Arthrotomography of the wrist: an experimental and preliminary clinical study

The Prevalence of Triangular Fibrocartilage Complex Signal Abnormalities on Magnetic Resonance Imaging Relative to Clinical Suspicion of Pathology

PURPOSE

To determine the prevalence of triangular fibrocartilage complex (TFCC) signal changes in patients undergoing magnetic resonance imaging (MRI) of the wrist and its relationship to a clinical suspicion of TFCC pathology. The secondary purpose was to study factors that are associated with TFCC signal changes.

METHODS

In this retrospective study, we looked for any TFCC signal changes in the reports of MRI findings performed during a 3-year period in 1,134 patients. Demographic characteristics, the categorized indications for MRI, and symptoms at the time of the MRI were also retrieved from the medical records. Patients were divided into 6 groups, based on age, to calculate the proportions of TFCC signal changes in the entire cohort and as an incidental finding among patients without a clinical suspicion of TFCC pathology within each age group.

RESULTS

A total of 321 patients (28%) had incidental TFCC signal changes. The prevalence among 18- to 30 year-olds was 19%, and increased to 64% in patients older than 70 years. Multivariable logistic regression analysis demonstrated that an increase in age is significantly associated with having TFCC signal changes on MRI in patients who have a low clinical suspicion of TFCC pathology. The rate of incidental TFCC signal changes steadily increases with age.

CONCLUSIONS

The TFCC signal abnormalities on MRI are more common with increasing age in patients with low clinical suspicion of TFCC pathology. At age 70, more than half of all patients will have TFCC signal changes, and more than 90% are present in patients with a low clinical suspicion of TFCC pathology.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic IV.

Computed tomography arthrography using a radial plane view for the detection of triangular fibrocartilage complex foveal tears

PURPOSE

To classify triangular fibrocartilage complex (TFCC) foveal lesions on the basis of computed tomography (CT) arthrography using a radial plane view and to correlate the CT arthrography results with surgical findings. We also tested the interobserver and intra-observer reliability of the radial plane view.

METHODS

A total of 33 patients with a suspected TFCC foveal tear who had undergone wrist CT arthrography and subsequent surgical exploration were enrolled. We classified the configurations of TFCC foveal lesions into 5 types on the basis of CT arthrography with the radial plane view in which the image slices rotate clockwise centered on the ulnar styloid process. Sensitivity, specificity, and positive predictive values were calculated for each type of foveal lesion in CT arthrography to detect foveal tears. We determined interobserver and intra-observer agreements using kappa statistics. We also compared accuracies with the radial plane views with those with the coronal plane views.

RESULTS

Among the tear types on CT arthrography, type 3, a roundish defect at the fovea, and type 4, a large defect at the overall ulnar insertion, had high specificity and positive predictive value for the detection of foveal tears. Specificity and positive predictive values were 90% and 89% for type 3 and 100% and 100% for type 4, respectively, whereas sensitivity was 35% for type 3 and 22% for type 4. Interobserver and intra-observer agreement was substantial and almost perfect, respectively. The radial plane view identified foveal lesion of each palmar and dorsal radioulnar ligament separately, but accuracy results with the radial plane views were not statistically different from those with the coronal plane views.

CONCLUSIONS

Computed tomography arthrography with a radial plane view exhibited enhanced specificity and positive predictive value when a type 3 or 4 lesion was identified in the detection of a TFCC foveal tear compared with historical controls.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Prevalence of triangular fibrocartilage complex abnormalities regardless of symptoms rise with age: systematic review and pooled analysis

BACKGROUND

Triangular fibrocartilage complex abnormalities seem to be more common with age, but the degree to which this is so, and the degree to which the presence of an abnormality is associated with symptoms, are topics of controversy.

QUESTIONS/PURPOSES

We wished to perform a systematic review to determine the prevalence of triangular fibrocartilage complex abnormalities, and to determine if the prevalence of abnormalities are greater with increasing age. In addition, we stratified age groups based on symptoms.

METHODS

We searched MEDLINE, EMBASE, and the Cochrane Library through August 15, 2013. Studies that reported triangular fibrocartilage complex abnormalities by age were included. Fifteen studies including 977 wrists met our criteria and reported a total of 368 (38%) triangular fibrocartilage complex abnormalities. Eight studies included symptomatic patients; the remainder studied cadavers (six studies) or asymptomatic volunteers (one study). Patients were divided into four age groups (< 30, 30-49, 50-69, and 70 years and older) for pooled analysis, comparing the proportions of patients with and without abnormalities between groups using chi-square analysis. We also evaluated the proportions after stratifying each age group by symptoms.

RESULTS

Overall, the prevalence of triangular fibrocartilage complex abnormalities increased with age, from 27% (80/301) in patients younger than 30 years to 49% (130/265) in patients 70 years and older (p < 0.001), odds ratio (OR), 2.7, 95% CI, 1.9-3.8 (p < 0.001). In asymptomatic patients, triangular fibrocartilage complex prevalence abnormality increased from 15% (24/159) to 49% (129/263) in the same age groups (p < 0.001), OR, 5.4, 95% CI, 3.3-8.9 (p < 0.001). For symptomatic patients prevalence ranged from 39% (56/142) to 70% (14/20) in patients between 50 and 69 years old (p < 0.034), OR, 3.6, 95% CI, 1.3-9.9 (p < 0.014).

CONCLUSION

Triangular fibrocartilage complex abnormalities are common in symptomatic and asymptomatic wrists, and they are increasingly common with age. As in all situations where abnormalities are so common that they may be incidental, we need (1) a reliable and accurate method for determining whether these abnormalities are the cause of symptoms; and (2) evidence that treatment of these abnormalities improves symptoms better than placebo.

LEVEL OF EVIDENCE

Level III, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Diagnostic arthroscopy: indications and interpretation of findings

Many authors recommend arthroscopy for diagnostic or therapeutic purposes. Arthroscopy is a sophisticated investigation, which can cause damage requiring wrist fusion. It allows visualization of findings, but these are subtle and difficult, if not impossible to interpret, since the contralateral wrist cannot be used as a standard for comparison. Furthermore, not all intracarpal ligaments are directly and reliably visible through the arthroscope: for example the scaphoid-trapezial ligament which is essential for the stabilization of the distal part of the scaphoid. Therefore, it is questionable whether we can define arthroscopy as a gold standard of diagnosis just because it permits direct vision, as if what cannot be seen does not exist! Traction, mandatory for examination, induces particular stresses that may distort intracarpal motion and so-called dynamic evaluation. Each author tends to present a specific classification, rendering comprehension even more difficult. Accordingly, teaching and learning become a real challenge. Arthroscopy may be important in particular cases, but it remains only one component of a complex clinical assessment.

MRI versus arthroscopy in the diagnosis of scapholunate ligament injury

In a prospective study 103 patients with clinically or radiologically suspected tears of the scapholunate interosseous ligament were investigated with magnetic resonance imaging (MRI) and wrist arthroscopy. MRI was performed with the conventional technique in 72 cases and after intravenous injection of contrast medium in the remaining 31 patients. The correct diagnosis was made by MRI in 75% of cases and its overall sensitivity and specificity were 63% and 86% respectively. There was no statistical difference in the accuracy of MRI for acute or chronic tears and the use of intravenous contrast medium did not improve its accuracy. In conclusion, MRI is not recommended for the diagnosis of scapholunate ligament injury.

Arthrography is superior to magnetic resonance imaging for diagnosing injuries of the triangular fibrocartilage

The ability of single-injection radiocarpal arthrography and magnetic resonance imaging (MRI) to detect full-thickness tears of the triangular fibrocartilage were compared with wrist arthroscopy in 102 patients with wrist pain. The sensitivity of arthrography was 85%, and of MRI was 73%. Specificity was 100% for arthrography and 72% for MRI. Accuracy was 92% for arthrography, and 73% for MRI. Although future advances in MRI technology will probably improve its usefulness, single-injection wrist arthrography currently is superior to routine MRI for the detection of full-thickness triangular fibrocartilage tears.

Evaluation of chronic wrist pain. Arthroscopy superior to arthrography: comparison in 39 patients

39 patients with chronic wrist pain underwent arthrography and arthroscopy to reveal disruptions of the triangular fibrocartilage complex (TFCC) and/or interosseous ligaments. TFCC disruption was diagnosed arthroscopically in 15 cases of which arthrography revealed the disruption in only 7. In 3 other patients, arthrography showed rupture of the TFCC: however, arthroscopy showed no defects. Rupture of an interosseous ligament was diagnosed arthroscopically in 6 patients in all of whom it was also revealed by arthrography. In 6 other patients, arthrography showed disruption of an interosseous ligament not verified by arthroscopy. We conclude that arthroscopy is superior to arthrography for diagnosing chronic wrist pain.

Arthroscopic diagnosis of ligament lesions of the wrist

144 patients with post-traumatic wrist pain but normal standard radiographs were examined by wrist arthroscopy. Ligamentous lesions were observed in 75 patients. TFCC lesions, classified according to the Palmer classification and including lunato-triquetral interosseous ligament lesions, were seen in 61, and scapho-lunate interosseous ligament lesions in 14 patients. Degenerative TFCC changes were equally common in patients younger than 40 years of age but significantly more common with more than 2 years duration of symptoms. Varying degrees of instability were noted in patients with scapho-lunate interosseous ligament lesions but no associated ligament lesions were observed. Because of the variety of pathological changes arthroscopy is recommended in the management of patients with post-traumatic wrist pain.

Anatomical and radiological evaluation of the triangular fibrocartilage complex of the wrist

109 wrists from 69 cadavers (mean age 74 years) have been studied to clarify the pathology and morphology of the triangular fibrocartilage complex (TFCC) and to correlate pathological and radiological findings. Perforation of the TFCC was observed in 65% of the specimens and was considered to be secondary to a degenerative process, because it was often accompanied by degenerative changes in the ulnar carpal bones and perforation of the lunotriquetral ligament. To detect TFCC perforations on plain postero-anterior radiographs, it is important to evaluate ulnar plus variance and degenerative changes in the ulnar carpus. Existence of ulnar plus variance alone is more sensitive but less specific in detection of TFCC perforation than the existence of degenerative changes in the ulnar carpus.

[The diagnostic value of arthrography of the wrist in the evaluation of carpal ligament injuries: radio-surgical correlations. Apropos of 20 cases]

Intra-carpal ligament tears lead to radiocarpal arthritis early diagnosis allows early treatment. Standard and dynamic X rays are not always able to make the diagnosis. In these cases, arthrography of the wrist may give the diagnosis. To establish the specificity of this examination we tried to correlate surgical findings with arthrographic suspicions. Exact diagnosis was established in 12 out of 13 cases of suspected scapholunate ligament tears in 5 out of 6 cases of suspected luno-triquetral ligament tear suspicion and none of the 3 cases of suspected T.F.C.C. rupture suspicion. Wrist arthrography appears to have a good specificity for first row intra-carpal ligament tears. The indication arthrography must be discussed with wrist arthroscopy for the diagnosis of long term wrist pain after clinical examination and standard and dynamic X rays.

Anatomic and biomechanical analysis of the arthroscopic wafer procedure

The ulnar impaction syndrome is a common clinical entity that is most often associated with positive ulnar variance and is characterized by triangular fibrocartilage complex (TFCC), lunate, and/or distal ulnar pathology. Traditional treatment for symptomatic ulnar impaction syndrome has been conservative; however, in cases refractory to nonoperative management, formal ulnar shortening has been successful in long-term clinical series. Recently, arthroscopic ulnar shortening, the "arthroscopic wafer procedure" (AWP) (debridement of the perforated TFCC margins and limited ulnar head resection using a motorized burr) has become an option to treat this clinical syndrome. In an attempt to evaluate the biomechanical efficacy of the AWP, an experimental study was undertaken using nine ulnar positive cadaver forearms. Each specimen was evaluated biomechanically using axial load cells and pressure-sensitive film to evaluate the effect of serial resection of the TFCC and distal ulna on axial load and ulnar carpal pressures. The results of this experimental study revealed a statistically significant unloading of the ulnar aspect of the wrist after excision of the centrum of the TFCC and resection of the radial two-thirds width of the ulnar head, to a depth of subchondral bone resection. Furthermore, additional bony resection tended to correlate favorably with the stage of TFCC pathology noted, i.e., the more advanced the stage, the more resection necessary to unload the ulnar aspect of the wrist. Based on this biomechanical study, a limited clinical series has been initiated with early favorable results. The AWP biomechanically unloads the ulnar carpal complex, and therefore has a theoretical potential of relieving the symptoms of the ulnar impaction syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)

Scaphoid non-union with D.I.S.I. deformity. A survey of clinical cases with special reference to ligamentous injury

To clarify whether or not scapho-lunate ligamentous injury is common in scaphoid non-union with D.I.S.I. deformity and whether ligamentous repair is required to treat scaphoid non-union with D.I.S.I. deformity, roentgenographic, arthrographic and arthroscopic findings were analysed and compared to those of scaphoid non-union without D.I.S.I. deformity. The carpal alignment of scaphoid non-union with D.I.S.I. deformity treated by reduction and anterior wedge grafting without ligamentous repair was also studied. No significant difference in the scapho-lunate gap was present between 26 patients with D.I.S.I. deformity and 20 without. No statistically significant difference was detected in the incidence of arthrographically-proved scapho-lunate ligamentous tears between the two groups. Arthroscopic examination carried out in 22 patients did not detect massive ligamentous injury, and carpal alignment was satisfactory in most patients who underwent anterior wedge grafting. These results show that ligamentous injury rarely causes D.I.S.I. deformity in scaphoid non-union, and anterior wedge grafting alone is sufficient to correct D.I.S.I. deformity in most cases.

Radiographic and orthopedic evaluation of wrist trauma

This paper was written to enable radiologists to contribute more usefully to the diagnosis and treatment of various wrist injuries. All imaging modalities are discussed to equip the radiologist for his difficult task. We present a systematic approach to the evaluation of wrist trauma patients beginning with initial plain films and proceeding through more invasive or sophisticated studies in order to achieve a definitive diagnosis. Toward this end a flow chart has been developed as a quick reference source. The authors have then described the anatomy and kinematics of the wrist to further the radiologist's understanding of the forces involved and the injuries produced by trauma. From this foundation individual injuries are then discussed together with the best methods of making the proper diagnosis of each. Criteria for adequate treatment of various injuries are also presented.

Arthroscopic debridement of triangular fibrocartilage complex tears

This prospective study, begun in 1984, involves 52 consecutive patients treated arthroscopically for triangular fibrocartilage complex (TFCC) tears. Wrist arthrography showed the tear on the initial radiocarpal injection in 86%, and only on the post-stress films in 14%. Triple-phase bone scan was positive in only 66%. Diagnostic arthroscopy showed linear defects in 34%, a central perforation in 46%, and ulnar or peripheral perforations in 20%. However, 11 patients proved to have no visible TFCC tear (9% false-positive arthrography rate, or 9% false-negative rate for arthroscopy). Of the 41 patients followed for 13-42 months, 88% considered the procedure worthwhile, and 73% had complete relief of pain. The authors conclude that arthroscopic debridement of TFCC tears (often with removal of 2-3 mm of ulnar head) may be of benefit in reducing symptoms without increasing clinical ulnar instability. Wrist arthrography is useful in diagnosing perforations but not useful in evaluating the type, size, or significance of the tear.

Calcium pyrophosphate dihydrate crystal deposition patterns in the triangular fibrocartilage complex

To define the patterns of calcium pyrophosphate dihydrate (CPPD) crystal deposition in the triangular fibrocartilage complex (TFCC), we examined the wrists of five adult, fresh-frozen cadavers using light and scanning electron microscopy and the wrist radiographs of 10 patients with a clinical diagnosis of CPPD disease. The radiographs consistently showed mineral deposits near or on the proximal and distal surfaces of the radial half of the TFCC. Light and electron microscopy showed that CPPD crystals formed distinct clusters sharply demarcated from uninvolved fibrocartilage. The density of crystal packing within clusters varied with the sharpness of demarcation of the clusters from the surrounding tissue. TFCC defects were consistently found in the vicinity of CPPD crystals, and degeneration of the articular cartilage on the ulnar half of the proximal surface of the lunate was associated with CPPD crystal deposition in the radial half of the TFCC. These observations suggest that degenerative tears of the TFCC and degeneration of the articular cartilage of the lunate are associated with CPPD crystal deposits in the TFCC.

Diagnosis and treatment of obscure ulnar-sided wrist pain

Thirty-seven patients were followed for symptoms of chronic ulnar-sided wrist pain in which specific physical examination and standard radiographs were unrevealing. Initial conservative treatment did not relieve the pain. The patients underwent further diagnostic studies including dynamic cineroentgenographic evaluation and radiocarpal arthrography. Nineteen of the 37 patients were demonstrated to have a triangular fibrocartilage complex (TFCC) tear on arthrography; 18 had a normal examination. The average follow up was 23 months. Seven of the 19 patients with TFCC tears have undergone operative treatment, and 5 (71%) remain symptomatic. Of the remaining 12 patients with TFCC tears treated nonoperatively, eight (67%) have persistent symptoms. Of the 18 patients whose arthrograms were normal, five eventually underwent surgical exploration, four of which remain symptomatic. Of the 13 patients without TFCC tears treated nonoperatively, seven (54%) continue to have symptoms. In our experience, both surgical exploration and nonoperative treatment have been less than satisfying. In addition, treatment results could not be correlated with arthrographic findings.

Triangular fibrocartilage complex lesions: a classification

Based on anatomic and biomechanical studies and review of our clinical experience of the past 10 years, a classification of injuries to the triangular fibrocartilage complex is presented. This classification is based on the clinical examination, routine x-ray films, wrist arthrograms, wrist arthroscopy, and wrist arthrotomy. The classification recognizes both traumatic and degenerative lesions. Traumatic lesions are classified according to their location. Degenerative lesions are classified by the location and severity of degenerative changes of the triangular fibrocartilage complex, ulnar head, ulnocarpal bones and lunotriquetral ligament.

Wrist pain: correlation of clinical and plain film findings with arthrographic results

A technique adding digital subtraction to otherwise standard wrist arthrography allows more precise determination of the site of radiocarpal-midcarpal communications. Since arthrographic results often do not correlate with clinical findings, we became interested in correlating these various modalities. The precision of our arthrographic interpretation makes these correlations meaningful. In 72 consecutive patients who had digital subtraction wrist arthrograms, both clinical sites of pain and plain film abnormalities were correlated with arthrographic findings. The results indicate that those patients with ulnar-sided pain more commonly have perforations in that region (88%). Radial-sided pain is a poor indicator of a radial site of perforation. Scapholunate dissociation does not correlate highly with scapholunate perforation (26%).

Dynamic radiographic evaluation of obscure wrist pain in the teenage patient

Chronic wrist pain in the teenage patient constitutes a diagnostic challenge. Carpal instability patterns and internal joint derangements may be difficult to diagnose by physical examination and conventional plain radiographs. Dynamic radiographic studies frequently provide a better understanding of abnormal wrist mechanics. We reviewed our experience with fluoroscopy and radiocarpal arthrography in 14 teenage patients with chronic wrist pain. Videotape fluoroscopy was performed in all 14 patients. Dynamic radiocarpal arthrography was then performed in 10 patients in whom fluoroscopic findings were normal or more information was needed. These imaging methods led to a diagnosis in 64% of the patients and excluded a significant anatomic carpal abnormality in the other patients. In the teenage patient, internal derangements of the intercarpal ligaments are usually posttraumatic rather than attritional in origin. Dynamic radiographic techniques provide an accurate means for the diagnosis of these specific anatomic carpal abnormalities.