Arthroscopic repair of Palmer 1B triangular fibrocartilage complex tears

Effectiveness of suture anchor and transosseous suture technique in arthroscopic foveal repair of the triangular fibrocartilage complex: a systematic review

BACKGROUND

Currently, there were two major surgical methods for arthroscopic triangular fibrocartilage complex (TFCC) foveal repair: suture anchor (SA) and transosseous suture (TOS). The purpose of this systematic review is to examine the relevant outcome improvement and safety of SA and TOS technique.

METHODS

Literature review of electronic databases for studies investigating the effects of SA and TOS in patients undergoing arthroscopic TFCC foveal repair was performed. We compared the pre-operative and postoperative functional outcomes, clinical outcomes [pain, range of motion (ROM) and grip strength], and complications of two methods. Minimal clinically important difference (MCID) was used to determine clinically meaningful improvement.

RESULTS

There were 1263 distinct studies identified, with 26 (904 patients) meeting the inclusion criteria. The mean age of participants ranged from 21.4 to 41 years, and the mean follow-up time ranged from 6 to 106 months. Both SA and TOS groups reported significant improvement in the modified mayo wrist score, the disabilities of the arm, shoulder, and hand (DASH) score, quick DASH score, patient-reported wrist evaluation (PRWE) score, and the visual analog scale (VAS) score. According to MCID, all the studies from both groups reporting DASH, quick DASH, PRWE and VAS score achieved clinically meaningful improvement. (MCID: 10 for DASH, 14 for quick DASH, 14 for PRWE and 1.6-18 for VAS). The ROM changes in both groups varied from improvement to deterioration. Grip strength improved in both SA and TOS group. Most complications were self-limited. The reoperation rates in SA and TOS ranged from 0 to 20% and 0 to 27.3%, respectively.

CONCLUSIONS

Both SA and TOS technique for arthroscopic TFCC foveal repair could achieve improvement in postoperative functional outcomes, pain, and grip strength with low reoperation rate. However, the ROM improvement was still inconclusive.

LEVEL OF EVIDENCE IV

Systematic review of level III and IV studies.

Return to Activity After Arthroscopically Assisted Triangular Fibrocartilage Complex Repair: A Systematic Review

OBJECTIVE

To evaluate patients' ability to return to preinjury activity level after arthroscopically assisted triangular fibrocartilage complex (TFCC) repair.

DATA SOURCES

The PubMed electronic library was systematically searched from inception to August 2021 for any eligible articles using a combination of the phrases "TFCC," "return to sport," "return to work," and "athlete."

RESULTS

Studies that evaluated patients who had undergone arthroscopic repair of isolated TFCC injury and reported objective or patient-reported outcome measures were included. Fifteen studies representing 478 patients fulfilled the inclusion criteria. An average of 84% of patients were able to fully return to their previous work or sport activities. Most studies reported that range of motion (ROM) and grip strength (GS) both returned to >90% of the contralateral side, and every study that evaluated pain levels found a significant reduction in pain postoperatively. Mayo Modified Wrist Score was reported as excellent or good in 83% of patients, and the average Disabilities of the Arm, Shoulder, and Hand score was 13.8 postoperatively.

CONCLUSION

Patients were able to return to their previous work or sport activities at a high rate after TFCC repair, even those participating in more strenuous activities. Measurable functional outcomes of ROM and GS were also reliably restored to near preinjury levels. Patient-reported outcomes of pain and disability were similarly improved after TFCC repair. Current literature has established the long-term success of TFCC repair but is lacking in evaluation of the time points at which patients can expect functional status to be restored.

Wrist and forearm range of motion commencement time following primary triangular fibrocartilage complex foveal repair surgery: A scoping review

STUDY DESIGN

Scoping review.

BACKGROUND

Rehabilitation guidelines following triangular fibrocartilage complex (TFCC) foveal repair surgery have been inconsistently reported in the published literature, with no consensus regarding wrist or forearm range of motion (ROM) commencement time.

PURPOSE OF THE STUDY

To scope the available literature to identify the extent and strength of the evidence supporting the clinical guidelines for wrist and forearm ROM commencement time following primary TFCC foveal repair surgery.

METHODS

A systematic search produced 26 studies (3 retrospective cohort studies, 1 prospective cohort study, 1 retrospective comparative study, and 21 retrospective case series) that described specific rehabilitation protocols following TFCC foveal repair surgery.

RESULTS

No supporting evidence was identified regarding rehabilitation protocol recommendations across all the included studies. Postsurgery wrist ROM commencement ranged from 2 to 8 weeks; forearm ROM commencement ranged from 2 to 12 weeks. ROM commencement times did not appear to systematically influence the rate of adverse events, although adverse events were poorly reported.

CONCLUSIONS

TFCC rehabilitation protocols were poorly reported and varied widely between the included studies. Additional research is recommended to comprehensively evaluate the association between wrist and/or forearm ROM and the rate of adverse events for this complex and multifaceted condition.

Morphologic Characteristics of the Sigmoid Notch of the Distal Radius for Patients With Peripheral Triangular Fibrocartilage Complex Tear

The distal radioulnar joint (DRUJ) is stabilized by the bony anatomy of the contact surfaces. The authors analyzed the morphologic characteristics and radiologic parameters at the sigmoid notch of patients with a peripheral triangular fibrocartilage complex (TFCC) tear compared with asymptomatic patients. Preoperative axial computed tomography scans were reviewed for 76 wrists with peripheral TFCC injuries, including foveal avulsion, and 76 wrists of age- and sex-matched control subjects. The authors used axial computed tomography scans of the DRUJ to classify the patients into 4 groups according to the type of sigmoid notch, namely, flat face, ski-slope, C-type, and S-type. They also measured the tilting angle, depth, width of the sigmoid notch, and radioulnar ratio (RUR). Statistical analyses were performed with the chi-square test or paired t test (P<.05). The mean proportions of flat face, ski-slope, C-type, and S-type sigmoid notches among patients with peripheral TFCC injuries were 42%, 22%, 29%, and 7%, respectively, whereas those for the control group were 33%, 1%, 65%, and 1%, respectively (P<.05). The tilting angle was lower (TFCC injury, 84.5°; control, 86.2°; P<.05) and the RUR was significantly higher (TFCC injury, 0.67; control, 0.56) in the TFCC group, particularly for men (P<.05). Depth (TFCC injury, 1.0 mm; control, 1.3 mm; P>.05) and width (TFCC injury, 14.8 mm; control, 14.5 mm; P>.05) were similar between the groups. Patients with ski-slope or dorsally tilted sigmoid notches may be at greater risk for peripheral TFCC injuries. [Orthopedics. 2021;44(6):e729-e734.].

Comparative outcomes between all-inside arthroscopic suture anchor technique versus arthroscopic transosseous suture technique in patients with triangular fibrocartilage complex tear: a retrospective comparative study

Background

Triangular fibrocartilage complex (TFCC) has become an interest over the last few decades, discovering its understanding in anatomy, pathomechanism, biomechanics, and management in treatments. Currently, TFCC does not have a golden standard procedure, and not one surgical procedure is superior to the other. This study is to evaluate the comparative outcomes in TFCC patients that underwent either in all-inside arthroscopic suture anchors or the arthroscopic transosseous suture technique.

Method

From 2017 to 2019, 30 patients were analyzed. Eight patients were in an arthroscopic transosseous group and 22 patients were in an all-inside arthroscopic group. Comparison between patients’ flexion and extension range of motion (ROM), grip strength, and visual analog pain scale (VAS) preoperative and six-month follow-up were analyzed.

Result

There were significant increases in flexion ROM, extension ROM, and VAS between preoperative and postoperative in all-inside arthroscopic and arthroscopic transosseous. Only the all-inside arthroscopic group had a significant increase in grip strength. Postoperative flexion ROM had a significant difference between all-inside arthroscopic and arthroscopic transosseous.

Conclusion

Both the all-inside arthroscopic suture anchor technique and the arthroscopic transosseous suture technique are appropriate treatments to treat patients with TFCC. Both procedures have achieved the ultimate goal of improved longevity and optimal function.

Level of evidence

Level III; retrospective comparative cohort study.

Long-term results of more than 13 years after arthroscopic repair of triangular fibrocartilage complex (TFCC) Palmer 1B tears: a comparison with short- and mid-term results

PURPOSE

Goal of this study was the assessment of long-term outcome of arthroscopically assisted repair of Palmer 1B/Atzei 1 triangular fibrocartilage complex tears and the comparison with short- and mid-term results.

METHODS

The study included nineteen patients (mean 49.2 years of age) with a mean follow-up time of 13.6 years (13.1-14.3 years). Examination parameters included disabilities of arm, shoulder, and hand (DASH) questionnaire, modified Mayo Wrist Score (MMWS), Krimmer Score, determination of range of motion in comparison to the contralateral extremity. Grip and pinch grip strength measurement and pain level assessment was performed, as well.

RESULTS

The mean MMWS after at least 13.1 years was 95.8 (85-100, SD 5.6). Mean DASH Score was 10.2 (0-55.8, SD 13.6). Mean Krimmer Score was 97.2 (85-100, SD 4.8). Grip strength reached 101% of the contralateral unaffected hand. Range of motion did not differ significantly in comparison to the healthy contralateral extremity. None of the patients suffered from major complications. Fourteen of nineteen patients regarded pain level reduction as excellent. Five patients reported a relevant pain level reduction. Sixteen of nineteen patients regarded functional outcome as excellent, the other three patients reported on a pleasing improvement of the functional outcome.

CONCLUSION

Arthroscopically assisted repair of Palmer 1B/Atzei 1 triangular fibrocartilage complex tears may be an efficacious and safe surgical technique for ulnar-sided TFCC tears in the long term.

Arthroscopic Transosseous Repair of Foveal Tears of the Triangular Fibrocartilage Complex: A Systematic Review of Clinical Outcomes

PURPOSE

To determine whether arthroscopic transosseous foveal repair of the triangular fibrocartilage complex (TFCC) results in significant and clinically relevant improvement in clinical outcomes including pain and function with low complication and reoperation rates.

METHODS

We reviewed studies investigating the clinical outcomes of arthroscopic transosseous foveal repair of the TFCC through MEDLINE, Embase, and the Cochrane Library. Studies on TFCC repair performed with an open or capsular technique and combined with other procedures, such as ulnar shortening osteotomy and a wafer procedure, were excluded. Methodologic quality was assessed using the Methodological Index for Non-randomized Studies score. Clinical outcomes were assessed using range of motion, grip strength, and patient-reported outcomes. Clinically relevant improvement was determined using the minimal clinically important difference (MCID).

RESULTS

A total of 443 unique studies were identified, of which 7 (131 patients) met the inclusion criteria. The mean age ranged from 27 to 37 years, and the mean follow-up period ranged from 23.5 to 31.1 months. The grip strength (as a percentage) increased after foveal repair of the TFCC in all studies (mean difference range, 11.8% to 22.3%). All studies also reported an improvement in the visual analog scale score (mean difference range, -9.8 to -1.88); Modified Mayo Wrist Score (mean difference range, 10.5 to 27); and Disabilities of the Arm, Shoulder and Hand score (mean difference range, -51.8 to -24.48). Considering clinically relevant improvements based on the MCID, 4 of 5 studies reporting the visual analog scale score showed improvements in this score (MCID, 2) and all studies reporting the Disabilities of the Arm, Shoulder and Hand score showed improvements in this score (MCID, 10). Most complications recovered without any treatment, and 3 patients (2.29%) needed a reoperation.

CONCLUSIONS

Arthroscopic transosseous foveal repair of the TFCC resulted in improvements in grip strength and functional outcomes with low complication and reoperation rates. However, the evidence for which technique produces better clinical outcomes remains limited.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Mid- and Long-Term Outcome After Arthroscopically Assisted Transosseous Triangular Fibrocartilage Complex Refixation-Good to Excellent Results in Spite of Some Loss of Stability of the Distal Radioulnar Joint

PURPOSE

To evaluate mid- and long-term outcomes after arthroscopically-assisted transosseous reattachment of the triangular fibrocartilage complex (TFCC) and to analyze the association of distal radioulnar joint (DRUJ) stability with the clinical outcome.

METHODS

Patients treated with an arthroscopically-assisted transosseous reattachment of the deep layer of the TFCC between 2000 and 2009 and a minimum follow-up of 12 months at mid-term and 4 years at long-term follow-up were retrospectively reviewed. Mayo Modified Wrist Score (MMWS); Disabilities of the Arm, Shoulder and Hand (DASH) score; pain visual analogue scale (VAS); grip strength and stability of the DRUJ were assessed at 2 follow-up clinical examinations. At the last follow-up, the Patient-Rated Wrist Evaluation score was additionally recorded.

RESULTS

Thirty patients with a mean age of 29 (±13) years were included. Most of the patients were female (70%, n = 21). The mid-term evaluation took place at a median of 30 months (range, 12-83 months). The assessed scores showed statistically significant clinical improvement (MMWS, P < .001; DASH score P < .001; VAS P < .001). Stability assessment showed a stable DRUJ in 23 (76.7%) patients. At a median of 106 months (range 52-215 months), the long-term clinical assessment was performed. The evaluated scores demonstrated persisting significant improvement (MMWS P < .001; DASH score P < .001; VAS P < .001). Stability assessment showed a stable DRUJ in 19 patients (63.3%). DRUJ instability did not correlate with clinical outcome. No permanent surgery-related complications occurred.

CONCLUSION

Arthroscopically-assisted transosseous reattachment of the deep fibers of radioulnar ligaments leads to excellent and good clinical results in mid- and long-term follow-up. In 95.5% of the analyzed patients, the measured improvement in the DASH score exceeded the in literature reported minimal clinically important difference of 13.5. Loss of DRUJ stability during follow-up was not associated with deterioration of clinical parameters and patient satisfaction.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Arthroscopic triangular fibrocartilage complex repair: A biomechanical comparison of anchor and pull-out techniques in Atzei type II lesions

Several open and arthroscopic techniques for repair triangular fibrocartilage complex (TFCC) tears have been used. The aim of this study, using a cadaveric model, was to compare the biomechanical resistance to the pronosupination movement of arthroscopic repair with anchor and pull-out techniques in TFCC tears of Atzei type II lesions. Eighteen forearms of cadaveric specimens were evaluated arthroscopically, of which 12 were selected according to the inclusion criteria. All specimens were injured with an Atzei type II lesion and were repaired arthroscopically. Six forearms were repaired using the anchor technique and the other six with the pull-out technique. To assess the biomechanical resistance of the repair, the forearms were tested to 300 cycles of 160° pronosupination. Two evaluators independently assessed the repair status every 10 cycles and the modified Desai classification was used to verify the presence of failure. The mean failure of the repair occurred at 41.6 cycles (SD 7.5) for the pull-out technique and at 28.3 cycles (SD 9.8) for the anchor technique, showing a difference of 13.3 cycles (p = 0.025) in favor of the pull-out technique. In all cases, repair failure occurred at the junction of the fibrocartilage with the suture. Arthroscopic repair with the pull-out technique showed greater biomechanical resistance to pronosupination movement in comparison to the anchor technique. Interestingly, the failure of arthroscopic repair of Atzei type II lesions occurs at the junction between the suture and the fibrocartilage.

Semiquantitative single-photon-emission computed tomography /computed tomography study to evaluate concomitant ulnar impaction syndrome in patients presenting with triangular fibrocartilage complex tears

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.

Arthroscopic Suture Repair With Additional Pronator Quadratus Advancement for the Treatment of Acute Triangular Fibrocartilage Complex Tear With Distal Radioulnar Joint Instability

Treatment of acute triangular fibrocartilage complex (TFCC) tear using arthroscopic suture repair has been used as a general treatment method, but it is difficult to obtain perfect results in all cases. We evaluated clinical and radiologic outcomes of the acute TFCC tear with distal radioulnar joint instability using the arthroscopic suture repair with pronator quadratus (PQ) advancement. Altogether, 80 patients (48 male, 32 female; mean ± SD age, 37.3 ± 11.5 years; mean ± SD follow-up, 23.7 ± 11.4 months) were enrolled in the study. Follow-up was at least 12 months (range, 12-38 months). Patients were divided into group 1 with arthroscopic suture repair alone (34 patients; 17 male, 17 female; mean ± SD age, 35.2 ± 10.8 years; mean ± SD follow-up, 28.1 ± 15.1 months) and group 2 with additional PQ advancement (46 patients; 29 male, 17 female; mean ± SD age, 38.9 ± 11.9 years; mean ± SD follow-up, 18.4 ± 6.2 months), and clinical and radiological assessment was performed. We also compared the ulnar translation of the injured wrist with that of the uninjured wrist using the Push Pull gauge.There was no difference in the range of motion and the grip strength between the 2 groups. However, the disabilities of the arm, shoulder, and hand score (P = 0.042) at 6-month follow-up and disabilities of the arm, shoulder, and hand score (P = 0.015) and patient-rated wrist evaluation score (P = 0.012) at 12-month follow-up were improved in group 2, and patients' satisfaction (P = 0.032) was also higher in group 2. The ulnar translation rate was also improved in group 2 at 6-month follow-up (P = 0.015) and 12-month follow-up (P = 0.045).Arthroscopic suture repair with PQ advancement provided more clinical improvement and proper stability; therefore, it will be an acceptable effective treatment option for acute TFCC tear with distal radioulnar joint instability.

What Is the Effect of the Ulnar-Plus Variance on the Outcomes of Arthroscopic Repair of the Peripheral Ulnar-Side Triangular Fibrocartilage Complex Tear?

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.

A Systematic Review and Analysis of Palmer Type I Triangular Fibrocartilage Complex Injuries: Outcomes of Treatment

Triangular fibrocartilage complex (TFCC) injuries can present incidentally as an asymptomatic lesion or can cause acute and chronic pain. This study compared different treatment approaches for symptomatic Palmer Type 1 TFCC injuries and rates of improvement using a systematic review of the literature. Two hundred thirty-one articles were identified, 43 met criteria and were included. Two of these articles indicated conservative therapy may be adequate. Patients who underwent debridement for any Type 1 Palmer class returned to work at a rate of 92% ( n = 182), but only 44% ( n = 38) were free of pain. For 1B lesions that underwent repair, 68.3% ( n = 226) were able to return to work and 41% ( n = 52) had persistent pain. 1D lesions were treated with both repair and debridement with similar results. Data for Types 1A and 1C were limited as no authors solely addressed these lesions. For 1A lesions, those treated with traditional treatment of debridement still had high rates of being unable to return to work. The literature remains insufficient, making comparison between studies and techniques difficult. For asymptomatic injuries, there is no need for treatment. For patients with recalcitrant symptoms, surgery improves pain, grip strength, and increases return to work and activity. The level of evidence is IV.

Open Versus Arthroscopic Repair of 1B Ulnar-Sided Triangular Fibrocartilage Complex Tears: A Systematic Review

Background: Peripheral 1B tears of the triangular fibrocartilage complex (TFCC) can result in distal radioulnar joint (DRUJ) instability. In the context of associated DRUJ instability, combined evidence supports successful outcomes for peripheral tear repair. Methods: The aim of this systematic review (SR) was to compare the surgical treatment of 1B TFCC tears via arthroscopic versus open methods of repair. The primary outcome measure was restored DRUJ stability. The secondary outcome measures included patient-reported outcomes and clinical outcome measures. An electronic database search of Ovid Embase, PubMed, and the Cochrane Central Register of Controlled Trials was performed to cover a 20-year period. Two authors independently screened records for eligibility and extracted data. Results: Only 3 studies met the strict inclusion criteria, highlighting the poor evidence base for TFCC 1B repairs. Hence, a "secondary analysis" group was developed with modified inclusion criteria which included a further 7 studies for analysis. Pooled data from the primary and secondary analysis groups demonstrated that postoperative DRUJ stability was achieved following open repair in 84% (76/90) of cases and following arthroscopic repair in 86% (129/150) of cases. Conclusions: This SR demonstrates a current lack of high-quality evidence required to draw firm conclusions on the merits of arthroscopic versus open repair of 1B TFCC tears. There is no scientific evidence to suggest superiority of one technique over the other, albeit some surgeons and authors may express a strong personal view.

Early Results of Surgical Treatment of Triangular Fibrocartilage Complex Tears in Children and Adolescents

PURPOSE

To investigate the clinical results and patient-reported outcomes following surgical treatment for triangular fibrocartilage complex (TFCC) tears in the pediatric and adolescent population.

METHODS

We reviewed 149 patients with 153 arthroscopy-confirmed TFCC tears. Mean age at surgery was 15.5 years (range, 7-19 years). There were 86 females. Plain radiographs and magnetic resonance imaging were used to characterize bony and soft tissue pathology. Mayo Modified Wrist Score (MMWS) and Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Short Form assessed functional outcomes. Median patient follow-up was 21.8 months (IQR:5.9-55.4).

RESULTS

Pre-operatively, all patients had wrist pain or instability with activities. The median pre-operative MMWS was 80 (interquartile range [IQR], 65-90). Fifty-six (35%) presented with positive ulnar variance. Concomitant pathology included distal radioulnar joint (DRUJ) instability (14%), ulnocarpal impaction (20%), ulnar styloid nonunion (33%), and distal radius growth arrest (30%). On arthroscopy, there were 15 (10%) isolated 1A, 79 (52%) 1B, 1 (1%) 1C, 30 (20%) 1D tears, and 25 (16%) cases of multiple tears. Twenty-six percent of wrists underwent TFCC debridement, 68% arthroscopy-assisted repair, 6% both for combined tears. Fifty-one percent of wrists underwent bony procedures-most commonly ulnar-shortening osteotomy to achieve neutral ulnar variance (40%) and symptomatic ulnar styloid nonunion excision with concomitant TFCC repair (39%). At final follow-up, pain, wrist range of motion, DRUJ stability, ulnar variance, and MMWS (median, 95 [IQR, 86.5-100]) improved significantly. The median PROMIS T-score at final follow-up was 57 (IQR, 45-57). The MMWS was better in those with concomitant bony procedures at index surgery than those with only repair or debridement of TFCC tears.

CONCLUSIONS

Most pediatric TFCC tears are posttraumatic and peripheral. Surgical treatment of TFCC tears and concomitant pathology in the pediatric and adolescent population results in decreased pain, improved motion and stability, and excellent functional outcomes in the majority of patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Long-Term Outcomes of All-Arthroscopic Pre-Tied Suture Device Triangular Fibrocartilage Complex Repair

Background  A pre-tied suture device has been utilized for all-arthroscopic peripheral triangular fibrocartilage complex (TFCC) repairs with promising early clinical results. Purpose  The purpose of this study was to evaluate long-term functional outcomes of these repairs. Patients and Methods  A retrospective review of patients undergoing arthroscopic TFCC repair was performed. Inclusion criteria were the Palmer type 1B TFCC tears diagnosed on arthroscopy and repaired using the all-arthroscopic pre-tied suture device. Patients with any evidence of concomitant wrist injury at the time of surgery, history of prior wrist surgery, or nonrepairable and nonperipheral TFCC tears were excluded. Postoperative complications, range of motion, grip strength, and outcome assessments were recorded for each patient. Results  Eleven patients (mean age, 36 years; range, 20-64 years) satisfied our inclusion criteria and comprised the study cohort. The mean follow-up period was 7.0 years (range, 4.3-10.9 years). Mean range of motion of the wrist revealed flexion of 76 ± 11 degrees and extension of 73 ± 12 degrees. Mean grip strength was 98 ± 15% of the nonsurgical extremity. QuickDASH, modified Mayo, and patient-rated wrist evaluation (PRWE) average scores were 9 ± 8, 80 ± 6, and 12 ± 12, respectively. No surgical complications were observed and no patient required any further surgical intervention. Conclusions  Our cohort of patients following all-arthroscopic pre-tied suture device repair of isolated Palmer type 1B TFCC tears demonstrated excellent clinical function at a mean follow-up of 7 years. These findings indicate that the pre-tied suture device is a reliable, safe, effective, and most importantly, durable treatment option for repair of peripheral TFCC tears. Level of Evidence  This is a Level IV, therapeutic study.

Biomechanical Analysis of Capsular Repair Versus Arthrex TFCC Ulnar Tunnel Repair for Triangular Fibrocartilage Complex Tears

Background: This study compares the effectiveness of a peripheral capsular repair with a knotless arthroscopic transosseous ulnar tunnel repair (TR) in restoring distal radioulnar joint (DRUJ) stability and stiffness in the setting of a massive triangular fibrocartilage complex (TFCC) tear. Methods: Eight matched pairs of fresh-frozen cadaveric forearms were tested. Each forearm was tested in supination and pronation using 3-dimensional (3D) optical tracking devices prior to any intervention. Each specimen then underwent a diagnostic wrist arthroscopy and sectioning of the TFCC's deep and superficial fibers. All specimens were then retested to assess instability secondary to the tear. The TFCC was repaired with either a peripheral capsular repair (CR) using three 2-0 polydioxanone sutures or a transosseous ulnar TR using a 2-0 FiberWire, and then retested (statistical significance; P < .05). Results: After TFCC arthroscopic sectioning, all specimens were unstable with a significant increase in translation and a significant decrease in stiffness. TFCC repair with TR resulted in displacement and stiffness similar to the native tissue. CR specimens were found to have significantly greater displacement and significantly decreased stiffness compared with the intact state. Conclusions: Arthroscopic sectioning of the TFCC resulted in DRUJ instability, as measured by stiffness and ulnar translation. TR effectively restored DRUJ stability and demonstrated no significant difference in postoperative stiffness or maximal displacement when compared with the intact specimen in pronation and supination. This study provides biomechanical evidence that an arthroscopic ulnar tunnel technique can restore stability to the DRUJ after a massive TFCC tear.

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.

What is the Natural History of the Triangular Fibrocartilage Complex Tear Without Distal Radioulnar Joint Instability?

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.

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 Transosseous Repair for both Proximal and Distal Components of Peripheral Triangular Fibrocartilage Complex Tear

BACKGROUND

Tears of the triangular fibrocartilage complex (TFCC) can result in instability of the distal radioulnar joint (DRUJ) and ulnar-sided wrist pain. This study evaluates clinical results of arthroscopic transosseous repair for both proximal and distal components of TFCC tear with DRUJ instability.

MATERIALS AND METHODS

Ten patients who underwent both proximal component and distal component of TFCC repair were retrospectively reviewed. The proximal component of TFCC was repaired through arthroscopic one-tunnel transosseous suture technique, and the combined distal component tear was repaired to the ulnar capsule using same transosseous tunnel in all cases. Visual analog scale (VAS) score for pain, wrist range of motion, grip strength, and postoperative complications were evaluated after a mean followup period of 23.5 months, and each patient was rated according to modified Mayo wrist score and quick disabilities of the arm, shoulder, and hand (DASH) questionnaire.

RESULTS

On arthroscopic findings, the hook test confirmed the proximal component of the TFCC tear and visible capsular detachment from TFCC confirmed combined distal component tear in all patients. At final followup, 7 patients had normal stability of DRUJ and 3 patients showed mild laxity compared with the contralateral side. The mean VAS for pain perception decreased from 4.1 to 0.7, and grip strength was increased significantly. The modified Mayo wrist score and Quick DASH score showed significant functional improvement. No surgery-related complications occurred.

CONCLUSIONS

Arthroscopic one-tunnel transosseous TFCC foveal repair and simulatneous transosseous capsular repair of distal component can be a safe and effective strategy for repair of complete TFCC tear combined with DRUJ instability.

Arthroscopic Management of Triangular Fibrocartilage Complex Peripheral Injury

Patients suffering from ulnar-sided wrist pain after trauma may develop tenderness, clicking, a positive fovea sign, or instability of the distal radioulnar joint. If the pain is persistent, conservative treatment does not help, and the patient agrees to surgery, arthroscopy may reveal a triangular fibrocartilage complex (TFCC) injury with capsular detachment, foveal avulsion, or a combination thereof. Capsular reattachment is possible using an arthroscopic assisted technique. The reattachment can be performed with an inside-out, outside-in, or all-inside technique, providing good to excellent results, which tend to persist over time, in 60% to 90% of cases.

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.

A scoping review of disabilities of the arm, shoulder, and hand scores for hand and wrist conditions

PURPOSE

To evaluate the variability of reported baseline Disabilities of the Arm, Shoulder, and Hand (DASH) scores for non-acute hand and wrist conditions. We hypothesized that DASH scores for evaluation of hand and wrist pathology would provide a map of scores that would correspond to severity. In addition to providing a catalog of DASH scores for various upper extremity pathologies, we hypothesized that this review would support the validity of the DASH instrument.

METHODS

A literature search was performed using 3 databases (MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials) from the earliest available date through January 1, 2013. Search terms included "DASH" and "hand" and combinations of conditions found in the initial search. The search was restricted to studies with baseline DASH scores and DASH scores for isolated conditions, and written in the English language.

RESULTS

Our search identified 1,770 citations; 136 full-text articles were reviewed and 85 studies were included in the scoping review. This provided 100 DASH scores mapped for 24 different diagnoses. Most articles (67%) included chronic conditions for inflammatory or degenerative pathologies rather than posttraumatic disorders. Posttraumatic DASH score reporting ranged from 4 months to 11 years after injury, and final outcome scores varied among studies assessing the same pathology. The greatest variation and highest scores were for de Quervain tendinitis (range, 29-93) and scapholunate advance collapse (range, 17-89). These scores indicated higher disability in de Quervain tendinitis and wrist osteoarthritis compared with conditions such as thumb amputation and upper extremity replantation.

CONCLUSIONS

Substantial variation in the DASH scores and methodology was found and indicates a need for further study of the DASH to allow for standardized interpretation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Common medical problems of instrumental athletes

The fields of sports medicine and performing arts medicine have begun recent initiatives to collaborate more closely and to share information pertinent to the treatment of athletes and performing artists. This article provides a review of the common musculoskeletal and neurological problems encountered among performing artists who play instruments. Approaches to history, examination, diagnosis, and treatment are offered, based on literature reviews, expert opinion, and the authors' own experiences in a musician's clinic. Treatments focus on conservative management within a multidisciplinary framework, and indications are given for appropriate surgical referral. Providers are encouraged to build an understanding of the unique issues affecting instrumental athletes.

Subjective and objective results of arthroscopic debridement of ulnar-sided TFCC (Palmer type 1B) lesions with stable distal radio-ulnar joint

PURPOSE

The purpose of this study was to determine functional and subjective results of patients who received arthroscopic debridement for their TFCC Palmer 1B lesions and to compare their results with those of arthroscopic suture repair.

METHODS

Between March 2007 and August 2011, 36 patients were diagnosed with Palmer type 1B tears and underwent arthroscopic debridement. 31 patients (15 males and 16 females) were followed up for an average of 26.7 months (±17.4 months) postoperatively. Their average age was 36.7 years (±12.7 years). Follow-up included the determination of range of motion (ROM), grip strength, pain, and wrist scores (modified Mayo wrist score (MMWS), Disabilities of the Arm, Shoulder and Hand questionnaire (DASH score)).

RESULTS

Postoperative ROM averaged 99.2 % for the extension/flexion arc, 95.5 % for the radial/ulnar deviation arc, and 99.4 % for the pronation/supination arc of motion when compared with the contralateral wrist. The MMWS was rated excellent in 48 % of patients, good in 39 %, fair in 13 %, and poor in 0 %. The average DASH score was 17.02 (±14.92). There was a significant reduction in pain. The grip strength was 96.7 % (±15.8), pulp-to-pulp pinch 101.9 % (±17.4), and the ulnar variance -0.12 ± 1.69 mm.

CONCLUSIONS

Arthroscopic debridement of Palmer type 1B lesions in stable DRUJ yields satisfactory to excellent results. Our study showed similar results compared with the studies of arthroscopic suture repair with shorter postoperative care and fewer complications.

[Therapy of triangular fibrocartilage complex lesions]

The triangular fibrocartilage complex (TFCC) represents an important anatomical structure interposed between the ulnar carpus and the distal ulnar. Injuries and degenerative changes of the TFCC are of high clinical relevance and there are numerous treatment options available based on different concepts and which are being used to varying extents. The aim of this systematic review was to evaluate the effectiveness of different therapies for lesions of the TFCC. Studies on TFCC lesions were systematically reviewed, classified into evidence levels and selected according to predefined criteria. A total of 259 publications were identified as being potentially relevant and finally 35 studies could be included in the review. In addition, a survey was performed among German hand surgeons in order to identify commonly used procedures for TFCC lesions in Germany. The classification of Palmer is mostly used both in the literature and in Germany and therapeutic decisions are predominantly based on this classification. The systematic review revealed some common treatment strategies for traumatic and degenerative lesions. Generally, the level of evidence was poor for all identified publications. For this reason, evidence-based recommendations for the treatment of TFCC lesions could not be derived from the literature. There was broad consent between the results of the literature review and the survey.

Arthroscopic repair of ulnar-sided triangular fibrocartilage complex (Palmer Type 1B) tears: a comparison between short- and midterm results

PURPOSE

To compare short- and midterm functional and subjective outcomes of arthroscopically repaired Palmer 1B tears.

METHODS

At 2 time points, we evaluated 49 patients with Palmer 1B tears who underwent arthroscopic repair. We examined 46 patients (23 males and 23 females) in the short-term at an average of 11 months (range, 6-23 mo) postoperatively. In a second midterm follow-up, we examined 40 patients (20 males and 20 females) an average of 4.8 years (range, 4.2-5.9 y) after repair. Between short- and midterm follow-ups, 6 patients underwent an ulnar-shortening osteotomy to alleviate persistent ulnar-sided symptoms. Objective and subjective evaluation included the determination of range of motion, grip strength, pain, and wrist scores (modified Mayo wrist score and Disabilities of Arm, Shoulder, and Hand score).

RESULTS

Compared with short-term repair results, midterm outcomes showed a further improvement in pain, wrist scores, grip strength, and motion. Neither static nor dynamic ulnar variance was correlated to preoperative and postoperative Disabilities of the Arm, Shoulder, and Hand scores, short-term modified Mayo wrist scores, or need for ulnar-shortening osteotomy. Five patients improved only after having received an ulnar shortening osteotomy.

CONCLUSIONS

After repair of Palmer 1B lesions, patients continued to improve in function and comfort at least into the second year, although some needed to have the ulna shortened to achieve this result.

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.

All-arthroscopic repair of peripheral triangular fibrocartilage complex tears using FasT-Fix

Injury to the triangular fibrocartilage complex (TFCC) is a major source of ulnar-sided wrist pain that results in disability with common activities of daily living involving forearm rotation, for which operative management is indicated if conservative management fails. Past results with open repairs have been successful, but recent surgical advances have allowed the development of arthroscopic management. This article describes and reviews an all-arthroscopic technique of repair of Palmer type IB TFCC injuries with FasT-Fix suture technology (Smith and Nephew, Andover, MA, USA), which is advantageous both biomechanically and in terms of decreasing risk of morbidity.

All-arthroscopic repair of Palmer 1B triangular fibrocartilage complex tears using the FasT-Fix device

PURPOSE

The FasT-Fix device (Smith and Nephew Endoscopy, Andover, MA), initially developed for knee meniscal tears, is described for all-arthroscopic triangular fibrocartilage complex (TFCC) repairs. Potential benefits of this technique are ease of use, the lack of prominent suture knots, and strength of repair. This case series evaluates the early clinical outcomes of this technique.

METHODS

We conducted a retrospective review of patients with TFCC Palmer type 1B injuries treated by 1 hand surgeon from 2005 to 2009. The patients' charts were reviewed for postoperative complications, range of motion, grip strength (percentage of contralateral), and return to full activity. In addition, each patient completed Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Patient-Rated Wrist Evaluation (PRWE) questionnaires.

RESULTS

Twelve patients had all-arthroscopic peripheral (1B) TFCC repairs using the FasT-Fix suture device. The mean follow-up period was 17.5 months (range, 11-27). Mean supination was 78° (± 14°), and mean grip strength was 64% (±16%) of the nonsurgical extremity by 3 months after surgery. All other range of motion was full. The mean QuickDASH score was 11 (±12), and the mean PRWE score was 19 (±14). Average time to full activity was 5 months. There were no surgical complications of the procedure. One patient complained of persistent ulnar-sided wrist pain 12 months after surgery and had an ulnar shortening osteotomy. Arthroscopy at the time of the osteotomy revealed that the TFCC was stable.

CONCLUSIONS

At mean 1-year follow-up, 11 out of 12 patients achieved excellent subjective outcomes based on QuickDASH and PRWE questionnaires. Although range of motion and grip strength were slightly decreased compared to prior case series reports, the short-term results indicate that the FasT-Fix all-arthroscopic, all-inside technique is a safe and effective technique for repair of Palmer type 1B TFCC tears.

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.

Expression of TRAIL and death receptor DR4 in Palmer type 2 TFCC lesions

INTRODUCTION

Degenerative articular disc perforations of the triangular fibrocartilage (TFC) of the wrist are characterized by fibrocartilage cell loss and are often associated with ulna-plus situations. Apoptosis has been found to play a crucial role in fibrocartilage cell loss, however, the molecular mechanism and mediators are still poorly understood.

AIM

The purpose of this study was to identify receptors to apoptosis in degenerative disc lesions.

PATIENTS

Included in the study were 17 patients with degenerative articular disc tears of the TFC (Palmer type 2C). Following arthroscopic debridement of the TFC, histological sections were examined to assess the presence of apoptosis. Apoptosis was determined using TRAIL and death receptor DR4 agonists for immunohistochemical analyses. The number of cells positive for apoptosis was then correlated with ulna length.

RESULTS

Cells positive for TRAIL and DR4 were found in all specimens. The number of cells positive for TRAIL was significantly increased in specimens of patients with an ulna positive variance (P = 0.040). However, DR4 was not significantly increased in ulna plus (P > 0.05). Both, TRAIL and DR4 positive cells were found to be evenly distributed throughout each specimen. There was no accumulation of any type of cells in any particular zone of the biopsies.

CONCLUSION

This is the first study that shows that TFCC cells express TRAIL and DR4, which suggests that apoptosis, as well as, mechanical trauma are involved in the development of disc perforation. The TRAIL/DR4 receptor system is a molecular mediator of apoptosis induction in TFC cells and therefore plays a role in cell loss in degenerative disc lesions.

Cartilage cell proliferation in degenerative TFCC wrist lesions

INTRODUCTION

The central zone of the triangular fibrocartilage complex (TFCC) of the wrist is thought to be avascular and is generally considered to lack any healing potential.

AIM

The purpose of this study was to investigate, if cartilage cells of degenerative disc lesions possess any healing or proliferation potential and whether ulna length plays a significant role in the proliferation process.

RESULTS

Cells positive for proliferating cell nuclear antigen (PCNA) were found in all specimens. Specimens of patients with ulna positive variance showed a decreased number of PCNA positive cells than specimens of patients with either negative or neutral ulna variance.

CONCLUSION

We found that cartilage cells of Palmer type 2C lesions undergo mitotic cell division, thus exhibiting proliferation capability. It could not be shown that ulnar length is significantly correlated with the number of PCNA positive cells.

Apoptotic pathways in degenerative disk lesions in the wrist

PURPOSE

Degenerative articular disk perforations of the triangular fibrocartilage (TFC) of the wrist could result from chronic loading of the ulnocarpal joint. Apoptosis played a crucial role in fibrocartilage cell loss, and the purpose of this study was to clarify which apoptotic pathway was involved in the development of degenerative disk lesions. We also investigated whether ulna length played an etiologic role in the occurrence of fibrocartilage cell loss.

METHODS

Included in the study were 17 patients with degenerative articular disk tears of the TFC (Palmer type 2C). After arthroscopic debridement of the TFC, histologic sections were examined to assess the presence of apoptosis. Apoptosis was determined by use of caspase 3, caspase 8, and caspase 9 immunohistochemistry. Furthermore, Fas ligand and BID (BH3 interacting domain death) agonist were applied for immunohistochemical analysis.

RESULTS

Cells positive for caspase 3, caspase 8, caspase 9, Fas ligand, and BID were found in all specimens. The number of cells positive for caspase 3 and BID was significantly increased in specimens from patients with an ulna-positive variance. In contrast, for cells positive for caspase 8, caspase 9, and Fas ligand, no significant difference was found between specimens from patients with an ulna-positive variance and those from patients with an ulna-neutral/ulna-negative variance.

CONCLUSIONS

The extrinsic and intrinsic apoptotic pathways are involved in the development of degenerative disk lesions. Fibrocartilage cell loss occurs mainly through the intrinsic apoptotic pathway. The accumulation of apoptotic cells is not significantly different between the 3 zones of the TFC. It could be verified that ulna length is correlated with fibrocartilage cell loss.

CLINICAL RELEVANCE

Ulnar shortening is a valuable treatment option for degenerative TFC lesions. Knowledge of the specific apoptotic pathway that is causing degenerative disk lesions is critical in selecting the appropriate and most beneficial therapeutic treatment to halt further cell loss and the degeneration of the TFC.