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

Treatment of Hand and Wrist Cartilage Defects in Athletes

Cartilage injuries of the hand and wrist can be debilitating in the athlete. Diagnosis is difficult given the broad spectrum of presenting symptomatology. History and physical examination is crucial to achieve the correct diagnosis, and advanced imaging can offer helpful assistance to the clinician as well. TFCC injuries and ulnar impaction syndrome are among the most common conditions in athletes with hand and wrist pain. Treatment of these injuries is initially nonoperative, but elite athletes may elect to bypass nonoperative treatment in favor of earlier return to sport. Surgical treatment varies but can include open and arthroscopic methods. The clinician should tailor treatment plans to each athlete based on level of competition, type of sport, and individual preferences and goals.

Foveal triangular fibrocartilage complex pathology: a potentially under-recognized injury

The primary aim of the present study was to present a case series of 24 patients with foveal triangular fibrocartilage complex (TFCC) injuries that were treated with arthroscopically assisted TFCC foveal repair. In total, 19 patients had a stable distal radioulnar joint (DRUJ) and five had an unstable DRUJ. Despite this, all patients were found to have a foveal tear upon DRUJ arthroscopy. Magnetic resonance imaging (MRI) scans detected only eight out of 23 patients with foveal injuries. In addition to their foveal injury, 19 of the 24 patients had additional pathology that required treatment. At a mean follow-up of 18 months, there was a statistically significant improvement in pain, range of motion, grip strength and functional scores. In this study, we demonstrate that having a stable DRUJ upon clinical examination and normal MRI findings does not rule out foveal TFCC injury and a high index of clinical suspicion is needed when managing patients with ulnar sided wrist pain.Level of evidence: IV.

Antegrade Fixation of Distal Metaphyseal Ulnar Shortening Osteotomy

The ulnar shortening osteotomy (USO) is a common procedure used to treat ulnar impaction syndrome secondary to static or dynamic ulnar-positive variance. There are many described techniques for the USO. The distal metaphyseal ulnar shortening osteotomy (DMUSO) with retrograde cannulated screw fixation was described to reduce complications seen with other techniques. Biomechanical analysis of fixation constructs demonstrates 2-screw constructs are significantly stiffer than 1 screw and antegrade constructs have similar or greater stiffness when compared with retrograde constructs. Here, we describe a technique of antegrade cannulated screw fixation for DMUSO that obviates the need for the disruption of the distal radioulnar joint for intra-articular exposure of the ulnar head. Similar to the traditional retrograde DMUSO technique, this construct may also decrease the risk of delayed union, symptomatic implants associated with diaphyseal osteotomies, and disruption of triangular fibrocartilaginous complex in wafer procedures.

Arthroscopic TFCC Ulnar Bone Tunnel Foveal Repair in Adult Patients

Triangular fibrocartilage complex (TFCC) tears may cause persistent ulnar-sided wrist pain, loss of grip strength, and associated loss of function. Although the majority of TFCC tears can be treated nonoperatively, surgical repair is considered when conservative measures fail. TFCC tears with foveal disruption and instability of the distal radioulnar joint (DRUJ) require direct repair of the TFCC to the ulnar fovea. The traditional method of foveal TFCC repair involves an open surgical approach through the floor of the 5th dorsal compartment. However, this open approach causes disruption of structures such as the dorsal ulnocarpal capsule, the extensor retinaculum, and, potentially, the distal radioulnar ligament (DRUL). This article describes, in detail, the recently developed arthroscopic assisted ulnar foveal bone tunnel repair. This method spares dorsal structures that may be disrupted during an open surgical approach and creates a robust repair of the TFCC deep fibers with restoration of DRUJ stability.

The Value Added of Advanced Imaging in the Diagnosis and Treatment of Triangular Fibrocartilage Complex Pathology

PURPOSE

Pathology of the triangular fibrocartilage complex is a prevalent cause of ulnar-sided wrist pain that presents a diagnostic challenge. We hypothesized that a history and physical examination (H&P) would be more cost-effective alone or with diagnostic injection than with magnetic resonance imaging (MRI) or magnetic resonance arthrogram (MRA) in the diagnosis and treatment of a symptomatic triangular fibrocartilage complex abnormality.

METHODS

A simple-chain decision analysis model was constructed to assess simulated subjects with ulnar-sided wrist pain and normal radiographs using several diagnostic algorithms: H&P alone, H&P + injection, H&P with delayed advanced imaging (MRI or MRA), and H&P + injection with delayed advanced imaging (MRI or MRA). Three years after diagnosis, effectiveness was calculated in Disabilities of the Arm, Shoulder, and Hand-adjusted life years. Costs were extracted from a commercial insurance database using US dollars. A probabilistic sensitivity analysis with 10,000 second-order trials with sampling of parameter distributions was performed. One-way and 2-way sensitivity analyses were performed.

RESULTS

All strategies had similar mean effectiveness between 2.228 and 2.232 Disabilities of the Arm, Shoulder, and Hand-adjusted life years, with mean costs ranging from $5,584 (H&P alone) to $5,980 (H&P, injection, and MRA). History and physical examination alone or with injection were the most cost-effective strategies. History and physical examination alone was the most preferred diagnostic strategy, though H&P + injection and H&P with delayed MRA were preferred with adjustments in willingness-to-pay and parameter inputs. As willingness-to-pay increased considerably (>$65,000 per Disabilities of the Arm, Shoulder, and Hand-adjusted life year), inclusion of MRA became the most favorable strategy.

CONCLUSIONS

Advanced imaging adds costs and provides minimal increases in effectiveness in the diagnosis and treatment of a symptomatic triangular fibrocartilage complex abnormality. The most cost-effective strategy is H&P, with or without diagnostic injection. Magnetic resonance arthrogram may be favored in situations with a high willingness-to-pay or poor examination characteristics.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic/Decision Analysis IV.

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.

The Combined Procedure of Ulnar Metaphyseal Shortening Osteotomy With Triangular Fibrocartilage Complex Foveal Knotless Repair

Ulnar impaction syndrome (UIS) and triangular fibrocartilage complex (TFCC) tear are common causes of ulnar-sided wrist pain. As a standard surgical treatment, ulnar-shortening osteotomy (USO) and TFCC repair are used respectively. Patient spectrums of UIS accompanied by distal radioulnar joint instability or traumatic TFCC foveal tear with UIS symptoms exist, and both USO and TFCC repair are necessary for treating some of these patients. However, there have been few reports on the procedure for performing these 2 operations concurrently. We introduce a combined procedure to concurrently perform USO and TFCC repair. We performed a USO in the ulnar metaphysis using a locking plate and open TFCC knotless repair using a suture anchor at the ulnar fovea. In this technique, USO is conducted in the metaphysis, which is favorable to union, using a small plate that is easy to handle, and knotless TFCC repair can be performed simultaneously through a single small incision.

Open and Arthroscopic Triangular Fibrocartilage Complex (TFCC) Repair

Triangular fibrocartilage complex (TFCC) tears, whether acute or chronic, can result in persistent ulnar-sided wrist pain. Although diagnosis and nonsurgical management of TFCC tears is well described, there remains ongoing discussion about the optimal surgical technique, specifically open or arthroscopic. This article reviews the most up-to-date literature regarding TFCC injury including demographics, risk factors for TFCC injury, classification of acute and chronic TFCC tears, history and physical examination, appropriate diagnostic imaging, surgical indications, pertinent surgical anatomy, open and arthroscopic TFCC repair, fixation biomechanics and techniques, postoperative rehabilitation, and clinical outcomes.

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.

Long-term radiographic outcomes and functional evaluation of ulnar shortening osteotomy in patients with ulnar impaction syndrome and reverse oblique sigmoid notch: a retrospective case series study

BACKGROUND

Ulnar shortening osteotomy (USO) is an effective treatment for ulnar impaction syndrome. However, there have been reports of osteoarthritis (OA) at the distal radioulnar joint (DRUJ) when USO was performed on patients with a reverse oblique sigmoid notch. This study aimed to evaluate the radiographic and functional outcomes following USO in patients with a reverse oblique sigmoid notch.

METHODS

We retrospectively reviewed patients having a reverse oblique sigmoid notch who underwent USO for ulnar impaction syndrome between 2002 and 2013. We evaluated radiographic changes of the DRUJ and functional outcomes of patients.

RESULTS

We enrolled 22 patients (22 wrists) with an average age of 49.6 years and a mean follow-up of 93.2 (range, 36-179; standard deviation [SD], 38.2) months. We found that there were changes in the inclination angle of the sigmoid notch, from an average reverse oblique of 14.9^o (range, 11^o-23^o; SD, 3.4^o) preoperatively to a more parallel 5.1^o (range, 0^o-11^o; SD, 3.2^o) at the final follow-up. The functional results at the final follow-up were good, with a mean visual analogue scale for pain of 0.2 (range, 0-1; SD, 0.4) at rest and 1.3 (range, 0-3; SD, 0.9) during activity, QuickDASH of 15.1 (range, 2.3-34.1; SD, 8.8), and modified Mayo Wrist Score of 91.6 (range, 70-100; SD, 6.4). Seven wrists (31.8%) had changes compatible with OA, but the wrists did not exhibit a significantly worse function when compared to wrists without OA changes, except for supination motion and grip strength.

CONCLUSIONS

For patients with a reverse oblique sigmoid inclination following USO, we observed that the inclination angle had a tendency to become parallel and some patients developed OA at the DRUJ. However, long-term functional outcomes could still be good. The reverse oblique sigmoid inclination does not seem to be an absolute contraindication for USO.

Surgical Repair of Triangular Fibrocartilage Complex Tears: A Systematic Review

Objective  This study systematically reviews the outcomes of surgical repair of triangular fibrocartilage complex (TFCC) tears. Existing surgical techniques include capsular sutures, suture anchors, and transosseous sutures. However, there is still no consensus as to which is the most reliable method for ulnar-sided peripheral and foveal TFCC tears. Methods  A systematic review of MEDLINE and EMBASE was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The focus was on traumatic Palmer 1B ulna-sided tears. Twenty-seven studies were included, including three comparative cohort studies. Results  There was improvement in all functional outcome measures after repair of TFCC tears. The outcomes following peripheral and foveal repairs were good overall: Mayo Modified Wrist Evaluation (MMWE) score of 80.1 and 85.1, Disabilities of the Arm, Shoulder and Hand (DASH) score of 15.7 and 15.8, grip strength of 80.3 and 92.7% (of the nonoperated hand), and pain intensity score of 2.1 and 1.7, respectively. For peripheral tears, transosseous suture technique achieved better outcomes compared with capsular sutures in terms of grip strength, pain, Patient-Rated Wrist Evaluation (PRWE), and DASH scores (grip 85.8 vs. 77.7%; pain 1.5 vs. 2.2; PRWE 11.6 vs. 15.8; DASH 14.4 vs. 16.1). For foveal tears, transosseous sutures achieved overall better functional outcomes compared with suture anchors (MMWE 85.4 vs. 84.9, DASH 10.9 vs. 20.6, pain score 1.3 vs. 2.1), but did report slightly lower grip strength than the group with suture anchors (90.2 vs. 96.2%). Arthroscopic techniques achieved overall better outcomes compared with open repair technique. Conclusion  Current evidence demonstrates that TFCC repair achieves good clinical outcomes, with low complication rates. Level of Evidence  This is a Level IV, therapeutic study.

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.

Editorial Commentary: Ulnar Variance Is Not the Sole Determinant of Arthroscopic Wrist Triangular Fibrocartilage Complex Repair Outcome: Considering the Forest From the Ulnar-Positive Tree

When choosing the best treatment option for patients with tears of the triangular fibrocartilage complex, there are multiple patient factors that should be carefully considered. The role of ulnar variance is often overemphasized when attempting to predict the success of arthroscopic repair. In practice, variables such as the age of the patient and location and nature of the tear as traumatic or degenerative should primarily drive the decision between arthroscopic repair and primary ulnar-shortening osteotomy. Arthroscopic repair should generally be avoided in favor of ulnar-shortening osteotomy in patients with degenerative tears and evidence of ulnar impaction syndrome. However, for acute, traumatic, ulnar-sided tears in young patients, arthroscopic repair remains an effective treatment option regardless of ulnar variance.

Surgical Repair of Acute TFCC Injury

Triangular fibrocartilage complex tears are a common source of ulnar-sided wrist pain and distal radioulnar joint instability. Symptoms recalcitrant to conservative management or injuries in high-demand athletes may indicate surgical management. Both open and arthroscopic techniques offer improvements in objective measures, patient-centered outcome scores, and return to work, but may be complicated by nerve irritation, persistent wrist instability, and pain. Recently developed knotless arthroscopic techniques are not well studied but may limit morbidity.

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.

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.

Outcomes of ulnar shortening osteotomy using a new compression plate

Ulnar impaction syndrome (UIS) is a frequent cause of ulnar-sided wrist pain. Several open and arthroscopic surgery techniques have been described. Ulnar shortening osteotomy (USO) is often the method of choice. It has the advantage of leveling the distal radioulnar joint extra-articularly while maintaining the integrity of the soft tissues that stabilize the joint. This retrospective study reports the short-term outcomes of 20 patients who underwent surgery between 2013 and 2015. USO was performed with a locked plate and a new compression device (Alians®, Newclip™, Haute Goulaine, France). Preoperative and postoperative ulnar variance were measured on wrist X-rays in neutral pronation-supination. Functional outcomes were evaluated with the QuickDASH score and the pain on VAS (visual analog scale). Postoperative range of motion and grip strength were compared to those of the contralateral wrist. The average follow-up was 16 months (4 to 28 months). Preoperative ulnar variance was positive with an average of 4mm (1-11mm). The average length of the final ulna shortening was 3.5mm (1.5-6mm); the mean time to union was 4 months (3-12 months). The average QuickDASH was 12 and pain had decreased 2.4mm on the VAS. The results achieved with this new compression plate designed specifically for USO are similar to those described in the literature. This kind of device has an easily reproducible technique and can reduce the operative time. LEVEL OF EVIDENCE: IV.

Nonunion Rates Among Ulnar-Shortening Osteotomy for Ulnar Impaction Syndrome: A Systematic Review

PURPOSE

The purpose of this study was to systematically review all available literature reporting nonunion rates of ulnar-shortening osteotomies (USO) used for the treatment of ulnar impaction syndrome (UIS) and to compare those rates among transverse versus oblique cuts for the osteotomy.

METHODS

Electronic databases including PubMed, EMBASE, and Cochrane Central Register of Controlled Trials were searched for studies that evaluated outcomes of both transverse and oblique USO for UIS. Level of evidence was determined by 2 independent reviewers. Studies were screened based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and inclusion and exclusion criteria were applied. A total of 37 studies (1,423 patients) were included in final analysis. The average rate of nonunion and delayed union for each group (transverse and oblique osteotomy) was calculated.

RESULTS

The average rate of nonunion among all osteotomies was 4.0%. The average rate of nonunion was 4.16% and 3.86% in transverse osteotomies and oblique osteotomies, respectively. This difference was not statistically significant. The average rate of delayed union, in those studies that reported delayed union, was 5.7%. The average rate of delayed union was 7.41% and 4.1% in transverse osteotomies and oblique osteotomies, respectively.

CONCLUSIONS

Based on our review of the literature, there is no difference in the rate of nonunion between transverse and oblique osteotomies. Therefore, the decision of which of the 2 surgical techniques should not be based on rate of nonunion.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.

Time-Dependent Recovery of Outcome Parameters in Ulnar Shortening for Positive Ulnar Variance: A Prospective Case Series

BACKGROUND

This study evaluates the results of ulnar shortening using the ulna osteotomy locking plate system (UOL; I.T.S. GmbH, Graz, Austria) with special regard to the time-dependent recovery of subjective and objective outcome parameters and surgeons' experiences.

METHODS

Ulnar shortening using the UOL was performed on 11 patients (3 men, 8 women) with an average age of 47 ± 19.6 years. Range of motion (ROM) and grip strength were compared with the contralateral hand. Patient-rated outcomes were measured using a visual analogue scale (VAS) for pain and the Disability of the Arm, Shoulder and Hand (DASH) and the Patient Rated Wrist Evaluation (PRWE) survey for subjective outcomes. Ulnar variance and bony union were assessed using conventional wrist radiographs. The surgeons evaluated intraoperative handling through a standardized feedback form.

RESULTS

ROM improved and grip strength increased significantly between preoperative values and final follow-up. Flexion and supination improved significantly between weeks 8 and 12 and grip strength from week 8 onward. Patient-rated outcomes changed significantly with a final DASH score of 14.2 ± 12.4 and a PRWE score of 24.3 ± 17.0. Pain levels improved significantly with no pain at rest and a mean VAS of 0.8 ± 1.2 during activity. The average amount of shortening was 4.0 ± 1.9 mm with a final ulnar variance of 0.2 ± 1.8 mm. All osteotomies healed with 2 cases of delayed union.

CONCLUSIONS

In ulnar shortening with the UOL, wrist function recovered after an initial decrease from week 8 onward. Subjective outcome parameters showed early recovery and improved continuously over time.

Microfracture for Ulnar Impaction Syndrome: Surgical Technique and Outcomes with Minimum 2-Year Follow-up

Purpose The purpose of this study is to assess functional and patient-reported outcomes after lunate microfracture for management of lunate chondral lesions in the setting of ulnar impaction syndrome. Methods This was a retrospective review of all patients undergoing wrist arthroscopy for triangular fibrocartilage complex pathology by one surgeon from 2007 until 2010. Disabilities of the arm, shoulder, and hand (DASH) scores were assessed preoperatively and at minimum 2-year follow-up. Patient-rated wrist evaluation and bilateral wrist range of motion, grip strength, and key pinch strength were assessed at final follow-up. Results A total of 22 patients underwent microfracture of the carpus during the study period, of which 7 met all inclusion and exclusion criteria. Mean DASH scores improved significantly (p < 0.001), from 58.3 (standard deviation: 13.5) before the procedure to 15.1 (standard deviation: 8.6) at minimum 2-year follow-up. Operative wrist pronation and supination showed equivalence with the contralateral wrist at final follow-up (p < 0.05, E = 15 degrees, standard deviation pronation: 3.25, supination: 3.49). Discussion This study suggests that lunate microfracture may be a useful technique for treating articular defects of the lunate in the setting of ulnar impaction syndrome. Type of Study/Level of Evidence Therapeutic, level IV.

The Outcomes of Arthroscopic Repair Versus Debridement for Chronic Unstable Triangular Fibrocartilage Complex Tears in Patients Undergoing Ulnar-Shortening Osteotomy

PURPOSE

The aim of this study was to compare the results of arthroscopic peripheral repair (AR) and arthroscopic debridement (AD) for the treatment of chronic unstable triangular fibrocartilage complex (TFCC) tears in ulnar-positive patients undergoing ulnar-shortening osteotomy (USO).

METHODS

A total of 31 patients who underwent arthroscopic treatments combined with USO for unstable TFCC tears and were followed-up at a minimum of 24 months were included in this retrospective cohort study. Fifteen patients were treated with AR, and 16 patients were treated with AD while at the same time undergoing a USO. Outcome measures included wrist range of motion, grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) and Patient-Rated Wrist Evaluation (PRWE) scores, and overall outcomes according to the modified Mayo wrist scoring system. In addition, a stress test to assess distal radioulnar joint (DRUJ) stability was performed before and after surgery to compare the 2 cohorts.

RESULTS

Both respective cohorts showed significant improvements in grip strength and subjective scores at the final follow-up. Grip strength, DASH, and PRWE scores were better in the AR group than in the AD group. The recovery rate from DRUJ instability observed during the preoperative examination was superior in the AR group.

CONCLUSIONS

Both AD and AR of the TFCC combined with USO are reliable procedures with satisfactory clinical outcomes for unstable TFCC tears in ulnar-positive patients. However, AR of the TFCC is suggested if DRUJ stability is concomitantly compromised.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.

Comparison of compression screw and perpendicular clamp in ulnar shortening osteotomy

PURPOSE

To biomechanically quantify 2 techniques, compression screw and perpendicular clamp, for generating compression during ulnar shortening osteotomy (USO) in order to promote reliable primary bone healing.

METHODS

Fourteen fresh-frozen cadaveric human forearms were randomly assigned to 1 of 2 groups. Group I (n = 7) underwent USO according to the traditional AO plate fixation technique using a screw placed eccentrically in an oblong hole to generate compression at the osteotomy site. Group II (n = 7) underwent USO with a commercially available USO plating system using a clamp placed perpendicular to the osteotomy site to generate compression. Both techniques involved a 2-mm resection osteotomy performed with cutting jigs to minimize variability and an interfragmentary lag screw to augment compression. A digital pressure sensor measured contact area at the osteotomy site and average pressure in the observed contact area; these values were used to calculate force across the osteotomy site. Measurements were obtained after the following steps: reduction of osteotomy, compression screw placement (group 1 only), lag screw placement, and final construct with all clamps removed.

RESULTS

Group II demonstrated significantly greater force than group I, and lag screw placement resulted in significantly increased force independent of fixation technique. The effect of the lag screw on force was maintained after clamp removal. Although technique of fixation did not significantly influence contact area, lag screw placement significantly increased contact area independent of fixation method. However, this effect was not maintained after clamp removal. Average pressure in the observed contact area was not significantly influenced by fixation technique or stage of fixation.

CONCLUSIONS

Perpendicular clamp compression significantly increased force as compared with traditional compression screw technique, and lag screw placement significantly increased force in both constructs.

CLINICAL RELEVANCE

Larger compressive forces across the osteotomy may promote primary bone union and decrease the rates of delayed union or nonunion.

Arthroscopically assisted reconstruction of triangular fibrocartilage complex foveal avulsion in the ulnar variance-positive patient

PURPOSE

Our aim was to evaluate the clinical results of patients treated by arthroscopically assisted reconstruction of foveal avulsion injury of the triangular fibrocartilage complex (TFCC) using a suture anchor.

METHODS

We retrospectively reviewed the results of 15 patients (11 men and 4 women; mean age, 30.5 years) who underwent surgical procedures for the treatment of TFCC foveal avulsion at our hospital. The patients were followed up for a mean of 29 months. The patients had TFCC foveal avulsion caused by sprains (n = 8), falls (n = 4), playing baseball (n = 2), and a motor vehicle accident (n = 1). All the patients underwent magnetic resonance imaging. Radiographs obtained to assess ulnar variance (UV), ulnar-dorsal subluxation, and function of the wrist based on grip power; Disabilities of the Arm, Shoulder and Hand score; and Mayo wrist score were examined for all patients both preoperatively and postoperatively.

RESULTS

On preoperative magnetic resonance imaging, TFCC foveal avulsion was observed in 13 of 15 cases. The mean UV value based on preoperative simple radiographic findings was 1.7 ± 1.0 mm, and dorsal subluxation at the distal ulna improved from 2.9 ± 3.0 mm to 0.2 ± 0.9 mm (P = .017). In all cases the distal radioulnar joint instability disappeared postoperatively. Grip power (compared with the uninvolved limb) was 79.3% preoperatively and 82.9% postoperatively (P = .086). The Disabilities of the Arm, Shoulder and Hand scores were 28.4 points preoperatively and 16.6 points postoperatively (P = .061). The Mayo wrist scores were excellent in 10 cases, good in 2, and fair in 3, and the mean score improved significantly from 64 points preoperatively to 84 points postoperatively (P = .007).

CONCLUSIONS

Arthroscopic-assisted suture anchor reattachment of the TFCC in patients with traumatic TFCC foveal avulsion can prevent or reduce distal radioulnar joint instability and reduce pain even in chronic cases with positive UV.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

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.

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.

Persistent ulnar-sided wrist pain after treatment of triquetral dorsal chip fracture: six cases related to triangular fibrocartilage complex injury

INTRODUCTION

Persistent ulnar-sided wrist pain after treatment of triquetral dorsal chip fracture even after union is a matter of concern. There could be various reasons for this persistent pain like arthritis, instability, fractures and non-union. We correlate our findings of physical examination and wrist arthroscopy as triangular fibrocartilage complex injury to be one of the causes of this persistent pain.

PATIENTS

Six subjects who had persistent ulnocarpal joint pain and tenderness after triquetral dorsal chip fracture, despite 2 months of conservative treatment, were subjected to physical tests. If the physical examination yields positive results, then magnetic resonance imaging followed by arthroscopic treatment was performed. The six patients were then evaluated using the visual analogue scale, the Mayo modified wrist score, and the grip strength test.

RESULTS

Triangular fibrocartilage complex (TFCC) injury was observed in all six cases and partial TFCC resection and synovectomy were performed. Analysis of the visual analogue scale, Mayo modified wrist score, and grip strength test data revealed statistically significant improvements (P < 0.05).

CONCLUSION

In addition to several causes reported in the published literature, TFCC injury can be a cause of persistent ulnar pain after treatment of triquetral dorsal chip fracture. Arthroscopic partial TFCC resection can be considered to be a suitable treatment for such cases.

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.