Clinical results of treatment of triangular fibrocartilage complex tears by arthroscopic debridement

Postoperative Benefits of Soft Tissue Wrist Arthroscopy: Retro- and Prospective Analyses of Outcome Measures

Background: Elective soft-tissue-only wrist arthroscopy is a standard procedure in hand surgery for the diagnosis and treatment of wrist pain. A number of pathologies can be treated arthroscopically, with the aim of pain reduction and improved wrist mobility. A postinterventional evaluation of the treatment using objective and patient-reported outcome measures (PROMs) allows for an evidence-based statement about the benefits of soft-tissue-only wrist arthroscopy. Methods: A dual-center study combining retro- and prospective clinical analyses of patient outcomes after soft-tissue-only wrist arthroscopies was performed. The data were collected at two hospitals with departments specializing in hand surgery. The outcome was measured by assessing the range of motion of the wrist and its manual strength, as well as PROMs, including Disabilities of the Arm, Shoulder and Hand (DASH) scores. Results: A total of 154 soft interventions met the study criteria and could be included. Seven months after the elective soft-tissue-only wrist arthroscopies, mobility improved significantly for active extension and flexion, as well as the ulnar and radial abduction of the wrist. The grip strength also improved significantly, by an average of 6 kg, during this period. The DASH score improved significantly, from 35 points to 14 points. Additionally, wrist pain at rest was reduced significantly. Conclusions: After elective soft-tissue-only wrist arthroscopy, patients showed an overall functional improvement in their wrist, with a significant reduction in pain and improvement of mobility and grip strength. This study emphasizes the importance of wrist arthroscopy as a successful treatment option for soft tissue pathologies of the wrist.

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.

An All-arthroscopic Technique of Repair of Substance Tears of the Triangular Fibrocartilage Complex in Symptomatic Patients

Substance tears of the triangular fibrocartilage complex (TFCC) can occur secondary to trauma of the wrist. On the dorsal periphery, they are considered Palmer 1B tears or Atzei class 1 tears. If along the radial side, they can manifest as a tear of the central disc, classified as a Palmar class 1A tear. If it involves the ligaments, it is stated as a pre-1D tear as per the new classification system by Luchetti and colleagues. Multiple excellent repair techniques exist in the current literature for dorsal peripheral tears and even for those in the substance of the TFCC, whereas there are successful evolving techniques of repair of avulsed tears and those involving the substance of the ligaments on the radial side adjacent to the sigmoid notch. Here, we describe our technique of repairing substance tears of the TFCC arthroscopically without the need for any specialized equipment apart from the basic arthroscopy set. The technique was conducted in a patient with a transverse substance tear on the radial side of the triangular fibrocartilage involving the central disc with complete resolution of symptoms. It is a simple technique, which can be used to repair class 1B peripheral tears and pre-1D tears in the substance of the TFCC.

Return to Activity After Arthroscopically Assisted Triangular Fibrocartilage Complex Repair: A Systematic Review

OBJECTIVE

To evaluate patients' ability to return to preinjury activity level after arthroscopically assisted triangular fibrocartilage complex (TFCC) repair.

DATA SOURCES

The PubMed electronic library was systematically searched from inception to August 2021 for any eligible articles using a combination of the phrases "TFCC," "return to sport," "return to work," and "athlete."

RESULTS

Studies that evaluated patients who had undergone arthroscopic repair of isolated TFCC injury and reported objective or patient-reported outcome measures were included. Fifteen studies representing 478 patients fulfilled the inclusion criteria. An average of 84% of patients were able to fully return to their previous work or sport activities. Most studies reported that range of motion (ROM) and grip strength (GS) both returned to >90% of the contralateral side, and every study that evaluated pain levels found a significant reduction in pain postoperatively. Mayo Modified Wrist Score was reported as excellent or good in 83% of patients, and the average Disabilities of the Arm, Shoulder, and Hand score was 13.8 postoperatively.

CONCLUSION

Patients were able to return to their previous work or sport activities at a high rate after TFCC repair, even those participating in more strenuous activities. Measurable functional outcomes of ROM and GS were also reliably restored to near preinjury levels. Patient-reported outcomes of pain and disability were similarly improved after TFCC repair. Current literature has established the long-term success of TFCC repair but is lacking in evaluation of the time points at which patients can expect functional status to be restored.

Is metaphyseal ulnar shortening osteotomy superior to diaphyseal ulnar shortening osteotomy in the treatment of ulnar impaction syndrome? A meta-analysis

BACKGROUND

Although metaphyseal ulnar shortening osteotomy (MUSO) is safer for the treatment of ulnar impaction syndrome (UIS) than diaphyseal ulnar shortening osteotomy (DUSO), DUSO is widely used for UIS treatment.

AIM

To evaluate the effectiveness of DUSO and MUSO for UIS treatment and determine the factors that should be considered when choosing surgical treatment for UIS.

METHODS

Articles comparing the effectiveness of DUSO and MUSO for UIS treatment were systematically retrieved from MEDLINE (Ovid), PubMed, EMBASE, and Cochrane Library. The demography, incidence of complications, secondary operation rate, postoperative DASH score, wrist pain on the visual analogue scale, and grip strength improvement were also evaluated. In addition, the correlation between the improvement of grip strength and the shortening of osteotomy length of ulna was analyzed. The outcome of the patient was discontinuous, and the odds ratio, risk ratio (RR), and 95%CI were calculated and analyzed via RevMan5.3 software.

RESULTS

Six studies, including 83 patients receiving MUSO (experimental group) and 112 patients receiving DUSO (control group), were included in the meta-analysis. The second operation rate was significantly higher after DUSO than after MUSO. The DASH scores were slightly lower in the MUSO group than in the DUSO group. The patients receiving MUSO had slightly better pain relief effect than patients receiving DUSO. However, the incidence of complications and improvement of grip strength were not significantly different between the two groups.

CONCLUSION

Although DUSO and MUSO provide similar effects for UIS, MUSO is associated with a lower secondary operation rate, slightly lower postoperative DASH scores and slightly better pain relief effect than DUSO, indicating that MUSO can effectively be used for UIS treatment.

Predictors of Secondary Ulnar Shortening and Reoperation After Arthroscopic TFCC Debridement

BACKGROUND

Predicting which patients will do well with arthroscopic triangular fibrocartilage complex (TFCC) debridement alone or which patients may benefit from arthroscopic debridement and ulnar shortening at the same time can be challenging. In this retrospective cohort study, we aimed to assess the rate and type of complications and reoperations after arthroscopic TFCC debridement. Furthermore, we aimed to identify factors associated with reoperation and specifically ulnar shortening osteotomy (USO) after this procedure.

METHODS

We included 163 patients who underwent arthroscopic TFCC debridement as a first surgery for treatment of their ulnar-sided wrist pain. Patient charts were manually reviewed, and ulnar variance was measured on preoperative posteroanterior radiographs of the wrist. Bivariate analysis and multivariable logistic regression analysis were performed to identify factors associated with reoperation. Additional subgroup analyses looking at USO after TFCC debridement were performed with Kaplan-Meier analysis and Cox regression survival analysis.

RESULTS

We found a complication rate of 14% and a reoperation rate of 19% (most common USO with 10%). Chondromalacia was independently associated with reoperation. Forty percent of patients with a positive ulnar variance later proceeded to USO. A hazard ratio of 1.8 per millimeter of ulnar variance was found.

CONCLUSIONS

Our data suggest that patients with a positive ulnar variance with frank chondral loss at the time of arthroscopic TFCC debridement may benefit from simultaneous USO.

Long-term outcome after arthroscopic debridement of Palmer type 2C central degenerative lesions of the triangular fibrocartilage complex

PURPOSE

The purpose of this study was to report long-term objective and patient-reported outcome after arthroscopic debridement of central degenerative triangular fibrocartilage complex (TFCC) lesions.

METHODS

A total of 17 patients with central degenerative TFCC (Palmer type 2C) lesions and ulnar positive variance who were treated by arthroscopic debridement were retrospectively reviewed. Mean follow-up was 8.8 years. Assessment facilitating the Modified Mayo Wrist score (MMWS), the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH score), recording of pain level and of patient satisfaction, and radiological examination were done.

RESULTS

Patients reached a pain level of 1.7 VAS, MMW score of 92, and DASH score of 22. No significant differences could be detected between the operated and the contralateral extremity regarding range of motion and grip strength for all patients. No perioperative complications occurred.

CONCLUSION

Arthroscopic debridement of central degenerative TFCC lesions is safe, reliable, and efficacious even for ulnar positive variance.

LEVEL OF EVIDENCE

Therapeutic IV.

Stress distribution pattern in the distal radioulnar joint before and after ulnar shortening osteotomy in patients with ulnar impaction syndrome

Ulnar shortening osteotomy (USO) for ulnar impaction syndrome potentially leads to degenerative changes of the distal radioulnar joint (DRUJ). This study was performed to evaluate the effect of the sigmoid notch morphology on the stress distribution pattern of the DRUJ using computed tomography (CT) osteoabsorptiometry (CT-OAM). We reviewed the pre- and postoperative transverse CT images of 15 wrists that had undergone USO. The examined wrists were classified into two groups based on the sigmoid notch morphology: the linear-type notch (type L) and the curved-type notch (type C). We calculated and statistically compared the percentage of the high-density area (%HDA) in each divided region of the sigmoid notch. In type L, %HDA was significantly larger in the distal-dorsal region of the sigmoid notch before USO. Postoperatively, in type L, no specific regions showed a significantly different %HDA. In type C, %HDA was significantly larger in the distal-volar region of the sigmoid notch before USO. Postoperatively, %HDA of type C was significantly larger in the proximal-volar region. Our results suggest that in patients with ulnar impaction syndrome, morphological evaluation of the sigmoid notch can serve as a predictor of osteoarthritis in the DRUJ with or without USO.

Narrative Review of Ligamentous Wrist Injuries

Ligamentous wrist injuries are common occurrences that require complex anatomical mastery and extensive understanding of diagnostic and treatment modalities. The purpose of this educational review article is to delve into the most clinically relevant wrist ligaments in an organized manner to provide the reader with an overview of relevant anatomy, function, clinical examination findings, imaging modalities, and options for management. Emphasis is placed on elucidating reported diagnostic accuracies and treatment outcomes to encourage evidence-based practice.

Clinical, functional and prognostic results after repair of peripheral lesions of the triangular fibrocartilage complex: a retrospective study of 21 patients

OBJECTIVES

The main objective of this study was to assess the clinical and functional outcomes of arthroscopic TFCC repair in patients with an isolated Atzei type 1, 2 or 3 lesion or after a distal radius fracture. The secondary objective was to identify which factors could contribute to poor functional outcome.

METHODS

A retrospective study was conducted from November 2017 to May 2019. The inclusion criteria were patients with an Atzei type 1, 2 or 3 TFCC lesion who underwent arthroscopic repair and with a minimum of 6-month follow-up. Wrist motion, grip and pronation-supination strength were noted. QuickDASH, MMWS and PRWE scores were performed. An analysis was conducted to search for poor outcomes predictive factors (MMWS < 80).

RESULTS

Twenty-one patients were included with a mean follow-up of 26 months. Seventeen patients (80%) had an Atzei 1 lesion, one (4.8%) had an Atzei 2, and 3 (14%) had an Atzei 3. Wrist motion significantly decreased compared to contralateral. Only pronation and supination were not significant. Grip strength was 73.4% compared to the contralateral (p = 0.002). Mean PRWE was 29.14 (1.5-70.5), QuickDASH was 30.72 (2.3-70.5), and MMWS was 79.3 (35-100). In all patients with a MMWS ≥ 80, none had lunotriquetral lesions when it was the case for 5 of 9 patients with a MMWS < 80 (p = 0.006). Except a story of workplace injury, no other prognosis factor was significant.

CONCLUSION

Patients with Atzei 1, 2 or 3 TFCC who underwent arthroscopic repair seem to have good outcomes. However, an associated lunotriquetral lesion appears to worsen the functional prognosis.

Inevitable nonunion after ulnar shortening osteotomy in patients with ulnar impaction syndrome and breast cancer under bisphosphonate treatment

BACKGROUND

Nonunion after ulnar shortening osteotomy (USO) was observed at a high rate in patients undergoing long-term bisphosphonate (BP) maintenance treatment after breast cancer surgery. Here, we report the unique features of these nonunions.

METHODS

In total, 485 patients who had undergone USO between March 2008 and September 2017 were screened for inclusion based on the following criteria: (1) definitive nonunion after USO; (2) prior history of or ongoing BP therapy after the diagnosis of breast cancer; and (3) no evidence of metastasis in the ulna treated with USO, as determined based on the radiological evaluation.

RESULTS

Five patients with histories of breast cancer and subsequent BP treatment were identified; all (100%) of these patients showed definitive nonunion after USO. The mean age was 56.2 years, and all ulnae were on the contralateral side to that of the original breast cancer. Intravenous Ibandronate^® and Zolendronate^® were administrated to one and four patients, respectively. The mean period of administration was 67.8 months. Three patients exhibited suspicious lesions impending atypical fracture on their femurs, and the other two patients were treated by intramedullary nailing after the occurrence of atypical fractures. Radiological evaluation revealed no evidence of a metastatic lesion, including in the musculoskeletal system, in any patient. Osteosynthesis was performed with cancellous iliac bone graft and mean of 4.3 months after osteosynthesis, union in all cases was achieved.

CONCLUSIONS

Problems associated with BP treatment are well known. Even in cases in which the agent is essential for preventing bony metastasis of breast cancer, the normal bony physiology, including bone turnover and healing, is likely to be compromised. In addition to atypical fractures of the femur and ulna, procedures such as USO are likely to be affected by BP. Furthermore, not only a primary iliac bone graft but also other method (oblique osteotomy) should be needed to avoid nonunion during plating in USO.

LEVEL OF EVIDENCE

IV, Retrospective case series.

TFCC injuries: How we treat?

The triangular fibrocartilage complex (TFCC) is a well defined anatomical entity located on the ulnar aspect of the wrist joint functioning primarily to stabilize the distal radio -ulnar joint (DRUJ) and also to act as a shock absorber across the ulno-carpal joint. Palmer and Werner were first to explain the anatomic details of the TFCC and to describe its biomechanical role at the wrist. The TFCC comprises of the fibro-cartilagenous disc, the dorsal and palmar ligaments spanning across radius and ulna, the ulno-carpal ligaments, a meniscal homolog, and the sub sheath of ulnar extensor of the wrist. The intricate anatomy of this area and complex load transmission kinematics renders it vulnerable to injury and attrition. Both traumatic and degenerative insults produce specific injury patterns which can present as vague ulnar-sided wrist pain particularly during forearm rotation. These injuries are managed initially by modification of daily activities to avoid aggravation of pain and injury, by complete abstinence from sporting/gym/yoga maneuvers which involve stressing the wrist joints, temporary splint or cast immobilisation are also used along with non-steroidal anti-inflammatory medication. Corticosteriod injection are also used in conjunction with physical therapy in grossly symptomatic patients. Surgical treatment is advocated if conservative management fails to provide relief, or in cases presenting initially with frank instability of the DRUJ or with unstable and displaced fractures. Choice of operative treatment is guided by type and extent of injury and may include debridement, repair and in TFCC injuries associated with degenerative changes, ulnar unloading procedures like shortening or Wafer procedure. With current understanding of arthroscopic anatomy of the wrist, availability of instrumentation as well as familiarity of surgeons with this tool, arthroscopic management can be instituted successfully in most if not all conditions afflicting the TFCC.

Perceptions and experiences of wrist surgeons on the management of triangular fibrocartilage complex tears: a qualitative study

There is lack of consensus on the management of triangular fibrocartilage injuries. The aim of this study was to investigate wrist surgeons' experiences and perceptions regarding treatment of triangular fibrocartilage complex injuries and to explore the rationale behind clinical decision-making. A purposive sample of consultant wrist surgeons (n = 10) was recruited through 'snow-balling' until data saturation was reached. Semi-structured interviews were conducted, digitally recorded and transcribed verbatim. Two researchers independently analysed data using an iterative/thematic approach. Findings suggest that surgeons rely more on their own training and experience, and patient-related factors such as individual expectations, to inform their decision-making, rather than on published material. Current classification systems are largely considered to be unhelpful. Level of evidence: V.

Return to sport following surgical management of triangular fibrocartilage tears: a systematic review

INTRODUCTION

This review aims to provide information on return rates and times to return to sport following surgical management of triangular fibrocartilage (TFC) tears.

SOURCES OF DATA

A systematic search of CINAHAL, Cochrane, EMBASE, Google Scholar, Medline, PEDro, Scopus, SPORTDiscus and Web of Science was performed using the keywords 'triangular', 'fibro-cartilage', 'complex', 'tear', 'distal radio-ulnar joint', 'athletes', 'sports', 'non-operative', 'conservative', 'operative' and 'return to sport'.

AREAS OF AGREEMENT

In all of the 10 studies included, conservative management for 6 weeks to 6 months was the first-line treatment. If symptoms persisted following this period, surgical management was advised. Arthroscopic debridement was recommended for central tears, and arthroscopic repair was recommended for peripheral tears.

AREAS OF CONTROVERSY

The optimal treatment modalities for TFC tears remain to be defined.

GROWING POINTS

Traumatic central tears can be treated with arthroscopic debridement alone. Arthroscopic repair with an all-inside repair can improve return rates to sport over an outside-in technique for ulna-sided tears.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future prospective studies should aim to establish the optimal treatment modalities for TFC tears.

Changes in Ulnar Variance after a Triangular Fibrocartilage Complex Tear

Purpose  The relationship between triangular fibrocartilage complex (TFCC) tear and ulnar impaction syndrome has not been fully understood. We hypothesized that a TFCC tear could change the ulnar variance, which may be the cause of ulnar impaction syndrome. Patients and Methods  A total of 72 patients who underwent TFCC foveal repair between January 2011 and June 2016 were included in this retrospective study. Among them, 44 patients diagnosed with TFCC foveal tear with distal radioulnar joint instability and no ulnar impaction syndrome underwent TFCC foveal repair only (group A) and 28 patients diagnosed with TFCC foveal tear with ulnar impaction syndrome underwent TFCC foveal repair and ulnar shortening osteotomy simultaneously (group B). We measured their ulnar variances in preoperative, postoperative, and last follow-up plain radiography. We also compared them with the ulnar variance of the contralateral (uninjured) wrist. Postoperative clinical outcomes, such as range of motions of the wrist, the visual analog scale (VAS) for pain, grip strength, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, were assessed. Results  Ulnar variance increased after TFCC tears compared with that on the uninjured side in both groups (group A: 0.98 vs. 0.52 mm, p  = 0.013; group B: 2.71 vs. 2.13 mm, p  = 0.001). Once the TFCC was repaired, ulnar variance decreased (group A: 0.98 to 0.01 mm, p  < 0.01; group B: 2.71 to 0.64 mm, p  < 0.01). However, it was increased on the last follow-up radiograph (group A: 0.01 to 0.81 mm, p  < 0.01; group B: 0.64 to 1.05 mm, p  = 0.004). There were no significant improvement of range of motion, except for pronation-supination motion ( p  = 0.04). Mean grip strength increased from 56.8 to 70.8% of the contralateral unaffected hand at the last assessment ( p  = 0.01). Mean VAS for pain decreased from 7.4 ± 2.5 preoperatively to 2.7 ± 2 postoperatively ( p  = 0.001). The QuickDASH score significantly improved from 45 to 9 ( p  = 0.001). Conclusion  Ulnar variance may be changed after a TFCC tear. In our study, it decreased after TFCC foveal repair. However, as time went on, the ulnar variance increased again, which could be one of the causes of ulnar impaction syndrome and ulnar-sided wrist pain. Level of Evidence  This is a therapeutic Level IV study.

Outcomes of Operative Treatment of Triangular Fibrocartilage Tears in Pediatric and Adolescent Athletes

BACKGROUND

Triangular fibrocartilage complex (TFCC) tears have been treated with increasing frequency in pediatric and adolescent patients over the past decade. There is little information on these injuries in young athletes and a scarcity of data regarding their ability to return to preinjury levels of athletic participation. The purpose of this study was to review the outcomes of pediatric and adolescent athletes with operatively treated TFCC tears with or without a concurrent ulnar shortening osteotomy and to determine their ability to return to their preoperative level of activity.

METHODS

A retrospective chart review was performed for all patients who underwent operative treatment of TFCC tears between 2006 and 2012 within one Upper Extremity practice. Patients were included if they were high-level athletes, unable to participate in their sport secondary to wrist pain and desired to return to their sport. All operative patients had imaging studies and clinical findings consistent with TFCC injury as the primary source of their activity-limiting pain and had failed nonoperative management prior to surgery. Patients without at least 3 months of documented postoperative follow up were excluded.

RESULTS

In total, 22 patients were included in the chart review with 20 patients willing to participate in a telephone survey and PODCI. Eighty percent of patients returned to their sport following operative treatment of their injury at an average of 4.8 months. Seven of the 22 patients underwent a concurrent ulnar shortening osteotomy for ulnar positive variance. All 20 patients reported satisfaction with the outcomes of their surgery and treatment.

CONCLUSIONS

Operative treatment of TFCC injuries in adolescent and pediatric athletes after failure of conservative treatment allowed return to sport at the previous level of participation. Concurrent ulnar shortening osteotomy in the setting of ulnar positive variance did not prohibit return to high-level athletic participation.

LEVEL OF EVIDENCE

Level IV.

Prognostic Factors of Arthroscopic Debridement for Central Triangular Fibrocartilage Complex Tears in Adults Younger Than 45 Years: A Retrospective Case Series Analysis

PURPOSE

The purpose of this study was to analyze factors that affect the treatment outcomes of arthroscopic debridement for central triangular fibrocartilage complex (TFCC) lesions in adults <45 years of age.

METHODS

A total of 71 patients (mean age, 39 years; range, 20-44 years) who had been arthroscopically diagnosed with central TFCC tears were treated with arthroscopic debridement. Demographic, clinical, and arthroscopic findings were examined and analyzed. The response to treatment, including pain numeric rating scale on an ulnar provocation test; Disability of the Arm, Shoulder, and Hand score; and satisfaction with treatment, was assessed at 12-month follow-up.

RESULTS

The mean pain numeric rating scale (6.6 ± 3.6 to 2.4 ± 2.0, P < .01) and Disability of the Arm, Shoulder, and Hand (59.3 ± 15.0 to 33.7 ± 14.1, P < .01) scores exhibited significant clinical improvement at 12-month follow-up. In terms of satisfaction, 43 patients (70.5%) were satisfied (enthusiastic or satisfied) and 18 (29.5%) were dissatisfied (noncommittal or disappointed). In the satisfied group, there were 24 flap and 19 wearing tears, whereas in the dissatisfied group, there were 4 flap and 14 wearing tears (P = .02). The extent of ulnar plus variance on preoperative radiographs also differed between the 2 groups (0.5 ± 1.2 vs 1.7 ± 1.1, P < .01). There were no significant differences in age, gender, hand dominance, or work level between the groups. After controlling for confounding variables, the wearing type tears (odds ratio, 3.4) and greater ulnar plus variance (odds ratio, 2.0) were associated with a higher likelihood of dissatisfaction after arthroscopic TFCC debridement.

CONCLUSIONS

Although clinical outcome scores showed significant improvement after arthroscopic debridement for central TFCC tears, wearing type tears and greater ulnar plus variance were associated with dissatisfaction and poorer postoperative outcomes after the procedure.

LEVEL OF EVIDENCE

Level IV, case series.

Prevalence and clinical characteristics of radiographic central triangular fibrocartilage complex tears in symptomatic and asymptomatic individuals younger than 50 years

BACKGROUND

Few studies have addressed the prevalence of central triangular fibrocartilage complex (TFCC) tears or their risk factors for symptom development. The aim of this study was to determine the prevalence of radiographic central TFCC tears in both symptomatic and asymptomatic individuals, and evaluate clinical characteristics of symptomatic individuals.

METHODS

In this retrospective case control study, 221 patients younger than 50 years who exhibited positive ulnocarpal provocation test and underwent MRI to identify abnormalities associated with TFCC were age- and sex-matched with 221 controls who had undergone hand or wrist MRI for tumorous lesions or pain in hand other than ulnar-sided wrist. Demographic and radiologic parameters including the degree of ulnar plus variance, the type of central TFCC lesions, the presence of ulna head or carpal bone enhancement, and cartilage degeneration of ulno-carpal or distal radio-ulnar joint were compared. Multivariable regression analysis was carried out to identify independent risk factors for symptom development in patients with central TFCC lesions.

RESULTS

The prevalence of central TFCC lesions was 68/221 in symptomatic patients, which was not significantly different from that (51/221) in asymptomatic controls. Patients in the symptomatic group had significantly greater ulnar plus variance (1.6 vs. 0.7). They were more likely to have type 1A tears and bony enhancement in ulnar head or carpus on MR images. Multivariable logistic regression analysis revealed that youth, female gender, and presence of bony enhancement were significant risk factors for symptom development in central TFCC lesions.

CONCLUSION

Based on the findings of this study, prevalence of central TFCC lesions detected on MRI in symptomatic patients seems to be similar to that in asymptomatic individuals. Younger age, female gender, and presence of bony enhancement on MR images seem to be risk factors for symptoms of central TFCC lesions.

Hand and Wrist Injuries: Common Problems and Solutions

Injuries to the hands and wrist are common in athletes. Injuries include acute fractures, dislocations, ligamentous, and tendon injuries, as well as more chronic injuries such as sprains and strains. Complications in the treatment of sports injuries of the hand and wrist may be divided into 2 categories: incorrect or delayed diagnosis and iatrogenic injury related to treatment. This article highlights common sports injuries of the hand and wrist and their complications, and includes tips for successful management.

Arthroscopic Assisted Resection of Triangular Fibrocartilage Complex Lesions: A 19-Year Follow-up

BACKGROUND

This study assesses long-term functional and subjective outcomes following arthroscopic assisted resection of lesions of the triangular fibrocartilage complex (TFCC).

METHODS

Functional and subjective outcomes were assessed based on review of patient charts for patient demographic characteristics, comprehensive clinical evaluation, obtained radiographs, and patient-reported questionnaires.

RESULTS

Fifteen patients, of whom 9 were female, and 10 dominant wrists, were included in this study. Median age was 60 (range, 37-73) years, and median duration of follow-up was 19 (range, 18-21) years. Median Mayo Wrist Score was 85 (range, 45-100). Four patients scored excellent, 7 good, 3 fair, and 1 poor result according to the Modified Mayo Wrist Score. Median Quick Disabilities of the Arm, Shoulder and Arm was 20 (range, 0-45) and Patient-Rated Wrist and Hand Evaluation was 8 (range, 0-61). Patients reported high rate for satisfaction and low rate for pain. All patients presented intact stability of the distal radioulnar joint.

CONCLUSIONS

This study demonstrates persisting satisfactory subjective and functional outcomes for patients following arthroscopic assisted resection for lesions of the TFCC at 19 years of follow-up. Arthroscopically assisted resection of selected TFCC lesions seems to be both a safe and efficient procedure.

Outcomes after Arthroscopic Debridement of the Triangular Fibrocartilage Complex in Adolescents

Background  To the best of our knowledge, we are not aware of any reports focusing on results of arthroscopic debridement of triangular fibrocartilage complex (TFCC) tears in immature patients. Purpose  The purpose of this study was to evaluate our results after arthroscopic debridement of TFCC tears in adolescents. Materials and Methods  We retrospectively identified all patients of 18 years or less, who received an arthroscopic TFCC debridement due to a traumatic or degenerative tear according to Palmer. These cases were clinically re-evaluated after a mean period of 6.7 years (SD ± 3.9 years). All patients completed the Modified Mayo Wrist Score (MMWS), Disabilities of the Arm, Shoulder and Hand (DASH) inventory, and Patient-Rated Wrist Evaluation (PRWE). Results  Thirteen adolescent patients (mean age: 15.6 ± 2.2 years at surgery) were included. The mean MMWS increased significantly from 70 ± 13.6 to 90 ± 6.5 after the TFCC debridement; mean postoperative DASH and PRWE scores of 17 ± 15.2 and 21 ± 18.5, respectively, indicated good and excellent outcomes for the majority of the cohort. The mean pain level decreased significantly from a mean of 5.7 ± 2.0 to 1.8 ± 2.0 at follow-up. Six patients needed a reoperation to achieve a successful outcome. Conclusion  Arthroscopic debridement of TFCC tears, performed as a concomitant wrist surgery in adolescents, efficiently reduced wrist pain and yielded good to excellent results in the long term. However, under certain circumstances, its results are unpredictable and further surgery may be necessary to eventually achieve the satisfying outcomes. Further studies are needed to confirm these findings. Level of Evidence  Level IV, therapeutic case series.

A Systematic Review of Outcomes after Arthroscopic Débridement for Triangular Fibrocartilage Complex Tear

BACKGROUND

Evidence regarding the effectiveness of arthroscopic débridement for a triangular fibrocartilage complex tear is uncertain. The purpose of this study was to conduct a systematic review of outcomes to evaluate the effectiveness of débridement for triangular fibrocartilage complex tears.

METHODS

The authors searched all available literature in the PubMed, Embase, and MEDLINE (Ovid) databases for articles reporting on triangular fibrocartilage complex tear débridement. Data collection included arc of motion, grip strength, patient-reported outcomes, and complications.

RESULTS

A total of 1723 unique studies were identified, of which 18 studies met the authors' criteria. The mean before and after arc of wrist extension/flexion motion values were 120 and 146 degrees (six studies). The mean before and after grip strength values were 65 percent and 91 percent of the contralateral side (10 studies). Disabilities of the Arm, Shoulder, and Hand scores (six studies) and pain visual analogue scale scores (seven studies) improved from 39 to 18, and from 7 to 3, respectively. The mean pain visual analogue scale score after débridement was 1.9 in the ulnar-positive group and 2.4 in the ulnar-neutral and ulnar-negative groups. Eighty-seven percent of patients returned to their original work.

CONCLUSIONS

Patients reported reduced pain and improved functional and patient-reported outcomes after débridement of triangular fibrocartilage complex tears. Most patients after débridement returned to previous work, with few complications. Although some of these cases may require secondary procedures, simple débridement can be performed with suitable satisfactory outcomes for cases with any type of ulnar variance.

Prognostic Factors Affecting Union After Ulnar Shortening Osteotomy in Ulnar Impaction Syndrome: A Retrospective Case-Control Study

BACKGROUND

Ulnar shortening osteotomy (USO) is a widely adopted procedure with excellent outcomes. However, delayed union or nonunion has occasionally been observed. The purpose of this retrospective case-control study was to identify variables affecting osseous consolidation after USO in patients with ulnar impaction syndrome.

METHODS

The study included 325 patients who had undergone USO between March 2008 and March 2014. We evaluated the association between union and basic demographic factors as well as preoperative pain (assessed on a visual analog scale [VAS]), range of wrist motion, grip strength, and modified Mayo wrist score. We also assessed the association of union with radiographic variables such as the degree of dorsal subluxation of the ulna, preoperative and postoperative ulnar variance, morphological type of the distal radioulnar joint, gap at the osteotomy site, and presence of newly developed arthritic changes during the follow-up period. Finally, variables associated with operative conditions, such as degeneration of the triangular fibrocartilage complex, use of a parallel double-blade saw, type of plate used for fixation, number of screws, and plate position on the volar or dorsal ulnar surface were investigated.

RESULTS

Ulnar union was achieved in 294 patients (group 1), and 31 patients had delayed union or nonunion (group 2). On univariate and multivariate analyses, smoking, low bone mineral density (BMD), a decreased range of motion of the wrist, and use of a double-blade saw were found to be significant factors for an adverse radiographic outcome (nonunion or delayed union).

CONCLUSIONS

Delayed union or nonunion occurred in about 10% of patients treated with USO. We suggest that it may be preferable to perform USO in nonsmokers, patients with normal bone density, and those without restricted wrist motion. Also, we recommend the use of a single-blade saw when performing the osteotomy.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Wrist Arthroscopy for Athletic Injuries

Management of hand and wrist injuries for athletes often places emphasis on an expeditious return to sport. Arthroscopic techniques have the advantage of directly visualizing joint derangements and correcting them via a minimally invasive approach. This article discusses the evaluation and management of common wrist injuries treated with arthroscopy in athletes, including scapholunate and lunotriquetral injury, triangular fibrocartilage complex tears, hamatolunate impingement, and arthroscopic-assisted reduction of wrist fractures.

Ulnar-Sided Wrist Pain in the Athlete

Ulnar-sided wrist pain can be a challenging entity for the hand surgeon and even more so in the athletic population. The authors present 8 causes of ulnar-sided wrist pain in an athlete (hook of hamate fracture, pisiform fracture, hypothenar hammer syndrome, triangular fibrocartilage complex injuries, ulnocarpal impaction syndrome, lunotriquetral ligament tears, extensor carpi ulnaris tendinitis, subluxation of extensor carpi ulnaris) and their associated imaging and treatment options.

Sports-related wrist and hand injuries: a review

Background

Hand and wrist injuries are common during athletics and can have a significant impact especially if initially disregarded. Due to their high level of physical demand, athletes represent a unique subset of the population.

Main body

The following is an overview of hand and wrist injuries commonly seen in athletics. Information regarding evaluation, diagnosis, conservative measures, and surgical treatment are provided.

Conclusion

Knowledge of these entities and special consideration for the athlete can help the team physician effectively treat these players and help them achieve their goals.

Functionality after arthroscopic debridement of central triangular fibrocartilage tears with central perforations

PURPOSE

To investigate functional and subjective outcome parameters after arthroscopic debridement of central articular disc lesions (Palmer type 2C) and to correlate these findings with ulna length.

METHODS

Fifty patients (15 men; 35 women; mean age, 47 y) with Palmer type 2C lesions underwent arthroscopic debridement. Nine of these patients (3 men; 6 women; mean static ulnar variance, 2.4 mm; SD, 0.5 mm) later underwent ulnar shortening osteotomy because of persistent pain and had a mean follow-up of 36 months. Mean follow-up was 38 months for patients with debridement only (mean static ulnar variance, 0.5 mm; SD, 1.2 mm). Examination parameters included range of motion, grip and pinch strengths, pain (visual analog scale), and functional outcome scores (Modified Mayo Wrist score [MMWS] and Disabilities of the Arm, Shoulder, and Hand [DASH] questionnaire).

RESULTS

Patients who had debridement only reached a DASH questionnaire score of 18 and an MMWS of 89 with significant pain reduction from 7.6 to 2.0 on the visual analog scale. Patients with additional ulnar shortening reached a DASH questionnaire score of 18 and an MMWS of 88, with significant pain reduction from 7.4 to 2.5. Neither surgical treatment compromised grip and pinch strength in comparison with the contralateral side. We identified 1.8 mm or more of positive ulnar variance as an indication for early ulnar shortening in the case of persistent ulnar-sided wrist pain after arthroscopic debridement.

CONCLUSIONS

Arthroscopic debridement was a sufficient and reliable treatment option for the majority of patients with Palmer type 2C lesions. Because reliable predictors of the necessity for ulnar shortening are lacking, we recommend arthroscopic debridement as a first-line treatment for all triangular fibrocartilage 2C lesions, and, in the presence of persistent ulnar-sided wrist pain, ulnar shortening osteotomy after an interval of 6 months. Ulnar shortening proved to be sufficient and safe for these patients. Patients with persistent ulnar-sided wrist pain after debridement who had preoperative static positive ulnar variance of 1.8 mm or more may be treated by ulnar shortening earlier in order to spare them prolonged symptoms.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Sensory innervation of the triangular fibrocartilage complex: a cadaveric study

PURPOSE

To describe the sensory innervation of the triangular fibrocartilage complex (TFCC) to understand the potential for selective denervation as an alternative treatment for recalcitrant pain from stable TFCC IA lesions after failed nonsurgical treatment.

METHODS

Eleven fresh cadaveric limbs were dissected with × 3.2 loupe magnification in a proximal to distal manner. The candidate nerves were the dorsal cutaneous branch of the ulnar nerve, volar sensory branch of the ulnar nerve, anterior interosseous nerve, posterior interosseous nerve, medial antebrachial cutaneous nerve, and palmar cutaneous branch of the median nerve. We identified neural continuity to the TFCC histologically with S-100 protein antibody staining.

RESULTS

In the 11 specimens, the TFCC was innervated by the dorsal cutaneous branch of the ulnar nerve (100%), medial antebrachial cutaneous nerve (91%), volar branch of the ulnar nerve (73%), anterior interosseous nerve (27%), posterior interosseous nerve (18%), and palmar branch of the median nerve (9%).

CONCLUSIONS

These results provide an initial step in planning an operative partial TFCC denervation for recalcitrant TFCC IA injuries that fail nonsurgical treatment and possibly also arthroscopic debridement.

CLINICAL RELEVANCE

Based on the results of this anatomic study, it is possible to create an algorithm for performing nerve blocks of the TFCC that would aid in planning a surgical denervation procedure.

Ulnar shortening osteotomy for ulnar-sided wrist pain

Background The purpose of ulnar shortening osteotomy is literally to shorten the ulna. It can tighten the triangular fibrocartilage complex (TFCC), ulnocarpal ligaments, and interosseous membrane. Nowadays, this method is used to treat ulnar-sided wrist pain, for which we have also started to use a treatment algorithm. The purpose of this study was to review the long-term and clinical results based on our algorithm. Materials and Methods We retrospectively reviewed 30 patients with ulnocarpal impaction syndrome after a minimum follow-up of 5 years (Group A) and then retrospectively evaluated 66 patients with recalcitrant ulnar wrist pain treated based on our algorithm (Group B). Description of Technique Ulnocarpal abutment was confirmed arthroscopically. The distal ulna was approached through a longitudinal incision between the extensor carpi ulnaris and flexor carpi ulnaris. We performed a transverse resection of the ulna fixed with a small locking compression plate. The contralateral side served as the reference for the length of shortening (mean, 2.4 mm; range, 1-5 mm). Disappearance of ulnar abutment was then confirmed again arthroscopically. Results (Group A) Most patients showed good long-term clinical results. About half of the patients showed a bony spur at the distal radioulnar joint (DRUJ), but the clinical results did not significantly correlate with presence of bony spurs. Radiological parameters wre not related to the presence of bony spurs. (Group B) Twenty-four of the 66 patients investigated prospectively underwent an ulnar shortening osteotomy, with all showing good clinical results at 18 months postoperatively. Conclusions Ulnar shortening osteotomy can change the load of the ulnar side of the wrist and appears useful for ulnar-sided wrist pain in the presence of ulnar impaction. Level of evidence IV.

Simple debridement has little useful value on the clinical course of recalcitrant ulnar wrist pain

The purpose of this study was to evaluate treatment results following arthroscopic triangular fibrocartilage complex (TFCC) debridement for recalcitrant ulnar wrist pain. According to the treatment algorithm, 66 patients (36 men and 30 women with a mean age of 38.1 years (15 to 67)) with recalcitrant ulnar wrist pain were allocated to undergo ulnar shortening osteotomy (USO; n = 24), arthroscopic TFCC repair (n = 15), arthroscopic TFCC debridement (n = 14) or prolonged conservative treatment (n = 13). The mean follow-up was 36.0 months (15 to 54). Significant differences in Hand20 score at 18 months were evident between the USO group and TFCC debridement group (p = 0.003), and between the TFCC repair group and TFCC debridement group (p = 0.029). Within-group comparisons showed that Hand20 score at five months or later and pain score at two months or later were significantly decreased in the USO/TFCC repair groups. In contrast, scores in the TFCC debridement/conservative groups did not decrease significantly. Grip strength at 18 months was significantly improved in the USO/TFCC repair groups, but not in the TFCC debridement/conservative groups. TFCC debridement shows little benefit on the clinical course of recalcitrant ulnar wrist pain even after excluding patients with ulnocarpal abutment or TFCC detachment from the fovea from the indications for arthroscopic TFCC debridement.

Minimally invasive approaches to ulnar-sided wrist disorders

Ulnar-sided wrist pain is a common cause of pain and disability, which has long been a diagnostic and therapeutic dilemma for hand surgeons. A thorough understanding of the anatomy, clinical examination, and radiographic evaluation is essential to establish a focused differential diagnosis, with the cause of disability often being multifactorial. Arthroscopy is particularly well suited to both directly visualize and treat multiple causes of ulnar-sided wrist pain, including pathology of the TFCC, UIS, LTIL tears, and hamate arthrosis.

Arthroscopic wafer procedure for ulnar impaction syndrome

Ulnar impaction syndrome is abutment of the ulna on the lunate and triquetrum that increases stress and load, causing ulnar-sided wrist pain. Typically, ulnar-positive or -neutral variance is seen on a posteroanterior radiograph of the wrist. The management of ulnar impaction syndrome varies from conservative, symptomatic treatment to open procedures to shorten the ulna. Arthroscopic management has become increasingly popular for management of ulnar impaction with ulnar-positive variance of less than 3 mm and concomitant central triangular fibrocartilage complex tears. This method avoids complications associated with open procedures, such as nonunion and symptomatic hardware. The arthroscopic wafer procedure involves debridement of the central triangular fibrocartilage complex tear, along with debridement of the distal pole of the ulna causing the impaction. Debridement of the ulna arthroscopically is taken down to a level at which the patient is ulnar neutral or slightly ulnar negative. Previous studies have shown good results with relief of patient symptoms while avoiding complications seen with open procedures.

[Pathology of wrist ligaments. 32 lesions of the carpal triangular fibrocartilage complex (TFCC). Prognostic significance of associated luno-triquetral lesions]

Trauma of the wrist is often responsible for multiple ligament injuries. We wanted to know if the association of a luno-triquetral ligament lesion and a triangular fibrocartilage disc lesion has a poor prognosis. We reviewed 32 patients with a traumatic injury of the triangular ligament, with a mean age of 35 years, and 32 months of follow up. The functional scores used were the Modified Mayo Wrist score, the Quick DASH score, and the Herzberg score. Patients were classified according to the severity of luno-triquetral lesions, in conformity with the Geissler's classification. Ten patients had a healthy ligament, 11 a stable lesion stage 1 and 11 an unstable lesion stage 2, 3 or 4. The joint mobility averages were 59.5° in flexion, 64.2° in extension, a pronation of 71.3°, a supination of 74.1°, an ulnar inclination of 33.8° and a radial inclination of 16.8°. The Modified Mayo Wrist score average was 75/100, the Herzberg score average was 81.5/100 and the average of the Quick DASH 8/100. The patients were all very satisfied or satisfied with their intervention. There was no statistically significant difference between the three groups studied regarding mobility and functional scores. In this study, an associated luno-triquetral ligament injury does not seem to worsen the functional outcome after surgery, provided appropriate treatment had been performed. However, a larger patient sample is needed to verify these findings.

Metaphyseal ulnar shortening osteotomy for the treatment of ulnocarpal abutment syndrome using distal ulna hook plate: case series

PURPOSE

To determine the efficacy of a transverse ulnar-shortening osteotomy at the metaphysis in combination with osteosynthesis using a low-profile, 2.0-mm, locking compression distal ulna plate for the treatment of ulnocarpal abutment syndrome.

METHODS

We enrolled into this prospective case series 6 patients with symptomatic ulnocarpal abutment syndrome without distal radioulnar joint ligamentous instability, who had previously failed conservative treatment. We recorded Quick Disability of Arm, Shoulder, and Hand score; wrist range of motion; and visual analog scale score for pain before and after surgery for statistical comparisons.

RESULTS

All parameters improved after the surgery. The Quick Disabilities of the Arm, Shoulder, and Hand improved from a mean of 65 to 17, and the visual analog score improved from a mean of 7 to 2. No hardware removal was required and no complications were reported.

CONCLUSIONS

Metaphyseal ulnar-shortening osteotomy provided the functional advantages of a midshaft ulnar-shortening osteotomy with the potential for improved bone healing and the reduced risk for complications. This technique was a useful alternative for treatment of ulnocarpal abutment syndrome, especially in patients with more than 2 mm ulnar positive variance.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Triangular fibrocartilage complex injuries in the elite athlete

Injuries to the triangular fibrocartilage complex (TFCC) in athletes can be caused by acute trauma, chronic repetitive loading, or a combination of both. Regardless of cause, the management of TFCC injuries in the high-performance athlete is often different from the basic tenets applied to the general population. The diagnosis, treatment, and rehabilitation regimen should be individualized and sport-specific in athletes, taking into consideration the priorities and needs of the athlete while striking a balance between healing, return to play, and long-term well-being.

The management of ulnocarpal abutment and degenerative triangular fibrocartilage complex tears in the competitive athlete

Ulnar-sided wrist pain is a frequent cause for loss of practice time and competitive play for athletes. Ulnocarpal abutment, a common source of ulnar-sided pain, typically burdens athletes who participate in gymnastics, racket sports, and baseball. Although many athletes respond to nonoperative management, surgical intervention should be considered when symptoms persist. Surgical options include arthroscopic debridement, arthroscopic wafer, open wafer, or ulnar-shortening osteotomy. Treatment should be tailored to the athletes' level of function, expectations, and goals. The timing of interventions also influences the treatment algorithm. A successful outcome can be anticipated when appropriate treatment is rendered.

Ulnar-sided wrist pain: evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears

Ulnar-sided wrist pain is a common cause of upper extremity disability. Presentation can vary from acute traumatic injuries to chronic degenerative conditions. Because of its overlapping anatomy, complex differential diagnosis, and varied treatment outcomes, the ulnar side of the wrist has been referred to as the "black box" of the wrist, and its pathology has been compared with low back pain. Common causes of ulnar-sided wrist pain include triangular fibrocartilaginous complex injuries, lunotriquetrial ligament injuries, and ulnar impaction syndrome.

Arthroscopic treatment of peripheral triangular fibrocartilage complex tears with the deep fibers intact

PURPOSE

We describe a variant of triangular fibrocartilage complex (TFCC) tears in which the superficial fibers attaching to the ulnar capsule are torn, with preservation of deep fibers inserting on the fovea. We present the clinical and magnetic resonance imaging findings and the results of arthroscopic repair in patients with this injury.

METHODS

Twenty-nine wrists were treated arthroscopically for peripheral TFCC tears with outside-in suture repair of the TFCC to the ulnar capsule. A retrospective review of all cases was performed to assess the physical examination, magnetic resonance imaging, and intraoperative findings. Patients were evaluated at greater than 1 year with range of motion, grip strength, standard outcome measures, and a survey assessing return to work and sports.

RESULTS

Before surgery, all patients had complaints of ulnar-sided wrist pain with a stable distal radioulnar joint on examination. Twenty-six wrists (90%) were available for follow-up at a mean of 31 months. There was one repeat surgery, a re-tear that required revision TFCC repair. The preoperative visual analog scale and Disabilities of the Arm, Shoulder, and Hand scores improved from 5 and 38 to 1 and 9, respectively, at final follow-up. Side-to-side comparisons demonstrated no measurable loss in motion or grip strength. There were no cases of distal radioulnar joint instability at final follow-up. Of 11 high-level athletes in the total cohort, 7 (64%) were able to return to sports, including all of those in racquet sports; however, athletes who bore weight through their hands were unable to return to their sporting activity.

CONCLUSIONS

Tears of the TFCC superficial fibers with the deep fibers intact present with ulnar-sided wrist pain but without distal radioulnar joint instability. The results of outside-in repair of the articular disk back to the ulnar capsule demonstrated improvement in pain and function with no measurable objective losses. Return to sport was variable and appeared worse for those who bear weight through the hands.

A comparison of ulnar shortening osteotomy alone versus combined arthroscopic triangular fibrocartilage complex debridement and ulnar shortening osteotomy for ulnar impaction syndrome

Background

This study compared the results of patients treated for ulnar impaction syndrome using an ulnar shortening osteotomy (USO) alone with those treated with combined arthroscopic debridement and USO.

Methods

The results of 27 wrists were reviewed retrospectively. They were divided into three groups: group A (USO alone, 10 cases), group B (combined arthroscopic debridement and USO, 9 cases), and group C (arthroscopic triangular fibrocartilage complex [TFCC] debridement alone, 8 cases). The wrist function was evaluated using the modified Mayo wrist score, disabilities of the arm, shoulder and hand (DASH) score and Chun and Palmer grading system.

Results

The modified Mayo wrist score in groups A, B, and C was 74.5 ± 8.9, 73.9 ± 11.6, and 61.3 ± 10.2, respectively (p < 0.05). The DASH score in groups A, B, and C was 15.6 ± 11.8, 19.3 ± 11.9, and 33.2 ± 8.5, respectively (p < 0.05). The average Chun and Palmer grading score in groups A and B was 85.7 ± 8.9 and 84.7 ± 6.7, respectively. The difference in the Mayo wrist score, DASH score and Chun and Palmer grading score between group A and B was not significant (p > 0.05).

Conclusions

Both USO alone and combined arthroscopic TFCC debridement with USO improved the wrist function and reduced the level of pain in the patients treated for ulnar impaction syndrome. USO alone may be the preferred method of treatment in patients if the torn flap of TFCC is not unstable.

Arthroscopic and open repair of the TFCC

Injury to the triangular fibrocartilage complex is the most common cause of ulnar-sided wrist pain. This functionally related complex of anatomic structures can be a source of pain secondary to acute injury or chronic degeneration. Strategies for the treatment of these injuries involve determining the anatomic location of the tear, the presence of associated distal radioulnar joint instability, and the presence of associated degenerative changes. Surgical management with open and arthroscopic techniques have been described, both with successful results.

Management of peripheral triangular fibrocartilage complex tears in the ulnar positive patient: arthroscopic repair versus ulnar shortening osteotomy

PURPOSE

One pattern of injury to the triangular fibrocartilage complex (TFCC) is a traumatic peripheral tear located at the ulnar end of the TFCC. Since 1989, this specific injury has been classified as a Palmer type 1B lesion. Various treatment options have been described for 1B injuries, yet when there is coexistent ulnar positive variance, it can make the choice of treatment difficult. The purpose of this article is to help the surgeon decide how to treat type 1B lesions in ulnar positive patients by directly comparing arthroscopic repair (repair) to ulnar shortening osteotomy (USO). The null hypothesis was that repair and USO would provide equivalent postoperative improvement with regard to motion; Disability of the Arm, Shoulder, and Hand (DASH) score; visual analog scale (VAS) score; and grip strength.

METHODS

We tested our hypothesis by retrospectively reviewing prospectively collected data from 51 patients treated surgically between 2000 and 2006 with type 1B tears in the setting of ulnar positive variance. Of these 51 patients, 27 were treated with arthroscopic repair and 24 with USO. All patients were evaluated before surgery as well as at final follow-up for active range of motion measurements, grip strength, DASH score, and VAS score. Radiographs were taken of all patients before surgery to confirm the presence of ulnar positive variance, and after surgery in the USO group to evaluate for bony union.

RESULTS

At the final follow-up, we found no statistically significant difference between the repair and USO groups with regard to flexion, extension, pronation, supination, radial deviation, or ulnar deviation. Likewise, there was no significant difference in grip strength, DASH scores, or VAS scores. When analyzing each cohort individually, both groups improved significantly after surgery with regard to DASH score, VAS score, and wrist extension. There was also a trend toward improved motion in all other directions except for an insignificant decrease in postoperative pronation in the repair group. Two patients in the USO group required additional surgery, with one revision performed for nonunion and one for painful hardware, which caused extensor carpi ulnaris tendonitis.

CONCLUSIONS

The results of our study suggest that type 1B TFCC tears in the ulnar positive patient can be managed equivalently well with repair or USO.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

A prospective study on the initial results of a low profile ulna shortening osteotomy system

Extra-articular ulna shortening osteotomy, in principle, is an accepted treatment option for symptomatic degenerative and traumatic triangular fibrocartilage complex (TFCC) tears. Despite the benefits of this surgical approach, potential disadvantages include risk of nonunion, soft tissue irritation, and the need for future hardware removal. A recently introduced low profile ulna shortening system was designed to decrease these potential complications. A single-surgeon prospective study was performed to evaluate this system. Ten consecutive patients undergoing ulna shortening for ulnar-sided wrist pain compatible with TFCC pathology participated in the study. Subjective, objective, and radiographic assessments were performed preoperatively and up to 24 weeks postoperatively. Based on visual analog scale (VOS) ratings (0 to 10), pain scores significantly improved (p < 0.05) and average patient satisfaction was 8.7. DASH and PRWE scores improved at three month follow-up (p < 0.05). Osteotomy healing time averaged 10.3 weeks, and there were no nonunions. Average discomfort associated with palpation of the plate at final follow-up was 3.3 (using VOS), and one patient requested removal of the hardware. In this short-term follow-up study, the assessed ulna shortening system appears effective and, in general, well tolerated.