Foveal Triangular Fibrocartilage Complex Tears: Recognition of a Combined Tear Pattern

The incidence and cause of reoperation for complications after volar locking plate fixation of distal radial fractures

BACKGROUND

Distal radial fractures are the most common upper extremity fractures. Volar locking plate fixation has become the standard surgical treatment, providing stable angular fixation, early rehabilitation, and effective support for comminuted and osteopenic bones. This study aimed to analyze the incidence and causes of major complications requiring secondary surgeries following volar plating for distal radial fractures and to investigate the correlation between demographic factors and postoperative outcomes, including major complications and reoperation.

METHODS

This retrospective study enrolled 1073 distal radial fracture cases from 1047 patients at a trauma medical center between January 2015 and June 2021. Patients under 18 years old and whose follow-up was less than 6 months or ended before the surgeon concluded their treatment were excluded. We also examined reasons for device removal, reoperation, and complications following volar plating, specifically identifying major complications requiring additional operations.

RESULTS

Among the 1073 distal radial fracture cases, 160 patients with 168 fractures underwent secondary orthopedic operations after volar plating. Ultimately, 33 cases required additional operations for major complications, resulting in a reoperation rate of 22 % and a major complication rate of 5.3 %. Major complications included: triangular fibrocartilage complex tear, deep infection, carpal tunnel syndrome, flexor pollicis longus injury and extensor pollicis longus injury, screw penetration or loosening, and complex regional pain syndrome. Logistic regression showed a higher reoperation incidence in males and patients under 65, although age and sex were not associated with major complications.

CONCLUSIONS

This study outlined the incidence and causes of reoperation for complications following volar plating for distal radial fractures. Surgeons could benefit from preoperative counseling on potential complications and early identification and treatment. As age and sex were unrelated to postoperative complications, surgeons may consider factors like fracture patterns, functional demands, and baseline activity when determining treatment options with patients.

Reliability of Wrist Arthroscopy in the Diagnosis and Treatment of Triangular Fibrocartilage Complex Tears

PURPOSE

Wrist arthroscopy is considered the gold standard for diagnosis of intra-articular wrist conditions including triangular fibrocartilage complex (TFCC) tears; however, the ability to reliably diagnose TFCC pathology during wrist arthroscopy is unclear. The purpose of this study was to assess the reliability of the diagnosis of TFCC tears on wrist arthroscopy videos.

METHODS

Five hand surgeons reviewed 43 cases on a secure web-based platform at two time points separated by 4-6 weeks. Each case included a deidentified clinical vignette and wrist radiographs with ulnar variance measurements and an arthroscopy video of ulnar wrist pathology, averaging 42 seconds. Surgeons were queried on the presence of TFCC tear and Palmer and Atzei classifications. Interobserver/intraobserver reliabilities were determined using kappa coefficients.

RESULTS

The interobserver reliability regarding the presence/absence of TFCC tear was fair-good, with kappa coefficients of 0.596 in the first round of case review and 0.708 in the second round. The overall intraobserver reliability for the presence/absence of TFCC tear was also fair-good, with a kappa coefficient of 0.567. For cases with central TFCC tears, the interobserver reliability regarding the presence of TFCC tear was perfect, with a kappa coefficient of 1.0. When central tears were excluded, the kappa coefficients decreased to 0.322 and 0.368 in each round. The interobserver reliability for the Palmer and Atzei classifications was low, with kappa coefficients of 0.220 and 0.121 in the first round and 0.222 and 0.123 in the second round.

CONCLUSIONS

Experienced wrist arthroscopy surgeons demonstrated fair-good interobserver reliability for the diagnosis of TFCC tear on wrist arthroscopy. However, when central TFCC tears were excluded, interobserver reliability was poor. These findings demonstrate a need for a focus on education for wrist arthroscopy anatomy.

CLINICAL RELEVANCE

This investigation demonstrated poor agreement in surgeon identification and classification of TFCC tears, aside from central TFCC tears. The low reliability has a direct bearing on treatment considerations for TFCC tears.

Generalized Joint Laxity Increases the Risk of Recurrence of Distal Radioulnar Joint Instability after Arthroscopic Foveal Repair of the Triangular Fibrocartilage Complex

PURPOSE

To compare the clinical results of the arthroscopic foveal repair of the triangular fibrocartilage complex (TFCC) for distal radioulnar joint (DRUJ) instability in patients with or without generalized joint laxity.

METHODS

Patients who underwent arthroscopic transosseous foveal TFCC repair of Palmer 1B foveal TFCC tears (Atzei classification class II or III) from January 2018 to October 2021 were identified. Patients treated for symptomatic DRUJ instability for more than 3 months, and with at least 2 years of follow-up, were included. Patients were categorized into two groups based on the Beighton and Horan criteria: those with generalized joint laxity (group L) and those without (group N). Clinical outcomes were measured by the Disabilities of the Arm, Shoulder, and Hand (DASH) score, modified Mayo wrist score (MMWS), wrist range of motion (ROM), grip strength, sports/recreation activity level, recurrent DRUJ instability, and achievement of minimal clinically important differences (MCID).

RESULTS

One-hundred-and-twenty patients (Group L, 51 patients; Group N, 69 patients) were included. Both groups showed significant improvements in preoperative DASH and MMWS at the final follow-up. Overall, 103 patients (85.8%) achieved MCID, with 82.4% in Group L and 88.4% in Group N, and no significant differences between the two groups (P = .347). At the final follow-up, ROM and sports/recreation activity levels were similar between the groups. Significantly, the rates of postoperative DRUJ instability recurrence were 17.7% in group L (9/51) and 5.8% in group N (4/69) (P=0.039). Beighton scores were an independent risk factor for recurrent DRUJ instability in the multivariable analysis (P=0.024; odds ratio=1.62).

CONCLUSIONS

Clinical outcomes after arthroscopic TFCC foveal repair in patients with generalized joint laxity are comparable to those without, with 82.4% achieving MCID. Generalized joint laxity impacts DRUJ instability recurrence over a minimum 2-year follow-up period.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

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

Aims

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

Methods

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

Results

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

Conclusion

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