Arthroscopic debridement of triangular fibrocartilage complex tears

Effectiveness of Platelet-rich Plasma Injection as an Adjunct Treatment to Arthroscopy for TFCC Injury: A Retrospective Cohort Study

Background

Triangular fibrocartilage complex (TFCC) injuries can cause significant patient dysfunction. Platelet-rich plasma (PRP) has emerged as a potential adjunctive treatment for arthroscopic TFCC repair, with some studies suggesting improved outcomes. This study aims to evaluate and compare PRP as an adjunctive treatment in arthroscopic TFCC tear repair.

Methods

This retrospective cohort study examined patients undergoing arthroscopic TFCC repair at Institut de la Main, Paris, France (December 2021-2022). Patients were split into two groups: arthroscopic repair alone (1) and repair with PRP injections (2). Physical examinations were conducted pre- and posttreatment, recording flexion, extension, and radial/ulnar deviation of the affected and contralateral wrists.

Results

A total of 33 patients (20 men and 13 women) with a mean age of 30.55 ± 9.17 years were included. PRP injections were given to 16 patients with arthroscopic TFCC repair; 17 had repair only. No significant differences existed preoperatively between groups in wrist function or pain (P > 0.05). The Quick Disabilities of the Arm, Shoulder, and Hand (DASH) score differed significantly (P = 0.004). The non-PRP group demonstrated better postoperative upper extremity function, with a mean Quick DASH score of 7.75 ± 5.91 compared with 12.64 ± 6.79 in the PRP group. No significant difference between groups was observed in the pain visual analog scale (P > 0.05).

Conclusions

PRP injections with TFCC repair did not improve function over repair alone. The non-PRP group showed better function (lower Quick DASH scores). Pain reduction was similar between groups. Larger trials and cost-effectiveness studies are needed to fully assess PRP's benefits in TFCC repair.

How Are Radial Height and Radial Shortening Defined in the Treatment of Distal Radius Fractures? A Critical Review

BACKGROUND

Radial height is a radiographic parameter used to guide the treatment of distal radius fractures. However, it is often used synonymously with other terms, and there are substantial discrepancies in its measurement/definition. These discrepancies can alter the measurement of radial height and affect treatment decisions. The purpose of this review is to identify the different definitions of radial height in the literature relevant to distal radius fractures.

METHODS

A literature review was conducted in the PubMed/MEDLINE database from inception to 2022. Full-length, English-language studies that pertained to distal radius fractures and reported radial height as a recorded measurement were included. The method of radial height measurement (definition) was extracted from included studies. Level of evidence was determined by the Oxford Centre for Evidence-based Medicine Levels of Evidence tool.

RESULTS

A total of 385 studies were identified. Of these, 183 (47.5%) did not provide a definition for radial height. Of the studies that defined radial height, 50.9% (103/202) measured radial height from the radial styloid to the distal ulna, 10.9% (22/202) measured from the radial styloid to the distal radius, and 29.2% (59/202) were "other" definitions.

CONCLUSIONS

There is substantial discrepancy in the way that radial height is measured and reported. We advocate for a standardized measurement of radial height (synonymous with radial length) from the radial styloid to the distal ulnar articular surface. Radial shortening is a different measurement and requires comparison with a reference value.

Prognostic factors for clinical outcomes after arthroscopic treatment of traumatic central tears of the triangular fibrocartilage complex

Aims

The study aimed to assess the clinical outcomes of arthroscopic debridement and partial excision in patients with traumatic central tears of the triangular fibrocartilage complex (TFCC), and to identify prognostic factors associated with unfavourable clinical outcomes.

Methods

A retrospective analysis was conducted on patients arthroscopically diagnosed with Palmer 1 A lesions who underwent arthroscopic debridement and partial excision from March 2009 to February 2021, with a minimum follow-up of 24 months. Patients were assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, Mayo Wrist Score (MWS), and visual analogue scale (VAS) for pain. The poor outcome group was defined as patients whose preoperative and last follow-up clinical score difference was less than the minimal clinically important difference of the DASH score (10.83). Baseline characteristics, arthroscopic findings, and radiological factors (ulnar variance, MRI, or arthrography) were evaluated to predict poor clinical outcomes.

Results

A total of 114 patients were enrolled in this study, with a mean follow-up period of 29.8 months (SD 14.4). The mean DASH score improved from 36.5 (SD 21.5) to 16.7 (SD 14.3), the mean MWS from 59.7 (SD 17.9) to 79.3 (SD 14.3), and the mean VAS pain score improved from 5.9 (SD 1.8) to 2.2 (SD 2.0) at the last follow-up (all p < 0.001). Among the 114 patients, 16 (14%) experienced poor clinical outcomes and ten (8.8%) required secondary ulnar shortening osteotomy. Positive ulnar variance was the only factor significantly associated with poor clinical outcomes (p < 0.001). Positive ulnar variance was present in 38 patients (33%); among them, eight patients (21%) required additional operations.

Conclusion

Arthroscopic debridement alone appears to be an effective and safe initial treatment for patients with traumatic central TFCC tears. The presence of positive ulnar variance was associated with poor clinical outcomes, but close observation after arthroscopic debridement is more likely to be recommended than ulnar shortening osteotomy as a primary treatment.

An All-arthroscopic Technique of Repair of Substance Tears of the Triangular Fibrocartilage Complex in Symptomatic Patients

Substance tears of the triangular fibrocartilage complex (TFCC) can occur secondary to trauma of the wrist. On the dorsal periphery, they are considered Palmer 1B tears or Atzei class 1 tears. If along the radial side, they can manifest as a tear of the central disc, classified as a Palmar class 1A tear. If it involves the ligaments, it is stated as a pre-1D tear as per the new classification system by Luchetti and colleagues. Multiple excellent repair techniques exist in the current literature for dorsal peripheral tears and even for those in the substance of the TFCC, whereas there are successful evolving techniques of repair of avulsed tears and those involving the substance of the ligaments on the radial side adjacent to the sigmoid notch. Here, we describe our technique of repairing substance tears of the TFCC arthroscopically without the need for any specialized equipment apart from the basic arthroscopy set. The technique was conducted in a patient with a transverse substance tear on the radial side of the triangular fibrocartilage involving the central disc with complete resolution of symptoms. It is a simple technique, which can be used to repair class 1B peripheral tears and pre-1D tears in the substance of the TFCC.

Advances in wrist arthroscopic surgery in Indonesia

Since the 1990s, new insights in wrist arthroscopy have led to the introduction of numerous treatment methods. Consequently, therapeutic procedures are no longer limited to resection as more specialized repair and functional reconstruction methods, involving tissue replacement and essential structural augmentation, have been shown to be beneficial. This article discusses the most prevalent reasons and uses for wrist arthroscopy, with an emphasis on Indonesia’s most recent and major advances in reconstructive arthroscopic surgery. Joint debridement, synovectomy, ganglionectomy, capsular release, and osteotomies are frequent resection operations. Ligament repair and arthroscopy-aided reduction and fixation for fractures and nonunion are all examples of reconstructive surgery.

Surveying the Use and Perceptions of Wrist Arthroscopy Among Upper Extremity Surgeons

This study describes current trends in the skill acquisition and practice patterns for wrist arthroscopy among upper extremity surgeons. A survey was sent to the membership of the American Association for Hand Surgery (AAHS). A total of 104 responses were available for analysis. Of those respondents who did not use wrist arthroscopy, lack of educational training was cited as the most common reason. Of those who did use arthroscopy, fellowship training was credited as the primary source. However, most of those who completed an instructional course felt immediately able to perform arthroscopy. Triangular fibrocartilage complex tears were recorded as the most common indication. Surgeons frequently evaluated the midcarpal joint, but did not frequently use arthroscopy for distal radio-ulnar joint or carpometacarpal joint pathology. Ultimately, this highlights an area of improvement for residency and fellowship education. [Orthopedics. 2022;45(5):310-313.].

Differentiated Approaches to Treat Lesions of the TFCC Based on new arthroscopic Classification

In this article, pathology of the TFCC lesions, image diagnosis and arthroscopic examination were described. According to the radiocarpal arthroscopic findings, TFCC lesions are classified into intra-disc lesions (Class 1), radial lesion (Class 2), peripheral disc lesions which indicate slight to moderate DRUJ instability (Class 3) and degenerative lesion (Class 4). The radioulnar ligament (RUL) lesions that indicate moderate to severe DRUJ instability were classified with staging system with DRUJ arthroscopic findings (Stage 1 to 5). Author's treatment algorism with wrist arthroscopic findings including DRUJ arthroscopy was demonstrated and along with this algorism, various arthroscopic and open techniques to treat TFCC injuries were selected and resulted in success. Precise diagnosis of the TFCC lesions helped to select an adequate treatment for each lesion.Dieser Artikel beschreibt die pathologischen Veränderungen des TFCC sowie deren Befunde in der Bildgebung und Arthroskopie. Am TFCC lassen sich mittels Arthroskopie bei Sicht von radiokarpal zentrale (Typ 1), radiale (Typ 2) sowie periphere Läsionen (Typ 3), die mit einer moderaten Instabilität des distalen Radioulnargelenkes (DRUG) einhergehen, und degenerative Läsionen (Typ 4) unterscheiden. Läsionen der radioulnaren Bänder, die mit einer moderaten bis ausgeprägten Instabilität des DRUG vergesellschaftet sind, werden anhand der Befunde bei der DRUG-Arthroskopie in fünf Stadien eingeteilt. Diesen unterschiedlichen Befunden angepasst wurde ein Behandlungsalgorithmus mit verschiedenen arthroskopischen und offenen Verfahren entwickelt, der sich als erfolgreich erwies. Eine exakte Klassifizierung von TFCC-Läsionen ermöglicht die Wahl des für die jeweilige Läsion adäquaten Therapieverfahrens.

Arthroscopic Wafer Procedure Versus Ulnar Shortening Osteotomy for Treatment of Idiopathic Ulnar Impaction Syndrome: A Randomized Controlled Trial

PURPOSE

We compared the arthroscopic wafer procedure (AWP) and ulnar shortening osteotomy (USO) for treatment of idiopathic ulnar impaction syndrome in terms of clinical, functional improvement and time of return to work.

METHODS

This single-center study was conducted at an academic level 1 referral center between 2014 and 2020. Sixty patients with idiopathic ulnar impaction syndrome were prospectively randomized to treatment with either AWP or USO. At the final follow-up, patients were evaluated by the Disabilities of the Arm, Shoulder, and Hand; the Modified Mayo Wrist Score; the visual analog scale for pain; wrist range of motion; and grip strength. Also, the time of return to work and complications were reported.

RESULTS

The mean follow-up periods were 22 ± 5.7 months in the AWP group and 21.1 ± 5.3 months in the USO group. All patients in the USO group achieved union by 12 weeks. At the final follow-up, there were no statistically significant differences in the outcome measures (Disabilities of the Arm, Shoulder, and Hand score; Modified Mayo Wrist Score; visual analog scale score; range of motion; and grip strength) in either group. Fewer complications and an earlier return to work were observed in the AWP group.

CONCLUSIONS

Both techniques yielded comparable outcomes, with earlier return to work, a lower incidence of complications, and fewer secondary procedures in the AWP group.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Ulnar shortening osteotomy vs. wafer resection for ulnar impaction syndrome: A systematic review and meta-analysis

BACKGROUND

Ulnar shortening osteotomy (USO) is the most common operation to treat ulnar impaction syndrome (UIS). An alternative to USO is the arthroscopic wafer procedure (AWP). Few studies have directly compared USO and AWP in patients with UIS. This study compared ulnar shortening osteotomy (USO) versus arthroscopic wafer procedure (AWP) for UIS treatment.

MATERIALS AND METHODS

PubMed, EMBASE, the Cochrane Library, Wanfang, and CNKI were systematically searched for reports published before March 2021. The outcomes included Modified Mayo Wrist Score, Darrow's Criteria, Disability of Arm, Shoulder, and Hand (DASH), grip strength, visual analog scale (VAS) score, and time to resume manual occupation.

RESULTS

Seven studies (133 and 118 patients with USO and AWP, respectively) were included. There were no differences in combined Darrow's Criteria or Modified Mayo Wrist Score, Modified Mayo Wrist Score, Darrow's Criteria, revision rate, DASH score, VAS score, and time to resume manual occupation. Grip strength was better with AWP (SMD = -0.73, 95%CI: -1.36, -0.11, P = 0.022). Differences were seen for ulna positive variation, favoring USO (WMD = -2.75, 95%CI: -5.17, -0.33, P = 0.026).

CONCLUSIONS

In the surgical treatment of UIS, AWP might be associated with improved grip strength, while USO seems to show better results in treating pronounced ulna positive variation. Only evidence of moderate quality could be included in this meta-analysis.

History of Wrist Arthroscopy

Wrist arthroscopy has a rich history, drawing on contributions from around the world. Its foundation was laid in Japan with Kenji Takagi and Masaki Watanabe, who developed the arthroscope and the techniques for arthroscopy. Across several decades they advanced the optic and lighting technology, allowing the miniaturization which made wrist arthroscopy technologically feasible. A safe and standardized technique for wrist arthroscopy was evolved by Terry Whipple, Gary Poehling, and James Roth in the 1980s, and they shared this with their fellow surgeons through courses and publications. The techniques then spread across the world, leading to widespread uptake and exploration of new therapeutic possibilities. The worldwide spread of wrist arthroscopy was accelerated by the European Wrist Arthroscopy Society (EWAS), founded in 2005 by Christophe Mathoulin. The Asia Pacific Wrist Association (APWA), founded by PC Ho in 2015, also extended the progression of wrist arthroscopy. This article brings together this history and tells the global story of its development through the recollections of those involved. The manuscript includes some amazing videos of the early historical arthroscopy. There are also videos of Gary and Terry describing some of their special memories of the early politics, developments, and evolution of wrist arthroscopy.

Revolutions in arthroscopic wrist surgeries

Recent technical and technological developments in wrist arthroscopic surgery allow for advanced treatments of difficult wrist disorders. In this review, world leaders of wrist arthroscopy describe bone graft for scaphoid nonunion, transosseous repair for triangular fibrocartilage fovea avulsion, palmaris longus reconstruction of the triangular fibrocartilage, and arthroscopic reconstruction of the scapholunate and lunotriquetral ligaments.

Long-term outcome after arthroscopic debridement of Palmer type 2C central degenerative lesions of the triangular fibrocartilage complex

PURPOSE

The purpose of this study was to report long-term objective and patient-reported outcome after arthroscopic debridement of central degenerative triangular fibrocartilage complex (TFCC) lesions.

METHODS

A total of 17 patients with central degenerative TFCC (Palmer type 2C) lesions and ulnar positive variance who were treated by arthroscopic debridement were retrospectively reviewed. Mean follow-up was 8.8 years. Assessment facilitating the Modified Mayo Wrist score (MMWS), the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH score), recording of pain level and of patient satisfaction, and radiological examination were done.

RESULTS

Patients reached a pain level of 1.7 VAS, MMW score of 92, and DASH score of 22. No significant differences could be detected between the operated and the contralateral extremity regarding range of motion and grip strength for all patients. No perioperative complications occurred.

CONCLUSION

Arthroscopic debridement of central degenerative TFCC lesions is safe, reliable, and efficacious even for ulnar positive variance.

LEVEL OF EVIDENCE

Therapeutic IV.

Arthroscopic Treatment Results of Triangular Fibrocartilage Complex Tears in Adolescents: A Systematic Review

INTRODUCTION

Injury to the triangular fibrocartilage complex (TFCC) may cause chronic wrist pain and instability if left untreated. The current literature of adult cases suggests that arthroscopic treatment offers favorable outcomes and is associated with a low complication rate. This systematic review evaluated the outcomes of arthroscopic TFCC surgery in adolescents.

MATERIALS AND METHODS

A PRISMA-guided literature search of PubMed, Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Cochrane Clinical Answers was conducted in May 2020. All studies reporting on (1) arthroscopic TFCC repair or debridement in (2) patients under the age of 19 years with (3) a minimum case number of four patients were extracted by two independent observers. The level of evidence of each study was assessed according to the Oxford Centre for Evidence-Based Medicine, and study quality was graded according to the Modified Coleman Methodology Score and the MINORS criteria. Clinical outcome scores, functional parameters, and any complications were reviewed.

RESULTS

The selected search terms initially resulted in a total of 986 possible articles. The authors eventually identified eight papers (all LoE IV) for inclusion in this systematic review. A total of 254 patients with verified TFCC tears and a mean age of 16 years (range, 7-19) received arthroscopic repair (162 patients, 67.1% of total) or debridement (77 patients, 29.7% of total). Arthroscopic treatment resulted in low pain levels, high patient satisfaction, and a fast return to sport. Complications overall were sparse and consisted mainly of persistent wrist pain (n = 31) and temporary paresthesia (n = 6) of the dorsal sensory branch of the ulnar nerve. Recurrent tears were sparse, with only four reported cases due to sports participation.

CONCLUSION

Wrist arthroscopy is a reliable surgical option for treating TFCC tears in adolescents. The results obtained are comparable to those published in the literature. However, the variety of repair techniques and the low level of evidence across all included articles demand further prospective studies.

Outcome of conservative treatment for triangular fibrocartilage complex lesions with stable distal radioulnar joint

Purpose

Triangular fibrocartilage complex (TFCC) lesions have high clinical relevance. Although multiple studies have been done in the past, there is a lack of data after conservative treatment and controversy remains regarding management. The purpose of this study was to compare the outcome of symptomatic TFCC lesions after conservative treatment and arthroscopic debridement.

Methods

Between 2012 and 2017, 33 patients were included. 16 patients were treated conservatively and 17 patients with arthroscopic debridement. The average age was 41 years (range 18–63). The mean follow-up was 22.2 months (range 6–74). Evaluation included pain, range of motion (ROM), grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) score, Modified Mayo Wrist Score (MMWS), and Purdue Pegboard test.

Results

Pain averaged 0.1 (range 0–1) in the conservative group compared to 1.3 (range 0–6) in the arthroscopic group. The mean ROM was 99% for wrist extension, and 100% for flexion and pro-/supination in the conservative group, and 96% for extension and flexion, and 100% for pro-/supination in the arthoscopic group compared to the contralateral side. Grip strength was 88% (range 63–100) in the conservative group versus 89% (range 33–100) in the arthroscopic group. The conservative group reached a DASH score of 16.8 and MMWS of 94.3 compared to 22.1 and 87.2 in the arthroscopic group. The differences were not statistically significant.

Conclusions

Our study demonstrated similar results of conservative compared to arthroscopic treatment. Because conservative treatment was a sufficient and reliable option, we propose it as first-line treatment for TFCC lesions with stable distal radioulnar joint.

Comparison between conventional MRI and MR arthrography in the diagnosis of triangular fibrocartilage tears and correlation with arthroscopic findings

PURPOSE

The triangular fibrocartilage complex is one of the most important stabilizers of the wrist and a defect in its anatomical structure is a possible cause of ulnar sided wrist pain. The aim of this study is to compare the diagnostic accuracy between conventional MRI and MR arthrography (MRA) in the depiction of triangular fibrocartilage complex (TFCC) tears.

METHODS-MATERIALS

A total of 60 patients with clinical findings that suggested TFCC tears underwent wrist MRI and MRA. All the MRI and MRA results were compared with the arthroscopic findings.

RESULTS

40 tears were confirmed by arthroscopy. 38/40 tears were identified by MRA while MRI identified 26/40 tears. There were also 8 false positives and 13 false negative results identified by MRI. Two false negative results were identified by MRA. No false positive results were identified.

CONCLUSION

MR arthrography is more sensitive and specific method in terms of the diagnosis of TFCC tears compared to conventional wrist MRI. There was no difference in the diagnostic accuracy between wrist arthroscopy and MRA.

Perceptions and experiences of wrist surgeons on the management of triangular fibrocartilage complex tears: a qualitative study

There is lack of consensus on the management of triangular fibrocartilage injuries. The aim of this study was to investigate wrist surgeons' experiences and perceptions regarding treatment of triangular fibrocartilage complex injuries and to explore the rationale behind clinical decision-making. A purposive sample of consultant wrist surgeons (n = 10) was recruited through 'snow-balling' until data saturation was reached. Semi-structured interviews were conducted, digitally recorded and transcribed verbatim. Two researchers independently analysed data using an iterative/thematic approach. Findings suggest that surgeons rely more on their own training and experience, and patient-related factors such as individual expectations, to inform their decision-making, rather than on published material. Current classification systems are largely considered to be unhelpful. Level of evidence: V.

Return to sport following surgical management of triangular fibrocartilage tears: a systematic review

INTRODUCTION

This review aims to provide information on return rates and times to return to sport following surgical management of triangular fibrocartilage (TFC) tears.

SOURCES OF DATA

A systematic search of CINAHAL, Cochrane, EMBASE, Google Scholar, Medline, PEDro, Scopus, SPORTDiscus and Web of Science was performed using the keywords 'triangular', 'fibro-cartilage', 'complex', 'tear', 'distal radio-ulnar joint', 'athletes', 'sports', 'non-operative', 'conservative', 'operative' and 'return to sport'.

AREAS OF AGREEMENT

In all of the 10 studies included, conservative management for 6 weeks to 6 months was the first-line treatment. If symptoms persisted following this period, surgical management was advised. Arthroscopic debridement was recommended for central tears, and arthroscopic repair was recommended for peripheral tears.

AREAS OF CONTROVERSY

The optimal treatment modalities for TFC tears remain to be defined.

GROWING POINTS

Traumatic central tears can be treated with arthroscopic debridement alone. Arthroscopic repair with an all-inside repair can improve return rates to sport over an outside-in technique for ulna-sided tears.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future prospective studies should aim to establish the optimal treatment modalities for TFC tears.

Prognostic Factors of Arthroscopic Debridement for Central Triangular Fibrocartilage Complex Tears in Adults Younger Than 45 Years: A Retrospective Case Series Analysis

PURPOSE

The purpose of this study was to analyze factors that affect the treatment outcomes of arthroscopic debridement for central triangular fibrocartilage complex (TFCC) lesions in adults <45 years of age.

METHODS

A total of 71 patients (mean age, 39 years; range, 20-44 years) who had been arthroscopically diagnosed with central TFCC tears were treated with arthroscopic debridement. Demographic, clinical, and arthroscopic findings were examined and analyzed. The response to treatment, including pain numeric rating scale on an ulnar provocation test; Disability of the Arm, Shoulder, and Hand score; and satisfaction with treatment, was assessed at 12-month follow-up.

RESULTS

The mean pain numeric rating scale (6.6 ± 3.6 to 2.4 ± 2.0, P < .01) and Disability of the Arm, Shoulder, and Hand (59.3 ± 15.0 to 33.7 ± 14.1, P < .01) scores exhibited significant clinical improvement at 12-month follow-up. In terms of satisfaction, 43 patients (70.5%) were satisfied (enthusiastic or satisfied) and 18 (29.5%) were dissatisfied (noncommittal or disappointed). In the satisfied group, there were 24 flap and 19 wearing tears, whereas in the dissatisfied group, there were 4 flap and 14 wearing tears (P = .02). The extent of ulnar plus variance on preoperative radiographs also differed between the 2 groups (0.5 ± 1.2 vs 1.7 ± 1.1, P < .01). There were no significant differences in age, gender, hand dominance, or work level between the groups. After controlling for confounding variables, the wearing type tears (odds ratio, 3.4) and greater ulnar plus variance (odds ratio, 2.0) were associated with a higher likelihood of dissatisfaction after arthroscopic TFCC debridement.

CONCLUSIONS

Although clinical outcome scores showed significant improvement after arthroscopic debridement for central TFCC tears, wearing type tears and greater ulnar plus variance were associated with dissatisfaction and poorer postoperative outcomes after the procedure.

LEVEL OF EVIDENCE

Level IV, case series.

Editorial Commentary: Arthroscopic Triangular Fibrocartilage Complex Debridement May or May Not Help With Ulnar-Sided Wrist Pain

After ruling out additional potential pain generators for ulnar-sided wrist pain, arthroscopic debridement for triangular fibrocartilage complex pathology can be an effective means for decreasing pain and improving function in the short term. Arthroscopic skills aside, this procedure will not work for all comers, and establishing realistic patient expectations is essential for optimal outcomes.

Prevalence and clinical characteristics of radiographic central triangular fibrocartilage complex tears in symptomatic and asymptomatic individuals younger than 50 years

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.

Arthroscopic Assisted Resection of Triangular Fibrocartilage Complex Lesions: A 19-Year Follow-up

BACKGROUND

This study assesses long-term functional and subjective outcomes following arthroscopic assisted resection of lesions of the triangular fibrocartilage complex (TFCC).

METHODS

Functional and subjective outcomes were assessed based on review of patient charts for patient demographic characteristics, comprehensive clinical evaluation, obtained radiographs, and patient-reported questionnaires.

RESULTS

Fifteen patients, of whom 9 were female, and 10 dominant wrists, were included in this study. Median age was 60 (range, 37-73) years, and median duration of follow-up was 19 (range, 18-21) years. Median Mayo Wrist Score was 85 (range, 45-100). Four patients scored excellent, 7 good, 3 fair, and 1 poor result according to the Modified Mayo Wrist Score. Median Quick Disabilities of the Arm, Shoulder and Arm was 20 (range, 0-45) and Patient-Rated Wrist and Hand Evaluation was 8 (range, 0-61). Patients reported high rate for satisfaction and low rate for pain. All patients presented intact stability of the distal radioulnar joint.

CONCLUSIONS

This study demonstrates persisting satisfactory subjective and functional outcomes for patients following arthroscopic assisted resection for lesions of the TFCC at 19 years of follow-up. Arthroscopically assisted resection of selected TFCC lesions seems to be both a safe and efficient procedure.

Results after arthroscopic treatment of central traumatic lesions of the triangular fibrocartilage complex

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.

Open versus arthroscopic repair of the triangular fibrocartilage complex: a systematic review

Background and purpose

To investigate the outcome of open versus arthroscopic repair of injuries of the triangular fibrocartilage complex (TFCC).

Methods

An electronic literature search of articles published between January 1, 1985, and May 26, 2016, in PubMed, Embase, and the Cochrane Library was carried out in May 2016 and updated in March and December 2017. Studies comparing open and arthroscopic repair of TFCC injury with a mean follow up of more than 1 year were eligible for inclusion. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist guided the extraction and reporting of data. The methodological quality of the included articles was assessed with the Cochrane Collaboration’s tool for assessing risk of bias. The primary outcome measure was the rate of postoperative distal radioulnar joint (DRUJ) re-instability. Secondary outcome measures were range of motion (ROM), grip strength, residual pain, functional wrist scores and the rates of complications and re-operations.

Results

A total of 868 articles were identified by the electronic search. After duplicate removal and subsequent study selection, a total of two studies were included in this systematic review. The methodological quality of the included articles displayed risks of bias. There was no difference in DRUJ re-instability between open and arthroscopic repair of the TFCC. There were no differences in obtained postoperative ROM, grip strength or values in functional outcome scores, between open and arthroscopic TFCC repair in the two included studies, except for the Disability of the Arm Shoulder and Hand (DASH) questionnaire - in favor of arthroscopic surgery - in one of the included studies.

Conclusions

This systematic review shows comparable results between open and arthroscopic repair of the TFCC, in terms of DRUJ re-instability and functional outcome scores. There is insufficient evidence to recommend one technique over the other in clinical practice. There is an immense lack of comparison studies with high level of evidence in the area of wrist ligament repair and reconstruction, including TFCC-injuries and DRUJ-instability.

Arthroscopic Wafer Procedure Versus Ulnar Shortening Osteotomy as a Surgical Treatment for Idiopathic Ulnar Impaction Syndrome

PURPOSE

To compare clinical and radiologic outcomes and complication rates of the arthroscopic wafer procedure (AWP) and ulnar shortening osteotomy (USO) for idiopathic ulnar impaction syndrome (UIS).

METHODS

From May 2009 to June 2014, 42 patients who were aged 45 years or older with idiopathic UIS underwent either the AWP or USO under the following identical surgical indications: (1) less than 4 mm of positive ulnar variance, (2) Palmer classification 2C or 2D lesion of the triangular fibrocartilage complex, (3) stable distal radioulnar joint (DRUJ) and/or lunotriquetral joint, and (4) no evidence of osteoarthritis of the DRUJ or ulnocarpal joint. The patient assignment was not randomized. Were used a visual analog scale for ulnar wrist pain; grip strength; range of motion; the Mayo Wrist Score (MWS); and the Disabilities of the Arm, Shoulder and Hand (DASH) score at 3, 6, 12, and 24 months after surgery to compare clinical outcomes. Ulnar variance, cystic changes of the lunate and triquetrum, and DRUJ arthritis on radiographs and operation-related complications were compared.

RESULTS

This study evaluated 19 patients after the AWP and 23 patients after USO. At 3 months, the AWP produced significantly better outcomes than USO regarding grip strength (79.6% ± 14.3% vs 62.7% ± 12.6%, P < .001), MWS (81.8 ± 7.9 points vs 71.3 ± 14.2 points, P = .005), and DASH score (19.4 ± 8.4 vs 31.5 ± 14.0, P = .001); clinical outcomes were similar at 6, 12, and 24 months. The complication rates were 34.8% for USO and 10.5% for the AWP; complications included DRUJ arthritis (n = 4), implant irritation (n = 6), and refracture after implant removal (n = 2) in the USO group and secondary surgery (n = 1) and tendinopathy (n = 1) in the AWP group.

CONCLUSIONS

The AWP and USO for idiopathic UIS with subtle positive ulnar variance achieved similar clinical and radiologic outcomes at 2 years after surgery. However, compared with USO, the AWP showed lower complication rates and better grip strength, MWS values, and DASH scores at 3 months after surgery.

LEVEL OF EVIDENCE

Level III, comparative trial.

Outcomes after Arthroscopic Debridement of the Triangular Fibrocartilage Complex in Adolescents

Background  To the best of our knowledge, we are not aware of any reports focusing on results of arthroscopic debridement of triangular fibrocartilage complex (TFCC) tears in immature patients. Purpose  The purpose of this study was to evaluate our results after arthroscopic debridement of TFCC tears in adolescents. Materials and Methods  We retrospectively identified all patients of 18 years or less, who received an arthroscopic TFCC debridement due to a traumatic or degenerative tear according to Palmer. These cases were clinically re-evaluated after a mean period of 6.7 years (SD ± 3.9 years). All patients completed the Modified Mayo Wrist Score (MMWS), Disabilities of the Arm, Shoulder and Hand (DASH) inventory, and Patient-Rated Wrist Evaluation (PRWE). Results  Thirteen adolescent patients (mean age: 15.6 ± 2.2 years at surgery) were included. The mean MMWS increased significantly from 70 ± 13.6 to 90 ± 6.5 after the TFCC debridement; mean postoperative DASH and PRWE scores of 17 ± 15.2 and 21 ± 18.5, respectively, indicated good and excellent outcomes for the majority of the cohort. The mean pain level decreased significantly from a mean of 5.7 ± 2.0 to 1.8 ± 2.0 at follow-up. Six patients needed a reoperation to achieve a successful outcome. Conclusion  Arthroscopic debridement of TFCC tears, performed as a concomitant wrist surgery in adolescents, efficiently reduced wrist pain and yielded good to excellent results in the long term. However, under certain circumstances, its results are unpredictable and further surgery may be necessary to eventually achieve the satisfying outcomes. Further studies are needed to confirm these findings. Level of Evidence  Level IV, therapeutic case series.

A Systematic Review of Outcomes after Arthroscopic Débridement for Triangular Fibrocartilage Complex Tear

BACKGROUND

Evidence regarding the effectiveness of arthroscopic débridement for a triangular fibrocartilage complex tear is uncertain. The purpose of this study was to conduct a systematic review of outcomes to evaluate the effectiveness of débridement for triangular fibrocartilage complex tears.

METHODS

The authors searched all available literature in the PubMed, Embase, and MEDLINE (Ovid) databases for articles reporting on triangular fibrocartilage complex tear débridement. Data collection included arc of motion, grip strength, patient-reported outcomes, and complications.

RESULTS

A total of 1723 unique studies were identified, of which 18 studies met the authors' criteria. The mean before and after arc of wrist extension/flexion motion values were 120 and 146 degrees (six studies). The mean before and after grip strength values were 65 percent and 91 percent of the contralateral side (10 studies). Disabilities of the Arm, Shoulder, and Hand scores (six studies) and pain visual analogue scale scores (seven studies) improved from 39 to 18, and from 7 to 3, respectively. The mean pain visual analogue scale score after débridement was 1.9 in the ulnar-positive group and 2.4 in the ulnar-neutral and ulnar-negative groups. Eighty-seven percent of patients returned to their original work.

CONCLUSIONS

Patients reported reduced pain and improved functional and patient-reported outcomes after débridement of triangular fibrocartilage complex tears. Most patients after débridement returned to previous work, with few complications. Although some of these cases may require secondary procedures, simple débridement can be performed with suitable satisfactory outcomes for cases with any type of ulnar variance.

Wrist Arthroscopy for Athletic Injuries

Management of hand and wrist injuries for athletes often places emphasis on an expeditious return to sport. Arthroscopic techniques have the advantage of directly visualizing joint derangements and correcting them via a minimally invasive approach. This article discusses the evaluation and management of common wrist injuries treated with arthroscopy in athletes, including scapholunate and lunotriquetral injury, triangular fibrocartilage complex tears, hamatolunate impingement, and arthroscopic-assisted reduction of wrist fractures.

Suture Anchor Repair of Ulnar-Sided Triangular Fibrocartilage Complex Tears

Traditional open repair of traumatic triangular fibrocartilage complex (TFCC) tears requires a relatively extensive exposure, and arthroscopic repair, though conceptually simple, can be technically demanding. We describe a mini-open suture anchor technique that, while minimally invasive, is easier to perform than previously described open or arthroscopic techniques. Results achieved using this technique in eight cases compare favourably with those reported for other techniques.

A long-term (20 years') follow-up after arthroscopically assisted repair of the TFCC

OBJECTIVE

The present study aimed to assess long-term functional outcome for patients after arthroscopic assisted suture for peripheral tears of the triangular fibrocartilage complex (TFCC).

METHODS

Eleven patients, 26 (15-59) years old at time of surgery, 48 (35-78) years old at time of follow-up, were available for this 20-year follow-up. Subjective and objective outcomes, such as range of motion, grip strength, patients' satisfaction, pain, and Mayo Modified Wrist Score, were assessed, as well as asking the question if the patients would have had the surgery done again, knowing the outcome, based on a clinical examination and patient reported questionnaires.

RESULTS

Median Mayo Wrist score was 85 (30-100) and, according to the Modified Mayo Wrist Score, seven patients presented good or excellent results. The patients reported median low 25 (0-66) on pain and median high 90 (1-100) on satisfaction. Ten patients presented with intact stability of the distal radioulnar joint at follow-up. Compared to the level of pain prior to surgery, two patients reported to be free of pain, five patients experienced major pain relief, two patients reported minor pain relief, while two patients reported no difference.

CONCLUSIONS

The findings of the present study support the trend of persisting good results for the majority of patients having undergone arthroscopically assisted repair with an outside-in suture technique for peripheral tears of the TFCC.

Effects on the Distal Radioulnar Joint of Ablation of Triangular Fibrocartilage Complex Tears With Radiofrequency Energy

PURPOSE

This cadaver study investigated the temperature profile in the wrist joint and distal radioulnar joint (DRUJ) during radiofrequency energy (RFE) application for triangular fibrocartilage complex resection.

METHODS

An arthroscopic partial resection of the triangular fibrocartilage complex using monopolar and bipolar RFE was simulated in 14 cadaver limbs. The temperature was recorded simultaneously in the DRUJ and at 6 other anatomic locations of the wrist during RFE application.

RESULTS

The mean temperature in the DRUJ was 43.3 ± 8.2°C for the bipolar system in the ablation mode (60 W) and 30.4 ± 3.4°C for the monopolar system in the cut mode (20 W) after 30 seconds. The highest measured temperature in the DRUJ was 54.3°C for the bipolar system and 68.1°C for the monopolar system.

CONCLUSIONS

The application of RFE for debridement or resection of the triangular fibrocartilage complex in a clinical setting can induce peak temperatures that might cause damage to the cartilage of the DRUJ. Bipolar systems produce higher mean temperatures than monopolar devices.

CLINICAL RELEVANCE

RFE application increases the mean temperature in the DRUJ after 30 seconds to a level that may jeopardize cartilage tissue.

The Value of Wrist Arthroscopy

In order to evaluate diagnostic and therapeutic wrist arthroscopy we analyzed 129 arthroscopies with a follow-up of at least 6 months. Seventy-seven arthroscopies were performed for therapeutic purposes; 52 arthroscopies were diagnostic. There were diagnostic benefits in 55 arthroscopies (42.5%), therapeutic benefits in 29 arthroscopies (22.5%), combined diagnostic and therapeutic benefits in 39 (30%) and no benefits in six (5%).

In 65 cases of the therapeutic group (with preoperative diagnosis) the authors found that the arthroscopy had been worthwhile. For the diagnostic group without a preoperative diagnosis, an arthroscopic diagnosis was made in 44 cases.

Complications occurred in two patients: one tendon incision over a Kirschner wire in the therapeutic group and one superficial infection in the diagnostic group.

High-Resolution 3T MR Imaging of the Triangular Fibrocartilage Complex

This study is intended as a review of 3Tesla (T) magnetic resonance (MR) imaging of the triangular fibrocartilage complex (TFCC). The recent advances in MR imaging, which includes high field strength magnets, multi-channel coils, and isotropic 3-dimensional (3D) sequences have enabled the visualization of precise TFCC anatomy with high spatial and contrast resolution. In addition to the routine wrist protocol, there are specific techniques used to optimize 3T imaging of the wrist; including driven equilibrium sequence (DRIVE), parallel imaging, and 3D imaging. The coil choice for 3T imaging of the wrist depends on a number of variables, and the proper coil design selection is critical for high-resolution wrist imaging with high signal and contrast-to-noise ratio. The TFCC is a complex structure and is composed of the articular disc (disc proper), the triangular ligament, the dorsal and volar radioulnar ligaments, the meniscus homologue, the ulnar collateral ligament (UCL), the extensor carpi ulnaris (ECU) tendon sheath, and the ulnolunate and ulnotriquetral ligaments. The Palmer classification categorizes TFCC lesions as traumatic (type 1) or degenerative (type 2). In this review article, we present clinical high-resolution MR images of normal TFCC anatomy and TFCC injuries with this classification system.

Ulnar Shortening Osteotomy After Distal Radius Fracture Malunion: Review of Literature

Malunion of distal radius fracture is often complicated with shortening of the radius with disturbed radio- ulnar variance, frequently associated with lesions of triangular fibrocartilage complex and instability of the distal radioulnar joint. Positive ulnar variance may result in wrist pain located in ulnar part of the joint, limited ulnar deviation and forearm rotation with development of degenerative changes due to the overloading that occurs between the ulnar head and corresponding carpus. Ulnar shortening osteotomy (USO) is the standard procedure for correcting positive ulnar variance. Goal of this procedure is to minimize the symptoms by restoring the neutral radio - ulnar variance. In this paper we present a variety of surgical techniques available for ulnar shorthening osteotomy, their advantages and drawbacks. Methods of ulnar shortening osteotomies are divided into intraarticular and extraarticular. Intraarticular method of ulnar shortening can be performed arthroscopically or through open approach. Extraarticular methods include subcapital osteotomy and osteotomy of ulnar diaphysis, which depending on shape can be transverse, oblique, and step cut. All of those osteotomies can be performed along wrist arthroscopy in order to dispose and treat possibly existing triangular fibrocartilage complex injuries. At the end we described surgical procedures that can be done in case of ulnar shorthening osteotomy failure.

Functionality after arthroscopic debridement of central triangular fibrocartilage tears with central perforations

PURPOSE

To investigate functional and subjective outcome parameters after arthroscopic debridement of central articular disc lesions (Palmer type 2C) and to correlate these findings with ulna length.

METHODS

Fifty patients (15 men; 35 women; mean age, 47 y) with Palmer type 2C lesions underwent arthroscopic debridement. Nine of these patients (3 men; 6 women; mean static ulnar variance, 2.4 mm; SD, 0.5 mm) later underwent ulnar shortening osteotomy because of persistent pain and had a mean follow-up of 36 months. Mean follow-up was 38 months for patients with debridement only (mean static ulnar variance, 0.5 mm; SD, 1.2 mm). Examination parameters included range of motion, grip and pinch strengths, pain (visual analog scale), and functional outcome scores (Modified Mayo Wrist score [MMWS] and Disabilities of the Arm, Shoulder, and Hand [DASH] questionnaire).

RESULTS

Patients who had debridement only reached a DASH questionnaire score of 18 and an MMWS of 89 with significant pain reduction from 7.6 to 2.0 on the visual analog scale. Patients with additional ulnar shortening reached a DASH questionnaire score of 18 and an MMWS of 88, with significant pain reduction from 7.4 to 2.5. Neither surgical treatment compromised grip and pinch strength in comparison with the contralateral side. We identified 1.8 mm or more of positive ulnar variance as an indication for early ulnar shortening in the case of persistent ulnar-sided wrist pain after arthroscopic debridement.

CONCLUSIONS

Arthroscopic debridement was a sufficient and reliable treatment option for the majority of patients with Palmer type 2C lesions. Because reliable predictors of the necessity for ulnar shortening are lacking, we recommend arthroscopic debridement as a first-line treatment for all triangular fibrocartilage 2C lesions, and, in the presence of persistent ulnar-sided wrist pain, ulnar shortening osteotomy after an interval of 6 months. Ulnar shortening proved to be sufficient and safe for these patients. Patients with persistent ulnar-sided wrist pain after debridement who had preoperative static positive ulnar variance of 1.8 mm or more may be treated by ulnar shortening earlier in order to spare them prolonged symptoms.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Simple debridement has little useful value on the clinical course of recalcitrant ulnar wrist pain

The purpose of this study was to evaluate treatment results following arthroscopic triangular fibrocartilage complex (TFCC) debridement for recalcitrant ulnar wrist pain. According to the treatment algorithm, 66 patients (36 men and 30 women with a mean age of 38.1 years (15 to 67)) with recalcitrant ulnar wrist pain were allocated to undergo ulnar shortening osteotomy (USO; n = 24), arthroscopic TFCC repair (n = 15), arthroscopic TFCC debridement (n = 14) or prolonged conservative treatment (n = 13). The mean follow-up was 36.0 months (15 to 54). Significant differences in Hand20 score at 18 months were evident between the USO group and TFCC debridement group (p = 0.003), and between the TFCC repair group and TFCC debridement group (p = 0.029). Within-group comparisons showed that Hand20 score at five months or later and pain score at two months or later were significantly decreased in the USO/TFCC repair groups. In contrast, scores in the TFCC debridement/conservative groups did not decrease significantly. Grip strength at 18 months was significantly improved in the USO/TFCC repair groups, but not in the TFCC debridement/conservative groups. TFCC debridement shows little benefit on the clinical course of recalcitrant ulnar wrist pain even after excluding patients with ulnocarpal abutment or TFCC detachment from the fovea from the indications for arthroscopic TFCC debridement.

Minimally invasive approaches to ulnar-sided wrist disorders

Ulnar-sided wrist pain is a common cause of pain and disability, which has long been a diagnostic and therapeutic dilemma for hand surgeons. A thorough understanding of the anatomy, clinical examination, and radiographic evaluation is essential to establish a focused differential diagnosis, with the cause of disability often being multifactorial. Arthroscopy is particularly well suited to both directly visualize and treat multiple causes of ulnar-sided wrist pain, including pathology of the TFCC, UIS, LTIL tears, and hamate arthrosis.

Biomechanical analysis of the distal metaphyseal ulnar shortening osteotomy

PURPOSE

To investigate the effect of a closing wedge osteotomy at the distal ulnar metaphysis on unloading the ulnar side of the wrist.

METHODS

Seven fresh frozen cadaver arms mounted in a wrist simulator were used for the analysis. A 6-degrees-of-freedom load cell was mounted on the distal radius and another on the distal ulna. Radioulnar carpal joint forces and transverse distal radioulnar joint (DRUJ) load were measured at static wrist positions and during dynamic wrist motions before and after the distal metaphyseal ulnar shortening osteotomy (DMUSO) was performed.

RESULTS

At each static position, significant decreases in ulnar load were noted after DMUSO. In addition, mean and maximum loads decreased for each dynamic wrist motion. There were no statistically significant differences in transverse forces across the DRUJ after DMUSO.

CONCLUSION

This study showed that DMUSO is an effective way to decrease the load across the ulnocarpal joint. The geometry of the osteotomy and resultant change in the position of the ulnar head did not increase transverse joint reaction forces.

CLINICAL RELEVANCE

This technique is an alternative to open diaphyseal techniques or methods that damage the articular surface of the distal ulna. Clinical studies will be necessary to associate the biomechanical correction noted in this study with clinical symptom improvement.

The management of ulnocarpal abutment and degenerative triangular fibrocartilage complex tears in the competitive athlete

Ulnar-sided wrist pain is a frequent cause for loss of practice time and competitive play for athletes. Ulnocarpal abutment, a common source of ulnar-sided pain, typically burdens athletes who participate in gymnastics, racket sports, and baseball. Although many athletes respond to nonoperative management, surgical intervention should be considered when symptoms persist. Surgical options include arthroscopic debridement, arthroscopic wafer, open wafer, or ulnar-shortening osteotomy. Treatment should be tailored to the athletes' level of function, expectations, and goals. The timing of interventions also influences the treatment algorithm. A successful outcome can be anticipated when appropriate treatment is rendered.

Anatomy and biomechanics of the distal radioulnar joint

The distal radioulnar joint (DRUJ) is a complex articulation allowing significant rotational and translational motion. Stability of the DRUJ depends on bony contact, intrinsic stabilizers of the triangular fibrocartilage complex, and extrinsic stabilizers of the distal forearm. Understanding the anatomy of this articulation is paramount in clinical decision making for the treatment of disorders involving the DRUJ.

Arthroscopic treatment of peripheral triangular fibrocartilage complex tears with the deep fibers intact

PURPOSE

We describe a variant of triangular fibrocartilage complex (TFCC) tears in which the superficial fibers attaching to the ulnar capsule are torn, with preservation of deep fibers inserting on the fovea. We present the clinical and magnetic resonance imaging findings and the results of arthroscopic repair in patients with this injury.

METHODS

Twenty-nine wrists were treated arthroscopically for peripheral TFCC tears with outside-in suture repair of the TFCC to the ulnar capsule. A retrospective review of all cases was performed to assess the physical examination, magnetic resonance imaging, and intraoperative findings. Patients were evaluated at greater than 1 year with range of motion, grip strength, standard outcome measures, and a survey assessing return to work and sports.

RESULTS

Before surgery, all patients had complaints of ulnar-sided wrist pain with a stable distal radioulnar joint on examination. Twenty-six wrists (90%) were available for follow-up at a mean of 31 months. There was one repeat surgery, a re-tear that required revision TFCC repair. The preoperative visual analog scale and Disabilities of the Arm, Shoulder, and Hand scores improved from 5 and 38 to 1 and 9, respectively, at final follow-up. Side-to-side comparisons demonstrated no measurable loss in motion or grip strength. There were no cases of distal radioulnar joint instability at final follow-up. Of 11 high-level athletes in the total cohort, 7 (64%) were able to return to sports, including all of those in racquet sports; however, athletes who bore weight through their hands were unable to return to their sporting activity.

CONCLUSIONS

Tears of the TFCC superficial fibers with the deep fibers intact present with ulnar-sided wrist pain but without distal radioulnar joint instability. The results of outside-in repair of the articular disk back to the ulnar capsule demonstrated improvement in pain and function with no measurable objective losses. Return to sport was variable and appeared worse for those who bear weight through the hands.

Safety analysis of all-inside arthroscopic repair of peripheral triangular fibrocartilage complex

PURPOSE

The purpose of this study was to determine whether an all-inside peripheral triangular fibrocartilage complex (TFCC) repair using the FasT-Fix device (Smith & Nephew Endoscopy, Andover, MA) is safe by measuring the proximity of the anchors to ulnar-sided anatomic structures.

METHODS

Eleven fresh-frozen cadaveric wrists were thawed and placed in traction. Under direct arthroscopic visualization, an all-inside arthroscopic peripheral TFCC repair was completed by placing a single FasT-Fix device in a vertical mattress fashion. The wrists were then dissected to visualize the 2 anchors. The distance between these anchors and the flexor carpi ulnaris (FCU), extensor carpi ulnaris (ECU), and dorsal branch of the ulnar sensory nerve (DBUN) were measured with digital calipers and recorded.

RESULTS

The peripheral anchor averaged 4.2 mm (range, 0 to 14 mm) from the ECU tendon, 3.8 mm (range, 0 to 9 mm) from the DBUN, and 8.3 mm (range, 1 to 15 mm) from the FCU tendon. The central anchor averaged 9.6 mm (range, 2 to 15 mm) from the ECU tendon, 6.8 mm (range, 1 to 13 mm) from the DBUN, and 7.6 mm (range, 1 to 13 mm) from the FCU tendon.

CONCLUSIONS

This study exposes some safety concerns with the all-inside peripheral TFCC repair using the FasT-Fix device, which was found to reside in close proximity to the ECU, FCU, and DBUN. In multiple wrists the anchors were noted to underlie the anatomic structure that we measured, making it possible to pierce these structures with the needle before deployment of the anchor.

CLINICAL RELEVANCE

Though technically feasible, all-inside arthroscopic repair of the peripheral TFCC risks injury to the ulnar-sided anatomy.

Management of peripheral triangular fibrocartilage complex tears in the ulnar positive patient: arthroscopic repair versus ulnar shortening osteotomy

PURPOSE

One pattern of injury to the triangular fibrocartilage complex (TFCC) is a traumatic peripheral tear located at the ulnar end of the TFCC. Since 1989, this specific injury has been classified as a Palmer type 1B lesion. Various treatment options have been described for 1B injuries, yet when there is coexistent ulnar positive variance, it can make the choice of treatment difficult. The purpose of this article is to help the surgeon decide how to treat type 1B lesions in ulnar positive patients by directly comparing arthroscopic repair (repair) to ulnar shortening osteotomy (USO). The null hypothesis was that repair and USO would provide equivalent postoperative improvement with regard to motion; Disability of the Arm, Shoulder, and Hand (DASH) score; visual analog scale (VAS) score; and grip strength.

METHODS

We tested our hypothesis by retrospectively reviewing prospectively collected data from 51 patients treated surgically between 2000 and 2006 with type 1B tears in the setting of ulnar positive variance. Of these 51 patients, 27 were treated with arthroscopic repair and 24 with USO. All patients were evaluated before surgery as well as at final follow-up for active range of motion measurements, grip strength, DASH score, and VAS score. Radiographs were taken of all patients before surgery to confirm the presence of ulnar positive variance, and after surgery in the USO group to evaluate for bony union.

RESULTS

At the final follow-up, we found no statistically significant difference between the repair and USO groups with regard to flexion, extension, pronation, supination, radial deviation, or ulnar deviation. Likewise, there was no significant difference in grip strength, DASH scores, or VAS scores. When analyzing each cohort individually, both groups improved significantly after surgery with regard to DASH score, VAS score, and wrist extension. There was also a trend toward improved motion in all other directions except for an insignificant decrease in postoperative pronation in the repair group. Two patients in the USO group required additional surgery, with one revision performed for nonunion and one for painful hardware, which caused extensor carpi ulnaris tendonitis.

CONCLUSIONS

The results of our study suggest that type 1B TFCC tears in the ulnar positive patient can be managed equivalently well with repair or USO.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Incidence and distribution of blood vessels in punch biopsies of Palmer 1A disc lesions in the wrist

INTRODUCTION

Although the partial excision of triangular fibrocartilage complex (TFCC) tears appears to be a clinically effective technique, little is known about the ability of the central disc tears to heal. Unlike peripheral tears, central tears do not have immediate access to blood supply. The purpose of this study was to examine the incidence and distribution of blood vessels in punch biopsies of symptomatic central TFCC tissue. In addition, the study investigated if arthroscopic debridement can reach vascularized tissue to enable a reparative response of the tear.

MATERIALS AND METHODS

Thirty-two patients with symptomatic central traumatic tears in the TFCC (Palmer 1A) were included in this study. The cartilage was debrided arthroscopically using a biopsy punch. The debrided tissue was then examined histologically. To visualize blood vessels, the histological sections were stained with CD 31 antibodies. The presence/absence of blood vessels was recorded on a qualitative level.

RESULTS

In six patients, five or more blood vessels (CD31 positive endothelial cells) could be detected. In eight patients, fewer than five vessels could be found in the periphery of the slides. In 18 patients no vessels could be identified. The incidence of vessels in the outer region was higher than in the inner region of the peripheral area. There was no correlation found between the time of trauma and incidence of blood vessels (P > 0.05).

CONCLUSION

Only in 43% of arthroscopic debridements of Palmer 1A tears vascularized tissue could be reached.

Correlation of ulnar length and apoptotic cell death in degenerative lesions of the triangular fibrocartilage

PURPOSE

The purpose of this study was to investigate apoptosis in degenerative disc lesions (Palmer type IIC) and differentiate between patients with ulna-plus and ulna-neutral variance.

METHODS

Seventeen patients with degenerative tears (Palmer type IIC) in the articular disc of the triangular fibrocartilage were included in this study. The triangular fibrocartilage was debrided arthroscopically with a punch and the histologic sections were used to analyze necrosis and apoptosis. Apoptosis and necrosis was quantified by terminal deoxyribonucleotidyl transferase (TdT)-mediated dUTP nick end labeling (TUNEL) assay. Apoptotic cells were visualized by poly(ADP-ribose) polymerase (PARP) p85 immunohistochemistry. The number of apoptotic and necrotic cells was then correlated with ulnar length.

RESULTS

PARP- and TUNEL-positive cells were found in each patient. In addition, patients with an ulna plus variance showed a significantly increased number of apoptotic cells in comparison to patients with an ulna neutral variance. The distribution of the apoptosis-positive cells did not show any accumulation in the inner part of the specimen, but were evenly distributed.

CONCLUSIONS

This study showed that patients with ulna plus present with significantly higher numbers of apoptotic cells in degenerative lesions in comparison to patients with ulna neutral. The apoptotic cells were evenly distributed throughout the entire specimen.

CLINICAL RELEVANCE

The results of this study revealed that increased length of the ulna is related to increased cell death. Therefore, techniques that decrease the ulna variance would appear to be appropriate and would improve the clinical situation by preventing further cell death.

New advances in wrist arthroscopy

Wrist arthroscopy is a commonly used procedure that has undergone many modifications and improvements since it was first described. The advent of new portals (both dorsal and volar) means that the wrist joint can be viewed from virtually any perspective ("box concept"). Indications for wrist arthroscopy have continued to expand and include diagnostic and reparative procedures and, more recently, reconstructive, soft-tissue, and bony procedures. Arthroscopic grading of Kienböck's disease better describes articular damage compared with plain radiographs and can help guide surgical treatment options. Triangular fibrocartilage complex injury diagnosis, classification, and treatment can be performed arthroscopically, including distal ulna resection (wafer procedure). Assessment of fracture reduction of the distal radius and scaphoid is superior to that obtained with fluoroscopy, with the advantage of being able to look for associated soft-tissue and chondral injuries. Arthroscopic assessment of intercarpal ligament injuries and instability is now considered the gold standard by many authors. Arthroscopy can also aid us in the management of post-traumatic capsular contraction, resection of ganglia, and the relatively rare isolated ulna styloid impaction. Complications of wrist arthroscopy are relatively uncommon. With the ever-expanding list of indications and procedures that can be performed with this technique, it exists as an essential diagnostic and therapeutic tool for the orthopaedic surgeon.