-023-04420-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/23/2023] [Accepted: 07/29/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVE Direct magnetic resonance arthrography (dMRA) is often considered the most accurate imaging modality for the evaluation of intra-articular structures, but utilization and performance vary widely without consensus. The purpose of this white paper is to develop consensus recommendations on behalf of the Society of Skeletal Radiology (SSR) based on published literature and expert opinion. MATERIALS AND METHODS The Standards and Guidelines Committee of the SSR identified guidelines for utilization and performance of dMRA as an important topic for study and invited all SSR members with expertise and interest to volunteer for the white paper panel. This panel was tasked with determining an outline, reviewing the relevant literature, preparing a written document summarizing the issues and controversies, and providing recommendations. RESULTS Twelve SSR members with expertise in dMRA formed the ad hoc white paper authorship committee. The published literature on dMRA was reviewed and summarized, focusing on clinical indications, technical considerations, safety, imaging protocols, complications, controversies, and gaps in knowledge. Recommendations for the utilization and performance of dMRA in the shoulder, elbow, wrist, hip, knee, and ankle/foot regions were developed in group consensus. CONCLUSION Although direct MR arthrography has been previously used for a wide variety of clinical indications, the authorship panel recommends more selective application of this minimally invasive procedure. At present, direct MR arthrography remains an important procedure in the armamentarium of the musculoskeletal radiologist and is especially valuable when conventional MRI is indeterminant or results are discrepant with clinical evaluation.
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Affiliation(s)
- Eric Y Chang
- Radiology Service, VA San Diego Healthcare System, San Diego, CA, USA
- Department of Radiology, University of California, San Diego Medical Center, San Diego, CA, USA
| | - Jenny T Bencardino
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Cristy N French
- Department of Radiology, Penn State Hershey Medical Center, Hummelstown, PA, USA
| | - Jan Fritz
- Department of Radiology, New York University Grossman School of Medicine, New York, NY, USA
| | | | - Zaid Jibri
- GNMI in Mississauga, Greater Toronto Area, Toronto, ON, Canada
| | - Ara Kassarjian
- Department of Radiology, Division of Musculoskeletal Imaging, Olympia Medical Center, Elite Sports Imaging, Madrid, Spain
| | - Kambiz Motamedi
- Department of Radiology, University of California, Los Angeles Medical Center, Los Angeles, CA, USA
| | | | - Colin D Strickland
- Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Richard E A Walker
- McCaig Institute for Bone and Joint Health, Calgary, Canada.
- Cumming School of Medicine, University of Calgary, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada.
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Zhao X, Yu A, Zhao H, Qiu Y. Diagnostic value of MRI in traumatic triangular fibrocartilage complex injuries: a retrospective study. BMC Musculoskelet Disord 2024; 25:63. [PMID: 38218805 PMCID: PMC10787402 DOI: 10.1186/s12891-023-07140-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 12/20/2023] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Triangular fibrocartilage complex (TFCC) injuries commonly manifest as ulnar-sided wrist pain and can be associated with distal radioulnar joint (DRUJ) instability and subsequent wrist functional decline. This study aimed to assess the diagnostic value of MRI compared to wrist arthroscopy in identifying traumatic TFCC injuries and to determine the distribution of different TFCC injury subtypes in a normal clinical setting. METHODS The data of 193 patients who underwent both preoperative wrist MRI and wrist arthroscopy were retrospectively reviewed. The analysis focused on the proportion of subtypes and the diagnostic value of MRI in traumatic TFCC injuries, utilizing Palmer's and Atzei's classification with wrist arthroscopy considered as the gold standard. RESULTS The most prevalent subtype of TFCC injuries were peripheral injuries (Palmer 1B, 67.9%), followed by combined injuries (Palmer 1 A + 1B, 14%; Palmer 1B + 1D, 8.3%). Compared with wrist arthroscopy, the diagnostic sensitivity, specificity, negative predictive value (NPV), and Kappa value of MRI was as follows: traumatic TFCC tears 0.99 (95% CI: 0.97-1), 0.90 (0.78-0.96), 0.97 (0.87-1), and 0.93; styloid lamina tears 0.93 (0.88-0.96), 0.53 (0.30-0.75), 0.47 (0.26-0.69), and 0.44; and foveal lamina tears 0.85 (0.74-0.92), 0.38 (0.29-0.49), 0.79 (0.65-0.89), and 0.21. CONCLUSIONS The diagnostic value of MRI in traumatic TFCC injuries has been confirmed to be almost perfect using Palmer's classification. In more detailed classification of TFCC injuries, such as pc-TFCC tears classified by Atzei's classification, the diagnostic accuracy of MRI remains lower compared to wrist arthroscopy. Radiological associated injuries may offer additional diagnostic value in cases with diagnostic uncertainty.
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Affiliation(s)
- Xuanyu Zhao
- Department of Hand and Upper Extremity Surgery, Jing' an District Central Hospital, Fudan University, Shanghai, 200040, China
- Research unit of synergistic reconstruction of upper and lower limbs after brain injury, Chinese Academy of Medical Sciences, Shanghai, 200040, China
| | - Aiping Yu
- Department of Plastic and Reconstructive Surgery, Shanghai Jiaotong University School of Medicine Affiliated 9th People's Hospital, Shanghai, 200011, China
| | - Huali Zhao
- Department of Radiology, Jing'an District Central Hospital, Fudan University, Shanghai, 200040, China
| | - Yanqun Qiu
- Department of Hand and Upper Extremity Surgery, Jing' an District Central Hospital, Fudan University, Shanghai, 200040, China.
- National Clinical Research Center for Aging and Medicine, Fudan University, Shanghai, 200040, China.
- Research unit of synergistic reconstruction of upper and lower limbs after brain injury, Chinese Academy of Medical Sciences, Shanghai, 200040, China.
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, 200040, China.
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Loewenstein SN, Regent-Smith A, LoGiudice A, Hoben G, Dellon AL. Ulnar Wrist Denervation: Articular Branching Pattern and Selective Blockade of the Dorsal Branch of the Ulnar Nerve. J Hand Surg Am 2023:S0363-5023(23)00072-2. [PMID: 36966047 DOI: 10.1016/j.jhsa.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 01/16/2023] [Accepted: 02/08/2023] [Indexed: 03/27/2023]
Abstract
PURPOSE Ulnar wrist denervation has been a successful treatment for patients with ulnar-sided wrist pain. The purpose of this study was to characterize the articular branches of the dorsal branch of the ulnar nerve (DBUN) and validate a technique for selective peripheral nerve blockade. METHODS In cadavers, we performed simulated local anesthetic injections using 0.5 mL of 0.5% methylene into the subcutaneous tissue at a point midway between the palpable borders of the pisiform and ulnar styloid. We then dissected the DBUN, characterized its articular branching pattern, and measured staining intensity of the DBUN and the ulnar nerve relative to a standard. RESULTS The DBUN branched from the ulnar nerve 7.0 ± 1.2 cm proximal to the ulnar styloid. Among 17 specimens, the DBUN provided an average of 1.2 (range, 0-2) ulnocarpal branches and 1.0 (range, 0-2) carpometacarpal articular branches. A simulated local anesthetic injection successfully stained 100% of the DBUN articular branches at or proximal to their takeoff. There was no staining of the proper ulnar nerves. In all specimens, the DBUN supplied at least one articular branch. CONCLUSIONS A point midway between the palpable border of the pisiform and ulnar styloid may be an effective location for selectively blocking the DBUN articular afferents. CLINICAL RELEVANCE In this study, we were able to identify a point halfway between the pisiform and ulnar styloid that has the potential to produce a selective peripheral nerve block of the portion of the DBUN that supplies articular fibers to the ulnocarpal joint and the fifth carpometacarpal joint. This technique may prove useful to surgeons treating ulnar-sided wrist pain.
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Affiliation(s)
- Scott N Loewenstein
- Department of Plastic Surgery, Medical College of Wisconsin, Wauwatosa, WI; Department of Plastic and Hand Surgery, HealthPartners Regions Hospital, Saint Paul, MN; Division of Plastic & Reconstructive Surgery, University of Minnesota, Minneapolis, MN.
| | | | - Anthony LoGiudice
- Department of Orthopedic Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Gwendolyn Hoben
- Department of Plastic Surgery, Medical College of Wisconsin, Wauwatosa, WI
| | - Arnold Lee Dellon
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD
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Ecker J, Shahbaz L, Kohli S, Breidahl W, Andrijich C. Arthroscopic Bone Graft and Internal Fixation of Non-Union of the Proximal Pole of the Scaphoid: Surgical Technique and Outcomes. J Wrist Surg 2022; 11:535-540. [PMID: 36504530 PMCID: PMC9731734 DOI: 10.1055/s-0041-1742097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/17/2021] [Indexed: 01/22/2023]
Abstract
Background Fractures of the proximal pole of the scaphoid have been associated with delayed union, non-union, and avascular necrosis. This has been attributed to avascularity of the proximal pole of the scaphoid. While proximal pole non-unions can be successfully treated using open techniques, there is little information in the literature regarding arthroscopic bone graft and internal fixation of proximal pole non-unions. Description of Technique After insertion of a 1.2-mm radiolunate K-wire, the scaphoid non-union was arthroscopically excised, bone grafted with iliac crest cancellous bone, and internally fixed with 3 × 1.2 mm K-wires. Patients and Methods This is a retrospective study of patients who had arthroscopic bone graft of non-union of the proximal pole of the scaphoid between 2009 and 2021. Results There were 30 cases in this study; 29 cases united. The one case that did not unite was caused by inadequate fixation of the proximal pole. The size of the proximal pole did not influence the outcome. Conclusion Arthroscopic bone graft and internal fixation is a reliable technique for the treatment of non-union of the proximal pole of the scaphoid.
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Affiliation(s)
- Jeff Ecker
- Jeff Ecker Clinic, Bethesda Hospital, Claremont, Western Australia, Australia
- Hand and Upper Limb Centre, Claremont, Western Australia, Australia
| | - Laiba Shahbaz
- Jeff Ecker Clinic, Bethesda Hospital, Claremont, Western Australia, Australia
| | - Sukhsimran Kohli
- Jeff Ecker Clinic, Bethesda Hospital, Claremont, Western Australia, Australia
| | - William Breidahl
- Perth Radiological Clinic, Subiaco, Western Australia, Australia
| | - Courtney Andrijich
- Jeff Ecker Clinic, Bethesda Hospital, Claremont, Western Australia, Australia
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Spies CK, Unglaub F, Bruckner T, Müller L, Eysel P, Rau J. Diagnostic accuracy of wrist MRI in comparison to wrist arthroscopy regarding TFCC lesions in clinical practice. Arch Orthop Trauma Surg 2022; 142:879-885. [PMID: 35006371 DOI: 10.1007/s00402-021-04329-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/19/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The purpose of this study was to arthroscopically verify MRI diagnostic accuracy for triangular fibrocartilage complex (TFCC) lesions in a regular clinical environment. METHODS A total of 859 patients' data with both preoperative MRI of the wrist and additional wrist arthroscopy were retrospectively reviewed. Two board-certified hand surgeons and one orthopaedic surgeon executed wrist arthroscopy, whereas more than 100 radiologists examined the MRI of the wrist. The accordance of TFCC lesion classification using MRI in comparison to wrist arthroscopy and diagnostic precision of the former depending on technical details were evaluated. RESULTS Diagnostic accuracy of MRI for TFCC lesions is poor in comparison to wrist arthroscopy as the reference standard. Technical specifications for MRI of the wrist are heterogeneous among the radiologists. These parameters have not improved accuracy of TFCC evaluation at large. CONCLUSION The accuracy of MRI in a regular clinical environment still remains inferior to wrist arthroscopy for detection of TFCC lesions. Development of a standard MRI protocol may be implemented on a regular basis and application of the Palmer classification for TFCC lesion should be sought.
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Affiliation(s)
- C K Spies
- Hand Surgery, Spital Langenthal, Spital Region Oberaargau SRO AG, 4900, Langenthal, Switzerland.
| | - F Unglaub
- Hand Surgery, Vulpius Klinik, Vulpiusstraße 29, 74906, Bad Rappenau, Germany
- Medical Faculty Mannheim, Ruprecht-Karls University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - T Bruckner
- Department of Medical Biometry and Informatics, University Heidelberg, Im Neuenheimer Feld 305, 69120, Heidelberg, Germany
| | - L Müller
- Department of Orthopaedic Surgery and Traumatology, University Hospital Cologne, Kerpener Str. 62, 50937, Köln, Germany
| | - P Eysel
- Department of Orthopaedic Surgery and Traumatology, University Hospital Cologne, Joseph-Stelzmann-Str. 24, 50931, Köln, Germany
| | - J Rau
- Hand Surgery, Vulpius Klinik, Vulpiusstraße 29, 74906, Bad Rappenau, Germany
- Medical Faculty Mannheim, Ruprecht-Karls University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Götestrand S, Björkman A, Björkman-Burtscher IM, Ab-Fawaz R, Kristiansson I, Lundin B, Geijer M. Visualization of wrist ligaments with 3D and 2D magnetic resonance imaging at 3 Tesla. Acta Radiol 2022; 63:368-375. [PMID: 33657847 DOI: 10.1177/0284185121994044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Wrist ligaments are challenging to visualize using magnetic resonance imaging (MRI). Injuries involving the scapholunate ligament (SLL), the lunotriquetral ligament (LTL), and the triangular fibrocartilage complex (TFCC) are common and difficult to diagnose, often requiring diagnostic arthroscopy. PURPOSE To compare the visualization of wrist ligaments on a three-dimensional (3D) sequence with two-dimensional (2D) sequences on 3-T MRI. MATERIAL AND METHODS Eighteen healthy volunteers were examined with a 3D SPACE (sampling perfection with application optimized contrasts using different flip angle evolution) sequence and 2D coronal, axial, and sagittal proton density-weighted (PD) sequences. Four musculoskeletal radiologists graded the anatomical visibility of the SLL, LTL, TFCC, and the image quality, using five grades in a visual grading characteristics (VGC) evaluation. After Bonferroni correction, a P value ≤0.005 was considered statistically significant. RESULTS The 3D images were graded significantly better than the 2D images in the visualization of the dorsal and palmar parts of the SLL and the LTL. Regarding the TFCC, the 3D images were graded significantly better for visualization of the foveal attachment. 2D imaging was not found significantly superior to 3D imaging in any aspect. CONCLUSION The 3D SPACE sequence was scored as superior to the 2D sequences at 3 T in the assessment of the SLL, the LTL, and the foveal attachment of the TFCC. Thus, 3D SPACE can replace 2D PD sequences when these ligaments need to be assessed.
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Affiliation(s)
- Simon Götestrand
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
- Department of Radiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Anders Björkman
- Department of Translational Medicine – Hand Surgery, Skåne University Hospital, Malmö, Sweden
- The Wallenberg Center for Molecular Medicine, Lund University, Sweden
| | - Isabella M Björkman-Burtscher
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Rana Ab-Fawaz
- Department of Radiology, Kristianstad Hospital, Kristianstad, Sweden
- European Telemedicine Clinic, Department of Musculoskeletal Radiology, Barcelona, Spain
| | - Ingvar Kristiansson
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
| | - Björn Lundin
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
- Department of Radiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Mats Geijer
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Radiology, Gothenburg, Sweden
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Ecker J, Andrijich C. Dry Arthroscopy Distal Radioulnar Joint and Foveal Insertion: Surgical Technique. J Wrist Surg 2022; 11:2-5. [PMID: 35127257 PMCID: PMC8807104 DOI: 10.1055/s-0041-1732414] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 06/15/2021] [Indexed: 10/20/2022]
Abstract
Background Arthroscopy of the distal radioulnar joint is considered to be difficult to perform. At this time the integrity of the foveal insertion is indirectly evaluated with a hook test. If a hook test is positive it is inferred that the foveal insertion is torn or incompetent. Description of Technique The ideal way to evaluate the foveal insertion is by direct visualization and probing. In order to do this, arthroscopic examination of the distal radioulnar joint and foveal insertion is required. The article describes how to reliably perform "dry" arthroscopy of the distal radioulnar joint and foveal insertion using a 1.9 mm arthroscope to accurately assess the triangular fibrocartilage complex and foveal insertion. Patient and Methods A total of 169 dry DRUJ arthroscopies were performed by the primary author between January 2018 and February 2021. Results Using this technique, the foveal insertion was successfully visualized in 168 cases (99%). Conclusion Dry arthroscopy of the DRUJ is a reliable technique to evaluate the integrity of the foveal insertion.
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Affiliation(s)
- Jeff Ecker
- Jeff Ecker Clinic, Bethesda Hospital, Claremont, Western Australia, Australia
- Hand and Upper Limb Centre, Claremont, Western Australia, Australia
| | - Courtney Andrijich
- Jeff Ecker Clinic, Bethesda Hospital, Claremont, Western Australia, Australia
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Cunningham DJ, Pidgeon TS, Saltzman EB, Mather RC, Ruch DS. The Value Added of Advanced Imaging in the Diagnosis and Treatment of Triangular Fibrocartilage Complex Pathology. J Hand Surg Am 2022; 47:19-30.e8. [PMID: 34481677 DOI: 10.1016/j.jhsa.2021.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 04/12/2021] [Accepted: 06/23/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Pathology of the triangular fibrocartilage complex is a prevalent cause of ulnar-sided wrist pain that presents a diagnostic challenge. We hypothesized that a history and physical examination (H&P) would be more cost-effective alone or with diagnostic injection than with magnetic resonance imaging (MRI) or magnetic resonance arthrogram (MRA) in the diagnosis and treatment of a symptomatic triangular fibrocartilage complex abnormality. METHODS A simple-chain decision analysis model was constructed to assess simulated subjects with ulnar-sided wrist pain and normal radiographs using several diagnostic algorithms: H&P alone, H&P + injection, H&P with delayed advanced imaging (MRI or MRA), and H&P + injection with delayed advanced imaging (MRI or MRA). Three years after diagnosis, effectiveness was calculated in Disabilities of the Arm, Shoulder, and Hand-adjusted life years. Costs were extracted from a commercial insurance database using US dollars. A probabilistic sensitivity analysis with 10,000 second-order trials with sampling of parameter distributions was performed. One-way and 2-way sensitivity analyses were performed. RESULTS All strategies had similar mean effectiveness between 2.228 and 2.232 Disabilities of the Arm, Shoulder, and Hand-adjusted life years, with mean costs ranging from $5,584 (H&P alone) to $5,980 (H&P, injection, and MRA). History and physical examination alone or with injection were the most cost-effective strategies. History and physical examination alone was the most preferred diagnostic strategy, though H&P + injection and H&P with delayed MRA were preferred with adjustments in willingness-to-pay and parameter inputs. As willingness-to-pay increased considerably (>$65,000 per Disabilities of the Arm, Shoulder, and Hand-adjusted life year), inclusion of MRA became the most favorable strategy. CONCLUSIONS Advanced imaging adds costs and provides minimal increases in effectiveness in the diagnosis and treatment of a symptomatic triangular fibrocartilage complex abnormality. The most cost-effective strategy is H&P, with or without diagnostic injection. Magnetic resonance arthrogram may be favored in situations with a high willingness-to-pay or poor examination characteristics. TYPE OF STUDY/LEVEL OF EVIDENCE Economic/Decision Analysis IV.
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Affiliation(s)
| | - Tyler S Pidgeon
- Department of Orthopaedic Surgery, Duke University, Durham, NC
| | | | | | - David S Ruch
- Department of Orthopaedic Surgery, Duke University, Durham, NC
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10
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Kreulen RT, Nayar SK, Alfaki Y, LaPorte D, Demehri S. Advanced Imaging of Ulnar Wrist Pain. Hand Clin 2021; 37:477-486. [PMID: 34602127 DOI: 10.1016/j.hcl.2021.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Ulnar-sided wrist pain can be a diagnostic challenge for clinicians and radiologists. The ulnar wrist has complex morphology and is composed of many small bone and soft tissue structures. Within these structures, a wide variety of pathologic conditions can occur. To successfully diagnose and treat these pathologic conditions, clinicians and radiologists must have a strong understanding of the advanced imaging techniques available to them. In this review, the authors present a brief review of the normal ulnar wrist anatomy, discuss the differential diagnosis of ulnar-sided wrist pain, and examine the indications for different advanced imaging modalities.
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Affiliation(s)
- R Timothy Kreulen
- Johns Hopkins Department of Orthopaedic Surgery, 601 North Caroline Street 5th Floor, Baltimore, MD 21205, USA.
| | - Suresh K Nayar
- Johns Hopkins Department of Orthopaedic Surgery, 601 North Caroline Street 5th Floor, Baltimore, MD 21205, USA
| | - Yasmin Alfaki
- Johns Hopkins University, 3400 North Charles Street, Mason Hall, Baltimore, MD 21218, USA
| | - Dawn LaPorte
- Johns Hopkins Department of Orthopaedic Surgery, 601 North Caroline Street 5th Floor, Baltimore, MD 21205, USA
| | - Shadpour Demehri
- Johns Hopkins Department of Musculoskeletal Radiology, 601 North Caroline Street 5th Floor, Baltimore, MD 21205, USA
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Abstract
Ulnocarpal impaction syndrome is a common cause for ulnarsided wrist pain caused by an abutment between the ulnar head and the lunotriquetral complex. This pain is typically triggered by load bearing and rotation of the forearm. Radiographic examination is often associated with positive ulnar variance and cysts in the lunate, edema of the ulnoproximal lunate is shown in MRI. Operative treatment aims to reduce load on the lunate, either by open ulnar shortening osteotomy or arthroscopic wafer procedure.
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12
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Ou Yang O, McCombe DB, Keating C, Maloney PP, Berger AC, Tham SKY. Ulnar-sided wrist pain: a prospective analysis of diagnostic clinical tests. ANZ J Surg 2021; 91:2159-2162. [PMID: 34459533 DOI: 10.1111/ans.17169] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 07/15/2021] [Accepted: 07/23/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Identifying the cause of pain on the ulnar side of the wrist can be challenging. The outcome and recovery following surgery can be unpredictable. The aim of this study was to document and analyse the clinical tests used to evaluate the cause of ulnar-sided wrist pain and determine their diagnostic relevance. METHODS This is a prospective evaluation of 110 patients who presented with pain on the ulnar side of the wrist. The clinical evaluation and results from radiological investigations were documented and analysed. RESULTS There were 17 different diagnoses. Eighty-five percent of the diagnoses were triangular fibrocartilage complex (TFCC) injuries, ulnocarpal abutment syndrome (UCAS), pisotriquetral arthritis (PTA), triquetral fracture or non-union, distal radioulnar joint arthritis (DRUJ OA) and extensor carpi ulnaris (ECU) pathology. The ulnocarpal stress test and ulnar foveal sign were positive in several diagnoses. The ulnar foveal sign had a sensitivity and specificity of 89% and 48% for TFCC injuries, and 85% and 37% for UCAS, respectively. The sensitivity and specificity of pisotriquetral shear test for PTA was 100% and 92%, respectively. Patients with PTA or ECU pathology localised their pain better on the patient's pain localisation chart. CONCLUSION Diagnosis of TFCC injuries, UCAS, DRUJ OA and ECU injuries are challenging as the clinical symptoms and signs for the four diagnoses were similar and required either magnetic resonance imaging or computed tomography for diagnostic confirmation after clinical examination. The ulnocarpal stress test and the ulnar foveal sign were not sufficiently specific.
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Affiliation(s)
- Owen Ou Yang
- Victorian Hand Surgery Associates, Fitzroy, Victoria, Australia.,Department of Plastic and Hand Surgery, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - David B McCombe
- Victorian Hand Surgery Associates, Fitzroy, Victoria, Australia.,Department of Plastic and Hand Surgery, St Vincent's Hospital, Fitzroy, Victoria, Australia.,Hand and Wrist Biomechanics Laboratory, O'Brien Institute/St Vincent's Institute, Fitzroy, Victoria, Australia.,Department of Paediatrics, Royal Children's Hospital, University of Melbourne, Flemington, Victoria, Australia
| | - Cameron Keating
- Victorian Hand Surgery Associates, Fitzroy, Victoria, Australia
| | - Peter P Maloney
- Victorian Hand Surgery Associates, Fitzroy, Victoria, Australia.,Department of Plastic and Hand Surgery, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Anthony C Berger
- Victorian Hand Surgery Associates, Fitzroy, Victoria, Australia.,Department of Plastic and Hand Surgery, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Stephen K Y Tham
- Victorian Hand Surgery Associates, Fitzroy, Victoria, Australia.,Department of Plastic and Hand Surgery, St Vincent's Hospital, Fitzroy, Victoria, Australia.,Hand and Wrist Biomechanics Laboratory, O'Brien Institute/St Vincent's Institute, Fitzroy, Victoria, Australia
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13
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Götestrand S, Björkman A, Björkman-Burtscher IM, Kristiansson I, Aksyuk E, Szaro P, Markenroth Bloch K, Geijer M. Visualization of wrist anatomy-a comparison between 7T and 3T MRI. Eur Radiol 2021; 32:1362-1370. [PMID: 34378077 PMCID: PMC8795032 DOI: 10.1007/s00330-021-08165-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/16/2021] [Accepted: 06/24/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Injuries to the wrist are, due to its small size and complex anatomical structures, difficult to assess by MR, and surgical interventions such as diagnostic arthroscopy are often necessary. Therefore, improved visualization using non-invasive methods could be of clinical value. As a first step of improvement, the purpose of this study was to evaluate visualization of anatomical structures at 7T compared with 3T MR. METHODS Eighteen healthy volunteers (three males and three females from each age decade between 20 and 49 years) were examined with 7T and 3T MR. Four musculoskeletal radiologists graded 2D and 3D images on a five-level grading scale for visibility of ligaments, cartilage, nerves, trabecular bone, and tendons, as well as overall image quality (i.e., edge sharpness, perceived tissue contrast, and presence of artefacts). Statistical analysis was done using a visual grading characteristics (VGC) analysis. RESULTS Visibility of cartilage, trabecular bone, tendons, nerves, and ligaments was graded significantly higher at 7T with an area under the curve (AUCVGC) of 0.62-0.88 (95% confidence interval [CI] 0.50-0.97, p = < 0.0001-0.03) using either 2D or 3D imaging. Imaging with 3T was not graded as superior to 7T for any structure. Image quality was also significantly superior at 7T, except for artefacts, where no significant differences were found. CONCLUSIONS Tendons, trabecular bone, nerves, and ligaments were all significantly better visualized at 7T compared to 3T. KEY POINTS • MRI of the wrist at 7T with a commercially available wrist coil is feasible at similar acquisition times as for 3T MRI. • The current study showed 7T to be superior to 3T in the visualization of anatomical structures of the wrist, including ligaments, tendons, nerves, and trabecular bone. • Image quality was significantly superior at 7T, except for artefacts, where no significant differences were found.
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Affiliation(s)
- Simon Götestrand
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden. .,Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden.
| | - Anders Björkman
- Department of Hand Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Isabella M Björkman-Burtscher
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Radiology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Ingvar Kristiansson
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
| | - Elenya Aksyuk
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Pawel Szaro
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Mats Geijer
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden.,Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Radiology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
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14
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Contrast-enhanced MRI of the wrist: Intravenous application of gadolinium improves diagnosis in ulnar-sided injuries of the TFCC. Eur J Radiol 2021; 143:109901. [PMID: 34392004 DOI: 10.1016/j.ejrad.2021.109901] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/26/2021] [Accepted: 08/04/2021] [Indexed: 11/20/2022]
Abstract
PURPOSE Although lesions of the triangular fibrocartilage complex (TFCC) frequently induce ulnar-sided wrist pain and potentially distal radioulnar joint instability, diagnosis can pose a challenge due to the intricate anatomy. This study aims to evaluate the benefits of contrast-enhanced sequences for the detection of TFCC injuries in magnetic resonance imaging of the wrist. METHOD 94 patients underwent wrist MRI with intravenous application of gadolinium-based contrast agents. For each patient, two datasets were analysed independently by two board-certified radiologists: One set comprised only plain T1- and fat-saturated proton-density-weighted sequences, while the second dataset included contrast-enhanced T1-weighted images with fat suppression. Arthroscopy or clinical reports served as reference standard with the former being used whenever available. Diagnostic confidence and TFCC component assessability were subjectively evaluated. Contrast-to-noise ratios (CNR) were calculated serve as an objective indicator of image contrast. RESULTS Lesions of the articular disc, the foveal and styloid ulnar attachment were present in 24 (25.5%), 61 (64.9%) and 53 (56.4%) patients. Access to contrast-enhanced T1 images improved the diagnostic accuracy for injuries of the styloid (R1/R2, 0.68/0.73 vs. 0.86/0.88) and foveal attachment (0.68/0.72 vs. 0.90/0.89) substantially compared to plain MRI (all p < 0.001), while no benefits could be identified for lesions of the central disc (0.89/0.90 vs. 0.87/0.90). Readers' diagnostic confidence and CNR for ulnar-sided lesions improved with contrast-enhanced T1 sequences available (p < 0.001). CONCLUSIONS With superior CNR in lesions of the TFCC's foveal and styloid attachment, contrast-enhanced, fat-saturated T1-weighted sequences facilitate higher diagnostic accuracy and confidence than fat-saturated PD- and plain T1-weighted MRI.
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15
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Lee Y, Oh D, Han JH, Gong HS, Lee WW. Semiquantitative single-photon-emission computed tomography /computed tomography study to evaluate concomitant ulnar impaction syndrome in patients presenting with triangular fibrocartilage complex tears. PLoS One 2020; 15:e0244256. [PMID: 33362280 PMCID: PMC7757893 DOI: 10.1371/journal.pone.0244256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 12/06/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction Patients presenting with tears of the triangular fibrocartilage complex (TFCC) can have ulnar positive variance, for which the clinical relevance to concomitant ulnar impaction syndrome (UIS) may be unclear. We hypothesized that maximum standardized uptake value (SUVmax), a semiquantitative single-photon-emission computed tomography/computed tomography (SPECT/CT) value, would distinguish between the traumatic TFCC tear and degenerative TFCC tear associated with the UIS. This study aimed to compare SUVmax between patients with TFCC tear only and patients with TFCC tear and UIS. Methods A total of 26 patients presenting with TFCC tears on magnetic resonance imaging (MRI) underwent semiquantitative SPECT/CT examinations. The diagnosis of concomitant UIS was made based on positive ulnar impaction tests and MRI findings. We compared the SUVmax between patients with and without concomitant UIS. We also calculated the cutoff value for the diagnosis of UIS using receiver operating characteristic curve analysis. Results Of 26 patients, 14 had concomitant UIS, and 12 had TFCC tears only. The SUVmax was significantly higher in patients with concomitant UIS than in those without UIS (p = 0.048). With a SUVmax cutoff value of 4.09 for UIS, sensitivity of 67% and specificity of 82% were obtained. Conclusions In the semiquantitative SPECT/CT examinations of patients with TFCC tears, those with concomitant UIS had a higher SUVmax than those without UIS. Semiquantitative SPECT/CT can be helpful in confirming concomitant UIS in patients with TFCC tears.
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Affiliation(s)
- Yohan Lee
- Department of Orthopaedic surgery, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Dongkyu Oh
- Department of Nuclear Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Hee Han
- Department of Nuclear Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Sik Gong
- Department of Orthopaedic surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
- * E-mail: (HSG); (WWL)
| | - Won Woo Lee
- Department of Nuclear Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
- * E-mail: (HSG); (WWL)
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16
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Krastman P, Mathijssen NMC, Bierma-Zeinstra SMA, Kraan GA, Runhaar J. Diagnostic accuracy of history taking, physical examination and imaging for non-chronic finger, hand and wrist ligament and tendon injuries: a systematic review update. BMJ Open 2020; 10:e037810. [PMID: 33154046 PMCID: PMC7646346 DOI: 10.1136/bmjopen-2020-037810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE The diagnostic work-up for ligament and tendon injuries of the finger, hand and wrist consists of history taking, physical examination and imaging if needed, but the supporting evidence is limited. The main purpose of this study was to systematically update the literature for studies on the diagnostic accuracy of tests for detecting non-chronic ligament and tendon injuries of the finger, hand and wrist. METHODS Medline, Embase, Cochrane Library, Web of Science, Google Scholar ProQuest and Cinahl were searched from 2000 up to 6 February 2019 for identifying studies. Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 checklist, and sensitivity (Se), specificity (Sp), accuracy, positive predictive value (PPV) and negative predictive value (NPV) were extracted. RESULTS None of the studies involved history taking. Physical examination, for diagnosing lesions of the triangular fibrocartilage complex (TFCC), showed Se, Sp, accuracy, PPV and NPV ranging from 58% to 90%, 20% to 69%, 56% to 73%, 53% to 71% and 55% to 65%, respectively. Physical examination in hand and finger injuries the Se, Sp, accuracy, PPV and NPV ranged from 88% to 99%, 75% to 100%, 34% to 88%, 91% to 100% and 75% to 95%, respectively. The accuracy of MRI with high-resolution (3 T) techniques for TFCC and interosseous ligaments of the proximal carpal row ranged from 89% to 91% and 75% to 100%, respectively. The accuracy of MRI with low-resolution (1.5 T) techniques for TFCC and interosseous ligaments of the proximal carpal row ranged from 81% to 100% and 67% to 95%, respectively. CONCLUSIONS There is limited evidence on the diagnostic accuracy of history taking and physical examination for non-chronic finger, hand and wrist ligament and tendon injuries. Although some imaging modalities seemed to be acceptable for the diagnosis of ligament and tendon injuries in the wrist in patients presenting to secondary care, there is no evidence-based advise possible for the diagnosis of non-chronic finger, hand or wrist ligament and tendon injuries in primary care.
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Affiliation(s)
- Patrick Krastman
- Department of General Practice, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Nina M C Mathijssen
- Department of Orthopaedic, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Sita M A Bierma-Zeinstra
- Department of General Practice, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Orthopedics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Gerald A Kraan
- Department of Orthopaedic, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Jos Runhaar
- Department of General Practice, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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17
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Kwon BC, Lee JH, Lee SY. What Is the Effect of the Ulnar-Plus Variance on the Outcomes of Arthroscopic Repair of the Peripheral Ulnar-Side Triangular Fibrocartilage Complex Tear? Arthroscopy 2020; 36:2415-2422. [PMID: 32442714 DOI: 10.1016/j.arthro.2020.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 05/04/2020] [Accepted: 05/08/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the outcomes of arthroscopic repair of peripheral ulnar-side triangular fibrocartilage complex (TFCC) tears between patients with and without ulnar-plus variance (UPV) and to identify factors associated with index surgery failure in these patients. METHODS We retrospectively analyzed 50 consecutive patients who underwent arthroscopic repair of peripheral ulnar-side TFCC tears from June 2014 to February 2018. We selected patients who were aged at least 18 years and underwent arthroscopic repair of peripheral ulnar-side TFCC tears. We excluded those with a fractured or dislocated wrist, ulnar impaction syndrome, degenerative or inflammatory arthritis of the wrist, or neurologic conditions that affect upper-extremity function, as well as those who received less than 12 months' follow-up. We evaluated the patients with a visual analog scale for pain in 3 domains (overall, with hard work, and at rest), the Patient-rated Wrist Evaluation, range of motion, and grip strength. Clinical outcomes and arthroscopic findings were compared between patients with and without UPV (UPV group and non-UPV group, respectively). We calculated the relative risk and 95% confidence interval for younger age (<30 years), sex, UPV, and coexisting degenerative central TFCC tear (type 2 tear) to determine the risk factors for arthroscopic repair failure. RESULTS No significant differences were noted between the 2 groups regarding visual analog scale pain and Patient-rated Wrist Evaluation scores and rates of excellent or improved outcomes (P > .05). Arthroscopic repair failure was found in 4 patients. A coexisting type 2 TFCC tear was the only significant risk factor (relative risk, 49.5; 95% confidence interval, 2.94-83.96; P = .007) for arthroscopic repair failure. CONCLUSIONS UPV did not significantly affect the outcomes of arthroscopic repair of peripheral ulnar-side TFCC tears. However, coexisting type 2 TFCC tears significantly increased the risk of index surgery failure in these patients. LEVEL OF EVIDENCE Level IV, prognostic study.
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Affiliation(s)
- Bong Cheol Kwon
- Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea.
| | - Jeong Hwan Lee
- Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Suk Yoon Lee
- Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
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18
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Ulnar shortening osteotomy as a treatment of symptomatic ulnar impaction syndrome after malunited distal radius fractures. Arch Orthop Trauma Surg 2020; 140:681-695. [PMID: 32193682 DOI: 10.1007/s00402-020-03374-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Indexed: 02/09/2023]
Abstract
A malunited distal radius fracture can lead to symptomatic ulnar impaction syndrome, which is a common cause for ulnar-sided wrist pain. If conservative treatment fails and symptoms persist after an arthroscopic ulnocarpal debridement, ulnar shortening osteotomy (USO) is the treatment of choice. Since the first USO described by Milch in 1941 after a malunited Colles fracture, many techniques have been described varying in surgical approach, type of osteotomy and osteosynthesis material used. Many studies demonstrated good to very good functional results after USO, reporting, however, a delayed union or non-union rate up to 18%. A modern, low profile, locking plate showed in our short-term study very good functional results and no implant-associated complications, in particular no non-union.
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19
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Andersson JK, Hagert EM, Fridén J. Patients With Triangular Fibrocartilage Complex Injuries and Distal Radioulnar Joint Instability Gain Improved Forearm Peak Pronation and Supination Torque After Reinsertion. Hand (N Y) 2020; 15:281-286. [PMID: 30081654 PMCID: PMC7076604 DOI: 10.1177/1558944718793198] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Forearm peak pronation and supination torque measurements are reduced up to 30% in patients with triangular fibrocartilage complex (TFCC) 1B injuries with concomitant distal radioulnar joint (DRUJ) instability. The aim of our study was to evaluate whether patients with TFCC 1B injuries, with concomitant DRUJ instability, improve in forearm peak pronation and supination torque following TFCC reinsertion surgery where postoperative DRUJ stability was achieved. Methods: We report a retrospective case series with short-term follow-up (20 months) of the postoperative forearm peak torque in pronation and supination in 11 patients (9 women/2 men, average age at surgery 32 years) operated on by TFCC reinsertion. Two of the initial 13 patients were later on reoperated due to recurring DRUJ instability and were therefore excluded in this follow-up study. Nine were treated by arthroscopic TFCC reinsertion and 2 by open technique. The forearm peak pronation and supination torque were measured pre- and postoperatively and compared with the uninjured side. Results: On average, a 16% improvement of the forearm peak torque was achieved in the injured wrist, as well as clinically assessed DRUJ stability. Functional postoperative improvement was noted in all patients, with reduced pain, good satisfaction, and acceptance of the surgery and the final result. Conclusion: We conclude that patients with TFCC injuries and DRUJ instability gain improved forearm peak pronation and supination torque after reinsertion. We also conclude that forearm peak pronation and supination torque is a valuable tool in the preoperative diagnostics of TFCC injuries with DRUJ instability as well as in the postoperative follow-up.
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Affiliation(s)
- Jonny K. Andersson
- SportsMed, Göteborg, Sweden,Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden,Jonny K. Andersson, SportsMed, Carlanderska Hospital, SE-405 45 Göteborg, Sweden.
| | - Elisabet M. Hagert
- Karolinska Institute, Stockholm, Sweden,ARCADEMY Stockholm, Sophiahemmet Hospital, Stockholm, Sweden
| | - Jan Fridén
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden,Sahlgrenska University Hospital, Mölndal, Sweden,Swiss Paraplegic Centre, Nottwil, Switzerland
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20
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Park JH, Ahn KS, Chang A, Kwon YW, Choi IC, Park JW. Changes in the morphology of the triangular fibrocartilage complex (TFCC) on magnetic resonance arthrography related to disruption of ulnar foveal attachment. Skeletal Radiol 2020; 49:249-256. [PMID: 31321453 DOI: 10.1007/s00256-019-03278-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/24/2019] [Accepted: 07/04/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess whether a proximal ligamentous component (PLC) of the triangular fibrocartilage complex (TFCC) with a distally prolapsing morphology is associated with the presence of a TFCC foveal tear on arthroscopy. METHODS One-hundred thirty-two patients (134 wrists) who underwent MR arthrography and subsequent wrist arthroscopy between September 2014 and March 2018 were retrospectively evaluated. The degree of distal PLC prolapse was measured on coronal MR arthrography using the height-to-length ratio (HLR). Subjects' demographics, ulnar variance, presence of a degenerative TFCC tear, and ulnar styloid nonunion were assessed. The association between specific variables and the presence of a foveal tear was investigated. RESULTS A TFCC foveal tear was identified in a total of 101 of 134 wrists examined by arthroscopy. Univariable analysis showed that the HLR of the PLC was significantly greater in the foveal tear group compared with the intact fovea group (44.6 vs. 38.9%, respectively, p < 0.001). Multivariable analysis showed that HLR was positively associated with a foveal tear (odds ratio [OR], 1.211; p < 0.001). The estimated cut-off value of the HLR was 41% (area under the curve [AUC] 0.77). CONCLUSIONS PLCs with a distal prolapse pattern and large HLR are associated with TFCC foveal tears. The HLR of the PLC measured on coronal MR images can therefore be used as an additional predictor of tears of the foveal attachment of the TFCC.
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Affiliation(s)
- Ji Hun Park
- Department of Orthopedic Surgery, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Kyung-Sik Ahn
- Department of Radiology, Korea University Anam Hospital, 73, Inchon-ro, Sungbuk-gu, Seoul, 06334, South Korea
| | - Anseong Chang
- Department of Orthopedic Surgery, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Young Woo Kwon
- Department of Orthopedic Surgery, Korea University Anam Hospital, 73, Inchon-ro, Sungbuk-gu, Seoul, 06334, South Korea
| | - In Cheul Choi
- Department of Orthopedic Surgery, Korea University Anam Hospital, 73, Inchon-ro, Sungbuk-gu, Seoul, 06334, South Korea
| | - Jong Woong Park
- Department of Orthopedic Surgery, Korea University Anam Hospital, 73, Inchon-ro, Sungbuk-gu, Seoul, 06334, South Korea.
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21
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Chang MK, Lim ZY, Tay SC. Positive Ulnar Fovea Sign - Audit of Patient Outcomes Following Nonsurgical and Surgical Management. J Hand Surg Asian Pac Vol 2019; 24:421-427. [PMID: 31690200 DOI: 10.1142/s242483551950053x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Patients with ulnar-sided wrist pain and positive ulnar fovea sign are usually treated nonsurgically before surgical options are considered. However, the outcomes of nonsurgical management are unknown. Many of these patients also have unstable distal radioulnar joint, but there has been no comparison between the outcomes of these patients with stable and unstable distal radioulnar joint. The objectives of this study are to (1) determine the outcomes of nonsurgical and surgical treatment of patients with positive ulnar fovea sign, and (2) compare the outcomes of patients with stable and unstable distal radioulnar joint. Methods: A retrospective analysis of the outcomes of patients with ulnar sided wrist pain and positive fovea sign was performed from March 2009 to December 2014. Outcomes were measured based on patient-reported pain improvement, grip strength and range of motion of the affected wrist before and after treatment. A total of 100 wrists in 98 patients were reviewed. Results: 54% of wrists managed nonsurgically experienced pain improvement. 83% of wrists managed surgically experienced pain improvement. The mean grip strength increased by 2.8 kg and 2.7 kg, while the range of motion decreased by 14° and 5° after nonsurgical and surgical treatment respectively. When comparing patients with stable and unstable distal radioulnar joint, there were statistically more wrists with unstable distal radioulnar joint that experienced pain improvement after treatment. Conclusions: The study showed that there is a role for nonsurgical treatment for wrists with positive ulnar fovea sign with more than half of the patients experiencing pain improvement. We also found that positive ulnar fovea sign patients with unstable distal radioulnar joint had better pain outcomes compared to those with stable distal radioulnar joint.
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Affiliation(s)
- Min Kai Chang
- Duke-NUS Medical School, Singapore General Hospital, Singapore
| | - Zeus Yiwei Lim
- Biomechanics Laboratory, Singapore General Hospital, Singapore
| | - Shian Chao Tay
- Biomechanics Laboratory, Singapore General Hospital, Singapore.,Department of Hand Surgery, Singapore General Hospital, Singapore
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22
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Löw S, Spies CK, Unglaub F, Oppermann J, Langer M, Erne H. [Diagnosis and treatment of degenerative disc lesions of the wrist]. DER ORTHOPADE 2019. [PMID: 29523902 DOI: 10.1007/s00132-018-3551-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
BACKGROUND The triangular fibrocartilage complex (TFCC) widens the radiocarpal joint and takes part in load transmission from the carpus to the forearm. It is thereby prone to degenerative changes. The painful situation that can accompany degeneration is called ulnar impaction. DIAGNOSIS Clinical examination helps differentiate between various causes of ulnar-sided wrist pain. Standard X‑rays are needed to determine ulnar variance and stress radiographs can depict narrowing of the ulnocarpal joint space under load. MRI may prove degeneration of the TFCC itself or may indirectly confirm ulnar impaction in the presence of bone marrow edema in the ulnar head or at the proximal ulnar aspect of the lunate. TREATMENT If conservative treatment fails to alleviate symptoms, arthroscopy may be indicated. On the one hand, this completes the diagnostic cascade, and, on the other hand, allows decompression of the ulnocarpal joint space by resection of the TFCC with partial resection of the ulnar head (wafer resection). In the case of ongoing pain, ulnar shortening sufficiently alleviates ulnar-sided wrist pain. Thereby, modern standardized operation techniques are safe enough to ensure bone healing at the osteotomy site. The aim of alleviating ulnar-sided wrist pain is mostly achieved if the correct treatment option is chosen.
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Affiliation(s)
- S Löw
- Praxis für Handchirurgie und Unfallchirurgie, Wolfgangstraße 2, 97980, Bad Mergentheim, Deutschland.
| | - C K Spies
- Abteilung Handchirurgie, Vulpius-Klinik, Bad Rappenau, Deutschland
| | - F Unglaub
- Abteilung Handchirurgie, Vulpius-Klinik, Bad Rappenau, Deutschland.,Medizinische Fakultät Mannheim, Universität Heidelberg, Heidelberg, Deutschland
| | - J Oppermann
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln, Köln, Deutschland
| | - M Langer
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - H Erne
- Klinik und Poliklinik für Plastische Chirurgie und Handchirurgie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
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23
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Terzis A, Neubrech F, Sebald J, Sauerbier M. [Surgical treatment of ulnar impaction syndrome : Ulnar shortening osteotomy through the ulnopalmar approach using a low-profile, locking plate]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2019; 31:547-556. [PMID: 31172214 DOI: 10.1007/s00064-019-0613-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 05/30/2018] [Accepted: 06/08/2018] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Extra-articular shortening of the distal ulna in order to decompress the ulnocarpal joint. INDICATIONS Congenital or posttraumatic, symptomatic ulnar impaction syndrome. CONTRAINDICATIONS Osteoarthritis or deformation of the distal radioulnar joint. SURGICAL TECHNIQUE Exactly defined oblique osteotomy in the distal third of the ulna using the saw guide, closing of the osteotomy gap using the compression spindle, osteosynthesis with the locking plate. POSTOPERATIVE MANAGEMENT Palmar forearm thermoplastic cast or splint for 3 weeks, load bearing after bony union. RESULTS Between June 2016 and March 2018 ulnar shortening was performed in 17 patients using the new locking plate. In all, 15 patients were reevaluated with complete follow-up data. Postoperatively patients experienced significant pain reduction (Visual Analog Scale 0-10) by 65% (7 before and 2.5 after surgery; p < 0.05) and a significant improvement of function (Disabilities of Arm, Shoulder and Hand 0-100) by 49% (47 before and 24 after surgery; p < 0.05). Bony union was observed in all patients after a mean time of 4 months. Overall patient satisfaction was high.
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Affiliation(s)
- A Terzis
- Abteilung für Plastische, Hand- und Rekonstruktive Chirurgie, BG Unfallklinik Frankfurt am Main, Akademisches Lehrkrankenhaus, Goethe-Universität Frankfurt am Main, Friedberger Landestr. 430, 60389, Frankfurt am Main, Deutschland.
| | - F Neubrech
- Abteilung für Plastische, Hand- und Rekonstruktive Chirurgie, BG Unfallklinik Frankfurt am Main, Akademisches Lehrkrankenhaus, Goethe-Universität Frankfurt am Main, Friedberger Landestr. 430, 60389, Frankfurt am Main, Deutschland
| | - J Sebald
- Abteilung für Plastische, Hand- und Rekonstruktive Chirurgie, BG Unfallklinik Frankfurt am Main, Akademisches Lehrkrankenhaus, Goethe-Universität Frankfurt am Main, Friedberger Landestr. 430, 60389, Frankfurt am Main, Deutschland
| | - M Sauerbier
- Abteilung für Plastische, Hand- und Rekonstruktive Chirurgie, BG Unfallklinik Frankfurt am Main, Akademisches Lehrkrankenhaus, Goethe-Universität Frankfurt am Main, Friedberger Landestr. 430, 60389, Frankfurt am Main, Deutschland
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What is the Natural History of the Triangular Fibrocartilage Complex Tear Without Distal Radioulnar Joint Instability? Clin Orthop Relat Res 2019; 477:442-449. [PMID: 30376460 PMCID: PMC6370105 DOI: 10.1097/corr.0000000000000533] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The triangular fibrocartilage complex (TFCC) tear is a common cause of ulnar-side wrist pain; however, its natural course is not well understood. QUESTIONS/PURPOSES We sought (1) to determine the natural course of TFCC tears without distal radioulnar joint (DRUJ) instability, and (2) to identify the factors associated with poor prognosis after nonsurgical treatment of TFCC tears. METHODS Over a 3-year period, we treated 117 patients with TFCC tears who did not have DRUJ instability. The diagnosis was made on the basis of ulnar-sided wrist pain, a positive ulnocarpal stress test or ulnar grinding test, and identification of a tear on MRI or CT arthrography. Of those, 25 were excluded during the initial evaluation period because they met the previously defined indications of surgery on the basis of clinical history. Another 19 patients (20%) were lost to followup before 6 months, and one patient was excluded because of prior wrist surgery, leaving 72 wrists in 72 patients for analysis in this retrospective study, which drew data from a review of electronic medical records of one institution. The group consisted of 42 men and 30 women, with a mean age of 40 years (range, 18-70 years). The study group was followed for a mean of 16 months (range, 6 to 36 months). We evaluated the pain VAS and patient-rated wrist evaluation (PRWE) at the initial visit, at 4, 8, and 12 weeks, and at more than 6 months after the initial visit. A PRWE score ≤ 20 points indicated complete recovery, and a PRWE score more than 20 points was considered an incomplete recovery. We used Kaplan-Meier survival analysis and Cox regression modelling to estimate the time to complete recovery and to identify factors associated with incomplete recovery among the seven possible factors of older age (≥ 45 years), male, obesity (body mass index ≥ 30 kg/m), dominant-hand involvement, chronic symptoms (≥ 6 months), traumatic tear, and ulnar-plus variance. RESULTS The Kaplan-Meier survival analysis showed that estimated cumulative incidence of complete recovery was 30% (95% confidence interval [CI], 20-40) at 6 months and 50% (95% CI, 39-61) at 1 year. We could not find any risk factors among the seven candidate factors, including older age (hazard ratio [HR], 0.608; 95% CI, 0.34-1.087; p = 0.093), male (HR, 1.152; 95% CI, 0.667-1.991; p = 0.612), obesity (HR, 1.433; 95% CI, 0.603-3.402; p = 0.415), dominant hand involvement (HR, 1.808; 95% CI, 0.927-3.527; p = 0.082), chronic symptoms (HR, 0.763; 95% CI, 0.443-1.922; p = 0.133), traumatic tear (HR, 0.756; 95% CI, 0.432-1.32; p = 0.325), and ulnar plus variance (HR, 0.804; 95% CI, 0.461-1.404; p = 0.443). CONCLUSIONS This study demonstrates that nonsurgical treatment is moderately successful for treating patients with TFCC tears without DRUJ instability. We recommend a minimum of 6 months nonsurgical treatment as the first-line treatment for this injury. Future studies are necessary to clarify predictors of persistent pain with nonsurgical treatment to avoid an unnecessary surgical delay. LEVEL OF EVIDENCE Level III, prognostic study.
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Roh YH, Yun YH, Kim DJ, Nam M, Gong HS, Baek GH. Prognostic factors for the outcome of arthroscopic capsular repair of peripheral triangular fibrocartilage complex tears. Arch Orthop Trauma Surg 2018; 138:1741-1746. [PMID: 29974215 DOI: 10.1007/s00402-018-2995-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Little information is available about prognostic factors of arthroscopic capsular repair for peripheral triangular fibrocartilage complex (TFCC) lesions. The purpose of this study was to analyze factors that affect the treatment outcomes of arthroscopic capsular repair for peripheral TFCC tears. METHODS This study retrospectively enrolled 60 patients who were treated with arthroscopic outside-in capsular repair for peripheral TFCC tears. Functional survey, including pain numeric rating scale (NRS) on an ulnar provocation test, distal radio-ulnar joint (DRUJ) stress test, Disability of the Arm, Shoulder, and Hand (DASH) score, and satisfaction with treatment, was conducted at 12-month follow-up. Patients who were enthusiastic or satisfied comprised the satisfied group, and those who were noncommittal or disappointed the dissatisfied group. Demographic, clinical, and arthroscopic findings were compared between the satisfied and dissatisfied groups. RESULTS The mean pain NRS and DASH scores exhibited significant clinical improvement at the 12-month follow-up. Out of the total participants, 46 were satisfied and 14 were dissatisfied about the treatment, with significantly more female subjects in the dissatisfied group than in the satisfied one. The patients in the satisfied group had a shorter duration of symptoms, were more likely to have trauma history, and exhibited positive DRUJ stress test results compared to the dissatisfied group. There were no significant group differences in age, hand dominance, work level, and the extent of ulnar plus variance. Multivariable analysis revealed that female gender, a longer duration of symptoms, or negative DRUJ stress test results were associated with an increased disability after arthroscopic TFCC repair. CONCLUSION Female gender, a longer duration of symptom, and a negative DRUJ stress test are associated with a higher likelihood of treatment failure after arthroscopic outside-in capsular repair of peripheral TFCC tears.
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Affiliation(s)
- Young Hak Roh
- Department of Orthopaedic Surgery, Ewha Womans University Medical Center, Ewha Womans University College of Medicine, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul, 07985, South Korea.
| | - Yeo-Hon Yun
- Department of Orthopaedic Surgery, Ewha Womans University Medical Center, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Dong Jun Kim
- Department of Orthopaedic Surgery, Ewha Womans University Medical Center, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Muhyun Nam
- Department of Orthopaedic Surgery, Ewha Womans University Medical Center, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Hyun Sik Gong
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Goo Hyun Baek
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
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Bendre HH, Oflazoglu K, van Leeuwen WF, Rakhorst H, Ring D, Chen NC. The Prevalence of Triangular Fibrocartilage Complex Signal Abnormalities on Magnetic Resonance Imaging Relative to Clinical Suspicion of Pathology. J Hand Surg Am 2018; 43:819-826.e1. [PMID: 30172277 DOI: 10.1016/j.jhsa.2018.06.117] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 05/12/2018] [Accepted: 06/29/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the prevalence of triangular fibrocartilage complex (TFCC) signal changes in patients undergoing magnetic resonance imaging (MRI) of the wrist and its relationship to a clinical suspicion of TFCC pathology. The secondary purpose was to study factors that are associated with TFCC signal changes. METHODS In this retrospective study, we looked for any TFCC signal changes in the reports of MRI findings performed during a 3-year period in 1,134 patients. Demographic characteristics, the categorized indications for MRI, and symptoms at the time of the MRI were also retrieved from the medical records. Patients were divided into 6 groups, based on age, to calculate the proportions of TFCC signal changes in the entire cohort and as an incidental finding among patients without a clinical suspicion of TFCC pathology within each age group. RESULTS A total of 321 patients (28%) had incidental TFCC signal changes. The prevalence among 18- to 30 year-olds was 19%, and increased to 64% in patients older than 70 years. Multivariable logistic regression analysis demonstrated that an increase in age is significantly associated with having TFCC signal changes on MRI in patients who have a low clinical suspicion of TFCC pathology. The rate of incidental TFCC signal changes steadily increases with age. CONCLUSIONS The TFCC signal abnormalities on MRI are more common with increasing age in patients with low clinical suspicion of TFCC pathology. At age 70, more than half of all patients will have TFCC signal changes, and more than 90% are present in patients with a low clinical suspicion of TFCC pathology. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic IV.
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Affiliation(s)
- Hersh H Bendre
- Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kamilcan Oflazoglu
- Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Wouter F van Leeuwen
- Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Hinne Rakhorst
- Department of Plastic and Reconstructive Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, TX
| | - Neal C Chen
- Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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Roh YH, Kim S, Gong HS, Baek GH. Prevalence and clinical characteristics of radiographic central triangular fibrocartilage complex tears in symptomatic and asymptomatic individuals younger than 50 years. Arch Orthop Trauma Surg 2018; 138:1173-1178. [PMID: 29855684 DOI: 10.1007/s00402-018-2969-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Few studies have addressed the prevalence of central triangular fibrocartilage complex (TFCC) tears or their risk factors for symptom development. The aim of this study was to determine the prevalence of radiographic central TFCC tears in both symptomatic and asymptomatic individuals, and evaluate clinical characteristics of symptomatic individuals. METHODS In this retrospective case control study, 221 patients younger than 50 years who exhibited positive ulnocarpal provocation test and underwent MRI to identify abnormalities associated with TFCC were age- and sex-matched with 221 controls who had undergone hand or wrist MRI for tumorous lesions or pain in hand other than ulnar-sided wrist. Demographic and radiologic parameters including the degree of ulnar plus variance, the type of central TFCC lesions, the presence of ulna head or carpal bone enhancement, and cartilage degeneration of ulno-carpal or distal radio-ulnar joint were compared. Multivariable regression analysis was carried out to identify independent risk factors for symptom development in patients with central TFCC lesions. RESULTS The prevalence of central TFCC lesions was 68/221 in symptomatic patients, which was not significantly different from that (51/221) in asymptomatic controls. Patients in the symptomatic group had significantly greater ulnar plus variance (1.6 vs. 0.7). They were more likely to have type 1A tears and bony enhancement in ulnar head or carpus on MR images. Multivariable logistic regression analysis revealed that youth, female gender, and presence of bony enhancement were significant risk factors for symptom development in central TFCC lesions. CONCLUSION Based on the findings of this study, prevalence of central TFCC lesions detected on MRI in symptomatic patients seems to be similar to that in asymptomatic individuals. Younger age, female gender, and presence of bony enhancement on MR images seem to be risk factors for symptoms of central TFCC lesions.
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Affiliation(s)
- Young Hak Roh
- Department of Orthopaedic Surgery, Ewha Womans University Medical Center, Ewha Womans University College of Medicine, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul, 07985, South Korea.
| | - Sangwoo Kim
- Department of Orthopaedic Surgery, Ewha Womans University Medical Center, Seoul, South Korea
| | - Hyun Sik Gong
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Goo Hyun Baek
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
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Roh YH, Kim S, Gong HS, Baek GH. Prognostic value of clinical and radiological findings for conservative treatment of idiopathic ulnar impaction syndrome. Sci Rep 2018; 8:9891. [PMID: 29959424 PMCID: PMC6026167 DOI: 10.1038/s41598-018-28060-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 06/14/2018] [Indexed: 11/16/2022] Open
Abstract
Ulnar impaction syndrome (UIS) is a common source of ulnar-sided wrist pain, yet not all cases of radiographic ulnar impaction are symptomatic. We retrospectively analyze clinical or radiologic factors that affect prognoses of conservative treatment for idiopathic UIS. A total of 114 patients who had been diagnosed with UIS were treated with 6 weeks of short arm orthosis followed by formal physiotherapy for 6 weeks, with lifestyle modification to limit aggravating movements. The response to treatment, including pain numeric rating scale on an ulnar provocation test, grip strength, Disability of the Arm, Shoulder, and Hand score (DASH), was assessed at 24-week follow-up. For the 24-week follow-up, 29 patients (25%) underwent ulnar shortening osteotomy due to persistent symptoms after conservative treatment, and 18 (16%) patients had pain scores of greater than 5, but they had not undergone surgery. After controlling for confounding variables, female gender (odds ratio (OR) 1.39), duration of symptom (OR 1.27), high pain NRS score on provocation test (OR 1.45), and enhanced carpal or distal ulna bone on MRI (OR 1.82) were associated with a higher likelihood of treatment failure. Knowledge of the factors offers physicians insight into predicting prognoses and helps patients set realistic expectations.
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Affiliation(s)
- Young Hak Roh
- Department of Orthopaedic Surgery, Ewha Womans University Medical Center, Ewha Womans University College of Medicine, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul, 07985, South Korea.
| | - Sangwoo Kim
- Department of Orthopaedic Surgery, Ewha Womans University Medical Center, Ewha Womans University College of Medicine, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul, 07985, South Korea
| | - Hyun Sik Gong
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 173 Gumi-ro, Bundang-gu, Sungnam, 13620, South Korea
| | - Goo Hyun Baek
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
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Oppermann J, Burkhart KJ, Löw S, Müller LP. [The proximal radioulnar joint in consideration of the distal radioulnar joint]. DER ORTHOPADE 2018; 47:663-669. [PMID: 29947876 DOI: 10.1007/s00132-018-3590-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The movement of the forearm follows a complex interplay of three main components: the proximal and distal radioulnar joint and the interosseous membrane. Injuries to one or even all components have a huge impact on the integrity of this system. The Essex-Lopresti lesion presented a high challenge in clinical diagnostics as well as therapy. Reconstructions of the length and stability are essential for a satisfactory postoperative outcome. If a reconstruction of the radial head by osteosynthesis is not possible, a radial head prosthesis should be implanted in the case of longitudinal instability - avoiding overlapping and/or oversizing. The reconstruction of the interosseous membrane should be considered, as well as the assessment of the distal radioulnar joint and/or the triangular fibrocartilage complex. Various reconstruction options are available in this regard.
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Affiliation(s)
- J Oppermann
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universität zu Köln, Kerpener Straße 62, 50937, Köln, Deutschland.
- Cologne Center for Musculoskeletal Biomechanics, Medical Faculty, University of Cologne, Köln, Deutschland.
| | | | - S Löw
- Praxis für Handchirurgie und Unfallchirurgie, Bad Mergentheim, Deutschland
| | - L P Müller
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universität zu Köln, Kerpener Straße 62, 50937, Köln, Deutschland
- Cologne Center for Musculoskeletal Biomechanics, Medical Faculty, University of Cologne, Köln, Deutschland
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Arsalan-Werner A, Grüter L, Mehling IM, Moll W, Wölfle O, Sauerbier M. Results after arthroscopic treatment of central traumatic lesions of the triangular fibrocartilage complex. Arch Orthop Trauma Surg 2018; 138:731-737. [PMID: 29508106 DOI: 10.1007/s00402-018-2910-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Injuries of the triangular fibrocartilage complex (TFCC) are of high clinical relevance; however, the clinical evidence for treatment is poor and long-term results are rarely published. The purpose of this study was to evaluate the clinical outcome of symptomatic central traumatic lesions of the TFCC (Palmer 1A) following arthroscopic debridement. MATERIALS AND METHODS Between 2007 and 2013, 87 patients were arthroscopically diagnosed with Palmer 1A lesion and accordingly treated with debridement. Follow-up was available for 43 patients. Activities of daily living (ADLs) were measured with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Pain perception was evaluated with visual analogue scale (VAS 0-10). Grip strength and wrist motion were assessed with conventional techniques using a Jamar dynamometer and a goniometer. Patient satisfaction was assessed using a questionnaire at follow-up. RESULTS Mean follow-up was 42.5 months (range 5-70). The mean age of the patients (22 male and 21 female) at time of surgery was 41 ± 15.9 years. No major complication occurred during surgery and follow-up. The DASH score (preoperatively 49.8 ± 19.3 vs. postoperatively 14.1 ± 17.9, p < 0.05) and pain perception (VAS: preoperatively 7.2 ± 2.0 vs. postoperatively 1.4 ± 1.6, p < 0.05) improved significantly. Grip strength was satisfactory after surgery (19.6 ± 13.1). Ulnar deviation improved significantly from 29.3 ± 10.4° to 35.6 ± 8.3° (p < 0.05) and wrist flexion improved from 53.8 ± 18.9° to 67.4 ± 12.9° (p < 0.05). Wrist extension, radial deviation, pronation and supination did not change significantly after surgery. Improved symptoms were reported by 41/43 (95.3%) patients and 40/43 (93%) patients would have had the same procedure again knowing the final outcome. Six of 43 patients (15%) had an ulnar plus variance. None of these needed ulnar shortening. CONCLUSIONS Central traumatic TFCC lesions can safely be treated by arthroscopic debridement. We showed a sustained pain relief with significantly improved quality of life (DASH score) and wrist motion at follow-up. This resulted in a high patient satisfaction and acceptance of the procedure. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic, level IV.
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Affiliation(s)
- A Arsalan-Werner
- Department for Plastic, Hand and Reconstructive Surgery, Hand Trauma Center, BG-Trauma Center Frankfurt am Main, Academic Hospital of the Johann Wolfgang Goethe-University Frankfurt am Main, Friedberger Landstrasse 430, 60389, Frankfurt am Main, Germany.
| | - L Grüter
- Department for Plastic and Aesthetic Surgery, Sana Hospital Düsseldorf, Gräulinger Strasse 120, 40625, Düsseldorf, Germany
| | - I M Mehling
- Department for Hand Surgery, St. Vinzenz Hospital Hanau gGmbH, Am Frankfurter Tor 25, 63450, Hanau, Germany
| | - W Moll
- Department for Plastic, Hand and Reconstructive Surgery, Hand Trauma Center, BG-Trauma Center Frankfurt am Main, Academic Hospital of the Johann Wolfgang Goethe-University Frankfurt am Main, Friedberger Landstrasse 430, 60389, Frankfurt am Main, Germany
| | - O Wölfle
- Department for Plastic, Hand- and Reconstructive Surgery, Main-Taunus Hospitals GmbH, Kronberger Strasse 36, 65812, Bad Soden am Taunus, Germany
| | - M Sauerbier
- Department for Plastic, Hand and Reconstructive Surgery, Hand Trauma Center, BG-Trauma Center Frankfurt am Main, Academic Hospital of the Johann Wolfgang Goethe-University Frankfurt am Main, Friedberger Landstrasse 430, 60389, Frankfurt am Main, Germany
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Löw S, Herold A, Unglaub F, Megerle K, Erne H. Treatment of Ulnar Impaction Syndrome with and without Central TFC Lesion. J Wrist Surg 2018; 7:133-140. [PMID: 29576919 PMCID: PMC5864492 DOI: 10.1055/s-0037-1607073] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 08/22/2017] [Indexed: 10/18/2022]
Abstract
Background Arthroscopic debridement of the triangular fibrocartilage (TFC) is well accepted in patients with ulnar impaction syndrome with central TFC lesions. Treatment remains controversial, however, when there is no such lesion from radiocarpal view. Purpose This study assessed the clinical outcome of arthroscopic central TFC resection and debridement and secondary ulnar shortening in patients with ulnar impaction with central TFC lesion compared with patients without TFC lesion. Patients and Methods Thirty-two consecutive patients with ulnar impaction syndrome were arthroscopically treated, 16 of whom had a central lesion of the TFC that was debrided. In the 16 patients with no lesion from the radiocarpal view, the TFC was centrally resected and debrided to decompress the ulnocarpal joint. Persisting symptoms necessitated ulnar shortening in four patients in each group. Two patients underwent repeat arthroscopic TFC debridement. All patients were examined at 3, 6, and 12 months, and at final follow-up (mean: 1.7 years) following arthroscopy, respectively ulnar shortening or hardware removal. Results In both groups, pain, Krimmer, and DASH scores significantly improved. Improvements of DASH scores were significantly higher in patients without lesion at 12 months and at final follow-up. For other parameters, no significant difference was found between the two groups. Conclusion In both situations, with and without central TFC lesion, resection and debridement sufficiently reduced the ulnar-sided wrist pain and improved function in three out of four patients, and therefore qualified as the first-line treatment of ulnar impaction syndrome as arthroscopy is performed, anyway. Those patients who complained of persisting or recurrent ulnar-sided wrist pain finally benefitted from ulnar shortening osteotomy as the secondary procedure. Level of Evidence Therapeutic III, case-control study.
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Affiliation(s)
- Steffen Löw
- Section of Hand Surgery, Department of Orthopaedic and Trauma Surgery, Caritas-Krankenhaus, Bad Mergentheim, Germany
| | - Alexandra Herold
- Section of Hand Surgery, Department of Orthopaedic and Trauma Surgery, Caritas-Krankenhaus, Bad Mergentheim, Germany
| | - Frank Unglaub
- Department of Hand Surgery, Vulpius Clinic, Bad Rappenau, Germany
| | - Kai Megerle
- Department of Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Holger Erne
- Department of Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technische Universität München, München, Germany
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Arthroscopic one-tunnel transosseous foveal repair for triangular fibrocartilage complex (TFCC) peripheral tear. Arch Orthop Trauma Surg 2018; 138:131-138. [PMID: 29124362 DOI: 10.1007/s00402-017-2835-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Indexed: 02/09/2023]
Abstract
PURPOSE Arthroscopic repair of a peripheral triangular fibrocartilage complex (TFCC) tear is a promising, minimally invasive surgical technique, especially in patients with symptomatic distal radioulnar joint (DRUJ) instability. The purpose of this study was to evaluate the clinical result of arthroscopic one-tunnel transosseous foveal repair for peripheral TFCC tears. METHODS Sixteen patients who underwent TFCC foveal repair were retrospectively evaluated. The mean follow-up period was 31.1 months. The torn TFCC of all patients was repaired with the arthroscopic one-tunnel transosseous foveal repair technique. Postoperative outcomes were evaluated using the visual analogue scale (VAS) for pain, wrist range of motion, grip strength, Mayo wrist score, Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH) score, and postoperative complications. RESULTS On arthroscopic examination, all 16 patients showed Palmer 1B type peripheral TFCC tears with foveal disruption. Among them, 13 patients had a proximal component TFCC tear (Atzei class 3) and 3 patients had a complete TFCC tear (Atzei class 2). At the final follow-up, the mean range of the pronation-supination arc (P = 0.03) and grip strength (P = 0.001) was significantly increased. Twelve patients had normal stability of the DRUJ and six patients showed mild laxity compared with the contralateral side. The mean VAS for pain perception decreased from 3.7 to 0.8 (P = 0.001). The modified Mayo wrist (P = 0.001) and Quick DASH (P = 0.001) scores showed significant functional improvement. No surgery-related complications occurred. CONCLUSIONS The present study shows that arthroscopic one-tunnel transosseous repair is a good treatment strategy for TFCC foveal tears in terms of reliable pain relief, functional improvement, and re-establishment of DRUJ stability.
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Abstract
Determining the etiology of ulnar-sided wrist pain is often challenging. The condition may be acute or chronic, and differential diagnoses include injuries to the ulnar carpal bones, ligament tears, tendinitis, vascular conditions, osteoarthritis and systemic arthritis, and ulnar nerve compression. An anatomically based, methodical physical examination coupled with provocative maneuvers, including piano key, ulnar impaction, shuck, foveal stress, and extensor carpi ulnaris synergy tests, further defines the differential diagnosis. Diagnostic imaging used in the evaluation of ulnar-sided wrist pain includes plain radiographs and MRI with or without arthrography. Wrist arthroscopy is becoming increasingly important in the diagnosis and management of ulnar-sided intra-articular wrist pathology.
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Andersson JK, Hansson-Olofsson E, Karlsson J, Fridén J. Cost description of clinical examination and MRI in wrist ligament injuries. J Plast Surg Hand Surg 2017; 52:30-36. [DOI: 10.1080/2000656x.2017.1319845] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Jonny K. Andersson
- Department of Hand Surgery, Sahlgrenska University Hospital, Göteborg, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Elisabeth Hansson-Olofsson
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Jón Karlsson
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Jan Fridén
- Department of Hand Surgery, Sahlgrenska University Hospital, Göteborg, Sweden
- Centre for Advanced Reconstruction of Extremities, Sahlgrenska University Hospital, Mölndal, Sweden
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35
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Löw S, Erne H, Pillukat T, Mühldorfer-Fodor M, Unglaub F, Spies CK. Diagnosing central lesions of the triangular fibrocartilage as traumatic or degenerative: a review of clinical accuracy. J Hand Surg Eur Vol 2017; 42:357-362. [PMID: 28080158 DOI: 10.1177/1753193416684658] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED This study examined the reliability of surgeons' estimations as to whether central lesions of the triangular fibrocartilage complex were traumatic or degenerative. A total of 50 consecutive central triangular fibrocartilage complex lesions were independently rated by ten experienced wrist surgeons viewing high-quality arthroscopy videos. The videos were reassessed after intervals of 3 months; at the second assessment surgeons were given the patient's history, radiographs and both, each in a randomized order. Finally, the surgeons assessed the histories and radiographs without the videos. Kappa statistics revealed fair interrater agreement when the histories were added to the videos. The other four modalities demonstrated moderate agreement, with lower Kappa values for the assessment without videos. Intra-rater reliability showed fair agreement for three surgeons, moderate agreement for two surgeons and substantial agreement for five surgeons. It appears that classification of central triangular fibrocartilage complex lesions depends on the information provided upon viewing the triangular fibrocartilage complex at arthroscopy. LEVEL OF EVIDENCE II.
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Affiliation(s)
- S Löw
- 1 Department of Orthopaedic and Trauma Surgery, Caritas-Krankenhaus, Bad Mergentheim, Germany
| | - H Erne
- 2 Department for Plastic Surgery and Hand Surgery, Technische Universität München, München, Germany
| | - T Pillukat
- 3 Clinic for Hand Surgery, Rhön-Klinikum AG, Bad Neustadt/Saale, Germany
| | - M Mühldorfer-Fodor
- 3 Clinic for Hand Surgery, Rhön-Klinikum AG, Bad Neustadt/Saale, Germany
| | - F Unglaub
- 4 Department of Hand Surgery, Vulpius Clinic, Bad Rappenau, Germany
| | - C K Spies
- 4 Department of Hand Surgery, Vulpius Clinic, Bad Rappenau, Germany
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