Arthroscopic repair of triangular fibrocartilage complex injuries

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.

Wrist Arthroscopy in Children and Adolescent With Chronic Wrist Pain: Arthroscopic Findings Compared With MRI

BACKGROUND

Wrist arthroscopy is a dynamic diagnostic procedure and its indications are growing as a treatment modality in the adult population. The aim of the study was to retrospectively report our series of pediatric and adolescence with chronic wrist pain, with or without wrist instability who underwent wrist arthroscopy after failing at least 4 months of conservative management. Our secondary aim was to report the sensitivity and specificity of clinical examination and magnetic resonance imaging evaluation for various injury subgroups against the gold standard of the arthroscopic findings. Technical challenges, complications, and outcomes are also discussed.

METHODS

A retrospective review of the medical records of 32 pediatric and adolescent patients who underwent wrist arthroscopy was conducted. Preoperative clinical diagnosis, radiographic, and intraoperative findings including classifications of triangular fibrocartilage complex (TFCC) and interosseous ligaments were obtained. Patients were followed up to 1 year postoperatively and were discharged if symptom free.

RESULTS

Thirty-three wrist arthroscopies in 32 patients were performed from 1996 to 2004. There were 2 male and 30 female patients. At arthroscopy 16 wrists were found to have TFCC injuries, 11 wrists had scapholunate injuries, and 8 had lunotriquetral (LT) injuries. Clinical examination for diagnosis of TFCC injury was too sensitive and nonspecific; however, clinical diagnosis of scapholunate injury was sensitive and specific. LT injury was under diagnosed clinically. Magnetic resonance imaging was found to have a low sensitivity for diagnosis of LT injury but diagnosis of TFCC was sensitive and specific.

CONCLUSIONS

The sex ratio of 2 males:30 females was startling. Nevertheless, this therapeutic level 3 study supports a thorough search for pathology in any patient with persistent wrist symptoms because pathology was identified in 32 of the 33 wrists at arthroscopy.

LEVEL OF EVIDENCE

Level III-Therapeutic.

Results of Arthroscopic Repair of Peripheral Triangular Fibrocartilage Complex Tear With Exploration of Dorsal Sensory Branch of Ulnar Nerve

Background:

Ulnar-sided approach in arthroscopic triangular fibrocartilage complex (TFCC) repair may jeopardize treatment success by exposing the dorsal sensory branch of ulnar nerve (DSBUN) in risk of injury. We aim to conduct a follow-up assessment of arthroscopic outside-in TFCC repair and efficacy of sensory nerve exploration.

Methods:

We conducted a retrospective chart review of 58 patients (59 wrists) who received arthroscopic repair of the peripheral attachment of the TFCC. Ulnar-sided skin incision and exploration of DSBUN were performed before arthroscopy setting. Arthroscopic outside-in repair through pullout suture ligation was performed. Functional survey at 6 months and 1 year postoperatively was based on Mayo Modified Wrist Score (MMWS), and compared to the preoperative assessment. A p-value of less than 0.05 was considered significant as calculated using paired t-test.

Results:

Postoperative MMWS averaged 74.32±11.50 at 6 months, and 84.41±9.52 at one year; both showed significant difference as compared to preoperative status. Significant improvement was noted in all 4 individual items except motion retrieval between 6 months and 1 year. Totally, 45 (76%) cases achieved good or excellent results at one year; however, less patients resumed pre-injury activity level when treatment delay was more than 6 months than those treated earlier (41% vs. 57%). Complication included 6 transient paresthesia; 1 anchor migration and 1 distal radioulnar arthrosis. No more nerve complication was found after modification of perineural dissection.

Conclusion:

Arthroscopy is effective in obtaining both correct diagnosis and treatment of peripheral TFCC tear. Modified perineural dissection can minimize sensory nerve complications.

Arthroscopic repair of the triangular fibrocartilage complex using a hypodermic needle: a technical note

Tears of the triangular fibrocartilage complex (TFCC) often lead to chronic wrist pain. The commonly used 2-needle outside-in and inside-out suturing techniques require an extra incision to tie the sutures subcutaneously. We use a practical and cost-effective arthroscopic technique for treatment of peripheral Palmer type 1B TFCC tears using a hypodermic needle. This obviates the need for an additional skin incision, thus lowering the risk of neurovascular damage, reducing postoperative pain, and enabling faster rehabilitation and better cosmesis.

All-arthroscopic triangular fibrocartilage complex repair: safety and biomechanical comparison with a traditional outside-in technique in cadavers

PURPOSE

To compare the biomechanical strength and safety of an all-arthroscopic triangular fibrocartilage (TFCC) repair technique with an outside-in technique in cadavers.

METHODS

Ten matched pairs of fresh-frozen cadaveric wrists were used for this study. The control group TFCC tears were treated with an outside-in technique using 2-0 polydioxane (PDS) sutures. The experimental group was treated with two FasT-Fix suture devices. I measured the location of the implants in relation to the neurovascular structures using a digital caliper. The strength of the repairs was then determined using a tensile testing machine with the load placed across the repair site. I compared results using the Student's t-test.

RESULTS

The most volar FasT-Fix block averaged 1.8 cm from the ulnar neurovascular bundle, whereas the PDS knots averaged 1.9 cm from it. The most dorsal FasT-Fix averaged 17.1 mm from the dorsal branch of the ulnar nerve, whereas the PDS knot was 4.6 mm. The average load to failure for the FasT-Fix repairs was 3.7 N, compared with 2.4 N for the PDS repairs (p < .05). The mode of failure for the FasT-Fix implants was the suture cutting through the TFCC tissue. The mode of failure for the PDS controls varied between the suture cutting through the tissue and the knots untying. One extensor carpi ulnaris tendon was injured by the PDS technique. No tendons were injured with the FasT-Fix technique.

CONCLUSIONS

This all-arthroscopic technique of TFCC repair is faster and stronger than the inside-out technique and is equally safe. Benefits of this repair are decreased operative time, reduced postoperative immobilization, and decreased irritation from prominent suture knots below the skin. For these reasons, it may be desirable to perform this technique to improve patient satisfaction.

The "ulnar fovea sign" for defining ulnar wrist pain: an analysis of sensitivity and specificity

PURPOSE

Eliciting tenderness in the region of the ulnar fovea is a possibly useful clinical test for defining the source of ulnar-sided wrist pain. Until now, no reports of the clinical sensitivity and specificity of this test have been available. Based on anecdotal observations, a hypothesis was developed stating that ulnar fovea tenderness (positive "ulnar fovea sign") is sensitive and specific in detecting two ulnar-sided wrist conditions: foveal disruption of the distal radioulnar ligaments and ulnotriquetral (UT) ligament injuries.

METHODS

The clinical records of 272 consecutive patients with wrist arthroscopy performed by the senior author from 1998 through to 2005 were reviewed. Relevant clinical and surgical data were abstracted. The ulnar fovea sign test is executed by pressing the examiner's thumb distally into the interval between the ulnar styloid process and flexor carpi ulnaris tendon, between the volar surface of the ulnar head and the pisiform. A positive ulnar fovea sign is designated when there is exquisite tenderness that the patient claims replicates their pain, with comparisons made with the contralateral side.

RESULTS

There were a total of 90 foveal disruptions and 68 UT ligament injuries diagnosed during wrist arthroscopy. The ulnar fovea sign was positive in 156 patients. The sensitivity of the fovea sign in detecting foveal disruptions and/or UT ligament injuries was 95.2%. Its specificity was 86.5%.

CONCLUSIONS

The hypothesis stating that the ulnar fovea sign is a useful clinical maneuver to detect foveal disruptions and UT ligament tears is supported. The conditions represent 2 common sources of ulnar-sided wrist pain. The differentiation between the 2 conditions may be made clinically, where UT ligament tears are typically associated with a stable distal radioulnar joint and foveal disruptions are typically associated with an unstable distal radioulnar joint.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Suture welding for arthroscopic repair of peripheral triangular fibrocartilage complex tears

This report presents a method of arthroscopic repair of the peripheral triangular fibrocartilage tears by using ultrasonic suture welding technique, thus avoiding the need for traditional suture knots. This technique eliminates the potential causes of ulnar-sided wrist discomfort especially during the postoperative period. Twenty-three patients (9 women and 14 men; mean age, 35 years; range, 18-52 years) were operated during a 1-year period in 2001 for Palmer grade 1B triangular fibrocartilage complex tear and followed up for 17 months. At the final follow-up, the average wrist arc of motion was as follows: extension, 65 degrees; flexion, 56 degrees; supination, 80 degrees; pronation, 78 degrees; radial deviation, 12 degrees; and ulnar deviation, 25 degrees. Grip strength measured with a dynamometer (Jamar) averaged 81% of the contralateral side at the final evaluation (range, 53%-105%).

Arthroscopic repair of peripheral triangular fibrocartilage complex tears with suture welding: a technical report

This report presents a method of arthroscopic repair of the peripheral triangular fibrocartilage complex tears that replaces traditional suture knots with ultrasonic welding of sutures. This will help eliminate potential causes of ulnar-sided wrist discomfort during the postoperative period.

Ulnar-positive variance as a predictor of distal radioulnar joint ligament disruption

PURPOSE

Previous cadaveric data show that disruption of the triangular fibrocartilage complex (TFCC) at the wrist allows 0.5 to 3.0 mm of proximal radius migration. Anatomic studies have documented the presence of superficial and deep fibers of both the palmar and the dorsal distal radioulnar joint (DRUJ) ligaments. The aim of this study was to determine the contribution of the superficial and deep fibers of the DRUJ ligaments to longitudinal forearm stability as measured by ulnar-positive variance.

METHODS

Eight fresh-frozen cadaver specimens were included in this study. Each specimen was secured with external fixation clamps to a sequential loading frame with the elbow in 90 degrees of flexion and the forearm and wrist in neutral pronation supination, neutral ulnar-radial deviation, and neutral volar-dorsal angulation. The radial head was resected and a force gauge was applied to the proximal radius. The peripheral TFCC was identified through an incision between the fifth and sixth extensor compartments and the dorsal capsulotomy of the DRUJ capsule. After baseline measurement sequential transection of the superficial and deep fibers of the TFCC was performed. Before and after each step load application and removal were performed by attaching an 88.90-N weight to the end of a force gauge and via longitudinal traction on the proximal part of the radius, and ulnar variance was measured with wrist fluoroscopy.

RESULTS

Transection of the superficial TFCC fibers resulted in radius migration of 0.70 mm. This migration, however, was not significantly different from that observed at baseline. After both the superficial and deep TFCC fibers were transected the radius migrated proximately with load. This change of ulnar variance was significantly greater than that observed at baseline or after transection of only the superficial TFCC fibers.

CONCLUSIONS

Traumatic injury to the TFCC with radiographic evidence of ulnar-positive variance may be an indication of disruption of the deep TFCC fibers.

Arthroscopic triangular fibrocartilage complex debridement using radiofrequency probes

The initial results of using radiofrequency probes for debridement of a torn triangular fibrocartilage complex were studied in 20 patients with a mean age of 44 (range 27-56) years presenting with ulnar-sided wrist pain. On arthroscopic examination, 18 central and two radial triangular fibrocartilage complex tears were identified and debrided to a stable rim using radiofrequency probes. The mean follow-up was 22 (range 9-35) months. Seventeen patients experienced substantial pain relief. In three, the pain was unchanged. The mean flexion extension arc was 132 degrees , pronosupination arc 155 degrees and mean grip strength was 83% of that of the unaffected side. Using the modified Mayo wrist score, there were ten excellent, seven good and three fair results. No perioperative complications occurred. Radiofrequency probes were found to be safe and effective for use in triangular fibrocartilage complex debridement. These results compare favourably with other standard methods of treatment of this problem.