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

A modified partial wedge-shaped metaphyseal ulnar osteotomy for the treatment of ulnar impaction syndrome with reverse oblique sigmoid notch

We describe a modified metaphyseal ulnar osteotomy to treat ulnar impaction syndrome with a reverse oblique sigmoid notch. Based on a computational analysis of radiographs, a modified wedge metaphyseal ulnar osteotomy was devised with its apex positioned at the ulnar styloid base to avoid impaction between the sigmoid notch and ulnar head. Subsequently, nine patients with ulnar impaction syndrome and a reverse oblique sigmoid notch underwent this operation, combined with arthroscopic exploration and transosseous triangular fibrocartilage complex repair. The mean follow-up was 14 months. All patients achieved bone union within 5 weeks, with no degenerative changes being observed during the follow-up assessments. The final follow-up assessments revealed decreases in ulnar variance and in the scores for Visual Analogue Scale, Quick Disabilities of the Arm, Shoulder and Hand questionnaire and the Patient-Rated Wrist Evaluation. All patients achieved excellent or good grades on the Modified Mayo Wrist Score. This technique is effective in treating the ulnar impaction syndrome with a reverse oblique sigmoid notch.Level of evidence: IV.

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.

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

Introduction: Injury to the triangular fibrocartilage complex (TFCC) may cause chronic wrist pain and instability if left untreated. The current literature of adult cases suggests that arthroscopic treatment offers favorable outcomes and is associated with a low complication rate. This systematic review evaluated the outcomes of arthroscopic TFCC surgery in adolescents. Materials and Methods: A PRISMA-guided literature search of PubMed, Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Cochrane Clinical Answers was conducted in May 2020. All studies reporting on (1) arthroscopic TFCC repair or debridement in (2) patients under the age of 19 years with (3) a minimum case number of four patients were extracted by two independent observers. The level of evidence of each study was assessed according to the Oxford Centre for Evidence-Based Medicine, and study quality was graded according to the Modified Coleman Methodology Score and the MINORS criteria. Clinical outcome scores, functional parameters, and any complications were reviewed. Results: The selected search terms initially resulted in a total of 986 possible articles. The authors eventually identified eight papers (all LoE IV) for inclusion in this systematic review. A total of 254 patients with verified TFCC tears and a mean age of 16 years (range, 7–19) received arthroscopic repair (162 patients, 67.1% of total) or debridement (77 patients, 29.7% of total). Arthroscopic treatment resulted in low pain levels, high patient satisfaction, and a fast return to sport. Complications overall were sparse and consisted mainly of persistent wrist pain (n = 31) and temporary paresthesia (n = 6) of the dorsal sensory branch of the ulnar nerve. Recurrent tears were sparse, with only four reported cases due to sports participation. Conclusion: Wrist arthroscopy is a reliable surgical option for treating TFCC tears in adolescents. The results obtained are comparable to those published in the literature. However, the variety of repair techniques and the low level of evidence across all included articles demand further prospective studies.

Prognostic Factors Affecting Clinical Outcomes of Arthroscopic Assisted Reduction and Volar Plating through Preservation of Pronator Quadratus for Intra-Articular Distal Radius Fracture

Background: This study aimed to evaluate the clinical and radiological outcomes following an arthroscopic-assisted reduction and volar plating (AR-VP) surgery through pronator quadratus (PQ) preservation for treating intra-articular distal radius fractures (IA-DRFs) and to assess prognostic factors that affect functional outcomes. Methods: Between March 2014 and February 2017, 54 patients who had intra-articular DRF and underwent AR-VP through the PQ preservation technique and completed 1-year follow-up were enrolled. Patients were divided into the satisfactory group (excellent and good results) and an unsatisfactory group (fair and poor results) based on the modified Mayo Wrist Scoring System (MMWS) scored at 1-year follow-up to determinate prognostic factors that affected clinical outcomes. Patients' demographics, clinical outcome measures (VAS, DASH, PRWE, etc.), and pre-and post-operative radiographic parameters were analyzed. Results: The outcomes according to MMWS were 10 excellent, 22 good, 14 fair, and 8 poor. A univariate analysis showed a significant difference between the groups (p < .05) for all radiographic parameters, sex, and the presence of an intra-articular comminution. In the multivariate analysis, female gender, presence of an intra-articular comminution, and difference of palmar articular tilt compared to uninjured wrist (> 20.1°) at trauma were considered as significant poor prognostic factors of functional outcome. Conclusions: AR-VP surgery through PQ preservation for intra-articular DRFs has reliable clinical and radiological outcomes. However, female gender, presence of an intra-articular comminution, and difference of palmar articular tilt compared to the uninjured wrist (> 20.1°) at initial injury were considered poor prognostic factors for AR-VP through PQ preservation for intra-articular DRF.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Determinants of Pain and Predictors of Pain Relief after Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

Background  The purpose of this study is to characterize patient- and surgery-specific factors associated with perioperative pain level in patients undergoing ulnar shortening osteotomy (USO) for ulnar impaction syndrome (UIS). We hypothesize that preoperative opiate consumption, tobacco utilization, and severity of ulnar variance will be associated with less postoperative pain relief. Methods  All cases of USO between January 2010 and December 2016 for management of UIS were retrospectively reviewed. Patient demographics, smoking status, type of labor, and opioid utilization before surgery were recorded. Radiographic measurements for ulnar variance, radial tilt and inclination, as well as triangular fibrocartilage complex and distal radial-ulnar joint (DRUJ) morphology were assessed. Pre- and postoperative pain score were recorded. Regression analysis was performed to determine predictors of pain scores. Results  A total of 69 patients were included for the final analysis with a mean age of 44 years (range 17-73 years). Seventeen patients reported use of daily opioid medications at the time of surgery (25%). Patients who used opioid analgesics daily, active laborers, smokers, and patients involved in worker compensation claims had significantly less pain relief after surgery. Patients with osteotomy performed at the metaphysis had significantly more pain relief than patients that had diaphyseal osteotomy. Regression analysis identified tobacco utilization and anatomic site of osteotomy as independent predictors of postoperative pain. Conclusion  The results from this study identified smoking and location of osteotomy as independent predictors of postoperative pain relief. While smoking cessation is paramount to prevent delayed/nonunion it may also help improve pain relief following USO. The potential to achieve greater shortening with a metaphyseal osteotomy suggests that in addition to the mechanical unloading the carpus, pain relief after USO may also stem from tensioning the ulnar collateral ligaments of the wrist, the ECU subsheath, and the radioulnar ligaments. Level of Evidence  This is a Level III, therapeutic study.

Evaluation of the triangular fibrocartilage: comparison of two-compartment wrist CT arthrography using the distal radioulnar and radiocarpal joints and unicompartment wrist CT arthrography using the radiocarpal joint

OBJECTIVE

To compare the diagnostic performance of two-compartment wrist CT arthrography of the distal radioulnar and radiocarpal joints and unicompartment wrist CT arthrography of the radiocarpal joint in depiction of the triangular fibrocartilage tear.

METHODS

From January 2016 to December 2017, two-compartment CT arthrography of 74 consecutive patients (36 females, 38 males; mean age, 37.2 years) and unicompartment CT arthrography of 51 consecutive patients (18 females, 33 males; mean age, 40.1 years) were obtained. All CT arthrography images were independently and blindly evaluated by two radiologists for the presence of the triangular fibrocartilage tear by grade (partial or full thickness) per its locations: central disc proper, central-peripheral junction, proximal and distal laminae of its ulnar attachment. Fisher's exact test was used for a statistical analysis, and a p-value less than 0.05 was considered as significant. The arthroscopic findings of 47 patients (34 patients with two-compartment CT arthrography and 13 patients with unicompartment CT arthrography) were evaluated for calculating sensitivity, specificity, and accuracy.

RESULTS

All partial and full thickness triangular fibrocartilage tears were identified more commonly by their location except for distal laminae on two-compartment CT arthrography than were unicompartment CT arthrography (p = 0.001-0.022). Two-compartment CT arthrography had high sensitivity (90.9-100%) and low specificity (33.3-76.5%) for detecting central disc proper and proximal lamina tears, comparing with unicompartment CT arthrography.

CONCLUSION

Two-compartment wrist CT arthrography is more helpful for detecting triangular fibrocartilage tears than unicompartment wrist CT arthrography.

ADVANCES IN KNOWLEDGE

It could be important to evaluate the ulnar foveal insertion of the TFCC in clinical practice, which plays the most important role in DRUJ instability and ulnar-sided wrist pain. Two-compartment wrist CTA of the DRUJ and RCJ could improve diagnostic sensitivity in the TFC tear in terms of its location and torn degree over that of unicompartment wrist CTA of the RCJ. Two-compartment wrist CTA of the DRUJ and RCJ may be recommended as a diagnostic imaging, rather than unicompartment wrist CTA of the RCJ, when peripheral foveal tear of TFC is suspected, especially in young patients.

Arthroscopic Trans-osseous Suture of Peripheral Triangular Fibrocartilage Complex Tear

The importance of foveal repair of the triangular fibrocartilage complex (TFCC) on stability of the distal radioulnar joint (DRUJ) has been emphasized with increasing knowledge of the anatomy and biomechanics of the TFCC and DRUJ. Although both open and arthroscopic techniques have been described for improving DRUJ stability, there has been a marked evolution of arthroscopic TFCC repair technique with successful clinical outcome. Recently, an arthroscopic trans-osseous technique has been described to repair foveal tears of the TFCC. The advantage of the technique is that it allows for anatomical repair of both the superficial and deep layers. This article describes the details of this novel technique.

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.

Metaphyseal Versus Diaphyseal Ulnar Shortening Osteotomy for Treatment of Ulnar Impaction Syndrome: A Comparative Study

PURPOSE

To compare the clinical and radiographic outcomes and complication rates of diaphyseal and metaphyseal ulnar shortening osteotomies for the treatment of ulnar abutment syndrome.

METHODS

We performed a retrospective study comparing 35 patients who underwent either a metaphyseal (n = 14) or diaphyseal (n = 21) osteotomy. Radiographic and clinical outcomes were compared. Complication rates including infection, hardware removal, and reoperations were also assessed.

RESULTS

There were no differences in patient characteristics, ulnar variance, or pain and functional scores between groups. Metaphyseal osteotomy surgery time was shorter (45.5 vs 71.7 minutes) and resulted in greater ulnar shortening (4.8 vs 3.4 mm) compared with diaphyseal osteotomies. At an average 19.2-month follow-up, metaphyseal osteotomies were associated with greater improvement in pain and Quick-Disabilities of the Arm, Shoulder, and Hand questionnaire scores. The need for implant removal was the same in both groups. There were no complications in either group.

CONCLUSIONS

Results from this study suggest that metaphyseal osteotomies are a safe and effective alternative to diaphyseal osteotomies for the management of ulnar abutment syndrome. Although improved surgical time and postoperative outcomes are encouraging, further large-scale and properly powered studies with long-term outcomes will help characterize the benefit of one technique over another. Ultimately, the decision between a metaphyseal and diaphyseal osteotomy may be surgeon preference.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL RELEVANCE

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