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

Peripheral tear of the triangular fibrocartilage complex: diagnostic accuracy of magnetic resonance imaging and diagnostic performance of the primary and secondary signs

OBJECTIVE

This study is to assess the diagnostic performance of magnetic resonance imaging (MRI) findings for type 1B triangular fibrocartilage complex (TFCC) tear of the wrist.

MATERIALS AND METHODS

This study retrospectively enrolled 78 patients to examine the diagnostic performance of preoperative MRI examinations in patients with type 1B TFCC tears. Thirty-nine participants had confirmed type 1B TFCC tear. The control group included 39 patients who were randomly selected from 1157 patients who underwent MRI for wrist pain. Both groups underwent a review of 19 MRI findings by two independent radiologists, and the correlation between each diagnostic finding and type 1B TFCC tear was assessed using the chi-squared test. The 19 MRI findings comprised eight primary signs of abnormalities in the distal or proximal lamina, in conjunction with 11 secondary signs suggestive of abnormalities in the surrounding structures.

RESULTS

The TFCC tear group demonstrated a significantly higher incidence of two primary MRI signs, i.e., fiber discontinuity and signal alteration in the distal lamina, as observed by both readers (R1, 74.4% vs. 38.5%, p = 0.003, and 87.2% vs. 43.6%, p < 0.001; R2, 74.4% vs. 35.9%, p = 0.001, and 87.2% vs. 53.8%, p < 0.003, respectively). Reader 2 identified a higher prevalence of two additional primary MRI signs: fiber discontinuity and signal alteration in the proximal lamina (all p < 0.05). None of the 11 secondary MRI signs demonstrated statistically significant associations with type 1B TFCC.

CONCLUSION

MRI manifestations of fiber discontinuity and signal alteration in the distal lamina may provide predictive markers for type 1B TFCC wrist tear.

All-Inside Versus Outside-in Repair of Triangular Fibrocartilage Complex Peripheral Tears

PURPOSE

Triangular fibrocartilage complex (TFCC) peripheral tears with persistent wrist pain can be treated with arthroscopic surgical repair owing to vascularization of the peripheral region. The safety and efficacy of all-inside repair has been shown in prior case series. The purpose of this study was to compare two methods of arthroscopic peripheral TFCC repair: all-inside vertical mattress and outside-in horizontal mattress.

METHODS

A 5-year retrospective review was performed on patients treated from 2016 to 2021 with wrist arthroscopy and TFCC repair for Palmer 1B tears. Patients with ulnar extrinsic ligament repair, distal radioulnar joint instability, concomitant ulnar shortening osteotomy, and extensor carpi ulnaris instability were excluded. Patient therapy and office visit records were reviewed. Outcomes including Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH); range of motion; grip strength; immobilization time; complications; and need for revision procedures were compared.

RESULTS

Fifty-two patients were included in the study, 32 in the outside-in group and 20 in the all-inside group. The average follow-up length was 24.8 weeks, with similar range of motion and strength in both groups. The average postoperative QuickDASH score was 13 in the outside-in group and 9 in the all-inside group at 43.5 months, compared with the preoperative QuickDASH scores of 47 and 50, respectively. Mean immobilization time was longer for outside-in than for all-inside (5.25 vs 2.0 weeks, respectively).

CONCLUSIONS

All-inside arthroscopic peripheral TFCC repair showed range of motion, grip strength, complications, revisions, and postoperative improvement in QuickDASH scores similar to those with the outside-in technique.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV; retrospective comparative study.

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.

Trans - 6R Portal Repair of Superficial TFCC Tears; A Modified Arthroscopic Outside-in Technique

Different arthroscopic repair techniques have been described for various tear types. Several series have reported successful outcomes for arthroscopic repair of superficial tear of the triangular fibrocartilage complex (TFCC) tears using the outside-in technique. Described techniques entail usage of special instruments for passage of sutures and/or use of many incisions. We describe an arthroscopic technique for repair of superficial part of TFCC through the 6R portal by single hypodermic needle, with no additional skin incisions or special equipment.

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.

Editorial Commentary: Arthroscopic Capsular Repair of Wrist Triangular Fibrocartilage Complex Tears: Beware That Apparent Isolated Atzei Class 1 (Isolated Distal Component) Tears May Include a Proximal Component

Accumulating knowledge about the anatomy of the triangular fibrocartilage complex (TFCC) and its function has revealed that the foveal insertion of the TFCC plays a key role in distal radioulnar joint stability rather than the superficial fibers that insert into the ulnar styloid. Recently, the interest in torn peripheral TFCC repair has been shifting from capsular repair for Atzei class 1 to foveal repair for Atzei class 2 or 3. Most acute Atzei class 1 tears spontaneously heal without surgical repair; in contrast, in cases of sustained pain and distal radioulnar joint instability even after successful Atzei class 1 repair, the unrecognized proximal component TFCC tear concomitant with a distal component TFCC tear may exist and appropriate treatment for the proximal component TFCC tear should be combined. Although overall successful results have been reported using various repair techniques, the most important consideration is re-establishing biologic regeneration potential at the insertion site of torn TFCC.

Functional Outcomes Are Similar After Arthroscopic Capsular Repair of Triangular Fibrocartilage Complex Tears Between Outside-In Technique and All-Inside Technique Using Pre-Tied Suture Device

PURPOSE

To compare outcomes of arthroscopic triangular fibrocartilage complex capsular repair at 2-year follow-up between outside-in and all-inside techniques.

METHODS

In total, 58 consecutive patients (wrists) with a Palmer 1B triangular fibrocartilage complex tear without symptomatic distal radioulnar joint instability underwent arthroscopic suture repair from 2011 to 2019 including 31 patients via the outside-in technique (group A) and 27 via the all-inside technique using a pre-tied needle device (group B). Two-year follow-up included visual analog scale (VAS) pain score, motion range, grip strength, Mayo Modified Wrist Score (MMWS), the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, and complication rate. Correlation between functional result and patient satisfaction was analyzed.

RESULTS

Score changes in VAS, wrist flexion-tension, supination-pronation, grip strength, MMWS, and QuickDASH at 2-year follow-up were not significantly different between group A (3.4 ± 0.8, 18.4 ± 17.5, 12.9 ± 13.3, 30.7 ± 11.2, 26.6 ± 7.9 and 19.4 ± 9.9 and group B (3.4 ± 1.0, 18.5 ± 18.3, 15.6 ± 13.7, 30.8 ± 11.4, 28.1 ± 8.6, and 7.6 ± 7.2) with P values of .400, .489, .223, .486, .240, and .223 respectively. Surgical time averaged 105 minutes (78 to 136) in group A and 94 minutes (61-126) in group B with significant difference (P = .012). Patient satisfaction averaged 1.1 (0-3.5) in group A and 1.0 (range 0-3.0) in group B. Satisfaction score was more strongly correlated with QuickDASH (coefficients: 0.863 in group A and 0.918 in group B) than with MMWS (-0.693 in group A and -0.465), grip strength (-0.619 in group A and -0.417 in group B) and VAS score (0.607 in group A and 0.222 in group B).

CONCLUSIONS

Both techniques achieved comparable outcomes with shorter surgical time in all-inside repair using pre-tied needle device. Patient satisfaction was strongly correlated with QuickDASH score.

LEVEL OF EVIDENCE

Level III, retrospective therapeutic comparative investigation.

Ulnar Wrist Pain in a Tennis Player: Case Review and Discussion: A Team-Based Approach

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Ulnar-sided wrist pain is a common cause of debilitating wrist pain in stick-handling athletes. Due to the complexity of surrounding anatomy, the evaluation and diagnosis can be challenging.

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Injury of the triangular fibrocartilage complex (TFCC) is the most common cause of ulnar-sided wrist pain. Repetitive, unrestricted pronosupination, wrist deviation, and axial-loading activity, such as in tennis, place substantial stress on the TFCC.

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The ulnotriquetral (UT) ligament is a palmar thickening of the ulnar capsule arising from the palmar radioulnar (PRU) ligament of the TFCC. When injured, the UT ligament can be a source of acute or chronic ulnar-sided wrist pain. The ligament can avulse off bone, can rupture completely, or can split longitudinally.

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Arthroscopic-assisted repair is a safe, reliable, and effective treatment for UT ligament split tears and peripheral TFCC tears.

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Although the benefit of a team-based approach may be realized by most patients, high-performing, stick-handling athletes are part of a unique population who execute repetitive, extraordinary wrist movements. The high demand and functional requirement expected of the wrists require a uniquely tailored approach to return them to the same level of competitive play.

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.].

Effects of peripheral tears of the triangular fibrocartilage complex on distal radioulnar joint stability: A biomechanical study

BACKGROUND

Peripheral triangular fibrocartilage complex (TFCC) tears may induce instability of the distal radioulnar joint (DRUJ). In this biomechanical study, simulated peripheral tears of the TFCC were examined on the stability of the DRUJ. Restabilization effect of the DRUJ by ulnar shortening and direct repair of those injuries were sequentially examined.

METHOD

The DRUJ stiffness was measured in intact, simulated two types of peripheral tears (ulnar and extended ulnodorsal) at three forearm positions: neutral, 60° pronation and 60° supination in 8 fresh frozen cadaver specimens. After the tears were sutured with stitches or after simulated ulnar shortening of 3 mm, the DRUJ stiffness was again measured.

RESULTS

The ulnar and ulnodorsal TFCC tears decreased the DRUJ stiffness significantly compared with the intact in all forearm positions. When ulnar shortening was done for the ulnar tear, the DRUJ stiffness increased significantly in the neutral and 60° pronated positions. When the ulnar TFCC tear was repaired, the DRUJ stiffness increased significantly in all forearm positions. DRUJ stiffness did not increase either with ulnar shortening or repair in ulnodorsal tear of the TFCC, however.

CONCLUSION

The simulated TFCC tears indicated significant loss of DRUJ stiffness. Direct repair or ulnar shortening was effective only on treatment of the ulnar tear of the TFCC in this study.

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 Capsular Repair for Triangular Fibrocartilage Complex Tears

Background  The triangular fibrocartilage complex (TFCC) lesions are frequently implicated as a cause of ulnar wrist pain following impact and loading injuries. The objective of this study was to describe the clinical outcomes following TFCC lesion repair with the arthroscopic outside-in technique. Description of Technique  We inserted a 21-gauge needle with 4-0 nylon loop perpendicular to the injured triangular fibrocartilage (TFC). We held two 4-0 nylon loops with mosquito forceps, drew them once out of the joint through a 4 to 5 portal, and put both sides through each loop. After that, we pulled out the 21-gauge needles and performed outside-in sutures after making a small incision and tying directly over the capsule. Patients and Methods  Twenty-one wrists who underwent arthroscopic capsular repair were included. Arthroscopic findings were evaluated, and we used a distal radioulnar joint (DRUJ) evaluation system to monitor relief of pain, forearm rotation range of motion, and DRUJ stability postoperatively. Results  Simple ulnar avulsion (Palmer 1B, Atzei Class 1) was recognized in ten wrists. A combination of the 1B tear with a horizontal TFC tear was noted in five wrists; and ulnar avulsion extending to the dorsal half of the TFC was identified in six wrists, including complete dorsal avulsion of the TFC from the capsule. There are significantly better results in the cases whose preoperative periods were 15 months or less. Conclusion  The outside-in TFC repair technique produced excellent clinical results for peripheral detachment of the TFC in cases without severe DRUJ instability and with a preoperative period less than 15 months.

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.

Management of Acute Distal Radioulnar Joint Instability Following a Distal Radius Fracture: A Systematic Review and Meta-Analysis

Purpose

We sought to review the clinical outcomes of conservative and operative treatment options for acute distal radioulnar joint (DRUJ) instability associated with distal radius fractures in adult patients.

Methods

A systematic search of PubMed, MEDLINE, and EMBASE for articles published between 1990 and 2020 involving DRUJ instability associated with distal radius fractures was performed. The primary outcomes analyzed included clinical grip strength; range of motion; the disability of the arm, shoulder and hand (DASH) score; and the modified Mayo wrist score (MMWS).

Results

Of the 531 articles identified in the literature search, 8 met our defined criteria and were included in the final analysis. The cumulative sample size was 258 patients at a mean follow-up of 11.1 months (range, 3–16.9 months). Treatment groups included cast immobilization in supination, K-wire stabilization, and triangular fibrocartilage complex (TFCC) repair. Statistical analysis revealed no difference across groups in active flexion-extension or DASH scores. A significant decrease in grip strength was found in patients who underwent TFCC repair compared with that in those who underwent both cast immobilization (P = .04) and K-wire stabilization (P = .02). Furthermore, we found a significant decrease in active pronation-supination between patients who underwent TFCC repair and those who underwent cast immobilization (P = .03). Patients who underwent TFCC repair were also found to exhibit decreased MMWS as compared with those who underwent K-wire stabilization (P = .05). Overall, persistent DRUJ instability was only found in 4 patients (1.5%), without a significant difference between treatment groups.

Conclusions

This study suggests functional advantages of certain treatment modalities over others, with the range of motion being highest in patients who underwent cast immobilization and grip strength being highest in patients who underwent K-wire stabilization. However, the mean DASH scores showed no difference across all groups, calling into question the clinical need to pursue operative treatment via K-wire stabilization or TFCC repair over conservative treatment via cast immobilization. This study will hopefully serve as a foundation for future prospective studies to help improve and standardize treatment algorithms in patients with DRUJ instability and distal radius fractures.

Type of study/level of evidence: Therapeutic II.

Distal radioulnar joint stabilization with open foveal reinsertion versus tendon graft reconstruction: an experimental study using radiostereometry

Purpose

Symptomatic instability of the distal radioulnar joint (DRUJ) caused by lesion of the Triangular Fibrocartilage Complex (TFCC) can be treated with a number of surgical techniques. Clinical examination of DRUJ translation is subjective and limited by inter-observer variability.

The aim of this study was to compare the stabilizing effect on DRUJ translation with two different surgical methods using the Piano-key test and a new precise low-dose, non-invasive radiostereometric imaging method (AutoRSA).

Methods

In a randomized experimental study we evaluated the DRUJ translation in ten human cadaver arms (8 males, mean age 78 years) after cutting the proximal and distal TFCC insertions, and after open surgical TFCC reinsertion (n = 5) or TFCC reconstruction using a palmaris longus tendon graft ad modum Adams (n = 5).

The cadaver arms were mounted in a custom-made fixture for a standardized Piano-key test. Radiostereometric images were recorded and AutoRSA software was used for image analyses. Standardised anatomical axes and coordinate systems of the forearm computer tomography bone models were applied to estimate DRUJ translation after TFCC lesions and after surgical repair.

Results

The DRUJ translation after cutting the proximal and distal TFCC insertions was 2.48 mm (95% CI 1.61; 3.36). Foveal TFCC reinsertion reduced DRUJ translation by 1.78 mm (95% CI 0.82; 2.74, p = 0.007), while TFCC reconstruction reduced DRUJ translation by 1.01 mm (95% CI -1.58; 3.60, p = 0.17).

Conclusion

In conclusion, foveal TFCC reinsertion significantly decreased DRUJ translation while the stabilizing effect of Adams TFCC reconstruction was heterogeneous. This supports the clinical recommendation of TFCC reinsertion in patients suffering from symptomatic DRUJ instability due to acute fovea TFCC lesions.

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.

Single-strand repair of EWAS 1 lesion of triangular fibrocartilage complex

PURPOSE

To report the results of our modified technique for repair of the EWAS 1 lesion of triangular fibrocartilage complex (TFCC).

METHODS

This retrospective case series reviewed 22 consecutive patients with EWAS 1 TFCC tear. Arthroscopic repair was done using our modified double-loop arthroscopic outside-in technique which is originally described by Mathoulin and Del Piñal. The repair was performed using single-strand suture and 18-gauge cannula, having three passes through the tear. Follow-ups ranged from 24 to 33 months with an average of 29.3 months. The results were evaluated by the Modified Mayo Wrist Score (MMWS), Visual Analog Score (VAS). In addition, range of motion (ROM) and power grip were compared with the contralateral side.

RESULTS

The mean age was 23 years. The dominant side was affected in 16 wrists. There was postoperative improvement of the all functional outcome measures (MMWS, VAS, ROM, and power grip). All the patients returned to their previous activities with no reported intra- or postoperative complications.

CONCLUSIONS

The described outside-in technique is safe and effective technique for repair of EWAS 1 TFCC tear.

LEVEL OF EVIDENCE

Therapeutic, case series, level IV.

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.

Wrist Arthroscopy in Athletes

Arthroscopy is a surgical technique whose indication for wrist injuries has grown in recent years. Athletes are subject to traumatic injury to the wrist due to training overload or the intensity of the activity during competition. The need of a quick return to sports practice makes arthroscopy a very useful minimally invasive technique in these situations. The authors present indications of sports-related injuries to the wrist that can be treated by arthroscopy. A literature review is also presented.

TFCC injuries: How we treat?

The triangular fibrocartilage complex (TFCC) is a well defined anatomical entity located on the ulnar aspect of the wrist joint functioning primarily to stabilize the distal radio -ulnar joint (DRUJ) and also to act as a shock absorber across the ulno-carpal joint. Palmer and Werner were first to explain the anatomic details of the TFCC and to describe its biomechanical role at the wrist. The TFCC comprises of the fibro-cartilagenous disc, the dorsal and palmar ligaments spanning across radius and ulna, the ulno-carpal ligaments, a meniscal homolog, and the sub sheath of ulnar extensor of the wrist. The intricate anatomy of this area and complex load transmission kinematics renders it vulnerable to injury and attrition. Both traumatic and degenerative insults produce specific injury patterns which can present as vague ulnar-sided wrist pain particularly during forearm rotation. These injuries are managed initially by modification of daily activities to avoid aggravation of pain and injury, by complete abstinence from sporting/gym/yoga maneuvers which involve stressing the wrist joints, temporary splint or cast immobilisation are also used along with non-steroidal anti-inflammatory medication. Corticosteriod injection are also used in conjunction with physical therapy in grossly symptomatic patients. Surgical treatment is advocated if conservative management fails to provide relief, or in cases presenting initially with frank instability of the DRUJ or with unstable and displaced fractures. Choice of operative treatment is guided by type and extent of injury and may include debridement, repair and in TFCC injuries associated with degenerative changes, ulnar unloading procedures like shortening or Wafer procedure. With current understanding of arthroscopic anatomy of the wrist, availability of instrumentation as well as familiarity of surgeons with this tool, arthroscopic management can be instituted successfully in most if not all conditions afflicting the TFCC.

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.

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

INTRODUCTION

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

SOURCES OF DATA

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

AREAS OF AGREEMENT

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

AREAS OF CONTROVERSY

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

GROWING POINTS

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

AREAS TIMELY FOR DEVELOPING RESEARCH

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

Hand and Wrist Injuries in Tennis Players

PURPOSE OF REVIEW

The purpose of this article is to review common hand and wrist injuries experienced by tennis players.

RECENT FINDINGS

A myriad of different wrist pathologies can be seen in tennis players ranging from metacarpal and carpal stress fractures to triangular fibrocartilage injuries and ulnar impaction. These vary depending upon the nature of the player, stroke mechanics, and time point within the season. A broad differential should guide work-up and management of wrist pain in tennis players.

Prognostic factors for the outcome of arthroscopic capsular repair of peripheral triangular fibrocartilage complex tears

BACKGROUND

Little information is available about prognostic factors of arthroscopic capsular repair for peripheral triangular fibrocartilage complex (TFCC) lesions. The purpose of this study was to analyze factors that affect the treatment outcomes of arthroscopic capsular repair for peripheral TFCC tears.

METHODS

This study retrospectively enrolled 60 patients who were treated with arthroscopic outside-in capsular repair for peripheral TFCC tears. Functional survey, including pain numeric rating scale (NRS) on an ulnar provocation test, distal radio-ulnar joint (DRUJ) stress test, Disability of the Arm, Shoulder, and Hand (DASH) score, and satisfaction with treatment, was conducted at 12-month follow-up. Patients who were enthusiastic or satisfied comprised the satisfied group, and those who were noncommittal or disappointed the dissatisfied group. Demographic, clinical, and arthroscopic findings were compared between the satisfied and dissatisfied groups.

RESULTS

The mean pain NRS and DASH scores exhibited significant clinical improvement at the 12-month follow-up. Out of the total participants, 46 were satisfied and 14 were dissatisfied about the treatment, with significantly more female subjects in the dissatisfied group than in the satisfied one. The patients in the satisfied group had a shorter duration of symptoms, were more likely to have trauma history, and exhibited positive DRUJ stress test results compared to the dissatisfied group. There were no significant group differences in age, hand dominance, work level, and the extent of ulnar plus variance. Multivariable analysis revealed that female gender, a longer duration of symptoms, or negative DRUJ stress test results were associated with an increased disability after arthroscopic TFCC repair.

CONCLUSION

Female gender, a longer duration of symptom, and a negative DRUJ stress test are associated with a higher likelihood of treatment failure after arthroscopic outside-in capsular repair of peripheral TFCC tears.

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.

Classification of ulnar triangular fibrocartilage complex tears. A treatment algorithm for Palmer type IB tears

The classical definition of 'Palmer Type IB' triangular fibrocartilage complex tear, includes a spectrum of clinical conditions. This review highlights the clinical and arthroscopic criteria that enable us to categorize five classes on a treatment-oriented classification system of triangular fibrocartilage complex peripheral tears. Class 1 lesions represent isolated tears of the distal triangular fibrocartilage complex without distal radio-ulnar joint instability and are amenable to arthroscopic suture. Class 2 tears include rupture of both the distal triangular fibrocartilage complex and proximal attachments of the triangular fibrocartilage complex to the fovea. Class 3 tears constitute isolated ruptures of the proximal attachment of the triangular fibrocartilage complex to the fovea; they are not visible at radio-carpal arthroscopy. Both Class 2 and Class 3 tears are diagnosed with a positive hook test and are typically associated with distal radio-ulnar joint instability. If required, treatment is through reattachment of the distal radio-ulnar ligament insertions to the fovea. Class 4 lesions are irreparable tears due to the size of the defect or to poor tissue quality and, if required, treatment is through distal radio-ulnar ligament reconstruction with tendon graft. Class 5 tears are associated with distal radio-ulnar joint arthritis and can only be treated with salvage procedures. This subdivision of type IB triangular fibrocartilage complex tear provides more insights in the pathomechanics and treatment strategies.

LEVEL OF EVIDENCE

II.

Upper Extremity Injuries in Gymnasts

Gymnastics is a unique sport, which loads the wrist and arms as weight-bearing extremities. Because of the load demands on the wrist in particular, stress fractures, physeal injury, and overuse syndromes may be observed. This spectrum of injury has been termed "gymnast's wrist," and incorporates such disorders as wrist capsulitis, ligamentous tears, triangular fibrocartilage complex tears, chondromalacia of the carpus, stress fractures, distal radius physeal arrest, and grip lock injury.

Arthroscopic-Assisted Outside-In Repair of Triangular Fibrocartilage Complex Tears

With advances in surgical instrumentation and techniques, as well as expanding surgical indications, wrist arthroscopy is now being used to treat a variety of conditions previously managed only with open techniques. Triangular fibrocartilage complex (TFCC) injuries remain among the most common causes of ulnar-sided wrist pain and can result from both acute and chronic mechanisms of injury. The most common mechanism of acute injury to the TFCC is a fall onto an outstretched hand with the wrist in a supinated, extended position. In patients with unrelenting pain, swelling, or mechanical symptoms despite a concerted effort at nonoperative management, which often consists of bracing, therapy, or injections, surgical intervention is often indicated. Treatment historically consisted of open exploration and repair; however, recently, arthroscopic-assisted and all-arthroscopic techniques have been described. We describe a safe, reproducible, and reliable surgical technique for arthroscopic-assisted outside-in repair of peripheral TFCC tears. In addition, a specific focus on surgical anatomy, including pearls and pitfalls for protecting the dorsal sensory branch of the ulnar nerve, is presented.

Anatomical transosseous fixation of the deep and superficial fibers of the radioulnar ligaments

INTRODUCTION

The triangular fibrocartilage complex is in conjunction with the interosseous membrane the most important stabilizer of the distal radioulnar joint. Lesions of the triangular fibrocartilage complex may cause instability of the distal radioulnar joint with serious consequences. Therefore, the goal is to reconstruct and provide stability to prevent further harm.

SURGICAL TECHNIQUE

Based on the anatomical configuration of the radioulnar ligaments, we present a technique which addresses both the deep and the superficial fibers of the radioulnar ligaments. This surgical procedure can be performed either openly or arthroscopically assisted. Two osseous 2-mm tunnels starting from the ulnar neck to the foveal surface are created. A nonabsorbable suture is passed through the tunnels and the triangular fibrocartilage using a 20-gauge venipuncture needle in order to attach the deep fibers. Then a third osseous tunnel starting from the lateral base of the styloid process to the medial aspect is created. The suture is passed through this tunnel and through the triangular fibrocartilage and around the styloid process palmarily using the same needle as before in order to anchor the superficial fibers anatomically. After reducing the ulna head the sutures are tightened.

CONCLUSION

This technique is quite simple and addresses the anatomical configuration of the radioulnar ligaments.

Comparison between open and arthroscopic-assisted foveal triangular fibrocartilage complex repair for post-traumatic distal radio-ulnar joint instability

The aim of this study was to assess the objective and subjective functional outcomes after foveal reattachment of proximal or complete ulnar-sided triangular fibrocartilage complex lesions by two surgical procedures: an open technique or an arthroscopically assisted repair. The study was done prospectively on 49 wrists affected by post-traumatic distal radio-ulnar joint instability. Twenty-four patients were treated with the open technique (Group 1) and 25 by the arthroscopically assisted technique (Group 2). Magnetic resonance imaging demonstrated a clear foveal detachment of the triangular fibrocartilage complex in 67% of the cases. Arthroscopy showed a positive ulnar-sided detachment of the triangular fibrocartilage complex (positive hook test) in all cases. Distal radio-ulnar joint stability was obtained in all but five patients at a mean follow-up of 6 months. Both groups had improvement of all parameters with significant differences in wrist pain scores, Mayo wrist score, Disability of the Arm, Shoulder and Hand questionnaire and Patient-Rated Wrist/Hand Evaluation questionnaire scores. There were no significant post-operative differences between the two groups in the outcome parameters except for the Disability of the Arm Shoulder and Hand questionnaire score, which was significantly better in Group 2 (p < 0.001).

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

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

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.

THE BEAUTY OF STABILITY: DISTAL RADIOULNAR JOINT STABILITY IN ARTHROSCOPIC TRIANGULAR FIBROCARTILAGE COMPLEX REPAIR

The triangular fibrocartilage complex (TFCC) has an important role in the stability of the distal radioulnar joint (DRUJ) stability. We designed a new method of TFCC tear repair that has satisfactory post-operative DRUJ stability. From May 2004 to August 2010, 14 patients who underwent this operation were reviewed. The average post-operative follow-up period was 8.2 months; 66.7% of the patients with TFCC tear in sigmoid notch had clinical DRUJ instability, while only 50% of tear in fovea and 16.7% of tear in base of ulnar styloid had clinical DRUJ instability. Transosseous suture via inside-outside technique was used for repair. At the final follow-up, all 14 patients have soft end point with < 5 mm translations of the DRUJ shown by the stress test. Based on this small sample with satisfactory outcome assessed by the Mayo modified wrist score and DRUJ stability, we recommend TFCC tear in sigmoid notch, which has a higher chance of DRUJ instability, to be repaired by transosseous suture.