Comparison of MRI & direct MR arthrography with arthroscopy in diagnosing ligament injuries of wrist

Incidental Triangular Fibrocartilage Complex Changes on Wrist MRI

BACKGROUND

Triangular fibrocartilage complex (TFCC) changes on wrist magnetic resonance imaging (MRI) may occur in patients without corresponding symptoms and examination consistent with TFCC pathology. This study aims to define the rate of asymptomatic TFCC changes in patients undergoing wrist MRI for indications other than ulnar-sided wrist pain and to compare this with the rate in ulnar-sided wrist pain patients.

METHODS

Patients who underwent wrist MRI at a single large orthopedic practice over a 2-year period were identified by Current Procedural Terminology (CPT) code 73221. Patients with an associated diagnosis, including "hand," "wrist," "radius," "radial," "scaphoid," "navicular," or "De Quervain," were retrospectively reviewed for demographics, symptoms, examination, trauma, and MRI findings. Patients with ulnar-sided wrist pain were used as the comparison group.

RESULTS

Wrist MRIs were available for 132 patients, with 92 in the primary cohort and 40 forming the comparison group. The MRI indications included wrist pain (other than ulnar-sided; 64%), hand/thumb pain (21%), mass (12%), and numbness/tingling (2%). The TFCC MRI changes were seen in 44% of the patients and abnormal TFCC was positively associated with age. In contrast, 80% of the 40 patients with ulnar-sided wrist pain had abnormal TFCC on MRI.

CONCLUSIONS

There is a high rate of abnormal TFCC identified on MRI in patients without corresponding ulnar-sided wrist symptoms. This highlights the importance of not treating MRI imaging in isolation without correlating with the patient's symptoms while also preparing patients for a high likelihood of asymptomatic TFCC changes on routine wrist MRI.

LEVEL OF EVIDENCE

Retrospective case series; Level IV.

Extensor carpi ulnaris tendon pathology and ulnar styloid bone marrow edema as diagnostic markers of peripheral triangular fibrocartilage complex tears on wrist MRI: a case-control study

OBJECTIVES

To evaluate extensor carpi ulnaris (ECU) tendon pathology and ulnar styloid process bone marrow edema (BME) as diagnostic MRI markers for peripheral triangular fibrocartilage complex (TFCC) tears.

METHODS

One hundred thirty-three patients (age range 21-75, 68 females) with wrist 1.5-T MRI and arthroscopy were included in this retrospective case-control study. The presence of TFCC tears (no tear, central perforation, or peripheral tear), ECU pathology (tenosynovitis, tendinosis, tear or subluxation), and BME at the ulnar styloid process were determined on MRI and correlated with arthroscopy. Cross-tabulation with chi-square tests, binary logistic regression with odds ratios (OR), and sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were used to describe diagnostic efficacy.

RESULTS

On arthroscopy, 46 cases with no TFCC tear, 34 cases with central perforations, and 53 cases with peripheral TFCC tears were identified. ECU pathology was seen in 19.6% (9/46) of patients with no TFCC tears, in 11.8% (4/34) with central perforations and in 84.9% (45/53) with peripheral TFCC tears (p < 0.001); the respective numbers for BME were 21.7% (10/46), 23.5% (8/34), and 88.7% (47/53) (p < 0.001). Binary regression analysis showed additional value from ECU pathology and BME in predicting peripheral TFCC tears. The combined approach with direct MRI evaluation and both ECU pathology and BME yielded a 100% positive predictive value for peripheral TFCC tear as compared to 89% with direct evaluation alone.

CONCLUSIONS

ECU pathology and ulnar styloid BME are highly associated with peripheral TFCC tears and can be used as secondary signs to diagnose tears.

KEY POINTS

• ECU pathology and ulnar styloid BME are highly associated with peripheral TFCC tears and can be used as secondary signs to confirm the presence of TFCC tears. • If there is a peripheral TFCC tear on direct MRI evaluation and in addition both ECU pathology and BME on MRI, the positive predictive value is 100% that there will be a tear on arthroscopy compared to 89% with direct evaluation alone. • If there is no peripheral TFCC tear on direct evaluation and neither ECU pathology nor BME on MRI, the negative predictive value is 98% that there will be no tear on arthroscopy compared to 94% with direct evaluation alone.

Twenty-four-channel high-impedance glove array for hand and wrist MRI at 3T

PURPOSE

To present a novel 3T 24-channel glove array that enables hand and wrist imaging in varying postures.

METHODS

The glove array consists of an inner glove holding the electronics and an outer glove protecting the components. The inner glove consists of four main structures: palm, fingers, wrist, and a flap that rolls over on top. Each structure was constructed out of three layers: a layer of electrostatic discharge flame-resistant fabric, a layer of scuba neoprene, and a layer of mesh fabric. Lightweight and flexible high impedance coil (HIC) elements were inserted into dedicated tubes sewn into the fabric. Coil elements were deliberately shortened to minimize the matching interface. Siemens Tim 4G technology was used to connect all 24 HIC elements to the scanner with only one plug.

RESULTS

The 24-channel glove array allows large motion of both wrist and hand while maintaining the SNR needed for high-resolution imaging.

CONCLUSION

In this work, a purpose-built 3T glove array that embeds 24 HIC elements is demonstrated for both hand and wrist imaging. The 24-channel glove array allows a great range of motion of both the wrist and hand while maintaining a high SNR and providing good theoretical acceleration performance, thus enabling hand and wrist imaging at different postures to extract kinematic information.

MRI Findings in Patients Undergoing Triangular Fibrocartilage Complex Repairs Versus Patients Without Ulnar-Sided Wrist Pain

Background: The clinical picture of ulnar-sided wrist pain is oftentimes confusing because various pathologies may be coexistent. In this study, we aimed: (1) to compare the prevalence of potential causes of ulnar-sided wrist pain on magnetic resonance imaging (MRI) in patients who underwent triangular fibrocartilage complex (TFCC) repair and control subjects: and (2) to evaluate whether inferior clinical results were associated with specific patient characteristics or other potential causes of ulnar-sided wrist pain. Methods: We included 67 patients who underwent a TFCC repair and 67 control subjects. The MRI scans were examined for sources of ulnar-sided wrist pain. After TFCC repair, 42 patients (63%) completed surveys, including Quick Disabilities of the Arm, Shoulder and Hand and pain scores. Bivariate analysis was performed to compare our groups and to identify factors associated with our outcomes. Results: We found significantly higher rates of distal radioulnar joint (DRUJ) arthritis (P = .033), extensor carpi ulnaris (ECU) pathology (P = .028), and ulnar styloid fractures (P = .028) in patients with TFCC repairs. With increasing age, increasing pathology in the pisotriquetral joint (P = .040), more ulnocarpal abutment (P = .0081), and more degenerative tears (P < .001) were seen in both groups. No demographic characteristics or MRI findings were significantly associated with our outcomes. Conclusions: We observed higher rates of DRUJ arthritis and ECU pathology in patients with TFCC tears undergoing repair compared with age- and sex-matched controls. This may be due to damage to the TFCC itself altering relationships of the DRUJ and the ECU subsheath, or it may reflect various pathologies that cause ulnar-sided wrist pain and drive patients toward surgery.

Magnetic Resonance Arthrography of the Wrist: The Impact on Operative Management of Wrist Injuries

Background  There is no consensus on the utility of arthrography in the evaluation of wrist injuries. This study evaluates ordering trends of different types of magnetic resonance imaging (MRI) of the wrist and compares rates of surgery following these imaging modalities. Methods  A national claims-based database was used to identify patients who underwent MRI within 90 days of a first-instance diagnosis of wrist injury from 2010 to 2018. The utilization of MRI without intravenous (IV) contrast, MRI with IV contrast, and MRI with arthrogram was investigated. The instances of operative procedures of the wrist within 1 year of MRI study were recorded. Patient demographics, comorbidities, type of operative procedure, and ordering physician specialty were obtained. Logistic regression analysis was used to evaluate the utilization of MRI and subsequent 1-year operative intervention rates as well as association of patient-related factors. Results  Magnetic resonance arthrography use was associated with higher rates of subsequent operative treatment. Surgeons were more likely to order an arthrogram at the time of MRI. Younger patients were more likely to undergo MRI-based advanced imaging. Conclusion  Surgeons may perceive MRA of the wrist to play an important role in operative decision-making following wrist injury. Level of Evidence  This is a Level III, retrospective cohort study.

Comparison between MRI and Arthroscopy of the Wrist for the Assessment of Posttraumatic Lesions of Intrinsic Ligaments and the Triangular Fibrocartilage Complex

Background  Magnetic resonance imaging (MRI) has been considered the most appropriate examination for wrist ligament injuries diagnosis, but it frequently fails to assess the intrinsic ligament lesion. Therefore, wrist arthroscopy is required to enhance and define the diagnosis. Purpose  We compare the MRI imaging with wrist arthroscopy for intrinsic wrist ligaments (scapholunate [SL] and lunotriquetral [LT]) and triangular fibrocartilage complex (TFCC) injuries detection. Patients and Methods  From 2007 to 2014, 532 patients affected by suspected SL, LT, and TFCC posttraumatic ligament injury have been investigated by 1.5-Tesla MRI and wrist arthroscopy. Inclusion and exclusion criteria were adopted. Only for SL ligament injury, the arthroscopic findings of complete (stage IV) and partial (stages I-III) SL ligament injury were compared with MRI findings. Statistical analysis, including sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, and the diagnostic odds ratio, was used to compare MRI with arthroscopic findings. Results  A total of 146 patients were accepted in the study. In 68 cases of arthroscopic SL ligament lesion, MRI confirmed the diagnosis only in 50% of the cases. In partial SL lesions, MRI was positive in 24.3% and in complete SL lesions, MRI was positive in 80.6% of the cases. In 10 cases of arthroscopic LT ligament lesion, MRI was positive in 30.0% of the cases. In 33 patients with arthroscopic TFCC lesion, MRI was positive in 66.7% of the cases. Conclusion  1.5-T MRI demonstrated to fail in confirming the lesion of SL, LP, and TFCC ligaments respectively in 50, 70, and 33.3% of the cases positive at arthroscopy. In complete SL ligament lesion, MRI reaches a higher sensitivity than in partial lesion. Arthroscopy remains the best method to demonstrate the ligament lesion and obtain more information regarding the extent and quality of the ligament damage. Level of Evidence  This is a Level II, retrospective comparative study.